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Dalli J, Epperlein JP, Hardy NP, Khan MF, Mac Aonghusa P, Cahill RA. Clinical and computational development of a patient-calibrated ICGFA bowel transection recommender. Surg Endosc 2024; 38:3212-3222. [PMID: 38637339 PMCID: PMC11133155 DOI: 10.1007/s00464-024-10827-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/23/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Intraoperative indocyanine green fluorescence angiography (ICGFA) aims to reduce colorectal anastomotic complications. However, signal interpretation is inconsistent and confounded by patient physiology and system behaviours. Here, we demonstrate a proof of concept of a novel clinical and computational method for patient calibrated quantitative ICGFA (QICGFA) bowel transection recommendation. METHODS Patients undergoing elective colorectal resection had colonic ICGFA both immediately after operative commencement prior to any dissection and again, as usual, just before anastomotic construction. Video recordings of both ICGFA acquisitions were blindly quantified post hoc across selected colonic regions of interest (ROIs) using tracking-quantification software and computationally compared with satisfactory perfusion assumed in second time-point ROIs, demonstrating 85% agreement with baseline ICGFA. ROI quantification outputs detailing projected perfusion sufficiency-insufficiency zones were compared to the actual surgeon-selected transection/anastomotic construction site for left/right-sided resections, respectively. Anastomotic outcomes were recorded, and tissue lactate was also measured in the devascularised colonic segment in a subgroup of patients. The novel perfusion zone projections were developed as full-screen recommendations via overlay heatmaps. RESULTS No patient suffered intra- or early postoperative anastomotic complications. Following computational development (n = 14) the software recommended zone (ROI) contained the expert surgical site of transection in almost all cases (Jaccard similarity index 0.91) of the nine patient validation series. Previously published ICGFA time-series milestone descriptors correlated moderately well, but lactate measurements did not. High resolution augmented reality heatmaps presenting recommendations from all pixels of the bowel ICGFA were generated for all cases. CONCLUSIONS By benchmarking to the patient's own baseline perfusion, this novel QICGFA method could allow the deployment of algorithmic personalised NIR bowel transection point recommendation in a way fitting existing clinical workflow.
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Affiliation(s)
- Jeffrey Dalli
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Niall P Hardy
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mohammad Faraz Khan
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Ronan A Cahill
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Catherine McAuley Centre, 21 Nelson St, Dublin 7, D07 KX5K, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
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2
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Dalli J, Nguyen C, Jindal A, Epperlein J, Hardy N, Pulitano C, Warrier S, Cahill R. A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy. JPRAS Open 2024; 40:32-47. [PMID: 38425697 PMCID: PMC10904167 DOI: 10.1016/j.jpra.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/21/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications. Methods ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data. Results The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity. Conclusion Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.
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Affiliation(s)
- J. Dalli
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
| | - C.L. Nguyen
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
- Department of Surgery, The University of Sydney, Camperdown, Australia
| | - A. Jindal
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
| | | | - N.P. Hardy
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
| | - C. Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
- Department of Surgery, The University of Sydney, Camperdown, Australia
| | - S. Warrier
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
- Department of Surgery, The University of Sydney, Camperdown, Australia
| | - R.A. Cahill
- UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Nijssen DJ, Joosten JJ, Osterkamp J, van den Elzen RM, de Bruin DM, Svendsen MBS, Dalsgaard MW, Gisbertz SS, Hompes R, Achiam MP, van Berge Henegouwen MI. Quantification of fluorescence angiography for visceral perfusion assessment: measuring agreement between two software algorithms. Surg Endosc 2024; 38:2805-2816. [PMID: 38594365 PMCID: PMC11078848 DOI: 10.1007/s00464-024-10794-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/09/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICG-FA) may reduce perfusion-related complications of gastrointestinal anastomosis. Software implementations for quantifying ICG-FA are emerging to overcome a subjective interpretation of the technology. Comparison between quantification algorithms is needed to judge its external validity. This study aimed to measure the agreement for visceral perfusion assessment between two independently developed quantification software implementations. METHODS This retrospective cohort analysis included standardized ICG-FA video recordings of patients who underwent esophagectomy with gastric conduit reconstruction between August 2020 until February 2022. Recordings were analyzed by two quantification software implementations: AMS and CPH. The quantitative parameter used to measure visceral perfusion was the normalized maximum slope derived from fluorescence time curves. The agreement between AMS and CPH was evaluated in a Bland-Altman analysis. The relation between the intraoperative measurement of perfusion and the incidence of anastomotic leakage was determined for both software implementations. RESULTS Seventy pre-anastomosis ICG-FA recordings were included in the study. The Bland-Altman analysis indicated a mean relative difference of + 58.2% in the measurement of the normalized maximum slope when comparing the AMS software to CPH. The agreement between AMS and CPH deteriorated as the magnitude of the measured values increased, revealing a proportional (linear) bias (R2 = 0.512, p < 0.001). Neither the AMS nor the CPH measurements of the normalized maximum slope held a significant relationship with the occurrence of anastomotic leakage (median of 0.081 versus 0.074, p = 0.32 and 0.041 vs 0.042, p = 0.51, respectively). CONCLUSION This is the first study to demonstrate technical differences in software implementations that can lead to discrepancies in ICG-FA quantification in human clinical cases. The possible variation among software-based quantification methods should be considered when interpreting studies that report quantitative ICG-FA parameters and derived thresholds, as there may be a limited external validity.
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Affiliation(s)
- D J Nijssen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - J J Joosten
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - J Osterkamp
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - R M van den Elzen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, The Netherlands
| | - D M de Bruin
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, The Netherlands
| | - M B S Svendsen
- Copenhagen Academy for Medical Education and Simulation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Computer Science, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - M W Dalsgaard
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - M P Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
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Sincavage J, Gulack BC, Zamora IJ. Indocyanine green (ICG) fluorescence-enhanced applications in pediatric surgery. Semin Pediatr Surg 2024; 33:151384. [PMID: 38245991 DOI: 10.1016/j.sempedsurg.2024.151384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The breadth of pediatric surgical practice and variety of anatomic anomalies that characterize surgical disease in children and neonates require a unique level of operative mastery and versatility. Intraoperative navigation of small, complex, and often abnormal anatomy presents a particular challenge for pediatric surgeons. Clinical experience with fluorescent tissue dye, specifically indocyanine green (ICG), is quickly gaining widespread incorporation into adult surgical practice as a safe, non-toxic means of accurately visualizing tissue perfusion, lymphatic flow, and biliary anatomy to enhance operative speed, safety, and patient outcomes. Experience in pediatric surgery, however, remains limited. ICG-fluorescence guided surgery is poised to address the challenges of pediatric and neonatal operations for a growing breadth of surgical pathology. Fluorescent angiography has permitted intraoperative visualization of colorectal flap perfusion for complex pelvic reconstruction and anastomotic perfusion after esophageal atresia repair, while its hepatic absorption and biliary excretion has made it an excellent agent for delineating the dissection plane in the Kasai portoenterostomy and identifying both primary and metastatic hepatoblastoma lesions. Subcutaneous and intra-lymphatic ICG injection can identify iatrogenic chylous leaks and improved yields in sentinel lymph node biopsies. ICG-guided surgery holds promise for more widespread use in pediatric surgical conditions, and continued evaluation of efficacy will be necessary to better inform clinical practice and identify where to focus and develop this technical resource.
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Affiliation(s)
- John Sincavage
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Brian C Gulack
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, United States.
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van Dam MA, Bijlstra OD, Faber RA, Warmerdam MI, Achiam MP, Boni L, Cahill RA, Chand M, Diana M, Gioux S, Kruijff S, Van der Vorst JR, Rosenthal RJ, Polom K, Vahrmeijer AL, Mieog JSD. Consensus conference statement on fluorescence-guided surgery (FGS) ESSO course on fluorescence-guided surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107317. [PMID: 38104355 DOI: 10.1016/j.ejso.2023.107317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/09/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Fluorescence-guided surgery (FGS) has emerged as an innovative technique with promising applications in various surgical specialties. However, clinical implementation is hampered by limited availability of evidence-based reference work supporting the translation towards standard-of-care use in surgical practice. Therefore, we developed a consensus statement on current applications of FGS. METHODS During an international FGS course, participants anonymously voted on 36 statements. Consensus was defined as agreement ≥70% with participation grade of ≥80%. All participants of the questionnaire were stratified for user and handling experience within five domains of applicability (lymphatics & lymph node imaging; tissue perfusion; biliary anatomy and urinary tracts; tumor imaging in colorectal, HPB, and endocrine surgery, and quantification and (tumor-) targeted imaging). Results were pooled to determine consensus for each statement within the respective sections based on the degree of agreement. RESULTS In total 43/52 (81%) course participants were eligible as voting members for consensus, comprising the expert panel (n = 12) and trained users (n = 31). Consensus was achieved in 17 out of 36 (45%) statements with highest level of agreement for application of FGS in tissue perfusion and biliary/urinary tract visualization (71% and 67%, respectively) and lowest within the tumor imaging section (0%). CONCLUSIONS FGS is currently established for tissue perfusion and vital structure imaging. Lymphatics & lymph node imaging in breast cancer and melanoma are evolving, and tumor tissue imaging holds promise in early-phase trials. Quantification and (tumor-)targeted imaging are advancing toward clinical validation. Additional research is needed for tumor imaging due to a lack of consensus.
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Affiliation(s)
- M A van Dam
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - O D Bijlstra
- Department of Surgery, Leiden University Medical Center, the Netherlands; Department of Surgery, Amsterdam University Medical Centers, the Netherlands
| | - R A Faber
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - M I Warmerdam
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - M P Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Denmark
| | - L Boni
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Italy
| | - R A Cahill
- Department of Surgery, UCD Centre for Precision Surgery, University College Dublin, Ireland
| | - M Chand
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - M Diana
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - S Gioux
- Intuitive Surgical, Aubonne, Switzerland
| | - S Kruijff
- Department of Surgical Oncology, University Medical Center Groningen, the Netherlands; Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands
| | - J R Van der Vorst
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | | | - K Polom
- The Academy of Applied Medical and Social Sciences, Lotnicza 2, Elblag, Poland; Gastrointestinal Surgical Oncology Department, Greater Poland Cancer Centre, Garbary 15, Poznan, Poland
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, the Netherlands.
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Chalopin C, Pfahl A, Köhler H, Knospe L, Maktabi M, Unger M, Jansen-Winkeln B, Thieme R, Moulla Y, Mehdorn M, Sucher R, Neumuth T, Gockel I, Melzer A. Alternative intraoperative optical imaging modalities for fluorescence angiography in gastrointestinal surgery: spectral imaging and imaging photoplethysmography. MINIM INVASIV THER 2023; 32:222-232. [PMID: 36622288 DOI: 10.1080/13645706.2022.2164469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/29/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Intraoperative near-infrared fluorescence angiography with indocyanine green (ICG-FA) is a well-established modality in gastrointestinal surgery. Its main drawback is the application of a fluorescent agent with possible side effects for patients. The goal of this review paper is the presentation of alternative, non-invasive optical imaging methods and their comparison with ICG-FA. MATERIAL AND METHODS The principles of ICG-FA, spectral imaging, imaging photoplethysmography (iPPG), and their applications in gastrointestinal surgery are described based on selected published works. RESULTS The main applications of the three modalities are the evaluation of tissue perfusion, the identification of risk structures, and tissue segmentation or classification. While the ICG-FA images are mainly evaluated visually, leading to subjective interpretations, quantitative physiological parameters and tissue segmentation are provided in spectral imaging and iPPG. The combination of ICG-FA and spectral imaging is a promising method. CONCLUSIONS Non-invasive spectral imaging and iPPG have shown promising results in gastrointestinal surgery. They can overcome the main drawbacks of ICG-FA, i.e. the use of contrast agents, the lack of quantitative analysis, repeatability, and a difficult standardization of the acquisition. Further technical improvements and clinical evaluations are necessary to establish them in daily clinical routine.
