B. G. Dalton1, A. A. Ali2, Z. T. Awad1 1University Of Florida-Jacksonville,Surgery,Jacksonville, FL, USA 2Wayne State University,Surgery,Detroit, MI, USA
Introduction:
Anastomotic leak and conduit necrosis can be devastating complications following Ivor Lewis esophagectomy. Conduit ischemia is the leading cause of graft necrosis and anastomotic leak. Near infrared imaging (NIR) using IndoCyanine Green (ICG) allows for real time assessment of tissue perfusion. We theorized that the use of intraoperative NIR during laparoscopic minimally invasive Ivor Lewis esophagectomy (MIE) would allow for resection of a greater portion of gastric conduit which may reduce leak rate.
Methods:
After IRB approval retrospective analysis of a prospectively collected data from 2014-2015 of 40 consecutive MIE was performed. All operations were performed for esophageal cancer by a single surgeon at a tertiary referral center. Intravenous ICG and laparoscopic NIR (Pinpoint, Novadaq, Canada) were used to visualize and assess gastric conduit perfusion for the most recent 20 patients in the study (NIR group). Extended conduit resection was performed if ischemia was present on NIR. The non-NIR group was composed of the 20 MIE cases immediately prior to the advent of NIR use in our practice. Comparative analysis was performed using student t test for continuous variables and Fishers exact for binary variables. Statistical significance is defined as P ≤ 0.05.
Results:
No differences were found between the 2 groups with regard to age, gender, BMI, clinical stage, pathologic stage, or comorbidities. Comparing non-NIR to NIR groups, no statistically significant differences were found in overall complication rate (55% vs 40%, p=0.53), reoperation within the same admission (5% vs 10%, p=1), 90 day readmission (10% vs 10%, p=1) and 90 day reoperation (10% vs 5%, p=1). NIR resulted in extended level of proximal conduit resection in 30% (6/20) in the NIR group. Two patients in NIR group developed anastomotic leak (2/20) while no patients in the non-NIR group were found to have leaks (p=0.48). Both leaks were in patients that had additional conduit resection after NIR technology was used to assess conduit perfusion. Endoscopic stent placement was used to manage both leaks, and operative drainage or repair were not required. One mortality related to graft necrosis was noted in the non-NIR group, while there were 0 mortalities in the NIR group. (p=1.0).
Conclusion:
Although near infrared angiography plays a vital role in assessment of tissue perfusion, in our study its use did not result in reduction of anastomotic leak rate. However, this technology did allow for additional resection of ischemic portions of the gastric conduit. This extended resection potentially prevented extensive conduit necrosis. Larger studies are needed to validate the use of this novel technology.