Abstract
Background
Redo/revisional ileal pouch-anal anastomosis (IPAA) surgery is technically challenging and more likely to require mesenteric lengthening maneuvers, largely due to mesenteric reach issues, which may affect the perfusion of the critical sites in the pouch. Indocyanine green fluorescence angiography (ICG-FA) offers real-time assessment of tissue perfusion and may reduce the risk of complications, such as anastomotic leak. We aimed to evaluate the impact of intraoperative ICG-FA on surgical outcomes in patients undergoing redo/revisional IPAA surgery.
Methods
This is a retrospective case-control study with 1:1 propensity score matching based on data from a high-volume quaternary inflammatory bowel disease center. Patients who underwent redo/revisional IPAA surgery between September 2016 and December 2023 were included. The primary objective was to evaluate the direct impact of ICG-FA on intraoperative decision-making, measured by the rate of change in surgical plan. Secondary objectives included an exploratory comparison of short- and long-term outcomes, such as anastomotic leak and major complications.
Results
A total of 46 patients were included, with 23 patients in each of the ICG and non-ICG groups. ICG-FA led to intraoperative changes in surgical management in 2 patients (8.7%), including one pouch augmentation with resection of the tip of the J pouch and one pouch excision. The 30-day major complication rate was lower in the ICG group (11.1%) compared to non-ICG (18.2%), though not statistically significant (p = 1.00). No significant difference was found in long-term complication rates after adjusting for a marked disparity in follow-up duration between the groups. No adverse reactions related to ICG-FA were observed.
Conclusions
ICG-FA is a safe and feasible adjunct during redo/revisional IPAA surgery. Its use may guide intraoperative decision-making, leading to timely revisions.
Keywords: Indocyanine green, Redo ileal pouch-anal anastomosis, Anastomotic leak
Introduction
An ileal pouch-anal anastomosis (IPAA) is the preferred surgery to restore intestinal continuity after proctocolectomy in patients with ulcerative colitis (UC), selected patients with proctocolonic Crohn’s disease (CD), and familial adenomatous polyposis (FAP) [1]. IPAA complications may lead to pouch failure in 10–15% of patients, leaving a redo IPAA as the only option for patients who are averse to a permanent stoma [2, 3].
A cornerstone of pelvic pouch surgery is creating a well-perfused, tension-free pouch-anal anastomosis. Although the bowel itself may preclude reach to the deep pelvis, it is typically the length of the mesentery that restricts the ability to create a tension-free pelvic pouch anastomosis. An increase in mesenteric tension on the pouch-anal anastomosis is associated with an increased complication rate and compromised pouch survival [4]. A redo IPAA is a challenging, staged-operation that requires significant expertise as the already tenuous mesenteric reach to the pelvis is often required to stretch even further in cases where a new pouch must be formed, a proctectomy is required, or the additional pouch reach of a mucosectomy with hand-sewn anastomosis is needed. Therefore, a redo IPAA is more likely to require complex mesenteric lengthening maneuvers, which may affect the perfusion of the anastomosis and other critical sites in the pouch. This demands critical intraoperative evaluation of bowel perfusion during redo pouch surgery.
Indocyanine green fluorescence angiography (ICG-FA) allows the surgeon to perform real-time intraoperative angiography to evaluate the perfusion of the anastomosis and reduce leak rates [5, 6]. Although it has been previously implemented in left- and right-sided colorectal resections to aid in the assessment of anastomotic perfusion, ICG-FA can also be used in the evaluation of the critical anatomic sites where perfusion is problematical, such as the tip of J in pelvic pouches.
In our practice, we have implemented the use of ICG-FA in patients undergoing redo IPAA surgery over the past decade as an additional assessment of pouch perfusion intraoperatively to minimize complication rates. The literature is scarce in the use of ICG-FA during pouch surgery, and this is the first study to evaluate the use of ICG-FA in redo IPAA patients. We aim to compare the surgical outcomes in patients who had intraoperative ICG assessment and discuss a different perspective in pouch surgery.
Materials and methods
This is a retrospective case-control analysis of patients who underwent redo/revisional pouch surgery for pouch failure between 09/2016 and 12/2023. Patients were included from a prospectively maintained inflammatory bowel disease (IBD) database, and the study was independently approved by the institutional review board (New York University Langone Health Ethics Committee protocol no: s24-00641). All reporting was in accordance with the STROBE statement [7].
