Brightening the path to safe liver transplants: the role of ICG fluorescence in biliary anastomosis

Abstract

Objectives: Evaluate the effectiveness of indocyanine green (ICG) fluorescence in enhancing the safety and precision of biliary anastomosis during liver transplantation (LT). The primary research question was whether ICG could provide real-time, objective assessment of bile duct vascularization to reduce postoperative biliary complications.

Design: Prospective, observational case series. IDEAL Stage 1 study.

Setting: Tertiary care academic medical center in Barcelona, Spain.

Participants: 10 adult patients who underwent LT between January 2023 and July 2024. Patients were selected based on the indication for LT with varying etiologies of liver failure. Donors included those with brain death and circulatory death (DCD).

Interventions: ICG was administered intravenously as a 3 mg bolus dose to evaluate the vascularization of the bile duct stumps. Fluorescence was visualized using a high-definition camera system during surgery, and adjustments to the anastomosis site were made based on the fluorescence patterns observed.

Main outcome measures: The primary outcome was the identification of non-vascularized (non-fluorescent) bile duct tissue and subsequent adjustments to the anastomosis site. Secondary outcomes included the incidence of biliary complications and patient survival during the follow-up period.

Results: ICG fluorescence successfully identified non-fluorescent areas in the bile duct stumps, leading to surgical adjustments in five cases (50%), particularly in DCD grafts. The procedure was well-tolerated with no adverse events related to ICG administration. The use of ICG fluorescence added an average of 3-5 min to the operative time. No biliary complications were reported during follow-up, and patient survival was 100%.

Conclusions: ICG fluorescence provides a valuable, objective tool for assessing bile duct vascularization during LT, potentially reducing biliary complications. This technique's integration into clinical practice could enhance surgical precision and improve patient outcomes. Further research is needed to confirm these findings in larger, more diverse populations.

Keywords: Health Technology; Technology.

Figure 1. Distal ischemia of the graft bile duct stump. Near-Infrared mode (A) and overlay mode (B), with a hypoperfused area (non-fluorescent area) (* pointing arrow). 1: common bile duct; 2: cystic stump; 3: Argyle tube; 4: gastroduodenal artery stump; 5: proper hepatic artery.

Figure 2. Correct vascularization of graft and receptor bile duct stumps. Near-Infrared mode (A) and overlay mode (B). 1: graft bile duct stump; 2: receptor bile duct stump.