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 (Imax), time to reach Imax (Tmax), time to reach Imax 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.

Recurrence of rectal anastomotic leakage following stoma closure: assessment of risk factors.

AIM: In patients with a previous history of rectal anastomotic leakage (AL), the surgical indications and timing for closure of a diverting stoma have to be carefully judged. Even if AL has apparently healed before stoma closure, re-leakage may occur after closure. The aim of this study was to determine the incidence and risk factors for recurrent AL following stoma closure. We also examined the treatment strategies aiming to minimize the risk of recurrent AL. METHODS: From January 2009 to December 2016, 1008 patients underwent sphincter-saving surgery [low anterior resection, all-sphincter-preserving rectal resection with hand-sewn coloanal anastomosis (CAA) and intersphincteric resection (ISR)] for primary rectal cancer with curative intent at our hospital. A total of 69 patients with AL with a Clavien-Dindo Grade III or more who subsequently underwent closure of a diverting stoma were retrospectively reviewed for this study. RESULTS: The incidence of recurrent leakage after stoma closure in this series was 13% overall with an incidence of 25% in the CAA/ISR group and 5% in the low anterior resection group. Significant risk factors included hand-sewn anastomosis (P = 0.0257) compared to stapled anastomosis, ischaemia at the anastomotic site as the cause of initial AL (P < 0.001) and a shorter interval between confirmation of healing and stoma closure (P = 0.00952). CONCLUSION: Ischaemia at the anastomotic site was the main risk factor for recurrent leakage, particularly after CAA/ISR. Additional treatment options before stoma closure should be considered to avoid re-leakage in such cases.

A case of severe stenosis of hepatic veins and inferior vena cava with stomal variceal bleeding induced by oxaliplatin-based chemotherapy.

A 27-year-old woman with colon cancer and liver metastasis was referred to our hospital. Colectomy and colostomy were performed to improve her ileus. Following 13 sessions of oxaliplatin-based chemotherapy (OC) with mFOLFOX6 + bevacizumab, thrombocytopenia and frequent peristomal bleeding occurred. Computed tomography showed severe ascites, splenomegaly, significant collateral veins around the stoma, and severe stenosis of the hepatic veins (HV) and inferior vena cava (IVC). Ultrasound elastography showed high liver (and spleen) stiffness values. Repeated OC appeared to cause IVC stenosis as a result of worsening sinusoidal obstruction syndrome (SOS), and peristomal variceal bleeding. After ultrasound-guided percutaneous embolization, bleeding did not recur. Unfortunately, the patient died of liver dysfunction caused by severe SOS. The incidence of OC-induced SOS is reported to be about 50%; however, there is apparently no report of OC-induced HV and IVC stenosis, and in most cases, portal hypertension is improved after OC cessation. This is the first report of OC-induced severe HV and IVC stenosis resulting in refractory peristomal variceal bleeding and eventual death.

Precision real-time evaluation of bowel perfusion: accuracy of confocal endomicroscopy assessment of stoma in a controlled hemorrhagic shock model.

BACKGROUND AND AIMS: Confocal laser endomicroscopy (CLE) can provide real-time evaluation of bowel perfusion. We aimed to evaluate CLE perfusion imaging in a hemorrhagic shock model. MATERIALS AND METHODS: Five pigs were equipped to ensure hemodynamic monitoring. Three ileostomies per animal (total n = 15) were randomly created (T0). Blood was withdrawn targeting a mean arterial pressure of 40 mmHg (shock phase, T1), for 90 min. Infusion of Ringer's lactate was started and continued for 90 min (T2). At the different time points: (a) stomas' mucosa was scanned with CLE; (b) capillary lactates were measured on blood obtained by puncturing stomas' mucosa; and (c) full-thickness stomas' biopsies were sampled for histology, mitochondrial respiratory rate (V 0 = basal and V ADP = respiratory rate in excess of adenosine diphosphate), and levels of superoxide anion evaluation. Functional capillary density (FCD) was measured using ad hoc software. RESULTS: Confocal scanning provided consistent and specific imaging of bowel hypoperfusion at T1: vascular hyperpermeability (blurred and enlarged capillaries) and edema (enhanced visualization of the brush border due to increased intercellular spaces and fluorescein leakage). At the end of T2, there was an improved capillary flow. FCD-A index expressed statistically significant correlation with (1) stoma capillary lactates (p = 0.023); (2) systemic capillary lactates (p = 0.031); (3) inflammation pathology score (p = 0.048); (4) central venous pressure (p = 0.0043); and (5) pulmonary artery pressure (p = 0.01). Stoma capillary lactates (mmol/L) were significantly increased at T1 (8.81 ± 4.23; p < 0.0001) and at T2 (4.77 ± 3.13; p < 0.01) when compared to T0 inclusion values (1.86 ± 0.56). V 0 and V ADP (pmol O2/min/mg tissue) were both significantly decreased at T1 versus T0 (p < 0.007 and p < 0.01, respectively) and recovered by the end of reanimation (T2 vs. T0, p = n.s.). Mean O 2·- production (µmol/min/mg/dry tissue) increased at T1 and significantly decreased at T2. CONCLUSIONS: Confocal laser endomicroscopy (CLE) imaging could identify morphological signs congruent with biochemical markers of bowel perfusion and could be useful for assessment of stomas.

