A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy.

Introduction: Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications. Methods: ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data. Results: The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity. Conclusion: Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

Safety and Feasibility of Indocyanine Green Fluorescence Angiography in Pediatric Gastrointestinal Surgery: A Systematic Review.

BACKGROUND: Although ICG-FA may be valuable in assessing anastomotic perfusion, reliable data on its use in pediatric gastrointestinal surgery is lacking. This systematic review analyzes whether ICG is useful for intestinal perfusion assessment in pediatric gastrointestinal surgery and safe to use in neonates. METHODS: Systematic searches of PubMed, EMBASE & MEDLINE and CENTRAL were performed (last conducted December 6, 2021). The main inclusion criteria were (1) use of ICG for intestinal perfusion assessment and (2) use of ICG in young infants. Exclusion criteria were lack of an English or Dutch full-text and MINORS quality score <60%. Data was presented in overview tables. The usefulness in pediatric gastrointestinal surgery was assessed by surgical outcome. Safety of ICG in neonates was assessed by complication or adverse event occurrence. RESULTS: Regarding intestinal perfusion assessment, four studies were included, reporting 45 patients (median age 1.5 years). ICG was considered useful for anastomotic blood flow evaluation and intraoperative determination of resection length. Regarding ICG safety in neonates, eight studies were included, reporting 46 infants (median age 24.9 days), of which 18 neonates. All but one studies reported the absence of complications or adverse events. Two studies reported subcutaneous dye retention, which fully disappeared within two weeks. CONCLUSION: Although the number of available studies is small, ICG might be useful for intraoperative intestinal perfusion assessment, perhaps even more than conventional clinical assessment. Furthermore, its safety profile looks promising in neonates. Larger prospective studies are necessary to confirm these assumptions and seem warranted given the safety profile. LEVELS OF EVIDENCE: Since this is a systematic review, a Level of Evidence for clinical studies cannot be determined for this manuscript.

Does intraoperative indocyanine green fluorescence angiography decrease the incidence of anastomotic leakage in colorectal surgery? A systematic review and meta-analysis.

BACKGROUND: Colorectal anastomoses in patients with colorectal cancer carry a high risk of leakage. Indocyanine green fluorescence angiography (ICG-FA) is a new technique that allows surgeons to assess the blood perfusion of the anastomosis during operation. This meta-analysis aimed to evaluate whether ICG-FA could prevent anastomotic leakage (AL) in colorectal surgery. METHODS: Four databases (PubMed, Embase, Web of Science, and Cochrane Library) were searched to identify suitable literatures until March 2020 that compared AL rates between intraoperative use and non-use of ICG-FA in colorectal surgery for cancer. The Review Manager 5.3 software was used to perform the statistical analysis. Evaluation of articles quality and analysis for publication bias were also conducted. RESULTS: Thirteen studies of 4037 patients were included in the meta-analysis. The study included 1806 patients in the ICG group and 2231 patients in the control group. The pooled incidence of AL in ICG group was 3.8% compared with 7.8% in control group. There was a significant difference in AL rate with or without use of ICG-FA (OR 0.44; 95% CI 0.33-0.59; P < 0.00001). Reoperation rates were 2.6% and 6.9% in ICG and control groups, respectively. Application of intraoperative ICG-FA was associated with a lower risk of reoperation (OR 0.39; 95% CI 0.16-0.94; P = 0.04). Overall complication rate was 15.6% in the ICG group compared with 21.2% in the control group. Overall complications were significantly reduced when using ICG-FA (OR 0.62; 95% CI 0.47-0.82; P = 0.0008). Mortality rate was not statistically different with or without the use of ICG-FA (OR 1.22; 95% CI 0.20-7.30; P = 0.83). CONCLUSION: The results revealed that ICG-FA reduced risks of AL, reoperation, and overall complications for colorectal cancer patients undergoing colorectal surgery. Well-designed RCTs are needed to confirm the usefulness of intraoperative ICG-FA for preventing surgical complications like AL and reoperation.

Indocyanine green fluorescence angiography for detection of cutaneous angiosarcoma of the scalp: A case report.

