Evaluation of Gastric Conduit Perfusion Using Indocyanine Green Fluorescence During Radical Esophagectomy and Its...

Background Anastomotic leak (AL) is a leading cause of morbidity after esophagectomy, with gastric conduit perfusion being a key predictor. The perfusion of the gastric conduit is often analyzed subjectively based on visual inspection, such as the presence of bright bleeding from the resection margin, pulsation of supplying arcade vessels, and tissue color. Indocyanine Green (ICG) fluorescence is a new tool that helps objectively assess the gastric conduit's perfusion. Aim To evaluate the role of ICG fluorescence in assessing gastric conduit perfusion and its correlation with AL. Methods This single-center prospective study from a tertiary hospital in South Asia included patients with esophageal cancer undergoing esophagectomy from December 2019 to December 2021. Gastric conduit perfusion was assessed using real-time ICG imaging with a near-infrared ICG camera (KARL STORZ® SE & Co. KG, Tuttlingen, Germany). It was done before and after trans-mediastinal pull-up and compared with visual perfusion assessment. AL was monitored for two weeks postoperatively. Results Sixteen patients (Male, 50%; mean age 53.7 years; squamous carcinoma, 81.2%; stage III-IVA, 50%; neoadjuvant treatment, 100%) undergoing minimally invasive esophagectomy (14 McKeown's, 2 Ivor Lewis) were included. Before and after the trans-mediastinal pull-up, visual assessment revealed "good" perfusion in 15 and 14 patients, respectively. However, according to the ICG-based evaluation, "good" perfusion was seen in just eight and two patients, respectively. Several conduits showing "good" visual perfusion exhibited "sluggish" perfusion on ICG fluorescence. One patient required conduit tip resection due to "poor" ICG perfusion despite a "good" visual assessment. Two patients (13.3%) developed AL, both of whom belonged to a group of five patients with a change in the ICG perfusion pattern of the gastric conduit from "good" to "sluggish" after its trans-mediastinal pull-up. A significant correlation (asymptotic sig. (2-tailed) P=0.022) was observed between real-time changes in the conduit's ICG perfusion speed between its abdominal and cervical positions and AL occurrence. Conclusion ICG fluorescence is a valuable tool for assessing gastric conduit perfusion during esophagectomy, identifying under-perfused conduits more accurately than visual evaluation. The time difference in perfusion speed before and after trans-mediastinal pull-up is critical, and we believe that assessing perfusion at both stages of the operation is crucial to identifying and addressing perfusion-related issues.