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Affiliation(s)
- Claire Chalopin
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Annekatrin Pfahl
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Luise Knospe
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Marianne Maktabi
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
- Department of Electrical, Mechanical and Industrial Engineering, Anhalt University of Applied Science, Köthen (Anhalt), Germany
| | - Michael Unger
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
- Department of General, Visceral and Oncological Surgery, St. Georg Hospital, Leipzig, Germany
| | - René Thieme
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Robert Sucher
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Thomas Neumuth
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig AöR, Leipzig, Germany
| | - Andreas Melzer
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
- Institute of Medical Science and Technology (IMSAT), University of Dundee, Dundee, UK
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Fransvea P, Fico V, Puccioni C, D'Agostino L, Costa G, Biondi A, Brisinda G, Sganga G. Application of fluorescence-guided surgery in the acute care setting: a systematic literature review. Langenbecks Arch Surg 2023; 408:375. [PMID: 37743419 DOI: 10.1007/s00423-023-03109-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 09/14/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Fluorescence-based imaging has found application in several fields of elective surgery, but there is still a lack of evidence in the literature about its use in emergency setting. The present review critically summarizes currently available applications and limitations of indocyanine green (ICG) fluorescence in abdominal emergencies including acute cholecystitis, mesenteric ischemia, and trauma surgery. METHODS A systematic review was performed according to the PRISMA statement identifying articles about the use of ICG fluorescence in the management of the most common general surgery emergency. Only studies focusing on the use of ICG fluorescence for the management of acute surgical conditions in adults were included. RESULTS Thirty-six articles were considered for qualitative analysis. The most frequent disease was occlusive or non-occlusive mesenteric ischemia followed by acute cholecystitis. Benefits from using ICG for acute cholecystitis were reported in 48% of cases (clear identification of biliary structures and a safer surgical procedure). In one hundred and twenty cases that concerned the use of ICG for occlusive or non-occlusive mesenteric ischemia, ICG injection led to a modification of the surgical decision in 44 patients (36.6%). Three studies evaluated the use of ICG in trauma patients to assess the viability of bowel or parenchymatous organs in abdominal trauma, to evaluate the perfusion-related tissue impairment in extremity or craniofacial trauma, and to reassess the efficacy of surgical procedures performed in terms of vascularization. ICG injection led to a modification of the surgical decision in 50 patients (23.9%). CONCLUSION ICG fluorescence is a safe and feasible tool also in an emergency setting. There is increasing evidence that the use of ICG fluorescence during abdominal surgery could facilitate intra-operative decision-making and improve patient outcomes, even in the field of emergency surgery.
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Affiliation(s)
- Pietro Fransvea
- UOC Chirurgia d'Urgenza E del Trauma, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy.
| | - Valeria Fico
- UOC Chirurgia d'Urgenza E del Trauma, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Caterina Puccioni
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Luca D'Agostino
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Gianluca Costa
- Colorectal Surgery Clinical and Research Unit Surgery Center, Fondazione Policlinico Universitario Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Alberto Biondi
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
- General Surgery Unit, Fondazione Policlinico Universitario A Gemelli IRCCS, 00168, Rome, Italy
| | - Giuseppe Brisinda
- UOC Chirurgia d'Urgenza E del Trauma, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Gabriele Sganga
- UOC Chirurgia d'Urgenza E del Trauma, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
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8
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Faber RA, Tange FP, Galema HA, Zwaan TC, Holman FA, Peeters KCMJ, Tanis PJ, Verhoef C, Burggraaf J, Mieog JSD, Hutteman M, Keereweer S, Vahrmeijer AL, van der Vorst JR, Hilling DE. Quantification of indocyanine green near-infrared fluorescence bowel perfusion assessment in colorectal surgery. Surg Endosc 2023; 37:6824-6833. [PMID: 37286750 PMCID: PMC10462565 DOI: 10.1007/s00464-023-10140-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Indocyanine green near-infrared fluorescence bowel perfusion assessment has shown its potential benefit in preventing anastomotic leakage. However, the surgeon's subjective visual interpretation of the fluorescence signal limits the validity and reproducibility of the technique. Therefore, this study aimed to identify objective quantified bowel perfusion patterns in patients undergoing colorectal surgery using a standardized imaging protocol. METHOD A standardized fluorescence video was recorded. Postoperatively, the fluorescence videos were quantified by drawing contiguous region of interests (ROIs) on the bowel. For each ROI, a time-intensity curve was plotted from which perfusion parameters (n = 10) were derived and analyzed. Furthermore, the inter-observer agreement of the surgeon's subjective interpretation of the fluorescence signal was assessed. RESULTS Twenty patients who underwent colorectal surgery were included in the study. Based on the quantified time-intensity curves, three different perfusion patterns were identified. Similar for both the ileum and colon, perfusion pattern 1 had a steep inflow that reached its peak fluorescence intensity rapidly, followed by a steep outflow. Perfusion pattern 2 had a relatively flat outflow slope immediately followed by its plateau phase. Perfusion pattern 3 only reached its peak fluorescence intensity after 3 min with a slow inflow gradient preceding it. The inter-observer agreement was poor-moderate (Intraclass Correlation Coefficient (ICC): 0.378, 95% CI 0.210-0.579). CONCLUSION This study showed that quantification of bowel perfusion is a feasible method to differentiate between different perfusion patterns. In addition, the poor-moderate inter-observer agreement of the subjective interpretation of the fluorescence signal between surgeons emphasizes the need for objective quantification.
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Affiliation(s)
- Robin A Faber
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Floris P Tange
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hidde A Galema
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Thomas C Zwaan
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Fabian A Holman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Pieter J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Centre of Human Drug Research, Zernikedreef 8, 2333 CL, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Merlijn Hutteman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Stijn Keereweer
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Joost R van der Vorst
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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9
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Zötterman J, Tesselaar E, Elawa S, Farnebo S. Correlation between Indocyanine Green Fluorescence Angiography and Laser Speckle Contrast Imaging in a Flap Model. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5187. [PMID: 38152716 PMCID: PMC10752484 DOI: 10.1097/gox.0000000000005187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/14/2023] [Indexed: 12/29/2023]
Abstract
Background Indocyanine green fluorescence angiography (ICG-FA) is used to assess tissue intraoperatively in reconstructive surgery. This requires an intra-venous dye injection for each assessment. This is not necessary in laser speckle contrast imaging (LSCI); therefore, this method may be better suited for tissue evaluation. To determine this, we compared the two methods in a porcine flap model. Methods One random and one pedicled flap were raised on each buttock of six animals. They were assessed with LSCI at baseline, when raised (T0), at 30 minutes (T30) and with ICG-FA at T0 and T30. Regions of interest (ROI) were chosen along the flap axis. Perfusion, measured as perfusion units (PU) in the LSCI assessment and pixel-intensity for the ICG-FA video uptake, was calculated in the ROI. Correlation was calculated between PU and pixel-intensity measured as time to peak (TTP) and area under curve for 60 seconds (AUC60). Results Correlation between LSCI and AUC60 for the ICG-FA in corresponding ROI could be seen in all flaps at all time points. The correlation was higher for T0 (r=0.7 for random flap and r=0.6 for pedicled flap) than for T30 (r=0.57 for random flap and r=0.59 for pedicled flap). Even higher correlation could be seen PU and TTP (T0: random flap r=-0.8 and pedicled flap r=0.76. T30: random flap r=-0.8 and pedicled flap r=0.71). Conclusion There is a correlation between PU from LSCI and TTP and AUC60 for ICG-FA, indicating that LSCI could be considered for intraoperative tissue assessment.
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Affiliation(s)
- Johan Zötterman
- From the Department of Hand and Plastic Surgery and Burns and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Erik Tesselaar
- Department of Medical Radiation Physics and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Sherif Elawa
- From the Department of Hand and Plastic Surgery and Burns and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Simon Farnebo
- From the Department of Hand and Plastic Surgery and Burns and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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10
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Nielsen LBJ, Ærenlund MP, Alouda M, Azzam M, Bjerke T, Burcharth J, Dibbern CB, Jensen TK, Jordhøj JQ, Lolle I, Malik T, Ngo-Stuyt L, Nielsen EØ, Olausson M, Skovsen AP, Tolver MA, Smith HG. Real-world accuracy of computed tomography in patients admitted with small bowel obstruction: a multicentre prospective cohort study. Langenbecks Arch Surg 2023; 408:341. [PMID: 37642708 PMCID: PMC10465641 DOI: 10.1007/s00423-023-03084-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Small bowel obstruction (SBO) is a common surgical emergency. Previous studies have shown the value computed tomography (CT) scanning in both confirming this diagnosis and identifying indications for urgent surgical intervention, such as strangulated bowel or closed loop obstructions. However, most of the literature is based on retrospective expert review of previous imaging and little data regarding the real-time accuracy of CT reporting is available. Here, we investigated the real-world accuracy of CT reporting in patients admitted with SBO. METHODS This was a multicentre prospective study including consecutive patients admitted with SBO. The primary outcomes were the sensitivity and specificity of CT scanning for bowel obstruction with ischaemia and closed loop obstruction. Data were retrieved from the original CT reports written by on-call radiologists and compared with operative findings. RESULTS One hundred seventy-six patients were included, all of whom underwent CT scanning with intravenous contrast followed by operative management of SBO. Bowel obstruction with ischaemia was noted in 20 patients, with a sensitivity and specificity of CT scanning of 40.0% and 85.5%, respectively. Closed loop obstructions were noted in 26 patients, with a sensitivity and specificity of CT scanning of 23.1% and 98.0%, respectively. CONCLUSIONS The real-world accuracy of CT scanning appears to be lower than previously reported in the literature. Strategies to address this could include the development of standardised reporting schemas and to increase the surgeon's own familiarity with relevant CT features in patients admitted with SBO.
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Affiliation(s)
- L B J Nielsen
- Abdominalcenter K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - M P Ærenlund
- Department of Gastrointestinal and Hepatic Diseases, Surgical Division, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - M Alouda
- Department of Gastrointestinal and Hepatic Diseases, Surgical Division, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - M Azzam
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
| | - T Bjerke
- Abdominalcenter K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - J Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Surgical Division, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - C B Dibbern
- Department of Surgery, Nordsjællands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - T K Jensen
- Department of Gastrointestinal and Hepatic Diseases, Surgical Division, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - J Q Jordhøj
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
| | - I Lolle
- Department of Surgery, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - T Malik
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
| | - L Ngo-Stuyt
- Department of Surgery, Zealand University Hospital, Koge, Denmark
| | - E Ø Nielsen
- Department of Surgery, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M Olausson
- Department of Surgery, Zealand University Hospital, Koge, Denmark
| | - A P Skovsen
- Department of Surgery, Nordsjællands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M A Tolver
- Department of Surgery, Zealand University Hospital, Koge, Denmark
| | - H G Smith
- Abdominalcenter K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark.
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark.
