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. 2022 Nov 4:10:1005879.
doi: 10.3389/fped.2022.1005879. eCollection 2022.

Intraoperative indocyanine green fluorescence cholangiography can rule out biliary atresia: A preliminary report

Chiyoe Shirota  1 , Akinari Hinoki  2 , Takao Togawa  3 , Shogo Ito  3 , Wataru Sumida  1 , Satoshi Makita  1 , Hizuru Amano  2 , Aitaro Takimoto  1 , Shunya Takada  1 , Masamune Okamoto  1 , Yoichi Nakagawa  1 , Daiki Kato  1 , Hiroo Uchida  1
Affiliations

Intraoperative indocyanine green fluorescence cholangiography can rule out biliary atresia: A preliminary report

Chiyoe Shirota et al. Front Pediatr. .

Abstract

Background: The prognosis of BA is known to be poor if definitive surgery is performed too late. Therefore, excluding BA as a diagnosis at an early stage is crucial. Conventional cholangiography requiring cannulation through the gallbladder may be unnecessarily invasive for patients, especially when ruling out BA. Therefore, a less invasive alternative such as indocyanine green (ICG) cholangiography, which does not require cannulation, should be established. In this study, we focused on excluding BA and confirmed the usefulness of intravenous ICG fluorescence cholangiography. To the best of our knowledge, this is the first preliminary study to report the use of intravenous ICG cholangiography for BA exclusion.

Methods: The study participants were patients who underwent liver biopsy and intraoperative cholangiography after they were suspected to have BA, between 2013 and 2022. ICG fluorescence cholangiography was performed on all patients who provided informed consent.

Results: During the study period, 88 patients underwent a laparoscopic liver biopsy and cholangiography. Among them, 65 (74%) were diagnosed with BA and underwent a subsequent laparoscopic Kasai portoenterostomy. BA was ruled out intraoperatively in 23 patients. Of the 23 patients in whom BA was ruled out, 14 underwent ICG cholangiography, 11 had gallbladder (GB) fluorescence, and 9 had both GB and common bile duct (CBD) fluorescence. Conventional cholangiography was very difficult in 2 of 23 cases: in 1 case, cannulation of the atrophic gallbladder was impossible, and cholecystectomy was indicated after multiple attempts; in 1 case, upstream cholangiography was not possible. In both cases, ICG fluorescence cholangiography successfully imaged the CBD and the GB.

Conclusions: In conclusion, intravenous ICG fluorescence cholangiography might be a useful and less invasive diagnostic procedure that can rule out BA in infants.

Keywords: ICG fluorescence cholangiography; biliary atresia; cholestasis; diagnosis; neonate.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Fluorescence and conventional cholangiography for non-biliary atresia (BA) patients. (A) Normal view. (B) Fluorescence cholangiography. (C) Cannulation of the gallbladder. (D) Conventional cholangiography.
Figure 2
Figure 2
Fluorescence cholangiography in patients with biliary atresia. Only the liver appeared to fluoresce strongly. (A) Normal view. (B) Fluorescence cholangiography.
Figure 3
Figure 3
A case of Alagille syndrome requiring cholecystectomy after contrast due to difficulty in contrast from an atrophic gallbladder. (A) Cannulation into the gallbladder was difficult and took many attempts. (B) Conventional cholangiography. (C) ICG Fluorescence cholangiography.
Figure 4
Figure 4
Our strategy to rule out Biliary Atresia. (A) If both the gallbladder and common bile duct fluoresce on ICG fluorescence cholangiography, conventional cholangiography is unnecessary. (B) If only the gallbladder fluoresces, only downstream should be confirmed by conventional cholangiography. (C) If neither the gallbladder nor the common bile duct fluoresces, both upstream and downstream should be confirmed by conventional cholangiography. GB, gallbladder.
See this image and copyright information in PMC

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