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Feasibility of Use of Indocyanine Green in Pediatric Colorectal Surgery

Primary Purpose

Hirschsprung Disease, Anorectal Malformations

Status
Recruiting
Phase
Phase 3
Locations
Canada
Study Type
Interventional
Intervention
Indocyanine green
Sponsored by
Lawson Health Research Institute
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Hirschsprung Disease

Eligibility Criteria

1 Month - 7 Years (Child)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  1. All patients with Hirschsprung's disease or anorectal malformations, diagnosed by:

    1. Clinical evaluation and physical examination
    2. Radiologic studies including abdominal x-rays and/or contrast enemas
    3. Pathologic diagnosis after rectal biopsies (HD only)
  2. Patients greater than one-month of age to 7 years of age at the time of surgery
  3. Patient requires surgical management for their diagnosis
  4. Patient/Substitute decision maker (SDM) able to read/write/understand English

Exclusion Criteria:

  1. Those patients and SDM unwilling to provide consent
  2. Pregnant and/or women who are breast feeding
  3. Patients with a known iodine allergy

Sites / Locations

  • Children's Hospital, London Health Sciences CentreRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

No Intervention

Arm Label

Treatment Arm (Indocyanine Green [ICG])

Control Arm (Standard Care)

Arm Description

The ICG group will involve the patient receiving standard care for either HD or ARM, in addition to 1.25mg (maximum dose less than 2mg/kg body weight) of ICG intraoperatively, administered intravenously. ICG will be administered by a member of the anesthesia team when directed by the surgeon (research team member).

The Standard Care group will have no change to the medical and surgical care they receive while in the hospital. The surgeon will perform the surgery as they normally would outside of this study. This involves a laparoscopic-assisted transanal pullthrough surgery.

Outcomes

Primary Outcome Measures

The number of eligible paediatric patients treated for HD or ARM at the local institute that would qualify for participation in this trial.
The number of eligible patients that are treated for HD and ARM at this institution regardless of if they enrolled in the study or not.
The number of eligible paediatric patients treated for HD or ARM that enroll in this study during the recruitment period of this study.
The number of eligible patient who enroll in this study during the recruitment period compared to the total number of eligible patient.
The number of eligible paediatric patients treated for HD or ARM that enroll in this study and attend al required study visits.
This outcome will capture the number of patient who are enrolled in the study and present to the hospital on the day of surgery, and for each follow-up visit where data will be collected.
The number of eligible paediatric patients treated for HD or ARM that enrolled in this study but are lost to attrition/drop-out during the study
This outcome captures the number of patient who enroll in the study but do not complete the study (including follow-up visits) or withdraw from the study before undergoing surgery.

Secondary Outcome Measures

If the use of ICG alters the intraoperative management of the patient, resulting in the surgeon resecting a longer segment of bowel.
This will be difference in where the surgeon would resect the bowel based on their clinical judgement and where the blood perfusion (indicated by ICG) suggests the resection should be made. This will be measure in millimeters.
If the use of ICG alters the length of operative time between ICG and control group
This will be measured by comparing the length of operation for similar cases/diagnoses that are randomized to each study arm. This will be measured in minutes
If the use of ICG alters the length of stay in hospital between ICG and control group
This outcome will be tracked by measuring the length of hospital stay post-surgery for each patient enrolled in the study. This will be recorded in days.
Rates of anastomotic dehiscence
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.
Rates of anal stricture (mild) not requiring anal dilatations
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.
Rate of anal stricture (moderate or severe) requiring anal dilatations
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.
Rate of hospital readmission in the first 30 days postoperatively
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the patient's medical chart.
Rate of an additional related procedure under general anaesthesia (i.e. return to the operating room or interventional radiology)
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.

