INDOCYANINE GREEN ENHANCED LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE PATIENTS: DO WE NEED A REVISION OF THE SAFETY PARADIGMS?

Introduction. Rapid developments in medical technology have allowed the incorporation of Indocyanine green (ICG) fluorescent cholangyography in the surgical technique armamentarium. The visualization of the biliary anatomy with augmented reality devices during surgery reduces complications and offer the perspective of challenging the safety paradigms which prohibited surgery in certain acute biliary conditions. Materials and methods. 43 consecutive patients were enrolled in a prospective interventional study and randomly divided into a cohort of 19 patients who had ICG injected prior to laparoscopic cholecystectomy and a cohort of 23 patients who received no fluorescent dye prior to surgery. In the ICG lot a Near Infrared Fluorescent System was used for the acquisition of fluorescent data in order to produce real time augmented reality imaging (ICG fluorescent cholangiography). The surgical technique and the indications for surgery were the same for the same in both cohorts of patients. Results and discussion. The cohort of patients receiving ICG had no complications and the mean operating time was 10 minutes less. The biliary anatomy was identified immediately in the ICG cohort with a specificity of 89.4% for the common bule duct and 73.6% for the cystic duct. In the non ICG cohort 21% of the CBDs and 43.4% of the cystic ducts were identified with difficulty during the procedure. Conclusion. We demonstrated in a small cohort of patients that early laparoscopic cholecystectomy is safe and can be performed quicker with the aid of fluorescent dyes. In order to challenge the safety paradigms around the early laparoscopic cholecystectomy a larger study is necessary.

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P11: NEAR INFRARED FLUORESCENT CHOLANGIOGRAPHY IN LAPAROSCOPIC CHOLECYSTECTOMY: A SINGLE CENTRE FEASIBILITY STUDY. THE OPTIMUM DOSING REGIME, LIMITATIONS AND WHERE NEXT?

British Journal of Surgery ◽

10.1093/bjs/znab117.096 ◽

2021 ◽

Vol 108 (Supplement_1) ◽

Author(s):

G Armstrong ◽

G Toogood ◽

DG Jayne ◽

AM Smith

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Indocyanine Green ◽

Feasibility Study ◽

Near Infrared ◽

Intravenous Dose ◽

Structure Identification ◽

Dosing Regimen ◽

Single Centre ◽

Fluorescent Cholangiography

Abstract Introduction This study explored near-infrared fluorescent cholangiography (NIRFC) with Indocyanine Green (ICG) during laparoscopic cholecystectomy (LC) surgery in a tertiary referral hepatobiliary unit. ICG binds to albumin and is excreted in bile. NIRFC utilises the fluorescent and excretory properties of ICG to provide dynamic extrahepatic bile duct mapping during LC. Method Non-randomised single centre feasibility study. Twenty-two participants were sequentially allocated to four dosing subgroups prior to NIRFC assisted LC. Each received a single intravenous dose of ICG prior to LC with the Stryker Novadaq NIR laparoscope. The biliary anatomy was assessed with NIRFC at three time-points, detection was compared to radiological cholangiogram where available and surgeon satisfaction was assessed. Result Eight participants received 2.5mg ICG 20-40min before surgery, four 0.25mg/kg 20-40min, five 90min – 180min and five 12 – 36 hour pre-operatively. Average age 50 years (S.D±15), BMI 27.5m2 (S.D±3.6), 6/22 were acute LC procedures. The prolonged dosing interval produced increased extrahepatic biliary structure identification (p = 0.016), reduced noise to signal ratio and was consistently preferred by the operating surgeon. NIRFC was inferior to radiological cholangiogram (n = 10) (p = 0.014) for bile duct mapping. We observed iatrogenic bile spillage saturating the field and obscuring structure differentiation and peri-hilar inflammation impeding fluorescent detection in acute LC. Conclusion The dosing regimen 0.25mg/kg ICG 12 to 36 hours prior to surgery provides optimum NIRFC structure visualisation. Fluorescent tissue penetrance is limited in acute peri-hilar inflammation. More research in to the efficiency of NIRFC in emergency LC is required. Take-home message An intravenous dose of 0.25mg/kg of Indocyanine Green 12 to 36 hours before surgery is the optimum dosing regimen for increased extra-hepatic bile duct structures with near infrared fluorescent cholangiography. The role of NIRFC in acute laparoscopic cholecystectomy surgery remains ill-defined.

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SP3.2.10 Establishing an Emergency Surgical Ambulatory Care (ESAC) pathway for acute laparoscopic cholecystectomies: a single centre experience from a District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab361.076 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Neil Donald ◽

Lavanya Varatharajan ◽

Kumaran Ratnasingham ◽

Shashi Irukulla

Keyword(s):

