Innovative ICG Application in Benign Gynaecological Surgery: Enhancing Safety and Precision.

In the context of increased adoption of minimally invasive surgery for benign gynaecological conditions, this study underscores the paramount importance of patient safety. We explored the efficacy of indocyanine green (ICG), a fluorescent dye, in enhancing the visualisation of critical anatomical structures during complex laparoscopic procedures. Our methods involved the direct administration of ICG into the ureters for precise identification and dissection, as well as an innovative vaginal application to delineate the rectovaginal plane in cases with distorted pelvic anatomy. The study presented two cases: a laparoscopic hysterectomy for a multifibroid uterus and a case of advanced endometriosis with rectal involvement. Results indicated that ICG use significantly improved real-time visualisation of the ureters and the rectovaginal plane, which facilitated the surgeries and reduced the cognitive load on surgeons. There were no intraoperative complications, and the postoperative phase showed positive patient outcomes. In conclusion, the application of ICG in these laparoscopic surgeries proved to be a beneficial adjunct, suggesting its potential for broader application in benign gynaecological surgeries. Future research is warranted to explore additional uses of ICG, with a focus on enhancing patient safety and surgical efficacy.

Coadministration of Quercetin and Indocyanine Green via PEGylated Phospholipid Micelles for Augmented Chem-Photothermal Combination Tumor Therapy.

A significant impediment persists in developing multicomponent nanomedicines designed to dismantle the heat shock protein (HSP)-based protective mechanism of malignant tumors during photothermal therapy. Herein, well-defined PEGylated phospholipid micelles were utilized to coencapsulate quercetin (QUE, a natural anticancer agent and potent HSP inhibitor) and indocyanine green (ICG, a photothermal agent) with the aim of achieving synchronized and synergistic drug effects. The subsequent investigations validated that the tailored micellar system effectively enhanced QUE's water solubility and augmented its cellular internalization efficiency. Intriguingly, the compositional PEGylated phospholipids induced extraordinary endoplasmic reticulum stress, thereby sensitizing the tumor cells to QUE. Furthermore, QUE played a crucial role in inhibiting the stress-induced overexpression of HSP70, thereby augmenting the photothermal efficacy of ICG. In systemic applications, the proposed nanotherapeutics exhibited preferential accumulation within tumors and exerted notable tumoricidal effects against 4T1 xenograft tumors under 808 nm near-infrared irradiation, facilitated by prominent near-infrared fluorescence imaging-guided chemo-photothermal therapy. Therefore, our strategy for fabricating multicomponent nanomedicines emerges as a coordinated platform for optimizing antitumor therapeutic efficacy and offers valuable insights for diverse therapeutic modalities.

Intraoperative angiography with indocyanine green, an aid in the diagnosis and treatment of obscure digestive tract bleeding, a case report.

Lower digestive tract bleeding occurs distal to the angle of Treitz. While many cases remit spontaneously; some pose a diagnostic challenge for surgeons. We present the case of a 68-year-old man with unexplained digestive tract bleeding. Despite various diagnostic efforts, the source remained unknown. Faced with the challenge of persistent bleeding and hemodynamic instability, surgery became necessary. During the procedure, intraoperative angiography with indocyanine green was used to facilitate the identification of the bleeding site, revealing a gastrointestinal stromal tumor in the small bowel. Resection was performed with favorable outcomes. Indocyanine green staining has become popular for locating intestinal bleeding during emergency surgeries, aiding surgeons in making precise decisions.

Indocyanine green uptake by human tumor and non­tumor cell lines and tissue.

Indocyanine green (ICG) is a potential promising dye for a better intraoperative tumor border definition and an improved patient outcome by potentially improving tumor border visualization compared with traditional white light guided surgery. Here, the cellular uptake of ICG in human squamous cell carcinoma (SCC026) and immortalized non-cancer skin (HaCaT) cell lines was evaluated to study the tumor-specific cellular uptake of ICG. The spatial distribution of ICG inside tumor tissue was investigated in tissue sections of head and neck squamous cell carcinoma at a microscopic level. ICG uptake and internalization was observed in living cells after 2.5 h and in the nucleus after 24 h. In dead cells, higher and faster uptake was observed. In the tissue sections, higher ICG signal intensity could be detected in connective tissue and surrounding clusters and blood vessels. In conclusion, no distinct ICG uptake by tumor cells was detected in cancer cell lines and tumor tissue. ICG localization in certain regions of tumor tissue appears to be a result of enhanced tissue permeability and retention, but not specific to tumor cells.

