(1705) Indocyanine Green for Detection of a Bile Leak in a Critically Ill Patient

Introduction: Indocyanine green (ICG) is commonly used for intra-operative assessment of biliary anatomy and bile leaks during cholecystectomy, partial hepatectomy, and even segmental liver transplant. ICG has been approved for use by the FDA since 1959 with a favorable side-effect profile and low cost of administration. We describe a novel ICU bedside use of ICG to diagnose a persistent bile leak in the presence of a post-surgical drain.

Description: Our patient is a 49-year-old male with a history of decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic hydrothorax, and encephalopathy who underwent planned orthotopic liver transplantation. His procedure was staged due to hemodynamic instability and coagulopathy: he underwent initial vascular anastomoses with external biliary drainage and temporary closure, followed by planned re-exploration, biliary anastomosis, and fascial closure. On post-operative day 10, after improvement from an episode of severe respiratory decompensation and hypotension, he developed bilious output from his surgical drain, prompting endoscopic cholangiography (ERCP) with stent placement to control a common bile duct anastomotic leak. His surgical drain remained bilious and highly suspicious for an ongoing leak, but his critical condition precluded repeat ERCP. We administered 12.5mg ICG IV, and 12h later visually evaluated the collected drain output with hand-held fluorescence imaging technology. This revealed fluorescence of the sample confirming ongoing biliary leak after stent placement. The patient subsequently underwent operative conversion to a Roux-en-Y hepaticojejunostomy. No other biliary complications were noted in his post-operative course.

Discussion: Here we provide a case presentation of ICU beside use of ICG to confirm clinical suspicion for a persistent biliary leak in a patient who was not clinically stable enough for ERCP. Bedside ICG administration may help critical care physicians in the identification of bile leak in complex patients who may be too ill for invasive imaging but would benefit from confirmation of diagnosis prior to potential operative therapy.