The Role of Fluorescent Cholangiography to Improve Operative Safety in Different Severity Degree of Acute Cholecystitis During Emergency Laparoscopic Cholecystectomy.
Conditions: Acute Cholecystitis
Sponsor: University Hospital of Ferrara

 
 
 
  DIPARTIMENTO INTERAZIENDALE DI CHIRURGIA 
 
  Unità Operativa di Chirurgia Generale Provinciale 
 
  Direttore Prof. Carlo FEO 
 
 
AZIENDE OSEPDALIERO-UNIVERSITARIA E USL DI FERRARA 
Azienda Unità Sanitaria Locale di Ferrara 
 
Dipartimento Intraziendale di Chirurgia 
Sede legale: Via Cassoli, 30 – 44121 Ferrara 
 
 
 
Unità Operativa di Chirurgia Generale Provinciale  
T. +39.0532.235.111 
 
Via Valle Oppio, 2 – 440323 Lagosanto (FE)  
F. +39.0532.235688 
 
T. +39.0532.723145 
www.ausl.fe.it 
 
E. carlo.feo@ausl.fe.it 
Partita IVA 01295960387 
Ferrara, 05/11/2021 
OFFICIAL TITLE 
The efficacy of near-infrared fluorescent cholangiography during emergency laparoscopic 
cholecystectomy in patients with acute cholecystitis and in difficult cholecystectomies. 
 
1. BACKGROUND 
Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures in the Western 
world, with over 750,000 surgeries in the United States alone [1]. Iatrogenic bile duct injuries represent a 
serious and feared complication, leading to a significant increase in morbidity and mortality, healthcare 
costs, and medico-legal consequences [2-4]. In most cases, iatrogenic bile duct injuries are related to an 
altered perception of the true extrahepatic biliary anatomy, regardless of the surgeon's experience and age. 
Since laparoscopic cholecystectomy became the "gold standard" for treating symptomatic gallstone disease 
and acute cholecystitis, the incidence of iatrogenic bile duct injuries has exponentially increased. The 
incidence rate of major bile duct injuries ranges between 0.25% and 1%, according to the latest literature 
data [2-4]. The use of intraoperative cholangiography (IOC) is a way to correctly visualize the extrahepatic 
biliary tree (reducing the risk of iatrogenic injuries) and to identify possible associated choledocholithiasis. 
The routine or selective use of intraoperative cholangiography is still debated today. It is certainly true that 
the method has a significant morbidity rate and requires adequate equipment, which can be costly. The 
advent of less invasive and certainly more economical alternative methods, such as near-infrared 
fluorescence cholangiography (NIRF-C), could reduce costs and allow the surgery to be performed with a 
lower morbidity rate. Fluorescence cholangiography uses an infrared system that allows the intraoperative 
visualization of the extrahepatic biliary tree through the intravenous administration of a vital dye, 
indocyanine green (ICG). The intravenous use of this dye before laparoscopic cholecystectomy is part of 
routine clinical practice, and its efficacy has been confirmed in several studies in the literature [5-7]. The 

 
 
 
 
 
 
 
 
correct anatomical identification of the bile ducts allows the surgeon to operate with greater safety, reducing  
the risk of iatrogenic injuries and the conversion rate. The method is extremely safe and poses no additional 
risks to the patient. 
Early laparoscopic cholecystectomy also represents the "gold standard" for patients with mild (grade I) and 
moderate (grade II) acute cholecystitis who do not respond to initial conservative treatment if performed 
within 24-72 hours from symptom onset, according to the 2018 Tokyo Guidelines [8]. 
Fluorescence cholangiography may be challenging in an emergency setting, as inflammation and adhesions 
of the hepatoduodenal ligament can impair the identification of biliary structures during dissection. 
Achieving the so-called "critical view of safety" (CVS) can be particularly difficult in such situations. 
In a recent meta-analysis, Dip F et al. [9] demonstrated that the use of fluorescence cholangiography during 
elective cholecystectomy reduces iatrogenic bile duct injuries and the conversion rate to open surgery 
compared to traditional white-light surgery. However, there is limited data on its feasibility and clinical 
impact in urgent acute cholecystitis cases. The identification of biliary structures can be challenging, 
especially in cases with extensive adhesions and severe inflammation, including necrosis, of the gallbladder 
wall and surrounding tissues. 
Currently, there is little evidence regarding the effectiveness of fluorescence cholangiography during 
emergency laparoscopic cholecystectomies for acute cholecystitis. Only two cohort studies [10,11], an 
international European registry [12], and a randomized controlled trial (RCT), including elective and 
emergency cholecystectomies [13] have been published. In a large retrospective study involving 184 
consecutive patients, Daskalaki E et al. [11] reported the results of 24 patients undergoing robotic 
cholecystectomy with ICG fluorescence for acute and gangrenous cholecystitis. The authors evaluated the 
percentage of visualization of four biliary structures, particularly the cystic duct (CD), common hepatic duct 
(CHD), common bile duct (CBD), and cystic duct-common hepatic duct junction (CD-CHD). In this 
subgroup of patients, the cystic duct (CD), CHD, CBD, and CD-CHD were successfully visualized in 91.6%, 
79.1%, 79.1%, and 75% of cases, respectively. 
Agnus V et al. [12] reported the results of the Euro-FIGS (Fluorescence-Image Guided-Surgery) European 
registry proposed by IRCAD center in Strasbourg in collaboration with the European Association of 

