Fluorescence Cholangiography for Extrahepatic Bile Duct Visualization in Urgent Mild and Moderate Acute Cholecystitis Patients Undergoing Laparoscopic Cholecystectomy: A Prospective Pilot Study

<b>Background:</b> Laparoscopic cholecystectomy for acute cholecystitis carries an increased risk of biliovascular injuries. Fluorescence cholangiography (FC) is a valuable diagnostic tool for identifying extrahepatic bile ducts (EHBD). The objective of this study was to evaluate the efficacy of FC in delineating EHBD anatomy, both before and after dissection, based on the critical view of safety (CVS) principles. <b>Methods:</b> Urgently admitted patients were prospectively stratified into two groups, depending on whether they had mild or moderate acute cholecystitis, in accordance with the 2018 Tokyo guidelines. All patients were scheduled for an early laparoscopic cholecystectomy using FC and were administered a fixed dose of indocyanine green (ICG) intravenously 12 h prior to the surgical procedure. <b>Results:</b> A total of 108 patients-75 patients with mild acute cholecystitis and 33 patients with moderate acute cholecystitis-were included. More than four CVS steps were performed in 101 patients (93.5%). Less than four CVS steps were performed only in seven patients-three (2.5%) patients with mild acute cholecystitis and four (4%) patients with moderate acute cholecystitis. The achievement of the CVS principles and the visualization rate using FC significantly increased in both patient groups, ranging from 3% before CVS to 100% after CVS (<i>p</i> < 0.001). In both groups, the cystic duct was visualized in most patients after CVS and FC, followed by the common bile duct and the common hepatic duct. Conversely, even after using CVS and FC, the visualization of the confluence of the cystic and common hepatic ducts remained less likely and challenging in both groups (57.3% in mild patients vs. 33.3% in moderate patients; <i>p</i> = 0.022). Background liver fluorescence disturbance was observed equally in both patient groups (6-11%), but it did not reach statistical significance. The median operative time was 60 ± 25 min in patients with mild acute cholecystitis compared to 85 ± 37 min in patients suffering from moderate acute cholecystitis (<i>p</i> < 0.001). No postoperative complications or biliovascular injuries were observed. <b>Conclusions:</b> FC is a convenient, safe, and efficacious procedure for attaining CVS principles and identifying the EHBD anatomy in most patients. The procedure showed superior results in mild acute cholecystitis patients in comparison to moderate acute cholecystitis patients.