Discriminatory influence of Pinpoint perfusion imaging on diversion ileostomy after laparoscopic low anterior resection

Ileostomy 101: Understanding the Basics for Optimal Patient Care

This comprehensive literature review explores the foundational aspects of ileostomy, encompassing surgical techniques, postoperative care, complications, and advancements. Ileostomy, a surgical procedure redirecting the ileal lumen through an abdominal opening, is a critical intervention for various gastrointestinal conditions. The review delves into surgical techniques, emphasizing the importance of stoma location and type selection, whether temporary or permanent. Complications associated with ileostomy are discussed, highlighting the significance of vigilant postoperative care, including stoma care and addressing potential complications. The profound impact of ileostomy on patients' quality of life is elucidated, underlining the necessity for a holistic approach to patient care. Additionally, advancements in the field, such as biodegradable stoma bags, smart stoma appliances, and telemedicine, are explored for their potential to enhance patient outcomes. The review emphasizes the need for individualized approaches and ongoing research to maximize the benefits of these advancements for ileostomy patients and improve their overall experience.

Artificial intelligence based real-time microcirculation analysis system for laparoscopic colorectal surgery

BACKGROUND

Colonic perfusion status can be assessed easily by indocyanine green (ICG) angiography to predict ischemia related anastomotic complications during laparoscopic colorectal surgery. Recently, various parameter-based perfusion analysis have been studied for quantitative evaluation, but the analysis results differ depending on the use of quantitative parameters due to differences in vascular anatomical structure. Therefore, it can help improve the accuracy and consistency by artificial intelligence (AI) based real-time analysis microperfusion (AIRAM).

AIM

To evaluate the feasibility of AIRAM to predict the risk of anastomotic complication in the patient with laparoscopic colorectal cancer surgery.

METHODS

The ICG curve was extracted from the region of interest (ROI) set in the ICG fluorescence video of the laparoscopic colorectal surgery. Pre-processing was performed to reduce AI performance degradation caused by external environment such as background, light source reflection, and camera shaking using MATLAB 2019 on an I7-8700k Intel central processing unit (CPU) PC. AI learning and evaluation were performed by dividing into a training patient group (n = 50) and a test patient group (n = 15). Training ICG curve data sets were classified and machine learned into 25 ICG curve patterns using a self-organizing map (SOM) network. The predictive reliability of anastomotic complications in a trained SOM network is verified using test set.

RESULTS

AI-based risk and the conventional quantitative parameters including T_1/2max, time ratio (TR), and rising slope (RS) were consistent when colonic perfusion was favorable as steep increasing ICG curve pattern. When the ICG graph pattern showed stepped rise, the accuracy of conventional quantitative parameters decreased, but the AI-based classification maintained accuracy consistently. The receiver operating characteristic curves for conventional parameters and AI-based classification were comparable for predicting the anastomotic complication risks. Statistical performance verifications were improved in the AI-based analysis. AI analysis was evaluated as the most accurate parameter to predict the risk of anastomotic complications. The F1 score of the AI-based method increased by 31% for T_1/2max, 8% for TR, and 8% for RS. The processing time of AIRAM was measured as 48.03 s, which was suitable for real-time processing.

CONCLUSION

In conclusion, AI-based real-time microcirculation analysis had more accurate and consistent performance than the conventional parameter-based method.

Visualization and quantification of anastomotic perfusion in colorectal surgery using near-infrared fluorescence

BACKGROUND

Anastomotic leakage (AL) is one of the most troublesome complications in colorectal surgery. Recently, near-infrared fluorescence (NIRF) imaging has been used intraoperatively to detect sentinel lymph nodes and visualize the blood supply at the region of interest (ROI). The aim of this study was to evaluate the role of visualization and quantification of bowel perfusion around the anastomosis using NIRF system in predicting AL.

METHODS

A prospective study was conducted on patients who had laparoscopic surgery for colorectal cancer at our institution. Perfusion of the anastomosis was evaluated with NIRF imaging after intravenous injection of indocyanine green (ICG). The time course of fluorescence intensity was recorded by an imaging analyzer We measured the time from ICG injection to the beginning of fluorescence (T₀), maximum intensity (I_max), time to reach I_max (T_max), time to reach I_max 50% ([Formula: see text]) and slope (S) after the anastomosis.

RESULTS

Tumor locations were as follows; cecum: 2, ascending colon: 2, transverse colon: 7, descending colon: 1, sigmoid colon: 2, rectosigmoid colon: 3 and rectum: 6 (one case with synchronous cancer). All operations were performed laparoscopically. Four patients were diagnosed with or suspected to have AL (2 patients with grade B anastomotic leakage after low anterior resection, 1 patient with minor leakage in transverse colon resection and 1 patient needing re-anastomosis intraoperatively in transverse colon resection). T₀ was significantly longer in the AL group than in patients without AL (64.3 ± 27.6 and 18.2 ± 6.6 s, p = 2.2 × 10^-3).

