LETTER TO THE EDITOR

Reply to correlation between indocyanine green retention testand esophageal varices among patients with hepatocellularcarcinoma

Shintaro Yamazaki • Tadatoshi Takayama

Received: 10 January 2014 / Accepted: 14 January 2014 / Published online: 11 February 2014

� Springer Japan 2014

To the Editor:

We would like to thank Dr. Lisotti for his interest in our

recently published article, entitled ‘‘Prophylactic impact of

endoscopic treatment for esophageal varices in liver

resection: a prospective study’’ [1].

Dr. Lisotti et al. also demonstrated a close relationship

between ICG retention rate at 15 min (ICGR15) and the

degree of portal hypertension. In their study, they further

analyzed the correlation between the ICGR15 and the

presence of esophageal varices. They defined the cut-off

value for esophageal varices (presence or absence) by

means of receiver operating characteristic curve analysis.

They advocated that ICGR15 was a good predictor of the

presence of esophageal varices. We have used the ICGR15

value to assess liver functional reserve and to assist in

decision making for liver resection [2]. We, therefore,

agree with their opinion that ICGR15 provides useful

information on liver function.

Dr. Lisotti et al. studied 96 consecutive patients with liver

cirrhosis who had Child-Pugh A liver function, but not

hepatocellular carcinoma. They calculated that an ICGR15 of

\10 % predicts the absence of esophageal varices, whereas

a value of C22.9 % predicts the presence of esophageal

varices. Although the mean ICGR15 in their study was

20.0 % (±SD 13.8), it is quite similar to the value in our

study group. In our study, the median ICGR15 value was

10.9 % (range 2.1–37.7 %) in patients without esophageal

varices and 15.4 % (3.7–46.0 %) in patients with esophageal

varices. These data support their opinion that there are two

(rule in and rule out) cut-off values of ICGR15.

Next, discrepancies between ICG values and laboratory

data are sometimes encountered clinically. The platelet

count, serum bilirubin level, and prothrombin international

normalized ratio are also reliable indices of liver function.

The ICGR15 is known to reflect not only liver cirrhosis, but

also the presence of external shunt of the liver, the presence

of varices, poor/rich blood flow in the liver parenchyma,

and high serum bilirubin levels. These factors strongly

correlate with the discrepancies between ICG values and

laboratory data. The use of 99mTc-GSA scintigraphic

analysis with a kinetic model permits the quantitative

measurement of receptor amount and hepatic blood flow

without blood samples [3]. Moreover, approximate

ICGR15 values can be calculated with this method. In our

institution, we have performed 99mTc-GSA scintigraphy

in patients with discrepancies between ICG values and

laboratory data to avoid overestimation and underestima-

tion of liver function.

As for the difference between Dr. Lisotti’s and our

study, the principal aim of our study was to identify

patients at high risk for postoperative ruptures of esopha-

geal varices. The predictive ICGR15 value for worsening

of esophageal varices after liver resection was[30 %. We

demonstrated that the ICGR15 can be used to predict

patients who have esophageal varices, as well as to identify

patients who require postoperative follow-up endoscopy.

The ICGR15 is one of the reliable indices of liver

function. Preoperative screening for esophageal varices is

indispensable, and the ICGR15 is one of the predictive

markers for esophageal varices. We, therefore, concluded

that F3 esophageal varices or F2 esophageal varices with

red-color signs should be treated prophylactically. We

This reply refers to the article available at doi:10.1007/s00535-014-

0935-1.

S. Yamazaki � T. Takayama (&)

Department of Digestive Surgery, Nihon University School of

Medicine, 30-1 Oyaguchikami-machi, Itabashi-ku,

Tokyo 173-8610, Japan

e-mail: takayama.tadatoshi@nihon-u.ac.jp

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J Gastroenterol (2014) 49:956–957

DOI 10.1007/s00535-014-0937-z

believe that this strategy for esophageal varices will con-

tribute to the goal of zero postoperative mortality in cir-

rhotic patients who undergo liver resection [4].

Conflict of interest The authors have no conflict of interest to

declare.

References

1. Yamazaki S, Takayama T, Nakamura M, et al. Prophylactic impact

of endoscopic treatment for esophageal varices in liver resection: a

prospective study. J Gastroenterol 2013 (in press). Doi:10.1007/

s00535-013-0841-y.

2. Lisotti A, Azzaroli F, Buonfiglioli F, et al. Indocyanine green

retention test as a non-invasive marker of portal hypertension and

esophageal varices in compensated liver cirrhosis. Hepatology

2014;59:643–50.

3. Miki K, Kubota K, Kokudo N, Inoue Y, Bandai Y, Makuuchi M.

Asialoglycoprotein receptor and hepatic blood flow using techne-

tium-99m-DTPA-galactosyl human serum albumin. J Nucl Med.

1997;38:1798–807.

4. Makuuchi M, Kosuge T, Takayama T, et al. Surgery for small liver

cancers. Semin Surg Oncol. 1993;9:298–304.

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