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11
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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: 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: 12/17/2022] [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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12
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Joosten JJ, Slooter MD, van den Elzen RM, Bloemen PR, Gisbertz SS, Eshuis WJ, Daams F, de Bruin DM, van Berge Henegouwen MI. Perfusion assessment by fluorescence time curves in esophagectomy with gastric conduit reconstruction: a prospective clinical study. Surg Endosc 2023:10.1007/s00464-023-10107-9. [PMID: 37208482 PMCID: PMC10338581 DOI: 10.1007/s00464-023-10107-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/30/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Intraoperative perfusion assessment with indocyanine green fluorescence angiography (ICG-FA) may reduce postoperative anastomotic leakage rates after esophagectomy with gastric conduit reconstruction. This study evaluated quantitative parameters derived from fluorescence time curves to determine a threshold for adequate perfusion and predict postoperative anastomotic complications. METHODS This prospective cohort study included consecutive patients who underwent FA-guided esophagectomy with gastric conduit reconstruction between August 2020 and February 2022. After intravenous bolus injection of 0.05-mg/kg ICG, fluorescence intensity was registered over time by PINPOINT camera (Stryker, USA). Fluorescent angiograms were quantitatively analyzed at a region of interest of 1 cm diameter at the anastomotic site on the conduit using tailor-made software. Extracted fluorescence parameters were both inflow (T0, Tmax, Fmax, slope, Time-to-peak) as outflow parameters (T90% and T80%). Anastomotic complications including anastomotic leakage (AL) and strictures were documented. Fluorescence parameters in patients with AL were compared to those without AL. RESULTS One hundred and three patients (81 male, 65.7 ± 9.9 years) were included, the majority of whom (88%) underwent an Ivor Lewis procedure. AL occurred in 19% of patients (n = 20/103). Both time to peak as Tmax were significantly longer for the AL group in comparison to the non-AL group (39 s vs. 26 s, p = 0.04 and 65 vs. 51 s, p = 0.03, respectively). Slope was 1.0 (IQR 0.3-2.5) and 1.7 (IQR 1.0-3.0) for the AL and non-AL group (p = 0.11). Outflow was longer in the AL group, although not significantly, T90% 30 versus 15 s, respectively, p = 0.20). Univariate analysis indicated that Tmax might be predictive for AL, although not reaching significance (p = 0.10, area under the curve 0.71) and a cut-off value of 97 s was derived, with a specificity of 92%. CONCLUSION This study demonstrated quantitative parameters and identified a fluorescent threshold which could be used for intraoperative decision-making and to identify high-risk patients for anastomotic leakage during esophagectomy with gastric conduit reconstruction. A significant predictive value remains to be determined in future studies.
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Affiliation(s)
- J J Joosten
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - M D Slooter
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - R M van den Elzen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - P R Bloemen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - W J Eshuis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - F Daams
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - D M de Bruin
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
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13
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Sutton PA, van Dam MA, Cahill RA, Mieog S, Polom K, Vahrmeijer AL, van der Vorst J. Fluorescence-guided surgery: comprehensive review. BJS Open 2023; 7:7162090. [PMID: 37183598 PMCID: PMC10183714 DOI: 10.1093/bjsopen/zrad049] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Despite significant improvements in preoperative workup and surgical planning, surgeons often rely on their eyes and hands during surgery. Although this can be sufficient in some patients, intraoperative guidance is highly desirable. Near-infrared fluorescence has been advocated as a potential technique to guide surgeons during surgery. METHODS A literature search was conducted to identify relevant articles for fluorescence-guided surgery. The literature search was performed using Medical Subject Headings on PubMed for articles in English until November 2022 and a narrative review undertaken. RESULTS The use of invisible light, enabling real-time imaging, superior penetration depth, and the possibility to use targeted imaging agents, makes this optical imaging technique increasingly popular. Four main indications are described in this review: tissue perfusion, lymph node assessment, anatomy of vital structures, and tumour tissue imaging. Furthermore, this review provides an overview of future opportunities in the field of fluorescence-guided surgery. CONCLUSION Fluorescence-guided surgery has proven to be a widely innovative technique applicable in many fields of surgery. The potential indications for its use are diverse and can be combined. The big challenge for the future will be in bringing experimental fluorophores and conjugates through trials and into clinical practice, as well as validation of computer visualization with large data sets. This will require collaborative surgical groups focusing on utility, efficacy, and outcomes for these techniques.
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Affiliation(s)
- Paul A Sutton
- The Colorectal and Peritoneal Oncology Centre, Christie Hospital, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Martijn A van Dam
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronan A Cahill
- RAC, UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
- RAC, Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sven Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Karol Polom
- Clinic of Oncological, Transplantation and General Surgery, Gdansk Medical University, Gdansk, Poland
| | | | - Joost van der Vorst
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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14
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Joosten JJ, Slooter MD, van den Elzen RM, Bloemen PR, Laméris W, de Bruin DM, Bemelman WA, Hompes R. Understanding fluorescence time curves during ileal pouch-anal anastomosis with or without vascular ligation. Surg Endosc 2023:10.1007/s00464-023-09921-y. [PMID: 36917344 DOI: 10.1007/s00464-023-09921-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/28/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Intraoperative indocyanine green fluorescence angiography (ICG-FA) may be of added value during pouch surgery, in particular after vascular ligations as lengthening maneuver. The aim was to determine quantitative perfusion parameters within the efferent/afferent loop and explore the impact of vascular ligation. Perfusion parameters were also compared in patients with and without anastomotic leakage (AL). METHODS All consenting patients that underwent FA-guided ileal pouch-anal anastomosis (IPAA) between July 2020 and December 2021 were included. After intravenous bolus injection of 0.1 mg/kg ICG, the near-infrared camera (Stryker Aim 1688) registered the fluorescence intensity over time. Quantitative analysis of ICG-FA from standardized regions of interests on the pouch was performed using software. Fluorescence parameters were extracted for inflow (T0, Tmax, Fmax, slope, Time-to-peak) and outflow (T90% and T80%). Change of management related to FA findings and AL rates were recorded. RESULTS Twenty-one patients were included, three patients (14%) required vascular ligation to obtain additional length, by ligating terminal ileal branches in two and the ileocolic artery (ICA) in one patient. In nine patients the ICA was already ligated during subtotal colectomy. ICG-FA triggered a change of management in 19% of patients (n = 4/21), all of them had impaired vascular supply (ligated ileocolic/ terminal ileal branches). Overall, patients with intact vascular supply had similar perfusion patterns for the afferent and efferent loop. Pouches with ICA ligation had longer Tmax in both afferent as efferent loop than pouches with intact ICA (afferent 51 and efferent 53 versus 41 and 43 s respectively). Mean slope of the efferent loop diminished in ICA ligated patients 1.5(IQR 0.8-4.4) versus 2.2 (1.3-3.6) in ICA intact patients. CONCLUSION Quantitative analysis of ICG-FA perfusion during IPAA is feasible and reflects the ligation of the supplying vessels.
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Affiliation(s)
- J J Joosten
- Department of Surgery, Amsterdam University Medical Centres (UMC), Academic Medical Centre (AMC), Postbox 22660, 1100 DD, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M D Slooter
- Department of Radiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R M van den Elzen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.,Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - P R Bloemen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.,Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - W Laméris
- Department of Surgery, Amsterdam University Medical Centres (UMC), Academic Medical Centre (AMC), Postbox 22660, 1100 DD, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - D M de Bruin
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.,Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam University Medical Centres (UMC), Academic Medical Centre (AMC), Postbox 22660, 1100 DD, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam University Medical Centres (UMC), Academic Medical Centre (AMC), Postbox 22660, 1100 DD, Amsterdam, The Netherlands. .,Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands. .,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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15
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Hardy NP, MacAonghusa P, Dalli J, Gallagher G, Epperlein JP, Shields C, Mulsow J, Rogers AC, Brannigan AE, Conneely JB, Neary PM, Cahill RA. Clinical application of machine learning and computer vision to indocyanine green quantification for dynamic intraoperative tissue characterisation: how to do it. Surg Endosc 2023:10.1007/s00464-023-09963-2. [PMID: 36894810 PMCID: PMC10338552 DOI: 10.1007/s00464-023-09963-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 02/12/2023] [Indexed: 03/11/2023]
Abstract
INTRODUCTION Indocyanine green (ICG) quantification and assessment by machine learning (ML) could discriminate tissue types through perfusion characterisation, including delineation of malignancy. Here, we detail the important challenges overcome before effective clinical validation of such capability in a prospective patient series of quantitative fluorescence angiograms regarding primary and secondary colorectal neoplasia. METHODS ICG perfusion videos from 50 patients (37 with benign (13) and malignant (24) rectal tumours and 13 with colorectal liver metastases) of between 2- and 15-min duration following intravenously administered ICG were formally studied (clinicaltrials.gov: NCT04220242). Video quality with respect to interpretative ML reliability was studied observing practical, technical and technological aspects of fluorescence signal acquisition. Investigated parameters included ICG dosing and administration, distance-intensity fluorescent signal variation, tissue and camera movement (including real-time camera tracking) as well as sampling issues with user-selected digital tissue biopsy. Attenuating strategies for the identified problems were developed, applied and evaluated. ML methods to classify extracted data, including datasets with interrupted time-series lengths with inference simulated data were also evaluated. RESULTS Definable, remediable challenges arose across both rectal and liver cohorts. Varying ICG dose by tissue type was identified as an important feature of real-time fluorescence quantification. Multi-region sampling within a lesion mitigated representation issues whilst distance-intensity relationships, as well as movement-instability issues, were demonstrated and ameliorated with post-processing techniques including normalisation and smoothing of extracted time-fluorescence curves. ML methods (automated feature extraction and classification) enabled ML algorithms glean excellent pathological categorisation results (AUC-ROC > 0.9, 37 rectal lesions) with imputation proving a robust method of compensation for interrupted time-series data with duration discrepancies. CONCLUSION Purposeful clinical and data-processing protocols enable powerful pathological characterisation with existing clinical systems. Video analysis as shown can inform iterative and definitive clinical validation studies on how to close the translation gap between research applications and real-world, real-time clinical utility.
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Affiliation(s)
- Niall P Hardy
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Jeffrey Dalli
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland
| | - Gareth Gallagher
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Conor Shields
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jurgen Mulsow
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ailín C Rogers
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ann E Brannigan
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John B Conneely
- Department of Hepatobiliary, Foregut and Bariatric Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Peter M Neary
- Department of General and Colorectal Surgery, University Hospital Waterford, University College Cork, Waterford, Ireland
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland.
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
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16
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Zimmermann A, Köhler H, Chalopin C, Jansen-Winkeln B, Nowotny R, Schönherr T, Mehdorn M, Uttinger KL, Thieme R, Gockel I, Moulla Y. The role of intraoperative hyperspectral imaging (HSI) in colon interposition after esophagectomy. BMC Surg 2023; 23:47. [PMID: 36864396 PMCID: PMC9983190 DOI: 10.1186/s12893-023-01946-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/23/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Colon conduit is an alternative approach to reconstructing the alimentary tract after esophagectomy. Hyperspectral imaging (HSI) has been demonstrated to be effective for evaluating the perfusion of gastric conduits, but not colon conduits. This is the first study to describe this new tool addressing image-guided surgery and supporting esophageal surgeons to select the optimal colon segment for the conduit and anastomotic site intraoperatively. PATIENTS AND METHODS Of 10 patients, eight who underwent reconstruction with a long-segment colon conduit after esophagectomy between 01/05/2018 and 01/04/2022 were included in this study. HSI was recorded at the root and tip of the colon conduit after clamping the middle colic vessels, allowing us to evaluate the perfusion and appropriate part of the colon segment. RESULTS Anastomotic leak (AL) was detected in only one (12.5%) of all the enrolled patients (n = 8). None of the patients developed conduit necrosis. Only one patient required re-anastomosis on postoperative day 4. No patient needed conduit removal, esophageal diversion, or stent placement. There was a change in the anastomosis site to proximal in two patients intraoperatively. There was no need to change the side of colon conduit intraoperatively in any patient. CONCLUSION HSI is a promising and novel intraoperative imaging tool to objectively assess the perfusion of the colon conduit. It helps the surgeon to define the best perfused anastomosis site and the side of colon conduit in this type of operation.
