Tissue viability assessment is one of the main challenges in trauma surgery. Vitality assessment using indocyanine green fluorescence angiography (ICG-FA) may improve surgical decision-making. This systematic review gives an overview of current applications of ICG-FA in surgical treatment of traumatic injury and its effects on the incidence of postoperative complications and intraoperative decision-making.

Systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

PubMed, EMBASE and MEDLINE were searched through 18 December 2023.

Primary research reports regarding indocyanine green (ICG)-fluorescence in patients with traumatic injury were included. Exclusion criteria were use of ICG for treatment of burn wounds, traumatic brain injury or reconstructive surgery, absence of an English or Dutch full-text and non-primary study design.

Two independent reviewers performed the search and screening process according to standardised methods. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies. Data were presented in text and overview tables.

Thirteen studies were included, of which six were case series/reports including three or fewer patients. Within the other seven studies, 301 patients received ICG-guided surgery. ICG was used for perfusion assessment in all studies. Injury types consisted of traumatic extremity and abdominal injury. All studies reported beneficial effects such as necrosis detection, determination of resection/debridement margins and reduction of debridement procedures. ICG could improve intraoperative decision-making and significantly decrease postoperative complications. No included studies reported ICG-related complications or adverse events.

The available literature regarding the use of ICG-FA in trauma surgery is limited, and comparability is low. Still, the results are promising and show a large potential of ICG-FA for better and more efficient treatment of trauma patients. Further research with larger samples and comparable conditions is thus necessary and highly recommended.

Anastomotic dehiscence, a feared complication in colorectal surgery, motivates the search for effective strategies to mitigate its risk. This meta-analysis encompasses all published randomized trials investigating and comparing the impact of indocyanine green (ICG) angiography on this complication. With four studies and 1,109 patients, the intraoperative ICG angiography group demonstrated a significant reduction in the overall rate of anastomotic dehiscence compared to the non-angiography group (7.3% vs. 11.5%; OR: 0.6; 95% CI: 0.4-0.9; p = 0.03). These differences were maintained in rectal surgery subgroup, with no prolongation of surgical time or increase in morbidity and mortality. There were no differences in the left colon surgery group. The evidence provided by this meta-analysis would support the effectiveness of ICG angiography in reducing the incidence of anastomotic leakage in colorectal surgery, advocating for its integration into routine surgical practice.

Fluorescence imaging is critical for intraoperative intestinal perfusion assessment in colorectal surgery, yet its clinical adoption remains limited by subjective interpretation and lack of quantitative standards. This study introduces an integrated approach combining fluorescence curve analysis, biophysical modeling, and machine learning to improve intraoperative perfusion assessment.

Laparoscopic fluorescence videos from 68 low rectal cancer patients were analyzed, with 1,263 measurement points (15-20 per case) selected along colonic bands. Fluorescence intensity dynamics were extracted via color space transformation, video stabilization and image registration, then modeled using the Random Sample Consensus (RANSAC) algorithm and nonlinear least squares fitting to derive biophysical parameters. Three clinicians independently scored perfusion quality (0-100 scale) using morphological features and biophysical metrics. An XGBoost model was trained on these parameters to automate scoring.

The model achieved superior test performance, with a root mean square error (RMSE) of 2.47, a mean absolute error (MAE) of 1.99, and an R2 of 97.2%, outperforming conventional time-factor analyses. It demonstrated robust generalizability, showing no statistically significant prediction differences across age, diabetes, or smoking subgroups (P > 0.05). Clinically, low perfusion scores in distal anastomotic regions were significantly associated with postoperative complications (P < 0.001), validating the scoring system's clinical relevance and discriminative capacity. The automated software we developed completed analyses within 2 min, enabling rapid intraoperative assessment.

This framework synergistically enhances surgical evaluation through three innovations: (1) Biophysical modeling quantifies perfusion dynamics beyond time-based parameters; (2) Machine learning integrates multimodal data for surgeon-level accuracy; (3) Automated workflow enables practical clinical translation. By addressing limitations of visual assessment through quantitative, rapid, and generalizable analysis, this method advances intraoperative perfusion monitoring and decision-making in colorectal surgery.

Performing a bowel anastomosis is a critical step in colorectal resection. Assessing the risk of anastomotic leakage remains challenging, even for experienced surgeons.

To evaluate the use of indocyanine green (ICG) fluorescence imaging in assessing perfusion at the anastomotic site before and after anastomosis and determine whether it helps reduce anastomotic leakages.

ICG-COLORAL is a prospective, randomized, multicenter study conducted from September 1, 2018, to December 31, 2023. Participants were recruited during preoperative outpatient clinic visits by clinicians not involved in the study, as well as by researchers. Participants were elective patients scheduled for laparoscopic resections, excluding low anterior resections, with planned primary anastomosis in 5 Finnish public hospitals experienced in laparoscopic colorectal surgery.

The intervention group received 5 mg of ICG intravenously before and after anastomosis formation. The fluorescence signal was assessed with a near-infrared-capable camera. The control group did not receive ICG fluorescence imaging.

The primary outcome measure was the anastomotic leak rate as detected by computed tomography.

Among 1136 patients in the intention-to-treat population, 526 (46.3%) were female and 610 (53.7%) male; they had a mean (SD) age of 70 (11) years, body mass index of 28 (5), and age-adjusted Charlson Comorbidity Index of 5 (3). Overall, the anastomotic leak rate was 5.8% (33/567) in the ICG fluorescence imaging group vs 7.9% (45/569) in the control group (odds ratio [OR], 0.73; 95% CI, 0.48-1.13; P = .16). For right-sided operations, the anastomotic leak rate with ICG fluorescence imaging was 5.9% (16/273) vs 6.7% (20/298) in the control group (OR, 0.87; 95% CI, 0.46-1.65). For left-sided operations, the anastomotic leak rate was 5.2% (14/267) with ICG fluorescence imaging vs 9.5% (23/243) without (OR, 0.55; 95% CI, 0.29-1.05). No patients reported adverse events related to ICG.

This study found that routine use of ICG fluorescence imaging does not significantly reduce the overall anastomotic leak rate in laparoscopic colorectal surgery if low anterior resections are excluded but may be beneficial in left-sided operations.

ClinicalTrials.gov Identifier: NCT03602677.

Indocyanine green fluorescence angiography (ICGFA) during colorectal surgery associates with reduced post-operative anastomotic complication rates. Because its interpretation is subjective, quantification has been proposed to address inter-user variability. This study reviews the published literature regarding ICGFA quantification during colorectal surgery with a focus on impactful clinical deployment.

A systematic review was performed of English language publications regarding clinical studies of ICGFA quantification in colorectal surgery in PubMed, Scopus, Web of Science and Cochrane Library on 29th August 2024, updated to 18th November 2024, following PRISMA guidelines. Newcastle Ottawa scale (NOS) was used to assess quality.

