Study of Learning Curve in a Surgeon for Near-Infrared Fluorescence Cholangiography During Laparoscopic Cholecystectomy-A Retrospective Evaluation.

BACKGROUND: Near-infrared indocyanine green fluorescence cholangiography (NIRF) has shown promising results on delineating extra-hepatic biliary anatomy during laparoscopic cholecystectomy to avoid bile duct injury. However its routine usage remains in question. In this study, the technique was evaluated further with learning curve estimation and learning factors were observed. METHODS: One hundred ninety-nine cases which underwent laparoscopic cholecystectomy for acute or chronic cholecystitis within a 2-year period including 51 cases with initial use of NIRF by 2 surgeons were studied retrospectively. The learning curve was evaluated for a surgeon as primary objective. A case-matched comparison of the operative time between NIRF and conventional group, in terms of acute and chronic cholecystitis was also conducted as a secondary calculation. RESULTS: Learning curve was evaluated with 61% learning rate for NIRF experience. Cysto-biliary junction non-illuminated cases under fluorescent view, had mean operative time of 80.83 ± 22.82 min, which was shorter than the cysto-biliary junction illuminated cases. The NIRF group exhibited longer operative time compared with the conventional group with mean difference of 34.39 min (significant at P < .05). CONCLUSIONS: While the initial learning phase might be affected by surgeons' behavior and attitude, our results may provide a reference to learn at one's own pace and to employ NIRF teaching strategies during surgical training programs to overcome the initial phase during training period itself and facilitate universal achievement.

Anatomical Versus Non-anatomical Resection for Hepatocellular Carcinoma, a Propensity-matched Analysis Between Taiwanese and Japanese Patients.

BACKGROUND/AIM: The aim of the study was to compare the outcomes of anatomical resection (AR) versus non-anatomical resection (NAR) for Japanese and Taiwanese patients with single, resectable hepatocellular carcinoma (HCC). PATIENTS AND METHODS: A propensity score matched (PSM) analysis was performed to compare the outcomes of the AR group to those of the NAR group. Tumor size <5 cm, T1 or T2 grade, without evidence of extrahepatic metastasis, invasion of portal or hepatic veins, or direct invasion of adjacent organs, were included in the study. RESULTS: A total of 385 cases (Taiwanese 105, Japanese 280) were analyzed. After PSM, a total of 152 cases remain (Taiwan and Japan both 76 cases). Disease-free survival (DFS) and overall survival (OS) data were not significantly different between the two groups at 5 years follow-up. CONCLUSION: AR of HCC in Japanese patients has a similar 5-year DFS and OS as NAR of HCC in Taiwanese patients.

Intracholecystic administration of indocyanine green for fluorescent cholangiography during laparoscopic cholecystectomy-A two-case report.

INTRODUCTION: The utility of intracystic administration of indocyanine green for near-infrared fluorescent cholangiography in acute calculous cholecystitis initially treated with percutaneous transhepatic gallbladder drainage (PTGBD) was described in this report. PRESENTATION OF CASE: Two cases who underwent near-infrared fluorescent cholangiography guided interval laparoscopic cholecystectomy two weeks post-PTGBD were studied retrospectively. Both patients were diagnosed with moderate acute calculous cholecystitis based on diagnostic criteria of the Tokyo guidelines. Two routes of indocyanine green administration were utilized during surgery, first through direct intracystic administration through PTGBD tube (5 ml of 12.5 mg ICG) to achieve critical view of safety and then intravenous administration (1 ml of 2.5 mg ICG) to visualize cystic artery. DISCUSSION: Both patients had critical view of safety visualized clearly with ICG with the operation time of 84 and 125 min in cases 1 and 2, respectively without any intra or postoperative complications. CONCLUSION: In comparison with intravenous ICG administration, trans-PTGBD ICG route can provide better signal-to-noise ratio by avoiding hepatic fluorescence and thus increasing the bile duct to liver contrast. However, ICG may enter the lymphatic system through necrotic and inflammatory gallbladder mucosa, of which lymph spillage during gallbladder dissection can obscure the fluorescent view.

The use of indocyanine green imaging technique in patient with hepatocellular carcinoma.

Near-infrared indocyanine green (ICG) fluorescence application in liver cancer surgery have been reported in the literature since 2008. To date, most reports emphasized not only to the safety, feasibility and reproducibility, but also the potential benefits of its clinical applications in term of demarcating segmentation for an anatomical resection, tumor identification to achieve tumor free resection margin, detection of small unidentifiable subcapsular nodules as well as extrahepatic metastatic lesions, and fluorescence cholangiography. The purpose of this review is to present the fundamental concept of the interpretation of fluorescence enhancement by different timing through intravascular ICG distribution to liver and biliary washout; to describe step-by-step technical aspects of its use in different purposes, and to expose the diagnostic and therapeutic perspectives of this innovative imaging technique in liver cancer surgery.

Preoperative MRCP to detect choledocholithiasis in acute calculous cholecystitis.

PURPOSE: There are risks of common bile duct (CBD) stones in acute cholecystitis, and there is a move among surgeons to identify choledocholithiasis before surgery. Magnetic resonance cholangiopancreaticography (MRCP) has the potential to accurately detect choledocholithiasis in patients with acute cholecystitis. The aim of this study was to evaluate the predictive values of MRCP and elevated biochemical predictors for choledocholithiasis in patients with acute cholecystitis. METHODS: Between September 2006 and August 2008, of 84 patients with acute cholecystitis based on the diagnosis criteria of the Tokyo guidelines, 57 had MRCP preoperatively. The predictive values of six biochemical predictors for choledocholithiasis were also evaluated. RESULTS: Of the 57 patients, seven (12.28%) had choledocholithiasis, of whom three had CBD stones in nondilated ducts. The smallest stone detected in a dilated CBD and nondilated duct was 3.19 and 4.55 mm in diameter, respectively. None of our patients whose MRCP showed a clear CBD returned with symptomatic choledocholithiasis during the follow-up period. All biochemical predictors and CBD diameter had limited positive predictive values. CONCLUSIONS: Magnetic resonance cholangiopancreaticography is a reliable evaluation technique for the detection of choledocholithiasis. It reduces the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and prevents the risk of overlooking choledocholithiasis. No single predictor or combined markers have been found to be reliable for including/excluding the presence of choledocholithiasis.

Successful use of extracorporeal membrane oxygenation and drotrecogin alpha in patients with acute life-threatening myocarditis.

Acute fulminant myocarditis may present with cardiogenic shock refractory to inotropics and intra-aortic balloon pumping (IABP). Benefit of extracorporeal membrane oxygenation (ECMO) support has been established. The effectiveness of combination with ECMO or IABP and activated protein C (drotrecogin alpha; Xigris) in treatment has yet to be defined. Four patients presented with congestive heart failure 3-4 days after flu-like symptoms. Chest roentgenograms showed cardiomegaly and bilateral pulmonary infiltrates. Two-dimensional echocardiograms demonstrated severe myocardial dysfunction with left ventricular ejection fraction (LVEF), measured between 18.4% to 27% (mean, 19.5%). Three patients having been treated with the combination of ECMO or IABP and activated protein C were weaned. Follow-up LVEF measured were 39.9%, 43%, 53%, and 55%, respectively. However, 1 patient died a month later because of systemic lupus erythematosus and repeated infection. There were no neurologic sequelae in the 3 survivors. Serological test and myocardial biopsy for Parvovirus B19 was positive in 3 of 4 patients. Use of circulatory support and activated protein C is an effective alternative for acute life-threatening myocarditis.