Research published in The Lancet Gastroenterology & Hepatology provides robust evidence for the use of a digital visualisation and decision support tool in colorectal (bowel) surgery. This is the first time that a digital decision support tool has been conclusively proven to significantly improve outcomes in this type of surgery.

Colorectal cancer is the third most common cancer globally. A serious complication of colorectal surgery in the treatment of cancer and other diseases - anastomotic leak - occurs in as many as one in four patients post-operation.

Indocyanine green fluorescence angiography (ICGFA) is a digital visualisation tool that surgeons can use to assess a key decision during colorectal surgery regarding the quality of the bowel segments being used to join back together the bowel after a cancer portion has been removed. Adequate perfusion is crucial for tissue healing, as impaired healing can lead to leakage and cause sepsis with significant morbidity and mortality.

Although evidence of the benefits of ICGFA had been promising to date, no single randomised controlled trial (RCT) has provided unequivocal proof of usefulness, and so combined RCT analysis was needed for robust recommendations regarding use.

Led by Professor Ronan Cahill, Director of University College Dublin (UCD) Centre for Precision Surgery, the study published today involved a PRISMA-compliant meta-analysis of nine RCTs including 4754 patients. The new research provides clear evidence that the risk of anastomotic leak in patients having colorectal, and especially rectal cancer surgery, is reduced by 40% when ICGFA is used.

Professor Cahill, Full Professor of Surgery at UCD School of Medicine and the Mater Misericordiae University Hospital, said, "Of the broad areas of innovations and advances in colorectal surgery over the past 20 years, ICGFA is now proven as the most useful added step that colorectal surgeons can make in ensuring safety and highest quality outcomes during cancer and other resectional operations.

“It assures surgeons and patients that the best decisions are being made during the operation and protects against the awful occurrence of anastomotic healing complications which cause great misery. Excitingly, this type of digital decision support paves the way for additional AI tools that can advance next generation surgery for patients by improving individualised decision-making during high risk operations."

Study Co-author Prof Jan Watanabe, Kansai Medical University, Japan, said, "This study marks an important turning point in colorectal surgery. The accumulated randomised evidence now clearly shows that intraoperative ICG fluorescence imaging can reduce anastomotic leakage, shifting the focus from proving efficacy to implementing this technology in routine surgical practice."

Co-author Prof David Jayne, University of Leeds, UK said, “Previous studies have highlighted the benefit of ICG fluorescence angiography in minimising anastomotic leaks following left colon and rectal cancer resections. This timely and rigorously performed meta-analysis now provides indisputable evidence of the benefit. It will be welcomed by clinicians and policy makers as the evidence needed to change practice and reduce the burden of this life-threatening complication for patients.”

Co-author Dr Denise Hilling, Leiden University Medical Center, said, ““Individual randomised trials are challenging but essential for advancing surgical care. By bringing all of these studies together, this meta-analysis now provides clear evidence that fluorescence angiography reduces anastomotic leaks in patients undergoing left-sided and rectal colorectal surgery. Rather than conducting more clinical trials, the focus should now shift to wider adoption of this technology among surgeons treating this patient group."

Alongside better outcomes generally, the ICGFA technique has been shown to provide a means to correct problems during the operation that would otherwise only present afterwards. It also provides a way to document the performance and decisions of a surgeon during the case.

The systematic review can now guide clinicians in practice and inform clinical guidelines regarding best practice. It also paves the way for AI and decision support tools based on the underlying ICGFA principle and method proven in this study.

Read the paper here: https://www.thelancet.com/journals/langas/article/PIIS2468-1253(25)00373-5/fulltext