Indocyanine green identification of the intrapancreatic bile duct during revisional pancreatic resection for congenital hyperinsulinism: A case report

Abstract

Introduction: Subtotal pancreatectomy to treat the diffuse form of congenital hyperinsulinism (CHI) sometimes requires revisional surgery, with further pancreatic resection. In such operations, the intrapancreatic bile duct is at risk of injury during dissection and resection. Case presentation: A macrosomic male infant male was born following elective induction at 35 weeks’ gestation, weighing 3.6kg. His nine-year-old sibling had a history of diazoxide-unresponsive diffuse CHI requiring near-total pancreatectomy at six weeks of age (one-week corrected age). That sibling had biallelic recessive (compound heterozygote) pathogenic ABCC8 variants c.[2041–21G > A]; [3130_3149del]. The same pathogenic variant was identified in utero in this infant, who was also unresponsive to diazoxide. A laparoscopic subtotal pancreatectomy was performed at six weeks of age (one-week corrected age), with a resection margin to the right side of the superior mesenteric/splenic veins and portal vein confluence. The uncinate process was also resected. Histological assessment confirmed diffuse disease. The patient had persisting hypoglycaemia refractory to maximal medical therapies, necessitating a further resection. Due to concerns regarding the exact course of the intrapancreatic bile duct, ICG was injected into the gall bladder at the commencement of the second dissection. This clearly demonstrated the intrapancreatic bile duct during dissection, becoming visible through the overlying pancreatic tissue during re-dissection. Damage to this duct was avoided by its early identification. Conclusion: Intracholecystic injection of indocyanine green may be used to aid identification of, and decrease the risk of intra-operative damage to, the bile duct during pancreatic surgery.

Keywords

• Congenital hyperinsulinism
• Indocyanine green
• Subtotal pancreatectomy
• Case report