Fluorescence-guided surgery in colorectal cancer: current evidence, quantitative advances, and future perspectives

Kyung-Ha Lee

doi:10.3393/ac.2025.01438.0205

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Review Colorectal cancer Fluorescence-guided surgery in colorectal cancer: current evidence, quantitative advances, and future perspectives: Kyung-Ha Lee; Annals of Coloproctology 2026;42(1):58-71.
DOI: https://doi.org/10.3393/ac.2025.01438.0205
Published online: February 25, 2026

Department of Colorectal Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea

Correspondence to: Kyung-Ha Lee, MD, PhD Department of Colorectal Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea Email: lllllkh@cnuh.co.kr

• Received: November 28, 2025 • Accepted: December 28, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
CLINICAL APPLICATIONS OF FGS IN COLORECTAL CANCER
FUTURE PERSPECTIVES
CONCLUSION
ARTICLE INFORMATION
REFERENCES

Abstract

Fluorescence-guided surgery (FGS) has progressed from a qualitative adjunct to a quantitative, data-driven tool in colorectal surgery. Fluorescence-guided angiography for perfusion assessment shows mixed randomized results overall, with signals of benefit in low anterior resection and less-severe leaks; emerging metrics (e.g., time-to-peak, slope, time from the initial fluorescence increase to half of the maximum [T_1/2MAX], time ratio [TR]) support objective decision-making. Fluorescence-guided lymphatic mapping can increase D3 yield, whereas consistent oncologic benefit remains uncertain; sentinel lymph node mapping in early colon cancer is feasible but not standard. In advanced rectal cancer, fluorescence may facilitate lateral pelvic node dissection with lower blood loss and selective clearance, though long-term outcomes require confirmation. Tumor-targeted imaging shifts FGS from anatomy to biology, aiding detection of occult disease, characterization of indeterminate lesions after therapy, and therapeutic decision-making for organ preservation. Near-infrared II (NIR-II) agents and hybrid positron emission tomography (PET)/NIR tracers promise deeper penetration and preoperative-to-intraoperative correlation but remain largely preclinical. Platform advances, automated data capture, tumor to background ratio thresholds, and artificial intelligence–assisted analytics are moving FGS toward integrated, reproducible workflows. Priorities include international standardization, prospective trials with long-term endpoints, validated tumor-targeted probes, and digital/robotic integration.
Keywords: Colorectal neoplasms; Surgery; Fluorescence; Angiography; Lymphography

INTRODUCTION

Surgeons are often compared to soldiers, and surgical instruments to weapons. Just as a soldier must confront unseen enemies in the dark, a surgeon often faces anatomical structures or tumors that cannot be seen by the naked eye. In such moments, fluorescence-guided surgery (FGS) functions as the surgeon’s night-vision goggle, revealing what was once hidden from the limits of human sight.

FGS uses targeted fluorophores and specific wavelengths to enable real-time visualization of tissue perfusion, lymphatic drainage, and tumor margins during surgery. This technology provides immediate intraoperative feedback that can enhance resection precision, reduce the risk of leaving behind microscopic disease, and ultimately improve oncologic and functional outcomes.

Indocyanine green (ICG), the most widely used near-infrared (NIR) dye, was initially developed for testing hepatic function but has since become indispensable for assessing tissue viability and vascular or lymphatic anatomy in colorectal surgery [1–3]. Over the last decade, fluorescence imaging has evolved from a qualitative visualization tool to a quantitative, data-driven, and even molecularly targeted technique [4, 5]. Today, FGS is applied in three principal domains: (1) perfusion assessment for anastomotic safety; (2) anatomical navigation such as lymphatic or ureteral mapping; and (3) tumor-targeted imaging for margin delineation and organ preservation.

Despite growing enthusiasm for and technical development of fluorescent agents and imaging systems, the clinical benefits of FGS remain inconsistently demonstrated. There is tremendous variability in the administration of these agents and imaging protocols. It is necessary to improve techniques for fluorescence quantification and evaluation of outcomes [6]. Further technical development and accumulation of evidence are expected to transform fluorescence imaging from a qualitative adjunct into an integrated component of digitally guided precision surgery.

In this review, we summarize the current evidence and technological advances in fluorescence-guided colorectal surgery, with an emphasis on perfusion assessment, anatomical navigation, and tumor-targeted imaging. We also discuss how these developments are shaping the future of digitally integrated precision surgery.

