Indocyanine Green Cholangiography Research Articles

Determining the patency of biliary tracts in dogs with gallbladder mucocele using near-infrared cholangiography with indocyanine green.

Cholecystectomy is indicated for gallbladder mucoceles (GBM). Evaluating the patency of the biliary duct and precise biliary tree visualization is crucial for reducing the risk of compromised bile flow after surgery. Therefore, intraoperative cholangiography (IOC) is recommended during cholecystectomy to prevent biliary tract injury. Although indocyanine green (ICG) cholangiography has been extensively reported in human medicine, only one study has been conducted in veterinary medicine. Therefore, this study aimed to demonstrate the use of ICG for IOC to identify fluorescent biliary tract images and determine the patency of the common bile duct during cholecystectomy in dogs. This study comprised 27 dogs, consisting of 17 with gallbladder mucoceles (GBM) and 10 controls, specifically including dogs that had undergone elective cholecystectomy for GBM. ICG injection (0.25 mg/kg) was administered intravenously at least 45 minutes before surgery. During the operation, fluorescent images from cholangiography were displayed on the monitor and obtained in black-and-white mode for the comparison of fluorescence intensity (FI). The FI values of the gallbladders (GBs) and common bile duct (CBD) were measured using FI analyzing software (MGViewer V1.1.1, MetapleBio Inc.). The results demonstrated successful CBD patency identification in all cases. Mobile GBM showed partial gallbladder visibility, whereas immobile GBM showed limited visibility. Additionally, insights into the adequate visualization of the remaining extrahepatic biliary tree anatomy were provided, extending beyond the assessment of CBD patency and gallbladder intensity. Our study demonstrates the potential of fluorescent IOC using intravenous injection of ICG for assessing the patency of the cystic duct and common bile duct during cholecystectomy in patients with GBM, eliminating the need for surgical catheterization and flushing of the biliary ducts. Further research is warranted to investigate and validate the broader applicability of ICG cholangiography in veterinary medicine.

Utility of indocyanine green cholangiography (ICG) in laparoscopic cholecystectomy for acute cholecystitis

Utility of indocyanine green cholangiography (ICG) in laparoscopic cholecystectomy for acute cholecystitis

Near-infrared fluorescence cholangiography in dogs: A pilot study.

To determine the effect of indocyanine green (ICG) dose and timing of administration on near-infrared fluorescence (NIRF) imaging of the normal canine biliary tree. Preclinical prospective study. Eight purpose-bred beagles. The dogs were randomized to receive two of four intravenous ICG dose (low [L]:0.05 mg/kg or high [H]:0.25 mg/kg)/time (0 and 3 h prior to NIRF) combinations. NIRF images were collected every 10 min for 120 min. Target (cystic duct)-to-background (liver) ratios were calculated for all timepoints and compared. ICG cholangiography was successful in all dogs. The contrast ratio was above 1 in the L0 group by 20 min and reached its peak at 100 min. In the H0 group, the ratio was above 1 by 60 min and reached its peak at 90 min. Contrast ratios above 2 (fluorescence twice as bright in the cystic duct compared to the liver) were maintained from 180 to 300 min for L3 and H3 and was achieved after 80 min for L0. Low dose ICG provided better ratios early after injection compared to the high dose which remained highly concentrated in the liver tissue after injection. Both doses provided excellent visualization of the biliary tree at 3 h post injection, low dose ICG provided better ratios from 3 to 5 h post injection. Based on these results, 0.05 mg/kg of ICG administered at anesthetic premedication, or as early as 3 h prior to laparoscopic surgery should yield optimal fluorescence images. This study provides guidelines for NIRF cholangiography in clinically normal dogs.

Intraoperative indocyanine green fluorescence cholangiography can rule out biliary atresia: A preliminary report

The prognosis of BA is known to be poor if definitive surgery is performed too late. Therefore, excluding BA as a diagnosis at an early stage is crucial. Conventional cholangiography requiring cannulation through the gallbladder may be unnecessarily invasive for patients, especially when ruling out BA. Therefore, a less invasive alternative such as indocyanine green (ICG) cholangiography, which does not require cannulation, should be established. In this study, we focused on excluding BA and confirmed the usefulness of intravenous ICG fluorescence cholangiography. To the best of our knowledge, this is the first preliminary study to report the use of intravenous ICG cholangiography for BA exclusion. The study participants were patients who underwent liver biopsy and intraoperative cholangiography after they were suspected to have BA, between 2013 and 2022. ICG fluorescence cholangiography was performed on all patients who provided informed consent. During the study period, 88 patients underwent a laparoscopic liver biopsy and cholangiography. Among them, 65 (74%) were diagnosed with BA and underwent a subsequent laparoscopic Kasai portoenterostomy. BA was ruled out intraoperatively in 23 patients. Of the 23 patients in whom BA was ruled out, 14 underwent ICG cholangiography, 11 had gallbladder (GB) fluorescence, and 9 had both GB and common bile duct (CBD) fluorescence. Conventional cholangiography was very difficult in 2 of 23 cases: in 1 case, cannulation of the atrophic gallbladder was impossible, and cholecystectomy was indicated after multiple attempts; in 1 case, upstream cholangiography was not possible. In both cases, ICG fluorescence cholangiography successfully imaged the CBD and the GB. In conclusion, intravenous ICG fluorescence cholangiography might be a useful and less invasive diagnostic procedure that can rule out BA in infants.

Application of indocyanine green cholangiography in accurate identification of the common bile duct in laparoscopic cholecystectomy

Application of indocyanine green cholangiography in accurate identification of the common bile duct in laparoscopic cholecystectomy

Propensity score matching between conventional laparoscopic cholecystectomy and indocyanine green cholangiography-guided laparoscopic cholecystectomy: observational study.

The injury of common bile duct (CBD) is one of the most common complications during laparoscopic cholecystectomy. Consequences of CBD injury are grave since CBD is the only pathway of bile from biliary tracts to duodenum. When CBD injury occurs, extra surgical procedures repairing CBD or reconstructing biliary tracts have to be performed on patients, which increase expenses of patients and physical trauma. A total of 238 patients undergoing laparoscopic cholecystectomy (LC) in Zhuhai People's Hospital from July 2020 to April 2021 were enrolled in this observational study, including 126 patients undergoing conventional LC and 112 patients undergoing ICG angiography-guided LC. Method of propensity score matching was used to balance the preoperative data of patients in the two groups. For both groups, the "Critical View of Safety" (CVS) was introduced. For the ICG group, the CBD, cystic duct (CD), and gallbladder were identified using near-infrared (NIR) ray. Intraoperative blood loss, operation time, postoperative hospitalization time, and the incidence rate of intraoperative complications were compared between the two groups. ICG angiography in LC shows safe and effective outcomes. The intraoperative blood loss, operation duration, postoperative hospitalization time, and complication incidence rate of the ICG group are significantly lower than those of the conventional group. ICG angiography in LC was a useful and effective method to identify the CBD and prevent intraoperative complications. Registration at Chinese Clinical Trial Registry, No: ChiCTR1900024594. Registration time: 18/07/2019.

Technique of robotic right donor hepatectomy.

Background:Although minimally invasive right donor hepatectomy (RDH) has been reported, this innovation is yet to be widely accepted by transplant community. Bleeding during transection, division of right hepatic duct (RHD), suturing of donor duct as well as retrieval with minimal warm ischemia are the primary concerns of most donor surgeons. We describe our simplified technique of robotic RDH evolved over 144 cases.Patients and Methods:Right lobe mobilization is performed in a clockwise manner from right triangular ligament over inferior vena cavae up to hepatocaval ligament. Transection is initiated using a combination of bipolar diathermy and monopolar shears controlled by console surgeon working in tandem with lap CUSA operated by assistant surgeon. With the guidance of indocyanine green cholangiography, RHD is divided with robotic endowrist scissors (Potts), and remnant duct is sutured with 6-0 PDS. Final posterior liver transection is completed caudocranial without hanging manoeuvre. Right lobe with intact vascular pedicle is placed in a bag, vascular structures then divided, and retrieved through Pfannenstiel incision.Conclusion:Our technique may be easy to adapt with the available robotic instruments. Further innovation of robotic platform with liver friendly devices could make robotic RDH the standard of care in future.

The role of indocyanine green cholangiography in minimally invasive surgery.

Near-infrared fluorescent cholangiography (NIFC) using indocyanine green (ICG) is increasingly used to aid in the identification of extrahepatic biliary anatomy. The use of ICG cholangiography for laparoscopic cholecystectomy is suggested to be safe and feasible. This article aimed at reviewing the dosage and timing of the intravenous administration of ICG, its efficacy and potential usage. MEDLINE and PubMed searches were performed using the key words "fluorescent cholangiography," "ICG cholangiography," "near-infrared fluorescent cholangiography" and "laparoscopic cholecystectomy" to identify relevant articles published in English during the years of 2010 to 2020. Reference lists from the articles were reviewed to identify additional pertinent articles. Several factors can influence the quality of the fluorescence imaging, including the dose and timing of ICG injection, liver function, the thickness of fatty tissue and the presence of inflamed tissues due to acute pathology. Various devices tested also have a different sensitivity to the fluorescence signal. RCTs showed fluorescence cholangiography were comparable to traditional intraoperative cholangiogram in visualizing the extrahepatic biliary anatomy. However, there is still no consensus in the dosing of ICG and the time interval between ICG injection and detection of biliary fluorescence. Fluorescence cholangiography's ability to enhance such visualization can potentially reduce bile duct injury risks and shorten the operative time. However, no valuable data for bile duct injury prevention or detection could be retrieved. NIFC is demonstrated as a safe, non-irradiating technique to identify and aid in the visualization of extrahepatic biliary anatomy. Laparoscopic cholecystectomy with real-time NIFC enables a better visualization and identification of biliary anatomy and therefore it is potentially as a means of increasing the safety of laparoscopic cholecystectomy. Whether this translates into reducing complication rates must still be determined. The dosage and timing of the intravenous administration of ICG relative to the operative procedure still requires optimization to ensure reliable images.

Micro-Dosing of Indocyanine Green for Intraoperative Fluorescence Cholangiography

Background: Surgery involving the biliary tree is common but has the potential for serious complications. Adjuncts such as intraoperative cholangiogram and, more recently, indocyanine green (ICG) fluorescence cholangiography, have been used to more accurately define the relevant anatomy and decrease the risk of common bile duct injury. The optimal ICG dose is unknown, but the most commonly cited dose in the literature is 2.5 mg. We describe our experience using micro-dosing of ICG as proof-of-concept for its successful use in the identification of biliary structures. Methods: A video library from a variety of hepatobiliary surgeries which included micro-dosing of ICG was compiled between 2018 and 2020. These videos were retrospectively reviewed and graded for the degree of visualization of biliary structures (complete, partial, none) and the degree of background liver fluorescence (significant, moderate, minimal). Results: Overall, 40 videos were reviewed; 70% were minimally invasive cholecystectomies. Micro-dosing was used in all patients; complete visualization was achieved in 52.5% of the patients, partial visualization in 40%, and no visualization in 7.6%. Eighty percent of patients had minimal to moderate background fluorescence. Despite ICG micro-dosing, 20% of the patients still had significant liver dye uptake. Conclusion: ICG cholangiography is an alternative to more invasive means of intraoperative imaging during biliary surgery, but the optimal dose of ICG is unknown. We have used a 0.05 mg micro-dose of ICG to successfully visualize biliary structures and reduce background liver fluorescence. This preliminary report can be used to develop further studies into whether micro-dosing of ICG is associated with improved clinical outcomes.

Near-Infrared Fluorescence Cholangiography can be a Useful Adjunct during Emergency Cholecystectomies.

Background. Emergency cholecystectomy is the gold standard treatment for acute cholecystitis according to National Institute for Health and Care Excellence recommendations. The procedure is feasible but carries a higher risk of iatrogenic injury to the bile duct, which should be considered preventable. Intraoperative fluorescence cholangiography following injection of indocyanine green (ICG) has been reported to aid identification of the extrahepatic bile duct. Data on its feasibility in the context of emergency cholecystectomies are missing. Materials and Methods. Fluorescent ICG was used intraoperatively to enhance the biliary anatomy during 33 consecutive emergency laparoscopic cholecystectomies at our institution. Primary outcomes of surgery were considered the length of hospital stay, conversion to open and complications rate, including bile duct injury. Secondary outcome was operating time. A historical population of emergency cholecystectomies was used as control. Results. There were no common bile duct injuries, no adverse effects from ICG, no conversion to open surgery and no deaths. 90% of patients went home within 48hours after the operation in the absence of complications. ICG demonstrated intraoperative biliary anatomy allowing greater confidence to the surgeon performing emergency cholecystectomies. Six patients were operated beyond 72hours from admission, without experiencing any complication Clavien-Dindo ≥3. ICG population had the same post-operative hospitalisation and complications rate of the control group, with a shorter operating time. Conclusion. Intraoperative augmented visualisation of biliary anatomy with ICG cholangiography can be a useful technology tool, with the potential to extend the 72hours window of safety for emergency cholecystectomies.

