title: Probe-based confocal laser endomicroscopy and fluorescence-based enhanced reality for real-time assessment of intestinal microcirculation in a porcine model of sigmoid ischemia.
abstract: OBJECTIVE
  Surgeons currently rely on visual clues to estimate the presence of sufficient vascularity for safe anastomosis. We aimed to assess the accuracy of endoluminal confocal laser endomicroscopy (CLE) and laparoscopic fluorescence-based enhanced reality (FLER), using near-infrared imaging and fluorescence from injected Indocyanine Green, to identify the transition from ischemic to vascular areas in a porcine model of mesenteric ischemia.
  
  
  METHODS
  Six pigs underwent 1-h sigmoid segmental ischemia. The ischemic area was evaluated by clinical assessment and FLER to determine presumed viable margins. For each sigmoid colon, 5 regions of interest (ROIs) were identified: ischemic (ROI 1), presumed viable margins ROI 2a (distal) and 2b (proximal), and vascular areas 3a (distal) and 3b (proximal). After injection of fluorescein, CLE scanning of the mucosa from the ischemic area toward viable margins was performed. Capillary blood samples were obtained by puncturing the serosa at the ROIs, and capillary lactates were measured with the EDGE(®) analyzer.
  
  
  RESULTS
  Capillary lactates were significantly higher at ROI 1 (4.91 mmol/L) when compared to resection margins (2.8 mmol/L; mean difference: 2.11; p < 0.05) identified by FLER. There was no significant difference in lactates between ROI1 and resection margins identified by clinical evaluation. In 50 % of cases, ROI 2aCLINIC-2bCLINIC were considered to match (<1 cm distance) with ROI 2aFLER-2bFLER. Confocal analysis revealed specific clues to identify the transition from ischemic to viable areas corresponding to those assessed by FLER in 11/12 cases versus 7/12 for those identified by clinical evaluation.
  
  
  CONCLUSIONS
  In this experimental model, FLER and CLE were more accurate than clinical evaluation to delineate bowel vascularization.
authors.affiliation: IRCAD Research Institute against Cancer of the Digestive System and IHU Minimally Invasive Image-Guided Surgical Institute, 1, place de l'Hôpital, 67095, Strasbourg, France, michele.diana@ircad.fr.
authors.forename: Michele
authors.initials: M
authors.lastname: Diana
authors.forename: Bernard
authors.initials: B
authors.lastname: Dallemagne
authors.forename: Hyunsoo
authors.initials: H
authors.lastname: Chung
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Nagao
authors.forename: Peter
authors.initials: P
authors.lastname: Halvax
authors.forename: Vincent
authors.initials: V
authors.lastname: Agnus
authors.forename: Luc
authors.initials: L
authors.lastname: Soler
authors.forename: Veronique
authors.initials: V
authors.lastname: Lindner
authors.forename: Nicolas
authors.initials: N
authors.lastname: Demartines
authors.forename: Pierre
authors.initials: P
authors.lastname: Diemunsch
authors.forename: Bernard
authors.initials: B
authors.lastname: Geny
authors.forename: Lee
authors.initials: L
authors.lastname: Swanström
authors.forename: Jacques
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D000818:Animals; D012809:Colon, Sigmoid / Q000098:blood supply*; D004396:Coloring Agents; D004195:Disease Models, Animal; D007089:Image Enhancement / Q000379:methods*; D007208:Indocyanine Green; D007511:Ischemia / Q000175:diagnosis* / Q000503:physiopathology; D008833:Microcirculation / Q000502:physiology*; D018613:Microscopy, Confocal / Q000379:methods*; D015203:Reproducibility of Results; D013552:Swine
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green