| Objective:Sufficient blood supply of anastomotic stoma is an important factor to prevent postoperative anastomotic leakage.At present,indocyanine green fluorescence imaging has shown a good application prospect,but it can only judge the good blood supply qualitatively,but not quantitatively.In this study,sidestream dark field imaging technology is applied to indocyanine green fluorescence laparoscopic anterior resection of rectal cancer,aiming at(1)quantitative detection of the ischemic line and its surrounding intestinal microcirculation by sidestream dark field imaging under indocyanine green imaging;(2)on the basis of indocyanine green fluorescence imaging,the accuracy of sidestream dark field imaging in measuring intestinal microcirculation is investigated(3)to discuss the feasibility of applying sidestream dark field imaging technique in anterior resection of rectal cancer.Methods:In accordance with the inclusion and exclusion criteria,the patients who underwent laparoscopic anterior resection of rectal cancer in our hospital were screened from December 2020 to January 2022.All patients underwent anterior resection of rectal cancer with indocyanine green(ICG)fluorescence imaging laparoscopic system:(1)When the operation goes to extraabdominal operation,confirm the location of the tumor,expose the periintestinal mesangium at the expected resection site near the tumor,and inject 3 ml ICG(concentration:2.5mg/ml)solution into the central vein,and observe it in the dark room for at least 30-60seconds to determine the location of the ischemic line,that is,the place where the intestinal tube breaks off;(2)Using sidestream dark field imaging equipment(SDF)to measure the microcirculation data of the ischemic line and 1 cm distal and proximal to the ischemic line under ICG imaging.Collect the microcirculation data measured by SDF at the edge 1cm(at the anastomosis)after the stapler nail seat is buried.After anal anastomosis in all patients,3 ml of ICG solution was injected again to evaluate the blood supply of the anastomotic stoma after anastomosis.;(3)Relevant patient clinical data(gender,age,BMI,preoperative ALB,preoperative HGB,tumor location,tumor stage,smoking and drinking,etc.),Intraoperative information(operation time,intraoperative bleeding,SDF measurement time,etc.)and postoperative observation index(anastomotic leakage,anastomotic bleeding,abdominal infection,incision infection,pulmonary infection,etc.)were collected.(4)The microvascular blood flow index(MFI),perfusion vessel ratio(PPV),perfusion vessel density(PVD)and total vessel density(TVD)data were obtained by analyzing the microcirculation of the ischemic line and its surrounding intestinal microcirculation under sidestream dark-field imaging.The he dates of the microcirculation of the anastomotic site also can be getted.(5)Image J software was used to analyze the gray value of ischemic line under indocyanine green development,and the percentage of intestinal perfusion was obtained.The percentage of microcirculation at ischemic line under sidestream dark field imaging technology was calculated,and the difference of intestinal perfusion between the two devices was compared.Results:According to the inclusion and exclusion criteria,a total of 29patients were included in the study,all patients successfully completed the operation,indocyanine green was successfully visualied,and microcirculation data collection was stable.Male patients are slightly higher than female patients(17:12).The average age of patients is(61.2±13)years,the average BMI was(23.0±5.0)kg/m2,the preoperative albumin was(39.0±3.4)g/L,and the preoperative hemoglobin was(128±18)g/L.The tumors is located in upper segment in 16 cases,middle segment in 7 cases and lower segment in 6 cases.There were 12 patients in stage I,8 patients in stage II,7 patients in stage III and 2 patients in stage IV.The preoperative ASA grading mainly focused on Grade II(24cases).There were 14 patients with drinking history and 9 patients with smoking history.The average operation time was(244.62±66.95)min,intraoperative bleeding was(81.38±46.35)ml,and the average measurement time of SDF was(5.47±1.67)min.One patient had anastomotic leakage after operation,and underwent surgical fistula again,and was discharged smoothly after operation.In all patients,the position of the ischemia line was displayed by intraoperative fluorescence,and the distance from the mesenteric border to the ischemia line was recorded.The median distance of good bowel perfusion was 1 cm at the distal of the mesangial border(range(-12)cm to(5)cm),of which two The ultra-long-distance imaging of the patients was found at 4cm and 12cm at the proximal of the mesangial border,and the SDF measurement also proved that there was indeed no obvious blood flow in the visual area.The infection of abdominal cavity,postoperative intestinal obstruction and unplanned reoperation occurred in one patient each and have 5 cases of incision infection,3 cases of pulmonary infection.Compare the microcirculation data of around ischemic line under ICG imaging measured by SDF.Comparing the microcirculation data between the ischemic line and 1 cm proximal to the ischemic line(MFI:2.04±0.74vs2.65±0.45P<0.01;PPV:((75.68±25.50vs87.83±20.28)%)P<0.05;PVD:((10.12±3.85vs12.91±3.71)mm/mm~2)P=0.07;TVD:((13.33±2.56vs14.49±3.83)mm/mm~2)P=0.183),the difference between MFI and PPV was statistically significant,the difference between PVD and TVD was not statistically significant.Comparing the microcirculation data between the ischemic line and 1cm distal to the ischemic line(MFI:2.04±0.74vs0.18±0.27;PPV:((75.68±25.50vs8.07±14.05)%);PVD:((10.12±3.85vs1.03±1.73)mm/mm2);TVD:((13.33±2.56vs15.59±3.03)mm/mm2),P<0.05,the difference was statistically significant.Comparing the microcirculation data between the ischemic line and around the stapler nailseat(MFI:2.04±0.74vs2.33±0.57,PPV:((75.68±25.50vs85.57±20.25)%);PVD:((10.12±3.85vs12.20±4.05mm/mm~2));TVD:((13.33±2.56vs14.11±2.97mm/mm~2),P>0.05,thedifferencewasnotstatistically significant.Comparing the data of intestinal blood supply under ICG imaging with the data of microcirculation under SDF,the ischemic line((66.44 13.75 vs 67.87 24.77)%)and the proximal 1cm of the ischemic line((90.89 5.82 vs 88.36 14.91)%),P>0.05,there was no significant difference between the two groups.Conclusion:(1)By measuring the microcirculation(MFI,PPV,PVD,TVD)of the ischemic line and the proximal and distal parts of the ischemic line under indocyanine green development by sidestream dark field imaging technology,it was found that the microcirculation of intestinal canal at the ischemic line was lower than that at the proximal part of the ischemic line 1cm,but it was difficult to identify with naked eyes under indocyanine green development.(2)The quantitative evaluation of intestinal microcirculation by sidestream dark field imaging is basically consistent with that by indocyanine green fluorescence imaging,and the accuracy of sidestream dark field imaging is preliminarily verified.(3)In laparoscopic anterior resection of rectal cancer,sidestream dark-field imaging technology is a promising,noninvasive,visual,repeatable and quantitative method to evaluate intestinal microcirculation,and it is simple to operate,convenient to move,low in cost,without affecting the operation and related postoperative complications.It can help surgeons to evaluate the intestinal blood perfusion of patients during the operation and provide important reference value for surgical decision-making. |
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