Fluorescent angiography using indocyanine green during esophagectomy with continuity restoration to prevent anastomotic complications

Anastomotic complicaties after esophagectomy with continuity restoration are associated with a high mortality. Among the risk factors that influence anastomotic integrity, poor perfusion is a surgically modifiable factor. Intraoperative real-time fluorescence angiography (FA) using indocyanine green (ICG) can assess perfusion, and thereby enables precise delineation of the ideal site for anastomosis and assessment of final anastomotic vitality. Although management according to FA findings seems to lower anastomotic complications rates afer esophagectomy, complications still occur. Besides the multifactorial etiology of anastomotic complications, an explanation might be that no fluorescent threshold is known for complications.
In this monocenter prospective explorative study (IDEAL phase 2S study), we aim to evaluate time to fluorescent enhancement as a quantitative fluorescent value, and to correlate the values with surgical morbidity, including anastomotic leakage, graft necrosis and anastomotic strictures.

Intraoperative real-time FA using ICG can assess perfusion, and thereby enables precise delineation of the ideal site for anastomosis and assessment of final anastomotic vitality. However, no quantitative threshold of the fluorescence signal is known for adequate perfusion. Time dependent change of the fluorescent signal seems a promising method for objective analysis of tissue perfusion. The hypothesis is that a quantitative threshold for this time dependent change can be identified to predict surgical morbidity.

Surgery and follow-up

Intraoperative FA is performed after intravenous ICG injection (0.05mg/kg/bolus). Time to first fluorescent enhancement is assessed using a digital clock and will be noted in a case-report form.