2017 Resarch Forum

SG: M-6 Applicant: Jorge Almodovar MD Principal Investigator: Andrea Pakula MD MPH FACS

Early experience with the application of indocyanine green fluorescence imaging for biliary anatomy identification at a teaching institution Jorge Almodovar MD, Ruby Skinner, MD FACS FCCP FCCM, Maureen Martin MD FACS, Andrea Pakula MD MPH FACS INTRODUCTION : Fluorescence imaging (FI) for variety of surgical procedures has been reported to favorably impact complications and enhance patient safety. It aids in the evaluation of tissue perfusion and enhances biliary anatomy identification. Recently we adopted the use of FI for laparoscopic and robotic surgery and have developed protocols for cholecystectomy to facilitate biliary and vascular anatomy. PURPOSE: To describe our initial experience with fluorescence imaging at a busy teaching hospital, and to evaluate the benefits of early identification of ductal anatomy during laparoscopic cholecystectomy (LC). We hypothesize that early biliary duct identification facilitates patient safety particularly in a resident training program. METHOD: A retrospective chart review was performed on n=35 patients who underwent laparoscopic cholecystectomies for both acute and elective cases. Fluorescence imaging was used to assess both biliary and vascular anatomy during LC in n=16 patients. Comparisons were made between patients undergoing laparoscopic cholecystectomy with and without the use of FI. Fluorescence imaging was also used for patients undergoing robotic cholecystectomies (n=16) during this time, but this cohort was not used for comparing outcomes as these procedures were not adopted in the residency training curriculum at the time of the study. RESULTS: Resident operators were present for all of the cases with four different general surgical staff. A defined protocol for florescence imaging was established: infusion of 0.3ml ICG followed by 10ml saline flush just prior to induction of anesthesia. Comparisons of laparoscopic cholecystectomies with and without fluorescence Lap Cholecystectomy Acute Age ASA > 3 BMI PGY4 or 5 OR time (min) Convert open Fluorescence N=16 N=7 36 + 15 N=6 32 + 5 15 60 + 31 0 Without Fluorescence N=19 N=9 P=0.7 34 + 10 N=5 P=0.7 32+ 7 15 P=0.3 85 + 22 P=0.008 2 P=0.4 The groups were similar for risk profile and had a similar incidence of senior residents performing the cases with surgical staff. Operative times were significantly shorter in the florescent group, and there were no open conversions. There were no bile duct injuries or leaks in either group. There were no mortalities or other complications. DISCUSSION/CONCLUSIONS: We describe our early experience with the use of FI for the assessment of biliary anatomy at our busy teaching institution. Early identification of biliary anatomy utilizing FI appears to favorably impact operative times both in elective and urgent cases. Further study is warranted on the impact of this technology on residency training proficiency and cost. We plan to evaluate our robotic applications as well.