Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper.

Zsolt J Balogh, Jean-Marc Regimbeau, Francesco Corradi, Mauro Podda, Salomone Di Saverio, Federico Coccolini, Belinda De Simone, Massimo Sartelli, Fausto Catena, Vishal G Shelat, Hajra Ashraf, Mario Testini, Ana Maria Gonzalez Castillo, Elisa Cassinotti, Francesco Di Maggio, Martina Bonafede, Hung Truong, Micheal Denis Kelly, Andrey Litvin, Gianluca Garulli, Andrew L Kirkpatrick, Luigi Boni, Elie Chouillard, Arda Isik, Nicola De'Angelis, Boris Sakakushev, Dieter Weber, Antonio Tarasconi, Alessandro Pasculli, Giovanna Di Meo, Walter L Biffl, Gian Luca Baiocchi, Michele Diana, Imtiaz Wani, Joseph M Galante, Ari Leppäniemi, Ernest E Moore, Raul Coimbra, Fikri M Abu-Zidan, Vanni Agnoletti, Luca Ansaloni

Journal: World journal of emergency surgery : WJES 2025;20(1):13

PMID: 39948641

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Abstract

BACKGROUND

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.

AIM

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

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Address: Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy. [email protected].; Department of Theoretical and Applied Sciences, eCampus University, Novedrate, CO, Italy. [email protected].; Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, UAE.; Department of General and Minimally Invasive Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico di Milano, Milan, Italy.; Emergency Surgery Unit, Department of General Surgery, Pompeu Fabra University, Hospital del Mar, Barcelona, Spain.; Department of Surgical, Medical andMolecularPathology and Critical Care Medicine, University of Pisa, Pisa, Italy.; Upper Gastro-Intestinal Surgery Unit, Department of General Surgery, Croydon University Hospital, London, UK.; Unit of General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.; UOC General Surgery, ASST Cremona, Cremona, Italy.; Acute Care and Minimally Invasive Surgery, Scripps Memorial Hospital - La Jolla, Green, and Encinitas, La Jolla, USA.; Unit of Robotic and Minimally Invasive Digestive Surgery, Ferrara University Hospital, Ferrara, Italy.; Department of Surgery, University Hospital of Geneva, 1205, Geneva, Switzerland.; ICube Laboratory, Photonics Instrumentation for Health, 67034, Strasbourg, France.; Riverside University Health System Medical Center, Riverside, CA, USA.; Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.; General Surgery Department, American Hospital of Paris, Paris, France.; Department of General Surgery, University Hospital of Pisa, Pisa, Italy.; MedAlliance, Albury, NSW, Australia.; General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy.; Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy.; Istanbul Medeniyet University, Istanbul, Turkey.; Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.; Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus.; Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA.; Department of General Surgery, Macerata Hospital, Macerata, Italy.; Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy.; Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India.; General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria.; Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore.; Department of General Surgery, Royal Perth Hospital & The University of Western Australia, Perth, Australia.; UC Davis Health, Hospital Clinical Care Services, University of California, Davis, USA.; Department of General Surgery, University of Pavia, Pavia, Italy.; Level 1 Trauma Center, Bufalini Hospital, AUSL Romagna, Cesena, Italy.; Service de Chirurgie Digestive du CHU d'Amiens, CHU Sud, Centre Hospitalier Universitaire Amiens-Picardie Site Sud, 80054, Amiens, France.; Department of Emergency and General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.; Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada.; Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA.; Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy.; Alma Mater Studiorum, University of Bologna, Bologna, Italy.

DOI: 10.1186/s13017-025-00575-w

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MeSH Terms: Humans, Indocyanine Green, Consensus, Surgery, Computer-Assisted, Optical Imaging, Delphi Technique