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Precision real-time evaluation of bowel perfusion: accuracy of confocal endomicroscopy assessment of stoma in a controlled hemorrhagic shock model

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Abstract

Background and aims

Confocal laser endomicroscopy (CLE) can provide real-time evaluation of bowel perfusion. We aimed to evaluate CLE perfusion imaging in a hemorrhagic shock model.

Materials and methods

Five pigs were equipped to ensure hemodynamic monitoring. Three ileostomies per animal (total n = 15) were randomly created (T0). Blood was withdrawn targeting a mean arterial pressure of 40 mmHg (shock phase, T1), for 90 min. Infusion of Ringer’s lactate was started and continued for 90 min (T2). At the different time points: (a) stomas’ mucosa was scanned with CLE; (b) capillary lactates were measured on blood obtained by puncturing stomas’ mucosa; and (c) full-thickness stomas’ biopsies were sampled for histology, mitochondrial respiratory rate (V 0 = basal and V ADP = respiratory rate in excess of adenosine diphosphate), and levels of superoxide anion evaluation. Functional capillary density (FCD) was measured using ad hoc software.

Results

Confocal scanning provided consistent and specific imaging of bowel hypoperfusion at T1: vascular hyperpermeability (blurred and enlarged capillaries) and edema (enhanced visualization of the brush border due to increased intercellular spaces and fluorescein leakage). At the end of T2, there was an improved capillary flow. FCD-A index expressed statistically significant correlation with (1) stoma capillary lactates (p = 0.023); (2) systemic capillary lactates (p = 0.031); (3) inflammation pathology score (p = 0.048); (4) central venous pressure (p = 0.0043); and (5) pulmonary artery pressure (p = 0.01). Stoma capillary lactates (mmol/L) were significantly increased at T1 (8.81 ± 4.23; p < 0.0001) and at T2 (4.77 ± 3.13; p < 0.01) when compared to T0 inclusion values (1.86 ± 0.56). V 0 and V ADP (pmol O2/min/mg tissue) were both significantly decreased at T1 versus T0 (p < 0.007 and p < 0.01, respectively) and recovered by the end of reanimation (T2 vs. T0, p = n.s.). Mean O 2 ·− production (µmol/min/mg/dry tissue) increased at T1 and significantly decreased at T2.

Conclusions

Confocal laser endomicroscopy (CLE) imaging could identify morphological signs congruent with biochemical markers of bowel perfusion and could be useful for assessment of stomas.

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Author information

Correspondence to Michele Diana.

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Disclosures

Jacques Marescaux is the president of both IRCAD and IHU institutes, which are partly funded by Karl Storz, Medtronic, and Siemens Healthcare. Michele Diana, Eric Noll, Anne-Laure Charles, Pierre Diemunsch, Bernard Geny, Yu-Yin Liu, Francesco Marchegiani, Luigi Schiraldi, Vincent Agnus, Veronique Lindner, Lee Swanström, and Bernard Dallemagne have no conflicts of interest or financial ties to disclose.

Electronic supplementary material

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The narrated video-clip displays the experimental setting and highlights the main morphological changes of bowel mucosa that could be identified by Confocal Endomicroscopy during the hemorrhagic shock and the fluid therapy (MP4 100563 kb)

Video Clip 1

The narrated video-clip displays the experimental setting and highlights the main morphological changes of bowel mucosa that could be identified by Confocal Endomicroscopy during the hemorrhagic shock and the fluid therapy (MP4 100563 kb)

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Diana, M., Noll, E., Charles, A. et al. Precision real-time evaluation of bowel perfusion: accuracy of confocal endomicroscopy assessment of stoma in a controlled hemorrhagic shock model. Surg Endosc 31, 680–691 (2017). https://doi.org/10.1007/s00464-016-5022-7

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Keywords

  • Confocal laser endomicroscopy
  • Functional capillary density area
  • Bowel perfusion
  • Stoma perfusion
  • Hemorrhagic shock model
  • Mitochondria respiratory rate
  • Electron paramagnetic resonance
  • Oxidative stress