Indocyanine Green Fluorescent Angiography During Laparoscopic Sleeve Gastrectomy: Preliminary Results

  • Marino Di FuriaEmail author
  • Lucia Romano
  • Andrea Salvatorelli
  • Denise Brandolin
  • Davide Lomanto
  • Giovanni Cianca
  • Mario Schietroma
  • Francesco Carlei
  • Antonio Giuliani
Original Contributions



Indocyanine green (ICG) fluorescent angiography has been routinely applied for various laparoscopic procedures to evaluate the tissue blood supply. A promising branch for this technology is represented by bariatric surgery, especially to estimate the risk of gastric leak after laparoscopic sleeve gastrectomy (LSG), which seems mainly related to ischemia of the stomach.

Materials and Methods

43 consecutive patients from January 2018 to March 2019 underwent in our institution LSG with intravenous injection of 5 ml ICG after the realization of gastric tube to evaluate the blood supply of the gastric tube.


In all 43 cases, there have been no adverse events related to ICG. The vascular supply to stomach was estimated “satisfactory” along the stapled line in all cases. However, one patient showed signs and symptoms indicative of gastric leak in the fifth post-op day and diagnosis was confirmed by CT scan with Gastrografin.


From our preliminary data, the intraoperative view of the blood supply of the stomach does not seem to represent a prognostic factor for the risk of gastric leak, suggesting a complex multifactorial etiology (intragastric hypertension? Abnormal inflammatory response?) which needs further data to be established.


