Optimization of anastomotic technique and gastric conduit perfusion with hyperspectral imaging and machine learning in an experimental model for minimally invasive esophagectomy

Nickel, Felix; Studier-Fischer, Alexander; Özdemir, Berkin; Odenthal, Jan; Müller, Lucas-Raphael; Knoedler, Samuel; Kowalewski, Karl‐Friedrich; Camplisson, Isabella; Dietrich, Maximilian; Schmidt, Karsten; Salg, Gabriel Alexander; Kenngott, Hannes; Billeter, Adrian T.; Gockel, Ines; Sagiv, C.; Hadar, O.E.; Gildenblat, J.; Ayala, Leonardo; Seidlitz, Silvia; Maier-Hein, Lena; Müller‐Stich, Beat P.

doi:10.1016/j.ejso.2023.04.007

Cited by 7 publications

(5 citation statements)

References 45 publications

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“…Therefore, optimization of conduit perfusion and maintenance of an efficient submucosal vascular network at the anastomotic site is desirable. Physiologic gastric perfusion is supported by large capillaries, distributed perpendicular to both gastric curvatures, and by small capillary branches that run parallel to both curvatures thus forming a complex vascular network 55 . Ligation of the left gastric artery, left gastroepiploic artery, and short gastric vessels determine a reorganization of this network.…”

Section: Discussionmentioning

confidence: 99%

Short-term Outcomes of Different Techniques for Gastric Ischemic Pre-Conditioning Before Esophagectomy

Aiolfi,

Bona,

Bonitta

et al. 2023

Annals of Surgery

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Background: Ischemia at the anastomotic site is a critical protagonist in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. Purpose: Compare short-term outcomes among different GIC techniques. Methods: Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference. Results: Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC vs. noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC vs. noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC vs. noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC vs. noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC vs. AngioGIC in term of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. Conclusions: Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.

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Section: Discussionmentioning

confidence: 99%

Short-term Outcomes of Different Techniques for Gastric Ischemic Pre-Conditioning Before Esophagectomy

Aiolfi,

Bona,

Bonitta

et al. 2023

Annals of Surgery

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“…Starting at the lesser curvature, the gastric conduit (GC) was created along the 56-Fr bougie using a stapling device (ENDO GIA™ equipped with 60 mm Blue Reloads, Medtronic, USA). Subsequently, the previously prepared sponge connected to a vacuum device (Invia Liberty, Medela Medizintechnik GmbH & Co. Handels KG, Eching, Germany) was placed in the gastric lumen and the tissue ischemia was induced toward the lesser curvature/staple line by disrupting the microcirculation by strong magnet compression of the tissue at the greater curvature parallel to the gastroepiploic vessels distally as previously described [ 34 ]. The incision was closed with 3–0 sutures to avoid loss of pressure during the subsequent EndoVAC therapy.…”

Section: Methodsmentioning

confidence: 99%

Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy

Felinska,

Studier-Fischer,

Özdemir

et al. 2024

Surg Endosc

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Background After esophagectomy, the postoperative rate of anastomotic leakage is up to 30% and is the main driver of postoperative morbidity. Contemporary management includes endoluminal vacuum sponge therapy (EndoVAC) with good success rates. Vacuum therapy improves tissue perfusion in superficial wounds, but this has not been shown for gastric conduits. This study aimed to assess gastric conduit perfusion with EndoVAC in a porcine model for esophagectomy. Material and methods A porcine model (n = 18) was used with gastric conduit formation and induction of ischemia at the cranial end of the gastric conduit with measurement of tissue perfusion over time. In three experimental groups EndoVAC therapy was then used in the gastric conduit (− 40, − 125, and − 200 mmHg). Changes in tissue perfusion and tissue edema were assessed using hyperspectral imaging. The study was approved by local authorities (Project License G-333/19, G-67/22). Results Induction of ischemia led to significant reduction of tissue oxygenation from 65.1 ± 2.5% to 44.7 ± 5.5% (p < 0.01). After EndoVAC therapy with − 125 mmHg a significant increase in tissue oxygenation to 61.9 ± 5.5% was seen after 60 min and stayed stable after 120 min (62.9 ± 9.4%, p < 0.01 vs tissue ischemia). A similar improvement was seen with EndoVAC therapy at − 200 mmHg. A nonsignificant increase in oxygenation levels was also seen after therapy with − 40 mmHg, from 46.3 ± 3.4% to 52.5 ± 4.3% and 53.9 ± 8.1% after 60 and 120 min respectively (p > 0.05). An increase in tissue edema was observed after 60 and 120 min of EndoVAC therapy with − 200 mmHg but not with − 40 and − 125 mmHg. Conclusions EndoVAC therapy with a pressure of − 125 mmHg significantly increased tissue perfusion of ischemic gastric conduit. With better understanding of underlying physiology the optimal use of EndoVAC therapy can be determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion. Graphical abstract

