Indocyanine green fluorescence imaging of the common bile duct blood supply in the prevention of biliary complications in liver transplantation: rationale and results

Objective: to enhance liver transplant (LT) outcomes by developing and implementing intraoperative fluorescence imaging of common bile duct (CBD) blood supply using indocyanine green (ICG).

Material and methods. The study analyzed treatment outcomes in 203 recipients who received a whole liver from deceased donors. In the first stage, the incidence and potential risk factors of biliary complications were assessed in Group I, comprising 138 patients. The median follow-up period was 35.6 months (IQR: 25–68 months). Group II consisted of 65 cases, with a median follow-up of 7.2 months (IQR: 6.5–13). In this group, intraoperative ICG fluorescence imaging was employed to assess CBD blood supply. Following cholecystectomy, a 5 mL intravenous injection of ICG solution (2.5 mg/mL) was administered. Near-infrared fluorescence imaging was then performed by overlaying near-infrared light onto white light to visualize ICG fluorescence in CBD tissues. In cases where fluorescence imaging indicated hypoperfusion of the distal part of the graft’s CBD, the affected segment was excised within the boundaries of well-perfused tissue. In all cases, the resected CBD portions were sent for histological exami- nation.

Results. In Group I, biliary anastomosis complications were recorded in 13 out of 138 cases (9.4%), all of which were strictures. Analysis of potential risk factors on both the recipient and donor sides did not reveal any statistically significant associations (p > 0.05). Comparison of intraoperative fluorescence imaging results with postoperative histological examination demonstrated a sensitivity of 87% and a specificity of 92% for detecting ischemic changes in CBD. In groups with comparable baseline characteristics (p > 0.05), the incidence of biliary anastomotic strictures (BAS) was significantly lower in the ICG imaging group: 9.4% in Group I versus 1.5% in Group II (p = 0.04).

Conclusion. The use of fluorescence imaging to assess the blood supply of the CBD in LT is an effective method for preventing biliary complications. This technique enables the formation of biliary anastomosis within a well-perfused tissue, significantly reducing the risk of BAS.

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