SAGES 2025 guidelines for fluorescence image-guided gastrointestinal surgery using indocyanine green

Area of Science:

• Surgical Oncology
• Medical Imaging
• Gastrointestinal Surgery

Background:

• Fluorescence image-guided surgery (FIGS) with indocyanine green (ICG) enhances intraoperative visualization.
• Its clinical utility for precision and safety is under ongoing evaluation.
• Variable evidence necessitates expert recommendations for optimal application.

Purpose of the Study:

• To provide evidence-based recommendations for the intraoperative use of FIGS with ICG.
• To support clinical and patient decision-making across various surgical applications.
• To address evidence gaps in gastrointestinal surgery.

Main Methods:

• Systematic literature review up to October 2022 addressing key questions on FIGS with ICG.
• Findings presented to an expert panel of adult and pediatric surgeons.
• Recommendations developed using the GRADE methodology.

Main Results:

• Recommendations support FIGS with ICG for metastasis detection, primary cancer identification, lymph node identification in GI cancers, and anastomosis quality.
• Evidence insufficient for thoracic duct identification and bariatric/pediatric pull-through anastomosis.
• Expert consensus deemed FIGS with ICG a reasonable option for all evaluated applications.

Conclusions:

• The recommendations provide guidance on FIGS with ICG use based on current evidence and expert consensus.
• Identified evidence gaps highlight areas for future research in FIGS for gastrointestinal surgery.
• A stronger evidence base is needed to further support FIGS in adult and pediatric GI surgery.