The impact of indocyanine-green fluorescence angiogram on colorectal resection Yuk Kwan Chang, Chi Chung Foo *,1 , Jeremy Yip, Rockson Wei, Ka Kin Ng, Oswens Lo, Hok Kwok Choi, Wai Lun Law Department of Surgery, The University of Hong Kong, Hong Kong, China article info Article history: Received 4 June 2018 Received in revised form 8 August 2018 Accepted 16 August 2018 Available online xxx Keywords: Indocyanine-green ICG Bowel perfusion Anastomotic leak Colorectal resection abstract Background: Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left- sided colorectal resections. Method: This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluo- rescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated. Results: 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1 e17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p ¼ 0.036, OR 3.58, 95% CI 1.09e11.78) and relatively under-perfused left colon (p ¼ 0.036, OR 1.01, 95% CI 1.01e1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%. Conclusion: ICG fluorescence angiogram altered operative decisions in a significant pro- portion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon. © 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Introduction Despite advances in surgical techniques and instruments, anastomotic leakage after colorectal resections remains the most dreadful complication. A recent systemic review and meta-analysis showed that the overall leakage rate for colonic and rectal anastomoses was 7.2%. For studies on colonic resection only, the mean leakage rate was 5.2%, while that for rectal resection was 8.8%. 1 More distal anastomosis was associated with higher leakage rate. It is associated with morbidities and increases the chance of mortality. The contributing factors are multi-factorial, 2 with many being non-modifiable. Perfusion to the anastomosis is one of the few aspects that surgeons can optimize and adequate perfusion has been shown to be the key to anastomotic healing. 3,4 This assessment is particular relevant in left colectomy for malig- nant pathologies, when high ligation of inferior mesenteric artery is often performed and the blood supply relies solely on the marginal artery of Drummond, which is subjected to * Corresponding author. Department of Surgery, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China. E-mail address: ccfoo@hku.hk (C.C. Foo). 1 Author Chang YK and author Foo CC contributed equally. the surgeon xxx (2018) 1 e7 Please cite this article in press as: Chang YK, et al., The impact of indocyanine-green fluorescence angiogram on colorectal resection, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.08.006 https://doi.org/10.1016/j.surge.2018.08.006 1479-666X/© 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.