We read with great interest the article recently published by Mizrahi et al. about the use of fluorescence angiography using indocyanine green during transanal total mesorectal excision (TaTME) to reduce the incidence of anastomotic leakage (1).
The main aim of the article “Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography” is to evaluate the impact of fluorescence angiography on any change in the proximal resection margin and anastomotic leak after TaTME for rectal cancer (1).
The authors performed a retrospective cohort analysis of 54 patients who underwent elective hybrid transabdominal laparoscopic low anterior resection and TaTME for rectal cancer with colorectal or coloanal anastomosis (<10 cm from the anal verge) in two different institutions, over a period of two years [2015–2017]. In all patients, fluorescence angiography was used to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis evaluated by intraoperative proctoscopy. High ligation of the inferior mesenteric artery and vein was routinely performed, defined as proximal to the left colic vessels. Thirty out of 54 (55%) patients received neoadjuvant chemoradiation and 46 patients (85%) had a loop ileostomy.
The proximal resection margin was modified in 10 patients (18.5%) after fluorescence angiography and anastomotic leakage was reported in 2 patients (3.7%). In both of these patients, splenic flexure mobilization was not performed during the index surgery and transanal specimen extraction was performed.
Extensive review of the literature on the use of fluorescent angiography is also presented (3-11) confirming the trend of reduction of anastomotic leakage rate with the use of this technique as described in two recent metanalysis and systematic reviews by Blanco-Colino et al. (12) and van den Bos et al. (13).
Notably, with all the limits of a retrospective analysis of the data, Mizrahi et al. reported an extremely low percentage of anastomotic leakage (3.7%) once compared with results of other authors performing TaTME, even lower of most of the reported results of standard anterior resection (14,15). Indeed, the rate of anastomotic leakage in literature after TaTME is between 5.43% and 15.7%. The international TaTME registry including 1,594 cases reported an overall 15.7% anastomotic failure rate (16).
Another multicentre prospective audit of the ESCP (European Society of Coloproctology) group, including 2,579 patients, reported a higher anastomotic leak rate in TaTME (12.9%, 45/311 patients) than non-transanal TME (8.9%, 135/1,520 patients), with a significant difference on univariate analysis (17).
Other meta-analysis and systematic reviews, including smaller sample size, reported lower anastomotic failure rate for this technique with non-significant difference when compared with non-transanal resections. The transanal resection was associated with 6.1% anastomotic failure rate by Ma et al. (194 patients), 5.43% failure rate by Rubinkiewicz et al. (331 patients), 9.8% leakage rate by Xu et al. (162 patients) and 11% leakage rate by Hasegawa et al. (226 patients) (18-21).
Detering et al. (22) recently published a study reporting results of a 3-year experience in rectal surgery comparing TaTME (416 patients) and laparoscopic TME (3,361 patients). The transanal technique was associated with 16.5% anastomotic leak rate that is remarkably higher than 3.6% of the current study.
It is difficult to advocate only to the use of fluorescence angiography the reasons of such difference, but it is at least interesting that in the Mizrahi’s study there was a change of strategy (level of anastomosis) very similar to the leak rate reported by Detering et al.
Furthermore, these findings are similar of those reported for laparoscopic anterior resections comparing standard and fluorescence groups.
We published a case-matched study comparing a group of laparoscopic anterior resections (42 patients) with the use of fluorescent angiography with a control group, reporting 0% and 5.4% anastomotic leakage rates, respectively (6). Jafari et al. reported 6% anastomotic failure rate after robotic rectal surgery with fluorescent angiography (16 patients) and 18% rate in the control group (22 patients) (7).
The creation of a tension-free colorectal or coloanal anastomosis is one of the factors that could influence the correct healing of intestinal anastomosis. In the present study the two patients who leaked did not have splenic flexure mobilization and this could also be a factor for developing of anastomotic leaks.
Transanal specimen extraction has also been indicated as one of the possible causes of leaks during TaTME: the mesentery of the descending colon (to be used for the anastomosis) could be accidentally damaged during the passage thorough the anal canal leading to complete or partial ischemia. Nevertheless, since Mizrahi et al. checked bowel perfusion both before and after anastomosis in their experience this possibility should be overcome, although one of the major limitations of fluorescence angiography is that the evaluation is done by a subjective surgeon’s visual judgement.
Some authors employed an objective manner to quantify fluorescence angiography signal in their paper. Kudszus et al. (4) reported their use of method IC-Calc, while Wada et al. (5) used a software named ROIs to quantify fluorescence intensity. Son et al. (23) reported their experience in quantitative analysis of colorectal and coloanal anastomosis perfusion with indocyanine in laparoscopic colorectal surgery. The authors defined three categories of colon perfusion patterns as fast, moderate or slow and demonstrated that slow perfusion was an independent factor for anastomotic complication (P=0.002).