 
 
 
 
 
 
 
 
Endoscopic Surgery (EAES), which enrolled 314 cases from 12 European surgical centers, including 
patients with symptomatic cholelithiasis (n= 248) and patients with acute cholecystitis (n= 58). A 5-point 
Likert scale was used to evaluate the quality of biliary anatomy visualization before and after dissection of 
the hepatocystic triangle during laparoscopic cholecystectomy with infrared devices. When comparing the 
two groups (cholelithiasis vs. acute cholecystitis), lower quality visualization scores were obtained for the 
CD (2.76 ± 1.9 vs. 3.54 ± 1.6, P = 0.001) and the CD-CHD junction (2.43 ± 2 vs. 3 ± 1.9, P = 0.04) before 
preliminary Calot dissection. The impact of inflammation on the ability to visualize the biliary tree was also 
confirmed through multivariate linear regression analysis. 
Similar data was reported in a single-blind randomized controlled trial [13] comparing the effectiveness of 
fluorescence cholangiography versus white light alone. The authors demonstrated that the degree of 
cholecystic inflammation is the most important variable, affecting not only the visualization of CD and CBD 
before and after dissection, but also the visualization of the cystic-infundibulum junction after complete 
dissection. 
The utility of NIRF-C was also confirmed by Yoshiya S et al. [14] during LC after percutaneous 
transhepatic gallbladder drainage in patients with severe acute cholecystitis. The ICG fluorescence 
cholangiography group showed a significantly shorter operative time, lower conversion rate, and lower rate 
of subtotal cholecystectomy [13]. 
2. SIGNIFICANCE OF THE STUDY 
This is a prospective observational cohort study of patients who underwent emergency laparoscopic 
cholecystectomy for acute cholecystitis. The study aims to to evaluate the efficacy of NIRF-C for real-time 
visualization of the biliary tree in emergency laparoscopic cholecystectomy at a regional health care center 
(Delta Hospital, AUSL of Ferrara, University of Ferrara, Italy) before and after hepatocystic triangle 
dissection and in different degrees of severity of acute cholecystitis according to the American Association 
of Surgery for Trauma (AAST) classification, specifically distinguishing between non-gangrenous (grade I) 
and gangrenous or complicated (grades II-V) forms. 
2. STUDY POPULATION. INCLUSION AND EXCLUSION CRITERIA. 
The study population consist of patients with lithiasic and alithiasic acute cholecystitis. 

 
 
 
 
 
 
 
 
Inclusion criteria: a) Patients aged >18 years-old with a clinical and ultrasound diagnosis of acute 
cholecystitis who underwent laparoscopic cholecystectomy within 24-72 hours from symptom onset. b) 
Operable patients (ASA score 0-3). 
Exclusion criteria: a) Patients with known allergy to indocyanine green. b) ASA score 4-5. c) Patients not 
operable with a laparoscopic approach due to high cardiopulmonary risk. d) Previous biliary tract surgeries. 
e) History of liver cirrhosis or severe liver disease. f) Pregnant and/or breastfeeding patients. 
3. STUDY DESIGN AND DESCRIPTION 
Primary objectives: 
 
Rate of correct visualization of extrahepatic bile ducts (CD, CHD, CBD, CD, CHD junction, and any 
accessory or aberrant ducts) in different severity degrees of acute cholecystitis according to the 
AAST classification, particularly distinguishing non-gangrenous forms (grade I) from gangrenous 
and complicated forms (grades II-V). 
Secondary objectives: 
 
Conversion rate; 
 
Bail-out procedures (such as subtotal cholecystectomy, antegrade cholecystectomy) ; 
 
Iatrogenic bile duct injuries ;  
 
Total surgery duration; 
 
Post-operative complications rate (30 days) ; 
 
Length of hospital stay; 
 
30-day mortality. 
 
