Near-infrared fluorescence cholangiography with indocyanine green for biliary atresia. Real-time imaging during the Kasai procedure: a pilot study

A Pilot Study for Biliary Atresia Diagnosis: Fluorescent Imaging of Indocyanine Green in Stool

BACKGROUND

Biliary atresia is the most common cause of obstructive jaundice in infants and conventional cholangiography is the current diagnostic gold standard. Fluorescent cholangiography with indocyanine green can enhance biliary tree visualization during surgery because it is exclusively excreted into the bile ducts and eventually into the intestine. Therefore, we hypothesized that indocyanine green presence in stool could confirm bile duct patency in infants.

METHODS

A prospective single center cohort study was performed on infants (age ≤ 12 months) with and without jaundice after obtaining IRB approval. Indocyanine green was administered intravenously (0.1 mg/kg). Soiled diapers collected post-injection were imaged for fluorescence.

RESULTS

After indocyanine green administration, fluorescence was detected in soiled diapers for control patients (n = 4, x = 14 h22 m post-injection) and jaundiced patients without biliary atresia (n = 11, x = 13 h28 m post-injection). For biliary atresia patients (n = 7), post-injection soiled diapers before and after Kasai portoenterostomy were collected. Fluorescence was not detected in stool from 6 of 7 biliary atresia patients. As a test, indocyanine green detection in stool was 97% accurate for assessing biliary patency.

CONCLUSION

Fluorescent Imaging for Indocyanine Green (FIInd Green) in stool is a fast and accurate approach to assess biliary patency non-invasively in infants.

LEVEL OF EVIDENCE

Level III.

Utilization of Indocyanine Green (ICG) Fluorescence in Patients with Pediatric Colorectal Diseases: The Current Applications and Reported Outcomes

In pediatric colorectal surgery, achieving and visualizing adequate perfusion during complex reconstructive procedures are paramount to ensure postoperative success. However, intraoperative identification of proper perfusion remains a challeng. This review synthesizes findings from the literature spanning from January 2010 to March 2024, sourced from Medline/PubMed, EMBASE, and other databases, to evaluate the role of indocyanine green (ICG) fluorescence imaging in enhancing surgical outcomes. Specifically, it explores the use of ICG in surgeries related to Hirschsprung disease, anorectal malformations, cloacal reconstructions, vaginal agenesis, bladder augmentation, and the construction of antegrade continence channels. Preliminary evidence suggests that ICG fluorescence significantly aids in intraoperative decision-making by improving the visualization of vascular networks and assessing tissue perfusion. Despite the limited number of studies, initial findings indicate that ICG may offer advantages over traditional clinical assessments for intestinal perfusion. Its application has demonstrated a promising safety profile in pediatric patients, underscoring the need for larger, prospective studies to validate these observations, quantify benefits, and further assess its impact on clinical outcomes. The potential of ICG to enhance pediatric colorectal surgery by providing real-time, accurate perfusion data could significantly improve surgical precision and patient recovery.

Indocyanine green (ICG) fluorescence-enhanced applications in pediatric surgery

The breadth of pediatric surgical practice and variety of anatomic anomalies that characterize surgical disease in children and neonates require a unique level of operative mastery and versatility. Intraoperative navigation of small, complex, and often abnormal anatomy presents a particular challenge for pediatric surgeons. Clinical experience with fluorescent tissue dye, specifically indocyanine green (ICG), is quickly gaining widespread incorporation into adult surgical practice as a safe, non-toxic means of accurately visualizing tissue perfusion, lymphatic flow, and biliary anatomy to enhance operative speed, safety, and patient outcomes. Experience in pediatric surgery, however, remains limited. ICG-fluorescence guided surgery is poised to address the challenges of pediatric and neonatal operations for a growing breadth of surgical pathology. Fluorescent angiography has permitted intraoperative visualization of colorectal flap perfusion for complex pelvic reconstruction and anastomotic perfusion after esophageal atresia repair, while its hepatic absorption and biliary excretion has made it an excellent agent for delineating the dissection plane in the Kasai portoenterostomy and identifying both primary and metastatic hepatoblastoma lesions. Subcutaneous and intra-lymphatic ICG injection can identify iatrogenic chylous leaks and improved yields in sentinel lymph node biopsies. ICG-guided surgery holds promise for more widespread use in pediatric surgical conditions, and continued evaluation of efficacy will be necessary to better inform clinical practice and identify where to focus and develop this technical resource.