Full Information

First Posted
May 14, 2021
Last Updated
January 13, 2023
Sponsor
Lawson Health Research Institute
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1. Study Identification

Unique Protocol Identification Number
NCT04904081
Brief Title
Feasibility of Use of Indocyanine Green in Pediatric Colorectal Surgery
Official Title
The Use of Indocyanine Green Angiography in Pediatric Colorectal Surgery: A Feasibility Randomized Controlled Trial
Study Type
Interventional

2. Study Status

Record Verification Date
January 2023
Overall Recruitment Status
Recruiting
Study Start Date
June 16, 2021 (Actual)
Primary Completion Date
May 2024 (Anticipated)
Study Completion Date
July 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Lawson Health Research Institute

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
Hirschsprung's Disease (HD) and anorectal malformations (ARM) are both paediatric diseases of the colon and rectum. Both of these conditions require surgery in order to correct them, frequently needing sections of the bowel to be removed. Some complications of removing parts of the bowel include forming a stricture (a narrowing of the place where the bowel is reattached), and leak from the join. These can be devastating complications, and can significantly impact a patient's quality of life. Indocyanine green (ICG) is a medication that binds to blood vessels and can be visualized using special cameras in the operating room. Once it binds, it "lights up" green on this equipment. This lends the advantage of being able to better see which parts of the bowel get good blood flow. The theory is that good blood flow can reduce the risks of previously mentioned complications. This has been shown to be true in a variety of bowel surgeries in adults. ICG has also been shown to be safe in children. Given that HD and ARM are both relatively rare conditions (~1/5000 live births), research in this area needs to be strategic. The investigators want to ensure that the investigators can recruit enough patients to the study using this protocol such that if this were to be scaled up to a multi-centre trial in the future, the investigators could demonstrate feasibility. The investigators will collect data both on the feasibility of recruitment as the primary outcome and secondary outcomes including stricture, leak, length of stay in hospital, and return to hospital.
Detailed Description
Pediatric colorectal conditions, such as Hirschsprung's disease (HD) and anorectal malformations (ARM), result in significant disease burden in pediatric populations in Canada. Both conditions are present in approximately 1 in 5000 live births. Surgical correction of these anomalies is typically performed in Children's Hospitals in Canada. Postoperative complications, such as anal stricture and anal stenosis, have been reported to occur in 2-35% and 2-10%, after posterior-sagittal anorectoplasty (PSARP) and laparoscopic-assisted pull through for ARM and HD, respectively. In addition, anastomotic leaks and dehiscence are life-threatening, and should be avoided at all costs. The literature estimates the rate of anastomotic leak in HD to be approximately 2%, but have been reported in as high as 10% in neonatal patients. Wound dehiscence post ARM repair has been estimated as high as 30-40%. It is hypothesized that the above post-operative complications occur due to compromised vascular supply to the bowel undergoing coloanal anastomosis at the time of pull-through. Traditionally, surgeons evaluate bowel viability with tactile and visual means, including discoloration, bleeding from the cut edge, and peristalsis after resection. With the push towards minimally invasive surgeries over recent decades, the adoption of surgical technology which can replace open or tactile assessments is necessary. One such example is the use of indocyanine green (ICG) for assessing bowel perfusion in laparoscopic surgery. ICG is a nontoxic, nonimmunogenic, water-soluble intravascular imagine agent. It has a short half-life (approximately 3-5 minutes) and when injected intravenously, it binds to plasma proteins and proteins in the lymph fluid keeping it in the intravascular compartment. ICG absorbs light in the near-infrared region (806 nm) and emits fluorescent light at 830 nm. ICG was approved by the Food and Drug Administration (FDA, New Drug Application [NDA] 211580 505(b)(2) via fda.gov) for use in adults in the late 1950s and has since been approved for use in adults by Health Canada. A review article published in 2012 identified over 200 manuscripts describing safe and reliable use of ICG in surgical procedures in adults. More specifically, qualitative analysis of bowel perfusion enhanced by ICG in colorectal cancer patients has been shown to reduce rates of anastomotic leak by approximately 4%. Practically speaking, the use of ICG florescence technique can be useful in identifying clinical vascular anatomy in colorectal surgery, both via open and laparoscopic approaches, allowing surgeons to better preserve important structures. Several studies have shown that ICG is safe among pediatric populations, with utility demonstrated in cases of difficult cholecystectomy, hydrocele repairs, and localizing metastatic disease. As such, the FDA has approved the use of ICG in paediatric patients. Research studies from the US, have examined the intravenous application of ICG for more than 60 years in adults and children with few reported adverse effects. However, Health Canada has not reported on the safety and efficacy of ICG and does not authorize an indication for its use. To our knowledge, there have only been two studies that have looked at intraoperative ICG to visualize intestinal perfusion for primary pull-through in Hirschsprung Disease and anorectal malformation repair patients and both were retrospective studies. A previous study included eight patients, diagnosed with HD undergoing transanal, open or laparoscopically-assisted pull-through procedures after biopsy confirmation of aganglionosis. Patients were given a dose of 1.25mg (<2 mg/kg) of ICG intraoperatively in the operating room. In five of the eight patients, the level of the bowel transection was changed based on the ICG visualization. In the other three patients, ICG confirmed the surgeon's assessment of where the resection should occur. There were no intraoperative complications or complications noted at two-week, one-month, and three-month follow-up visits. Further no leaks, incontinence, or strictures were noted at any of these follow-up visits. Another study 16 included 13 patients in total, nine undergoing cloacal reconstruction, four with HD and one with an ARM. ICG was used to predict the vascular supply during the reconstruction procedure and patients were given an intravenous dose of ICG between 0.1 to 0.3mg/kg in the operating room. There were no intraoperative adverse events or side effects from the ICG. ICG changed the operative plan in four out of 13 cases (31%), one of those four cases being a pull-through for HD. For this HD case, ICG resulted in the detection of 10cm of non-viable colon which may not have previously been detected. Although the level of evidence is limited by study design and small sample sizes, these studies help to provide rationale for the continued study of ICG use in paediatric patients. Despite the results from these studies, future work is needed before he investigators can determine the effectiveness of ICG in reducing rates of post PSARP and pull-through complications. Practically speaking, the main inhibitors to widespread adoption of ICG in these surgeries is the cost of the technology, and lack of data to support that it truly reduces the rates of complications associated with these surgeries. Our research team, looks to be the first group to explore the feasibility of using ICG in a paediatric population with Hirschsprung's Disease and anorectal malformations. The investigators hope that the results from the study will help to initiate future multicenter, randomized controlled trials to provide high level evidence to support the use of ICG in colorectal surgeries in paediatric patients.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Hirschsprung Disease, Anorectal Malformations

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 3
Interventional Study Model
Parallel Assignment
Masking
Participant
Masking Description
Single-blind (participants only)
Allocation
Randomized
Enrollment
12 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Treatment Arm (Indocyanine Green [ICG])
Arm Type
Experimental
Arm Description
The ICG group will involve the patient receiving standard care for either HD or ARM, in addition to 1.25mg (maximum dose less than 2mg/kg body weight) of ICG intraoperatively, administered intravenously. ICG will be administered by a member of the anesthesia team when directed by the surgeon (research team member).
Arm Title
Control Arm (Standard Care)
Arm Type
No Intervention
Arm Description
The Standard Care group will have no change to the medical and surgical care they receive while in the hospital. The surgeon will perform the surgery as they normally would outside of this study. This involves a laparoscopic-assisted transanal pullthrough surgery.
Intervention Type
Drug
Intervention Name(s)
Indocyanine green
Intervention Description
The ICG group will involve the patient receiving standard care for either HD or ARM, in addition to 1.25mg (maximum dose less than 2mg/kg body weight) of ICG intraoperatively, administered intravenously. ICG will be administered by a member of the anesthesia team when directed by the surgeon (research team member).
Primary Outcome Measure Information:
Title
The number of eligible paediatric patients treated for HD or ARM at the local institute that would qualify for participation in this trial.
Description
The number of eligible patients that are treated for HD and ARM at this institution regardless of if they enrolled in the study or not.
Time Frame
12 months
Title
The number of eligible paediatric patients treated for HD or ARM that enroll in this study during the recruitment period of this study.
Description
The number of eligible patient who enroll in this study during the recruitment period compared to the total number of eligible patient.
Time Frame
12 months
Title
The number of eligible paediatric patients treated for HD or ARM that enroll in this study and attend al required study visits.
Description
This outcome will capture the number of patient who are enrolled in the study and present to the hospital on the day of surgery, and for each follow-up visit where data will be collected.
Time Frame
12 months
Title
The number of eligible paediatric patients treated for HD or ARM that enrolled in this study but are lost to attrition/drop-out during the study
Description
This outcome captures the number of patient who enroll in the study but do not complete the study (including follow-up visits) or withdraw from the study before undergoing surgery.
Time Frame
12 months
Secondary Outcome Measure Information:
Title
If the use of ICG alters the intraoperative management of the patient, resulting in the surgeon resecting a longer segment of bowel.
Description
This will be difference in where the surgeon would resect the bowel based on their clinical judgement and where the blood perfusion (indicated by ICG) suggests the resection should be made. This will be measure in millimeters.
Time Frame
5 hours
Title
If the use of ICG alters the length of operative time between ICG and control group
Description
This will be measured by comparing the length of operation for similar cases/diagnoses that are randomized to each study arm. This will be measured in minutes
Time Frame
5 hours
Title
If the use of ICG alters the length of stay in hospital between ICG and control group
Description
This outcome will be tracked by measuring the length of hospital stay post-surgery for each patient enrolled in the study. This will be recorded in days.
Time Frame
2 weeks
Title
Rates of anastomotic dehiscence
Description
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.
Time Frame
Up to 6 months post surgery
Title
Rates of anal stricture (mild) not requiring anal dilatations
Description
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.
Time Frame
Up to 6 months post surgery
Title
Rate of anal stricture (moderate or severe) requiring anal dilatations
Description
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.
Time Frame
Up to 6 months post surgery
Title
Rate of hospital readmission in the first 30 days postoperatively
Description
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the patient's medical chart.
Time Frame
Up to 6 months post surgery
Title
Rate of an additional related procedure under general anaesthesia (i.e. return to the operating room or interventional radiology)
Description
This will be monitored as per standard surgical aftercare and monitoring by the surgeon. This data will be collected from the assessment of the surgeon and the patient's medical chart.
Time Frame
Up to 6 months post surgery
Other Pre-specified Outcome Measures:
Title
Adverse reaction to ICG resulting in anaphylaxis
Description
Patient will be monitored for this condition in the operating room during the surgery and up until they are discharged from hospital post-surgery.
Time Frame
Up to 2 weeks post-op
Title
Adverse reaction to ICG resulting in urticarial reactions
Description
Patient will be monitored for this condition in the operating room during the surgery and up until they are discharged from hospital post-surgery.
Time Frame
Up to 2 weeks post-op
Title
Adverse reaction to ICG resulting in drug interactions
Description
Patient will be monitored for this condition in the operating room during the surgery and up until they are discharged from hospital post-surgery.
Time Frame
Up to 2 weeks post-op
Title
Adverse reaction to ICG resulting in adverse events/complications
Description
Patient will be monitored for this condition in the operating room during the surgery and up until they are discharged from hospital post-surgery.
Time Frame
Up to 2 weeks post-op

