Preoperative Endoscopic Marking Research Articles

Surgical disconnection of high delineated immature debilitating jejunal fistulas using posterolateral access

Objective. The aim of the study was to develop the safest technique for surgical disconnection of high, unformed jejunal fistulas, so as to avoid problems with detection the intestine leading to the fistula and to avoid complications of viscerolysis. Material and methods. The authors present their experience in surgical management of 35 patients with high delimited unformed debilitating jejunal fistulas. Of these, 22 patients were included in the comparison group; their fistulas were closed or disconnected with the known methods. Findings obtained from other 172 patients with adhesive intestinal obstruction after infectious complications of laparotomic wounds and topography of visceroparietal planar adhesions of the peritoneum were analyzed. After studying the nature and location of visceroparietal adhesions, the authors could develop a technique for proximal disconnection of high delimited unformed debilitating jejunal fistulas using posterolateral access which was applied in 13 patients from the studied group. Research results. The proposed technique of unilateral disconnection of high unformed jejunal fistulas reduces duration, damage and risk of prolonged bowel deserosing. As a result, a significant decrease in postoperative mortality from 59.1 ± 9.2% to 23.1 ± 11.2% (t=2.5; p<0.05) was registered. Due to the preoperative endoscopic marking showing direction to the fistula of intestinal loop and duodenojejunal junction, intraoperative orientation was more accurate and took much less time than in the comparison group. The posterolateral surgical approach to the fistula in the jejunal loop reduced the risk of its damage, since there was no need for extensive enterolysis anymore. Therefore, postoperative period in patients of the studied group was better and with fewer complications than in the comparison group. Conclusion. The posterolateral access prevented extended viscerolysis and allowed to put a reliable and atraumatic interintestinal anastomosis so as to disconnect the fistula. The unilateral disconnection of the jejunal fistula at postoperative intestinal paresis unloaded the interintestinal anastomosis, similar to Meidl’s definitive jejunostomy. The abovementioned positive aspects of the proposed surgical intervention allowed to significantly decrease postoperative complications and mortality rate, if to compare with outcomes after known surgical interventions with a similar purpose.

Preoperative endoscopic marking of the gastrointestinal tract using fluorescence imaging: submucosal indocyanine green tattooing versus a novel fluorescent over-the-scope clip in a survival experimental study

BackgroundIntraoperative localization of endoluminal lesions is can be difficult during laparoscopy. Preoperative endoscopic marking is therefore necessary. Current methods include submucosal tattooing using visible dyes, which in case of transmural injection can impair surgical dissection. Tattooing using indocyanine green (ICG) coupled to intraoperative near-infrared (NIR) laparoscopy has been described. ICG is only visible under NIR-light, therefore, it doesn’t impair the surgical workflow under white light even if there is spillage. However, ICG tattoos have rapid diffusion and short longevity. We propose fluorescent over-the-scope clips (FOSC), using a novel biocompatible fluorescent paint, as durable lesion marking.MethodsIn six pigs, gastric and colonic endoscopic tattoos using 0.05 mg/mL of ICG and markings using the fluorescent OSC were performed (T0). Simultaneously, NIR laparoscopy was executed. Follow-up laparoscopies were conducted at postoperative day (POD) 4–6 (T1) and POD 11–12 (T2). During laparoscopy, fluorescence intensity was assessed. In one human cadaver, FOSC was used to mark a site on the stomach and on the sigmoid colon, respectively. Intraoperative detection during NIR laparoscopy was assessed.ResultsGastric and colonic ICG tattooing and OSC markings were easily visible using NIR laparoscopy on T0. All FOSC were visible at T1 and T2 in both stomach and colon, whereas the ICG tattooing at T1 was only visible in the stomach of 2 animals and in the colon of 3 animals. At T2, tattoos were not visible in any animal. FOSC were still visible in both stomach and colon of the human cadaver at 10 days.ConclusionEndoscopic marking using FOSC can be an efficient and durable alternative to standard methods.

Endoscopic Preoperative Tattooing and Marking in the Gastrointestinal Tract: A Systematic Review of Alternative Methods.

Background: An accurate and reliable localization of endoluminal gastrointestinal (GI) lesions is crucial, particularly during minimally invasive surgery. As an extreme consequence, a misdetected GI lesion can lead to the resection of the wrong segment, especially in colorectal surgery. A preoperative endoscopic marking is recommended in case of GI lesions, which are expected to be difficult to detect from the serosal side. In clinical practice, three preoperative endoscopic marking methods are currently used: India ink, SPOT™, and endoclips with intraoperative fluoroscopy. All of them have substantial limitations. This has encouraged research on alternative solutions. Methods: In the current systematic review, animal and clinical studies about alternative preoperative endoscopic marking methods of GI lesions were analyzed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Thirty studies were found using PubMed/MEDLINE, EMBASE/Ovid, and the Cochrane Library for the qualitative analysis. Conclusion: Although several smart solutions have been proposed and tested successfully, all of them seem to have a substantial drawback related either to scarce stability on the marking site or potential spreading on the bowel wall or diffusion into the surgical planes.