Laparoscopic indocyanine green fluorescence imaging technique in rare type II cystic biliary atresia

In recent years, it has been reported that indocyanine green can be used for intraoperative navigation in Kasai surgery. However, there are no reports of its application in surgery for rare type II cystic biliary atresia. We report a girl presented with jaundice and light-colored stools. Laboratory tests showed impaired liver function with elevated serum bilirubin and bile acid levels. The abdominal ultrasound and MRCP suggested a common hepatic duct cyst. A diagnosis of choledochal cyst was suspected and biliary atresia could not be excluded. Conservative treatment was unsatisfactory. Laparoscopic exploration with indocyanine green fluorescence was performed on the 38th day of her life, and intraoperative diagnosis of type II CBA was made because the common hepatic duct cyst and its downstream anatomical structures did not show fluorescence. The postoperative bilirubin and bile acid levels decreased significantly and she was discharged two weeks after surgery. This result suggests that indocyanine green can be safely used in laparoscopic surgery for type II CBA, which not only helps in the differential diagnosis of CBA and choledochal cyst, but also confirms bile flow in real time.

Evaluating the Development Status of Fluorescence-Guided Surgery (FGS) in Pediatric Surgery Using the Idea, Development, Exploration, Assessment, and Long-Term Study (IDEAL) Framework

Fluorescence-guided surgery (FGS) is used in many pediatric subspecialties but there are currently no standard guidelines or outcome data. We aimed to assess the current status of FGS in pediatrics using the Idea, Development, Exploration, Assessment, and Long-term study (IDEAL) framework. Clinical papers on FGS in children published from January 2000 to December 2022 were systematically reviewed. The stage of research development was measured considering seven fields of application: biliary tree imaging, vascular perfusion for gastrointestinal procedures, lymphatic flow imaging, tumor resection, urogenital surgery, plastic surgery, and miscellaneous procedures. Fifty-nine articles were selected. For each field of application, the overall IDEAL stage was determined to be 2a for biliary tree imaging (10 publications, 102 cases), 1 for vascular perfusion for gastrointestinal procedures (8 publications, 28 cases), 1 for lymphatic flow imaging (12 publications, 33 cases), 2a for tumor resection (20 publications, 238 cases), 2a for urogenital surgery (9 publications, 197 cases), and 1-2a for plastic surgery (4 publications, 26 cases). One report did not belong to any categories. FGS in children is still in an early phase of adoption and development. We recommend using the IDEAL framework as a guide and suggest developing multicenter studies to define the standard guidelines, effectiveness, and outcomes.

Fluorescence-guided surgery: National trends in adoption and application in pediatric surgery

BACKGROUND

Fluorescence-guided surgery (FGS) with indocyanine green (ICG) is a rapidly diffusing surgical innovation, but its utilization in pediatrics remains unknown. We present a cross-sectional descriptive analysis of trends from a national database.

METHODS

The Pediatric Health Information System (PHIS) database was queried for patient encounters between January 2016 and July 2021 with an associated ICG administration within 3 days prior to surgery. All procedure codes from each encounter were reviewed by two surgeons to determine the most likely associated FGS procedure and assign an operative category.

RESULTS

1270 encounters were identified from 38 participating hospitals. The mean patient age (SD) was 8.3 (6.4) years, 54.5% were male, 63.8% were white, and 30.1% were Hispanic. The most common categories for ICG use were neurosurgery (21.3%), biliary (18.3%), perfusion (14.8%), urology (12.5%), gastrointestinal (10.8%), ophthalmology (8.8%), and thoracic (5.6%). Utilization over time increased for some categories (thoracic, visceral perfusion, and neurological procedures) or remained stable for other categories. Overall ICG utilization has increased in 2020 (n = 314) compared to 2016 (N = 83). The number of centers utilizing ICG has also increased from 14 hospitals in 2016 to 29 hospitals in 2020 though adoption remains unevenly distributed, with 5 high-utilization hospitals accounting for 56.8% of all ICG FGS cases.