New technical development for pure laparoscopic donor hepatectomy: indocyanine green cholangiography and three-dimensional laparoscopy

New technical development for pure laparoscopic donor hepatectomy: indocyanine green cholangiography and three-dimensional laparoscopy

Does Indocyanine Green Cholangiography Identify Critical View of Safety Earlier in Laparoscopic Cholecystectomy ? Results from a Randomised Control Study in University Malaya Medical Centre

Introduction: Indocyanine green (ICG) cholangiography helps identify biliary structures during laparoscopic cholecystectomy (LC). Our study aims to determine if ICG cholangiography assisted LC (ICG –LC) could reach critical view of safety (CVS) earlier compared to conventional white light LC. Method: Patients were randomly grouped into ICG-LC and LC. ICG was administered intravenously to patients preoperatively in the ICG-LC group. Laparoscopic fluorescence imaging system was used during dissection of Calot’s triangle in this group. Duration of time from gallbladder retraction until identification of CVS for each group was measured. All surgeries were performed by the same surgeon and the intraoperative difficulty was rated arbitrarily from level 1 being least difficult to level 4 being most difficult. The data was compared and analysed. Result: Fifty two patients were randomised, 24 patients in ICG-LC and 28 in LC group. There was no significant difference in the median time to identification of CVS in the overall analysis, which was 22 minutes in ICG-LC group and 18 minutes in LC group (p value 0.556). In the subgroup analysis, both ICG-LC and LC group recorded a median time of 13 minutes to reach CVS in level 1 difficulty cholecystectomy, while level 2 was 21 minutes in the ICG- LC group compared to 17 minutes in the LC group (p value 0.662). In level 3, ICG-LC took 41 minutes compared to 38 minutes in LC (p value 0.346). Median time for ICG-LC was faster for Level 4 where it took 48 minutes compared to 54.5 minutes in LC (p value 0.221). No major adverse events were recorded. Conclusion: Use of ICG does not shorten duration of CVS identification. The longer duration taken with ICG could be attributed to more careful dissection from aided visualised anatomy. ICG may be useful to identify CVS earlier for difficult gallbladders but further study is needed.

Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: A retrospective study.

Intraoperative cholangiography involving the excretion of fluorescent indocyanine green (ICG) into the bile is used to determine biliary anatomy in laparoscopic cholecystectomy (LC). This study aimed to evaluate the features of intraoperative ICG cholangiography, in LC with cholecystitis, and compared the delineation of the cystic duct (CD) between ICG cholangiography and magnetic resonance cholangiopancreatography (MRCP).Participants comprised 65 patients undergoing LC using ICG cholangiography.Fifty-eight patients (89.2%) were diagnosed with gallbladder stones and 32 (49.2%) with acute cholecystitis. ICG cholangiography identified CD in 54 patients (83.1%) and did not identify CD in 11 patients (16.9%). The mean value of the fluorescence intensity in the identified CD group by ICG cholangiography was 87.6 ± 31.5 arbitrary unit and that in the not identified CD group by ICG cholangiography was 24.4 ± 10.1 arbitrary unit (P < .001). Compared with the patients in the identified CD group, those in the not identified CD group had higher incidence of acute cholecystitis (P < .001), and higher conversion rates (P = .003). A correlation between the delineation of CD by ICG cholangiography and MRCP was analyzed, and it revealed a correlation between each other (P = .002)Inflammation had harmful effects with regard to the passing of CD. If we can identify CD or common bile duct with ICG cholangiography, we may be able to perform LC with confidence, even in the presence of severe inflammation.