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Annals of Surgery:
doi: 10.1097/SLA.0b013e31828d4ab3
Original Articles

Enhanced-Reality Video Fluorescence: A Real-Time Assessment of Intestinal Viability

Diana, Michele MD*,¶; Noll, Eric MD; Diemunsch, Pierre MD, PhD; Dallemagne, Bernard MD*; Benahmed, Malika A. PhD; Agnus, Vincent PhD*; Soler, Luc PhD*; Barry, Brian MD, FRCSI*; Namer, Izzie Jacques MD; Demartines, Nicolas MD, FACS; Charles, Anne-Laure PhD§; Geny, Bernard MD, PhD§; Marescaux, Jacques MD, FACS, (Hon) FRCS, (Hon) FJSES*

Supplemental Author Material
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Abstract

Objective: Our aim was to evaluate a fluorescence-based enhanced-reality system to assess intestinal viability in a laparoscopic mesenteric ischemia model.

Materials and Methods: A small bowel loop was exposed, and 3 to 4 mesenteric vessels were clipped in 6 pigs. Indocyanine green (ICG) was administered intravenously 15 minutes later. The bowel was illuminated with an incoherent light source laparoscope (D-light-P, KarlStorz). The ICG fluorescence signal was analyzed with Ad Hoc imaging software (VR-RENDER), which provides a digital perfusion cartography that was superimposed to the intraoperative laparoscopic image [augmented reality (AR) synthesis]. Five regions of interest (ROIs) were marked under AR guidance (1, 2a-2b, 3a-3b corresponding to the ischemic, marginal, and vascularized zones, respectively). One hour later, capillary blood samples were obtained by puncturing the bowel serosa at the identified ROIs and lactates were measured using the EDGE analyzer. A surgical biopsy of each intestinal ROI was sent for mitochondrial respiratory rate assessment and for metabolites quantification.

Results: Mean capillary lactate levels were 3.98 (SD = 1.91) versus 1.05 (SD = 0.46) versus 0.74 (SD = 0.34) mmol/L at ROI 1 versus 2a-2b (P = 0.0001) versus 3a-3b (P = 0.0001), respectively. Mean maximal mitochondrial respiratory rate was 104.4 (±21.58) pmolO2/second/mg at the ROI 1 versus 191.1 ± 14.48 (2b, P = 0.03) versus 180.4 ± 16.71 (3a, P = 0.02) versus 199.2 ± 25.21 (3b, P = 0.02). Alanine, choline, ethanolamine, glucose, lactate, myoinositol, phosphocholine, sylloinositol, and valine showed statistically significant different concentrations between ischemic and nonischemic segments.

Conclusions: Fluorescence-based AR may effectively detect the boundary between the ischemic and the vascularized zones in this experimental model.

© 2014 by Lippincott Williams & Wilkins.

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