Application of fluorescence image guided cholangiography for the assessment of biliary anatomy in patients with acute cholecystitis: review of a case series

Bile duct injuries (BDI) remain one of the most threatening complications during laparoscopic cholecystectomy (LC). In patients with acute cholecystitis (AC) the risk of BDI may increase up to 20 times. Near–infrared fluorescent cholangiography (NIRF-C) is a novel, noninvasive method for a real-time intraoperative biliary mapping. The aim of this study is to preliminary evaluate  effect of NIRF-C for detection of biliary anatomy in patients with AC. Urgently admitted patients with AC were considered for surgery using NIRF-C and included in study. The patients were stratified into two groups according to the Tokyo Guidelines 2018: Group1 mild; Group2 moderate AC. 12.5 mg of Indocyanine green (ICG) was administered intravenously 12 hours before surgery to avoid strong liver background and visualise extrahepatic bile ducts (EHBD). Fluorescence effect was scored both before and after the dissection according to Critical View of Safety principle. Adapted visualization scales: Likert scale, Helpful score, Disturbed score were applied to document significance of NIRF-C. A total 11 patients underwent LC with NIRF-C. Mild AC was diagnosed in 9 (82%) and moderate AC in 2 (18%) patients. The near–infrared visualization rate of the cystic duct (CD), common bile duct (CBD) and common hepatic duct (CHD) prior to dissection was 82%, 45%, 27% but after the dissection it improved to 91% (p=0.187), 73% (p=0.026), 73% (p=0.01), respectively. NIRF-C was considered to be helpful or highly helpful to detect CD in 9 (82%), CBD in 4 (36%) and CHD in 2 (18%) patients. Disturbed score showed that fluorescence of liver background did not disturbed detection of anatomy in 5 (45%), slightly disturbed in 4 (36%), and heavily disturbed in 1 (9%) patient. The mean operative time was 74±28.6 minutes. No postoperative complications were reported. NIRF-C is easy applicable method for real-time visualization of EHBD that enhances surgeon's confidence performing LC.