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Intraoperative fluorescence imaging with indocyanine green in hepatic resection for malignancy: a systematic review and meta-analysis of diagnostic test accuracy studies

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Abstract

Background

Fluorescence imaging during hepatic resection has the potential to identify additional malignant tumors, increasing the chance for complete tumor resection. Indocyanine green (ICG) is an FDA approved, fluorescent dye used in a variety of surgical procedures. The objective of this study was to define the sensitivity of intraoperative ICG fluorescent imaging in the detection of hepatic malignancy in adult patients during hepatic resection, which was accomplished by performing a systematic review and meta-analysis.

Methods

The databases Medline, EMBASE, Scopus and Web of Science were assessed in September 2018. Article inclusion criteria was (1) Liver resection for malignancy (2) ICG injected pre or intraoperatively (3) Use of infrared electronic endoscopy or near-infrared fluorescence imaging intraoperatively (4) Patient age ≥ 18 years (5) N > 5 patients (6) Human and English studies only. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) guidelines were used for quality assessment. Data synthesis was completed using Meta-Disc and MedCalc software. A DerSimonian–Laird random effects model was used for the meta-analysis.

Results

21 studies and 841 patients were included in our systematic review. Seven studies and 319 patients were included in the meta-analysis. The pooled sensitivity of intraoperative ICG fluorescence was 0.75 (0.71–0.79). Sensitivity for superficial tumors ranged from 0.96 to 1.00. Heterogeneity (I2) was calculated at 65.1%. ICG-related fluorescence imaging detected new malignant tumors not detected by conventional means in 42 of 362 patients across 13 studies.

Conclusion

The sensitivity of intraoperative ICG-related imaging for superficial tumors is high; however, overall sensitivity is low, at 0.75, suggesting that it would have to be used in combination with current identification methods such as intraoperative ultrasound. Our study also found that intraoperative ICG fluorescence imaging was able to detect additional malignant hepatic tumors in 11.6% of patients.

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Acknowledgements

The authors thank Chunhong Tian for assistance with the literature search.

Funding

This study was unfunded.

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Authors and Affiliations

  1. Division of General Surgery, Faculty of Medicine and Dentistry, 2D Walter C. Mackenzie Health Sciences Centre, University of Alberta Department of Surgery, Edmonton, AB, Canada

    Kieran Purich, Jerry T. Dang, Warren Y. L. Sun, David Bigam, Daniel Birch & Shahzeer Karmali

  2. Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada

    Ali Poonja

  3. Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, Canada

    Daniel Birch & Shahzeer Karmali

  4. 2G2 Walter C. Mackenzie Health Sciences Centre, Dvorkin Lounge Mailroom, 8440 – 112 ST NW, Edmonton, AB, T6G 2B7, Canada

    Kieran Purich

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Correspondence to Kieran Purich.

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Kieran Purich, Jerry T. Dang, Ali Poonja, Warren Y. L. Sun, David Bigam, Daniel Birch and Shahzeer Karmali have no conflicts of interest or financial ties to disclose.

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Purich, K., Dang, J.T., Poonja, A. et al. Intraoperative fluorescence imaging with indocyanine green in hepatic resection for malignancy: a systematic review and meta-analysis of diagnostic test accuracy studies. Surg Endosc 34, 2891–2903 (2020). https://doi.org/10.1007/s00464-020-07543-2

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