CONCLUSIONS

Perfusion of the anastomosis could be successfully visualized and quantified using NIRF imaging with ICG. T₀ might be a useful parameter for prediction of AL.

Clipping of an anterior spinal artery aneurysm using an endoscopic fluorescence imaging system for craniocervical junction epidural arteriovenous fistula: technical note

The authors report the case of a 78-year-old man with a craniocervical junction epidural arteriovenous fistula who presented with subarachnoid hemorrhage from a ruptured anterior spinal artery (ASA) aneurysm. Because endovascular embolization was difficult, a posterolateral approach was chosen and a novel endoscopic fluorescence imaging system was utilized to clip the aneurysm. The fluorescence imaging system provided clear and magnified views of the ventral spinal cord simultaneously with the endoscope-integrated indocyanine green videoangiography, which helped safely obliterate the ASA aneurysm. With the aid of this novel imaging system, surgeons can appreciate and manipulate complex vascular pathologies of the ventral spinal cord through a posterolateral approach, even when the lesion is closely related to the ASA.

The significance of intraoperative fluorescence angiography in miniinvasive low rectal resections

Introduction

Anastomotic leak is a very serious complication in colorectal surgery. Tissue perfusion of the anastomosis plays an integral role in its multifactorial etiology. Fluorescence angiography using indocyanine green allows visualization of perfusion in real time.

Aim

To evaluate the effectiveness of intraoperative fluorescence angiography as a tool to decrease the incidence of anastomotic leak after laparoscopic or robotic low resection of the rectum for cancer.

Material and methods

Intraoperative fluorescence angiography was performed sequentially in 50 patients during low rectal resection for cancer with total mesorectal excision, primary anastomosis and protective ileostomy using laparoscopic or robotic technique. The results were compared to a historical control group of 50 patients with the same procedure without the use of fluorescence angiography.

Results

The patient sets were comparable in basic demographic and clinical parameters. Intraoperative visualization of perfusion by fluorescence angiography was achieved in all patients without unwanted side-effects. In 6 (12%) patients, the resection line was adjusted based on the fluorescence angiography. The incidence of anastomotic leak was insignificantly lower in the group with fluorescence angiography (18% vs. 10%), which led to significantly shorter hospital stay. Other postoperative complications were comparable between the two groups.

Conclusions

Fluorescence angiography using indocyanine green is a safe and effective method with the potential of reducing anastomotic leak during minimally invasive low resection of the rectum for cancer.

Quantitative analysis of colon perfusion pattern using indocyanine green (ICG) angiography in laparoscopic colorectal surgery

Purpose

This study aimed to quantitatively evaluate colon perfusion patterns using indocyanine green (ICG) angiography to find the most reliable predictive factor of anastomotic complications after laparoscopic colorectal surgery.

Methods

Laparoscopic fluorescence imaging was applied to colorectal cancer patients (n = 86) from July 2015 to December 2017. ICG (0.25 mg/kg) was slowly injected into peripheral blood vessels, and the fluorescence intensity of colonic flow was measured sequentially, producing perfusion graphs using a video analysis and modeling tool. Colon perfusion patterns were categorized as either fast, moderate, or slow based on their fluorescence slope, T_1/2MAX and time ratio (TR = T_1/2MAX/T_MAX). Clinical factors and quantitative perfusion factors were analyzed to identify predictors for anastomotic complications.

Results

The mean age of patients was 65.4 years, and the male-to-female ratio was 63:23. Their operations were laparoscopic low anterior resection (55 cases) and anterior resection (31 cases). The incidence of anastomotic complication was 7%, including colonic necrosis (n = 1), anastomotic leak (n = 3), delayed pelvic abscess (n = 1), and delayed anastomotic dehiscence (n = 1). Based on quantitative analysis, the fluorescence slope, T_1/2MAX, and TR were related with anastomotic complications. The cut-off value of TR to categorize the perfusion pattern was determined to be 0.6, as shown by ROC curve analysis (AUC 0.929, P < 0.001). Slow perfusion (TR > 0.6) was independent factor for anastomotic complications in a logistic regression model (OR 130.84; 95% CI 6.45–2654.75; P = 0.002). Anastomotic complications were significantly correlated with the novel factor TR (> 0.6) as the most reliable predictor of perfusion and anastomotic complications.

Conclusions

Quantitative analysis of ICG perfusion patterns using T_1/2MAX and TR can be applied to detect segments with poor perfusion, thereby reducing anastomotic complications during laparoscopic colorectal surgery.