Indocyanine Green-Enhanced Colorectal Surgery—between Being Superfluous and Being a Game-Changer

Abstract

Nowadays, surgical innovations incorporate new technological conquests and must be validated by evidence-based medicine. The use of augmented reality-assisted indocyanine green (ICG) fluorescence has generated a myriad of intraoperative applications such as demonstration of key anatomical landmarks, sentinel lymph nodes, and real-time assessment of local blood flow. This paper presents a systematic review of the clinical evidence regarding the applications of ICG near-infrared (NIR) fluorescence in colorectal surgery. After we removed duplicate publications and screened for eligibility, a total of 36 articles were evaluated: 23 on perfusion assessment, 10 on lymph node mapping, and 3 on intraoperative identification of ureters. Lack of homogenous studies, low statistical power, and confounding evidence were found to be common amongst publications supporting the use of ICG in colorectal surgery, raising concerns over this seductive technique′s cost efficiency and redundancy. The compiled data showed that ICG NIR fluorescence may be a game-changer in particular situations, as proven for low colorectal anastomosis or lateral pelvic lymph node dissection, but it remains controversial for routine use and sentinel lymph node assessment. Further randomized studies are needed to confirm these conclusions. Future research directions include tumor-targeted fluorescence imaging and digital software for quantitative evaluation of fluorescence.

Small bowel adenocarcinoma arising in longstanding fibrostenotic Crohn’s disease

“…However, when malignancy and perforation are associated, anastomosis is not recommended, being associated with high morbidity and mortality (17)(18)(19)(20). Careful examination of the vascularization of anastomosis tranches is important to prevent anastomosis leaks, one of the most frequent causes of postoperative morbidity (21).…”

Fluorescence‐guided cancer surgery—A new paradigm

“…The benefit was greater in left‐sided colorectal cancer procedures (25.74%, range 5.7%–88%). The average rate of AL was 2.1% (0%–7.5%) when all colorectal procedures were included 10 . In the cohort of patients undergoing left colorectal surgery, the AL rate was 3.75% (0%–8.8%) in the ICG group against 11.45% (5.4%–14.7%) in the non‐ICG group 10 .…”

“…Trans-anal endoscopic evaluation to assess the anastomotic perfusion has also been reported. 9 Alius et al 10 performed a systematic review of the applications of NIR evaluation in colorectal surgery and documented its benefits.…”

“…Alius et al 10 performed a systematic review of the applications of NIR evaluation in colorectal surgery and documented its benefits. Following NIR evaluation, a change in the surgical plan was observed in 5.68% of patients (range of 0%–7.5%) for all colorectal procedures.…”

“…The average rate of AL was 2.1% (0%–7.5%) when all colorectal procedures were included 10 . In the cohort of patients undergoing left colorectal surgery, the AL rate was 3.75% (0%–8.8%) in the ICG group against 11.45% (5.4%–14.7%) in the non‐ICG group 10 . Table 2 summarizes some of the major studies, which have evaluated the role of ICG in perfusion assessment for colorectal anastomoses.…”