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Indocyanine Green Tissue Angiography Can Reduce Extended Bowel Resections in Acute Mesenteric Ischemia

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Purpose

Surgical exploration and bowel resection are frequently required for treating non-occlusive mesenteric ischemia. Intraoperative evaluation of intestinal perfusion is subjective and challenging. In this feasibility study, ICG fluorescence angiography was performed in order to evaluate intestinal perfusion in patients with acute mesenteric ischemia.

Methods

This is a retrospective analysis of 52 patients who were operated for acute mesenteric ischemia using ICG fluorescence angiography. Patients with occlusive disease requiring recanalization were excluded. The SPY and PinPoint imaging systems were used for open and laparoscopic surgery, respectively. Intraoperative macroscopic assessment of perfusion was compared with the ICG angiography results.

Results

Surgical exploration was performed for ischemia of the colon (n = 12), the small bowel (n = 23), or both (n = 16). One patient had ischemia of the esophagus and stomach. All patients had a preoperative CT angiography to rule out stenosis or occlusion of the mesenteric vessels. In 18 cases (34.6%), ICG fluorescence angiography provided information that was supplemental to macroscopic evaluation, but most patients did not survive the postoperative course. However, in six of those cases (11.5%), ICG angiography led to a major change in operative strategy resulting in a significant clinical benefit for those patients. For two cases, ICG fluorescence produced false negative results.

Discussion

ICG tissue angiography is feasible and technically reliable for evaluating intestinal perfusion in acute mesenteric ischemia and led to a significant clinical benefit in 11% of our patients. A relevant discrepancy between surgical visual assessment and fluorescence angiography was found in 35% of the cases, which may help to define resection margins more accurately and thus support surgical decision-making.

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References

  1. Adaba, F., et al., Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies. Colorectal Dis, 2015. 17(7): p. 566–77.

    Article  CAS  Google Scholar 

  2. Karkkainen, J.M. and S. Acosta, Acute mesenteric ischemia (part I) - Incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol, 2017. 31(1): p. 15–25.

    Article  Google Scholar 

  3. Treskes, N., A.M. Persoon, and A.R.H. van Zanten, Diagnostic accuracy of novel serological biomarkers to detect acute mesenteric ischemia: a systematic review and meta-analysis. Intern Emerg Med, 2017.

  4. Beaulieu, R.J., et al., Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg, 2014. 59(1): p. 159–64.

    Article  Google Scholar 

  5. Eker, A., et al., Mesenteric ischemia after coronary artery bypass grafting: should local continuous intra-arterial perfusion with papaverine be regarded as a treatment? Eur J Cardiothorac Surg, 1999. 15(2): p. 218–20.

    Article  CAS  Google Scholar 

  6. Niederhauser, U., et al., Mesenteric ischemia after a cardiac operation: conservative treatment with local vasodilation. Ann Thorac Surg, 1996. 61(6): p. 1817–9.

    Article  CAS  Google Scholar 

  7. Klotz, S., et al., Diagnosis and treatment of nonocclusive mesenteric ischemia after open heart surgery. Ann Thorac Surg, 2001. 72(5): p. 1583–6.

    Article  CAS  Google Scholar 

  8. Tilsed, J.V., et al., ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg, 2016. 42(2): p. 253–70.

    Article  CAS  Google Scholar 

  9. Danse, E.M., et al., Early diagnosis of acute intestinal ischaemia: contribution of colour Doppler sonography. Acta Chir Belg, 1997. 97(4): p. 173–6.

    CAS  PubMed  Google Scholar 

  10. Singh, D.B., et al., Intraoperative measurement of colonic oxygenation during bowel resection. Adv Exp Med Biol, 2009. 645: p. 261–6.

    Article  Google Scholar 

  11. Nowak, K., et al., Ischemic and injured bowel evaluation by Fluorescence imaging. Colorectal Dis, 2015. 17 Suppl 3: p. 12–5.

    Article  Google Scholar 

  12. Kassahun, W.T., et al., Unchanged high mortality rates from acute occlusive intestinal ischemia: six year review. Langenbecks Arch Surg, 2008. 393(2): p. 163–71.

    Article  Google Scholar 

  13. Mamode, N., I. Pickford, and P. Leiberman, Failure to improve outcome in acute mesenteric ischaemia: seven-year review. Eur J Surg, 1999. 165(3): p. 203–8.

    Article  CAS  Google Scholar 

  14. Phillips, J.P., et al., Pulse oximetry and photoplethysmographic waveform analysis of the esophagus and bowel. Curr Opin Anaesthesiol, 2008. 21(6): p. 779–83.

    Article  Google Scholar 

  15. Lynch, T.G., et al., Doppler ultrasound, laser Doppler, and perfusion fluorometry in bowel ischemia. Arch Surg, 1988. 123(4): p. 483–6.

    Article  CAS  Google Scholar 

  16. Urbanavicius, L., et al., How to assess intestinal viability during surgery: A review of techniques. World J Gastrointest Surg, 2011. 3(5): p. 59–69.

