The authors thank Prof. Yu Guo and Prof. Yunpeng Hua (Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University) for providing advice and careful review. This work was supported by the National Natural Science Foundation of China (81201919), the Natural Science Foundation of Guangdong Province (2017A030313495).

Study protocol was approved by the ethics committee of the First Affiliated Hospital of Sun Yat-sen University and the study was conducted in accordance with the Helsinki Declaration. Written informed consents were obtained from patients.
1. Inclusion-exclusion criteria
<ol>
	<li>Include adult acute pancreatitis patients with evidence of infected necrosis that required an indication for invasive intervention. 
	NOTE: Acute pancreatitis is defined when at least two of th...

<ol>
	<li>Trikudanathan, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+concepts+in+severe+acute+and+necrotizing+pancreatitis:+An+evidence-based+approach.">Current concepts in severe acute and necrotizing pancreatitis: An evidence-based approach.</a> Gastroenterology. 156 (7), 1994-2007 (2019).</li><li>Baron, T. H., DiMaio, C. J., Wang, A. Y., Morgan, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+Gastroenterological+Association+clinical+practice+update:+Management+of+pancreatic+necrosis.">American Gastroenterological Association clinical practice update: Management of pancreatic necrosis.</a> Gastroenterology. 158 (1), 67-75 (2020).</li><li>Raraty, M. G. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimal+access+retroperitoneal+pancreatic+necrosectomy:+improvement+in+morbidity+and+mortality+with+a+less+invasive+approach.">Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach.</a> Annals of Surgery. 251 (5), 787-793 (2010).</li><li>Dhingra, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single+or+multiport+percutaneous+endoscopic+necrosectomy+performed+with+the+patient+under+conscious+sedation+is+a+safe+and+effective+treatment+for+infected+pancreatic+necrosis+(with+video).">Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video).</a> Gastrointestinal Endoscopy. 81 (2), 351-359 (2015).</li><li>Gomatos, I. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+from+minimal+access+retroperitoneal+and+open+pancreatic+necrosectomy+in+394+patients+with+necrotizing+pancreatitis.">Outcomes from minimal access retroperitoneal and open pancreatic necrosectomy in 394 patients with necrotizing pancreatitis.</a> Annals of Surgery. 263 (5), 992-1001 (2016).</li><li>Boni, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+applications+of+indocyanine+green+(ICG)+enhanced+fluorescence+in+laparoscopic+surgery.">Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery.</a> Surgical Endoscopy. 29 (7), 2046-2055 (2015).</li><li>Nardi, P. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+angiography+with+indocyanine+green+to+assess+anastomosis+perfusion+in+patients+undergoing+laparoscopic+colorectal+resection:+results+of+a+multicenter+randomized+controlled+trial.">Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial.</a> Surgical Endoscopy. 34 (1), 53-60 (2020).</li><li>Newton, A. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+near-infrared+imaging+can+identify+neoplasms+and+aid+in+real-time+margin+assessment+during+pancreatic+resection.">Intraoperative near-infrared imaging can identify neoplasms and aid in real-time margin assessment during pancreatic resection.</a> Annals of Surgery. 270 (1), 12-20 (2019).</li><li>Cai, Y., Zheng, Z., Gao, P., Li, Y., Peng, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+duodenum-preserving+total+pancreatic+head+resection+using+real-time+indocyanine+green+fluorescence+imaging.">Laparoscopic duodenum-preserving total pancreatic head resection using real-time indocyanine green fluorescence imaging.</a> Surgical Endoscopy. 35 (3), 1355-1361 (2021).</li><li>Santvoort, H. C. v., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dutch+pancreatitis+study+group.+A+step-up+approach+or+open+necrosectomy+for+necrotizing+pancreatitis.">Dutch pancreatitis study group. A step-up approach or open necrosectomy for necrotizing pancreatitis.</a> The New England Journal of Medicine. 362 (16), 1491-1502 (2010).</li><li>Bakker, O. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dutch+Pancreatitis+Study+Group.+Endoscopic+transgastric+vs+surgical+necrosectomy+for+infected+necrotizing+pancreatitis:+a+randomized+trial.">Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial.</a> JAMA. 307 (10), 1053-1061 (2012).</li><li>Brunschot, S. v., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dutch+Pancreatitis+Study+Group.+Endoscopic+or+surgical+step-up+approach+for+infected+necrotising+pancreatitis:+a+multicentre+randomised+trial.">Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial.</a> Lancet. 391 (10115), 51-58 (2018).</li><li>Bang, J. 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The present study reveals that ICG-guided real-time intraoperative near-infrared fluorescence imaging may provide benefit to perfusion assessment and visualization of adjacent normal tissues during debridement in VARD.
In the minimally invasive era, the step-up approach consisting of PCD or endoscopic transmural drainage followed by endoscopic necrosectomy or surgical debridement, such as VARD, has been regarded as standard treatment of severe acute necrotizing pancreatitis patients<sup class=...

