Fluorescent-Guided Liver Surgery: Paul Brousse Experiences and Perspective

Introduction

Dr Irwin Fox reported the clinical use of indocyanine green (ICG) for the first time in 1960 at Mayo Clinic. Its high safety profile and sensitivity makes it appealing for many clinical applications. Since it is exclusively removed from the body via the biliary system, the study of liver function using the indocyanine green became widely adopted. The indocyanine green 15 min retention test is commonly used for preoperative assessment of liver reserve.

Furthermore, its plasma clearance rate was a significant predictor of liver regeneration after portal vein embolization (PVE). Recently, with the development of easily installed near-infrared camera systems, the live intraoperative evaluation of liver fluorescence became available. In general, the evaluation of tissues uptake and excretion of ICG requires prior to surgery administration. The time window between injection and evaluation ranges from 24 to 72 h. On the other hand, evaluation of vascular structures and perfusion requires intraoperative administration of ICG. In most instances the required preoperative dose is between 0.25 and 0.5 mg/kg. Intraoperatively, we inject 1 cm of a diluted ICG solution once or twice for a total dose of 0.25 mg.

In Paul Brousse, we first used the infrared camera systems PDE developed by Hamamatsu Photonics (Hamamatsu, Japan) in 28 patients operated for colorectal liver metastases or hepatocellular carcinoma by laparotomy. All patients received intravenously ICG at a dose of 0.5 mg/kg between 12 and 24 h before the surgical procedure. Four (14.3 %) patients presented new lesions that were neither detected by preoperative imaging nor by intraoperative ultrasound. Three (75 %) of those four patients had lesions confirmed to be CRLM. This sensitivity was supposed to improve the surgical radicality in 11% of our series. Because of these encouraging results of PDE and our leading French experience in this field, since our group performs around 230 liver resections and 130 liver transplantations by year, we tested a new device (Fluobeam ®) developed by a French company (Fluoptic, Grenoble). 

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