Preliminary Use of Indocyanine Green Fluorescence Angiography and Value in Predicting the Vascular Supply of Tissues Needed to Perform Cloacal, Anorectal Malformation, and Hirschsprung Reconstructions

Abstract

Introduction Reconstructive techniques for cloaca, anorectal malformations (ARM), and Hirschsprung disease (HD) may require intestinal flaps on vascular pedicles for vaginal reconstruction and/or colonic pull-throughs. Visual assessment of tissue perfusion is typically the only modality used. We investigated the utility of intraoperative indocyanine green fluorescence angiography (ICG-FA) and hypothesized that it would be more accurate than the surgeon's eye.

Materials and Methods Thirteen consecutive patients undergoing cloacal reconstruction (9), HD (3), and ARM repair (1) underwent ICG-FA laser SPY imaging to assess colonic, rectal, vaginal, and neovaginal tissue perfusion following intraoperative visual clinical assessment. Operative findings were correlated with healing at 6 weeks, 3 months, and 1 year postoperatively.

Results ICG-FA resulted in a change in the operative plan in 4 of the 13 (31%) cases. In three cases, ICG-FA resulted in the distal bowel being transected at a level (>10 cm) higher than originally planned, and in one case the distal bowel was discarded, and the colostomy used for pull-through.

Conclusion ICG-FA correctly identified patients who might have developed a complication from poor tissue perfusion. Employing this technology to assess rectal or neovaginal pull-throughs in cloacal reconstructions, complex HD, and ARM cases may be a valuable technology.

Keywords

indocyanine green fluorescence angiography - cloaca - Hirschsprung disease - fluorescence angiography - anorectal malformation

Publication History

Received: 20 June 2019

Accepted: 17 September 2019

Article published online:
13 December 2019

• References

• 1 Nachiappan S, Askari A, Currie A, Kennedy RH, Faiz O. Intraoperative assessment of colorectal anastomotic integrity: a systematic review. Surg Endosc 2014; 28 (09) 2513-2530
• 2 Boni L, David G, Dionigi G, Rausei S, Cassinotti E, Fingerhut A. Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection. Surg Endosc 2016; 30 (07) 2736-2742
• 3 Sujatha-Bhaskar S, Jafari MD, Stamos MJ. The role of fluorescent angiography in anastomotic leaks. Surg Technol Int 2017; 30: 83-88
• 4 Lane VA, Skerritt C, Wood RJ. et al. A standardized approach for the assessment and treatment of internationally adopted children with a previously repaired anorectal malformation (ARM). J Pediatr Surg 2016; 51 (11) 1864-1870
• 5 Rother U, Gerken ALH, Karampinis I. et al. Dosing of indocyanine green for intraoperative laser fluorescence angiography in kidney transplantation. Microcirculation 2017; 24 (08) DOI: 10.1111/micc.12392.
• 6 Markus PM, Martell J, Leister I, Horstmann O, Brinker J, Becker H. Predicting postoperative morbidity by clinical assessment. Br J Surg 2005; 92 (01) 101-106
• 7 Kin C, Vo H, Welton L, Welton M. Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks. Dis Colon Rectum 2015; 58 (06) 582-587
• 8 Vignali A, Gianotti L, Braga M, Radaelli G, Malvezzi L, Di Carlo V. Altered microperfusion at the rectal stump is predictive for rectal anastomotic leak. Dis Colon Rectum 2000; 43 (01) 76-82
• 9 Gust L, Ouattara M, Coosemans W, Nafteux P, Thomas PA, D’Journo XB. European perspective in Thoracic surgery-eso-coloplasty: when and how?. J Thorac Dis 2016; 8 (Suppl. 04) S387-S398
• 10 Meyers MA. Griffiths' point: critical anastomosis at the splenic flexure. Significance in ischemia of the colon. AJR Am J Roentgenol 1976; 126 (01) 77-94
• 11 Wada T, Kawada K, Takahashi R. et al. ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery. Surg Endosc 2017; 31 (10) 4184-4193
• 12 Kudszus S, Roesel C, Schachtrupp A, Höer JJ. Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage. Langenbecks Arch Surg 2010; 395 (08) 1025-1030
• 13 van den Bos J, Al-Taher M, Schols RM, van Kuijk S, Bouvy ND, Stassen LPS. Near-infrared fluorescence imaging for real-time intraoperative guidance in anastomotic colorectal surgery: a systematic review of literature. J Laparoendosc Adv Surg Tech A 2018; 28 (02) 157-167
• 14 Nelson JA, Fischer JP, Grover R. et al. Intraoperative perfusion management impacts postoperative outcomes: an analysis of 682 autologous breast reconstruction patients. J Plast Reconstr Aesthet Surg 2015; 68 (02) 175-183
• 15 Bahrainwala ZS, Grega MA, Hogue CW. et al. Intraoperative hemoglobin levels and transfusion independently predict stroke after cardiac operations. Ann Thorac Surg 2011; 91 (04) 1113-1118
• 16 Hellan M, Spinoglio G, Pigazzi A, Lagares-Garcia JA. The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg Endosc 2014; 28 (05) 1695-1702
• 17 Jafari MD, Wexner SD, Martz JE. et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg 2015; 220 (01) 82-92.e1
• 18 Yeung TM, Volpi D, Tullis ID. et al. Identifying ureters in situ under fluorescence during laparoscopic and open colorectal surgery. Ann Surg 2016; 263 (01) e1-e2
• 19 Verbeek FP, van der Vorst JR, Schaafsma BE. et al. Intraoperative near infrared fluorescence guided identification of the ureters using low dose methylene blue: a first in human experience. J Urol 2013; 190 (02) 574-579