Research ArticlePortal uptake function in veno-occlusive regions evaluated by real-time fluorescent imaging using indocyanine green
Introduction
It is well known that hepatic venous outflow obstruction can cause decreased sinusoidal perfusion, sinusoidal congestion, and hepatocellular apotosis, leading to hepatic dysfunction in conditions such as veno-occlusive disease, Budd-Chiari syndrome, and congestive hepatopathy associated with cardiac diseases [1]. In surgical settings, venous occlusion in the remnant liver after resection or in the graft in partial liver transplantation can make portal veins function as a drainage vessel [2], resulting in necrosis [3], or insufficient regeneration [4] of such veno-occlusive regions, which can cause severe difficulty in postoperative management [5], [6]. In order to prevent postoperative hepatic dysfunction in veno-occlusive regions, stumps of the major hepatic vein tributaries are sometimes reconstructed during liver resection [7] and living donor liver transplantation [8], [9]. In particular, recent advances in imaging studies based on preoperative three-dimensional computed tomography (CT) have enabled accurate estimation of regional liver volumes with postoperative venous occlusion [10], [11], [12]. However, liver function in such veno-occlusive hepatic regions has been a “black box”. No matter how accurately we can estimate the liver volumes with venous occlusion, such information cannot be fully utilized for deciding the surgical indications and the need/lack of it for venous reconstruction, which requires clarification of the extent of functional decrease in the veno-occlusive regions.
In a previous study, Hashimoto et al. evaluated the extent of decrease in sinusoidal perfusion in veno-occlusive regions in the remnant liver after graft procurement, by estimating the intrahepatic concentrations of indocyanine green (ICG) by near-infrared spectroscopy [13]. Although they reported that the median value of the ratio of the hepatic ICG uptake constant in the veno-occlusive regions to that in the non-veno-occlusive regions was approximately 0.5, it ranged widely from 0.1 to 0.9, probably because of the large inter- and intra-individual variability in the degree of venous occlusion, which could not be revealed by fixed-point observation with the thin probe tip of spectroscopy. Recently, the fluorescent imaging technique utilizing ICG as the fluorescent source has been developed and applied to hepatobiliary surgery for intraoperative visualization of bile ducts [14], [15], [16], liver cancers [17], [18], and hepatic segments to be resected [19], [20]. In the present study, we evaluated the regional differences in the portal uptake function in the remnant livers or transplanted liver grafts by directly converting the fluorescence intensity (FI) values to estimated concentrations of ICG using a fluorescent imaging system, which enabled real-time visualization of the distribution of ICG to the entire liver surface.
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Patients and methods
This study was conducted with the approval of the Institutional Ethics Review Board of Tokyo University and registered in the UMIN-CTR (UMIN000003656, https://center.umin.ac.jp/ctr/index.htm). Informed consent was obtained from all the patients.
Preoperative estimation of the regional LV with and without venous occlusion
Results of preoperative estimation of the regional LV are summarized in Table 1. The ratio of LVVO to RLV (or the graft volume in recipients) was significantly higher in the donors who underwent surgery for procurement of a left liver graft than in those who underwent surgery for procurement of a right liver graft (29.0 [15.8–34.0]% vs. 2.7 [1.5–24.3]%, p = 0.0013); it was also higher in the right liver graft than in the left liver graft (27.5 [10.8–61.4]% vs. 7.6 [2.6–18.7]%, p = 0.0006).
Discussion
Our results suggested that the portal uptake function in veno-occlusive regions is usually 30–40% of that in the non-veno-occlusive regions, in terms of both the hepatic uptake rate constant and the plateau concentration of ICG, which represent the efficacy of portal uptake function in the early phase and distribution of portal substance to hepatocytes in the equilibrium phase after ICG injection, respectively. In the exceptional patients with large communications among hepatic vein
Financial support
This work was supported by Grants from the Takeda Science Foundation, the Kanae Foundation for the Promotion of Medical Science, and the Ministry of Education, Culture, Sports, Science and Technology of Japan (No. 23689060).
Conflict of interest
The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.
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