| Objective: Blood supply is the key factor in the healing of anastomoses after rectal cancer surgery,and microcirculation is an intuitive manifestation of tissue blood supply.However,there is no quantitative and convenient way to detect microcirculation.We apply the Sidestream dark field imaging technology to laparoscopic anterior rectal resection,and aims to(1)explore the correlation between the microcirculation parameters in the Sidestream dark field imaging technique and the postoperative anastomotic fistula and evaluate the feasibility of its application in laparoscopic anterior rectal resection.(2)Using Sidestream dark field imaging technology to identify the changes in the Colonic microcirculation after Mesangectomy;(3)Using Sidestream dark field imaging technology to determine whether the preservation of the left colon artery affects the microcirculation of the Mesangial margin and anastomotic stump during rectal surgery.Methods: Patients who underwent laparoscopic radical rectal cancer surgery from January 2019 to December 2020 in Gastrointestinal Surgery of Sichuan Provincial People’s Hospital were selected according to clear inclusion and exclusion criteria as the research subjects.(1)Serous membrane microcirculation state of the contralateral mesangium was measured by the Sidestream dark field imaging device(Microsee V100 sublingual microcirculation imaging system)at the 15 cm proximal to the end of the mesangium,the mesangial edge and the 1,2cm distal to the end of the mesangium.(2)The microcirculation state of the edge of the anastomosis was measured by Sidestream dark field imaging device after embedding the anastomosis nail anvil and determine the edge of the anastomosis.(3)Relevant patient clinical data(gender,age,BMI,HGB,underlying disease,tumor location,tumor stage),intraoperative data(operation time,measurement time,intraoperative blood loss,preventive ileostomy,preservation of left colon)and Postoperative complication data(anastomotic leakage,postoperative bleeding,anastomotic stenosis,abdominal infection,lung infection,subcutaneous emphysema,incision infection)was collected.(4)Analyze the state of microcirculation and determine the parameters of microcirculation[Microvascular fow index(MFI),Proportion of perfused vessels(PPV),Perfused vessel density(PVD),Total vessel density(TVD)].(5)We compare the changes of microcirculation parameters in different parts,contrast the microcirculation parameters relationship between preservation and resection of left colon artery at the mesangial margin or anastomosis,analyze the microcirculation parameters correlation of postoperative anastomotic leakage patients and evaluate the application feasibility in Sidestream dark field imaging technology.Results:(1)A total of 33 patients including 22 males and 11 females were enrolled.All patients successfully completed the operation and obtained stable microcirculation images,The average age of the patients was(62.0±10.7)years and the average BMI was(23.5±2.7)kg/m2.The average preoperative hemoglobin was(125.2±18.8)g/L.There were 10 cases of stage I,10 cases of stage II,11 cases of stage III,and 2 cases of stage IV.The tumor was located in the upper segment in 13 cases,in the middle segment in 12 cases,and in the lower segment in 8 cases.The average intraoperative measurement time was(5.6±0.9)min,and the average operation time was(255.0±71.9)min.Intraoperative bleeding(80.0±57.3)ml.Eleven patients retained the left colon artery,and 10 patients underwent intraoperative preventive fistula.A total of 3 cases of anastomotic leakage occurred,3 cases had abdominal cavity infection after operation,and 5 cases had delayed incision healing.Three patients had subcutaneous emphysema,no anastomotic stenosis or bleeding,no lung infection or intestinal obstruction.Compared with the normal colon,the microcirculation parameters(MFI(1.528±0.394 vs 2.976±0.135),PPV((56.68±16.11 vs 100.00±0.00)%),PVD((6.67±2.08 vs 11.82±1.62)mm/mm2)at anastomosis decreased significantly(P<0.05).However,the difference in TVD((11.80±1.37 vs 11.82±1.62)mm/mm2)was not statistically significant(P=0.964).A total of three cases of anastomotic leakage occurred.The microcirculation parameters(MFI(0.667;0.889;0.982),PPV(0.00;36.20;45.70(%))and PVD((0.00;4.47;5.04)mm/mm2))of the three patients were lower when Compared with patients without anastomotic leakage(MFI(1.667(1.444,1.889));PPV(62.40(54.80,68.20))%;PVD(7.13(6.15,8.79))mm/mm2),the difference was statistically significant Significance(P<0.01).The difference in TVD(11.64(6.15,8.79)vs 13.50(9.77,13.91))mm/mm2 was not statistically significant(P=0.576).(2)In the microcirculation parameters,For MFI,PPV and PVD,the perfusion value of the microcirculation at the normal descending colon,mesangial margin,1cm and 2cm at the distal end decreased sequentially(P trend<0.01).For TVD,the value at 2 cm distal to the mesangium increased significantly,and the value at 1 cm distal to the mesangium also increased(P trend <0.01).For the intestinal tube at the distal 2 cm,the microcirculation perfusion parameters(MFI,PPV,PVD)were significantly lower than those of the normal intestine [MFI(0.213±0.190 vs 2.976±0.135),PPV(2.38±3.75 vs100.00±0.00)%,PVD(0.32±0.52 vs 11.82±1.62)mm/mm2].The blood supply state is almost completely ischemic.(3)After grouping whether to keep the left colon artery,it was found that the central venous pressure of the patients in the reserved group was higher than that in the non-reserved group(P=0.039).There was no statistically significant difference between the other clinical data(P>0.05).For the unreserved group,the mesangial margin and the anastomotic microcirculation parameters were higher in MFI,PPV and PVD,and the difference was statistically significant(P<0.05).While for TVD of the mesangial margin and anastomoses,there was no statistically significant difference between the two groups(P>0.05).Conclusion: Sidestream dark field imaging technology can accurately identify the microcirculation state around the anastomosis.The microcirculation indicators(MFI,PPV,PVD)near the anastomosis are significantly lower than the normal descending colon tissue,but there is no significant difference between the TVD.The microcirculation parameters(MFI,PPV and PVD)of the anastomotic leakage in patients with anastomotic leakage were significantly lower than those in the non-occurring patients,but there was no significant difference in TVD.It shows that functional capillaries rather than total blood vessel density are important factors affecting the healing of anastomoses.For the proximal intestinal tube of the anastomosis during laparoscopic anterior rectal resection,the microcirculation tends to decrease sharply after the mesangial blood supply is lost,and the state of perfusion is almost present at the 2cm distal end of the mesangial margin;For those who have not preserved the left colon artery,the preservation of the left colon artery can increase the blood supply of the mesangial margin microcirculation,and the selective preservation of the left colon artery may reduce the occurrence of postoperative anastomotic leakage to a certain extent.The application of Sidestream dark field imaging technology in laparoscopic anterior rectal resection has the advantages of convenience,simplicity,non-invasiveness,and strong reproducibility.It can sensitively measure the subtle changes of the colonic intestine serous microcirculation in different positions.It does not increase the occurrence of postoperative complications.The application of this technology may reduce the incidence of postoperative anastomotic leakage.So it is worthy of clinical promotion and application!... |
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