Balla Andrea, Corallino Diletta, Quaresima Silvia, Palmieri Livia, Meoli Francesca, Cordova Herencia Ingrid, Paganini Alessandro M
Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy.
Front Surg. 2022 May 26;9:906133. doi: 10.3389/fsurg.2022.906133. eCollection 2022.
Indocyanine green (ICG) fluorescence angiography (FA) is used for several purposes in general surgery, but its use in bariatric surgery is still debated. The objective of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery in order to focus future research on a reliable tool to reduce the postoperative leak rate.
Thirteen patients (4 men, 30.8%, 9 women, 69.2%) with median age of 52 years (confidence interval, CI, 95% 46.2-58.7 years) and preoperative median body mass index of 42.6 kg/m (CI, 95% 36 to 49.3 kg/m) underwent bariatric surgery with ICG-FA in our center. Three mL of ICG diluted with 10 cc sterile water were intravenously injected after gastric tube creation during laparoscopic sleeve gastrectomy (LSG) and after the gastric pouch and gastro-jejunal anastomosis creation during laparoscopic gastric by-pass (LGB). For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest and zoomed vision modality were used to identify the vascular supply. The perfusion pattern was assessed by the surgical team according to a score. The score ranged from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures.
Fom January 2021 to February 2022, six patients underwent LSG (46.2%), three patients underwent LGB (23.1%), and four patients underwent re-do LGB after LSG (30.8%). No adverse effects to ICG were observed. In 11 patients (84.6%) ICG-FA score was 5. During two laparoscopic re-do LGB, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (15.4%). At a median follow-up of five months postoperatively, leaks did not occur in any case.
ICG-FA during bariatric surgery is a safe, feasible and promising procedure. It could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger sample of patients are required to draw definitive conclusions.
吲哚菁绿（ICG）荧光血管造影（FA）在普通外科有多种用途，但其在减肥手术中的应用仍存在争议。本前瞻性研究的目的是评估ICG-FA在减肥手术中的术中效用，以便将未来的研究重点放在降低术后渗漏率的可靠工具上。
13例患者（4例男性，占30.8%；9例女性，占69.2%），中位年龄52岁（95%置信区间[CI]为46.2 - 58.7岁），术前中位体重指数为42.6 kg/m²（95% CI为36至49.3 kg/m²），在本中心接受了ICG-FA辅助的减肥手术。在腹腔镜袖状胃切除术（LSG）中，在放置胃管后，以及在腹腔镜胃旁路术（LGB）中，在构建胃囊和胃空肠吻合术后，将3 mL用10 cc无菌水稀释的ICG静脉注射。对于ICG-FA，使用Karl Storz Image 1S D-Light系统（Karl Storz Endoscope GmbH & C. K., 德国图特林根），该系统距离感兴趣的结构固定距离为5 cm，并采用变焦视觉模式来识别血管供应。手术团队根据评分评估灌注模式。根据血管化结构荧光的强度和时间，评分范围为1分（血管化差）至5分（血管化良好）。
从2021年1月至2022年2月，6例患者接受了LSG（占46.2%），3例患者接受了LGB（占23.1%），4例患者在LSG后接受了再次LGB（占30.8%）。未观察到ICG的不良反应。11例患者（占84.6%）的ICG-FA评分为5分。在两次腹腔镜再次LGB手术中，血管供应不满意（评分为2/5），并根据ICG-FA改变了手术策略（占15.4%）。术后中位随访5个月，无一例发生渗漏。
减肥手术中使用ICG-FA是一种安全、可行且有前景的方法。即使该操作的标准化和客观荧光定量仍不完善，它仍有助于降低缺血性渗漏率。需要进一步开展更大样本量患者的前瞻性研究以得出明确结论。
