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Near-infrared fluorescence cholangiography at a very low dose of indocyanine green: quantification of fluorescence intensity using a colour analysis software based on the RGB color model

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A Correction to this article was published on 03 September 2022

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Abstract

Background

Indocyanine green (ICG) near-infrared fluorescence cholangiography (NIRF-C) is widely used to visualize the biliary tract during laparoscopic cholecystectomy (LC). However, the ICG dose and its dosing time vary in the literature so there is not a standard ICG protocol. The objectives of this descriptive prospective study were to demonstrate that NIRF-C at a very low dose of ICG provides good visualization of the extrahepatic biliary tree while avoiding hepatic hyperluminescence and to assess the surgeon-perceived benefit. Furthermore, another additional aim was quantifying the amount of ICG dye in the liver tissue and biliary tract through a green colour intensity (GCI) analysis according to red green blue (RGB) color model and correlating it to surgeon-perceived benefit.

Method

Forty-four patients were scheduled for LC. We recorded demographics, surgical indication, intraoperative details, adverse reactions to ICG, hepatic hyperluminescence, visualization of the cystic duct (CD), the common bile duct (CBD) and the cystic duct–bile duct junction (CDBDJ) before and after dissection of Calot’s triangle, operation time, surgical complications and subjective surgeon data. For all procedures, a unique dose of 0.25 mg of ICG was administered intravenously during the anaesthetic induction. ICG NIRF-C was performed using the overlay mode of the VISERA ELITE II Surgical Endoscope in all surgeries. Video recordings of all 44 LC were reviewed. Using a color analysis software, the GCI of CBD versus adjacent liver tissue was calculated using RGB color model.

Results

ICG NIRF-C was performed in all 44 cases. The mean operation time was 45 ± 15 min. There were no bile duct injuries (BDIs) or allergic reactions to ICG. The postoperative course was uneventful in all of cases. The mean postoperative hospital stay was 28 ± 4 h. ICG NIRF-C identified the CBD in 100% of the patients, the CD in 71% and the CDBDJ in 84%, with a surgeon satisfaction of 4/5 or 5/5 in almost 90% of surgeries based on a visual analogue scale (VAS). No statistically significant differences were found in the visualization of the biliary structures after the dissection of Calot’s triangle in obese patients or with gallbladder inflammation. Furthermore, 25% of patients with a BMI ≥ 30, 27% of patients with a Nassar grade ≥ 3 and 21% of patients with gallbladder inflammation had a VAS score 5/5 compared to 6% of patients with a BMI < 30 (p = 0.215), 6% of patients with a Nassar grade < 3 (p = 0.083) and none of the patients without gallbladder inflammation (p = 0.037). Measured pixel GCI of CBD was higher than adjacent hepatic tissue for all cases regardless of the degree of gallbladder inflammation, the Nassar scale grades or the patient’s BMI (p < 0.0001). In addition, a significant correlation was observed between surgeon-perceived benefit and the amount of ICG dye into the CBD according the RGB color model (p < 0.0001).

Conclusion

ICG NIRF-C at a very low dose of ICG (0.25 mg of ICG 20 min before surgery) enables the real-time identification of biliary ducts, thereby avoiding the hepatic hyperluminescence even in cases of obese patients or those with gallbladder inflammation.

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Change history

Abbreviations

LC:

Laparoscopic cholecystectomy

BDI:

Bile duct injury

ICG:

Indocyanine green

NIRF-C:

Near-infrared fluorescence cholangiography

NIR:

Near-infrared

WL:

White light

CD:

Cystic duct

CBD:

Common bile duct

CDBDJ:

Cystic duct–bile duct junction

VAS:

Visual analogue scale

BMI:

Body mass index

ASA:

American Society of Anaesthesiologists

RGB:

Red green blue

GCI:

Green color intensity

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Authors and Affiliations

  1. Department of General Surgery, Hospital Universitario Son Espases, Palma, Spain

    Natalia Pujol-Cano, Francesc Xavier Molina-Romero, Elías Palma-Zamora, Jaume Bonnin-Pascual, Magdalena Coll-Sastre, Francesc Xavier González-Argenté & José Miguel Morón-Canis

  2. Faculty of Medicine, Universidad de Las Illes Balears, Palma, Spain

    Francesc Xavier Molina-Romero & Francesc Xavier González-Argenté

  3. Simmulation and 3D Group (S-3D), Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain

    Francesc Xavier Molina-Romero, Jaume Bonnin-Pascual & José Miguel Morón-Canis

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  1. Natalia Pujol-Cano
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Contributions

The corresponding author attests that all listed authors meet authorship criteria and that no other meeting the criteria have been omitted.

The manuscript’s guarantor affirms that the manuscript is an honest, accurate and transparent account of the study being reported; no important aspects of the study have been omitted and any discrepancies from the study as planned have been explained. Drs. Natalia Pujol-Cano, Francesc Xavier Molina-Romero, Elías Palma-Zamora, Jaume Bonnin-Pascual, Magdalena Coll-Sastre, Francesc Xavier González-Argenté and José Miguel Morón-Canis have no conflicts of interest or financial ties to disclose.

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Correspondence to Francesc Xavier Molina-Romero.

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All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

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Pujol-Cano, N., Molina-Romero, F.X., Palma-Zamora, E. et al. Near-infrared fluorescence cholangiography at a very low dose of indocyanine green: quantification of fluorescence intensity using a colour analysis software based on the RGB color model. Langenbecks Arch Surg 407, 3513–3524 (2022). https://doi.org/10.1007/s00423-022-02614-5

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