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After ligation of the targeted hepatic segmental portal vein, a novel ICG protocol is used (0.5mg ICG powder is added to 20mL normal saline containing 500mg human albumin, shaken and allowed to stand for more than 5 minutes to form a stable complex, with final concentrations of ICG 0.025mg/mL and human albumin 25mg/mL). This ICG-albumin conjugate solution is then administered intravenously at a rate of 1mL/min. The infusion is stopped when sufficient fluorescence enhancement is observed in the negative-staining liver regions.

After ligation of the targeted hepatic segmental portal vein, 2.5mg of ICG (concentration 2.5mg/mL) is administered intravenously as a bolus injection.

After ligation of the target hepatic segmental portal vein, the novel ICG regimen (0.5 mg ICG powder and 500 mg human serum albumin added to 20 ml saline, shaken and allowed to stand for more than 5 minutes, ICG: 0.025 mg/ml, human serum albumin: 25 mg/ml) was intravenously infused continuously at a rate of 1 ml/min until significant fluorescence imaging appeared in the demarcated area, upon which the infusion was terminated.

NIF image-guided laparoscopic anatomical liver resection with the novel ICG@HSA administration

After ligation of the target hepatic segmental portal vein, 2.5 mg of ICG (2.5 mg/ml) was intravenously injected.

NIF image-guided laparoscopic anatomical liver resection with the guideline-recommended ICG administration

Hong Wu, Professor

QingYun Xie, MD

Qingyun Xie, MD

This study is a single-center, prospective, randomized controlled trial that aims to compare the efficacy and safety of a new indocyanine green (ICG) administration protocol with the current guideline-recommended protocol for near-infrared (NIR) fluorescence imaging in laparoscopic anatomical hepatic resection. Primary liver cancer is a common malignancy worldwide. Laparoscopic liver resection has become increasingly popular due to its minimally invasive nature. During open and laparoscopic liver resection surgery, ICG, a fluorescent dye, is widely used to visualize liver segments and define tumor margins. However, there is a lack of high-level evidence regarding the timing and dosage of ICG administration in current protocols. In our preliminary study, we discovered a new method of pre-mixing ICG with albumin, which creates a more stable conjugate that could enhance fluorescence imaging during NIR laparoscopic hepatectomy. This study will include 100 patients with primary liver malignancies who are scheduled for laparoscopic anatomical hepatic resection. The patients will be randomly assigned in a 1:1 ratio to either the new ICG-albumin protocol (experimental group) or the standard ICG alone protocol (control group). The primary outcome will be the efficacy of fluorescence imaging, which will be evaluated using a 5-point scoring system by three independent experts. Secondary outcomes will include operation time, blood loss, tumor margin status, complications, length of stay, long-term recurrence, and survival.

The hypothesis of this study is that pre-binding ICG with albumin creates a more stabilized fluorescent complex, which could significantly improve the efficacy of fluorescence navigation and hepatectomy outcomes compared to standard ICG alone. This study aims to provide high-quality evidence on optimal protocols for ICG use in laparoscopic fluorescent image-guided liver surgery. The results of this study could help establish standardized guidelines to improve the application of this important navigation technique and enhance surgical precision and outcomes for liver cancer patients worldwide. The study protocol will be approved by the Ethics Review Board and publicly registered before enrollment starts. All participants will be required to provide informed consent. This study will be conducted in compliance with the Declaration of Helsinki and national regulations on human subject protection to ensure ethics, privacy, and safety.

1. Study Design:

   This study is designed as a single center, prospective, randomized, double-blinded, controlled trial. The participants will be randomly assigned to either the experimental group (using the new ICG-albumin protocol) or the control group (using the standard ICG protocol) at a 1:1 ratio. The randomization will be done using a centralized web-based system.
2. Participants:

   The study aims to enroll 100 patients aged 18-75 years old with primary liver malignancies who are planned for laparoscopic anatomical hepatic resection at our institution. The main inclusion criteria are a Child-Pugh grade A or B liver function and an ECOG performance score of 0-1. The main exclusion criteria include an ICG R15 value of \>=20%, coagulation disorders, severe heart/lung disease, active bleeding, allergy to ICG, severe gastroesophageal varices, and pregnancy/lactation.
3. Interventions:

   The interventions in the experimental group will involve mixing 0.5mg of ICG powder with 20mL saline containing 500mg of human albumin for at least 5 minutes. This mixture will then be intravenously infused at a rate of 1mL/min after occlusion of the target hepatic pedicles. On the other hand, the control group will receive a slow intravenous infusion of 2.5mg ICG (2.5mg/mL) following the current guidelines after pedicle occlusion.
4. Outcomes:

   The primary outcome is the efficacy of fluorescence imaging, which will be evaluated by a 5-point scoring system by three independent experts. Secondary outcomes include operation time, blood loss, conversion to open surgery, parenchymal transection time, use of hemostatic clips, tumor margins, postoperative complications, liver function recovery, length of stay, long-term recurrence and survival. Safety outcomes include complications, mortality, and adverse reactions associated with ICG.
5. Participant Timeline:

   Screening will take place within 2 weeks before surgery. Participants will be followed up during hospitalization. After discharge, follow-up will take place at month 1, 3, 6, 12, 18, 24, 30, 36 post-surgery.
6. Sample Size:

   With a two-sided 0.05 significance level, 90% power, and expecting a 1-point improvement in fluorescence imaging efficacy score (SD 1.5), 49 participants per group are needed, 100 in total.
7. Data Collection and Management:

   All data will be collected on paper case report forms and then entered into a centralized electronic data capture system. Data will go through quality check, cleaning, coding and logic validation. Any changes will be tracked. Cleaned and locked database will be used for final analysis. Original forms will be archived securely.
8. Statistical Analysis :

   Efficacy of fluorescence imaging will be compared between groups using t-test or Mann-Whitney U test. Operation parameters will be analyzed by t-test or Wilcoxon rank test. Tumor margins will be evaluated by chi-square test. Complication rates will be compared using t-test or Fisher's exact test. Survival outcomes will be depicted by Kaplan-Meier curves and compared by Log-rank tests. Multivariate Cox regression will be used to identify factors affecting recurrence and survival. Sensitivity analysis will be performed to account for missing data.
9. Data Monitoring:

   An independent data safety monitoring board will review study progress and safety data regularly. Any serious adverse events will be reported to investigators, IRB and regulatory agencies within 24 hours.
10. Ethics and Dissemination and Trial Status:

The study protocol will be approved by the IRB before initiation. All participants will provide written informed consent. Results will be disseminated through scientific conferences and peer-reviewed publications. The study is currently preparing for ethics submission and enrollment is expected to start in December 2023 and complete in November 2026.

This study utilizes a double-blind design to ensure impartiality among operators, outcome assessors, and patients. The randomization assignment is only known to the research nurse, who administers the two different ICG administration protocols during surgery based on the assigned randomization number and group allocation. To maintain blinding, an opaque curtain is placed over the anesthesia operation area on the patient's head side, preventing the surgical operator from knowing the randomization assignment. The entire process of grouping and drug delivery is observed solely by the dedicated research nurse. In order to minimize assessment bias, the evaluators and data collectors are also blinded and have no knowledge of the patient's grouping information, thus reducing the potential impact of bias on the results. The efficacy of fluorescence imaging will be evaluated and scored independently by three experts in the field of fluorescence.

Application of ICG@HSA Complexes in Fluorescence Image-Guided Laparoscopic Anatomical Liver Resection

Application of Indocyanine Green(ICG)@Human Serum Albumin(HSA) Complexes in Fluorescence Image-Guided Laparoscopic Anatomical Liver Resection: A Prospective, Double-Blinded, Randomized Controlled Trial

Post-discharge follow-up (once every 3 months) using the follow-up center function of the professional EDC data management software to record follow-up via WeChat, questionnaires, and telephone calls

The entire surgical video was recorded and then scored by experts

Based on the duration of the surgery as recorded

Based on the amount of bleeding recorded during the surgery

Based on intraoperative records to determine whether to convert to open laparotomy

Organize a dedicated person to review the surgical video and record the duration after the surgery is over

Specimen tumor margins will be measured by pathologists using calipers

Organize a dedicated person to record postoperative complications

Regularly measure liver function, coagulation, and other biochemical indicators after surgery after the patient returned to the ward

Organize a dedicated person to record the time of rectal gas passage after surgery afer he patient returned to the ward

Organize a dedicated person to record the postoperative hospital stay

Nanjing Chia-Tai Tianqing Pharmaceutical Company

West China Hospital

Clinical Professor

Symptoms and General Pathology

Carcinoma

Carcinoma, Hepatocellular

Neoplasm Micrometastasis

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Adenocarcinoma

Total laparoscopic anatomical hepatectomy were performed, combined with cholecystectomy when necessary. The intraoperative ultrasound, hepatic segmental staining were used selectively.