The patients were divided into two groups; one group who had intraoperative ICG-FA to assess perfusion of the bowel during the redo pouch surgery (ICG) and the other where no ICG-FA was used (non-ICG). In the non-ICG group, perfusion was assessed by standard surgical judgment, based on clinical signs such as bowel color, mesenteric pulsation, and the presence of bleeding from the transected bowel edge. Preoperative patient characteristics (patient age, sex, body mass index (BMI kg/m2), smoking status, American Society of Anesthesiology score (ASA), clinical characteristics of primary pouch surgery (diagnosis, stage, approach type, and pouch configuration) and redo pouch surgery (time between primary and redo IPAA, history of medication use, presence of associated mechanical and septic complications during redo IPAA surgery, type of redo anastomosis and configuration), operative details (operation time, estimated blood loss, length of hospital stay, 30-day major/minor complications, readmission, reoperation) were reported.
Short-term outcomes included postoperative complications occurring within 30 days. All complications were recorded and graded using the Clavien-Dindo classification system. For the purpose of analysis, complications were grouped as ‘Minor’ (Clavien-Dindo grades 1–2) and ‘Major’ (Clavien-Dindo grades 3–4). Major complications were defined as an anastomotic leak (AL), intra-abdominal abscess requiring drainage, or any other complication requiring returning to the operating room. Anastomotic leak was defined as a break in the integrity of the anastomosis documented by a combination of clinical, endoscopic, radiologic, and operative findings.
Additionally, we determined functional results using the Cleveland Clinic Foundation (CCF) Pelvic Pouch Questionnaire which included details pertaining to bowel frequency (number of bowel movements per 24 h), urgency (inability to defer bowel movements for more than 15 min), fecal incontinence (inadvertent passage of liquid or solid stool), need to wear pads, and restrictions (dietary, social, work, sexual). The Cleveland Global Quality of Life (CGQL) score was used to perform assessment of quality of life [8]. Patients were asked to rate current quality of life, current quality of health and current energy level, each on a scale of 0 to 10 (0, worst; 10, best). The scores were added, and the final CGQL utility score was obtained by dividing the sum by 30.
Outcomes
This study had a primary and a secondary objective. The primary objective was to determine the direct impact of ICG-FA on surgical strategy, for which the main endpoint was the rate of additional resection or change in plan inspired by ICG-FA findings. As this can only occur in the ICG group, this is a descriptive endpoint, not a comparative one.
The secondary objective was to conduct an exploratory comparison of clinical outcomes between the ICG and non-ICG groups. Key secondary outcomes included the anastomotic leak (AL) rate, 30-day major complications, and long-term pouch failure.
Surgical technique
During revisional pouch surgery, if the existing pouch is salvaged, ICG-FA was performed before the new anastomosis was constructed (Figs. 1 and 2). If a new pouch was made, ICG-FA was performed prior to the construction of the new pouch. Under sterile conditions, 25 mg of Indocyanine green (Diagnostic Green, LLC) was diluted with 10 mL of saline to a concentration of 2.5 mg/mL. Once diluted, 2–3 mL (5–7.5 mg) of the solution was injected intravenously followed by 10 mL saline flush. The bowel was inspected using either a portable handheld fluorescent imaging device (SPY-PHI, Stryker, Kalamazoo, MI, USA) or a 10-mm laparoscopic camera connected to the Olympus VISERA ELITE III imaging system (VISERA ELITE III, Olympus Corporation Ltd., Tokyo, Japan) and assessed for perfusion. If the ICG signal was found to be adequate and homogeneous, no further intervention was made on the pouch or the small bowel (Fig. 3). If any under-perfused or inadequately perfused segments of the pouch were identified, it was addressed by further resection and augmentation of the area. Extra attention was paid to the pouch’s tip of the J, as this is the most distal site of the pouch and is also the least likely for spontaneous healing in the event of a leak (Fig. 4).
Fig. 1.
Intraoperative images in a patient undergoing redo pouch surgery. a Identification of the previous anastomosis site (yellow arrow). b Excision of the ischemic pouch segment (yellow arrow) following evaluation. c Mesenteric lengthening maneuver via targeted mesenteric incisions (black arrows) to facilitate a tension-free anastomosis. d Intraoperative ICG-FA confirms adequate perfusion of the bowel and mesentery following mesenteric lengthening (black arrows)
Fig. 2.
Intraoperative findings in a patient undergoing redo pouch surgery. a Mesenteric incisions performed as a lengthening maneuver to facilitate a tension-free anastomosis. b ICG-FA demonstrating adequate perfusion at the planned anastomotic site prior to reconstruction. c ICG-FA assessment of the tip of the J pouch confirming adequate vascularization
Fig. 3.
