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Surgical Endoscopy

, Volume 33, Issue 1, pp 126–134 | Cite as

Intraoperative ICG-based imaging of liver neoplasms: a simple yet powerful tool. Preliminary results

  • Marie Sophie Alfano
  • Sarah MolfinoEmail author
  • Sara Benedicenti
  • Beatrice Molteni
  • Paola Porsio
  • Elisa Arici
  • Federico Gheza
  • Maristella Botticini
  • Nazario Portolani
  • Gian Luca Baiocchi
Article

Abstract

Background

Detecting small nodules that are grossly unidentifiable remains a major challenge in liver resection for cancer. Novel developments in navigation surgery, especially indocyanine green (ICG)-based fluorescence imaging, are making a clear breakthrough in addressing this issue. ICG is almost routinely administered during the preoperative stage in hepatobiliary surgery. However, its full potential has yet to be realized, partly because there are no precise guidelines regarding the optimal dose or timing of ICG injections before liver surgery. The main goal of this study was to design an algorithm for the management of ICG injections to achieve optimal liver staining results.

Methods

Twenty-seven consecutive, unselected patients undergoing liver resection for cancer were enrolled and underwent preoperative liver function assessment by the LiMON test. Extra ICG i.v. injections at different doses and timings were performed. In vivo intraoperative analysis of the stain detected by near-infrared fluorescence imaging of the liver and ex vivo analysis of each resected nodule was performed and compared to the pathological analysis.

Results

(i) The success rate of ICG injections in terms of liver staining was 92.6%; (ii) in the absence of or with 7 or more days from a previous ICG injection, the best dose to inject before the operation was 0.2 mg/kg, and the best timing was between 24 and 48 h before the scheduled surgery; and (iii) the ICG fluorescence patterns observed in the tumors were total fluorescence staining (41% of the cases), partial fluorescence staining (15%), rim fluorescence staining surrounding the tumor (30%), and no staining (15%).

Conclusions

This study is a building block for the characterization of liver nodules and the search for additional surface lesions undetected by preoperative radiological work-up—a crucial task for the successful treatment of liver cancer at an early stage using a safe, minimally invasive, and inexpensive technique.

Keywords

Fluorescence imaging Intraoperative imaging Indocyanine green Liver cancer Navigation surgery 

Notes

Acknowledgements

This study was supported by the University Hospital of Brescia (Spedali Civili di Brescia), Italy, the University of Brescia, and RicerChiAmo onlus (http://www.ricerchiamobrescia.it). The equipment used in this study was made available by both Karl Storz and Stryker companies.

Author contributions

GLB developed the original idea and methodology of the project and made substantial contributions to the manuscript. MSA wrote the first draft of the paper and incorporated the conceptual feedback sent by the coauthors. SM, SB, BM, PP, and EA collected intraoperative images and performed the literature search and review. NP, FG, and MB made scientific contributions to the project and critically revised the manuscript.

Compliance with ethical standards

Disclosures

GL Baiocchi was the scientific organizer of the international workshop “Intraoperative ICG Fluorescence Imaging in Hepatobiliary and Visceral Surgery: State of the Art and New Frontiers,” (Brescia, Italy, October 21, 2017) partly funded (travel expenses) by Karl Storz and Stryker companies though he has no direct conflict of interest with the content discussed in this manuscript. Drs. MS Alfano, S Molfino, S Benedicenti, B Molteni, P Porsio, E Arici, F Gheza, Profs. M Botticini, and N Portolani have no conflicts of interest or financial ties to disclose.

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Marie Sophie Alfano
    • 1
  • Sarah Molfino
    • 1
    • 4
    Email author
  • Sara Benedicenti
    • 1
  • Beatrice Molteni
    • 1
  • Paola Porsio
    • 1
  • Elisa Arici
    • 1
  • Federico Gheza
    • 2
  • Maristella Botticini
    • 3
  • Nazario Portolani
    • 1
    • 4
  • Gian Luca Baiocchi
    • 1
    • 4
  1. 1.3rd Division of General SurgerySpedali Civili di BresciaBresciaItaly
  2. 2.Division of Minimally Invasive and Robotic Surgery, Department of SurgeryUniversity of Illinois at ChicagoChicagoUSA
  3. 3.IGIER Università BocconiMilanoItaly
  4. 4.Department of Clinical and Experimental Sciences, Surgical ClinicUniversity of BresciaBresciaItaly

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