Preclinical feasibility of bronchoscopic fluorescence-guided lung sentinel lymph node mapping

ObjectiveLung sentinel lymph node mapping, where peritumorally injected material is tracked through the lymphatics, aims to find the first potential sites of nodal metastasis. We sought to evaluate the preclinical feasibility of bronchoscopic fluorescence-guided sentinel lymph node mapping.MethodsHealthy Yorkshire pigs were used; sentinel lymph node mapping was performed with indocyanine green. The primary fluorescence imaging method was an ultrathin composite fiberscope placed in the bronchoscope working channel. Secondary methods used a fluorescence thoracoscope placed in the trachea (rigid bronchoscopy) and pretracheal fascial plane (mediastinoscopy) to validate ultrathin composite fiberscope settings for sentinel lymph node detection. A tracheostomy was created, and the pig was placed in a lateral decubitus position. Transbronchial intraparenchymal indocyanine green injection was performed primarily in the right lower lobe. Ultrathin composite fiberscope and rigid bronchoscopy were performed with (n = 6) or without (n = 2) mediastinoscopy, with the former group guiding dose and ultrathin composite fiberscope optimization. Fluorescent targets were interrogated by endobronchial ultrasound before ultrathin composite fiberscope–guided transbronchial needle aspiration. Specimen fluorescence was documented before creating cytological smears. Pigs were killed postprocedure for nodal dissection.ResultsA total of 100 μL of 10 mg/mL indocyanine green generated strong transbronchial fluorescence with low risk of indocyanine green contamination. Fluorescence was detectable by 10 minutes postinjection. There was concordance among ultrathin composite fiberscope, rigid bronchoscopy, and mediastinoscopy. Except for 1 pig with airway contamination, ultrathin composite fiberscope–guided endobronchial ultrasound transbronchial needle aspiration obtained fluorescent material in all pigs. Specimen fluorescence was associated with specimen adequacy.ConclusionsBronchoscopic fluorescence-guided sentinel lymph node mapping was feasible, with specimen fluorescence providing real-time feedback on sentinel lymph node biopsy success. If translated to clinical practice, attention must be paid to minimizing indocyanine green leakage.     

Successful Surgical Closure of an Esophagobronchial Fistula Caused by a Foreign Body in the Esophagus of a Female Octogenarian with a Delayed Diagnosis: A Case Report

Esophagobronchial fistula (EBF) caused by an esophageal foreign body is rare in adults. All surgical interventions in the reported cases were performed via right thoracotomy. We have successfully treated an 88-year-old woman with EBF caused by a thick 2 × 2 cm piece of cake decorating paper that was swallowed accidentally. There was a 2-month interval between ingestion of the foreign body and correct diagnosis. The bronchial opening of the EBF was on the cephalic wall of the proximal left main bronchus (LMB), so we planned a primary repair of the bronchial wall with sutures via left thoracotomy. We performed a division of the fistula and primary closure of the openings on the esophageal and bronchial walls and covered the suture sites with an intercostal muscle flap and pericardial fat, respectively. The patient resumed oral intake on postoperative day 11 and was subsequently transferred to other hospital for rehabilitation.     

硬脊膜内背侧动静脉瘘的显微外科治疗

目的 探讨硬脊膜内背侧动静脉瘘的显微外科治疗及其疗效,初步探索术中吲哚菁绿荧光血管造影的应用.方法 2004年1月至2008年8月共有24例硬脊膜内背侧动静脉瘘患者进行了半椎板切除显微外科治疗并获得随访.其中2例为先接受介入栓塞治疗,后因复发再接受外科手术治疗.3例接受术中吲哚菁绿荧光血管造影.脊髓功能评价采用改良阿米诺夫量表,结合影像学检查结果对术后疗效进行综合评价.结果 术后平均随访36个月,影像学随访未见病变残留或复发.脊髓功能评价16例为优,阿米诺夫评分平均0.7分;4例为良,平均4.8分;3例为中,平均6.7分;1例为差,平均9.0分.综合疗效评价,治愈16例,改善6例,无变化2例.结论 单侧半椎板切除入路显微外科治疗足对硬脊膜内背侧动静脉瘘的有效治疗方法,术中吲哚菁绿荧光血管造影有助于手术.     

