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88. Spinoglio G, Marano A, Formisano G.Robotic surgery using rey system. In: Dip F, Ishizawa T, Kokudo N, Rosenthal R, editors. Fluorescence
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D. Hui et al.
Use ofFluorescence Guidance
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inColorectal Surgery
MichaelR.Freund, AnnaDuprée,
andStevenD.Wexner
Anastomotic Leak
Introduction
One of the most signicant persistent challenges of colorectal surgery is trying to reduce or eliminate the rate of anastomotic leaks
(AL). Despite recent advances in technology and surgical technique, AL rates remain between 1% and 19% contingent on the
location of anastomosis. The more distal the anastomosis, the
M. R. Freund
Ellen Leifer Shulman and Steven Shulman Digestive Disease Center,
Cleveland Clinic Florida, Weston, FL, USA
Department of General Surgery, Shaare Zedek Medical Center, Faculty
of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
A. Duprée
Department of General, Visceral and Thoracic Surgery, University
Medical Center Hamburg-Eppendorf, Hamburg, Germany
e-mail: adupree@uke.de
S. D. Wexner (*)
Ellen Leifer Shulman and Steven Shulman Digestive Disease Center,
Cleveland Clinic Florida, Weston, FL, USA
e-mail: wexners@ccf.org
3
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
N. Szoka et al. (eds.), The SAGES Manual of Fluorescence-Guided
Surgery, https://doi.org/10.1007/978-3-031-40685-0_3
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M. R. Freund et al.
higher the leak rate: ileocolic (1–8%), colocolonic (2–3%), ileorectal (3–7%), colorectal, or coloanal (5–19%) [1–3]. The anastomosis most prone to AL is a distal pelvic anastomosis, usually
performed for low anterior resection (LAR) in patients who were
previously treated with neoadjuvant chemoradiotherapy [4]. In
these high-risk patients, AL rates can range between 10% and
20% and therefore these patients have been traditionally preemptively diverted with a loop ileostomy. Table3.1 presents AL rates
and reoperation rates for colorectal anastomoses.
In addition to the short-term postoperative morbidity, AL is
also associated with suboptimal long- term function and oncologic
outcomes including increased local recurrence rates and reduced
5-year survival rates [4, 15, 16]. Stormark et al. [4] reviewed
22,985 patients from the Swedish, Norwegian, and Danish
colorectal cancer registries and showed that ve-year relative survival in patients with anastomotic leak was 64.7% compared with
87% for patients with no leak (P<0.001). The clinical and economic outcomes of AL were assessed by Hammond etal. [17]
using the Premier Perspective™ database. In their study 6174
patients with colorectal AL were propensity-score matched to
patients who did not suffer an AL, and the leak rate was approximately 6%. The authors showed that patients with AL had a 1.3
higher 30-day readmission rate and 0.8–1.9 times higher rate of
postoperative infection compared to patients without AL
(P<0.001). They also showed that AL was associated with additional length of stay and hospital cost of 7.3days and $24,129,
respectively, per patient, within the index hospitalization
(Table3.1).
A variety of risk factors for AL have been recognized and have
been generally classied as modiable and non-modiable risk
factors. Well-known non-modiable risk include male gender and
increasing age, previous pelvic radiation, diabetes, emergency
surgery, and tumor-related factors such as a rectal tumor necessitating a distal anastomosis [18–20].
One of the more important intraoperative considerations for
forming an anastomosis is ensuring adequate vascularity to the
anastomosis. Previous studies have shown that the surgeon’s
intraoperative evaluation and judgment is subjective and that pre-
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Reoperation
Leak
rate (%)
rate (%)
14 NR
12 7.4
14 NR
NR
20 (>30d)
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anastomoses
Author/year Journal Location Sample size
Karliczek etal. (2009) [5] Int J Colorect Dis Netherlands 191 colorectal
Table 3.1 Colorectal anastomosis leak rate and re-operative rate in selected series
Ashraf etal. (2013) [6] Colorectal Dis UK 285 LAR 10 5.6
anastomoses
Cauled etal. (2013) [7] JAMA Surg USA 198 LAR 15 NR
Senagore etal. (2014) [8] Dis. Colon Rectum USA 258 colorectal
anastomoses
Mongin etal. (2014) [9] Int J Colorect Dis France 171 LAR 12 7.6
Leahy etal. (2014) [10] J Gastroinest. Surg USA 245 colorectal
Shiomi etal. (2015) [11] JACS Japan 936 LAR 13 4.7
Borstlap etal. (2017) [12] Ann Surg Netherlands 998 LAR 13 (<30d)
Detering etal. (2019) [13] JACS Netherlands 396 LAP 12.2 NR
396 TatME 16.5 NR
Furnee etal. (2019) [14] J Gastroinest. Surg Netherlands 746 LAR 14.2 NR
LAR low anterior resection, NR not reported, UK United Kingdom, USA United States of America, taTME transanal total mesorectal
excision, LAP laparoscopic
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diction of postoperative AL, based on traditional methods such as
tissue color or palpable mesenteric pulses, is fairly limited [21,
22]. In recent years, indocyanine green (ICG) uorescence had
been increasingly employed for intraoperative perfusion evaluation to try to reduce the incidence of AL [23–26]. Its application
and use in colorectal surgery are hereby explained and discussed.