Intraoperative evaluation in a patient undergoing redo pouch surgery. a Multiple mesenteric incisions (white arrows) performed as a lengthening maneuver to facilitate adequate reach for a tension-free anastomosis. ICG-FA demonstrating adequate perfusion of the pouch body (b) and tip of the J pouch (black arrow) (c)
Fig. 4.
Intraoperative assessment of the tip of the J pouch (a) and the planned anastomotic site (b, c) using ICG-FA in a patient undergoing redo pouch surgery
Statistical analysis
Categorical data were reported as proportions and continuous data as median and interquartile range (IQR) as appropriate. Categorical variables were compared via Pearson’s Chi Squared or Fisher’s Exact tests, and continuous variables were compared via Mann–Whitney U test considering the normality. For pouch survival estimate comparison between two groups, Kaplan–Meier method with log-rank test was applied. To reduce the selection bias due to the retrospective design of the current study, propensity score matching (PSM) was conducted to match the ICG and non-ICG patients in a 1:1 ratio. Covariates for PSM were chosen based on their potential influence on the outcomes. The covariates used in the PSM were the following: age, BMI, presence of pelvic sepsis, creation of new pouch at the time of redo IPAA, and anastomosis type. P values of < 0.05 were considered statistically significant.
Results
From a total of 258 cases for redo pouch surgery, 58 patients were assigned in the ICG group, and 200 patients were assigned to the non-ICG group. After 1:1 PSM, 23 patients were selected in each group (Fig. 5). As a result, differences in the matching criteria, including age, BMI, presence of pelvic sepsis, creation of new pouch at the time of redo IPAA, and anastomosis type were nonsignificant between the two groups. Table 1 summarizes the characteristics of the patients and primary IPAA surgery. Other patient characteristics, such as sex, smoking status, and ASA scores were comparable between groups. Additionally, diagnosis at primary IPAA surgery, stages, configuration and anastomosis type of the primary IPAA were similar between groups.
Fig. 5.
Flowchart of patient selection and propensity score matching
Table 1.
Patient demographics and clinical characteristics at primary IPAA surgery, N = 46
| Total | Indocyanine green (ICG) use | p-value | ||
|---|---|---|---|---|
| No ICG | ICG | |||
| Variables | N (%) | N (%) | N (%) | |
| 46 (100.0) | 23 (50.0) | 23 (50.0) | ||
| Demographic characteristics | ||||
| Age, years, median (IQR) | 39 (33–44) | 39 (33–44) | 39 (33–44) | - |
| Female | 27 (58.7) | 13 (56.5) | 14 (60.9) | 0.77 |
| BMI, kg/m2, median (IQR) | 24.3 (21.5- 26.5) | 24.3 (21.2–26.5) | 24.2 (22.2–26.9) | - |
| Smoking status | 0.70 | |||
| Never | 38 (82.6) | 18 (78.3) | 20 (87.0) | |
| Former | 8 (17.4) | 5 (21.7) | 3 (13.0) | |
| ASA score | 0.23 | |||
| 1/2 | 28 (60.9) | 16 (69.6) | 12 (52.2) | |
| 3/4 | 18 (39.1) | 7 (30.4) | 11 (47.8) | |
| Clinical characteristics at primary IPAA surgery | ||||
| Diagnosis | 0.08 | |||
| Ulcerative colitis | 39 (84.8) | 17 (73.9) | 22 (95.7) | |
| Crohn’s disease | 2 (4.4) | 1 (4.4) | 1 (4.4) | |
| Indeterminate | 4 (8.7) | 4 (17.4) | 0 (0.0) | |
| FAP | 1 (2.2) | 1 (4.4) | 0 (0.0) | |
| Stages for primary IPAA | 0.12 | |||
| One stage | 2 (4.4) | 1 (4.4) | 1 (4.4) | |
| Two stage | 21 (45.7) | 7 (30.4) | 14 (60.9) | |
| Three stage | 21 (45.7) | 13 (56.5) | 8 (34.8) | |
| Unknown | 2 (4.4) | 2 (8.7) | 0 (0.0) | |
| Approach type | 0.08 | |||
| Open | 24 (52.2) | 15 (65.2) | 9 (39.1) | |
| Minimally invasive (laparoscopic/robotic) | 22 (47.8) | 8 (34.8) | 14 (60.9) | |
| Pouch configuration | 1.00 | |||
| J Pouch | 45 (97.8) | 22 (95.7) | 23 (100.0) | |
| S Pouch | 1 (2.2) | 1 (4.4) | 0 (0.0) | |
BMI body mass index, ASA American society of anesthesiology, FAP familial adenomatous polyposis
Characteristics of redo IPAA surgery were listed in Table 2. The median time between primary and redo pouch surgeries was 7 (3–18) years in non-ICG group, and 10 (3–19) years in the ICG group (p = 0.56). Eighteen patients (78.3%) in each group had at least one previous repair attempt via a trans-abdominal or perineal approach before our redo IPAA surgery. Indications for redo IPAA surgery were comparable between groups, except for 6 patients who had CD-like features in their pouches (p < 0.01). There was no significance between the groups in the configuration types of the redo pouches. Twenty-two patients (95.7%) in the ICG group and 19 patients (82.6%) in the non-ICG group had J pouch. Furthermore, in the non-ICG group, 2 patients (8.7%) had a S-pouch, and 2 patients (8.7%) had an H-pouch. Only one patient in the ICG group had an H-pouch, which was the only non-J shaped pouch evaluated by ICG-FA.