A total of 1428 studies were screened with 22 studies (1469 patients) selected. There was significant heterogeneity of ICGFA methodology, quantification methods and parameter selection and only three studies were NOS "high" quality. Extracorporeal application was most common. Four studies (154 patients) conducted real-time ICGFA analyses (others were post hoc) and four utilised artificial intelligence methods. Eleven studies only included patients undergoing left-sided resection (six focusing specifically on rectal resections). Only one study employed the quantification method to guide intra-operative decision-making regarding colonic transection. Twenty-six different perfusion parameters were assessed, with time from injection to visible fluorescence and maximum intensity the most commonly (but not only) correlated parameters regarding anastomotic complication (n = 18). Other grounding correlates were tissue oxygenation (n = 3, two with hyperspectral imagery), metabolites (n = 2) and surgeon interpretation (n = 5).

Quantification of the ICGFA signal for colorectal surgery is feasible but has so far seen limited academic advancement beyond feasibility.

Indocyanine green fluorescence angiography (ICGFA) during colorectal surgery either reassures surgeons regarding intestinal perfusion sufficiency or prompts changed surgical strategy by indicating unsuspected insufficiency. This study describes existing evidence supporting ICGFA use in colorectal surgery, particularly regarding impact on intraoperative decisions.

Searches were performed on PubMed, ScienceDirect, Scopus, Web of Science, Cochrane Collaboration databases on 5th December 2023, updated to 19th August 2024. Full English language publications of clinical studies in human patients undergoing colorectal resection with primary anastomosis with the use of ICGFA to assess bowel perfusion intraoperatively, with a control group, were included. Pooling of anastomotic leak (AL) rates was performed for primary outcome analysis with odds ratio (OR) and number-needed-to-treat (NNT) calculated regarding leak reduction.

45 studies comprising 14,333 patients were included, with 7 randomised controlled trials (2911 patients). Overall, AL rate was 6.8%, 4.5% with ICGFA and 8.5% without (OR:0.47, p < 0.001, NNT 23), increasing to 9.5%, 7.5% and 11.6%, respectively, in randomised controlled trials (OR:0.62, p < 0.01, NNT 25). In rectal resections, AL rate was 4.7% with ICGFA vs 11.5% without (OR: 0.38, p < 0.0001). 26 studies performed ICGFA before and after anastomosis formation and 19 used ICGFA only prior to bowel transection, with no significant difference of AL rate reduction on subgroup testing. ICGFA prompted a change in surgical plan in 8.4% of thirty-four studies reporting this. Interestingly, in these studies, leak rates overall were 3.7% when ICGFA matched surgeon judgement versus 5.7% when it prompted change (OR 0.51, p < 0.0025), versus 7.7% without (OR 0.45, p < 0.0001). In rectal resections, these figures were 5%, 8.8% (OR 0.42, p = 0.01) and 12.0% (OR0.39, p < 0.0001), respectively.

ICGFA colorectal perfusion assessment is associated with lower anastomotic leak rates, especially when confirming surgeons' judgement, and may so stratify patients post-operatively regarding subsequent anastomotic leak rate.

Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries.

This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings.

Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval.

ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection.

Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.

Anastomotic leak (AL) is a major complication in colorectal surgery, significantly contributing to perioperative morbidity and mortality. Among strategies to prevent AL, Indocyanine Green Fluorescence Angiography (ICG-FA) has emerged as a promising method for assessing bowel perfusion intraoperatively. This systematic review evaluates the impact of ICG-FA on AL rates and other postoperative outcomes following colorectal anastomoses.

A systematic search was conducted in PubMed, PubMed Central, MEDLINE, and Google Scholar, following PRISMA guidelines. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and retrospective cohort studies comparing ICG-FA to controls in adult patients undergoing colorectal resections and anastomoses. Data on AL rates, intraoperative characteristics, and postoperative outcomes were extracted. Quality assessment was performed using the Newcastle-Ottawa Scale and the Revised Cochrane Risk-of-Bias Tool.

Sixteen studies (12 retrospective, 1 prospective, and 3 RCTs) involving 3231 patients (1562 ICG-FA and 1669 controls) were included. AL rates were significantly lower in the ICG-FA group (5.18%) compared to controls (11.50%) (p < 0.01). ICG-FA influenced surgical plans in 16.31% of cases. Operative time and ileostomy formation rates were comparable between groups. Reoperation, ileus, and wound infection rates showed minimal differences. Mortality rates were low in both groups (ICG-FA: 0.55%, control: 0.51%).

ICG-FA significantly reduces AL rates without increasing operative time or postoperative complications. This technique provides a reliable and safe assessment of bowel perfusion, supporting its integration into colorectal surgery protocols. Further high-quality RCTs are needed to confirm these findings and optimise its application.

Anastomotic leaks are a significant complication in colorectal surgery. Indocyanine green fluorescence angiography (ICG-FA) has been suggested as a method to reduce the risk. This meta-analysis aims to evaluate the effect of ICG-FA on reducing anastomotic leaks in colorectal surgery. This study follows PRISMA guidelines and is registered on PROSPERO (CRD42022370748). We conducted a comprehensive search of multiple databases and registers for randomized controlled trials (RCTs) comparing ICG-FA with standard methods in colorectal surgery. Data extraction and quality assessment were performed by two independent reviewers, with a third resolving disputes. Odds ratios (OR) and mean differences (MD) were calculated using comprehensive meta-analysis software, version 3. Heterogeneity and publication bias were assessed, and a sensitivity analysis was performed. The analysis included five RCTs with a total of 1369 patients from four countries. The ICG-FA was associated with a 45% reduction in the risk of overall anastomotic leaks (OR: 0.550, p = 0.012). Subgroup analysis showed a 47% reduction in leaks for low anastomoses (OR: 0.53, p = 0.143) and a 69% reduction in grade A leaks (OR: 0.31, p = 0.008). No significant effects were observed for grade B and C leaks, blood loss, surgery duration, hospital stay, mortality, postoperative ileus, reoperation, or surgical site infections. ICG-FA significantly reduces the overall risk of anastomotic leaks, especially grade A leaks, and shows a trend towards fewer leaks in low anastomosis. No significant impact was found on secondary outcomes. Further RCTs are needed to confirm these findings.

We investigated the impact of Indocyanine Green (ICG) angiography on reducing anastomotic leakage (AL) after elective left segmental colon resection, including transverse resection. While ICG is widely used in colorectal surgery to assess vascularization, its true effect on AL, particularly in left segmental resections, remains unclear.

This retrospective, monocentric cohort study included patients undergoing left and transverse colon resection from January 2017 to July 2023. Patients were divided into ICG and no-ICG groups. The primary outcome was AL, with secondary outcomes including postoperative morbidity and length of stay.

Of the 115 patients enrolled, 53 received ICG and 63 did not. AL occurred in 6 patients in the no-ICG group, but none in the ICG group. No significant correlation was found between ICG use and other confounding factors. Postoperative length of stay was also shorter in the ICG group.

The use of ICG was associated with a reduction in AL, with no cases in the ICG group. These findings suggest a potential benefit of ICG, warranting confirmation in future large-scale studies.

clinicaltrial.gov (NCT05981937).

