Efficacy of Intraoperative vs Preoperative Indocyanine Green Administration for Near-Infrared Cholangiography During Laparoscopic Cholecystectomy: An Open-Label, Non-Inferiority, Randomized Controlled Trial

BACKGROUND: Near-infrared fluorescence cholangiography (NIRFC) improves the clinical effects of laparoscopic cholecystectomy. However, the administration of indocyanine green (ICG) remains controversial. Both the intraoperative (IS, 0.05mg) and preoperative (PS, 0.25mg/kg body weight, 1 day before operation) strategies have been shown to be superior to standard strategy (2.5mg, intraoperative). This trial was designed to determine whether IS offers non-inferior visualization of biliary ducts compared to PS. STUDY DESIGN: A total of 168 eligible patients undergoing laparoscopic cholecystectomy were enrolled in this non-inferiority, open-label, randomized controlled trial at Zhujiang hospital between August 2023 and November 2023. Participants were randomized in a 1:1 ratio into PS and IS groups after stratification by BMI and inflammation level. The fluorescence visualization of biliary structures was assessed by comparing the signal-to-background ratio (SBR) and surgeon evaluations. RESULTS: The common bile duct-liver SBR did not significantly differ between IS and PS groups (3.0±0.8 vs 3.1±1.2; p =0.636). The liver fluorescence intensity (FI) of the IS group was significantly lower than that of the PS group (46.3±12.9 vs 70.4±26.2; p <0.01). The visualization score of common hepatic ducts was significantly greater in the IS than in the PS group (4.1±0.7 vs 3.7±0.6; p ＜0.01). The critical view of safety (CVS) was achieved more rapidly in the IS group compared to the PS group (9.4 vs 11.0 minutes, p <0.01). CONCLUSION: While IS did not improve the SBR, it significantly reduced the FI of the liver background, potentially enhancing the surgeon’s subjective perception and thereby increasing the visualization score. Compared to PS, IS offers greater convenience and is more effective in facilitating CVS exposure.