CLINICAL APPLICATIONS OF FGS IN COLORECTAL CANCER

Perfusion assessment for anastomotic safety: fluorescence-guided angiography

Anastomotic leak (AL) is one of the most critical complications that occurs after colorectal resection, with an incidence ranging from 3% to 10%, depending on tumor location and risk profile [7]. The multifactorial pathogenesis of AL is characterized by incomplete tissue healing due to the patient’s underlying disease or therapeutic history, including radiotherapy; technical failure of surgical devices; and postprocedural anatomical tension. Nevertheless, insufficient tissue perfusion at the anastomotic site is one of the most salient causes and can potentially be detected and prevented prior to the conclusion of the intraoperative period. Conventionally, surgeons have relied on subjective indicators, such as bowel color, pulsation of marginal arteries, and bleeding at the bowel edge, to assess perfusion [8]. Recently, fluorescence-guided angiography (FA) has emerged as a promising technology for objective perfusion assessment and is currently being actively applied [9]. This technique facilitates intraoperative visualization of perfusion through the simple injection of ICG prior to or concurrent with surgery. Consequently, it enables the implementation of enhanced recovery protocols, thereby enhancing postoperative recovery outcomes.

Evidence and clinical impact

Although the safety and efficacy of ICG-guided perfusion assessment for reducing AL have been investigated in multiple studies and meta-analyses report a promising trend toward a reduced AL rate [10, 11], many prospective randomized trials have reported no significant superiority. While early feasibility studies, such as the PILLAR II trial, reported that FA is a safe and feasible tool and there was no AL in patients whose anastomosis was revised using this technique [2], subsequent randomized evidence has not consistently demonstrated statistical superiority. A multicenter randomized controlled trial reported no statistically significant reduction in AL in the ICG arm, although this method led to additional proximal bowel resection in some cases [12], and the PILLAR III trial reported no difference in AL despite successful visualization of perfusion and argued that adding routine ICG FA offers no evident clinical benefit in experienced hands [13].

However, recent large-scale evidence suggests that the clinical value of ICG may lie specifically in preventing severe complications. The EssentiAL trial reported that ICG FA significantly reduced the AL rate, although the actual reduction rate of AL in the ICG+ group was lower than expected [14]. They evaluated AL according to the International Study Group of Rectal Cancer (ISREC) proposal [15]: grade A, radiological leakage (no clinical symptoms or active therapeutic intervention); grade B, symptomatic leakage without re-laparotomy; and grade C, symptomatic leakage requiring re-laparotomy. In their results, the overall AL rate (grade A+B+C) was significantly lower in the ICG+ group than in the ICG− group (7.6% vs. 11.8%; P=0.041), and the clinically relevant AL rate (grade B+C) was significantly lower (4.7% vs. 8.2%; P=0.044), as was the reoperation rate (0.5% vs. 2.4%; P=0.021). These findings indicate that intraoperative perfusion assessment significantly mitigates the risk of severe, clinical AL rather than minor subclinical radiological AL.

The efficacy of ICG FA appears to be particularly pronounced in low anterior resections (LAR). The FLAG trial reported a significant reduction in AL specifically for low anastomoses (4–8 cm from the anal verge), whereas no benefit was observed for higher anastomoses (9–15 cm from the anal verge), and concluded that ICG FA is associated with a reduction in AL following LAR [16]. Because ensuring perfusion of the proximal colon is more challenging in LAR than in anterior resection due to the longer reach, this location-specific benefit may help refine selection of cases in which ICG FA provides meaningful benefit. However, considering the benefit of ICG FA according to AL grade, the findings of the FLAG trial [16] were not similar to the findings of the EssentiAL trial. They also reported that intraoperative FA was an independent factor for AL in their following study. These discrepancies may have resulted from differences in study design, including inclusion criteria; the presence of other AL risk factors beyond ischemia; creation of ileostomy; or diagnostic protocols for AL. They also reported that intraoperative FA was an independent factor for AL [17].

Consequently, the routine application of ICG across all colorectal procedures remains controversial. The AVOID trial reported that ICG did not reduce 90-day AL rates across all types of colorectal surgeries and suggested further research in subgroups, such as rectosigmoid resection, where ICG FA might be beneficial [18]. The recent IntAct trial reported no significant overall benefit for ICG FA, but suggested that ICG may help prevent grade A or B AL, whereas grade C AL rates were similar between the ICG and standard-care groups [19]. This finding, which contrasts with the ESSENTIAL trial but aligns with the FLAG trial, suggest that ICG FA may help prevent less-severe AL due to subtle ischemia but may not prevent more severe AL driven by other factors, such as preoperative radiation. Despite conflicting findings regarding grade A and grade C AL, ICG FA generally tends to show a benefit for grade B AL. More recently, the ICG-COLORAL trial reported that routine use of ICG FA for colon surgery excluding LAR does not significantly reduce the overall AL rate but may be beneficial in LAR [20].

Collectively, while the statistically significant benefit of routine ICG FA across all colorectal cancer surgery remains unclear; multiple lines of evidences consistently point toward a protective effect, particularly in high-risk scenarios such as LAR and for the prevention of grade B AL [21–24].

Table 1 summarizes prospective trials of ICG FA for AL: Although findings on overall AL reduction remain inconsistent, a number of studies suggest a potential benefit of ICG FA in LAR [2, 12–14, 16, 18–20].