Despite spectacular visuals and the seemingly convincing rationale of using indocyanine-green-enhanced fluorescence in assessing bowel perfusion during colorectal resections, a lingering sense of subjectivity remains in the challenge of quantifying this fluorescence. This prospective study analyzed the application of O2C® spectrophotometry to quantify zones of fluorescence on the large bowel during low anterior resection.

Patients receiving a low anterior resection for cancer of the mid- and lower rectum were enrolled in this observational prospective study between February 2020 and December 2022. O2C® blood-flow measurement was performed at three different zones of fluorescence intensity (optimal [O], sufficient [S], and absent [A]), visualized at the designated and already skeletonized site of colon transection. The primary end point was to assess whether the O2C® flow value exceeds 164 arbitrary units (AU) at the zone of optimal fluorescence. The secondary objective was to assess whether there were statistically significant differences in flow parameters between the three zones, thus confirming reproducibility of measurements.

A total of 40 patients were enrolled in this study. Of these, 38 patients remained for statistical analysis with regard to O2C® measurement of the fluorescence zones. The O2C® flow parameter measured at the zone of optimal fluorescence was greater than 164 AU in all cases (100%, p < 0.0001). There were statistically significant differences in flow parameters measured at the three different zones of fluorescence (O-S: p < 0.0001; O-A: p < 0.0001; S-A: p = 0.0023).

This study proves the feasibility and reproducibility of quantifying zones of indocyanine green (ICG)-enhanced fluorescence on the bowel. All O2C® flow measurements that were collected at the zone of optimal fluorescence exceeded 164 AU, thereby adding more evidence to this value as a suggested cut-off parameter in terms of bowel perfusion.

The objective of this systematic review and meta-analysis was to pool randomized trials of patients undergoing left-sided colorectal anastomosis, comparing the use of fluorescence perfusion imaging versus visual inspection in reducing anastomotic leaks.

Databases searched included PubMed, Cochrane Library, Scopus, CINHAL (EBSCO), and Google Scholar based on the concepts: randomized, colorectal, anastomotic leak, and fluorescence imaging. The risk of bias was assessed using RoB2 and the certainty of the evidence with the GRADE Pro tool. The analysis used the log odds ratio for dichotomous data with 95% confidence intervals. Back-transformation of the log odds to odds ratio was performed for the summary of findings. All syntheses used the Random-effects model.

Six randomized trials were included with 1949 patients and 204 events (leaks). Three trials included exclusively rectal cancer patients, while the other three involved benign and malignant pathologies of the sigmoid and rectum. The use of ostomy and preoperative radiation was variable. None of the studies had a high risk of bias. The pooled odds ratio for anastomotic leak reduction with Indocyanine Green (ICG) fluorescence was 0.586 (95% CI: 0.434-0.792). An absolute reduction of 4.7% in leak rates was observed, with no statistical heterogeneity (I2 = 0; p = 0.529). Due to clinical heterogeneity, the quality of evidence was rated moderate.

The use of ICG is associated with reduced leak rates following left-sided colorectal anastomosis with moderate confidence. ICG may be considered a standard of care given the clinically significant benefit in decreasing anastomotic leaks.

The use of fluorescence agents and imaging systems is a promising adjunct in the surgical management of colorectal cancer. This systematic review and meta-analysis aimed to assess the safety and efficacy of fluorescence-guided surgery in the management of colorectal cancer, with a comparison to conventional (non-fluorescence-guided) surgery.

A literature search of MEDLINE, Embase, Emcare, and CINAHL databases was performed for studies that reported data on the outcomes of fluorescence-guided surgery, with or without a comparison group undergoing conventional surgery, for colorectal cancer between January 2000 and January 2024. A meta-analysis was performed using random-effect models, and between-study heterogeneity was assessed.

35 studies of 3217 patients with colorectal cancer were included: 26 studies (964 patients) reported on fluorescence-guided surgery and 9 studies (2253 patients) reported on fluorescence versus conventional surgery. The weighted mean of the cancer detection rate of fluorescence-guided surgery was 71% (95% CI 0.55-0.85), with no significant difference in lymph node yield ratio (WMD -0.04; 95% CI -0.10-0.02; p = 0.201) between fluorescence and conventional surgery groups. There was a significantly lower blood loss (WMD -4.38; 95% CI -7.05--1.70; p = 0.001) and complication rate (WMD -0.04; 95% CI -0.07-0.00; p = 0.027) in the fluorescence-guided surgery group, with a potentially lower anastomotic leak rate (WMD -0.05; 95% CI -0.10-0.01; p = 0.092).

Fluorescence-guided surgery is a safe and effective approach in the management of colorectal cancer, potentially reducing blood loss and complications. Further randomised controlled trials are required comparing fluorescence-guided surgery with conventional surgery to determine its prognostic benefit and where it should precisely fit within the management pathway of colorectal cancer.

Anastomotic leakage is a severe postoperative complication in colorectal surgery and compromised bowel perfusion is considered a major contributing factor. Conventional methods to assess bowel perfusion have a low predictive value for anastomotic leakage. We therefore aimed to evaluate the efficacy of real-time assessment with near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) in the prevention of anastomotic leakage.

This multicentre, randomised, controlled, phase 3 trial was done in eight hospitals in the Netherlands. We included adults (aged >18 years) who were scheduled for laparoscopic or robotic colorectal surgery (with planned primary anastomosis) for benign and malignant diseases. Preoperatively, patients were randomly assigned (1:1) to fluorescence-guided bowel anastomosis (FGBA) or conventional bowel anastomosis (CBA) by variable block randomisation (block sizes 4, 6, and 8) and stratified by site. The operating surgeon and investigators analysing the data were not masked to group assignment. Patients were unmasked after the surgical procedure or after study end. In the FGBA group, surgeons marked anastomosis levels per conventional perfusion assessment and then administered 5 mg of ICG by 2 mL intravenous bolus. They assessed bowel perfusion using NIR fluorescence imaging and adjusted (or kept) transection lines accordingly. Only conventional methods for bowel perfusion assessment were used in the CBA group. The primary outcome was the difference in the rate of clinically relevant anastomotic leakage (ie, requiring active therapeutic intervention but manageable without reoperation [grade B] or requiring reoperation [grade C], per the International Study Group of Rectal Cancer) between the FGBA group and the CBA group within 90 days post-surgery. The primary outcome and safety were assessed in the intention-to-treat population. This study was registered with ToetsingOnline.nl (NL7502) and ClinicalTrials.gov (NCT04712032) and is complete.

