Fluorescent imaging using indocyanine green during esophagectomy to prevent surgical morbidity: a systematic review and meta-analysis

Abstract

Background: Fluorescent imaging using indocyanine green (ICG) is an emerging technique that aids the surgeon with intraoperative decision making during upper gastrointestinal cancer surgery. In this systematic review we aim to provide an overview of current practice of fluorescence imaging using ICG during esophagectomy, and to show how this technology can prevent surgical morbidity, such as anastomotic leakage, graft necrosis and chylothorax. Methods: The PRISMA standard for systematic reviews was used. The PubMed and Embase database were searched to identify articles matching our systematic literature search. Two authors screened all included articles for eligibility. Risk of bias was assessed for all included articles. Results: A total of 25 articles were included in this review: 22 articles on perfusion assessment, and three on the detection of chyle fistula. Five out of 22 articles concerning perfusion assessment evaluated fluorescence signals in quantitative values. In 20 articles the pooled incidence of anastomotic leakage and graft necrosis in the ICG group was 11.10% (95% CI: 8.06-15.09%) and in eight studies the pooled change in management rate was 24.55% (95% CI: 19.16-30.88%). After change in management, the pooled incidence of anastomotic leakage and graft necrosis was 14.08% (95% CI: 6.55-27.70%). A meta-analysis showed that less anastomotic leakages and graft necrosis occur in the ICG group (OR 0.30, 95% CI: 0.14-0.63). Three case-reports (N=3) were identified regarding chyle fistula detection, and ICG lymphography detected the thoracic duct in all cases and the chyle fistula in one case. Conclusions: Fluorescence imaging using ICG is a promising and safe technology to reduce surgical morbidity after esophagectomy with continuity restoration. ICG fluorescence angiography showed a reduction in anastomotic leakage and graft necrosis. Future studies are needed to demonstrate the feasibility of ICG lymphography for chyle fistula detection.

Successful management of gastric remnant necrosis after proximal gastrectomy using a double elementary diet tube: a case report

“…It has also been reported that ICG fluorescence was used to assess blood flow at the colonic anastomosis to reduce the suture failure rate [17,18]. In esophagectomy, ICG fluorescence has been used to assess gastric conduit blood flow [19][20][21][22]. In the present case, there was no visual evidence of poor blood flow in the rest of the stomach but there was a possibility of poor blood flow near the tip of the remnant stomach due to poor blood flow network in the gastric wall.…”

Indocyanine Green (ICG) fluorescence angiography of gastric conduit after transhiatal thoracic esophagectomy with proximal gastrectomy for esophagogastric junction adenocarcinoma: A case report and initial experience at a tertiary government hospital in the Philippines

“…However, anastomotic leakages are associated with postoperative mortality, reoperations, prolonged hospital and critical care unit stay, delayed or non-administration of adjuvant therapy, and stricture formation that may require subsequent endoscopic or surgical treatment [ [9] , [10] , [11] , [12] , [13] ]. There are several patient, disease, and technical factors that contribute to anastomotic leakage but adequacy of perfusion at the anastomotic site, a surgically modifiable factor, is considered one of the most crucial [ [11] , [12] , [13] , [14] , [15] , [16] , [17] ].…”

“…Complete washout of the ICG occurs within 20 min of injection [ 23 ]. The technology is informative, easy to use, and not linked to any major complication [ 14 , 15 , 19 ].…”

“…Studies have investigated several applications of ICG in gastric conduit construction including evaluation of blood supply, choice of appropriate site of anastomosis, prediction of anastomotic leakage risk, and as adjunct during gastric mobilization particularly during minimally-invasive esophagectomy [ 5 , 7 , [11] , [12] , [13] , [14] , [15] , [16] , [17] , 19 , 23 , 24 ].…”

Application of Mediastinal Drainage Tube in Intrathoracic Esophageal Anastomotic Leakage for Early Diagnosis and Effective Treatment: A Retrospective Study

“…AL after esophagectomy is a severe postoperative complication with potential poor prognosis. In recent years, a wide range of measures to prevent AL has been suggested, including improvement in anastomotic techniques [15][16][17] and gastric tube formation [18,19] , utilization of pedicled omental aps [20,21] or mobilized pleura [22] , avoiding excessive tension at the anastomosis [23] , intraoperative perfusion monitor [24,25] , e cient gastric decompression [26] , and meticulous perioperative management. Nevertheless, among them, only few interventions are supported by strong clinical evidence, and then anastomotic leakage has still been an important postoperative complication.…”