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an island of stomach tissue that was previously stripped of its blood supply from the left gastroepiploic artery and now loses more blood ow generated from the left gastric artery. As such, it is at risk of ischemia, and an evaluation with ICG may also be useful in this situation in determining the need for resection (Video 7.7). Following the gastric pouch formation, assuming no ischemia concerns exist, a GJ and jejunojejunal anastomosis is then created. After the new GJ anastomosis is constructed, ICG is placed inside the stomach lumen to verify the integrity of the GJ anastomosis. The leak test is performed in the same method as it was previously explained during primary RYGB operations.
E. B. Chen et al.
Revision ofGJ Anastomosis
Marginal ulcers are a known complication after RYGB.The rate of marginal ulcers ranges from 0.6% to 25% [74]. Though most marginal ulcers resolve with medical and endoscopic therapies, surgery is required for refractory marginal ulcers. Rates of reop­eration for marginal ulcers are as high as 32% [75]. Refractory marginal ulcers are typically surgically corrected with a resection of the GJ anastomosis and jejunum with recreation of the GJ anas­tomosis or formation of an esophagojejunostomy. Given the reop­erative nature in a hostile, inammatory area, the rate of complications from this type of surgery is considerable compared to primary bariatric surgery. In a small study by Chau etal., 25% of patients who required revisional surgery for marginal ulcers had a postoperative complication that required a reoperation [76]. Patel etal. indicated a 5% chance of anastomotic leak [75]. In these high-risk anastomoses, ICG may again be benecial when given intraluminally to ensure the integrity of the new GJ anasto­mosis and potentially reduce the incidence of complications. Intraluminal ICG would be delivered in the same solution and manner as described previously in this chapter. Intravenous ICG can also be used to assess perfusion of the GJ (Video 7.8) and gastric pouch during revisional surgery (Video 7.9).
Novel Fluorescence-Guided Gastric Calibration Tube
The Endolumik Fluorescence-Guided Gastric Calibration Tube (Figs.7.1 and 7.2) is a novel single-use, uorescence-guided cali­bration tube indicated for use in bariatric, gastric, and esophageal
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Fig. 7.1 The Endolumik Fluorescence-Guided Gastric Calibration Tube after turning on NIR lighting system, white light view
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surgery to improve visualization of tube position and to serve as a sizing and measurement guide, for the application of suction, gas­tric decompression/drainage of gastric uids, and irrigation and leak testing [77]. This device combines the functionality of a nasogastric or orogastric tube, a calibration tube, and a leak test­ing system. The device was designed to improve intraoperative visualization and provide surgeons with additional visual cues to identify anatomic structures and delineate tissue planes with the goal of improving the precision of surgical dissection.
The Endolumik Gastric Calibration Tube is lit using NIR spec­trum LEDs which enable transillumination through esophagogas­tric tissues. The tube is 80cm long and is available in two different diameters: 36 and 40 French. It has a rounded tip and small side holes at the distal end to enable gastric decompression and/or irrigation. The proximal end includes a handle with an integral suction regulator. An additional squeeze bulb with pressure gauge may be attached to the end of the regulator to perform leak testing. Pilot studies have been completed using the device to improve visualization during laparoscopic sleeve gastrectomy and laparo­scopic gastric bypass (Figs. 7.3, 7.4 and 7.5). The three black
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E. B. Chen et al.
Fig. 7.2 The Endolumik Fluorescence-Guided Gastric Calibration Tube after turning on NIR lighting system, NIR light view
stripes at the distal end of the device enable uorescence-guided measurement of up to 10cm of length (Fig.7.6). The device was FDA approved on March 3, 2023, via the 510K pathway. It is the
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Fig. 7.3 Use of the Endolumik Fluorescence-Guided Gastric Calibration Tube during gastric sleeve construction
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Fig. 7.4 Fluorescence-guided gastric sleeve construction during sleeve gas­trectomy operation using the Endolumik calibration tube
rst device to be approved through the Safer Technologies Program (STeP) [78], a voluntary program for medical devices that are reasonably expected to signicantly improve the safety of currently available treatments.
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Fig. 7.5 Fluorescence-guided gastric pouch construction during gastric bypass operation using the Endolumik calibration tube
E. B. Chen et al.
Fig. 7.6 Use of the Endolumik Fluorescence-Guided Gastric Calibration Tube to make uorescence-guided measurements of gastric pouch length dur­ing gastric bypass
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Pearls andPitfalls
• Transillumination device which provides enhanced
intraoperative visualization to enable more precise surgical
dissection.
• Combines functionality of orogastric tube, calibration tube,
and leak testing system.
• Compatible with all NIR surgical camera systems.
• LED-powered NIR device obviates the need for ICG dye
injection.
Conclusion
Bariatric surgery is a powerful tool for treating obesity and its associated comorbidities. Sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duode­nal switch (BPD/DS) are the main primary operations. The num­ber of revisional bariatric surgeries continues to grow and often involves creation of a gastrojejunostomy. ICG has emerged as a useful tool in assessing perfusion and the integrity of the tissue perfusion and anastomoses in these surgeries. Further investiga­tion into the application of intraoperative uorescence guidance will make the primary and revisional bariatric surgeries a safer and more effective option for patients.
Conicts of Interest None.
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