Quantitative perfusion analysis

Because judging perfusion status with fluorescent imaging is subjective, recent investigations have advanced from qualitative visualization toward quantitative perfusion analysis [25]. In a retrospective study that conducted quantitative analyses of parameters such as the fluorescence difference between maximum and baseline intensity (ΔF), the perfusion time from first fluorescence to maximum (ΔT), and the fluorescence slope (ΔF/ΔT), the time from the initial fluorescence increase to half of the maximum (T_1/2MAX) and the time ratio (TR=T_1/2MAX/T_MAX) correlated with AL. TR >0.6, indicating slow perfusion, was significantly associated with AL, and the authors suggested that TR may be the most reliable perfusion predictor of AL [26]. In addition, a significant correlation between lower F_pos (level of fluorescence at a subjectively selected point of section) and Slope (F_max/∆T, in units per second) and AL has been reported. The researchers suggested to change the division site when F_pos is lower than 169 U or Slope is lower than 14.4 U/sec [27]. In contrast, another study reported that although time-to-maximum intensity was an important metric, it did not correlate significantly with AL [28]. For more accurate analysis, the integration of artificial intelligence (AI) has also been actively studied [29–31].

Several recent systematic reviews reported that the clinical application of quantitative ICG analysis is scarce and that methods vary widely across studies and devices [32], and that this area has so far seen limited clinical advancement beyond feasibility studies [33].

Limitations and future outlook

Despite the aforementioned evidence, fluorescence perfusion imaging continues to face several limitations. These limitations include the heterogeneity of methodologies, an absence of substantial evidence supporting its benefits, and a lack of clarity regarding which subgroups of patients would benefit. Additionally, there is a need for standardization in the acquisition and quantitative analysis of perfusion data, as well as the practical application of devices for this purpose. In the future, the integration of fluorescence data with AI and digital surgical platforms will represent the next step. The implementation of automated quantification techniques holds considerable promise in providing objective perfusion thresholds, real-time alerts for ischemic risk, and post hoc quality metrics for surgical auditing. As these technologies continue to develop and mature, it is anticipated that perfusion assessment will undergo a transformation, evolving from a visual process to one that is quantifiable, standardized, and assisted by algorithms.

Effective lymph node dissection: fluorescence-guided lymph node mapping

Completeness of D3 dissection

Navigational surgery with fluorescence-guided lymph node mapping (FLNM) has emerged as an efficient technique for achieving D3 lymph node (LN) dissection completeness. Peritumoral injection of ICG enables real-time visualization of tumor-draining lymphatic routes, including apical LNs, during central vascular ligation, and offers a distinct anatomical advantage [34]. Indeed, comparative studies indicate that FLM significantly enhances the quantitative yield of lymphadenectomy. For instance, in right hemicolectomy (RHC), the use of FLM has been associated with a significantly higher harvest of central and total LNs compared to conventional methods, effectively targeting the D3 area without altering the yield of pericolic or intermediate nodes [35, 36]. Thus, real-time tracking appears to technically facilitate the removal of apical nodes, particularly in advanced right-sided colon cancer.

However, increased nodal harvest has not consistently translated into superior oncologic staging or outcomes. Across multiple studies, including the aforementioned RHC trials and those focusing on sigmoid and rectal cancer, the number of metastatic LNs (D1, D2, or D3) remained statistically similar between fluorescence and standard groups [35–37]. Although many studies report improved LN detection of ICG FLM [38], this technique can drive LN dissection beyond D3 boundaries, which means distant LNs, and it remains unclear whether such preventive extension improves long-term oncologic outcomes, especially when that area harbors no metastatic LN. Long-term data support this skepticism. A comparative study reported that FLM RHC increased the number of total, intermediate, and central LNs, but 3-year relapse-free survival and overall survival were unchanged [39]. A recent meta-analysis conducted for stage II/III colorectal cancer showed no significant improvement in long-term outcomes, including 3-year overall survival, relapse-free survival, or local recurrence, despite favorable overall detection rate and the metastatic rate of ICG-positive nodes [40]. These findings suggest that D3 or extended (beyond D3) dissection increases LN yield without demonstrating oncologic benefit, including local control. The oncologic benefit of this procedure remains uncertain and requires further evaluation [41].

Nevertheless, the value of FLM may lie in surgical precision and procedural safety rather than nodal yield alone, particularly in technically demanding procedures for disease with extensive LN involvement. In challenging scenarios such as mid-low rectal cancer, FLM has been shown to enhance the accuracy of dissection. Recently, a multicenter comparative study reported significantly more metastatic IMA LNs in rectal cancer surgery [42], and a nonrandomized controlled prospective study reported that radical surgery assisted by lymphadenectomy with FLM significantly improved the accuracy and yield of LN dissection in mid-low rectal cancer, with a higher median number of harvested station 253 LNs and a significantly shorter hospital stay compared with controls [43]. If navigational lymphadenectomy with FLM improves procedural safety and postoperative recovery, it may enhance not only pathologic and oncologic outcomes but also surgical outcomes. It is also necessary to define subgroups most likely to benefit from FLM, such as advanced colorectal cancer with apical LN or even distant LN metastases. Although right and mid-colon cancers may have greater procedural advantages with FLM because of the more variable vasculature from the superior mesenteric artery, the technique may still be considered for lymphatically advanced left colon and rectal cancers [44]. In 2025, the ISCAPE trial reported an ICG lymphatic mapping sensitivity of 95.6%, which was favorable but did not meet the predefined sensitivity threshold (99%) [45]. In addition to the demonstration of the oncological benefits of FLM, further refinement of the technique's quality is imperative.

