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In vivo real-time assessment of the anastomotic blood supply in colorectal surgery using confocal laser endomicroscopy in an anastomotic model. Surg Endosc 2022; 36:4136-4144. [PMID: 34515870 DOI: 10.1007/s00464-021-08738-x] [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: 01/07/2021] [Accepted: 09/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Anastomotic ischemia can affect healing and eventually lead to anastomotic leakage, and confocal laser endomicroscopy (CLE) can offer detailed observations at the subcellular level. We aimed to evaluate the anastomotic microcirculation in different anastomotic perfusion models using CLE. METHODS Anastomotic perfusion models were established using twelve rabbits distributed into two groups: group A (good perfusion, n = 6) and group B (poor perfusion, n = 6). Afterward, intraoperative detection of anastomotic perfusion was carried out using CLE, and quantitative analysis of blood cells was performed. Rabbits that satisfied the criteria underwent a second exploratory operation and specimens were stained by hematoxylin and eosin. RESULTS Enhanced with fluorescein sodium, capillaries were obviously highlighted in group A, while few capillaries were viewed in group B. Delayed development of fluorescence occurred in group B. The average flow of blood cells was 37.0 ± 5.93 per minute in group A and 6.33 ± 2.16 per minute in group B (p < 0.001). In addition, during the second exploratory surgery, rabbits with inadequate anastomotic perfusion exhibited more serious intestinal adhesion and ischemia. Anastomotic leakage and abdominal infection occurred in all rabbits in group B. CONCLUSION CLE can realize real-time imaging of the anastomotic microcirculation and is a feasible technique for performing intraoperative evaluation in different anastomotic perfusion situations. This animal experiment provides the groundwork for future in vivo research in humans.
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Mak G, Zaunders JJ, Bailey M, Seddiki N, Rogers G, Leong L, Phan TG, Kelleher AD, Koelsch KK, Boyd MA, Danta M. Preservation of Gastrointestinal Mucosal Barrier Function and Microbiome in Patients With Controlled HIV Infection. Front Immunol 2021; 12:688886. [PMID: 34135912 PMCID: PMC8203413 DOI: 10.3389/fimmu.2021.688886] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/04/2021] [Indexed: 01/02/2023] Open
Abstract
Background Despite successful ART in people living with HIV infection (PLHIV) they experience increased morbidity and mortality compared with HIV-negative controls. A dominant paradigm is that gut-associated lymphatic tissue (GALT) destruction at the time of primary HIV infection leads to loss of gut integrity, pathological microbial translocation across the compromised gastrointestinal barrier and, consequently, systemic inflammation. We aimed to identify and measure specific changes in the gastrointestinal barrier that might allow bacterial translocation, and their persistence despite initiation of antiretroviral therapy (ART). Method We conducted a cross-sectional study of the gastrointestinal (GIT) barrier in PLHIV and HIV-uninfected controls (HUC). The GIT barrier was assessed as follows: in vivo mucosal imaging using confocal endomicroscopy (CEM); the immunophenotype of GIT and circulating lymphocytes; the gut microbiome; and plasma inflammation markers Tumour Necrosis Factor-α (TNF-α) and Interleukin-6 (IL-6); and the microbial translocation marker sCD14. Results A cohort of PLHIV who initiated ART early, during primary HIV infection (PHI), n=5), and late (chronic HIV infection (CHI), n=7) infection were evaluated for the differential effects of the stage of ART initiation on the GIT barrier compared with HUC (n=6). We observed a significant decrease in the CD4 T-cell count of CHI patients in the left colon (p=0.03) and a trend to a decrease in the terminal ileum (p=0.13). We did not find evidence of increased epithelial permeability by CEM. No significant differences were found in microbial translocation or inflammatory markers in plasma. In gut biopsies, CD8 T-cells, including resident intraepithelial CD103+ cells, did not show any significant elevation of activation in PLHIV, compared to HUC. The majority of residual circulating activated CD38+HLA-DR+ CD8 T-cells did not exhibit gut-homing integrins α4ß7, suggesting that they did not originate in GALT. A significant reduction in the evenness of species distribution in the microbiome of CHI subjects (p=0.016) was observed, with significantly higher relative abundance of the genus Spirochaeta in PHI subjects (p=0.042). Conclusion These data suggest that substantial, non-specific increases in epithelial permeability may not be the most important mechanism of HIV-associated immune activation in well-controlled HIV-positive patients on antiretroviral therapy. Changes in gut microbiota warrant further study.
