Somashekhar S P, Reddy Revanth Gangasani, Rohit Kumar C, Ashwin K R
Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore, 560017 India.
Aware Global Hospitals, Hyderabad, India.
Indian J Surg Oncol. 2020 Dec;11(4):642-648. doi: 10.1007/s13193-020-01207-2. Epub 2020 Sep 1.
Anastomotic leakage continues to be the most feared postoperative complications in rectal surgery with negative impact on both short- and long-term outcomes. Fortunately, new surgical strategies have helped to offset this complication and improve surgical outcomes. Traditionally, perfusion is assessed by intraoperative visual judgment by the surgeon. These subjective methods lack predictive accuracy resulting in either excess or insufficient colonic resection. Indocyanine green (ICG) fluorescence has shown promise in identifying the adequacy of perfusion. After injection of ICG, the system projected high-resolution near-infrared real-time images of blood flow in mesentery and bowel wall. This novel imaging method is used intraoperatively for taking real-time informed decisions. We conducted a single institutional prospective study to identify the feasibility of ICG identification of vascularity of anastomotic site and its impact on the change of plan of surgical management in robotic rectal cancer surgery. Between September 2017 and April 2019, fifty patients undergoing robotic rectal cancer surgery were included in the study. The aim was to analyze the feasibility and clinical benefit of intraoperative near-infrared fluorescence imaging in determining the line of transection in comparison with the traditional method. Line of proximal transection of the bowel subjectively assessed by the surgical team was marked point B and that after ICG injection was marked point A if moved proximally and point C if moved distally. The vascular anatomy was clearly identified with no intraoperative or injection-related adverse effects. Of the 50 patients, the line of transaction remained the same in 6 patients (12%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 3 patients (6%) and distally in 41 patients (82%). ICG-based infrared image-guided localization gives a real-time image of colon vascularity possibly affecting anastomotic leak. The ICG fluorescence imaging system is a simple, safe, and useful technique, performed within a short time, and it enables visual evaluation of the blood flow in the intestinal tract prior to anastomosis. Larger studies are needed before this can become the standard of care.
吻合口漏仍然是直肠手术中最令人担忧的术后并发症，对短期和长期预后均有负面影响。幸运的是，新的手术策略有助于抵消这一并发症并改善手术效果。传统上，灌注情况由外科医生术中视觉判断评估。这些主观方法缺乏预测准确性，导致结肠切除过多或不足。吲哚菁绿（ICG）荧光在识别灌注是否充足方面显示出前景。注射ICG后，该系统可投射出肠系膜和肠壁血流的高分辨率近红外实时图像。这种新颖的成像方法在术中用于做出实时明智决策。我们进行了一项单机构前瞻性研究，以确定ICG识别吻合口部位血管情况的可行性及其对机器人直肠癌手术中手术管理计划变更的影响。在2017年9月至2019年4月期间，50例接受机器人直肠癌手术的患者被纳入该研究。目的是分析术中近红外荧光成像与传统方法相比在确定切断线方面的可行性和临床益处。手术团队主观评估的肠近端切断线标记为B点，注射ICG后若切断线向近端移动则标记为A点，若向远端移动则标记为C点。血管解剖结构清晰可辨，未出现术中或与注射相关的不良反应。50例患者中，6例（12%）的切断线保持不变。基于荧光成像结果，手术团队选择将切断线进一步向近端变更至“足够”的荧光部分的有3例（6%），向远端变更的有41例（82%）。基于ICG的红外图像引导定位可提供可能影响吻合口漏的结肠血管实时图像。ICG荧光成像系统是一种简单、安全且有用的技术，操作时间短，能够在吻合术前对肠道血流进行视觉评估。在这成为标准治疗方法之前，还需要进行更大规模的研究。