Indocyanine green does not decrease the need for bail-out operation in an acute care surgery population

BackgroundThe use of indocyanine green during laparoscopic cholecystectomy has been postulated to help to define anatomy. Studies have not specifically evaluated patients with acute cholecystitis. We sought to assess whether use of indocyanine green can decrease the rate of bail-out operation (subtotal cholecystectomy or conversion to an open operation) in an acute care surgery population where acute cholecystitis is more frequent.MethodsUsing a retrospective cohort design, we examined all inpatient cholecystectomies performed by the acute care surgery service under urgent or semiurgent (biliary colic as the presentation in the emergency room) conditions at a single institution from 7/1/18 to 6/30/19 during which indocyanine green was available for use at the surgeon’s discretion.ResultsA total of 198 patients were included in the analysis. Demographic variables were similar in groups receiving indocyanine green versus not. Pathology confirmed acute cholecystitis was present in 96 of 198 (48.5%) patients; of those, 55 (57.2%) received indocyanine green. Indocyanine green did not change the rate of bail-out operation between patients who received indocyanine green and those who did not (6.7% vs 4.3%, P = .468). No significant differences in complications were observed. Bail-out operation was more likely in cases of acute cholecystitis (9.4%) versus nonacute cholecystitis (2.0%) (odds ratio = 5.172, P = .039). In patients with acute cholecystitis, indocyanine green did not change the rate of bail-out operation (indocyanine green: 12.7% vs no indocyanine green: 4.9%, P = .293).ConclusionThis is the first series looking at the use of indocyanine green specifically in an acute care surgery population. Indocyanine green did not decrease operative time or need for a bail-out operation in acute cholecystitis. Further study is needed to determine whether indocyanine green use is justified in this population.     

Benign esophagobronchial fistula with and without esophageal obstruction: two ends of the surgical spectrum

Acquired esophagobronchial fistula (EBF) is uncommon and its surgical remediation is challenging. Management depends on the cause, degree of pulmonary involvement, and existence of esophageal obstruction. We report management of two EBF cases representing extremes of the surgical spectrum. One patient with EBF secondary to mediastinal fungal infection underwent pulmonary resection and esophageal repair. Another, who was positive for human immunodeficiency virus, required esophageal resection and fistula closure, but no pulmonary resection. Successful outcome was achieved in both patients.     

External Biliary Fistula in Orthotopic Liver Transplantation

During orthotopic liver transplantation (OLT), various situations may occur in which biliary reconstruction is neither technically feasible nor recommended. One bridge to a delayed anastomosis can be an external biliary fistula (EBF). This procedure allows the surgeon to execute hemostatic maneuvers, such as abdominal packing; therefore, biliary reconstruction can be subsequently performed in a bloodless operative field without edematous tissues. EBF can be made by placing in the donor biliary tract a cannula that is fixed to the bile duct using 2-0 silk ties and secured outside the abdominal wall. The biliary anastomosis will be performed within 2 days after the OLT. The aim of this study was to examine the safety of EBF in terms of the incidence of biliary complications compared with a direct anastomosis. Among 1634 adult OLTs performed in 17 years in our center, 1322 were carried out with termino-terminal hepaticocholedochostomy (HC-TT); two with side-to-side hepaticocholedochostomy; 208 with hepaticojejunostomy (HJ); 31 with EBF and delayed HC-TT, and 71 with EBF and delayed HJ. Biliary complication rates in the EBF group were 24.5%, including 23.9% in the delayed HJ and 25.8% in the delayed HC-TT. Biliary complication incidence among all OLTs was 24.6% (P = NS). No complications related to the procedure were observed. Therefore, EBF is a safe technique without a higher biliary complication rate. It may be useful when a direct biliary anastomosis is dangerous.     

POST-CHOLECYSTECTOMY EXTERNAL BILIARY FISTULA

Background : External biliary fistula (EBF) following bile duct injury is a serious complication of cholecystectomy. Methods : From January 1989 to December 1994, 37 patients with post-cholecystectomy external biliary fistula were seen at this centre. There were 14 partial, 22 complete and one sub-vesical duct of Luschka injury. Sixteen patients had a controlled EBF at presentation; 10 patients had intra-abdominal collections and seven patients presented with peritonitis. Results : A staged approach to the management of these patients was adopted in which the initial management aimed at creating a ‘controlled’ fistula. This approach comprised conservative treatment (n= 9), percutaneous catheter drainage of intra-abdominal collections (n= 10), biliary drainage (n= 6), and surgical intervention (n= 7). One patient died because of progressive liver failure in spite of intensive management. Definitive management comprised the surgical repair of biliary strictures wherever indicated, after waiting for the acute problems to settle. Conclusions: By adopting a staged approach along with a judicious use of endoscopy, radiology and surgery that were based on clinical circumstances, it was possible to achieve satisfactory results for this otherwise distressing condition.     

