ICG Fluorescence Imaging in Colorectal Surgery: A Snapshot from the ICRAL Study Group

Abstract

BackgroundFluorescence-guided visualization represents a recently proposed technology in colorectal surgery. Possible uses include perfusion evaluation, lymph node navigation and search for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique gained considerable popularity among colorectal surgeons, due to its significant reliability, easy and safe use and the relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date.MethodsThe survey was conducted on April 2020 among 44 centres dealing with colorectal diseases, participating to the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were about equally divided on the basis of a geographical criterion from multiple Italian regions, with a large proportion of public (89.1%) and non-academic (75.7%) centres. They were invited answering to an online survey in order to make a snapshot of their current behaviours regarding the use of fluorescence-guided visualization in colorectal surgery. Questions about technological availability, indications and techniques, personal approach and feeling were collected in a 23-item questionnaire.ResultsQuestionnaire replies were received from 37 institutions, and partially answered by 8 of them, who don’t have the fluorescence technology (21.6%). Out of the remaining 29 centres (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only in selected cases in the remaining 27.6%, while 62.1% of respondents don’t use fluorescence in open surgery (unless the perfusion is macroscopically doubtful with the naked eye for 41.4% of them). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted, based on personal belief. Only about half of surgeons reported reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement in colorectal surgery in the future. ConclusionThe survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perception of results is still not enough to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidences.

Clinical effect and standardization of indocyanine green angiography in the laparoscopic colorectal surgery

“…The expectations and interests of ICG angiography among surgeons are continually increasing. However, since ICG angiography has been carried out with various protocols, standardization is required [8,9]. In this review, we discuss the clinical utility and standardization of ICG angiography for colonic perfusion assessment.…”