Application of a sodium alginate hydrogel for clear preoperative endoscopic marking using India ink

Preoperative marking or tattooing is a clinical procedure conducted during laparoscopic surgeries in which gastrointestinal lesions are identified by injecting India ink. However, diffusion of the carbon particles from the ink leads to its spreading in the surrounding tissues, resulting in unnecessarily extensive tissue resectioning. In this study, we determined whether this diffusion could be prevented using a sodium alginate (Alg-Na) hydrogel. We observed that the use of a 1.75% Alg-Na solution could significantly prevent the diffusion of carbon particles into the tissues of mice after subcutaneously injecting them with India ink. Similar results were observed in resected porcine large intestines. A good correlation between the concentration of Alg-Na and tattooed area was observed, in which an increase in its concentration led to an increase in its viscosity and injection pressure. To examine the effect of the molecular weight of Alg-Na on the tattooing area, a solution of 2% Alg-Na was irradiated with an electron beam at varying electron doses. Since irradiation could reduce the molecular weight, viscosity, and injection pressure of Alg-Na, a good correlation between these parameters and the tattooed area was observed. We concluded that an adequately viscous Alg-Na hydrogel could be used for clear preoperative marking. Preoperative marking or tattooing is performed in clinical situations using an India ink to identify gastrointestinal lesions. However, diffusion of the carbon particles from the ink results in unclear marking. We observed that subcutaneously injected sodium alginate solutions formed a gel and prevented the diffusion of carbon particles into the tissues of mice. Similar results were observed in resected porcine large intestines. The tattooed area was well correlated with the molecular weight and viscosity of sodium alginate, indicating that an adequately viscous sodium alginate hydrogel is useful for clear marking.

Magnetic tracer technique in laparoscopic localization for gastrointestinal lesions

Objective To evaluate the feasibility and safety of magnetic tracer technique for preoperative endoscopic marking in laparoscopic surgery. Methods In the preliminary study, a total of 8 patients with gastric (n=3) or colorectal (n=5) tumors underwent endoscopic magnetic marking before laparoscopic surgery from April to June in 2019. First, a magnet was attached to the lesion by 2 titanium clips under the endoscope. Second, during the subsequent laparoscopic operations, the other magnet was sent to the vicinity of the lesion through the laparoscopic tunnel. The magnet in the abdominal cavity was quickly attracted to the one in the gastrointestinal tract to successfully locate the lesions. Data of preoperative marking and operations of 8 patients were reviewed. Results All 8 lesions were marked successfully, rapid and accurate intraoperative positioning was achieved. The mean time of endoscopic marking was 5.75±2.45 minutes, and the mean time of intraoperative localization was 1.94±0.56 minutes. All patients underwent laparoscopic tumor resections with accurate localization. The mean proximal and distal resection margins of colorectal tumors were 105 mm and 74 mm respectively. No complications occurred. Conclusion Magnetic tracer technique for laparoscopic localization, simple, safe and accurate for gastrointestinal lesions, can be performed without additional equipment or endoscopic procedures involved. Key words: Gastrointestinal tract; Laparoscopes; Orientation; Magnet

New marking method involving a light-emitting diode and power source device to localize gastrointestinal cancer in laparoscopic surgery

Although the preoperative endoscopic marking method using dye is widely used, the dye can spread into the tissue or abdominal cavity, inducing the inflammation and leading to the wrong dissection. We developed a novel marking method using an endoscopic clip with a light emitting diode (LED) and a power source device to detect the accurate location of the site of interest. We performed this new marking method in three patients with gastrointestinal cancers. We placed an endoscopic clip with an LED on the gastrointestinal mucosa and used a power source device outside of the human body to detect the LED. We detected the clip with the LED using the power source device. We also confirmed the usefulness of this clip in three of three (100%) patients with colorectal and gastric cancer. We developed a novel marking device using an LED to identify an objective location successfully.

