Institute of Image-Guided Surgery, IHU Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France.
IRCAD, Research Institute against Digestive Cancer, Strasbourg, France.
Surg Endosc. 2021 Feb;35(2):962-970. doi: 10.1007/s00464-020-08000-w. Epub 2020 Sep 30.
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.
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.
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.
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.
结直肠外科受益于精准医学的进步，如全直肠系膜切除术，最近还有结肠系膜切除术、荧光灌注成像和荧光淋巴结绘图。然而，这些进步未能解决结肠系膜分离的质量差异以及血管分离的定向程度（包括高位结扎）或术前吻合灌注绘图，从而影响吻合口漏。我们提出了一种新的精准图像指导结直肠手术范式，涉及 3D 术前切除建模和术中荧光透视和荧光血管成像，根据我们的假设，更好地定义了最佳的分离平面和基于血管与解剖的切除线。
六头猪进行术前 CT 血管 3D 重建，以便进行基于血管的分离术前规划。在杂交手术室（OR）进行腹腔镜手术。超选择性动脉导管插入肠系膜上动脉（SMA）或肠系膜下动脉（IMA）分支。术中给予 0.1mg/kg 的单次推注或 0.01mg/mL 的吲哚菁绿（ICG）持续输注，以指导荧光引导的乙状结肠和回肠切除术。使用专有的软件在右半结肠和左半结肠的几个感兴趣区域（ROI）评估荧光。
该方法是可行和安全的。选择性导管插入术平均需要 43 分钟。单次推注和持续输注均能清晰标记预先识别的血管（动脉/静脉）和目标结肠段，根据可见的血管解剖学实现精确的切除。定量软件分析表明了每个 ROI 的最佳切除边界。
经动脉荧光绘图可显示主要血管结构和节段性结肠灌注。这有助于防止对主要血管结构的任何意外损伤，并精确确定基于灌注的切除平面和边界。这可以实现切除结肠量的个体化，确保良好的吻合灌注，并改善肿瘤学结果。
