Background Anastomotic leak (AL) is a leading cause of morbidity after esophagectomy, with gastric conduit perfusion being a key predictor. The perfusion of the gastric conduit is often analyzed subjectively based on visual inspection, such as the presence of bright bleeding from the resection margin, pulsation of supplying arcade vessels, and tissue color. Indocyanine Green (ICG) fluorescence is a new tool that helps objectively assess the gastric conduit's perfusion. Aim To evaluate the role of ICG fluorescence in assessing gastric conduit perfusion and its correlation with AL. Methods This single-center prospective study from a tertiary hospital in South Asia included patients with esophageal cancer undergoing esophagectomy from December 2019 to December 2021. Gastric conduit perfusion was assessed using real-time ICG imaging with a near-infrared ICG camera (KARL STORZ® SE & Co. KG, Tuttlingen, Germany). It was done before and after trans-mediastinal pull-up and compared with visual perfusion assessment. AL was monitored for two weeks postoperatively. Results Sixteen patients (Male, 50%; mean age 53.7 years; squamous carcinoma, 81.2%; stage III-IVA, 50%; neoadjuvant treatment, 100%) undergoing minimally invasive esophagectomy (14 McKeown's, 2 Ivor Lewis) were included. Before and after the trans-mediastinal pull-up, visual assessment revealed "good" perfusion in 15 and 14 patients, respectively. However, according to the ICG-based evaluation, "good" perfusion was seen in just eight and two patients, respectively. Several conduits showing "good" visual perfusion exhibited "sluggish" perfusion on ICG fluorescence. One patient required conduit tip resection due to "poor" ICG perfusion despite a "good" visual assessment. Two patients (13.3%) developed AL, both of whom belonged to a group of five patients with a change in the ICG perfusion pattern of the gastric conduit from "good" to "sluggish" after its trans-mediastinal pull-up. A significant correlation (asymptotic sig. (2-tailed) P=0.022) was observed between real-time changes in the conduit's ICG perfusion speed between its abdominal and cervical positions and AL occurrence. Conclusion ICG fluorescence is a valuable tool for assessing gastric conduit perfusion during esophagectomy, identifying under-perfused conduits more accurately than visual evaluation. The time difference in perfusion speed before and after trans-mediastinal pull-up is critical, and we believe that assessing perfusion at both stages of the operation is crucial to identifying and addressing perfusion-related issues.

Technological advances are crucial for the optimization of gastric cancer surgery, and the success of any gastric cancer surgery is based on the correct and precise anatomical determination of the primary tumour and tissue structures. Real-time imaging-guided surgery is showing increasing potential and utility, mainly because it helps to aid intraoperative decision-making. However, intraoperative imaging faces many challenges in the field of gastric cancer. This article summarizes and discusses the following clinical applications of real-time optical imaging and fluorescence-guided surgery for gastric cancer: (1) the potential of quantitative fluorescence imaging in assessing tissue perfusion, (2) vascular navigation and determination of tumour margins, (3) the advantages and limitations of lymph node drainage assessment, and (4) identification of peritoneal metastases. In addition, preclinical study of tumour-targeted fluorescence imaging are discussed.

Anastomotic leak (AL) remains a significant complication after esophagectomy. Indocyanine green fluorescent angiography (ICG-FA) is a promising and safe technique for assessing gastric conduit (GC) perfusion intraoperatively. It provides detailed visualization of tissue perfusion and has demonstrated usefulness in oesophageal surgery. GC perfusion analysis by ICG-FA is crucial in constructing the conduit and selecting the anastomotic site and enables surgeons to make necessary adjustments during surgery to potentially reduce ALs. However, anastomotic integrity involves multiple factors, and ICG-FA must be combined with optimization of patient and procedural factors to decrease AL rates. This review summarizes ICG-FA's current applications in assessing esophago-gastric anastomosis perfusion, including qualitative and quantitative analysis and different imaging systems. It also explores how fluorescent imaging could decrease ALs and aid clinicians in utilizing ICG-FA to improve esophagectomy outcomes.

Applying indocyanine green (ICG) fluorescence in surgery has created a new dimension of navigation surgery to advance in various disciplines. The research in this field is nascent and fragmented, necessitating academic efforts to gain a comprehensive understanding. The present review aims to integrate diverse perspectives and recent advances in its application in gastrointestinal surgery. The relevant articles were selected by using the appropriate keyword search in PubMed. The angiography and cholangiography property of ICG fluorescence is helpful in various hepatobiliary disorders. In gastroesophageal and colorectal surgery, the lymphangiography and angiography property of ICG is applied to evaluate bowel vascularity and guide lymphadenectomy. The lack of objective parameters to assess ICG fluorescence has been the primary limitation when ICG is used to evaluate bowel perfusion. The optimum dose and timing of ICG administration need to be standardized in some new application areas in gastrointestinal surgery. Binding tumor-specific ligands with fluorophores can potentially widen the fluorescence application to detect primary and metastatic gastrointestinal tumors. The narrative review outlines prior contributions, limitations, and research opportunities for future studies across gastrointestinal sub-specialty. The findings of the present review would be helpful for scholars and practitioners to explore and progress in this exciting domain of gastrointestinal surgery.

Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

Near-infrared (NIR) imaging with indocyanine green (ICG) has proven to be useful in general, visceral, and transplant surgery. However, most studies have performed only qualitative assessments. Therefore, a systematic overview of all studies performing quantitative indocyanine green evaluation in general, visceral, and transplant surgeries should be conducted. Free term and medical subject heading (MeSH) term searches were performed in the Medline and Cochrane databases until October 2022. The main categories of ICG quantification were esophageal surgery (24.6%), reconstructive surgery (24.6%), and colorectal surgery (21.3%). Concordantly, anastomotic leak (41%) was the main endpoint, followed by the assessment of flap perfusion (23%) and the identification of structures and organs (14.8%). Most studies examined open surgery (67.6%) or laparoscopic surgery (23.1%). The analysis was mainly carried out using manufacturer software (44.3%) and open-source software (15.6%). The most frequently analyzed parameter was intensity over time for blood flow assessment, followed by intensity alone or intensity-to-background ratios for structure and organ identification. Intraoperative ICG quantification could become more important with the increasing impact of robotic surgery and machine learning algorithms for image and video analysis.

The blood supply of the right gastroepiploic artery after esophagectomy with gastric tube reconstruction is essential for avoiding anastomotic leakage. Near-infrared fluorescence (NIRF) imaging with indocyanine green is widely used to assess the blood supply because it can visualize it in real-time during navigation surgery. However, there is no established protocol for this modality. One reason for this lack of protocol is that NIRF provides subjective information. This study aimed to evaluate NIRF quantification. We conducted a literature review of risk factors for anastomotic leakage after esophagectomy, NIRF procedures, NIRF quantification, and new methods to compensate for NIRF limitations. Major methods for the quantification of NIRF include measuring the blood flow speed, visualization time, and fluorescence intensity. The cutoff value for the blood flow speed is 2.07 cm/s, and that for the visualization time is 30-90 s. Although the time-intensity curve provided patterns of change in the blood flow, it did not show an association with anastomotic leakage. However, to compensate for the limitations of NIRF, new devices have been reported that can assess tissue oxygenation perfusion, organ hemoglobin concentration, and microcirculation.

In recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community.

An expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021.

A total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications.

Overall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.

A correct perioperative fluid administration represents one of the most important items proposed by the Enhanced Recovery After Surgery Society. Upper gastrointestinal (UGI) surgery patients undergoing major oncological procedures are often elderly and frail. Should we prefer a wet or a dry patient? Both conditions should probably be avoided in this surgical setting. We present a narrative review on perioperative fluid administration in UGI patients undergoing major surgery, also analyzing the role of Goal Directed therapy.

Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.

Indocyanine green fluorescence angiography (ICG-FA) allows for real-time intraoperative assessment of the perfusion of the gastric conduit during esophagectomy. The aim of this study was to investigate the effect of the implementation of ICG-FA during robot-assisted minimally invasive esophagectomy (RAMIE) with an intrathoracic anastomosis. In this prospective cohort study, a standardized protocol for ICG-FA was implemented in a high-volume center in December 2018. All consecutive patients who underwent RAMIE with an intrathoracic anastomosis were included. The primary outcome was whether the initial chosen site for the anastomosis on the gastric conduit was changed based on ICG-FA findings. In addition, ICG-FA was quantified based on the procedural videos. Out of the 63 included patients, the planned location of the anastomosis was changed in 9 (14%) patients, based on ICG-FA. The median time to maximum intensity at the base of the gastric conduit was shorter (25 s; range 13-49) compared to tip (34 s; range 12-83). In patients with anastomotic leakage, the median time to reach the FImax at the tip was 56 s (range 30-83) compared to 34 s (range 12-66) in patients without anastomotic leakage (p = 0.320). The use of ICG-FA resulted in an adaptation of the anastomotic site in nine (14%) patients during RAMIE with intrathoracic anastomosis. The quantification of ICG-FA showed that the gastric conduit reaches it maximum intensity in a base-to-tip direction. Perfusion of the entire gastric conduit was worse for patients with anastomotic leakage, although not statistically different.

Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis.

A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes.

A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29).

The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

We investigated the effectiveness of indocyanine green (ICG) fluorescence blood flow imaging of the gastric conduit to evaluate anastomotic leakage after esophagectomy. We identified 19 articles using the PRISMA standard for systematic reviews. The more recent studies reported attempts at objective quantification of ICG fluorescence imaging, rather than qualitative assessment. Anastomotic leakage after esophagectomy occurred in 0-33% of the patients who underwent ICG fluorescence imaging. According to the six studies that compared the incidence of anastomotic leakage in the ICG group and the control group, it ranged from 0 to 18.3% in the ICG group and from 0 to 25.2% in the control group, respectively. Overall, the incidence of anastomotic leakage in the ICG group (8.4%) was lower than that in the control group (18.5%). Although the incidence of anastomotic leakage was as high as 43.1% in patients who did not undergo any intraoperative intervention for poor blood flow, it was only 24% in patients who underwent intraoperative intervention. This systematic review revealed that ICG fluorescence imaging may be a crucial adjunctive tool for reducing anastomotic leakage after esophagectomy, suggesting that it should be performed during esophageal reconstruction.