Intraoperative indocyanine green (ICG) fluorescence to assess mucosal integrity during laparoscopic Heller–Dor surgery: a pilot randomized study

Achalasia is a rare oesophageal motility disorder, and minimally invasive Heller-Dor (HD) surgery remains the gold standard surgical treatment for type I and II disease. Mucosal injury is a relevant intraoperative risk during laparoscopic Heller-Dor (LHD) myotomy. Real-time assessment of mucosal integrity remains challenging. This study aimed to evaluate whether the intraoperative use of Indocyanine Green (ICG) fluorescence during this surgery could reliably assess mucosal integrity and potentially reduce the need for intra- and postoperative additional diagnostic tests. In this prospective pilot randomized study, patients undergoing LHD for type I-II achalasia were randomly assigned (1:1) to intraoperative ICG fluorescence assessment or standard intraoperative evaluation with endoscopy and postoperative contrast radiography. The primary outcome was intraoperative detection of mucosal leaks. Secondary outcomes included operative time, intraoperative and postoperative complications, length of stay, postoperative pain, inflammatory markers, dietary progression and 12-month follow-up (ClinicalTrials.gov Identifier: NCT07181070). Seventy-one patients were included (37 ICG, 34 standard). No significant differences were observed between groups in intraoperative or postoperative complications, postoperative recovery, or inflammatory markers. Operative time was significantly shorter in the ICG group compared with the standard group (median 95 [90-95] vs. 105 [95-110] minutes; p = 0.04). Intraoperative ICG fluorescence is safe and feasible, providing real-time visualization of mucosal integrity during LHD surgery. This technique may represent a valuable adjunct to standard practice, optimizing surgical efficiency and resource utilization. Larger studies are needed to confirm these findings.