Abstract
Background
Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)—PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak.
Methods
We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit).
Results
100 patients (81 males, median age 68 [60–72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260 mL [95–463] versus 75 mL [48–150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak.
Conclusion
Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.
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References
Schröder W, Raptis DA, Schmidt HM, Gisbertz SS, Moons J, Asti E, Luyer MDP, Hölscher AH, Schneider PM, van Berge Henegouwen MI, Nafteux P, Nilsson M, Räsanen J, Palazzo F, Mercer S, Bonavina L, Nieuwenhuijzen GAP, Wijjnhoven BPL, Pattyn P, Grimminger PP, Bruns CJ, Gutschow CA (2019) Anastomotic techniques and associated morbidity in total minimally invasive transthoracic esophagectomy: results from the EsoBenchmark database. Ann Surg 270:820–826
Luketich JD, Pennathur A, Franchetti Y, Catalano PJ, Swanson S, Sugarbaker DJ, De Hoyos A, Maddaus MA, Nguyen NT, Benson AB, Fernando HC (2015) Minimally invasive esophagectomy: results of a prospective phase II multicenter trial-the eastern cooperative oncology group (E2202) study. Ann Surg 261:702–707
Kassis ES, Kosinski AS, Ross P, Koppes KE, Donahue JM, Daniel VC (2013) Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg 96:1919–1926
Zehetner J, DeMeester SR, Alicuben ET, Oh DS, Lipham JC, Hagen JA, DeMeester TR (2015) Intraoperative assessment of perfusion of the gastric graft and correlation with anastomotic leaks after esophagectomy. Ann Surg 262:74–78
Campbell C, Reames MK, Robinson M, Symanowski J, Salo JC (2015) Conduit vascular evaluation is associated with reduction in anastomotic leak after esophagectomy. J Gastrointest Surg 19:806–812
Clavien PA, Barkun J, De Oliveira ML, Vauthey JN, Dindo D, Schulick RD, De Santibañes E, Pekolj J, Slankamenac K, Bassi C (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196
Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205
Awad ZT, Abbas S, Puri R, Dalton B, Chesire DJ (2020) Minimally invasive Ivor Lewis esophagectomy (MILE): technique and outcomes of 100 consecutive cases. Surg Endosc 34:3243–3255
Naffouje SA, Salloum RH, Khalaf Z, Salti GI (2019) Outcomes of open versus minimally invasive Ivor-Lewis esophagectomy for cancer: a propensity-score matched analysis of NSQIP database. Ann Surg Oncol 26:2001–2010
Straatman J, van der Wielen N, Nieuwenhuijzen GAP, Rosman C, Roig J, Scheepers JJG, Cuesta MA, Luyer MDP, van Berge Henegouwen MI, van Workum F, Gisbertz SS, van der Peet DL (2016) Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers. Surg Endosc 31:119–126
Sabra MJ, Alwatari YA, Wolfe LG, Xu A, Kaplan BJ, Cassano AD, Shah RD (2020) Ivor Lewis vs Mckeown esophagectomy: analysis of operative outcomes from the ACS NSQIP database. Gen Thorac Cardiovasc Surg 68:370–379
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
Alekseev M, Rybakov E, Shelygin Y, Chernyshov S, Zarodnyuk I (2020) A study investigating the perfusion of colorectal anastomoses using fluorescence angiography: results of the FLAG randomized trial: study of the perfusion of colorectal anastomoses. Colorectal Dis 22:1147–1153
Van Daele E, Van Nieuwenhove Y, Ceelen W, Vanhove C, Braeckman BP, Hoorens A, Van Limmen J, Varin O, Van de Putte D, Willaert W, Pattyn P (2019) Near-infrared fluorescence guided esophageal reconstructive surgery: a systematic review. World J Gastrointest Oncol 11:250–263
Ladak F, Dang JT, Switzer N, Mocanu V, Tian C, Birch D, Turner SR, Karmali S (2018) Indocyanine green for the prevention of anastomotic leaks following esophagectomy: a meta-analysis. Surg Endosc 33:384–394
Kumagai Y, Hatano S, Sobajima J, Ishiguro T, Fukuchi M, Ishibashi K-I, Mochiki E, Nakajima Y, Ishida H (2018) Indocyanine green fluorescence angiography of the reconstructed gastric tube during esophagectomy: efficacy of the 90-second rule. Dis Esophagus 31:doy052
Koyanagi K, Ozawa S, Oguma J, Kazuno A, Yamazaki Y, Ninomiya Y, Ochiai H, Tachimori Y (2016) Blood flow speed of the gastric conduit assessed by indocyanine green fluorescence: new predictive evaluation of anastomotic leakage after esophagectomy. Medicine 95:e4386
Yukaya T, Saeki H, Kasagi Y, Nakashima Y, Ando K, Imamura Y, Ohgaki K, Oki E, Morita M, Maehara Y (2015) Indocyanine green fluorescence angiography for quantitative evaluation of gastric tube perfusion in patients undergoing esophagectomy. J Am Coll Surg 221:e37–e42
Hall BR, Flores LE, Parshall ZS, Shostrom VK, Are C, Reames BN (2019) Risk factors for anastomotic leak after esophagectomy for cancer: a NSQIP procedure-targeted analysis. J Surg Oncol 120:661–669
Schardey HM, Joosten U, Finke U, Staubach KH, Schauer R, Heiss A, Kooistra A, Rau HG, Nibler R, Lüdeling S, Unertl K, Ruckdeschel G, Exner H, Schildberg FW (1997) The prevention of anastomotic leakage after total gastrectomy with local decontamination. A prospective, randomized, double-blind, placebo-controlled multicenter trial. Ann Surg 225:172–180
Shogan BD, Carlisle EM, Alverdy JC, Umanskiy K (2013) Do we really know why colorectal anastomoses leak? J Gastrointest Surg 17:1698–1707
van Workum F, Stenstra MHBC, Berkelmans GHK, Slaman AE, van Berge Henegouwen MI, Gisbertz SS, van den Wildenberg FJH, Polat F, Irino T, Nilsson M, Nieuwenhuijzen GAP, Luyer MD, Adang EM, Hannink G, Rovers MM, Rosman C (2019) Learning curve and associated morbidity of minimally invasive esophagectomy: a retrospective multicenter study. Ann Surg 269:88–94
Dalton BGA, Ali AA, Crandall M, Awad ZT (2018) Near infrared perfusion assessment of gastric conduit during minimally invasive Ivor Lewis esophagectomy. Am J Surg 216:524–527
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Drs. K Pather, AM Deladisma, IR Kriley, and ZT Awad, and Ms. C Guerrier have no conflicts of interest or financial ties to disclose.
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Pather, K., Deladisma, A.M., Guerrier, C. et al. Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy. Surg Endosc 36, 896–903 (2022). https://doi.org/10.1007/s00464-021-08346-9
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DOI: https://doi.org/10.1007/s00464-021-08346-9