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De Simone B, Abu-Zidan FM, Boni L, Castillo AMG, Cassinotti E, Corradi F, Di Maggio F, Ashraf H, Baiocchi GL, Tarasconi A, Bonafede M, Truong H, De'Angelis N, Diana M, Coimbra R, Balogh ZJ, Chouillard E, Coccolini F, Kelly MD, Di Saverio S, Di Meo G, Isik A, Leppäniemi A, Litvin A, Moore EE, Pasculli A, Sartelli M, Podda M, Testini M, Wani I, Sakakushev B, Shelat VG, Weber D, Galante JM, Ansaloni L, Agnoletti V, Regimbeau JM, Garulli G, Kirkpatrick AL, Biffl WL, Catena F. Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper. World J Emerg Surg 2025; 20:13. [PMID: 39948641 PMCID: PMC11823064 DOI: 10.1186/s13017-025-00575-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 01/04/2025] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries. AIM This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings. METHODS Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval. RESULTS ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection. CONCLUSIONS Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- Department of Theoretical and Applied Sciences, eCampus University, Novedrate, CO, Italy.
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, UAE
| | - Luigi Boni
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ana Maria Gonzalez Castillo
- Emergency Surgery Unit, Department of General Surgery, Pompeu Fabra University, Hospital del Mar, Barcelona, Spain
| | - Elisa Cassinotti
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Francesco Corradi
- Department of Surgical, Medical andMolecularPathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Di Maggio
- Upper Gastro-Intestinal Surgery Unit, Department of General Surgery, Croydon University Hospital, London, UK
| | - Hajra Ashraf
- Upper Gastro-Intestinal Surgery Unit, Department of General Surgery, Croydon University Hospital, London, UK
| | - Gian Luca Baiocchi
- Unit of General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | | | - Hung Truong
- Acute Care and Minimally Invasive Surgery, Scripps Memorial Hospital - La Jolla, Green, and Encinitas, La Jolla, USA
| | - Nicola De'Angelis
- Unit of Robotic and Minimally Invasive Digestive Surgery, Ferrara University Hospital, Ferrara, Italy
| | - Michele Diana
- Department of Surgery, University Hospital of Geneva, 1205, Geneva, Switzerland
- ICube Laboratory, Photonics Instrumentation for Health, 67034, Strasbourg, France
| | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | | | | | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Joseph M Galante
- UC Davis Health, Hospital Clinical Care Services, University of California, Davis, USA
| | - Luca Ansaloni
- Department of General Surgery, University of Pavia, Pavia, Italy
| | - Vanni Agnoletti
- Level 1 Trauma Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Jean-Marc Regimbeau
- Service de Chirurgie Digestive du CHU d'Amiens, CHU Sud, Centre Hospitalier Universitaire Amiens-Picardie Site Sud, 80054, Amiens, France
| | - Gianluca Garulli
- Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Andrew L Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Fransvea P, Chiarello MM, Fico V, Cariati M, Brisinda G. Indocyanine green: The guide to safer and more effective surgery. World J Gastrointest Surg 2024; 16:641-649. [PMID: 38577071 PMCID: PMC10989327 DOI: 10.4240/wjgs.v16.i3.641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/15/2024] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
In this editorial we comment on the article by Kalayarasan and co-workers published in the recent issue of the World Journal of Gastrointestinal Surgery. The authors present an interesting review on the use of indocyanine green fluorescence in different aspects of abdominal surgery. They also highlight future perspectives of the use of indocyanine green in mini-invasive surgery. Indocyanine green, used for fluorescence imaging, has been approved by the Food and Drug Administration and is safe for use in humans. It can be administered intravenously or intra-arterially. Since its advent, there have been several advancements in the applications of indocyanine green, especially in the surgical field, such as intraoperative mapping and biopsy of sentinel lymph node, measurement of hepatic function prior to resection, in neurosurgical cases to detect vascular anomalies, in cardiovascular cases for patency and assessment of vascular abnormalities, in predicting healing following amputations, in helping visualization of hepatobiliary anatomy and blood vessels, in reconstructive surgery, to assess flap viability and for the evaluation of tissue perfusion following major trauma and burns. For these reasons, the intraoperative use of indocyanine green has become common in a variety of surgical specialties and transplant surgery. Colorectal surgery has just lately begun to adopt this technique, particularly for perfusion visualization to prevent anastomotic leakage. The regular use of indocyanine green coupled with fluorescence angiography has recently been proposed as a feasible tool to help improve patient outcomes. Using the best available data, it has been shown that routine use of indocyanine green in colorectal surgery reduces the rates of anastomotic leak. The use of indocyanine green is proven to be safe, feasible, and effective in both elective and emergency scenarios. However, additional robust evidence from larger-scale, high-quality studies is essential before incorporating indocyanine green guided surgery into standard practice.
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Affiliation(s)
- Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | | | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Giuseppe Brisinda
- Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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Kalayarasan R, Chandrasekar M, Sai Krishna P, Shanmugam D. Indocyanine green fluorescence in gastrointestinal surgery: Appraisal of current evidence. World J Gastrointest Surg 2023; 15:2693-2708. [PMID: 38222003 PMCID: PMC10784830 DOI: 10.4240/wjgs.v15.i12.2693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/12/2023] [Accepted: 11/09/2023] [Indexed: 12/27/2023] Open
Abstract
Applying indocyanine green (ICG) fluorescence in surgery has created a new dimension of navigation surgery to advance in various disciplines. The research in this field is nascent and fragmented, necessitating academic efforts to gain a comprehensive understanding. The present review aims to integrate diverse perspectives and recent advances in its application in gastrointestinal surgery. The relevant articles were selected by using the appropriate keyword search in PubMed. The angiography and cholangiography property of ICG fluorescence is helpful in various hepatobiliary disorders. In gastroesophageal and colorectal surgery, the lymphangiography and angiography property of ICG is applied to evaluate bowel vascularity and guide lymphadenectomy. The lack of objective parameters to assess ICG fluorescence has been the primary limitation when ICG is used to evaluate bowel perfusion. The optimum dose and timing of ICG administration need to be standardized in some new application areas in gastrointestinal surgery. Binding tumor-specific ligands with fluorophores can potentially widen the fluorescence application to detect primary and metastatic gastrointestinal tumors. The narrative review outlines prior contributions, limitations, and research opportunities for future studies across gastrointestinal sub-specialty. The findings of the present review would be helpful for scholars and practitioners to explore and progress in this exciting domain of gastrointestinal surgery.
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Affiliation(s)
- Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Murugesan Chandrasekar
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Pothugunta Sai Krishna
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Dasarathan Shanmugam
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
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Abdelrahman H, El-Menyar A, Peralta R, Al-Thani H. Application of indocyanine green in surgery: A review of current evidence and implementation in trauma patients. World J Gastrointest Surg 2023; 15:757-775. [PMID: 37342859 PMCID: PMC10277941 DOI: 10.4240/wjgs.v15.i5.757] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/18/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023] Open
Abstract
Background: Modern surgical medicine strives to manage trauma while improving outcomes using functional imaging. Identification of viable tissues is crucial for the surgical management of polytrauma and burn patients presenting with soft tissue and hollow viscus injuries. Bowel anastomosis after trauma-related resection is associated with a high rate of leakage. The ability of the surgeon’s bare eye to determine bowel viability remains limited, and the need for a more standardized objective assessment has not yet been fulfilled. Hence, there is a need for more precise diagnostic tools to enhance surgical evaluation and visualization to aid early diagnosis and timely management to minimize trauma-associated complications. Indocyanine green (ICG) coupled with fluorescence angiography is a potential solution for this problem. ICG is a fluorescent dye that responds to near-infrared irradiation. Methods: We conducted a narrative review to address the utility of ICG in the surgical management of patients with trauma as well as elective surgery. Discussion: ICG has many applications in different medical fields and has recently become an important clinical indicator for surgical guidance. However, there is a paucity of information regarding the use of this technology to treat traumas. Recently, angiography with ICG has been introduced in clinical practice to visualize and quantify organ perfusion under several conditions, leading to fewer cases of anastomotic insufficiency. This has great potential to bridge this gap and enhance the clinical outcomes of surgery and patient safety. However, there is no consensus on the ideal dose, time, and manner of administration nor the indications that ICG provides a genuine advantage through greater safety in trauma surgical settings. Conclusions: There is a scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy to facilitate intraoperative decisions and to limit the extent of surgical resection. This review will improve our understanding of the utility of intraoperative ICG fluorescence in guiding and assisting trauma surgeons to deal with the intraoperative challenges and thus improve the patients’ operative care and safety in the field of trauma surgery.
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Affiliation(s)
| | - Ayman El-Menyar
- Trauma and Vascular Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Ruben Peralta
- Trauma Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Hassan Al-Thani
- Trauma and Vascular Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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Intraluminal Anastomotic Assessment Using Indocyanine Green Near-Infrared Imaging for Left-Sided Colonic and Rectal Resections: a Systematic Review. J Gastrointest Surg 2023; 27:615-625. [PMID: 36604377 DOI: 10.1007/s11605-022-05564-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICG-FA) has been used in colorectal surgery to assess anastomotic perfusion and reduce the risks of anastomotic leaks. The main objective of this paper is to review the data on the transanal application of ICG-FA for the intraluminal assessment of colorectal anastomosis. METHODS A literature search was conducted for articles published between 2011 and 2021 using PubMed and Cochrane databases, related to the application of ICG for the intraluminal assessment of colorectal anastomosis. Original scientific manuscripts, review articles, meta-analyses, and case reports were considered eligible. RESULTS A total of 305 studies have been identified. After abstract screening for duplicates, 285 articles remained. Of those, 271 were not related to the topic of interest, 4 were written in a language other than English, and 4 had incomplete data. Six articles remained for the final analysis. The intraluminal assessment of colorectal anastomosis with ICG-FA is feasible, safe, and may reduce the incidence of leaks. CONCLUSION The intraluminal assessment of anastomotic perfusion via ICG-FA may be a promising novel application of ICG technology. More data is needed to support this application further to reduce leak rates after colorectal surgery, and future randomized clinical trials are awaited.
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Kishiki T, Kojima K, Aso N, Iioka A, Wakamatsu T, Kataoka I, Kim S, Ishii S, Isobe S, Sakamoto Y, Abe N, Sunami E. Intraoperative Colonoscopy in Laparoscopic Rectal Cancer Surgery Reduces Anastomotic Leakage. J Anus Rectum Colon 2022; 6:159-167. [PMID: 35979268 PMCID: PMC9328792 DOI: 10.23922/jarc.2022-003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/22/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: Anastomotic leakage (AL) is the most severe complication of colorectal surgery and is a frequent cause of postoperative mortality. This study aimed to identify the risk factors for AL, including the type of air leak test (ALT) performed, in patients undergoing laparoscopic colorectal cancer surgery. Methods: This study involved a retrospective review of 201 patients who underwent elective laparoscopic procedures using circular stapled anastomosis for colorectal cancer between January 2015 and December 2020 at Kyorin University Hospital, Tokyo, Japan. In all cases, the distance from the anal verge to the anastomotic site was within 15 cm. Results: Overall, AL was observed in 16 patients (8.0%). Univariate analysis revealed that the risk factors for AL included diabetes (P = 0.068), tumor location (P = 0.049), level of anastomosis (P = 0.002), number of linear stapler firings (P = 0.007), and intraoperative colonoscopy (IOCS; P = 0.069). Multivariate analysis revealed that the level of anastomosis (P = 0.029) and IOCS (P = 0.039) were significant and independent risk factors for AL. One of the 107 patients undergoing ALT without IOCS and 3 of the 94 patients undergoing ALT with IOCS were proven to be positive for air leak. However, these four patients underwent additional suturing intraoperatively and developed no AL following surgery. Conclusions: This study identified the level of anastomosis and ALT with IOCS as predictors for AL. The results of our study indicate that ALT with IOCS may be more effective than ALT without IOCS in the diagnosis and prevention of AL.
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Affiliation(s)
| | | | - Nobuyoshi Aso
- Department of Surgery, Kyorin University School of Medicine
| | - Aiko Iioka
- Department of Surgery, Kyorin University School of Medicine
| | | | - Isao Kataoka
- Department of Surgery, Kyorin University School of Medicine
| | - Sangchul Kim
- Department of Surgery, Kyorin University School of Medicine
| | - Shun Ishii
- Department of Surgery, Kyorin University School of Medicine
| | - Satoshi Isobe
- Department of Surgery, Kyorin University School of Medicine
| | | | - Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine
| | - Eiji Sunami
- Department of Surgery, Kyorin University School of Medicine
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Aawsaj Y, Mustafa A, Winstanley J, O'loughlin P. The Impact of Indocyanine Green Fluorescence Angiography on Intraoperative Decision Making in Right Hemicolectomy: A Case-Control Study. Surg Laparosc Endosc Percutan Tech 2021; 32:209-212. [PMID: 34739425 DOI: 10.1097/sle.0000000000001018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Anastomotic leak (AL) after right hemicolectomy remains a significant clinical challenge with an incidence of 4.2% to 8.2% in European series. Near infrared imaging with indocyanine green (NIR-ICG) allows real-time assessment of bowel perfusion. However, there is a lack of published data assessing the clinical utility of this new technology in right sided colonic resection. MATERIALS AND METHODS Data from electronic records were retrospectively analyzed for consecutive patients undergoing right hemicolectomy in a single center between March 1, 2016 and October 31, 2019. Primary outcomes were the incidence of AL and the frequency with which ICG-NIR imaging altered the intraoperative course. RESULTS Our study included 127 patients, with 65 in the NIR-ICG group and 62 in the control group. Median length of follow-up was 24 months. There was no significant difference in demographic or pathologic characteristics between the 2 cohorts. There was no significant difference in operation length between the NIR-ICG and control groups (164.7 vs. 162.9 min, P=0.88). The use of NIR-ICG altered the intraoperative course in 4/65 (6.2%) patients. The rate of AL was lower in the NIR-ICG group (1.5% vs. 4.8%), although this did not reach statistical significance. CONCLUSION The use of NIR-ICG altered the intraoperative course for notable subset of patients undergoing right hemicolectomy without prolonging operative time. Larger prospective studies are required to evaluate the potential for the routine use of this technology to reduce AL rate in right hemicolectomy.
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Affiliation(s)
- Yousif Aawsaj
- Department of Colorectal Surgery, Gateshead Health NHS Foundation Trust
| | - Abdalla Mustafa
- Department of Colorectal Surgery, Gateshead Health NHS Foundation Trust
| | - Joseph Winstanley
- Department of Colorectal Surgery, Queen Elizabeth Hospital, University Hospital of North Tees, Gateshead, Stockton-on-Tees, England
| | - Paul O'loughlin
- Department of Colorectal Surgery, Gateshead Health NHS Foundation Trust
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Ryu S, Hara K, Goto K, Okamoto A, Kitagawa T, Marukuchi R, Ito R, Nakabayashi Y. Fluorescence angiography vs. direct palpation for bowel viability evaluation with strangulated bowel obstruction. Langenbecks Arch Surg 2021; 407:797-803. [PMID: 34664121 DOI: 10.1007/s00423-021-02358-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE In surgery for strangulated bowel obstruction, intestinal blood flow (IBF) is usually evaluated by observing bowel colour, peristalsis, intestinal temperature and arterial pulsations in the mesentery. We investigated whether indocyanine green (ICG) fluorescence angiography (ICG-FA) is an effective alternative to palpation. METHODS Thirty-eight patients who underwent emergency surgery for strangulated bowel obstruction from January 2017 to April 2021 were divided into two groups: (i) the ICG + group, in which ICG was used during laparoscopic surgery (n = 16), and (ii) the ICG - group, in which palpation without ICG was used during open surgery (n = 22). Starting in July 2019, ICG and laparoscopic surgery were applied in all cases except emergency cases when the fluorescence laparoscope was not ready. Surgical outcomes and patient characteristics were compared. RESULTS Patient characteristics, the operative duration and postoperative hospitalization duration did not significantly differ between the groups. Bowel resection was performed in 4 cases (25%) among ICG + patients and 11 cases (50%) among ICG - patients. The ratios of pathological findings (ischaemia:mucosal necrosis:transmural necrosis) were 0:2:2 and 1:6:4 in the two groups, respectively. Blood loss was measured with gauze and suction tubes and was 1 (0-5) mL in the ICG + group and 12.5 (0-73) mL in the ICG - group (p = 0.002). Postoperative complications occurred in 1 case (6.3%) in the ICG + group and 9 cases (40.9%) in the ICG - group (p = 0.025). CONCLUSION Although there were few intestinal resections in the ICG + group, the rate of pathological necrosis tended to be high, and no complications due to ineligibility were noted in the intestinal preservation group. During laparoscopic surgery, ICG-FA is useful as a substitute for palpation and has the potential to improve surgical outcomes. CLINICAL TRIAL REGISTRATION Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2019-40.
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Affiliation(s)
- Shunjin Ryu
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan.
| | - Keigo Hara
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan
| | - Keisuke Goto
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan
| | - Atsuko Okamoto
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan
| | - Takahiro Kitagawa
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan
| | - Rui Marukuchi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan
| | - Ryusuke Ito
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan
| | - Yukio Nakabayashi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi City , Saitama, 333-0833, Japan
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Bobel MC, Altman A, Gaertner WB. Immunofluorescence in Robotic Colon and Rectal Surgery. Clin Colon Rectal Surg 2021; 34:338-344. [PMID: 34504405 DOI: 10.1055/s-0041-1729866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The indocyanine green fluorescence imaging system is a surgical tool with increasing applications in colon and rectal surgery that has received growing acceptance in various surgical disciplines as a potentially valid method to enhance surgical field visualization, improve lymph node retrieval, and decrease anastomotic leak. Small noncomparative prospective trials have shown that intraoperative fluorescence imaging is a safe and feasible method to assess anastomotic perfusion and that its use may impact anastomotic leak rates. However, larger prospective and randomized studies are required to validate its role and impact in colorectal surgery. The purpose of this article is to review the current status of the use of immunofluorescence in colon and rectal surgery, as well as new applications in robotic colon and rectal resections.
