The usefulness of fluorescence in detecting ischemia during bariatric and metabolic surgery

The usefulness of fluorescence in detecting ischemia during bariatric and metabolic surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The usefulness of fluorescence in detecting ischemia during bariatric and metabolic surgery Mateusz Wityk, Natalia Dowgiałło-Gornowicz, Maciej Bobowicz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4313382/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Fluorescence is used in various surgical fields to detect tissue ischemia. However, its use in obesity surgery is still limited. This study aims to investigate whether fluorescence can help detect ischemia during metabolic and bariatric surgery and assess its effectiveness in reducing complications. The main objective was to determine the percentage of patients with improper blood flow assessed by fluorescence and the leak rate. The second outcome measured was the morbidity and mortality within 30 days. This single-centre, prospective observational study analysed patients who underwent primary metabolic and bariatric surgery. Data was collected from 66 consecutive patients who qualified for primary one anastomosis gastric bypass and Roux-en-Y gastric bypass procedures. 30-day postoperative morbidity and mortality were assessed. In total, improper blood supply was observed in two cases out of 66 (3%). No leakage incidents were reported. One patient (1.5%) experienced non-ischemic-related complications. No morbidity and mortality were observed 30 days after the surgical procedures. No complications related to ICG administration were observed. This research shows that adding ICG-fluorescence may reduce the number of MBS-related complications, namely leakage secondary to ischemia. However, this field lacks systematic data, and further research with a larger patient group is necessary to establish conclusive evidence. Health sciences/Diseases/Endocrine system and metabolic diseases/Metabolic syndrome Health sciences/Diseases/Endocrine system and metabolic diseases/Obesity Physical sciences/Optics and photonics/Optical techniques ICG bariatric surgery metabolic surgery fluorescence-guided surgery Figures Figure 1 Figure 2 Key points Fluorescence can be helpful in detecting ischemia in metabolic and bariatric surgery. The use of fluorescence may potentially reduce the risk of leaks. Indocyanine green is safe for obesity surgery. Introduction As the number of metabolic and bariatric surgeries (MBS) performed worldwide continues to rise, it is crucial to find effective solutions to reduce the risk of complications [ 1 ]. One of the most dangerous adverse events associated with MBS is leakage, which can result in high morbidity and mortality rates. The exact cause of MBS leak is still unknown, but abnormal tissue blood supply can lead to leaks or anastomotic dehiscence after any abdominal surgery [ 2 , 3 ]. Fluorescence has already been utilised in various surgical fields, including tissue ischemia detection, as it can potentially reduce complications [ 4 – 7 ]. However, there is limited data on its use during obesity surgery. This study aims to investigate whether fluorescence can help detect ischemia during MBS and assess its potential impact on reducing the complication rate. Aim The study aimed to determine the percentage of patients with tissue ischemia assessed by fluorescence and the leak rate used as the primary outcome. The secondary outcomes were the morbidity and mortality within 30 days. Methods The article was prepared according to the STROBE Reporting Guidelines. It is a single-centre, prospective study that analysed patients who underwent primary one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB). Data was collected from July 2022 to November 2023. All patients who were qualified for surgery met the criteria for surgical obesity treatment [ 8 ]. All consecutive patients with primary OAGB and RYGB performed in our centre were included. The only exclusion criterion was the lack of consent to participate in the study. The database consisted of age, preoperative weight and body mass index (BMI), length of hospital stay and duration of the surgical procedures. 30-day morbidity and mortality data were collected at a follow-up visit one month after surgery. All complications were described according to the Clavien-Dindo classification [ 9 ]. Surgical technique One team of surgeons performed all procedures using standardised laparoscopic techniques. They used the same equipment for all surgeries, including trocars, staplers, surgical sutures, and high-energy devices. All cases were performed with a pneumoperitoneum level of 12mmHg. All patients received standard care following the Enhanced Recovery After Surgery (ERAS) Society Recommendations for bariatric surgery [ 10 ]. The dissection process started along the lesser curvature of the stomach, below the incisura angularis. Once the lesser sac was reached, the stomach was transacted with staplers transversely and vertically after the complete release of the fundus from the left diaphragmatic crus. A 34F bougie was used to calibrate the pouch. After measuring 150cm from the ligament of Treitz, a 2.5 cm stapled side-to-side gastrojejunal (GJ) anastomosis was performed. The common channel of the anastomosis was closed with two layers of absorbable barbed 3.0 suture. The functional valve was created by sewing the afferent loop to the pouch's lateral wall with a length of 6 cm. The first stage of the RYGB was performed similarly as in the OAGB. The pouch was shorter, with a length of 12cm and the calibration was also performed on a 34F bougie. After GJ anastomosis creation, a 150cm long enzymatic limb was