Search

BACKGROUND Gastroenteropancreatic neuroendocrine tumors are often diagnosed when metastatic. The liver is the main site of metastases. Unfortunately, optimal management of neuroendocrine liver metastases remains a topic of debate. The aim of this study was to make a systematic review of the current literature about the results of the different treatments of neuroendocrine liver metastases. METHODS A systematic review was conducted for English language publications from 1995 to 2021. Outcomes were analyzed according to survival, disease-free survival, and in the case of systemic therapies, progression-free survival. RESULTS 5509 patients were analyzed in the review. 67% of patients underwent surgery achieving 5 years overall survival despite only 30% percent without a recurrence. 60% of patients that had received a transplant reached 5 years survival with a low disease-free survival rate (20%). Five-year survival rate was 36.2% for patients undergoing loco-regional therapies. CONCLUSION Surgical resection is the best treatment when metastases are resectable, with the highest rate of survival, although liver transplantation shows good results for patients not eligible for surgery. Loco-regional therapies may be useful when surgical resection is contraindicated, or selectively used as a bridge to surgery or transplantation. Systemic therapies are indicated in patients for whom curative treatment cannot be obtained.

Despite recent technological progress in surgical guidance, current intraoperative assessment of tissue that should be removed (e.g., cancer) or avoided (e.g., nerves) is still performed subjectively. Optical imaging is a non-contact, non-invasive modality that has the potential to provide feedback regarding the condition of living tissues by imaging either an exogenously administered contrast agent or endogenous constituents such as hemoglobin, water, and lipids. As such, optical imaging is an attractive modality to provide physiologically and structurally relevant information for decision-making in real-time during surgery. The Trident imaging platform has been designed for real-time surgical guidance using state-of-the-art optical imaging. This platform is capable of dual exogenous and endogenous imaging owing to a unique filter and source combination, allowing to take advantage of both imaging modalities. This platform makes use of a real-time and quantitative imaging method working in the spatial frequency domain, called Single Snapshot imaging of Optical Properties (SSOP). The Trident imaging platform is designed to comply with all relevant standards for clinical use. In this manuscript, we first introduce the rationale for developing the Trident imaging platform. We then describe fluorescence and endogenous imaging modalities where we present the details of the design, assess the performance of the platform on the bench. Finally, we perform the validation of the platform during an in vivo preclinical experiment. Altogether, this work lays the foundation for translating state-of-the-art optical imaging technology to the clinic.

The interaction between the mitochondria and the endoplasmic reticulum (ER) is essential for hepatocyte function. An increase in ER–mitochondria contacts (ERMCs) is associated with various metabolic diseases. Non-alcoholic fatty liver disease (NAFLD) is associated with obesity and type 2 diabetes, and its progressive form non-alcoholic steatohepatitis (NASH) can lead to cirrhosis and hepatocellular carcinoma. However, the role of ERMCs in the progression of NAFL to NASH is still unclear. We assessed whether ERMCs could correlate with NAFLD severity. We used a proximity ligation assay to measure the abundance of ERMCs in liver biopsies from patients with biopsy-proven NAFLD (n = 48) and correlated the results with histological and metabolic syndrome (MetS) features. NAFLD patients were included according to inclusion and exclusion criteria, and then assigned to NAFL (n = 9) and NASH (n = 39) groups. ERMCs density could discriminate NASH from NAFL (sensitivity 61.5%, specificity 100%). ERMCs abundance correlated with hepatocellular ballooning. Moreover, the density of ERMCs increased with an increase in the number of MetS features. In conclusion, ERMCs increased from NAFL to NASH, in parallel with the number of MetS features, supporting a role for this interaction in the pathophysiology of NASH.

The interaction between the mitochondria and the endoplasmic reticulum (ER) is essential for hepatocyte function. An increase in ER-mitochondria contacts (ERMCs) is associated with various metabolic diseases. Non-alcoholic fatty liver disease (NAFLD) is associated with obesity and type 2 diabetes, and its progressive form non-alcoholic steatohepatitis (NASH) can lead to cirrhosis and hepatocellular carcinoma. However, the role of ERMCs in the progression of NAFL to NASH is still unclear. We assessed whether ERMCs could correlate with NAFLD severity. We used a proximity ligation assay to measure the abundance of ERMCs in liver biopsies from patients with biopsy-proven NAFLD (

MRI is the reference for the diagnosis of arterial cerebral ischemia, but its role in acute mesenteric ischemia (AMI) is poorly known.To assess MRI detection of early ischemic bowel lesions in a porcine model of arterial AMI.Prospective/cohort.Porcine model of arterial AMI obtained by embolization of the superior mesenteric artery (seven pigs).A 5-T. T1 gradient-echo-weighted-imaging (WI), half-Fourier-acquisition-single-shot-turbo-spin-echo, T2 turbo-spin-echo, true-fast-imaging-with-steady-precession (True-FISP), diffusion-weighted-echo-planar (DWI).T1-WI, T2-WI, and DWI were performed before and continuously after embolization for 6 hours. The signal intensity (SI) of the ischemic bowel was assessed visually and quantitatively on all sequences. The apparent diffusion coefficient (ADC) was assessed.Paired Student's t-test or Mann-Whitney U-test, significance at P 0.05.One pig died from non-AMI-related causes. The remaining pigs underwent a median 5 h53 (range 1 h24-6 h01) of ischemia. Visually, the ischemic bowel showed signal hyperintensity on DWI-b800 after a median 85 (57-276) minutes compared to the nonischemic bowel. DWI-b800 SI significantly increased after 2 hours (+19%) and the ADC significant decrease within the first hour (-31%). The ischemic bowel was hyperintense on precontrast T1-WI after a median 87 (70-171) minutes with no significant quantitative changes over time (P = 0.46-0.93). The ischemic bowel was hyperintense on T2-WI in three pigs with a significant SI increase on True-FISP after 1 and 2 hours.Changes in SI and ADC can be seen early after the onset of arterial AMI with DWI. The value of T2-WI appears to be limited.1 TECHNICAL EFFICACY: Stage 2.

Introduction/objective Gastric conduit (GC) is used for reconstruction after esophagectomy. Anastomotic leakage (AL) incidence remains high, given the extensive disruption of the gastric circulation. Currently, there is no reliable method to intraoperatively quantify gastric perfusion. Hyperspectral imaging (HSI) has shown its potential to quantify serosal StO2. Confocal laser endomicroscopy (CLE) allows for automatic mucosal microcirculation quantification as functional capillary density area (FCD-A). The aim of this study was to quantify serosal and mucosal GC’s microperfusion using HSI and CLE. Local capillary lactate (LCL) served as biomarker. Methods GC was formed in 5 pigs and serosal StO2% was quantified at 3 regions of interest (ROI) using HSI: fundus (ROI-F), greater curvature (ROI-C), and pylorus (ROI-P). After intravenous injection of sodium-fluorescein (0.5 g), CLE-based mucosal microperfusion was assessed at the corresponding ROIs, and LCLs were quantified via a lactate analyzer. Results StO2 and FCD-A at ROI-F (41 ± 10.6%, 3.3 ± 3.8, respectively) were significantly lower than ROI-C (68.2 ± 6.7%, p value: 0.005; 18.4 ± 7, p value: 0.01, respectively) and ROI-P (72 ± 10.4%, p value: 0.005; 15.7 ± 3.2 p value: 0.001). LCL value at ROI-F (9.6 ± 4.7 mmol/L) was significantly higher than at ROI-C (2.6 ± 1.2 mmol/L, p value: 0.04) and ROI-P (2.6 ± 1.3 mmol/L, p value: 0.04). No statistically significant difference was found in all metrics between ROI-C and ROI-P. StO2 correlated with FCD-A (Pearson’s r = 0.67). The LCL correlated negatively with both FCD-A (Spearman’s r = − 0.74) and StO2 (Spearman’s r = − 0.54). Conclusions GC formation causes a drop in serosal and mucosal fundic perfusion. HSI and CLE correlate well and might become useful intraoperative tools.

Background Intraoperative 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. Methods In 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. Results Gastric 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. Conclusion Endoscopic marking using FOSC can be an efficient and durable alternative to standard methods.

Anatomical liver resection (ALR) is the preferred oncological approach for the treatment of primary liver malignancies, such as hepatocellular carcinoma and intrahepatic cholangiocarcinoma. The demarcation line (DL) is formed by means of selective vascular occlusion and is used by surgeons to guide ALR. Emerging intraoperative technologies are playing a major role to enhance the surgeon’s vision and ensure a precise oncologic surgery. In this article, a brief overview of modalities to assess the DL during ALRs is presented, from the established conventional techniques to future perspectives.

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.

Aim Transanal total mesorectal excision is a promising novel sphincter-saving procedure for low rectal cancer. However, the transanal bottom-up dissection is associated with increased rates of iatrogenic urethral injuries. Near-infrared fluorescence (NIRF) imaging, given its deeper tissue penetration, has been explored in a limited number of studies for enhanced intra-operative urethral visualization. In this study, we explored the feasibility of a novel, ultrabright, biocompatible fluorescent polymer to coat urinary catheters for the purpose of intra-operative urethral visualization. Methods In an ex vivo experiment, using a near-infrared laparoscope, the fluorescent signal of a coated catheter (near-infrared coating of equipment, NICE) was qualitatively and quantitatively compared to the signal of indocyanine green (ICG)/Instillagel® mixtures and ICG-filled catheters at several concentrations. Also, in three male human torsos, using fluorescent urinary catheters, NIRF-guided perineal dissections and a transanal total mesorectal excision were performed. Intra-operative NIRF-based urethral visualization was performed systematically. Results During the qualitative and quantitative fluorescence signal assessment, NICE-coated catheters were clearly superior to the ICG-based solutions. In the cadaveric experiments, enhanced urethral visualization was possible even at early stages of dissection, when the organ was covered by several tissue layers. Conclusions NICE-coated catheters represent a promising potential to allow for NIRF-based intra-operative urethral visualization.

