Indocyanine Green-Guided Decision-Making for Cervical Esophagogastric Anastomosis Using the Modified Collard Technique: Implementation and Temporal Stability in a Consecutive Cohort.

Abstract

Anastomotic leakage (AL) remains a major complication after cervical esophagogastric anastomosis. Although indocyanine green (ICG) fluorescence imaging has been used to assess gastric conduit perfusion, its role in structured intraoperative decision-making and the temporal stability of outcomes remain unclear. This single-center retrospective study included 507 consecutive patients who underwent esophagectomy with cervical esophagogastric anastomosis using the modified Collard technique under a standardized ICG-guided protocol. Intraoperative ICG imaging was used to identify poorly perfused distal conduit segments for exclusion. Temporal trends were evaluated using moving average and cumulative sum (CUSUM) analyses. Anastomotic leakage occurred in 19 patients (3.75%), including clinically relevant leakage (grade ≥ III) in 13 (2.56%). Reoperation was required in one case, with no leakage-related mortality. ICG assessment prompted additional proximal resection in 49.9% of evaluable patients, reflecting frequent detection of marginal distal perfusion; however, final anastomoses were consistently constructed within adequately perfused zones. Temporal analyses, including CUSUM, demonstrated sustained performance below a stringent 5% target rate throughout the study period. A standardized ICG-guided intraoperative decision-making strategy for cervical esophagogastric anastomosis using the modified Collard technique was associated with a low (3.75%) and temporally stable anastomotic leakage rate. Rather than serving as a binary perfusion test, ICG imaging functioned as a practical rule-out tool to exclude clearly unsafe conduit segments. When embedded within a structured decision-making framework, this approach enabled consistent implementation and durable reconstructive quality in routine clinical practice.