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Affiliation(s)
- Anne Zimmermann
- grid.411339.d0000 0000 8517 9062Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - Hannes Köhler
- grid.9647.c0000 0004 7669 9786Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany
| | - Claire Chalopin
- grid.9647.c0000 0004 7669 9786Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany
| | - Boris Jansen-Winkeln
- grid.459389.a0000 0004 0493 1099Department of General, Visceral, Thoracic and Vascular Surgery, St. Georg Hospital, Delitzscher Str. 141, D-04129 Leipzig, Germany
| | - Robert Nowotny
- grid.411339.d0000 0000 8517 9062Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - Till Schönherr
- grid.411339.d0000 0000 8517 9062Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - Matthias Mehdorn
- grid.411339.d0000 0000 8517 9062Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - Konstantin Lukas Uttinger
- grid.411339.d0000 0000 8517 9062Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - René Thieme
- grid.411339.d0000 0000 8517 9062Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - Ines Gockel
- grid.411339.d0000 0000 8517 9062Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, D-04103, Leipzig, Germany.
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Liu YZ, Mehrotra S, Nwaiwu CA, Buharin VE, Oberlin J, Stolyarov R, Schwaitzberg SD, Kim PCW. Real-time quantification of intestinal perfusion and arterial versus venous occlusion using laser speckle contrast imaging in porcine model. Langenbecks Arch Surg 2023; 408:114. [PMID: 36859714 DOI: 10.1007/s00423-023-02845-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/16/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Real-time intraoperative perfusion assessment may reduce anastomotic leaks. Laser speckle contrast imaging (LSCI) provides dye-free visualization of perfusion by capturing coherent laser light scatter from red blood cells and displays perfusion as a colormap. Herein, we report a novel method to precisely quantify intestinal perfusion using LSCI. METHODS ActivSight™ is an FDA-cleared multi-modal visualization system that can detect and display perfusion via both indocyanine green imaging (ICG) and LSCI in minimally invasive surgery. An experimental prototype LSCI perfusion quantification algorithm was evaluated in porcine models. Porcine small bowel was selectively devascularized to create regions of perfused/watershed/ischemic bowel, and progressive aortic inflow/portal vein outflow clamping was performed to study arterial vs. venous ischemia. Continuous arterial pressure was monitored via femoral line. RESULTS LSCI perfusion colormaps and quantification distinguished between perfused, watershed, and ischemic bowel in all vascular control settings: no vascular occlusion (p < 0.001), aortic occlusion (p < 0.001), and portal venous occlusion (p < 0.001). LSCI quantification demonstrated similar levels of ischemia induced both by states of arterial inflow and venous outflow occlusion. LSCI-quantified perfusion values correlated positively with higher mean arterial pressure and with increasing distance from ischemic bowel. CONCLUSION LSCI relative perfusion quantification may provide more objective real-time assessment of intestinal perfusion compared to conventional naked eye assessment by quantifying currently subjective gradients of bowel ischemia and identifying both arterial/venous etiologies of ischemia.
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Affiliation(s)
- Yao Z Liu
- Department of Surgery, Brown University, Providence, RI, USA
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | - Saloni Mehrotra
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
- Department of Surgery, University of Buffalo, Buffalo, NY, USA
| | - Chibueze A Nwaiwu
- Department of Surgery, Brown University, Providence, RI, USA
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | | | - John Oberlin
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | - Roman Stolyarov
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | | | - Peter C W Kim
- Department of Surgery, Brown University, Providence, RI, USA.
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA.
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Dalli J, Jindal A, Gallagher G, Epperlein JP, Hardy NP, Malallah R, O’Donoghue K, Cantillon-Murphy P, Mac Aonghusa PG, Cahill RA. Evaluating clinical near-infrared surgical camera systems with a view to optimizing operator and computational signal analysis. JOURNAL OF BIOMEDICAL OPTICS 2023; 28:035002. [PMID: 37009578 PMCID: PMC10050972 DOI: 10.1117/1.jbo.28.3.035002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/14/2023] [Indexed: 06/19/2023]
Abstract
SIGNIFICANCE As clinical evidence on the colorectal application of indocyanine green (ICG) perfusion angiography accrues, there is also interest in computerizing decision support. However, user interpretation and software development may be impacted by system factors affecting the displayed near-infrared (NIR) signal. AIM We aim to assess the impact of camera positioning on the displayed NIR signal across different open and laparoscopic camera systems. APPROACH The effects of distance, movement, and target location (center versus periphery) on the displayed fluorescence signal of different systems were measured under electromagnetic stereotactic guidance from an ICG-albumin model and in vivo during surgery. RESULTS Systems displayed distinct fluorescence performances with variance apparent with scope optical lens configuration (0 deg versus 30 deg), movement, target positioning, and distance. Laparoscopic system readings fitted inverse square function distance-intensity curves with one device and demonstrated a direction dependent sigmoid curve. Laparoscopic cameras presented central targets as brighter than peripheral ones, and laparoscopes with angled optical lens configurations had a diminished field of view. One handheld open system also showed a distance-intensity relationship, whereas the other maintained a consistent signal despite distance, but both presented peripheral targets brighter than central ones. CONCLUSIONS Optimal clinical use and signal computational development requires detailed appreciation of system behaviors.
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Affiliation(s)
- Jeffrey Dalli
- University College, UCD Centre for Precision Surgery, Dublin, Ireland
| | - Abhinav Jindal
- University College, UCD Centre for Precision Surgery, Dublin, Ireland
| | - Gareth Gallagher
- University College, UCD Centre for Precision Surgery, Dublin, Ireland
| | | | - Niall P. Hardy
- University College, UCD Centre for Precision Surgery, Dublin, Ireland
| | - Ra’ed Malallah
- University College, UCD Centre for Precision Surgery, Dublin, Ireland
- University of Basrah, Physics Department, Faculty of Science, Basrah, Iraq
| | | | - Padraig Cantillon-Murphy
- University College Cork, School of Engineering, Cork, Ireland
- Tyndall National Institute, Cork, Ireland
| | | | - Ronan A. Cahill
- University College, UCD Centre for Precision Surgery, Dublin, Ireland
- Mater Misericordiae University Hospital, Department of Surgery, Dublin, Ireland
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Xu D, Li C, Li W, Lin B, Lv R. Recent advances in lanthanide-doped up-conversion probes for theranostics. Front Chem 2023; 11:1036715. [PMID: 36846851 PMCID: PMC9949555 DOI: 10.3389/fchem.2023.1036715] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
Up-conversion (or anti-Stokes) luminescence refers to the phenomenon whereby materials emit high energy, short-wavelength light upon excitation at longer wavelengths. Lanthanide-doped up-conversion nanoparticles (Ln-UCNPs) are widely used in biomedicine due to their excellent physical and chemical properties such as high penetration depth, low damage threshold and light conversion ability. Here, the latest developments in the synthesis and application of Ln-UCNPs are reviewed. First, methods used to synthesize Ln-UCNPs are introduced, and four strategies for enhancing up-conversion luminescence are analyzed, followed by an overview of the applications in phototherapy, bioimaging and biosensing. Finally, the challenges and future prospects of Ln-UCNPs are summarized.
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Affiliation(s)
| | | | | | - Bi Lin
- Engineering Research Center of Molecular and Neuro Imaging, Ministry of Education, School of Life Science and Technology, Xidian University, Xi’an, Shaanxi, China
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20
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Serra-Aracil X, Lucas-Guerrero V, Garcia-Nalda A, Mora-López L, Pallisera-Lloveras A, Serracant A, Navarro-Soto S. When should indocyanine green be assessed in colorectal surgery, and at what distance from the tissue? Quantitative measurement using the SERGREEN program. Surg Endosc 2022; 36:8943-8949. [PMID: 35668312 DOI: 10.1007/s00464-022-09343-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/13/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Suture dehiscence is one of the most feared postoperative complications. Correct intestinal vascularization is essential for its prevention. Indocyanine green (ICG) is one of the methods used to assess vascularization, but this assessment is usually subjective. Our group designed the SERGREEN program to obtain an objective measurement of the degree of vascularization. We do not know how long after ICG administration the fluorescence of the tissues should be evaluated, or how far away the measurement should be performed. The aim of this study is to establish the optimal moment and distance for analyzing the fluorescence saturation of ICG. METHODS Prospective observational study in patients undergoing elective laparoscopic colorectal surgery. The optimal time for ICG analysis was tested in a sample of 20 patients (10 right colon and 10 left colon), and the optimal distance in a sample of ten patients. ICG was administered intravenously, and colon vascularization was quantified using SERGREEN; RGB (Red, Green, Blue) encoding was used. The intensity curve of the ICG was analyzed for ten minutes after its administration. Distances of 1, 3, and 5 cm were tested. RESULTS The intensity of fluorescence increased until 1.5 min after ICG administration (reaching figures of 112.49 in the right colon and 93.95 in the left). It then remained fairly stable until 3.5 min (98.49 in the right and 83.35 in the left), at which point it began to decrease gradually. ICG saturation was inversely proportional to the distance between the camera and the tissue. The best distance was 5 cm, where the confidence interval was narrower [CI 86.66-87.53]. CONCLUSION The optimal time for determining ICG in the colon is between 1.5 and 3.5 min, in both right and left colon. The optimal distance is 5 cm. This information will help to establish parameters of comparison in normal and pathological situations.
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Affiliation(s)
- X Serra-Aracil
- Unidad de Coloproctología. Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain.
- Unidad de Cirugía Colorrectal, Departamento de Cirugía General y Ap Digestivo, Hospital Universitari Parc Taulí, Universitat Autonoma de Barcelona (UAB), Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain.
| | - V Lucas-Guerrero
- Unidad de Coloproctología. Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - A Garcia-Nalda
- Unidad de Coloproctología. Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - L Mora-López
- Unidad de Coloproctología. Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - A Pallisera-Lloveras
- Unidad de Coloproctología. Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - A Serracant
- Unidad de Coloproctología. Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - S Navarro-Soto
- Unidad de Coloproctología. Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
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21
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Hardy NP, Joosten JJ, Dalli J, Hompes R, Cahill RA, van Berge Henegouwen MI. Evaluation of inter-user variability in indocyanine green fluorescence angiography to assess gastric conduit perfusion in esophageal cancer surgery. Dis Esophagus 2022; 35:6568917. [PMID: 35428892 DOI: 10.1093/dote/doac016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/21/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
Abstract
Indocyanine Green Fluorescence Angiography (ICGFA) has been deployed to tackle malperfusion-related anastomotic complications. This study assesses variations in operator interpretation of pre-anastomotic ICGFA inflow in the gastric conduit. Utilizing an innovative online interactive multimedia platform (Mindstamp), esophageal surgeons completed a baseline opinion-practice questionnaire and proceeded to interpret, and then digitally assign, a distal transection point on 8 ICGFA videos of esophageal resections (6 Ivor Lewis, 2 McKeown). Annotations regarding gastric conduit transection by ICGFA were compared between expert users versus non-expert participants using ImageJ to delineate longitudinal distances with Shapiro Wilk and t-tests to ascertain significance. Expert versus non-expert correlation was assessed via Intraclass Correlation Coefficients (ICC). Thirty participants (13 consultants, 6 ICGFA experts) completed the study in all aspects. Of these, a high majority (29 participants) stated ICGFA should be used routinely with most (21, including 5/6 experts) stating that 11-50 cases were needed for competency in interpretation. Among users, there were wide variations in dosing (0.05-3 mg/kg) and practice impact. Agreement regarding ICGFA video interpretation concerning transection level among experts was 'moderate' (ICC = 0.717) overall but 'good' (ICC = 0.871) among seven videos with Leave One Out (LOO) exclusion of the video with highest disagreement. Agreement among non-experts was moderate (ICC = 0.641) overall and in every subgroup including among consultants (ICC = 0.626). Experts choose levels that preserved more gastric conduit length versus non-experts in all but one video (P = 0.02). Considerable variability exists with ICGFA interpretation and indeed impact. Even adept users may be challenged in specific cases. Standardized training and/or computerized quantitative fluorescence may help better usage.