Ectopic variceal bleeding from colonic stoma: two case reports.

Parastomal variceal bleeding is a rare complication of portal hypertension, which often occurs in a recurrent manner and might be life-threatening in extreme situations. Treatment options vary, and no standard therapy has been established. Herein, we report 2 such cases. The first patient suffered from parastomal variceal bleeding after Hartmann procedure for rectal cancer. Stomal revision was performed, but bleeding recurred 1 month later. The second patient developed the disease after Miles procedure for rectal cancer. Embolization via the percutaneous transhepatic approach was performed using the Onyx liquid embolic system (LES) (Micro Therapeutics Inc, dba ev3 Neurovascular) in combination with coils, and satisfactory results were obtained after a 4-month follow-up. Our cases illustrate that surgical revision should be used with caution as a temporary solution due to the high risk of rebleeding, whereas transhepatic embolization via the Onyx LES and coils could be considered a safe and effective choice for skillful managers.

The role of minimally invasive percutaneous embolisation technique in the management of bleeding stomal varices.

INTRODUCTION: Stomal varices can develop in patients with ostomy in the setting of portal hypertension. Bleeding from the stomal varices is uncommon, but the consequences can be disastrous. Haemorrhage control measures that have been described in the literature include pressure dressings, stomal revision, mucocutaneous disconnection, variceal suture ligation and sclerotherapy. These methods may only serve to temporise the stomal bleeding and have a high risk of recurrent bleed. While transjugular intrahepatic porto-systemic shunting has been advocated as the treatment of choice in patients with underlying liver cirrhosis, histoacryl glue or coil embolisation has been successfully employed in patients who are not suitable candidates for TIPS. METHODS AND RESULTS: Direct percutaneous embolisation of the dominant varices was performed successfully under ultrasound and fluoroscopic guidance in two patients using a combination of coils and histoacryl glue. RESULTS: While transjugular intrahepatic porto-systemic shunting has been advocated as the treatment of choice in patients with underlying liver cirrhosis, histoacryl glue or coil embolisation has been successfully employed in patients who are not suitable candidates for TIPS. CONCLUSION: Direct percutaneous embolisation is a safe and effective treatment for stomal varices in selected patients.

Video. Surgical optimisation of the gastric conduit for minimally invasive oesophagectomy.

BACKGROUND: Total minimally invasive oesophagectomy (MIO) is a valid alternative to open surgery for the management of oesophagogastric cancer and may lead to a more rapid restoration of health-related quality of life post surgery. However, a high incidence of gastric conduit failure (GCF) has also been observed which could be detrimental to any potential benefits of this approach. Technical modifications have been introduced in an attempt to reduce conduit morbidity, and the aim of this study was to evaluate their efficacy. METHODS: Minimally invasive oesophagectomy has been the procedure of choice in our unit since April 2004. Data on patient and surgical variables are entered onto a prospective database. Laparoscopic ischaemic conditioning (LIC) by ligation of the left gastric vessels 2 weeks prior to MIO was introduced in April 2006. Extracorporeal formation of the gastric conduit through a minilaparotomy was offered to patients since January 2008. Where present, GCF was characterised as one of three types: I, simple anastomotic leak; II, conduit tip necrosis; and III, whole conduit necrosis. RESULTS: As of January 2010, 131 patients had undergone an MIO and GCF was observed in 21 patients (16.0%). Sixty-seven patients had LIC and 9 of them (13.4%) developed GCF (I, 10.4%; II, 0%; III, 3.0%) compared to 12 (18.8%) of 64 patients who did not have LIC (I, 6.3%; II, 7.8%; III, 4.7%). A total of 43 patients had an extracorporeally fashioned conduit and 6 (14.0%) developed GCF (I, 11.6%; II, 0%; III, 2.3%), whilst 88 had an intracorporeal conduit with 15 (17.0%) developing GCF (I, 6.8%; II, 5.7%; III, 4.5%). GCF can be reduced with the incorporation of LIC and an extracorporeally fashioned conduit, with possible elimination of type II conduit tip necrosis. CONCLUSIONS: Surgical modification of a three-stage minimally invasive oesophagectomy technique, with the further incorporation of laparoscopic ischaemic conditioning and extracorporeal conduit formation, reduces gastric conduit morbidity, allowing the potential benefits of this approach to be realised.

[Comparative observation of microcirculation and tissue healing process in gastrointestinal anastomosis with apposition or inverted suturing].

