Advertisement

Surgical Endoscopy

, Volume 28, Issue 11, pp 3224–3233 | Cite as

Probe-based confocal laser endomicroscopy and fluorescence-based enhanced reality for real-time assessment of intestinal microcirculation in a porcine model of sigmoid ischemia

  • Michele Diana
  • Bernard Dallemagne
  • Hyunsoo Chung
  • Yoshihiro Nagao
  • Peter Halvax
  • Vincent Agnus
  • Luc Soler
  • Veronique Lindner
  • Nicolas Demartines
  • Pierre Diemunsch
  • Bernard Geny
  • Lee Swanström
  • Jacques Marescaux
Article

Abstract

Background and aim

Surgeons currently rely on visual clues to estimate the presence of sufficient vascularity for safe anastomosis. We aimed to assess the accuracy of endoluminal confocal laser endomicroscopy (CLE) and laparoscopic fluorescence-based enhanced reality (FLER), using near-infrared imaging and fluorescence from injected Indocyanine Green, to identify the transition from ischemic to vascular areas in a porcine model of mesenteric ischemia.

Methods

Six pigs underwent 1-h sigmoid segmental ischemia. The ischemic area was evaluated by clinical assessment and FLER to determine presumed viable margins. For each sigmoid colon, 5 regions of interest (ROIs) were identified: ischemic (ROI 1), presumed viable margins ROI 2a (distal) and 2b (proximal), and vascular areas 3a (distal) and 3b (proximal). After injection of fluorescein, CLE scanning of the mucosa from the ischemic area toward viable margins was performed. Capillary blood samples were obtained by puncturing the serosa at the ROIs, and capillary lactates were measured with the EDGE® analyzer.

Results

Capillary lactates were significantly higher at ROI 1 (4.91 mmol/L) when compared to resection margins (2.8 mmol/L; mean difference: 2.11; p < 0.05) identified by FLER. There was no significant difference in lactates between ROI1 and resection margins identified by clinical evaluation. In 50 % of cases, ROI 2aCLINIC–2bCLINIC were considered to match (<1 cm distance) with ROI 2aFLER–2bFLER. Confocal analysis revealed specific clues to identify the transition from ischemic to viable areas corresponding to those assessed by FLER in 11/12 cases versus 7/12 for those identified by clinical evaluation.

Conclusions

In this experimental model, FLER and CLE were more accurate than clinical evaluation to delineate bowel vascularization.

Keywords

Confocal laser endomicroscopy Anastomotic perfusion Fluorescence-based enhanced reality 

Abbreviations

CLE

Confocal laser endomicroscopy

FLER

Fluorescence-based enhanced reality

ICG

Indocyanine green

IMA

Inferior mesenteric artery

IVM

Intravital microscopy

NIRS

Near-infrared spectroscopy

ROI

Regions of interest

SpO2

Arterial oxygen saturation

StO2

Hemoglobin oxygen saturation

VLS

Visible light spectroscopy

Notes

Acknowledgments

This study was partly funded by a research grant from Karl Storz, Tuttlingen, Germany. The authors are grateful to Christopher Burel and Guy Temporal (medical English reviewers working for IRCAD-IHU Institutes) for their valuable help in proofreading the manuscript.

Disclosure

Michele Diana is recipient of a research grant from Karl Storz, Tuttlingen, Germany. Karl Storz was NOT involved in study design nor data acquisition/interpretation. Jacques Marescaux is the President of the IRCAD-IHU Institutes, partly funded by Karl Storz Endoscopy, Covidien, and Siemens Healthcare. Remaining authors have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Karliczek A, Benaron DA, Baas PC et al (2010) Intraoperative assessment of microperfusion with visible light spectroscopy for prediction of anastomotic leakage in colorectal anastomoses. Colorectal Dis 12:1018–1025PubMedCrossRefGoogle Scholar
  2. 2.
    Karliczek A, Harlaar NJ, Zeebregts CJ et al (2009) Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 24:569–576PubMedCrossRefGoogle Scholar
  3. 3.
    Urbanavicius L, Pattyn P, de Putte DV et al (2011) How to assess intestinal viability during surgery: a review of techniques. World J Gastrointest Surg 3:59–69PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Diana M, Noll E, Diemunsch P et al (2014) Enhanced-reality video fluorescence: a real-time assessment of intestinal viability. Ann Surg 259(4):700–707PubMedCrossRefGoogle Scholar
  5. 5.
    Laemmel E, Genet M, Le Goualher G et al (2004) Fibered confocal fluorescence microscopy (Cell-viZio) facilitates extended imaging in the field of microcirculation. A comparison with intravital microscopy. J Vasc Res 41:400–411PubMedCrossRefGoogle Scholar
  6. 6.
    Carus T, Dammer R (2012) Laparoscopic fluorescence angiography with indocyanine green to control the perfusion of gastrointestinal anastomoses intraoperatively. Surg Technol Int 22:27–32PubMedGoogle Scholar
  7. 7.
    Alves WF, Aguiar EE, Guimaraes SB et al (2010) L-alanyl-glutamine preoperative infusion in patients with critical limb ischemia subjected to distal revascularization reduces tissue damage and protects from oxidative stress. Ann Vasc Surg 24:461–467PubMedCrossRefGoogle Scholar
  8. 8.
    Kuiper T, van den Broek FJ, van Eeden S et al (2011) New classification for probe-based confocal laser endomicroscopy in the colon. Endoscopy 43:1076–1081PubMedCrossRefGoogle Scholar
  9. 9.
    Wu J, Pan YM, Wang TT et al (2014) Confocal laser endomicroscopy for detection of neoplasia in Barrett’s esophagus: a meta-analysis. Dis Esophagus 27(3):248–254PubMedCrossRefGoogle Scholar
  10. 10.
    Wang SF, Yang YS, Wei LX et al (2012) Diagnosis of gastric intraepithelial neoplasia by narrow-band imaging and confocal laser endomicroscopy. World J Gastroenterol 18:4771–4780PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Dong YY, Li YQ, Yu YB et al (2013) Meta-analysis of confocal laser endomicroscopy for the detection of colorectal neoplasia. Colorectal Dis 15:e488–e495PubMedGoogle Scholar
  12. 12.
    Yasumura M, Mori Y, Takagi H et al (2003) Experimental model to estimate intestinal viability using charge-coupled device microscopy. Br J Surg 90:460–465PubMedCrossRefGoogle Scholar
  13. 13.
    Schmidt C, Lautenschlager C, Petzold B et al (2013) Confocal laser endomicroscopy reliably detects sepsis-related and treatment-associated changes in intestinal mucosal microcirculation. Br J Anaesth 111(6):996–1003PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Michele Diana
    • 1
    • 3
    • 5
  • Bernard Dallemagne
    • 1
  • Hyunsoo Chung
    • 1
  • Yoshihiro Nagao
    • 1
  • Peter Halvax
    • 1
  • Vincent Agnus
    • 1
  • Luc Soler
    • 1
  • Veronique Lindner
    • 2
  • Nicolas Demartines
    • 3
  • Pierre Diemunsch
    • 4
  • Bernard Geny
    • 5
  • Lee Swanström
    • 1
  • Jacques Marescaux
    • 1
  1. 1.IRCAD Research Institute against Cancer of the Digestive System and IHU Minimally Invasive Image-Guided Surgical InstituteStrasbourgFrance
  2. 2.Department of PathologyHospital of MulhouseMulhouseFrance
  3. 3.Department of Visceral Surgery, CHUVUniversity Hospital of LausanneLausanneSwitzerland
  4. 4.Department of AnesthesiologyUniversity of StrasbourgStrasbourgFrance
  5. 5.Institute of Physiology, EA 3072: Oxidative Stress, Mitochondria and Muscle ProtectionStrasbourgFrance

Personalised recommendations