Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
Surg Endosc. 2023 Aug;37(8):6343-6352. doi: 10.1007/s00464-023-10107-9. Epub 2023 May 19.
Intraoperative perfusion assessment with indocyanine green fluorescence angiography (ICG-FA) may reduce postoperative anastomotic leakage rates after esophagectomy with gastric conduit reconstruction. This study evaluated quantitative parameters derived from fluorescence time curves to determine a threshold for adequate perfusion and predict postoperative anastomotic complications.
This prospective cohort study included consecutive patients who underwent FA-guided esophagectomy with gastric conduit reconstruction between August 2020 and February 2022. After intravenous bolus injection of 0.05-mg/kg ICG, fluorescence intensity was registered over time by PINPOINT camera (Stryker, USA). Fluorescent angiograms were quantitatively analyzed at a region of interest of 1 cm diameter at the anastomotic site on the conduit using tailor-made software. Extracted fluorescence parameters were both inflow (T, T, F, slope, Time-to-peak) as outflow parameters (T and T). Anastomotic complications including anastomotic leakage (AL) and strictures were documented. Fluorescence parameters in patients with AL were compared to those without AL.
One hundred and three patients (81 male, 65.7 ± 9.9 years) were included, the majority of whom (88%) underwent an Ivor Lewis procedure. AL occurred in 19% of patients (n = 20/103). Both time to peak as T were significantly longer for the AL group in comparison to the non-AL group (39 s vs. 26 s, p = 0.04 and 65 vs. 51 s, p = 0.03, respectively). Slope was 1.0 (IQR 0.3-2.5) and 1.7 (IQR 1.0-3.0) for the AL and non-AL group (p = 0.11). Outflow was longer in the AL group, although not significantly, T 30 versus 15 s, respectively, p = 0.20). Univariate analysis indicated that T might be predictive for AL, although not reaching significance (p = 0.10, area under the curve 0.71) and a cut-off value of 97 s was derived, with a specificity of 92%.
This study demonstrated quantitative parameters and identified a fluorescent threshold which could be used for intraoperative decision-making and to identify high-risk patients for anastomotic leakage during esophagectomy with gastric conduit reconstruction. A significant predictive value remains to be determined in future studies.
术中应用吲哚菁绿荧光血管造影（ICG-FA）评估灌注情况可能会降低胃管重建食管切除术后吻合口漏的发生率。本研究评估了荧光时间曲线得出的定量参数，以确定足够灌注的阈值，并预测术后吻合口并发症。
这是一项前瞻性队列研究，纳入了 2020 年 8 月至 2022 年 2 月间接受 FA 引导下胃管重建食管切除术的连续患者。静脉注射 0.05mg/kg ICG 后，使用 PINPOINT 相机（美国 Stryker）实时记录荧光强度。使用定制软件在吻合部位的吻合管上直径为 1cm 的感兴趣区域定量分析荧光血管造影。提取的荧光参数包括流入参数（T₁、T₂、F、斜率、达峰时间）和流出参数（T₁₅和 T₁₅）。记录吻合口并发症，包括吻合口漏（AL）和狭窄。比较有 AL 与无 AL 的患者的荧光参数。
共纳入 103 例患者（81 例男性，65.7±9.9 岁），其中 88%（91/103）接受了 Ivor Lewis 手术。19%（20/103）的患者发生了 AL。与非 AL 组相比，AL 组的达峰时间 T₁和 T₂均显著延长（39s 比 26s，p=0.04 和 65s 比 51s，p=0.03）。AL 组和非 AL 组的斜率分别为 1.0（IQR 0.3-2.5）和 1.7（IQR 1.0-3.0）（p=0.11）。AL 组的流出时间较长，但无统计学意义，分别为 T₃₀ 比 T₁₅ 30s 和 15s（p=0.20）。单因素分析表明 T₁可能是 AL 的预测因素，但无统计学意义（p=0.10，曲线下面积 0.71），得出 97s 的截断值，特异性为 92%。
本研究表明，定量参数可以识别荧光阈值，可用于术中决策，并识别胃管重建食管切除术中吻合口漏的高危患者。在未来的研究中，仍需要确定其显著的预测价值。
