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September 10, 2025

Quantitative Blood Flow Assessment With Indocyanine Green Imaging in Gastric Conduit Reconstruction

DKDaisuke KajiyamaNational Cancer Center Hospital East YKYuto KuboKeio University KSKazuma SatoNational Cancer Center Hospital East

Key Points

Patients without anastomotic leakage had significantly higher fluorescence intensity than those with leakage, with a p-value of 0.004.
Multivariate analysis identified fluorescence intensity in the anastomotic line as an independent risk factor for leakage, with p = 0.01.
Gastric conduit blood flow was assessed using quantitative ICG fluorescence imaging, enabling real-time evaluation.
The integration of ICG imaging into surgical practice may improve decision-making and patient outcomes in esophageal cancer surgeries.

Abstract

Abstract Background Indocyanine green (ICG) fluorescence is used to evaluate gastric conduit blood flow in esophageal cancer surgery in order to prevent anastomotic leakage (AL), but it is difficult to evaluate objectively. In this study, we investigated the evaluation of gastric conduit blood flow using quantitative ICG fluorescence. Methods This study included 100 esophageal cancer patients who underwent subtotal esophagectomy and gastric conduit reconstruction with ICG evaluation from July 2023 to May 2024. ICG fluorescence was detected by SPY PHI system with SPY-QP software (Stryker) which enables real-time evaluation of fluorescence intensity (FI) in other regions as a relative percentage by setting at a reference point (100% perfusion). We measured the time from ICG injection to the right gastroepiploic artery (RGEA) endpoint and assessed FI throughout the gastric conduit using its first branch as the reference point. And the anastomotic site was recorded, and FI was analyzed. Results The cervical anastomosis was performed using totally mechanical Collard technique in 88 cases. AL occurred in 9 patients. At the distal end line of RGEA supply zone, the median values of enhancement time are similar without significant difference between patients with and without AL (p = 0.66). Patients without AL exhibit significantly higher FI than those with AL, with a statistically significant difference (p = 0.004). At the actual anastomotic site, FI is significantly lower in patients with AL compared to those without AL (p = 0.009). Moreover, on multivariate analysis, FI in the anastomotic line (p = 0.01) were independent risk factors of AL. Conclusion Our study demonstrates that FI of ICG at the anastomotic site is a significant predictor of AL following esophagectomy and gastric conduit reconstruction. The integration of ICG fluorescence imaging into routine surgical practice may help identify patients at higher risk of AL and guide intraoperative decision-making to improve patient outcomes.

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