Standardization of indocyanine green (ICG) fluorescence in emergency surgery for small bowel obstruction: a preliminary experience

Aim: Indocyanine green (ICG) fluorescence is not routinely used in acute small bowel obstruction (SBO), and standardized methods for its use in assessing intestinal perfusion, particularly via laparoscopy, remain lacking. Therefore, we aimed to explore its role in acute SBO in elderly and frail patients undergoing operative management. Methods: In this single-center, prospective, non-randomized study, we included a case series of patients who underwent emergency laparoscopic surgery for SBO from January 2024 to January 2025 at an Italian community hospital. Patients included were those with acute SBO confirmed by computed tomography scan, who provided signed informed consent, had no allergy to ICG, and were ≥ 18 years old. In borderline cases of intestinal ischemia, we standardized the application of ICG fluorescence to help determine the need for intestinal resection: ICG dosage, timing of injection, timing of fluorescence imaging capture and assessment of the intestinal segment. The postoperative course and the need for re-intervention were evaluated. Results: ICG fluorescence was applied in 16 patients. Half of the cases were male, the median age was 72 years old, 63% presented an American Society of Anesthesiologists (ASA) Physical Status score of 3-4, and the median Charlson Comorbidity Index was 3. Conversion rate was 37%. Main causes of SBO were strangulated hernia, adhesive bands, adhesions and vascular ischemia. In 6 patients, ICG fluorescence showed a non-fluorescent or perivascular pattern, prompting an intestinal resection. Two patients needed re-intervention. Postoperative complications occurred in 43% of the patients. Conclusion: SBO often affects elderly and frail patients. ICG fluorescence serves as a useful and feasible tool in emergency laparoscopic surgery. It facilitates the surgical assessment in borderline cases of intestinal ischemia, thereby preventing unnecessary bowel resections.