Robot-assisted Surgery for Gastrointestinal Cancer Using Indocyanine Green Conjugated Endoscopic Marking Clip Under Firefly Fluorescence Imaging.

BACKGROUND/AIM: Intraoperative identification of the cancer location is often difficult during robot-assisted surgery, especially in early stage cancers. This study aimed to investigate the feasibility and accuracy of a novel endoscopic clip emitting near-infrared (NIR) fluorescence during robot-assisted surgery for gastrointestinal cancer. PATIENTS AND METHODS: Preoperative placement of endoscopic marking clips equipped with NIR fluorescent resin was performed to determine the resection margins in six patients with gastrointestinal cancer. During robot-assisted surgery, a NIR fluorescence imaging system was used to detect the fluorescence. The evaluation examined whether fluorescence from the clips was visualized during robot-assisted surgery. RESULTS: The NIR fluorescent signals emitted from the clips were successfully detected in all six patients from the serosal surfaces, resulting in the quick and accurate identification of the resection line. There were no significant differences in age, sex, or body mass index between the patients in whom we could detect NIR fluorescence. CONCLUSION: This novel NIR fluorescent clip is a promising diagnostic tool for accurately detecting tumor locations during robot-assisted surgery for gastrointestinal cancer.

Genetic alteration of SLCO1B3 defines constitutional indocyanine green excretory defect in patients who underwent hepatectomy.

AIM: Constitutional indocyanine green (ICG) excretory defects must be distinguished when assessing liver function. The absence of OATP1B3 expression due to homogenous alterations in the SLCO1B3 gene has been recently reported to induce ICG excretory defects; however, its association with the clinical examinations and the clinical implications of heterogeneous SLCO1B3 gene alteration remain unclear. METHODS: OATP1B3 expression was evaluated in 49 patients who underwent hepatectomy after evaluation of the ICG retention rate at 15 min (ICGR15) and technetium-99 m-galactosyl serum albumin (99mTc-GSA) hepatic scintigraphy. Additionally, alterations in SLCO1B3 were analyzed in patients without OATP1B3 expression. Subsequently, 59 patients who underwent hepatectomy for colorectal liver metastasis (CRLM) were analyzed. RESULTS: Of 49 patients, 6 (12%) had absent OATP1B3 expression. They had significantly higher ICGR15 value (74.7% vs. 23.5%; p < 0.0001), better modified albumin-bilirubin (ALBI) grade (≤grade 2A, 100% vs. 42%; p = 0.010), more normal 99mTc-GSA hepatic scintigraphy (100% vs. 28%; p = 0.0003), and better pathological liver fibrosis (F0-1, 100% vs. 49%; p = 0.027) compared to those with OATP1B3 expression. Three available frozen blocks of cases without OATP1B3 expression showed homozygous alterations in SLCO1B3. Of 59 patients with CRLM in normal liver background, five (8.5%) had heterozygous insertion in SLCO1B3, however they had no difference in ICGR15 values or other clinical findings compared to the other patients. CONCLUSIONS: Constitutional ICG excretory defects may be defined by the complete absence of OATP1B3 expression. The modified ALBI grade and 99mTc-GSA hepatic scintigraphy were useful for detecting constitutional ICG excretory defects.

Indocyanine Green and Hepatobiliary Surgery: An Overview of the Current Literature.

Indocyanine green (ICG) is an inert polypeptide that almost totally binds to high molecular weight plasma proteins; it is cleared by the hepatocytes and directly excreted into the bile with a half-life of about 3-5 minutes. Specific systems are required to see fluorescent images. The use of this dye has been reported in different surgical specialties, and the applications in hepatobiliary surgery are widening. Being firstly used to evaluate the preoperative liver function, intra- and postoperative dynamic checking of hepatic activity has been reported and integrated within perioperative protocols allowing a tailored treatment allocation. Intravenous injection (IV) or injection into the gallbladder can ease difficult cholecystectomy. Biliary leakage detection could be enhanced by IV ICG injection. Although with some contrasting results, the use of ICG for both delineating the limits of the resection and tumor-enhanced visualization was demonstrated to improve short- and long-term outcomes. Although the lack of strong evidence still precludes the introduction of this tool in clinical practice, it harbors great potential in liver surgery.

Clinical Consensus Statement on the Use of Indocyanine Green Fluorescence-guided Surgery in Pediatric Patients.

BACKGROUND AND AIMS: Indocyanine Green Fluorescence (ICG-F)- guided surgery is becoming an increasingly helpful tool in pediatric surgical care. This consensus statement investigates the utility of ICG-F in various pediatric surgical applications, primarily focusing on its evidence base, safety, indications, use across different surgical specialties and dosing strategies. The aim is to establish an international consensus for ICG-F use in pediatric surgery. METHODS: An international panel of 15 pediatric surgeons from 9 countries was assembled. The structured process consisted of a rapid scoping review, iterative discussion sessions, mixed-methods studies with key stakeholders, and voting rounds on individual statements to create draft consensus statements. RESULTS: 100 articles were identified during the review and summarized by application. Based on this condensed evidence, consensus statements were generated after 3 iterative rounds of anonymous voting. Key areas of agreement were quality of evidence, the safety of ICG, pediatric surgical indications, utilization per surgical specialty, and dosing of ICG. CONCLUSION: This consensus statement aims to guide healthcare professionals in managing ICG-F use in pediatric surgical cases based on the best available evidence, key stakeholder consultation, and expert opinions. Despite ICG-F's promising potential, the need for higher-quality evidence, prospective trials, and safety studies is underscored. The consensus also provides a framework for pediatric surgeons to utilize ICG-F effectively. LEVEL OF EVIDENCE: III.

Validation of a semi-quantitative scoring system and workflow for analysis of fluorescence quantification in companion animals.

Significance: Many commercially available near-infrared (NIR) fluorescence imaging systems lack algorithms for real-time quantifiable fluorescence data. Creation of a workflow for clinical assessment and post hoc analysis may provide clinical researchers with a method for intraoperative fluorescence quantification to improve objective outcome measures. Aim: Scoring systems and verified image analysis are employed to determine the amount and intensity of fluorescence within surgical specimens both intra and postoperatively. Approach: Lymph nodes from canine cancer patients were obtained during lymph node extirpation following peritumoral injection of indocyanine green (ICG). First, a semi-quantitative assessment of surface fluorescence was evaluated. Images obtained with a NIR exoscope were analysed to determine fluorescence thresholds and measure fluorescence amount and intensity. Results: Post hoc fluorescence quantification (threshold of Hue = 165-180, Intensity = 30-255) displayed strong agreement with semi-quantitative scoring (k = 0.9734, p < 0.0001). Fluorescence intensity with either threshold of 35-255 or 45-255 were significant predictors of fluorescence and had high sensitivity and specificity (p < 0.05). Fluorescence intensity and quantification had a strong association (p < 0.001). Conclusion: The validation of the semi-quantitative scoring system by image analysis provides a method for objective in situ observation of tissue fluorescence. The utilization of thresholding for ICG fluorescence intensity allows post hoc quantification of fluorescence when not built into the imaging system.

Use of indocyanine green dye for sentinel lymph node mapping in patients with endometrial cancer and a history of iodinated contrast allergy.

Objectives: Sentinel lymph node (SLN) mapping is a surgical technique with high accuracy in detecting metastases while limiting morbidity associated with full lymphadenectomy in endometrial cancer. Cervical injection of indocyanine green (ICG) dye is associated with very high SLN detection rates; however, iodinated contrast allergy has traditionally been viewed as a contraindication to ICG use. The objective of this study was to describe the use of ICG in a population of patients with iodinated contrast allergies undergoing surgical staging for endometrial cancer. Methods: IRB approval was obtained. All patients with clinically early-stage endometrial cancer who underwent minimally invasive surgical staging with SLN mapping with ICG at a single academic institution from 1/1/2017 to 12/31/2020 were identified retrospectively. Patients with reported iodinated contrast allergies prior to surgery were identified. Data were collected through electronic medical record review and compared using descriptive statistics. Results: 820 patients who underwent minimally invasive surgical staging with SLN mapping with ICG were identified, and 25 had documented iodinated contrast allergies. Documented reactions included rash/hives (n = 10, 40 %), anaphylaxis (n = 6, 24 %), shortness of breath (n = 5, 20 %), diarrhea (n = 1, 4 %), and not specified (n = 3, 12 %). A majority (24/25, 96 %) received 4 mg intravenous dexamethasone during induction of general anesthesia as per the institutional enhanced recovery after surgery (ERAS) protocol. No patients experienced allergic reactions or other adverse events after ICG injection. Conclusions: No patients in this cohort demonstrated an adverse reaction after ICG injection for SLN mapping. This study supports the reasonable safety of ICG in patients with contrast allergies, particularly when routine ERAS protocols containing dexamethasone are utilized.

