1
|
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.
Collapse
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
| |
Collapse
|
2
|
Dalli J, Epperlein JP, Hardy NP, Khan MF, Mac Aonghusa P, Cahill RA. Clinical and computational development of a patient-calibrated ICGFA bowel transection recommender. Surg Endosc 2024; 38:3212-3222. [PMID: 38637339 PMCID: PMC11133155 DOI: 10.1007/s00464-024-10827-6] [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: 11/22/2023] [Accepted: 03/23/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Intraoperative indocyanine green fluorescence angiography (ICGFA) aims to reduce colorectal anastomotic complications. However, signal interpretation is inconsistent and confounded by patient physiology and system behaviours. Here, we demonstrate a proof of concept of a novel clinical and computational method for patient calibrated quantitative ICGFA (QICGFA) bowel transection recommendation. METHODS Patients undergoing elective colorectal resection had colonic ICGFA both immediately after operative commencement prior to any dissection and again, as usual, just before anastomotic construction. Video recordings of both ICGFA acquisitions were blindly quantified post hoc across selected colonic regions of interest (ROIs) using tracking-quantification software and computationally compared with satisfactory perfusion assumed in second time-point ROIs, demonstrating 85% agreement with baseline ICGFA. ROI quantification outputs detailing projected perfusion sufficiency-insufficiency zones were compared to the actual surgeon-selected transection/anastomotic construction site for left/right-sided resections, respectively. Anastomotic outcomes were recorded, and tissue lactate was also measured in the devascularised colonic segment in a subgroup of patients. The novel perfusion zone projections were developed as full-screen recommendations via overlay heatmaps. RESULTS No patient suffered intra- or early postoperative anastomotic complications. Following computational development (n = 14) the software recommended zone (ROI) contained the expert surgical site of transection in almost all cases (Jaccard similarity index 0.91) of the nine patient validation series. Previously published ICGFA time-series milestone descriptors correlated moderately well, but lactate measurements did not. High resolution augmented reality heatmaps presenting recommendations from all pixels of the bowel ICGFA were generated for all cases. CONCLUSIONS By benchmarking to the patient's own baseline perfusion, this novel QICGFA method could allow the deployment of algorithmic personalised NIR bowel transection point recommendation in a way fitting existing clinical workflow.
Collapse
Affiliation(s)
- Jeffrey Dalli
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Niall P Hardy
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mohammad Faraz Khan
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Ronan A Cahill
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
| |
Collapse
|
3
|
Dalli J, Joosten JJ, Jindal A, Hardy NP, Camilleri-Brennan J, Andrejevic P, Hompes R, Cahill RA. Impact of standardising indocyanine green fluorescence angiography technique for visual and quantitative interpretation on interuser variability in colorectal surgery. Surg Endosc 2024; 38:1306-1315. [PMID: 38110792 DOI: 10.1007/s00464-023-10564-2] [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: 07/08/2023] [Accepted: 10/24/2023] [Indexed: 12/20/2023]
Abstract
AIM/BACKGROUND Intra-operative colonic perfusion assessment via indocyanine green fluorescence angiography (ICGFA) aims to address malperfusion-related anastomotic complications; however, its interpretation suffers interuser variability (IUV), especially early in ICGFA experience. This work assesses the impact of a protocol developed for both operator-based judgement and computational development on interpretation consistency, focusing on senior surgeons yet to start using ICGFA. METHODS Experienced and junior gastrointestinal surgeons were invited to complete an ICGFA-experience questionnaire. They subsequently interpreted nine operative ICGFA videos regarding perfusion sufficiency of a surgically prepared distal colon during laparoscopic anterior resection by indicating their preferred site of proximal transection using an online annotation platform (mindstamp.com). Six ICGFA videos had been prepared with a clinical standardisation protocol controlling camera and patient positioning of which three each had monochrome near infrared (NIR) and overlay display. Three others were non-standardised controls with synchronous NIR and overlay picture-in-picture display. Differences in transection level between different cohorts were assessed for intraclass correlation coefficient (ICC) via ImageJ and IBM SPSS. RESULTS 58 clinicians (12 ICGFA experts, 46 ICGFA inexperienced of whom 23 were either finished or within one year of finishing training and 23 were junior trainees) participated as per power calculations. 63% felt that ICGFA should be routinely deployed with 57% believing interpretative competence requires 11-50 cases. Transection level concordance was generally good (ICC = 0.869) across all videos and levels of expertise (0.833-0.915). However, poor agreement was evident with the standardised protocol videos for overlay presentation (0.208-0.345). Similarly, poor agreement was seen for the monochrome display (0.392-0.517), except for those who were trained but ICG inexperienced (0.877) although even here agreement was less than with unstandardised videos (0.943). CONCLUSION Colorectal ICGFA acquisition and display standardisation impacts IUV with this specific protocol tending to diminish surgeon interpretation consistency. ICGFA video recording for computational development may require dedicated protocols.