Table 2.
Characteristics of redo IPAA surgery and short-term (30-day) surgical outcomes, N = 46
| Total | Indocyanine green (ICG) use | p-value | ||
|---|---|---|---|---|
| No ICG | ICG | |||
| Variables | N (%) | N (%) | N (%) | N (%) |
| 46 (100.0) | 23 (50.0) | 23 (50.0) | ||
| Clinical characteristics of redo IPAA surgery | ||||
| Time between primary and redo IPAA surgery, years, median (IQR) | 7 (3–18) | 7 (3–18) | 10 (3–19) | 0.56 |
| History of biologic or steroid use | 21 (45.7) | 12 (52.2) | 9 (39.1) | 0.38 |
| Previous repair attempt | 36 (78.3) | 18 (78.3) | 18 (78.3) | 1.00 |
| Indications for Redo IPAA* | ||||
| Mechanical indications | 37 (80.4) | 18 (78.3) | 19 (82.6) | 1.00 |
| Long cuff/remnant mesorectum | 16 (43.2) | 8 (44.4) | 8 (42.1) | 0.89 |
| Twist | 16 (43.2) | 9 (50.0) | 7 (36.8) | 0.42 |
| Small pouch | 14 (37.8) | 8 (44.4) | 6 (31.6) | 0.42 |
| Stricture | 12 (32.4) | 4 (22.2) | 8 (42.1) | 0.30 |
| Concerns of the CD of the pouch | 6 (13.0) | 6 (26.1) | 0 (0.0) | < 0.01 |
| Dysplasia | 1 (2.2) | 1 (4.4) | 0 (0.0) | 1.00 |
| Chronic pelvic sepsis | 35 (76.1) | 18 (78.3) | 17 (73.9) | - |
| Fistula | 18/35 (51.4) | 11/18 (61.1) | 7/17 (41.2) | 0.24 |
| Type of fistula | 0.63 | |||
| Perianal | 10/18 (55.6) | 7/11 (63.6) | 3/7 (42.9) | |
| Pouch vaginal | 8/18 (44.4) | 4/11 (36.4) | 4/7 (57.1) | |
| Type of Redo IPAA | - | |||
| Redo IPAA with new pouch | 34 (73.9) | 17 (73.9) | 17 (73.9) | |
| Redo IPAA with old pouch | 10 (21.7) | 5 (21.7) | 5 (21.7) | |
| Redo IPAA with revision | 7 (70.0) | 3 (60.0) | 4 (80.0) | |
| Redo IPAA without revision | 3 (30.0) | 2 (40.0) | 1 (20.0) | |
| Only revision of pouch | 2 (4.4) | 1 (4.4) | 1 (4.4) | |
| Configuration of redo pouch | 0.41 | |||
| J pouch | 41 (89.1) | 19 (82.6) | 22 (95.7) | |
| S pouch | 2 (4.4) | 2 (8.7) | 0 (0.0) | |
| H pouch | 3 (6.5) | 2 (8.7) | 1 (4.4) | |
| Anastomosis type (N = 44) | - | |||
| Handsewn | 34 (77.3) | 17 (77.3) | 17 (77.3) | |
| Stapled | 10 (22.7) | 5 (22.7) | 5 (22.7) | |
| Operative and postoperative 30-day outcomes after redo IPAA | ||||
| Operation duration, min, median (IQR) | 284 (239–335) | 282 (233–331) | 290 (255–352) | 0.31 |
| Blood loss, cc, median (IQR) | 300 (200–500) | 300 (100–500) | 300 (200–400) | 0.91 |
| Length of hospital stay, days, median (IQR) | 8 (6–10) | 8 (6–10) | 8 (7–11) | 0.77 |
| Intraoperative plan change due to ICG-FA† | 2 (4.4) | N/A | 2 (8.7) | N/A |
| 30-day readmission | 4 (8.7) | 4 (17.4) | 0 (0.0) | 0.11 |
| 30-day reoperation | 1 (2.2) | 1 (4.4) | 0 (0.0) | 1.00 |
| 30-day morbidity† | 20 (43.5) | 11 (47.8) | 9 (39.1) | 0.55 |
| Major complication (Clavien-Dindo 3–4) | 3 (15.0) | 2 (18.2) | 1 (11.1) | 1.00 |
| Pelvic abscess requiring drainage | 2 (66.7) | 1 (50.0) | 1 (100.0) | |
| Anastomosis leak | 1 (33.3) | 1 (50.0) | 0 (0.0) | |
| Minor complication (Clavien-Dindo 1–2) | 18 (90.0) | 10 (90.9) | 8 (88.9) | 1.00 |