10. Eligibility

Sex
All
Minimum Age & Unit of Time
1 Month
Maximum Age & Unit of Time
7 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: All patients with Hirschsprung's disease or anorectal malformations, diagnosed by: Clinical evaluation and physical examination Radiologic studies including abdominal x-rays and/or contrast enemas Pathologic diagnosis after rectal biopsies (HD only) Patients greater than one-month of age to 7 years of age at the time of surgery Patient requires surgical management for their diagnosis Patient/Substitute decision maker (SDM) able to read/write/understand English Exclusion Criteria: Those patients and SDM unwilling to provide consent Pregnant and/or women who are breast feeding Patients with a known iodine allergy
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Jacob Davidson, MSc
Phone
519-685-8500
Ext
53298
Email
Jacob.Davidson@lhsc.on.ca
First Name & Middle Initial & Last Name or Official Title & Degree
Andreana Butter, MD
Phone
519-685-8500
Ext
58401
Email
Andreana.Butter@lhsc.on.ca
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Andreana Butter, MD
Organizational Affiliation
Pediatric Surgeon, Children's Hospital, LHSC
Official's Role
Principal Investigator
Facility Information:
Facility Name
Children's Hospital, London Health Sciences Centre
City
London
State/Province
Ontario
ZIP/Postal Code
N6A5W9
Country
Canada
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Jacob Davidson, MSc
Phone
519-685-8500
Ext
53298
Email
Jacob.Davidson@lhsc.on.ca
First Name & Middle Initial & Last Name & Degree
Andreana Butter, MD
First Name & Middle Initial & Last Name & Degree
Natashia Seemann, MD
First Name & Middle Initial & Last Name & Degree
Jennifer Lam, MD
First Name & Middle Initial & Last Name & Degree
Neil Merritt, MD
First Name & Middle Initial & Last Name & Degree
Robin Wiggen, MD

12. IPD Sharing Statement

Plan to Share IPD
No
IPD Sharing Plan Description
We will not be sharing individual participant data (IPD)
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Feasibility of Use of Indocyanine Green in Pediatric Colorectal Surgery

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