CONCLUSION

ICG is being used across a wide variety of pediatric surgical disciplines. Trends over time show increasingly frequent adoption across the country, with a few high-volume centers driving the innovation. Fluorescence-guided surgery is commercially available and is becoming more commonplace for pediatric surgeons. Dedicated efforts will now be needed to assess outcomes using this promising technology.

LEVEL OF EVIDENCE

Level IV.

STUDY TYPE

Retrospective study.

Pediatric robotic surgery: An overview

Pediatric robotic surgery offers children a minimally invasive approach with numerous advantages over open or thoracoscopic and laparoscopic surgery. However, despite its widespread adoption for adult patients, the utilization of robotic surgery within pediatrics has been relatively slower to progress. This paper provides an overview of pediatric robotic surgery and discusses benefits, limitations, and strategies for successful implementation of robotics within pediatric surgical practice.

Thoracoscopic repair for esophageal pulmonary fistula after esophageal atresia repair

BACKGROUND

Esophageal pulmonary fistula is a special type of acquired tracheoesophageal fistula that occurs after esophageal atresia/tracheoesophageal fistula repair. Thoracotomy is the surgical repair method currently in use, but postoperative outcomes are unclear. Therefore, we aimed to explore the preliminary safety, effectiveness, and feasibility of thoracoscopic surgical repair of esophageal pulmonary fistula.

METHODS

We retrospectively collected data from all patients with esophageal atresia/tracheoesophageal fistula at Beijing Children's Hospital from January 2017 to October 2021, and the clinical characteristics of patients with esophageal pulmonary fistula were analyzed. Clinical information was recorded, and follow-up was performed.

RESULTS

Seven patients (five boys and two girls) were diagnosed as esophageal pulmonary fistula. All patients underwent multiple esophageal surgeries and had esophageal strictures before surgical repair. Clinical manifestations included cough, expectoration, and recurrent pneumonia. Esophagography indicated the location of the fistula with a 100% positive rate, while the positive rate of flexible bronchoscopy and chest computed tomography was 57% (4/7) and 43% (3/7), respectively. Surgical repair was achieved using thoracoscopy with an average operation time of 172 min. All patients developed esophageal strictures, four of which had refractory esophageal strictures and underwent esophageal dilations ranged from 5 to 56 times before this surgery, but anastomotic leakage or acquired esophageal pulmonary fistulas were absent post-surgery. After a median follow-up of 22 months, all patients survived, and the symptoms were well controlled.

CONCLUSIONS

Esophageal pulmonary fistula is a rare complication of atresia/tracheoesophageal fistula repair. Thoracoscopic surgery is still possible even after previous multiple surgeries in the chest with significant complications and satisfactory results can be achieved in the short term.

LEVEL OF EVIDENCE

Level III.

Safety and feasibility of indocyanine green fluorescence angiography in pediatric gastrointestinal surgery: A systematic review

BACKGROUND

Although ICG-FA may be valuable in assessing anastomotic perfusion, reliable data on its use in pediatric gastrointestinal surgery is lacking. This systematic review analyzes whether ICG is useful for intestinal perfusion assessment in pediatric gastrointestinal surgery and safe to use in neonates.

METHODS

Systematic searches of PubMed, EMBASE & MEDLINE and CENTRAL were performed (last conducted December 6, 2021). The main inclusion criteria were (1) use of ICG for intestinal perfusion assessment and (2) use of ICG in young infants. Exclusion criteria were lack of an English or Dutch full-text and MINORS quality score <60%. Data was presented in overview tables. The usefulness in pediatric gastrointestinal surgery was assessed by surgical outcome. Safety of ICG in neonates was assessed by complication or adverse event occurrence.

RESULTS

Regarding intestinal perfusion assessment, four studies were included, reporting 45 patients (median age 1.5 years). ICG was considered useful for anastomotic blood flow evaluation and intraoperative determination of resection length. Regarding ICG safety in neonates, eight studies were included, reporting 46 infants (median age 24.9 days), of which 18 neonates. All but one studies reported the absence of complications or adverse events. Two studies reported subcutaneous dye retention, which fully disappeared within two weeks.

CONCLUSION

Although the number of available studies is small, ICG might be useful for intraoperative intestinal perfusion assessment, perhaps even more than conventional clinical assessment. Furthermore, its safety profile looks promising in neonates. Larger prospective studies are necessary to confirm these assumptions and seem warranted given the safety profile.

