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Fluorescent cholangiography could prevent bile duct injury during laparoscopic cholecystectomy

JAMA Surgery
Reuters Health - 03/09/2020 - Fluorescent cholangiography during laparoscopic cholecystectomy could prevent bile duct injury by improving visualization of biliary anatomy, according to a new review.

"I think that fluorescence is a nice illustration of how surgeons can carefully and thoughtfully introduce beneficial new technology into clinical practice with informed patient consent and with minimal additional risk," Dr. Seth D. Goldstein of Ann and Robert H. Lurie Children's Hospital of Chicago told Reuters Health by email.

Dr. Goldstein and Dr. Timothy D. Lautz, also at Lurie Children's, review fluorescent cholangiography in this setting in their report in JAMA Surgery.

With fluorescent cholangiography (FC), indocyanine green is administered intravenously at least one hour preoperatively. Its exclusive hepatic clearance with biliary excretion allows its visualization after florescence in the near-infrared range.

The fact that near-infrared light passes through more than 1 cm of overlying tissue ensures visualization of target structures before, during, and after their dissection from adjacent tissue.

FC can be used intermittently throughout the laparoscopic cholecystectomy without interrupting surgeon workflow, and there is no ionizing radiation associated with its use.

The use of FC as an adjunct to laparoscopic cholecystectomy has not been rigorously studied to date, and the relatively low rate of bile duct injury will likely preclude significant assessment of its benefits and harms without the use of multicenter, consortium, or large national databases.

The limited available data suggest that FC provides visualization of biliary structures that is nearly as accurate as intraoperative cholangiography.

The cost of the equipment required is the principal barrier to broad implementation of FC. While indocyanine green is widely available and inexpensive, almost all existing laparoscopic systems would require costly upgrades to be capable of excitation and detection in the near-infrared range.

Efforts by market suppliers to integrate fluorescent capabilities into their standard offerings, however, could make FC routine over the next decade.

Other notable barriers to implementation of FC include its inability to identify stones in the common bile duct, the need for indocyanine green administration well before the operation begins, and the uncertainty of its utility in technically difficult situations.

"At this point FC is available to all but only implemented in a fraction of nonacademic hospitals, probably 10% or fewer," Dr. Goldstein said. "This will change as operating suites undergo their routine upgrades, which occur every 10-15 years at any given institution."

"The broad appeal of this technology over a number of surgical specialties makes it attractive to hospitals," he said. "Plastic, general, pediatric, oncologic, and gynecological surgeons all have procedures that are amenable to fluorescence guidance. For any of these individual surgeons/operations, the incentive is to augment the 'white-light' (normal vision) visual field so that the surgeon can see hidden or difficult-to-identify structures, thus rendering the operation safer or more thorough."

Dr. Raul J. Rosenthal of Lerner College of Medicine at Case Western Reserve University and Cleveland Clinic, in Weston, Florida, who has researched various aspects of FC, told Reuters Health by email, "Near-infrared technology is the next most important advancement in surgery. It improves outcomes by preventing complications."

"Hospitals should invest in near-infrared (NIR) technology before they do in robots," he said. "Robots are expensive and NIR is not. While robots help average surgeons complete an operation, NIR technology helps patients by preventing complications."

By Will Boggs

SOURCE: https://bit.ly/34POjoJ JAMA Surgery, online August 26, 2020.

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