Antonello Forgione1, Manuel Barberio2, Vincent Agnus2, Lee Swanström2, Jacques Marescaux2,3, Michele Diana2,3,4,5, Benoit Gallix2,6,7,8. 1. Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France. antonello.forgione@gmail.com. 2. Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France. 3. IRCAD, Research Institute against Digestive Cancer, Strasbourg, France. 4. Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France. 5. ICUBE Laboratory, Photonics Instrumentation for Health, Strasbourg, France. 6. University of Strasbourg, Strasbourg, France. 7. University Hospital of Strasbourg, Strasbourg, France. 8. Faculty of Medicine, McGill University, Montreal, Canada.
Abstract
BACKGROUND: Colorectal surgery has benefited from advances in precision medicine such as total mesorectal resection, and recently, mesocolon resection, fluorescent perfusion imaging, and fluorescent node mapping. However, these advances fail to address the variable quality of mesocolon dissection and the directed extent of vascular dissection (including high ligation) or pre-resection anastomotic perfusion mapping, thereby impacting anastomotic leaks. We propose a new paradigm of precision image-directed colorectal surgery involving 3D preoperative resection modeling and intraoperative fluoroscopic and fluorescence vascular imaging which better defines optimal dissection planes and vascular vs. anatomy-based resection lines according to our hypothesis. METHODS: Six pigs had preoperative CT with vascular 3D reconstruction allowing for the preoperative planning of vascular-based dissection. Laparoscopic surgery was performed in a hybrid operating room (OR). Superselective arterial catheterization was performed in branches of the superior mesenteric artery (SMA) or the inferior mesenteric artery (IMA). Intraoperative boluses of 0.1 mg/kg or a continuous infusion of indocyanine green (ICG) (0.01 mg/mL) were administered to guide fluorescent-based sigmoid and ileocecal resections. Fluorescence was assessed using proprietary software at several regions of interest (ROI) in the right and left colon. RESULTS: The approach was feasible and safe. Selective catheterization took an average of 43 min. Both bolus and continuous perfusion clearly marked pre-identified vessels (arteries/veins) and the target colon segment, facilitating precise resections based on the visible vascular anatomy. Quantitative software analysis indicated the optimal resection margin for each ROI. CONCLUSION: Intra-arterial fluorescent mapping allows visualization of major vascular structures and segmental colonic perfusion. This may help to prevent any inadvertent injury to major vascular structures and to precisely determine perfusion-based resection planes and margins. This could enable tailoring of the amount of colon resected, ensure good anastomotic perfusion, and improve oncological outcomes.
BACKGROUND: Colorectal surgery has benefited from advances in precision medicine such as total mesorectal resection, and recently, mesocolon resection, fluorescent perfusion imaging, and fluorescent node mapping. However, these advances fail to address the variable quality of mesocolon dissection and the directed extent of vascular dissection (including high ligation) or pre-resection anastomotic perfusion mapping, thereby impacting anastomotic leaks. We propose a new paradigm of precision image-directed colorectal surgery involving 3D preoperative resection modeling and intraoperative fluoroscopic and fluorescence vascular imaging which better defines optimal dissection planes and vascular vs. anatomy-based resection lines according to our hypothesis. METHODS: Six pigs had preoperative CT with vascular 3D reconstruction allowing for the preoperative planning of vascular-based dissection. Laparoscopic surgery was performed in a hybrid operating room (OR). Superselective arterial catheterization was performed in branches of the superior mesenteric artery (SMA) or the inferior mesenteric artery (IMA). Intraoperative boluses of 0.1 mg/kg or a continuous infusion of indocyanine green (ICG) (0.01 mg/mL) were administered to guide fluorescent-based sigmoid and ileocecal resections. Fluorescence was assessed using proprietary software at several regions of interest (ROI) in the right and left colon. RESULTS: The approach was feasible and safe. Selective catheterization took an average of 43 min. Both bolus and continuous perfusion clearly marked pre-identified vessels (arteries/veins) and the target colon segment, facilitating precise resections based on the visible vascular anatomy. Quantitative software analysis indicated the optimal resection margin for each ROI. CONCLUSION: Intra-arterial fluorescent mapping allows visualization of major vascular structures and segmental colonic perfusion. This may help to prevent any inadvertent injury to major vascular structures and to precisely determine perfusion-based resection planes and margins. This could enable tailoring of the amount of colon resected, ensure good anastomotic perfusion, and improve oncological outcomes.
Authors: Jarmo T Alander; Ilkka Kaartinen; Aki Laakso; Tommi Pätilä; Thomas Spillmann; Valery V Tuchin; Maarit Venermo; Petri Välisuo Journal: Int J Biomed Imaging Date: 2012-04-22
Authors: Christian Heiliger; Jerzy Piecuch; Alexander Frank; Dorian Andrade; Viktor von Ehrlich-Treuenstätt; Dobromira Evtimova; Florian Kühn; Jens Werner; Konrad Karcz Journal: Sci Rep Date: 2021-07-20 Impact factor: 4.379