Use of NIFC Cholangiography for the Identification of the Anatomy in Biliary Surgery

Use of Near-infrared Incisionless Fluorescent Cholangiography (NIFC) for Identification of the Anatomy in Biliary Surgery Francisco

Authors: A. Ferri, MD; Felice De Stefano, MD; Vicente J. Cogollo, MD; Alejandro Cracco, MD; Emanuele Lo Menzo, MD, PhD, FACS, FASMBS; Mayank Roy, MD, FACS; Fernando Dip, MD, FACS.
Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida.

Summary: Bile duct injuries during laparoscopic cholecystectomy remain a potentially devastating complications and are responsible for major morbidity and prolonged hospitalization1. Visual misperception, anatomical variations in the extrahepatic biliary tree, combined with inflammatory changes and surgeon inexperience in recognizing the anatomy, are among the most common reasons for these injuries. Near-infrared Incisionless Fluorescent Cholangiography (NIFC) has been shown to improve the visualization and identification of the biliary structures compared to traditional white light.

Patient Background: The following case study discusses a 37 years old, morbidly obese woman (BMI 43 Kg/m2) with impaired fasting glucose and no significant surgical history who presented to the clinic with a 3-month history of right upper quadrant (RUQ) abdominal pain, especially after meals. The physical exam revealed tenderness in the RUQ with a negative Murphy sign and no evidence of peritonitis. An ultrasound showed a 3.8 cm gallstone without gallbladder wall thickening and hepatic steatosis. Esophagogastroduodenoscopy did not reveal any pathologic findings. The patient was referred to the bariatric surgery clinic for evaluation in view of her elevated BMI and her comorbidity. After discussing surgical options, the patient elected to undergo a combined laparoscopic sleeve gastrectomy and cholecystectomy using NIFC.

Procedure: Under general anesthesia, the abdominal cavity was accessed through an optical trocar in the supraumbilical position. After insertion of accessory trocars, a sleeve gastrectomy was performed in standard fashion. Next, 3mL of Indocyanine green for Injection, USP (ICG) were injected
intravenously. The gallbladder was cranially retracted. The hepatoduodenal ligament was exposed. Using near-infrared imaging we identified the ICG perfusion times of the liver, common hepatic duct and gallbladder at 1, 12 and 22 minutes after the injection of the ICG, respectively (Figures 2-4).
The cystic duct and cystic artery entrance into the gallbladder were both clearly identified (Figure 5) and transected between clips. The very large and chronically inflamed gallbladder was excised from the liver bed in retrograde fashion and retrieved with the specimen through the umbilicus. All trocar sites were closed with sutures and injected with local anesthesia.

For images, references and conclusions please click here

HTA Approach on Surgical Endoscopy Procedures using ICG

Indocyanine Green ICG use in Fluorescence Guided Surgery

Economic Health Technology Assessment (HTA) Approach on Surgical Endoscopy Procedures using Indocyanine Green (ICG)

Authors: Vettoretto, N; Foglia, E; Ferrario, L; Gerardi, C; Molteni, B; Nocco, U; Lettieri, E; Molfino, S; Baiocchi, G.L; Elmore, U; Rosati, R; Currò, G; Cassinotti, E; Boni, L; Cirocchi, R; Marano, A, Petz, W.L; Arezzo, A; Bonino, M.A; Davini, F; Biondi, A; Anania A; Agresta, A; Silecchia, G.

This paper offers a summary of a number of key findings published in Surgical Endoscopy, April 2020.
Could fluorescence‑guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary.

A paper published in Surgical Endoscopy, April 2020, undertook a Health Technology Assessment (HTA) approach to investigate the economic, social, ethical and organizational implications related to the adoption of ICG based fluorescence guided surgery, summurizing the key findings.

With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated Questionnaires and self reported interviews. Research included a systematic search of literature. This present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an Health Technology Assessment (HTA) approach, supports “the use of fluorescence guided vision in minimally invasive surgery, ….as an efficient and economically sustainable technology”.