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Affiliation(s)
- Niall P Hardy
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Johanna J Joosten
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jeffrey Dalli
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland.,Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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22
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Sperling J, Grade M, von Heesen M, Ghadim M. [Intraoperative fluorescence-guided perfusion assessment using indocyanine green-Increased safety in gastrointestinal anastomoses?]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:934-939. [PMID: 35804154 DOI: 10.1007/s00104-022-01679-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 06/15/2023]
Abstract
Insufficiency of gastrointestinal anastomoses represents a relevant risk of morbidity and mortality for affected patients. The perfusion quality of the ends of the intestine is the decisive parameter for ensuring sufficient healing of an anastomosis. Intraoperative fluorescence-guided perfusion assessment with indocyanine green is increasingly being used in modern visceral surgery to evaluate tissue perfusion prior to the fashioning of gastrointestinal anastomoses. This technique provides the possibility to distinguish between adequately and inadequately perfused tissue in order to place the anastomosis in the region with the best possible perfusion. Thus, surgeons have a measuring instrument that enables an objective assessment of the perfusion quality of the tissue to be undertaken in addition to a purely subjective macroscopic visual assessment, in order to achieve a better functional result for the patients. Currently, however, the value of this technique has not yet been conclusively clarified. The aim of this review article is to characterize the benefits of intraoperative fluorescence-guided perfusion assessment and to classify it with respect to its significance for routine clinical practice.
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Affiliation(s)
- J Sperling
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - M Grade
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - M von Heesen
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - M Ghadim
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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23
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The effect of intracorporeal versus extracorporeal anastomosis in robotic right colectomy on perianastomotic perfusion: a substudy to a multicenter RCT. Langenbecks Arch Surg 2022; 407:3577-3586. [PMID: 36171282 DOI: 10.1007/s00423-022-02693-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Previous studies have shown that intracorporeal anastomosis (ICA) in minimally invasive right colectomy may improve postoperative recovery compared with extracorporeal anastomosis (ECA). It has been hypothesized that creating the anastomosis extracorporeally may cause mesenteric traction and compromised intestinal perfusion. The purpose of this study was to investigate the effect of either ICA or ECA on intestinal perfusion. METHOD This was a substudy to a multicenter, triple-blind randomized clinical trial comparing ICA with ECA in patients undergoing robotic right colectomy for colonic cancer. Videos from intraoperative Indocyanine Green (ICG) fluorescence imaging were analyzed with quantitative ICG perfusion assessment (q-ICG). q-ICG was performed by extracting perfusion metrics from a time-intensity curve generated from an image analysis software: FMAX: maximal fluorescence intensity, TMAX: time until maximal fluorescent signal, T1/2MAX: time until half-maximal fluorescent signal, time ratio (T1/2MAX/TMAX) and slope. RESULTS A total of 68 patients (33 ICA and 35 ECA) were available for analysis. Demographics were similar between the groups, except for mean arterial blood pressure at the time of ICG infusion, which was significantly lower in the ICA group. We found a significantly steeper slope in the ICA group compared to the ECA group (6.3 vs. 4.7 AU/sec, P = .048). There were no significant differences in FMAX, TMAX, T1/2MAX, and time ratio. CONCLUSION We found evidence of an improved intestinal perfusion following ICA compared with ECA. This finding may be related to patient outcomes and should be explored further in the future. TRIAL REGISTRATION CLINICALTRIALS gov NCT03130166.
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Utility and usability of laser speckle contrast imaging (LSCI) for displaying real-time tissue perfusion/blood flow in robot-assisted surgery (RAS): comparison to indocyanine green (ICG) and use in laparoscopic surgery. Surg Endosc 2022:10.1007/s00464-022-09590-3. [PMID: 36109357 PMCID: PMC9483347 DOI: 10.1007/s00464-022-09590-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/25/2022] [Indexed: 11/12/2022]
Abstract
Background Utility and usability of laser speckle contrast imaging (LSCI) in detecting real-time tissue perfusion in robot-assisted surgery (RAS) and laparoscopic surgery are not known. LSCI displays a color heatmap of real-time tissue blood flow by capturing the interference of coherent laser light on red blood cells. LSCI has advantages in perfusion visualization over indocyanine green imaging (ICG) including repeat use on demand, no need for dye, and no latency between injection and display. Herein, we report the first-in-human clinical comparison of a novel device combining proprietary LSCI processing and ICG for real-time perfusion assessment during RAS and laparoscopic surgeries. Methods ActivSight™ imaging module is integrated between a standard laparoscopic camera and scope, capable of detecting tissue blood flow via LSCI and ICG in laparoscopic surgery. From November 2020 to July 2021, we studied its use during elective robotic-assisted and laparoscopic cholecystectomies, colorectal, and bariatric surgeries (NCT# 04633512). For RAS, an ancillary laparoscope with ActivSight imaging module was used for LSCI/ICG visualization. We determined safety, usability, and utility of LSCI in RAS vs. laparoscopic surgery using end-user/surgeon human factor testing (Likert scale 1–5) and compared results with two-tailed t tests. Results 67 patients were included in the study—40 (60%) RAS vs. 27 (40%) laparoscopic surgeries. Patient demographics were similar in both groups. No adverse events to patients and surgeons were observed in both laparoscopic and RAS groups. Use of an ancillary laparoscopic system for LSCI/ICG visualization had minimal impact on usability in RAS as evidenced by surgeon ratings of device usability (set-up 4.2/5 and form-factor 3.8/5). LSCI ability to detect perfusion (97.5% in RAS vs 100% in laparoscopic cases) was comparable in both RAS and laparoscopic cases. Conclusions LSCI demonstrates comparable utility and usability in detecting real-time tissue perfusion/blood flow in RAS and laparoscopic surgery. Graphical abstract ![]()
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25
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Morales-Conde S, Licardie E, Alarcón I, Balla A. Indocyanine green (ICG) fluorescence guide for the use and indications in general surgery: recommendations based on the descriptive review of the literature and the analysis of experience. Cir Esp 2022; 100:534-554. [PMID: 35700889 DOI: 10.1016/j.cireng.2022.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/26/2021] [Indexed: 06/15/2023]
Abstract
Indocyanine Green is a fluorescent substance visible in near-infrared light. It is useful for the identification of anatomical structures (biliary tract, ureters, parathyroid, thoracic duct), the tissues vascularization (anastomosis in colorectal, esophageal, gastric, bariatric surgery, for plasties and flaps in abdominal wall surgery, liver resection, in strangulated hernias and in intestinal ischemia), for tumor identification (liver, pancreas, adrenal glands, implants of peritoneal carcinomatosis, retroperitoneal tumors and lymphomas) and sentinel node identification and lymphatic mapping in malignant tumors (stomach, breast, colon, rectum, esophagus and skin cancer). The evidence is very encouraging, although standardization of its use and randomized studies with higher number of patients are required to obtain definitive conclusions on its use in general surgery. The aim of this literature review is to provide a guide for the use of ICG fluorescence in general surgery procedures.
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Affiliation(s)
- Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital Virgen del Rocio, University of Sevilla, Sevilla, Spain; Unit of General and Digestive Surgery, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Eugenio Licardie
- Unit of General and Digestive Surgery, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Isaias Alarcón
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital Virgen del Rocio, University of Sevilla, Sevilla, Spain.
| | - Andrea Balla
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital Virgen del Rocio, University of Sevilla, Sevilla, Spain; UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Civitavecchia, Rome, Italy.
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26
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Serra-Aracil X, García-Nalda A, Serra-Gómez B, Serra-Gómez A, Mora-López L, Pallisera-Lloveras A, Lucas-Guerrero V, Navarro-Soto S. Experimental study of the quantification of indocyanine green fluorescence in ischemic and non-ischemic anastomoses, using the SERGREEN software program. Sci Rep 2022; 12:13120. [PMID: 35908045 PMCID: PMC9338976 DOI: 10.1038/s41598-022-17395-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
Tissue ischemia is a key risk factor in anastomotic leak (AL). Indocyanine green (ICG) is widely used in colorectal surgery to define the segments with the best vascularization. In an experimental model, we present a new system for quantifying ICG fluorescence intensity, the SERGREEN software. Controlled experimental study with eight pigs. In the initial control stage, ICG fluorescence intensity was analyzed at the level of two anastomoses, in the right and in the left colon. Control images of the two segments were taken after ICG administration. The images were processed with the SERGREEN program. Then, in the experimental ischemia stage, the inferior mesenteric artery was sectioned at the level of the anastomosis of the left colon. Fifteen minutes after the section, sequential images of the two anastomoses were taken every 30 min for the following 2 h. At the control stage, the mean scores were 134.2 (95% CI 116.3–152.2) for the right colon and 147 (95% CI 134.7–159.3) for the left colon (p = 0.174) (Scale RGB—Red, Green, Blue). The right colon remained stable throughout the experiment. In the left colon, intensity fell by 47.9 points with respect to the pre-ischemia value (p < 0.01). After the first post-ischemia determination, the values of the ischemic left colon remained stable throughout the experiment. The relative decrease in ICG fluorescence intensity of the ischemic left colon was 32.6%. The SERGREEN program quantifies ICG fluorescence intensity in normal and ischemic situations and detects differences between them. A reduction in ICG fluorescence intensity of 32.6% or more was correlated with complete tissue ischemia.
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Affiliation(s)
- X Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Service, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain. .,Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain.
| | - A García-Nalda
- Coloproctology Unit, General and Digestive Surgery Service, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain.,Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain
| | - B Serra-Gómez
- Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain
| | - A Serra-Gómez
- Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain
| | - L Mora-López
- Coloproctology Unit, General and Digestive Surgery Service, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain.,Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain
| | - A Pallisera-Lloveras
- Coloproctology Unit, General and Digestive Surgery Service, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain.,Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain
| | - V Lucas-Guerrero
- Coloproctology Unit, General and Digestive Surgery Service, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain.,Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain
| | - S Navarro-Soto
- Coloproctology Unit, General and Digestive Surgery Service, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain.,Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Departament de Cirurgia, Universitat Autònoma de Barcelona, Parc Taulí s/n, 08208, Sabadell, Barcelona, Spain
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Feasibility of Novel Software-Based Perfusion Indicators for the Ileal J-Pouch-On the Path towards Objective and Quantifiable Intraoperative Perfusion Assessment with Indocyanine Green Near-Infrared Fluorescence. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081144. [PMID: 36013324 PMCID: PMC9410361 DOI: 10.3390/life12081144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND In restorative proctocolectomy with ileal J-pouch, perfusion assessment is vital to prevent complications such as anastomotic leak (AL). Indocyanine green near-infrared fluorescence (ICG-NIRF) is gaining popularity, while its interpretation and relevance remain subjective. This study aimed to evaluate a standardized ICG-NIRF imaging protocol combined with a novel, software-based assessment to detect areas of impaired perfusion and a possible correlation with AL of the pouch. METHODS In this prospective study, patients undergoing ileal J-pouch for ulcerative colitis at an inflammatory bowel disease (IBD) referral center were included. Intraoperatively, strictly standardized ICG-NIRF visualization was performed and video-recorded. Postoperatively, a specific software was utilized to determine the change in fluorescence intensity per second (i/s) for systematic regions of interest, generating perfusion-time curves and a pixel-to-pixel map. These were analysed in detail and correlated with clinical outcome (primary end point: AL within 30 days; clearly defined and screened for by pouchoscopy). RESULTS Four out of 18 included patients developed AL of the ileal pouch-anal anastomosis (IPAA). In the AL group, the perfusion curves on the area adjacent to the IPAA (pouch apex) displayed considerably lower ingress/inflow (median = 1.7; range = 8.5; interquartile-range = 3.8 i/s) and egress/outflow (median = -0.1; range = 0.7; interquartile-range = 0.5 i/s) values than in the non-AL group (ingress: median = 4.3; range = 10.3; interquartile-range = 4.0 i/s); egress: median = (-1.1); range = 3.9; interquartile range = 1.0 i/s). This was confirmed by further novel parameters of pouch perfusion (maximum ingress; maximum egress) and pixel-to-pixel analysis. CONCLUSIONS This study presents the feasibility of a novel methodology to precisely assess pouch perfusion with ICG-NIRF, identifying comparable, quantifiable, and objective parameters to potentially detect perfusion-associated complications in surgery in real-time.