Total laparoscopic aon-anatomical hepatectomy were performed, combined with cholecystectomy when necessary. The intraoperative ultrasound or hepatic segmental staining will be used to ensure the tumour was completely resected.

We let the 110 patients divide into A, B groups randomly who are meet the inclusion criteria .Group A is Laparoscopic Anatomical Hepatectomy: Anatomy the corresponding liver segment pedicle and hepatectomy along the Glisson fiber sheath

Laparoscopic Anatomical Hepatectomy

We let the 110 patients divide into A, B groups randomly who are meet the inclusion criteria .Group B is Laparoscopic Aon-anatomical Hepatectomy:1 to 2 cm along the edge of the tumor complete hepatectomy

Laparoscopic Aon-anatomical Hepatectomy

Shuguo Zheng

Shuguo Zheng, Professor

shuguo Zheng, professer

The purpose of this study is to compare short-term and long-term efficacy of two surgical methods by laparoscopic hepatectomy, and provide the evidence for the choice of surgical method from the pathology and cytology.

Background:Hepatocellular carcinoma is the world's most common and most malignant tumor, accounting for more than 90% of primary liver cancer, the incidence ranked fifth of malignant tumors in the world. surgery and comprehensive treatment is recognized by the medical profession Surgical approach, including the open HCC hepatectomy and laparoscopic hepatectomy, minimally invasive surgery is the main theme of the 21st century, and laparoscopy as the one of the elements in the field of minimally invasive surgery which carried out more and more in liver surgery, but which one of the two methods to choice to hepatectomy lack of sufficient scientific evidence.The RCT research of laparoscopic anatomical and non-anatomical hepatectomy for HCC has not been reported at home and abroad; Intervention:We let the 110 patients divide into A, B groups randomly who are meet the inclusion criteria .Group A is Laparoscopic Anatomical Hepatectomy: Anatomy the corresponding liver segment pedicle and hepatectomy along the Glisson fiber sheath.Group B is Laparoscopic Aon-anatomical Hepatectomy:1 to 2 cm along the edge of the tumor complete hepatectomy

Results:

1. operation time, intraoperative blood loss, rate of blood transfusion, complications and mortality, postoperative liver function, resection margin, number of micrometastases ,long-term curative effect and survival time were collected and analysed.
2. groups t-test ，univariate/multivariate analysis, logistic regression analysis, mixed linear regression, Cox survival analysis ，Kaplan-Meier survival analysis，Log-rank survival curves were used.

Laparoscope Anatomical and Aon-anatomical Hepatectomy

The Prospective, Randomized Case-control(RCT) Research of Laparoscope Anatomical and Aon-anatomical Hepatectomy Treat HCC

follow-up after the surgery every 2 months, to understand relapse, death, statistics 1 year, 3-year and 5-year survival, disease-free survival, recurrence rate.

hepatic failure,hemorrhage,biliary leakage,ascites,intra-abdominal infection,pleural effusion,pulmonary infection,cardiac insufficiency.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Application of ICG@HSA Complexes in Fluorescence Image-Guided Laparoscopic Anatomical Liver Resection	NCT06219096	Malignant Tumor... Randomized Cont...	NIF image-guide... NIF image-guide...	18 Years - 75 Years	West China Hospital
Laparoscope Anatomical and Aon-anatomical Hepatectomy	NCT02009176	Hepatocellular ...	Laparoscopic An... Laparoscopic Ao...	18 Years - 70 Years	Southwest Hospital, China
Application of ICG@HSA Complexes in Fluorescence Image-Guided Laparoscopic Anatomical Liver Resection	NCT06219096	Malignant Tumor... Randomized Cont...	NIF image-guide... NIF image-guide...	18 Years - 75 Years	West China Hospital

Spots Global Cancer Trial Database for laparoscopic anatomical hepatectomy