The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis

Abstract

Purpose: Indocyanine green fluorescence angiography (ICG-FA) is a validated non-invasive imaging technique used to assess tissue vascularization and guide intraoperative decisions in many surgical fields including plastic surgery, neurosurgery, and general surgery. While this technology is well-established in adult surgery, it remains sparsely used in pediatric surgery. Our aim was to systematically review and provide an overview of all available evidence on the perioperative use of indocyanine green fluorescence angiography in pediatric surgical patients.Methods: We conducted a systematic review with narrative synthesis in conformity with the PRISMA guidelines using PubMed, Medline, All EBM Reviews, EMBASE, PsycINFO, and CINAHL COMPLETE databases to identify articles describing the perioperative use of ICG-FA in pediatric patients. Two independent authors screened all included articles for eligibility and inclusion criteria. We extracted data on study design, demographics, surgical indications, indocyanine green dose, and perioperative outcomes. We developed a risk of bias assessment tool to evaluate the methodological quality of included studies.Results: Of 1,031 articles retrieved, a total of 64 articles published between 2003 and 2020 were included reporting on 664 pediatric patients. Most articles were case reports and case series (n = 36; 56%). No adverse events related to ICG-FA were reported in the included articles. Risk of bias was high. We did not conduct a meta-analysis given the heterogeneous nature of the populations, interventions, and outcome measures. A narrative synthesis is presented.Conclusion: Indocyanine green fluorescence angiography is a safe imaging technology and its use is increasing rapidly in pediatric surgical specialties. However, the quality of evidence supporting this trend currently appears low. Case-control and randomized trials are needed to determine the adequate pediatric dose and to confirm the potential benefits of ICG-FA in pediatric surgical patients.Systematic Review Registration: This study was registered on Prospero a priori, identifier: CRD42020151981.

A surgical first: Application of indocyanine green fluorescence imaging for endoscopic third ventriculostomy in an infant

“…1 The application of indocyanine green for pediatric applications has been proven so far to be safe and being without adverse side effects. 2 This could be shown also for pediatric neurosurgical indications such as surgery of the brainstem in children. 3 So far, the use of indocyanine green uorescence imaging in pediatric neurosurgical applications has been limited to tumor surgery and to surgery of vascular malformations such as aneurysm only.…”

Endoscopic‐Indocyanine Green Angiography Assisted Microtia Reconstruction

“…ICG is a validated non‐invasive imaging technique utilized to assess tissue vascularization and guide intraoperative decisions. A systematic review of ICG use across multiple surgical specialties showed a lack of any adverse events in pediatric patients 4 . In endoscopic TPFF harvest for microtia reconstruction, the addition of ICG angiography allows the surgeon to clearly visualize key vascular elements upon which the entire ear reconstruction relies upon.…”

Indocyanine green fluorescence imaging as an adjunct for the localization of a bile leak after split liver transplantation

“…While ICG has been commonly utilized in adult hepatobiliary surgery, it has only recently been gaining popularity in the pediatric surgical population, 9 mostly to assist in performing intraoperative cholangiography at the time of cholecystectomy or for tumor detection in pediatric oncology. ICG fluorescence imaging used specifically to detect a post‐transplant biliary leak has not previously been described, neither in the adult nor the pediatric transplant population.…”

“…4 Also, ICG injection directly through the biliary system has successfully been used to detect the presence of bile leaks after non-transplant related hepatectomy. 8 While ICG has been commonly utilized in adult hepatobiliary surgery, it has only recently been gaining popularity in the pediatric surgical population, 9…”