The Feasibility and Safety of Preoperative Fluorescence Marking with Indocyanine Green (ICG) in Laparoscopic Gastrectomy for Gastric Cancer

BackgroundSecuring the surgical margin is the most essential and important task in curative surgery. However, it is difficult to accurately identify the tumor location during laparoscopic surgery for gastric cancer, and existing methods, such as preoperative endoscopic marking with tattooing and clipping, have multiple disadvantages. AimsWe investigated the feasibility and safety of indocyanine green (ICG) fluorescence marking for determining the tumor location during laparoscopic gastrectomy. MethodsWe retrospectively analyzed preoperative and perioperative data from consecutive patients with gastric cancer undergoing planned laparoscopic distal gastrectomy. Data was maintained in a prospectively compiled surgical database, and patients were categorized into ICG (n = 84) or non-ICG (n = 174) groups based on whether they underwent preoperative endoscopic mucosal ICG injection. One-to-one propensity score matching (PSM) was performed to compare outcomes between the two groups. ResultsWe included 84 patient pairs after PSM, and there were no significant differences in preoperative patient characteristics. The ICG group had shorter procedure time (p < 0.001), lower estimated blood loss (p = 0.005), and significantly shorter postoperative hospital stay (p < 0.001). Positive resection margins were confirmed in five cases (6.0%) in the non-ICG group, whereas there were none in the ICG group (p = 0.008). Real-time confirmation was possible during laparoscopy, and the injected ICG did not affect the surgical procedure or result in adverse events. ConclusionICG fluorescence imaging is feasible and safe and can potentially be used as a tumor-marking agent for determining the surgical resection line.

A novel option for preoperative endoscopic marking with India ink in totally laparoscopic distal gastrectomy for gastric cancer: A useful technique considering the morphological characteristics of the stomach.

In totally laparoscopic distal gastrectomy (TLDG) for gastric cancer, accurately determining the proximal resection line may be difficult. This is because identifying the lesion intracorporeally is impossible, due to the lack of tactile sense, and, in addition, unlike the intestine, the most proximal site of the lesion is often different from the main site due to the distorted shape of the stomach. The aim of this study was to introduce a novel method of preoperative endoscopic marking with India ink, taking into consideration the morphological characteristics of the stomach. Between July, 2013 and April, 2016, 20 patients who underwent TLDG were enrolled in this study. Within the 3 days preceding the operation, after identifying the most proximal site of the lesion on the overlooking image of an endoscope, India ink was injected into the spot on the oral side of this site. The stomach was transected along the proximal border of the marked area. In all cases, the marked sites were localized and clearly identified during the operation, and the proximal resection margins were found to be negative on postoperative pathological examination. The mean length of the proximal margin was 46.0±14.0 mm. In conclusion, this preoperative endoscopic marking method may be useful in TLDG for gastric cancer.

Successful Left Thoracoscopic Esophagectomy for Congenital Esophageal Stenosis with a Useful Adjunct of Preoperative Endoscopic Marking

Abstract Introduction: Minimally invasive surgery is an alternative to open surgery in esophageal resection. Several studies have described thoracoscopic esophagectomy for esophageal stenosis in children.1–3 It is standard to conduct esophagectomy from the right thoracic cavity, so the aorta does not obstruct the procedure. So far, there have been no reports on left thoracoscopic esophagectomy in children. In a case of congenital esophageal stenosis, where the lesioned part was close to the esophagogastric junction, we show a successful left thoracoscopic esophagectomy with a useful adjunct of preoperative endoscopic marking. Materials and Methods: A 3-year-old female with Down's syndrome presented with the chief complaint of vomiting after eating solid food. The esophagogram and the esophageal endoscope revealed a pinhole stenosis in the lower esophagus, diagnosed as congenital esophageal stenosis. Balloon dilation was performed twice; however, esophageal perforation occurred on the second dilation. The ...

Role of endoscopy in the staging and management of colorectal cancer

Role of endoscopy in the staging and management of colorectal cancer

Bowel obstruction associated with endoscopic tattooing of the colon with India ink

During a laparoscopic resection of small colorectal lesions, preoperative endoscopic marking with India ink is useful for identifying the location of the lesion. India ink has been thought to be a safe agent with few adverse effects. We herein report a case who suffered from postoperative abdominal pain resulting in bowel obstruction, due to massive adhesion around the area with India ink. A 61-year-old man with early transverse colon cancer underwent a laparoscopy-assisted transverse colon resection. Prior to the operation, endoscopic tattooing with India ink was performed. At the operation, spillage of India ink into the peritoneal cavity was observed. Many small black spots were thereafter seen on the peritoneum, mesentery and omentum, but neither severe inflammation nor any adhesion was noticed. The operation was performed without any difficulty. Though his immediate postoperative course was uneventful, a bowel obstruction gradually developed from a week postoperatively. Finally, he had to undergo a re-operation, and was found to have diffuse and massive adhesion around areas with India ink. Especially, severe omental adhesion involved and squeezed the transverse colon. A resection of the omentum with stenotic colon and re-anastomosis was performed. India ink can cause severe inflammation and adhesion when it accidentally leaks into the peritoneal cavity.