| Wound infection/dehiscence | 9 (50.0) | 7 (70.0) | 2 (25.0) | |
| Ileus/SBO | 3 (16.7) | 1 (10.0) | 2 (25.0) | |
| Urinary tract infection | 1 (5.6) | 0 (0.0) | 1 (12.5) | |
| Hemorrhage | 8 (44.4) | 3 (30.0) | 5 (62.5) | |
| Thrombosis (DVT, PE) | 2 (11.1) | 1 (10.0) | 1 (12.5) | |
| Dehydration/AKI | 3 (16.7) | 2 (20.0) | 1 (12.5) | |
| Urinary retention | 1 (5.6) | 1 (10.0) | 0 (0.0) | |
*Several patients had several indications
†Several patients had several complications
†This outcome is by definition only observable in the ICG group and is presented as a descriptive measure of intraoperative impact
N/A not applicable, SBO small bowel obstruction, DVT deep venous thrombosis, PE pulmonary embolism, AKI acute kidney injury
As a primary objective of this study, two patients (8.7%) required additional resection after assessment with ICG-FA during redo pouch surgery. One patient required pouch augmentation with resection of the tip of the J pouch because of lack of adequate perfusion, while another required pouch excision after the distal limb of the pouch was found to be less well-perfused (compared to the proximal limb) after assessment with ICG-FA. Both patients had an uneventful immediate postoperative recovery. Critically, at their last follow-up of 6 and 8 months respectively, both patients have retained a well-functioning pouch and have not experienced pouch failure or major long-term complications.
Additionally, operative and short-term (30-day) postoperative outcomes, operation duration, blood loss, length of hospital stays, readmission, and reoperation rates were similar between groups. The major complication (Clavien-Dindo grades 3–4) rate was higher in non-ICG group (18.2%), including one patient who had an AL, compared to ICG group (11.1%); however, this difference did not reach statistical significance (p = 1.00).
Long-term surgical and functional outcomes were listed in Table 3. The median follow-up was 38.9 (22.0–58.4) months in the non-ICG group and 14.8 (8.1–18.1) months in the ICG group (p < 0.01). Given this substantial bias, to provide a more valid comparison, we performed a post-hoc landmark analysis, assessing complications occurring within the first 15 months of follow-up for both groups. In this adjusted analysis, the rate of long-term complications was similar between the non-ICG and ICG groups (8.7% [2/23] vs. 8.7% [2/23], p = 1.00). Four patients (17.4%) in the non-ICG group and 2 patients (8.7%) in the ICG group had pouch failure at last follow-up. Additionally, 1 patient in the non-ICG group, and 1 patient in the ICG group, preferred to keep their ileostomies after redo IPAA surgery. Furthermore, in the ICG group, 2 patients had pouch-vaginal fistulas after redo IPAA surgery and have not had their ileostomy closed yet. After excluding these 10 patients, the functioning pouch rate was 78.3% in each group (p = 1.00).
Table 3.