transected from the anastomosis with a stapler. Then, a 75cm long alimentary limb was measured, and a 45mm stapled side-to-side jejunojejunal (JJ) anastomosis was performed. The common channel was closed in a similar way to the GJ anastomosis. Petersen's space and mesenteric gap were closed in all cases of OAGB and RYGB using non-absorbable barbed 2.0 purse-string sutures. Fluorescence assessment. The study protocol was created based on our centre's experience and available evidence in the field due to the lack of a clear consensus on the use of fluorescence in MBS. After completing the main stages of the surgery, 1 mg of indocyanine green (ICG), diluted in 1 ml of 0.9% sodium chloride solution, was administered through an intravenous catheter placed in the left antecubital fossa and followed by the flush of 10 ml of 0.9% sodium chloride solution. Simultaneously, an infrared camera was turned on (1588 AIM + SPY Fluorescence Technology by Stryker). The stomach and small intestine tissues were assessed in real-time for at least 90 seconds from the beginning of ICG detection in gastric and jejunal tissues for abnormal ICG flow. The level of tissue saturation was qualitatively assessed based on the decision of all surgeons in the surgical team as normal or abnormal (insufficient). The surgical strategy should be changed if an ischemic focus is detected to minimise the risk of complications. The occurrence of ischemia and the action method should be precisely documented in the operating protocol. Results Patients The study included 66 patients, of whom 54 were women (81.8%). The group had a mean age of 41.8 ± 9.6 years, a mean preoperative BMI of 40.5 ± 5.6 kg/m2, and a mean preoperative weight of 114.1 ± 19.6 kg. The hospital stay lasted an average of 2.1 ± 0.3 days, and the surgery took an average of 122.8 ± 52.1 minutes, Table 1 . Table 1 Patients' characteristics Variable Value Female/Male, n (%) 54(81.8%)/12(18.2%) OAGB (n) 17 RYGB (n) 49 Age (mean) [years] ± SD (range) 41.8 ± 9.6 years (18–66) Preoperative BMI (mean) [kg/m 2 ] ± SD (range) 40.5 ± 5.6 (32.7–55.8) Preoperative weight (mean) [kg] ± SD (range) 114.1 ± 19.6 85–169) Preoperative weight loss (mean) [%] ± SD (range) 7.9 ± 5.6 (0-30.7) Operative time (mean) [min] ± SD (range) 122.8 ± 52.1 (45–235) Length of hospital stay (mean) [days] ± SD (range) 2.1 ± 0.3 (2–4) Use of ICG During all procedures, the ICG administration and fluorescence assessment protocol were utilised for all patients, with close attention to the perfusion assessment. In one of 17 OAGBs, impaired blood supply to the medial part of the GJ anastomosis was observed, Fig. 1 . The ischemic site was invaginated with single absorbable sutures. The postoperative course was uneventful. Out of the 49 RYGB procedures performed, there was a single instance where the distal segment of the enzymatic limb, measuring roughly 1-1.5 cm, displayed a blue discolouration. Following the administration of ICG, venous stasis was ruled out, and ischemia was confirmed, Fig. 2 . The intestinal mesentery was unharmed in the area of ischemia. The anomalous jejunal portion was excised with the linear stapler. No complications were observed 30 days after the surgical procedures. In total, improper blood supply was observed in two cases out of 66 (3%). Figure 1 . Figure 2 . Complications No leakage incidents were reported. One patient (1.5%) who underwent RYGB suffered bleeding from the GJ anastomotic line and was successfully treated with hemoclips through endoscopy - the Clavien-Dindo Classification IIIa complication. Throughout the 30-day follow-up, no additional complications were observed, and there were no fatalities. No complications related to ICG administration were observed. Risk of bias The primary risk of bias is the subjective evaluation of tissue fluorescence saturation with ICG rather than an objective quantitative assessment. Quantitative assessment was not possible at this stage of technology readiness due to the lack of nomograms for tissue saturation with ICG in the ischaemic tissue. Discussion Our research has shown that utilising ICG fluorescence in MBS can effectively detect ischemia. In 3% of cases, we observed incorrect flow, which prompted us to adjust the surgical strategy. Thanks to this technique, we were able to prevent any potential instances of leaks. No adverse symptoms related to the use of ICG were observed. Our centre has a leakage rate of 0.4% in MBS. The intraoperative fluorescence assessment can potentially assist in MGB and reduce the risk of leaks. Anastomotic leaks can be attributed to tissue ischemia, influenced by various well-known factors such as hypotension, inflammation, and smoking. To minimise the risk of anastomotic leakage, fluorescence technology in MBS is being explored, similar to the technology utilised in other areas of visceral surgery [ 3 , 11 , 12 ]. ICG has been used in medicine for a long time. Fluorescence is widely used during surgery to assess tissue blood supply, lymphatic vessel location or anastomosis leak test [ 4 , 6 , 13 , 14 ]. Our team conducted extensive database research before planning the study. The number of publications dealing with fluorescence in MBS is still limited and mainly covers small numbers of patients with LSG as a primary procedure. In our previous publication, we categorised fluorescence functions based on their usefulness in the surgical treatment of obesity. This aided us in designing our current study [ 15 ]. To the best of our knowledge, this is the first published study regarding the use of ICG to assess tissue blood supply in OAGB [ 16 – 20 ]. Our findings support previous data published on detecting ischemia using fluorescence in MBS. Pavone et al. also reported a reduced risk of LSG-related leakage in patients receiving ICG than those who did not (1.2% vs. 2.5%) [ 17 ]. In our study, no leak occurred in patients with fluorescence-supported surgery. It is an improvement compared to the 0.4% of leaks after procedures performed in our centre in the last five years before the introduction of ICG. Balla et al. reported that in two patients (15.4%), a change in surgical strategy was necessary due to abnormal blood supply, which was confirmed by fluorescence. There were no complications. However, the study group consisted of only 13 patients [ 20 ]. Despite demonstrating proper blood flow of the gastric sleeve, one leak occurred in 43 LSGs, as described by Di Furia et al. This emphasises the multifactorial nature of the occurrence of leaks in MBS and confirms that ischemia is only one of the components that can potentially be eliminated using fluorescence [ 18 ]. So far, no randomised controlled trials on ICG-related reduction of complications after MBS are available, highlighting the need for further research before reaching definitive conclusions. Limitations A small sample size limits the study. However, it represents a significant contribution to fluorescence application in metabolic and bariatric surgery, where research is currently lacking. Overall, this study advances knowledge and understanding in this field and can potentially guide future research efforts in this area. Conclusion This study shows that adding ICG-fluorescence may reduce the number of MBS-related complications, namely leakage secondary to ischemia. However, this field lacks systematic data, and further research with a larger patient group is necessary to establish conclusive evidence. Declarations Author Contribution M. Wityk and M. Bobowicz M. conception of the study; M. Wityk, N. Dowgiałło-Gornowicz, M. Bobowicz prepared the main manuscript text; M. Wityk collected the data, M.Wityk, N. Dowgiałło-Gornowicz and M. Bobowicz and checked the data; M. Wityk, N. Dowgiałło-Gornowicz prepared Figure 1 and Figure2. M. Wityk and M.Bobowicz prepared Table 1. All authors criticallyreviewed all the manuscript versions. Supervision M. Bobowicz. Conflict of interests The authors declare that they have no conflict of interest. Ethical Approval The study was conducted according to the guidelines of the Declaration of Helsinki. The study was approved by the Bioethics Committee of the District Medical Chamber in Gdansk (KB-32/22). Informed consent Informed consent was obtained from the participants included in the study. Data availability statement The data that support the findings of this study are available on request from the corresponding author. References Welbourn R, Hollyman M, Kinsman R, Dixon J, Liem R, Ottosson J, Ramos A, Våge V, Al-Sabah S, Brown W, Cohen R, Walton P, Himpens J. Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Fourth IFSO Global Registry Report 2018. Obes Surg. 2019;29(3):782–795. doi: 10.1007/s11695-018-3593-1 Lim R, Beekley A, Johnson DC, Davis KA. Early and late complications of bariatric operation. Trauma Surg Acute Care Open. 2018;3(1):e000219. doi: 10.1136/tsaco-2018-00021 Lam A, Fleischer B, Alverdy J. The Biology of Anastomotic Healing-the Unknown Overwhelms the Known. J Gastrointest Surg. 2020;24(9):2160–2166. doi: 10.1007/s11605-020-04680 Tang G, Du D, Tao J, Wei Z. Effect of Indocyanine Green Fluorescence Angiography on Anastomotic Leakage in Patients Undergoing Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials and Propensity-Score-Matched Studies. Front Surg. 2022;9:815753. doi: 10.3389/fsurg.2022.815753 Zhang W, Che X. Effect of indocyanine green fluorescence angiography on preventing anastomotic leakage after colorectal surgery: a meta-analysis. Surg Today. 2021; 51(9):1415–1428. doi: 10.1007/s00595-020-02195-0 Slooter, Maxime D., Wietse J. Eshuis, Miguel A. Cuesta, Suzanne S. Gisbertz, & Mark I. van Berge Henegouwen. Fluorescent imaging using indocyanine green during esophagectomy to prevent surgical morbidity: a systematic review and meta-analysis. Journal of Thoracic Disease, 2019; 1(1)S755-S765. doi: 10.21037/jtd.2019.01.30 Li Z, Zhou Y, Tian G, Liu Y, Jiang Y, Li X, Song M. Meta-Analysis on the Efficacy of Indocyanine Green Fluorescence Angiography for Reduction of Anastomotic Leakage After Rectal Cancer Surgery. Am Surg. 2021; 87(12):1910–1919. doi: 10.1177/0003134820982848 Szeliga J, Wyleżoł M, Major P, Budzyński A, Binda A, Proczko-Stepaniak M, Boniecka I, Matłok M, Sekuła M, Kaska Ł, Myśliwiec P, Szewczyk T, Możański M, Kowalski G, Pesta W, Lisik W, Michalik M, Lewandowski T, Paśnik K. Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons. Bariatric and metabolic surgery care standards. Wideochir Inne Tech Maloinwazyjne. 2020;15(3):391–394. doi: 10.5114/wiitm.2020.97935 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13. doi: 10.1097/01.sla.0000133083.54934.ae Stenberg E, Dos Reis Falcão LF, O'Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg. 2022;46(4):729–751. doi: 10.1007/s00268-021-06394-9 Alverdy JC, Schardey HM. Anastomotic Leak: Toward an Understanding of Its Root Causes. J Gastrointest Surg. 2021;25(11):2966–2975. doi: 10.1007/s11605-021-05048-4 Sripathi S, Khan MI, Patel N, Meda RT, Nuguru SP, Rachakonda S. Factors Contributing to Anastomotic Leakage Following Colorectal Surgery: Why, When, and Who Leaks? Cureus. 2022;14(10):e29964. doi: 10.7759/cureus.29964 Reinhart MB, Huntington CR, Blair LJ, Heniford BT, Augenstein VA. Indocyanine Green: Historical Context, Current Applications, and Future Considerations. Surg Innov. 2016;23(2):166–75. doi: 10.1177/1553350615604053 Goonawardena J, Yong C, Law M. Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis. Am J Surg. 2020;220(3):665–676. doi: 10.1016/j.amjsurg.2020.02.001 Wityk M, Dowgiałło-Gornowicz N, Feszak I, Bobowicz M. Fluorescence use in minimally invasive metabolic and bariatric surgery - a systematic review of the literature. Langenbecks Arch Surg. 2023;408(1):216. doi: 10.1007/s00423-023-02955-9 Ortega CB, Guerron AD, Yoo JS. The Use of Fluorescence Angiography During Laparoscopic Sleeve Gastrectomy. JSLS. 2018 Apr-Jun;22(2):e2018.00005. doi: 10.4293/JSLS.2018.00005 Pavone G, Fersini A, Pacilli M, De Fazio M, Panzera P, Ambrosi A, Tartaglia N. Can indocyanine green during laparoscopic sleeve gastrectomy be considered a new intraoperative modality for leak testing? BMC Surg. 2022;22(1):341. doi: 10.1186/s12893-022-01796-5 Di Furia M, Romano L, Salvatorelli A, Brandolin D, Lomanto D, Cianca G, Schietroma M, Carlei F, Giuliani A. Indocyanine Green Fluorescent Angiography During Laparoscopic Sleeve Gastrectomy: Preliminary Results. Obes Surg. 2019;29(12):3786–3790. doi: 10.1007/s11695-019-04085-y Frattini F, Lavazza M, Mangano A, Amico F, Rausei S, Rovera F, Boni L, Dionigi G. Indocyanine green-enhanced fluorescence in laparoscopic sleeve gastrectomy. Obes Surg. 2015;25(5):949–50. doi: 10.1007/s11695-015-1640-8 Balla A, Corallino D, Quaresima S, Palmieri L, Meoli F, Cordova Herencia I, Paganini AM. Indocyanine Green Fluorescence Angiography During Laparoscopic Bariatric Surgery: A Pilot Study. Front Surg. 2022;9:906133. doi: 10.3389/fsurg.2022.906133 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4313382","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":297244958,"identity":"01c55cbc-2241-43af-ade4-8b31282feb1f","order_by":0,"name":"Mateusz Wityk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDADNgYGZoYPIAY7QbXMUC1sDMyMM0AMZmK1AK1hZuZBFsAFdNvPH3zM86cusU++x9jY5tc2eT5mBsYPH3NwazE7k8xszNvGltjGxmOcnNt327CNmYFZcuY2PFoOJLNJ8zbw5IK0HM7tuc0I1MLGzItPy/nH7L95/khAtFj23LYnrOVGMhszD5sBWEsyw4/biURoeWwsObctob6NLa3YsLfhdnIbM2Mzfr+cT3z44c2fOmP55sObJX78uW07v7354IePeLQgAQ4DBsY2EIOxgSj1QMD+gIHhD7GKR8EoGAWjYCQBAM6KScR1IkSPAAAAAElFTkSuQmCC","orcid":"","institution":"Regional Health Centre","correspondingAuthor":true,"prefix":"","firstName":"Mateusz","middleName":"","lastName":"Wityk","suffix":""},{"id":297244964,"identity":"1fe3b27d-09cd-49aa-b46a-cb280f19a690","order_by":1,"name":"Natalia Dowgiałło-Gornowicz","email":"","orcid":"","institution":"University of Warmia and Mazury in Olsztyn","correspondingAuthor":false,"prefix":"","firstName":"Natalia","middleName":"","lastName":"Dowgiałło-Gornowicz","suffix":""},{"id":297244970,"identity":"1a715c5a-63ca-4353-8d56-2a4b690bc0dd","order_by":2,"name":"Maciej Bobowicz","email":"","orcid":"","institution":"Medical University of Gdansk17","correspondingAuthor":false,"prefix":"","firstName":"Maciej","middleName":"","lastName":"Bobowicz","suffix":""}],"badges":[],"createdAt":"2024-04-23 16:30:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4313382/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4313382/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55767251,"identity":"2fa4556d-3871-4ab7-a153-8adf185131d6","added_by":"auto","created_at":"2024-05-02 20:17:07","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62107,"visible":true,"origin":"","legend":"\u003cp\u003eGJ anastomosis – ischemia in the medial part of the pouch (the area of ischemia is marked with a long white arrow, the gastric pouch is marked with a short white arrow and the jejunum is marked with two short white arrows).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4313382/v1/d9f24b742b4cfafed25f2bcd.jpg"},{"id":55767250,"identity":"024f7420-e540-460b-8703-b7d4eb7b9650","added_by":"auto","created_at":"2024-05-02 20:17:07","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":97142,"visible":true,"origin":"","legend":"\u003cp\u003eEnzymatic loop ischemia (the area of ischemia is marked with a white arrow).\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4313382/v1/0cecd2583d3ebb46be08b993.jpg"},{"id":66635809,"identity":"f98cbdb6-ef63-49e8-859a-c785d5bc0253","added_by":"auto","created_at":"2024-10-15 05:24:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":434027,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4313382/v1/88dab912-1d2f-41dc-afc4-255e2c72527e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The usefulness of fluorescence in detecting ischemia during bariatric and metabolic surgery","fulltext":[{"header":"Key points","content":"\u003cp\u003eFluorescence can be helpful in detecting ischemia in metabolic and bariatric surgery.\u003c/p\u003e\n\u003cp\u003eThe use of fluorescence may potentially reduce the risk of leaks.\u003c/p\u003e\n\u003cp\u003eIndocyanine green is safe for obesity surgery.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAs the number of metabolic and bariatric surgeries (MBS) performed worldwide continues to rise, it is crucial to find effective solutions to reduce the risk of complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. One of the most dangerous adverse events associated with MBS is leakage, which can result in high morbidity and mortality rates. The exact cause of MBS leak is still unknown, but abnormal tissue blood supply can lead to leaks or anastomotic dehiscence after any abdominal surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Fluorescence has already been utilised in various surgical fields, including tissue ischemia detection, as it can potentially reduce complications [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, there is limited data on its use during obesity surgery. This study aims to investigate whether fluorescence can help detect ischemia during MBS and assess its potential impact on reducing the complication rate.\u003c/p\u003e \u003cp\u003eAim\u003c/p\u003e \u003cp\u003eThe study aimed to determine the percentage of patients with tissue ischemia assessed by fluorescence and the leak rate used as the primary outcome. The secondary outcomes were the morbidity and mortality within 30 days.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e The article was prepared according to the STROBE Reporting Guidelines. It is a single-centre, prospective study that analysed patients who underwent primary one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB). Data was collected from July 2022 to November 2023. All patients who were qualified for surgery met the criteria for surgical obesity treatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. All consecutive patients with primary OAGB and RYGB performed in our centre were included. The only exclusion criterion was the lack of consent to participate in the study. The database consisted of age, preoperative weight and body mass index (BMI), length of hospital stay and duration of the surgical procedures. 30-day morbidity and mortality data were collected at a follow-up visit one month after surgery. All complications were described according to the Clavien-Dindo classification [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSurgical technique\u003c/p\u003e\u003cp\u003eOne team of surgeons performed all procedures using standardised laparoscopic techniques. They used the same equipment for all surgeries, including trocars, staplers, surgical sutures, and high-energy devices. All cases were performed with a pneumoperitoneum level of 12mmHg. All patients received standard care following the Enhanced Recovery After Surgery (ERAS) Society Recommendations for bariatric surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The dissection process started along the lesser curvature of the stomach, below the incisura angularis. Once the lesser sac was reached, the stomach was transacted with staplers transversely and vertically after the complete release of the fundus from the left diaphragmatic crus. A 34F bougie was used to calibrate the pouch. After measuring 150cm from the ligament of Treitz, a 2.5 cm stapled side-to-side gastrojejunal (GJ) anastomosis was performed. The common channel of the anastomosis was closed with two layers of absorbable barbed 3.0 suture. The functional valve was created by sewing the afferent loop to the pouch's lateral wall with a length of 6 cm. The first stage of the RYGB was performed similarly as in the OAGB. The pouch was shorter, with a length of 12cm and the calibration was also performed on a 34F bougie. After GJ anastomosis creation, a 150cm long enzymatic limb was transected from the anastomosis with a stapler. Then, a 75cm long alimentary limb was measured, and a 45mm stapled side-to-side jejunojejunal (JJ) anastomosis was performed. The common channel was closed in a similar way to the GJ anastomosis. Petersen's space and mesenteric gap were closed in all cases of OAGB and RYGB using non-absorbable barbed 2.0 purse-string sutures.\u003c/p\u003e\u003cp\u003eFluorescence assessment.\u003c/p\u003e\u003cp\u003eThe study protocol was created based on our centre's experience and available evidence in the field due to the lack of a clear consensus on the use of fluorescence in MBS. After completing the main stages of the surgery, 1 mg of indocyanine green (ICG), diluted in 1 ml of 0.9% sodium chloride solution, was administered through an intravenous catheter placed in the left antecubital fossa and followed by the flush of 10 ml of 0.9% sodium chloride solution. Simultaneously, an infrared camera was turned on (1588 AIM + SPY Fluorescence Technology by Stryker). The stomach and small intestine tissues were assessed in real-time for at least 90 seconds from the beginning of ICG detection in gastric and jejunal tissues for abnormal ICG flow. The level of tissue saturation was qualitatively assessed based on the decision of all surgeons in the surgical team as normal or abnormal (insufficient). The surgical strategy should be changed if an ischemic focus is detected to minimise the risk of complications. The occurrence of ischemia and the action method should be precisely documented in the operating protocol.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThe study included 66 patients, of whom 54 were women (81.8%). The group had a mean age of 41.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6 years, a mean preoperative BMI of 40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 kg/m2, and a mean preoperative weight of 114.1\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6 kg. The hospital stay lasted an average of 2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 days, and the surgery took an average of 122.8\u0026thinsp;\u0026plusmn;\u0026thinsp;52.1 minutes, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients' characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale/Male, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54(81.8%)/12(18.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOAGB (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean) [years]\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6 years (18\u0026ndash;66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative BMI (mean) [kg/m\u003csup\u003e2\u003c/sup\u003e]\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 (32.7\u0026ndash;55.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative weight (mean) [kg]\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114.1\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6 85\u0026ndash;169)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative weight loss (mean) [%]\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 (0-30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (mean) [min]\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122.8\u0026thinsp;\u0026plusmn;\u0026thinsp;52.1 (45\u0026ndash;235)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (mean) [days]\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 (2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eUse of ICG\u003c/h2\u003e \u003cp\u003eDuring all procedures, the ICG administration and fluorescence assessment protocol were utilised for all patients, with close attention to the perfusion assessment. In one of 17 OAGBs, impaired blood supply to the medial part of the GJ anastomosis was observed, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The ischemic site was invaginated with single absorbable sutures. The postoperative course was uneventful. Out of the 49 RYGB procedures performed, there was a single instance where the distal segment of the enzymatic limb, measuring roughly 1-1.5 cm, displayed a blue discolouration. Following the administration of ICG, venous stasis was ruled out, and ischemia was confirmed, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The intestinal mesentery was unharmed in the area of ischemia. The anomalous jejunal portion was excised with the linear stapler. No complications were observed 30 days after the surgical procedures. In total, improper blood supply was observed in two cases out of 66 (3%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eNo leakage incidents were reported. One patient (1.5%) who underwent RYGB suffered bleeding from the GJ anastomotic line and was successfully treated with hemoclips through endoscopy - the Clavien-Dindo Classification IIIa complication. Throughout the 30-day follow-up, no additional complications were observed, and there were no fatalities.\u003c/p\u003e \u003cp\u003eNo complications related to ICG administration were observed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRisk of bias\u003c/h2\u003e \u003cp\u003eThe primary risk of bias is the subjective evaluation of tissue fluorescence saturation with ICG rather than an objective quantitative assessment. Quantitative assessment was not possible at this stage of technology readiness due to the lack of nomograms for tissue saturation with ICG in the ischaemic tissue.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur research has shown that utilising ICG fluorescence in MBS can effectively detect ischemia. In 3% of cases, we observed incorrect flow, which prompted us to adjust the surgical strategy. Thanks to this technique, we were able to prevent any potential instances of leaks. No adverse symptoms related to the use of ICG were observed. Our centre has a leakage rate of 0.4% in MBS. The intraoperative fluorescence assessment can potentially assist in MGB and reduce the risk of leaks.\u003c/p\u003e \u003cp\u003eAnastomotic leaks can be attributed to tissue ischemia, influenced by various well-known factors such as hypotension, inflammation, and smoking. To minimise the risk of anastomotic leakage, fluorescence technology in MBS is being explored, similar to the technology utilised in other areas of visceral surgery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eICG has been used in medicine for a long time. Fluorescence is widely used during surgery to assess tissue blood supply, lymphatic vessel location or anastomosis leak test [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur team conducted extensive database research before planning the study. The number of publications dealing with fluorescence in MBS is still limited and mainly covers small numbers of patients with LSG as a primary procedure. In our previous publication, we categorised fluorescence functions based on their usefulness in the surgical treatment of obesity. This aided us in designing our current study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first published study regarding the use of ICG to assess tissue blood supply in OAGB [\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our findings support previous data published on detecting ischemia using fluorescence in MBS. Pavone et al. also reported a reduced risk of LSG-related leakage in patients receiving ICG than those who did not (1.2% vs. 2.5%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In our study, no leak occurred in patients with fluorescence-supported surgery. It is an improvement compared to the 0.4% of leaks after procedures performed in our centre in the last five years before the introduction of ICG. Balla et al. reported that in two patients (15.4%), a change in surgical strategy was necessary due to abnormal blood supply, which was confirmed by fluorescence. There were no complications. However, the study group consisted of only 13 patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Despite demonstrating proper blood flow of the gastric sleeve, one leak occurred in 43 LSGs, as described by Di Furia et al. This emphasises the multifactorial nature of the occurrence of leaks in MBS and confirms that ischemia is only one of the components that can potentially be eliminated using fluorescence [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. So far, no randomised controlled trials on ICG-related reduction of complications after MBS are available, highlighting the need for further research before reaching definitive conclusions.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eA small sample size limits the study. However, it represents a significant contribution to fluorescence application in metabolic and bariatric surgery, where research is currently lacking. Overall, this study advances knowledge and understanding in this field and can potentially guide future research efforts in this area.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows that adding ICG-fluorescence may reduce the number of MBS-related complications, namely leakage secondary to ischemia. However, this field lacks systematic data, and further research with a larger patient group is necessary to establish conclusive evidence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eM. Wityk and M. Bobowicz M. conception of the study; M. Wityk, N. Dowgiałło-Gornowicz, M. Bobowicz prepared the main manuscript text; M. Wityk collected the data, M.Wityk, N. Dowgiałło-Gornowicz and M. Bobowicz and checked the data; M. Wityk, N. Dowgiałło-Gornowicz prepared Figure 1 and Figure2. M. Wityk and M.Bobowicz prepared Table 1. All authors criticallyreviewed all the manuscript versions. Supervision M. Bobowicz.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki.\u0026nbsp;The study was approved by the Bioethics Committee of the District Medical Chamber in Gdansk (KB-32/22).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWelbourn R, Hollyman M, Kinsman R, Dixon J, Liem R, Ottosson J, Ramos A, V\u0026aring;ge V, Al-Sabah S, Brown W, Cohen R, Walton P, Himpens J. Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Fourth IFSO Global Registry Report 2018. Obes Surg. 2019;29(3):782\u0026ndash;795. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11695-018-3593-1\u003c/span\u003e\u003cspan address=\"10.1007/s11695-018-3593-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim R, Beekley A, Johnson DC, Davis KA. Early and late complications of bariatric operation. Trauma Surg Acute Care Open. 2018;3(1):e000219. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/tsaco-2018-00021\u003c/span\u003e\u003cspan address=\"10.1136/tsaco-2018-00021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLam A, Fleischer B, Alverdy J. The Biology of Anastomotic Healing-the Unknown Overwhelms the Known. J Gastrointest Surg. 2020;24(9):2160\u0026ndash;2166. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11605-020-04680\u003c/span\u003e\u003cspan address=\"10.1007/s11605-020-04680\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang G, Du D, Tao J, Wei Z. Effect of Indocyanine Green Fluorescence Angiography on Anastomotic Leakage in Patients Undergoing Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials and Propensity-Score-Matched Studies. Front Surg. 2022;9:815753. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2022.815753\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2022.815753\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang W, Che X. Effect of indocyanine green fluorescence angiography on preventing anastomotic leakage after colorectal surgery: a meta-analysis. Surg Today. 2021; 51(9):1415\u0026ndash;1428. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00595-020-02195-0\u003c/span\u003e\u003cspan address=\"10.1007/s00595-020-02195-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlooter, Maxime D., Wietse J. Eshuis, Miguel A. Cuesta, Suzanne S. Gisbertz, \u0026amp; Mark I. van Berge Henegouwen. Fluorescent imaging using indocyanine green during esophagectomy to prevent surgical morbidity: a systematic review and meta-analysis. Journal of Thoracic Disease, 2019; 1(1)S755-S765. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/jtd.2019.01.30\u003c/span\u003e\u003cspan address=\"10.21037/jtd.2019.01.30\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Z, Zhou Y, Tian G, Liu Y, Jiang Y, Li X, Song M. Meta-Analysis on the Efficacy of Indocyanine Green Fluorescence Angiography for Reduction of Anastomotic Leakage After Rectal Cancer Surgery. Am Surg. 2021; 87(12):1910\u0026ndash;1919. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0003134820982848\u003c/span\u003e\u003cspan address=\"10.1177/0003134820982848\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSzeliga J, Wyleżoł M, Major P, Budzyński A, Binda A, Proczko-Stepaniak M, Boniecka I, Matłok M, Sekuła M, Kaska Ł, Myśliwiec P, Szewczyk T, Możański M, Kowalski G, Pesta W, Lisik W, Michalik M, Lewandowski T, Paśnik K. Metabolic and Bariatric Surgery Chapter of the Association of Polish Surgeons. Bariatric and metabolic surgery care standards. Wideochir Inne Tech Maloinwazyjne. 2020;15(3):391\u0026ndash;394. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5114/wiitm.2020.97935\u003c/span\u003e\u003cspan address=\"10.5114/wiitm.2020.97935\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205\u0026ndash;13. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.sla.0000133083.54934.ae\u003c/span\u003e\u003cspan address=\"10.1097/01.sla.0000133083.54934.ae\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStenberg E, Dos Reis Falc\u0026atilde;o LF, O'Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg. 2022;46(4):729\u0026ndash;751. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-021-06394-9\u003c/span\u003e\u003cspan address=\"10.1007/s00268-021-06394-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlverdy JC, Schardey HM. Anastomotic Leak: Toward an Understanding of Its Root Causes. J Gastrointest Surg. 2021;25(11):2966\u0026ndash;2975. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11605-021-05048-4\u003c/span\u003e\u003cspan address=\"10.1007/s11605-021-05048-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSripathi S, Khan MI, Patel N, Meda RT, Nuguru SP, Rachakonda S. Factors Contributing to Anastomotic Leakage Following Colorectal Surgery: Why, When, and Who Leaks? Cureus. 2022;14(10):e29964. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.29964\u003c/span\u003e\u003cspan address=\"10.7759/cureus.29964\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReinhart MB, Huntington CR, Blair LJ, Heniford BT, Augenstein VA. Indocyanine Green: Historical Context, Current Applications, and Future Considerations. Surg Innov. 2016;23(2):166\u0026ndash;75. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1553350615604053\u003c/span\u003e\u003cspan address=\"10.1177/1553350615604053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoonawardena J, Yong C, Law M. Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis. Am J Surg. 2020;220(3):665\u0026ndash;676. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjsurg.2020.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2020.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWityk M, Dowgiałło-Gornowicz N, Feszak I, Bobowicz M. Fluorescence use in minimally invasive metabolic and bariatric surgery - a systematic review of the literature. Langenbecks Arch Surg. 2023;408(1):216. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00423-023-02955-9\u003c/span\u003e\u003cspan address=\"10.1007/s00423-023-02955-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrtega CB, Guerron AD, Yoo JS. The Use of Fluorescence Angiography During Laparoscopic Sleeve Gastrectomy. JSLS. 2018 Apr-Jun;22(2):e2018.00005. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4293/JSLS.2018.00005\u003c/span\u003e\u003cspan address=\"10.4293/JSLS.2018.00005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePavone G, Fersini A, Pacilli M, De Fazio M, Panzera P, Ambrosi A, Tartaglia N. Can indocyanine green during laparoscopic sleeve gastrectomy be considered a new intraoperative modality for leak testing? BMC Surg. 2022;22(1):341. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12893-022-01796-5\u003c/span\u003e\u003cspan address=\"10.1186/s12893-022-01796-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Furia M, Romano L, Salvatorelli A, Brandolin D, Lomanto D, Cianca G, Schietroma M, Carlei F, Giuliani A. Indocyanine Green Fluorescent Angiography During Laparoscopic Sleeve Gastrectomy: Preliminary Results. Obes Surg. 2019;29(12):3786\u0026ndash;3790. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11695-019-04085-y\u003c/span\u003e\u003cspan address=\"10.1007/s11695-019-04085-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrattini F, Lavazza M, Mangano A, Amico F, Rausei S, Rovera F, Boni L, Dionigi G. Indocyanine green-enhanced fluorescence in laparoscopic sleeve gastrectomy. Obes Surg. 2015;25(5):949\u0026ndash;50. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11695-015-1640-8\u003c/span\u003e\u003cspan address=\"10.1007/s11695-015-1640-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalla A, Corallino D, Quaresima S, Palmieri L, Meoli F, Cordova Herencia I, Paganini AM. Indocyanine Green Fluorescence Angiography During Laparoscopic Bariatric Surgery: A Pilot Study. Front Surg. 2022;9:906133. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2022.906133\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2022.906133\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ICG, bariatric surgery, metabolic surgery, fluorescence-guided surgery","lastPublishedDoi":"10.21203/rs.3.rs-4313382/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4313382/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFluorescence is used in various surgical fields to detect tissue ischemia. However, its use in obesity surgery is still limited. This study aims to investigate whether fluorescence can help detect ischemia during metabolic and bariatric surgery and assess its effectiveness in reducing complications. The main objective was to determine the percentage of patients with improper blood flow assessed by fluorescence and the leak rate. The second outcome measured was the morbidity and mortality within 30 days.\u003cstrong\u003e \u003c/strong\u003eThis single-centre, prospective observational study analysed patients who underwent primary metabolic and bariatric surgery. Data was collected from 66 consecutive patients who qualified for primary one anastomosis gastric bypass and Roux-en-Y gastric bypass procedures. 30-day postoperative morbidity and mortality were assessed.\u003cstrong\u003e \u003c/strong\u003eIn total, improper blood supply was observed in two cases out of 66 (3%). No leakage incidents were reported. One patient (1.5%) experienced non-ischemic-related complications. No morbidity and mortality were observed 30 days after the surgical procedures. No complications related to ICG administration were observed.\u003cstrong\u003e \u003c/strong\u003eThis research shows that adding ICG-fluorescence may reduce the number of MBS-related complications, namely leakage secondary to ischemia. However, this field lacks systematic data, and further research with a larger patient group is necessary to establish conclusive evidence.\u003c/p\u003e","manuscriptTitle":"The usefulness of fluorescence in detecting ischemia during bariatric and metabolic surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-02 20:17:02","doi":"10.21203/rs.3.rs-4313382/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0cd8f57-4293-4cfb-880b-947123417340","owner":[],"postedDate":"May 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31356517,"name":"Health sciences/Diseases/Endocrine system and metabolic diseases/Metabolic syndrome"},{"id":31356518,"name":"Health sciences/Diseases/Endocrine system and metabolic diseases/Obesity"},{"id":31356520,"name":"Physical sciences/Optics and photonics/Optical techniques"}],"tags":[],"updatedAt":"2024-10-15T05:23:51+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-02 20:17:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4313382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4313382","identity":"rs-4313382","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}