Near-infrared fluorescent cholangiography does not facilitate the identification of biliary anatomy in acute cholecystitis during laparoscopic cholecystectomy.

Jennifer Schwartz, MD1, Sylvester Osayi, MD1, Michael P Meara, MD1, Peter Muscarella, MD1, Kyle A Perry, MD1, Umer I Chaudhry, MD2, Daniel A Eiferman, MD1, W. Scott Melvin, MD3, Jeffrey W Hazey1, Vimal K Narula, MD1. 1The Ohio State University Wexner Medical Center, 2Kaiser Permanente, San Diego, CA, 3Montefiore Medical Center

Background: Intraoperative cholangiography (IOC) is the gold standard for identification of biliary anatomy during laparoscopic cholecystectomy. A previous study performed by Osayi et al demonstrated the Near-infrared fluorescence cholangiography (NIRF-C), which allows for imaging of biliary anatomy in real-time, was an effective alternative to IOC for patients with symptomatic biliary disease who underwent elective laparoscopic cholecystectomy. This study is to assess the efficacy of NIRF-C for identification of biliary anatomy in the acute cholecystitis.

Methods: Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used identify extrahepatic biliary structures before and after dissection of Calot’s triangle. Routine intraoperative cholangiogram (IOC) was performed in each case. Identification of biliary structures and NIRF-C was evaluated.

Results: 6 patients underwent laparoscopic cholecystectomy for acute cholecystitis with NIRF-C and IOC. Mean age and BMI were 50 years and 31.14 kg/m² respectively. IOC was only able to be completed in 3/6 (50%) of patients, with 2/3 (66%) patients with complete biliary anatomy visualization. In the patients where IOC was able to be performed, NIRF-C was significantly faster than IOC (1.08 vs 17.87 minutes). NIRF-C did not visualize the biliary structures in 6/6 (100%) of patients prior to dissection of the anatomy. Complete biliary anatomy visualization, including right and left hepatic ducts, common hepatic, cystic duct, and common bile duct, failed in all 6 patients (100%). After final dissection, the common hepatic duct and common bile duct were visualized in 2 patients and the cyst duct visualized in 3 patients. Visualization did not always correlate with ability to perform cholangiogram, as 1 patient had partial biliary visualization with NIRF-C despite inability to perform IOC. No adverse events were observed with NIRF-C.

Conclusions: Acute cholecystitis can make visualization of the biliary system quite difficult and a method for identification of structures in this setting is of particular interest. While NIRF-C was promising for identification of biliary anatomy in the elective setting for non-acute gallbladder pathology, it does not appear to assist with identification of complete biliary anatomy with acute inflammation. IOC still remains the gold standard in this subset of patients.

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