Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation

Pernille O Larsen; Nikolaj Nerup; Jesper Andersen; Niclas Dohrn; Mads Falk Klein; Steffen Brisling; Soren Salomon; Per V Andersen; Soren Möller; Morten B S Svendsen; Hans B Rahr; Lene H Iversen; Ismail Gögenur; Niels Qvist; Mark B Ellebaek

doi:10.1007/s00464-022-09819-1

Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation

Pernille O Larsen^*, Nikolaj Nerup, Jesper Andersen, Niclas Dohrn, Mads Falk Klein, Steffen Brisling, Soren Salomon, Per V Andersen, Soren Möller, Morten B S Svendsen, Hans B Rahr, Lene H Iversen, Ismail Gögenur, Niels Qvist, Mark B Ellebaek

^*Corresponding author for this work

13 Citations (Scopus)

Abstract

BACKGROUND: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL.

METHOD: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion.

RESULTS: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04).

CONCLUSION: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04766060.

Original language	English
Journal	Surgical Endoscopy
Volume	37
Issue number	5
Pages (from-to)	3602-3609
Number of pages	8
ISSN	0930-2794
DOIs	https://doi.org/10.1007/s00464-022-09819-1
Publication status	Published - May 2023

Keywords

Anastomosis, Surgical/methods
Anastomotic Leak/etiology
Colorectal Neoplasms/surgery
Fluorescein Angiography
Humans
Indocyanine Green
Laparoscopy/methods
Observer Variation
Perfusion
Robotics

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Larsen, P. O., Nerup, N., Andersen, J., Dohrn, N., Klein, M. F., Brisling, S., Salomon, S., Andersen, P. V., Möller, S., Svendsen, M. B. S., Rahr, H. B., Iversen, L. H., Gögenur, I., Qvist, N., & Ellebaek, M. B. (2023). Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation. Surgical Endoscopy, 37(5), 3602-3609. https://doi.org/10.1007/s00464-022-09819-1

Larsen, PO, Nerup, N, Andersen, J, Dohrn, N , Klein, MF, Brisling, S, Salomon, S, Andersen, PV, Möller, S, Svendsen, MBS, Rahr, HB, Iversen, LH, Gögenur, I, Qvist, N & Ellebaek, MB 2023, 'Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation', Surgical Endoscopy, vol. 37, no. 5, pp. 3602-3609. https://doi.org/10.1007/s00464-022-09819-1

@article{b2523b1ec7a34c0b99e501c1b0c24bfb,

title = "Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation",

abstract = "BACKGROUND: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL.METHOD: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion.RESULTS: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04).CONCLUSION: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04766060.",

keywords = "Anastomosis, Surgical/methods, Anastomotic Leak/etiology, Colorectal Neoplasms/surgery, Fluorescein Angiography, Humans, Indocyanine Green, Laparoscopy/methods, Observer Variation, Perfusion, Robotics",

author = "Larsen, {Pernille O} and Nikolaj Nerup and Jesper Andersen and Niclas Dohrn and Klein, {Mads Falk} and Steffen Brisling and Soren Salomon and Andersen, {Per V} and Soren M{\"o}ller and Svendsen, {Morten B S} and Rahr, {Hans B} and Iversen, {Lene H} and Ismail G{\"o}genur and Niels Qvist and Ellebaek, {Mark B}",

note = "{\textcopyright} 2023. The Author(s).",

year = "2023",

month = may,

doi = "10.1007/s00464-022-09819-1",

language = "English",

volume = "37",

pages = "3602--3609",

journal = "Surgical Endoscopy",

issn = "0930-2794",

publisher = "Springer",

number = "5",

}

TY - JOUR

T1 - Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation

AU - Larsen, Pernille O

AU - Nerup, Nikolaj

AU - Andersen, Jesper

AU - Dohrn, Niclas

AU - Klein, Mads Falk

AU - Brisling, Steffen

AU - Salomon, Soren

AU - Andersen, Per V

AU - Möller, Soren

AU - Svendsen, Morten B S

AU - Rahr, Hans B

AU - Iversen, Lene H

AU - Gögenur, Ismail

AU - Qvist, Niels

AU - Ellebaek, Mark B

PY - 2023/5

Y1 - 2023/5

N2 - BACKGROUND: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL.METHOD: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion.RESULTS: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04).CONCLUSION: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04766060.

AB - BACKGROUND: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL.METHOD: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion.RESULTS: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04).CONCLUSION: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04766060.

KW - Anastomosis, Surgical/methods

KW - Anastomotic Leak/etiology

KW - Colorectal Neoplasms/surgery

KW - Fluorescein Angiography

KW - Humans

KW - Indocyanine Green

KW - Laparoscopy/methods

KW - Observer Variation

KW - Perfusion

KW - Robotics

UR - http://www.scopus.com/inward/record.url?scp=85145910613&partnerID=8YFLogxK

U2 - 10.1007/s00464-022-09819-1

DO - 10.1007/s00464-022-09819-1

M3 - Journal article

C2 - 36624218

SN - 0930-2794

VL - 37

SP - 3602

EP - 3609

JO - Surgical Endoscopy

JF - Surgical Endoscopy

IS - 5

ER -

Anastomotic perfusion assessment with indocyanine green in robot-assisted low-anterior resection, a multicenter study of interobserver variation

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