Liver metastases through a glass less darkly

Here is my latest highlight from the journal HPB December issue.

Achieving R0 resection margins is the best way to cure colorectal liver metastases but patterns of recurrence within the liver suggest that some lesions are missed by pre-operative imaging or intraoperative ultrasound (IOUSS). Peloso and colleagues in this edition of HPB, describe a pilot study using the autofluorescent qualities of indocyanine green (ICG) to increase the sensitivity of intraoperative detection of occult liver metastases. They took a cohort of 25 patients who had undergone pre-operative CT and administered a bolus of ICG the day before liver resection. At laparotomy, they used a near infrared camera to look for ICG-related fluorescence and detected a number of occult metastases that were not seen on either pre-operative CT or IOUSS. This study is interesting as it reports an improvement of detection in lesions that might currently be missed. There are a number of limitations not least that CT was the comparative mode of cross-sectional imaging used in this study whereas many centres use magnetic resonance imaging and fluorodeoxyglucose positron emission tomography as a routine part of the pre-operative work up for colorectal metastases. New imaging innovations must be compared with current gold standards to gain credibility. ICG is excreted by hepatocytes through the biliary system and can accumulate in the gall bladder and bile ducts. It would be interesting to know whether this creates a strong signal around the gall bladder which might potentially mask metastases in this area. ICG has potential as an adjunct to intraoperative imaging in liver surgery and it will be interesting to see how this story unfolds.Slide1

Combined use of intraoperative ultrasound and indocyanine green fluorescence imaging to detect liver metastases from colorectal cancer (pages 928–934)

Andrea Peloso, Eloisa Franchi, Maria C. Canepa, Letizia Barbieri, Laura Briani, Jacopo Ferrario, Carolina Bianco, Pietro Quaretti, Silvia Brugnatelli, Paolo Dionigi and Marcello Maestri HPB December 2013

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