The IPA-CUP study: Indocyanine green perfusion assessment and cholangiography during pancreaticoduodenectomy-Evaluation of the pancreaticojejunostomy and hepaticojejunostomy.

Abstract

Postoperative pancreatic fistula is a critical and feared complication after pancreaticoduodenectomy. While indocyanine green fluorescence angiography has successfully reduced anastomotic leaks in other surgeries, its role in assessing pancreaticojejunostomy perfusion remains unclear. Similarly, the use of indocyanine green-cholangiography for the early detection of bile leakage from the hepaticojejunostomy has limited evidence. This study aimed to evaluate intraoperative indocyanine green fluorescence angiography for assessing pancreaticojejunostomy perfusion and correlation with postoperative pancreatic fistula risk (primary endpoint) and to assess indocyanine green-cholangiography for detecting bile leakage from the hepaticojejunostomy during pancreaticoduodenectomy (secondary endpoint). We conducted a prospective cohort study of 100 patients undergoing pancreaticoduodenectomy. Indocyanine green fluorescence angiography was used to evaluate pancreaticojejunostomy perfusion and indocyanine green-cholangiography to assess hepaticojejunostomy integrity. Four blinded expert surgeons independently performed visual perfusion scoring of the pancreaticojejunostomy using a standardized 1-10 scale. Interobserver variability was assessed. Outcomes, including postoperative pancreatic fistula grades and bile leakage, were analyzed. Clinically relevant postoperative pancreatic fistula (grades B/C) occurred in 21 patients. Median visual indocyanine green risk scores were significantly higher in patients with postoperative pancreatic fistula compared with those without (4.75 vs 3.5; P = .014). Interobserver agreement was good (intraclass correlation coefficient, 0.76). Intraoperative indocyanine green-cholangiography detected bile leakage in 5 patients; 4 subsequently developed a postoperative leak. No adverse events from indocyanine green administration were observed. Intraoperative indocyanine green fluorescence angiography is feasible during pancreaticoduodenectomy and may assist in identifying patients at increased risk of postoperative pancreatic fistula, although its interpretation is limited by subjectivity. Indocyanine green-cholangiography offers valuable real-time insight into hepaticojejunostomy sufficiency, enabling the immediate detection of bile duct leakage and potentially facilitating timely surgical intervention.