Between July 2, 2020, and Feb 21, 2023, 982 patients were enrolled, of whom 490 were assigned to FGBA and 492 were assigned to CBA. After excluding 51 patients, the intention-to-treat population comprised 931 (463 assigned FGBA and 468 assigned CBA). Patients had a median age of 68·0 years (IQR 59·0-75·0) and 485 (52%) were male and 446 (48%) were female. Ethnicity data were not available. The overall 90-day rate of clinically relevant anastomotic leakage was not significantly different between the FGBA group (32 [7%] of 463 patients) and the CBA group (42 [9%] of 468 patients; relative risk 0·77 [95% CI 0·50-1·20]; p=0·24). No adverse events related to ICG use were observed. 313 serious adverse events in 229 (25%) patients were at 90-day follow-up (159 serious adverse events in 113 [24%] patients in the FGBA group and 154 serious adverse events in 116 [25%] patients in the CBA group). 18 (2%) people died by 90 days (ten in the FGBA group and eight in the CBA group).

ICG NIR fluorescence imaging did not reduce 90-day anastomotic leakage rates in this trial across all types of colorectal surgeries. Further research should be done in subgroups, such as rectosigmoid resections, for which evidence suggests ICG NIR might be beneficial.

Olympus Medical, Diagnostic Green, and Intuitive Foundation.

Reducing anastomotic leak rates after bowel resection is a priority among patients undergoing gynecologic oncology surgery. While near-infrared (NIR) angiography has been investigated in the colorectal literature, more recent work has demonstrated promising results when used in gynecologic cancer surgery. It has been repeatedly shown to be a safe intervention that can offer real time assessment of bowel perfusion, offering the surgeon the opportunity to act on the results in the hopes of decreasing the risk of complications.

Subjective surgeon interpretation of near-infrared perfusion video is limited by low inter-observer agreement and poor correlation to clinical outcomes. In contrast, quantification of indocyanine green fluorescence video (Q-ICG) correlates with histologic level of perfusion as well as clinical outcomes. Measuring dye volume over time, however, has limitations, such as it is not on-demand, has poor spatial resolution, and is not easily repeatable. Laser speckle contrast imaging quantification (Q-LSCI) is a real-time, dye-free alternative, but further validation is needed. We hypothesize that Q-LSCI will distinguish ischemic tissue and correlate over a range of perfusion levels equivalent to Q-ICG.

Nine sections of intestine in three swine were devascularized. Pairs of indocyanine green fluorescence imaging and laser speckle contrast imaging video were quantified within perfused, watershed, and ischemic regions. Q-ICG used normalized peak inflow slope. Q-LSCI methods were laser speckle perfusion units (LSPU), the base unit of laser speckle imaging, relative perfusion units (RPU), a previously described methodology which utilizes an internal control, and zero-lag normalized cross-correlation (X-Corr), to investigate if the signal deviations convey accurate perfusion information. We determine the ability to distinguish ischemic regions and correlation to Q-ICG over a perfusion gradient.

All modalities distinguished ischemic from perfused regions of interest; Q-ICG values of 0.028 and 0.155 (p < 0.001); RPU values of 0.15 and 0.68 (p < 0.001); and X-corr values of 0.73 and 0.24 (p < 0.001). Over a range of perfusion levels, RPU had the best correlation with Q-ICG (r = 0.79, p < 0.001) compared with LSPU (r = 0.74, p < 0.001) and X-Corr (r = 0.46, p < 0.001).

These results demonstrate that Q-LSCI discriminates ischemic from perfused tissue and represents similar perfusion information over a broad range of perfusion levels comparable to clinically validated Q-ICG. This suggests that Q-LSCI might offer clinically predictive real-time dye-free quantification of tissue perfusion. Further work should include validation in histologic studies and human clinical trials.

Anastomotic leak is a relatively common and debilitating complication. Colorectal leak rates vary widely in the literature, ranging from 1% to 20%. In modern surgical practice, there is much emphasis on the use of indocyanine green (ICG). This is a fluorescent dye administered intravenously to locate and predict an adequate line of anastomosis. We sought to analyse the current literature and supporting evidence behind the use of ICG in the context of elective colorectal surgery.

A literature search was conducted for papers published between January 1991 and December 2022 concerning the use of ICG in colorectal surgery. Data on anastomotic leak, overall complication rate, operative time and involvement of artificial intelligence (AI) were compared.

A total of 24 studies were selected, including 3 randomised controlled trials. There was an anastomotic leak rate of 4.3% in cases with ICG administration compared with 9.5% in the control group (p<0.00001). Seven studies mentioned overall complication rates. These were lower in the ICG cohort than in the control group (15.5% vs 24.5%). There was no significant correlation between ICG use and operative time (p=0.78). Five studies looked at AI, with results suggesting that use of AI leads to much better accuracy in ICG metric analysis. However, the current literature is still inconclusive.

While there is strong evidence behind ICG use in the existing literature, more randomised controlled trials are required for better recommendations. AI in ICG metric interpretation has proved to be difficult owing to interpatient variability. Nevertheless, new data suggest better understanding and standardisation.

Fluorescence imaging is a real-time intraoperative navigation modality to enhance surgical vision and it can guide emergency surgeons while performing difficult, high-risk surgical procedures. The aim of this study is to assess current knowledge, attitudes, and practices of emergency surgeons in the use of indocyanine green (ICG) in emergency settings. Between March 08, 2023 and April 10, 2023, a questionnaire composed of 27 multiple choice and open-ended questions was sent to 200 emergency surgeons who had previously joined the ARtificial Intelligence in Emergency and trauma Surgery (ARIES) project promoted by the WSES. The questionnaire was developed by an emergency surgeon with an interest in advanced technologies and artificial intelligence. The response rate was 96% (192/200). Responders affirmed that ICG fluorescence can support the performance of difficult surgical procedures in the emergency setting, particularly in the presence of severe inflammation and in evaluating bowel viability. Nevertheless, there were concerns regarding accessibility and availability of fluorescence imaging in emergency settings. Eighty-seven out of 192 (45.3%) respondents have a fluorescence imaging system of vision for both elective and emergency surgical procedures; 32.3% of respondents have this system solely for elective procedures; 21.4% of respondents do not have this system, 15% do not have experience with it, and 38% do not use this imaging in emergency surgery. Less than 1% (2/192) affirmed that ICG fluorescence changed always their intraoperative decision-making. Precision surgery effectively tailors surgical interventions to individual patient characteristics using advanced technology, data analysis and artificial intelligence. ICG fluorescence can serve as a valid and safe tool to guide emergency surgery in different scenarios, such as intestinal ischemia and severe acute cholecystitis. Due to the lack of high-level evidence within this field, a consensus of expert emergency surgeons is needed to encourage stakeholders to increase the availability of fluorescence imaging systems and to support emergency surgeons in implementing ICG fluorescence in their daily practice.

Current evidence about intraoperative anastomotic testing after left-sided colorectal resections is still controversial. The aim of this study was to analyze the impact of Indocyanine Green fluorescent angiography (ICG-FA) and air-leak test (ALT) over standard assessment on anastomotic leakage (AL) rates according to surgeon's perception of anastomosis perfusion and/or integrity in clinical practice.

A database of 2061 patients who underwent left-sided colorectal resections was selected from patients enrolled in a prospective multicenter study. It was retrospectively analyzed through a multi-treatment machine-learning model considering standard visual assessment (NW; No. = 899; 43.6%) as the reference treatment arm, compared to ICG-FA alone (WP; No. = 409; 19.8%), ALT alone (WI; No. = 420; 20.4%) or both (WPI; No. = 333; 16.2%). Twenty-four covariates potentially affecting the outcomes were included and balanced into the model within the subgroups. The primary endpoint was AL, the secondary endpoints were overall morbidity (OM), major morbidity (MM), reoperation for AL, and mortality. All the results were reported as odds ratio (OR) with 95% confidence intervals (95%CI).

The WPI subgroup showed significantly higher AL risk (OR 1.91; 95% CI 1.02-3.59; p 0.043), MM risk (OR 2.35; 95% CI 1.39-3.97; p 0.001), and reoperation for AL risk (OR 2.44; 95% CI 1.12-5.31; p 0.025). No other significant differences were recorded.

This study showed that the surgeons' perception of both anastomotic perfusion and integrity (WPI subgroup) was associated to a significantly higher risk of AL and related morbidity, notwithstanding the extensive use of both ICG-FA and ALT testing.

Background: Anastomotic leakage (AL) is one of the most feared complications in colorectal surgery, with an incidence of 12-39% and associated risk of mortality of 2-24%. The causes of AL and the ways to prevent it are currently under investigation. This study aims to verify if a quadruple assessment of colorectal anastomosis could reduce AL incidence. Methods: A retrospective analysis of prospectively collected data on rectal cancer surgery performed from January 2015 to December 2017 and from January 2021 to December 2023 at a tertiary referral cancer centre was performed. Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. Results: A total of 293 patients were enrolled. AL incidence was lower in the quadruple assessment group than in the control group, reaching a statistically significant result (7.7% vs. 16%; p = 0.001). This result was also confirmed after a propensity score match analysis (PSM), in which the AL rate was lower in the quadruple assessment group (5.4% vs. 12.3%; p = 0.01). Conclusions: This study shows how the systematic implementation of a quadruple assessment when performing a colorectal anastomosis could increase awareness on anastomotic success and reduce the incidence of AL.

Indocyanine green (ICG) fluorescence imaging has revolutionized surgical practice across various medical and surgical specialties. This article reviews the clinical applications of ICG in abdominal, urological, thoracic, and gynecological surgery. ICG fluorescence imaging has been widely adopted in general surgery for various applications, including perfusion assessment, intraoperative visualization of the ureter, and tumor localization. It is particularly valuable in evaluating anastomotic leaks and aiding in precise tumor resection during minimally invasive surgeries. Studies have shown mixed results on its effectiveness in reducing anastomotic leak rates, highlighting the need for further research. In thoracic surgery, ICG facilitates the identification and resection of pulmonary bullae, as well as the precise localization of pulmonary nodules during video-assisted surgery. In urology, ICG aids in localizing renal tumors and guiding selective arterial occlusion during partial nephrectomy. Its role in identifying the lymphatic pathway in prostate cancer and sentinel lymph node biopsy in gynecological cancer is also discussed. Despite its benefits, the use of ICG fluorescence faces challenges such as limited tissue penetration, the potential for false results, a lack of standardized protocols, and high equipment costs. Nonetheless, it remains a powerful tool that could improve surgical outcomes.

This manuscript aims to provide a better understanding of methods and techniques with which one can better quantify the impact of image-guided surgical technologies.

A literature review was conducted with regard to economic and technical methods of medical device evaluation in various countries. Attention was focused on applications related to image-guided interventions that have enabled procedures to be performed in a minimally invasive manner, produced superior clinical outcomes, or have become standard of care.

The review provides examples of successful implementations and adoption of image-guided surgical techniques, mostly in the field of neurosurgery. Failures as well as newly developed technologies still undergoing cost-efficacy analysis are discussed.

The field of image-guided surgery has evolved from solely using preoperative images to utilizing highly specific tools and software to provide more information to the interventionalist in real time. While deformations in soft tissue often preclude the use of such instruments outside of neurosurgery, recent developments in optical and radioactive guidance have enabled surgeons to better account for organ motion and provide feedback to the surgeon as tissue is cut. These technologies are currently undergoing value assessments in many countries and hold promise to improve outcomes for patients, surgeons, care teams, payors, and society in general.

Colorectal cancer remains a major cause of cancer death and morbidity worldwide. Surgery is a major treatment modality for primary and, increasingly, secondary curative therapy. However, with more patients being diagnosed with early stage and premalignant disease manifesting as large polyps, greater accuracy in diagnostic and therapeutic precision is needed right from the time of first endoscopic encounter. Rapid advancements in the field of artificial intelligence (AI), coupled with widespread availability of near infrared imaging (currently based around indocyanine green (ICG)) can enable colonoscopic tissue classification and prognostic stratification for significant polyps, in a similar manner to contemporary dynamic radiological perfusion imaging but with the advantage of being able to do so directly within interventional procedural time frames. It can provide an explainable method for immediate digital biopsies that could guide or even replace traditional forceps biopsies and provide guidance re margins (both areas where current practice is only approximately 80% accurate prior to definitive excision). Here, we discuss the concept and practice of AI enhanced ICG perfusion analysis for rectal cancer surgery while highlighting recent and essential near-future advancements. These include breakthrough developments in computer vision and time series analysis that allow for real-time quantification and classification of fluorescent perfusion signals of rectal cancer tissue intraoperatively that accurately distinguish between normal, benign, and malignant tissues in situ endoscopically, which are now undergoing international prospective validation (the Horizon Europe CLASSICA study). Next stage advancements may include detailed digital characterisation of small rectal malignancy based on intraoperative assessment of specific intratumoral fluorescent signal pattern. This could include T staging and intratumoral molecular process profiling (e.g. regarding angiogenesis, differentiation, inflammatory component, and tumour to stroma ratio) with the potential to accurately predict the microscopic local response to nonsurgical treatment enabling personalised therapy via decision support tools. Such advancements are also applicable to the next generation fluorophores and imaging agents currently emerging from clinical trials. In addition, by providing an understandable, applicable method for detailed tissue characterisation visually, such technology paves the way for acceptance of other AI methodology during surgery including, potentially, deep learning methods based on whole screen/video detailing.

Application of indocyanine green (ICG) fluorescence has led to new developments in gastrointestinal surgery. However, little is known about the use of ICG for the diagnosis of postoperative gut leakage (GL). In addition, there is a lack of rapid and intuitive methods to definitively diagnose postoperative GL.

To investigate the effect of ICG in the diagnosis of anastomotic leakage in a surgical rat GL model and evaluate its diagnostic value in colorectal surgery patients.

Sixteen rats were divided into two groups: GL group (n = 8) and sham group (n = 8). Approximately 0.5 mL of ICG (2.5 mg/mL) was intravenously injected postoperatively. The peritoneal fluid was collected for the fluorescence test at 24 and 48 h. Six patients with rectal cancer who had undergone laparoscopic rectal cancer resection plus enterostomies were injected with 10 mL of ICG (2.5 mg/mL) on postoperative day 1. Their ostomy fluids were collected 24 h after ICG injection to identify the possibility of the ICG excreting from the peripheral veins to the enterostomy stoma. Participants who had undergone colectomy or rectal cancer resection were enrolled in the diagnostic test. The peritoneal fluids from drainage were collected 24 h after ICG injection. The ICG fluorescence test was conducted using OptoMedic endoscopy along with a near-infrared fluorescent imaging system.