Laparoscopic Cholecystectomy ◽

Length Of Stay ◽

Ambulatory Care ◽

Operating Time ◽

District General Hospital ◽

Gallstone Pancreatitis ◽

Early Laparoscopic Cholecystectomy ◽

Patient Demographics ◽

Day Range ◽

Cost Efficiencies

Abstract Aims Early laparoscopic cholecystectomy is the gold standard for acute cholecystitis and gallstone pancreatitis. In order to deliver this service, a local Emergency Surgical Ambulatory Care (ESAC) pathway with a dedicated ESAC theatre list was established. The aim of this audit was to determine whether ESAC was associated with (1) improved length of stay and (2) cost efficiencies. Methods Consecutive patients who underwent an emergency laparoscopic cholecystectomy between October 2018 to October 2019 were identified. Data related to patient demographics, operating time, complications length of stay (LOS), reason for inpatient stay and re-admissions were collected. A dedicated ESAC service was introduced in July 2020. Outcomes were re-audited (July – December 2020). Results Prior to the introduction of ESAC, 142 patients (42% male, mean age 51 years (range 14 -82 years)) underwent an acute cholecystectomy, of which 13% were discharged on the same day. Median pre-operative LOS was 2 days (range 0-12 days) and median post-operative LOS was 1 day (range 1-16 days). Following the introduction of ESAC, 78 patients (32% male, mean age 49 years (range 22 – 89 years)) underwent an acute cholecystectomy, of which 76% were discharged on the same day and 90% within 1 day. Median pre-operative LOS was 0 days (range 0 to 7 days) and median post-operative LOS was 0 days (range 0-16 days). Conclusions Our results show that the introduction of a dedicated ESAC pathway improved both pre- and post-operative LOS. This subsequently saves approximately £80,000 per annum in hospital bed days.

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

Surgical Innovation ◽

10.1177/1553350620958562 ◽

2020 ◽

pp. 155335062095856

Author(s):

Francesco Di Maggio ◽

Naveed Hossain ◽

Andrea De Zanna ◽

Danya Husain ◽

Luca Bonomo

Keyword(s):

Bile Duct ◽

Near Infrared ◽

Extrahepatic Bile Duct ◽

Operating Time ◽

Length Of Hospital Stay ◽

Secondary Outcome ◽

Control Group ◽

Biliary Anatomy ◽

Conversion To Open Surgery ◽

Complications Rate

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 48 hours 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 72 hours 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 72 hours window of safety for emergency cholecystectomies.

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Biliary tract visualization using near-infrared imaging with indocyanine green during laparoscopic cholecystectomy: results of a systematic review

Surgical Endoscopy ◽

10.1007/s00464-016-5318-7 ◽

2016 ◽

Vol 31 (7) ◽

pp. 2731-2742 ◽

Cited By ~ 33

Author(s):

S. L. Vlek ◽

D. A. van Dam ◽

S. M. Rubinstein ◽

E. S. M. de Lange-de Klerk ◽

L. J. Schoonmade ◽

...

Keyword(s):

Systematic Review ◽

Laparoscopic Cholecystectomy ◽

Indocyanine Green ◽

Biliary Tract ◽

Near Infrared ◽

Infrared Imaging ◽

Near Infrared Imaging

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Systematic review of the role of indocyanine green near‑infrared fluorescence in safe laparoscopic cholecystectomy (Review)

Experimental and Therapeutic Medicine ◽

10.3892/etm.2021.11110 ◽

2021 ◽

Vol 23 (2) ◽

Author(s):

Dragos Serban ◽

Dumitru Badiu ◽

Dragos Davitoiu ◽

Ciprian Tanasescu ◽

Mihail Tudosie ◽

...

Keyword(s):

Systematic Review ◽

Laparoscopic Cholecystectomy ◽

Indocyanine Green ◽

Near Infrared ◽

Near Infrared Fluorescence

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Low dose Indocyanine Green is effective for Near Infrared Fluorescence Cholangiography during Laparoscopic Cholecystectomy

10.26226/morressier.596648e4d462b80290b521a0 ◽

2017 ◽

Author(s):

Vy Nguyen

Keyword(s):

Laparoscopic Cholecystectomy ◽

Indocyanine Green ◽

Low Dose ◽

Near Infrared ◽

Green Is ◽

Near Infrared Fluorescence

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Fluorescent Imaging With Indocyanine Green During Laparoscopic Cholecystectomy in Patients at Increased Risk of Bile Duct Injury

Surgical Innovation ◽

10.1177/1553350617690309 ◽

2017 ◽

Vol 24 (3) ◽

pp. 245-252 ◽

Cited By ~ 21

Author(s):

Marjolein Ankersmit ◽

Dieuwertje A. van Dam ◽

Anne-Sophie van Rijswijk ◽

Baukje van den Heuvel ◽

Jurriaan B. Tuynman ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Indocyanine Green ◽

Bile Duct Injury ◽

Near Infrared ◽

Fluorescent Imaging ◽

Added Value ◽

Optimal Dosage ◽

Nir Light ◽

Increased Risk

Background. Although rare, injury to the common bile duct (CBD) during laparoscopic cholecystectomy (LC) can be reduced by better intraoperative visualization of the cystic duct (CD) and CBD. The aim of this study was to establish the efficacy of early visualization of the CD and the added value of CBD identification, using near-infrared (NIR) light and the fluorescent agent indocyanine green (ICG), in patients at increased risk of bile duct injury. Materials and Methods. Patients diagnosed with complicated cholecystitis and scheduled for LC were included. The CBD and CD were visualized with NIR light before and during dissection of the liver hilus and at critical view of safety (CVS). Results. Of the 20 patients originally included, 2 were later excluded due to conversion. In 6 of 18 patients, the CD was visualized early during dissection and prior to imaging with conventional white light. The CBD was additionally visualized with ICG-NIR in 7 of 18 patients. In 1 patient, conversion was prevented due to detection of the CD and CBD with ICG-NIR. Conclusions. Early visualization of the CD or additional identification of the CBD using ICG-NIR in patients with complicated cholecystolithiasis can be helpful in preventing CBD injury. Future studies should attempt to establish the optimal dosage and time frame for ICG administration and bile duct visualization with respect to different gallbladder pathologies.

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