Enhanced endoscopic papilla visualization for ERCP under endoscenic green, proof-of-concept in a preclinical model. These are our disclosures. The learning curve in ERCP is long and advanced cannulation techniques are difficult to master. Novel advances in biliary surgery include the use of endoscenic green and has proven a better visualization of biliary anatomy to prevent adverse events. ICG infrared technology has been applied in flexible endoscopy but it is not integrated in duodenoscopes. We present the images of the duodenal papilla under the administration of human-validated dose of ICG in a porcine model to enhance its visualization. We perform a cooperative approach for proof-of-concept for the potential use of ICG on complex ERCPs, especially in papillas with challenging anatomy and to facilitate advanced cannulation techniques. One hour before the procedure, a dose of 0.05 mg per kg of ICG was administered intravenously for fluorescence guidance. Under general anesthesia, in a 31 kg secondary male pig, we perform a procedure laparotomy to insert the infrared laparoscope into the duodenum and duodenoscopy to keep air in sufflation and position. At the beginning of the procedure, we injected 0.5 mg of escopolamine to avoid excessive peristalsis. A reference card ICG was placed near the region of interest to compute the normalized fluorescence afterward. Then, a complete scan of the extrapathic piliary tract was performed from the gallbladder following the common bile duct until the entrance to the duodenum. We endoscopically located the papilla and guided the enterotomy to introduce a near-infrared laparoscope in a comfortable position, 4 cm away from the area of interest, to finally have a rendezvous. While insufflation was maintained by the colonoscope, the papilla was inserted into the duodenum. We noticed that the distance between the area of interest and the infrared light intensity can improve its visualization. While insufflation was maintained by the colonoscope, the papilla was stabilized in position and then exposed to near-infrared light. We noticed that the distance between the area of interest and the infrared light intensity can improve its visualization. A cannulation of the bile duct was attempted with the frontal view colonoscope without success. Thus, we continued the access with a needle-knife pre-cut and confirmed the access through direct palpation of the guide wire inside the bile duct by hand. Finally, we complete the sphincterotomy with the duodenum open to facilitate the registration of the direction of the sphincterotome wire and the aspiration of the bile through endoscopic instrument under the near-infrared light. Conclusions. Enhanced endoscopic visualization of the papilla and the biliary tract under ICG is feasible in the animal model. Human-validated dosage of IV ICG is safe and effective previous and during the procedure in preclinical settings. ICG infrared technology could potentially improve cannulation rates in ERCP, especially in cases where advanced techniques are required and lower the learning curve.

ICG infrared technology

ERCP procedures

advanced cannulation

biliary tract visualization

human-validated dose