Table 2 summarizes key studies on ICG-guided FLM for D3 dissection [35–37, 39, 40, 42, 43, 45]. Overall, FLM was associated with an increased central and total LN harvest, whereas the number of metastatic LNs remained largely unchanged, with no clear evidence of a benefit in long-term oncologic outcomes.

Detection of sentinel LN

The concept of sentinel LN (SLN) mapping aims to de-escalate surgical extent by identifying the primary drainage basin, thereby sparing patients from unnecessary extensive lymphadenectomy in early-stage disease. While this approach is the standard of care in breast cancer and melanoma, its application in colorectal surgery has not yet been universally established despite reports of safety and feasibility. This discrepancy is primarily attributed to the complex, multidirectional nature of mesenteric lymphatic drainage, which complicates the reproducible identification of a single sentinel basin and leads to inconsistent diagnostic performance regarding staging accuracy and survival [46–50].

However, evidence suggests that the efficacy of SLN mapping (SLNM) is stage dependent. Meta-analyses indicate that detection rates, accuracy, and sensitivity are notably favorable in early-stage (T1/T2) colon cancer compared to advanced (T3/T4) disease, where lymphatic flow is more erratic [51]. To further overcome anatomical limitations, future integration of tumor-targeted fluorescence tracers is anticipated to enhance nodal stratification by identifying micrometastatic spread.

Recent advancements integrating robotic platforms and molecular techniques have begun to address these precision gaps. For instance, robot-assisted fluorescence guidance has demonstrated the capacity to detect SLNs as small as 1 mm in cT1–2N0M0 cases, confirming high technical precision. Furthermore, combining peritumoral ICG injection with molecular assays, such as 1-step nucleic acid amplification, has been shown to enhance staging accuracy and expedite the transition to adjuvant chemotherapy [52, 53]. Nevertheless, despite these technological strides, a standardized methodology for intraoperative decision-making remains to be established before SLNM can be adopted as a routine procedure.

Lateral pelvic LN dissection

Lateral pelvic LN dissection (LPLND) is pivotal for reducing local recurrence in advanced rectal cancer, yet it remains a technically formidable procedure associated with significant morbidity, including hemorrhage and nerve injury. Fluorescence imaging has emerged as a vital navigational tool, visualizing lateral lymphatic routes and vascular structures to facilitate radical yet safe dissection [54]. Clinical evidence indicates a technical benefit; studies have reported that fluorescence guidance is associated with reduced intraoperative blood loss and increased lateral nodal yield [55, 56]. More importantly, these technical advantages may translate into improved long-term oncologic outcomes. Regarding long-term outcomes, a propensity score-matched analysis demonstrated a significant difference in local recurrence rates (0% in the ICG group vs. 9.3% in the non-ICG group), suggesting that improved visualization may contribute to better local control [57]. Moreover, fluorescence guidance is being explored to facilitate "selective" LPND strategies. Recent studies on lateral pelvic SLNM reported favorable diagnostic accuracy with no false negatives, indicating that this technique might help identify candidates for whom prophylactic dissection could be omitted [58, 59]. However, more robust evidence with long-term outcomes is required to establish oncologic benefit.

This approach is particularly relevant in the post-neoadjuvant setting, where fluorescence can identify functional drainage channels not visible on magnetic resonance image (MRI), potentially enabling more targeted removal. The integration of AI-assisted interpretation could further refine this process by analyzing lymphatic flow patterns and correlating them with preoperative data to predict metastasis risk.

Limitations and future outlook

Despite these advances, standardizing the methodology for lymphatic mapping and quantitative evaluation remains a challenge. To enhance precision, intraoperative fluorescence signals need to be integrated with preoperative imaging within a unified workflow. The application of AI analytics and robotic platforms could facilitate this integration by generating automated lymphatic maps and objective kinetic metrics. This evolution represents a move toward a data-driven decision-support system that optimizes surgical strategy. Looking ahead, the development of tumor-targeted fluorescence tracers is a key area for future research. By offering higher specificity for LN metastasis compared to non-specific agents, these tracers have the potential to reduce false positives and improve staging accuracy.

