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 results of the current up-to-date overview confirmed the efficacy of ICG-fluorescence cholangiography in detecting biliary anatomy, its importance as a teaching tool for young surgeons, and the effects on the reduction of conversion rate and BDI, even if further considerable research remains necessary to optimize its use. This frontier method has enormous potential to become the gold standard during all cholecystectomies in elective and emergency settings due to its safety and limited costs. However, clear clinical guidelines are necessary for the surgical community.

https://www.wjgnet.com/1007-9327/full/v27/i36/5989.htm

Indocyanine green (ICG) assessment of ureteral perfusion during pediatric robotic surgery

Vascular preservation is a tenet of successful ureteral reconstruction. Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) provides real-time identification of tissue perfusion during robotic surgery. Here, we present our utilization of NIRF with ICG to ensure adequate ureteral perfusion during robotic reconstruction in 3 pediatric patients. Between July 2019 and May 2020, we utilized NIRF with ICG during 3 consecutive robotic ureteral reconstructive cases in an academic pediatric urology practice. Patients were 3-, 14-, and 17-years-old and presented with congenital ureteral stricture, mid-ureteral polyp disease, and distal-ureteral polyp disease, respectively. Following surgical reconstruction of each patient’s underlying pathology, ICG doses of 0.039–0.086 mg/kg IV were used to elucidate blood supply to the affected segment of ureter prior to closing. In all 3 cases, NIRF with da Vinci Xi endoscope’s Firefly® technology confirmed perfusion proximal and distal to target anatomy within 60 seconds of administration.

Conclusion: Use of ICG appears to be low-cost, safe, and useful during pediatric urologic robotic surgery. This technology may be helpful to confirm satisfactory blood supply to the ureter following robotic ureteral reconstruction, as demonstrated in our case series of 3 pediatric patients.

https://www.sciencedirect.com/science/article/pii/S2213576621002797

Recent publication “Innovative Endoscopic and Surgical Technology in the GI Tract” supporting use of Indocyanine Green (ICG) as standard of care for lap chole procedures.

The first chapter of this publication by Ryan C. Broderick, Jeff Reeves and Santiago Horgan highlights the use of Fluorescence Guided Surgery in Biliary Tree procedures.

Abstract: Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the United States, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring biliary tree cannulation with intraoperative cholangiogram (IOC). Literature review and analysis of our institutional data shows fluorescence cholangiography used in conjunction with the “critical view of safety” is a non-invasive adjunct to laparoscopic cholecystectomy with improved patient outcomes. These findings support ICG as standard of care during laparoscopic cholecystectomy.

https://link.springer.com/chapter/10.1007/978-3-030-78217-7_33

Review of fluorescence guided surgery systems: identification of key performance capabilities beyond indocyanine green imaging

There is growing interest in using fluorescence imaging instruments to guide surgery, and the leading options for open-field imaging are reviewed here. There has been a steady growth in commercially marketed FGS systems, each with their own differentiated performance characteristics and specifications. In this review, United States Food and Drug Administration 510(k) cleared commercial systems and some leading premarket FGS research systems were evaluated to illustrate the continual increase in this performance feature base. Generally, the systems designed for ICG-only imaging have sufficient sensitivity to ICG, There is no perfect imaging system, but the feature differences among them are important differentiators in their utility, as outlined in the data and tables.

https://www.spiedigitallibrary.org/journals/journal-of-biomedical-optics/volume-21/issue-08/080901/Review-of-fluorescence-guided-surgery-systems–identification-of-key/10.1117/1.JBO.21.8.080901.full?SSO=1

The Use of Indocyanine Green Fluorescence Angiography in Predicting Distal Ischemia Following Arteriovenous Fistula Placement

Objective: Vascular steal syndrome of the distal extremity following Arterio-Venous (AV) fistula placement can occur in up to 2-20% of patients. This occurrence often leads to additional surgery such as the Distal Revascularization with Interval Ligation (DRIL) procedure, or fistula ligation. Although multiple risk factors have been shown to be associated with steal, there currently exists no reliable means by which to predict its development at the time of fistula creation. The purpose of this study was to apply a well-established perfusion measurement examination to the ipsilateral hand at the time of access in order to identify those patients at high risk for steal syndrome.

Results: In 29 consecutive controls with full data, the overall change in the hand perfusion ingress rate after AV fistula placement was 0.17 units/sec or 6%. None of these patients developed vascular steal.

