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Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography

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Abstract

Background

The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC).

Methods

This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions’ prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates.

Results

Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%.

Conclusions

FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.

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Funding

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Authors and Affiliations

  1. Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA

    I. Mizrahi, M. Abu-Gazala, L. M. Fernandez, D. R. Sands & S. D. Wexner

  2. Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Barcelona, Spain

    F. B. de Lacy, A. Otero & A. M. Lacy

Authors
  1. I. Mizrahi
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  2. F. B. de Lacy
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  3. M. Abu-Gazala
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  4. L. M. Fernandez
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  5. A. Otero
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  6. D. R. Sands
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  7. A. M. Lacy
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  8. S. D. Wexner
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Corresponding author

Correspondence to S. D. Wexner.

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Conflict of interest

SDW is a paid consultant for Medtronic, NOVADAQ, Intuitive Surgical, and Karl Storz Endoscopy and is entitled to royalty payments from Karl Storz Endoscopy, Medtronic and Intuitive Surgical. The other authors declare that they have no conflict of interest.

Ethical approval

This retrospective study was approved by the Institutional Review Board (IRB), or equivalent, of all centers participating in this study. In addition, the data was retrieved from IRB-approved databases from all centers. IRB approval from all centers has been clearly stated in the manuscript.

Informed consent

All patients at all centers were consented prior to undergoing surgery.

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Mizrahi, I., de Lacy, F.B., Abu-Gazala, M. et al. Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography. Tech Coloproctol 22, 785–791 (2018). https://doi.org/10.1007/s10151-018-1869-z

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  • DOI: https://doi.org/10.1007/s10151-018-1869-z

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