A quantitative assessment of perfusion of the gastric conduit after oesophagectomy using near-infrared fluorescence with indocyanine green

IntroductionAnastomotic leakage is a severe complication after oesophageal resection with gastric conduit reconstruction. Poor perfusion of the gastric conduit plays an important role in the development of anastomotic leakage. Quantitative near-infrared (NIR) fluorescence angiography with indocyanine green (ICG-FA) is an objective technique that can be used for perfusion assessment. This study aims to assess perfusion patterns of the gastric conduit with quantitative ICG-FA.MethodsIn this exploratory study, 20 patients undergoing oesophagectomy with gastric conduit reconstruction were included. A standardized NIR ICG-FA video of the gastric conduit was recorded. Postoperatively, the videos were quantified. Primary outcomes were the time-intensity curves and nine perfusion parameters from contiguous regions of interest on the gastric conduit. A secondary outcome was the inter-observer agreement of subjective interpretation of the ICG-FA videos between six surgeons. The inter-observer agreement was tested with an intraclass correlation coefficient (ICC).ResultsIn a total of 427 curves, three distinct perfusion patterns were recognized: pattern 1 (steep inflow, steep outflow); pattern 2 (steep inflow, minor outflow); and pattern 3 (slow inflow, no outflow). All perfusion parameters were significantly different between the perfusion patterns. The inter-observer agreement was poor – moderate (ICC:0.345,95%CI:0.164–0.584).DiscussionThis was the first study to describe perfusion patterns of the complete gastric conduit after oesophagectomy. Three distinct perfusion patterns were observed. The poor inter-observer agreement of the subjective assessment underlines the need for quantification of ICG-FA of the gastric conduit. Further studies should evaluate the predictive value of perfusion patterns and parameters on anastomotic leakage.     

Impact of indocyanine green fluorescent image-guided surgery for parapharyngeal space tumours

In parapharyngeal space dissection, significant complications such as dysphagia and carotid artery rupture have been reported. In order to resect tumours safely in narrow parapharyngeal space, we propose indocyanine green (ICG) florescence image for navigation surgery.ObjectiveTo evaluate the usefulness of ICG fluorescent image-guided surgery for parapharyngeal space tumours.Methods0.5 mg/kg of ICG was injected via the cephalic vein. Observation of the fluorescent image was performed with HEMS (HyperEye Medical System) at 10–30 min after injection. At first, the position of the tumour was marked over pharyngeal mucosa according to ICG fluorescence imaging with HEMS. We also confirmed submucosal tumours hidden under fascia using HEMS imaging again and resected them.ResultsAll tumours displayed bright fluorescence emissions which clearly contrasted with the normal structures. Even with the submucosal tumour covered with and obscured by fasciae, we could observe the tumour clearly under HEMS imaging. Tumours behind the carotid artery and lower cranial nerves also were displayed bright fluorescence emissions and were clearly detected. As a result, we could completely remove the tumour safely and noninvasively to preserve pharyngeal functions.ConclusionICG fluorescence imaging is effective for the detection and resection of the parapharyngeal space tumours with preserving functions.     

Limited contribution of indocyanine green (ICG) angiography for the detection of parathyroid glands and their vascularization during total thyroidectomy: A STROBE observational study

IntroductionIn total thyroidectomy, indocyanine green (ICG) angiography has mainly been evaluated at end of procedure to predict postoperative hypoparathyroidism. By using it during surgery, we sought to determine whether it could also be an aid to the surgeon.ObjectiveTo determine whether ICG used intraoperatively in total thyroidectomy modified the surgical procedure.Material and methodThirty-two patients who underwent ICG angiography during total thyroidectomy were included in our single-center retrospective study. The number of parathyroid (PT) glands visualized in white light and on ICG angiography was collected, as well as PT vitality of at end of surgery according to these two modalities. Vitality scores were 0 (no vascularity), 1 (moderately vascularized) or 2 (well vascularized). Postoperative calcemia at D1, D2 and D7 was analyzed.ResultsIn the 32 operations, the surgical procedure was modified in 10 cases (31%). The average number of PTs detected was 2.4 (77 PT) on ICG angiography and 2 (65 PT) in white light. Eleven patients (37.5%) had postoperative hypocalcemia. Cumulative vitality scores at end of procedure were 3.75/8 and 3.37/8 in white light and on ICG angiography respectively (P = 0.648). The use of the device did not predict the occurrence of postoperative hypocalcemia.ConclusionIndocyanine green angiography used in thyroid surgery could assist the surgeon in the identification of PT glands, sparing them in one third of cases.     

