Kashchenko V A, Dzhemilova Z N, Zavrazhnov A A, Ratnikov V A, Bogatikov A A, Petrova V V, Guschina O B
North-Western District Scientific and Clinical Center named after L.G. Sokolov of the Federal Medical-Biological Agency, St. Petersburg, Russia.
Saint Petersburg State University, St. Petersburg, Russia.
Khirurgiia (Mosk). 2024(4):82-92. doi: 10.17116/hirurgia202404182.
To assess the possibilities of fluorescent detection system in qualitative and quantitative assessment of bowel perfusion in colorectal resections.
From May to August 2023, a single-center pilot cross-sectional unblinded study with inclusion of 18 patients with colon cancer (of left-sided - 12, of right-sided - 6, mean age - 72.9 years, m/w - 61/39%) was conducted. All patients underwent laparoscopic colorectal resections with extracorporeal stage of bowel transection. The evaluation of the bowel's ICG perfusion was conducted to assist in decision making about the level of its resection. Qualitative (visual) assessment was carried out in all 18 patients, in one patient twice, quantitative assessment of perfusion was conducted in 8 patients (left-sided resections - 6, right-sided hemicolectomy - 2). The qualitative evaluation was performed in real time on the analysis of the color gradient. The time parameters and fluorescence intensity at different level proximally and distally from the resection line were quantitatively estimated: T - time of occurrence of minimal fluorescence in the areas of interest after the ICG injection (sec); T - time to achieve maximum fluorescence intensity after the ICG injection (sec); T - time interval between T and T, I - level of maximum fluorescence intensity (I).
Visual qualitative analysis of fluorescence revealed unsatisfactory perfusion characteristics (black, dark-gray color) in the area planned by the surgeon to anastomose the bowel in 3 of 18 patients (16.6%). When analyzing the quantitative data of this group of patients, there was a 2-6-fold decrease in Imax level, and one patient had an increase in T at the level of intended resection compared to the bowel's sections in the favorable zone. In all cases, the final bowel transection was conducted in the area of good perfusion. There was no clinical evidence of anastomotic dehiscence in the study group.
Intraoperative evaluation of bowel perfusion is an important component of safe anastomosis formation in colorectal surgery. The use of ICG-FA allows to conduct qualitative and quantitative assessment of tissue perfusion of the bowel in order to assist in making intraoperative decisions. Quantitative evaluation of fluorescence provides more objective information about perfusion parameters. I and T are the most promising quantitative indicators of local bowel's perfusion. Nevertheless, the precise interpretation of the quantitative indicators of ICG perfusion needs to be clarified.
评估荧光检测系统在结直肠癌切除术中对肠灌注进行定性和定量评估的可能性。
2023年5月至8月，开展了一项单中心前瞻性非盲横断面研究，纳入18例结肠癌患者（左侧结肠癌12例，右侧结肠癌6例，平均年龄72.9岁，男/女比例为61/39%）。所有患者均接受了腹腔镜结直肠癌切除术，并在体外进行肠横断。对肠的吲哚菁绿（ICG）灌注情况进行评估，以辅助确定肠切除的水平。对18例患者均进行了定性（视觉）评估，其中1例患者评估了两次，对8例患者（左侧切除术6例，右侧半结肠切除术2例）进行了灌注的定量评估。定性评估通过实时分析颜色梯度进行。对距切除线近端和远端不同水平的时间参数和荧光强度进行了定量估计：T1 - ICG注射后感兴趣区域出现最小荧光的时间（秒）；T2 - ICG注射后达到最大荧光强度的时间（秒）；T3 - T1与T2之间的时间间隔，Imax - 最大荧光强度水平（I）。
荧光的视觉定性分析显示，在18例患者中有3例（16.6%），外科医生计划进行肠吻合的区域灌注特征不理想（黑色、深灰色）。在分析这组患者的定量数据时，Imax水平下降了2至6倍，与良好灌注区域的肠段相比，1例患者在预期切除水平处T1增加。在所有病例中，最终的肠横断均在灌注良好的区域进行。研究组中没有吻合口裂开的临床证据。
术中评估肠灌注是结直肠癌手术中安全吻合口形成的重要组成部分。使用吲哚菁绿荧光血管造影（ICG-FA）能够对肠组织灌注进行定性和定量评估，以辅助术中决策。荧光的定量评估提供了关于灌注参数的更客观信息。Imax和T1是局部肠灌注最有前景的定量指标。然而，ICG灌注定量指标的确切解读仍需阐明。
