Résumé
Objective:To investigate the feasibility and potential of fluorescent cholecystic bile duct visualization with direct intravenous injection of indocyanine green(ICG) in obese patients undergoing laparoscopic cholecystectomy(LC).Methods:The clinical data of 132 patients with LC combined with obesity admitted to the Department of Hepatobiliary and Pancreatic Surgery of the Second People′s Hospital of Changzhou City, affiliated to Nanjing Medical University, from January 2023 to July 2023 were retrospectively analyzed. They were divided into fluorescence group( n=65) and control group( n=67) according to whether indocyanine green fluorescence navigation was used or not. There were 50 males and 82 females, and all the enrolled patients body mass index≥28 kg/m 2. Two groups identify the time of the three tubes, intraoperative bleeding, operation time, postoperative hospitalization time, white blood cell count(WBC), C-reactive protein(CRP), alanine aminotransferase(ALT), gamma-glutamyl transferase(GGT), and postoperative follow-up in the fluorescent and control groups were counted respectively. Measurement data with skewed distribution were expressed as M( Q1, Q3), and intergroup comparisons were performed using the Mann-Whitney U test; counting data were described by frequency(rate), and intergroup comparisons were made by applying the chi-square test, Fisher′s exact probability method, and chi-square corrected test according to the difference in the minimum frequency. Results:Surgery was successfully completed in both groups. Preoperative inflammatory indicators and liver function levels were also not statistically significant( P>0.05). The time to identify the three tubes, operation time, intraoperative bleeding, and postoperative hospitalization in the fluorescence group were 18.00(13.50, 20.00) min, 40.00(30.00, 50.00) min, 5.00(5.00, 10.00) mL, and 2.00(1.50, 3.00) d, and in the control group were 32.00(25.00, 45.00) min, 65.00(50.00, 85.00) min, 41.00(41.00, 46.00) mL, and 4.00(3.00, 5.00) d. The differences between the two groups were statistically significant( P<0.05). The postoperative leukocyte count, postoperative CRP, and postoperative GGT were 9.15(7.10, 11.75)×10 9/L, 7.19(3.22, 20.00) mg/L, and 34.0(20.0, 49.0) U/L in the fluorescence group, and 13.05(11.02, 15.59)×10 9/L, and 18.78(12.90, 32.95) mg/L in the control group, respectively, 82.5(68.5, 114.5) U/L, and the differences between the two groups were statistically significant ( P<0.05). None of the patients showed abdominal pain, abnormal liver function and hepatobiliary ultrasound in the follow-up findings within 2 months after surgery. Conclusion:The effect of obesity, a factor that interferes with ICG fluorescence, is extremely limited, and ICG fluorescence cholangiography is a useful technique in the obese population that not only improves the efficiency of the procedure, but also increases intraoperative safety, with results superior to those of conventional laparoscopic cholecystectomy.
Résumé
Objective:To investigate the feasibility and efficacy of transcystic injection of indocyanine green during laparoscopic cholecystectomy (LC) surgery in the treatment of patients with gallbladder stones combined with liver cirrhosis.Methods:The clinical data of 96 patients with cirrhosis who underwent LC for gallbladder stones with cholecystitis attacks in the Department of Hepatobiliary and Pancreatic Surgery of the Second People′s Hospital of Changzhou City from January 2018 to May 2022 were retrospectively analyzed. All patients were diagnosed by clinical history and auxiliary examination before surgery and underwent cholecystectomy according to their groups, which were divided into fluorescence group ( n=49) and white light group ( n=47) according to whether ICG was used or not, where the fluorescence group underwent LC in fluorescence mode after direct intraoperative injection of ICG via gallbladder. The two groups were compared in terms of identification time of the three tubes, operation time, intraoperative bleeding, intraoperative injury, intraoperative open abdomen and blood transfusion, postoperative drainage time, postoperative hospitalization time, postoperative complications and changes in infection and liver function indexes before and after surgery. The measurement data obeying normal distribution were expressed as mean±standard deviation( ± s), and independent sample t-test was used for comparison between groups. The measurement data obeying the skewed distribution were expressed by M( Q1, Q3), and the Mann-Whitney U test was used for comparison between groups. Count data were expressed as rates (%), and the chi-square test or Fisher′s exact probability method was used for comparison between groups. Results:The procedure was successfully performed in both groups, and the identification of triple-tube time, operative time, intraoperative bleeding, postoperative drainage time, postoperative hospital stay, postoperative ALT, postoperative GGT, and postoperative TBIL in the fluorescent group were (14.96±1.49) min, (52.14±7.36) min, 5(5, 10) mL, (1.61±0.61) d, (2.37±0.49) d, 31.5(22.0, 44.8) U/L, 38.0(21.0, 91.5) U/L, 18.0(11.5, 22.8) μmol/L, and (29.87±3.37) min, (84.36±13.25) min, 10(10, 20) mL, (2.70±0.69) d, (3.15±0.42) d, 45.0(28.0, 64.8) U/L, 73.0(32.0, 132.0) U/L, 23.0(16.1, 29.3) μmol/L in the white light group and the differences were statistically significant compared with the two groups( P<0.05). In the fluorescence group, there was no intraoperative injury and no cases of intraoperative opening, and there were 2 cases of postoperative complications, while in the white light group, there were 2 cases of intraoperative injury, 1 case of intraoperative opening, and 5 cases of postoperative complications, and there were no cases of blood transfusion in both groups. There was no statistically significant difference between the fluorescence group and the white light group when comparing the preoperative laboratory indexes of both groups ( P>0.05). When comparing the first postoperative white blood cell count, C-reactive protein, aspartate aminotransferase, and alkaline phosphatase indexes in the fluorescence group and the white light group, there was no statistically significant difference between the two groups ( P>0.05). Conclusion:When LC is performed in patients with symptomatic gallbladder stones combined with cirrhosis, intraoperative injection of indocyanine green via the gallbladder to visualize the gallbladder and bile duct structures is simple and easy to perform, and the safe and efficient dissection of extrahepatic bile ducts and gallbladder bed speeds up the procedure while reducing postoperative trauma.
