The Effect of Chemoradiotherapy on Gastric Perfusion in Patients With Gastric Cancer.
Phase: PHASE4
Conditions: Gastric Cancer
Sponsor: Rigshospitalet, Denmark

Version 4.0 25/8-2021 
 
 
The effect of chemotherapy on gastric perfusion in patients with gastric 
cancer 
 
 
 
 
 
 
 
 
Principal investigator:  
Jens Osterkamp 
Position 
 
MD, PhD-fellow 
Address: 
 
Dept. of Surgical Gastroenterology, Rigshospitalet   
Telephone:  
+45-53862647 
E-mail: 
 
jens.osterkamp@outlook.com 
 
 
 
 
 
 
 

Version 4.0 25/8-2021 
 
 
Content  
1. Investigators and affiliations ......................................................................................................................... 3 
2. Introduction ................................................................................................................................................... 4 
2.1 Summary of the study .......................................................................................................................... 4 
2.2 Gastric perfusion after neoadjuvant chemotherapy treatment ............................................................. 4 
2.3 Fluorescence guided surgery with Indocyanine Green. ....................................................................... 5 
2.3 Aim .......................................................................................................................................................... 7 
2.4 Hypothesis ............................................................................................................................................... 7 
2.5 Primary endpoint ..................................................................................................................................... 7 
2.6 Secondary endpoint ................................................................................................................................. 7 
3. Methods ......................................................................................................................................................... 7 
3.1 Study design / Sample size ...................................................................................................................... 7 
3.2 Inclusion criteria ...................................................................................................................................... 8 
3.3 Exclusion criteria..................................................................................................................................... 8 
3.4 Recruitment ............................................................................................................................................. 8 
3.5 Indocyanine green ................................................................................................................................... 9 
3.6 Surgical procedure and perfusion assessment ......................................................................................... 9 
3.7.1 Screening Laparoscopy ..................................................................................................................... 9 
3.7.2 Resection of gastric cancer ............................................................................................................... 9 
3.7.3 Fluorescence angiography .............................................................................................................. 10 
3.8 Statistics ................................................................................................................................................. 10 
4. Adverse events, risks, and disadvantages .................................................................................................... 10 
5. Patient data .................................................................................................................................................. 10 
6. Ethical considerations .................................................................................................................................. 11 
7. Publication ................................................................................................................................................... 11 
8. Timeframe ................................................................................................................................................... 12 
9. Economy ...................................................................................................................................................... 12 
10. Insurance.................................................................................................................................................... 12 
11. References ................................................................................................................................................. 13 
 
 
 

Version 4.0 25/8-2021 
 
 
1. Investigators and affiliations  
 
Title: The effect of chemotherapy on gastric perfusion in patients with gastric cancer. 
.   
Principal investigator: Jens Osterkamp, MD, PhD-student 1 
 
Principal supervisor: Michael Patrick Achiam, MD, Associate professor, PhD, DMSci 1 
 
Addition supervisors: Nikolaj Nerup, MD, PhD1, Rune Broni Strandby, MD, PhD1, Jesper Frank 
Christensen, PhD1,2, Morten Bo Svendsen, MScEng, PhD3, Lars Bo Svendsen, MD, Professor, 
DMSci 1, Ekse Kvanner Aasvang MD, Associate professor, PhD4 
 
Affiliations: 
 
1. Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of 
Copenhagen, Inge Lehmanns Vej 7, DK-2100 Copenhagen Ø, Denmark 
2. Center of Inflammation and Metabolism/Center for Physical Activity Research 
(CIM/CFAS), Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 9, 
DK-2100 Copenhagen Ø, Denmark  
3. Center for Medical Education and Simulation (CAMES), Capital Region of Denmark, 
Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark 
4. Department of Anaesthesiology, Rigshospitalet, University of Copenhagen, Inge Lehmanns 
Vej 7, DK-2100 Copenhagen Ø, Denmark 
 
Correspondence:  
Jens Osterkamp 
Department of Surgical Gastroenterology, 
Rigshospitalet, University Hospital of Copenhagen  
Inge Lehmanns Vej 7, DK-2100 Copenhagen Ø,  
Denmark  
Jens.thomas.fredrik.osterkamp.02@regionh.dk 
Tele: +45 35 45 86 15 
 

