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Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers

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Abstract

Background

The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications.

Methods

Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment between January 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6 weeks after surgery via contrast enema and pouchoscopy.

Results

One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3 years and average body mass index was 24.9 kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of the ileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemia and the leak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7 weeks.

Conclusion

ICG perfusion assessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.

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Authors and Affiliations

  1. Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA

    M. R. Freund, I. Kent, S. Agarwal & S. D. Wexner

Authors
  1. M. R. Freund
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  2. I. Kent
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  3. S. Agarwal
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  4. S. D. Wexner
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Contributions

All authors made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; all authors drafted the work or revised it critically for important intellectual content; all authors approved the version to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to S. D. Wexner.

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Conflict of interest

SDW is a paid consultant for Intuitive Surgical, Medtronic, Olympus, Stryker and receives royalty payments for intellectual property license from Intuitive Surgical, Karl Storz Endoscopy, and Medtronic.

Ethical approval

Approved by the Institutional Review Board (IRB) of our institution.

Consent to participate

A waiver of consent was granted by our institutional IRB since this is a retrospective chart review study.

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All patients signed consent to include their de-identified data for publication purposes.

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Supplementary Information

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Supplementary file1 Video 1: Animation showing mesenteric lengthening maneuvers including initial scoring of the peritoneum overlying the superior mesenteric artery and ligation of the ileocolic at its base, enabling the pouch to adequately reach the anal cuff while maintaining the integrity of the supplying vessel to the pouch. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2021. All Rights Reserved. (MP4 20898 KB)

Supplementary file2 (PDF 314 KB)

Supplementary file3 (PDF 312 KB)

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Freund, M.R., Kent, I., Agarwal, S. et al. Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers. Tech Coloproctol 26, 181–186 (2022). https://doi.org/10.1007/s10151-021-02557-x

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  • DOI: https://doi.org/10.1007/s10151-021-02557-x

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