Indocyanine green fluorescence in robot-assisted minimally invasive esophagectomy with intrathoracic anastomosis: a prospective study

Current status of indocyanine green fluorescent angiography in assessing perfusion of gastric conduit and oesophago-gastric anastomosis

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.

Fluorescent Imaging in Visceral Surgery: Current Opportunities and Future Perspectives

Background

Fluorescent imaging using indocyanine green (FI-ICG) has become quite popular in the past century, giving the surgeon various pre- and intraoperative approaches in visceral surgery. Nevertheless, several aspects and pitfalls of using the technology need to be addressed.

Summary

This article focused on the applications of FI-ICG in esophageal and colorectal surgery as this is where the clinical relevance is most important. Important benchmark studies were summarized to explain the background. In addition, dosage, the timing of application, and future perspectives - especially quantification methods - were the article's content.

Key Message

There are currently encouraging data on the use of FI-ICG, particularly concerning perfusion assessment to reduce anastomotic leakage, although its use is mainly subjective. The optimal dosage remains unclear; for perfusion evaluation, it should be around 0.1 mg/kg body weight. Moreover, the quantification of FI-ICG opens new possibilities, so that reference values may be available in the future. However, in addition to perfusion measurement, the detection of additional hepatic lesions such as liver metastases or lesions of peritoneal carcinomatosis is also possible. A standardization of FI-ICG and further studies are needed to fully utilize FI-ICG.

The effect of anastomotic leakage on the incidence of recurrence after tri-modality therapy for esophageal adenocarcinomas

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRTx) reduces the incidence of recurrence, while anastomotic leakage has shown increase the risk of recurrence. The primary objective of this retrospective study was to investigate the incidence and pattern of recurrence and secondary median recurrence-free interval and post-recurrence survival in patients with and without anastomotic leakage after multimodal therapy for esophageal adenocarcinoma.

METHODS

Patients with recurrence after multimodal therapy between 2010 and 2018 were included.

RESULTS

Six hundred and eighteen patients were included, 91 (14.7%) had leakage and 278 (45.0%) recurrence. Patients with leakage did not develop recurrence more often (48.4%) than those without (44.4%, [p = 0.484]). Recurrence-free interval for patients with (n = 44) and without leakage (n = 234) was 39 and 52 weeks, respectively (p = 0.049). Post-recurrence survival was 11 and 16 weeks, respectively (p = 0.702). Specified by recurrence site, post-recurrence survival for loco-regional recurrences was 27 versus 33 weeks (p = 0.387) for patients with and without leakage, for distant 9 versus 13 (p = 0.999), and for combined 11 versus 18 weeks (p = 0.492).

CONCLUSION AND DISCUSSION

No higher incidence of recurrent disease was observed in patients with anastomotic leakage, however it is associated with a shorter recurrence-free interval. This could have implications for surveillance, as early detection of recurrent disease could influence therapeutic options.

Implementation of the robotic abdominal phase during robot-assisted minimally invasive esophagectomy (RAMIE): results from a high-volume center

BACKGROUND

Evidence on the added value of robotic-assistance in the abdominal phase during esophagectomy is scarce. In 2003, our center implemented the robotic thoracic phase for esophagectomy. In November 2018 the robot was also implemented in the abdominal phase. The aim of this study was to evaluate the implementation of the abdominal phase during robot-assisted minimally invasive esophagectomy (RAMIE).

METHODS

Consecutive patients who underwent full RAMIE with intrathoracic anastomosis for esophageal cancer were included. Patients were extracted from a prospectively maintained institutional database. A cumulative sum (CUSUM) analysis was performed for abdominal operation time and abdominal lymph node yield. Intraoperative, postoperative and oncological outcomes including collected lymph nodes per abdominal lymph node station were reported.

RESULTS

Between 2018 and 2021, 70 consecutive patients were included. The majority of the patients had an adenocarcinoma (n = 55, 77%) and underwent neoadjuvant chemo(radio)therapy (n = 65, 95%). The median operative time for the abdominal phase was 180 min (range 110-233). The CUSUM analysis for abdominal operation time showed a plateau at case 22. There were no intraoperative complications or conversions during the abdominal phase. The most common postoperative complications were pneumonia (n = 18, 26%) and anastomotic leakage (n = 14, 20%). Radical resection margins were achieved in 69 (99%) patients. The median total lymph node yield was 42 (range 23-83) and the median abdominal lymph node yield was 16 (range 2-43). The CUSUM analysis for abdominal lymph node yield showed a plateau at case 21. Most abdominal lymph nodes were collected from the left gastric artery (median 4, range 0-20).

CONCLUSIONS

This study shows that a robotic abdominal phase was safely implemented for RAMIE without compromising intraoperative, postoperative and oncological outcomes. The learning curve is estimated to be 22 cases in a high-volume center with experienced upper GI robotic surgeons.

Robot-assisted esophagectomy with robot-sewn intrathoracic anastomosis (Ivor Lewis): surgical technique and early results

Esophagectomy is the selected treatment for nonmetastatic esophageal and esophagogastric junction cancer, although high perioperative morbidity and mortality incur. Robot-assisted minimally invasive esophagectomy (RAMIE) effectively reduces cardiopulmonary complications compared to open esophagectomy and offers a technical advantage, especially for lymph node dissection and intrathoracic anastomosis. This article aims at describing our initial experience of Ivor Lewis RAMIE, focusing on the technique's main steps and robotic-sewn esophagogastrostomy. Prospectively collected data from all consecutive patients who underwent Ivor Lewis RAMIE for cancer was reviewed. Reconstruction was performed with a gastric conduit pull-up and a robotic-sewn intrathoracic anastomosis. Intraoperative and postoperative complications were recorded as prescribed by the Esophagectomy Complications Consensus Group (ECCG). Thirty patients underwent Ivor Lewis RAMIE with complete mediastinal lymph node dissection and robot-sewn anastomosis. No intraoperative complications nor conversion occurred. Pulmonary complications totaled 26.7%. Anastomotic leakage (ECCG, type III) and conduit necrosis (ECCG, type III) both occurred in one patient (3.3%). Chylothorax appeared in 2 patients (6.7%) (ECCG, Type IIA). Anastomotic stricture, successfully treated with endoscopic dilatations, occurred in 8 cases (26.7%). Median overall postoperative stay was 11 days (range, 6-51 days). 30 day and 90 day mortality was 0%. R0 resection was performed in 96.7% of patients with a median number of 47 retrieved lymph nodes. RAMIE with robot-sewn intrathoracic anastomosis appears to be feasible, safe and effective, with favorable perioperative results. Nevertheless, further high-quality studies are needed to define the best anastomotic technique for Ivor Lewis RAMIE.