In conclusion, anastomotic leakage is a multifactorial complication and adequate blood supply is one of the main factors influencing anastomotic healing. According to available literature, intraoperative indocyanine green fluorescence angiography is associated with a lower risk of anastomotic leakage in colorectal surgery. Further studies are needed to define a reproducible quantitative assessment of anastomotic perfusion.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Mizrahi I, de Lacy FB, Abu-Gazala M, et al. Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography. Tech Coloproctol 2018;22:785-91. [Crossref] [PubMed]
- Rutegård M, Rutegård J. Anastomotic leakage in rectal cancer surgery: the role of blood perfusion. World J Gastrointest Surg 2015;7:289-92. [Crossref] [PubMed]
- Jafari MD, Wexner SD, Martz JE, et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg 2015;220:82-92.e1. [Crossref] [PubMed]
- Kudszus S, Roesel C, Schachtrupp A, et al. Intraoperative laser fluorescence angiography in colorectal surgery: A noninvasive analysis to reduce the rate of anastomotic leakage. Langenbecks Arch Surg 2010;395:1025-30. [Crossref] [PubMed]
- Wada T, Kawada K, Takahashi R, et al. ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery. Surg Endosc 2017;31:4184-93. [Crossref] [PubMed]
- 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. [Crossref] [PubMed]
- Jafari MD, Lee KH, Halabi WJ, et al. The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc 2013;27:3003-8. [Crossref] [PubMed]
- Kim JC, Lee JL, Yoon YS, et al. Utility of indocyanine-green fluorescent imaging during robot-assisted sphincter-saving surgery on rectal cancer patients. Int J Med Robot 2016;12:710-7. [Crossref] [PubMed]
- Boni L, David G, Dionigi G, et al. Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection. Surg Endosc 2016;30:2736-42. [Crossref] [PubMed]
- Ris F, Hompes R, Cunningham C, et al. Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endosc 2014;28:2221-6. [Crossref] [PubMed]
- Hellan M, Spinoglio G, Pigazzi A, et al. The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg Endosc 2014;28:1695-702. [Crossref] [PubMed]
- Blanco-Colino R, Espin-Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis. Tech Coloproctol 2018;22:15-23. [Crossref] [PubMed]
- van den Bos J, Al-Taher M, Schols RM, et al. Near-Infrared Fluorescence Imaging for Real-Time Intraoperative Guidance in Anastomotic Colorectal Surgery: A Systematic Review of Literature. J Laparoendosc Adv Surg Tech A 2018;28:157-67. [Crossref] [PubMed]
- Cong ZJ, Hu LH, Bian ZQ, et al. Systematic review of anastomotic leakage rate according to an international grading system Following Anterior Resection for Rectal Cancer. PLoS One 2013;8:e75519. [Crossref] [PubMed]
- McDermott FD, Heeney A, Kelly ME, et al. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomoticleaks. Br J Surg 2015;102:462-79. [Crossref] [PubMed]
- Penna M, Hompes R, Arnold S, et al. Incidence and Risk Factors for Anastomotic Failure in 1594 patients treated by Transanal Total Mesorectal Excision: Results from the International TaTME registry. Ann Surg 2019;269:700-11. [Crossref] [PubMed]
- 2017 European Society of Coloproctology (ESCP) collaborating group. An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME). Colorectal Dis 2018;7:33-46.
- Ma B, Gao P, Song Y, et al. 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 2016;16:380. [Crossref] [PubMed]
- Xu W, Xu Z, Cheng H, et al. Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis. Eur J Surg Oncol 2016;42:1841-50. [Crossref] [PubMed]
- Rubinkiewicz M, Czerwi A, Zarzycki P, et al. Comparison of Short-Term Clinical and Pathological Outcomes after Transanal versus Laparoscopic Total Mesorectal Excision for Low Anterior Rectal Resection Due to Rectal Cancer: A Systematic Review with Meta-Analysis. J Clin Med 2018;7:448. [Crossref] [PubMed]
- Hasegawa S, Yoshida Y, Morimoto M, et al. Transanal TME: new standard or fad? J Anus Rectum Colon 2019;3:1-9. [Crossref]
- Detering R, Roodbeen SX, van Oostendorp SE, et al. Three-Year Nationwide Experience with Transanal Total Mesorectal Excision for Rectal Cancer in the Netherlands: A Propensity Score-Matched Comparison with Conventional Laparoscopic Total Mesorectal Excision. J Am Coll Surg 2019;228:235-44.e1. [Crossref] [PubMed]
- Son GM, Kwon MS, Kim Y, et al. Quantitative analysis of colon perfusion pattern using indocyanine green (ICG) angiography in laparoscopic colorectal surgery. Surg Endosc 2018. [Epub ahead of print]. [Crossref] [PubMed]
Cite this article as: Baldari L, Boni L, Macina S, della Porta M, Cassinotti E. Fluorescence angiography for a safer anastomosis during transanal total mesorectal excision. Ann Laparosc Endosc Surg 2019;4:34.