Pay attention to the application of indocyanine green fluorescence imaging technology in laparoscopic liver cancer resection.

Traditional laparoscopic liver cancer resection faces challenges, such as difficulties in tumor localization and accurate marking of liver segments, as well as the inability to provide real-time intraoperative navigation. This approach falls short of meeting the demands for precise and anatomical liver resection. The introduction of fluorescence imaging technology, particularly indocyanine green, has demonstrated significant advantages in visualizing bile ducts, tumor localization, segment staining, microscopic lesion display, margin examination, and lymph node visualization. This technology addresses the inherent limitations of traditional laparoscopy, which lacks direct tactile feedback, and is increasingly becoming the standard in laparoscopic procedures. Guided by fluorescence imaging technology, laparoscopic liver cancer resection is poised to become the predominant technique for liver tumor removal, enhancing the accuracy, safety and efficiency of the procedure.

[Indocyanine green is an integral part of breast reconstructive surgery using perforator flaps]. / Indotsianin zelenyi ­ neot"emlemaya chast' rekonstruktivnoi khirurgii molochnoi zhelezy s ispol'zovaniem perforantnykh loskutov.

INTRODUCTION: The use of allotransplants for breast reconstruction in surgical stage of the the breast cancer treatment requires tissue perfusion control. The aim of the study was to analyze the effectiveness of using indocyanine green as a drug for determining the perfusion of perforant flaps in breast reconstructive surgery. MATERIAL AND METHODS: A retrospective series of observations of 27 breast reconstructions using autologous transplants is presented: 19 reconstructions with DIEP-flap, 2 with SIEA-flap, 5 with TD-flap; 1 with thoracoepigastric flap. Intraoperative fluorescence angiography was performed using a Stryker device (5900 Optical Court, USA). The intensity of the flap fluorescence was recorded after intravenous bolus injection of 7.5 mg indocyanine green. RESULTS AND DISCUSSION: The optimal time interval from the moment of drug administration to indicative visualization of flap perfusion was 55-60 seconds. In all patients, the area of insufficient blood flow was excised within intensively blood-supplied tissues, according to mapping data with the indocyanine green. With free transplant of flaps postoperative complications during follow-up were recorded in 1 (4.8%) case (marginal necrosis), which is associated with insufficient compression of auxiliary vessels (violation of the dominant vessel contrast technique). With non-free transplant of flaps no complications were detected in the postoperative period. CONCLUSIONS: Indocyanine green allows to prevent necrotic changes and reduce the rehabilitation period. The optimal time for the indicative visualization of flap perfusion was 55-60 seconds. The use of indocyanine green in free transplant of flaps ensured a postoperative period without complications in 20 (95.2%) cases, in non-free flap transplantation - in 6 (100%) cases.

[Experience of indocyanine green use in acute calculous cholecystitis]. / Opyt primeneniya indotsianina zelenogo pri ostrom kal'kuleznom kholetsistite.

OBJECTIVE: To assess the safety and effectiveness of the indocyanine green use in acute cholecystitis for identification of anatomical variants of the biliary tree; prevention and timely detection of intraoperative complications. MATERIAL AND METHODS: The medication of indocyanine green made by OOO «Ferment¼ domestic manufacturer was used. The drug dose from 2.5 mg to 10 mg was applied according to studied materials (8). Time of the surgery beginning was from 2 to 6 hours after intravenous injection of aqueous solution, respectively. In addition, it has been established that the optimal drug dose is 5 mg. The surgery should be performed not earlier than 3 hours after, but no later than 6 hours. This allows to achieve the most comfortable fluorescence of the extrahepatic biliary tract. The drug concentration in the liver cells decreases by this time and increases in the biliary tract. It is not always possible to perform the operation strictly within the specified time limit considering the urgency of the surgical intervention. In this connection, the surgery was carried out not earlier than 3 hours after the drug injection, but not later than 6 hours. Endoscopic equipment with the ability to display near-infrared fluorescence was used. A laser light source with a wavelength of 820 nm in the Arthrex imaging system with 4K resolution as well as the Olympus imaging system with HD resolution were used for fluorescence excitation. RESULTS: The implementation of intraoperative fluorescent navigation with indocyanine green contributes to the improvement of safety and effectiveness of surgical treatment through visualization of topography and identification of anatomical variants of the biliary tree; possibilities of prevention and timely detection of intraoperative complications. The use of indocyanine green allows to intraoperatively reveal atypical location and different variations of the extrahepatic biliary tract.

How to increase the success rate in microsurgical free and pedicled flap reconstructions with intraoperative multistep ICG imaging: A case series with 400 consecutive cases.

BACKGROUND: Over the last decade, microsurgical soft-tissue transfer became the gold standard for various reconstructions throughout the body. Continuous improvement of instruments and surgical techniques, such as intraoperative indocyanine green angiography (ICG-A), allowed for a very high success rate. This study aimed to assess and validate the role of a standard intraoperative ICG-A in free and pedicled flap surgery to improve overall outcomes. PATIENTS AND METHODS: From April 2018 to April 2023, 400 consecutive patients who underwent reconstruction using free and pedicled flaps were enrolled. ICG-A was always performed in a free flap after flap elevation, after microsurgical anastomosis, immediately after the flap inset, and after wound closure. In the pedicled flap, the sequential procedure was performed after flap elevation, flap inset, and wound closure. RESULTS: All 400 patients who underwent flap reconstruction using intraoperative ICG-A had an extremely low incidence of necrosis (0.75% partial necrosis among free and pedicled flaps) and reoperation for perfusion-related complications (0.75% due to acute ischemia and 0.50% due to flap congestion). Minor complications, such as hematoma, seroma, wound dehiscence, and wound infections, were managed with a second operation. No flaps were lost, and all patients were successfully treated. CONCLUSIONS: This study showed how systematic multistep ICG-A for intraoperative assessment of free and pedicled flap perfusion can significantly reduce the complication rate, including flap loss and re-exploration surgeries, in a time- and cost-effective manner.

Effect of oxygen generating nanozymes on indocyanine green and IR 820 mediated phototherapy against oral cancer.

The hypoxic environment within a solid tumor is a limitation to the effectiveness of photodynamic therapy. Here, we demonstrate the use of oxygen generating nanozymes (CeO2, Fe3O4, and MnO2) to improve the photodynamic effect. The optimized combination of process parameters for irradiation was obtained using the Box Behnken experimental design. Indocyanine green, IR 820, and their different combinations with oxygen generators were studied for their effect on oral carcinoma. Dynamic light scattering technique showed the average particle size of CeO2, MnO2, and Fe3O4 to be 211 ± 16, and 157 ± 28, 143 ± 19 nm with PDI of 0.23, 0.28 and 0.20 and a zeta potential of -2.6 ± 0.45, -2.4 ± 0.60 and  -6.1 ± 0.23 mV, respectively. The formation of metal oxides was confirmed using UV-visible, FTIR, and X-ray photon spectroscopies. The amount of dissolved oxygen produced by CeO2, MnO2, and Fe3O4 in the presence of H2O2 within 2 min was 1.7 ± 0.15, 1.7 ± 0.16, and 1.4 ± 0.12 mg/l, respectively. Growth inhibition studies in the FaDu oral carcinoma spheroid model showed a significant (P < 0.05) increase in growth reduction from 81 ± 2.9 and 88 ± 2.1% to 97 ± 1.2 and 99 ± 1.0% for ICG and IR 820, respectively, after irradiation (808 nm laser, 1 W/cm2, 5 min) in the presence of CeO2 (25 µg/ml). In conclusion, oxygen-generating nanozymes can improve the photodynamic effect of ICG and IR 820.

