Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Summary

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Abstract

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

Introduction

Acute pancreatitis (AP) is one of the most common digestive diseases and brings enormous medical and economic burden to patients. About 20% of AP patients develop severe acute pancreatitis (SAP) that gets complicated with infected necrosis or persistent organ dysfunction¹. SAP is usually associated with higher morbidity rate and mortality rate (up to 30%)¹. In SAP patients with infected necrosis having persistent organ dysfunction or failure to recover after percutaneous drainage (PCD), or suffering from gastrointestinal or biliary obstruction, operative debridement should be considered

Protocol

Study protocol was approved by the ethics committee of the First Affiliated Hospital of Sun Yat-sen University and the study was conducted in accordance with the Helsinki Declaration. Written informed consents were obtained from patients.

1. Inclusion-exclusion criteria

1. Include adult acute pancreatitis patients with evidence of infected necrosis that required an indication for invasive intervention.
   NOTE: Acute pancreatitis is defined when at least two of the three following features are observed in patients 1) typical upper abdominal pain, 2) level of serum amylase or lipase above three times the upper l....

Results

ICG-guided VARD had been successfully performed in three severe acute necrotizing pancreatitis patients from June 2021. Characteristics of these patients at baseline and after VARD are included in Table 1. The first patient who received ICG-guided VARD was a male, 41-year-old patient who was admitted on 20th June 2021. He suffered from moderately acute necrotizing pancreatitis. Abdominal contrast enhanced CT scan revealed (as shown in Figure 1 and Table 1) t.......

Discussion

The present study reveals that ICG-guided real-time intraoperative near-infrared fluorescence imaging may provide benefit to perfusion assessment and visualization of adjacent normal tissues during debridement in VARD.

In the minimally invasive era, the step-up approach consisting of PCD or endoscopic transmural drainage followed by endoscopic necrosectomy or surgical debridement, such as VARD, has been regarded as standard treatment of severe acute necrotizing pancreatitis patients

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
The 4K Ultra HD Fluorescence Endoscopic Navigation System	Guangdong OptoMedic Technologies Inc	OPTO-CAM214K	fluorescence laparoscopy
indocyanine green	DanDong YiChuang Pharmaceutical CO., LTD	H20055881	indocyanine green injection for fluorescence imaging