Anastomotic leak is the most dangerous complication occurring after esophagectomy and its relationship with inadequate visceral perfusion is widely recognized. Currently, the adequate perfusion of the gastric conduit is intraoperatively assessed by surgeons using subjective indicators (e.g., serosal color or pulsatile flow of vessels). During the last decades, several innovative optical techniques based on the interaction of light with tissue have been developed to monitor perfusion in esophagogastric surgery. However, these innovative approaches are characterized by a lack of video rate and reproducibility. They also provide operator-dependent results and lengthen the surgical workflow. Single Snapshot imaging of Optical Properties (SSOP) is an optical technique, which can overcome such limitations, providing quantitative information on the optical properties of biological tissues over a large field of view. It is the first study to demonstrate the accuracy of SSOP in the quantification of serosal StO2% in a porcine gastric conduit model.

Background: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. Methods: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. Results: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013–0.89mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. Conclusion: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.

Hyperspectral imaging (HSI) is a novel optical imaging modality, which has recently found diverse applications in the medical field. HSI is a hybrid imaging modality, combining a digital photographic camera with a spectrographic unit, and it allows for a contactless and non-destructive biochemical analysis of living tissue. HSI provides quantitative and qualitative information of the tissue composition at molecular level in a contrast-free manner, hence making it possible to objectively discriminate between different tissue types and between healthy and pathological tissue. Over the last two decades, HSI has been increasingly used in the medical field, and only recently it has found an application in the operating room. In the last few years, several research groups have used this imaging modality as an intraoperative guidance tool within different surgical disciplines. Despite its great potential, HSI still remains far from being routinely used in the daily surgical practice, since it is still largely unknown to most of the surgical community. The aim of this study is to provide clinical surgeons with an overview of the capabilities, current limitations, and future directions of HSI for intraoperative guidance.

Thermal ablation is an acceptable alternative treatment for primary liver cancer, of which laser ablation (LA) is one of the least invasive approaches, especially for tumors in high-risk locations. Precise control of the LA effect is required to safely destroy the tumor. Although temperature imaging techniques provide an indirect measurement of the thermal damage, a degree of uncertainty remains about the treatment effect. Optical techniques are currently emerging as tools to directly assess tissue thermal damage. Among them, hyperspectral imaging (HSI) has shown promising results in image-guided surgery and in the thermal ablation field. The highly informative data provided by HSI, associated with deep learning, enable the implementation of non-invasive prediction models to be used intraoperatively. Here we show a novel paradigm “peak temperature prediction model” (PTPM), convolutional neural network (CNN)-based, trained with HSI and infrared imaging to predict LA-induced damage in the liver. The PTPM demonstrated an optimal agreement with tissue damage classification providing a consistent threshold (50.6 ± 1.5 °C) for the damage margins with high accuracy (~0.90). The high correlation with the histology score (r = 0.9085) and the comparison with the measured peak temperature confirmed that PTPM preserves temperature information accordingly with the histopathological assessment.

Nerves are critical structures that may be difficult to recognize during surgery. Inadvertent nerve injuries can have catastrophic consequences for the patient and lead to life-long pain and a reduced quality of life. Hyperspectral imaging (HSI) is a non-invasive technique combining photography with spectroscopy, allowing non-invasive intraoperative biological tissue property quantification. We show, for the first time, that HSI combined with deep learning allows nerves and other tissue types to be automatically recognized in in vivo hyperspectral images. An animal model was used, and eight anesthetized pigs underwent neck midline incisions, exposing several structures (nerve, artery, vein, muscle, fat, skin). State-of-the-art machine learning models were trained to recognize these tissue types in HSI data. The best model was a convolutional neural network (CNN), achieving an overall average sensitivity of 0.91 and a specificity of 1.0, validated with leave-one-patient-out cross-validation. For the nerve, the CNN achieved an average sensitivity of 0.76 and a specificity of 0.99. In conclusion, HSI combined with a CNN model is suitable for in vivo nerve recognition.