Tumor-targeted FGS

Concept and rationale

Perfusion analysis and LN mapping have markedly improved surgical quality, but they are not cancer-specific technologies. Although many reports describe detection of peritoneal and hepatic metastases [60–62], the underlying mechanism is largely attributable to the enhanced permeability and retention effect of tumor tissue [63]. Fluorescence imaging with tumor-targeting probes has therefore evolved over the past decades to enable more precise intraoperative tumor detection, the paradigm has shifted from depicting anatomy to depicting biology. A substantial number of probes conjugated to NIR fluorophores have been developed in numerous preclinical studies (Fig. 1) [64] and evaluated in the clinical settings [5]. For gastrointestinal cancers including colorectal cancer, promising candidates under active investigation include anti–carcinoembryonic antigen (CEA) antibodies (e.g., SGM-101, the most extensively studied), CXC chemokine receptor 4 (CXCR4), epidermal growth factor receptor (EGFR), epithelial cell adhesion molecule (EpCAM), matrix metalloproteinases (MMPs), mucins, vascular endothelial growth factor (VEGF), cathepsins, tumor-associated glycoprotein 72 (TAG-72), and folate receptor alpha (FRα) among others [65]. Tumor-targeted techniques may be particularly valuable in three challenging scenarios: (1) detection of occult tumor; (2) characterization of indeterminate lesions; and (3) therapeutic decision-making after preoperative treatment.

Detection of occult tumor

As evidence of the oncologic benefit of active radical resection of metastatic colorectal cancer has been accumulated, indications for radical surgery have expanded and operations for multiple lesions have increased. During surgery with curative intention, small lesions frequently escape visual detection under white light. Tumor-targeted FGS enables real-time identification of these lesions and verification of R0 resection.

Multiple studies have consistently demonstrated that ICG fluorescence improves the detection of peritoneal metastases compared to white-light inspection alone. The application of the VEGF-targeted NIR tracer bevacizumab-IRDye800CW during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) was shown to achieve a negative predictive value of 100% and a positive predictive value of 53%, and it enabled detection of lesions initially missed by surgeons [61]. The SGM-101 study group reported that SGM-101 use in patients with peritoneal metastasis from colorectal cancer was feasible and allowed intraoperative detection of tumor deposits with modification of the peritoneal carcinomatosis index (PCI) (Fig. 2) [66]. They reported the first clinical use of CEA-targeted detection in colorectal cancers and showed that SGM-101 was safe and improved clinical decision-making during surgery. A dose of 10 mg administered 4 days before surgery yielded the highest tumor to background ratio (TBR) without adverse events [67]. Subsequently, they confirmed 10 mg 4 days before surgery as the optimal imaging dose and noted that the surgical plan was altered in 24% of patients, with additional malignant lesions detected in some patients [68]. They also reported a prospective, open-label feasibility study of SGM-101 for colorectal lung metastases [69], in which closed-field imaging showed excellent targeting of the tumor nodules, though challenges remained for in vivo detection. Technical evolution continues with dual-modality probes; the introduction of In-DOTA-labetuzumab-IRDye800CW, a dual-labeled anti-CEA antibody conjugate, enables both preoperative imaging and intraoperative radio- and fluorescent-guidance during CRS for colorectal peritoneal metastases [69].

However, the translation of improved detection into survival benefit remains the critical question. Recent follow-up data from 2025 regarding SGM-101 reported no statistically significant improvement in long-term outcomes, although this finding was constrained by a small, single-arm cohort design. Consequently, a randomized controlled trial evaluating SGM-101 for primary and metastatic colorectal cancer has been ongoing since 2019 (ClinicalTrials.gov identifier: NCT03659448).

Characterization of intermediate lesions

Since the development of conversion systemic therapy for borderline-resectable metastatic colorectal cancer and total neoadjuvant therapy (TNT) for locally advanced rectal cancer, intraoperative differentiation of indeterminate nodules or LN, distinguishing tumor-bearing from tumor-free lesions, has become increasingly common and clinically important. Intraoperative molecular imaging with tumor-targeted FGS can enable real-time discrimination between malignant and benign tissue/complete response. Avoiding unnecessarily extensive resection of liver, peritoneum, and LPN may improve surgical outcomes, expedite postoperative recovery, and allow timely postoperative systemic therapy. A preclinical investigation utilizing dual-labeled tilmanocept (a receptor-targeted radiopharmaceutical) has demonstrated the feasibility of lateral pelvic SLNM in porcine models and suggested that this technique could reduce morbidity and operative time by identifying patients who will not require LPND [70]. These findings suggest a potential future strategy where functional mapping guides the omission of extensive dissection in node-negative patients, thereby reducing operative time and associated complications.

Therapeutic decision-making after preoperative treatment

The development of TNT has shifted the paradigm for rectal cancer treatment from sphincter preservation to organ preservation. Accurate clinical response assessment is now central to organ preservation strategies. Numerous methods including digital rectal exam, MRI, and endoscopy have been used to assess tumor response, distinguish viable tumor from posttreatment fibrosis, and to select the patients who may be managed with a watch-and-wait strategy.