Indocyanine green angiography reveals choroidal hypoperfusion in subacute sclerosing panencephalitis (SSPE).

We report the choroidal findings on indocyanine green angiography (ICGA) in two cases of subacute sclerosing panencephalitis (SSPE). The two immunocompetent patients (31-year-old and 30-year-old Asian Indian males) presented with acute-onset rapidly progressing vision loss with findings of necrotizing retinitis involving the central macula. Both patients tested negative for serological evidence of herpes or varicella, and toxoplasma antibodies. The patients demonstrated high serum and cerebrospinal fluid titers of anti-measles antibody (and abnormal electroencephalogram in one patient) leading to the diagnosis of SSPE. ICGA of both patients revealed distinct "dark dots" which showed hypofluorescence in the early and late phases suggestive of choroidal involvement/hypoperfusion. Choroidal involvement in SSPE has not been evaluated before and must be considered in the pathological manifestations of the disease.

Assessing superficial temporal artery-middle cerebral artery anastomosis patency using FLOW 800 hemodynamics.

OBJECTIVE: The objective of this study was to investigate the use of indocyanine green videoangiography with FLOW 800 hemodynamic parameters intraoperatively during superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery to predict patency prior to anastomosis performance. METHODS: A retrospective and exploratory data analysis was conducted using FLOW 800 software prior to anastomosis to assess four regions of interest (ROIs; proximal and distal recipients and adjacent and remote gyri) for four hemodynamic parameters (speed, delay, rise time, and time to peak). Medical records were used to classify patients into flow and no-flow groups based on immediate or perioperative anastomosis patency. Hemodynamic parameters were compared using univariate and multivariate analyses. Principal component analysis was used to identify high risk of no flow (HRnf) and low risk of no flow (LRnf) groups, correlated with prospective angiographic follow-ups. Machine learning models were fitted to predict patency using FLOW 800 features, and the a posteriori effect of complication risk of those features was computed. RESULTS: A total of 39 cases underwent STA-MCA bypass surgery with complete FLOW 800 data collection. Thirty-five cases demonstrated flow after anastomosis revascularization and were compared with 4 cases with no flow after revascularization. Proximal and distal recipient speeds were significantly different between the no-flow and flow groups (proximal: 238.3 ± 120.8 and 138.5 ± 93.6, respectively [p < 0.001]; distal: 241.0 ± 117.0 and 142.1 ± 103.8, respectively [p < 0.05]). Based on principal component analysis, the HRnf group (n = 10) was characterized by high-flow speed (> 75th percentile) in all ROIs, whereas the LRnf group (n = 10) had contrasting patterns. In prospective long-term follow-up, 6 of 9 cases in the HRnf group, including the original no-flow cases, had no or low flow, whereas 8 of 8 cases in the LRnf group maintained robust flow. Machine learning models predicted patency failure with a mean F1 score of 0.930 and consistently relied on proximal recipient speed as the most important feature. Computation of posterior likelihood showed a 95.29% chance of patients having long-term patency given a lower proximal speed. CONCLUSIONS: These results suggest that a high proximal speed measured in the recipient vessel prior to anastomosis can elevate the risk of perioperative no flow and long-term reduction of flow. With an increased dataset size, continued FLOW 800-based ROI metric analysis could be used to guide intraoperative anastomosis site selection prior to anastomosis and predict patency outcome.

The application of real-time indocyanine green fluorescence cholangiography in laparoscopic living donor left lateral sectionectomy.

