Effectiveness of near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary study

Pay attention to the application of indocyanine green fluorescence imaging technology in laparoscopic liver cancer resection

Traditional laparoscopic liver cancer resection faces challenges, such as difficulties in tumor localization and accurate marking of liver segments, as well as the inability to provide real-time intraoperative navigation. This approach falls short of meeting the demands for precise and anatomical liver resection. The introduction of fluorescence imaging technology, particularly indocyanine green, has demonstrated significant advantages in visualizing bile ducts, tumor localization, segment staining, microscopic lesion display, margin examination, and lymph node visualization. This technology addresses the inherent limitations of traditional laparoscopy, which lacks direct tactile feedback, and is increasingly becoming the standard in laparoscopic procedures. Guided by fluorescence imaging technology, laparoscopic liver cancer resection is poised to become the predominant technique for liver tumor removal, enhancing the accuracy, safety and efficiency of the procedure.

Variations in the cystic duct: frequency and the relationship among insertion sides and heights on the bile duct

BACKGROUND

Evaluation of the cystic duct anatomy prior to bile duct or gallbladder surgery is important, to decrease the risk of bile duct injury. This study aimed to clarify the frequency of cystic duct variations and the relationship between them.

METHODS

Data of 205 patients who underwent cholecystectomy after imaging at Sada Hospital, Japan, were analyzed. The Chi-square test was used to analyze the relationships among variations.

RESULTS

The lateral and posterior sides of the bile duct were the two most common insertion points (92 patients, 44.9%), and the middle height was the most common insertion height (135 patients, 65.9%). Clinically important variations (spiral courses, parallel courses, low insertions, and right hepatic duct draining) relating to the risk of bile duct injury were observed in 24 patients (11.7%). Regarding the relationship between the insertion sides and heights, we noticed that the posterior insertion frequently existed in low insertions (75.0%, P < 0.001) and did not exist in high insertions. In contrast, the anterior insertion coexisted with high and never low insertions. Spiral courses have two courses: anterior and posterior, and anterior ones were only found in high insertion cases.

CONCLUSIONS

The insertion point of the cystic duct and the spiral courses tended to be anterior or lateral superiorly and posterior inferiorly. Clinically significant variations in cystic duct insertions are common and surgeons should be cautious about these variations to avoid complications.

Preliminary exploration of hepatic parenchymal near-infrared fluorescence imaging technique via retrograde biliary approach: a feasibility study (with video)

This paper explores the feasibility and principle of hepatic parenteral fluorescence imaging technology after retrograde injection of indocyanine green (ICG) through endoscopic nasobiliary drainage (ENBD). The data were collected from 53 patients with cholecystolithiasis and choledocholithiasis, from October 2022 to March 2023, diagnosed by fluorescence imaging technique retrograde biliary approach (FIT-RB). We divided the patients into two groups according to the features of liver parenchyma, the poor group (n = 34, including scattered or no imaging) and the good group (n = 19, regular uniform imaging). We compared and analyzed the perioperative results of the two groups and explored the influencing factors of the success of FIT-RB and the ICG concentration suitable for this imaging technique. The good imaging rate of the 53 enrolled cases was 35.8%. The bilirubin level before ENBD and laparoscopic cholecystectomy in the poor group was significantly higher than that in the good group (P < 0.001). The proportion of higher ICG concentrations (0.5 mg/mL) was significantly higher in the good group (P = 0.028). Our results demonstrated that the success rate of good imaging was 4.53 times higher than that of low-dose ICG (0.125 or 0.25 mg/L) cases at 0.5 mg/ml of ICG. The level of total bilirubin and direct bilirubin were negatively correlated with the imaging effect, and total bilirubin and direct bilirubin levels were important predictors of the efficacy of FIT-RB. FIT-RB is safe and feasible in patients with low site bilirubin levels. An ICG concentration of 0.5 mg/ml may be ideal for implementing this technique.

Clinical study on the necessity and feasibility of routine MRCP in patients with cholecystolithiasis before LC

BACKGROUND

In the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis.

METHODS

According to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups.

RESULTS

Among the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05).

CONCLUSIONS

The preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Laparoscopic cholecystectomy (LC) is one of the most frequently performed gastrointestinal surgeries worldwide. Bile duct injury (BDI) represents the most serious complication of LC, with an incidence of 0.3%-0.7%, resulting in significant perioperative morbidity and mortality, impaired quality of life, and high rates of subsequent medico-legal litigation. In most cases, the primary cause of BDI is the misinterpretation of biliary anatomy, leading to unexpected biliary lesions. Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings. The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

The role of indocyanine green cholangiography in minimally invasive surgery

INTRODUCTION

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.

EVIDENCE ACQUISITION

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.

EVIDENCE SYNTHESIS

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.

CONCLUSIONS

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.