Intraoperative indocyanine green fluorescence lymphography,a novel imaging technique to detect a chyle fistula after an esophagectomy: Report of a case

Intraoperative indocyanine green (ICG) lymphography was performed on a 62-year-old man, who was diagnosed to have chylothorax after an esophagectomy for esophageal cancer. After exploration of the thorax, a slowly increasing effusion was identified in the mediastinal space above the diaphragm, but the exact site of the lymph fistula could not be identified. By injecting 1.5 ml of ICG subcutaneously at the bilateral inguinal region, fluorescence images of the lymph flow in the thoracic cavity were obtained using a near-infrared camera system. The detected leakage point was sutured and the chyle ooze stopped. The postoperative course was uneventful. The patient was discharged on the 16th postoperative day. This is the first report using ICG fluorescence lymphography for the successful intraoperative detection of the exact site of a fistula causing chylothorax.     

Técnica de punción de verde de indocianina intravesicular para conseguir una visión crítica de seguridad durante la colecistectomía por laparoscopia

IntroductionBile duct injury is one of the most severe complications after cholecystectomy. The aim of this study is to demonstrate how with a simple technique, an optimal critical view may be achieved by injecting indocyanine green directly into the gallbladder.MethodsTwenty-three patients were prospectively studied in which direct gallbladder injection of indocyanine green during laparoscopy was administered with a fine needle using an easily reproducible technique.ResultsBiliary tree identification was reported before and after injection. Critical view of safety was achieved in all cases.ConclusionsOur technique of direct gallbladder injection of indocyanine green is simple, efficient and shows a real time fluorescent cholangiography and an optimal critical view of safety decreasing the risk for bile duct injury.     

Indocyanine green. Its use as an early indicator of hepatic dysfunction following injury in man

To evaluate hepatic function, the kinetics of indocyanine green clearance were studied in seven injured patients with hepatic venous catheters. Indocyanine green clearance after a bolus injection of 20 mg was relatively monoexponential on the first day after injury. Following this, a second slower compartment of indocyanine green clearance was uniformly evident, becoming most prominent around the fourth day after injury. Indocyanine green clearance again became more uniform as recovery continued. Fractional indocyanine green extraction ten minutes after injection decreased from 0.9 on the first day after injury to 0.2 three days later, and then returned to 0.7 on the seventh day after injury. These decreases in indocyanine green clearance preceded an increase in total serum bilirubin concentration to a mean value of 1.9 mg/dL. Indocyanine green clearance was thus found to be an early and sensitive indicator of impaired hepatic function.     

Surgical treatment of H-type tracheoesophageal fistula diagnosed in an adult

A new method is described for the repair of a congenital tracheoesophageal fistula in an adult. This technique uses a fiberoptic bronchoscope and passes a flexible vascular guidewire across the tracheoesophageal fistula. This maneuver then simplifies the intraoperative identification of the tracheoesophageal fistula, which is exposed and repaired through a left transcervical approach.     

Surgical Management of Combined Intramedullary Arteriovenous Malformation and Perimedullary Arteriovenous Fistula within the Hybrid Operating Room after Five Years of Performing Focus Fractionated Radiotherapy: Case Report

