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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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Intraoperative Perfusion Assessment in Enhanced Reality Using Quantitative Optical Imaging: An Experimental Study in a Pancreatic Partial Ischemia Model. Diagnostics (Basel) 2021; 11:diagnostics11010093. [PMID: 33430038 PMCID: PMC7826658 DOI: 10.3390/diagnostics11010093] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 02/06/2023] Open
Abstract
To reduce the risk of pancreatic fistula after pancreatectomy, a satisfactory blood flow at the pancreatic stump is considered crucial. Our group has developed and validated a real-time computational imaging analysis of tissue perfusion, using fluorescence imaging, the fluorescence-based enhanced reality (FLER). Hyperspectral imaging (HSI) is another emerging technology, which provides tissue-specific spectral signatures, allowing for perfusion quantification. Both imaging modalities were employed to estimate perfusion in a porcine model of partial pancreatic ischemia. Perfusion quantification was assessed using the metrics of both imaging modalities (slope of the time to reach maximum fluorescence intensity and tissue oxygen saturation (StO2), for FLER and HSI, respectively). We found that the HSI-StO2 and the FLER slope were statistically correlated using the Spearman analysis (R = 0.697; p = 0.013). Local capillary lactate values were statistically correlated to the HSI-StO2 and to the FLER slope (R = −0.88; p < 0.001 and R = −0.608; p = 0.0074). HSI-based and FLER-based lactate prediction models had statistically similar predictive abilities (p = 0.112). Both modalities are promising to assess real-time pancreatic perfusion. Clinical translation in human pancreatic surgery is currently underway.
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Barberio M, Felli E, Pop R, Pizzicannella M, Geny B, Lindner V, Baiocchini A, Jansen-Winkeln B, Moulla Y, Agnus V, Marescaux J, Gockel I, Diana M. A Novel Technique to Improve Anastomotic Perfusion Prior to Esophageal Surgery: Hybrid Ischemic Preconditioning of the Stomach. Preclinical Efficacy Proof in a Porcine Survival Model. Cancers (Basel) 2020; 12:cancers12102977. [PMID: 33066529 PMCID: PMC7602144 DOI: 10.3390/cancers12102977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Esophagectomy has a high rate of anastomotic complications thought to be caused by poor perfusion of the gastric graft, which is used to restore the continuity of the gastrointestinal tract. Ischemic gastric preconditioning (IGP), performed by partially destroying preoperatively the gastric vessels either by means of interventional radiology or surgically, might improve the gastric conduit perfusion. Both approaches have downsides. The timing, extent and mechanism of IGP remain unclear. A novel hybrid IGP method combining the advantages of the endovascular and surgical approach was introduced in this study. IGP improves unequivocally the mucosal and serosal blood-flow at the gastric conduit fundus by triggering new vessels formation. The proposed timing and extent of IGP were efficacious and might be easily applied to humans. This novel minimally invasive IGP technique might reduce the anastomotic leak rate of patients undergoing esophagectomy, thus improving their overall oncological outcome. Abstract Esophagectomy often presents anastomotic leaks (AL), due to tenuous perfusion of gastric conduit fundus (GCF). Hybrid (endovascular/surgical) ischemic gastric preconditioning (IGP), might improve GCF perfusion. Sixteen pigs undergoing IGP were randomized: (1) Max-IGP (n = 6): embolization of left gastric artery (LGA), right gastric artery (RGA), left gastroepiploic artery (LGEA), and laparoscopic division (LapD) of short gastric arteries (SGA); (2) Min-IGP (n = 5): LGA-embolization, SGA-LapD; (3) Sham (n = 5): angiography, laparoscopy. At day 21 gastric tubulation occurred and GCF perfusion was assessed as: (A) Serosal-tissue-oxygenation (StO2) by hyperspectral-imaging; (B) Serosal time-to-peak (TTP) by fluorescence-imaging; (C) Mucosal functional-capillary-density-area (FCD-A) index by confocal-laser-endomicroscopy. Local capillary lactates (LCL) were sampled. Neovascularization was assessed (histology/immunohistochemistry). Sham presented lower StO2 and FCD-A index (41 ± 10.6%; 0.03 ± 0.03 respectively) than min-IGP (66.2 ± 10.2%, p-value = 0.004; 0.22 ± 0.02, p-value < 0.0001 respectively) and max-IGP (63.8 ± 9.4%, p-value = 0.006; 0.2 ± 0.02, p-value < 0.0001 respectively). Sham had higher LCL (9.6 ± 4.8 mL/mol) than min-IGP (4 ± 3.1, p-value = 0.04) and max-IGP (3.4 ± 1.5, p-value = 0.02). For StO2, FCD-A, LCL, max- and min-IGP did not differ. Sham had higher TTP (24.4 ± 4.9 s) than max-IGP (10 ± 1.5 s, p-value = 0.0008) and min-IGP (14 ± 1.7 s, non-significant). Max- and min-IGP did not differ. Neovascularization was confirmed in both IGP groups. Hybrid IGP improves GCF perfusion, potentially reducing post-esophagectomy AL.