Hyperspectral imaging (HSI) is a non-invasive imaging modality already applied to evaluate hepatic oxygenation and to discriminate different models of hepatic ischemia. Nevertheless, the ability of HSI to detect and predict the reperfusion damage intraoperatively was not yet assessed. Hypoxia caused by hepatic artery occlusion (HAO) in the liver brings about dreadful vascular complications known as ischemia-reperfusion injury (IRI). Here, we show the evaluation of liver viability in an HAO model with an artificial intelligence-based analysis of HSI. We have combined the potential of HSI to extract quantitative optical tissue properties with a deep learning-based model using convolutional neural networks. The artificial intelligence (AI) score of liver viability showed a significant correlation with capillary lactate from the liver surface (r = −0.78, p = 0.0320) and Suzuki’s score (r = −0.96, p = 0.0012). CD31 immunostaining confirmed the microvascular damage accordingly with the AI score. Our results ultimately show the potential of an HSI-AI-based analysis to predict liver viability, thereby prompting for intraoperative tool development to explore its application in a clinical setting.

Iatrogenic ureteral injuries (IUI) occur in 0.5–1.3% of cases during abdominal surgery. If not recognized intraoperatively, IUI increase morbidity/mortality. A universally accepted method to prevent IUI is lacking. Near-infrared fluorescent imaging (NIRF), penetrating deeper than normal light within the tissue, might be useful, therefore ureter visualization combining NIRF with special dyes (i.e. IRDye 800BK) is promising. Aim of this work is to evaluate the detection of ureters using stents coated with a novel biocompatible fluorescent material (NICE: near-infrared coating of equipment), during laparoscopy. female pigs underwent placement of NICE-coated stents (NS). NIRF was performed, and fluorescence intensity (FI) was computed. Successively, 0.15 mg/kg of IRDye 800BK was administered intravenously, and FI was computed at different timepoints. Ureter visualization using NS only was further assessed in a human cadaver. Both methods allowed in vivo ureter visualization, with equal FI. However, NS were constantly visible whereas IRDye 800BK allowed visualization exclusively during the ureteral peristaltic phases. In the human cadaver, NS provided excellent ureter visualization in its natural anatomical position. NS provided continuous ureteral visualization with similar FI as the IRDye 800BK, which exclusively allowed intermittent visualization, dependent on ureteral peristalsis. NS might prove useful to visualize ureters intraoperatively, potentially preventing IUI.

To reduce the risk of pancreatic fistula after pancreatectomy, a satisfactory blood flow at the pancreatic stump is considered crucial. Our group has developed and validated a real-time computational imaging analysis of tissue perfusion, using fluorescence imaging, the fluorescence-based enhanced reality (FLER). Hyperspectral imaging (HSI) is another emerging technology, which provides tissue-specific spectral signatures, allowing for perfusion quantification. Both imaging modalities were employed to estimate perfusion in a porcine model of partial pancreatic ischemia. Perfusion quantification was assessed using the metrics of both imaging modalities (slope of the time to reach maximum fluorescence intensity and tissue oxygen saturation (StO2), for FLER and HSI, respectively). We found that the HSI-StO2 and the FLER slope were statistically correlated using the Spearman analysis (R = 0.697, p = 0.013). Local capillary lactate values were statistically correlated to the HSI-StO2 and to the FLER slope (R = &minus, 0.88, p &lt, 0.001 and R = &minus, 0.608, p = 0.0074). HSI-based and FLER-based lactate prediction models had statistically similar predictive abilities (p = 0.112). Both modalities are promising to assess real-time pancreatic perfusion. Clinical translation in human pancreatic surgery is currently underway.

This work presents the potential of hyperspectral imaging (HSI) to monitor the thermal outcome of laser ablation therapy used for minimally invasive tumor removal. Our main goal is the establishment of indicators of the thermal damage of living tissues, which can be used to assess the effect of the procedure. These indicators rely on the spectral variation of temperature-dependent tissue chromophores, i.e., oxyhemoglobin, deoxyhemoglobin, methemoglobin, and water. Laser treatment was performed at specific temperature thresholds (from 60 to 110 &deg, C) on in-vivo animal liver and was assessed with a hyperspectral camera (500&ndash, 995 nm) during and after the treatment. The indicators were extracted from the hyperspectral images after the following processing steps: the breathing motion compensation and the spectral and spatial filtering, the selection of spectral bands corresponding to specific tissue chromophores, and the analysis of the areas under the curves for each spectral band. Results show that properly combining spectral information related to deoxyhemoglobin, methemoglobin, lipids, and water allows for the segmenting of different zones of the laser-induced thermal damage. This preliminary investigation provides indicators for describing the thermal state of the liver, which can be employed in the future as clinical endpoints of the procedure outcome.