LEVELS OF EVIDENCE

Since this is a systematic review, a Level of Evidence for clinical studies cannot be determined for this manuscript.

Exploratory application of indocyanine green quantification in biliary atresia observational study

BACKGROUND

Indocyanine green (ICG) is known to facilitate real-time imaging of the bile outflow during the Kasai procedure. This study explored more possibilities for applying ICG quantification in biliary atresia (BA).

METHODS

We enrolled nine BA patients in this study. All patients received intravenous ICG injections before surgery and underwent Kasai operation. With a fluorescence imaging system (Nanjing Nuoyuan, REAL-IGS FLI-108) to observe the ICG and quantify the ICG fluorescence intensity (ICG-FI) changes of the hepatic portal fibrous tissue and the liver during the operation. As a short-term prognosis assessment, we monitored the postoperative ICG metabolism time in stool and used the jaundice-free (TBIL < 2 mg/dl) at 1-3 months after the operation.

RESULTS

The average age of the patients at the time of surgery was 73 days. There were no adverse reactions after ICG injection. All patients were observed ICG-FI increased after the dissection of hepatic portal fibrous tissue, and the ICG-FI of the liver decreased during the operation. They all received standardized treatment after surgery. Four patients completely metabolized ICG within about two weeks (no fluorescence detected in stool), and the other five were longer than two weeks. Five patients achieved a jaundice-free outcome in the short-term postoperatively, and the other four did not.

CONCLUSIONS

It is feasible to quantify ICG-FI in real-time to evaluate the anatomical degree of hepatic portal fibrous tissue in BA. The variations of ICG-FI in the liver and postoperative ICG metabolism time may be related to prognosis.

Intraoperative uses of near-infrared fluorescence spectroscopy in pediatric surgery: A systematic review

BACKGROUND

The application of near infrared spectroscopy (NIRS) imaging in surgery is growing. This study aimed to systematically review the literature to summarize the intraoperative uses of NIRS in pediatric surgery.

METHODS

A PRISMA-compliant literature search was conducted in PubMed, Embase, Scopus, and Web of Science from inception to February 2020. Title/abstract and then full-text screening were performed. The Oxford centre for Evidence Based Medicine tool (OCEBM) was used to evaluate the level of evidence of included studies.

RESULTS

Reviewers identified 53 articles. Of which, 34 studies (64.2%) were case-series and 11 (20.8%) were case reports. Most of the studies (n = 45, 84.9%) were level 4 on the OCEBM tool. The most common uses of NIRS were to visualize the biliary tree and to identify primary and metastatic malignant tissues. Other applications include assessment of perfusion of tissues including bowel anastomoses, and lymphatic surgery. Several advantages of the introduction of NIRS in pediatric surgery exist including having the potential to reduce operative time and intra/post-operative complications. Moreover, NIRS helps in detecting malignant tissues that can be missed by conventional imaging. However, NIRS has important limitations such as difficulty in identification of the biliary tree in obese patients or inflamed gallbladder, detection of small deeply localized malignant tissues, as well as the high cost.

CONCLUSIONS

NIRS is a promising modality that can be used intraoperatively to augment different pediatric surgical procedures. NIRS has important advantages and limitations compared to conventional surgery, however, more studies are required to evaluate its outcomes and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

Co-injection of Bile and Indocyanine Green for Detecting Pancreaticobiliary Maljunction of Choledochal Cyst

The usage of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in many procedures in pediatric surgery. ICG generates fluorescent light only when it combines with a protein. We herein report a novel technique for detecting pancreaticobiliary maljunction (PBMJ) with co-injection of bile and ICG in laparoscopic choledochal cyst resection and hepaticojejunostomy for a pediatric patient. A 4-year-old girl presented with abdominal pain and intermittent vomiting. Enhanced computed tomography and magnetic resonance cholangiopancreatography showed a 17-mm type Ia choledochal cyst. Definitive PBMJ was not detected preoperatively. Laparoscopic choledochal cyst resection and hepaticojejunostomy were performed using five ports. A percutaneous silicon catheter was inserted into the gallbladder, and bile juice was aspirated. The amylase level of the bile juice was over 3 × 105 IU/L. The aspirated bile juice and ICG were mixed and co-injected into the gallbladder through the catheter. ICG combined with protein in bile juice and generated fluorescent light. Dilated common bile duct and pancreas were detected by NIR fluorescence imaging. This imaging technique was helpful for detecting the dissection margin of the distal side of the choledochal cyst inside the pancreatic tissue and preventing injury of the pancreatic tissue. This is the first case of ICG application for laparoscopic choledochal cyst resection in a pediatric patient. After resection of the choledochal cyst, laparoscopic hepaticojejunostomy was completely performed. Our technique is a safe and low-invasive method of detecting and excising the distal side of the cyst without a risk of radiography and residual bile duct.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

In conclusion, intravenous ICG fluorescence cholangiography might be a useful and less invasive diagnostic procedure that can rule out BA in infants.

