Farah Ladak1,2, Jerry T Dang3, Noah Switzer3, Valentin Mocanu3, Chunhong Tian3, Daniel Birch3,4, Simon R Turner3,4, Shahzeer Karmali3,4. 1. Department of Surgery, Faculty of Medicine and Dentistry, 2D, Walter C Mackenzie Health Sciences Centre, University of Alberta, 840-112 Street, Edmonton, T6G 2B7, Canada. farah.ladak@gmail.com. 2. MPH| School of Public Health, Brown University, Providence, RI, USA. farah.ladak@gmail.com. 3. Department of Surgery, Faculty of Medicine and Dentistry, 2D, Walter C Mackenzie Health Sciences Centre, University of Alberta, 840-112 Street, Edmonton, T6G 2B7, Canada. 4. Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, Edmonton, Canada.
Abstract
BACKGROUND: Intraoperative evaluation with fluorescence angiography using indocyanine green (ICG) offers a dynamic assessment of gastric conduit perfusion and can guide anastomotic site selection during an esophagectomy. This study aims to evaluate the predictive value of ICG for the prevention of anastomotic leak following esophagectomy. METHODS: A comprehensive search of electronic databases using the search terms "indocyanine/fluorescence" AND esophagectomy was completed to include all English articles published between January 1946 and 2018. Articles were selected by two independent reviewers. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. RESULTS: Seventeen studies were included for meta-analysis after screening and exclusions. The pooled anastomotic leak rate when ICG was used was found to be 10%. When limited to studies without intraoperative modifications, the pooled sensitivity, specificity, and diagnostic odds ratio were 0.78 (95% CI 0.52-0.94; p = 0.089), 0.74 (95% CI 0.61-0.84; p = 0.012), and 8.94 (95% CI 1.24-64.21; p = 0.184), respectively. Six trials compared ICG with an intraoperative intervention to improve perfusion to no ICG. ICG with intervention was found to have a risk reduction of 69% (OR 0.31, 95% CI 0.15-0.63). CONCLUSIONS: In non-randomized trials, the use of ICG as an intraoperative tool for visualizing microvascular perfusion and conduit site selection to decrease anastomotic leaks is promising. However, poor data quality and heterogeneity in reported variables limits generalizability of findings. Randomized, multi-center trials are needed to account for independent risk factors for leak rates and to better elucidate the impact of ICG in predicting and preventing anastomotic leaks.
BACKGROUND: Intraoperative evaluation with fluorescence angiography using indocyanine green (ICG) offers a dynamic assessment of gastric conduit perfusion and can guide anastomotic site selection during an esophagectomy. This study aims to evaluate the predictive value of ICG for the prevention of anastomotic leak following esophagectomy. METHODS: A comprehensive search of electronic databases using the search terms "indocyanine/fluorescence" AND esophagectomy was completed to include all English articles published between January 1946 and 2018. Articles were selected by two independent reviewers. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. RESULTS: Seventeen studies were included for meta-analysis after screening and exclusions. The pooled anastomotic leak rate when ICG was used was found to be 10%. When limited to studies without intraoperative modifications, the pooled sensitivity, specificity, and diagnostic odds ratio were 0.78 (95% CI 0.52-0.94; p = 0.089), 0.74 (95% CI 0.61-0.84; p = 0.012), and 8.94 (95% CI 1.24-64.21; p = 0.184), respectively. Six trials compared ICG with an intraoperative intervention to improve perfusion to no ICG. ICG with intervention was found to have a risk reduction of 69% (OR 0.31, 95% CI 0.15-0.63). CONCLUSIONS: In non-randomized trials, the use of ICG as an intraoperative tool for visualizing microvascular perfusion and conduit site selection to decrease anastomotic leaks is promising. However, poor data quality and heterogeneity in reported variables limits generalizability of findings. Randomized, multi-center trials are needed to account for independent risk factors for leak rates and to better elucidate the impact of ICG in predicting and preventing anastomotic leaks.
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