Intraoperative Assessment of Perfusion of the Gastric Graft and Correlation With Anastomotic Leaks After Esophagectomy

Abstract

Objective: The aim of the study was to evaluate laser-assisted fluorescent-dye angiography (LAA) to assess perfusion in the gastric graft and to correlate perfusion with subsequent anastomotic leak.

Background: Anastomotic leaks are a major source of morbidity after esophagectomy with gastric pull-up (GPU). In large part, they occur as a consequence of poor perfusion in the gastric graft.

Methods: Real-time intraoperative perfusion was assessed using LAA before bringing the graft up through the mediastinum. When there was a transition from rapid and bright to slow and less robust perfusion, this site was marked with a suture. The location of the anastomosis relative to the suture was noted and the outcome of the anastomosis ascertained by retrospective record review.

Results: Intraoperative LAA was used to assess graft perfusion in 150 consecutive patients undergoing esophagectomy with planned GPU reconstruction. An esophagogastric anastomosis was performed in 144 patients. A leak was found in 24 patients (16.7%) and were significantly less likely when the anastomosis was placed in an area of good perfusion compared with when the anastomosis was placed in an area of less robust perfusion by LAA (2% vs 45%, P < 0.0001). By multivariate analysis perfusion at the site of the anastomosis was the only significant factor associated with a leak.

Conclusions: Intraoperative real-time assessment of perfusion with LAA correlated with the likelihood of an anastomotic leak and confirmed the critical relationship between good perfusion and anastomotic healing. The use of LAA may contribute to reduced anastomotic morbidity.

Figures

FIGURE 1.

Rapid and bright perfusion of the entire gastric graft by LAA.

FIGURE 2.

A transition point is seen between rapid and bright versus slower, less robust perfusion (arrow). A suture is placed at the site of this transition point and if possible the anastomosis was placed proximal to this suture in an area of good perfusion by LAA.

FIGURE 3.

The frequency of major and minor leaks in patients where the anastomosis was placed in an area of good perfusion by LAA [either entire graft with good perfusion (n = 66) or anastomosis placed proximal to suture at site of transition (n = 29)] versus those patients that had an anastomosis placed at or distal to the site of the suture at the transition point (n = 49) (2% vs 45%, P < 0.0001).

FIGURE 4.

Perfusion by LAA shown in (A) qualitative mode versus (B) with quantitative (SPY-Q) overlay.