Quantitative indocyanine green fluorescence angiography for anastomotic perfusion assessment during thoracoscopic esophageal atresia repair: a two-phase study.

INTRODUCTION: Thoracoscopic esophageal atresia (EA) repair is associated with high rates of anastomotic complications. Impaired perfusion may contribute to poor healing. Quantitative indocyanine green fluorescence angiography (ICG-FA) may enable objective anastomotic perfusion assessment. This study describes the implementation of quantitative ICG-FA during thoracoscopic EA repair and explores its association with anastomotic complications (leakage and/or stenosis). METHODS: A two-phase study was conducted, including patients undergoing fluorescence-guided thoracoscopic EA repair according to a standardized protocol between February 2024 and February 2026. Phase one consisted of retrospective qualitative and exploratory quantitative assessment. Phase two consisted of prospective quantitative assessment. Fluorescence recordings were postoperatively analyzed for time-to-peak (TTP), normalized peak slope (NPS) and hypoperfusion width. RESULTS: Twenty-nine patients underwent fluorescence-guided thoracoscopic EA repair. No ICG-related adverse events occurred. Anastomotic complications occurred in 17 patients (58.6%). Qualitative assessment demonstrated limited concordance with outcome (62.1%). In the prospective cohort, postoperative quantitative assessment was feasible in 13 patients (86.7%). Patients with anastomotic complications demonstrated a significantly larger hypoperfusion width at the anastomotic site (5 mm vs 2 mm, p = 0.019). No significant differences were observed in TTP and NPS. CONCLUSION: Quantitative anastomotic perfusion assessment using ICG-FA is feasible in thoracoscopic EA repair. Quantitative analysis can provide objective, comparable and reproducible information beyond visual interpretation but requires strict adherence to standardized protocols. Anastomotic complications may be, at least partially, associated with (pre-existent) local perfusion deficits rather than mechanical factors (e.g. tension) only. Future research to validate quantitative parameters may contribute to optimized risk stratification and surgical decision-making.