Image-guided surgery and novel intraoperative devices for enhanced visualisation in general and paediatric surgery: a review

Fluorescence guided surgery, augmented reality, and intra-operative imaging devices are rapidly pervading the field of surgical interventions, equipping the surgeon with powerful tools capable of enhancing the surgical visualisation of anatomical normal and pathological structures. There is a wide range of possibilities in the adult population to use these novel technologies and devices in the guidance for surgical procedures and minimally invasive surgeries. Their applications and their use have also been increasingly growing in the field of paediatric surgery, where the detailed visualisation of small anatomical structures could reduce procedure time, minimising surgical complications and ultimately improve the outcome of surgery. This review aims to illustrate the mechanisms underlying these innovations and their main applications in the clinical setting.

Fluorescence imaging in pediatric surgery: State-of-the-art and future perspectives

BACKGROUND

The employment of fluorescence imaging has gained popularity in many fields of adult surgery where it has demonstrated great potentials to improve both surgical and oncological outcomes while minimizing anesthetic time and lowering health-care costs. However, the clinical application of fluorescence-guided surgery (FGS) in pediatrics is just at the initial phase.

MATERIAL AND METHODS

A systematic review of current clinical uses of FGS in pediatric surgery was performed along with a discussion on its advantages, limitations and future developments.

RESULTS

21 studies were included: 9 retrospective and 1 prospective study, 8 case reports, 2 case series and a review article reporting authors' institutional experience. Great emphasis was given to surgical resection of hepatoblastoma and its metastasis (n = 6), real-time imaging of the biliary tree (n = 3) and urogenital system (n = 2). Other current uses concern the assessment of blood perfusion (intestine, n = 3; myocutaneous flap, n = 1; transplanted liver, n = 1) and lymphatic flow imaging (n = 4).

CONCLUSION

Despite a paucity of clinical studies evaluating its role in pediatric surgery, FGS has shown promising results in helping guide tumor resection and improving the accuracy of anatomical delineation.

TYPE OF STUDY

Review article.

LEVEL OF CONFIDENCE

Level IV.

[Clinical guidelines for the diagnosis and treatment of neonatal necrotizing enterocolitis (2020)]

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of neonates, especially of preterm infants, with high morbidity and mortality. The surviving infants may have digestive tract and neurological sequelae. Therefore, the prevention and treatment of NEC are of great significance in improving survival rate and survival quality of neonates. To provide evidence-based recommendations for management of NEC, the guidelines were developed based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the current domestic and overseas studies.

The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis

Purpose: Indocyanine green fluorescence angiography (ICG-FA) is a validated non-invasive imaging technique used to assess tissue vascularization and guide intraoperative decisions in many surgical fields including plastic surgery, neurosurgery, and general surgery. While this technology is well-established in adult surgery, it remains sparsely used in pediatric surgery. Our aim was to systematically review and provide an overview of all available evidence on the perioperative use of indocyanine green fluorescence angiography in pediatric surgical patients. Methods: We conducted a systematic review with narrative synthesis in conformity with the PRISMA guidelines using PubMed, Medline, All EBM Reviews, EMBASE, PsycINFO, and CINAHL COMPLETE databases to identify articles describing the perioperative use of ICG-FA in pediatric patients. Two independent authors screened all included articles for eligibility and inclusion criteria. We extracted data on study design, demographics, surgical indications, indocyanine green dose, and perioperative outcomes. We developed a risk of bias assessment tool to evaluate the methodological quality of included studies. Results: Of 1,031 articles retrieved, a total of 64 articles published between 2003 and 2020 were included reporting on 664 pediatric patients. Most articles were case reports and case series (n = 36; 56%). No adverse events related to ICG-FA were reported in the included articles. Risk of bias was high. We did not conduct a meta-analysis given the heterogeneous nature of the populations, interventions, and outcome measures. A narrative synthesis is presented. Conclusion: Indocyanine green fluorescence angiography is a safe imaging technology and its use is increasing rapidly in pediatric surgical specialties. However, the quality of evidence supporting this trend currently appears low. Case-control and randomized trials are needed to determine the adequate pediatric dose and to confirm the potential benefits of ICG-FA in pediatric surgical patients. Systematic Review Registration: This study was registered on Prospero a priori, identifier: CRD42020151981.

