Evaluation of cholecystic venous flow using indocyanine green fluorescence angiography.
OBJECTIVE
The cholecystic veins are thought to be an important metastatic route of gallbladder carcinoma to the liver. In the present study we evaluated the cholecystic venous drainage area, utilizing a novel method, indocyanine green (ICG) fluorescence angiography after superselective catheterization of the cholecystic artery, to detect and elucidate cholecystic venous flow.


METHODS
Cannulation of the cholecystic artery was performed under laparotomy in nine patients who required a cholecystectomy. After ICG injection into the cholecystic artery, the cholecystic venous flow images were visualized with a near-infrared camera system and were analyzed according to site, shape, and time of fluorescence.


RESULTS
Fluorescence images of the cholecystic venous flow could be viewed as real-time images in all patients. We demonstrated that the route of the cholecystic venous flow could be classified into two patterns: type 1, in which the cholecystic veins flowed directly into the hepatic parenchyma adjacent to the gallbladder; and type 2, in which the veins flowed into sites separate from the gallbladder. In the type 1 pattern, fluorescence was observed in segment (S; defined according to Couinaud's nomenclature) 4a or S5 adjacent to the gallbladder in all cases. On the other hand, in the type-2 pattern, fluorescence was observed in S4a (6/9), S5 (8/9), S4b (2/9), S3 (2/9), S1 (1/9), S2 (1/9), and S8 (1/9) distant from the gallbladder. Overall, two-thirds of the cases showed fluorescence in segments other than S4a or S5.


CONCLUSIONS
Indocyanine green (ICG) fluorescence angiography is considered to be a useful method to detect and elucidate cholecystic venous flow in real time. This study showed that the cholecystic venous flow spread to the liver through two different pathways, one that flowed directly into the hepatic parenchyma adjacent to the gallbladder, while the other flowed into sites separate from the gallbladder. Taking these findings into consideration, we may therefore need to reconsider the preventive effects of a hepatic resection.
Department of Surgery, Japanese Red Cross Society Himeji Hospital, 1-12-1 Shimoteno, Himeji, Hyogo 670-8540, Japan. kai@hrc-hp.com
Kyohei
K
Kai
Shizou
S
Satoh
Takanori
T
Watanabe
Yoshikatsu
Y
Endo
D002763:Cholecystectomy / Q000379:methods; D004396:Coloring Agents; D003937:Diagnosis, Differential; D005260:Female; D005451:Fluorescein Angiography / Q000379:methods*; D005704:Gallbladder / Q000098:blood supply*; D005706:Gallbladder Neoplasms / Q000098:blood supply / Q000175:diagnosis* / Q000601:surgery; D006499:Hepatic Artery / Q000473:pathology / Q000503:physiopathology; D006503:Hepatic Veins / Q000473:pathology / Q000503:physiopathology; D006801:Humans; D007208:Indocyanine Green; D007813:Laparotomy; D008297:Male; D012039:Regional Blood Flow / Q000502:physiology*
D004396:Coloring Agents; D007208:Indocyanine Green