EP393 - Laparoscopic and Endoscopic Perfusion Monitoring in Colorectal Anastomoses

ePoster Presenter(s)

• 

  Alexis Peters, MD

  Resident Physician
  University of Southern California/Los Angeles General Medical Center
  University of Southern California/Los Angeles General Medical Center
  Los Angeles, CA, United States

  Disclosure information not submitted.

Author(s)

• 

  Anthony Lim, MD

  Resident Physician
  University of Southern California/Los Angeles General Medical Center
  Los Angeles, California, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Aubrey Swinford, MD

  Research Fellow
  Keck Medicine of USC
  University of Southern California
  South Pasadena, CA, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• 

  Jordan Martucci, MD

  Resident
  University of Southern California/ Los Angeles General
  Keck Hospital of USC/ Los Angeles General Medical Center
  Los Angeles, CA, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.
• AG

  Abhinav Gupta, MD

  General Surgery Resident
  University of Southern California
  Los Angeles, California, United States

  Disclosure information not submitted.
• 

  Brian N. Williams, MD

  Surgery Resident
  University of Southern California
  University of Southern California
  Los Angeles, California, United States

  Disclosure information not submitted.
• 

  Kyle G. Cologne, MD

  Professor of Surgery
  Keck School of Medicine of the University of Southern California
  Keck School of Medicine of the University of Southern California
  Los Angeles, California, United States

  Disclosure information not submitted.
• JS

  Joongho Shin, MD

  Clinical Associate Professor
  Keck Medicine of USC
  Pasadena, California, United States

  Disclosure information not submitted.
• MD

  Marjun Philip Duldulao, MD

  Los Angles, CA

  Disclosure information not submitted.
• CH

  Christine Hsieh, MD

  Assistant Professor of Clinical Surgery
  Keck School of Medicine, University of Southern California
  Los Angeles, California, United States

  Disclosure information not submitted.
• SB

  Sacha Broccard, MD

  Assistant Professor of Clinical Surgery
  University of Southern California
  Los Angeles, California, United States

  Disclosure information not submitted.
• 

  Sarah Choi, MD, MS

  Colorectal Surgeon, Assistant Professor of Clinical Surgery
  Keck Medicine of USC (University of Southern California)
  Los Angeles, California, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no financial relationships with ineligible companies.

Senior Author(s)

• 

  Sang W. Lee, MD

  Professor and Chief of Colon and Rectal Surgery
  Keck School of Medicine of USC
  Los Angeles, California, United States

  Disclosure information not submitted.

Purpose/Background: Thorough evaluation of colorectal anastomoses using white light endoscopy and leak testing is critical. Indocyanine green fluorescence angiography has emerged as a tool to assess bowel perfusion but has limitations, including allergies, lack of dosage standardization, and subjective evaluation. The FUJIFILM ELUXEO® VISION System allows for visualization of tissue oxygenation saturation (StO2) on both laparoscopic and endoscopic platforms, without requiring dye injection. This system uses multispectral illuminations and absorption properties of oxy- and deoxyhemoglobin to determine StO2 measurements and creates a superimposed perfusion map. We looked to investigate this approach in an effort to establish standardized, objective data on perfusion at colon anastomoses.

Methods/Interventions: This prospective cohort study involved patients undergoing surgeries involving a colorectal anastomosis. Intraoperatively, the serosa at the proximal end of the anastomosis (laparoscopic camera mode) and the mucosa at the proximal and distal ends of the anastomosis (endoscopic camera mode) were assessed with the StO2 maps generated by the FUJIFILM ELUXEO® VISION System. Numeric StO2 values were calculated from postoperative analysis of the StO2 maps using proprietary Fujifilm software. The average StO2 of four points was used for analysis. Patients were followed prospectively via chart review to collect information on clinical outcomes. Independent samples t-tests were used to compare StO2 measurements in SPSS.

Results/Outcomes: 52 patients were included in our study. Most common surgeries were sigmoidectomy (55.8%), low anterior resection (28.8%), and Hartmann's reversal (13.5%). The surgical approach was laparoscopic in 71.2% of cases, robotic-assisted laparoscopic in 21.2%, and open in 7.7%. The addition of saturation imaging changed the surgical plan in 3 cases, who went on to have uncomplicated post-operative courses. In response to the poor StO2 maps, the first case had anastomotic takedown and with resection and reanastomosis, the second had resection of additional colon prior to anastomosis, and the third had creation of diverting loop ileostomy to protect the anastomosis. 37 sets of measurements (11.86%) were excluded from final analysis due to failure of data collection (n = 23) or environmental interference (n = 14). The anastomotic leak rate was 3.85% (n = 2). One leak had satisfactory StO2 levels, while the other had poor StO2 levels. There was a statistically significant difference between the StO2 levels at the proximal mucosal surface in the anastomosis of the first patient who developed an anastomotic leak and the patients without leaks (proximal base 48.0% vs. 68.6%, p = 0.047; proximal staple line 31.0% vs. 58.9%, p = 0.021).

Conclusion/Discussion: Intraoperative tissue oxygen saturation monitoring using the FUJIFILM ELUXEO® VISION System serves as a useful adjunct to the standard subjective evaluation of colorectal anastomoses. Our experience suggests that using the StO2 assessment, with emphasis on the proximal portion of the anastomosis, to determine the need for revision of an otherwise well-appearing anastomosis may help to decrease the rate of anastomotic leaks. Limitations of this technology include post-operative StO2 analysis and environmental interference with readings. Currently, software is in development to provide StO2 values in real time.

Figure 1.
Intraoperative endoscopic white light images (left) with superimposed StO2 maps (right) of patients who did not (A) and who did (B) develop post-operative anastomotic leak using FUJIFILM ELUXEO® VISION System. Proximal staple line StO2 values depicted.
Table 1.
Intra-operative and post-operative outcomes for study cohort.