Intraoperative indocyanine green clearance in liver surgery: a useful tool to promote parenchymal preservation?

A 66-year-old woman was diagnosed with sigmoid carcinoma with bilobar unresectable liver metastases. Primary tumor resection was performed. Neoadjuvant chemotherapy was administered to downstage liver disease. Following FOLFOX/panitumumab (4 cycles), disease progression was observed within the liver. Therefore, chemotherapy regimen was switched to FOLFIRI/cetuximab (12 cycles). At restaging, 7 out of 10 metastases showed complete radiologic response and 3 showed disease progression. Selective internal radiation therapy (SIRT) with Yttrium-90 was performed on these 3 metastases with very good local radiologic response. Surgical resection with curative intent was attempted.  ICG was administered 72 hours before surgery to help localization of liver metastases. Intraoperatively, very poor ICG clearance was demonstrated and therefore parenchyma-sparing resections were performed (segment II, III, IV and VII). At final histology, major pathologic response was observed with steatosis of the liver parenchyma. Postoperative course was uneventful and adjuvant capecitabine was administered (8 cycles). No recurrence was demonstrated at 38 months follow-up. However, eighteen months following surgery, she developed impairment of hepatic function and portal hypertension. Conclusion: Preoperative ICG administration could be helpful to intraoperatively detect patients that can develop late post hepatectomy impairment of hepatic function, especially following SIRT2 (REF2), and promote parenchymal preservation.