Role and limitations of Indocyanine green Near Infrared Fluorescent Cholangiography: Experience in 100 patients

Pedro Ferraina, MD, Fernando Dip, MD, Mario Nahmod, MD, Lisandro Alle, MD, Carolina Ampudia, MD, Abraham Abdemur, MD, Lo Menzo Emanuele, MD, PhD, Conrad Simpfendorfer, MD, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS. Cleveland Clinic Florida.

Intra-operative cholangiography (IOC) has been demonstrated to allow earlier recognition of biliary injuries, but it does not decrease their incidence, increases operative time and costs, and expose the patient and the surgical staff to radiation. Fluorescent cholangiography (FC) seems to be a promising technique for the intraoperative identification of the biliary tree anatomy. The aim of this study is to analyze the role and limitations of this novel technique.

Materials and Methods:
All the patients undergoing LC between June 2012 and July 2013 were asked to participate in this institutional review board (IRB) approved study. Fluoroscopic and fluorescent cholangiographies were performed to delineate the extrahepatic biliary ducts. For the FC a single dose of 0.05 mg/kg of indocyanine green (ICG) was administered intravenously one hour prior to surgery. During the procedure, alternate exposure from xenon to infrared lights was used to identify the biliary structures before and after dissection. A questionnaire to assess the surgeon’s visibility of extrahepatic bile ducts was administered.

One hundred patients were enrolled in the study, 51 with cholelithiasis, 37 with acute cholecystitis, and 12 with chronic cholecystitis. At least one biliary structure was identified with fluorescence cholangiography in all patients before dissection. The cystic duct was fluorescently visible before dissection in 69% of the cases, and in 96% with some dissection. CBD was identified in 73% of the cases prior to dissection, and in 90% of the cases after some dissection.
No pre- or postoperative complications were observed.

Near infrared fluorescent cholangiography allows the delineation of at least one extrahepatic biliary duct in 73% of cases prior dissection. Partial dissection increases the identification to 100%.

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