Version 4.0 25/8-2021 
 
 
2. Introduction 
2.1 Summary of the study 
A study from our group (Osterkamp et al. in preparation) used ICG to evaluate intraoperative 
changes in gastric perfusion when reducing the circulating blood volume by blood withdrawal in 
pigs. We saw a significant reduction in gastric perfusion with decreased blood volume, and this 
reduction of gastric perfusion was detectable with ICG. As data from a previous trial (PRESET 
phase 2 Protocol nr: H-15014904) has shown that chemotherapy decreases the circulating red blood 
cell volume in patients with gastroesophageal cancer, we wish to evaluate if standard care 
neoadjuvant chemotherapy also influences gastric perfusion. Gastric perfusion will be assessed 
during a screening laparoscopy (before chemotherapy) and then compared with a second assessment 
during gastric resection (after chemotherapy). The gastric perfusion will be measured using 
fluorescence-guided surgery with Indocyanine Green.  
 
2.2 Gastric perfusion after neoadjuvant chemotherapy treatment 
In the preoperative period during chemotherapy, there is a risk of disease progression in non-
responders, all the while physical deterioration and chemo-toxicity can increase the risk of severe 
peri- or postoperative complications due to poor performance status. Indeed, strong observational 
evidence supports that poor muscular function, defined as either a low muscle mass/area 
(sarcopenia) or low functional strength, is a strong independent predictor of post-surgical outcomes 
including mortality and surgical complications in patients undergoing surgery for gastrointestinal 
cancers 1. Thus, it remains a critical double-sided challenge to ensure that patients diagnosed with 
resectable gastric cancer attain surgery while in a sufficient physiological condition 2.  
 
Impaired blood perfusion of an anastomosis is a significant risk factor for anastomotic 
leakages after surgery 3–7. Inadequate perfusion appears to be related to intraoperative events such 
as low arterial oxygen saturation, metabolic acidosis, and physical tension on the anastomosis, 
which all may lead to impaired anastomotic healing 8–10. However, ways to improve tissue blood 
perfusion during surgery are poorly understood, but maintaining the total blood volume may be a 
key factor for preventing marked drops in organ perfusion during surgery. Blood volume - 
including hemoglobin mass, red blood cell volume, plasma volume, and total blood volume - is a 
complex physiological feature which is not captured by “just” measuring hemoglobin concentration 
11. In order to evaluate if chemotherapy leads to impaired blood perfusion is, we aim to investigate 
the gastric perfusion before and after oncological treatment.  

Version 4.0 25/8-2021 
 
 
 
In a collaboration between Center for Physical Activity Research (CIM/CFAS) and the 
Departments of Surgical Gastroenterology and Oncology, Copenhagen University Hospital, 
Rigshospitalet (from April 2016 to September 2017), a phase 2 study (PRESET phase 2 Protocol nr: 
H-15014904) was conducted. Patients (n = 21) presenting with cancer of the gastroesophageal 
junction were allocated without randomization (based on geographical residence) to standard care 
or a 12 weeks exercise training intervention during neoadjuvant chemotherapy. Various clinical 
outcomes were collected to investigate if improvements in exercise capacity, muscle strength, or 
patient-reported symptoms, translated into overall improved treatment tolerability. Results showed a 
potentially lower risk in the exercise-group for treatment failure, defined as patients precluded from 
surgery due to death, disease progression or physical deterioration, treatment toxicities, and/or 
hospitalization 12. These results have led to the initiation of a more extensive phase 3 randomized 
controlled trial (Protocol nr: H-18009502) of preoperative exercise training vs. standard care during 
neoadjuvant chemotherapy in patients with gastroesophageal cancer. Preliminary data from this trial 
show a substantial (up to 25%) reduction in red blood cell volume after chemotherapy. Importantly, 
the corresponding changes in hemoglobin concentration (as measured by standard hematological 
assessment) overestimate the loss of red blood cells and has a poor level of agreement with total Hb 
mass. For example, patients experiencing a median of approx. 15% drop in Hb concentration range 
showed a reduction in Hb mass from 0% to 25%. 
 
