Fluorescence in Liver surgery

Pr Eric Vibert, MD, PhD

Centre Hépato-Biliaire,

Hop. Paul Brousse, Villejuif

Disclosures

• Fees from Bayer, BMS, Johnson&Johnson

• Consultant for Nanobiotix and MID

• Academic collaboration with EchoSens, Fluoptics and IntraSense

Liver Surgery

Must be feasible Must be useful

Liver Surgery & Transplantation are the only curatives treatments of

liver cancer

If the patient stays alive after surgery….

Surgical Margins are Crucial

Feasibility of Liver Surgery ?

MELD < 10

MELD < 12

Independant predictivefactor of mortality

Cuccheti et al. Liver Transpl 2006Farges et al. Ann Surg 2012 Bruix et al. Gastroenterology 1996

When I plan a treatment to MisterDurand, I think to Mister Dupond…Who will be more beneficiated ofliver transplantation relatively toresection ?

Risk and Interest of oncologic hepatectomy ?

VS

The location of HCC is determinant…

LiverSP by SIGHT

Liver Surgery

Must continue to improve

Impact of laparoscopic liver resection in patients with cirrhosison post-operative liver failure : A Propensity Score Analysis

M. Prodeau, S. Truant, E. Vibert, O. Farges, J.Y. Mabrut,

J. Hardwigsen, J.M. Régimbeau, G. Millet, O. Soubrane,

R. Adam, D. Cherqui, F.R. Pruvot, E. Boleslawski

The ACHBT French Hepatectomy Study Group

Oct 2012 – June 20166 French HPB Centers

343 Hepatectomies in F3/F4 89 pts by Lap (26%)

Incidence of Post-Operative Liver Failure

Matched-LAP Matched-OPEN

Age (years) 65.3 65.3

BMI (kg/m²) 26.9 26.9

MELD 8.6 8.5

Platelets (x 1000/mm3) 167 167

ICG (15 min) 15.2 % 15.0 %

HVPG (mmHg) 7.9 8.1

LS (kPa) 21.8 21.9

RLV (%) 88.6 87.6

16% in LAP and 32% in OPEN

OR 0.31 [0.12-0.78]; p<0.001

Fluorescent Guided Liver Surgery

Ishizawa. Cancer 2009 Ishizawa. Surg Endos 2016Ishizawa. Ann Surg Onc 2010

FluoBeam ® FluoSoft™

Collaboration with Centre Hepato-Biliaire and Fluoptic CompanyProvision of Open Device (Fluobeam™) - No financial interest

• Indocyanine Green Dye (ICG) – Intravenous injection

• Passive hepatocytes captation and active biliary secretion

• Decrease of the ICG secretion Decrease of liver function

100%

40%

30%

iFLOW (ANR Tecsan) (2014-2017)

Coordination : Eric Vibert, Hop. Paul Brousse

Computer modelisation of hemodynamic, histological and fonctional events after major hepatectomy in pig to optimize of mecanical portal flow modulation

Indocyanine green processing by the liver

Time in s

Indocyanine green pharmaco-kinetic model

Predict intra-operatively the risk of post-operative liver failureaims to modified liver hemodynamics using mechanical portal flow modulation (Bucur et al… Vibert, Ann Surg 2017)

Audebert et al… Vignon-Clementel, J Biomech 2017 Bucur et al… Vibert, Ann Surg 2017

26 patients (20 HCC – 6 Colorectal LM) : intraoperative exploration with ICG cam

Only to detect subcapsular lesion / No clear data on clinical rentability

Cancer 2009

HCC : Fluorescent spot CRLM : Fluorescent ring

HCC : No functional

hepatocytes

170 patients operated by laparotomy for HCC who had received ICG (0.5 mg/kg) at least 48 hours before liver surgery

Intraop. detection of 21 new spots in 19 patients 14 HCC (8.2%) and 7 False-Positive

Low specificity in severe cirrhosis

With the courtesy of T. Ishizawa and M. Terasawa

Intraoperative Pathological Data

Macroscopic Scale and,in a very next future, atMicroscopic scale…

Conclusions

• Fluorescent guided liver surgery could improved

Certainly, the diagnosis of superficial liver cancer

Probably, the liver graft evaluation at the end of LT

Perhaps, post-operative courses by decreasing the risk of post-operative liver failure

For more questions…eric.vibert.pbr@gmail.fr

Golse, Cottin, Vibert et al.

Pessaux et al.

From virtual to real…

Open or Lap