Use of Near Infrared Fluorescent Cholangiography to Reduce Bile Duct Injury in Cholecystectomy

By Raul J. Rosenthal, MD

Most cholecystectomies are now performed laparoscopically, since smaller incisions decrease morbidity and hospital stay and accelerate recovery. Yet the procedure has a significant drawback in that it prevents the surgeon from using tactile discrimination or clearly differentiating between important anatomical structures. As a result, the rate of bile duct injury has increased from approximately 0.2 percent with open cholecystectomy to 0.5 percent, even with the routine use of intraoperative cholangiography.

Bile duct injuries can be devastating, disabling or even fatal for patients. We believe these injuries could be significantly decreased or avoided with the use of near infrared fluorescent cholangiography (NIFC) to improve the visualization of critical anatomical structures.

Fluorescent dye helps light the path

NIFC is performed with a fluorescent imaging system incorporated into a laparoscope. The system consists of a light source that emits both infrared and xenon light.

To perform NIFC, a fluorescent dye known as indocyanine green (ICG) is given intravenously 45 to 60 minutes prior to the procedure. ICG has been in clinical use since 1956 and is today widely used in multiple clinical and surgical specialties. When illuminated by infrared light, the dye manifests fluorescence. NIFC enables us to clearly visualize all biliary anatomy in real time and operate without causing injury to the bile ducts.

Multiple benefits clearly evident

Since we started using NICF, we have conducted clinical trials together with our colleagues at Cleveland Clinic main campus, not only to validate its effectiveness, but also to understand how it compares to intraoperative cholangiography (IOC). We identified 10 reasons why NIFC is preferable to IOC:

1. It can be accomplished in 100 percent of patients, compared with 93 percent with IOC.
2. It is less expensive (Average cost $14 vs $778).
3. It is faster, because there is no need to mobilize equipment and radiology personnel for an X-ray.
4. It is highly specific. (Cystic duct was identified in 44 of 45 patients, the common hepatic duct in 27/45 and the common bile duct in 36/45).
5. It is an excellent teaching tool that can be utilized by residents at all levels. (Residents identified the extrahepatic structures in 45/45 patients).
6. It is incisionless.
7. It is safe. (No allergic or adverse reactions were identified secondary to the dye).
8. There is no learning curve.
9. No X-rays are used, therefore, there is no radiation exposure.
10. It enables real-time surgery. (Dissection, transection and resection were safely performed in 45/45 patients).

We recently initiated a multicenter, international, randomized, controlled, patient-blinded clinical trial comparing NICF to standard white light imaging in visualizing and identifying the main biliary and hepatic structures (cystic duct, right hepatic duct, common hepatic duct, common bile duct, cystic-CBD junction, cystic-gallbladder junction and any accessory ducts) during laparoscopic cholecystectomy.

We expect the trial to finish by June 2017 and the results to be available shortly thereafter.