Such a reduction in total oxygen-carrying capacity may reduce the peripheral tissue 
perfusion and oxygenation, e.g. in the tissue used for the construction of the anastomosis. Thus,  
giving rise to a risk of anastomotic leakage as other types of postoperative complications. Yet, this 
association has not been examined previously.  
 
2.3 Fluorescence guided surgery with Indocyanine Green. 
Fluorescence guided surgery enables visualization of tissue circulation and structures that otherwise 
are hidden from the human eye. A fluorescent contrast agent is used, often Indocyanine Green 
(ICG), and by illuminating the tissue with near-infrared light, the excited ICG can be detected by a 
camera with an optical filter. ICG is a tricarbocyanine dye with few adverse events, a short half-life, 
it is metabolized exclusively in the liver, and excreted unchanged in the bile 13,14. The safety of ICG 
is well established, and it is used routinely in surgical clinics worldwide and also has gained 
popularity in oncological surgery in recent years 13–15.  

Version 4.0 25/8-2021 
 
 
ICG binds to plasma proteins after intravenous injection, and by illuminating the 
tissue with near-infrared red light, a fluorescence signal time-series during first passage past tissue 
is considered proportional to microvascular flow, i.e., perfusion.  
Assessing gastrointestinal blood supply without the use of ICG is challenging, even 
for experienced surgeons. Of specific concern is the vascular supply of the anastomosis since an 
inadequate blood supply is a significant risk factor for anastomotic leakage 3–7. As ICG angiography 
allows for real-time visualization of visceral perfusion, an inadequate vascularisation of the 
anastomosis can be detected and addressed intraoperatively 16–19. Of importance, the use of 
perioperative ICG angiography has been shown to lower the risk of anastomotic leakage 20–23.  
We have developed an ICG quantification algorithm that has been validated and 
described earlier 24. This algorithm has now been incorporated into a touch screen tablet, allowing 
for live perioperative quantitative perfusion assessments with ICG (q-ICG) (Nerup et. al 
Langenbeck Arch Surg 2020, accepted for publication). A color-coded map of the perfusion-
intensity is provided as an overlay on the white light visualized tissue (Figure 1).  
 
 
Figure 1. Gastric conduit after pull-up to the thorax viewed by white light, Near-Infrared Light (ICG), and with q-ICG 
overlay.  
 
A study from our group (Osterkamp et al. in preparation) used q-ICG to evaluate 
intraoperative changes in gastric microcirculation when reducing the circulating blood volume by 
withdrawal of blood in pigs. We found a significant reduction in gastric perfusion as detected by q-
ICG as the blood volume decreased.  
 
By using q-ICG, we aim to assess gastric perfusion during the standardized diagnostic 
staging laparoscopy (before chemotherapy) in patients with gastric cancer. After treatment with 
neoadjuvant chemotherapy, we will re-assess the gastric perfusion in the same patients with q-ICG 

Version 4.0 25/8-2021 
 
 
during the surgical resection. The difference in perfusion before and after neoadjuvant 
chemotherapy will be evaluated. 
 
2.3 Aim 
We aim to evaluate if standard care neoadjuvant chemotherapy influences gastric perfusion.   
 
 2.4 Hypothesis 
We hypothesize that standard care neoadjuvant chemotherapy will reduce gastric perfusion. 
 
2.5 Primary endpoint 
The primary endpoint is the difference in gastric perfusion (obtained with q-ICG) before and after 
neoadjuvant chemotherapy. 
 
2.6 Secondary endpoint 
Secondary endpoints are: 
Short term outcome; postoperative events and complications as graded by the Dindo-Clavien 
classification and the Comprehensive Complication Index, length of hospital stay (data will be 
noted 30 days postoperatively). Complications after surgery will be defined as any deviation from 
the ordinary postoperative course. This definition also takes into account asymptomatic 
complications such as arrhythmia and atelectasis. 
 
