The Utility of Indocyanine Green Angiography in the Assessment of Perfusion of Gastric Conduit and Proximal Esophageal Stump Against Visual Assessment in Patients Undergoing Esophagectomy: a Prospective Study

Post esophagectomy anastomotic leakage is a crucial factor in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complication. This prospective study compares the utility of intraoperative indocyanine green (ICG) fluorescence angiography and visual assessment in assessing the vascularity of gastric conduit and proximal esophageal stump in patients undergoing esophagectomy. Thirteen consecutive patients who underwent esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019 were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic-assisted esophagectomy. Reconstruction was done by gastric pull-up via posterior mediastinal route. All patients underwent assessment of perfusion of gastric conduit and proximal esophageal stump by ICG angiography and by visual assessment based on inspection of the color, the palpation of warmth, pulse, and bleeding from the edges. Visual assessment revealed the tip of the gastric conduit was dusky and ischemic in 11 patients, pink and well perfused in two. ICG fluorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, adequate in one, overall requiring revision in 12 cases. There was a discrepancy in one patient where visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit's tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and by ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 s (10 to 23 s). In all the cases, the pattern of blush was simultaneous, with the concurrent appearance of ICG blush in the gastric conduit and gastro-epiploic arcade. No anastomotic leaks were noted. Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is an accurate and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. But its utility needs to be validated in randomized trials.