Conditions: Laparoscopic Cholecystectomy
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 200
Healthy volunteers: no

Brief summary:
Laparoscopic cholecystectomy is one of the most performed surgical procedures worldwide. One of its most serious complications is injury to the main bile duct, with an incidence of less than 1%. There are different surgical strategies that try to reduce this complication, with indocyanine green fluorescence cholangiography being one of the most recent to appear. This technique is becoming a great tool during laparoscopic cholecystectomy. Despite the great rise of the procedure, today there is a great disparity in the administration protocols of indocyanine green during the procedure.

Goals. The main objective of the study is to analyze whether there are differences between different types of doses and administration intervals of indocyanine green to obtain quality fluorescent cholangiography during laparoscopic cholecystectomy. In addition, the factors that influence the results of the technique will be sought.

Detailed description:
Symptomatic cholelithiasis is a pathology of great relevance in the world population, with prevalence rates of up to 20%. The standard treatment for cholelithiasis is laparoscopic cholecystectomy (LC). One of the most serious complications of LC is injury to the main bile duct (LVB). Although this complication has incidences of less than 1% (0.3-0.7% in the different series), the consequences it causes are highly relevant. LVB is related to a significant increase in patient morbidity and mortality, a significant deterioration in quality of life, a very significant increase in healthcare costs and not insignificant medical-legal consequences. Indocyanine green fluorescence cholangiography (CF-VI) is a novel technique that allows precise and real-time anatomical visualization of the extrahepatic biliary anatomy, facilitating surgery and reducing the risk of complications. Currently, there are large differences in LV administration protocols during CF in LC. The precise dose and the ideal moment of administration are key to achieving adequate visualization of the critical vascular and biliary structures and to reduce the fluorescence emitted by the hepatic parenchyma, which could hinder correct anatomical visualization. In relation to the dose, there are many protocols for IV administration, by means of a single dose or a dose adjusted for the patient's body weight. Some authors advocate the administration of IV 24 hours before the procedure, in order to avoid hepatic fluorescence. However, in the context of major outpatient surgery, outpatient surgery or short-stay surgery, we believe that this practice is not currently logistically feasible. Other groups administer the IV with a variable range of time interval. The recent preliminary results of the European Registry of Fluorescent Image Guided Surgery show the great disparity of preoperative LV administration protocols. Therefore, it is necessary to protocolize the administration of the drug based on the results of randomized clinical trials.. The precise dose and the ideal moment of administration are key to achieving adequate visualization of the critical vascular and biliary structures and to reduce the fluorescence emitted by the hepatic parenchyma, which could hinder correct anatomical visualization.

Arms:
arm 1: Fixed dose 2.5 mg with IV administration at a time greater than 3 hours before surgery. arm 2: Fixed dose 2.5 mg with IV administration during the immediate preoperative period (15-30 minutes before surgery). arm 3: Weight-adjusted dose (0.05 mg/kg of total body weight) with IV administration greater than 3 hours before surgery. arm 4: Weight-adjusted dose (0.05 mg/kg of total body weight) with IV administration during the immediate preoperative period (15-30 minutes before surgery).

Interventions: intervention 1: VERDYE powder for solution for injection 25 mg
Intervention descriptions: intervention 1: Verdye 25 mg contains sodium VI powder for solution for injection. VI is a water-soluble agent with a spectral absorption peak of 800 nm. It is a drug approved for diagnostic use only and is indicated for the measurement of the excretory function of the liver.

Protocol document:
ICF_002.pdf: 
Version 2.0 of 7 March 2022
Page17
INFORMATION AND INFORMED CONSENT SHEET
Title:
Randomised clinical trial to evaluate the dose and time of 
administration of indocyanine green in near-infrared fluorescein 
cholangiography during laparoscopic cholecystectomy:
Code:
DOTIG study.
No. EudraTC
2022-000904-36
Version:
2.0
Promoter:
Biomedical Research Institute of Salamanca (IBSAL)
Principal 
Investigator
Jaime López Sánchez MD, PhD.
Department of General and Digestive System Surgery. Complejo 
Asistencial Universitario de Salamanca. Salamanca, Spain.
Institute of Biomedical Research of Salamanca (IBSAL). University of
Salamanca. Salamanca, Spain.
Introduction
We are writing to inform you about a research study  which you are invited to participate. Our 
intention is that you receive sufficient and correct information so that you can decide whether 
or not to take part in this study. To do this, please take the time to read this information sheet 
carefully and thoroughly and discuss it with whomever you feel appropriate. Ask the doctor or 
study staff to explain any words or information that you do not understand clearly, as well as 
any questions you may have.
If you decide to participate, we will ask you to sign the attached informed consent document. 
We will provide you with an original copy of this signed and dated document for you to keep 
and the original document will be kept on file with the rest of the study documentation.
The study has been approved by the Ethics Committee for Research with Medicines of the 
University Hospital of Salamanca, in accordance with current legislation, the Royal Decree 
1090/2015 regulating clinical trials with medicines, the Ethics Committees for Research with 
Medicines and the Spanish Register of Clinical Studies, Royal Decree 1591/2009 regulating 
medical devices, Royal Decree 1616/2009 on active implantable medical devices (if applicable), 
and Circular 7/2004 of the Spanish Agency for Medicines and Medical Devices on clinical 
research with medical devices.
It has also been designed and will be carried out in accordance the recommendations set out in 
the Declaration of Helsinki and the Standards of Good Clinical Practice.
You should be aware that your participation in this study is voluntary and that you may choose 
NOT to participate. If you decide to participate, you may change your decision and withdraw 
your consent at any time without changing your relationship with your doctor or your health 
care.
You should also be aware that you may be withdrawn from the study if the sponsor or 
investigators deem it appropriate, either for safety or other reasons. In either case, you will 
receive an adequate explanation of the reason for your withdrawal from the study.


Version 2.0 of 7 March 2022
Page27
Aim of the study
You are invited to participate in the study because you have been diagnosed with symptomatic 
cholelithiasis (a very common disease of the gallbladder). The standard and universally 
accepted treatment for your disease is removal of the gallbladder (cholecystectomy), ideally by 
a minimally invasive route (laparoscopy).
To avoid some of the complications that arise from laparoscopic cholecystectomy, a tool called 
fluorescent cholangiography has recently been developed. This technique attempts to 
fluorescently map critical anatomical structures that appear during surgery, using a substance 
called indocyanine green. This drug is usually administered intravenously and is eliminated in 
its entirety by bile. Thanks to the fluorescent characteristics of indocyanine green, and its 
biliary elimination, we will be able to obtain real-time and accurate images of the biliary 
anatomy. This will aid intraoperative anatomical identification and may prevent injury to 
important structures. However, administration interval and the exact dose of indocyanine 
green to obtain an accurate technique is currently not defined. The DOTIG study (Dose and 
administration time of indocyanine green in near-infrared fluorescein cholangiography during 
laparoscopic cholecystectomy) will attempt to find the optimal dose and ideal administration 
time for performing laparoscopic cholecystectomy with fluorescein cholangiography.
Study procedures and potential risks and discomforts
The study will be carried out in all patients who present an indication for laparoscopic 
gallbladder removal, accept inclusion in the study and meet the study inclusion . You will not 
be able to participate in this study if you have any of the following contraindications: being a 
minor, pregnancy or breastfeeding at the time of surgery, advanced chronic kidney disease, 
allergies or adverse reactions to the product, its excipients, iodinated contrasts or diseases of 
the thyroid gland.
The total number of patients planned to be included in the study is 160 subjects. The product 
to be administered is called Veryde (Diagnostic Green GMBH, Aschheim-Dornach, Germany) 
and contains indocyanine green sodium as active substance. All patients who agree to enter 
the study will be administered the drug at a variable dose and interval prior to surgery. The 
study will have four treatment groups divided into different doses and times. The doses will be 
calculated as a fixed dose or as a ratio to total body weight. The administration interval will 
vary from the time of admission to the hospital ward to the time of anaesthetic induction. The 
allocation of dose and time of administration prior to surgery shall be randomised using a 
computer application.
This work does not collect biological samples for research purposes and does not perform 
procedures or tests that are not part of routine clinical practice.
All the information on this study will be stored in coded form and will be used exclusively for 
the purposes specified herein. In the event that your data is transferred to other research 
groups, this will always be done in accordance with current legislation, keeping your data 
coded, in order to carry out studies related to the objectives of this work, and with the prior 
authorisation of the Research Ethics Committee. In the event that the objectives of the 
research work proposed by other research groups are different from those of the present 
project, you will be asked for a new consent.
Indocyanine green (Veryde) is a product authorised by the Spanish Food Safety Agency.


Version 2.0 of 7 March 2022
Page37
Medicines and Health Products (AEMPS) and the European Medicines Agency (EMA). It has 
been marketed since 2017 for hospital use only and in authorised diagnostic centres. 
Indocyanine green is approved for diagnostic use in the field of heart, brain, eyeball and liver 
studies. The drug has been widely used for fluorescein cholangiography since the first study 
was published in 2009 to the present day. It has been shown to be safe in humans, with a very 
low rate of adverse events.
As a drug approved by the competent health authorities, information on the side effects of 
indocyanine green (Veryde) is available to everyone. There may be side effects or reactions 
that you should be aware of. Serious allergic reactions (anaphylactic reactions) are extremely 
rare (affecting less than 1 in 10,000 patients). Patients with kidney disease may be more at risk 
of developing allergic reactions. Only two cases of death have been reported with the use 
indocyanine green during cardiology studies (frequency less than 1/330,000 estimated cases). 
Cases of indocyanine green overdose are unknown at present. No additional risks are foreseen 
as you will not be undergoing any procedures outside standard clinical practice.
As a participant in the study, you will be expected to fulfil a number of responsibilities as 
outlined below:
-
Compliance with the scheduled visit during the first postoperative month.
-
Report any adverse events that happen to you or changes in medication, advising that, 
except in an emergency, do not change the medication you are taking or take other 
medications or "herbal products" without first consulting with the study doctor.
Please speak to your study doctor for a full list of side effects reported with this drug and in 
any case, if you wish, you will be given the package leaflet for both drugs.
Voluntary participation and withdrawal
You are free to decide whether or not you wish to take part in this study, participation is 
entirely voluntary. If you decide to participate, you still have the possibility to withdraw at any 
time, without having to give any explanation, and without any penalty or negative 
consequences for you. If you change your mind about your data, you have the right to request 
its destruction or anonymisation, through your doctor/researcher. However, you should be 
aware that the data obtained in the analyses carried out up to that point may be used for the 
purposes requested and may be retained in compliance with the corresponding legal 
obligations.
Potential benefits
No direct benefit is expected from your participation in the study. However, the information 
obtained from this research project may contribute to medical progress and could help other 
patients in the future. ´will not receive any financial benefit from the donation of the samples 
and the transfer of the data provided, nor will´  have any rights to any commercial benefits 
from the discoveries that may be made as a result of the research carried out.


Version 2.0 of 7 March 2022
Page47
Alternative treatments
If you do not participate in the study, you will be treated according to standard clinical practice.
Data protection and confidentiality
All information about your results will be treated in the strictest confidence. Both the centre, 
the promoter and the research team are responsible for the processing of your data and 
undertake to comply with the data protection regulations in force, currently Organic Law 
3/2018, of 5 December, on the Protection of Personal Data and guarantee of digital rights and 
Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on 
Data Protection (RGPD). The data collected for the study will be identified by a code, so that no 
information that can identify you is included, and only the research team will be able to relate 
this data to you. ,
their identity shall not be´ disclosed to any other person except to the health authorities, when 
requested to do so by´ or in cases of medical urgency. The Research Ethics Committees, the 
Research Ethics Committee, the
representatives of inspecting Health Authority and personnel authorised by the Sponsor may 
only have access to check personal data, clinical trial procedures and compliance with the 
standards of good clinical practice (while maintaining the confidentiality of the information).
Your data will be kept under appropriate security conditions and it is ensured that subjects 
cannot be identified through means considered reasonable by persons other than those 
authorised. The research team will analyse your data based on the legitimate interest of 
achieving the purposes of the study. The Investigator and the Sponsor are obliged to retain the 
data collected for the study for at least 25 years after completion of the study. Thereafter, your 
personal information will only be retained by the facility for your health care and by the 
research team for other scientific research purposes if you have given your consent to do so 
and if permitted by applicable law and ethical requirements.
If the results of the study are likely to be published in scientific journals, no personal data of 
the participants in this research will be provided at any time. We inform you that you have the 
right to access, rectify or cancel your data, and you may limit the processing of data that are 
incorrect, request a copy or that the data you have provided for the study be transferred to a 
third party. To exercise your rights, or in the event that the participant wishes further 
information on the processing of your personal data, you may contact the principal 
investigator of the study whose details are specified at the end of this document, the Data 
Protection Officer of the Regional Health Authority (dpd@saludcastillayleon.es ) or our centre 
(protecciondedatos@ibsal.es ). We remind you that the data cannot be deleted, even if you 
stop participating in the trial in order to ensure the validity of the research and to comply with 
legal obligations. You also have the right to contact the Data Protection Agency if you are not 
satisfied.


Version 2.0 of 7 March 2022
Page57
Information on results
At your request, at the end of the study and in accordance with article 27 of Law 14/2007 on 
Biomedical Research, you may be provided with information on the results of this research 
work.
I consent to the future use of the data collected in this research study for further research 
related to the medical specialty or research area of this study.
□ YES
□  NO
I consent to future re-accessing of my medical records to collect data deemed important for 
further research related to the medical specialty or research area of this study.
□ YES
□  NO
Contact details of the research team:
If you have any questions or need further information, please contact: Name:
Telephone:
your decision, both the promoter and the research team would like to thank you for your time 
and attention.


Version 2.0 of 7 March 2022
Page67
INFORMED CONSENT
Title:
Randomised clinical trial to evaluate the dose and time of 
administration of indocyanine green in near-infrared fluorescein 
cholangiography during cholecystectomy.
laparoscopic:
Code:
DOTIG study.
I (Name and Surname
I have read the information sheet I have been given about the study. I 
have been able to ask questions about the study.
I have received sufficient information about the study.
I have read the information sheet provided to me.
I have spoken to the Investigator 
I understand that my participation is voluntary. I 
understand that I may withdraw from the study:
1st Whenever you want
2nd Without having to give explanations
3º Without having any negative repercussions
I voluntarily agree to participate in the clinical trial and consent to the use of all 
information obtained. I understand that I will receive a signed copy of this informed 
consent form.
Participant's signature
Date
Name and signature of the researcher
Date
Signature of the legal representative, family member or de facto related person
Date


Version 2.0 of 7 March 2022
Page77
INFORMED ORAL CONSENT IN THE PRESENCE OF WITNESSES
Title:
Randomised clinical trial to evaluate the dose and time of 
administration of indocyanine green in near-infrared fluorescein 
cholangiography during cholecystectomy.
laparoscopic:
Code:
DOTIG Studio
I (Name and Surname
As a witness, I affirm that in my presence I have been informed to:
MR/MS 
- You have been read the information sheet you have been given about the study.
- You have been able to ask questions about the study.
- You have received sufficient information about the study.
- You have spoken to the 
You understand that your participation is voluntary. You 
understand that you may withdraw from the study:
1º
Whenever you want
2º
Without having to explain
3º
Without any negative impact
You voluntarily agree to participate in the clinical trial and consent to the use of all 
information obtained. You understand that you will receive a signed copy of this 
informed consent form.
Signature of witness
Date
(Date in handwriting of the witness)
Name and signature of the researcher
Date

Prot_000.pdf: 
Page137
DOTIG STUDY. Version 2.0 of 16 December 2022
RESEARCH PROTOCOL
Study promoter
Castilla y Institute of Health Sciences Studies Foundation (IECSCYL)-
Institute of Biomedical Research of Salamanca (IBSAL)
EUDRA CT number
2022-000904-36
Promoter's Protocol 
Code
IBS-DOTIG-ECM-2202
Title
Randomised clinical trial to evaluate the dose and time of 
administration of indocyanine green in near-infrared fluorescein 
cholangiography during laparoscopic cholecystectomy.
Date
16/12/2022
Version
V 2.0
PROPERTY OF THE 
AUTHORS 
CONFIDENTIAL
NO USE, DISCLOSURE OR PUBLICATION WITHOUT THE CONSENT OF THE AUTHORS 
IS PERMITTED.


Page237
DOTIG STUDY. Version 2.0 of 16 December 2022
1. SUMMARY OF THE STUDY
Background. Laparoscopic cholecystectomy is one of the most commonly performed surgical 
procedures worldwide. One of its most serious complications is injury to the main bile duct, with an 
incidence of less than 1%. There are different surgical strategies that attempt to reduce this 
complication, with indocyanine green fluorescence cholangiography being one of the most recent 
to appear. This technique is becoming a great tool during laparoscopic cholecystectomy. Despite 
the boom in the procedure, there is currently a wide disparity in the protocols for administration of 
indocyanine green during the procedure.
Objectives. The main objective of the study is to analyse whether there are differences between 
different types of doses and administration intervals of indocyanine green to obtain quality 
fluorescein cholangiography during laparoscopic cholecystectomy. In addition, factors influencing the 
results of the technique will be sought.
Material and Methods. Open multicentre randomised clinical trial with 4 intervention groups (two doses and 
two administration times). The expected duration of the study will be 12 months. The main variables to be 
studied will be the degree of identification critical anatomical structures during laparoscopic 
cholecystectomy. Patients will be analysed per protocol, without intermediate analyses.


Page337
DOTIG STUDY. Version 2.0 of 16 December 2022
2. SIGNATURE OF APPROVAL OF THE PROTOCOL
Signature of the Promoter:
PROTOCOL TITLE: Randomised clinical trial to evaluate the dose and time of administration of 
indocyanine 
green 
in 
near-infrared 
fluorescein 
cholangiography 
during 
laparoscopic 
cholecystectomy: DOTIG study.
Project: IBS-DOTIG-ECM-2202
Eudract number: 2022-000904-36
Promoter's representative: Ms. María Lorenzo Santiago
Signature Date
Signature of the Coordinating Researcher:
PROTOCOL TITLE: Randomised clinical trial to evaluate the dose and time of administration of 
indocyanine 
green 
in 
near-infrared 
fluorescein 
cholangiography 
during 
laparoscopic 
cholecystectomy: DOTIG study.
Project: IBS-DOTIG-ECM-2202
Eudract number: 2022-000904-36
Coordinating Researcher of the Study: Prof. Luis Muñoz Bellvís.
Signature Date


Page437
DOTIG STUDY. Version 2.0 of 16 December 2022
3. PRINCIPAL INVESTIGATOR'S SIGNATURE HOMEPAGE
PROTOCOL TITLE: Randomised clinical trial to evaluate the dose and time of administration of 
indocyanine 
green 
in 
near-infrared 
fluorescein 
cholangiography 
during 
laparoscopic 
cholecystectomy.
Project: IBS-DOTIG-ECM-2202
EudraCT Number: 2022-000904-36
CONFIDENTIALITY AND DECLARATION OF CONFORMITY OF THE BPC
I have read the above clinical study protocol entitled: "Randomised clinical trial to evaluate the 
dose and time of administration of indocyanine green in near-infrared fluorescein 
cholangiography during laparoscopic cholecystectomy", and agree that it contains all the 
information necessary to conduct the study.
I hereby confirm that I have thoroughly read and understand this clinical trial protocol, and agree 
that my staff and I will conduct the trial in accordance with the protocol and comply with its 
requirements, including ethical and safety considerations.
I understand that if the Promoter decides to terminate or suspend the study prematurely for any 
reason, this decision will be communicated to me in writing. , if I decide to withdraw from the 
execution of the study, I will immediately communicate this decision to the Promoter.
I agree not to publish any part of the results of the study conducted under this clinical trial 
protocol without the prior written consent of the Sponsor.
Principal Investigator:
Hospital Centre:
Signature
Date
Fundación Instituto de Estudios Ciencias de la Salud de Castilla y León (IECSCYL) - Institute of 
Biomedical Research of Salamanca (IBSAL)
Salamanca University Hospital
Edificio Virgen de la Vega, 10.ª planta Pº San Vicente, 58-182. 37007 
Salamanca


Page537
DOTIG STUDY. Version 2.0 of 16 December 2022
4. ACRONYMS
AA: Adverse event.
AAG: Serious adverse event.
AEMPS: Spanish Agency for Medicines and Health Products.
ASA: American Society of Anaesthesiologists.
GCP: Good Clinical Practice. CCAA: 
Autonomous Communities
CRD: Data Collection Notebook.
CRDe: Electronic Data Collection Logbook.
CEIm: Committee on Ethics and Medicines Research.
CF: Fluorescent cholangiography. 
IC: Informed consent. LC: 
Laparoscopic cholecystectomy.
DSUR: Periodic Safety Reports. EC: Clinical 
Trial
EMA: European Medicines Agency.
FDA: Food and Drug Administration of the United States of America. FV: 
Pharmacovigilance
HC: Medical History.
HIP: Patient Information Sheet.
IBSAL: Institute of Biomedical Research of Salamanca.
ICH: International Conference on Harmonisation.
IECSCYL: Castilla y León Institute of Health Sciences Studies Foundation. PI: Principal 
Investigator.
BMI: Body Mass Index.
LVB: Bile duct injury.
RIP: Product under investigation.
RAGI: Serious Unexpected Adverse Reactions.
VCS: Critical Security Vision.
VI: Indocyanine green.


Page637
DOTIG STUDY. Version 2.0 of 16 December 2022
5. Table of contents
1.
SUMMARY OF THE STUDY.............................................................................................2
2.
SIGNATURE OF APPROVAL OF THE PROTOCOL..............................................................3
3.
PRINCIPAL INVESTIGATOR'S SIGNATURE HOMEPAGE....................................................4
4.
ACRONYMS...................................................................................................................5
5.
Table of contents..........................................................................................................6
6.
General Information .....................................................................................................8
7.
Justification ..................................................................................................................9
8.
Aim and Purpose of the Trial.......................................................................................11
9.
Trial Design.................................................................................................................12
10.
Research Product Characteristics (RPP).......................................................................13
11.
Selection and Withdrawal of Subjects.........................................................................14
12.
Informed Consent (IC) and Patient Information Sheet (PIS).........................................15
13.
Data Collection Notebook -CRD...................................................................................16
14.
Medical History -HC- and source documents ...............................................................16
15.
Monitoring..................................................................................................................18
16.
Researcher and collaborators......................................................................................19
17.
Facilities......................................................................................................................19
18.
Treatment of Subjects.................................................................................................19
19.
Effectiveness Assessment............................................................................................21
20.
Security Assessment ...................................................................................................21
21.
Statistics .....................................................................................................................28
22.
Direct Access to Source Data/Documents....................................................................29
23.
Quality Control and Quality Assurance........................................................................29
24.
Ethical and legal aspects .............................................................................................29
25.
Data Management and Record Archiving....................................................................30
26.
Financing and Insurance..............................................................................................30
27.
Other test procedures. Management Delivery of other test materials30
28.
Audits and inspections................................................................................................31
29.
Changes to the protocol..............................................................................................31
30.
Difficulties and limitations of the study.......................................................................31
31.
Periodic Security Reports (DSUR) ................................................................................31
32.
Publication Policy........................................................................................................32
33.
References..................................................................................................................32


Page737
DOTIG STUDY. Version 2.0 of 16 December 2022
ANNEXES ................................................................................................................................35
Annex 1: Classifications............................................................................................................35
Annex 2: Documentation upon delivery of the Protocol...........................................................37
Annex 3 (attached separately): Patient Information Sheet - Informed Consent.
........................................................................................................................................................37
Annex 4 (attached separately): AAG Notification Form ............................................................37
Annex 5 (separate attachment): Pregnancy Notification Form .................................................37


Page837
DOTIG STUDY. Version 2.0 of 16 December 2022
6. General Information
6.1. Title
•
Randomised clinical trial to evaluate the dose and time of administration of 
indocyanine green in near-infrared fluorescein cholangiography during laparoscopic 
cholecystectomy.
•
IBS-DOTIG-ECM-2202
•
Protocol Version 1.4.
6.2. Name and address of the promoter:
•
Fundación Instituto de Estudios Ciencias de la Salud de Castilla y León (IECSCYL)- 
Instituto de Investigación Biomédica de Salamanca (IBSAL).
•
Complejo Asistencial Universitario de Salamanca. Hospital Virgen de la Vega, 10th 
Floor. Paseo de San Vicente, 58-182. 37007 Salamanca.
6.3. Reference CEIm.
•
Salamanca Health Area.
6.4. Phase of the study.
•
Phase IV.
6.5. Name and title of study coordinator, address and contact details.
•
Prof. Luis Muñoz Bellvís.
o
Head of the General and Digestive System Surgery Department. University 
Hospital of Salamanca. Salamanca, Spain. Paseo de San Vicente 182, 37007 
Salamanca. Tlf: 923 29 11 00
o
Institute of Biomedical Research of Salamanca (IBSAL). University of 
Salamanca, Salamanca, Spain.
o
e-mailluismb@usal.es
6.6. In case of a multi-centre study, name and title of all investigators responsible for the 
conduct of the trial and the address and telephone numbers of trial sites.
•
Dr. Jaime López Sánchez.
o
Department of General and Digestive System Surgery. University Hospital of 
Salamanca. Salamanca, Spain. Paseo de San Vicente 182, 37007 Salamanca.
Tlf: 923 29 11 00
o
Institute of Biomedical Research of Salamanca (IBSAL). University of 
Salamanca, Salamanca, Spain.
o
e-mailjalopsan@hotmail.com
•
Dr. Fernando Pardo Aranda
o
Department of General and Digestive System Surgery. Germans Trias i Pujol 
University Hospital. Badalona, Spain. Carretera de Canyet s/n, 08916 Badalona, 
Barcelona. Tlf: 934 651200
o
e-mailfpardoaranda@gmail.com


Page937
DOTIG STUDY. Version 2.0 of 16 December 2022
6.7. Name and addresses of clinical laboratories and medical or technical departments or 
institutions involved in the trial.
•
Department of General and Digestive System Surgery. University Hospital of 
Salamanca. Salamanca, Spain. Paseo de San Vicente 182, 37007 Salamanca.
•
Department of General and Digestive System Surgery Hospital Universitario Germans 
Trias i Pujol. Badalona, Spain. Carretera de Canyet s/n, 08916 Badalona, Barcelona.
7. Justification
Symptomatic cholelithiasis is a highly relevant pathology in the world population, with 
prevalence rates of up to 20%. Regardless of the symptom or complication causing cholelithiasis, 
the current standard treatment is cholecystectomy, preferably through the minimally invasive 
laparoscopic approach(1,2). One of the most serious complications is injury to the main bile duct 
(MBV). Although the incidence of this complication is less than 1% (0.3-0.7% in different series), the 
consequences are very important. LVB is associated with a significant increase in patient morbidity 
and mortality, a significant deterioration in quality of life, a major increase in healthcare costs and 
significant medical-legal consequences(3). Misidentification of gallbladder anatomy has been 
described as one of the main factors in LVB(4). This could be favoured by the great anatomical 
variability of this region and the inflammatory changes that occur in many patients.
To date, there have been many recommendations to reduce the incidence of this complication, 
perhaps the most widely implemented being the critical safety view (CSV) published by Strasberg in 
1995(5). Other techniques, such as the B-SAFE rule, are in the process of implementation(6). A 
recent approach using artificial intelligence and machine learning has been applied in the field of 
safe 
laparoscopic 
cholecystectomy 
(LC)(7). 
Among 
invasive 
methods, 
intraoperative 
cholangiography (IOC) has classically been the most widely used system for the prevention and 
early detection of LVB, as well for the diagnosis of choledocholithiasis(8). However, the 
disadvantages of this technique are the use of ionising radiation, the learning curve, the need prior 
surgical dissection and consequently the possibility of iatrogenic injury, as well as the need for 
infrastructure, organisation and coordination that is not widely available(9). Furthermore, it has not 
been shown to decrease the incidence of LVB.
Near-infrared (NIR) fluorescence cholangiography (FC) is a relatively recent technique(10) that 
applies the fluorescent property and biliary-only elimination of indocyanine green (IV) to map the 
extrahepatic biliary tree(3). VI has previously been described in the fields of cardiology, 
ophthalmology and currently in hepatology for the study of hepatic functional reserve(11). CF-VI 
allows minimally invasive, real-time visualisation of the anatomy of the extrahepatic bile duct. It is a 
fast method with a minimal learning curve. In addition, it does not require prior surgical dissection 
and costs less than CIO. However, it is currently not widely available and requires a dedicated 
imaging infrastructure(9,12). Recently, CF-VI has been shown to be superior to traditional white 
light CL in reducing LVB(13), and a 2021 meta-analysis estimates that this technique could 
significantly reduce LVB during CL(14). However, it has not yet been shown to be significantly 
superior to CIO(9,12). Furthermore, different authors show disparate rates


Page1037
DOTIG STUDY. Version 2.0 of 16 December 2022
anatomical visualisation depending on the characteristics of the patient, the pathological process, 
the technique used, the instruments, etc. (3,15).
Currently, there are major differences in LV administration protocols during FC in LC. The 
precise dose and timing of administration are key to achieve adequate visualisation of critical 
vascular and biliary structures and to reduce the fluorescence emitted by the liver parenchyma, 
which could hinder correct anatomical visualisation(15). Regarding dosage, there are a multitude of 
VI administration protocols, using single doses or doses adjusted for the patient's body weight. 
Some authors advocate administration of the IV 24 hours before the procedure in order to avoid 
hepatic fluorescence(16). However, in the context of major ambulatory surgery, outpatient surgery 
or short-stay surgery(17), we believe that this practice is not logistically feasible at present. Other 
groups administer LV with a variable range of time interval(15). Recent preliminary results from the 
European Fluorescence Image Surgery Registry show the great disparity of preoperative LV 
administration protocols(18). Therefore, there is a need for protocolisation of drug administration 
through the results of randomised clinical studies.
The investigational medicinal product is Verdye. Verdye (Diagnostic Green GMBH, Aschheim-
Dornach, Germany) contains the active substance VI sodium as a powder for solution for injection. 
This product is approved by the US Food and Drug Administration (FDA), the European Medicines 
Agency (EMA) and the Spanish Agency for Medicines and Medical Devices (AEMPS) as of 
30/8/2017. It is a medical device for hospital use and authorised diagnostic centres. VI is a water-
soluble agent with a peak spectral absorption of 800 nm. Once administered intravenously, it has 
an affinity for plasma proteins (β-apolipoprotein B in 95% of cases), remaining constant in the 
intravascular space. The IV does not undergo any metabolisation process in the body. The uptake of 
the drug from plasma is exclusively hepatic, with biliary excretion within 30 minutes to 2 hours 
after intravenous injection. The fluorescent characteristics of the product appear after stimulation 
with near-infrared light beams (700-900 nm). It is indicated for cardiac, circulatory and 
microcirculatory diagnostics, liver function diagnostics and ophthalmic angiography.
Risks from the administration of the medicinal product are rare. Severe allergic reactions have 
been reported in one in 10,000 patients, causing symptoms such as: constriction of the throat, 
pruritus, blotchy skin, urticaria, coronary artery spasm, facial oedema, shortness of breath, chest 
tightness or pain, tachycardia, low blood pressure, dyspnoea, heart failure or cardiac arrest, 
restlessness, nausea, sensation of heat, flushing. The possibility of severe allergic reaction is higher 
in patients with severe renal insufficiency.
The route of administration of the IV will be intravenous, as specified in its data sheet. The drug 
administration protocols will be divided according to the dosage and time interval until surgery, as 
detailed below:
- Dosage. 2 groups: fixed bolus dose of 2.5 mg and bolus dose adjusted for body weight 
(0.05 mg/kg total body weight).
- Time of administration. On admission (>3 hours prior to surgery) and immediately 
preoperatively (15-30 minutes prior to surgery).
There is no treatment period as it is considered a diagnostic method. This period shall include 
intraoperative time.
The investigator shall ensure that this study is conducted in accordance with the principles of 
the 1964 Declaration of Helsinki and its subsequent revisions, GCP as well as


Page1137
DOTIG STUDY. Version 2.0 of 16 December 2022
The study will be conducted in accordance with the ICH guidelines and in full compliance with 
ethical and deontological standards. Individuals participating in this study will be qualified by 
education, training and experience to perform their respective tasks.
The study population in this CEA is patients with an indication for elective, scheduled or early 
CL. The inclusion criteria are detailed below:
•
Over 18 years of age.
•
Autonomy, self-sufficiency and independence.
•
Indication of CL programmed:
-
Symptomatic cholelithiasis: history of biliary colic, acute calculous cholecystitis, 
choledocholithiasis, acute ascending cholangitis of calculous origin or acute calculous 
pancreatitis.
-
Gallbladder polyps with indication for laparoscopic surgery.
-
Vesicular adenomyomatosis with indication for laparoscopic surgery.
•
Indication for early LC (<72 hours of admission for acute calculous cholecystitis/acute 
calculous cholecystitis/complicated biliary colic).
•
Indication of deferred emergency CL.
•
Understanding information.
•
Signing the informed consent form.
The exclusion criteria are detailed below:
•
Under 18 years of age.
•
Incapacity.
•
Pregnancy or breastfeeding.
•
Chronic kidney disease (Stage> IIIb).
•
Adverse reactions or allergies prior to IV.
•
Previous adverse reactions or allergies to VI excipients.
•
Confirmed adverse reactions or allergies to iodinated contrast agents.
•
Functional thyroid pathology (hyperthyroidism, thyroiditis, toxic multinodular goitre, 
functioning thyroid adenoma).
•
Urgent non-deferrable/emergent gallbladder surgery.
•
Initial surgery by laparotomy.
•
Previous suspicion of gallbladder carcinoma.
•
Inability to understand the information needed to participate in the study.
•
Refusal of inclusion in the study protocol.
8. Aim and Purpose of the Trial
The objectives of this CE are detailed :
•
Main objective. To analyse whether there are differences between different doses 
(single dose and weight-adjusted dose) and different VI administration intervals to 
achieve ideal visualisation of biliary structures during CF in LC.


Page1237
DOTIG STUDY. Version 2.0 of 16 December 2022
•
Secondary objectives.
o
1. To analyse the influence of body mass index on FC outcomes during CL.
o
2. To analyse the influence of the type of biliary pathology requiring surgery on 
the results of FC during LC.
o
3. To analyse the influence of the type of surgery (elective/early/ delayed surgery) 
on the outcome of FC during LC.
o
4. To analyse the influence of previous inflammatory changes on the results of FC 
during LC.
o
5. To analyse the influence of previous gallbladder or bile duct instrumentation on 
the results of FC during LC.
o
6. To analyse the influence of different laparoscopic imaging systems on the 
results of FC during LC.
o
7. To analyse the rate of intraoperative complications related to CF during LC.
o
8. To analyse the rate of postoperative complications related to CF during LC.
o
9. To analyse the impact of FC during LC on general surgeons and/or surgeons 
specialised in hepatobiliopancreatic pathology and their subjective assessment of 
the procedure.
o
10. To assess the impact of a history of previous liver disease on fluorescein 
cholangiography.
9. Trial Design
For this JU, the following key variables to be assessed in the trial are determined. Primary variables:
•
Identification of biliary structures prior to dissection of the hepatocystic triangle.
o
Identification of cystic duct (yes/no).
o
Identification of common bile duct (yes/no).
o
Identification of the junction of the cystic duct with the common bile duct (yes/no).
o
Identification of the junction of the cystic duct with the gall bladder (yes/no).
o
Identification of the common hepatic duct (yes/no).
o
Identification of anatomical variables (yes/no. Specify).
•
Identification of biliary structures after dissection of the hepatocystic triangle.
o
Identification of cystic duct (yes/no).
o
Identification of common bile duct (yes/no).
o
Identification of the junction of the cystic duct with the common bile duct (yes/no).
o
Identification of the junction of the cystic duct with the gall bladder (yes/no).
o
Identification of the common hepatic duct (yes/no).
o
Identification of anatomical variables (yes/no. Specify).
•
Degree of identification of biliary structures prior to dissection of the hepatocystic triangle 
(1=poor, 2=sufficient, 3=sufficient, 4=good, 5=excellent).


Page1337
DOTIG STUDY. Version 2.0 of 16 December 2022
•
Degree of identification of biliary structures after dissection of the hepatocystic triangle 
(1=poor, 2=sufficient, 3=sufficient, 4=good, 5=excellent).
•
Degree to which fluorescence cholangiography was perceived as useful for surgery (0=not 
useful, 1=moderately useful, 2=very useful).
•
Degree to which the fluorescence of the liver background (contrast between liver and 
ducts) was perceived as disturbed (0=absence of disturbance, 1=slightly disturbed, 
2=disturbed visualisation, but cystic-choledochal junction was clearly visible before 
dissection, 3=disturbed visualisation and cystic-choledochal junction was only visible after 
dissection, 4=very disturbed: it was impossible to visualise the biliary structures correctly).
The design of this CE is reflected in the following flowchart.
10. Research Product Characteristics (RPP)
Verdye 25 mg contains VI sodium powder for solution for injection. VI is a water-soluble agent 
with a peak spectral absorption of 800 nm. It is approved for diagnostic use only and is indicated for 
the measurement of the excretory function of the liver.


Page1437
DOTIG STUDY. Version 2.0 of 16 December 2022
liver. This medicine is included in the University Hospital of Salamanca and routinely used in the 
General and Digestive System Surgery Service.
Diagnostic use of this medicinal product should be performed under surveillance. The total daily 
dose should be less than 5 mg/kg body weight. The medicinal product should not be diluted with 
saline solutions and  be stored at a temperature below 30°C. Administration should be intravenous 
and handled under sterile conditions. A previous tolerance test with Verdye in which no problems 
have been encountered should not be considered an absolute guarantee of safety. Patients with 
end-stage renal failure have a higher rate of adverse effects. Two cases of death from anaphylactic 
reaction following administration of IV during cardiac catheterisation have been reported.
The delivery of the IMP will be carried out through the Hospital Pharmacy Service. Each vial of 
medicine will be for individual use, discarding the remaining active ingredient according to the 
protocol for handling pharmacological products. A document will be sent to the Hospital Pharmacy 
Service detailing the vials needed for the study in each centre (estimating 10 additional vials per 
centre). These vials will be stored in the operating room storerooms in a place outside the usual 
product use and with a "only use for DOTIG study" label. Once the study is completed, unused VI 
vials will be returned to the Hospital Pharmacy Service. A drug traceability document will be signed 
to ensure proper delivery and storage of the drugs.
VI administration protocols will be prespecified depending on the randomised treatment group. 
The product will be prescribed by the medical staff once the dosage and administration interval is 
known.
11. Selection and Withdrawal of Subjects
11.1.
Criteria for inclusion of subjects
•
Over 18 years of age.
•
Autonomy, self-sufficiency and independence.
•
Indication of CL programmed:
-
Symptomatic cholelithiasis: history of biliary colic, acute calculous cholecystitis, 
choledocholithiasis, acute ascending cholangitis of calculous origin or acute calculous 
pancreatitis.
-
Gallbladder polyps with indication for laparoscopic surgery.
-
Vesicular adenomyomatosis with indication for laparoscopic surgery.
•
Indication for early LC (<72 hours of admission for acute calculous cholecystitis/acute 
calculous cholecystitis/complicated biliary colic).
•
Indication of deferred emergency CL.
•
Understanding information.
•
Signing the informed consent form.
11.2.
Exclusion criteria for subjects.
•
Under 18 years of age.
•
Incapacity.
•
Pregnancy or breastfeeding.


Page1537
DOTIG STUDY. Version 2.0 of 16 December 2022
•
Chronic kidney disease (Stage> IIIb).
•
Adverse reactions or allergies prior to IV.
•
Previous adverse reactions or allergies to VI excipients.
•
Confirmed adverse reactions or allergies to iodinated contrast agents.
•
Functional thyroid pathology (hyperthyroidism, thyroiditis, toxic multinodular goitre, 
functioning thyroid adenoma).
•
Urgent non-deferrable/emergent gallbladder surgery.
•
Initial surgery by laparotomy.
•
Previous suspicion of gallbladder carcinoma.
•
Inability to understand the information needed to participate in the study.
•
Refusal of inclusion in the study protocol.
11.3.
Termination and interruption criteria
•
Study termination criteria. Completion of the 30-day follow-up period of the last 
patient included in the study.
•
Patient completion criteria. Completion of the follow-up 30 days after the 
intervention.
•
Patient discontinuation criteria. At least one of the following must be met:
o
Serious adverse events related to drug administration.
o
Development of contraindications or study exclusion criteria within the inclusion 
period and prior to surgery.
o
Voluntary drop-out of previously included patients.
12. Informed Consent (IC) and Patient Information Sheet (PIS)
The investigator will explain to each patient (witness or legal representative) the nature of the 
study/trial and the purposes, procedures, estimated duration, possible risks and benefits of their 
participation in the study/trial and possible inconveniences that this may cause them. All patients 
will be informed of the voluntary nature of their participation and that they may withdraw at any 
time, without affecting their future medical care or their relationship with the physician responsible 
for their treatment.
The patient shall be given sufficient time to read and understand the explanations included in 
the patient information sheet before giving informed consent (Annex 3). No patient shall be 
included in the study/trial before informed consent has been obtained.
Each patient will be assigned to an intervention group which will involve the administration of a 
dose at a predetermined time. All patients will receive the study product as there is no placebo 
group. The reason for the existence of 4 comparative groups is to study the efficacy of different 
dosage and interval of administration of the IV. Participation in the study


Page1637
DOTIG STUDY. Version 2.0 of 16 December 2022
does not involve a different surgical procedure or an increase in the number of scheduled visits.
13. Data Collection Notebook -CRD-.
The data collected will be recorded in a CRD, the veracity of which will be validated by the 
designated monitors. Each patient will be identified in the CRD by means of an alphanumeric code 
that identifies the patient (and the centre if it is a Multicentre) and in correlative order. The data 
protection provisions of Organic Law 3/2018 on Personal Data Protection and guarantee of digital 
rights will be respected at all times.
The data will be obtained from the personal interview with the patient and access to the 
patient's clinical history. If the patient does not attend any of the scheduled visits, the investigator 
will contact the patient by telephone to confirm that the absence is not due to a conscious 
abandonment of follow-up. If the patient is not contacted, the researcher will access the local or 
regional digital medical record to find out if there have been any events related to the study that 
have been assessed in another health centre.
The procedures for correctly completing the data collection notebook will be through the 
specific sessions of the General and Digestive System Surgery Department, by means of the 
presentation and explanation of the notebook. In addition, any doubts and problems that may arise 
will be resolved.
The specific requirements will be determined by the electronic data collection record keeper:
1.
The principal investigators (PIs) will be the only individuals who can sign the registry. These 
individuals have all functions with the exception of the monitor function and the electronic data 
collection logbook manager (CRDe).
2.
Sub-researchers and study coordinators may include data in the study, but may not sign 
the registry. You can resolve queries.
3.
The monitor will be able to review the data and generate queries.
4.
The data manager has the power to block-unblock the electronic data collection logbook. 
In addition, he/she is responsible for data management. He/she has access to all the centres 
included in the study.
Randomisation will be carried out using algorithms proposed by the CRD. Block randomisation 
will be carried out.
All patient data will be included for the first 45 days after the patient's surgery.
14. Medical History -HC- and source documents
The electronic medical record will be available through the Jimena computer software (version 
III and version IV) of the Castilla y León Health System (SACYL) and the SAP software of the Catalan 
Health System. In addition, those paper documents that must be kept in the medical record and 
cannot be computerised (informed consent for surgery, informed consent for clinical trials, surgical 
protocol, hospital discharge report), will be collected in the paper medical record of each patient, 
and stored in the Clinical Documentation Service of the University Hospital of Salamanca and the 
University Hospital of Salamanca.


Page1737
DOTIG STUDY. Version 2.0 of 16 December 2022
Germans Trias i Pujol University of Badalona. Paper documents can be scanned and stored in the digital 
repository of both servers.
Definitions:
•
Source data: All information in original documents and certified true copies of original 
records of clinical results, observations, or other activities of a clinical trial necessary for 
the reconstruction and evaluation of the trial. Source data shall be included in the 
source documents (original records or certified copies).
•
Source documents: original documents, data and records (e.g., patient records, medical 
or consultation records, laboratory notes, memoranda, registers, data recorded on 
automated instruments, copies or transcripts certified after verification, microfiche, 
photographic negatives, microfilm or magnetic media, X-rays, subject files, and 
pharmacy records in the laboratories and in the medico-technical departments involved 
in the clinical trial).
Patients must have given written consent for their medical records to be read by personnel 
authorised by the sponsor and regulatory authorities. This information is included in the informed 
consent.
The following data specific to this CB shall be collected in the HC and shall also be collected in 
the CRDe:
•
Pre-operative period:
o
Date of birth (dd-mm-yyyy), age (years), sex (male/female), weight (kg), height 
(cm), body mass index-BMI (kg/m2), anaesthetic-surgical risk classification 
(American Association of Anaesthesiologists-ASA classification), previous 
abdominal surgeries (biliary tract, liver, pancreas, intestinal, others), previous 
endoscopic or radiological explorations of the biliary tract (endoscopic 
retrograde cholangiopancreatography (ERCP) or endoscopic retrograde 
cholangiopancreatography (ERCP)), liver, pancreas, intestinal, others), previous 
endoscopic or radiological explorations of the biliary tract (endoscopic 
retrograde 
cholangiopancreatography 
(ERCP) 
or 
transparihepatic 
cholangiography (TPHC)), previous biliary prosthesis placements (yes/no). 
History of acute cholecystitis (yes/no).
/previous acute cholangitis (yes/no). History of previous percutaneous 
gallbladder drainage (no/radiological percutaneous cholecystectomy or 
endoscopic transduodenal/transgastric). Previous liver disease (no/fatty liver 
steatosis/hepatitis/cirrhosis).
o
Indication for surgery [Symptomatic cholelithiasis (biliary colic, acute 
cholecystitis, choledocholithiasis, acute ascending cholangitis, acute lithiasic 
pancreatitis), gallbladder polyps, gallbladder adenomyomatosis].
•
Perioperative period:
o
Date of entry (dd-mm-yyyy).
o
Time of entry (hour:minutes)
o
Date of surgery (dd-mm-yyyy).
o
Time of surgery (hour:minutes).


Page1837
DOTIG STUDY. Version 2.0 of 16 December 2022
o
Type of surgery (elective/early/ delayed emergency).
o
Grade of cholecystitis in case of early surgery / delayed emergency (18th Tokyo 
Classification).
o
Intervention group (group 1/group 2/group 3/group 4).
o
Characteristics of the procedure. IV dosage (fixed dose/weight-adjusted dose). 
IV administration interval (>3 hours preoperatively, 15-30 minutes 
preoperatively). Immediate adverse reactions (yes/no. Specify). Number of 
trocars (3/4). Imaging system used (Olympus/Karl-Storz/Stryker). Optics used 
(0º/30º). Gall bladder puncture/emptying (yes/no). Bile culture (yes/no). Result 
of bile culture if any (specify).
o
Conversion to laparotomy (yes/no), intraoperative complications (yes/no), 
specification of intraoperative complications (cystic artery injury, right hepatic 
artery injury, liver injury with/without bleeding, gallbladder opening 
(intraperitoneal biliary contamination: yes/no, lithiasis outflow into peritoneal 
cavity: yes/no), hollow viscus perforation, trocar bleeding, other). Operating 
time (minutes).
•
Postoperative period:
o
Hospital 
stay 
(days), 
postoperative 
complications 
(intra-abdominal 
haematoma, bilioma, abscess, paralytic ileus, surgical site infection-ISQ, trocar 
evisceration, 
trocar 
eventration, 
others), 
postoperative 
complications 
according 
to 
Clavien-Dindo 
classification,bile 
duct 
injury 
(Strasberg 
classification), time of diagnosis bile duct injury (intraoperative / 
postoperative), treatment of bile duct injury (immediate surgical, radiological, 
endoscopic or delayed surgical). Mortality during admission (yes/no), 30-day 
mortality (yes/no), causes of mortality (specify). Adverse drug reactions within 
30 days (yes/no. Specify).
All preoperative data will be collected for patients withdrawn from the study, as well the type of 
complication developed and any adverse events during the first 30 days of the study (if any). 
Subjects will not be replaced in the study. The follow-up period will be identical for subjects who do 
not undergo the study intervention.
15. Monitoring
Required data to be accurately recorded in CRDs and agree with source data. Revised according to 
the Monitoring Manual.
-
Patient identification.
-
Date and time of surgery.
-
Dose and time of VI administration.
-
Target variables (set out above).


Page1937
DOTIG STUDY. Version 2.0 of 16 December 2022
After each monitoring, the monitor will be able to generate a discrepancy document with the 
inconsistencies and errors detected in the study. These problems can be communicated through 
the CDRe or by e-mail.
16. Researcher and collaborators
The principal investigator shall maintain a register of all persons involved in the trial (medical, 
nursing, and other personnel). He/she shall confirm that appropriate training relevant to the trial is 
given to all such personnel and that any new information relevant to the conduct of the trial is 
conveyed to the personnel involved.
17. Facilities
•
Hospitalisation ward. This is where the patient is admitted prior to surgery. This is 
where all mandatory documentation is checked and the patient is prepared for surgery.
•
Pre-operative conditioning room. A surgical checklist and a new preparation of the 
patient will be performed.
•
Operating theatres. In addition to the equipment necessary for any laparoscopic 
surgical activity, which is no different from the study activity, these operating theatres 
will be equipped with the necessary equipment to perform CF-VI (optics, light cable and 
compatible image processing system).
•
Postoperative recovery room. Controlled by the Anaesthesiology and Resuscitation 
Service.
•
Outpatient clinics. Place where the postoperative control will be carried out after the 
patient is discharged.
•
Hospital Pharmacy Service. Responsible for dispensing the medicine.
•
Operating theatre storeroom. This is where the necessary equipment and drugs are 
stored, including the active ingredient of the study.
18. Treatment of Subjects
Subjects included in this CE will be treated with VI [Verdye (Diagnostic Green GMBH, Aschheim-
Dornach, Germany)]. The following patient groups are established in the CE.
•
Group 1. Fixed dose 2.5 mg with IV administration more than 3 hours before surgery.
•
Group 2. Fixed dose 2.5 mg with immediate pre-operative VI administration (15-30 minutes 
before surgery).
•
Group 3. Weight-adjusted dose (0.05 mg/kg total body weight) with administration of the 
LV more than 3 hours before surgery.
•
Group 4. Weight-adjusted dose (0.05 mg/kg total body weight) with immediate pre-
operative administration of the IV (15-30 minutes prior to surgery).


Page2037
DOTIG STUDY. Version 2.0 of 16 December 2022
Verdye contains the active substance VI sodium powder for solution for injection. Each ampoule 
contains 25 mg of active substance. The dissolution medium for the product should be water for 
injectable preparations. The solution for injection should be inspected before administration and 
discarded in case of turbidity. The drug solution shall be prepared with 10 ml of water for injectable 
solutions, obtaining a ratio of 2,5 mg/ml. Once the solution is prepared according to the above 
protocol, it shall be injected directly through a peripheral venous line of the patient's upper limb. 
The medicinal product should be stored at a temperature below 30°C, keeping its original outer 
packaging in order to protect the medicinal product from light. Once the solution for injection has 
been prepared, it should be protected from light and used immediately.
The expected duration of subject participation will be 31 days, including preoperative, 
intraoperative, immediate postoperative (<24 hours), early postoperative (<7 days) and late 
postoperative (<30 days) periods. The patient recruitment period will be 12 months. The end of the 
clinical trial will take place from day 30 after discharge of the last patient recruited, with the aim of 
analysing the 30-day morbidity and mortality of the study patients.
The frequency of patient visits will be as follows:
1-
Consultation prior to admission. The objective of the study and the entire study protocol 
will be explained, along with the delivery of the HIP and the IC.
2-
Visit prior to surgery. This visit will corroborate the correct understanding of the 
information, the presence of the correctly signed ICs and the resolution of any doubts or 
problems.


Page2137
DOTIG STUDY. Version 2.0 of 16 December 2022
3-
In-hospital post-operative visits. These will be carried out daily in the morning shift (8-15 
hours). No different from postoperative visits of other operated patients.
4-
Postoperative control visit. This will take place 30 days after the surgical intervention 
through the General and Digestive System Surgery Outpatient Department.
There is no treatment period as it is considered a diagnostic method. This period shall include 
intraoperative time.
A computerised block randomisation will be performed through CDRe. Participants will be 
assigned to each of the 4 treatment groups by non-stratified 1:1:1:1:1 randomisation.
As it is an intervention without a control group, blinding will not be performed in the trial. The 
end-of-study criterion will be completion of the follow-up period at the end of the trial.
30 days from the last patient included in the study.
19. Effectiveness Assessment
The following efficacy parameters shall be used:
•
Degree identification of biliary structures prior to dissection of the hepatocystic triangle 
(1=poor, 2=sufficient, 3=sufficient, 4=good, 5=excellent).
•
Degree of identification of biliary structures after dissection of the hepatocystic triangle 
(1=poor, 2=sufficient, 3=sufficient, 4=good, 5=excellent).
•
Degree to which FC was perceived as useful for surgery (0=not useful, 1=moderately 
useful, 2=very useful).
•
Degree to which the fluorescence of the liver background (contrast between liver and 
ducts) was perceived as disturbed (0=absence of disturbance, 1=slightly disturbed, 
2=disturbed visualisation, but cystic-choledochal junction was clearly visible before 
dissection, 3=disturbed visualisation and cystic-choledochal junction was only visible 
after dissection, 4=very disturbed: it was impossible to visualise the biliary structures 
correctly.
20. Security Assessment
20.1. Definitions
•
Adverse Event (AE): An adverse event is any undesirable medical reaction experienced by the 
patient at any time during the course of the study, whether or not it is considered to be related 
to the study treatment. This definition includes new disease onset and exacerbation of pre-
existing conditions other than the indication under study.
•
Adverse Reaction (AR): An AR is any unintended, harmful reaction to an investigational 
medicinal product, regardless of the dose administered.


Page2237
DOTIG STUDY. Version 2.0 of 16 December 2022
•
Serious Adverse Event (SAE) and Serious Adverse Reaction (SAR)
Serious AEs or ARs are considered to be those which, at any dose, may result in death, threaten 
the life of the subject, require hospitalisation of the patient or prolong an existing 
hospitalisation, cause permanent or major disability or incapacity, or result in a congenital 
anomaly or malformation. Suspected AE or AR that is medically significant, even if it does not 
meet the above criteria, including major medical events that require intervention to prevent 
one of the consequences described above, are also considered serious. In addition, all 
suspected transmission of an infectious agent via a medicinal product shall be reported as 
serious.
The concept of "threatening the life of the subject" in the definition refers to the fact that, in 
the opinion of the investigator, the patient at the time of the AA or AR is at real risk of death; it 
does not refer to the fact that the AA/AR hypothetically could have resulted in death had it 
been more severe.
The term "requiring hospitalisation" shall exclude both planned hospitalisations for scheduled 
treatments and hospitalisations that have been planned or are anticipated prior to the start of 
the study in relation to a pre-existing medical condition.
•
Unexpected Adverse Reaction (UAR)
Any AR whose nature, intensity or consequences do not correspond to the reference safety 
information.
•
Serious Unexpected Adverse Reaction (SUAR)
RAG (previously defined), the nature, severity or consequences of which do not correspond to 
the reference safety information.
20.2.Causality Criteria (see section 20.7)
• Related AA: The temporal relationship of the AA with the study medication indicates a 
possible causal relationship and cannot be explained by factors such as the patient's clinical 
status, therapeutic interventions.
• Unrelated AA: The temporal relationship of the AA to the study medication indicates an 
unlikely causal relationship, or other factors (medication or concomitant conditions), other 
therapeutic interventions provide a satisfactory explanation for the AA.
20.3. Security reference information
In this study, the reference safety information (RSI) will be the information available in the 
corresponding product label of the medicinal product under study: Verdye.


Page2337
DOTIG STUDY. Version 2.0 of 16 December 2022
20.4. Safety variables and parameters
The safety assessment of the drugs under study will be carried out by means of clinical 
examination (physical, analytical and/or radiological) and collecting serious adverse effects and 
those that may be directly related to the medication under study.
The key safety parameter will be the bile duct injury rate, which is currently at incidences of 
0.3%-0.7%.
20.5. Information on Adverse Events
All adverse events shall be recorded in the data collection notebook. For each adverse event, 
the dates of onset and resolution, intensity, duration, and its impact on study treatment (e.g. 
discontinuation) shall be recorded. The severity of the adverse event and its relationship to the 
study should be assessed according to specific guidelines. Any action taken or outcome 
achieved (e.g. hospitalisation, withdrawal of treatment, etc.) should also be noted.
The investigator or a co-worker shall question and/or examine the subject for the occurrence 
of adverse events.
Adverse events will be collected once the subject has been randomised. If a subject 
experiences an adverse event after signing the informed consent document (inclusion), but 
prior to treatment assignment (recruitment), the event will NOT be recorded unless the 
investigator considers it to be causally related to a procedure in the protocol.
During the course of the study, site staff will again note any changes in the disorder and nature 
of possible adverse events.
20.6.Assessment of the intensity of adverse events and their relation to treatment
The following definitions shall be used to assess the intensity of adverse events:
- Mild: sign, symptom or event is known but easily tolerated.
- Moderate: there is sufficient discomfort to interfere with normal activity and may 
warrant intervention.


Page2437
DOTIG STUDY. Version 2.0 of 16 December 2022
- Severe: is disabling and results in inability to perform usual activities or significantly 
affects the clinical condition and warrants intervention.
- Life-threatening: immediate risk of death.
- Death
20.7. Assessment of the imputability of adverse events and serious adverse events with study 
treatment: Imputability criteria.
The sponsor will classify adverse events, based on their causal relationship with the drug, 
according to the Algorithm of Karch and Lasagna (1977), as follows:
• Definitive: there is a reasonable time sequence between the administration of the 
drug and the appearance of the AE. The event coincides with the ARs described for the 
drug, improves with drug withdrawal, reappears after re-administration and cannot be 
explained by alternative causes.
• Probable: there is a reasonable time sequence between the administration of the 
drug and the occurrence of the AE. The event coincides with the ARs described for the 
drug, improves after discontinuation of treatment and cannot be explained by other 
alternatives.
• Possible: there is a reasonable time sequence between drug administration and the 
occurrence of AA. The event coincides with the ARs described for the drug but can be 
explained by alternative causes.
• Conditional or Improbable: there is a reasonable time sequence between the 
administration of the drug and the occurrence of the AE. The event does not coincide 
with the ARs described for the drug and can be explained by alternative causes.
• Unrelated: there is no reasonable time sequence between the administration of the 
drug and the occurrence of the AE. The event does not coincide with the ARs described 
for the drug and can be explained by alternative causes.
For the purposes of expedited reporting, the definite, probable and possible categories of the 
Karch and Lasagna (1977) algorithm shall be considered as related and the conditional or 
improbable category of the Karch and Lasagna (1977) algorithm shall be considered as 
unrelated.
The determination of the possible relationship to the study treatment is the responsibility of 
the principal investigator of the research site or his/her designee and, once notified, will be 
reviewed by the study sponsor and/or his/her designee.
20.8. Monitoring of adverse events
Subjects with adverse events will be monitored by appropriate clinical assessments and 
laboratory tests as directed by the investigator. All adverse   events   should   be tracked   
until   their   satisfactory resolution      or   their


Page2537
DOTIG STUDY. Version 2.0 of 16 December 2022
stabilisation. All actions taken and monitoring results should be recorded in the appropriate 
section of the data collection notebook. If abnormalities in laboratory values are clinically 
significant and result in clinical symptoms or meet the criteria for a serious adverse event, the 
diagnosis shall be reported as a serious adverse event.
20.9.AAG notification, expedited notification and notification of pregnancy 
Serious Adverse Event Notification
All serious adverse events (as defined below), whether or not they are considered treatment-
related or expected, should be reported to the Pharmacovigilance department by the principal 
investigator or a collaborator within 24 hours (one working day) of becoming aware of them, 
using the appropriate reporting form. Serious adverse events occurring at any time from the 
patient's randomisation into the study until the subject completes or leaves the study must be 
reported. A subject is considered complete: upon completion of the last visit or contact (e.g., 
telephone contact with the investigator or a collaborator) as indicated in the protocol 
evaluation schedule or after the last dose of study medication, whichever is later. Withdrawal 
is defined as the date on which a subject and/or the investigator determines that the subject 
can no longer meet the study requirements at any subsequent visits and assessments. AAG 
follow-ups will follow the same form indicating follow-up and should be submitted within 7 
days, (noting that it is the "follow-up" form). The follow-up report will indicate whether the 
event has resolved or is still active, whether and how it has been treated, and whether the 
patient's participation in the trial has continued or ended. The trial site will retain the form.
The notifying investigator should complete and sign the AAG notification form (Annex 4) for 
the trial and send it by fax or e-mail to:
PhD Patricia Rodríguez Fortúnez 
Head of Pharmacovigilance 
Telephone: 615510900
E-mailpatriciarodriguezfortunez@yahoo.es
The PV staff shall review the form received and, if appropriate, request additional information 
from the investigator. The investigator shall provide information to the sponsor or to the 
person assuming the tasks delegated by the sponsor (PV Manager) whenever requested to do 
so, and in any case when the investigator's initial assessment of severity or causality changes.


Page2637
DOTIG STUDY. Version 2.0 of 16 December 2022
The reporting procedure described above shall be followed for communicating follow-up 
information.
The original copy of the AAG Forms (either initial or follow-up) shall be retained at the trial site, 
along with all other trial documentation.
The PV manager shall keep a detailed record of all AAGs or of special interest reported to 
him/her by the investigators.
In the event that a medication error occurs or the investigational medicinal product is used 
outside the protocol during the conduct of the trial, the investigator shall notify the VF 
manager within 24 hours of becoming aware of it. The reporting circuit and form will be the 
same as for AAGs.
Serious adverse events are those AEs that meet the severity criteria described in the definitions 
section. Clinically significant events that not life-threatening, life-threatening or require 
hospitalisation may be considered as serious adverse drug experiences when, based on sound 
medical judgement, they are likely to endanger the subject or require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. Examples of such medical 
events are allergic bronchospasm requiring intensive, home or emergency department 
treatment, blood dyscrasias or seizures not resulting in hospitalisation, or development of 
dependence or substance abuse.
Laboratory test abnormalities that are considered clinically relevant also need to be reported, 
unless otherwise stated in this section of the protocol.
Expedited notification of RAGIs
The sponsor or the person delegated by the sponsor is responsible for notifying the 
EMA/AEMPS and the Autonomous Regions where the trial is conducted of all RAGI collected in 
the study, following the procedure indicated in the legislation in force.
The maximum period for notification of an individual case of suspected RAGI shall be 15 
calendar days from the time the sponsor becomes aware of the suspected RAGI. Where the 
suspected RAGI has resulted in the death or endangerment of the patient, the sponsor shall 
submit the information within 7 calendar days of becoming aware of the suspected . He/she 
shall complete the information, if possible, within 8 days.
This information should include an assessment of the significance and implication of the 
findings, including relevant previous experience with the same or similar medicinal products.
Likewise, the competent body of each of the Autonomous Communities where the trial is 
carried out should be notified of suspicions of RAGI occurring in the centres.


Page2737
DOTIG STUDY. Version 2.0 of 16 December 2022
health services in your Community. In both cases, the RAGI notification form shall be used for 
this purpose.
Expedited notification of other relevant safety information
The sponsor or its delegate should report as soon as possible and no later than 15 days after 
becoming aware of it any information that could change the risk/benefit balance of the 
investigational product (e.g. an increase in the rate of occurrence of expected AGRs, AGIRs 
occurring after completion of a clinical trial, new events related to the conduct of the trial or 
the development of the investigational product, any recommendations of the data monitoring 
committee relevant to subject safety, etc.).
Pregnancy Notification
In the event of any pregnancy occurring during the conduct of the trial, the investigator shall 
notify the sponsor or the person assuming the tasks delegated by the within 24 hours of 
knowledge of the pregnancy. The pregnancy will also be followed up to document the outcome 
of the pregnancy and the health status of the newborn. If the outcome of the pregnancy meets 
GABA criteria or if the newborn presents a serious event, the procedures described for GABA 
notification will be followed. Notification shall be made using the specific pregnancy 
notification form (Annex 5) which shall be sent by e-mail to the same contact person who will 
receive the HCA notifications.
The original copy of the Pregnancy Form will be kept at the trial site, along with the rest of the 
study documentation.
20.10. Blind opening and unmasking
Not applicable as the study is open-ended and therefore there is no blind.
20.11. Periodic security report
The annual safety reports, which will include the RAGIs and AAGs collected in the study from the 
time the patient is randomised, will be sent by the sponsor or the person delegated by the sponsor 
to the AEMPS (Clinical Trials Area of the Subdirectorate General for Medicines for Human Use), to 
the corresponding Autonomous Regions and to the CEIm, within the deadlines established in the 
legislation in force.


Page2837
DOTIG STUDY. Version 2.0 of 16 December 2022
The submission of the annual safety report and other safety reports by the developer shall in any 
case comply with the criteria and procedure specified in Articles 43, 45 and 53 of Regulation (EU) 
No 536/2014 of the European Parliament and of the Council of 16 April 2014 and in accordance 
with RD1090/20015.
20.12. Report to researchers
The sponsor will submit safety information that could impact the safety of the patients 
enrolled in the trial to the investigators as early as possible. In addition, the investigator will be 
informed throughout the study of any safety issues, including protocol modifications due to 
safety concerns.
21. Statistics
For the calculation of the sample size we estimated an average annual number of laparoscopic 
cholecystectomies of 300 cases. Assuming a minimum recruitment rate of 50% in the study, a 
duration of 12 months and possible losses of patients, we estimate a sample size of 200 patients.
Since the main objective is to analyse whether there are differences between the doses and 
administration times of the 4 treatment groups in which categorical variables will be measured, the effect of 
the chosen sample size (n= 200) on the statistical contrasts in this type of variables is w=0.25 with a 
power.95 and a significance error of the null hypothesis α=0.05.
The procedure used to account for missing, unused and erroneous data will be the "Pairwise 
Delection" method. The confidence intervals of the statistics will be 95% and the contrasts will be 
performed at a significance level of 5%. All analyses will be performed with the free software R 
(version 4.1.2+, R Core Team, Vienna, https://www.R-project.org/) and the RStudio interface 
(version 1.4.1103+).
The study will have no planned intermediate analyses as no partial analysis of results is 
envisaged. Once all data have been collected, verified and validated, a statistical analysis of the 
data will be performed according to the specifications described in the protocol. If this analysis 
leads to the conclusion that further analysis is necessary, this will be reported in the final analysis of 
results. All treated and evaluable subjects shall be analysed. Different statistical tools will be used 
depending on the nature of the variables collected in the study, accompanying the results with 
their corresponding graphs.
Lilliefors-Kolmogorov-Smirnov and Shapiro-Wilks tests shall be performed to study the 
normality of the distribution of quantitative variables, and to their distribution they shall be 
represented by the mean (standard deviation) or the median (median deviation) and may be 
accompanied by their corresponding confidence intervals. The relationship between such variables 
shall be measured with Pearson's or Spearman's correlation coefficients.
The distributions of the categorical variables will be studied by means of frequencies and 
percentages. To represent and measure the dependence between them, contingency tables will be 
used with Pearson's Chi-square test, Fisher's exact test, McNemar's test


Page2937
DOTIG STUDY. Version 2.0 of 16 December 2022
or Cochran's Q. A category comparison study could also be done using odds ratios between 
categories of clinical interest. To study the influence that some categorical variables might have on 
quantitative variables, ANOVA tests could be performed.
Finally, all the statistical information obtained on the relevance of each variable in the study 
could be used to apply classification tools to the individuals in the study (decision trees, logistic 
regression, ROC curves).
22. Direct Access to Source Data/Documents
The Promoter will enter into appropriate arrangements to appoint a monitor to oversee this 
study and to liaise regularly with the site, including arranging site visits. The investigator agrees to 
allow the monitor direct access to all relevant documents and to give his/her time and that of 
his/her staff to the monitor to discuss the results and any issues of concern.
23. Quality Control and Quality Assurance
In order to ensure the quality of the data, the promoter:
• Provide quality instruction and training to the research staff prior to the start of the study. 
Training topics include, but are not limited : Good Clinical Practice (GCP) certificates, Adverse Event 
(AE) reporting, study details and procedures, study documentation, informed consent, and patient 
recruitment.
• Conduct regular monitoring in accordance with the International Conference on 
Harmonisation (ICH) for Good Clinical Practice (GCP). Data will be assessed for compliance with the 
protocol and for accuracy in relation to the source documents. Monitors will verify that the clinical 
trial is conducted, that data are generated, documented and reported in compliance with the 
protocol, good clinical practice and any applicable local regulatory requirements.
Direct access to the data should be granted to the PIs, monitors, members of the evaluating 
IRB/IEC and AEMPS, as well as to the authorities as necessary, to allow for study-related monitoring 
and surveillance, audits and inspections. At each site, they may review the trial records and 
compare them directly with the source documents, may discuss the conduct of the trial with the 
investigator, and may verify that the facilities are maintained in an acceptable manner. Audit 
reports will be treated confidentially.
24. Ethical and legal aspects.
The trial will be conducted in accordance with the recommendations for clinical trials and drug 
evaluation in man, as contained in the 1964 Declaration of Helsinki, as revised in Tokyo, Venice, 
Hong-Kong, South Africa, Edinburgh, Washington, Tokyo and Seoul, Fortaleza (2013) and in the 
AEPMS Instructions for the conduct of clinical trials in Spain (Version 9 of 27 July 2018). The 
investigator will conduct the study in compliance with the ethical principles of the Declaration of 
Helsinki.
The study/trial must adhere to the protocol, which ensures compliance with Good Clinical 
Practice, as described in the ICH Tripartite Harmonised Guidelines for Good Clinical Practice.


Page3037
DOTIG STUDY. Version 2.0 of 16 December 2022
This study/trial will be submitted for evaluation by a Medicines Research Ethics Committee and 
notified to the AEMPS.
25. Data Management and Archiving of Records
The confidentiality of individual patient data will be respected at all times. The original data will 
be kept in the relevant department and will only be accessible to the study/trial investigators or to 
inspectors in case of inspection the Spanish Health Authorities.
Patients in the study/trial will be identified by a patient code. The investigator will inform 
patients that data collected during the study/trial will be stored and analysed electronically, in 
compliance with Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 
April 2016 on the protection of individuals with regard to the processing of personal data and on 
the free movement of such data and with Organic Law 3/2018 of 5 December on the Protection of 
Personal Data).
The researcher is the only person who can and should know the origin of the data obtained and 
who can associate it with the patient.
The personal data (full name, address, place of work, VAT number) of the investigators will be 
recorded in a computer file, for the sole purpose of facilitating the organisational and logistical 
aspects necessary for the conduct of the study/trial.
In compliance with the above regulations, the data file will be treated confidentially and 
researchers may exercise their rights of access, rectification, cancellation and opposition with 
respect to the personal data recorded, if they so request by writing to the Data Protection Officer 
of the promoter at protecciondedatos@ibsal.es
26. Financing and Insurance
The trial sponsor is responsible for ensuring that an insurance or financial guarantee is in place 
to cover damages incurred as a result of the clinical trial.
This clinical trial is considered a low-intervention level clinical trial accordance with RD 
1090/2015 and European Regulation No. 536/2014 due to the following conditions:
1.
The medicinal product (indocyanine green) studied in the present project is used in 
accordance with the authorised label.
2.
In the present trial, no additional procedures are performed with respect to those that 
would have been performed on participants in the context of routine clinical practice, both 
in Spain and in the European Union and other international settings.
Therefore, and in accordance with chapter III, article 9 of Royal Decree 1090/2015: "Damage to 
the study subject that may result as a consequence of a low-intervention clinical trial will not need 
to be covered by an insurance contract or financial guarantee, if they are covered by the individual 
or collective professional liability insurance or equivalent financial guarantee of the healthcare 
centre where the clinical trial is carried out"; no ad hoc insurance has been taken out for this 
clinical trial.
27. Other test procedures. Management Delivery of other test materials


Page3137
DOTIG STUDY. Version 2.0 of 16 December 2022
No "extra" materials are required for the realisation of this CE. All materials are
available at participating CE centres.
Details of the documentation to be submitted to the Protocol are set out in Annex 2.
28. Audits and inspections
Health authorities or IRB/IECs may visit the site to conduct audits or inspections with 
verification of the original data. The objective of this audit is to systematically and independently 
evaluate all trial-related activities and documentation to determine whether these activities have 
been performed and whether the data have been analysed and reported in accordance with the 
protocol, GCP Standards, ICH Guidelines, and legal requirements.
29. Changes to the protocol
If an amendment to the trial protocol is necessary, the amendment or a new version of the trial 
protocol (amended protocol) should be notified to the IRB/IEC for approval by the IRB/IEC and, if 
applicable, also by the health authorities, prior to implementation. Local requirements should be 
met.
If an amendment to the protocol requires a change in the informed consent for a particular site, 
the IRB/IEC must be notified. Approval by the IRB/IEC is required prior to use of the new version of 
the consent form. The sponsor will distribute the amendments and new versions of the protocol to 
each principal investigator, who in turn is responsible for distributing these documents to the site 
staff. The distribution of these documents to the health authorities will follow the applicable 
regulations.
30. Difficulties and limitations of the study
Some of the difficulties could be found in the period of patient selection and inclusion in the 
study, due to the presence of numerous exclusion criteria. Other difficulties arise during the 
intervention, due to alleged problems arising from the use of fluorescent technology or 
laparoscopic surgical equipment. The subjectivity inherent in the visual assessment of the target 
variables and the presence of the surgeon factor is another limitation of the study. Finally, four 
groups with specific doses and administration periods are being evaluated, which could lead to the 
establishment of multiple different combinations, although methodologically impossible to carry 
out with an adequate number of cases.
31. Periodic Security Reports (DSUR)
Following the standards of good clinical practice and current regulations, the Pharmacovigilance 
Officer will prepare a safety report once a year. This report will contain the safety assessment of 
the drug according to all AAGs received by the Node's Pharmacovigilance Officer.
The Pharmacovigilance Officer will send the DSUR to the Project Manager for review, indicating 
the need for a response within 15 days and the deadline.


Page3237
DOTIG STUDY. Version 2.0 of 16 December 2022
The Pharmacovigilance Officer will then send the DSUR to the Sponsor for approval, indicating 
the need for a response within 15 days and the deadline.
All modifications suggested by the GP or sponsor will be carried out by the Pharmacovigilance 
Officer.
The latest version of the DSUR will be signed by the PV manager, then by the GP (as reviewer) 
and finally by the developer giving his approval.
The annual safety report (DSUR) shall be sent by the developer to:
•
AEMPS: via ECM portal using "E iv) Annual Safety Report (DSUR) [Only
AEMPS]"
•
CEIm del Área de Salud de Salamanca: via ECM portal using "E ii) Trial progress ".
•
Contact points for clinical trials in the Autonomous Communities via email 
(https://).www.aemps.gob.es/investigacionClinica/ptoContacto.do)
The Project Manager will send a copy of the acknowledgement of receipt from the AEMPS to the 
Pharmacovigilance Officer.
Follow-up and completion reports
The Sponsor, in accordance with the current regulations and instructions regulating clinical trials 
by the AEMPS, will send the relevant follow-up reports.
Three months after the completion of patient enrolment, a statistical report including all results 
of the study shall be drawn up. This report shall be made available to the participating investigator. 
In addition, copies of the report shall be sent to the IRB that evaluated the study and to the AEMPS.
Any report obtained from this study will be treated as confidential, at least until it has been 
reviewed and analysed by the person responsible for the study. The data set may be used for 
general publications, which should always refer to the study. The investigator agrees not to provide 
information related to the study or to provide access to the study data to third parties.
32. Publication Policy
Regardless of the results of the study, the sponsor agrees to present them to the medical 
community through scientific publications, conferences or other means.
Any formal presentation or publication of the results of the study shall be considered a joint 
publication by the investigator(s) and the sponsor.
33. References
1.
Ansaloni L, Pisano M, Coccolini F, Peitzmann AB, Fingerhut A, Catena F, et al. 2016 WSES 
guidelines on acute calculous cholecystitis. World J Emerg Surg 2016;11:25.
2.
Tazuma S, Unno M, Igarashi Y, Inui K, Uchiyama K, Kai M, et al. Evidence-based clinical


Page3337
DOTIG STUDY. Version 2.0 of 16 December 2022
practice guidelines for cholelithiasis 2016. J Gastroenterol 2017;52(3):276-300.
3.
Pesce A, Piccolo G, Lecchi F, Fabbri N, Diana M, Feo CV. Fluorescent cholangiography: An up-
to-date overview twelve years after the first clinical application. World J Gastroenterol 
2021;27(36):5989-6003.
4.
Nuzzo G, Giuliante F, Giovannini I, Ardito F, D'Acapito F, Vellone M, et al. Bile duct injury 
during laparoscopic cholecystectomy: results of an Italian national survey on 56591 
cholecystectomies. Arch Surg. 2005;140:986-92.
5.
Strasberg SM, Hertl M, Soper N. An analysis of the problem of biliary injury during 
laparoscopic cholecystectomy. J Am Coll Surg 1995;180(1):101-25.
6.
Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universal culture of safety 
in cholecystectomy. World J Gastrointest Surg 2019;11(2):62-84.
7.
Mascagni P, Vardazaryan A, Alapatt D, Urade T, Emre T, Fiorillo C, et al. Artificial Intelligence 
for Surgical Safety: Automatic Assessment of the Critical View of Safety in Laparoscopic 
Cholecystectomy Using Deep Learning. Ann Surg 2020 [Epub ahead of print].
8.
Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T. Intraoperative Cholangiography and 
Risk of Common Bile Duct Injury During Cholecystectomy. JAMA 2003;289(13):1639.
9.
Vlek SL, van Dam DA, Rubinstein SM, de Lange-de Klerk ESM, Schoonmade LJ, Tuynman JB, 
et al. Biliary tract visualization using near-infrared imaging with indocyanine green during 
laparoscopic cholecystectomy: results of a systematic review. Surg Endosc 2017;31(7):2731-
42.
10.
Ishizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N. Fluorescent 
cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg 
2010;97(9):1369-77.
11.
Reinhart MB, Huntington CR, Blair LJ, Heniford BT, Augenstein VA. Indocyanine Green: 
Historical Context, Current Applications, and Future Considerations. Surg Innov 
2016;23(2):166-75.
12.
Lim SH, Tan HTA, Shelat VG. Comparison of indocyanine green dye fluorescent 
cholangiography with intra-operative cholangiography in laparoscopic cholecystectomy: a 
meta-analysis. Surg Endosc 2021;35(4):1511-20.
13.
Dip F, LoMenzo E, Sarotto L, Phillips E, Todeschini H, Nahmod M, et al. Randomized Trial of 
Near-infrared Incisionless Fluorescent Cholangiography. Ann Surg 2019;270(6):992-9.
14.
Dip F, Lo Menzo E, White KP, Rosenthal RJ. Does near-infrared fluorescent cholangiography 
with indocyanine green reduce bile duct injuries and conversions to open surgery during 
laparoscopic or robotic cholecystectomy? - A meta-analysis. Surgery 2021;169(4):859-67.
15.
van den Bos J, Wieringa FP, Bouvy ND, Stassen LPS. Optimizing the image of fluorescence 
cholangiography using ICG: a systematic review and ex vivo experiments. Surg Endosc 
2018;32(12):4820-32.
16.
Verbeek FPR, Schaafsma BE, Tummers QRJG, van der Vorst JR, van der Made WJ, Baeten 
CIM, et al. Optimization of near-infrared fluorescence cholangiography for open and 
laparoscopic surgery. Surg Endosc 2014;28(4):1076-82.


Page3437
DOTIG STUDY. Version 2.0 of 16 December 2022
17.
Widjaja SP, Fischer H, Brunner AR, Honigmann P, Metzger J. Acceptance of Ambulatory 
Laparoscopic Cholecystectomy in Central Switzerland. World J Surg 2017;41(11):2731-4.
18.
Agnus V, Pesce A, Boni L, Van Den Bos J, Morales-Conde S, Paganini AM, et al. Fluorescence-
based cholangiography: preliminary results from the IHU-IRCAD-EAES EURO-FIGS registry. 
Surg Endosc 2020;34(9):3888-96.
19.
Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal 
with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 
2004;240(2):205-13.
20.
Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 
2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J 
Hepatobiliary Pancreat Sci 2018 J;25(1):41-54.


Page3537
DOTIG STUDY. Version 2.0 of 16 December 2022
ANNEXES
Annex 1: Classifications
Classification of postoperative complications (Clavien-Dindo classification)(19):
-
Grade I. Any deviation from the normal postoperative course not 
requiring pharmacological, endoscopic, radiological or surgical treatment. 
The following are allowed: antiemetics, antipyretics, analgesics, diuretics, 
electrolytes and physiotherapy. Includes drainage of the surgical wound 
infection on the hospital ward.
-
Grade II. Use of other medication not included in Grade I (blood 
transfusion or parenteral nutrition).
-
Grade III. Complications requiring surgical, radiological or endoscopic 
intervention:
▪
Grade IIIA. Interventions without general anaesthesia.
▪
Grade IIIB. Interventions under general anaesthesia.
-
Grade IV. Severe complications requiring admission to the Intensive Care 
Unit.
▪
Grade IVA. Organ failure, including dialysis.
▪
Grade IVB. Multi-organ failure.
-
Grade V. Death of the patient.
LVB classification (Strasberg)(5):
-
Type A. Injury from small hepatic ducts draining from the hepatic bed or 
cystic duct.
-
Type B. Aberrant right hepatic duct obstruction.
-
Type C. Transverse section, without ligation of the aberrant right hepatic 
duct.
-
Type D. Lateral lesion of the main bile duct.
-
Type E. Lesions of the main hepatic duct.
-
E1. Lesion more than 2 cm from the confluence of the hepatic ducts.
-
E2 Lesion less than 2 cm from the confluence of the hepatic ducts.
-
E3. Hilar lesion with preservation of the confluence of the hepatic ducts.
-
E4. Destruction of the biliary confluence.
-
E5. Aberrant right hepatic duct lesion.


Page3637
DOTIG STUDY. Version 2.0 of 16 December 2022
Grade of severity of acute cholecystitis (Tokyo Guidelines 2018)(20):
-
Grade I (mild). Acute cholecystitis in a healthy patient, without organ 
dysfunction, only mild inflammatory changes in the gallbladder.
-
Grade II (moderate). Acute cholecystitis accompanied by the following 
conditions:
▪
Leukocytosis >18,000 mm3.
▪
Palpable mass in the right upper quadrant of the abdomen.
▪
Duration of the picture of more than 72 hours.
▪
Marked local inflammation (biliary peritonitis, perivesicular 
abscess, liver abscess, gangrenous cholecystitis, emphysematous 
cholecystitis).
-
Grade III (severe). Cholecystitis associated with dysfunction of the 
following organs or systems:
▪
Cardiovascular dysfunction (hypotension requiring treatment 
with dopamine >5 ug/kg/min or any dose of dobutamine).
▪
Neurological dysfunction (decreased level of consciousness).
▪
Respiratory dysfunction (PaO2/FiO2 <300).
▪
Renal dysfunction (oliguria, creatinine >2 mg/dl).
▪
Liver dysfunction (PT-INR >1.5).
▪
Haematological dysfunction (platelets <100,000/mm3).


Page3737
DOTIG STUDY. Version 2.0 of 16 December 2022
Annex 2: Documentation upon delivery of the Protocol:
1.
Essential documents and other documents provided
1.1.
Researcher's file revised and complete in all its sections
1.2.
Place for the maintenance of the Researcher's Archive. Detail
1.3.
The submission of the Researcher's File assumes that all documentation is complete. 
Highlight, if appropriate, specially submitted or annotated documents. Examples:
1.3.1.
Contract(s) and agreement of the centre's management
1.3.2.
Authorisation by the competent health authority, e.g. AEMPS.
1.3.3.
Favourable opinion of the ECIC
2.
Essential documents and other collected documents (if applicable)
2.1.
Signing of the visit log (with the Investigation Team and/or Pharmacy as appropriate)
2.2.
Signed CVs of researchers, collaborators and pharmacy personnel
2.3.
Laboratory ranges
2.4.
Laboratory and equipment certificates. Accreditations
2.5.
Signed Declaration of Conflict of Interest forms (if applicable) /"".
Financial Disclosure".
2.6.
Signed receipt of delivery of Researcher's File and other trial material
2.7.
Signed receipt of delivery of medication
2.8.
Page for registering signatures, functions and delegation of tasks
2.9.
Training record (if applicable) specific to the project - on GCP, visit attendance, 
procedures for completing CRD, etc.
Annex 3 (attached separately): Patient Information Sheet - Informed Consent.
Annex 4 (attached separately): AAG Notification Form. Annex 5 
(attached separately): Pregnancy Notification Form.

SAP_001.pdf: 
DOTIG CLINICAL TRIAL (NCT05419947) 
STATISTICAL ANALYSIS 
 
 
 
  
 
1. Working hypothesis. There are diﬀerences in the visualisaƟon rates of 
extrahepaƟc biliary structures as a funcƟon of drug dose and Ɵme of 
administraƟon.  
 
To test the hypothesis, we created four intervenƟon groups combining two doses (ﬁxed 
dose of 2.5 mg and weight-adjusted dose raƟo of 0.05 mg/kg body weight) and two 
administraƟon Ɵmes (15-30 minutes preoperaƟvely and >3 hours preoperaƟvely). The 
primary endpoints are dichotomous and polytomous qualitaƟve variables.  
 
 
Before analysing the main and secondary objecƟves, the groups (G1, G2, G3, G4) and 
their baseline characterisƟcs should be compared in order to demonstrate that they are 
homogeneous and the randomisaƟon has been correct. To do this, the following 
variables collected in the CRDe should be compared: 
 
 Sex (male/female) 
 Age (years) 
 BMI (kg/m2) 
 ASA classiﬁcaƟon (ASA I/II/III/IV/IV/V) 
 Previous abdominal surgeries (NO/SI). In the YES group, break down the 
variables biliary/liver/pancreas/intesƟnal/other). 
 Previous liver disease (NO/SI). In the SI group, break down the variables: 
faƩy liver disease, hepaƟƟs, liver cirrhosis.  
 Previous biliary examinaƟons (NO/SI). In the SI group, break down the 
ERCP/CTPH variables. 
 Previous biliary prostheses (NO/YES) 
 Previous acute cholecysƟƟs (NO/SI). 
 Previous acute cholangiƟs (NO/SI). 


 Previous gallbladder drainage (NO/SI). In the SI group, break down the 
variables percutaneous cholecystostomy/endoscopic cholecystostomy.  
 IndicaƟon 
for 
surgery 
(biliary 
colic/acute 
cholecysƟƟs/choledocholithiasis/acute 
cholangiƟs/acute 
lithiasic 
pancreaƟƟs/bladder polyps/bladder adenomyomatosis).  
 Type of surgery (elecƟve/early/deferred surgery). Probably in this variable 
we do not have a very similar N, because most of them, at least in our 
centre, were elecƟve.  
 Grade of cholecysƟƟs (1/2/3). In case of early indicaƟon/delayed urgency.  
 Imaging system (Olympus/Karl-Storz/Stryker) 
 Type of opƟcs (30 degrees/ 0 degrees).  
 
 
2. Main objective. To analyse whether there are differences between different 
doses (single dose and weight-adjusted dose) and different VI administration 
intervals in the visualisation rates of extrahepatic biliary structures.  
 
Carry out a comparaƟve analysis between the diﬀerent groups (G1/G2/G3/G4) and the 
following qualitaƟve variables: 
 
- Identification of biliary structures prior to dissection of the hepatocystic triangle.  
o Identification of cystic duct (yes/no). 
o Identification of common bile duct (Y/N). 
o Identification of the junction of the cystic duct with the common bile duct 
(Y/N).  
o Identification of the junction of the cystic duct with the gall bladder (Y/N). 
o Identification of the common hepatic duct (Y/N). 
o Identification of anatomical variables (yes/no).  
- Identification of biliary structures after dissection of the hepatocystic triangle.  
o Identification of cystic duct (yes/no). 
o Identification of common bile duct (Y/N). 
o Identification of the junction of the cystic duct with the common bile duct 
(Y/N).  
o Identification of the junction of the cystic duct with the gall bladder (yes/no).  
o Identification of the common hepatic duct (Y/N). 
o Identification of anatomical variables (yes/no.).  
 


 
Degree of identification of biliary structures prior to dissection of the 
hepatocystic triangle 
1=slightly 
2=suﬃcient 
3=quite a lot 
4=good 
5=excellent  
 
Degree of identification of biliary structures after dissection of the hepatocystic 
triangle: 
1=slightly 
2=suﬃcient 
3=quite a lot 
4=good 
5=excellent  
 
 Extent to which ﬂuorescence cholangiography was perceived to be useful for 
surgery 
 
Not useful 
Moderately useful 
Very useful  
 
Extent to which the fluorescence of the liver background (contrast between liver 
and ducts) was perceived as disturbing.  
0=absence of disturbance 
1=slightly disturbed 
2=disturbed visualisaƟon, but cysƟc-choledochal juncƟon was clearly 
visible before dissecƟon 
3= visualisaƟon disturbed and the cysƟc-choledochal juncƟon was visible 
only aŌer dissecƟon 
4= very disturbed: it was impossible to visualise the biliary structures 
correctly.  
 
3. Secondary objectives.  
 
In these secondary objectives, we tried to analyse predictors of the quality of the 
fluorescence technique. To this end, we have found numerous factors in the literature 
that could influence cholangiography. We want to show whether there are differences 
between the factors listed below and the different working groups.  
 


a) To analyse the influence of body mass index on FC outcomes during CL. 
In this section, we could recode the qualitative variable BMI into the different BMI 
subgroups defined by the World Health Organisation or use normal weight/overweight 
as the cut-off point.  
 
We could also analyse it as a quantitative variable and see if there is a correlation 
between them.  
b) To analyse the influence of the type of biliary pathology requiring surgery and 
previous liver disease on the results of FC during LC.  
Analyse whether there are diﬀerences between "Previous liver disease (NO/SI). In the SI 
group, break down the variables: faƩy liver disease, hepaƟƟs, liver cirrhosis". And the 
main variables shown.  
c) To analyse the influence of the type of surgery (elective/early/ delayed surgery) 
on the results of FC during LC.  
To analyse whether there are differences between the variables "type of surgery" and 
"indication for surgery".  
d) To analyse the influence of previous gallbladder or bile duct instrumentation on 
the results of FC during LC.  
To analyse whether there are differences between the variables "previous biliary 
explorations", "previous biliary prostheses" and "previous gallbladder drainage". Both 
separately and united in a single variable.  
e) To analyse the influence of different laparoscopic imaging systems on the results 
of FC during LC.  


To analyse whether there are differences between the variable "image system" and the 
main target variables.  
f) To analyse the rate of intraoperative complications related to CF during LC. 
To analyse intraoperative complication rates in the series.  
g) To analyse the rate of postoperative complications related to CF during LC.  
To analyse the postoperative complication rate for the series overall and for each type 
of Clavien-Dindo classification (consecutive variable).  
Also to analyse separately the rate of bile duct injury and the characteristics of bile duct 
injuries (consecutive variables).  
Analyse in-hospital and 30-day mortality rates.  
h) To analyse the impact of FC during LC on general surgeons and/or surgeons 
specialised in hepatobiliopancreatic pathology and their subjective assessment 
of the procedure.  
To analyse this secondary objecƟve, we should analyse globally the primary variable 
detailed above "Extent to which ﬂuorescence cholangiography was perceived to be 
useful for surgery". We should also analyse it individually in each group.  
 
i) Analyse the rate and characterisƟcs of late adverse reacƟons and AEs (separate 
Excel).  
j) To analyse the rate of anatomical variables (for this purpose we only analysed 
the variables (idenƟﬁcaƟon of biliary anatomical variables prior to dissecƟon 
and the variable idenƟﬁcaƟon of biliary anatomical variables aŌer dissecƟon) 
globally.  
k) To analyse the inﬂuence of the technique on surgical Ɵme. To do so, we 
analysed the median complete surgical Ɵme (variable surgical Ɵme).  
 
 
Note: in the study protocol we have put "Finally, all the statistical information obtained 
about the relevance of each variable in the study could be used to apply classification 
tools to the individuals in the study (decision trees, logistic regression, ROC curves)". I 
think this is a very interesting aspect but I need to talk about it and I need you to explain 
this section to me