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Affiliation(s)
- Matthew C Bobel
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ariella Altman
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Nakashima K, Ryu S, Okamoto A, Hara K, Ishida K, Ito R, Nakabayashi Y. Usefulness of blood flow evaluation with indocyanine green fluorescence imaging during laparoscopic surgery for strangulated bowel obstruction: A cohort study. Asian J Surg 2021; 45:867-873. [PMID: 34518078 DOI: 10.1016/j.asjsur.2021.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/06/2021] [Accepted: 08/04/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Intestinal blood flow evaluation during strangulated bowel obstruction is often based on the subjective assessment of the operator. Therefore, we aimed to comprehensively determine the presence or absence of intestinal blood flow based on normal light and indocyanine green (ICG) fluorescence imaging. Moreover, we ascertained whether the chosen surgical plan was appropriate, based on the patients' postoperative course and pathological findings. METHODS All 14 patients diagnosed with strangulated bowel obstruction at our hospital who underwent laparoscopic surgery between July 2019 and January 2021 were enrolled. Surgical plans were chosen based on normal light imaging combined with near-infrared imaging after intravenous ICG injection. Intestinal resection was performed via a small laparotomy if resection was considered necessary. In the intestinal resection group, the presence of intestinal necrosis was examined based on the pathological findings of the resected specimens. In the intestinal preservation group, postoperative complications, such as delayed intestinal perforation and intestinal stricture, were examined. RESULTS Intestinal resection was performed in 4 cases. The pathological findings of the resected specimens showed necrosis of the small intestine in all cases. No intra-abdominal complication occurred any of the cases, and the median postoperative hospital stay was 9.9 days. CONCLUSIONS The selection of a surgical plan in conjunction with ICG fluorescence findings was valid in all 14 cases. ICG fluorescence imaging is useful in laparoscopic surgery for strangulated bowel obstruction and may be a novel method for evaluating intestinal blood flow during surgery.
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Affiliation(s)
- Keigo Nakashima
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180 Nishiaraijyuku Kawaguchi, Saitama, 333-0833, Japan.
| | - Shunjin Ryu
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180 Nishiaraijyuku Kawaguchi, Saitama, 333-0833, Japan.
| | - Atsuko Okamoto
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180 Nishiaraijyuku Kawaguchi, Saitama, 333-0833, Japan.
| | - Keigo Hara
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180 Nishiaraijyuku Kawaguchi, Saitama, 333-0833, Japan.
| | - Kota Ishida
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180 Nishiaraijyuku Kawaguchi, Saitama, 333-0833, Japan.
| | - Ryusuke Ito
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180 Nishiaraijyuku Kawaguchi, Saitama, 333-0833, Japan.
| | - Yukio Nakabayashi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180 Nishiaraijyuku Kawaguchi, Saitama, 333-0833, Japan.
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11
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Ryu S, Okamoto A, Nakashima K, Hara K, Ishida K, Ito R, Nakabayashi Y. Ureteral navigation using a fluorescent ureteral catheter during laparoscopic colorectal surgery. Surg Endosc 2021; 35:4882-4889. [PMID: 33978850 DOI: 10.1007/s00464-021-08538-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 04/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ureteral injury is the most common urological complication of pelvic surgery, with a reported incidence during colon resection of 0.3-1.5%. Ureteral stenting is commonly performed preoperatively to prevent ureteral injury. Because tactile sensation is not reliable during laparoscopic surgery, the effect of the ureteral stent is considered limited. Recently, fluorescence imaging has been used in laparoscopic surgery. The Near-Infrared Ray Catheter (NIRC™) fluorescent ureteral catheter (NIRFUC) is a new catheter with built-in NIR fluorescent resin. This pilot study was performed to evaluate the utility of fluorescence ureteral navigation using the NIRFUC during laparoscopic colorectal surgery. METHODS We evaluated the intraoperative utility of the NIRFUC and the short-term outcomes in 20 patients treated with colorectal surgery at Kawaguchi Municipal Medical Center between February and July 2020. In all, 18 patients with malignant tumors and 2 patients with benign disease, i.e., a sigmoid colovesical fistula, were included. Ten patients developed preoperative intestinal obstruction. One patient experienced preoperative perforation. Nine patients developed preoperative peritumoral abscesses. Laparoscopic surgery was performed with the VISERA ELITE2 system. RESULTS In all cases, the ureters were very clearly identified as fluorescent without the need for dissection. In all cases, only a moment was required to identify the ureter by fluorescence observation. In all cases, R0 resection was performed. The mean surgical duration was 334 min (161-1014), the mean blood loss was 10 ml (1-500), and the mean postoperative hospital stay was 11 days (8-47). There were no cases of ureteral injury. CONCLUSION The NIRFUC was very clearly identified as fluorescent in a moment during surgery without dissection around the ureter. Fluorescence ureteral navigation using the NIRFUC may make colorectal surgery easier and facilitate completion of complex minimally invasive surgery, especially during surgery in patients with invasion of the surrounding tissue or a history of pelvic surgery or radiation.
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Affiliation(s)
- Shunjin Ryu
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi, Saitama, 333-0833, Japan.
| | - Atsuko Okamoto
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi, Saitama, 333-0833, Japan
| | - Keigo Nakashima
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi, Saitama, 333-0833, Japan
| | - Keigo Hara
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi, Saitama, 333-0833, Japan
| | - Kota Ishida
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi, Saitama, 333-0833, Japan
| | - Ryusuke Ito
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi, Saitama, 333-0833, Japan
| | - Yukio Nakabayashi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, 180, Nishiaraijuku, Kawaguchi, Saitama, 333-0833, Japan
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Gräfitsch A, Kirchhoff P, Soysal SD, Däster S, Hoffmann H. Dynamic Serosal Perfusion Assessment during Colorectal Resection Using Visible Light Spectroscopy. Eur Surg Res 2021; 62:25-31. [PMID: 33906197 DOI: 10.1159/000514921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) in colorectal surgery occurs with an incidence of up to 20%. Bowel perfusion is deemed to be one of the most important factors for anastomotic healing. However, not much is known about its variability during colorectal surgery and its impact on the outcome. Therefore, this study aims to evaluate serosal oxygen saturation patterns during colorectal resections with visible light spectroscopy (VLS). MATERIALS AND METHODS Bowel perfusion in patients undergoing left-sided colorectal resections was assessed at different timepoints during surgery using VLS on the colonic serosa. The primary outcome parameter was serosal oxygen saturation (StO2) at the anastomosis during different timepoints of surgery. RESULTS We included 50 patients who underwent colorectal resection for bowel cancer (58%) and diverticular disease (34%). StO2 at the proximal site of the anastomosis increased significantly throughout the surgery (mean difference 3.61%; 95% CI -6.22 to -1.00; p = 0.008). However, aberrancy from this identified perfusion pattern had no impact on the postoperative outcome. CONCLUSION During colorectal resections, we could demonstrate an increase of the colonic StO2 throughout surgery. Appearance of AL was not associated with lower StO2, underlining the multifactorial genesis of developing AL.
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Affiliation(s)
- Alexander Gräfitsch
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland.,Visceral Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Kirchhoff
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland.,Center for Hernia Surgery and Proctology, ZweiChirurgen GmbH, Basel, Switzerland
| | - Savas D Soysal
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Silvio Däster
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Henry Hoffmann
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland.,Center for Hernia Surgery and Proctology, ZweiChirurgen GmbH, Basel, Switzerland
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13
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Laparoscopic fluorescence navigation for left-sided colon and rectal cancer: Blood flow evaluation, vessel and ureteral navigation, clip marking and trans-anal tube insertion. Surg Oncol 2020; 35:434-440. [DOI: 10.1016/j.suronc.2020.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/21/2020] [Accepted: 10/02/2020] [Indexed: 12/16/2022]
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Yeo E, Thompson J, Hanseman D, Dunki-Jacobs A, Thompson B, Goodman M, Diwan T. Increased staple loading pressures and reduced staple heights in laparoscopic sleeve gastrectomy reduce intraoperative bleeding. Surgery 2020; 169:1110-1115. [PMID: 33261823 DOI: 10.1016/j.surg.2020.10.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/22/2020] [Accepted: 10/31/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In laparoscopic sleeve gastrectomy, tissue thickness and closed staple height of the staple cartridge determine the pressure applied to the tissue. Prior studies have suggested 8 g/mm2 to be ideal to minimize leaks or bleeding. METHODS We evaluated the relationship between staple loading pressure applied to gastric tissue and bleeding rate prospectively with a novel tissue measuring device and video-recorded operative findings for 116 patients undergoing laparoscopic sleeve gastrectomy performed by 2 surgeons at a single institution. Stapling protocol 1 was used for 64 cases, defined as standard practice, typically using green-blue-blue-blue Ethicon staple cartridges. Stapling protocol 2 was defined as blue-blue-white-white or gold-blue-white-white. RESULTS Tissue thickness measurements from 39 cases and staple load selection showed that surgeons preferred a median staple loading pressure of 15 g/mm2. Tissue thickness measurements at 15 g/mm2 had a mean of 1.86 mm at the antrum, 1.71 mm at the body, and 1.15 mm at the fundus, all significantly thinner than tissue thickness at 8 g/mm2. For each 10 g/mm2 increase in minimum pressure and maximum pressure value within each cartridge zone, there was a reduction in bleeding rate by 59.8% and 38.7%, respectively. Compared with stapling protocol 1, stapling protocol 2 had a lower intraoperative bleeding rate (90.2% vs 70.7%; P < .0001), usage of preventive hemostatic techniques (100% vs 10%; P < .0001), and hemostatic treatments (66% vs 46%; P = .04). In the 30-day postoperative period, there was 1 bleed in stapling protocol 1; there were no leaks. CONCLUSION Our data suggest using shorter closed staple heights to exert higher staple loading pressures decreases intraoperative bleeding rates in laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Eujin Yeo
- Department of Surgery, University of Cincinnati School of Medicine, OH
| | - Jonathan Thompson
- Department of Surgery, University of Cincinnati School of Medicine, OH; Standard Bariatrics, Inc, Cincinnati, OH
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati School of Medicine, OH
| | | | | | - Michael Goodman
- Department of Surgery, University of Cincinnati School of Medicine, OH
| | - Tayyab Diwan
- Department of Surgery, University of Cincinnati School of Medicine, OH; Mayo Clinic Rochester, MN.
