Efficacy and Safety of Near-Infrared Florescence Cholangiography Using Indocyanine Green in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

Indocyanine green fluorescent cholangiography in laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis of randomized controlled trials

BACKGROUND

Indocyanine green fluorescent cholangiography is a noninvasive, real-time visualization method to prevent misinterpretation of biliary anatomy during laparoscopic cholecystectomy. This systematic review and meta-analysis focuses exclusively on randomized controlled trials that assess the efficacy of this technique during laparoscopic cholecystectomy.

METHODS

MEDLINE, Embase, and Cochrane databases were searched up to August 2024. The main endpoints of interest included bile duct injuries and identification success rates of biliary structures. A trial sequential analysis was performed to establish implications for further research.

RESULTS

Eight studies comprising 1,586 patients were included. The results showed no statistically significant differences in bile duct injuries (odds ratio, 0.73; 95% confidence interval, 0.05-10.80; I2 = 32%), identification success rates of the cystic duct (odds ratio, 1.73; 95% confidence interval, 0.78-3.86; I2 = 32%) or common hepatic duct (odds ratio, 2.80; 95% confidence interval, 0.96-8.15; I2 = 82%). However, a significant difference was observed in the success rate odds for identifying the common bile duct (odds ratio, 4.08; 95% confidence interval, 1.77-9.41; I2 = 64%). The trial sequential analysis provided certainty that the improved success rate for identifying the common bile duct is not a result of type 1 error, but further studies are necessary to assess the results of most outcomes.

CONCLUSION

Indocyanine green fluorescent cholangiography significantly improved the odds of success in identifying the common bile duct during laparoscopic cholecystectomy. However, additional randomized controlled trials are needed to confirm its effects on identifying other biliary structures and affecting patient outcomes.

Evaluating the Role of Indocyanine Green Fluorescence Imaging in Enhancing Safety and Efficacy During Laparoscopic Cholecystectomy: A Systematic Review

Laparoscopic cholecystectomy (LC) is the standard treatment for gallbladder disease, offering less invasive treatment and quicker recovery. However, bile duct injury (BDI) remains a critical complication. Indocyanine green (ICG) fluorescence imaging has emerged as a valuable technique to improve biliary structure visualization and potentially reduce BDI during LC. This systematic review assesses the efficacy of ICG in reducing BDI over the past decade. A comprehensive search of studies comparing ICG fluorescence and conventional white light (WL) in LC identified 14 studies. Key outcomes such as operative time, incidence of BDI, and visualization of biliary anatomy were analyzed. The results indicate that ICG significantly reduced operative times in complex cases, with an average reduction of approximately 20 minutes compared to WL (p<0.0001). In routine cases, no significant difference in operative time was observed between the two methods. ICG consistently enhanced visualization of key biliary structures, such as the cystic duct and common bile duct, with the greatest benefits seen in anatomically challenging cases. Although the overall incidence of BDI was low, use of ICG showed a trend toward lower BDI rates compared to WL, though the difference was not statistically significant. In conclusion, the use of ICG fluorescence in LC offers notable advantages, particularly in improving visualization of biliary anatomy and reducing operative time in complex cases. While the overall reduction in BDI rates may appear marginal, the clinical importance of avoiding even a single BDI should not be understated, given the serious complications associated with BDI. Our review suggests that the benefits of ICG are most pronounced in more complex cases where biliary anatomy is challenging to identify.

Indocyanine Green and Hepatobiliary Surgery: An Overview of the Current Literature

Indocyanine green (ICG) is an inert polypeptide that almost totally binds to high molecular weight plasma proteins; it is cleared by the hepatocytes and directly excreted into the bile with a half-life of about 3-5 minutes. Specific systems are required to see fluorescent images. The use of this dye has been reported in different surgical specialties, and the applications in hepatobiliary surgery are widening. Being firstly used to evaluate the preoperative liver function, intra- and postoperative dynamic checking of hepatic activity has been reported and integrated within perioperative protocols allowing a tailored treatment allocation. Intravenous injection (IV) or injection into the gallbladder can ease difficult cholecystectomy. Biliary leakage detection could be enhanced by IV ICG injection. Although with some contrasting results, the use of ICG for both delineating the limits of the resection and tumor-enhanced visualization was demonstrated to improve short- and long-term outcomes. Although the lack of strong evidence still precludes the introduction of this tool in clinical practice, it harbors great potential in liver surgery.

