Vascular Imaging of the Staple Line in Bowel Anastamoses in the Regional Hospital Setting

Ali Mahmood, MD. Houston Methodist Hospital System

Objective

Anastamotic leaks are one of the most feared complications with colon and rectal surgery.  The majority of the time, an anastamotic breakdown is due to insufficient vascular supply.  With increasing amounts of colon and rectal resection performed laparoscopically, a laparoscopic imaging modality was trialed to value its efficacy in revealing vascular integrity following an intestinal anastomosis.  PINPOINT endoscopic fluorescent imaging was used and evaluated during 40 consecutive studies.

Methods

After an anastomosis was created, the PINPOINT was introduced laparoscopically to evaluate the anastomosis.  A 30 degree 10 mm PINPOINT camera was used for our cases. The anesthesiology team administered 3mL of the imaging dye intravenously, followed by 10 cc of normal saline to flush the dye.  The imaging/PINPOINT scope was controlled by the surgeon.  Within minutes of the dye being introduced, the anastomosis was easily studied to see its vascular integrity, and a decision could be rendered whether the blood supply was sufficient or marginal warranting further operative intervention. 

Results

40 consecutive cases were reviewed, each involving a low colorectal anastomosis with PINPONT imaging to study the vascularity.  39 of the cases showed excellent flow to the staple line from the proximal and distal origin.  1 case showed marginal blood supply, with the fluorescence compromised at the proximal staple line.  This facilitated the decision to revise the anastomosis.  There were 0 anastamotic breakdowns, 0 stricutures from the anastomosis on follow up colonoscopy/proctoscopy and the patients did not exhibit any undue effects of the PINPOINT dye. 

Conclusion/Future Direction

Anastamotic breakdown leads to a very complicated post operative course.  From multiple subsequent surgeries, to sepsis and possible death, this complication is the most feared with colon and rectal surgery.  The prevailing etiology of anastamotic breakdown is poor vascular supply to the staple line.  Historically, this has been a very subjective process, with the surgeon evaluating the bowel with his/her eyes.  With the advent of PINPOINT technology, the surgeon now has the advantage of evaluating the vascularity of the remaining bowel to be anastamosed with realtime vascular imaging.  This technology will allow the surgeon an objective study to evaluate the colon and rectum prior to or immediately after an anastomosis.  The best way to deal with an anastamotic breakdown is to prevent one from occurring in the first place.