The peritoneal fluids from the GL group showed ICG-dependent green fluorescence in contrast to the sham group. Six samples of ostomy fluids showed green fluorescence, indicating the possibility of ICG excreting from the peripheral veins to the enterostomy stoma in patients. The peritoneal fluid ICG test exhibited a sensitivity of 100% and a specificity of 83.3% for the diagnosis of GL. The positive predictive value was 71.4%, while the negative predictive value was 100%. The likelihood ratios were 6.0 for a positive test result and 0 for a negative result.

The postoperative ICG test in a drainage tube is a valuable and simple technique for the diagnosis of GL. Hence, it should be employed in clinical settings in patients with suspected GL.

Indocyanine green (ICG), a well-known molecule employed in medicine for over five decades, has emerged as a versatile dye widely embraced across various surgical disciplines. In gynecologic oncology, its prevalent use revolves around the detection of sentinel lymph nodes. However, the true potential of ICG extends beyond this singular application, owing to its pragmatic utility, cost-effectiveness, and safety profile. Furthermore, ICG has been introduced in the theranostic landscape, marking a significant juncture in the evolution of its clinical utility. This narrative review aims to describe the expanding horizons of ICG fluorescence in gynecologic oncology, beyond the sentinel lymph node biopsy. The manifold applications reported within this manuscript include: 1) lymphography; 2) angiography; 3) nerve visualization; 4) ICG-driven resections; and 5) theranostic. The extensive exploration across these numerous applications, some of which are still in the preclinical phase, serves as a hypothesis generator, aiming to stimulate the development of clinical studies capable of expanding the use of this drug in our field, enhancing the care of gynecological cancer patients.

Anastomotic leakage (AL) is defined as the failure of complete healing or disruption of the anastomosis subsequent to rectal cancer surgery, resulting in the extravasation of intestinal contents into the intra-abdominal or pelvic cavity. It is a serious complication of rectal cancer surgery, accounting for a considerable increase in morbidity and mortality. The use of fluorescence imaging technology in surgery allows surgeons to better evaluate blood perfusion. However, the conclusions of some existing studies are not consistent, so a consensus on whether the near-infrared indocyanine green (NIR-ICG) imaging system can reduce the incidence of AL is needed.

This POSTER trial is designed as a multicentre, prospective, randomised controlled clinical study adhering to the "population, interventions, comparisons, outcomes (PICO)" principles. It is scheduled to take place from August 2019 to December 2024 across eight esteemed hospitals in China. The target population consists of patients diagnosed with rectal cancer through pathological confirmation, with tumours located≤10 cm from the anal verge, eligible for laparoscopic surgery. Enrolled patients will be randomly assigned to either the intervention group or the control group. The intervention group will receive intravenous injections of ICG twice, with intraoperative assessment of anastomotic blood flow using the near-infrared NIR-ICG system during total mesorectal excision (TME) surgery. Conversely, the control group will undergo conventional TME surgery without the use of the NIR-ICG system. A 30-day follow-up period postoperation will be conducted to monitor and evaluate occurrences of AL. The primary endpoint of this study is the incidence of AL within 30 days postsurgery in both groups. The primary outcome investigators will be blinded to the application of ICG angiography. Based on prior literature, we hypothesise an AL rate of 10.3% in the control group and 3% in the experimental group for this study. With a planned ratio of 2:1 between the number of cases in the experimental and control groups, and an expected 20% lost-to-follow-up rate, the initial estimated sample size for this study is 712, comprising 474 in the experimental group and 238 in the control group.

This study has been approved by Ethics committee of Beijing Friendship Hospital, Capital Medical University (approval number: 2019-P2-055-02). The results will be disseminated in major international conferences and peer-reviewed journals.

NCT04012645.

An anastomotic leak is one of the most dreaded complications in colorectal surgery because it increases postoperative morbidity and mortality. The aim of the present study was to identify whether indocyanine green fluorescence angiography (ICGFA) reduced the anastomotic dehiscence rate in colorectal surgery.

A retrospective study on patients that underwent colorectal surgery with colonic resection or low anterior resection and primary anastomosis, within the time frame of January 2019 and September 2021, was conducted. The patients were divided into the case group, in which ICGFA was performed for the intraoperative evaluation of blood perfusion at the anastomosis site, and the control group, in which ICGFA was not utilized.

A total of 168 medical records were reviewed, resulting in 83 cases and 85 controls. Inadequate perfusion that required changing the surgical site of the anastomosis was identified in 4.8% of the case group (n = 4). A trend toward reducing the leak rate with ICGFA was identified (6% [n = 5] in the cases vs 7.1% in the controls [n = 6] [p = 0.999]). The patients that underwent anastomosis site change due to inadequate perfusion had a 0% leak rate.

ICGFA as a method to evaluate intraoperative blood perfusion showed a trend toward reducing the incidence of anastomotic leak in colorectal surgery.

Indocyanine green is a useful tool in colorectal surgery. Quantitative values may enhance and standardize its application.

To determine whether quantitative indocyanine green metrics correlate with standard subjective indocyanine green perfusion assessment in acceptance or rejection of anastomotic margins.

Prospective single-arm, single-institution cohort study. Surgeons viewed subjective indocyanine green images but were blinded to quantitative indocyanine green metrics.

Tertiary academic center.

Adults undergoing planned intestinal resection.

Accepted perfusion and rejected perfusion of the intestinal margin were defined by the absence or presence of ischemia by subjective indocyanine green and gross inspection. The primary outcomes included quantitative indocyanine green values, maximum fluorescence, and time-to-maximum fluorescence in accepted compared to rejected perfusion. Secondary outcomes included maximum fluorescence and time-to-maximum fluorescence values in anastomotic leak.

There were 89 perfusion assessments comprising 156 intestinal segments. Nine segments were subjectively assessed to have poor perfusion by visual inspection and subjective indocyanine green. Maximum fluorescence (% intensity) exhibited higher intensity in accepted perfusion (accepted perfusion 161% [82%-351%] vs rejected perfusion 63% [10%-76%]; p = 0.03). Similarly, time-to-maximum fluorescence (seconds) was earlier in accepted perfusion compared to rejected perfusion (10 seconds [1-40] vs 120 seconds [90-120]; p < 0.01). Increased BMI was associated with higher maximum fluorescence. Anastomotic leak did not correlate with maximum fluorescence or time-to-maximum fluorescence.

Small cohort study, not powered to measure the association between quantitative indocyanine green metrics and anastomotic leak.

We demonstrated that blinded quantitative values reliably correlate with subjective indocyanine green perfusion assessment. Time-to-maximum intensity is an important metric in perfusion evaluation. Quantitative indocyanine green metrics may enhance intraoperative intestinal perfusion assessment. Future studies may attempt to correlate quantitative indocyanine green values with anastomotic leak. See Video Abstract .

