Comparative effectiveness of nasobiliary versus intravenous indocyanine green fluorescence guidance for early laparoscopic cholecystectomy after ERCP: a retrospective cohort study

Abstract This study aimed to evaluate whether direct ICG administration through a pre-existing indwelling nasobiliary drain (NBD-ICG) was associated with improved biliary visualization and surgical efficiency compared with IV-ICG and white-light (WL) laparoscopy. This single-center retrospective cohort study included 181 patients undergoing early LC 2–3 days after ERCP, all with an indwelling NBD placed as part of routine post-ERCP care (November 2023–February 2026). Patients received NBD-ICG ( n = 47), IV-ICG ( n = 53), or white-light laparoscopy (WL, n = 81). Propensity score matching (caliper 0.03) yielded 21, 30, and 45 patients, respectively. The primary outcome was biliary visualization quality, assessed by fluorescence contrast and identification of the common hepatic, cystic, and common bile ducts. Three blinded surgeons independently evaluated subjective image quality, with inter-rater agreement assessed using Fleiss’ kappa. Secondary outcomes included operative time, Calot’s triangle dissection time, blood loss, and postoperative recovery. All patients underwent laparoscopic cholecystectomy without conversion. After propensity score matching, baseline characteristics were well balanced among the three groups. Compared with IV-ICG, NBD-ICG was associated with higher fluorescence contrast ( P = 0.009) and a higher rate of successful biliary visualization (85.71% vs. 60.00%, P = 0.047). Identification rates of the common hepatic, cystic, and common bile ducts were also higher with NBD-ICG (all P < 0.05). Operative time and Calot’s triangle dissection time were shorter with NBD-ICG than with both IV-ICG and WL (all pairwise P < 0.05). Postoperative recovery and complications were comparable among the groups (all P > 0.05). For early LC after ERCP, NBD-ICG was associated with improved biliary fluorescence visualization compared with IV-ICG and shorter operative and Calot’s triangle dissection times compared with both IV-ICG and white-light laparoscopy. In patients with an NBD already in place as part of routine post-ERCP care, this approach may provide a practical strategy for fluorescence-guided biliary navigation without requiring additional invasive access.