Simple Summary Anastomotic leak is the most dangerous complication occurring after esophagectomy and its relationship with inadequate visceral perfusion is widely recognized. Currently, the adequate perfusion of the gastric conduit is intraoperatively assessed by surgeons using subjective indicators (e.g., serosal color or pulsatile flow of vessels). During the last decades, several innovative optical techniques based on the interaction of light with tissue have been developed to monitor perfusion in esophagogastric surgery. However, these innovative approaches are characterized by a lack of video rate and reproducibility. They also provide operator-dependent results and lengthen the surgical workflow. Single Snapshot imaging of Optical Properties (SSOP) is an optical technique, which can overcome such limitations, providing quantitative information on the optical properties of biological tissues over a large field of view. It is the first study to demonstrate the accuracy of SSOP in the quantification of serosal StO2% in a porcine gastric conduit model. Abstract Anastomotic leakage (AL) is a serious complication occurring after esophagectomy. The current knowledge suggests that inadequate intraoperative perfusion in the anastomotic site contributes to an increase in the AL rate. Presently, clinical estimation undertaken by surgeons is not accurate and new technology is necessary to improve the intraoperative assessment of tissue oxygenation. In the present study, we demonstrate the application of a novel optical technology, namely Single Snapshot imaging of Optical Properties (SSOP), used to quantify StO2% in an open surgery experimental gastric conduit (GC) model. After the creation of a gastric conduit, local StO2% was measured with a preclinical SSOP system for 60 min in the antrum (ROI-A), corpus (ROI-C), and fundus (ROI-F). The removed region (ROI-R) acted as ischemic control. ROI-R had statistically significant lower StO2% when compared to all other ROIs at T15, T30, T45, and T60 (p < 0.0001). Local capillary lactates (LCLs) and StO2% correlation was statistically significant (R = −0.8439, 95% CI −0.9367 to −0.6407, p < 0.0001). Finally, SSOP could discriminate resected from perfused regions and ROI-A from ROI-F (the future anastomotic site). In conclusion, SSOP could well be a suitable technology to assess intraoperative perfusion of GC, providing consistent StO2% quantification and ROIs discrimination.

PURPOSE The hepato-mesenteric trunk is an extremely rare condition in which the common hepatic artery (CHA) originates from the superior mesenteric artery (SMA). Usually, CHA passes behind the head of the pancreas. A systematic review was performed to provide guidelines for the perioperative management of patients with this anatomical variation who underwent a pancreaticoduodenectomy (PD). A case report was also included. METHODS A systematic search of the literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. The risk of bias within individual studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Case report was structured according to the CARE guidelines. RESULTS After an initial selection of 141 titles, 9 articles were included in the study (n���=���10 patients). A postoperative surgical complication which required a reintervention occurred only one time. In four patients, CHA had a posterior position relative to pancreas, while in three cases, it was anterior. The remaining three patients had an intrapancreatic course. The CHA was resected in two patients, with an end-to-end reconstruction or using the splenic artery stump. In only three patients, a preoperative multidisciplinary presentation was performed and in four cases, the CHA variation was not described by radiologists in formal CT-scan reports. CONCLUSION Although there are no definitive guidelines, improvements in the preoperative knowledge of such a rare anatomical variation may ensure better postoperative outcomes, avoiding intraoperative accidents and life-threatening postoperative complications.

Liver ischemia/reperfusion injury (IRI) is a dreadful vascular complication, which leads to liver damage. It is often associated with graft loss in liver transplantation and with a higher morbidity and mortality. IRI can have different causes, such as inflow clumping during surgical procedures in hepatic resection, liver transplantation, trauma, as well as during the stenosis of the vasculature caused by cancer. Here, we show a detailed IRI protocol in a porcine model.

Background Sickle cell disease is a group of autosomal recessive disorders characterised by haemolytic anaemia. Liver is one of the most affected organs, ranging from liver tests alterations to acute liver failure for which liver transplantation is the only life-saving treatment. Methods This study aims to make a systematic review of the current literature to evaluate indications, timing, and results of liver transplantation for patients affected by SCD. Results Twenty-nine patients in total were reported worldwide until 2018, the average patient age is 28.7 (0.42–56), all patients have a pre-transplant diagnosis of SCD. Cirrhosis at transplantation was present in six-teen (n = 16, 55.1%) patients. In ten patients (n = 10, 34.5%), acute liver failure arises from healthy liver and presented sickle cell intrahepatic cholestasis. Eleven patients (n = 11, 39.2%) died, three (n = 3, 10.7%) in the first postoperative month, and seven (n = 7, 25%) in the first year. Mean follow-up was 27 months (range: 7–96), one-year overall survival was 48.7%. Discussion Liver transplantation for SCD has been increasingly reported with encouraging results. Indications are presently reserved for acute liver failure arising both in healthy liver and end-stage liver disease.

