Application of Fluorescence Image Guided Cholangiography for Assessment of Biliary Anatomy in Patients with Acute Cholecystitis. Summary of the Doctoral Thesis

Abstract

Laparoscopic cholecystectomy for acute cholecystitis carries an increased risk of biliovascular injuries. Fluorescence cholangiography (FC) is a valuable diagnostic tool for identification extrahepatic bile ducts (EHBD). The objective of this Thesis was to evaluate the efficacy of FC in delineating EHBD anatomy, both before and after dissection, based on the Critical View of Safety (CVS) principles. Urgently admitted patients were prospectively stratified into two groups, mild or moderate acute cholecystitis, in accordance with the Tokyo Guidelines 2018. All patients were scheduled for early laparoscopic cholecystectomy using FC and were administered a fixed dose of indocyanine green (ICG) intravenously 12 hours prior to the surgical procedure. A total of 108 patients – 75 patients with mild acute cholecystitis and 33 patients with moderate acute cholecystitis were included. More than 4 steps of CVS were performed in 101 patients (93.5 %). Less than 4 CVS steps were performed only in seven patients – three (2.5 %) patients with mild acute cholecystitis and four (4 %) patients with moderate acute cholecystitis. The achievement of CVS principle and visualisation rate using FC significantly increased in both patient groups, ranging from 3 % before CVS to 100 % after CVS (p < 0,001). In both groups, cystic duct was visualised in most patients after CVS and FC, followed by common bile duct, and common hepatic duct. Conversely, even after using CVS and FC, visualisation of the confluence of cystic and common hepatic ducts remained less likely and challenging in both groups (57.3 % in mild patients vs 33.3 % in moderate patients; p = 0,022). Liver background fluorescence disturbance was observed equally in both patient groups (6–11 %) and it did not reach statistical significance. Median operative time was 60 ± 25 minutes in patients with mild compared to 85 ± 37 minutes in patients suffering moderate acute cholecystitis (p < 0,001). No postoperative complications or biliovascular injuries were observed. FC is a convenient, safe, and efficacious procedure for attaining CVS principles and identifying EHBD anatomy in most patients. The procedure showed superior results in mild acute cholecystitis patients in comparison to moderate acute cholecystitis patients. Using both FC and Critical View of Safety principles in all patients, ductus cysticus was identified.