Objective assessment of remnant pancreatic perfusion using intraoperative indocyanine green angiography: a novel technique to predict postoperative pancreatic fistula

Abstract

Background: Postoperative pancreatic fistula (POPF) remains a major complication following pancreaticoduodenectomy (PD). Indocyanine green (ICG) fluorescence angiography offers real-time perfusion assessment but is underutilized in pancreatic surgery. Although pancreatic stump hypo-perfusion has been suggested as a risk factor for POPF, but its role remains underexplored. Objective: To evaluate whether quantitative perfusion parameters derived from ICG fluorescence angiography are associated with POPF. Methods: In this prospective cohort study, 30 patients undergoing PD were assessed using ICG near-infrared fluorescence angiography. Fluorescence intensity-time curves were generated using a Python-based algorithm and analyzed for intensity and flow parameters. Associations between perfusion metrics and POPF, classified by ISGPS criteria, were statistically evaluated. Results: Clinically relevant POPF (CR-POPF) occurred in 30 % of patients. Significant associations were observed between CR-POPF and perfusion parameters including higher fluorescence distribution heterogeneity (p = 0.032) and a slower slope of fluorescence increase (p = 0.008). Conclusions: Quantitative ICG fluorescence angiography provides objective metrics that correlate with POPF development. Parameters such as slope, peak intensity and fluorescence heterogeneity may serve as intraoperative indicators of perfusion adequacy, supporting surgical decision-making during PD. Larger, multicenter studies are warranted to validate these findings.