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“…They were acclimatized for 48 h in an enriched environment following circadian cycles of light and dark periods, had free access to water and were fed regularly until being starved 24 h prior to surgery. Pharmaceutical treatment and narcosis (but also other protocols such as for corrosion casting and histopathology) were performed according to institution standard as described in earlier publications 23 , 25 . Body weight adapted pharmacological calculations are generalized for a 40 kg pig.…”

Section: Methodsmentioning

confidence: 99%

“…In its basic application without ICG, HSI captures spectral fingerprints of tissue pigments and chromophores such as haemoglobin. In the past, these spectral features were shown to be highly characteristic for organ entities 23 – 25 . However, as the physiology of ICG is so unbribably intertwined with tissue perfusion, it bears the question whether ICG-augmented HSI (IA-HSI) offers diagnostic value.…”

Section: Introductionmentioning

confidence: 99%

ICG-augmented hyperspectral imaging for visualization of intestinal perfusion compared to conventional ICG fluorescence imaging: an experimental study

Studier-Fischer,

Schwab,

Rees

et al. 2023

International Journal of Surgery

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Background: Small bowel malperfusion (SBM) can cause high morbidity and severe surgical consequences. However, there is no standardized objective measuring tool for the quantification of SBM. Indocyanine green (ICG) imaging can be used for visualization, but lacks standardization and objectivity. Hyperspectral imaging (HSI) as a newly emerging technology in medicine might present advantages over conventional ICG fluorescence or in combination with it. Methods: HSI baseline data from physiological small bowel, avascular small bowel and small bowel after intravenous application of ICG was recorded in a total number of 54 in-vivo pig models. Visualizations of avascular small bowel after mesotomy were compared between HSI only (1), ICG-augmented HSI (IA-HSI) (2), clinical evaluation through the eyes of the surgeon (3) and conventional ICG-imaging (4). The primary research focus was the localization of resection borders as suggested by each of the 4 methods. Distances between these borders were measured and histological samples were obtained from the regions in between in order to quantify necrotic changes 6 hours after mesotomy for every region. Results: StO2 images (1) were capable of visualizing areas of physiological perfusion and areas of clearly impaired perfusion. However, exact borders where physiological perfusion started to decrease could not be clearly identified. Instead, IA-HSI (2) suggested a sharp resection line where StO2 values started to decrease. Clinical evaluation (3) suggested a resection line 23 mm (±7 mm) and conventional ICG-imaging (4) even suggested a resection line 53 mm (±13 mm) closer towards the malperfused region. Histopathological evaluation of the region that was sufficiently perfused only according to conventional ICG (R3) already revealed a significant increase in pre-necrotic changes in 27% (±9%) of surface area. Therefore, conventional ICG seems less sensitive than IA-HSI with regards to detection of insufficient tissue perfusion. Conclusions: In this experimental animal study, IA-HSI (2) was superior for the visualization of segmental SBM compared to conventional HSI imaging (1), clinical evaluation (3) or conventional ICG imaging (4) regarding histopathological safety. ICG application caused visual artifacts in the StO2 values of the HSI camera as values significantly increase. This is caused by optical properties of systemic ICG and does not resemble a true increase in oxygenation levels. However, this empirical finding can be used to visualize segmental SBM utilizing ICG as contrast agent in an approach for IA-HSI. Clinical applicability and relevance will have to be explored in clinical trials. Level of Evidence: Not applicable. Translational animal science. Original article.

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Optimization of anastomotic technique and gastric conduit perfusion with hyperspectral imaging and machine learning in an experimental model for minimally invasive esophagectomy

Cited by 7 publications

References 45 publications

Short-term Outcomes of Different Techniques for Gastric Ischemic Pre-Conditioning Before Esophagectomy

Short-term Outcomes of Different Techniques for Gastric Ischemic Pre-Conditioning Before Esophagectomy

Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy

ICG-augmented hyperspectral imaging for visualization of intestinal perfusion compared to conventional ICG fluorescence imaging: an experimental study

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