ICG fluorescence in oncologic robotic colonic resections.

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First results in the Amphia. Presented by Winesh RamphalJune 16th 2017 Frankfurt

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Colorectal perfusion with indocyanine green in oncologic colonic resection performed in robotic surgery: Reducing the risk of anastomotic leakage? W. Ramphal, J.M.J. Schreinemakers, P.D. Gobardhan, J.H. Wijsman, G.P. Schelling van der, R.M.P.H. Crolla Amphia Hospital Breda, the Netherlands European Association for Endoscopic Surgery Frankfurt 16 th June 2017 Gerhard Buess Technology Award session

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Disclosure (s) Author Disclosure (s) W. Ramphal (speaker) None J.M.J. Schreinemakers None P.D. Gobardhan None J.H. Wijsman None G.P. Schelling van der Proctor Intuitive Surgery da Vinci R.M.P.H. Crolla Proctor Intuitive Surgery da Vinci

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Introduction Anastomotic leakage (AL) is the most severe complication in colorectal surgery Several factors contributing to AL Vascularization of the colon Since 2012 Robotic surgery was formed in the Amphia Hospital Since 2014 Indocyanine Green (ICG) in combination with Near Infra-Red (NIR) is used as a fluorescensic tool in robotic surgery to objectify colorectal perfusion

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Aim To determine if ICG-NIR could be used as a peroperative tool to reduce the number of anastomotic leakages in robotic oncologic colorectal surgery Secondly , could we reduce the number of protective ileostomies ?

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Methods Single centre retrospective observational study Inclusion Patients with colorectal cancer who had curative surgery between 2012 and 2016 performed with the robot Primary anastomosis was made with or without the use of ICG-NIR peroperatively

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Results (1) C olorectal cancer N=333 No ICG-NIR 211 ICG-NIR 122 Anastomosis + 134 Anastomosis - 77 Anastomosis + 107 Anastomosis - 15

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Results (2) Type of resection Anastomosis without ICG-NIR Anastomosis with ICG-NIR Low anterior resection 79 58 Anterior resection 26 37 Sigmoid resection 23 9 Right hemicolectomy 1 - Left hemicolectomy 5 2 Transverse resection - 1 Total 134 107

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Results (3) C olorectal cancer N=333 No ICG-NIR 211 ICG-NIR 122 Anastomosis + 134 Anastomosis + 107 Anastomotic leakage 7 (5.2%) Anastomotic leakage 7 (6.5%)

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Results (4) C olorectal cancer N=333 No ICG-NIR 211 ICG-NIR 122 Anastomosis + 134 Anastomosis + 107 Protective ileostomy 74 (5 5 %) Protective ileostomy 31 (29%)

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Results (5) Patients Anastomosis without ICG-NIR (N=134) Anastomosis with ICG-NIR (N= 107) P- value Anastomotic leakage 7 (5.2%) 7 (6.5%) P=0.664 Protective ileostomy 74 (55%) 31 (29%) P<0.001

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Results (5) Chemoradiation Anastomosis without ICG-NIR (n=21) Anastomosis with ICG-NIR (n=15) P- value Anastomotic leakage 1 (4.7%) 1 (6.6%) P=0.44 Protective ileostomy 20 (95 %) 9 (60%) P=0.01

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Conclusions Peroperative use of ICG-NIR in patients who had robotic surgery because of colorectal cancer did not result in less anastomotic leakages With the use of ICG-NIR there was a significant lower number of protective ileostomies ICG-NIR could be used peroperatively as a decision making tool in robotic colorectal surgery

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Consequences of ICG Consequence of ICG Number of patients (18/122) Extra proximal resection 11 (60%) Extra distal resection 3 (17%) Change in vascular dissection 2 (11%) Resection of an appendix epiploica 1 (6%) Resection of avital omentum 1 (6%)

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