Cutaneous angiosarcoma is a rare neoplasm. One important predictor of recurrence is the resection margin; however, identifying the tissue area containing malignant cells is difficult. Indocyanine green fluorescence angiography (ICG-FA) has been used to identify superficial malignancies, including malignant tumors in the liver and sentinel lymph node metastasis of breast cancer. ICG-FA is also used to identify and define the resection margin of cutaneous angiosarcomas. However, there are currently only a few reports on the application of ICG-FA for detecting cutaneous angiosarcomas. We report a case of cutaneous angiosarcoma in the scalp in which one lesion, located in the parietal scalp, showed high fluorescence intensity corresponding exactly with the lesion was defined by physical examination, whereas the malignant area of the second lesion, located in the occipital scalp, was revealed more accurately by ICG-FA than by physical examination. Further, the second lesion was the first case diagnosed as angiosarcoma by the limited-area biopsy for a high-intensity area of ICG-FA. By determining where ICG is located within cutaneous angiosarcomas and quantitating the ICG intensity level corresponding to the malignant area, ICG-FA could be a promising tool for identifying cutaneous angiosarcomas.

Indocyanine green fluorescence angiography: a new ERAS item.

ERAS protocol and indocyanine green fluorescence angiography (ICG-FA) represent the new surgical revolution minimizing complications and shortening recovery time in colorectal surgery. As of today, no studies have been published in the literature evaluating the impact of the ICG-FA in the ERAS protocol for the patients suitable for colorectal surgery. The aim of our study was to assess whether the systematic evaluation of intestinal perfusion by ICG-FA could improve patients outcomes when managed with ERAS perioperative protocol, thus reducing surgical complication rate. This is a retrospective case-control study. From March 2014 to April 2017, 182 patients underwent laparoscopic colorectal surgery for benign and malignant diseases. All the patients were enrolled in ERAS protocol. Two groups were created: Group A comprehended 107 patients managed within the ERAS pathway only and Group B comprehended 75 patients managed as well as with ERAS pathway plus the intraoperative assessment of intestinal perfusion with ICG-FA. Two board-certified laparoscopic colorectal surgeons jointly performed all procedures. Six (5.6%) clinically relevant anastomotic leakages (AL) occurred in Group A, while there was none in Group B, demonstrating that ICG-FA integrated in the ERAS protocol can lead to a statistically significant reduction of the AL. Mean operative time between the two groups was not statistically significant. In five cases (6.6%), the demarcation line set by the fluorescence made the surgeon change the resection line previously marked. The prevalence of all other complications did not differ statistically between the two groups. Our study confirms that combination between ICG and ERAS protocol is feasible and safe and reduces the anastomotic leakage, possibly leading to consider ICG-FA as a new ERAS item.

Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction.

BACKGROUND: The high incidence of breast cancer and growing number of breast cancer patients undergoing mastectomy has led to breast reconstruction becoming an important part of holistic treatment for these patients. In planning autologous reconstructions, preoperative assessment of donor site microvascular anatomy with advanced imaging modalities has assisted in the appropriate selection of flap donor site, individual perforators, and lead to an overall improvement in flap outcomes. In this review, we compare the accuracy of fluorescent angiography, computed tomographic angiography (CTA), and magnetic resonance angiography (MRA) and their impact on clinical outcomes. METHODS: A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE was undertaken. RESULTS: Fluorescent angiography is technically limited by its inability to evaluate deep-lying perforators and hence, it has a minimal role in the preoperative setting. However, it may be useful intraoperatively in evaluating microvascular anastomotic patency and the mastectomy skin perfusion. CTA is currently widely considered the standard, due to its high accuracy and reliability. Multiple studies have demonstrated its ability to improve clinical outcomes, such as operative length and flap complications. However, concerns surrounding exposure to radiation and nephrotoxic contrast agents exist. MRA has been explored, however despite recent advances, the image quality of MRA is considered inferior to CTA. CONCLUSIONS: Preoperative imaging is an essential component in planning autologous breast reconstruction. Fluorescent angiography presents minimal role as a preoperative imaging modality, but may be a useful intraoperative adjunct to assess the anastomosis and the mastectomy skin perfusion. Currently, CTA is the gold standard preoperatively. MRA has a role, particularly for women of younger age, iodine allergy, and renal impairment.