ANTECEDENTES:El verde de indocianina es una herramienta útil en la cirugía colorrectal. Los valores cuantitativos pueden mejorar y estandarizar su aplicación.OBJETIVO:Determinar si las métricas cuantitativas de verde de indocianina se correlacionan con la evaluación subjetiva estándar de perfusión de verde de indocianina en la aceptación o rechazo de los márgenes anastomóticos.DISEÑO:Estudio de cohorte prospectivo de un solo brazo y de una sola institución. Los cirujanos vieron imágenes subjetivas de verde de indocianina, pero no conocían las métricas cuantitativas de verde de indocianina.AJUSTE:Centro académico terciario.PACIENTES:Adultos sometidos a resección intestinal planificada.PRINCIPALES MEDIDAS DE RESULTADO:La perfusión aceptada y la perfusión rechazada del margen intestinal se definieron por la ausencia o presencia de isquemia mediante verde de indocianina subjetiva y la inspección macroscópica. Los resultados primarios fueron los valores cuantitativos de verde de indocianina, la fluorescencia máxima y el tiempo hasta la fluorescencia máxima en la perfusión aceptada en comparación con la rechazada. Los resultados secundarios incluyeron la fluorescencia máxima y el tiempo hasta alcanzar los valores máximos de fluorescencia en la fuga anastomótica.RESULTADOS:Se realizaron 89 evaluaciones de perfusión, comprendiendo 156 segmentos intestinales. Se evaluó subjetivamente que 9 segmentos tenían mala perfusión mediante inspección visual y verde de indocianina subjetiva. La fluorescencia máxima (% de intensidad) mostró una mayor intensidad en la perfusión aceptada [Perfusión aceptada 161% (82-351) vs Perfusión rechazada 63% (10-76); p = 0,03]. De manera similar, el tiempo hasta la fluorescencia máxima (segundos) fue más temprano en la perfusión aceptada en comparación con la rechazada [10 s (1-40) frente a 120 s (90-120); p < 0,01]. Aumento del índice de masa corporal asociado con una fluorescencia máxima más alta. La fuga anastomótica no se correlacionó con la fluorescencia máxima ni con el tiempo hasta la fluorescencia máxima.LIMITACIONES:Estudio de cohorte pequeño, sin poder para medir la asociación entre las mediciones cuantitativas del verde de indocianina y la fuga anastomótica.CONCLUSIÓN:Demostramos que los valores cuantitativos ciegos se correlacionan de manera confiable con la evaluación subjetiva de la perfusión de verde de indocianina. El tiempo hasta la intensidad máxima es una métrica importante en la evaluación de la perfusión. Las métricas cuantitativas de verde de indocianina pueden mejorar la evaluación de la perfusión intestinal intraoperatoria. Los estudios futuros pueden intentar correlacionar los valores cuantitativos de verde de indocianina con la fuga anastomótica. (Traducción-Dr. Yolanda Colorado).

Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery.

PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool.

Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG.

Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.

This retrospective study explores the utility of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) in enhancing the intraoperative identification and guidance for the resection of abdominal paragangliomas. They can be challenging to detect during minimally invasive surgery, due to their anatomical location, varying size and similar appearance in regard to their surrounding tissue. Patients with suspected abdominal paragangliomas planned for a minimally-invasive resection were included. As part of standard of care they received single intravenous dose of 5 mg ICG after abdominal exploration. NIR fluorescence imaging of the anatomical region of the suspected lesion was performed immediately following intravenous administration, to assess fluorescence signals, intraoperative identification, and histopathological correlation. Out of five resected suspicious lesions, four were imaged with NIR fluorescence, pathology confirming four as paragangliomas, the latter turned out to be an adrenal adenoma. NIR fluorescence identified all four lesions, surpassing the limitations of white-light visualization. Homogeneous fluorescence signals appeared 30-60 s post-ICG administration, which lasted up to 30 min. The study demonstrates the feasibility and potential clinical value of fluorescence-guided minimally-invasive resections of abdominal paragangliomas using a single intravenous ICG dose. These findings support the scientific basis for routine use of ICG-fluorescence-guided surgery in challenging anatomical cases, providing valuable assistance in lesion detection and resection.

Fluorescence-guided surgery (FGS) has emerged as an innovative technique with promising applications in various surgical specialties. However, clinical implementation is hampered by limited availability of evidence-based reference work supporting the translation towards standard-of-care use in surgical practice. Therefore, we developed a consensus statement on current applications of FGS.

During an international FGS course, participants anonymously voted on 36 statements. Consensus was defined as agreement ≥70% with participation grade of ≥80%. All participants of the questionnaire were stratified for user and handling experience within five domains of applicability (lymphatics & lymph node imaging; tissue perfusion; biliary anatomy and urinary tracts; tumor imaging in colorectal, HPB, and endocrine surgery, and quantification and (tumor-) targeted imaging). Results were pooled to determine consensus for each statement within the respective sections based on the degree of agreement.

In total 43/52 (81%) course participants were eligible as voting members for consensus, comprising the expert panel (n = 12) and trained users (n = 31). Consensus was achieved in 17 out of 36 (45%) statements with highest level of agreement for application of FGS in tissue perfusion and biliary/urinary tract visualization (71% and 67%, respectively) and lowest within the tumor imaging section (0%).

FGS is currently established for tissue perfusion and vital structure imaging. Lymphatics & lymph node imaging in breast cancer and melanoma are evolving, and tumor tissue imaging holds promise in early-phase trials. Quantification and (tumor-)targeted imaging are advancing toward clinical validation. Additional research is needed for tumor imaging due to a lack of consensus.

With the use of indocyanine green fluorescence imaging, intraoperative lymphatic flow assessment is possible. However, no report has indicated mid-term outcomes of indocyanine green fluorescence imaging-guided laparoscopic right-sided colectomy.

To analyze the mid-term outcomes of indocyanine green fluorescence imaging-guided laparoscopic right-sided colectomy.

This was a retrospective, multi-institutional study that used propensity score matching.

We conducted this study within the framework of the Yokohama Clinical Oncology Group in Japan.

A total of 921 patients who underwent laparoscopic right-sided colectomy with lymph node dissection for colon cancer with clinical stages I to III between January 2009 and December 2020 were included. The patients were divided into 2 groups: 233 patients who underwent the lymphatic flow evaluation (indocyanine green group) and 688 patients who did not undergo lymphatic flow evaluation (non-indocyanine green group).

The 3-year relapse-free survival after laparoscopic right-sided colectomy with and without indocyanine green fluorescence imaging were compared.

After propensity score matching, 231 patients were matched in each group. The numbers of dissected central lymph nodes (6 vs 4, p < 0.001), intermediate lymph nodes (7 vs 6, p = 0.03), and the total number of dissected lymph nodes (31 vs 27, p = 0.047) were significantly higher in the indocyanine green group. The median follow-up was 36.9 months. The estimated respective 3-year relapse-free survival and overall survival rates were 88.8% and 94.5% in the indocyanine green group and 89.4% and 94.7% in the non-indocyanine green group ( p = 0.721 and 0.300), respectively, with no difference between the 2 groups.