Long-term surgical and functional outcomes after redo IPAA surgery, N = 46
| Total | Indocyanine green (ICG) use | p-value | ||
|---|---|---|---|---|
| No ICG | ICG | |||
| Variables | N (%) | N (%) | N (%) | N (%) |
| 46 (100.0) | 23 (50.0) | 23 (50.0) | ||
| Long-term surgical outcomes | ||||
| Follow-up, months, median (IQR) | 21.1 (12.2–41.1) | 38.9 (22.0–58.4) | 14.8 (8.1–18.1) | < 0.01 |
| Ileostomy not closed after Redo IPAA | 6 (13.0) | 2 (8.7) | 4 (17.4) | 0.67 |
| Patient preference, ileostomy still present | 2/6 (33.3) | 1/2 (50.0) | 1/4 (25.0) | |
| Re-redo IPAA, successful, ileostomy closed after re-redo IPAA | 2/6 (33.3) | 1/2 (50.0) | 1/4 (25.0) | |
| Pouch vaginal fistula, pending for reversal | 2/6 (33.3) | 0 (0.0) | 2/4 (50.0) | |
| Yes | 40 (87.0) | 21 (91.3) | 19 (82.6) | |
| Long term complications* | 23 (50.0) | 17 (73.9) | 6 (26.1) | < 0.01 |
| Long term complications within 15 months | 4 (8.7) | 2 (8.7) | 2 (8.7) | 1.00 |
| Septic complications | 14 (60.9) | 9 (52.9) | 5 (83.3) | 0.34 |
| Stricture | 5 (21.7) | 4 (23.5) | 1 (16.7) | 1.00 |
| Incontinence | 3 (13.0) | 3 (17.7) | 0 (0.0) | 0.54 |
| Functioning pouch | 36 (78.3) | 18 (78.3) | 18 (78.3) | 1.00 |
| Pouch failure | 6 (13.0) | 4 (17.4) | 2 (8.7) | 0.67 |
| Rediversion, end ileostomy | 3 (50.0) | 2 (50.0) | 1 (50.0) | 1.00 |
| Pouch excision and permanent ileostomy | 1 (16.7) | 1 (25.0) | 0 (0.0) | 1.00 |
| Re-redo IPAA | 2 (33.3) | 1 (25.0) | 1 (50.0) | 1.00 |
| Functional results and quality of life scores† | 22 (47.8) | 16 (69.6) | 6 (26.1) | 0.77 |
| Bowel movements | ||||
| Total | 8 (7–11) | 9 (8–12) | 7 (6–10) | |
| Daytime | 7 (5–10) | 7 (6–10) | 6 (5–9) | |
| Nighttime | 2 (1–2) | 2 (1–5) | 2 (1–2) | |
| Urgency | ||||
| Never/rarely | 13 (59.1) | 8 (50.0) | 5 (83.3) | |
| Sometimes | 5 (22.7) | 5 (31.3) | 0 (0.0) | |
| Mostly/always | 4 (18.2) | 3 (18.8) | 1 (16.7) | |
| Incontinence (N = 21) | ||||
| Never/rarely | 16 (76.2) | 11 (73.3) | 5 (83.3) | |
| Sometimes | 2 (9.5) | 1 (6.7) | 1 (16.7) | |
| Mostly/always | 3 (14.3) | 3 (20.0) | 0 (0.0) | |
| Seepage | ||||
| Daytime | 10 (45.5) | 9 (56.3) | 1 (16.7) | |
| Nighttime | 16 (72.7) | 12 (75.0) | 4 (66.7) | |
| Pad use (N = 21) | ||||
| Daytime | 9 (42.9) | 6 (40.0) | 3 (50.0) | |
| Nighttime | 15 (71.4) | 10 (66.7) | 5 (83.3) | |
| Reason for pad use (N = 20) | ||||
| None | 5 (25.0) | 4 (25.0) | 1 (25.0) | |
| Necessity | 11 (55.0) | 8 (50.0) | 3 (75.0) | |
| Peace of mind | 4 (20.0) | 4 (25.0) | 0 (0.0) | |
| Restrictions | ||||
| Dietary | 10 (45.5) | 8 (50.0) | 2 (33.3) | |
| Work | 8 (36.4) | 7 (43.8) | 1 (16.7) | |
| Sexual (N = 21) | 5 (23.8) | 5 (31.3) | 0 (0.0) | |
| Social | 7 (31.8) | 6 (37.5) | 1 (16.7) | |
| CGQL | 7.8 (6.7–9.3) | 7.8 (6.8–9.0) | 8.5 (6.3–9.3) | |
| Recommendation of surgery to others | 21 (95.5) | 15 (93.8) | 6 (100.0) | |
| Willingness to undergo surgery again if needed | 21 (95.5) | 15 (93.8) | 6 (100.0) | |
*Several patients had several complications
†Due to significant differential bias in data availability between groups (p = 0.007), a direct comparison is not valid. Data is presented descriptively for the subset with available information
CGQL Cleveland Global Quality of Life
In the Kaplan–Meier analysis of pouch survival, the estimated pouch survival rate was 95.7% (95% CI: 72.9–99.4%) in the ICG group and 91.3% (95% CI: 69.5–97.8%) in the non-ICG group at 12 months (Fig. 6) (Table 4).
