Florida State University College of Medicine, Sarasota, FL, USA.
East Carolina University, Greenville, NC, USA.
Surg Endosc. 2023 Nov;37(11):8720-8727. doi: 10.1007/s00464-023-10258-9. Epub 2023 Aug 2.
Ischemia is known to be a major contributor for anastomotic leaks and indocyanine green (ICYG) fluorescence angiography has been utilized to assess perfusion. Experienced esophageal surgeons have clinically assessed the gastric conduit with acceptable outcomes for years. We sought to examine the impact of ICYG in a surgeon's decision-making during esophagectomy.
We queried a prospectively maintained database to identify patients who underwent robotic esophagectomy. Time to initial perfusion, time to maximum perfusion, and residual ischemia were measured and used as a guide to resection of residual stomach. During esophagectomy the surgeon identified the anticipated line of ischemic demarcation (LOD) prior to ICYG injection. The distance between the surgeon's LOD and ICYG LOD was measured.
We identified 312 patients who underwent robotic esophagectomy, 251 without ICYG and 61 with ICGY. There were no differences in age, sex, race, body mass index, histology, stage, or neoadjuvant therapy use between groups. The incidence of anastomotic leak did not differ between groups (non-ICYG, 5.2% vs. ICYG, 6.6%), p = 0.67. The initial perfusion time was ≥ 10 s and max perfusion was > 25 s in all the patients in the ICYG that developed anastomotic leaks. All patients were noted to have at least 1 cm of residual gastric ischemia. Fifteen patients underwent independent surgeon evaluation of the ischemic LOD prior to ICYG. Differential distances were noted in 12 (80%) patients with a mean distance between surgical line of demarcation and ICYG LOD of 0.77 cm.
While the implementation of ICYG during esophagectomy demonstrates no significant improvements in anastomotic leak rates compared to historical controls, surgeon's decision-making is impacted in 80% of cases resulting in additional resection of the gastric conduit. Elevated times to initial perfusion and maximum perfusion were associated with increased gastric ischemia and anastomotic leaks.
缺血被认为是吻合口漏的主要原因，吲哚菁绿（ICYG）荧光血管造影已被用于评估灌注。有经验的食管外科医生多年来一直通过临床评估胃管。我们试图检查在食管切除术中 ICG 对外科医生决策的影响。
我们查询了一个前瞻性维护的数据库，以确定接受机器人食管切除术的患者。测量初始灌注时间、最大灌注时间和残余缺血时间，并将其作为切除残余胃的指南。在食管切除术中，外科医生在注射 ICG 之前确定预期的缺血边界线（LOD）。测量外科医生的 LOD 和 ICG 的 LOD 之间的距离。
我们确定了 312 例接受机器人食管切除术的患者，其中 251 例无 ICG，61 例有 ICGY。两组在年龄、性别、种族、体重指数、组织学、分期或新辅助治疗使用方面无差异。吻合口漏的发生率在两组之间无差异（非 ICG，5.2%比 ICGY，6.6%），p=0.67。所有在 ICGY 中发生吻合口漏的患者的初始灌注时间均≥10s，最大灌注时间均>25s。所有患者均发现至少有 1cm 的残余胃缺血。15 例患者在 ICGY 之前接受了独立外科医生对缺血 LOD 的评估。在 12 例（80%）患者中注意到差异距离，外科医生的标记线和 ICG 标记线之间的平均距离为 0.77cm。
虽然与历史对照相比，在食管切除术中实施 ICG 并没有显著降低吻合口漏的发生率，但 80%的病例中外科医生的决策受到影响，导致胃管的额外切除。初始灌注和最大灌注时间的延长与胃缺血和吻合口漏的增加有关。