Acute pancreatitis (AP) is one of the most common digestive diseases and brings enormous medical and economic burden to patients. About 20% of AP patients develop severe acute pancreatitis (SAP) that gets complicated with infected necrosis or persistent organ dysfunction1. SAP is usually associated with higher morbidity rate and mortality rate (up to 30%)1. In SAP patients with infected necrosis having persistent organ dysfunction or failure to recover after percutaneous drainage (PCD), or suffering from gastrointestinal or biliary obstruction, operative debridement should be considered1,2.
In the minimally invasive era, there are multiple approaches to operative debridement beside open surgery, including endoscopic transluminal necrosectomy, laparoscopic or open transgastric debridement, and video-assisted retroperitoneal debridement (VARD), which is the part of the step-up approach1,2. VARD is the preferred approach for patients with left-sided distribution of infected necrosis extended to paracolic gutter or deep to the retroperitoneum2. As there are rarely any visually clear separating surface in white light image under laparoscopy between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is inevitably accompanied by the risk of vascular injury, external pancreatico-cutaneous, or enterocutaneous fistulae3,4,5.
Real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) has been applied to facilitate perfusion assessment of bowel6,7 and visualization of biliary and vascular anatomy8,9. In view of the above disadvantages of VARD, we apply real-time near-infrared fluorescence imaging with ICG during VARD that enables the visualization of the well-perfused adjacent normal tissues and vascular structure. This modified technique (ICG-guided VARD) can provide a clear separating surface during operative debridement and reduced risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>The 4K Ultra HD Fluorescence Endoscopic Navigation System</td>
			<td>Guangdong OptoMedic Technologies Inc</td>
			<td>OPTO-CAM214K</td>
			<td>fluorescence laparoscopy</td>
		</tr>
		<tr>
			<td>indocyanine green</td>
			<td>DanDong YiChuang Pharmaceutical CO., LTD</td>
			<td>H20055881</td>
			<td>indocyanine green injection for fluorescence imaging</td>
		</tr>
	</tbody>
</table>

indocyanine green-guided intraoperative imaging to facilitate video-assisted retroperitoneal debridement for treating acute necrotizing pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

ICG-guided VARD had been successfully performed in three severe acute necrotizing pancreatitis patients from June 2021. Characteristics of these patients at baseline and after VARD are included in Table 1. The first patient who received ICG-guided VARD was a male, 41-year-old patient who was admitted on 20th June 2021. He suffered from moderately acute necrotizing pancreatitis. Abdominal contrast enhanced CT scan revealed (as shown in Figure 1 and Table 1) t...

Watch this Scientific Journal Video about Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis at JoVE.c

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

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2.2K vistas.  Sun Yat-sen University. Este protocolo presenta el desbridamiento retroperitoneal asistido por video guiado por verde de indocianina para el tratamiento de la pancreatitis necrotizante aguda grave. El VARD guiado por ICG es un enfoque fácil y factible para visualizar los tejidos normales adyacentes bien perfundidos y la estructura vascular de los vasos mesentéricos. Comience insertando un trocar laparoscópico de 12 milímetros a lo largo del tracto dilatado hasta las colecciones necróticas retroperitoneales....

Video: Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis