Probe-based confocal laser endomicroscopy and fluorescence-based enhanced reality for real-time assessment of intestinal microcirculation in a porcine model of sigmoid ischemia
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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.
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.
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.
In this experimental model, FLER and CLE were more accurate than clinical evaluation to delineate bowel vascularization.
KeywordsConfocal laser endomicroscopy Anastomotic perfusion Fluorescence-based enhanced reality
Confocal laser endomicroscopy
Fluorescence-based enhanced reality
Inferior mesenteric artery
Regions of interest
Arterial oxygen saturation
Hemoglobin oxygen saturation
Visible light spectroscopy
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.
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.