Laser speckle contrast imaging identifies ischemic areas on gastric tube reconstructions following esophagectomy

Dan M J Milstein, Can Ince, Suzanne S Gisbertz, Kofi B Boateng, Bart F Geerts, Markus W Hollmann, Mark I van Berge Henegouwen, Denise P Veelo, Dan M J Milstein, Can Ince, Suzanne S Gisbertz, Kofi B Boateng, Bart F Geerts, Markus W Hollmann, Mark I van Berge Henegouwen, Denise P Veelo

Abstract

Gastric tube reconstruction (GTR) is a high-risk surgical procedure with substantial perioperative morbidity. Compromised arterial blood supply and venous congestion are believed to be the main etiologic factors associated with early and late anastomotic complications. Identifying low blood perfusion areas may provide information on the risks of future anastomotic leakage and could be essential for improving surgical techniques. The aim of this study was to generate a method for gastric microvascular perfusion analysis using laser speckle contrast imaging (LSCI) and to test the hypothesis that LSCI is able to identify ischemic regions on GTRs.Patients requiring elective laparoscopy-assisted GTR participated in this single-center observational investigation. A method for intraoperative evaluation of blood perfusion and postoperative analysis was generated and validated for reproducibility. Laser speckle measurements were performed at 3 different time pointes, baseline (devascularized) stomach (T0), after GTR (T1), and GTR at 20° reverse Trendelenburg (T2).Blood perfusion analysis inter-rater reliability was high, with intraclass correlation coefficients for each time point approximating 1 (P < 0.0001). Baseline (T0) and GTR (T1) mean blood perfusion profiles were highest at the base of the stomach and then progressively declined towards significant ischemia at the most cranial point or anastomotic tip (P < 0.01). After GTR, a statistically significant improvement in mean blood perfusion was observed in the cranial gastric regions of interest (P < 0.05). A generalized significant decrease in mean blood perfusion was observed across all GTR regions of interest during 20° reverse Trendelenburg (P < 0.05).It was feasible to implement LSCI intraoperatively to produce blood perfusion assessments on intact and reconstructed whole stomachs. The analytical design presented in this study resulted in good reproducibility of gastric perfusion measurements between different investigators. LSCI provides spatial and temporal information on the location of adequate tissue perfusion and may thus be an important aid in optimizing surgical and anesthesiological procedures for strategically selecting anastomotic site in patients undergoing esophagectomy with GTR.

Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Frames obtained intraoperatively illustrating photo images (top row) of both the intact stomach and gastric tube reconstruction (GTR) analysis methodology with the targeted regions of interest. A matching sequence of typical laser speckle flux images (bottom row) is presented corresponding with the measurements of intact stomach (T0), after GTR (T1), and 20° reverse Trendelenburg GTR (T2).
Figure 2
Figure 2
ICC (A) and Bland–Altman (B) analyses for all speckle datasets (i.e., T0, T1, and T2) between investigators 1 and 2. ICC = intraclass correlation coefficient.
Figure 3
Figure 3
Graph summarizing 2-way ANOVA results of time points (T0, T1, and T2) for each region of interest (ROI) with laser speckle perfusion unit (LSPU) (flux data). ANOVA = analysis of variance.
Figure 4
Figure 4
Supplementary intraoperative data from 1 patient illustrating the effects of administering ephedrine for treating low blood pressure on the most ischemic regions of the gastric tube during 20° reverse Trendelenburg. Flux perfusion measured by LSCI increased significantly from before (A) to after administering ephedrine (B) across all regions of interest (C), extending from the watershed towards the cranial (fundus) anastomotic tip. LSCI = laser speckle contract imaging.

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