Perimedullary arteriovenous fistula (AVF) shunts occur on the spinal cord surface and can be treated surgically or by endovascular embolization. In contrast, the nidus of an intramedullary arteriovenous malformation (AVM) is located in the spinal cord and is difficult to treat surgically or by endovascular techniques. The benefits of radiotherapy for treating intramedullary AVM have been published, but are anecdotal and consist largely of case reports. We present a case of combined cervical intramedullary AVM and perimedullary AVF which received surgical treatment within a hybrid operating room (OR) after 5 years of focus fractionated radiotherapy. A 37-year-old male presented with stepwise worsening myelopathy. Magnetic resonance imaging and spinal angiography revealed intramedullary AVM and perimedullary AVF at the C3 to C5 levels. In order to reduce nidus size and blood flow, we first performed focal fractionated radiotherapy. Five years later, the lesion volume was reduced. Following this, direct surgery was performed by an anterior approach using corpectomy in the hybrid OR. The spinal cord was monitored by motor-evoked potential throughout the surgery. Complete obliteration of the fistulous connection was confirmed by intraoperative indocyanine green video-angiography and intraoperative angiography, preserving the anterior spinal artery. We conclude that surgical treatment following focal fractionated radiotherapy may become one strategy for patients who are initially deemed ineligible for endovascular embolization and surgical treatment. Furthermore, the hybrid OR enables safe and precise treatment for spinal vascular disorders in the fields of endovascular treatment and neurosurgery.     

Assessment of incomplete clipping of aneurysms intraoperatively by a near-infrared indocyanine green-video angiography (Niicg-Va) integrated microscope

OBJECTIVE: The objective of this article was to assess the clinical use and the completeness of clipping with total occlusion of the aneurysmal lumen, real-time assessment of vascular patency in the parent, branching and perforating vessels, intraoperative assessment of blood flow, image quality, spatial resolution and clinical value in difficult aneurysms using near infrared indocyanine green video angiography integrated on to an operative Pentero neurosurgical microscope (Carl Zeiss, Oberkochen Germany). MATERIALS AND METHODS: Thirteen patients with aneurysms were operated upon. An infrared camera with near infrared technology was adapted on to the OPMI Pentero microscope with a special filter and infrared excitation light to illuminate the operating field which was designed to allow passage of the near infrared light required for excitation of indocyanine green (ICG) which was used as the intravascular marker. The intravascular fluorescence was imaged with a video camera attached to the microscope. ICG fluorescence (700-850 nm) from a modified microscope light source on to the surgical field and passage of ICG fluorescence (780-950 nm) from the surgical field, back into the optical path of the microscope was used to detect the completeness of aneurysmal clipping RESULTS: Incomplete clipping in three patients (1 female and 2 males) with unruptured complicated aneurysms was detected using indocyanine green video angiography. There were no adverse effects after injection of indocyanine green. The completeness of clipping was inadequately detected by Doppler ultrasound miniprobe and rigid endoscopy and was thus complemented by indocyanine green video angiography. CONCLUSION: The operative microscope-integrated ICG video angiography as a new intraoperative method for detecting vascular flow, was found to be quick, reliable, cost-effective and possibly a substitute or adjunct for Doppler ultrasonography or intraoperative DSA, which is presently the gold standard. The simplicity of the method, the speed with which the investigation can be performed, the quality of the images, and the outcome of surgical procedures have all reduced the need for angiography. This technique may be useful during routine aneurysm surgery as an independent form of angiography and/or as an adjunct to intraoperative or postoperative DSA.     

Indocyanine green video-angiography as an aid to surgical treatment of spinal dural arteriovenous fistulae

Purpose  

To illustrate the use of indocyanine green (ICG) video-angiography to confirm abolition of spinal dural arteriovenous fistula (SDAVF) and preserve the normal vascular anatomy intraoperatively.     

Intraoperative fibreoptic bronchoscopy during neonatal tracheo-oesophageal fistula ligation and oesophageal atresia repair.

Maintenance of adequate ventilation under anaesthesia can be difficult during identification and ligation of congenital tracheo-oesophageal fistula with repair of oesophageal atresia. Anaesthesia may also be complicated by problems associated with prematurity, pre-existing aspiration pneumonitis, and difficulty positioning the endotracheal tube to prevent inflation of the stomach with increased risk of aspiration and diaphragmatic splinting. Even intubation of the fistula and gastric rupture may occur. Two neonatal cases are presented where use of a 2.2 mm neonatal bronchoscope passed through a 3.0 mm ID tracheal tube facilitated surgical identification of the fistula, diagnosis of fistula intubation and other airway problems intraoperatively.     

Measurement of Cardiac Output with Indocyanine Green Transcutaneous Fluorescence Dilution Technique

Background: Cardiac output is an essential parameter for the hemodynamic assessment of patients with cardiovascular disease. The authors tested in an animal model the feasibility of measuring cardiac output by transcutaneous fluorescence monitoring of an intravenous bolus injection of indocyanine green.