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Affiliation(s)
- Gerald Mak
- St. Vincent's Clinical School, UNSW, Darlinghurst, NSW, Australia
| | - John J Zaunders
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, NSW, Australia
| | | | - Nabila Seddiki
- IDMIT Department/IBFJ, Immunology of Viral Infections and Autoimmune Diseases (IMVA), INSERM U1184, CEA, Université Paris Sud, Paris, France
| | - Geraint Rogers
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia.,Faculty of Science, Flinders University, Adelaide, SA, Australia
| | - Lex Leong
- Microbiology and Infectious Diseases, South Australia (SA) Pathology, Adelaide, SA, Australia
| | - Tri Giang Phan
- St. Vincent's Clinical School, UNSW, Darlinghurst, NSW, Australia.,Immunology Division Garvan Institute of Medical Research, Sydney, NSW, Australia
| | | | | | - Mark A Boyd
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.,South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Mark Danta
- St. Vincent's Clinical School, UNSW, Darlinghurst, NSW, Australia.,Department of Gastroenterology, St. Vincent's Hospital, Sydney, NSW, Australia
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Nojkov B, Zhou SY, Dolan RD, Davis EM, Appelman HD, Guo X, Jackson K, Sturm MB, Wang TD, Owyang C, Liu JJ, Chey WD. Evidence of Duodenal Epithelial Barrier Impairment and Increased Pyroptosis in Patients With Functional Dyspepsia on Confocal Laser Endomicroscopy and "Ex Vivo" Mucosa Analysis. Am J Gastroenterol 2020; 115:1891-1901. [PMID: 33156108 PMCID: PMC8409129 DOI: 10.14309/ajg.0000000000000827] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Duodenal epithelial barrier impairment and immune activation may play a role in the pathogenesis of functional dyspepsia (FD). This study was aimed to evaluate the duodenal epithelium of patients with FD and healthy individuals for detectable microscopic structural abnormalities. METHODS This is a prospective study using esophagogastroduodenoscopy enhanced with duodenal confocal laser endomicroscopy (CLE) and mucosal biopsies in patients with FD (n = 16) and healthy controls (n = 18). Blinded CLE images analysis evaluated the density of epithelial gaps (cell extrusion zones), a validated endoscopic measure of the intestinal barrier status. Analyses of the biopsied duodenal mucosa included standard histology, quantification of mucosal immune cells/cytokines, and immunohistochemistry for inflammatory epithelial cell death called pyroptosis. Transepithelial electrical resistance (TEER) was measured using Ussing chambers. Epithelial cell-to-cell adhesion proteins expression was assessed by real-time polymerase chain reaction. RESULTS Patients with FD had significantly higher epithelial gap density on CLE in the distal duodenum than that of controls (P = 0.002). These mucosal abnormalities corresponded to significant changes in the duodenal biopsy samples of patients with FD, compared with controls, including impaired mucosal integrity by TEER (P = 0.009) and increased number of epithelial cells undergoing pyroptosis (P = 0.04). Reduced TEER inversely correlated with the severity of certain dyspeptic symptoms. Furthermore, patients with FD demonstrated altered duodenal expression of claudin-1 and interleukin-6. No differences in standard histology were found between the groups. DISCUSSION This is the first report of duodenal CLE abnormalities in patients with FD, corroborated by biopsy findings of epithelial barrier impairment and increased cell death, implicating that duodenal barrier disruption is a pathogenesis factor in FD and introducing CLE a potential diagnostic biomarker in FD.
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Affiliation(s)
- Borko Nojkov
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Shi-Yi Zhou
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Russell D. Dolan
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Elisabeth M. Davis
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Henry D. Appelman
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Xueyan Guo
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kenya Jackson
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Matthew B. Sturm
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Thomas D. Wang
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Chung Owyang
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Julia J. Liu
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - William D. Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
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Charalampaki P, Nakamura M, Athanasopoulos D, Heimann A. Confocal-Assisted Multispectral Fluorescent Microscopy for Brain Tumor Surgery. Front Oncol 2019; 9:583. [PMID: 31380264 PMCID: PMC6657348 DOI: 10.3389/fonc.2019.00583] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/14/2019] [Indexed: 01/14/2023] Open
Abstract
Optimal surgical therapy for brain tumors is the combination of complete resection with minimal invasion and damage to the adjacent normal tissue. To achieve this goal, we need advanced imaging techniques on a scale from macro- to microscopic resolution. In the last decade, the development of fluorescence-guided surgery has been the most influential breakthrough, marginally improving outcomes in brain tumor surgery. Multispectral fluorescence microscopy (MFL) is a novel imaging technique that allows the overlapping of a fluorescent image and a white light image in real-time, with delivery of the merged image to the surgeon through the eyepieces of a surgical microscope. MFL permits the detection and characterization of brain tumors using fluorescent molecular markers such as 5-aminolevulinic acid (5-ALA) or indocyanine green (ICG), while simultaneously obtaining high definition white light images to create a pseudo-colored composite image in real-time. Limitations associated with the use of MFL include decreased light imaging intensity and decreased levels of magnification that may compromise maximal tumor resection on a cellular scale. Confocal laser endomicroscopy (CLE) is another novel advanced imaging technique that is based on miniaturization of the microscope imaging head in order to provide the possibility of in vivo microscopy at the cellular level. Clear visualization of the cellular cytoarchitecture can be achieved with 400-fold-1,000-fold magnification. CLE allows on the one hand the intra-operative detection and differentiation of single tumor cells (without the need for intra-operative histologic analysis of biopsy specimens) as well as the definition of borders between tumor and normal tissue at a cellular level, dramatically improving the accuracy of surgical resection. The application and implementation of CLE-assisted surgery in surgical oncology increases not only the number of options for real-time diagnostic imaging, but also the therapeutic options by extending the resection borders of cancer at a cellular level and, more importantly, by protecting the functionality of normal tissue in the adjacent areas of the human brain. In this article, we describe our experience using these new techniques of confocal-assisted fluorescent surgery including analysis on the technology, usability, indications, limitations, and further developments.
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Affiliation(s)
- Patra Charalampaki
- Department of Neurosurgery, Cologne Medical Center, University Witten-Herdecke, Witten, Germany
| | - Makoto Nakamura
- Department of Neurosurgery, Cologne Medical Center, University Witten-Herdecke, Witten, Germany
| | | | - Axel Heimann
- Institute of Neurosurgical Pathophysiology, Medical University Mainz, Mainz, Germany
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Luthra AK, Mishra G. Novel diagnostic and therapeutic modalities using endoscopic ultrasound in pancreatic disease. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Anjuli Kristin Luthra
- Section on General Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Girish Mishra
- Department of Gastroenterology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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