Collapse
Affiliation(s)
- Jeffrey Dalli
- UCD Centre for Precision Surgery, Catherine McAuley Centre, University College Dublin, 21 Nelson St, Phibsborough, Dublin 7, D07 KX5K, Ireland
| | - Johanna J Joosten
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Abhinav Jindal
- UCD Centre for Precision Surgery, Catherine McAuley Centre, University College Dublin, 21 Nelson St, Phibsborough, Dublin 7, D07 KX5K, Ireland
| | - Niall P Hardy
- UCD Centre for Precision Surgery, Catherine McAuley Centre, University College Dublin, 21 Nelson St, Phibsborough, Dublin 7, D07 KX5K, Ireland
| | - John Camilleri-Brennan
- Forth Valley Royal Hospital, Larbert, Stirlingshire, Scotland, UK
- University of Glasgow, Glasgow, Scotland, UK
| | - Predrag Andrejevic
- Department of Surgery, Mater Dei Hospital, Msida, Malta
- University of Malta, Msida, Malta
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, Catherine McAuley Centre, University College Dublin, 21 Nelson St, Phibsborough, Dublin 7, D07 KX5K, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
| |
Collapse
|
4
|
Indocyanine green dye clearance test: early graft (dys)-function and long-term mortality after liver transplant. Should we continue to use it? An observational study. J Clin Monit Comput 2020; 35:505-513. [PMID: 32166552 DOI: 10.1007/s10877-020-00493-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 03/04/2020] [Indexed: 12/27/2022]
Abstract
Early allograft dysfunction (EAD) can be a serious complication in the immediate postoperative period following liver transplantation. Our aim was to study the prognostic role of the indocyanine green plasma disappearance rate (ICG-PDR) in predicting early and late EAD and mortality at 3 and 12 months and 5 years after liver transplantation. ICG-PDR values were also assessed for association with the Donor Risk Index (DRI). 220 patients underwent orthotopic liver transplantation. In 77 patients, ICG-PDR was assessed on the 1st post-operative (PO) day. ICG, a water-soluble dye almost entirely excreted into the bile, was measured by spectrophotometry to evaluate graft (dys)-function. DRI was calculated in all patients. The primary study outcomes were the presence (or absence) of EAD after transplant and the results of mortality risk factor analysis. EAD occurred in 18 patients. 1st PO day ICG-PDR was significantly associated with EAD (p < 0.005). A threshold ICG-PDR value < 16%/min on the 1st PO day was also associated with patient probability to survive at 3 and 12 months and 5 years. The sensitivity and specificity of the AUC was good in predicting EAD, being 83% and 56%, respectively, for a 1st PO day ICG-PDR cut-off value < 16%/min. In this study, ICG-PDR on the 1st PO day following OLT can reliably predict EAD and survival at 3 and 12 months and 5 years. ICG-PDR should, therefore, be routinely performed on the 1st PO day following OLTx in all patients in light of its important prognostic role.
Collapse
|
5
|
Vos JJ, Wietasch JKG, Absalom AR, Hendriks HGD, Scheeren TWL. Green light for liver function monitoring using indocyanine green? An overview of current clinical applications. Anaesthesia 2014; 69:1364-76. [PMID: 24894115 DOI: 10.1111/anae.12755] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2014] [Indexed: 12/12/2022]
Abstract
The dye indocyanine green is familiar to anaesthetists, and has been studied for more than half a century for cardiovascular and hepatic function monitoring. It is still, however, not yet in routine clinical use in anaesthesia and critical care, at least in Europe. This review is intended to provide a critical analysis of the available evidence concerning the indications for clinical measurement of indocyanine green elimination as a diagnostic and prognostic tool in two areas: its role in peri-operative liver function monitoring during major hepatic resection and liver transplantation; and its role in critically ill patients on the intensive care unit, where it is used for prediction of mortality, and for assessment of the severity of acute liver failure or that of intra-abdominal hypertension. Although numerous studies have demonstrated that indocyanine green elimination measurements in these patient populations can provide diagnostic or prognostic information to the clinician, 'hard' evidence - i.e. high-quality prospective randomised controlled trials - is lacking, and therefore it is not yet time to give a green light for use of indocyanine green in routine clinical practice.
Collapse
Affiliation(s)
- J J Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | |
Collapse
|
6
|
Vos JJ, Scheeren TWL, Lukes DJ, de Boer MT, Hendriks HGD, Wietasch JKG. Intraoperative ICG plasma disappearance rate helps to predict absence of early postoperative complications after orthotopic liver transplantation. J Clin Monit Comput 2013; 27:591-8. [DOI: 10.1007/s10877-013-9474-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/06/2013] [Indexed: 01/27/2023]
|
7
|
Reekers M, Boer F, Vuyk J. In Response. Anesth Analg 2010. [DOI: 10.1213/ane.0b013e3181ef35e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|