In this diagnostic landscape, tumor-targeted fluorescence imaging may not only enhance intraoperative decision-making and surgical outcomes but also improve assessment of treatment response and decisions regarding organ preservation. Quantitative fluorescence endoscopy targeting VEGF-A indicated a significantly higher fluorescence in tumor than in benign fibrosis and improved prediction of final pathology compared with standard MRI and white-light endoscopy (Fig. 3) [71]. Notably, this molecular interrogation showed superior predictive accuracy, suggesting a potential role in refining patient selection for nonoperative management.

Outlook and future directions

Although the methodology is conceptually attractive, it still yields both false negatives and false positives in preclinical studies and clinical settings. Signal interpretation should be quantitative, for example by using TBR, and additional antibodies requires regimen-specific evaluation and validation to improve accuracy. The next step for tumor-targeted FGS is to integrate it with digital and robotic imaging platforms, combine it with preoperative imaging modalities, and apply AI for quantitative signal analysis. As these technologies mature, tumor-specific FGS may function as an intraoperative molecular diagnostic and decision-making tool and guide therapeutic choices after preoperative treatment.

FUTURE PERSPECTIVES

Expansion into the NIR-II window

Current FGS primarily uses NIR-I range (700–1,000 nm). Most research has focused on developing and implementing fluorescent probes near 800 nm; many commercially available agents, including ICG, lie within this region. However, the higher spatial resolution in NIR-I comes at the cost of limited tissue penetration, and signal is attenuated by tissue and water absorption [72]. To overcome these physical constraints, seminal optical studies have identified that tissue transparency is maximized within the 1.0–1.4 μm range, designated as the NIR-II window [73].

The NIR-II window offers distinct optical advantages over its predecessor. First, the physics of longer wavelengths results in substantially reduced photon scattering within biological tissues, enabling visualization depths ranging from several millimeters to centimeters. Second, background noise is minimized because endogenous chromophores, such as collagen and hemoglobin, exhibit negligible autofluorescence in this spectral region. Consequently, this combination of deep penetration and high signal-to-background ratios allows for the high-contrast, real-time delineation of vascular, lymphatic, and tumor structures, even within optically dense tissues [74].

Despite this potential, the clinical translation of NIR-II imaging requires further maturation. Although conventional dyes have been explored for NIR-II tail emission in applications such as lymphatic mapping and tumor margin detection [75], most putative NIR-II fluorophores (e.g., CH1055, IR-1061, rare-earth nanoparticles) remain preclinical [76], and no clinically approved NIR-II agents are currently available. Furthermore, implementation necessitates specialized detection hardware distinct from standard NIR-I platforms [77]. Nevertheless, accumulating evidence supports NIR-II as a promising foundation for the next generation of FGS, poised to deliver superior precision in deep-tissue imaging.

Optimization of imaging platforms and digital quantification

Achieving more precise FGS requires not only the development of novel promising fluorophores and wavelength optimization but also optical/hardware enhancements to imaging platforms and their digital evolution. Modern laparoscopic and robotic systems enable real-time NIR overlays and refined depth perception, providing stable conditions for perfusion assessment and tumor localization with high-quality visualization. However, current platforms remain largely limited to ICG-based imaging and lack standardized quantitative metrics and automated data capture. Ongoing work focuses on integrated perfusion analytics capable of extracting fluorescence kinetics, such as time-to-peak, Slope, and intensity ratio, to objectively assess tissue viability [78, 79]. Likewise, real-time intraoperative identification of tumor-positive lesions with quantitative TBR threshold is needed for precise tumor-targeted FGS. Many studies have evaluated whether AI/deep learning can advance these capabilities [80]. As robotic systems evolve toward data-centric frameworks, FGS is poised to function as a core sensor modality, linking optical signals with machine intelligence to establish reproducible, evidence-based surgical standards.

Development of hybrid and dual-modality probes

Integrating fluorescence imaging with magnetic resonance or nuclear imaging aims to combine the molecular specificity of FGS with the quantitative, deep-tissue information of conventional imaging modalities. Recent preclinical studies have demonstrated the feasibility of dual-labeled probes, such as ⁶⁸Ga-IRDye800CW-BBN, anti-CEA antibody–IRDye800CW conjugates, and positron emission tomography (PET)/NIR dual-labeled peptides, for accurate tumor localization and resection-margin validation in colorectal and other gastrointestinal cancer models [81, 82]. Although these approaches remain at the animal and translational research stages, they highlight the potential of hybrid tracers to provide seamless preoperative-to-intraoperative correlation, quantitative preoperative staging, and real-time optical guidance during resection.

The main challenges include complex probe synthesis, limited regulatory pathways for dual-labeled agents, and the high cost of hybrid imaging platforms, all of which must be addressed before clinical application. Despite current limitations, fully integrating preoperative and intraoperative imaging with combined interpretation may represent a mature form of surgical information flow in the future.

CONCLUSION

FGS has evolved from a visual adjunct to a data-driven instrument of precision. Continuous refinement of fluorophores, imaging systems, and analytic frameworks now provide real-time insight into perfusion, lymphatic flow, and tumor biology—domains once invisible to the human eye. Clinical evidence supports its role in enhancing intraoperative judgment, especially in complex pelvic and metastatic surgery, while ongoing trials are defining its quantitative impact on outcomes.