Background:Iatrogenic ureteral injury is one of the feared complications during intrapelvic surgery. There are limited data on the use of novel near-infrared fluorescence (NIRF) imaging dyes for the purpose of noninvasive ureteral visualization in robot-assisted laparoscopic surgery (RALS). In this study, we evaluated the feasibility of NIRF imaging of the ureter using the IRDye(R)800BK dye as the fluorescence dye and a robotic platform with Firefly (TM) technology as an imaging system. Materials and Methods:An intravenous dose of 0.15 mg/kg was administered in 3 pigs and NIRF imaging was performed for a total duration of 60 minutes. The intraoperative video recordings were analyzed to determine fluorescence intensities and the target-to-background ratio (TBR). Results:In all included animals, a clear delineation of the ureter was achieved from 5 minutes after dye administration until the end of the study. During this time period, the ureter was clearly distinguishable from its surroundings and no statistical differences in TBR were observed. Conclusion:The IRDye 800BK dye, a novel NIRF dye currently undergoing clinical translation, is a promising contrast agent used for noninvasive ureteral imaging, which has the potential to be valuable during RALS.

Background: Peripheral arterial disease has high incidence and complication rates. Vessel recanalization represents the main therapy. However, it induces reperfusion injury. Preconditioning with si...

Minimally invasive techniques are gaining a major role in treating superficial gastrointestinal cancers. Energy-based approaches have been investigated as potential alternative to the gold-standard techniques (e.g., Endoscopic Submucosal Dissection). Among these techniques, the laser has been studied for achieving a selective ablation of the gastric mucosa. Together with the optimization of the laser settings for avoiding tissue perforation or insufficient ablation, a tool providing quantitative information about the intraoperative tissue state can support the treatment guidance. This work aims at providing a novel non-invasive approach based on the use of hyperspectral imaging (HSI) for monitoring ablative therapy in in vivo gastric mucosa. The three-dimensional datasets generated by the HSI provide spatial and spectral information of the scene, thus collecting tissue optical features during the ablation therapy in each pixel of the images. The operation of a diode laser focused on the porcine gastric mucosa was controlled in accordance with chosen temperature thresholds (i.e., 36, 60, 70, 80, 100, 110 °C), measured with a thermographic camera. HSIs of the living gastric mucosa undergoing laser procedure hold diagnostic information about the thermal outcome. Two tests have been performed, and the temperature dependence of three characteristic spectral wavelengths have been analysed: oxyhemoglobin (Hb02) in the visible range 500-600 nm, methemoglobin (metHb) around 630 nm, and deoxyhemoglobin (Hb) at 760 nm. The data have been processed in terms of absorbance at the set temperature relative to the absorbance at initial body temperature (36 °C). After 60 °C the percentage relative absorbance of metHb increased significantly in both tests (i.e., 92.3±1.9 % at 70 °C and 229.4±4.7% at 100 °C in Test2); regarding the Hb at 110 °C, Test1 reported an increase of 43.8±1.7 %, versus 127.2±3.8% in the Test2. On the other hand, HbO2 chromophore experiences an increase only for the first stages of heating later decreasing in favour of metHb and Hb formation.In both tests, similar trends for characteristic wavelengths are found, thus demonstrating the potential of the HSI measurement in laser-induced thermal damage monitoring. Although optical response show dependence on the tissue type and condition, this finding encourages future studies to standardize this promising technique.

