Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study

Jeffrey W Chen; Sanne Lof; Maurice J W Zwart; Olivier R Busch; Freek Daams; Sebastiaan Festen; Zhi Ven Fong; Melissa E Hogg; Maxime D Slooter; Els J M Nieveen van Dijkum; Marc G Besselink

doi:10.1097/AS9.0000000000000354

Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study

Ann Surg Open. 2023 Nov 29;4(4):e354. doi: 10.1097/AS9.0000000000000354. eCollection 2023 Dec.

Authors

Jeffrey W Chen^{1

2}, Sanne Lof^{1

2}, Maurice J W Zwart^{1

2}, Olivier R Busch^{1

2}, Freek Daams^{2

3}, Sebastiaan Festen⁴, Zhi Ven Fong⁵, Melissa E Hogg⁶, Maxime D Slooter^{1

2}, Els J M Nieveen van Dijkum^{1

2}, Marc G Besselink^{1

2}

Affiliations

¹ From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands.
² Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands.
³ Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands.
⁴ Department of Surgery, OLVG, Location Oost, Amsterdam, The Netherlands.
⁵ Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ.
⁶ Department of Surgery, Northshore University HealthSystem, Chicago, IL.

Abstract

Background: A potential downside of robotic pancreatoduodenectomy (RPD) is the lack of tactile feedback when tying sutures, which could be especially perilous during pancreatic anastomosis. Near-infrared fluorescence imaging with indocyanine green (NIRF-ICG) could detect transpancreatic-suture-induced hypoperfusion of the pancreatic stump during RPD, which may be related to postoperative pancreatic fistula (POPF) grade B/C, but studies are lacking.

Methods: This prospective study included 37 patients undergoing RPD to assess the relation between pancreatic stump hypoperfusion as objectified with NIRF-ICG using Firefly and the rate of POPF grade B/C. In 27 patients, NIRF-ICG was performed after tying down the transpancreatic U-sutures. In 10 'negative control' patients, NIRF-ICG was performed before tying these sutures.

Results: Pancreatic stump hypoperfusion was detected using NIRF-ICG in 9/27 patients (33%) during RPD. Hypoperfusion was associated with POPF grade B/C (67% [6/9 patients] versus 17% [3/18 patients], P = 0.026). No hypoperfusion was objectified in 10 'negative controls'.

Conclusions: Transpancreatic-suture-induced pancreatic stump hypoperfusion can be detected using NIRF-ICG during RPD and was associated with POPF grade B/C. Surgeons could use NIRF-ICG to adapt their suturing approach during robotic pancreatico-jejunostomy. Further larger prospective studies are needed to validate the association between transpancreatic-suture-induced hypoperfusion and POPF.

Keywords: fluorescence; indocyanine green; pancreatic fistula; pancreatoduodenectomy; perfusion assessment; robotic surgery; whipple.