Indocyanine green fluorescence angiography in mechanical bowel obstruction: impact on intraoperative decision-making and clinical guidance-a systematic review.

BACKGROUND

Mechanical bowel obstruction (MBO) is a common indication for emergency surgery. Intraoperative assessment of bowel viability remains challenging and relies largely on subjective visual criteria, while tactile evaluation is limited during laparoscopy. Indocyanine green fluorescence angiography (ICG-FA) has been proposed as an adjunct for real-time assessment of intestinal perfusion. This systematic review evaluated ICG-FA in MBO, focusing on intraoperative decision-making and postoperative outcomes.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library was performed on February 27, 2026, in accordance with PRISMA 2020 guidelines. The protocol was registered in PROSPERO (CRD420261322769). The primary outcome was change in intraoperative surgical decision-making after ICG-FA. Secondary outcomes included bowel resection rate, postoperative complications, reoperation, and mortality. Qualitative synthesis and exploratory pooled descriptive analyses were performed.

RESULTS

Six studies including 125 patients met the inclusion criteria. ICG-FA was generally performed after obstruction resolution to assess bowel perfusion and inform surgical strategy. When explicitly assessed, changes in intraoperative strategy after ICG-FA were reported in 22-32% of cases, most frequently toward bowel preservation or less extensive resection. In pooled descriptive comparisons, bowel resection rates were numerically lower with ICG-FA than with conventional assessment alone (22.2% vs 41.9%). Postoperative complications showed a similar pattern (8% vs 32%). These findings should be interpreted as exploratory and descriptive.

CONCLUSION

ICG-FA may assist intraoperative assessment of bowel perfusion in MBO, particularly when bowel viability is uncertain. By organizing the available evidence in an emerging field, this review outlines a practical framework for ICG-FA use and may help guide standardized reporting and future prospective studies. Current evidence suggests a potential role in supporting intraoperative decision-making, often favoring bowel-preserving strategies. However, evidence remains limited and hypothesis-generating. Standardized protocols, decision modification reporting, prospective registries, and comparative studies are needed before the clinical impact of ICG-FA in MBO can be established.