ICG fluorescence in restorative proctocolectomy with ileal J-pouch anal anastomosis after mesenteric lengthening: go green or go home.

Purpose: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is a challenging procedure. Anastomotic leak and intraoperative pouch abandonment are among the most feared complications and could both be related to inadequate pouch perfusion, especially after lengthening maneuvers. Near-infrared fluorescence imaging (NIR-FI) has been used as a confirmatory technology to assess bowel viability before anastomosis creation. The aim of this article was to present a case series in which NIR-FI was used to reveal an adequate blood supply to macroscopically hypoperfused ileal pouches. Methods This was a retrospective report of prospectively recorded outcomes of patients who underwent pouch creation and experienced intraoperative hypoperfusion after elongation maneuvers, requiring NIR-FI in order to avoid pouch abandonment. Results Thirty patients underwent RPC and IPAA between 2018–2021; six patients presented with intraoperative macroscopic ileal hypoperfusion after elongation maneuvers; however, following NIR-FI assessment, they successfully underwent pouch creation with minor postoperative complications. After both pouchoscopy and a pouchgram, all patients underwent ileostomy closure within 3 months from the index surgery. Nine months after the pouch creation, no complications were observed, and all patients reported a satisfactory quality of life. Conclusions This small series showed the utility of NIR-FI technology not just as a confirmatory tool but also as a determinant in the case of macroscopic hypoperfusion allowing surgeons to have a better understanding of the blood supply and to avoid pouch abandonment.