Utility of indocyanine-green fluorescent imaging during robot-assisted sphincter-saving surgery on rectal cancer patients : Indocyanine green in robot surgery

To examine the long-term oncological impact of anastomotic leakage (AL) after restorative surgery for colorectal cancer using meta-analytical methods. Outcomes evaluated were local recurrence, distant recurrence, and survival. Recurrence after potentially curative surgery for colorectal cancer remains a significant clinical problem and has a poor prognosis. AL may be a risk factor for disease recurrence, however available studies have been conflicting. A meta-analysis was conducted to investigate the impact of AL on disease recurrence and long-term survival. Studies published between 1965 and 2009 evaluating the long-term oncological impact of AL were identified by an electronic literature search. Outcomes evaluated included local recurrence, distant recurrence, and cancer specific survival. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute odds ratio and 95% confidence intervals. Study heterogeneity was evaluated using Q statistics and I and publication bias assessed with funnel plots and Egger's test. Twenty-one studies comprising 13 prospective nonrandomized studies, 1 prospective randomized, and 7 retrospective studies met the inclusion criteria, yielding a total of 21,902 patients. For rectal anastomoses, the odd ratios (OR) of developing a local recurrence when there was AL was 2.05 (95% CI = 1.51-2.8; P = 0.0001). For studies describing both colon and rectal anastomoses, the OR of local recurrence when there was an AL was 2.9 (95% CI = 1.78-4.71; P < 0.001). The OR of developing a distant recurrence after AL was 1.38 (95% CI = 0.96-1.99; P = 0.083). Long term cancer specific mortality was significantly higher after AL with an OR of 1.75 (95% CI = 1.47-2.1; P = 0.0001). AL has a negative prognostic impact on local recurrence after restorative resection of rectal cancer. A significant association between colorectal AL and reduced long-term cancer specific survival was also noted. No association between AL and distant recurrence was found. @ 2011 Lippincott Williams & Wilkins, Inc.

Background Recently major developments in video imaging have been achieved: among these, the use of high definition and 3D imaging systems, and more recently indocyanine green (ICG) fluorescence imaging are emerging as major contributions to intraoperative decision making during surgical procedures. The aim of this study was to present our experience with different laparoscopic procedures using ICG fluorescence imaging. Patients and methods 108 ICG-enhanced fluorescence-guided laparoscopic procedures were performed: 52 laparoscopic cholecystectomies, 38 colorectal resections, 8 living-donor nephrectomies, 1 laparoscopic kidney autotransplantation, 3 inguino-iliac/obturator lymph node dissections for melanoma, and 6 miscellanea procedures. Visualization of structures was provided by a high definition stereoscopic camera connected to a 30° 10 mm scope equipped with a specific lens and light source emitting both visible and near infra-red (NIR) light (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany). After injection of ICG, the system projected high-resolution NIR real-time images of blood flow in vessels and organs as well as highlighted biliary excretion . Results No intraoperataive or injection-related adverse effects were reported, and the biliary/vascular anatomy was always clearly identified. The imaging system provided invaluable information to conduct a safe cholecystectomy and ensure adequate vascular supply for colectomy, nephrectomy, or find lymph nodes. There were no bile duct injuries or anastomotic leaks. Conclusions In our experience, the ICG fluorescence imaging system seems to be simple, safe, and useful. The technique may well become a standard in the near future in view of its different diagnostic and oncological capabilities. Larger studies and more specific evaluations are needed to confirm its role and to address its disadvantages.

Up to 19% of all colorectal resections develop clinically apparent insufficiencies. Insufficient perfusion of the anastomosis is recognized as an important risk factor. As tissue perfusion can be objectified intraoperatively using laser fluorescence angiography (LFA), its effect on the rate of anastomotic complications was evaluated in a retrospective matched-pairs analysis. Between 2003 and 2008, all anastomosis or resection margins in colorectal cancer resections were investigated intraoperatively using LFA (LFA group). Patients with colorectal cancer resections between 1998 and 2003 without LFA served as the control group. Four hundred two patients were matched for age, T-stage, type of resection and anastomosis, defunctioning stoma, administration of blood, emergency conditions, and body mass index. Statistical analysis was performed using the Fisher and the Wilcoxon tests. Twenty-two surgical revisions were necessary due to anastomotic leakage, seven (3.5%) in the LFA group and 15 (7.5%) in the control group. Subgroup analysis revealed that in elective resections the rate of revision was 3.1% (LFA group) and 7.7% (control group) (p = 0.04, risk of revision (ROR) reduced by 60%). In patients older than 70 years, the rate of revision was 4.3% (LFA group) compared to 11.9% (control group) (p = 0.04, ROR reduced by 64%). After hand-sewn anastomosis, the rate of revision was 1.2% (LFA group) and 8.5% (control group) (p = 0.03, ROR reduced by 84%). Hospital stay was significantly reduced in the LFA group (Wilcoxon test; p = 0.01). There was an overall reduction in the absolute revision rate of 4% in the LFA group and a significantly reduced rate of revision in the subgroup analysis of patients undergoing elective colorectal resections, in patients older than 70 years and in patients with hand-sewn anastomosis. This demonstrates that LFA is a method that may significantly reduce not only the rate of severe complications in colorectal surgery but also the hospital length of stay.