OBJECTIVE: To compare microcirculation and tissue healing process in gastrointestinal anastomosis with apposition or inverted suture. METHODS: The study was performed in adult rabbits. Animals were randomly assigned to two groups. In group A, small intestine was transected at 20 cm and 40 cm from duodenojejunal ligament and apposition sutures were performed at 20 cm and inverted sutures at 40 cm. In group B, transaction and anastomosis were at the same location with group A while the suturing method was reversed. Anastomotic microcirculation and number of capillary were observed in vivo with naked eyes to evaluate inflammatory response, collagen proliferation and healing of epithelium and smooth muscle in both groups at postoperative day 3, 7, 14 and 28. RESULTS: In group A, tissue layers at the anastomosis were approximated tight and neat with mild inflammation and primary wound healing. In group B, displacement and poor alignment of layers were seen with severe inflammation and secondary wound healing. Low frequency of microcirculation was detected in group A at day 3, and blood flow velocity significantly increased at day 7. Blood flow velocity was close to normal at day 14 and completely restored to the normal level at day 28. Microcirculation was lower in group A than that in group B at each time point. There were more capillaries, lower number of inflammatory cells, less collagen proliferation, and better healing of anastomotic epithelium and smooth muscle in group A than group B. CONCLUSION: Apposition suturing is better than inverted suturing in restoring local anastomotic microcirculation and healing of intestinal tissues.

Direct percutaneous approach for endoluminal glue embolization of stomal varices.

The present report describes the authors' experience with direct endoluminal embolization for bleeding stomal varices. Between December 1998 and July 2006, seven patients with enterostomies, portal hypertension, and recurrent stomal variceal bleeding resistant to medical treatment were treated at a single institution. Ultrasonography was used to guide direct puncture of the varices. Direct endoluminal embolization with cyanoacrylate glue was performed under fluoroscopic control imaging. Embolization was successful in six of seven cases. One patient with hepatocellular carcinoma and complete portal thrombosis had three recurrences treated with the same technique, with clinical success. Three patients died at 3, 8, and 18 months without recurrence of bleeding. Although further evaluation is indicated, direct percutaneous embolization appears to be a potential alternative treatment for bleeding stomal varices.

[Stomal varices treated by glue embolization]. / Embolisation de varices stomiales par injection percutanée de colle biologique.

In patients with cirrhosis and enterostomy, although bleeding stomal varices are rare, they can been severe and difficult to be treat. We report the first two cases of bleeding stomal varices treated by cyanoacrylate embolization, in patients with cirrhosis and colostomy. In each case, after pharmacological treatment of portal hypertension (propranolol) failed, embolization of the stomal varices by transdermal injection of biological glue effectively stopped the bleeding, without recurrence or side effects, after 8 and 16 months of follow-up. The embolization of stomal varices by biological glue is a safe, easy and efficient treatment for bleeding stomal varices.

TIPSS in the treatment of ectopic variceal bleeding.

BACKGROUND/AIMS: Bleeding from ectopic varices is a well recognized life-threatening complication of portal hypertension but the optimal treatment of this problem is yet to be established. METHODOLOGY: We retrospectively reviewed patients with ectopic variceal bleeding who underwent transjugular intrahepatic portosystemic shunting for recurrent bleeding not responding to conservative management. RESULTS: Over an eleven-year period we identified ten patients who underwent TIPSS for ectopic variceal hemorrhage. Six patients bled from rectal varices and four from stomal varices. TIPSS was successful in nine patients. The Childs-Pugh grade of the patients was A=3, B=3 and C=4. The follow-up period ranged from 7 days to 1380 days. Rebleeding occurred in three patients, two of whom died. The remaining patient had a blocked TIPSS and successfully underwent repeat stenting which re-established patency. Four patients (Childs B=2, Childs C=2) died within 60 days. All three patients with Childs A liver disease were alive at one year. CONCLUSIONS: TIPSS can be used effectively to treat ectopic variceal bleeding. Patients with Childs grade A liver disease appear to do well with TIPSS. Those with advanced liver disease (Childs B & C) have a uniformly poor outcome. In these patients ectopic variceal hemorrhage is likely to represent a terminal event.

Chronic stomal variceal bleeding after colonic surgery in patients with portal hypertension: efficacy of beta-blocking agents?

In patients with portal hypertension, ileostomy or colostomy carries the risk of the development of stomal varices at the site of the mucocutaneous junction of a stoma. Such varices are often the source of difficult-to-treat recurrent or chronic bleeding. In this setting, transjugular intrahepatic portosystemic shunt insertion and embolisation is considered the best therapeutic approach in spite of relatively high mortality and morbidity rates. We report the cases of three consecutive patients with portal hypertension of various causes and chronic stomal variceal bleeding in whom beta-blocking therapy resulted in the drying up of bleeding and the prevention of its recurrence for periods of time ranging between 2 and 42 months.

Hemorragia por varices ectópicas periostomales: una rara complicación de la hipertensión portal / Hemorrhage due to peristomal ectopic varices: an infrequent complication of portal hypertension

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