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Meisner JW, Kamran A, Staffa SJ, Mohammed S, Yasuda JL, Ngo P, Manfredi M, Zurakowski D, Jennings RW, Hamilton TE, Zendejas B. Qualitative features of esophageal fluorescence angiography and anastomotic outcomes in children. J Pediatr Surg 2022:S0022-3468(22)00455-9. [PMID: 35934523 DOI: 10.1016/j.jpedsurg.2022.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Indocyanine green (ICG) is commonly used to assess perfusion, but quality defining features are lacking. We sought to establish qualitative features of esophageal ICG perfusion assessments, and develop an esophageal anastomotic scorecard to risk-stratify anastomotic outcomes. METHODS Single institution, retrospective analysis of children with an intraoperative ICG perfusion assessment of an esophageal anastomosis. Qualitative perfusion features were defined and a perfusion score developed. Associations between perfusion and clinical features with poor anastomotic outcomes (PAO, leak or refractory stricture) were evaluated with logistic and time-to-event analyses. Combining significant features, we developed and tested an esophageal anastomotic scorecard to stratify PAO risk. RESULTS From 2019 to 2021, 53 children (median age 7.4 months) underwent 55 esophageal anastomoses. Median (IQR) follow-up was 14 (10-19.9) months; mean (SD) perfusion score was 13.2 (3.4). Fifteen (27.3%) anastomoses experienced a PAO and had significantly lower mean perfusion scores (11.3 (3.3) vs 14.0 (3.2), p = 0.007). Unique ICG perfusion features, severe tension, and primary or rescue traction-induced esophageal lengthening [Foker] procedures were significantly associated with PAO on both logistic and Cox regression. The scorecard (range 0-7) included any Foker (+2), severe tension (+1), no arborization on either segment (+1), suture line hypoperfusion >twice expected width (+2), and segmental or global areas of hypoperfusion (+1). A scorecard cut-off >3 yielded a sensitivity of 73% and specificity of 93% (AUC 0.878 [95%CI 0.777 to 0.978]) in identifying a PAO. CONCLUSIONS A scoring system comprised of qualitative ICG perfusion features, tissue quality, and anastomotic tension can help risk-stratify esophageal anastomotic outcomes accurately. LEVELS OF EVIDENCE Diagnostic - II.
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Affiliation(s)
- Jay W Meisner
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jessica L Yasuda
- Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter Ngo
- Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael Manfredi
- Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
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Kashchenko VA, Zaytsev VV, Ratnikov VA, Kamshilin AA. Intraoperative visualization and quantitative assessment of tissue perfusion by imaging photoplethysmography: comparison with ICG fluorescence angiography. BIOMEDICAL OPTICS EXPRESS 2022; 13:3954-3966. [PMID: 35991934 PMCID: PMC9352280 DOI: 10.1364/boe.462694] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/09/2022] [Accepted: 06/09/2022] [Indexed: 05/02/2023]
Abstract
Intraoperative monitoring of tissue perfusion is of great importance for optimizing surgery and reducing postoperative complications. To date, there is no standard procedure for assessing blood circulation in routine clinical practice. Over the past decade, indocyanine green (ICG) fluorescence angiography is most commonly used for intraoperative perfusion evaluation. Imaging photoplethysmography (iPPG) potentially enables contactless assessment of the blood supply to organs. However, no strong evidence of this potential has been provided so far. Here we report results of a comparative assessment of tissue perfusion obtained using custom-made iPPG and commercial ICG-fluorescence systems during eight different gastrointestinal surgeries. Both systems allow mapping the blood-supply distribution over organs. It was demonstrated for the first time that the quantitative assessment of blood perfusion by iPPG is in good agreement with that obtained by ICG-fluorescence imaging in all surgical cases under study. iPPG can become an objective quantitative monitoring system for tissue perfusion in the operating room due to its simplicity, low cost and no need for any agent injections.
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Affiliation(s)
- Victor A. Kashchenko
- First Surgical Department, North-Western District Scientific and Clinical Center named after L.G. Sokolov of the Federal Medical and Biological Agency, 4 Kultury Pr., St. Petersburg 194291, Russia
- Department of Faculty Surgery, Saint Petersburg State University, 8A 21st Vasilyevskogo Ostrova Line, Saint-Petersburg 199106, Russia
| | - Valeriy V. Zaytsev
- Laboratory of New Functional Materials for Photonics, Institute of Automation and Control Processes of the Far-Eastern Branch of the Russian Academy of Sciences, 5 Radio str., Vladivostok 690041, Russia
| | - Vyacheslav A. Ratnikov
- Department of Radiology, North-Western District Scientific and Clinical Center named after L.G. Sokolov of the Federal Medical and Biological Agency, 4 Kultury Pr., St. Petersburg 194291, Russia
- Institute of Advanced Medical Technologies, Saint Petersburg State University, 8A 21st Vasilyevskogo Ostrova Line, Saint-Petersburg 199106, Russia
| | - Alexei A. Kamshilin
- Laboratory of New Functional Materials for Photonics, Institute of Automation and Control Processes of the Far-Eastern Branch of the Russian Academy of Sciences, 5 Radio str., Vladivostok 690041, Russia
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Deep Learning to Measure the Intensity of Indocyanine Green in Endometriosis Surgeries with Intestinal Resection. J Pers Med 2022; 12:jpm12060982. [PMID: 35743768 PMCID: PMC9224804 DOI: 10.3390/jpm12060982] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/11/2022] [Accepted: 06/15/2022] [Indexed: 01/03/2023] Open
Abstract
Endometriosis is a gynecological pathology that affects between 6 and 15% of women of childbearing age. One of the manifestations is intestinal deep infiltrating endometriosis. This condition may force patients to resort to surgical treatment, often ending in resection. The level of blood perfusion at the anastomosis is crucial for its outcome, for this reason, indocyanine green (ICG), a fluorochrome that green stains the structures where it is present, is injected during surgery. This study proposes a novel method based on deep learning algorithms for quantifying the level of blood perfusion in anastomosis. Firstly, with a deep learning algorithm based on the U-Net, models capable of automatically segmenting the intestine from the surgical videos were generated. Secondly, blood perfusion level, from the already segmented video frames, was quantified. The frames were characterized using textures, precisely nine first- and second-order statistics, and then two experiments were carried out. In the first experiment, the differences in the perfusion between the two-anastomosis parts were determined, and in the second, it was verified that the ICG variation could be captured through the textures. The best model when segmenting has an accuracy of 0.92 and a dice coefficient of 0.96. It is concluded that segmentation of the bowel using the U-Net was successful, and the textures are appropriate descriptors for characterization of the blood perfusion in the images where ICG is present. This might help to predict whether postoperative complications will occur during surgery, enabling clinicians to act on this information.
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Pfahl A, Radmacher GK, Köhler H, Maktabi M, Neumuth T, Melzer A, Gockel I, Chalopin C, Jansen-Winkeln B. Combined indocyanine green and quantitative perfusion assessment with hyperspectral imaging during colorectal resections. BIOMEDICAL OPTICS EXPRESS 2022; 13:3145-3160. [PMID: 35774324 PMCID: PMC9203086 DOI: 10.1364/boe.452076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 05/26/2023]
Abstract
Anastomotic insufficiencies still represent one of the most severe complications in colorectal surgery. Since tissue perfusion highly affects anastomotic healing, its objective assessment is an unmet clinical need. Indocyanine green-based fluorescence angiography (ICG-FA) and hyperspectral imaging (HSI) have received great interest in recent years but surgeons have to decide between both techniques. For the first time, two data processing pipelines capable of reconstructing an ICG-FA correlating signal from hyperspectral data were developed. Results were technically evaluated and compared to ground truth data obtained during colorectal resections. In 87% of 46 data sets, the reconstructed images resembled the ground truth data. The combined applicability of ICG-FA and HSI within one imaging system might provide supportive and complementary information about tissue vascularization, shorten surgery time, and reduce perioperative mortality.
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Affiliation(s)
- A. Pfahl
- Innovation Center Computer Assisted Surgery
(ICCAS), Faculty of Medicine, Leipzig
University, Leipzig, 04103, Germany
- Contributed equally
| | - G. K. Radmacher
- Department of Visceral, Thoracic,
Transplant, and Vascular Surgery, University Hospital of
Leipzig, Leipzig, 04103, Germany
- Contributed equally
| | - H. Köhler
- Innovation Center Computer Assisted Surgery
(ICCAS), Faculty of Medicine, Leipzig
University, Leipzig, 04103, Germany
| | - M. Maktabi
- Innovation Center Computer Assisted Surgery
(ICCAS), Faculty of Medicine, Leipzig
University, Leipzig, 04103, Germany
| | - T. Neumuth
- Innovation Center Computer Assisted Surgery
(ICCAS), Faculty of Medicine, Leipzig
University, Leipzig, 04103, Germany
| | - A. Melzer
- Innovation Center Computer Assisted Surgery
(ICCAS), Faculty of Medicine, Leipzig
University, Leipzig, 04103, Germany
- Institute for Medical Science and
Technology (IMSaT), University of Dundee,
Dundee, DD2 1FD, United Kingdom
| | - I. Gockel
- Department of Visceral, Thoracic,
Transplant, and Vascular Surgery, University Hospital of
Leipzig, Leipzig, 04103, Germany
| | - C. Chalopin
- Innovation Center Computer Assisted Surgery
(ICCAS), Faculty of Medicine, Leipzig
University, Leipzig, 04103, Germany
| | - B. Jansen-Winkeln
- Department of Visceral, Thoracic,
Transplant, and Vascular Surgery, University Hospital of
Leipzig, Leipzig, 04103, Germany
- Department of General, Visceral, Thoracic,
and Vascular Surgery, Klinikum St. Georg,
Leipzig, 04129, Germany
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Perfusion Visualization during Ileal J-Pouch Formation—A Proposal for the Standardization of Intraoperative Imaging with Indocyanine Green Near-Infrared Fluorescence and a Postoperative Follow-Up in IBD Surgery. Life (Basel) 2022; 12:life12050668. [PMID: 35629337 PMCID: PMC9147668 DOI: 10.3390/life12050668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/16/2022] Open
Abstract
Background: An anastomotic leak (AL) after a restorative proctocolectomy and an ileal J-pouch increases morbidity and the risk of pouch failure. Thus, a perfusion assessment during J-pouch formation is crucial. While indocyanine green near-infrared fluorescence (ICG-NIRF) has shown potential to reduce ALs, its suitability in a restorative proctocolectomy remains unclear. We aimed to develop a standardized approach for investigating ICG-NIRF and ALs in pouch surgery. Methods: Patients undergoing a restorative proctocolectomy with an ileal J-pouch for ulcerative colitis at an IBD-referral-center were included in a prospective study in which an AL within 30 postoperative days was the primary outcome. Intraoperatively, standardized perfusion visualization with ICG-NIRF was performed and video recorded for postoperative analysis at three time points. Quantitative clinical and technical variables (secondary outcome) were correlated with the primary outcome by descriptive analysis and logistic regression. A novel definition and grading of AL of the J-pouch was applied. A postoperative pouchoscopy was routinely performed to screen for AL. Results: Intraoperative ICG-NIRF-visualization and its postoperative visual analysis in 25 patients did not indicate an AL. The anastomotic site after pouch formation appeared completely fluorescent with a strong fluorescence signal (category 2) in all cases of ALs (4 of 25). Anastomotic site was not changed. ICG-NIRF visualization was reproducible and standardized. Logistic regression identified a two-stage approach vs. a three-stage approach (Odds ratio (OR) = 20.00, 95% confidence interval [CI] = 1.37–580.18, p = 0.029) as a risk factor for ALs. Conclusion: We present a standardized, comparable approach of ICG-NIRF visualization in pouch surgery. Our data indicate that the visual interpretation of ICG-NIRF alone may not detect ALs of the pouch in all cases—quantifiable, objective methods of interpretation may be required in the future.
