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Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial

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Insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. Intraoperative indocyanine-green (ICG) angiography has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections, and thus possibly reducing the leak rate. Aim of this study was to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using ICG angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis.


This randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative ICG or to subjective visual evaluation of the bowel perfusion without ICG. The primary aim was to assess whether ICG angiography could lead to a reduction in anastomotic leak rate. Secondary outcomes were possible changes in the surgical strategy and postoperative morbidity.


After randomization, 12 patients were excluded. Accordingly, 240 patients were included in the analysis; 118 were in the study group, and 122 in the control group. ICG angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection in 13 cases (11%). An anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.).


Intraoperative ICG fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. This method led to further proximal bowel resection in 13 cases, however, there was no statistically significant reduction of anastomotic leak rate in the ICG arm.

Clinical trial NCT02662946.

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  1. Park JS1, Choi GS, Kim SH, Kim HR, Kim NK, Lee KY, Kang SB, Kim JY, Lee KY, Kim BC, Bae BN, Son GM, Lee SI, Kang H (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 257:665–671

    Article  PubMed  Google Scholar 

  2. Kang CY, Halabi WJ, Chaudhry OO, Nguyen V, Pigazzi A, Carmichael JC, Mills S, Stamos MJ (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg 148:65–71

    Article  PubMed  Google Scholar 

  3. Kingham TP1, Pachter HL (2009) Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg 208:269–278

    Article  PubMed  Google Scholar 

  4. Buchs NC1, Gervaz P, Secic M, Bucher P, Mugnier-Konrad B, Morel P (2008) Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study. Int J Colorectal Dis 23:265–270

    Article  PubMed  Google Scholar 

  5. Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253:890–899

    Article  PubMed  Google Scholar 

  6. Vignali A, Gianotti L, Braga M, Radaelli G, Malvezzi L, Di Carlo V (2000) Altered microperfusion of the rectal stump is predictive for rectal anastomotic leak. Dis Colon Rectum 30:867–871

    Google Scholar 

  7. Urbanavičius L, Pattyn P, de Putte DV, Venskutonis D (2011) How to assess intestinal viability during surgery: A review of techniques. World J Gastrointest Surg 3:59–69

    Article  PubMed  PubMed Central  Google Scholar 

  8. Luo S, Zhang E, Su Y, Cheng T, Shi C (2011) A review of NIR dyes in cancer targeting and imaging. Biomaterials 37:7127–7138

    Article  Google Scholar 

  9. Gossedge G, Vallance A, Jayne D (2015) Diverse applications for near infra-red intraoperative imaging. Colorectal Dis 17(Suppl 3):7–11

    Article  PubMed  Google Scholar 

  10. Degett TH, Andersen HS, Gögenur I (2016) Indocyanine green fluorescence angiography for intraoperative assessment of gastrointestinal anastomotic perfusion: a systematic review of clinical trials. Langenbecks Arch Surg 401:767–775.

    Article  PubMed  Google Scholar 

  11. Dindo D, Clavien PA, Demartines N (2004) Classification of surgical complications. Ann Surg 240:205–213

    Article  PubMed  PubMed Central  Google Scholar 

  12. Rahbari NN1, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147:339–351.

    Article  PubMed  Google Scholar 

  13. Pommergaard HC, Gessler B, Burcharth J, Angenete E, Haglind E, Rosenberg J (2014) Preoperative risk factors for anastomotic leakage after resection for colorectal cancer: a systematic review and meta-analysis. Colorectal Dis 16:662–671.

    Article  CAS  PubMed  Google Scholar 

  14. Guraieb-Trueba M, Frering T, Atallah S (2016) Combined endoscopic and laparoscopic real-time intra-operative evaluation of bowel perfusion using fluorescence angiography. Tech Coloproctol 20:883–884

    Article  CAS  PubMed  Google Scholar 

  15. Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM (2009) Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 24:569–576.

    Article  CAS  PubMed  Google Scholar 

  16. Cahill RA, Ris F, Mortensen NJ (2011) Near-infrared laparoscopy for real-time intra-operative arterial and lymphatic perfusion imaging. Colorectal Dis 13:12–17.