Effects of Indocyanine Green (ICG) Imaging-Assisted Cholecystectomy on Intraoperative and Postoperative Complications: A meta-Analysis

BACKGROUND

Accurate recognition of Calot's triangle during cholecystectomy is important in preventing intraoperative and postoperative complications. The use of indocyanine green (ICG) fluorescence imaging has become increasingly prevalent in cholecystectomy procedures. Our study aimed to evaluate the specific effects of ICG-assisted imaging in reducing complications.

MATERIALS AND METHODS

A comprehensive search of databases including PubMed, Web of Science, Europe PMC, and WANFANGH DATA was conducted to identify relevant articles up to July 5, 2023. Review Manager 5.3 software was applied to statistical analysis.

RESULTS

Our meta-analysis of 14 studies involving 3576 patients compared the ICG group (1351 patients) to the control group (2225 patients). The ICG group had a lower incidence of postoperative complications (4.78% vs 7.25%; RR .71; 95%CI: .54-.95; P = .02). Bile leakage was significantly reduced in the ICG group (.43% vs 2.02%; RR = .27; 95%CI: .12-.62; I2 = 0; P = .002), and they also had a lower bile duct drainage rate (24.8% vs 31.8% RR = .64, 95% CI: .44-.91, P = .01). Intraoperative complexes showed no statistically significant difference between the 2 groups (1.16% vs 9.24%; RR .17; 95%CI .03-1.02), but the incidence of intraoperative bleeding is lower in the ICG group.

CONCLUSION

ICG fluorescence imaging-assisted cholecystectomy was associated with a range of benefits, including a lower incidence of postoperative complications, decreased rates of bile leakage, reduced bile duct drainage, fewer intraoperative complications, and reduced intraoperative bleeding.

Near-infrared cholangiography with intragallbladder indocyanine green injection in minimally invasive cholecystectomy

Laparoscopic cholecystectomy (LC) remains one of the most commonly performed procedures in adult and paediatric populations. Despite the advances made in intraoperative biliary anatomy recognition, iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems. A series of methods have been proposed to prevent bile duct injury, among them the use of indocyanine green (ICG) fluorescence. The most commonly reported method of ICG injection is the intravenous administration, while literature is lacking studies investigating the direct intragallbladder ICG injection. This narrative mini-review aims to assess the potential applications, usefulness, and limitations of intragallbladder ICG fluorescence in LC. Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy, as well as special issues regarding its use. Literature search retrieved four prospective cohort studies, three case-control studies, and one case report. In the three case-control studies selected, intragallbladder near-infrared cholangiography (NIRC) was compared with standard LC under white light, with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography (IOC). In total, 133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC. Literature includes several reports of intragallbladder ICG administration, but a standardized technique has not been established yet. Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping, overwhelming limitations of IOC including intervention and radiation exposure, as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence. Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Detection and management of bile duct injury during cholecystectomy

INTRODUCTION

Cholecystectomy represents one of the most performed surgical procedures. Bile duct injuries (BDIs) are a dangerous complication of this intervention. With the advent of the laparoscopy, the rate of BDIs showed a growing trend that was partially justified by the learning curve of this technique.

EVIDENCE ACQUISITION

A literature search was conducted on Embase, Medline, and Cochrane databases to identify studies published up to October 2022 that analyzed the intraoperative detection and management of BDIs diagnosed during cholecystectomy.

EVIDENCE SYNTHESIS

According to the literature, approximately 25% of BDIs is diagnosed during the laparoscopic cholecystectomy. In the clinical suspicion of BDI, an intraoperative cholangiography is performed to confirm it. Complimentary technology, such as near-infrared cholangiography, can be also adopted. Intraoperative ultrasound represents a useful tool to furtherly define the biliary and the vascular anatomy. The proper classification of the type of BDI allows to identify the correct treatment. When a good expertise in hepato-pancreato-biliary surgery is available, a direct repair is performed with good outcomes both in case of simple and complex lesions. When the local resources are limited or there is a lack of dedicated surgical experience, patient referral to a reference center shows better outcomes. In particular, complex vasculo-biliary injuries require a highly specialized treatment. The key elements to transfer the patients are a good documentation of the injury, a proper drainage of the abdomen, and an antibiotic therapy.

CONCLUSIONS

BDI management requires a proper diagnostic process and prompt treatment to reduce the morbidity and mortality of this feared complication occurring during cholecystectomy.