Indocyanine Green Clearance as a Tool to Predict Postoperative Liver Failure and Major Complications: First Systematic Review of Current Literature and Meta-analysis

Abstract

Purpose: Perioperative liver function evaluation with indocyanine green (ICG) has been widely used in Asian countries. This study aims to review current strategies for postoperative liver failure (PLF) assessment with ICG in patients undergoing hepatectomy or liver transplant. Method: A systematic review was performed according to PRISMA guidelines. PubMed, Scopus, WoS, and Cochrane Library were searched up to 2021. The primary outcome measure was PLF. As a secondary outcome, major postoperative complications defined by Clavien-Dindo III-V grades were assessed. Quantitative analysis by random-effects model was performed for studies reporting similar methods. Results: This is the first systematic review to date. Out of 1674 studies, 40 were included in the review. Most were prospective studies (21/40) from Asia (23/40). Of the 31 studies including hepatectomies, only 15 reported PLF by ISGLS criteria. 94% of studies used ICG preoperatively, though some combined intraoperative and/or postoperative use. 77% of them obtained significant results and recommended its use. For liver resection, preoperative ICG-R15>15% was the most frequent cut-off related to PLF. For liver transplant, early postoperative ICG-PDR<12%/min was generally related to worse outcomes. Meta-analysis was performed over 4 studies including 478 patients undergoing hepatectomy for hepatocarcinoma. The pooled MD of ICG-R15 between patients with and without PLF was 0.59 (95% CI: 0.16-1.03; I2=64%). Finally, 3 studies reporting complications after hepatectomy by ICG-R15 cut-off were assessed. No significant association between ICG-R15 and major complications (OR 0.8; 95% CI: 0.47 - 1.35; I2=83%) was found. Conclusion: Literature suggests ICG clearance is a useful non-invasive method to predict PLF in liver surgery. However, due to different parameters and variable usage methods across studies, a global consensus should be defined.