Colorectal surgeons' perspectives on the efficacy of intraoperative bowel perfusion technology with a focus on indocyanine green fluorescence angiography.

Background: Level one evidence supports indocyanine green fluorescence angiography (ICGFA) use reducing anastomotic leak rates in colorectal surgery. We surveyed surgeons exploring perceptions and factors affecting its use in daily practice and adoption as routine standard of care.

Methods: Validated electronic survey distributed via the Irish Association of Coloproctology, Royal College of Surgeons in Ireland, European Society of Surgical Oncology, European Association for Endoscopic Surgery, Milan Colorectal Congress and social media.

Results: 200 colorectal surgeons (143 consultants) responded. 147 (73.5%) surgeons already use ICGFA, with 90 (61.2%) using it routinely and 69 (46.9%) having a concomitant research interest. Strong clinical evidence base (83.5%) and protocol standardisation (78%) were overall rated most important for bowel perfusion technology with a majority of surgeons rating lack of standardisation and inter-user variability as challenges (similar between consultants and non-consultants). Lack of training and staff, reliability concerns and data security were perceived as significant barriers by selective users compared to non-users, and cost and operating time were perceived as significant barriers by selective users compared to routine users. Most surgeons (41.5%) ideated a number needed to treat (NNT) between 20 and 40 acceptable to advocate routine ICGFA use with 28% requiring a NNT < 20. Most surgeons (38.5%) indicate a per case cost savings of €250-500 supports routine use with 17% advocating it > €750.

Conclusions: With now a strong evidence base regarding clinical benefit, the survey respondents articulate remaining challenges for ICGFA as standard of care. Levels of expected benefit are largely in keeping with its reported performance.