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15
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Validation of quantitative assessment of indocyanine green fluorescent imaging in a one-vessel model. PLoS One 2020; 15:e0240188. [PMID: 33206647 PMCID: PMC7673564 DOI: 10.1371/journal.pone.0240188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/22/2020] [Indexed: 01/06/2023] Open
Abstract
Objectives Evaluation of intestinal perfusion remains subjective and depends on the surgeon´s individual experience. Intraoperative quality assessment of tissue perfusion with indocyanine green (ICG) fluorescence using a near-infrared camera system has been described in different ways and for different indications. The aim of the present study was to evaluate fluorescent imaging (FI) in the quantitative assessment of intestinal perfusion in a gastric tube model in pigs and to compare the results to results obtained with florescent microspheres (FM), the gold standard for tissue perfusion. Methods Seven pigs (56.0±3.0 kg), both males and females, underwent gastric tube formation after transection and ligation of the gastric arteries, except the right gastroepiploic artery, to avoid collateral blood flow. After baseline assessment (T0), hypotension (T1) was induced by propofol (Karampinis et al 2017) (< 60 mmHg). Then, propofol was paused to obtain normotension (T2, Mean arterial pressure (MAP) 60–90 mmHg). Finally, hypertension (T3, MAP>90 mmHg) was induced by norepinephrine. Measurements were performed in three regions of interest (ROIs) under standardized conditions: the fundus (D1), corpus (D2), and prepyloric area (D3). Hemodynamic parameters and transit-time flow measurement (TTFM) in the right gastroepiploic artery were continuously assessed. FI, FM and the partial pressure of tissue oxygen (TpO2) were quantified in each ROI. Results The study protocol could successfully be performed during stable hemodynamics. Flow in the gastroepiploic artery measured by transit time flow measurement (TTFM) was related to hemodynamic changes between the measurements, indicating improved blood flow with increasing MAP. The distal part of the gastric tube (D1) showed significantly (p<0.05) impaired perfusion compared to the proximal parts D3 and D2 using FM. ICG-FI also showed the highest values in D3 and the lowest values in D1 at all hemodynamic levels (T1-T3; p<0,05). Conclusion Visual and quantitative assessment of gastric tube perfusion is feasible in an experimental setting using ICG-FI. This might be a promising tool for intraoperative assessment during visceral surgery in the future.
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Seeliger B, Agnus V, Mascagni P, Barberio M, Longo F, Lapergola A, Mutter D, Klymchenko AS, Chand M, Marescaux J, Diana M. Simultaneous computer-assisted assessment of mucosal and serosal perfusion in a model of segmental colonic ischemia. Surg Endosc 2020; 34:4818-4827. [PMID: 31741157 DOI: 10.1007/s00464-019-07258-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/11/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fluorescence-based enhanced reality (FLER) enables the quantification of fluorescence signal dynamics, which can be superimposed onto real-time laparoscopic images by using a virtual perfusion cartogram. The current practice of perfusion assessment relies on visualizing the bowel serosa. The aim of this experimental study was to quantify potential differences in mucosal and serosal perfusion levels in an ischemic colon segment. METHODS An ischemic colon segment was created in 12 pigs. Simultaneous quantitative mucosal and serosal fluorescence imaging was obtained via intravenous indocyanine green injection (0.2 mg/kg), using two near-infrared camera systems, and computer-assisted FLER analysis. Lactate levels were measured in capillary blood of the colonic wall at seven regions of interest (ROIs) as determined with FLER perfusion cartography: the ischemic zone (I), the proximal and distal vascularized areas (PV, DV), and the 50% perfusion threshold proximally and distally at the mucosal and serosal side (P50M, P50S, D50M, D50S). RESULTS The mean ischemic zone as measured (mm) for the mucosal side was significantly larger than the serosal one (56.3 ± 21.3 vs. 40.8 ± 14.9, p = 0.001) with significantly lower lactate values at the mucosal ROIs. There was a significant weak inverse correlation between lactate and slope values for the defined ROIs (r = - 0.2452, p = 0.0246). CONCLUSIONS Mucosal ischemic zones were larger than serosal zones. These results suggest that an assessment of bowel perfusion from the serosal side only can underestimate the extent of ischemia. Further studies are required to predict the optimal resection margin and anastomotic site.
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Affiliation(s)
- Barbara Seeliger
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
- Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Vincent Agnus
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
| | - Pietro Mascagni
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
| | - Manuel Barberio
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
| | - Fabio Longo
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
| | - Alfonso Lapergola
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
| | - Didier Mutter
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
- Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Andrey S Klymchenko
- Faculty of Pharmacy, Nanochemistry and Bioimaging Laboratory, UMR 7021, CNRS, University of Strasbourg, Strasbourg, France
| | - Manish Chand
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Jacques Marescaux
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France
- Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France.
- Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France.
- Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.
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17
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Bourdel N, Jaillet L, Bar-Shavit Y, Comptour A, Pereira B, Canis M, Chauvet P. Indocyanine green in deep infiltrating endometriosis: a preliminary feasibility study to examine vascularization after rectal shaving. Fertil Steril 2020; 114:367-373. [DOI: 10.1016/j.fertnstert.2020.03.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 12/12/2022]
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18
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Anayama T, Sato T, Hirohashi K, Miyazaki R, Yamamoto M, Okada H, Orihashi K, Inoue K, Kobayashi M, Yoshida M, Hanazaki K. Near-infrared fluorescent solid material for visualizing indwelling devices implanted for medical use. Surg Endosc 2020; 34:4206-4213. [PMID: 32430529 DOI: 10.1007/s00464-020-07634-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In clinical practice, various devices are implanted into the body for medical reasons. As X-ray fluoroscopy is necessary to visualize medical devices implanted into the body, the development of a less-invasive visualization method is highly desired. This study aimed to investigate the clinical applicability of our novel solid material that emits near-infrared fluorescence. METHODS We developed a solid resin material that emits near-infrared fluorescence. This material incorporates a near-infrared fluorescent pigment, with quantum yield ≥ 20 times than that of indocyanine green. It can be sterilized for medical treatment. This resin material is designed to be molded into a catheter and inserted into the body with an endoscope clip. In this preclinical experiment using a swine model, the resin material was embedded into the body of the swine and visualized with a near-infrared fluorescence camera system. RESULTS Endoscopic clips were placed in the mucosa of the stomach, esophagus, and large intestine, and the indwelling ureteral catheters were successfully visualized by near-infrared fluorescence laparoscopy. CONCLUSIONS We confirmed the tissue permeability of the fluorescence emitted by our novel near-infrared fluorescent material and the possibility of its clinical application. This material may allow visualization of devices embedded in the body.
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Affiliation(s)
- Takashi Anayama
- Department of Thoracic Surgery, Kochi Medical School, Kochi University, Kohasu Oko, Nankoku, 783-8505, Japan.
| | - Takayuki Sato
- Department of Cardiovascular Control, Kochi Medical School, Nankoku, Japan
| | - Kentaro Hirohashi
- Department of Thoracic Surgery, Kochi Medical School, Kochi University, Kohasu Oko, Nankoku, 783-8505, Japan
| | - Ryohei Miyazaki
- Department of Thoracic Surgery, Kochi Medical School, Kochi University, Kohasu Oko, Nankoku, 783-8505, Japan
| | - Marino Yamamoto
- Department of Thoracic Surgery, Kochi Medical School, Kochi University, Kohasu Oko, Nankoku, 783-8505, Japan
| | - Hironobu Okada
- Department of Thoracic Surgery, Kochi Medical School, Kochi University, Kohasu Oko, Nankoku, 783-8505, Japan
| | | | - Keiji Inoue
- Center for Photodynamic Medicine, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Michiya Kobayashi
- Cancer Treatment Center, Kochi Medical School Hospital, Nankoku, Japan
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Kazuhiro Hanazaki
- Center for Photodynamic Medicine, Kochi Medical School, Kochi University, Nankoku, Japan
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Abstract
The present chapter summarizes progress with optical methods that go beyond human vision. The focus is on two particular technologies: fluorescence molecular imaging and optoacoustic (photoacoustic) imaging. The rationale for the selection of these two methods is that in contrast to optical microscopy techniques, both fluorescence and optoacoustic imaging can achieve large fields of view, i.e., spanning several centimeters in two or three dimensions. Such fields of views relate better to human vision and can visualize large parts of tissue, a necessary premise for clinical detection. Conversely, optical microscopy methods only scan millimeter-sized dimensions or smaller. With such operational capacity, optical microscopy methods need to be guided by another visualization technique in order to scan a very specific area in tissue and typically only provide superficial measurements, i.e., information from depths that are of the order of 0.05-1 mm. This practice has generally limited their clinical applicability to some niche applications, such as optical coherence tomography of the retina. On the other hand, fluorescence molecular imaging and optoacoustic imaging emerge as more global optical imaging methods with wide applications in surgery, endoscopy, and non-invasive clinical imaging, as summarized in the following. The current progress in this field is based on a volume of recent review and other literature that highlights key advances achieved in technology and biomedical applications. Context and figures from references from the authors of this chapter have been used here, as it reflects our general view of the current status of the field.
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Affiliation(s)
- Daniel Razansky
- Faculty of Medicine and Institute of Pharmacology and Toxicology, University of Zurich, Zurich, Switzerland
- Department of Information Technology and Electrical Engineering, Institute for Biomedical Engineering, ETH Zurich, Zurich, Switzerland
| | - Vasilis Ntziachristos
- Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.
- Institute of Biological and Medical Imaging, Helmholtz Zentrum München, Neuherberg, Germany.
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Aly M, O'Brien JW, Clark F, Kapur S, Stearns AT, Shaikh I. Does intra-operative flexible endoscopy reduce anastomotic complications following left-sided colonic resections? A systematic review and meta-analysis. Colorectal Dis 2019; 21:1354-1363. [PMID: 31243879 DOI: 10.1111/codi.14740] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
AIM Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity. METHODS PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates. RESULTS Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB. CONCLUSION This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.
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Affiliation(s)
- M Aly
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - J W O'Brien
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - F Clark
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - S Kapur
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - A T Stearns
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - I Shaikh
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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Duprée A, Rieß H, Detter C, Debus ES, Wipper SH. Utilization of indocynanine green fluorescent imaging (ICG-FI) for the assessment of microperfusion in vascular medicine. Innov Surg Sci 2018; 3:193-201. [PMID: 31579783 PMCID: PMC6604578 DOI: 10.1515/iss-2018-0014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/26/2018] [Indexed: 01/06/2023] Open
Abstract
Intraoperative valuation of organ and tissue microperfusion is always a current topic in different surgical situations. Although indocyanine green fluorescent imaging (ICG-FI) has turned to be a more and more common technique to evaluate organ perfusion, only few studies tried to quantitatively validate the technique for microperfusion assessment. The aim of the following manuscript is to present the results of our interdisciplinary research confirming additional quantitative assessment tools in different surgical conditions. Thus, we are implementing the background-subtracted peak fluorescent intensity (BSFI), the slope of fluorescence intensity (SFI), and the time to slope (TTS) using ICG-FI in several regions of interest (ROI).
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Affiliation(s)
- Anna Duprée
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
- Anna Dupréee and Henrik Rieß contributed equally to the manuscript
| | - Henrik Rieß
- Department of Vascular Medicine, University Heart Center, University Medical Center, Hamburg-Eppendorf, Germany
- Anna Dupréee and Henrik Rieß contributed equally to the manuscript
| | - Christian Detter
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Eike S. Debus
- Department of Vascular Medicine, University Heart Center, University Medical Center, Hamburg-Eppendorf, Germany
| | - Sabine H. Wipper
- Department of Vascular Medicine, University Heart Center, University Medical Center, Hamburg-Eppendorf, Germany
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van Manen L, Handgraaf HJM, Diana M, Dijkstra J, Ishizawa T, Vahrmeijer AL, Mieog JSD. A practical guide for the use of indocyanine green and methylene blue in fluorescence-guided abdominal surgery. J Surg Oncol 2018; 118:283-300. [PMID: 29938401 PMCID: PMC6175214 DOI: 10.1002/jso.25105] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/21/2018] [Indexed: 12/14/2022]
Abstract
Near-infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.
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Affiliation(s)
- Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Jouke Dijkstra
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | - Jan Sven David Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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23
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Alius C, Oprescu S, Balalau C, Nica AE. Indocyanine green enhanced surgery; principle, clinical applications and future research directions. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2018. [DOI: 10.25083/2559.5555/31.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Over the past decade a new emergent technology has become very popular in all fields of surgery using Indocyanine green and near infrared fluorescent optical systems. This revolutionary approach overlaps conventional and near infrared images to produce highly informative intraoperative images on the anatomy and physiology of various tissues. Near infrared fluorescence is employed for perioperative angiography in vascular mapping, assessment of anastomoses, location of sentinel lymph nodes and delineation of biliary tree anatomy, highlighting tumours and metastatic deposits, improving surgical techniques and for many other uses. A lot of researchers have reported better surgical outcomes and technique innovations facilitated by this novel technology which although in its early stages, it lights up great interest worldwide. This article reviews the principle of the method, the properties of the fluorescent dye, the main clinical applications and discusses future research directions.
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Ris F, Liot E, Buchs NC, Kraus R, Ismael G, Belfontali V, Douissard J, Cunningham C, Lindsey I, Guy R, Jones O, George B, Morel P, Mortensen NJ, Hompes R, Cahill RA. Multicentre phase II trial of near-infrared imaging in elective colorectal surgery. Br J Surg 2018; 105:1359-1367. [PMID: 29663330 PMCID: PMC6099466 DOI: 10.1002/bjs.10844] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 12/28/2017] [Accepted: 01/28/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near-infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR-ICG imaging in colorectal surgery. METHODS This was a prospective phase II study (NCT02459405) of non-selected patients undergoing any elective colorectal operation with anastomosis over a 3-year interval in three tertiary hospitals. A standard protocol was followed to assess NIR-ICG perfusion before and after anastomosis construction in comparison with standard operator visual assessment alone. RESULTS Five hundred and four patients (median age 64 years, 279 men) having surgery for neoplastic (330) and benign (174) pathology were studied. Some 425 operations (85·3 per cent) were started laparoscopically, with a conversion rate of 5·9 per cent. In all, 220 patients (43·7 per cent) underwent high anterior resection or reversal of Hartmann's operation, and 90 (17·9 per cent) low anterior resection. ICG angiography was achieved in every patient, with a median interval of 29 s to visualization of the signal after injection. NIR-ICG assessment resulted in a change in the site of bowel division in 29 patients (5·8 per cent) with no subsequent leaks in these patients. Leak rates were 2·4 per cent overall (12 of 504), 2·6 per cent for colorectal anastomoses and 3 per cent for low anterior resection. When NIR-ICG imaging was used, the anastomotic leak rates were lower than those in the participating centres from over 1000 similar operations performed with identical technique but without NIR-ICG technology. CONCLUSION Routine NIR-ICG assessment in patients undergoing elective colorectal surgery is feasible. NIR-ICG use may change intraoperative decisions, which may lead to a reduction in anastomotic leak rates.
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Affiliation(s)
- F Ris
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - E Liot
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - N C Buchs
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland.,Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - R Kraus
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - G Ismael
- Department of Surgery, Mater Misericordiae University Hospital, and Section of Surgery and Surgical Sciences, University College Dublin, Dublin, Ireland
| | - V Belfontali
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - J Douissard
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - C Cunningham
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - I Lindsey
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - R Guy
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - O Jones
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - B George
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - P Morel
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - N J Mortensen
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - R Hompes
- Departments of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - R A Cahill
- Department of Surgery, Mater Misericordiae University Hospital, and Section of Surgery and Surgical Sciences, University College Dublin, Dublin, Ireland
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25
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van den Bos J, Al-Taher M, Schols RM, van Kuijk S, Bouvy ND, Stassen LPS. Near-Infrared Fluorescence Imaging for Real-Time Intraoperative Guidance in Anastomotic Colorectal Surgery: A Systematic Review of Literature. J Laparoendosc Adv Surg Tech A 2017; 28:157-167. [PMID: 29106320 DOI: 10.1089/lap.2017.0231] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The aims of this review are to determine the feasibility of near-infrared fluorescence (NIRF) angiography in anastomotic colorectal surgery and to determine the effectiveness of the technique in improving imaging and quantification of vascularization, thereby aiding in decision making as to where to establish the anastomosis. METHODS A systematic literature search of PubMed and EMBASE was conducted. Searching through the reference lists of selected articles identified additional studies. All English language articles presenting original patient data regarding intraoperative NIRF angiography were included without restriction of type of study, except for case reports, technical notes, and video vignettes. The intervention consisted of intraoperative NIRF angiography during anastomotic colorectal surgery to assess perfusion of the colon, sigmoid, and/or rectum. Primary outcome parameters included ease of use, added surgical time, complications related to the technique, and costs. Other relevant outcomes were whether this technique changed intraoperative decision making, whether effort was taken by the authors to quantify the signal and the incidence of postoperative complications. RESULTS Ten studies were included. Eight of these studies make a statement about the ease of use. In none of the studies complications due to the use of the technique occurred. The technique changed the resection margin in 10.8% of all NIRF cases. The anastomotic leak rate was 3.5% in the NIRF group and 7.4% in the group with conventional imaging. Two of the included studies used an objective quantification of the fluorescence signal and perfusion, using ROIs (Hamamatsu Photonics) and IC-Calc® respectively. CONCLUSIONS Although the feasibility of the technique seems to be agreed on by all current research, large clinical trials are mandatory to further evaluate the added value of the technique.
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Affiliation(s)
- Jacqueline van den Bos
- 1 Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands .,2 NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University , Maastricht, The Netherlands
| | - Mahdi Al-Taher
- 1 Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands
| | - Rutger M Schols
- 1 Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands .,3 Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center , Maastricht, The Netherlands
| | - Sander van Kuijk
- 4 Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center , Maastricht, The Netherlands
| | - Nicole D Bouvy
- 1 Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands .,2 NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University , Maastricht, The Netherlands
| | - Laurents P S Stassen
- 1 Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands .,2 NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University , Maastricht, The Netherlands
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Indocyanine green fluorescence imaging in colorectal surgery: overview, applications, and future directions. Lancet Gastroenterol Hepatol 2017; 2:757-766. [DOI: 10.1016/s2468-1253(17)30216-9] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023]
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Laser Angiography with Indocyanine Green to Assess Vaginal Cuff Perfusion during Total Laparoscopic Hysterectomy: A Pilot Study. J Minim Invasive Gynecol 2017; 24:432-437. [PMID: 28063908 DOI: 10.1016/j.jmig.2016.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/21/2016] [Accepted: 12/28/2016] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To determine feasibility of using laser angiography with indocyanine green (ICG) to assess vaginal cuff vascular perfusion during total laparoscopic hysterectomy (TLH). DESIGN Pilot feasibility trial (Canadian Task Force classification II-2). SETTING Academic-affiliated hospital. PATIENTS Twenty women undergoing TLH for benign disease. INTERVENTIONS Participants underwent 1:1 randomization of energy method used for colpotomy (ultrasonic vs monopolar) and vaginal cuff closure suture (barbed vs nonbarbed). After intravenous administration of ICG, laser angiography was used to capture images of the vaginal cuff before and after closure. Three reviewers analyzed fluorescent images of vaginal cuffs to determine percent of cuff perimeter with adequate perfusion when open and length of vaginal cuff adequately perfused when closed. MEASUREMENTS AND MAIN RESULTS ICG fluorescence was visible at the vaginal cuff in all participants. Mean time to appearance of ICG in the pelvis after administration was 19.8 ± 6.8 seconds (mean ± SD) preclosure, and 26.0 ± 22.2 seconds postclosure. With ultrasonic energy 67.5% ± 17.4% of open cuff perimeter and 74.4% ± 20.5% of closed cuff length were adequately perfused, whereas with monopolar energy use 59.1% ± 17.4% of the open cuff perimeter and 66.3% ± 15.4% of closed cuff length were adequately perfused. Cuffs closed with barbed suture showed adequate perfusion along 71.5% ± 15.1% of the length, whereas those closed with nonbarbed suture showed 68.9% ± 20.9% adequate perfusion. When normalized to cervical cup circumference, ultrasonic energy required 1.0 ± .2 s/mm, whereas monopolar energy required .8 ± .3 s/mm (p = .162). Linear regression showed no association of normalized time of energy activation to percentage of perimeter of open cuff (R2 = .007) or length of closed cuff (R2 = .005) with adequate perfusion. No complications related to intravenous ICG administration occurred. CONCLUSION Laser angiography with ICG allows evaluation of vascular perfusion at the vaginal cuff during TLH. This technique may facilitate future prospective studies examining causes for vaginal cuff dehiscence, a complication with potential for severe morbidity.
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Mizrahi I, Wexner SD. Clinical role of fluorescence imaging in colorectal surgery - a review. Expert Rev Med Devices 2016; 14:75-82. [PMID: 27899040 DOI: 10.1080/17434440.2017.1265444] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Anastomotic leak (AL) after colorectal surgery is a devastating complication; decreased blood perfusion is an important risk factor. Surgeons rely on subjective measures to assess bowel perfusion. Fluorescence imaging (FI) with indocyanine green (ICG) provides a real-time objective assessment of intestinal perfusion. Areas covered: A PubMed search using the terms 'fluorescence imaging', 'indocyanine green', 'colon and rectal surgery' was undertaken. Sixteen articles between 2010 to present were identified. Main outcomes were leak rate reduction, change in surgical plan, and technical feasibility. Change in surgical strategy due to FI was recorded in 11 studies. Two case control studies showed overall reduction of 4% and 12% in AL rate and one showed no change in AL rate between groups. Expert commentary: According to the available literature, FI is technically feasible and alters surgical strategy in a non-negligible number of patients possibly effecting AL rates.
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Affiliation(s)
- Ido Mizrahi
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
| | - Steven D Wexner
- a Department of Colorectal Surgery , Cleveland Clinic Florida , Weston , FL , USA
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29
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Intraoperative ICG fluorescence contrast imaging of the main artery watershed area in colorectal cancer surgery: Report of a case. Int J Surg Case Rep 2016; 26:176-8. [PMID: 27497042 PMCID: PMC4976611 DOI: 10.1016/j.ijscr.2016.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/10/2016] [Accepted: 06/11/2016] [Indexed: 01/01/2023] Open
Abstract
We have reported the case that underwent colorectal resection with intraoperative indocyanine green (ICG) fluorescence angiography from the resection-side of the superior rectal artery. Watershed area of the SRA fluoresced 33 s after the intra-arterial injection of ICG. PINPOINT, a brightfield color fluorescence camera was used for ICG fluorescence. This method can be expected to provide useful information for maintaining the blood flow at the anastomotic site. Introduction Visualization of the main artery watershed area may be useful for determining the area that should be resected in colorectal cancer surgery. Resection of the main artery watershed area may result in complete resection of lymph nodes along the main artery and area of potential ischemia. Presentation of case A man in his 60 s with a chief complaint of hematochezia visited our hospital, was diagnosed with colorectal cancer and underwent surgery. A case that underwent colorectal resection with intraoperative indocyanine green (ICG) fluorescence angiography from the resection-side of the superior rectal artery (SRA) in order to confirm the watershed area is reported. Observation was performed using a PINPOINT® bright-field, color, near-infrared fluorescence camera, and the watershed area of the SRA fluoresced 33 s after the intra-arterial injection of ICG. After observation resection and anastomosis was performed. The patient’s postoperative course was good. Discussion The method is simple and can be performed within a short time, and it enables visual evaluation of the blood flow in the intestinal tract before anastomosis. Conclusion This method can be expected to provide useful information for complete resection of lymph nodes along the main artery and area of potential ischemia.
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30
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Degett TH, Andersen HS, Gögenur I. Indocyanine green fluorescence angiography for intraoperative assessment of gastrointestinal anastomotic perfusion: a systematic review of clinical trials. Langenbecks Arch Surg 2016; 401:767-75. [PMID: 26968863 DOI: 10.1007/s00423-016-1400-9] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 03/02/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE Anastomotic leakage following gastrointestinal surgery remains a frequent and serious complication associated with a high morbidity and mortality. Indocyanine green fluorescence angiography (ICG-FA) is a newly developed technique to measure perfusion intraoperatively. The aim of this paper was to systematically review the literature concerning ICG-FA to assess perfusion during the construction of a primary gastrointestinal anastomosis in order to predict anastomotic leakage. METHODS The following four databases PubMed, Scopus, Embase, and Cochrane were independently searched by two authors. Studies were included in the review if they assessed anastomotic perfusion intraoperatively with ICG-FA in order to predict anastomotic leakage in humans. RESULTS Of 790 screened papers 14 studies were included in this review. Ten studies (n = 916) involved patients with colorectal anastomoses and four studies (n = 214) patients with esophageal anastomoses. All the included studies were cohort studies. Intraoperative ICG-FA assessment of colorectal anastomoses was associated with a reduced risk of anastomotic leakage (n = 23/693; 3.3 % (95 % CI 1.97-4.63 %) compared with no ICG-FA assessment (n = 19/223; 8.5 %; 95 % CI 4.8-12.2 %). The anastomotic leakage rate in patients with esophageal anastomoses and intraoperative ICG-FA assessment was 14 % (n = 30/214). None of the studies involving esophageal anastomoses had a control group without ICG-FA assessment. CONCLUSION No randomized controlled trials have been published. ICG-FA seems like a promising method to assess perfusion at the site intended for anastomosis. However, we do not have the sufficient evidence to determine that the method can reduce the leak rate.
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Affiliation(s)
- Thea Helene Degett
- Center for Surgical Science (CSS), Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | - Helene Schou Andersen
- Center for Surgical Science (CSS), Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
| | - Ismail Gögenur
- Center for Surgical Science (CSS), Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
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Affiliation(s)
- Maximilian Koch
- Helmholtz Zentrum München, German Research Center for Environmental Health, Institute for Biological and Medical Imaging, 85764 Neuherberg, Germany;
- Munich School of Bioengineering, Translational Oncology Center (TRANSLATUM), Technische Universität München (TUM), 81675 Munich, Germany;
| | - Vasilis Ntziachristos
- Helmholtz Zentrum München, German Research Center for Environmental Health, Institute for Biological and Medical Imaging, 85764 Neuherberg, Germany;
- Munich School of Bioengineering, Translational Oncology Center (TRANSLATUM), Technische Universität München (TUM), 81675 Munich, Germany;
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Abstract
BACKGROUND Intraoperative laser fluorescence angiography is a relatively new tool that can be used by colorectal surgeons to ensure adequate perfusion to bowel that remains after resection. It has been used mostly to determine an appropriate point of transection of the proximal bowel, as well as to ensure perfusion after the anastomosis has been constructed. We propose a different use of the technology in complex cases to ensure the ability to safely transect a major vascular pedicle and to ensure that perfusion will remain adequate. OBJECTIVE The purpose of this article is to describe a new use for fluorescence angiography technology. DESIGN This is a technical note. SETTINGS The work was conducted at a tertiary care military medical center. PATIENTS Patients included individuals requiring oncologic colorectal resection where the status of 1 major vascular pedicle was unknown or impaired. MAIN OUTCOME MEASURES We assessed perfusion after occlusion of a major vascular pedicle for the short term in hospital outcomes. RESULTS Adequate studies were obtained, and perfusion was maintained in both patients. Oncologic resections were performed, and short-term outcomes were comparable with any individual undergoing these procedures. LIMITATIONS This study was limited because it is early experience that was not performed in the setting of a scientific investigation. CONCLUSIONS Application of intraoperative fluorescence angiography in this setting appears to be safe and may assist the surgeon in estimating reliable vascular perfusion in patients such as these who require oncologic colorectal resection.
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Gröne J, Koch D, Kreis ME. Impact of intraoperative microperfusion assessment with Pinpoint Perfusion Imaging on surgical management of laparoscopic low rectal and anorectal anastomoses. Colorectal Dis 2015; 17 Suppl 3:22-8. [PMID: 26394739 DOI: 10.1111/codi.13031] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 05/29/2015] [Indexed: 02/08/2023]
Abstract
AIM Inadequate intestinal blood flow may contribute to anastomotic leakage accounting for substantial morbidity and mortality in colorectal surgery. Precise intraoperative assessment of microperfusion may have an impact on the surgeons intraoperative management and leakage rate. METHOD In this single center observational study we implemented and integrated intraoperative indocyanin green (ICG) based microperfusion assessment of anastomosis with Pinpoint Perfusion Imaging in a series of consecutive rectal cancer patients who underwent laparoscopic anterior and lower anterior resection with primary anastomosis during a 5-months period. RESULTS We could demonstrate the feasibility and safety of intraoperative fluorescence angiography for colorectal microperfusion assessment. Technology implementation was immediately successful. No adverse effects have been documented related to fluorescent dye. Microperfusion angiography of the colon succeeded in all cases and assessment of perfusion imaging influenced surgical decision making in 28% of the patients, of which all patients showed primary healing of the anastomosis. We found a leakage rate of 6% with one leakage of a coloanal anastomosis in all patients. CONCLUSION Fluorescence angiography is an accurate tool for assessing microperfusion and is most likely associated with improved outcomes with regard to anastomotic healing.
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Affiliation(s)
- J Gröne
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Charité University Medicine Berlin, Berlin, Germany
| | - D Koch
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Charité University Medicine Berlin, Berlin, Germany
| | - M E Kreis
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Charité University Medicine Berlin, Berlin, Germany
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James DRC, Ris F, Yeung TM, Kraus R, Buchs NC, Mortensen NJ, Hompes RJ. Fluorescence angiography in laparoscopic low rectal and anorectal anastomoses with pinpoint perfusion imaging--a critical appraisal with specific focus on leak risk reduction. Colorectal Dis 2015; 17 Suppl 3:16-21. [PMID: 26394738 DOI: 10.1111/codi.13033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 05/29/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Anastomotic dehiscence is one of the most feared complications in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. One of the key factors is the perfusion of the bowel to be joined. Presently, surgeons rely on a variety subjective measures to determine anastomotic perfusion and mechanical integrity however these have shortcomings. The aim of this paper is to appraise the literature on the use of fluorescence angiography (FA) in laparoscopic rectal surgery. MATERIALS AND METHODS A Pubmed search was undertaken using terms 'fluorescence angiography' and 'rectal surgery'. The search was expanded using the related articles function. Studies were included if they used FA specifically for rectal surgery. Outcomes of interest including anastomotic leak rate, change of operative strategy and time taken for FA were recorded. RESULTS Eleven papers detailing the use of FA in rectal surgery are outlined demonstrating that this technique may change operative strategy and lead to a reduction in anastomotic leak rate. CONCLUSION In this paper, we discuss assessment of colorectal blood supply using FA and how this technique holds great potential to detect insufficiently perfused bowel. In so doing, the operator can adjust their operative strategy to mitigate these affects with the aim of reducing the complications of anastomotic leak and stenosis. However, it is highlighted that there is a clear need for randomised controlled trials in order to determine this definitively.
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Affiliation(s)
- D R C James
- Department of Colorectal Surgery, Oxford University Hospitals NHS trust, Oxford, UK
| | - F Ris
- Division of Visceral Surgery, Departments of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - T M Yeung
- Department of Colorectal Surgery, Oxford University Hospitals NHS trust, Oxford, UK
| | - R Kraus
- Department of Colorectal Surgery, Oxford University Hospitals NHS trust, Oxford, UK
| | - N C Buchs
- Department of Colorectal Surgery, Oxford University Hospitals NHS trust, Oxford, UK.,Division of Visceral Surgery, Departments of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - N J Mortensen
- Department of Colorectal Surgery, Oxford University Hospitals NHS trust, Oxford, UK
| | - R J Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS trust, Oxford, UK
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Daskalaki D, Aguilera F, Patton K, Giulianotti PC. Fluorescence in robotic surgery. J Surg Oncol 2015; 112:250-6. [PMID: 25974861 DOI: 10.1002/jso.23910] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 03/08/2015] [Indexed: 12/14/2022]
Abstract
Currently, there are several clinical applications for intraoperative ICG, such as identification of vascular and biliary anatomy, assessment of organ and tissue perfusion, lymph node mapping, and real-time identification of lesions. In this paper we present a review of the available literature related to the use of ICG fluorescence in robotic surgery in order to provide a better understanding of the current applications, show the rapid growth of this technique, and demonstrate the potential future applications.
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Affiliation(s)
- Despoina Daskalaki
- Department of Surgery, Division of Minimally Invasive and Robotic Surgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Fabiola Aguilera
- Department of Surgery, Division of Minimally Invasive and Robotic Surgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Kristin Patton
- Department of Surgery, Division of Minimally Invasive and Robotic Surgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Pier Cristoforo Giulianotti
- Department of Surgery, Division of Minimally Invasive and Robotic Surgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Sherwinter DA. Merged Near-Infrared and White-Light Imaging in Minimally Invasive Surgery. World J Surg 2015; 39:2105. [PMID: 25790945 DOI: 10.1007/s00268-015-3026-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Intraoperative assessment of colorectal anastomotic integrity: a systematic review. Surg Endosc 2014; 28:2513-30. [PMID: 24718665 DOI: 10.1007/s00464-014-3520-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 03/21/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgeons have attempted to minimize postoperative anastomotic complications by employing intraoperative tests and manoeuvres to assess colorectal anastomotic integrity. These have evolved over time with improvement in operative technology and techniques. This systematic review aims to examine the impact of such intraoperative assessments. METHODS A systematic review of studies assessing intraoperative anastomotic assessments and their impact on postoperative anastomotic complications was performed. Intraoperative measures undertaken as a result of intraoperative assessments and postoperative anastomotic complications were analysed. RESULTS 37 Studies were identified. 13 studies evaluated basic mechanical patency tests, ten studies evaluated endoscopic visualisation techniques and 14 studies evaluated microperfusion techniques. Postoperative anastomotic complications were significantly lower in patients tested with basic mechanical patency tests compared to those untested (non-RCT: 4.1 vs. 8.1 %, p = 0.03, RCTs: 5.8 vs. 16.0 %, p = 0.024). There were no differences in postoperative anastomotic complications between tested and non-tested cohorts in non-randomised cohort studies evaluating endoscopic visualisation techniques. However, intraoperative measures taken after abnormal intraoperative tests may have reduced the number of postoperative complications. Perfusion analysis techniques are not in routine widespread clinical practice as yet, but newer techniques such as fluorescent dyes and imaging under near infrared light show technical feasibility. CONCLUSIONS Intraoperative colorectal anastomotic assessment has evolved together with advancement of technology in the surgical setting. Moderate benefit in terms of lower postoperative anastomotic complications has been shown with basic mechanical patency testing and more recently with intraoperative endoscopic visualisation of colorectal anastomoses. The next advance and possible introduction into routine practice may include the use of microperfusion techniques. The latest in this group of techniques, which utilise autofluorescent dyes such as Indocyanine green, hold great potential. Well-planned controlled studies or ideally, randomised controlled trials need to be conducted to further assess the benefit of these latest techniques.
