The role of fluorescent cholangiography to improve operative safety in different severity degrees of acute cholecystitis during emergency laparoscopic cholecystectomy: a prospective cohort study

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BACKGROUND: Currently, there is limited scientific evidence regarding the effectiveness of fluorescent cholangiography in emergency cholecystectomy for acute cholecystitis. The primary aim of this study was to assess the efficacy of near-infrared fluorescent cholangiography (NIRF-C) in different severity degrees of acute cholecystitis. MATERIALS AND METHODS: Inclusion criteria were patients with a clinical and radiological (abdominal ultrasound and/or computed tomography) diagnosis of acute cholecystitis based on the revised 2018 Tokyo guidelines who underwent laparoscopic cholecystectomy within 24-72 h from the onset of symptoms and patients with ASA score of 0-3. NIRF-C was performed at three-time points during laparoscopic cholecystectomy: (i) following exposure of Calot's triangle, prior to any dissection; (ii) after partial dissection of Calot's triangle; and (iii) after complete dissection of Calot's triangle. The intraoperative severity degree of acute cholecystitis was assessed according to the American Association of Surgery for Trauma (AAST) classification. RESULTS: NIRF-C was successfully performed in all 81 consecutive patients who underwent emergency laparoscopic cholecystectomy. The cystic duct was identified by NIRF-C in 46 (56.8%) and 77 (95.1%) of the 81 patients before and after Calot's dissection, respectively. The common hepatic duct and common bile duct were successfully identified in 11 (13.6%) and 32 patients (39.5%) before Calot's dissection, respectively, and in 45 (55.6%) and 76 patients (93.8%) after complete Calot's dissection, respectively. When comparing the visualization rate of biliary structures before and after Calot dissection in different severity degrees of cholecystitis, the authors found a statistically significant difference in nongangrenous (AAST I) versus gangrenous and complicated forms (AAST II-V) for all biliary structures, both before and after Calot's dissection. CONCLUSIONS: The study indicates that the use of fluorescence cholangiography during emergency laparoscopic cholecystectomy for acute cholecystitis may represent a valuable and useful tool for intraoperative visualization of the extrahepatic biliary tract.