    Article  PubMed  Google Scholar 

  17. Ris F, George B, Cahill RA, Mortensen NJ (2014) Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endosc 28:2221–2226

    Article  PubMed  PubMed Central  Google Scholar 

  18. Boni L, David G, Dionigi G, Rausei S, Cassinotti E, Fingerhut A (2016) Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection. Surg Endosc 30:2736–2742

    Article  PubMed  Google Scholar 

  19. Kudszus S, Roesel C, Schachtrupp A, Höer JJ (2010) Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage. Langenbecks Arch Surg 395:1025–1030.

    Article  PubMed  Google Scholar 

  20. Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD (2010) Postoperative complications following surgery for rectal cancer. Ann Surg 251:807–818.

    Article  PubMed  Google Scholar 

  21. Guillou PJ, Quirke P, Thorpe H et al (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718e1726

    Article  Google Scholar 

  22. van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WCJ, Bonjer HJ, COLOR II Study Group (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218

    Article  PubMed  Google Scholar 

  23. Braga M, Frasson M, Zuliani W, Vignali A, Pecorelli N, Di Carlo V (2010) Randomized clinical trial of laparoscopic versus open left colonic resection. Br J Surg 97:1180–1186.

    Article  CAS  PubMed  Google Scholar 

  24. Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T (2017) Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients. Colorectal Dis 19:288–298.

    Article  CAS  PubMed  Google Scholar 

  25. Alves A, Panis Y, Trancart D et al (2002) Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients. World J Surg 26:499–502

    Article  PubMed  Google Scholar 

  26. Van den Bos J, Al-Taher M, Schols RM, van Kuijk S, Bouvy ND, Stassen LPS (2018) Near-infrared fluorescence imaging for real-time intraoperative guidance in anastomotic colorectal surgery: a systematic review of literature. J Laparoendosc Adv Surg Tech A 28:157–167.

    Article  PubMed  Google Scholar 

  27. Foppa C, Denoya PI, Tarta C, Bergamaschi R (2014) Indocyanine green fluorescent dye during bowel surgery: are the blood supply “guessing days”. over? Techol Coloproctol 18:753–758.

    Article  CAS  Google Scholar 

  28. Hellan M, Spinoglio G, Pigazzi A, Lagares-Garcia JA (2014) The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg Endosc 28:1695–1702.

    Article  PubMed  Google Scholar 

  29. Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter DA, Lee SW, Senagore AJ, Phelan MJ, Stamos MJ (2015) Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg 220:82–92.e1.

    Article  PubMed  Google Scholar 

  30. Boni L, Fingerhut A, Marzorati A, Rausei S, Dionigi G, Cassinotti E (2016) Indocyanine green fluorescence angiography during laparoscopic low anterior resection: results of a case-matched study. Surg Endosc 31:1836–1840.

    Article  PubMed  Google Scholar 

  31. Kin C, Vo H, Welton L, Welton M (2015) Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks. Dis Colon Rectum 58:582–587.

    Article  PubMed  Google Scholar 

  32. Jafari MD, Lee KH, Halabi WJ, Mills SD, Carmichael JC, Stamos MJ, Pigazzi A (2013) The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc 27:3003–3008.

    Article  PubMed  Google Scholar 

  33. Hope-Ross M, Yannuzzi LA, Gragoudas ES, Guyer DR, Slakter JS, Sorenson JA, Krupsky S, Orlock DA, Puliafito CA (1994) Adverse reactions due to indocyanine green. Ophthalmology 101:529–533

    Article  CAS  PubMed  Google Scholar 

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Correspondence to Paola De Nardi.

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P. De Nardi, U. Elmore, G. Maggi, R. Maggiore, L. Boni, E. Cassinotti, U. Fumagalli, M. Gardani, S. De Pascale, P. Parise, A. Vignali, and R. Rosati have no conflicts of interest or financial ties to disclose.

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De Nardi, P., Elmore, U., Maggi, G. et al. Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc 34, 53–60 (2020).

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