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Affiliation(s)
- Manuel Barberio
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
- Correspondence:
| | - Eric Felli
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
| | - Raoul Pop
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Margherita Pizzicannella
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Bernard Geny
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
| | - Veronique Lindner
- Department of Pathology, University Hospital of Strasbourg, 67000 Strasbourg, France;
| | - Andrea Baiocchini
- Department of Surgical Pathology, San Camillo Hospital, 00152 Rome, Italy;
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Vincent Agnus
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Jacques Marescaux
- Research Institute against Digestive Cancer (IRCAD), 67000 Strasbourg, France; (J.M.); (M.D.)
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Michele Diana
- Research Institute against Digestive Cancer (IRCAD), 67000 Strasbourg, France; (J.M.); (M.D.)
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Barberio M, Felli E, Pizzicannella M, Agnus V, Al-Taher M, Seyller E, Moulla Y, Jansen-Winkeln B, Gockel I, Marescaux J, Diana M. Quantitative serosal and mucosal optical imaging perfusion assessment in gastric conduits for esophageal surgery: an experimental study in enhanced reality. Surg Endosc 2020; 35:5827-5835. [PMID: 33026514 PMCID: PMC8437861 DOI: 10.1007/s00464-020-08077-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/01/2020] [Indexed: 12/19/2022]
Abstract
Abstract
Introduction/objective
Gastric conduit (GC) is used for reconstruction after esophagectomy. Anastomotic leakage (AL) incidence remains high, given the extensive disruption of the gastric circulation. Currently, there is no reliable method to intraoperatively quantify gastric perfusion. Hyperspectral imaging (HSI) has shown its potential to quantify serosal StO2. Confocal laser endomicroscopy (CLE) allows for automatic mucosal microcirculation quantification as functional capillary density area (FCD-A). The aim of this study was to quantify serosal and mucosal GC’s microperfusion using HSI and CLE. Local capillary lactate (LCL) served as biomarker.
Methods
GC was formed in 5 pigs and serosal StO2% was quantified at 3 regions of interest (ROI) using HSI: fundus (ROI-F), greater curvature (ROI-C), and pylorus (ROI-P). After intravenous injection of sodium-fluorescein (0.5 g), CLE-based mucosal microperfusion was assessed at the corresponding ROIs, and LCLs were quantified via a lactate analyzer.
Results
StO2 and FCD-A at ROI-F (41 ± 10.6%, 3.3 ± 3.8, respectively) were significantly lower than ROI-C (68.2 ± 6.7%, p value: 0.005; 18.4 ± 7, p value: 0.01, respectively) and ROI-P (72 ± 10.4%, p value: 0.005; 15.7 ± 3.2 p value: 0.001). LCL value at ROI-F (9.6 ± 4.7 mmol/L) was significantly higher than at ROI-C (2.6 ± 1.2 mmol/L, p value: 0.04) and ROI-P (2.6 ± 1.3 mmol/L, p value: 0.04). No statistically significant difference was found in all metrics between ROI-C and ROI-P. StO2 correlated with FCD-A (Pearson’s r = 0.67). The LCL correlated negatively with both FCD-A (Spearman’s r = − 0.74) and StO2 (Spearman’s r = − 0.54).
Conclusions
GC formation causes a drop in serosal and mucosal fundic perfusion. HSI and CLE correlate well and might become useful intraoperative tools.