 3. Methods 
3.1 Study design / Sample size 
We aim to assess gastric perfusion before and after standard of care neoadjuvant chemotherapy. The 
sample size calculation is based on the relationship between changes in blood volume and the 
fluorescent signal from an earlier study (Osterkamp et al. in preparation) as on data an ongoing trial 
(chemotherapy-induced reduction in whole blood volume; Protocol nr: H-18009502). The sample 
size required is n=25 to attain a correlation coefficient of 0.5 with a probability of a type I error (α) 
of 0.05 and power (1 − β) of 0.8). Taking into account an average dropout-rate of approximately 
20% in clinical trial, 30 patients will be included 25. Prospective evaluations of the surgical outcome 
will be recorded by means of anastomotic leakage rates (verified endoscopically or/and 

Version 4.0 25/8-2021 
 
 
radiologically), delayed gastric emptying (verified with barium swallow examination and/or 
endoscopy), and other postoperative complications including mortality. The trial will be conducted 
in accordance with the CONSORT guidelines 26.    
 
3.2 Inclusion criteria 
Patients (above 18 years) scheduled for planned open or robot-assisted resection of gastric cancer. 
 
3.3 Exclusion criteria 
- Allergy towards; iodine, indocyanine green or shellfish 
- Severe liver insufficiency  
- Thyrotoxicosis 
- Nephropathy requiring dialysis 
- Pregnancy or lactation 
- Legally incompetent for any reason 
- Withdrawal of inclusion consent  
- Disseminated disease or other that contraindicates curative surgery 
 
3.4 Recruitment 
Upon meeting in the outpatient clinic, the patients will be informed about an ongoing study and 
asked if they wish further information. If accepted, the principal investigator will be called to the 
outpatient clinic to briefly inform the patient about the project and ask about allergy towards iodine, 
indocyanine green or shellfish, liver insufficiency, thyrotoxicosis, pregnancy or lactation. If there 
are no allergies or other contraindications for inclusion, the patient will receive written and oral 
information about the project from a separate office by the principal investigator. The potential 
participant will be asked if he or she wishes to bring a family member or other bystander to the 
information interview. If no bystander is present, and the patient wishes for one to be present, a new 
meeting will be arranged to conduct the information interview in which a bystander can participate. 
The meeting office is a closed office occupied by the principal investigator. After the meeting, a 
follow-up telephone call regarding inclusion will be held roughly one week after the first meeting. 
The principal investigators’ telephone number and email will be handed out, allowing the patient to 
get in contact if necessary. If interested in participation, the patient will supply the principal 
investigator with written consent. All patients are informed of the possibility of withdrawal of their 

Version 4.0 25/8-2021 
 
 
consent at any time during the trial without any consequence for the operation or their treatment. 
First, after written consent, will inclusion in the study be possible.  
 
3.5 Indocyanine green  
Indocyanine green is a well-described non-toxic tricarbocyanine dye used for decades in 
ophthalmology, cardiology, and hepatology. Very few mild adverse reactions have been reported, 
but caution in patients with thyrotoxicosis, allergy towards iodine, or indocyanine green should be 
made. When injected, it binds to blood lipoproteins and is solely metabolized by the liver and 
excreted in the bile, with a short half-life of approximately 4-5 minutes 13,15,27. Indocyanine green is 
already used routinely in many specialties, here among surgery, ophthalmology, hepatology, and 
cardiology 13–15,27,28.  
 
3.6 Surgical procedure and perfusion assessment 
 
3.7.1 Screening Laparoscopy 
As part of the standard care for gastric cancer, all patients undergo a screening laparoscopy before 
entering neoadjuvant chemotherapy. The procedure is performed to detect overt metastases not 
detected on the CT/PET-CT scans. First, the patient is placed under a standardized general 
anesthesia, and the laparoscopic set-up is completed. After anesthesia a peripheral arterial catheter 
will be placed in order acquire reading of cardia output and stroke volume. The patient will then be 
fluid optimized using a standardized stroke volume (SV) optimization algorithm. The abdomen is 
inspected visually for signs of metastatic disease. The small bowel is then manipulated, allowing for 
visualization of the stomach. A bolus of ICG (0.2 mg/kg body weight) will be injected 
intravenously and flushed with 5 mL of saline. Gastric perfusion will subsequently be assessed 
along specific regions of interest (ROI) with q-ICG to obtain baseline perfusion values.  
 