Background: The judgment of the division point of the bile duct has always been one of the difficulties of laparoscopic left lateral sectionectomy (LLLS). The purpose of this study was to assess the effects of indocyanine green (ICG) fluorescence cholangiography during LLLS on the occurrence of biliary complications in both donors and recipients. The optimal dose and injection time of ICG were also investigated. Methods: This is a retrospective cohort study. From October 2016 to December 2022, the clinical data of 103 donors who underwent LLLS and relevant recipients were retrospectively analyzed. According to whether ICG fluorescence cholangiography was used, they were divided into a non-ICG group (n=46) and an ICG group (n=57). Biliary complications were observed and the optimal dose and injection time of ICG were explored. Results: Three donors in the non-ICG group suffered from bile leakage. Four grafts had multiple bile duct openings and biliary complications were observed in the relevant recipients who received these grafts in the non-ICG group. Two recipients had bile leakage, and the other two had biliary stenosis. There was no biliary complications both in donors and recipients in the ICG group. The fluorescence intensity of the liver was 108.1±17.6 at a dose of 0.004 mg/kg 90 minutes after injection, significantly weaker than that at 0.05 mg/kg 30 minutes (200.3±17.6, P=0.001) and 90 minutes after injection (140.2±15.4, P=0.001). The fluorescence intensity contrast value at a dose of 0.004 mg/kg was stronger than that at 0.05 mg/kg, both measured 90 minutes after injection (0.098±0.032 vs. 0.078±0.022, P=0.021). Conclusions: ICG fluorescence cholangiography is safe and feasible in LLLS. It reduces biliary complications in both donors and recipients. The optimal ICG dose was 0.004 mg/kg, and 90 minutes after injection was the best observation time. ICG fluorescence cholangiography is recommended for routine use in LLLS.

Complete removal of a cavernous malformation in the dorsal pons, in contact with the expanded transpontine vein: illustrative case.

BACKGROUND: Craniotomy is required for the removal of brainstem cavernous malformations (CMs) with repeated hemorrhage, and this condition is often complicated by an accompanying developmental venous anomaly (DVA). However, a DVA of the brainstem or cerebellum with drainage penetrating the pons is an exceptional finding. OBSERVATIONS: A 57-year-old man presented with double vision. Computed tomography revealed progressive enlargement of the hemorrhage in the dorsal pons. Contrast-enhanced magnetic resonance angiography revealed an expanded transverse vessel penetrating the center of the pons in contact with the CM. Digital subtraction angiography revealed that the DVA, comprising the expanded transpontine vein and some cerebellar medullary veins acting as normal venous drainage, coexisted with the CM. By utilizing the angioarchitecture and intraoperative neuronavigation system data, electrophysiological mapping, and indocyanine green videoangiography, complete removal of the CM was accomplished while preserving the DVA and brain function. LESSONS: This study presents the intraoperative images of an expanded transpontine vein as a DVA, which has never been depicted in a live patient before, accompanied by a CM in the dorsal portion of the pons. https://thejns.org/doi/10.3171/CASE24314.

Blood perfusion assessment by near-infrared fluorescence angiography of epiploic appendages in prevention of anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study.

BACKGROUND: The role of intraoperative near-infrared fluorescence angiography with indocyanine green in reducing anastomotic leakage (AL) has been demonstrated in colorectal surgery, however, its perfusion assessment mode, and efficacy in reducing anastomotic leakage after laparoscopic intersphincteric resection (LsISR) need to be further elucidated. AIM: Aim was to study near-infrared fluorescent angiography to help identify bowel ischemia to reduce AL after LsISR. MATERIAL AND METHODS: A retrospective case-matched study was conducted in one referral center. A total of 556 consecutive patients with ultra-low rectal cancer including 140 patients with fluorescence angiography of epiploic appendages (FAEA)were enrolled. Perfusion assessment by FAEA in the monochrome fluorescence mode. Patients were divided into two groups based on perfusion assessment by FAEA. The primary endpoint was the AL rate within 6 months, and the secondary endpoint was the structural sequelae of anastomotic leakage (SSAL). RESULTS: After matching, the study group (n = 109) and control group (n = 190) were well-balanced. The AL rate in the FAEA group was lower before (3.6% vs. 10.1%, P = 0.026) and after matching (3.7% vs. 10.5%, P = 0.036). Propensity scores matching analysis (OR 0.275, 95% CI 0.035-0.937, P 0.039), inverse probability of treatment weighting (OR 0.814, 95% CI 0.765-0.921, P 0.002), and regression analysis (OR 0.298, 95% CI 0.112-0.790, P = 0.015), showed that FAEA was an independent protector factor for AL. This technique can significantly shorten postoperative hospital stay [9 (6-13) vs. 10 (8-13), P = 0.024] and reduce the risk of SSAL (1.4% vs. 6.0%, P = 0.029). CONCLUSIONS: Perfusion assessment by FAEA can achieve better visualization in LsISR and reduce the incidence of AL, subsequently avoiding SSAL after LsISR.