Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey.
Wexner S., Abu-Gazala M., Boni L., Buxey K., Cahill R., Carus T., Chadi S., Chand M., Cunningham C., Emile SH., Fingerhut A., Foo CC., Hompes R., Ioannidis A., Keller DS., Knol J., Lacy A., de Lacy FB., Liberale G., Martz J., Mizrahi I., Montroni I., Mortensen N., Rafferty JF., Rickles AS., Ris F., Safar B., Sherwinter D., Sileri P., Stamos M., Starker P., Van den Bos J., Watanabe J., Wolf JH., Yellinek S., Zmora O., White KP., Dip F., Rosenthal RJ.
BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.