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Panettella T, Meroni M, Scaglioni MF. How to increase the success rate in microsurgical free and pedicled flap reconstructions with intraoperative multistep ICG imaging: A case series with 400 consecutive cases. J Plast Reconstr Aesthet Surg 2024; 97:147-155. [PMID: 39151286 DOI: 10.1016/j.bjps.2024.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/08/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Over the last decade, microsurgical soft-tissue transfer became the gold standard for various reconstructions throughout the body. Continuous improvement of instruments and surgical techniques, such as intraoperative indocyanine green angiography (ICG-A), allowed for a very high success rate. This study aimed to assess and validate the role of a standard intraoperative ICG-A in free and pedicled flap surgery to improve overall outcomes. PATIENTS AND METHODS From April 2018 to April 2023, 400 consecutive patients who underwent reconstruction using free and pedicled flaps were enrolled. ICG-A was always performed in a free flap after flap elevation, after microsurgical anastomosis, immediately after the flap inset, and after wound closure. In the pedicled flap, the sequential procedure was performed after flap elevation, flap inset, and wound closure. RESULTS All 400 patients who underwent flap reconstruction using intraoperative ICG-A had an extremely low incidence of necrosis (0.75% partial necrosis among free and pedicled flaps) and reoperation for perfusion-related complications (0.75% due to acute ischemia and 0.50% due to flap congestion). Minor complications, such as hematoma, seroma, wound dehiscence, and wound infections, were managed with a second operation. No flaps were lost, and all patients were successfully treated. CONCLUSIONS This study showed how systematic multistep ICG-A for intraoperative assessment of free and pedicled flap perfusion can significantly reduce the complication rate, including flap loss and re-exploration surgeries, in a time- and cost-effective manner.
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Affiliation(s)
- Tania Panettella
- Department of Hand, and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Zentrum für Plastische Chirurgie, Pyramide Clinic, Zurich, Switzerland
| | - Mario F Scaglioni
- Department of Hand, and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Zentrum für Plastische Chirurgie, Pyramide Clinic, Zurich, Switzerland.
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Dalli J, Reilly F, Epperlein J, Potter S, Cahill R. Advancing indocyanine green fluorescence flap perfusion assessment via near infrared signal quantification. JPRAS Open 2024; 41:203-214. [PMID: 39050743 PMCID: PMC11266865 DOI: 10.1016/j.jpra.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/25/2024] [Indexed: 07/27/2024] Open
Abstract
Introduction Intraoperative indocyanine green fluorescence angiography (ICGFA) perfusion assessment has been demonstrated to reduce complications in reconstructive surgery. This study sought to advance ICGFA flap perfusion assessment via quantification methodologies. Method Patients undergoing pedicled and free flap reconstruction were subjected to intraoperative ICGFA flap perfusion assessment using either an open or endoscopic system. Patient demographics, clinical impact of ICGFA and outcomes were documented. From the ICGFA recordings, fluorescence signal quality, as well as inflow/outflow milestones for the flap and surrounding (control) tissue were computationally quantified post hoc and compared on a region of interest (ROI) level. Further software development intended full flap quantification, metric computation and heatmap generation. Results Fifteen patients underwent ICGFA assessment at reconstruction (8 head and neck, 6 breast and 1 perineum) including 10 free and 5 pedicled flaps. Visual ICGFA interpretation altered on-table management in 33.3% of cases, with flap edges trimmed in 4 and a re-anastomosis in 1 patient. One patient suffered post-operative flap dehiscence. Laparoscopic camera use proved feasible but recorded a lower quality signal than the open system.Using established and novel metrics, objective ICGFA signal ROI quantification permitted perfusion comparisons between the flap and surrounding tissue. Full flap assessment feasibility was demonstrated by computing all pixels and subsequent outputs summarisation as heatmaps. Conclusion This trial demonstrated the feasibility and potential for ICGFA with operator based and quantitative flap perfusion assessment across several reconstructive applications. Further development and implementation of these computational methods requires technique and device standardisation.