Usefulness of endoscopic marking for determining the location of transanal endorectal pull-through in the treatment of Hirschsprung’s disease

In the treatment of Hirschsprung's disease, transanal endorectal pull-through (TEPT) is being performed without laparoscopic assistance or laparotomy for short-segment aganglionosis. Preoperative ascertainment of the extent of aganglionosis is required, as this affects the planning for TEPT. The present study investigated the usefulness of preoperative endoscopic marking as an intraoperative marker of the location of pull-through. Since 1998, we have performed TEPT using a prolapsing technique for the treatment of Hirschsprung's disease. Subjects comprised 17 patients with short-segment aganglionosis and 2 patients with long-segment aganglionosis in whom endoscopic marking was performed preoperatively. Median age at time of surgery was 2.7 months. The relationship between pathologic findings at the marked area and location of actual pull-through was investigated. For endoscopic marking, each patient was sedated using intravenous ketamine hydrochloride. The junction between normal bowel with peristalsis and aganglionic bowel without peristalsis ("shorebreak" finding) was marked by either tattooing or clipping. Normal ganglion cells were seen in the marked area of 14 patients, and pull-through was performed at the marked area in each of these patients. In three patients, ganglion cells existed in the marked area, but the number of ganglion cells was considered insufficient. Additional frozen sections were thus prepared to ascertain the area with normal ganglion cells, showing that normal ganglion cells were seen 1, 3 or 5 cm proximal to the marked area. In one patient, no ganglion cells were seen in the marked area, but were present 5 cm proximal to the marked area. In the remaining one patient, normal ganglion cells were seen 7 cm distal to the marked area. Pathologic findings revealed ganglion cells at the shorebreak finding in 17 of the 19 patients (89.5%), suggesting that this junction basically matches the distribution of ganglion cells. Endoscopic marking of the junction is very useful for determining the tip of pull-through.

Locating polyps by endoscopy with or without videolaparoscopy, radioguided occult colonic lesion identification or magnetic endoscopic imaging: the way forward to complete polyp removal

Endoscopic polypectomy is the gold standard for the treatment of colorectal polyps. In the case of non-palpable lesions or to complete polyp removal, the lesions are located intra-operatively. With the advent of laparoscopy, identifying their position is even more important because there is no opportunity for intestinal palpation. Several methods of preoperative endoscopic marking have been proposed using different types of tattooing and recently using clips followed by ultrasonography detection. Innovative methods are analysed; magnetic endoscopic imaging is a reliable and accurate method for determining the anatomical position of the tip of the endoscope during colonoscopy. Radioguided colonic lesion identification needs a gamma detection probe. Endoscopic removal can be converted to endo-laparoscopic rendezvous, failing which, laparoscopic resection is a reliable and safe choice, offering all the advantages of minimally invasive surgical techniques.

Radioguided occult colonic lesion identification (ROCLI) during open and laparoscopic surgery.

Intraoperative localization, during open and laparoscopic surgery, of small, nonpalpable colonic lesions located at peculiar sites or with concurrent inflammatory bowel alterations (diverticulosis, perivisceritis) is often difficult. The aim of our work was to assess the validity of radioguided identification after preoperative labeling. Patients who were candidates for colon surgery for occult lesions that, because of their size and location, were assumed to be difficult to detect, underwent colonoscopy 1 to 2.5 hours before surgery. A small dose of labeled albumin macroaggregates was injected with a sclerotherapy needle into the subserosa underneath the lesion. Immediately following the injection the lesion was identified with a transcutaneously placed gamma detecting probe. Intraoperative tracer detection was performed either during open surgery or by means of a laparoscopic probe (detection time 3-5 mins). The position of the lesion was marked with a suture or with a clip. Surgery was performed according to the type of lesion to be treated. In our initial clinical experience 15 colon lesions were preoperatively marked in 14 patients and were subsequently detected during surgery (four under laparoscopy) with a gamma detecting probe. This technique allows highly accurate, fast, and inexpensive surgical localization of lesions without irradiation and without complications. Our experience shows that preoperative endoscopic marking of nonpalpable colon lesions with 99mTc-labeled albumin macroaggregates followed by intraoperative detection with a gamma probe is a useful clinical method that is highly accurate and without complications.