Evaluation of the role of indocyanine green fluoroscopy for intraoperative bile duct visualization and prevention of CBD injury during laparoscopic cholecystectomy

DISCUSSION

The laparoscopic cholecystectomy (LC) procedure is one of the most prevalent in the world, with over 750 000 procedures done each year in the United States. Bile duct injury (BDI) is among the most feared complications of LC, with a rate ranging from 0.4% to 1%. It has an effect on long-term life quality and death rates, as well as puts a financial strain on healthcare systems.⁸

Many strategies, such as intraoperative cholangiography (IOC), laparoscopic U/S, cholecysto-cholangiography, and the safety critical view, were used to reduce the incidence of complications over the year.⁹

The effectiveness of any of these procedures, however, is dependent on the correct evaluation of normal biliary anatomy, anatomical changes, and abnormal discoveries.¹⁰

The goal of this study is to evaluate the role of ICG versus laparoscopic cholecystectomy, through introducing statistics about how much ICG is effective, accurate, feasible, and safe in delineating the biliary tree, in detecting anatomical and pathological anomalies like filling deficiencies, fistulas, cysts, and biliary system tumors, and in detecting the role of ICG in decreasing morbidity and mortality rates.

The present study has been carried out as a controlled randomized  study  and  conducted  in  the elective  surgery theatres of the department of general surgery at  El-Hussien &Sayed Galal hospitals  including  50 patients of mean age of (39.73 ± 10.69) years and dominance of female gender. These demographic features revealed statistically significant differences across the two groups. The study population consisted of 50 patients who were allocated into two groups at random; the first one submitted to laparoscopic cholecystectomy with ICG, and the 2nd group submitted to laparoscopic cholecystectomy only.

Shabanzadeh agree with us that is no significant gender-related difference in prediction of biliary stones.¹⁰

Tan JT stated  that  the  advancing  age  as  a  predictor  valuable  but  suggest  male  gender  as  a  predictor  instead.¹¹

Arulampalam augments the old age theory too, many studies validates that the older the age the greater likelihood there is positive GB stones. ¹²

Regarding morbidities of the selected patients, 17.5% of the patients were hypertensive. 12.5% of them were diabetic, and 0% of them had IHD.

Patients of the study had done laparoscopic cholycystectomy for chronic calcular cholycystitis (92.5%), 0% had acute calcular cholycystitis, also 7.5% had chronic calcular cholecystitis with history of jundice.

Regarding type of surgery all patients had been performed in elective basis. Visualization ability it is evident that one of the drawbacks of LC is the poor visualization, which might lead to bile duct injury. However, ICG compensates for this limitation by providing best rate of visualization. ⁹

In our study, ICG successfully identified the structures of the biliary tree in 24 patients in group II. This agrees with previous studies with varying degrees,  where ICG visualization  rate  of the  cystic  duct  ranged  between  71.4 to 100%, and that of the common hepatic duct was 33.3– 100%, the CBD was 50–100%, and the junction of the cystic duct and the common hepatic duct was 25–100%. ⁸

These variations in the visualization ability of ICG are attributed to many factors. For example, the patient position, the contrast material itself and the surgeons experience.  Improper position aside from supine position might affect visualization. Different quantity and quality of contrast materials also play a great role in visualization.

Expert surgeons are aware of the possible factors that hinder visualization such as air trapping and inadequate filling and adequate contrast materials. ^9-7

The high visualization ability of ICG is considered an advantage that counterweighs ICG invasiveness. Moreover, it surpasses other modalities such as ultrasound which cannot detect all biliary structures. ⁷

Laparoscopic ultrasound can sometimes achieve 100% visualization rate, however, it has some limitations that made it underused.  Firstly, it is highly dependent on the operators‟ experience. ⁶ Secondly, it is associated with a learning curve for initial using .⁶ thirdly, it is inefficient in differentiation of anatomical variations of the bile duct.  Last but not least, it cannot determine the flow of bile into the duodenum. ⁷

We proved that ICG is accurate in detection of biliary stones with high sensitivity and specificity (100%). Previous studies augment this finding with similar high statistics.Ayloo S found that the sensitivity of ICG for detection of CBD stones is 97% and specificity is 99%.¹

It's worthy to mention that all cases with ICG had a better visualization, feasibility and safety than other modalities such as ERCP and MRCP ⁷

 With the usage of ICG there was zero conversion to open cholecystectomy, less liability to other complications and better postoperative outcome.

CONCLUSION

paroscopic cholecystectomy with real-time indocyanine green fluorescence cholangiography improves vision and detection of the biliary tree and, as a result, ought to be regarded as a way to increase laparoscopic cholecystectomy safety.