UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland.
Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland.
Surg Endosc. 2021 Dec;35(12):7074-7081. doi: 10.1007/s00464-020-08223-x. Epub 2021 Jan 4.
Despite increasing endorsement of near-infrared perfusion assessment using indocyanine green (ICG) during colorectal surgery, little work has yet been done regarding learning curve and interobserver variation most especially on surgical video reflective of real-world usage.
Surgeons with established expertise in ICG usage were invited to participate in the study along with others without such experience including trainees. All participants completed an opinion questionnaire and interpreted video presentations of fluorescence angiograms in a variety of colorectal case scenarios. An interactive video platform (Mindstamp) enabled dynamic annotation. Statistical analysis of data was performed using Kruskal-Wallis and Mann-Whitney testing as well as Intraclass Correlation Coefficients and Fleiss Multi-rater Kappa Scoring.
Forty participants (six experts) completed questionnaire data and provided judgement of 14 videos (nine showing proximal colonic transection site perfusion, four showing completed anastomoses and one an acutely strangulated bowel). 70% felt > 10 cases were needed for competency in use with the majority of experts advocating > 50 (p < 0.05). Overall agreement among experts was "good" for videos showing colonic transection perfusion (versus "moderate" among in-experts) with experts clustering more distally. In contrast, there was no interpretation concordance among experts or in-experts when judging ICG perfusion sufficiency on a yes/no basis.
Significant experience is recommended before reliance on ICG perfusion angiograms. ICG fluorescence assessment is prone to variable interpretation and influenced by experience and, perhaps, knowledge of preassessment operative steps suggesting a role for objective flow analysis with artificial intelligence methods as the next phase of this technology.
尽管在结直肠手术中越来越多地支持使用吲哚菁绿（ICG）进行近红外灌注评估，但在反映实际使用情况的手术视频中，关于学习曲线和观察者间差异的工作几乎没有。
邀请具有 ICG 使用专业知识的外科医生以及其他没有此类经验的外科医生（包括受训者）参加研究。所有参与者都完成了一份意见调查问卷，并对荧光血管造影术的视频演示进行了各种结直肠病例场景的解释。交互式视频平台（Mindstamp）使动态注释成为可能。使用 Kruskal-Wallis 和 Mann-Whitney 检验以及组内相关系数和 Fleiss 多评分者 Kappa 评分对数据进行了统计分析。
40 名参与者（6 名专家）完成了问卷调查数据，并对 14 个视频（9 个显示近端结肠横断部位灌注，4 个显示完成的吻合，1 个显示急性绞窄肠）进行了判断。70%的人认为需要进行 10 例以上的手术才能熟练掌握，大多数专家主张需要进行 50 例以上的手术（p<0.05）。对于显示结肠横断灌注的视频，专家之间的总体一致性为“良好”（而非专家之间为“中度”），专家的聚类更为分散。相比之下，当以是否为基础判断 ICG 灌注是否充足时，专家和非专家之间没有解释一致性。
建议在依赖 ICG 灌注血管造影之前，先进行大量的实践经验。ICG 荧光评估容易产生不同的解释，并且受到经验和（可能）对术前操作步骤的了解的影响，这表明人工智能方法的客观流量分析可能在该技术的下一阶段发挥作用。
