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Intraoperative indocyanine green fluorescence angiography improves bowel perfusion assessment in colorectal anastomosis surgeryNew standards aim to improve blood flow monitoring in colorectal surgery

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Key Takeaway
Consider using time-intensity kinetics over single snapshots for more reproducible bowel perfusion assessment in colorectal surgery.

This clinical guideline establishes a framework for standardizing the acquisition, quantification, interpretation, and reporting of indocyanine green fluorescence angiography (ICG-FA) signals during colorectal anastomosis. The guidelines aim to improve the comparability and clarify the clinical value of perfusion imaging in surgical settings.

The guidance indicates that ICG-FA is beneficial for bowel perfusion, particularly in left-sided and rectal surgeries based on pooled randomized evidence and 2025 SAGES guidance. However, the authors note that single fluorescence-intensity snapshots are unstable for comparison due to variability in injection, hemodynamics, and camera geometry. In contrast, time-intensity kinetics and spatial heterogeneity measures are reported as more reproducible and physiologically meaningful than single snapshots.

A primary limitation noted is that current evidence for kinetic metrics, such as Time Ratio, is preliminary and requires multicenter validation. The guideline serves as an expert-opinion framework intended to establish future consensus rather than a validated clinical trial result. These standards aim to improve reporting consistency in surgical practice.

How this fits prior evidence

This guideline addresses the clinical management of colorectal cancer patients by providing standardized methods for intraoperative perfusion assessment. While previous evidence noted that antibiotic exposure is associated with an 18.7% higher risk of gastrointestinal cancers, this guidance focuses on improving surgical outcomes through improved imaging techniques. It does not directly address the gut microbiome biomarkers or inflammatory markers previously reported.

When surgeons perform operations on the colon or rectum, ensuring that tissue receives enough blood is vital for healing. A new set of guidelines aims to standardize how doctors use a specific dye called indocyanine green. This dye glows under special cameras, helping surgeons see exactly where blood is flowing during surgery.

The research shows that while simple snapshots of this glow can be inconsistent because of different camera angles or injection methods, tracking the movement and spread of the dye over time is much more reliable. These detailed measurements provide a clearer picture of how well the tissue is being fed by blood, especially in surgeries involving the left side or rectum.

Because these new standards are based on expert opinions rather than large clinical trials, some parts of the technology are still early. For example, certain advanced metrics for measuring blood flow need more testing across multiple hospitals before they can be fully relied upon. The goal is to create a consistent way for surgeons to communicate and interpret these images.

What this means for you:
New guidelines aim to make tracking blood flow during colorectal surgery more reliable and consistent.

Common questions

What is the purpose of using indocyanine green in surgery?

Indocyanine green is a dye that allows surgeons to see blood flow in tissue. It is especially helpful during left-sided and rectal surgeries because it helps them confirm that the area has enough blood to heal properly after the operation.

Why are new standards being created for this imaging technique?

Simple snapshots of the dye can be unreliable because things like camera angles or how much dye is injected can change the look. New standards focus on tracking how the dye moves over time, which provides a more consistent and meaningful way to check blood flow.

Is this technology fully proven for all types of measurements?

Some advanced ways to measure blood flow, such as time-intensity kinetics, are still in the early stages. These specific metrics need more testing across many different hospitals before they can be fully confirmed as standard tools.

Study Details

Study typeGuideline
EvidenceLevel 5
PublishedJul 2026
View Original Abstract ↓
BackgroundIntraoperative indocyanine green fluorescence angiography (ICG-FA) is increasingly utilized to assess bowel perfusion during colorectal anastomosis. Although recent multicenter randomized trials have yielded mixed findings, pooled randomized evidence and 2025 SAGES guidance indicate an overall benefit, particularly in left-sided and rectal surgery. However, acquisition protocols, interpretation criteria, and reported endpoints remain heterogeneous.Main messageICG-FA reflects the dynamics of an intravascular dye signal and is affected by injection technique, hemodynamic status, camera geometry, display mode, and platform-specific processing. Visual interpretation shows substantial interobserver variability. Thus, single fluorescence-intensity snapshots are unstable for comparison. In contrast, time-intensity kinetics and spatial heterogeneity measures are more reproducible and physiologically meaningful. Among reported kinetic metrics, the time ratio (TR = T1/2Max/Tmax) is promising. However, current evidence is preliminary and needs multicenter validation.ProposalWe propose a practical minimum acquisition and reporting standard for colorectal ICG-FA studies as an expert-opinion framework for future consensus development. This includes consistent reporting of ICG administration, physiological status at assessment, imaging conditions, camera geometry, analysis methodology, measured outcomes, decision impact, and software/version details. We also describe other relevant approaches, such as laser speckle contrast imaging (LSCI), hyperspectral imaging (HSI), and artificial intelligence (AI)-assisted interpretation.ConclusionsThe key question is no longer only whether ICG-FA should be used, but how its signal should be acquired, quantified, interpreted, and reported. Better standardization should improve comparability, support multicenter validation, and clarify where perfusion imaging adds the greatest clinical value.
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