The Use of Fluorescent Imaging for Intraoperative Cholangiogram During Laparoscopic Cholecystectomy
Condition: Cholelithiasis; Cholecystitis; Pancreatitis Biliary; Colic of Gallbladder Without Mention of Cholecystitis
MeSH terms: Pancreatitis; Cholecystitis; Acalculous Cholecystitis; Cholelithiasis; Cholecystolithiasis; Gallstones
Study type: Interventional

Summary: 
      The purpose of this study is to evaluate whether a fluorescent die and a special infrared
      camera can assist with the identification of the important structures during laparoscopic
      cholecystectomy. This finding may assist surgeons to perform laparoscopic cholecystectomy in
      less time and in a safer fashion than standard laparoscopic cholecystectomy.
    

Detailed description: 
      The purpose of this study is to evaluate whether systemically injected ICG, when fluorescing
      in response to NIR illumination, can assist with the identification of the CBD (common bile
      duct)during laparoscopic cholecystectomy. This finding may assist surgeons to perform
      laparoscopic cholecystectomy in less time and with less morbidity than standard laparoscopic
      cholecystectomy.It is expected that a successful outcome to such a trial will result in less
      time in the operating room and less morbidity following laparoscopic cholecystectomy.

      Laparoscopic cholecystectomy is indicated for cholecystitis, biliary colic, resolved biliary
      pancreatitis, and symptomatic cholelithiasis. Laparoscopic cholecystectomy involves the
      introduction of surgical instruments through a number (usually 4) of small incisions
      measuring about 5-12 mm each with visual guidance being provided by means of a camera
      attached to an endoscope introduced through a similarly small access port. Laparoscopic
      techniques offer numerous benefits including a decrease in postoperative pain, some
      improvement in time to tolerance of food and return of bowel function, shorter hospital stay
      and more rapid return to normal activity.

      Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures in
      the United States. Iatrogenic bile duct injuries are a serious complication and patients
      undergoing the laparoscopic type of cholecystectomy are at increased risk for this
      complication. To minimize risk of injury, techniques such as "critical view" (dissection and
      visualization of the cystic duct and cystic artery) have been developed. However, adhesions,
      inflammation and anatomical variation can make surgical dissection and identification of
      significant structures difficult. In addition significantly longer operative times are seen
      when attempting to obtain the critical view. Some advocate the routine use of cholangiography
      (IOC) but the national standard of care remains to only perform IOC selectively. IOC requires
      cannulation of the cystic duct, injection of iodinated dye, and fluoroscopy which adds
      significantly to the operative time and morbidity especially in centers where routine IOC is
      not performed.

      The present study will investigate whether the use of NIRF after injection of ICG will make
      identification of the Biliary structures and CBD clearer and decrease the time required to
      dissect out critical structures and perform safe cholecystectomy.

      The SPY® Intraoperative Imaging System is cleared for use in Canada, Japan, Europe and the
      US. SPY was originally developed for applications in cardiac surgery and allows cardiac
      surgeons to visually assess bypass graft quality in real-time while the patient is still in
      the operating room. Subsequently, SPY has received clearance from the FDA for use in plastic
      and reconstructive surgery and in solid organ transplant.

      The SPY Intraoperative Imaging System was originally developed for open surgical procedures
      using ICG, which is an FDA approved drug. ICG is a fluorescent compound, which can be
      administered intravenously or intra-arterially. The dye absorbs light in the near infrared
      (NIR) region at 806 nm, and emits light at a slightly longer wavelength, 830 nm. When
      injected intravenously, ICG rapidly and extensively binds to plasma proteins and is confined
      to the intravascular compartment with minimal leakage into the interstitium under normal
      conditions. ICG is taken up by the liver and then excreted into the biliary system where it
      can be imaged. The SPY System has been the subject of numerous peer reviewed publications
      demonstrating its safety .

      SPY scope, the endoscopic version of SPY, is an endoscopic visible (VIS) NIR imaging system
      consisting of:

        1. An endoscopic light source that provides illumination for visible light imaging and NIR
           fluorescence excitation to the endoscope via a flexible light guide

        2. Rigid endoscopes optimized for illuminating the field of view and transmitting images in
           the visible and NIR spectrum, and

        3. A high definition (HD) endoscopic camera system connected to the endoscope eyepiece and
           acquiring high resolution visible and NIR fluorescence images The ICG (25 mg per vial)
           will be reconstituted according to the manufacturer's instructions using the entire
           contents (10 ml) of the sterile diluent supplied, yielding a 2.5 mg/ml solution of ICG
           or using half of the diluent supplied (5 ml) yielding a 5 mg/ml solution.

      ICG Diagnostic Procedure: 3ml of 2.5 mg/ml solution (Akorn product, US Monograph) The ICG may
      be administered through a peripheral venous access. Based on our prior experience in
      colorectal cases 1.0 ml of a 2.5 mg/ml solution of ICG (flushed with 10 ml saline) will be
      administered.

      Our study will include patients undergoing laparoscopic cholecystectomy for both acute
      cholecystitis and non-acute symptomatic cholelithiasis. The standard operating technique will
      be used for all patients including the critical view technique and fluoroscopic IOC if
      clinically indicated.

      Our primary endpoint will be operative time measured as the time from the beginning of the
      dissection until the gallbladder is separated entirely from the gall bladder fossa.

      Secondary endpoints will be time to identification of structures and safety of the operation.
      Other endpoints such as CBD injury and postop bile leak will be included if identified.
    

Intervention name(s): Indocyanine Green (ICG)
Intervention type(s): Drug
Intervention description(s): Injection of ICG intravenously then intraoperative imaging of the biliary anatomy during laparoscopic cholecystectomy using a near infrared (NIRF) imaging camera(Spy scope, Novadaq Canada)
Other intervention name(s): Spy scope
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment