背景:在急性外科手术过程中评估肠活力可能具有挑战性,尤其是关于肠系膜缺血。术中荧光血管造影术(FA)可能是外科医生确定是否需要肠切除并定义最合适的切除边缘的有价值的工具。这项研究的目的是报告在急性环境中使用FA,并判断其对术中决策的影响。
方法:这是一个多中心,2016年2月至2021年期间在3个普通/结直肠病房接受急诊腹部手术的患者的回顾性病例系列,术中进行FA以评估肠活力.主要终点是FA评估后管理的变化。
结果:共有93名患者(50名男性,66.6±19.2年,85%的ASA评分≥III)进行了鉴定和研究。最初的手术方法是66例(71%)患者的剖腹手术和27例(29%和7例,26%的转化率)。最常见的病因是肠系膜缺血(n=42,45%)和与粘连/疝相关的绞窄(n=41,44%)。在50例患者中进行了肠切除术。切除后吻合的总率,再次手术和30天死亡率为48%(n=24/50,一次泄漏),12%和18%,分别。FA改变了27例(29%)患者的管理。在四名患者中(总体占4%),避免了切除,并且在21(23%)中保留了额外的肠长度(保留了50厘米的肠,IQR28-98),尽管三名患者进一步发展为缺血。FA提示扩大切除(中位数为20cm,IQR10-50肠外)在六名(6%)患者中。
结论:术中使用FA会影响肠缺血肠切除术的手术决策,可能使大约四分之一的患者的肠道保存。需要进行前瞻性研究,以优化该技术在该适应症中的最佳使用,并确定FA图像的解释标准以及后续对二次手术的潜在需求。
Assessing bowel viability can be challenging during acute surgical procedures, especially regarding mesenteric ischaemia. Intraoperative fluorescence angiography (FA) may be a valuable tool for the surgeon to determine whether bowel resection is necessary and to define the most appropriate resection margins. The aim of this study is to report on FA use in the acute setting and to judge its impact on intraoperative decision making.
This is a multi-centre, retrospective
case series of patients undergoing emergency abdominal surgery between February 2016 and 2021 in three general/colorectal units where intraoperative FA was performed to assess bowel viability. Primary endpoint was change of management after the FA assessment.
A total of 93 patients (50 males, 66.6 ± 19.2 years, ASA score ≥ III in 85%) were identified and studied. Initial surgical approach was laparotomy in 66 (71%) patients and laparoscopy in 27 (29% and seven, 26% conversions). The most common aetiologies were mesenteric ischaemia (n = 42, 45%) and adhesional/herniae-related strangulation (n = 41, 44%). In 50 patients a bowel resection was performed. Overall rates of anastomosis after resection, reoperation and 30-day mortality were 48% (n = 24/50, one leak), 12% and 18%, respectively. FA changed management in 27 (29%) patients. In four patients (4% overall), resection was avoided and in 21 (23%) extra bowel length was preserved (median 50 cm of bowel saved, IQR 28-98) although three patients developed further ischaemia. FA prompted extended resection (median of 20 cm, IQR 10-50 extra bowel) in six (6%) patients.
Intraoperative use of FA impacts surgical decisions regarding bowel resection for intestinal ischaemia, potentially enabling bowel preservation in approximately one out of four patients. Prospective studies are needed to optimize the best use of this technology for this indication and to determine standards for the interpretation of FA images and the potential subsequent need for second-look surgeries.