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Hyperspectral enhanced reality (HYPER) for anatomical liver resection. Surg Endosc 2020; 35:1844-1850. [DOI: 10.1007/s00464-020-07586-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 04/22/2020] [Indexed: 12/19/2022]
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Barberio M, Felli E, Seyller E, Longo F, Chand M, Gockel I, Geny B, Swanström L, Marescaux J, Agnus V, Diana M. Quantitative fluorescence angiography versus hyperspectral imaging to assess bowel ischemia: A comparative study in enhanced reality. Surgery 2020; 168:178-184. [PMID: 32223983 DOI: 10.1016/j.surg.2020.02.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/27/2020] [Accepted: 02/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fluorescence-based enhanced reality is a software that provides quantitative fluorescence angiography by computing the fluorescence intensity time-to-peak after intravenous indocyanine green. Hyperspectral imaging is a contrast-free, optical imaging modality which measures tissue oxygenation. METHODS In 8 pigs, an ischemic bowel segment created by dividing the arcade branches was imaged using hyperspectral imaging and fluorescence-based enhanced reality. Tissue oxygenation values were acquired through a hyperspectral imaging system. Subsequently, fluorescence angiography was performed using a near-infrared laparoscopic camera after intravenous injection of 0.2 mg/kg of indocyanine green. The time-to-peak fluorescence signal was analyzed through a proprietary software to realize a perfusion map. This was overlaid onto real-time images to obtain fluorescence-based enhanced reality. Simultaneously, 9 adjacent regions of interest were selected and superimposed onto the real-time video, thereby obtaining hyperspectral-based enhanced reality. Fluorescence-based enhanced reality and hyperspectral-based enhanced reality were superimposed allowing a comparison of both imaging modalities. Local capillary lactate levels were sampled at the regions of interest. Two prediction models using the local capillary lactate levels were extrapolated based on both imaging systems. RESULTS For all regions of interest, the mean local capillary lactate levels were 4.67 ± 4.34 mmol/L, the mean tissue oxygenation was 45.9 ± 18.9%, and the mean time-to-peak was 10 ± 9.4 seconds. Pearson's test between fluorescence-based enhanced reality-time-to-peak and hyperspectral imaging-tissue oxygenation at the corresponding regions of interest gave an R = -0.66 (P < .0001). The hyperspectral imaging lactate prediction model proved more accurate than the fluorescence-based enhanced reality-based model (P < .0001). CONCLUSION Bowel perfusion was quantified using hyperspectral imaging and fluorescence angiography. Hyperspectral imaging yielded more accurate results than fluorescence angiography. Hyperspectral-based enhanced reality may prove to be a useful, contrast-free intraoperative tool to quantify bowel ischemia.
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Affiliation(s)
- Manuel Barberio
- IHU-Strasbourg Institute of Image-Guided Surgery, France; Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Germany; EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, France.
| | - Eric Felli
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Emilie Seyller
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Fabio Longo
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Manish Chand
- Division of Surgery & Interventional Science, University College London, United Kingdom
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Germany
| | - Bernard Geny
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, France
| | - Lee Swanström
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Jacques Marescaux
- IHU-Strasbourg Institute of Image-Guided Surgery, France; Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
| | - Vincent Agnus
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Michele Diana
- IHU-Strasbourg Institute of Image-Guided Surgery, France; EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, France; Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
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Barberio M, Longo F, Fiorillo C, Seeliger B, Mascagni P, Agnus V, Lindner V, Geny B, Charles AL, Gockel I, Worreth M, Saadi A, Marescaux J, Diana M. HYPerspectral Enhanced Reality (HYPER): a physiology-based surgical guidance tool. Surg Endosc 2019; 34:1736-1744. [PMID: 31309313 DOI: 10.1007/s00464-019-06959-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/01/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND HSI is an optical technology allowing for a real-time, contrast-free snapshot of physiological tissue properties, including oxygenation. Hyperspectral imaging (HSI) has the potential to quantify the gastrointestinal perfusion intraoperatively. This experimental study evaluates the accuracy of HSI, in order to quantify bowel perfusion, and to obtain a superposition of the hyperspectral information onto real-time images. METHODS In 6 pigs, 4 ischemic bowel loops were created (A, B, C, D) and imaged at set time points (from 5 to 360 min). A commercially available HSI system provided pseudo-color maps of the perfusion status (StO2, Near-InfraRed perfusion) and the tissue water index. An ad hoc software was developed to superimpose HSI information onto the live video, creating the HYPerspectral-based Enhanced Reality (HYPER). Seven regions of interest (ROIs) were identified in each bowel loop according to StO2 ranges, i.e., vascular (VASC proximal and distal), marginal vascular (MV proximal and distal), marginal ischemic (MI proximal and distal), and ischemic (ISCH). Local capillary lactates (LCL), reactive oxygen species (ROS), and histopathology were measured at the ROIs. A machine-learning-based prediction algorithm of LCL, based on the HSI-StO2%, was trained in the 6 pigs and tested on 5 additional animals. RESULTS HSI parameters (StO2 and NIR) were congruent with LCL levels, ROS production, and histopathology damage scores at the ROIs discriminated by HYPER. The global mean error of LCL prediction was 1.18 ± 1.35 mmol/L. For StO2 values > 30%, the mean error was 0.3 ± 0.33. CONCLUSIONS HYPER imaging could precisely quantify the overtime perfusion changes in this bowel ischemia model.
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Affiliation(s)
- Manuel Barberio
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Fabio Longo
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Claudio Fiorillo
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Barbara Seeliger
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
| | - Pietro Mascagni
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Vincent Agnus
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Veronique Lindner
- Department of Pathology, University Hospital of Strasbourg, Strasbourg, France
| | - Bernard Geny
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
| | - Anne-Laure Charles
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Marc Worreth
- Department of Surgery, Pourtalès Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Alend Saadi
- Department of Surgery, Pourtalès Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Jacques Marescaux
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
- IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France
| | - Michele Diana
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France.
- IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France.
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France.
- Department of Surgery, Pourtalès Neuchâtel Hospital, Neuchâtel, Switzerland.
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Quero G, Saccomandi P, Kwak JM, Dallemagne B, Costamagna G, Marescaux J, Mutter D, Diana M. Modular laser-based endoluminal ablation of the gastrointestinal tract: in vivo dose-effect evaluation and predictive numerical model. Surg Endosc 2018; 33:3200-3208. [PMID: 30456508 DOI: 10.1007/s00464-018-6603-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection allows for "en bloc" removal of early gastrointestinal neoplasms. However, it is technically demanding and time-consuming. Alternatives could rely on energy-based techniques. We aimed to evaluate a predictive numerical model of thermal damage to preoperatively define optimal laser settings allowing for a controlled ablation down to the submucosa, and the ability of confocal endomicroscopy to provide damage information. MATERIALS AND METHODS A Nd:YAG laser was applied onto the gastric mucosa of 21 Wistar rats on 10 spots (total 210). Power settings ranging from 0.5 to 2.5W were applied during 1-12 s, with a consequent energy delivery varying from 0.5 to 30 J. Out of the 210 samples, a total of 1050 hematoxilin-eosin stained slides were obtained. To evaluate thermal injury, the ratio between the damage depth (DD) over the mucosa and the submucosa thickness (T) was calculated. Effective and safe ablation was considered for a DD/T ratio ≤ 1 (only mucosal and submucosal damage). Confocal endomicroscopy was performed before and after ablation. A numerical model, using human physical properties, was developed to predict thermal damage. RESULTS No full-thickness perforations were detected. On histology, the DD/T ratio at 0.5 J was 0.57 ± 0.21, significantly lower when compared to energies ranging from 15 J (a DD/T ratio = 1.2 ± 0.3; p < 0.001) until 30 J (a DD/T ratio = 1.33 ± 0.31; p < 0.001). Safe mucosal and submucosal ablations were achieved applying energy between 4 and 12 J, never impairing the muscularis propria. Confocal endomicroscopy showed a distorted gland architecture. The predicted damage depth demonstrated a significant positive linear correlation with the experimental data (Pearson's r 0.85; 95% CI 0.66-0.94). CONCLUSIONS Low-power settings achieved effective and safe mucosal and submucosal ablation. The numerical model allowed for an accurate prediction of the ablated layers. Confocal endomicroscopy provided real-time thermal damage visualization. Further studies on larger animal models are required.
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Affiliation(s)
- Giuseppe Quero
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Paola Saccomandi
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Department of Mechanical Engineering, Politecnico di Milano, Milan, Italy
| | - Jung-Myun Kwak
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Bernard Dallemagne
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Guido Costamagna
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Didier Mutter
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France. .,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France. .,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.
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Diana M, Noll E, Legnèr A, Kong SH, Liu YY, Schiraldi L, Marchegiani F, Bano J, Geny B, Charles AL, Dallemagne B, Lindner V, Mutter D, Diemunsch P, Marescaux J. Impact of valve-less vs. standard insufflation on pneumoperitoneum volume, inflammation, and peritoneal physiology in a laparoscopic sigmoid resection experimental model. Surg Endosc 2018; 32:3215-3224. [DOI: 10.1007/s00464-018-6039-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 01/03/2018] [Indexed: 01/19/2023]
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10
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Thaker AM, Muthusamy VR. Advanced Imaging Techniques in Gastrointestinal Endoscopy. J Laparoendosc Adv Surg Tech A 2016; 27:234-241. [PMID: 27996369 DOI: 10.1089/lap.2016.0566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The fundamental approach to endoscopy is to identify concerning and potentially premalignant lesions in the gastrointestinal tract, sample or resect the area of interest, await histologic results, and subsequently formulate a treatment and/or surveillance strategy. Detecting subtle lesions and deciding whether they are clinically significant are challenges that rely on the endoscopist's observation skills and experience. Enhanced imaging technologies have been developed to aid in lesion identification and classification, enabling better visualization of the lumen from a wide-field view while also enabling real-time near-field, including cellular level, imaging of the tissue. These innovations can potentially help reduce the rate of missed lesions, the need for extensive surveillance biopsies, and the frequency of surveillance. Several of these advanced imaging technologies are discussed in this review.
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Affiliation(s)
- Adarsh M Thaker
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA , Los Angeles, California
| | - V Raman Muthusamy
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA , Los Angeles, California
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