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Objective Perfusion Assessment in Gracilis Muscle Interposition—A Novel Software-Based Approach to Indocyanine Green Derived Near-Infrared Fluorescence in Reconstructive Surgery. Life (Basel) 2022; 12:life12020278. [PMID: 35207565 PMCID: PMC8874768 DOI: 10.3390/life12020278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Gracilis muscle interposition (GMI) is an established treatment option for complex perineal fistulas and reconstruction. The outcome is limited by complications such as necrosis, impaired wound healing and fistula persistence or recurrence. Quantifiable methods of assessing muscle flap perfusion intraoperatively are lacking. This study evaluates a novel and objective software-based assessment of indocyanine green near-infrared fluorescence (ICG-NIRF) in GMI. Methods: Intraoperative ICG-NIRF visualization data of five patients with inflammatory bowel disease (IBD) undergoing GMI for perineal fistula and reconstruction were analyzed retrospectively. A new software was utilized to generate perfusion curves for the specific regions of interest (ROIs) of each GMI by depicting the fluorescence intensity over time. Additionally, a pixel-to-pixel and perfusion zone analysis were performed. The findings were correlated with the clinical outcome. Results: Four patients underwent GMI without postoperative complications within 3 months. The novel perfusion indicators identified here (shape of the perfusion curve, maximum slope value, distribution and range) indicated adequate perfusion. In one patient, GMI failed. In this case, the perfusion indicators suggested impaired perfusion. Conclusions: We present a novel, software-based approach for ICG-NIRF perfusion assessment, identifying previously unknown objective indicators of muscle flap perfusion. Ready for intraoperative real-time use, this method has considerable potential to optimize GMI surgery in the future.
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Guía de uso e indicaciones de la fluorescencia con verde de indocianina (ICG) en cirugía general: recomendaciones basadas en la revisión descriptiva de la literatura y el análisis de la experiencia. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2021.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hennig S, Jansen-Winkeln B, Köhler H, Knospe L, Chalopin C, Maktabi M, Pfahl A, Hoffmann J, Kwast S, Gockel I, Moulla Y. Novel Intraoperative Imaging of Gastric Tube Perfusion during Oncologic Esophagectomy—A Pilot Study Comparing Hyperspectral Imaging (HSI) and Fluorescence Imaging (FI) with Indocyanine Green (ICG). Cancers (Basel) 2021; 14:cancers14010097. [PMID: 35008261 PMCID: PMC8750976 DOI: 10.3390/cancers14010097] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/13/2021] [Accepted: 12/20/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Novel intraoperative imaging techniques, namely, hyperspectral (HSI) and fluorescence imaging (FI), are promising with respect to reducing severe postoperative complications, thus increasing patient safety. Both tools have already been used to evaluate perfusion of the gastric conduit after esophagectomy and before anastomosis. To our knowledge, this is the first study evaluating both modalities simultaneously during esophagectomy. Methods: In our pilot study, 13 patients, who underwent Ivor Lewis esophagectomy and gastric conduit reconstruction, were analyzed prospectively. HSI and FI were recorded before establishing the anastomosis in order to determine its optimum position. Results: No anastomotic leak occurred during this pilot study. In five patients, the imaging methods resulted in a more peripheral adaptation of the anastomosis. There were no significant differences between the two imaging tools, and no adverse events due to the imaging methods or indocyanine green (ICG) injection occurred. Conclusions: Simultaneous intraoperative application of both modalities was feasible and not time consuming. They are complementary with regard to the ideal anastomotic position and may contribute to better surgical outcomes. The impact of their simultaneous application will be proven in consecutive prospective trials with a large patient cohort.
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Affiliation(s)
- Sebastian Hennig
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (S.H.); (B.J.-W.); (L.K.)
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (S.H.); (B.J.-W.); (L.K.)
- Department of General, Visceral, Thoracic and Vascular Surgery, St. Georg Hospital, Delitzscher Str. 141, D-04129 Leipzig, Germany
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany; (H.K.); (C.C.); (M.M.); (A.P.)
| | - Luise Knospe
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (S.H.); (B.J.-W.); (L.K.)
| | - Claire Chalopin
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany; (H.K.); (C.C.); (M.M.); (A.P.)
| | - Marianne Maktabi
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany; (H.K.); (C.C.); (M.M.); (A.P.)
| | - Annekatrin Pfahl
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Semmelweisstr. 14, D-04103 Leipzig, Germany; (H.K.); (C.C.); (M.M.); (A.P.)
| | - Jana Hoffmann
- Department of Sports Medicine and Prevention, University Leipzig, Rosa Luxemburg Str. 20-30, D-04103 Leipzig, Germany; (J.H.); (S.K.)
| | - Stefan Kwast
- Department of Sports Medicine and Prevention, University Leipzig, Rosa Luxemburg Str. 20-30, D-04103 Leipzig, Germany; (J.H.); (S.K.)
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (S.H.); (B.J.-W.); (L.K.)
- Correspondence: (I.G.); (Y.M.); Tel.: +49-(0)341-9717211(I.G.); Fax: +49-(0)341-9717209
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (S.H.); (B.J.-W.); (L.K.)
- Correspondence: (I.G.); (Y.M.); Tel.: +49-(0)341-9717211(I.G.); Fax: +49-(0)341-9717209
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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: 5] [Impact Index Per Article: 1.7] [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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Demarchi MS, Seeliger B, Lifante JC, Alesina PF, Triponez F. Fluorescence Image-Guided Surgery for Thyroid Cancer: Utility for Preventing Hypoparathyroidism. Cancers (Basel) 2021; 13:cancers13153792. [PMID: 34359693 PMCID: PMC8345196 DOI: 10.3390/cancers13153792] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/08/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Hypoparathyroidism is one of the most frequent complications of thyroid surgery, especially when associated with lymph node dissection in cases of thyroid cancer. Fluorescence-guided surgery is an emerging tool that appears to help reduce the rate of this complication. The present review aims to highlight the utility of fluorescence imaging in preserving parathyroid glands during thyroid cancer surgery. Methods: We performed a systematic review of the literature according to PRISMA guidelines to identify published studies on fluorescence-guided thyroid surgery with a particular focus on thyroid cancer. Articles were selected and analyzed per indication and type of surgery, autofluorescence or exogenous dye usage, and outcomes. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess the methodological quality of the included articles. Results: Twenty-five studies met the inclusion criteria, with three studies exclusively assessing patients with thyroid cancer. The remaining studies assessed mixed cohorts with thyroid cancer and other thyroid or parathyroid diseases. The majority of the papers support the potential benefit of fluorescence imaging in preserving parathyroid glands in thyroid surgery. Conclusions: Fluorescence-guided surgery is useful in the prevention of post-thyroidectomy hypoparathyroidism via enhanced early identification, visualization, and preservation of the parathyroid glands. These aspects are notably beneficial in cases of associated lymphadenectomy for thyroid cancer.
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Affiliation(s)
- Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland;
- Department of Endocrine Surgery, Lyon Sud University Hospitals, 69310 Pierre Benite, France;
| | - Barbara Seeliger
- IHU—Strasbourg, Institute of Image-Guided Surgery, 67091 Strasbourg CEDEX, France;
- IRCAD, Research Institute against Digestive Cancer, 67091 Strasbourg CEDEX, France
- Department of General, Digestive, and Endocrine Surgery, Strasbourg University Hospitals, 67091 Strasbourg CEDEX, France
- Department of Surgery and Center of Minimally Invasive Surgery, Evangelische Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, 45136 Essen, Germany;
| | - Jean-Christophe Lifante
- Department of Endocrine Surgery, Lyon Sud University Hospitals, 69310 Pierre Benite, France;
- Health Services and Performance Research Lab (EA 7425 HESPER), Université Claude Bernard Lyon 1, 69622 Lyon, France
| | - Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Evangelische Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, 45136 Essen, Germany;
- Department of Surgery, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland;
- Correspondence: ; Tel.: +41-(0)22-372-78-62
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Osterkamp J, Strandby RB, Nerup N, Svendsen MBS, Svendsen LB, Achiam MP. Time to maximum indocyanine green fluorescence of gastric sentinel lymph nodes and feasibility of combined indocyanine green/sodium fluorescein gastric lymphography. Langenbecks Arch Surg 2021; 406:2717-2724. [PMID: 34245352 DOI: 10.1007/s00423-021-02265-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/01/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Indocyanine green (ICG) and sodium fluorescein (SF) are fluorescent dyes used for sentinel lymph node mapping. In oncological gastric surgery, ICG lymphography has increased the number of resected lymph nodes. However, the optimal time to administer ICG is unclear, and both preoperative and intraoperative injections have been practised. As dye spillage will diminish lymphogram visibility, a second dye with different excitation and emission spectra may present a clinical alternative. We measured the time until maximum ICG fluorescence of gastric sentinel lymph nodes and investigated the feasibility of combined lymphography with two fluorescent dyes: ICG and SF. METHODS Ten Danish Landrace/Yorkshire pigs were used in this study. After completion of the laparoscopic setup, ICG and then SF were endoscopically injected into the gastric submucosa. Lymphograms for both dyes were recorded, and the time until maximum ICG sentinel lymph node fluorescence was determined. RESULTS The mean time until maximum ICG fluorescence of gastric sentinel lymph nodes was 50 s (± 12.5), and the fluorescent signal then remained stable until the end of the recorded period (45 min). A lymphogram showing both ICG and SF was acquired for eight of the ten pigs. CONCLUSIONS Because of the short time until maximum ICG fluorescence of sentinel lymph nodes, intraoperative injections could be a sufficient alternative to preoperative injections for oncological gastric surgery. Combined ICG and SF lymphography was feasible and resulted in clear lymphograms with no interference between the two dyes. The ability to use multiple dyes during a surgical procedure offers the exciting prospect of simultaneously assessing perfusion and performing fluorescence lymphography.