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Affiliation(s)
- J. Dalli
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
| | - F. Reilly
- Department of Plastic & Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - S. Potter
- Department of Plastic & Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- UCD School of Medicine, UCD, Dublin, Ireland
| | - R. Cahill
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Nguyen CL, Cui R, Zhou M, Ali F, Easwaralingam N, Chan B, Graham S, Azimi F, Mak C, Warrier S. Cost-Effectiveness of Radar Localisation Versus Wire Localisation for Wide Local Excision of Non-palpable Breast Cancer. Ann Surg Oncol 2024; 31:3916-3925. [PMID: 38472677 PMCID: PMC11076345 DOI: 10.1245/s10434-024-15142-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Wire localisation (WL) is the "gold standard" localisation technique for wide local excision (WLE) of non-palpable breast lesions but has disadvantages that have led to the development of wireless techniques. This study compared the cost-effectiveness of radar localisation (RL) to WL. METHODS This was a single-institution study of 110 prospective patients with early-stage breast cancer undergoing WLE using RL with the SCOUT® Surgical Guidance System (2021-2023) compared with a cohort of 110 patients using WL. Margin status, re-excision rates, and surgery delays associated with preoperative localisation were compared. Costs from a third-party payer perspective in Australian dollars (AUD$) calculated by using microcosting, break-even point, and cost-utility analyses. RESULTS A total of 110 WLEs using RL cost a total of AUD$402,281, in addition to the device cost of AUD$77,150. The average additional cost of a surgery delay was AUD$2318. Use of RL reduced the surgery delay rate by 10% (p = 0.029), preventing 11 delays with cost savings of AUD$25,496. No differences were identified in positive margin rates (RL: 11.8% vs. WL: 17.3%, p = 0.25) or re-excision rates (RL: 14.5% vs. WL: 21.8%, p = 0.221). In total, 290 RL cases are needed to break even. The cost of WLE using RL was greater than WL by AUD$567. There was a greater clinical benefit of 1.15 quality-adjusted life-years (QALYs) and an incremental cost-utility ratio of AUD$493 per QALY favouring RL. CONCLUSIONS Routine use of RL was a more cost-effective intervention than WL. Close to 300 RL cases are likely needed to be performed to recover costs of the medical device. CLINICAL TRIAL REGISTRATION ACTRN12624000068561.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia.
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia.
| | - Rebecca Cui
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Michael Zhou
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Fatema Ali
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Neshanth Easwaralingam
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Belinda Chan
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
| | - Susannah Graham
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
| | - Farhad Azimi
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Cindy Mak
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Sanjay Warrier
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
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Dalli J, Nguyen C, Jindal A, Epperlein J, Hardy N, Pulitano C, Warrier S, Cahill R. A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy. JPRAS Open 2024; 40:32-47. [PMID: 38425697 PMCID: PMC10904167 DOI: 10.1016/j.jpra.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/21/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications. Methods ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data. Results The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity. Conclusion Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.
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Affiliation(s)
- J. Dalli
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
| | - C.L. Nguyen
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
- Department of Surgery, The University of Sydney, Camperdown, Australia
| | - A. Jindal
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
| | | | - N.P. Hardy
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
| | - C. Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
- Department of Surgery, The University of Sydney, Camperdown, Australia
| | - S. Warrier
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
- Department of Surgery, The University of Sydney, Camperdown, Australia
| | - R.A. Cahill
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Nguyen CL, Dayaratna N, Graham S, Azimi F, Mak C, Pulitano C, Warrier S. Evolution of Indocyanine Green Fluorescence in Breast and Axilla Surgery: An Australasian Experience. Life (Basel) 2024; 14:135. [PMID: 38255750 PMCID: PMC10821188 DOI: 10.3390/life14010135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/05/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
The evolution of indocyanine green (ICG) fluorescence in breast and axilla surgery from an Australasian perspective is discussed in this narrative review with a focus on breast cancer and reconstruction surgery. The authors have nearly a decade of experience with ICG in a high-volume institution, which has resulted in publications and ongoing future research evaluating its use for predicting mastectomy skin flap perfusion for reconstruction, lymphatic mapping for sentinel lymph node (SLN) biopsy, and axillary reverse mapping (ARM) for prevention of lymphoedema. In the authors' experience, routine use of ICG angiography during breast reconstruction postmastectomy was demonstrated to be cost-effective for the reduction of ischemic complications in the Australian setting. A novel tracer combination, ICG-technetium-99m offered a safe and effective substitute to the "gold standard" dual tracer for SLN biopsy, although greater costs were associated with ICG. An ongoing trial will evaluate ARM node identification using ICG fluorescence during axillary lymph node dissection and potential predictive factors of ARM node involvement. These data add to the growing literature on ICG and allow future research to build on this to improve understanding of the potential benefits of fluorescence-guided surgery in breast cancer and reconstruction surgery.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Nirmal Dayaratna
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Susannah Graham
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Farhad Azimi
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Cindy Mak
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
| | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Sanjay Warrier
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
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Cheng A. Commentary on: Mastectomy Skin Flap Stability Prediction Using Indocyanine Green Angiography: A Randomized Prospective Trial. Aesthet Surg J 2023; 43:NP1061-NP1062. [PMID: 37668372 DOI: 10.1093/asj/sjad259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023] Open
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