The convergence of optical physics, robotics, and AI is transforming fluorescence into an integrated digital ecosystem. Quantitative metrics establish objective perfusion thresholds, AI converts photons into biologic information, and robotic platforms ensure stability and reproducibility, together advancing surgery toward a closed-loop paradigm in which data guide real-time action.

Future progress will depend on international standardization, open data sharing, and equitable access to innovation. As fluorophores evolve from nonspecific dyes to molecularly targeted and NIR-II agents, and as imaging shifts from observation to interpretation, fluorescence is poised to become a cornerstone of intelligent, image-based surgery. Ultimately, this field is not merely enhancing what surgeons see, it is empowering how surgeons decide, marking the beginning of the next era in surgical science.

ARTICLE INFORMATION

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Fig. 1.

Intra-abdominal imaging of orthotopic nude mouse models of colorectal liver metastases (CRLMs) derived from LS174T cells with a Stryker 1688 Imaging System (Stryker Corp) 72 hours after M5A-IR800 injection. (A–C) White light images showing liver metastases. (D–F) SPY overlay images with M5A-IR800 labeling of CRLMs in green. (G–I) SPY contrast images with bright M5A-IR800 labeling of CRLMs. Reproduced from Lee et al. [64] under the Creative Commons CC BY license.

Fig. 2.

Ex vivo fluorescence imaging of a lesion in the omentum. (A) White light. (B) Near-infrared (NIR) fluorescence. (C) White light and NIR fluorescence merged image, revealing a clinically unsuspected lesion detected in vivo, raising the peritoneal carcinomatosis index from 4 to 6. Histopathological examination confirmed that this lesion was malignant. Reproduced from Schaap et al. [66] under the Creative Commons CC BY-NC-ND license.

Fig. 3.

Representative images of the quantitative fluorescence endoscopy (QFE) procedure after neoadjuvant chemoradiotherapy of a patient with (A) residual tumor, (B) submucosal tumor, (C) mucosal high-grade dysplasia (HGD) and (D) a pathological complete response. Arrows and dotted circles indicate the tumor. From left to right: a high-definition white-light video endoscope image of the rectal tumor; a white-light image from the QFE fiberoptic; the corresponding near-infrared (NIR) fluorescence image captured with an exposure time of 100 msec; the composite image of both modalities; and a hematoxylin-eosin (HE) staining of the surgical specimen in which the pathological TNM stage is indicated. The maximum quantified fluorescence value is depicted on the NIR fluorescence image. Reproduced from Tjalma et al. [71] under the Creative Commons CC BY license.

Table 1.

Clinical evidence on fluorescence-guided perfusion assessment

Study	Trial	Study design	No. of subjects	AL	Outcome
Jafari et al. [2] (2015)	PILLAR II	Prospective, multicenter, open label	139	1.4%	Change of surgical plan: 8% (AL, 0%)
De Nardi et al. [12] (2020)	-	Multicenter, randomized	240 (118 vs. 122)	5% vs. 9% (P=NS)	Extended bowel resection: 11%
Alekseev et al. [16] (2020)	FLAG trial	Single center, randomized	377 (187 vs. 190)	9.1% vs. 16.3% (P=0.04)	High anastomosis: 1.3% vs. 4.6% (P=0.37)
Alekseev et al. [16] (2020)	FLAG trial	Single center, randomized	377 (187 vs. 190)	9.1% vs. 16.3% (P=0.04)	Low anastomosis: 14.4% vs. 25.7% (P=0.04)
Jafari et al. [13] (2021)	PILLAR III	Multicenter, randomized	347 (178 vs. 169)	9.0% vs 9.6% (P=0.37)	Postop abscess: 5.7% vs. 4.2% (P=0.75)
Watanabe et al. [14] (2023)	EssentiAL	Multicenter, randomized, open label, phase 3	839 (422 vs. 417)^a	Grade A+B+C: 7.6% vs. 11.8% (P=0.041)	Reoperation rate: 0.5% vs. 2.4% (P=0.021)
Watanabe et al. [14] (2023)	EssentiAL	Multicenter, randomized, open label, phase 3	839 (422 vs. 417)^a	Grade B+C: 4.7% vs. 8.2% (P=0.044)	Reoperation rate: 0.5% vs. 2.4% (P=0.021)
Faber et al. [18] (2024)	AVOID	Multicenter, randomized, phase 3	982 (490 vs. 492)	90-Day clinical AL: 7% vs. 9% (P=0.24)	90-Day serious adverse events: 25% vs. 24%
Jayne et al. [19] (2025)	IntAct	Unblinded, randomized	698 (343 vs 355)	90-Day clinical AL: 10% vs. 15% (P=0.087)	Grade A: 3% vs 6%
					Grade B: 3% vs 9%
					Grade C: 7% vs 6%
Rinne et al. [20] (2025)	ICG-COLORAL	Randomized	1,136 (567 vs. 569)	5.8% vs. 7.9% (P=0.16)	Right colon: 5.9% vs. 6.7%
Rinne et al. [20] (2025)	ICG-COLORAL	Randomized	1,136 (567 vs. 569)	5.8% vs. 7.9% (P=0.16)	Left colon: 5.2% vs. 9.5%

AL, anastomotic leakage; NS, not significant.