Hepatic transport of serum bilirubin,bromsulfophthalein, and indocyanine green in patients with congenital non-hemolytic hyperbilirubinemia and patients with constitutional indocyanine green excretory defect

We carried out a retrospective study of 71 patients with congenital non-hemolytic hyperbilirubinemia who had been treated at our institution over the 25 years from 1965 to 1990. Twenty patients had Gilbert's syndrome, 1 had Crigler-Najjar syndrome, 1 had new type unconjugated hyperbilirubinemia, 21 had Dubin-Johnson syndrome, and 28 had Rotor's syndrome. We also reviewed 20 patients with constitutional indocyanine green (ICG) excretory defect. The study focused on the hepatic transport of serum bilirubin, bromsulfophthalein (BSP), and ICG. In Dubin-Johnson syndrome, a defect appeared in late-stage transport, while uptake and storage capacity were normal. In Rotor's syndrome, defects were found in the early stage, and storage capacity was reduced, while excretion into bile was slightly suppressed. A secondary rise in serum ICG was seen in 5 of the 10 patients with Dubin-Johnson syndrome. The transport defect in Gilbert's syndrome was unclear. It could not be considered to be homogeneous, but it may exist at multiple sites, from the conjugation with serum proteins to excretion into bile. Following phenobarbital administration, the ICG secondary rise in the 5 patients with Dubin-Johnson syndrome disappeared, and ICG was rapidly cleared from blood. However, in patients with Dubin-Johnson syndrome, BSP clearance in serum did not show any change before and after phenobarbital administration. ICG excretion in patients with constitutional ICG excretory defect was due only to the impairment o ICG transport, and the defect was suggested to be hepatic uptake. These results indicate that studies of the hepatic transport of bilirubin, BSP, and ICG are useful for determining the etiological factors involved in congenital hyperbilirubinemia and constitutional ICG excretory defect.     

Hyperendothelinemia and ICG Clearance in Alcoholic and Nonalcoholic Cirrhosis

Plasma endothelin (ET) levels are generally increased in cirrhosis patients in line with the severity of disease; however, the pathophysiological significance remains to be clarified. We evaluated the plasma ET levels in 49 patients with alcoholic cirrhosis and in 53 patients with nonalcoholic cirrhosis of the same disease severity. The plasma ET level was significantly elevated in alcoholic patients (P < 0.0001) and slightly so in nonalcoholic patients (P < 0.01); the difference was significant between the groups (P < 0.0001). The plasma ET level was positively correlated with the Child-Pugh score (P < 0.0001) and negatively correlated with prothrombin index (P < 0.001) and indocyanine green (ICG) clearance (P < 0.0001). The plasma ET level decreased 32% in alcoholic patients after abstinence (P < 0.001), but remained correlated with ICG clearance (P < 0.001) and the Child-Pugh score (P < 0.01), but not with prothrombin index. Regression analysis revealed that the plasma ET level was correlated with estimated hepatic blood flow and alcohol abuse. These findings suggest that hyperendothelinemia in cirrhosis patients is related to alcohol abuse and disease severity, especially to impaired hepatic hemodynamics.     

Using indocyanine green fluorescent imaging to successfully resect metachronous regional lymph node recurrence of rectosigmoid cancer

A 39‐year‐old female patient underwent anterior resection with locoregional lymph node dissection for rectosigmoid cancer at another hospital. The procedure involved transection of the superior rectal artery just below the origin of the left colic artery. Postoperative diagnosis was stage III B. The patient received adjuvant chemotherapy with oxaliplatin plus capecitabine for 6 months. Sixteen months after the operation, PET‐CT scans revealed regional lymph node metastases around the root of the inferior mesenteric artery. The patient was referred to our hospital with a recurrence of rectosigmoid cancer. We performed laparoscopic lymph node dissection with real‐time indocyanine green fluorescent images superimposed on color images to prevent intraoperative vascular insufficiency. We were able to successfully observe the sufficient blood flow in the descending colon. Postoperative pathological findings showed lymph node recurrence after initial surgery. She was discharged 7 days after the operation. In the 8 months since the second operation, the patient has not had any indication of further recurrence.     

Immediate direct-to-implant breast reconstruction with acellular dermal matrix: Evaluation of complications and safety

ObjectiveImmediate direct-to-implant breast reconstruction with acellular dermal matrix (ADM) is the method of choice for many plastic surgeons and patients, but the use of ADM remains a controversial subject in the literature.This study aimed to investigate complications, reconstructive failure and possible risk factors in direct-to-implant breast reconstruction with ADM (primarily Strattice™).MethodsWe retrospectively examined all patients undergoing immediate direct-to-implant breast reconstruction with ADM, during a five-year period (2014–2019) at a university clinic. Study outcomes were all complications and explantations. Complications were stratified within and after 6 months postoperatively and subcategorized by type of intervention. Explantations were subcategorized into loss of implant or salvage with immediate insertion of a tissue expander, the same or a new implant.ResultsWe included 154 patients and 232 breasts. Complications within 6 months per patient included hematoma (4%), seroma (8%), infection (9%), necrosis, wound dehiscence and delayed wound healing (19%). The total complication rate per patient was 34%. Explantation occurred in 20 patients (13%) of which 9 (6% of all) had implant loss. Preoperative radiotherapy was a significant predictor of explantation (adjusted OR 4.9, 95% confidence interval (CI), 1.0–23.5; p = 0.045), and smoking was also associated with risk of explantation, although only borderline significant (adjusted OR 4.0, 95% CI, 1.0–15.8; p = 0.050).ConclusionThis study demonstrates acceptable rates of re-operations and implant loss compared to other studies but highlights the importance of proper patient selection with regards to risk factors to minimize complications.