Methods: Fluorescence dilution cardiac output was measured in 10 anesthetized rabbits and compared with cardiac output measured with a pulmonary thermodilution catheter and to aortic velocity measured by Doppler ultrasound. Indocyanine green fluorescence was excited with a near-infrared laser and measured with an optical probe positioned on the central ear artery. Measurements were obtained during baseline conditions as well as during short-term decreases and increases of the cardiac output.

Results: The fluorescence of circulating indocyanine green detected transcutaneously varied proportionally to that of arterial blood samples, which allowed for calibration in terms of blood concentration of indocyanine green. Average values of fluorescence dilution cardiac output and thermodilution cardiac output measured in baseline conditions were 412 (+/- 13) and 366 (+/- 11) ml/min, respectively. Fluorescence dilution cardiac output showed a close, one-to-one linear relation with thermodilution cardiac output in each animal and in the pooled data from all animals (slope = 0.95 x 0.03; R = 0.94). Fluorescence dilution cardiac output overestimated thermodilution cardiac output by an average of 46 (+/- 6) ml/min during baseline conditions. Fluorescence dilution cardiac output was tightly correlated with aortic velocity.     

Anaesthetic and surgical airway management during tracheo-oesophageal fistula repair

A retrospective review of 61 cases of airway management for newborn tracheo-oesophageal fistula (TOF)/oesophageal atresia repair is presented. Standard management included induction of general anaesthesia and muscle relaxation before tracheal intubation, rigid bronchoscopy, careful placement of the tracheal tube below the TOF if possible, and occlusion of the fistula with a Fogarty embolectomy catheter in certain high risk cases. Gastrostomy was not routinely performed. Ventilation proceeded without difficulty in 48 cases. Ventilation difficulties were encountered in 13 cases. Eight of the 13 cases had large TOF, and four had other causes of difficult ventilation not related to the fistula. No patient with a small TOF had ventilation problems because of the TOF. Three patients had a large TOF successfully occluded with an embolectomy catheter through the bronchoscope. There were no complications ascribed to this technique. An algorithm is suggested for anaesthetic-surgical airway management in these cases.     

Endoscopic closure of the postoperative bronchopleural fistula]

A case of successful endoscopic closure of a bronchopleural fistula with fibrin glue was reported. Fifty-eight-year-old man underwent right lower lobectomy for lung carcinoma. On the 21st postoperative day, he suffered from high fever and diagnosed as right side pyothorax. Then tube thoracotomy was done under UCG-guide. As a fistula in the right lower bronchial stump was found tiny by BFS, we tried to close the fistula bronchoscopically with fibrin glue. The fibrin glue was injected into the fistula via the ERCP tube, which was passed through the bronchoscope. This procedure was performed twice for two weeks interval. The fistula was completely closed about a month after the trial. This method is useful to close postoperative small bronchopleural fistula without surgical intervention.     

Successful conservative management of colorenal fistula after percutaneous cryoablation of renal-cell carcinoma

BACKGROUND: Cryoablation is an increasingly utilized treatment for renal-cell carcinoma. We describe the first reported case of colorenal fistula resulting from percutaneous renal cryoablation. CASE REPORT: A 63-year-old man with hematuria was found to have an enhancing renal mass that was treated with percutaneous CT-guided cryoablation. Two months later, he presented with lower urinary-tract symptoms, and CT imaging revealed a colorenal fistula at the ablation site. Ureteral stent placement resulted in resolution of the fistula. CONCLUSIONS: Contrary to previously reported animal and clinical studies, our case report demonstrates that it is possible to incur serious harm to the renal collecting system as a result of percutaneous renal cryoablation. In stable patients, an attempt at conservative management of a fistula should precede extensive reconstructive efforts.     

吲哚菁绿荧光成像技术在胸外科的应用

吲哚菁绿荧光成像技术是利用近红外光线激发吲哚菁绿的荧光属性,所发出的荧光信号再由专门的腔镜系统进行收集,并将信号传输到显示器上,从而实现术中实时成像的一门技术。它可以观察术中特定组织的靶向标记或评估组织血流灌注情况。近年随着对吲哚菁绿的物理特性研究越来越深入,吲哚菁绿荧光成像技术已经在血管探查、实质脏器灌注显影、软组织灌注评估、淋巴显影等方面得到应用。笔者围绕吲哚菁绿荧光成像技术在胸外科的应用进行阐述。