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Intraluminal indocyanine green for intraoperative staple line leak testing in bariatric surgery

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Abstract

Background

Bariatric surgical procedures have recognized benefits for morbidly obese patients. Unfortunately, staple line leaks remain a profound complication after these procedures. Currently available intraoperative surveillance modalities have multiple drawbacks, such as requiring an available upper endoscope and experienced endoscopist. Additionally, increased procedure time and resources are needed to perform intraoperative endoscopy and maintain equipment.

Methods

This is a retrospective cohort study of all bariatric patients undergoing Roux-en-Y gastric bypass or sleeve gastrectomy procedures performed by one attending surgeon at a tertiary care facility designated as a bariatric surgical center of excellence. Patients were grouped based on procedure date being before (September 2016 to mid-October 2018) or after (mid-October 2018 to March 2019) implementation of a novel intraluminal indocyanine green leak testing protocol. Diluted indocyanine green was injected via orogastric bougie intraluminally at the location of the gastric staple line and observed with near-infrared imaging from the intraperitoneal perspective for evidence of immunofluorescence extravasation. Data from the electronic medical record and bariatric surgical outcomes database were gathered to analyze the sensitivity and specificity of this new intraoperative diagnostic modality.

Results

Total of 196 patients underwent bariatric surgery with intraoperative leak testing using the gastroscopy method; of these, there were 3 false negatives and 193 true negatives. Total of 59 patients underwent bariatric surgery with intraoperative leak testing using the intraluminal ICG method; of these, there was 1 true positive, 1 false positive, 0 false negatives, and 57 true negatives. Indocyanine green leak testing had a sensitivity of 100.00% and specificity of 98.28%.

Conclusions

Intraluminal indocyanine green is an alternative for intraoperative detection of staple line integrity during bariatric surgical procedures with comparable specificity to intraoperative gastroscopy.

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Abbreviations

ICG:

Indocyanine green

MBSAQIP:

Metabolic and bariatric surgery accreditation and quality improvement program

BMI:

Body mass index

RYGB:

Roux-en-Y gastric bypass

SG:

Sleeve gastrectomy

SD:

Standard deviation

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Acknowledgements

Authors would like to acknowledge Katherine Shaver for her expert assistance verifying our statistical analysis.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Surgery, Virginia Tech Carilion, 1906 Belleview Ave SE, Roanoke, VA, 24014, USA

    Christopher L. Kalmar, Christopher M. Reed & Arnold D. Salzberg

  2. Department of Surgery, Sanford Health, Sioux Falls, SD, USA

    Curtis L. Peery

Authors
  1. Christopher L. Kalmar
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  2. Christopher M. Reed
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  3. Curtis L. Peery
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  4. Arnold D. Salzberg
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Correspondence to Christopher L. Kalmar.

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CLK, CMR, CLP and ADS do not have any financial or nonfinancial conflicts of interest to disclose.

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This research was approved by the Institutional Review Board of Virginia Tech Carilion.

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Kalmar, C.L., Reed, C.M., Peery, C.L. et al. Intraluminal indocyanine green for intraoperative staple line leak testing in bariatric surgery. Surg Endosc 34, 4194–4199 (2020). https://doi.org/10.1007/s00464-020-07606-4

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  • DOI: https://doi.org/10.1007/s00464-020-07606-4

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