The use of fluorescence guided vision in minimally invasive surgery, ….as an efficient and economically sustainable technology

Recently image-guided by indocyanine green (ICG) fluorescence has been introduced in minimally invasive clinical practice. The fluorescence approach is detected thanks to special cameras that are sensitive to the nearinfrared (NIR) spectrum. Indocyanine Green (ICG) absorbs Near-infrared light (NIR) at wavelengths of 800 to 810 nm. This fluorophore emits fluorescence at 830 nm when bound to tissue proteins if excited, with specific wavelength light in the Near-infrared light (NIR) spectrum (w820 nm).

85% of those interviewed believe Indocyanine Green (ICG) Fluorescence Guided Surgery will become standard in the near future

Fifty-six surgeons working in both teaching and community, public and private hospitals (covering 75% of the Italian regions), answered a questionnaire. 66.1% of the respondents already used fluorescence during their everyday practice. 63.3% of the surgeons consider Indocyanine Green (ICG) fluorescence guided surgery as an improvement of their practice, while 62.5% think that this technology can help in surgical education. When asked about the potential growth of Indocyanine Green (ICG), 85% of those interviewed believe that it has the potential to become a standard vision technology, in the near future.

“The use of ICG is perceived as improving the precision of the surgical technique, the identification of the blood vessels, allowing for a better image quality compared with standard white light”

To read the full summary of the paper click here

Full reference Source: Could fluorescence‑guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment (HTA) summary

Case Study: Colorectal Surgery

Evaluation of Anastomotic Perfusion following Laparoscopic Anterior Resection with Coloanal Anastomosis
A case study by Dr. Cyrus Jahansouz, Dr. Hayim Gilshtein and Dr. Steven D. Wexner, Cleveland Clinic Florida, USA

Summary: A cornerstone of colorectal surgery is the bowel anastomosis. Anastomotic leak is a devastating complication to the patient that can result in infection, sepsis, and even death.1 Healing of the anastomosis depends on both the patient’s general health condition as well as technical factors related to surgery, namely the creation of a well perfused and tension free anastomosis. The evaluation of anastomotic perfusion at the time of surgery remains a significant challenge, even to the most experienced of colorectal surgeons. Ensuring adequate blood flow at the anastomosis has the potential to reduce anastomotic leaks and improve patient outcomes following colorectal
surgery. Real-time visualization of tissue perfusion using the Indocyanine Green (ICG) pharmaceutical enables real-time assessment of anastomotic tissue perfusion allowing for a rapid determination of adequacy of the bowel anastomosis.

Case Details: The following case study Evaluation of Anastomotic Perfusion following Laparoscopic Anterior Resection with Coloanal Anastomosis discusses a patient who underwent laparoscopic anterior resection with coloanal anastomosis for rectal cancer. The patient is a 77 year old female who presented after a rectal mass was discovered during a colonoscopy. Further imaging and biopsy results were consistent with the diagnosis of a Stage 2 (T3, N0, M0) rectal cancer, the distal edge of which was situated approximately 7 cm from the anal verge. After discussion at National Accreditation for Rectal Cancer multidisciplinary tumor board, a laparoscopic anterior resection with coloanal anastomosis was offered to the patient.

Procedure: The procedure began laparoscopically with mobilization of the descending and sigmoid colon and splenic flexure, followed by high ligations of the inferior mesenteric artery and vein. The mesentery was intracorporeally divided to the distal descending colon and a total mesorectal excision was undertaken. A Lone Star retractor® (Cooper Surgical, Trumbull, CT) was placed and a circumferential full thickness incision was made 1 cm above the dentate line. Once dissection was completed, the specimen containing the tumor was carefully delivered though a wound protector placed through the enlarged umbilical port site. After resection of the rectosigmoid, a 5 cm x 5 cm colonic J-pouch was fashioned and delivered to the perineum; 3.5 mL of Indocyanine Green for Injection, USP (ICG) followed by 10 mL of saline solution was administered. Fluorescence angiography
confirmed excellent serosal perfusion of the colonic J pouch (Figure A). A hand-sewn coloanal anastomosis was then fashioned, and an additional 3.5 mL of ICG was administered confirming excellent mucosal perfusion of the anastomosis (Figure B). In addition, a reverse leak test was undertaken.

For the conclusion and full list of references please download the case study here.