Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA.
University of Florida, Jacksonville, FL, USA.
Surg Endosc. 2022 Feb;36(2):896-903. doi: 10.1007/s00464-021-08346-9. Epub 2021 Feb 12.
Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak.
We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit).
100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260 mL [95-463] versus 75 mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak.
Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.
吻合口漏是食管切除术后的一种严重并发症。本研究旨在报告我们使用吲哚菁绿荧光血管造影（ICG-FA）-PINPOINT®辅助微创 Ivor Lewis 食管切除术（MILE）的经验，并评估与吻合口漏相关的因素。
我们回顾了 2013 年至 2018 年间连续接受 MILE 治疗的患者。术中使用 PINPOINT®进行 ICG-FA 实时评估胃管。灌注分为良好灌注（快速 ICG 可视化至导管尖端）或非灌注（导管上任何分界线）。
100 例患者（81 例男性，中位年龄 68 [60-72] 岁）因恶性肿瘤行 MILE 手术 96 例，良性疾病 4 例。所有患者均采用内镜支架置入治疗吻合口漏。无术中死亡，漏诊患者无 30 天内死亡。漏诊患者更有可能超重（BMI>25%，100%与 53%，p=0.03），合并糖尿病（50%与 13%，p=0.04），术中估计出血量更高（260ml[95-463]与 75ml[48-150]，p=0.03）。非灌注（67%）与良好灌注（33%）组吻合口漏发生率较高（p=0.03）。多变量分析显示，糖尿病（比值比[OR]6.42；p=0.04）和非灌注（OR 6.60；p=0.04）与漏诊独立相关。
术中使用 ICG-FA 可能是评估胃管灌注的有用辅助手段，非灌注与漏诊独立相关。尽管灌注在吻合口完整性中起重要作用，但漏诊是多因素的，ICG-FA 应与优化患者和程序组件结合使用，以最大限度地降低漏诊率。需要前瞻性、随机研究来验证该新技术在微创食管切除术中的解释、疗效和应用。