Fig. 6.
Kaplan–Meier survival analysis of pouch failure
Table 4.
Kaplan–Meier estimates of pouch survival after redo IPAA surgery
| Group | Period (months) | Survival probability | 95% confidence interval |
|---|---|---|---|
| ICG | 12 | 95.7% | 72.9%–99.4% |
| 36 | 76.5% | 24.1%–95.1% | |
| 60 | 76.5% | 24.1%–95.1% | |
| No-ICG | 12 | 91.3% | 69.5%–97.8% |
| 36 | 85.9% | 62.2%–95.3% | |
| 60 | 85.9% | 62.2%–95.3% |
Regarding functional results and quality of life scores, data was only available for 22 patients and its availability, being far more common in the non-ICG historical cohort than in the ICG group (69.6% vs. 26.1%, p = 0.007). Therefore, a direct comparison between the ICG and non-ICG groups was not performed due to a significant and systematic bias in data availability. No adverse events (side effects or allergic reaction) related to ICG-FA administration were recorded during the study period.
Discussion
To our knowledge, this is the first study to specifically evaluate the use of ICG-FA in redo/revisional pouch surgery. Our primary objective was to assess the direct impact of ICG-FA on surgical strategy. We found that in 8.7% of cases, the use of ICG-FA led to a direct change in the operative plan, such as pouch augmentation or excision. We contend this is a clinically significant finding, as it demonstrates that in nearly one in ten of these complex operations, the technology provided novel, actionable information that prompted a crucial course correction. In our exploratory analysis of secondary, comparative outcomes, we observed a numerically lower rate of 30-day major complications (11.1% vs 18.2%) and the absence of an anastomotic leak in the ICG group, though these differences were not statistically significant, likely due to the small sample size.
There are several risk factors associated with AL in colorectal surgery [9, 10]. Decreased tissue perfusion and inadequate blood supply at the peri-anastomotic site are believed to be major causes for anastomotic dehiscence and leak [11–14]. In the setting of pouch surgery, an AL from the tip of the J-pouch, the most distal part of the pouch, and theoretically is the most susceptible to ischemia [15]. In our series, one of the two patients who underwent an intraoperative revision after ICG use, had a revision at the site of the tip of the J-pouch, which is a high-risk site aligning with the literature and our experience. Similarly, an anastomotic stricture in patients undergoing pelvic pouch surgery, may be the result of tissue ischemia, inflammation, or AL, and the literature supporting the role of these factors in the pathophysiology of anastomotic strictures is scarce.
Allowing the ileal pouch to reach the pelvic floor with a tension-free anastomosis is crucial for the success of pouch surgery. High mesenteric tension after IPAA surgery is adversely associated with postoperative complications and pouch survival. On long-term follow-up, patients with high mesenteric tension were found to be more likely to suffer from anastomotic stricture and pouch failure, while pouch function was not influenced by mesenteric tension [4].
In the revisional pouch surgery setting, pouch reach is a major concern, and therefore all patients receive a "thoughtful ileostomy" for 6 months prior to the redo pouch operation [16]. Additionally, we employ a high ligation of the ileocolic artery in the initial total colectomy of the 3-stage primary IPAA, or during the revisional pouch surgery if not ligated before, which is believed to assist in the mobilisation of the superior mesenteric artery and allow for a tension-free pelvic anastomosis. Additional lengthening manoeuvres include peritoneal-scoring incisions, and/or the creation of an S- or H- pouch configuration [17]. In this study, one patient’s H-shaped pelvic pouch was performed and evaluated with ICG intraoperatively.
In colorectal surgery, fluorescence technology has emerged as an additional tool that can be employed to evaluate perfusion, thus reducing the potential complications and its feasibility has been reported [18]. In a meta-analysis of 20 studies, including 5,498 patients, the use of ICG-FA was found to be associated with an over 50 percent decrease in AL (3.7 versus 8.6 percent) [5]. In 9.7 percent of the patients the anastomotic sites were changed after ICG-FA was employed. In a prospective, multicenter clinical trial that assessed the feasibility and utility of FA during left-sided colectomy and anterior resection, Jafari et al. reported that FA changed surgical plans in 8% of the patients [19].
