Optimal Dosage of Indocyanine Green Fluorescence for Intraoperative Positive Staining in Laparoscopic Anatomical Liver Resection.

Abstract

Introduction Fluorescence imaging technology, specifically utilizing indocyanine green (ICG), has emerged as a valuable tool in laparoscopic hepatectomy. In particular, laparoscopic anatomical liver resection (ALR) has benefited from the implementation of both positive and negative staining methods. A case series study reported a success rate of 53% for the positive staining method, citing potential issues regarding the proper ICG dosage needed for accurate fluorescence. Thus, it is crucial to conduct research to investigate the optimal dosage for ICG-positive staining in clinical practice to maximize the benefits of this technique. Materials and methods This retrospective study was conducted at a single center, Meiwa Hospital, and received approval from the hospital's ethics committee in accordance with the Helsinki Declaration. We reviewed the records of 264 patients who underwent open and laparoscopic hepatectomies for benign and malignant liver diseases from January 2019 to January 2023. Of these, 18 patients who underwent laparoscopic ALR with the ICG-positive staining method were evaluated. Fluorescence-emitting segmental borders were assessed immediately after puncture (first stage) and during parenchymal dissection (second stage). In the first stage, we evaluated the intensity of fluorescence emission, categorizing it as "strong" or "weak." The absence of visible fluorescence emission was considered a puncture failure. During the second stage of evaluation, from parenchymal resection to completion, we assessed the sustainability of fluorescence emission, defining it as "clear" or "contaminated." Both evaluations were subjectively judged by three surgeons at our center. The ICG quantity per targeted portal vein-bearing liver volume (mg/100 mL) was calculated for each patient, and the optimal dosage was determined using receiver operating characteristic (ROC) curve analysis. To ascertain the minimum value for adequate fluorescence emission intensity, ROC curve analysis was performed to discriminate between binary outcomes of "strong" or "weak" emission. Furthermore, to establish the maximum value for maintaining a clear fluorescence border, ROC curve analysis was conducted to discriminate between "clear" and "contaminated" during the second evaluation. Results Among the 18 successful puncture cases, the first-stage evaluation of fluorescence intensity revealed 14 punctures with "strong" intensity and four punctures with "weak" intensity. In the second-stage evaluation, 13 cases demonstrated "clear" borders, while five cases exhibited "contaminated" borders. ROC curve analysis was performed to determine the optimal ICG dose for adequate fluorescence intensity and preservation of clear borders during dissection. The analysis indicated that the appropriate ICG dose for achieving optimal intensity was 0.028 mg/100 mL (area under the curve [AUC]: 0.893), while the dose that prevented contamination of fluorescence in non-target areas until after dissection was 0.083 mg/100 mL (AUC: 0.723). Conclusions Laparoscopic anatomical resection using the positive staining method requires an optimal ICG dosage of 0.028-0.083 mg per 100 mL of liver volume. By employing this methodology, more precise and safer laparoscopic anatomical resections can be conducted, thereby enhancing the safety of the surgical procedure for patients.