    Article  Google Scholar 

  17. Nitori, N., et al., Successful treatment of non-occlusive mesenteric ischemia (NOMI) using the HyperEye Medical System for intraoperative visualization of the mesenteric and bowel circulation: report of a case. Surg Today, 2014. 44(2): p. 359–62.

    Article  Google Scholar 

  18. Diana, M., et al., Probe-based confocal laser endomicroscopy and fluorescence-based enhanced reality for real-time assessment of intestinal microcirculation in a porcine model of sigmoid ischemia. Surg Endosc, 2014. 28(11): p. 3224–33.

    Article  Google Scholar 

  19. Diana, M., et al., Enhanced-reality video fluorescence: a real-time assessment of intestinal viability. Ann Surg, 2014. 259(4): p. 700–7.

    Article  Google Scholar 

  20. Alemanno, G., et al., Combination of diagnostic laparoscopy and intraoperative indocyanine green fluorescence angiography for the early detection of intestinal ischemia not detectable at CT scan. Int J Surg Case Rep, 2016. 26: p. 77–80.

    Article  Google Scholar 

  21. Ishizuka, M., et al., Usefulness of intraoperative observation using a fluorescence imaging instrument for patients with nonocclusive mesenteric ischemia. Int Surg, 2015. 100(4): p. 593–9.

    Article  Google Scholar 

  22. Karampinis, I., et al., Indocyanine green tissue angiography affects anastomotic leakage after esophagectomy. A retrospective, case-control study. Int J Surg, 2017. 48: p. 210–214.

    Article  Google Scholar 

  23. Gupta, P.K., et al., Morbidity and mortality after bowel resection for acute mesenteric ischemia. Surgery, 2011. 150(4): p. 779–87.

    Article  Google Scholar 

  24. Diebel, L.N., S.A. Dulchavsky, and R.F. Wilson, Effect of increased intra-abdominal pressure on mesenteric arterial and intestinal mucosal blood flow. J Trauma, 1992. 33(1): p. 45–8; discussion 48-9.

    Article  CAS  Google Scholar 

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Acknowledgements

We would like to thank our colleague, Ms. Joy Fest, for language editing.

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Authors and Affiliations

  1. Department of Surgery, Mannheim University Medical Centre, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany

    Ioannis Karampinis, Jens Jakob MD, Vytautas Stasiunaitis MD, Andreas Gerken MD, Stefan Post MD, Peter Kienle MD & Kai Nowak MD

  2. Mannheim University Medical Centre, University of Heidelberg, Mannheim, Germany

    Michael Keese MD

  3. Institute of Clinical Radiology and Nuclear Medicine, Mannheim University Medical Centre, University of Heidelberg, Mannheim, Germany

    Ulrike Attenberger MD

Authors
  1. Ioannis Karampinis
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  2. Michael Keese MD
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  3. Jens Jakob MD
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  4. Vytautas Stasiunaitis MD
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  5. Andreas Gerken MD
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  6. Ulrike Attenberger MD
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  7. Stefan Post MD
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  8. Peter Kienle MD
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  9. Kai Nowak MD
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Contributions

Ioannis Karampinis was responsible for the acquisition of data, analysis, interpretation, and drafting of the manuscript.

Michael Keese was involved in the study conception and design and revised the manuscript.

Jens Jakob was involved in the study conception and design and revised the manuscript.

Vytautas Stasiunaitis participated in the acquisition of the data and the data analysis.

Andreas Gerken was involved in the acquisition of the data and the data analysis.

Ulrike Attenberger was involved in the acquisition of the data and the data analysis.

Stefan Post critically revised the manuscript.

Peter Kienle was involved in data analysis and revision of the manuscript.

Kai Nowak planed the study, performed the acquisition of data, drafted and revised the manuscript.

Corresponding author

Correspondence to Ioannis Karampinis.

Ethics declarations

Ethical Approval

The study was approved by the ethic committee of the Mannheim medical faculty at the University of Heidelberg, Germany (2015-854R-MA). ICG is approved for intravenous application. Written informed consent was obtained whenever possible. Severely septic patients were operated on as emergency procedures.

Availability of Data and Materials

The datasets generated during the current study are not publicly available as the main findings are included in this article. The complete database is available from the corresponding author upon reasonable request.

Conflict of Interests

IK has no competing interests to declare.

MK has no competing interests to declare.

JJ has no competing interests to declare.

VS has no competing interests to declare.

UA has no competing interests to declare.

SP has no competing interests to declare.

PK has no competing interests to declare.

KN serves as a consultant in the field of intraoperative fluorescent technology for Stryker and Novadaq.

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Karampinis, I., Keese, M., Jakob, J. et al. Indocyanine Green Tissue Angiography Can Reduce Extended Bowel Resections in Acute Mesenteric Ischemia. J Gastrointest Surg 22, 2117–2124 (2018). https://doi.org/10.1007/s11605-018-3855-1

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  • DOI: https://doi.org/10.1007/s11605-018-3855-1

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