Although this is the first study that showed the role and implication of ICG during revisional pouch surgery, previous reports showed the technique and efficacy of the use of ICG during IPAA [20–24]. Spinelli et al. have shown that the postoperative AL rate after IPAA in their FA group was similar to the non-FA group, even though ligation of the ileocolic artery was performed more often within the FA group than non-FA group (47% versus 16%) [24]. Similarly, Freund et al. reported that their results revealed that 16 patients who underwent IPAA surgery required advanced lengthening maneuvers and the use of intraoperative ICG assessment may be associated with reduced ischemia and leak rates [25].
Our results revealed that the use of ICG intraoperatively was not associated with the prolongation of operating time. Similarly, in a meta-analysis of twenty-five comparative studies, including a total of 7735 patients, no difference in duration of surgery related to ICG use intraoperatively was observed [26]. If institutional infrastructure allows the use of ICG, its incorporation into intraoperative decision-making can enhance surgical precision without adding significant operative time. Given its safety profile and potential to reduce anastomotic complications, ICG can be a valuable adjunct in complex colorectal procedures when available.
There are several limitations to this report. The most significant limitation is the introduction of temporal bias, which is inherent in the study’s retrospective design. The use of ICG-FA was implemented and became routine at our institution during the latter half of the study period. Consequently, the ICG group represents a more recent patient cohort, while the non-ICG group is composed of historical patients. This temporal separation is the direct cause of the significant imbalance in median follow-up duration and is a major confounder. It is reasonable that improvements in surgical technique, perioperative management, and overall institutional expertise have occurred over time, which may have contributed to better outcomes in the more recent ICG cohort, independent of ICG-FA use. While propensity score matching can balance measured covariates, it cannot account for these unmeasured temporal factors.
The impact of this bias was most evident in our initial analysis of long-term complications. The uncorrected finding of a lower complication rate in the ICG group was likely an artifact of shorter observation time. To mitigate this, we performed a landmark analysis standardizing the follow-up period, which correctly showed no statistical difference between the groups.
A third major limitation is significant residual confounding, despite propensity score matching. Our small sample size limited the effectiveness of matching, and critically, failed to balance a key prognostic factor: the rate of "concerns for CD of the pouch" remained significantly higher in the non-ICG group. This imbalance is a major confounder, as Crohn’s-like pathology is an independent risk factor for septic complications and pouch failure.
Furthermore, a key limitation is that the assessment of bowel perfusion with ICG-FA remains largely subjective. In our study, as is common practice, the decision to revise was based on the surgeon’s qualitative interpretation of the signal’s brightness and homogeneity, rather than on standardized, objective criteria. We did not employ quantitative tools such as fluorescence intensity thresholds, time-to-perfusion analysis, or dedicated software. The development and validation of such objective assessment systems are critical for standardising the use of ICG-FA and represent an important area for future research, including the potential application of artificial intelligence. Moreover, our data reflects a single, high-volume redo pouch surgery center experience and the generalizability could be limited. The small sample size also reduces the statistical power to detect differences between groups and increases the risk of a Type II error. For example, while the 30-day major complication rate was numerically lower in the ICG group (11.1%) compared to the non-ICG group (18.2%), our study was underpowered to determine if this was a true difference. Therefore, our findings regarding complication rates should be considered exploratory. A definitive conclusion on the impact of ICG-FA on anastomotic leak and major complications in this setting would require a larger, multicenter study. Finally, redo IPAA surgery is a challenging procedure and there are several factors associated with leak besides those which we discussed above.
Maintaining an adequate blood supply and a tension-free anastomosis when creating a pelvic pouch, specifically ensuring critical sites such as anastomosis and tip of the J are well-perfused decreases the complication rate and associated outcomes. ICG-FA is a safe and feasible adjunct during redo/revisional IPAA surgery and influences the intraoperative plan in a meaningful percentage of cases. Larger prospective studies are needed to validate the clinical benefit of this technology on clinical outcomes in this high-risk population.
Acknowledgements
None.
Author contributions
M.G wrote the main manuscript. P.H, M.A, E.E did the data collection. M.J.G, H.H.A, D.S, A.E, A.M prepared figures and tables. F.R and J.M did critical review. All authors reviewed the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.