Role of Indocyanine Green Fluorescence Imaging for Evaluating Blood Supply in the Gastric Conduit via the Substernal Route after McKeown Minimally Invasive Esophagectomy

Authors
Doan Thuy Nguyen, Tran Quang Dat, Dang Quang Thong, Nguyen Viet Hai, Nguyen Hoang Bac, Vo Duy Long

Affiliations
Department of Gastro-intestinal Surgery, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam

Background
Anastomotic leakage (AL) is a determining factor of morbidity and mortality after esophagectomy. Adequate perfusion of the gastric conduit is crucial for AL prevention. The aim of this study was to determine whether intraoperative angiography using indocyanine green fluorescence (ICG) improves the incidence of AL after McKeown minimally invasive esophagectomy (MIE) with gastric conduit via the substernal route.

Methods
This retrospective cohort study included 120 patients who underwent MIE with gastric conduit via substernal route for esophageal cancer from February-2019 to April-2023. Among these, eighty-eight patients experienced intraoperative angiography using indocyanine green (ICG group) and thirty-two patients did not (nICG group). Baseline characteristics and operative outcomes including anastomotic leak as the main concern, were compared between the two groups. We also compared the outcomes between ICG patients with different levels of fluorescence intensity.

Results
The ICG and nICG groups were comparable in baseline characteristic and operative outcomes. There were not significant differences between the two groups regarding the rate of AL (31.0% vs. 37.5%), median dates of AL (9 days vs. 9 days), and severity of AL (88.9%, 11.11%, 0% vs. 66.7%, 16.7%, 16.7% for grade I, II, III, respectively). ICG patients with lower intensity of ICG had higher rates of leak (24.6%, 39.3%, and 100% in level I, II, III of ICG intensity, respectively).

Conclusion
The application of ICG did not seem to reduce the rate of anastomotic leak. However, abnormal intensity of ICG fluorescence was associated with a higher rate of anastomotic leak, which implies a predictive potential.