A comparison of quantitative versus qualitative indocyanine green imaging for anastomotic viability assessment: Impact on surgeons’ intraoperative decision-making confidence

Anastomotic leak (AL) remains a serious and feared complication. While indocyanine green (ICG) fluorescence angiography is widely adopted. However, its assessment is typically qualitative and subjective. Quantitative ICG (q-ICG) offers an objective alternative, yet its impact on the surgeon's decision-making confidence remains unknown. To determine whether q-ICG enhances intraoperative surgeon confidence in anastomotic perfusion compared to standard qualitative assessment. A prospective, single-center, randomized controlled trial (Registration: NCT06222645) was conducted. Patients undergoing colorectal anastomosis were randomized to either qualitative ICG assessment or q-ICG assessment (providing objective Tmax and Slope metrics). The primary outcome was the surgeon's confidence score (0-10 scale) assessed before abdominal closure. Secondary outcomes included AL rates and the correlation between confidence and q-ICG parameters. 120 patients were enrolled (60 per group). The q-ICG group demonstrated a significantly higher median confidence score (9 [IQR 8-10]) versus the qualitative group (7 [IQR 6-8], p < 0.001). A low confidence score (<7) was a strong independent predictor for AL (OR 5.2, 95% CI 2.1-13.0, p = 0.001). The AL rate was lower in the q-ICG group (3.3% vs. 8.3%), although this difference did not reach statistical significance (p = 0.28). Surgeon confidence strongly correlated with objective Tmax and Slope values. Quantitative ICG angiography significantly enhances surgeon confidence in assessing anastomotic viability. This enhanced confidence, driven by objective data, is associated with a strong trend towards reduced AL rates, positioning q-ICG as a crucial decision-support tool.