Résumé
Objective:To investigate the clinical value of intraoperative intravenous injection of indocyanine green in differentiating extrahepatic bile duct structure in chronic atrophic cholecystitis.Methods:A retrospective analysis was performed on the data of 110 patients diagnosed with chronic AC who underwent laparoscopic cholecystectomy (LC) admitted to the Department of Hepatobiliary and pancreatic Surgery of Changzhou Second People′s Hospital from January 2020 to July 2021. All patients were confirmed by abdominal B-ultrasound before surgery. The patients in the experimental group were divided into experimental group ( n=55) and control group ( n=55) according to whether indocyanine green was intravenously injected during the operation. The experimental group was intravenously injected with 5 mg indocyanine green during the operation, and LC was navigated by indocyanine green fluorescence imaging technique during the operation. The control group received routine LC. The imaging rate and imaging time of the cystic duct, common bile duct, and common hepatic duct in the experimental group were compared. The clinical data, identify three tube time, operation time, intraoperative blood loss, abdominal cavity drainage placement and extubation time, transfer laparotomy and bile duct injury, postoperative hospital stay, postoperative first review of alanine aminotransferase (ALT), glutamine transferase (GGT) of leveling and follow-up were compared between the two groups. The measurement data subject to normal distribution were expressed by Mean±standard deviation ( ± s), and the two groups were compared by independent sample t test. The measurement data of skewness distribution were described by M( Q1, Q3)and the manhui method in nonparametric test was used Mann-whitney U test.The chi-square test or Fisher′s exact probability method was used for comparison between groups of count data. Results:Operation was performed successfully in both groups. In the experimental group, the common hepatic duct, common bile duct and gallbladder duct were developed successfully in all patients, 54 cases and 52 cases respectively, and the developing time of the three tubes was (15.8±1.2) min. In the experimental group, the time of three tubes, operation time, intraoperative blood loss and abdominal drainage tube placement were (18.5±1.3) min, (64.0±6.8) min, (16.3±6.7) mL, 43 cases, respectively. In the control group, there were (46.3±8.1) min, (98.7±10.5) min, (53.6±14.9) mL and 55 cases, respectively. The experimental group was significantly lower than the control group, and the difference between the two groups was statistically significant ( P< 0.05). There was no case of conversion to laparotomy and bile duct injury in the experimental group, and 1 case of conversion to laparotomy and 1 case of bile duct injury in the control group, and there was no statistical significance between the two groups ( P>0.05). There were significant differences in postoperative extubation time and postoperative hospital stay between the two groups ( P<0.05). ALT and GGT levels were 47(31, 75) U/L and 38(19, 114) U/L in the experimental group and 62(53, 92) U/L and 76(63, 96) U/L in the control group at the first postoperative review, with statistically significant differences between the two groups ( P<0.05). Patients in both groups were followed up for 3 months after discharge. There were no obvious complications in the experimental group, and 1 case had a small amount of peritoneal effusion 7 days after discharge in the control group. Conclusion:In the face of LC with chronic AC, intraoperative intravenous injection of indocyanine green to develop extrahepatic bile duct can help to distinguish its anatomical structure and avoid bile duct injury, improve the safety and progress of surgery, and maximize training and improve the level of the surgeon.
Résumé
In the era of precision medicine, compared with open surgery, laparoscopic cholecystectomy has the advantages of less trauma, less postoperative complications and shorter hospital stay, but it cannot escape the risk of bile duct injury, and bile duct injury can occur at any time for various reasons, and its unpredictability greatly increases the difficulty of surgery. Although traditional cholangiography can avoid bile duct injury, it has not been widely used due to its limitations such as time consuming, high cost, high radiation and so on. Early indocyanine green has been widely used in lymph node examination, angiography, tumor localization and treatment due to its characteristics. Now, indocyane green fluorescence imaging technology has been gradually applied in LC, which can dynamically reflect the intraoperative situation and realize real-time surgical navigation, so it has achieved ideal effects in the identification of duct structure and prevention of bile duct injury. Indocyanine green injection preoperatively or intraoperatively through the gallbladder to develop extrahepatic bile ducts significantly improves the safety rate of surgery, but there is no unified standard for the use time and dosage of inddocyanine green. In this paper, the time and dose selection and clinical value of indocyanine green were reviewed based on the current research status and the author's experience.