Anastomotic leak (AL) is the most feared complication in colorectal surgery. Indocyanine green (ICG) fluorescence angiography allows for real-time intraoperative evaluation of bowel perfusion. This study aimed to assess the impact of ICG on perioperative outcomes in patients treated with transanal total mesorectal excision (TaTME) for rectal cancer.
Comparative study based on a retrospective analysis of prospectively collected data, to validate the use of ICG assessment (ICGA) during TaTME (November/2011–June/2018). The primary outcome was the clinical AL rate. The secondary outcomes included modification of proximal colonic transection, anastomotic redo, additional surgical maneuvers and surgical morbidity.
Two hundred and eighty-four patients were included, 204 (71.8%) in non-ICG group and 80 (28.2%) in ICG group. No significant differences were found in patient and tumor features. Mean anastomotic height was 4.85 cm vs. 5.04 cm (p = 0.500), diverting stoma was constructed in 205 patients (72.1% vs. 72.5%; p = 0.941). Fluorescence angiography modified the surgical plan in 23 patients (28.7%). AL was diagnosed in 23 patients (11.3%) in the non-ICG group and in two patients (2.5%) in the ICG group (p = 0.020). Postoperative intraabdominal collection was diagnosed in 19 patients (7.4% vs. 5.1%; p = 0.490), and reintervention was needed in 24 patients (10.8% vs. 7.6%; p = 0.420). Median length of hospital stay was 6.0 (IQR 5.0–9) vs. 4.0 (IQR 3.0–8.5) (p = 0.005). ICGA was found as independent protective factor for AL in the multivariate analysis of the whole cohort (n = 284) (OR 0.142; 95% CI 0.032–0.633; p = 0.010).
ICG fluorescence angiography modified the proximal colonic transection in more than one-quarter of patients, leading to a significant decrease of AL rate.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Alberts JCJ, Parvaiz A, Moran BJ (2003) Predicting risk and diminishing the consequences of anastomotic dehiscence following rectal resection. Colorectal Dis 5(5):478–482
Mäkelä JT, Kiviniemi H, Laitinen S (2003) Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis. Dis Colon Rectum 46(5):653–660
Sorensen LT, Jorgensen T, Kirkeby LT, Skovdal J, Vennits B, Wille-Jorgensen P (1999) Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg 86(7):927–931
Golub R, Golub RW, Cantu R, Stein HD (1997) A multivariate analysis of factors contributing to leakage of intestinal anastomoses. J Am Coll Surg 184(4):364–372
Park JS, Choi G-S, Kim SH, Kim HR, Kim NK, Lee KY, Kim BC, Bae BN, Son GM, Lee SI, Kang H (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision. Ann Surg 257(4):665–671
Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter DA, Lee SW, Senagore AJ, Phelan MJ, Stamos MJ (2015) Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg 220(1):82–92
Pigazzi A, Luca F, Patriti A, Valvo M, Ceccarelli G, Casciola L, Biffi R, Garcia-Aguilar J, Baek JH (2010) Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol 17(6):1614–1620
Senagore A, Lane FR, Lee E, Wexner S, Dujovny N, Sklow B, Rider P, Bonello J, Bioabsorbable Staple Line Reinforcement Study Group (2014) Bioabsorbable staple line reinforcement in restorative proctectomy and anterior resection: a randomized study. Dis Colon Rectum 57(3):324–330
Kingham TP, Pachter HL (2009) Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg 208(2):269–278
Kudszus S, Roesel C, Schachtrupp A, Höer JJ (2010) Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage. Langenbeck’s Arch Surg 395(8):1025–1030
Kawada K, Hasegawa S, Hida K, Hirai K, Okoshi K, Nomura A, Kawamura J, Nagayama S, Sakai Y (2014) Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc 28(10):2988–2995
Boni L, David G, Dionigi G, Rausei S, Cassinotti E, Fingerhut A (2016) Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection. Surg Endosc 30(7):2736–2742
James DRC, Ris F, Yeung TM, Kraus R, Buchs NC, Mortensen NJ, Hompes RJ (2015) Fluorescence angiography in laparoscopic low rectal and anorectal anastomoses with pinpoint perfusion imaging a critical appraisal with specific focus on leak risk reduction. Colorectal Dis 3:16–21
Koh FH, Tan K-K (2016) Fluorescent angiography used to evaluate the perfusion status of anastomosis in laparoscopic anterior resection. Ann Surg Oncol 23(5):692
Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24(5):1205–1210
Wolthuis AM, Bislenghi G, Van Overstraeten ADB, D’Hoore A (2015) Transanal total mesorectal excision: Towards standardization of technique. World J Gastroenterol 21(44):12686–12695
Ma B, Gao P, Song Y, Zhang C, Zhang C, Wang L, Liu H, Wang Z (2016) Transanal total mesorectal excision (taTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision. BMC Cancer 16(1):380
Simillis C, Hompes R, Penna M, Rasheed S, Tekkis pp. (2016) A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery? Colorectal Dis 18(1):19–36
Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J et al (2017) Transanal Total Mesorectal Excision. Ann Surg 266(1):111–117
Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP (2019) International TaTMERegistry Collaborative incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the International TaTME Registry. Ann Surg. 269(4):700–711
Deijen CL, Tsai A, Koedam TWA, Veltcamp Helbach M, Sietses C, Lacy AM, Bonjer HJ, Tuynman JB (2016) Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review. Tech Coloproctol 20(12):811–824
Arroyave MC, DeLacy FB, Lacy AM (2017) Transanal total mesorectal excision (TaTME) for rectal cancer: step by step description of the surgical technique for a two-teams approach. Eur J Surg Oncol 43(2):502–505
Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147(3):339–351
McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC (2015) Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. British J Surgery 102(5):462–479
Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, Heath RM, Brown JM, MRC CLASICC Trial Group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet (London, England). 365(9472):1718–1726
Sauer R, Fietkau R, Wittekind C, Rödel C, Martus P, Hohenberger W, Tschmelitsch J, Sabitzer H, Karstens JH, Becker H, Hess C, Raab R, German Rectal Cancer Group (2003) Adjuvant vs. neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO-94. Colorectal Dis. 5(5):406–415
Jafari MD, Lee KH, Halabi WJ, Mills SD, Carmichael JC, Stamos MJ, Pigazzi A (2013) The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc 27(8):3003–3008
Markus PM, Martell J, Leister I, Horstmann O, Brinker J, Becker H (2005) Predicting postoperative morbidity by clinical assessment. Br J Surg 92(1):101–106
Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM (2009) Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 24(5):569–576
Kim JC, Lee JL, Yoon YS, Alotaibi AM, Kim J (2016) Utility of indocyanine-green fluorescent imaging during robot-assisted sphincter-saving surgery on rectal cancer patients. Int J Med Robot 12(4):710–717
Kin C, Vo H, Welton L, Welton M (2015) Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks. Dis Colon Rectum 58(6):582–587
Kawada K, Hasegawa S, Wada T, Takahashi R, Hisamori S, Hida K, Sakai Y (2017) Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis. Surg Endosc. 31(3):1061–1069
Mizrahi I, Abu-Gazala M, Rickles AS, Fernandez LM, Petrucci A, Wolf J, Sands DR, Wexner SD (2018) Indocyanine green fluorescence angiography during low anterior resection for low rectal cancer: results of a comparative cohort study. Tech Coloproctol 22(7):535–540
Fernández-Hevia M, Delgado S, Castells A, Tasende M, Momblan D, Del Gobbo GD, DeLacy B, Balust J, Lacy AM (2015) Transanal total mesorectal excision in rectal cancer short-term outcomes in comparison with laparoscopic surgery. Ann Surg 261(2):221–227
Trencheva K, Morrissey KP, Wells M, Mancuso CA, Lee SW, Sonoda T, Michelassi F, Charlson ME, Milsom JW (2013) Identifying important predictors for anastomotic leak after colon and rectal resection. Ann Surg 257(1):108–113
Meyers MA (1976) Griffiths’ point: critical anastomosis at the splenic flexure. Significance in ischemia of the colon. AJR Am J Roentgenol 126(1):77–94
Fujii S, Ishibe A, Ota M, Watanabe K, Watanabe J, Kunisaki C, Endo I (2018) Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer. BJS Open 2(4):195–202
Mari GM, Crippa J, Cocozza E, Berselli M, Livraghi L, Carzaniga P, Valenti F, Roscio F, Ferrari G, Mazzola M, Magistro C, Origi M, Forgione A, Zuliani W, Scandroglio I, Pugliese R, Costanzi ATM, Maggioni D (2018) Low ligation of inferior mesenteric artery in laparoscopic anterior resection for rectal cancer reduces genitourinary dysfunction: results from a randomized controlled trial (HIGHLOW Trial). Ann Surg. 296:1018–1024
Sciuto A, Merola G, De Palma GD, Sodo M, Pirozzi F, Bracale UM, Bracale U (2018) Predictive factors for anastomotic leakage after laparoscopic colorectal surgery. World J Gastroenterol 24(21):2247–2260. https://doi.org/10.3748/wjg.v24.i21.2247
Dr. Antonio M. Lacy is a consultant for Medtronic, Conmed Corporation, Olympus Medical, Touchstone International Medical Science Co. Ltd., Applied Medical, and Johnson & Johnson. Drs. Otero-Piñeiro AM, de Lacy FB, Van Laarhoven JJ, Martín-Perez B, Valverde S, Bravo R has no conflicts of interest or financial ties to disclose.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Otero-Piñeiro, A.M., de Lacy, F.B., Van Laarhoven, J.J. et al. The impact of fluorescence angiography on anastomotic leak rate following transanal total mesorectal excision for rectal cancer: a comparative study. Surg Endosc 35, 754–762 (2021). https://doi.org/10.1007/s00464-020-07442-6
- Colorectal surgery
- Rectal cancer
- Anastomotic leak
- New technologies