Retrospective design of the study.

Indocyanine green fluorescence imaging-guided laparoscopic right-sided colectomy could increase the number of total, intermediate, and central lymph nodes. However, there was no difference in mid-term outcomes. See Video Abstract.

ANTECEDENTES:Con el uso de imágenes de fluorescencia verde de indocianina, es posible la evaluación del flujo linfático intraoperatorio. Sin embargo, no hay ningún reporte que indique los resultados a medio plazo de la colectomía laparoscópica del lado derecho guiada por imágenes de fluorescencia con verde de indocianina.OBJETIVO:Examinar los resultados a mediano plazo de la colectomía laparoscópica del lado derecho guiada por imágenes de fluorescencia con verde de indocianina.DISEÑO:Estudio multiinstitucional retrospectivo con emparejamiento de puntuación de propensión.CONFIGURACIÓN:Realizado en el marco del Grupo de Oncología Clínica de Yokohama en Japón.PACIENTES:Un total de 921 pacientes sometidos a colectomía laparoscópica del lado derecho con disección de ganglios linfáticos por cáncer de colon con estadio clínico I a III entre enero de 2009 y diciembre de 2020. Los pacientes se dividieron en dos grupos: 233 pacientes sometidos a la evaluación del flujo linfático (grupo con verde de indocianina) y 688 pacientes que no sometidos a la evaluación del flujo linfático (grupo sin verde de indocianina).PRINCIPALES MEDIDAS DE RESULTADOS:Se comparó la supervivencia libre de recaídas a los 3 años después de la colectomía laparoscópica del lado derecho con y sin imágenes de fluorescencia con verde de indocianina.RESULTADOS:Después de emparejar el puntaje de propensión, 231 pacientes fueron emparejados en cada grupo. El número de ganglios linfáticos centrales disecados (6 frente a 4, p < 0,001) y de ganglios linfáticos intermedios (7 frente a 6, p = 0,03) y el número total de ganglios linfáticos disecados (31 frente a 27, p = 0,047) fueron significativamente mayor en el grupo verde de indocianina. La mediana de seguimiento fue de 36,9 meses. Las tasas respectivas estimadas de supervivencia libre de recaídas y supervivencia general a los 3 años fueron del 88,8 % y el 94,5 % en el grupo con verde de indocianina y del 89,4 % y el 94,7 % en el grupo sin verde de indocianina ( p = 0,721 y 0,300), sin diferencias entre los dos grupos.LIMITACIONES:Estudio de diseño retrospectivo.CONCLUSIONES:La colectomía laparoscópica del lado derecho guiada por imágenes de fluorescencia con verde de indocianina puede aumentar el número de ganglios linfáticos totales, intermedios y centrales. Sin embargo, no hubo diferencias en los resultados a medio plazo. (Traducción-Dr. Fidel Ruiz Healy ).

Some colorectal surgeons advocate routine splenic flexure mobilization (SFM) when performing anterior resection for rectal cancer to ensure a tension-free anastomosis. Meta-analyses of smaller studies suggest that this approach does not influence anastomotic leakage rates, but larger multicentre studies are needed to confirm the safety of a selective strategy. The aim of this study is to evaluate the impact of SFM on anastomotic leakage.

This is a retrospective multicentre cohort study, comprising 1109 patients operated with anterior resection for rectal cancer in 2014-2018. Exposure was SFM, while anastomotic leakage within a year constituted the outcome. Stratified analyses were performed for type of mesorectal excision and surgical approach, as well as sensitivity analysis considering vascular tie placement. Multivariable Cox regression with hazard ratios (HRs) and 95% confidence intervals (CIs) was employed to adjust for confounding, while multiple imputation was used for missing data.

SFM was performed in 381 patients (34.4%). Anastomotic leakage occurred in 83 (21.8%) and 123 (20.3%) patients operated with and without SFM, respectively. SFM was neither clearly detrimental nor beneficial regarding anastomotic leakage (adjusted HR = 0.82; 95% CI: 0.59-1.15), with no apparent differences for total or partial mesorectal excision and minimally invasive or open surgery. Concurrent high vascular ligation did not impact these results, and there was no evidence of interaction from centers with a more common use of SFM.

SFM did not seem to influence the risk of anastomotic leakage after anterior resection for rectal cancer, regardless of type of mesorectal excision, use of minimally invasive surgery, or high vascular ligation.

In recent years, the rise of minimally invasive surgery has driven the development of surgical devices. Indocyanine green (ICG) fluorescence imaging is receiving increased attention in colorectal surgery for improved intraoperative visualization and decision-making. ICG, approved by the U.S. Food and Drug Administration in 1959, rapidly binds to plasma proteins and is primarily intravascular. ICG absorption of near-infrared light (750-800 nm) and emission as fluorescence (830 nm) when bound to tissue proteins enhances deep tissue visualization. Applications include assessing anastomotic perfusion, identifying sentinel lymph nodes, and detecting colorectal cancer metastasis. However, standardized protocols and research on clinical outcomes remain limited. This study explores ICG's role, advantages, disadvantages, and potential clinical impact in colorectal surgery.

The aim of the present randomized controlled trial was to evaluate the superiority of indocyanine green fluorescence imaging (ICG-FI) in reducing the rate of anastomotic leakage in minimally invasive rectal cancer surgery.

The role of ICG-FI in anastomotic leakage in minimally invasive rectal cancer surgery is controversial according to the published literature.

This randomized, open-label, phase 3, trial was performed at 41 hospitals in Japan. Patients with clinically stage 0-III rectal carcinoma less than 12 cm from the anal verge, scheduled for minimally invasive sphincter-preserving surgery were preoperatively randomly assigned to receive a blood flow evaluation by ICG-FI (ICG+ group) or no blood flow evaluation by ICG-FI (ICG- group). The primary endpoint was the anastomotic leakage rate (grade A+B+C, expected reduction rate of 6%) analyzed in the modified intention-to-treat population.

Between December 2018 and February 2021, a total of 850 patients were enrolled and randomized. After the exclusion of 11 patients, 839 were subject to the modified intention-to-treat population (422 in the ICG+ group and 417 in the ICG- group). The rate of anastomotic leakage (grade A+B+C) was significantly lower in the ICG+ group (7.6%) than in the ICG- group (11.8%) (relative risk, 0.645; 95% confidence interval 0.422-0.987; P =0.041). The rate of anastomotic leakage (grade B+C) was 4.7% in the ICG+ group and 8.2% in the ICG- group ( P =0.044), and the respective reoperation rates were 0.5% and 2.4% ( P =0.021).

Although the actual reduction rate of anastomotic leakage in the ICG+ group was lower than the expected reduction rate and ICG-FI was not superior to white light, ICG-FI significantly reduced the anastomotic leakage rate by 4.2%.