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Karakaş BR, Sırcan-Küçüksayan A, Elpek OE, Canpolat M. Investigating viability of intestine using spectroscopy: a pilot study. J Surg Res 2014; 191:91-8. [PMID: 24746953 DOI: 10.1016/j.jss.2014.03.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 02/21/2014] [Accepted: 03/18/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND The differentiation of "viable" from "nonviable" bowel remains a challenge in the treatment of acute mesenteric ischemia. In this study, diffuse reflectance spectroscopy (DRS) was used to investigate the viability of bowel tissue after ischemia and reperfusion in an animal model in vivo and in real time. METHODS A total of 25 females Sprague-Dawley rats were divided into five groups based on different bowel ischemia times. In each study group for four of them, the superior mesenteric artery was occluded using a vascular clamp for a different period (i.e., 30, 45, 60, and 90 min; n = 5 for each group). Intestinal reperfusion was accomplished by releasing the clamps after the given occlusion period for each group. Spectra were acquired by gently touching the optical fiber probe to the bowel tissue before the induce ischemia, at the end of the induced ischemia, and after the reperfusion. The data acquired before the ischemia were used as a control group. Without occluding the superior mesenteric artery, the spectra were acquired on the bowel with the same time intervals of the experiments were used as a sham group (n = 5). Subsequently, the same bowel segments were sent for histopathologic examination. RESULTS Based on the correlation between the spectra acquired from the bowel segments and the results from the histopathologic investigation, DRS is able to differentiate the histopathologic grading that appears when the Chiu/Park score ≥5 (i.e., high-level ischemic injury) than Chiu/Park score <5. Eight out of nine low-level ischemic injury tissue samples were correctly defined using the spectroscopic classification system. All eleven high-level ischemic injury tissues that were histopathologically assigned grade 5 and above were correctly defined using the spectroscopic classification system in the ischemia-reperfusion groups. CONCLUSIONS DRS could potentially be used intraoperatively for the assessment of bowel viability in real time. These preliminary findings suggest that DRS has the potential to reduce unnecessary resection of viable tissue or insufficient resection of nonviable tissues may reduce the mortality and morbidity rates of intestinal ischemia-reperfusion as acute mesenteric ischemia.
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Affiliation(s)
- Barış R Karakaş
- Department of General Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - Aslınur Sırcan-Küçüksayan
- Department of Biophysics, Faculty of Medicine, Biomedical Optics Research Unit, Akdeniz University, Antalya, Turkey
| | - Ozlem E Elpek
- Department of Pathology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Murat Canpolat
- Department of Biophysics, Faculty of Medicine, Biomedical Optics Research Unit, Akdeniz University, Antalya, Turkey.
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Yi X, Wang F, Qin W, Yang X, Yuan J. Near-infrared fluorescent probes in cancer imaging and therapy: an emerging field. Int J Nanomedicine 2014; 9:1347-65. [PMID: 24648733 PMCID: PMC3956734 DOI: 10.2147/ijn.s60206] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Near-infrared fluorescence (NIRF) imaging is an attractive modality for early cancer detection with high sensitivity and multi-detection capability. Due to convenient modification by conjugating with moieties of interests, NIRF probes are ideal candidates for cancer targeted imaging. Additionally, the combinatory application of NIRF imaging and other imaging modalities that can delineate anatomical structures extends fluorometric determination of biomedical information. Moreover, nanoparticles loaded with NIRF dyes and anticancer agents contribute to the synergistic management of cancer, which integrates the advantage of imaging and therapeutic functions to achieve the ultimate goal of simultaneous diagnosis and treatment. Appropriate probe design with targeting moieties can retain the original properties of NIRF and pharmacokinetics. In recent years, great efforts have been made to develop new NIRF probes with better photostability and strong fluorescence emission, leading to the discovery of numerous novel NIRF probes with fine photophysical properties. Some of these probes exhibit tumoricidal activities upon light radiation, which holds great promise in photothermal therapy, photodynamic therapy, and photoimmunotherapy. This review aims to provide a timely and concise update on emerging NIRF dyes and multifunctional agents. Their potential uses as agents for cancer specific imaging, lymph node mapping, and therapeutics are included. Recent advances of NIRF dyes in clinical use are also summarized.
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Affiliation(s)
- Xiaomin Yi
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Fuli Wang
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Weijun Qin
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Xiaojian Yang
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Jianlin Yuan
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
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Ris F, Hompes R, Cunningham C, Lindsey I, Guy R, Jones O, George B, Cahill RA, Mortensen NJ. Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endosc 2014; 28:2221-6. [PMID: 24566744 PMCID: PMC4065377 DOI: 10.1007/s00464-014-3432-y] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 01/03/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage is a devastating complication of colorectal surgery. However, there is no technology indicative of in situ perfusion of a laparoscopic colorectal anastomosis. METHODS We detail the use of near-infrared (NIR) laparoscopy (PinPoint System, NOVADAQ, Canada) in association with fluorophore [indocyanine green (ICG), 2.5 mg/ml] injection in 30 consecutive patients who underwent elective minimally invasive colorectal resection using the simultaneous appearance of the cecum or distal ileum as positive control. RESULTS The median (range) age of the patients was 64 (40-81) years with a median (range) BMI of 26.7 (20-35.5) kg/m(2). Twenty-four patients had left-sided resections (including six low anterior resections) and six had right-sided resections. Of the total, 25 operations were cancer resections and five were for benign disease [either diverticular strictures (n = 3) or Crohn's disease (n = 2)]. A high-quality intraoperative ICG angiogram was achieved in 29/30 patients. After ICG injection, median (range) time to perfusion fluorescence was 35 (15-45) s. Median (range) added time for the technique was 5 (3-9) min. Anastomotic perfusion was documented as satisfactory in every successful case and encouraged avoidance of defunctioning stomas in three patients with low anastomoses. There were no postoperative anastomotic leaks. CONCLUSION Perfusion angiography of colorectal anastomosis at the time of their laparoscopic construction is feasible and readily achievable with minimal added intraoperative time. Further work is required to determine optimum sensitivity and threshold levels for assessment of perfusion sufficiency, in particular with regard to anastomotic viability.
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Affiliation(s)
- Frederic Ris
- Department of Colorectal Surgery, Oxford University Hospitals, Churchill Hospital, Old Road, Oxford, OX3 7LJ, Headington, UK,
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The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg Endosc 2014; 28:1695-702. [PMID: 24385249 DOI: 10.1007/s00464-013-3377-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 12/06/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypoperfusion is an important risk factor for anastomotic leakage in colorectal surgery. This study was designed to evaluate the impact of fluorescence imaging on visualization of perfusion and subsequent change of transection line during left-sided robotic colorectal resections. METHODS Patients scheduled for robotic left-sided colon or rectal resections were enrolled in this prospective, multicenter study. Resections were performed as per each surgeon's preference. After complete colorectal mobilization, ligation of blood vessels, and distal transection of the bowel, the mesocolon was completely divided to the planned proximal or distal transection line, which was marked in white light. Indocyanine green was injected intravenously and the transection location(s) and/or distal rectal stump, if applicable, were re-assessed in fluorescent imaging mode. Imaging information, perioperative, and early postoperative outcomes were recorded. An independent video review of the surgeries was performed. RESULTS Data for 40 patients (20 female/20 male) with a mean age of 63.9 years and a mean body mass index of 27.6 kg/m(2) were analyzed. Fluorescence imaging resulted in a change of the proximal transection location in 40 % (16/40) of patients. There was one change in the distal transection location in a patient with benign disease. The use of fluorescence imaging took an average of 5.1 min of the mean overall operative room time of 232 min. Two patients (5 %) with a change in transection line developed an anastomotic leak at postoperative days 15 and 40. CONCLUSION Fluorescence imaging provides additional information during determination of transection location in left-sided colorectal procedures. This results in a significant change of transection location, particularly at the proximal transection site. Further research needs to be conducted with larger patient cohorts and in comparative design to determine actual effect on anastomotic leak rate.
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