Routine Use of ICG Angiography During Colorectal Surgery

Educational Objectives

The goal of this program is to improve the use of indocyanine green (ICG) fluorescence in colorectal surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Compare the overlay and monochromatic modes of detection in ICG fluorescence imaging.

Summary

Indocyanine green (ICG) fluorescence imaging: is used in a wide range of procedures, eg, laparoscopic cholecystectomy, elective colorectal resection (left, ie, rectosigmoid or right, ie, ileocecal), Hartmann reversal, ileoanal or ileorectal anastomoses; ICG helps surgeons identify lymph nodes, colonic tattooing, and areas of adequate blood flow for anastomosis or dissection, specialized endoscopes with built in ICG detection capabilities are available; multiple monitors help ensure optimal viewing for the entire surgical team; 0.2 mg/kg is administered intravenously and provides a visual indication of blood flow in 20 to 30 sec; assess perfusion during the first minute; delay may lead surgeons to overestimate tissue perfusion because of dye diffusion; assessment of the perfusion of the surgical resection line and anastomoses helps prevent postoperative complications, eg, anastomotic leaks; a rectoscope is helpful to assess rectal mucosa perfusion transanally

Modes: the 2 detection modes are overlay and monochromatic; the speaker uses the overlay mode for laparoscopic cholecystectomy to visualize the biliary system; the speaker prefers the monochromatic mode for colorectal and gastrointestinal anastomosis because it offers better contrast; clips are placed at the anticipated dissection line, then perfusion is assessed

Evidence: a 2024 meta-analysis by the speaker’s group (European Association for Endoscopic Surgery) showed that ICG fluorescence imaging significantly reduces the risk for anastomotic leak; ICG may lead to adjustments in the resection line, but it does not increase operative time; it reduces the length of hospital stays and overall morbidity; the authors recommend using ICG fluorescence in colorectal surgery to reduce risk for anastomotic leak, and they suggest its use to reduce overall morbidity; a meta-analysis by Steven et al (2023) showed that the level of evidence is low but the results are promising, especially for reducing anastomotic leak; research is under way to identify the role of ICG in lymphatic mapping and ureter identification

Final points: visual assessment of perfusion can underestimate actual perfusion; the disadvantage of ICG imaging is its lack of ability to quantify perfusion

Readings

Duprée A, Rieß H, Detter C, et al. Utilization of indocynanine green fluorescent imaging (ICG-FI) for the assessment of microperfusion in vascular medicine. Innov Surg Sci. 2018;3(3):193-201. Published 2018 Sep 5. doi:10.1515/iss-2018-0014; Garoufalia Z, Wexner SD. Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery. J Clin Med. 2023;12(2):494. Published 2023 Jan 7. doi:10.3390/jcm12020494; Hayami S, Matsuda K, Iwamoto H, et al. Visualization and quantification of anastomotic perfusion in colorectal surgery using near-infrared fluorescence. Tech Coloproctol. 2019;23(10):973-980. doi:10.1007/s10151-019-02089-5; Li Z, Zhou Y, Tian G, et al. Meta-Analysis on the Efficacy of Indocyanine Green Fluorescence Angiography for Reduction of Anastomotic Leakage After Rectal Cancer Surgery. Am Surg. 2021;87(12):1910-1919. doi:10.1177/0003134820982848; Xia S, Wu W, Luo L, et al. Indocyanine green fluorescence angiography decreases the risk of anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis. Front Med (Lausanne). 2023;10:1157389. Published 2023 May 12. doi:10.3389/fmed.2023.1157389.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Carus was recorded at the 21st Surgery of the Foregut Symposium, held February 25-27, 2024, in Aventura, FL, and presented by the Cleveland Clinic Center for Continuing Education. For information on upcoming CME activities from this presenter, please visit clevelandclinicmeded.com. Audio Digest thanks the speakers and the Cleveland Clinic Center for Continuing Education for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.25 CE contact hours.

Lecture ID:

GS720401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.