The Role of Fluorescent Angiography in Anastomotic Leaks

Anastomotic leaks following colorectal anastomosis has substantial implications including increased morbidity, longer hospitalization, and reduced overall survival. The etiology of leaks includes patient factors, technical factors, and anastomotic perfusion. An intact anastomotic blood supply is especially crucial in the physiology of anastomotic healing. To date, no established intraoperative methods have been developed that reliably and reproducibly identify and prevent leak occurrence. Recently, fluorescent angiography (FA) with indocyanine green (ICG) has emerged as an innovative modality for intraoperative perfusion assessment. ICG-FA can be performed before or after intestinal resection or, alternatively, after creation of the anastomosis. Angiographic assessment with near-infrared camera filters allows determination of perfusion adequacy, guiding additional intestinal resection and anastomotic revision. Early clinical experiences with ICG-FA demonstrated safety and feasibility. Large, multi-center prospective trials, such as the Perfusion Assessment in Laparoscopic Left-Sided/Anterior Resection Study (PILLAR II), demonstrated ease of use with remarkably low anastomotic leak rates after ICG-FA-guided intraoperative revision. Current randomized control trials featuring utilization in ICG-FA in low anterior resection are currently underway and will further clarify the role of ICG-FA in leak identification and prevention. Apart from colorectal surgery, FA has also been successfully employed in other surgical disciplines such as plastic surgery, vascular surgery, foregut surgery, urology, and gynecology.