The study will involve the systematic use of fluorescence cholangiography during all laparoscopic 
cholecystectomy procedures for acute cholecystitis, with the intravenous administration of the vital dye 

 
 
 
 
 
 
 
 
Verdye 45-60 minutes before surgery at a dosage of 0.05 mg/kg or 2.5 mg/dL, according to the recent 
guidelines of the International Society for Fluorescence Guided-Surgery (ISFGS) and the latest consensus 
conference published in Annals of Surgery 2021 [16]. The patient will sign an informed consent form 
regarding the administration of the vital dye, with all relevant information about the method, possible 
benefits, and risks. The patient will also have the option to withdraw from the study at any time without 
affecting the care they receive. The equipment used will be Stryker's fluorescence imaging system (Stryker, 
Portage, Miami, USA): the systems has a 10-mm laparoscope, a camera head, a xenonlight guide cable, a 
video processor/illuminator, and a high-definition monitor. The charge-coupled device camera and the xenon 
light source could filter out light with wavelengths below 810 nm and above 800 mm. The laparoscope was 
able to transmit near-infrared light, allowing images to be switched from full color to fluorescence images. 
At the end of each procedure, the operator will fill out a form reporting the following data: 
a) Patient’s demographic data (surname, name, age, gender); b) B.M.I. (Body Mass Index); c) Previous 
cholangio-MR and/or ERCP; d) Surgeon’s experience (defined as more than 50 laparoscopic 
cholecystectomy procedures performed); e) Biliary structures visualized after administration of the vital dye 
before and after dissection of Calot’s triangle; f) Identification of any biliary anomalies, accessory or 
aberrant ducts; g) Time taken to achieve CVS; h) Total surgery duration; i) Possible conversion to open 
surgery; j) Any minor and/or major complications; k) Need for and use of any additional drains; l) Total 
length of postoperative hospital stay; m) 30-day mortality. 
The study data will be collected by authorized personnel and analyzed in compliance with the current 
European privacy regulations, safeguarding patient confidentiality. The study will be  performed in 
accordance with the Declaration of Helsinki guidelines. 
4. STATISTICAL ANALYSIS 
All collected data will be included in a study-specific database and analyzed using MedCalc 20.011 (Ostend, 
Belgium). Descriptive statistics were used to characterize the population, including proportions, medians, 
means ± standard deviations (SDs), and ranges. The two-tailed Chi-square test was used for the statistical 
comparison of proportions. The Chi-square test was used to compare the proportion of successful FC 
visualization (i.e., visualization rates) of the biliary tree (cystic duct [CD], common hepatic duct [CHD], and 
common bile duct [CBD]) before and after Calot’s dissection in all patients. Comparisons of the proportion 

 
 
 
 
 
 
 
 
of successful FC visualization of the biliary tree were performed by comparing the different degrees of acute 
cholecystitis according to the intra-operative AAST classification. A P-value <0.05 was considered 
statistically significant. 
5. STUDY DURATION 
The study will last 18-24 months. 
6. FINANCIAL ASPECTS 
The study is not for profit and is carried out without external funding. 
7. INSURANCE 
No specific insurance is required. 
8. APPROVAL OF THE LOCAL ETHICS COMMITTEE 
The study will be conducted in accordance with the Declaration of Helsinki, the European Union Medical 
Device Directive (93/42/ECC art.15), and the local transpositions of the Member States. The study will be 
carried out in accordance with the guidelines for clinical studies as outlined in EN ISO 14155 and in 
compliance with good clinical practice. It will start after obtaining the favorable opinion of the local Ethics 
Committee. 
9. RESPONSIBLE FOR DATA MANAGEMENT AND METHODS OF DATA EVALUATION AND 
PROCESSING 
The study Principal Investigator (P.I.) is Prof. Carlo Vittorio Feo; the data management will be overseen by 
Dr. Antonio Pesce, as co-principal investigator and study director. 
 
 
 
 

 
 
 
 
 
 
 
 
 
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Prof. Carlo FEO 
UOC di Chirurgia Generale Provinciale, Azienda USL di Ferrara, 
Via Valle Oppio, 2, Lagosanto, Ferrara 
Dipartimento di Scienze mediche - Università degli Studi di Ferrara  
Email: fcl@unife.it 
 
 
Dr Antonio PESCE 
UOC di Chirurgia Generale Provinciale, Azienda USL di Ferrara, 
Via Valle Oppio, 2, Lagosanto, Ferrara 
Dipartimento di Scienze mediche - Università degli Studi di Ferrara  
Email: antonio.pesce@unife.it