Challenges in the interpretation of colorectal indocyanine green fluorescence angiography – A video vignette

Dalli, Jeffrey; Hardy, Niall; Aonghusa, Pól G. Mac; Epperlein, Jonathan P.; Murphy, Padraig Cantillon; Ra, Chisei

doi:10.1111/codi.15592

Cited by 11 publications

(15 citation statements)

References 13 publications

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“…In addition, protocolized approaches are needed to be developed. From our own experience, endorsed by this study, we suggest that perfusion judgement should be determined within the first minute as, even though the bowel may fluoresce later, this may be falsely positive occurring due to diffusion of ICG into the tissue rather than true perfusion [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

The use of fluorescence angiography to assess bowel viability in the acute setting: an international, multi-centre case series

et al. 2022

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Introduction Assessing bowel viability can be challenging during acute surgical procedures, especially regarding mesenteric ischaemia. Intraoperative fluorescence angiography (FA) may be a valuable tool for the surgeon to determine whether bowel resection is necessary and to define the most appropriate resection margins. The aim of this study is to report on FA use in the acute setting and to judge its impact on intraoperative decision making. Materials and methods This is a multi-centre, retrospective case series of patients undergoing emergency abdominal surgery between February 2016 and 2021 in three general/colorectal units where intraoperative FA was performed to assess bowel viability. Primary endpoint was change of management after the FA assessment. Results A total of 93 patients (50 males, 66.6 ± 19.2 years, ASA score ≥ III in 85%) were identified and studied. Initial surgical approach was laparotomy in 66 (71%) patients and laparoscopy in 27 (29% and seven, 26% conversions). The most common aetiologies were mesenteric ischaemia (n = 42, 45%) and adhesional/herniae-related strangulation (n = 41, 44%). In 50 patients a bowel resection was performed. Overall rates of anastomosis after resection, reoperation and 30-day mortality were 48% (n = 24/50, one leak), 12% and 18%, respectively. FA changed management in 27 (29%) patients. In four patients (4% overall), resection was avoided and in 21 (23%) extra bowel length was preserved (median 50 cm of bowel saved, IQR 28–98) although three patients developed further ischaemia. FA prompted extended resection (median of 20 cm, IQR 10–50 extra bowel) in six (6%) patients. Conclusion Intraoperative use of FA impacts surgical decisions regarding bowel resection for intestinal ischaemia, potentially enabling bowel preservation in approximately one out of four patients. Prospective studies are needed to optimize the best use of this technology for this indication and to determine standards for the interpretation of FA images and the potential subsequent need for second-look surgeries.

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Section: Discussionmentioning

confidence: 99%

The use of fluorescence angiography to assess bowel viability in the acute setting: an international, multi-centre case series

et al. 2022

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“…This heterogeneity in practice and techniques is also reflected in research studies with some either disregarding [16] or variably appreciating [6,7] the chronology of the fluorescence intensity. Technical considerations such as ICG-tissue interaction and NIR system performance (including brand specific on-screen display) [17][18][19][20] may further impair correct ICGFA perfusion signal interpretation. All of this means that correct interpretation of ICGFA signals may require some experience.…”

Section: Discussionmentioning

confidence: 99%

Deconstructing mastery in colorectal fluorescence angiography interpretation

et al. 2022

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Introduction Indocyanine green fluorescence angiography (ICGFA) is commonly used in colorectal anastomotic practice with limited pre-training. Recent work has shown that there is considerable inconsistency in signal interpretation between surgeons with minimal or no experience versus those consciously invested in mastery of the technique. Here, we deconstruct the fluorescence signal patterns of expert-annotated surgical ICGFA videos to understand better their correlation and combine this with structured interviews to ascertain whether such interpretative capability is conscious or unconscious. Methods For fluorescence signal analysis, expert-annotated ICGFA videos (n = 24) were quantitatively interrogated using a boutique intensity tracker (IBM Research) to generate signal time plots. Such fluorescence intensity data were examined for inter-observer correlation (Intraclass Correlation Coefficients, ICC) at specific curve milestones: the maximum fluorescence signal (Fmax), the times to both achieve this maximum (Tmax), as well as half this maximum (T1/2max) and the ratio between these (T1/2/Tmax). Formal tele-interview with contributing experts (n = 6) was conducted with the narrative transcripts being thematically mapped, plotted, and qualitatively analyzed. Results Correlation by mathematical measures was excellent (ICC0.9–1.0) for Fmax, Tmax, and T1/2max (0.95, 0.938, and 0.925, respectively) and moderate (0.5–0.75) for T1/2/Tmax (0.729). While all experts narrated a deliberate viewing strategy, their specific dynamic signal appreciation differed in the manner of description. Conclusion Expert ICGFA users demonstrate high correlation in mathematical measures of their signal interpretation although do so tacitly. Computational quantification of expert behavior can help develop the necessary lexicon and training sets as well as computer vision methodology to better exploit ICGFA technology.

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“…These differences may impact operator-based interpretation and the development of computational tools. For instance, the distance 14 – 16 and angulation 16 from the tissue, as well as the positioning of the target in relation to the center of the screen, 17 have been demonstrated to significantly impact the fluorescence signal. The relative importance of these physical variables may vary between systems.…”

Section: Introductionmentioning

confidence: 99%

Evaluating clinical near-infrared surgical camera systems with a view to optimizing operator and computational signal analysis

et al. 2023

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. Significance As clinical evidence on the colorectal application of indocyanine green (ICG) perfusion angiography accrues, there is also interest in computerizing decision support. However, user interpretation and software development may be impacted by system factors affecting the displayed near-infrared (NIR) signal. Aim We aim to assess the impact of camera positioning on the displayed NIR signal across different open and laparoscopic camera systems. Approach The effects of distance, movement, and target location (center versus periphery) on the displayed fluorescence signal of different systems were measured under electromagnetic stereotactic guidance from an ICG-albumin model and in vivo during surgery. Results Systems displayed distinct fluorescence performances with variance apparent with scope optical lens configuration (0 deg versus 30 deg), movement, target positioning, and distance. Laparoscopic system readings fitted inverse square function distance-intensity curves with one device and demonstrated a direction dependent sigmoid curve. Laparoscopic cameras presented central targets as brighter than peripheral ones, and laparoscopes with angled optical lens configurations had a diminished field of view. One handheld open system also showed a distance-intensity relationship, whereas the other maintained a consistent signal despite distance, but both presented peripheral targets brighter than central ones. Conclusions Optimal clinical use and signal computational development requires detailed appreciation of system behaviors.

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Challenges in the interpretation of colorectal indocyanine green fluorescence angiography – A video vignette

Cited by 11 publications

References 13 publications

The use of fluorescence angiography to assess bowel viability in the acute setting: an international, multi-centre case series

The use of fluorescence angiography to assess bowel viability in the acute setting: an international, multi-centre case series

Deconstructing mastery in colorectal fluorescence angiography interpretation

Evaluating clinical near-infrared surgical camera systems with a view to optimizing operator and computational signal analysis

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