M. R. Freund et al.
Use ofICG toEvaluate Anastomotic Perfusion:
Technical Aspects
All patients are preoperatively screened for allergy to shellsh or
any prior hypersensitivity reaction to ICG.Immediately prior to
bowel resection, after the surgeon decides on the intended location of the resection margins, an intravenous injection of 3.5ml
ICG is administered followed by a 10mL intravenous saline ush.
The recommended ICG dose in assessing bowel perfusion should
be in the range of 0.1–0.3mg/Kg. This dose is usually achieved
by dilution of the ICG vial containing 25mg of ICG powder with
10ml of sterile water prior to administration, resulting in a concentration of 2.5mg per 1ml of reconstituted solution. Using a
laparoscope equipped with a near-infrared (NIR) camera and lter, visual assessment of tissue perfusion is performed. This
assessment can be achieved by switching the camera from white
light mode (Fig.3.1a) to contrast (spy) or overlay uorescence
mode (Fig.3.1b). At this point, the proximal margin may be modied based on uorescence perfusion assessment ndings.
After extracorporeal extraction and after placing the EEA or
stapler but prior to ring, ICG perfusion assessment may be again
performed by injecting a second bolus of 3.5ml of ICG, again
followed by a 10ml ush of saline solution (Fig.3.2). For intracorporal anastomosis, an NIR-equipped laparoscope is used to
assess the serosal aspects of both ends of the intended anastomosis (Fig. 3.3). For pelvic anastomosis, it is our practice to also
ascertain mucosal perfusion using a custom-designed rigid proctoscope equipped with an NIR camera. A third bolus of 3.5ml of
ICG is administered, again followed by a 10ml ush, and the
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a
b
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Fig. 3.1 (a) White light, (b) Fluorescence mode
mucosal appearance of both proximal and distal mucosal aspects
of the anastomosis is visually assessed.
For extracorporeal anastomosis, following mobilization and
division of the mesentery, 3.5mL of ICG followed by 10mL of
saline is administrated (Fig.3.4a). Using ICG uorescence angiog-
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Fig. 3.2 For extracorporeal anastomosis, indocyanine green (ICG) perfusion
assessment performed by injecting a second bolus of 3.5ml of ICG, followed
by a 10ml ush of saline solution
M. R. Freund et al.
raphy guidance, each end of the bowel is divided with a standard
linear stapler (Fig.3.4b). The anastomosis is then formed with a
stapler in a side-to-side functional end-to-end manner. Once the
anastomosis is completed, ICG perfusion assessment is performed
using a 0-degree NIR camera-equipped laparoscope (Fig. 3.5).
Prior to uorescence assessment, an additional standard dose of
3.5mL of ICG followed by 10mL of saline is injected. For accurate assessment, all room lighting is turned off to minimize artifacts for extracorporeal uorescence perfusion assessment.
Pearls andPitfalls
Timing ICG uorescence perfusion assessment is time depen-
dent. The ingress phase takes approximately 20–30s for ICG to
become visible on NIR camera depending on different patientrelated factors [27]. The optimal time to assess perfusion is
approximately 30–120 s from ICG administration, when ICG
uorescence is at its peak. After 2min, ICG uorescence will start
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Fig. 3.3 For intracorporal anastomosis, a near-infrared (NIR) equipped laparoscope is used to assess the serosal aspects of both ends of the intended
anastomosis
to decrease, although some degree of ICG uorescence may still
be visible up until 15–17min from initial administration.
Initially, the circular stapler line is compressed by the stapler
and therefore does not uoresce as well as the rest of the tissue at
rst. After the circular stapler is red and removed, the tissue surrounding the staple line is able to decompress and appropriately
uoresces after a few seconds.
Gain When utilizing uorescence for bowel perfusion assess-
ment, we generally recommend establishing set gain of 5 or 6 bars
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M. R. Freund et al.
a
b
Fig. 3.4 (a) For extracorporeal anastomosis, following mobilization and
division of the mesentery, 3.5mL of indocyanine green (ICG) followed by
10mL of saline is administrated. (b) Using ICG uorescence angiography
guidance, each end of the bowel is divided with a standard linear stapler
as a baseline. We nd it useful in setting a standard for comparison and to reduce subjective assessment bias.
Ureters ICG uorescence imaging of the ureters can be quite
helpful during colorectal surgery [28]. The same dilution method
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Fig. 3.5 Once the anastomosis is completed, indocyanine green (ICG) perfusion assessment is performed using a 0-degree near-infrared (NIR) cameraequipped laparoscope
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can be used (dilution of the ICG vile containing 25mg of ICG
powder with 10ml of sterile water), and after ureteral stents are
placed under cystoscopy, a 5ml of reconstituted solution can be
injected in each ureter. To insure long-standing visualization during surgery, the ureteral stent can be occluded for approximately
30s to allow the ICG to bind to the protein molecules in the urine
(Fig. 3.6). Recent data also suggest that ICG injection alone is
faster than with indwelling ureteral catheter placement and
equally reliable at intraoperative ureteral identication [29].
Either way, injecting ICG will stain the urine green for the remain-
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