Does routine use of indocyanine green fluorescence angiography prevent anastomotic leaks? A retrospective cohort analysis.

BACKGROUND: Insufficient perfusion to anastomoses in colorectal surgery is known to lead to complications. This study aims to evaluate whether routine use of fluorescence angiography (FA) alters the incidence of anastomotic leaks after colorectal surgery. METHODS: This was a retrospective study of 554 colorectal resections with and without the use of intraoperative fluorescence angiography. Anastomotic leak rates and whether angiography altered surgical management were the main outcomes measured. RESULTS: The anastomotic leak rate was found to be 1.3% both with and without use of FA (p > 0.05). Significantly more alterations were made to planned anastomotic site in FA group (n = 13, 5.6%) as compared to the group prior to use of FA in whom no alterations were made (p < 0.05). CONCLUSIONS: No significant difference was found in anastomotic leak rates between the two groups studied. Routine use of fluorescence angiography significantly altered intra-operative decision-making without discernible change in clinical outcome.

Intraoperative indocyanine green fluorescence angiography--an objective evaluation of anastomotic perfusion in colorectal surgery.

The essentials for any bowel anastomosis are: adequate perfusion, tension free, accurate tissue apposition, and minimal local spillage. Traditionally, perfusion is measured by assessing palpable pulses in the mesentery, active bleeding at cut edges, and lack of tissue discoloration. However, subjective methods lack predictive accuracy for an anastomotic leak. We used intraoperative indocyanine green (ICG) fluorescence angiography to objectively assess colon perfusion before a bowel anastomosis. Seventy-seven laparoscopic colorectal operations, between June 2013 and June 2014, were retrospectively reviewed. The perfusion to the colon and ileum was clinically assessed, and then measured using the SPY Elite Imaging System. The absolute value provided an objective number on a 0-256 gray-scale to represent differences in ICG fluorescence intensity. The lowest absolute value was used in data analysis for each anastomosis (including small bowel) to represent the theoretical least perfused/weakest anastomotic area. The lowest absolute value recorded was 20 in a patient who underwent a laparoscopic right hemicolectomy for an adenoma, with no postoperative complications. Four low anterior resection patients had additional segments of descending colon resected. There was one mortality in a patient who underwent a laparoscopic right hemicolectomy. This study illustrates an initial experience with the SPY system in colorectal surgery. The SPY provides an objective, numerical value of bowel perfusion. However, evidence is scant as to the significance of these numbers. Large-scale randomized controlled trials are required to determine specific cutoff values correlated with surgical outcomes, specifically anastomotic leak rates.

The use of bone anchors for autologous flap fixation in perineal reconstruction: a case report.

The purpose of this case report is to demonstrate the use of bone anchors with an autologous flap in perineal reconstruction. This technique has not been reported before. A 64-year-old female presented to our office with a chief complaint of perineal hernia 1.5 years after abdominoperineal resection. She had a history of recurrent rectal cancer for which she received chemotherapy, radiation and surgery. To repair the hernia, a standard vertical rectus abdominismyocutaneous was harvested and de-epithelialized. It was secured into place in the pelvis utilizing several bone anchors. Mesh was used to repair the donor site defect. At 18 month follow-up, there was good healing of all the wounds and no recurrence of the hernia. She was pain free and able to resume her activities of daily living. Bone anchor fixation is a viable technique for fixation of autologous flaps in perineal reconstruction.