Conclusions: Early data shows indocyanine green fluorescence angiography may be useful in predicting the development of vascular steal following AV fistula placement and the success of DRIL procedures.

https://www.gavinpublishers.com/article/view/the-use-of-indocyanine-green-fluorescence-angiography-in-predicting-distal-ischemia-following-arteriovenous-fistula-placement

Role of near-infrared fluorescence in colorectal surgery, published in World J Gastroenterol.

Near-infrared fluorescence (NIRF) is a technique of augmented reality that, when applied in the operating theatre, allows the colorectal surgeon to visualize and assess bowel vascularization, to identify lymph nodes draining a cancer site and to identify ureters. Herein, we review the literature regarding NIRF in colorectal surgery. Near-infrared fluorescence appears to be a useful tool that assists surgeons performing colorectal surgery by identifying poorly vascularized areas of the bowel and therefore decreasing the incidence of anastomotic leak, visualizing lymphatic drainage and identifying the ureters during difficult surgery.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384744/

Three reasons why managing elective surgeries will be different this year

  • The context of Covid-19 is different than before– We also have experience with necessary changes to hospital operations such as screening patients and separating infected from non-infected patients. And, of course, we now have vaccines that reduce the risk of severe Covid-19 cases and a better understanding of how to treat those that do require hospitalization.
  • There are negative effects of postponing elective cases – Postponing elective cases can cause serious detriment to patient health and wellbeing. Numerous studies have recorded excess mortalities across 2020 that are likely due to these disruptions in care for those with non-Covid-19 health needs. Additionally, hospitals now understand the degree to which elective surgeries support their bottom line and ability to sustainably operate.
  • Hospitals can (and should) be more selective about which cases to postpone – many hospitals and health systems are now reviewing elective on a case-by-case basis to determine what can be safely postponed.

https://www.advisory.com/daily-briefing/2021/08/18/elective-surgeries

Immunofluorescence in Robotic Colon and Rectal Surgery

The indocyanine green fluorescence imaging system is a surgical tool with increasing applications in colon and rectal surgery that has received growing acceptance in various surgical disciplines as a potentially valid method to enhance surgical field visualization, improve lymph node retrieval, and decrease anastomotic leak. Small noncomparative prospective trials have shown that intraoperative fluorescence imaging is a safe and feasible method to assess anastomotic perfusion and that its use may impact anastomotic leak rates. However, larger prospective and randomized studies are required to validate its role and impact in colorectal surgery. The purpose of this article is to review the current status of the use of immunofluorescence in colon and rectal surgery, as well as new applications in robotic colon and rectal resections.

https://pubmed.ncbi.nlm.nih.gov/34504405/

Use of Near-Infrared Imaging using Indocyanine Green Associates with the Lower Incidence of Postoperative Complications After Surgery for Intestinal and Mesenteric Injury

Anastomotic leakage after intestinal resection is one of the most serious complications of surgical intervention for hollow viscus injury. Adequate vascular perfusion of the anastomotic site is essential to prevent anastomotic leakage. Near-infrared imaging using indocyanine green (NIR-ICG) is useful for the objective assessment of vascular perfusion. The aim of this study was to evaluate the association of NIR-ICG with intestinal and mesenteric injuries.

This was a retrospective, single-center study of patients undergoing surgery for intestinal and mesenteric injuries due to abdominal trauma from December 2006 to March 2021. NIR-ICG was used to evaluate vascular perfusion. Postoperative complications were assessed between NIR-ICG and non-NIR-ICG groups.  The use of NIR-ICG was associated with a lower incidence of Clavien-Dindo grade ≥ III complications with a statistical tendency (p = 0.076). No Clavien-Dindo grade ≥ II intestinal complications were observed in the NIR-ICG group. When limited to patients that underwent intestinal resection, the use of NIR-ICG was significantly associated with a lower risk of perioperative complications (p = 0.009).

Conclusions: The use of NIR-ICG tended to associate with the lower incidence of postoperative complications after intestinal and mesenteric trauma surgery. NIR-ICG was associated with a significantly lower risk of complications in patients undergoing intestinal resection. The NIR-ICG procedure is simple and quick and is expected to be useful for intestinal and mesenteric trauma.

https://www.researchsquare.com/article/rs-829393/v1