Sleeve Gastrectomy Indocyanine green fluorescent angiography Obesity Gastric leakage 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Ogden CL, Carroll MD, Fryar CD, et al. Prevalence of obesity among adults and youth: United States, 2011–2014: National Center for Health Statistics data brief; 2015. p. 29.Google Scholar
  2. 2.
    Carubbi F, Ruscitti P, Pantano I, et al. Jejunoileal bypass as the main procedure in the onset of immune-related conditions: the model of BADAS. Expert Rev Clin Immunol. 2013;9(5):441–52.CrossRefGoogle Scholar
  3. 3.
    Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery and endoluminal procedures: IFSO Worldwide Survey 2014. Obes Surg. 2017;25:1822–32.CrossRefGoogle Scholar
  4. 4.
    Galloro G, Ruggiero S, Russo T, et al. Staple-line leak after sleeve gastrectomy in obese patients: a hot topic in bariatric surgery. World J Gastrointest Endosc. 2015;7:843–6.CrossRefGoogle Scholar
  5. 5.
    Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol. 2014;20:13904–10.CrossRefGoogle Scholar
  6. 6.
    Sakran N, Goitein D, Raziel A, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc. 2013;27:240–5.CrossRefGoogle Scholar
  7. 7.
    Marchese M, Romano L, Giuliani A, et al. Corrigendum to “A case of intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak” [Int. J. Surg. Case Rep. 53 (2018) 367–369]. Int J Surg Case Rep. 2019;56:49. Scholar
  8. 8.
    Giuliani A, Romano L, Marchese M, et al. Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review. Surg Obes Relat Dis. 2019; pii: S1550-7289(19)30087-5. [Epub ahead of print]
  9. 9.
    Perez M, Brunaud L, Kedaifa S, et al. Does anatomy explain the origin of a leak after sleeve gastrectomy? Obes Surg. 2014;24:1717–23.CrossRefGoogle Scholar
  10. 10.
    Giuliani A, Romano L, Papale E, et al. Complications post-laparoscopic sleeve gastric resection: review of surgical technique. Minerva Chir. 2019;74(3):213–7. Scholar
  11. 11.
    Degett TH, Andersen HS, Gögenur I. Indocyanine green fluorescence angiography for intraoperative assessment of gastrointestinal anastomotic perfusion: a systematic review of clinical trials. Langenbeck's Arch Surg. 2016;401(6):767–75. Scholar
  12. 12.
    Boni L, Fingerhut A, Marzorati A, et al. Indocyanine green fluorescence angiography during laparoscopic low anterior resection: results of a case-matched study. Surg Endosc. 2017;31:1836–40.CrossRefGoogle Scholar
  13. 13.
    Jafari MD, Wexner SD, Martz JE, et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multiinstitutional study. J Am Coll Surg. 2015;220:82–92.CrossRefGoogle Scholar
  14. 14.
    Zehetner J, DeMeester SR, Alicuben ET, et al. Intraoperative assessment of perfusion of the gastric graft and correlation with anastomotic leaks after esophagectomy. Ann Surg. 2015;262:74–8.CrossRefGoogle Scholar
  15. 15.
    Deitel M, Gagner M, Erickson AL, et al. Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7(6):749–59.CrossRefGoogle Scholar
  16. 16.
    Rosenthal RJ. International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis. 2012;8(1):8–19.CrossRefGoogle Scholar
  17. 17.
    Kim J, Azagury D, Eisenberg D, et al. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015;11(4):739–48. Scholar
  18. 18.
    Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2012;26(6):1509–15.CrossRefGoogle Scholar
  19. 19.
    Benedix F, Benedix DD, Knoll C, et al. Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity? Obes Surg. 2014;24(10):1610–6.CrossRefGoogle Scholar
  20. 20.
    Delle Monache S, Calgani A, Sanità P, et al. Adipose-derived stem cells sustain prolonged angiogenesis through leptin secretion. Growth Factors. 2016;34(3–4):87–96. Scholar
  21. 21.
    Angrisani L, Cutolo PP, Buchwald JN, et al. Laparoscopic reinforced sleeve gastrectomy: early results and complications. Obes Surg. 2011;21(6):783–93.CrossRefGoogle Scholar
  22. 22.
    Chen B, Kiriakopoulos A, Tsakayannis D, et al. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences. Obes Surg. 2009;19(2):166–72.CrossRefGoogle Scholar
  23. 23.
    Dapri G, Cadière GB, Himpens J. Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing three different techniques. Obes Surg. 2010;20(4):462–7.CrossRefGoogle Scholar
  24. 24.
    Gentileschi P, Camperchioli I, D’Ugo S, et al. Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial. Surg Endosc. 2012;26(9):2623–9.CrossRefGoogle Scholar
  25. 25.
    Giannopoulos GA, Tzanakis NE, Rallis GE, et al. Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and metaanalysis. Surg Endosc. 2010;24(11):2782–8.CrossRefGoogle Scholar
  26. 26.
    Glaysher M, Khan OA, Mabvuure NT, et al. Staple line reinforcement during laparoscopic sleeve gastrectomy: does it affect clinical outcomes? Int J Surg Lond Engl. 2013;11(4):286–9.CrossRefGoogle Scholar
  27. 27.
    Parikh M, Issa R, McCrillis A, et al. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and metaanalysis of 9991 cases. Ann Surg. 2013;257(2):231–7.CrossRefGoogle Scholar
  28. 28.
    Aggarwal S, Bhattacharjee H, Chander Misra M. Practice of routine intraoperative leak test during laparoscopic sleeve gastrectomy should not be discarded. Surg Obes Relat Dis. 2011;7(5):e24–5.Google Scholar
  29. 29.
    Frattini F, Lavazza M, Mangano A, et al. Indocyanine green-enhanced fluorescence in laparoscopic sleeve gastrectomy. Obes Surg. 2015;25(5):949–50.

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Marino Di Furia
    • 1
    Email author
  • Lucia Romano
    • 1
  • Andrea Salvatorelli
    • 1
  • Denise Brandolin
    • 1
  • Davide Lomanto
    • 2
  • Giovanni Cianca
    • 1
  • Mario Schietroma
    • 1
  • Francesco Carlei
    • 1
  • Antonio Giuliani
    • 1
  1. 1.Department of General Surgery, Hospital San Salvatore L’AquilaUniversity of L’AquilaL’AquilaItaly
  2. 2.Department of Surgery, Division of Upper Gastrointestinal SurgeryNational University HospitalSingaporeSingapore

Personalised recommendations