Real-time fluorescence angiography by intra-arterial indocyanine green injection to identify obscure gastrointestinal bleeding territory: proof of concept in the porcine model.
BACKGROUND
Despite intensive preoperative localization workouts, intraoperative localization of the bleeding source in case of obscure gastrointestinal bleeding (OGIB) can be cumbersome and time-consuming. Our aim was to assess the feasibility of image-guided laparoscopic identification of the small bowel loop containing the bleeding source with and without near-infrared angiographic enhancement.


METHODS
Angiography of superior mesenteric artery (SMA) branches was performed in 11 pigs using a right femoral artery approach, followed by a three-port laparoscopy, using a near-infrared-equipped laparoscope. Two pigs were used to identify the optimal intra-arterial indocyanine green (ICG) dose. Eight pigs were divided into two groups: ICG near-infrared angiography-assisted laparoscopy (n = 4) and fluoroscopic-assisted laparoscopy (n = 4). Finally, in one pig, a novel OGIB model was created and used to evaluate the ICG enhancement pattern in the presence of active bleeding.


RESULTS
Mean time to identify the fluorescence signal from the small bowel segment fed by the catheterized SMA branch was 13.75 ± 7.8 s, which was statistically significantly shorter than the time required to identify the tip of the catheter by fluoroscopic guidance, i.e., 243.25 ± 107 s (p = 0.02).


CONCLUSIONS
Near-infrared fluorescence angiography using intra-arterial ICG injection provides a fast image-guided intraoperative localization of the small bowel loop fed by the arterial territory identified as bleeding by digital subtraction angiography and could help target the bleeding source during OGIB surgery.
IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.|Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan.
Yu-Yin
YY
Liu
IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France.
Raoul
R
Pop
IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France. michele.diana@ircad.fr.|IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France. michele.diana@ircad.fr.
Michele
M
Diana
IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France.
Seong-Ho
SH
Kong
IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France.
Andras
A
Lègner
IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France.
Rémy
R
Beaujeux
IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.|IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France.
Jacques
J
Marescaux
D000818:Animals; D004396:Coloring Agents / Q000494:pharmacology*; D004195:Disease Models, Animal; D005260:Female; D005451:Fluorescein Angiography / Q000295:instrumentation; D006471:Gastrointestinal Hemorrhage / Q000000981:diagnostic imaging* / Q000473:pathology; D007208:Indocyanine Green / Q000494:pharmacology*; D008297:Male; D061848:Optical Imaging; D013552:Swine; D014656:Vascular Surgical Procedures
D004396:Coloring Agents; D007208:Indocyanine Green
Fluorescence angiography; Fluorescence-guided surgery; Indocyanine green (ICG); Near-infrared fluorescence videography; Obscure gastrointestinal bleeding (OGIB)