Correlation Between Anastomotic Leakage and the Anastomotic Position of the Gastric Conduit After Esophagectomy Using ICG Fluorescence Imaging Stratification

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BACKGROUND: This study aimed to clarify the correlation between anastomotic leakage and anastomotic position after esophagectomy for esophageal cancer, stratified by gastric conduit blood flow assessed using indocyanine green (ICG) fluorescence imaging. METHODS: A total of 136 patients who underwent esophagectomy with retrosternal gastric conduit reconstruction were included. After creating the gastric conduit, three points were identified: point A (anastomotic site), point B (terminal end of the gastroepiploic artery stained with ICG), and point C (terminal end of the gastric conduit wall stained with ICG). Anastomotic position was defined by the relative location of point A between points B and C, and blood flow speed before reconstruction (pre-speed) was quantified using ICG fluorescence imaging. Associations of anastomotic position and pre-speed with anastomotic leakage were evaluated. RESULTS: Anastomotic leakage occurred in 22 patients (16.2%). Mean distance BA (point B to A) was 2.05 cm in the leakage group and 0.15 cm in the non-leakage group (p = 0.018). Mean distance AC (point A to C) was 4.00 cm in the leakage group and 5.89 cm in the non-leakage group (p = 0.016). Logistic regression revealed that BA > -0.50 cm and pre-speed < 2.19 cm/s were independent risk factors for anastomotic leakage (odds ratio 4.67, p = 0.046, and odds ratio 56.16, p < 0.001, respectively). Among patients with delayed blood flow, the anastomotic leakage rate was significantly lower in the proximal group than in the distal group (p = 0.034). CONCLUSIONS: ICG fluorescence imaging provides useful information for determining an appropriate anastomotic position. Performing the anastomosis at a more proximal site within the gastric conduit may reduce the risk of anastomotic leakage.