Influence of preoperative indocyanine green clearance on multidisciplinary decision-making before liver surgery: a real-world Western cohort study

Abstract Purpose Indocyanine green (ICG) clearance testing may refine preoperative assessment before liver resection, but its role in multidisciplinary decision-making in Western practice remains unclear. This study aimed to evaluate changes in clinical management following preoperative ICG assessment in patients considered for liver resection. Methods This retrospective cohort study included 206 patients undergoing ICG clearance as part of preoperative evaluation for potential liver resection at a tertiary HPB center from June 2021 to March 2026. Secondary outcomes included adherence to the Makuuchi criteria and postoperative outcomes among resected patients. The primary outcome was change in management following ICG assessment. Results Management changed in 55 patients (27%), most commonly cancellation of surgery because of insufficient ICG clearance ( n = 40). Among 113 resected patients, 83.9% of assessable patients fulfilled the classical Makuuchi criteria. Clinically relevant posthepatectomy liver failure occurred in 15 patients (13.3%). ICG-R15 was not associated with clinically relevant posthepatectomy liver failure or severe complications among resected patients. Conclusion In this selected Western cohort, preoperative ICG clearance frequently influenced multidisciplinary management before potential liver resection. The study demonstrates the role of ICG in clinical decision-making but does not establish that ICG-guided management improves patient outcomes. The lack of association with postoperative outcomes may partly reflect selection of higher-risk patients away from resection.