Main text
Biliary fistulas (BFs) after hepatectomy are a challenging complication
and are occasionally accompanied by serious conditions such as liver
failure or severe infection despite recent improvements in perioperative
care and surgical techniques. The bile leak test has been reported to be
efficient in detecting bile leakage during surgery1;
however, it is not valid for identifying bile leaks that do not involve
the common bile duct (e.g., Nagano Type D bile
leakage2).
In our institution, indocyanine green (ICG) (10 mg/body) is administered
intravenously to determine the hepatic resection area, and the liver is
observed with an ICG camera system (Stryker AIM1588, Kalamazoo, MI)
after the completion of hepatectomy. Since intravenous ICG is taken up
by the hepatocytes and then in bile, this property can be used to
identify the bile ducts. In the section plane after hepatectomy, bile
leakage could be observed more clearly, compared to naked-eye
observation, as an ICG-fluorescence contamination of the gauze (Fig. 1,
Supplementary video 1). This allows for the appropriate treatment of
intraoperative subclinical bile leakage, thus preventing BF. Further,
the method seems useful for the detection of Nagano Type D bile
leakage2, which cannot be detected via conventional
bile leak tests.