Post-operative pancreatic fistula is the most dreadful complication of pancreatic resections. Tissue perfusion is a recognized risk factor of fistula in gastrointestinal anastomosis, but has been poorly studied in case of pancreatic surgery. Organ perfusion can be estimated by several intraoperative optical imaging modalities, including exogenous fluorescence imaging with Indocyanine Green (ICG). A limitation of ICG fluorescence angiography is the lack of a quantitative analytic method. Our group has developed and validated a real-time computational imaging analysis of tissue perfusion, based on the slope of the time of fluorescence peak, defined fluorescence-based enhance reality (FLER). This consists in encoding tissue hemodynamics into a virtual perfusion cartography that is superimposed on intraoperative images in real time, in order to provide the perfusion information to surgeons. Another emerging technology is hyperspectral imaging (HSI), which combines a spectrometer and a camera. HSI obtains spectral tissue curves pixel by pixel in a wide wavelength range and can provide absolute values of concentration and/or oxygen saturation of hemoglobin. The aim of this study was to investigate the efficacy of both imaging modalities, FLER and HSI, to estimate pancreatic perfusion. Methods Twelve pigs were involved and randomly assigned to interventional group (n=6) and a control group (n =6). After a median laparotomy the pancreas was fully exposed. In the interventional group, under radiographic guidance, a segmental ischemia of the pancreas was induced by means of coil embolization in small splenic arterial branches, via a femoral artery approach. No ischemia was induced in the control group. HSI images were obtained using the TIVITA camera (Diaspective Vision, Germany). FLER was obtained after injecting 0.2 mg/kg of ICG and image processing using a dedicated software (ER PERFUSION, IRCAD, France). The augmented reality of color-coded images derived from both FLER and HSI were overlapped on the video image. Local capillary lactates (LCL) were sampled in different regions of interests (ROIs) of the pancreas. LCL were correlated to the absolute values provided by the imaging analyses (slope of time-to-peak and StO2, respectively for fluorescence and HSI). Results In all pigs from the interventional group, the segmental ischemic areas were successfully created. The mean slope was slower; the mean StO2 was lower; and mean LCL were lower in the ischemic zone than in the transition and vital zones. The scatter plot between the slope and StO2, the slope and LCL, and StO2 and LCL in all 12 pigs showed statistically significant correlation. In addition, LCL can be predicted from FLER and StO2. The prediction from HSI StO2 (median error: 0.67 mmol/L) is significantly more accurate than FLER (median error: 0.8 mmol/L) (P=0.02). Conclusions FLER and HSI, enable both to precisely quantify and visualize real-time perfusion of the pancreas in this porcine model of pancreas ischemia. HSI showed a greater accuracy in predicting the value of capillary local lactates when compared to quantitative exogenous fluorescence analysis.

Esophagectomy often presents anastomotic leaks (AL), due to tenuous perfusion of gastric conduit fundus (GCF). Hybrid (endovascular/surgical) ischemic gastric preconditioning (IGP), might improve GCF perfusion. Sixteen pigs undergoing IGP were randomized: (1) Max-IGP (n = 6): embolization of left gastric artery (LGA), right gastric artery (RGA), left gastroepiploic artery (LGEA), and laparoscopic division (LapD) of short gastric arteries (SGA), (2) Min-IGP (n = 5): LGA-embolization, SGA-LapD, (3) Sham (n = 5): angiography, laparoscopy. At day 21 gastric tubulation occurred and GCF perfusion was assessed as: (A) Serosal-tissue-oxygenation (StO2) by hyperspectral-imaging, (B) Serosal time-to-peak (TTP) by fluorescence-imaging, (C) Mucosal functional-capillary-density-area (FCD-A) index by confocal-laser-endomicroscopy. Local capillary lactates (LCL) were sampled. Neovascularization was assessed (histology/immunohistochemistry). Sham presented lower StO2 and FCD-A index (41 &plusmn, 10.6%, 0.03 &plusmn, 0.03 respectively) than min-IGP (66.2 &plusmn, 10.2%, p-value = 0.004, 0.22 &plusmn, 0.02, p-value &lt, 0.0001 respectively) and max-IGP (63.8 &plusmn, 9.4%, p-value = 0.006, 0.2 &plusmn, 0.0001 respectively). Sham had higher LCL (9.6 &plusmn, 4.8 mL/mol) than min-IGP (4 &plusmn, 3.1, p-value = 0.04) and max-IGP (3.4 &plusmn, 1.5, p-value = 0.02). For StO2, FCD-A, LCL, max- and min-IGP did not differ. Sham had higher TTP (24.4 &plusmn, 4.9 s) than max-IGP (10 &plusmn, 1.5 s, p-value = 0.0008) and min-IGP (14 &plusmn, 1.7 s, non-significant). Max- and min-IGP did not differ. Neovascularization was confirmed in both IGP groups. Hybrid IGP improves GCF perfusion, potentially reducing post-esophagectomy AL.

Liver ischaemia reperfusion injury (IRI) is a dreaded pathophysiological complication which may lead to an impaired liver function. The level of oxygen hypoperfusion affects the level of cellular damage during the reperfusion phase. Consequently, intraoperative localisation and quantification of oxygen impairment would help in the early detection of liver ischaemia. To date, there is no real-time, non-invasive, and intraoperative tool which can compute an organ oxygenation map, quantify and discriminate different types of vascular occlusions intraoperatively. Hyperspectral imaging (HSI) is a non-invasive optical methodology which can quantify tissue oxygenation and which has recently been applied to the medical field. A hyperspectral camera detects the relative reflectance of a tissue in the range of 500 to 1000 nm, allowing the quantification of organic compounds such as oxygenated and deoxygenated haemoglobin at different depths. Here, we show the first comparative study of liver oxygenation by means of HSI quantification in a model of total vascular inflow occlusion (VIO) vs. hepatic artery occlusion (HAO), correlating optical properties with capillary lactate and histopathological evaluation. We found that liver HSI could discriminate between VIO and HAO. These results were confirmed via cross-validation of HSI which detected and quantified intestinal congestion in VIO. A significant correlation between the near-infrared spectra and capillary lactate was found (r = − 0.8645, p = 0.0003 VIO, r = − 0.7113, p = 0.0120 HAO). Finally, a statistically significant negative correlation was found between the histology score and the near-infrared parameter index (NIR) (r = − 0.88, p = 0.004). We infer that HSI, by predicting capillary lactates and the histopathological score, would be a suitable non-invasive tool for intraoperative liver perfusion assessment.