3.7.2 Resection of gastric cancer 
The patient is placed under general anesthesia and after the stomach is visualized through surgical 
incision, a bolus of ICG (0.2 mg/kg body weight) will be injected intravenously and flushed with 5 
mL of saline. The ROIs (the same ROIs as described in 3.7.1) will then be assessed with q-ICG. 
The anesthetic protocol will up to this point match that of the setting during the screening 
laparoscopy.  

Version 4.0 25/8-2021 
 
 
 
3.7.3 Fluorescence angiography 
During the screening laparoscopy, a laparoscope (ICG-Hopkins telescope 30°, 10 mm, Karl Storz 
Gmbh and Co. KG, Tüttlingen, Germany) will be connected to a camera system (IMAGE1, Karl 
Storz Gmbh, and Co. KG, Tüttlingen, Germany) and a light-source (D-light P, Karl Storz Gmbh 
and Co. KG, Tüttlingen, Germany) will supply the excitatory light and record the ICG angiography. 
The laparoscope will be fixed in a mechanical holding arm 10 cm from the tissue of interest, 
ensuring a stable position throughout the experiment.  
 
  
3.8 Statistics 
A comparison of the gastric perfusion before and after chemotherapy will be performed using 
Friedman’s test or a repeated measures ANOVA / linear mixed-effects depending on a non- or 
parametric nature of the data. A P-value < 0.05 will be considered significant. Statistic evaluation 
will be performed using IBM SPSS Statistics © (v 22.0 SPSS Inc. Chicago, IL, USA).  
 
4. Adverse events, risks, and disadvantages 
Adverse events associated with the use of ICG are rare and severe anaphylactic reactions extremely 
rare 14,27. However, safety precautions will be made by excluding patients with allergy to iodine, 
ICG, or shellfish. Also, we will not include patients with severe kidney and liver insufficiency, 
thyrotoxicosis, and pregnant or lactating women. The total dose of dye injected 
will be kept well below the recommended 2 mg/kg 29. There are no data available describing the 
signs, symptoms, or laboratory findings accompanying overdosage. The  LD50 after I.V. 
administration ranges between 60 and 80 mg/kg in mice, 50 and 70 mg/kg in rats and 50 and 80 
mg/kg in rabbits 29. 
 
5. Patient data  
Upon meeting in the outpatient clinic, the patients will be informed about an ongoing study and 
asked if they wish further information. If accepted, the principal investigator will be called and to 
briefly inform the patient about the project, and ask about allergy towards; iodine, indocyanine 
green or shellfish, liver insufficiency, thyrotoxicosis, pregnancy or lactation. If no allergies exist, 
the patient will then receive written, and oral information about the project and a follow-up 

Version 4.0 25/8-2021 
 
 
telephone call regarding inclusion will be held. If interested in participation, the patient will supply 
the principal investigator with written consent. First, after written consent has been provided, will 
the patient’s electronic journal be available to the principal investigator. This, to see information 
about the subject’s health and the course during hospitalization necessary as part of the research 
project. Including self-control, quality control, and monitoring, which are obligatory. Data obtained 
from electronic patient records are registered prospectively and pseudo-anonymized in a database 
and kept at the secure server provided by Region Hovedstaden (L: PerfussionVentrikel). Thus, data 
in this database may not be identified back to the patient without access to a patient participation list 
linking patient identification number and the pseudo anonymization number. This participation list 
will be stored in another folder on the secure server provided by the Region Hovedstaden (V: 
PerfussionVentrikel). Only the principal investigator and principal supervisor will have access to 
these folders and files. The law on the processing of personal data (databeskyttelsesforordningen 
and databeskyttelsesloven) will be followed. No data will be sent to other countries. Permission 
from the national data protection (Datatilsynet) agency will be obtained.  
 
