Indocyanine green enhanced near-infrared fluorescence imaging for perfusion assessment of colonic conduit for esophageal replacement: Utility of a novel techniqueR Gupta, V Madaan, S Kumar, D Govil
Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.JPGM_1227_20
Source of Support: None, Conflict of Interest: None
Keywords: Colonic conduit, colonic interposition, esophagectomy, ICG fluorescence imaging, indocyanine green, perfusion assessment
Assessment of conduit perfusion is the most crucial step to prevent conduit ischemia. There is paucity of data regarding the role of Indocyanine Green enhanced near-infrared fluorescence imaging (ICG FI) for assessing perfusion of colonic conduits. Although in the present case, colonic conduit was performed for a benign indication, the primary aim of presenting this case is to highlight the utility of ICG FI during colonic interposition, which constitutes an important step during esophago-gastrectomy for benign as well as malignant conditions.
A 22-year-old female had undergone partial gastrectomy with feeding jejunostomy 9 months back, for gastric necrosis with perforation following corrosive ingestion. She was now planned for colonic interposition for absolute dysphagia secondary to long segment corrosive esophageal stricture. Colonoscopy and CT abdominal angiography were normal.
Intraoperatively, ascending, transverse, and descending colon were mobilized in preparation for a right colonic conduit (ascending and right transverse colon) supplied by the marginal arcade through left colic artery. Following trial clamping of middle colic, right colic, and the branch communicating ileocolic with right colic artery, the conduit appeared well perfused grossly; however, pulsations near the proximal end of conduit were found to be diminished and feeble [Figure 1]a. This raised concern about the possibility of inadequate perfusion. We, therefore, decided to perform ICG FI. A bolus of 0.1 mg/kg ICG solution was administered intravenously and fluorescence was visualized under near-infrared light. Within 45 s, uniform fluorescence was noticed at the proximal end of conduit [Figure 1]b. Fluorescence was homogenous and similar in intensity as compared to remaining colon. Following substernal transposition to the neck, the ascending colon appeared congested [Figure 1]c. All mechanical factors were ruled out. Repeat fluorescence imaging was performed which showed homogenous perfusion at the tip of the conduit [Figure 1]d. End to side, hand-sewn, esophago-colic anastomosis was performed [Figure 1]e. Fluorescence imaging after the anastomosis confirmed adequate perfusion [Figure 1]f. Distally, roux-en-y colo-jejunal anastomosis, and ileo-colic anastomosis were performed with feeding jejunostomy.
Postoperative course was uneventful. Swallow study on postoperative day 10 [Figure 2] revealed no leak, following which she was started on oral feeds.
ICG enhanced near-infrared fluorescence imaging has emerged as a useful technique for assessment of bowel perfusion. While the role of ICG FI for assessing perfusion of gastric conduits has been published extensively, literature regarding its use for colonic conduits is sparse. Extensive search revealed fewer than five cases worldwide and no cases in Indian literature, describing the use of ICG FI for colonic conduits.,, This may be because colonic conduit is used only when stomach is not available for reconstruction. Thomas et al. reported that colonic interposition constitutes only 18.5% of all procedures for esophageal replacement.
A recent meta-analysis revealed that ICG FI results in decreased anastomotic leaks and graft necrosis following esophagectomy. Shimada et al. and Kesler et al. reported the earliest experiences with ICG use for assessment of colonic conduit. However, recently, Weisel et al. were the first to report the technical description of ICG FI for assessing perfusion of colonic conduit.
The importance of pulsatile flow in the marginal arcade supplying the conduit has been well described., Although early studies revealed highest rates of conduit ischemia (~13.3%) with colonic interposition, recent data suggests that the prevalence is similar for gastric and colonic conduits. Nevertheless. conduit ischemia and necrosis is a difficult situation to manage.
Apart from postoperative morbidity resulting from conduit necrosis, another important consideration is that further options for reconstruction are limited. Therefore, all measures must be taken intraoperatively to confirm adequate vascularization of the colonic conduit. The use of supercharged conduit or jejunal interposition has been suggested in case of suspected conduit hypo-perfusion., By confirming the findings of clinical assessment, ICG FI may help in deciding whether such steps are warranted or not.
This report is relevant from an Indian perspective, given the fact that colonic interposition is a common procedure for esophageal replacement for corrosive esophageal strictures, which form an important benign cause of dysphagia in developing countries. Moreover, a rising trend of esophago-gastric junction carcinoma has been reported recently from a tertiary care center in India. Such lesions often require an esophago-gastrectomy with colonic conduit. Therefore, the number of cases requiring creation of a colonic conduit with adequate intraoperative assessment of conduit perfusion, appears to be on the rise.
ICG fluorescence imaging appears to be a valuable technique for assessment of colonic conduit perfusion during esophageal replacement. When there is clinical concern regarding perfusion, fluorescence imaging can confirm or refute the findings of clinical evaluation. Conduit hypo-perfusion based on fluorescence imaging may suggest the need for intraoperative measures to improve vascularity of the conduit. It can, thus, help in avoiding postoperative morbidity resulting from conduit ischemia and necrosis. Our case highlights the usefulness of ICG FI for colonic conduit during difficult intraoperative situations. However, larger studies are required to further clarify its role in decreasing anastomotic leaks & conduit necrosis.
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[Figure 1], [Figure 2]