Intraoperative ICG-NIR Fluorescence Angiography Visualization of Intestinal Perfusion in Primary Pull-Through for Hirschsprung Disease

Authors: Mohammad Emran, Colton Wayne, Shannon M Koehler, P. Stephen Almond, Haroon Patel

Abstract:

Purpose: Assessment of anastomotic perfusion in Hirschsprung disease using Indocyanine Green (ICG)-near-infrared (NIR) fluorescence angiography. Introduction: Anastomotic stricture and leak are well-known complications of Hirschsprung pull-through procedures. Complications are due to tension, infection, and/or poor perfusion. While a surgeon can visually determine and control the amount of tension and contamination, assessment of perfusion is subject to surgeon determination. Intraoperative use of ICG-NIR enhances this decision-making process by illustrating perfusion intensity and adequacy in the pulled-through bowel segment. This technique, proven to reduce anastomotic stricture and leak in adults, has not been studied in children to our knowledge. ICG, an FDA approved, nontoxic, non-immunogenic, intravascular (IV) dye, has been used in adults and children for over 60 years, with few side effects. ICG-NIR was used in this report to demonstrate the adequacy of perfusion during transanal pullthrough for Hirschsprung’s disease. Method: 8 patients with Hirschsprung disease were evaluated with ICG-NIR technology. Levels of affected area ranged from sigmoid to total colonic Hirschsprung disease. After leveling, but prior to anastomosis, ICG was administered at 1.25 mg (< 2 mg/kg) and perfusion visualized using an NIR camera, before and during anastomosis. Video and photo imaging was performed and perfusion of the bowel was compared to surrounding tissues. This showed the degree of perfusion and demarcation of perfused and non-perfused bowel. The anastomosis was completed uneventfully and the patients all did well. Results: There were no complications of stricture or leak. 5 of 8 patients (62.5%) had modification of the plan based on ICG-NIR imaging. Conclusion: Technologies that enhance surgeons’ ability to visualize bowel perfusion prior to anastomosis in Hirschsprung’s patients may help reduce post-operative complications. Further studies are needed to assess the potential benefits.

Keywords: Colonic anastomosis, fluorescence angiography, Hirschsprung disease, pediatric surgery, SPY, ICG, NIR.

References:

[1] Gröne J, Koch D, Kreis ME. “Impact of intraoperative microperfusion assessment with pinpoint perfusion imaging on surgical management of laparoscopic low rectal and anorectal anastomoses”. Colorectal Dis. 2015 Oct; 17 Suppl 3:22-8.
[2] Mangano A, Gheza F, Chen LL, Minerva EM, Giulianotti PC. “Indocyanine green (Icg)-enhanced fluorescence for intraoperative assessment of bowel microperfusion during laparoscopic and robotic colorectal surgery: The quest for evidence-based results”. Surgical Technology International. 2018 Jun 1;32:101-104.
[3] Jafari MD, Wexner SD, Martz JE, et al. “Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): A multi-institutional study”. Journal of the American College of Surgeons. 2015;220(1). doi:10.1016/j.jamcollsurg.2014.09.015.
[4] Degett TH, Andersen HS, Gögenur I. “Indocyanine green fluorescence angiography for intraoperative assessment of gastrointestinal anastomotic perfusion: a systematic review of clinical trials”. Langenbecks Archives of Surgery. 2016;401(6):767-775.
[5] Boni L, David G, Dionigi G, Rausei S, Cassinotti E, Fingerhut A. “Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection”. Surgical Endoscopy. 2015;30(7):2736-2742.
[6] Tannuri AC, Tannuri U, Romão RL.Transanal endorectal pull-through in children with Hirschsprung's disease-technical refinements and comparison of results with the Duhamel procedure. Journal of Pediatric Surgery. 2009 Apr;44(4):767-72.
[7] Cassinotti E, Costa S, DE Pascale S, Oreggia B, Palazzini G, Boni L. “How to reduce surgical complications in rectal cancer surgery using fluorescence techniques”. Minerva Chirurgica. 2018 Apr;73(2):210-216.
[8] Tsai YY, Chen WTL. “Management of anastomotic leakage after rectal surgery: a review article”. Journal of Gastrointestinal Oncology. 2019 Dec; 10(6):1229-1237.
[9] Foppa C, Denoya PI, Tarta C, Bergamaschi R. “Indocyanine green fluorescent dye during bowel surgery: Are the blood supply “guessing days” over?” Techniques in Coloproctology. 2014;18(8):753-758. doi:10.1007/s10151-014-1130-3.
[10] Kin C, Vo H, Welton L, Welton M. “Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks”. Diseases of the Colon & Rectum. 2015;58(6):582-587. doi:10.1097/dcr.0000000000000320.
[11] Ris F, Liot E, Buchs NC, Kraus R, Ismael G, Belfontali V, Douissard J, Cunningham C, Lindsey I, Guy R, Jones O, George B, Morel P, Mortensen NJ, Hompes R, Cahill RA; “Near-infrared anastomotic perfusion assessment network VOIR. Multicentre phase II trial of near-infrared imaging in elective colorectal surgery”. British Journal of Surgery. 2018 Sep;105(10):1359-1367.
[12] Mangano A, Masrur MA, Bustos R, Chen LL, Fernandez E, Giulianotti PC. “Near-infrared indocyanine green-enhanced fluorescence and minimally invasive colorectal surgery: Review of literature”. Surgical Technology International. 2018 Nov 11;33:77-83.
[13] Urbanavičius L, Pattyn P, Van de Putte D, Venskutonis D. “How to assess intestinal viability during surgery: A review of techniques”. World Journal of Gastrointestinal Surgery. 2011 May; 3(5):59-69.
[14] Starker PM, Chinn B. “Using outcomes data to justify instituting new technology: a single institution’s experience”. Surgical Endoscopy. 2018: 32(3):1586-1592.
[15] Chattergee A, Krishnan N, Vliet M, Powell S, Rosen J, Ridgway E. “A Comparison of Free Autologous Breast Reconstruction with and without the Use of Laser-Assisted Indocyanine Green Angiography: A Cost-Effectiveness Analysis”. Journal of Plastic and Reconstructive Surgery. 2013 May; 131(5):693e-701e.
[16] Moyer H, Losken A. “Predicting Mastectomy Skin Flap Necrosis with indocyanine Green Angiography: The Gray Area Defined”. Journal of Plastic and Reconstructive Surgery. 2012 May; 129(5):1043-1048.
[17] Schade, Valerie L., et al. (2015). “How Fluorescence Angiography Illuminates the Potential for Limb Salvage”. Podiatry Today, Volume 28 Issue 9.
[18] Snyder, Mark (2016). “How Fluorescence Angiography Can Clarify Treatment Options for Patients with PAD”. Podiatry Today.
[19] Christensen, Joani M., et al. (2012). “Indocyanine Green Near-Infrared Laser Angiography Predicts Timing for the Division of a Forehead Flap”. Journal of Plastic Surgery. Volume 12.
[20] Park JS, Huh JW, Park YA, Cho YB, Yun SH, Kim HC, Lee WY. “Risk Factors of Anastomotic Leakage and Long-Term Survival after Colorectal Surgery”. Medicine (Baltimore). 2016 Feb; 95(8):e2890.
[21] Hammond J, Lim S, Wan Y, Gao X, Patkar A. “The Burden of Gastrointestinal Anastomotic Leaks: an Evaluation of Clinical and Economic Outcomes”. Journal of Gastrointestinal Surgery. 2014: 18(6):1176-1185.