6. Ethical considerations 
Approval from the regional ethical committee and the national data protection agency will be in 
place before initiating the study.  
ICG is a safe and non-toxic fluorescent dye as described and has been used for decades in 
ophthalmology, cardiology, and hepatology. Very few adverse reactions are reported 14,27. Patients 
may withdraw from the study at any time. The patients participating in the study will not be paid to 
participate.  
 
 
7. Publication 
We will publish negative, positive, and inconclusive results in international reputed surgical 
journals, possibly as open access with Jens Osterkamp as the primary and corresponding author. 
Also, we will present the work at national and/or international surgical conferences and meetings to 
share the findings with a large crowd of clinicians and researchers.   
 

Version 4.0 25/8-2021 
 
 
8. Timeframe 
The study will be initiated as soon as we have approval from the ethical committee and the national 
data protection agency. Hopefully, starting in the fall of 2021, and completed ultimo 2023.  
 
9. Economy 
This study is a part of the principal investigators’ PhD-thesis, which is covered by a grant to 
department C-Tx from Medtronic with a total amount of 2.255.842 DKK. in which salary and 
experimental costs (acquisition of ICG) will be covered. With regards to study design, realization, 
and presentation, the research group has complete autonomy. No remuneration will be given to 
patients participating in the trial. The principal investigator has in collaboration with the project 
group, initiated the project. There are no financial interests for the project group in this project. 
Equipment (tablet, video-capture device, laparoscopic equipment, surgical robot) is already present 
in the department. If additional support is granted, the name of the foundation(s), size of the 
amount, any relation between the grant provider and investigators, as well as any requirements of 
the grants will be announced to the committee and project participants (patients).  
 
10. Insurance  
Patients will be covered by the national Danish patient insurance. 
 
 

Version 4.0 25/8-2021 
 
 
11. References 
1. 
Simonsen, C. et al. Sarcopenia and Postoperative Complication Risk in Gastrointestinal Surgical 
Oncology. Ann. Surg. 1 (2018). doi:10.1097/SLA.0000000000002679 
2. 
Horowitz, M., Neeman, E., Sharon, E. & Ben-Eliyahu, S. Exploiting the critical perioperative period to 
improve long-term cancer outcomes. Nat.Rev.Clin.Oncol. 12, 213–226 (2015). 
3. 
Pommergaard, H.-C., Achiam, M. P., Burcharth, J. & Rosenberg, J. Impaired blood supply in the 
colonic anastomosis in mice compromises healing. Int. Surg. 100, 70–6 (2015). 
4. 
Fawcett, A. et al. Smoking, hypertension, and colonic anastomotic healing; a combined clinical and 
histopathological study. Gut 38, 714–8 (1996). 
5. 
Kim, M. J. et al. The impact of heavy smoking on anastomotic leakage and stricture after low 
anterior resection in rectal cancer patients. World J. Surg. 35, 2806–10 (2011). 
6. 
Kruschewski, M., Rieger, H., Pohlen, U., Hotz, H. G. & Buhr, H. J. Risk factors for clinical anastomotic 
leakage and postoperative mortality in elective surgery for rectal cancer. Int. J. Colorectal Dis. 22, 
919–927 (2007). 
7. 
Kassis, E. S. et al. Predictors of Anastomotic Leak After Esophagectomy: An Analysis of The Society of 
Thoracic Surgeons General Thoracic Database. Ann. Thorac. Surg. 96, 1919–1926 (2013). 
8. 
Chadi, S. A. et al. Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal 
Anastomotic Leakage. J. Gastrointest. Surg. 20, 2035–2051 (2016). 
9. 
Trencheva, K. et al. Identifying Important Predictors for Anastomotic Leak After Colon and Rectal 
Resection. Ann. Surg. 257, 108–113 (2013). 
10. 
Thompson, S. K., Chang, E. Y. & Jobe, B. A. Clinical review: Healing in gastrointestinal anastomoses, 
Part I. Microsurgery 26, 131–136 (2006). 
11. 
Otto, J. M. et al. Total haemoglobin mass, but not haemoglobin concentration, is associated with 
preoperative cardiopulmonary exercise testing-derived oxygen-consumption variables. Br. J. 
Anaesth. 118, 747–754 (2017). 
12. 
Christensen, J. F. et al. Safety and efficacy of resistance training in germ cell cancer patients 
undergoing chemotherapy: A randomized controlled trial. Br. J. Cancer 111, 8–16 (2014). 
13. 
Staller, B. J., Staller, B. J., Hepner, G., Banka, V. S. & Finney, R. A. Adverse Reactions After 
Administration of Indocyanine Green. JAMA J. Am. Med. Assoc. 240, 635 (1978). 
14. 
Alander, J. T. et al. A Review of Indocyanine Green Fluorescent Imaging in Surgery. Int. J. Biomed. 
Imaging 2012, 1–26 (2012). 
15. 
Baiocchi, G. L., Diana, M. & Boni, L. Indocyanine green-based fluorescence imaging in visceral and 
hepatobiliary and pancreatic surgery: State of the art and future directions. World J. Gastroenterol. 
24, 2921–2930 (2018). 
16. 
Mangano, A. et al. Near-Infrared Indocyanine Green-Enhanced Fluorescence and Evaluation of the 
Bowel Microperfusion During Robotic Colorectal Surgery: a Retrospective Original Paper. Surg. 
Technol. Int. 34, (2019). 