Protein-Enhanced NIR-IIb Emission of Indocyanine Green for Functional Bioimaging

Fluorescence imaging performed in the 1500-1700 nm spectral range (labeled near-infrared IIb, NIR-IIb) promises high imaging contrast and spatial resolution for its little photon scattering effect and minimum autofluorescence. Though inorganic and organic probes have been developed for NIR-IIb bioimaging, most are in the preclinical stage, hampering further clinical application. Herein, we showed that indocyanine green (ICG), a US Food and Drug Administration (FDA)-approved agent, exhibited a remarkable amount of NIR-IIb emission when dissolved into different protein solutions, including human serum albumin, rat bile, and fetal bovine serum. We performed fluorescence imaging in the NIR-IIb window to visualize structures of the lymph system, extrahepatic biliary tract, and cerebrovascular. The results demonstrated that proteins promoted NIR-IIb emission of ICG in vivo and that NIR-IIb imaging with ICG preserved a higher signal-to-background ratio and spatial resolution compared with the conventional NIR-II fluorescence imaging. Our findings confirm that NIR-IIb fluorescence imaging can be successfully performed using the clinically approved agent ICG. Further clinical application in the NIR-IIb region would hopefully be carried out with appropriate ICG-protein solutions.

The outcome of real-time evaluation of biliary flow using near-infrared fluorescence cholangiography with Indocyanine green in biliary atresia surgery

BACKGROUND

Indocyanine green (ICG) fluorescence imaging is a promising tool for intraoperative decision-making. The aim of this study was to evaluate the utility of near-infrared fluorescence cholangiography (NIR-FCG) with ICG in primary surgery for biliary atresia (BA).

METHODS

We performed NIR-FCG with ICG in 10 BA patients and observed the fluorescence of their hilar micro-bile ducts and hilar exudate in order to assess the appropriate level at which to dissect the hilar fibrous corn. We compared the jaundice outcome of 10 patients using NIR-FCG (Group A) to that of 35 historical patients in whom NIR-FCG had not been used (Group B).

RESULTS

The mean age of patients was 74.8 days. The classification of BA was type I in two cases and type-III in eight cases. NIR-FCG visualized the hilar micro-bile ducts, and the incidence of positive fluorescence was 80%. The ratio of postoperative normalization of hyperbilirubinemia in Group A was significantly higher than that in Group B (1.0 vs. 0.65, p < 0.05).

CONCLUSION

NIR-FCG provided important objectifiable information about the biliary structures in surgery of BA. Although the number of cases was small, our results suggest that NIR-FCG may be useful for improving the outcome of primary surgery for BA.

TYPE OF STUDY

Study of Diagnostic Test.

LEVEL OF EVIDENCE

Level III.

Application of indocyanine green in pediatric surgery

The use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in many fields in adult surgery, such as sentinel lymph node mapping, intra-operative solid tumor identification, and organ perfusion assessment. However, the clinical application of ICG in pediatric surgery is just at the beginning. This review paper presents the advantages, current applications and potential developments of NIR fluorescence imaging with ICG in our field.

Fluorescence Imaging for Minimally Invasive Cancer Surgery

This article demonstrates surgical techniques of intraoperative fluorescence imaging using indocyanine green, focusing on its application in minimally invasive hepatobiliary and pancreatic surgery. In this area, indocyanine green fluorescence imaging has been applied to liver cancer identification, fluorescence cholangiography, delineation of hepatic segments, and fluorescence angiography and perfusion assessment. The development of target-specific fluorophores and advances in imaging technology will allow real-time intraoperative fluorescence imaging to develop into an essential intraoperative navigation tool. This property may contribute to enhancing both accuracy and safety of minimally invasive surgery.