Systematic Reviews
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Mar 15, 2019; 11(3): 250-263
Published online Mar 15, 2019. doi: 10.4251/wjgo.v11.i3.250
Near-infrared fluorescence guided esophageal reconstructive surgery: A systematic review
Elke Van Daele, Yves Van Nieuwenhove, Wim Ceelen, Christian Vanhove, Bart P Braeckman, Anne Hoorens, Jurgen Van Limmen, Oswald Varin, Dirk Van de Putte, Wouter Willaert, Piet Pattyn
Elke Van Daele, Yves Van Nieuwenhove, Wim Ceelen, Oswald Varin, Dirk Van de Putte, Wouter Willaert, Piet Pattyn, Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
Christian Vanhove, Department of Electronics and information systems, Ghent University, Ghent B-9000, Belgium
Bart P Braeckman, Department of Biology, Ghent University, Ghent B-9000, Belgium
Anne Hoorens, Department of Pathology, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
Jurgen Van Limmen, Department of Anaesthesiology, Ghent University Hospital/ Ghent University, Ghent B-9000, Belgium
Author contributions: Van Daele E, Pattyn P, Van Nieuwenhove Y and Ceelen W designed the research; Van Daele E and Pattyn P performed the research and analysed the data; Van Daele E, Van Nieuwenhove Y and Ceelen W wrote the paper; Van Daele E and Ceelen W performed the statistical analysis; Vanhove C, Braeckman BP, Hoorens A, Van Limmen J, Varin O, Willaert W and Van de Putte D contributed to the manuscript reviewing and editing;
Supported by “ Kom op tegen Kanker” (Stand up to Cancer), the Flemish cancer society which has no role in the design of the study, nor in the collection, analysis or interpretation of the data or in the manuscripts’ writing.
Conflict-of-interest statement: The authors declare no conflicting interests related to this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Elke Van Daele, MD, Surgeon, Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, University Hospital 2K12 IC, C. Heymanslaan 10, Ghent B-9000, Belgium. elke.vandaele@uzgent.be
Telephone: +32-9-3320829 Fax: +32-9-3323891
Received: November 27, 2018
Peer-review started: November 27, 2018
First decision: January 4, 2019
Revised: January 21, 2019
Accepted: January 29, 2019
Article in press: January 30, 2019
Published online: March 15, 2019
Abstract
BACKGROUND

After an esophagectomy, the stomach is most commonly used to restore continuity of the upper gastrointestinal tract. These esophago-gastric anastomoses are prone to serious complications such as leakage associated with high morbidity and mortality. Graft perfusion is considered to be an important predictor for anastomotic integrity. Based on the current literature we believe Indocyanine green fluorescence angiography (ICGA) is an easy assessment tool for gastric tube (GT) perfusion, and it might predict anastomotic leakage (AL).

AIM

To evaluate feasibility and effectiveness of ICGA in GT perfusion assessment and as a predictor of AL.

METHODS

This study was designed according to the PRISMA guidelines and registered in the PROSPERO database. PubMed and EMBASE were independently searched by 2 reviewers for studies presenting data on intraoperative ICGA GT perfusion assessment during esophago-gastric reconstruction after esophagectomy. Relevant outcomes such as feasibility, complications, intraoperative surgical changes based on ICGA findings, quantification attempts, anatomical data and the impact of ICGA on postoperative anastomotic complications, were collected by 2 independent researchers. The quality of the included articles was assessed based on the Methodological Index for Non-Randomized Studies. The 19 included studies presented data on 1192 esophagectomy patients, in 758 patients ICGA was used perioperative to guide esophageal reconstruction.

RESULTS

The 19 included studies for qualitative analyses all described ICGA as a safe and easy method to evaluate gastric graft perfusion. AL occurred in 13.8% of the entire cohort, 10% in the ICG guided group and 20.6% in the control group (P < 0.001). When poorly perfused cases are excluded from the analyses, the difference in AL was even larger (AL well-perfused group 6.3% vs control group 20.5%, P < 0.001). The AL rate in the group with an altered surgical plan based on the ICG image was 6.5%, similar to the well perfused group (6.3%) and significantly less than the poorly perfused group (47.8%) (P < 0.001), suggesting that the technique is able to identify and alter a potential bad outcome.

CONCLUSION

ICGA is a safe, feasible and promising method for perfusion assessment. The lower AL rate in the well perfused group suggest that a good fluorescent signal predicts a good outcome.

Keywords: Indocyanine green, Angiography, Fluorescence, Esophagectomy, Anastomotic leak, Near-infrared spectroscopy, Esophageal neoplasms, Esophageal cancer

Core tip: Esophagectomy is a surgery known for its complexity and potentially high morbidity associated with postoperative anastomotic leakage (AL). This review evaluates Indocyanine green fluorescence angiography (ICGA) as a safe, feasible and promising method to assess graft perfusion during esophageal reconstructive surgery. We discuss the safety, the methodology and the effectiveness of ICGA and its potential to reduce AL rate.