BACKGROUND: Clinical evaluation of the demarcation line separating ischemic from non-ischemic liver parenchyma may be challenging. Hyperspectral imaging (HSI) is a noninvasive imaging modality, which combines a camera with a spectroscope and allows quantitative imaging of tissue oxygenation. Our group developed a software to overlay HSI images onto the operative field, obtaining HSI-based enhanced reality (HYPER). The aim of the present study was to evaluate the accuracy of HYPER to identify the demarcation line after a left vascular inflow occlusion during an anatomical left hepatectomy. MATERIALS AND METHODS: In the porcine model (n = 3), the left branches of the hepatic pedicle were ligated. Before and after vascular occlusion, HSI images based on tissue oxygenation (StO(2)), obtained through the Near-Infrared index (NIR index), were regularly acquired and superimposed onto RGB video. The demarcation line was marked on the liver surface with electrocautery according to HYPER. Local lactates were measured on blood samples from the liver surface in both ischemic and perfused segments using a strip-based device. At the same areas, confocal endomicroscopy was performed. RESULTS: After ligation, HSI demonstrated a significantly lower oxygenation (NIR index) in the left medial lobe (LML) (0.27% ± 0.21) when compared to the right medial lobe (RML) (58.60% ± 12.08; p = 0.0015). Capillary lactates were significantly higher (3.07 mmol/L ± 0.84 vs. 1.33 ± 0.71 mmol/L; p = 0.0356) in the LML versus RML, respectively. Concordantly, confocal videos demonstrated the absence of blood flow in the LML and normal perfusion in the RML. CONCLUSIONS: HYPER has made it possible to correctly identify the demarcation line and quantify surface liver oxygenation. HYPER could be an intraoperative tool to guide perfusion-based demarcation line assessment and segmentation.

Redox regulation has recently been proposed as a critical intracellular mechanism affecting cell survival, proliferation, and differentiation. Redox homeostasis has also been implicated in a variety of degenerative neurological disorders such as Parkinson's and Alzheimer's disease. In fact, it is hypothesized that markers of oxidative stress precede pathologic lesions in Alzheimer's disease and other neurodegenerative diseases. Several therapeutic approaches have been suggested so far to improve the endogenous defense against oxidative stress and its harmful effects. Among such approaches, the use of artificial antioxidant systems has gained increased popularity as an effective strategy. Nanoscale drug delivery systems loaded with enzymes, bioinspired catalytic nanoparticles and other nanomaterials have emerged as promising candidates. The development of degradable hydrogels scaffolds with antioxidant effects could also enable scientists to positively influence cell fate. This current review summarizes nanobiomaterial-based approaches for redox regulation and their potential applications as central nervous system neurodegenerative disease treatments.

Laser ablation (LA) is a minimally invasive procedure based on light/tissue interaction aimed to induce a controlled tumor necrosis by increasing tissue temperature. Given the relationship between tissue damage and produced heat, LA needs a fine control of evolving thermal effects in order to evaluate and control procedure outcome. This study relies on biomedical optics principles for non-invasive diagnostic tools development, and presents a contactless approach based on hyperspectral imaging (HSI) to monitor thermal damage during in vivo porcine LA. By collecting relative pixel-by-pixel reflectance/absorbance of a wide range spectrum (500-1000nm), HSI can track molecular structure modifications caused by the thermoablative procedure. Indeed, these modifications alter tissue light scattering and absorption. In order to investigate tissue spectrum change by increasing temperature, HSI was collected at fixed maximum temperatures (37, 60, 70, 80, 90, 100, 110 °C) and immediately after LA (1, 2, 3, 4, and 5 minutes). Tissue spectral response for two tests was analyzed also relying on the ablated area considered. Regions of Interest of different dimensions (16, 77, and 170 pixels) were placed in the images after applying a motion correction. Obtained spectra show noticeable variations once a specific temperature threshold has been reached (80-100 °C). Specifically, the measured absorbance variation for selected wavelengths (630, 760, 960nm, for methemoglobin, deoxyhemoglobin, and water respectively) confirms tissue optical behavior dependence with its thermal state. This preliminary investigation discloses the potential of HSI measurement to characterize LA damage, encouraging future studies to standardize this novel technique.