Version 4.0 25/8-2021 
 
 
17. 
Zehetner, J. et al. Intraoperative Assessment of Perfusion of the Gastric Graft and Correlation With 
Anastomotic Leaks After Esophagectomy. Ann. Surg. 262, 74–8 (2015). 
18. 
Mangano, A., Gheza, F., Chen, L. L., Minerva, E. M. & Giulianotti, P. C. Indocyanine Green (Icg)-
Enhanced Fluorescence for Intraoperative Assessment of Bowel Microperfusion During Laparoscopic 
and Robotic Colorectal Surgery: The Quest for Evidence-Based Results. Surg. Technol. Int. 32, 101–
104 (2018). 
19. 
Gossedge, G., Vallance, A. & Jayne, D. Diverse applications for near infra-red intraoperative imaging. 
Color. Dis. 17, 7–11 (2015). 
20. 
Watanabe, J. et al. Indocyanine green fluorescence imaging to reduce the risk of anastomotic 
leakage in laparoscopic low anterior resection for rectal cancer: a propensity score-matched cohort 
study. Surg. Endosc. (2019). doi:10.1007/s00464-019-06751-9 
21. 
Sujatha-Bhaskar, S., Jafari, M. D. & Stamos, M. J. The Role of Fluorescent Angiography in 
Anastomotic Leaks. Surg. Technol. Int. 30, 83–88 (2017). 
22. 
Alekseev, M., Rybakov, E., Shelygin, Y., Chernyshov, S. & Zarodnyuk, I. A Study investigating the 
Perfusion of Colorectal Anastomoses Using FLuorescence AnGiography: results of FLAG randomized 
trial. Color. Dis. (2020). doi:10.1111/codi.15037 
23. 
Ladak, F. et al. Indocyanine green for the prevention of anastomotic leaks following esophagectomy: 
a meta-analysis. Surg. Endosc. 33, 384–394 (2019). 
24. 
Nerup, N. et al. Quantification of fluorescence angiography in a porcine model. Langenbeck’s Arch. 
Surg. 402, 655–662 (2017). 
25. 
Bell, M. L., Kenward, M. G., Fairclough, D. L. & Horton, N. J. Differential dropout and bias in 
randomised controlled trials: when it matters and when it may not. BMJ 346, (2013). 
26. 
Moher, D. et al. CONSORT 2010 Explanation and Elaboration: updated guidelines for reporting 
parallel group randomised trials. BMJ 340, c869 (2010). 
27. 
Owens, S. L. Indocyanine green angiography. Br. J. Ophthalmol. 80, 263–6 (1996). 
28. 
Spinoglio, G., Bertani, E., Borin, S., Piccioli, A. & Petz, W. Green indocyanine fluorescence in robotic 
abdominal surgery. Updates Surg. 70, 375–379 (2018). 
29. 
FDA Professional Drug Information. Indocyanine Green - FDA prescribing information, side effects 
and uses. (2018).