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Early Experience with Intraoperative Leak Test Using a Blend of Methylene Blue and Indocyanine Green During Robotic Gastric Bypass Surgery

  • Monika E. Hagen
  • John Diaper
  • Jonathan Douissard
  • Minoa K. Jung
  • Leo Buehler
  • Florence Aldenkortt
  • Gleicy Keli Barcelos
  • Philippe Morel
Original Contribution
  • 27 Downloads

Abstract

Introduction

Leak tests using air or methylene blue (MB) for gastrojejunal anastomoses are often performed during gastric bypass surgeries to avoid leaks due to technical errors. Still, early leaks have been reported in the literature. Indocyanine green (ICG) fluorescence with laser excitement makes this dye easily visible even in small amounts, and, thus, may be an excellent agent for leak testing.

Methods

During robotic gastric bypass surgery, a leak test of a gastrojejunal anastomosis was performed with air through a nasogastric tube under manual occlusion of the jejunum. Afterward, 50 ml of a mix of 100 ml sterile water, 2 mg of MB, and 5 mg ICG was injected through the same tube. The entire anastomosis was inspected for integrity under both fluorescent and normal light modes.

Results

Leak tests with air and the blend of MB and ICG have been performed in 95 patients from January 2017 to April 2018. No intraoperative leak test-related adverse events occurred. Zero (0%) patients had a positive leak test with air, 0 patients showed MB excretion, and an ICG leak was observed in four (4.2%) patients. No anastomotic complications, including leaks and/or strictures, were found 30 days postoperatively.

Conclusions

Leak tests using a blend of MB and ICG appear to be more sensitive for small defect detection of gastrojejunal anastomoses during robotic gastric bypass surgery. Larger datasets and research that is more stringent are needed to determine the exact clinical value of this new method.

Keywords

Leak test Gastric bypass Anastomotic test Indocyanine green Methylene blue 

Notes

Compliance with Ethical Standards

Ethical Approval

Our local ethics committee approved the review of our gastric bypass surgeries.

Informed Consent

A statement regarding informed consent does not apply.

Conflict of Interest

Dr. Hagen received personal fees and non-financial support by Intuitive Surgical Inc. and Ethicon Endosurgery Inc., outside this project. Dr. Jung received non-financial support by Intuitive Surgical Inc. and Ethicon Endosurgery Inc., outside this project. Prof. Morel received personal fees and by Intuitive Surgical Inc. All other authors have nothing to disclose.

References

  1. 1.
    Stenberg E, Szabo E, Agren G, et al. Early complications after laparoscopic gastric bypass surgery: results from the Scandinavian obesity surgery registry. Ann Surg. 2014;260(6):1040–7.CrossRefGoogle Scholar
  2. 2.
    Kim J, Azagury D, Eisenberg D, et al. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015;11(4):739–48.CrossRefGoogle Scholar
  3. 3.
    Shin RB. Intraoperative endoscopic test resulting in no postoperative leaks from the gastric pouch and gastrojejunal anastomosis in 366 laparoscopic Roux-en-Y gastric bypasses. Obes Surg. 2004;14(8):1067–9.CrossRefGoogle Scholar
  4. 4.
    Sekhar N, Torquati A, Lutfi R, et al. Endoscopic evaluation of the gastrojejunostomy in laparoscopic gastric bypass: a series of 340 patients without postoperative leak. Surg Endosc. 2006;20(2):199–201.CrossRefGoogle Scholar
  5. 5.
    Kligman MD. Intraoperative endoscopic pneumatic testing for gastrojejunal anastomotic integrity during laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2007;21(8):1403–5.CrossRefGoogle Scholar
  6. 6.
    Haddad A, Tapazoglou N, Singh K, et al. Role of intraoperative esophagogastroenteroscopy in minimizing gastrojejunostomy-related morbidity: experience with 2,311 laparoscopic gastric bypasses with linear stapler anastomosis. Obes Surg. 2012;22(12):1928–33.CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Alander JT, Kaartinen I, Laakso A, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging. 2012;2012:1–26.CrossRefGoogle Scholar
  8. 8.
    Zhu B, Sevick-Muraca EM. A review of performance of near-infrared fluorescence imaging devices used in clinical studies. Br J Radiol. 2015;88(1045):20140547.CrossRefGoogle Scholar
  9. 9.
    Boni L, David G, Mangano A, et al. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc. 2015;29(7):2046–55.CrossRefGoogle Scholar
  10. 10.
    Kaibori M, Ishizaki M, Matsui K. Kwon AH intraoperative indocyanine green fluorescent imaging for prevention of bile leakage after hepatic resection. Surgery. 2011;150(1):91–8.  https://doi.org/10.1016/j.surg.20.CrossRefGoogle Scholar
  11. 11.
    Jafari MD, Lee KH, Halabi WJ, et al. The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc. 2013;27(8):3003–8.CrossRefGoogle Scholar
  12. 12.
    Ohi M, Toiyama Y, Mohri Y, et al. Prevalence of anastomotic leak and the impact of indocyanine green fluorescin imaging for evaluating blood flow in the gastric conduit following esophageal cancer surgery. Esophagus. 2017;14(4):351–9.CrossRefPubMedCentralGoogle Scholar
  13. 13.
    Hagen ME, Pugin F, Chassot G, et al. Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass. Obes Surg. 2012;22(1):52–61.CrossRefGoogle Scholar
  14. 14.
    Baiocchi GL, Diana M, Boni L. Indocyanine green-based fluorescence imaging in visceral and hepatobiliary and pancreatic surgery: state of the art and future directions. World J Gastroenterol. 2018;24(27):2921–30.CrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Digestive and Transplant Surgery, Department of SurgeryUniversity Hospital GenevaGenevaSwitzerland
  2. 2.Division of Digestive and Transplant Surgery, Department of SurgeryUniversity Hospital GenevaGenevaSwitzerland
  3. 3.Department of AnesthesiologyUniversity Hospital GenevaGenevaSwitzerland

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