Optimizing the image of fluorescence cholangiography using ICG: a systematic review and ex vivo experiments

Jacqueline van den Bos, Fokko P Wieringa, Nicole D Bouvy, Laurents P S Stassen, Jacqueline van den Bos, Fokko P Wieringa, Nicole D Bouvy, Laurents P S Stassen

Abstract

Background: Though often only briefly described in the literature, there are clearly factors that have an influence on the fluorescence intensity, and thereby the usefulness of the technique. This article aims to provide an overview of the factors influencing the fluorescence intensity of fluorescence imaging with Indocyanine green, primarily focussed on NIRF guided cholangiography.

Methods: A systematic search was conducted to gain an overview of currently used methods in NIRF imaging in laparoscopic cholecystectomies. Relevant literature was searched to gain advice on what methods to use. Ex vivo experiments were performed to assess various factors that influence fluorescence intensity and whether the found clinical advices can be confirmed.

Results: ICG is currently the most widely applied fluorescent dye. Optimal ICG concentration lies between 0.00195 and 0.025 mg/ml, and this dose should be given as early as achievable-but maximum 24 h-before surgery. When holding the laparoscope closer and perpendicular to the dye, the signal is most intense. In patients with a higher BMI and/or cholecystitis, fluorescence intensity is lower, but NIRF seems to be more helpful. There are differences between various marketed fluorescence systems. Also, no uniform method to assess fluorescence intensity is available yet.

Conclusions: This study identified and discussed several factors that influence the signal of fluorescence cholangiography. These factors should be taken into account when using NIRF cholangiography. Also, surgeons should be aware of new dyes and clinical systems, in order to benefit most from the potential of NIRF imaging.

Keywords: Fluorescence intensity; Indocyanine green; NIRF; Near-infrared fluorescence imaging.

Conflict of interest statement

Jacqueline van den Bos, Fokko P. Wieringa, Nicole D. Bouvy and Laurents P.S. Stassen have no conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Setup ex vivo Experiments. Legend 9 times 1 ml of ICG in a dilution of 0.125 mg/ml in the cups of a Wells plate. Left: in white light. Middle: in NIRF light. Right: in NIRF light with one plate (0.9 mm) of beeswax on top of the Wells plate
Fig. 2
Fig. 2
Flowchart of systematic search
Fig. 3
Fig. 3
Results ex vivo experiments. LegendA Maximum distance of visibility fluorescent signal for the tested concentrations. B Fluorescence intensity at 2 cm distance for the tested concentrations. C Maximum penetration depth of fluorescent signal for the tested concentrations. D Fluorescence intensity at increased distance between laparoscope and dye-surface

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