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

Fluorescence image-guided surgery (FIGS) with indocyanine green (ICG) is a surgical adjunct that provides real-time, advanced visualization during surgery. It has been increasingly used in clinical practice for its potential to enhance intraoperative precision and safety. However, evidence to date regarding its utility remains variable. An expert panel was convened to provide evidence-based recommendations on the intraoperative use of FIGS with ICG across several surgical applications to support clinicians and patients in decision-making.

A systematic review was carried out, including a literature search up to October 2022, addressing eight key questions regarding FIGS with ICG compared to its absence in various surgical settings and service lines. The findings were subsequently presented to a panel of adult and pediatric surgeons. Subject matter experts then used the GRADE methodology to develop evidence-based recommendations.

Recommendations in favor of using FIGS with ICG were made for detection of non-regional metastases, intraoperative identification of primary cancers, LN identification in GI cancers, and anastomosis quality in esophageal and left-sided colorectal anastomosis. Thoracic duct identification and bariatric and pediatric pull-through anastomosis did not have sufficient evidence to make a formal recommendation. Still, the expert consensus was that FIGS with ICG is a reasonable option for those surgical applications.

These recommendations guide the use of FIGS with ICG in different surgical areas according to the existing literature and expert input. The panel also highlighted evidence gaps to support future research for a stronger evidence base around FIGS in adult and pediatric gastrointestinal surgery.