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Affiliation(s)
- Jens Osterkamp
- Oesophago Gastric Cancer Surgery Group (OGCS), Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen Ø, Denmark.
| | - Rune B Strandby
- Oesophago Gastric Cancer Surgery Group (OGCS), Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen Ø, Denmark
| | - Nikolaj Nerup
- Oesophago Gastric Cancer Surgery Group (OGCS), Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen Ø, Denmark
| | - Morten Bo Søndergaard Svendsen
- Copenhagen Academy for Medical Education and Simulation (CAMES) - CAMES Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Lars Bo Svendsen
- Oesophago Gastric Cancer Surgery Group (OGCS), Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen Ø, Denmark
| | - Michael Patrick Achiam
- Oesophago Gastric Cancer Surgery Group (OGCS), Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen Ø, Denmark
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Hardy NP, Dalli J, Mac Aonghusa P, Neary PM, Cahill RA. Biophysics inspired artificial intelligence for colorectal cancer characterization. Artif Intell Gastroenterol 2021; 2:77-84. [DOI: 10.35712/aig.v2.i3.77] [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: 01/28/2021] [Revised: 05/21/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Over the last ten years artificial intelligence (AI) methods have begun to pervade even the most common everyday tasks such as email filtering and mobile banking. While the necessary quality and safety standards may have understandably slowed the introduction of AI to healthcare when compared with other industries, we are now beginning to see AI methods becoming more available to the clinician in select settings. In this paper we discuss current AI methods as they pertain to gastrointestinal procedures including both gastroenterology and gastrointestinal surgery. The current state of the art for polyp detection in gastroenterology is explored with a particular focus on deep leaning, its strengths, as well as some of the factors that may limit its application to the field of surgery. The use of biophysics (utilizing physics to study and explain biological phenomena) in combination with more traditional machine learning is also discussed and proposed as an alternative approach that may solve some of the challenges associated with deep learning. Past and present uses of biophysics inspired AI methods, such as the use of fluorescence guided surgery to aid in the characterization of colorectal lesions, are used to illustrate the role biophysics-inspired AI can play in the exciting future of the gastrointestinal proceduralist.
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Affiliation(s)
- Niall P Hardy
- UCD Centre for Precision Surgery, Dublin 7 D07 Y9AW, Ireland
| | - Jeffrey Dalli
- UCD Centre for Precision Surgery, Dublin 7 D07 Y9AW, Ireland
| | | | - Peter M Neary
- Department of Surgery, University Hospital Waterford, University College Cork, Waterford X91 ER8E, Ireland
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, Dublin 7 D07 Y9AW, Ireland
- Department of Surgery, Mater Misericordiae University Hospital (MMUH), Dublin 7, Ireland
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Koyanagi K, Ozawa S, Ninomiya Y, Yatabe K, Higuchi T, Yamamoto M, Kanamori K, Tajima K. Indocyanine green fluorescence imaging for evaluating blood flow in the reconstructed conduit after esophageal cancer surgery. Surg Today 2021; 52:369-376. [PMID: 33977382 DOI: 10.1007/s00595-021-02296-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/27/2021] [Indexed: 11/26/2022]
Abstract
We investigated the effectiveness of indocyanine green (ICG) fluorescence blood flow imaging of the gastric conduit to evaluate anastomotic leakage after esophagectomy. We identified 19 articles using the PRISMA standard for systematic reviews. The more recent studies reported attempts at objective quantification of ICG fluorescence imaging, rather than qualitative assessment. Anastomotic leakage after esophagectomy occurred in 0-33% of the patients who underwent ICG fluorescence imaging. According to the six studies that compared the incidence of anastomotic leakage in the ICG group and the control group, it ranged from 0 to 18.3% in the ICG group and from 0 to 25.2% in the control group, respectively. Overall, the incidence of anastomotic leakage in the ICG group (8.4%) was lower than that in the control group (18.5%). Although the incidence of anastomotic leakage was as high as 43.1% in patients who did not undergo any intraoperative intervention for poor blood flow, it was only 24% in patients who underwent intraoperative intervention. This systematic review revealed that ICG fluorescence imaging may be a crucial adjunctive tool for reducing anastomotic leakage after esophagectomy, suggesting that it should be performed during esophageal reconstruction.
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Affiliation(s)
- Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Tadashi Higuchi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Kanamori
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Tajima
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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Goncalves LN, van den Hoven P, van Schaik J, Leeuwenburgh L, Hendricks CHF, Verduijn PS, van der Bogt KEA, van Rijswijk CSP, Schepers A, Vahrmeijer AL, Hamming JF, van der Vorst JR. Perfusion Parameters in Near-Infrared Fluorescence Imaging with Indocyanine Green: A Systematic Review of the Literature. Life (Basel) 2021; 11:life11050433. [PMID: 34064948 PMCID: PMC8151115 DOI: 10.3390/life11050433] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/01/2021] [Accepted: 05/05/2021] [Indexed: 01/16/2023] Open
Abstract
(1) Background: Near-infrared fluorescence imaging is a technique capable of assessing tissue perfusion and has been adopted in various fields including plastic surgery, vascular surgery, coronary arterial disease, and gastrointestinal surgery. While the usefulness of this technique has been broadly explored, there is a large variety in the calculation of perfusion parameters. In this systematic review, we aim to provide a detailed overview of current perfusion parameters, and determine the perfusion parameters with the most potential for application in near-infrared fluorescence imaging. (2) Methods: A comprehensive search of the literature was performed in Pubmed, Embase, Medline, and Cochrane Review. We included all clinical studies referencing near-infrared perfusion parameters. (3) Results: A total of 1511 articles were found, of which, 113 were suitable for review, with a final selection of 59 articles. Near-infrared fluorescence imaging parameters are heterogeneous in their correlation to perfusion. Time-related parameters appear superior to absolute intensity parameters in a clinical setting. (4) Conclusions: This literature review demonstrates the variety of parameters selected for the quantification of perfusion in near-infrared fluorescence imaging.
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Pang HY, Chen XL, Song XH, Galiullin D, Zhao LY, Liu K, Zhang WH, Yang K, Chen XZ, Hu JK. Indocyanine green fluorescence angiography prevents anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:261-271. [PMID: 33409585 DOI: 10.1007/s00423-020-02077-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of intraoperative use of indocyanine green (ICG) fluorescence angiography (ICGFA) to prevent anastomotic leakage (AL) in rectal cancer surgery remains controversial. METHODS The systematic review for studies evaluating ICGFA in patients undergoing rectal cancer surgery in PubMed, Embase, Web of Science, and the Cochrane Library was performed up to April 30, 2020. The primary outcome was the incidence of AL. The analysis was performed using RevMan v5.3 and Stata v12.0 software. RESULTS Eighteen studies comprising 4038 patients were included. In the present meta-analysis, intraoperative use of ICGFA markedly reduced AL rate (OR = 0.33; 95% CI: 0.24-0.45; P < 0.0001; I2 = 0%) in rectal cancer surgery, which was still significant in surgeries limited to symptomatic AL (OR = 0.44; 95% CI: 0.31-0.64; P < 0.0001; I2 = 22%). This intervention was also associated with shorter postoperative stays (MD = - 1.27; 95% CI: - 2.42 to - 0.13; P = 0.04; I2 = 60%). However, reoperation rate (OR = 0.61; 95% CI: 0.34-1.10; P = 0.10; I2 = 6%), ileus rate (OR = 1.30; 95% CI: 0.60-2.82; P = 0.51; I2 = 56%), and surgical site infection rate (OR = 1.40; 95% CI: 0.62-3.20; P = 0.42; I2 = 0%) were not significantly different between the two groups. CONCLUSION The use of ICGFA was associated with a lower AL rate after rectal cancer resection. However, more multi-center RCTs with large sample size are required to further verify the value of ICGFA in rectal cancer surgery.
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Affiliation(s)
- Hua-Yang Pang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Xiao-Long Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Xiao-Hai Song
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Danil Galiullin
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China.,Central Research Laboratory, Bashkir State Medical University, Ufa, Russia
| | - Lin-Yong Zhao
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Kai Liu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Wei-Han Zhang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Kun Yang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Xin-Zu Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Jian-Kun Hu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China.
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Hardy NP, Dalli J, Khan MF, Andrejevic P, Neary PM, Cahill RA. Inter-user variation in the interpretation of near infrared perfusion imaging using indocyanine green in colorectal surgery. Surg Endosc 2021; 35:7074-7081. [PMID: 33398567 DOI: 10.1007/s00464-020-08223-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/03/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Despite increasing endorsement of near-infrared perfusion assessment using indocyanine green (ICG) during colorectal surgery, little work has yet been done regarding learning curve and interobserver variation most especially on surgical video reflective of real-world usage. METHODS Surgeons with established expertise in ICG usage were invited to participate in the study along with others without such experience including trainees. All participants completed an opinion questionnaire and interpreted video presentations of fluorescence angiograms in a variety of colorectal case scenarios. An interactive video platform (Mindstamp) enabled dynamic annotation. Statistical analysis of data was performed using Kruskal-Wallis and Mann-Whitney testing as well as Intraclass Correlation Coefficients and Fleiss Multi-rater Kappa Scoring. RESULTS Forty participants (six experts) completed questionnaire data and provided judgement of 14 videos (nine showing proximal colonic transection site perfusion, four showing completed anastomoses and one an acutely strangulated bowel). 70% felt > 10 cases were needed for competency in use with the majority of experts advocating > 50 (p < 0.05). Overall agreement among experts was "good" for videos showing colonic transection perfusion (versus "moderate" among in-experts) with experts clustering more distally. In contrast, there was no interpretation concordance among experts or in-experts when judging ICG perfusion sufficiency on a yes/no basis. CONCLUSION Significant experience is recommended before reliance on ICG perfusion angiograms. ICG fluorescence assessment is prone to variable interpretation and influenced by experience and, perhaps, knowledge of preassessment operative steps suggesting a role for objective flow analysis with artificial intelligence methods as the next phase of this technology.
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Affiliation(s)
- Niall P Hardy
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Jeffrey Dalli
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Mohammad Faraz Khan
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland
| | | | - Peter M Neary
- Department of Surgery, University Hospital Waterford, University College Cork, Waterford, Ireland
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland.
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Osterkamp J, Strandby R, Nerup N, Svendsen M, Svendsen L, Achiam M. Quantitative fluorescence angiography detects dynamic changes in gastric perfusion. Surg Endosc 2020; 35:6786-6795. [PMID: 33258036 DOI: 10.1007/s00464-020-08183-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The use of Indocyanine green (ICG) fluorescence angiography (ICG-FA) is an applied method to assess visceral perfusion during surgical procedures worldwide. Further development has entailed quantification of the fluorescence signal; however, whether quantified ICG-FA can detect intraoperative changes in perfusion after hemorrhage has not been investigated previously. In this study, we investigated whether a quantification method, developed and validated in our department (q-ICG), could detect changes in gastric perfusion induced by hemorrhage and resuscitation. METHODS Ten pigs were included in the study. Specific regions of interest of the stomach were chosen, and three q-ICG measurements of gastric perfusion obtained: 20 min after completion of the laparoscopic setup (baseline), after reducing the circulating blood volume by 30%, and after reinfusion of the withdrawn blood volume. Hemodynamic variables were recorded, and blood samples were collected every 10 min during the procedure. RESULTS The reduction in blood volume generated decreased gastric perfusion (q-ICG) from baseline (p = 0.023), and gastric perfusion subsequently increased (p < 0.001) after the reintroduction of the withdrawn blood volume. Cardiac output (CO) and mean arterial blood pressure (MAP) shifted correspondingly and the gastric perfusion correlated to CO (r = 0.575, p = 0.001) and MAP (r = 0.436, p = 0.018). CONCLUSION We present a novel study showing that the q-ICG method can detect dynamic changes in local tissue perfusion induced by hemorrhage and resuscitation. As regional gastrointestinal perfusion may be significantly reduced, while hemodynamic variables such as MAP or heart rate remain stable, q-ICG may provide an objective, non-invasive method for detecting regional early ischemia, strengthening surgical decision making.
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Affiliation(s)
- Jens Osterkamp
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark.
| | - Rune Strandby
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Morten Svendsen
- Copenhagen Academy of Medical Education and Simulation, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Michael Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
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