^aExpected reduction rate of AL, 6%.

Table 2.

Clinical evidence on fluorescence-guided LN dissection

Study	Study design	No. of subjects	Inclusion criteria	Total no. of harvested LN	Outcome	Oncologic outcome
Park et al. [35] (2020)	Retrospective, 1:2 matched case-control	75 (25 vs. 50)	Right colon cancer (cT3–T4)	39 vs. 30 (P=0.003)	Central LN: 14 vs. 7 (P<0.001)	-
Wan et al. [37] (2022)	Randomized	66	Sigmoid and rectal cancer	28 vs. 19 (P=0.001)	D3 LN: 7 vs. 5 (P=0.003)	-
Wan et al. [37] (2022)	Randomized	66	Sigmoid and rectal cancer	28 vs. 19 (P=0.001)	No difference in positive LN	-
Son et al. [36] (2023)	Prospective, case-control	291	RHC	-	D3 area FLM > control (P<0.001)	-
Son et al. [36] (2023)	Prospective, case-control	291	RHC	-	No difference in metastatic D3 LN (P=0.730)
Daibo et al. [39] (2024)	Multicenter, retrospective, PSM	462 (231 vs. 231)	RHC	31 vs. 27 (P=0.047)	Central LN: 6 vs. 4 (P<0.001)	3Y RFS: 88.8 vs 89.4 (P=0.721)
Daibo et al. [39] (2024)	Multicenter, retrospective, PSM	462 (231 vs. 231)	RHC	31 vs. 27 (P=0.047)	Intermediate LN: 7 vs. 6 (P=0.03)	3Y OS: 94.5 vs 94.7 (P=0.300)
Guo et al. [40] (2024)	Systematic review and meta-analysis	1,552 (922 vs. 630)	Colorectal cancer (stage II/III)	23.5 vs. 18.9 (P<0.00001)	Overall detection rate of SLN: 86.8	3Y OS: 94.1 vs 93.1 (P=0.61)
					Metastatic rate of ICG+ LN: 22.8	3Y RFS: 85.1 vs 86.2 (P=0.72)
						3Y LR 7.6 vs 9.7 (P=0.38)
Chen et al. [42] (2025)	Multicenter, retrospective, PSM	282 (141 vs. 141)	Rectal cancer	21 vs. 17 (P<0.001)	Metastatic IMA LN: 15.6 vs. 5.7 (P=0.007)	-
Panaiotti et al. [45] (2025)	Prospective, single-center, single-arm, phase 2 interventional	101	Colon cancer	-	FLM sensitivity 95.6% (not met the predefined sensitivity threshold 99%)	-
Qiu et al. [43] (2025)	Nonrandomized, controlled, prospective	64 vs. 65	Mid-low rectal cancer	20 vs. 17 (P=0.407)	Station 253 LN: 2.0 vs. 1.0 (P=0.0007)	-
					Station 252 LN: 6.0 vs. 5.0 (P=0.369)
					Station 251 LN: 10.0 vs. 11.0 (P=0.872)

LN, lymph node; RHC, right hemicolectomy; FLM, fluorescence-guided lymph node mapping; RFS, relapse-free survival; OS, overall survival; PSM, propensity score matching; SLN, sentinel lymph node; ICG, indocyanine green; LR, local recurrence; IMA, inferior mesenteric artery.

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Fluorescence-guided surgery in colorectal cancer: current evidence, quantitative advances, and future perspectives

Ann Coloproctol. 2026;42(1):58-71. Published online February 25, 2026

DOI: https://doi.org/10.3393/ac.2025.01438.0205

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Fluorescence-guided surgery in colorectal cancer: current evidence, quantitative advances, and future perspectives

Fig. 1. Intra-abdominal imaging of orthotopic nude mouse models of colorectal liver metastases (CRLMs) derived from LS174T cells with a Stryker 1688 Imaging System (Stryker Corp) 72 hours after M5A-IR800 injection. (A–C) White light images showing liver metastases. (D–F) SPY overlay images with M5A-IR800 labeling of CRLMs in green. (G–I) SPY contrast images with bright M5A-IR800 labeling of CRLMs. Reproduced from Lee et al. [64] under the Creative Commons CC BY license.

Fig. 2. Ex vivo fluorescence imaging of a lesion in the omentum. (A) White light. (B) Near-infrared (NIR) fluorescence. (C) White light and NIR fluorescence merged image, revealing a clinically unsuspected lesion detected in vivo, raising the peritoneal carcinomatosis index from 4 to 6. Histopathological examination confirmed that this lesion was malignant. Reproduced from Schaap et al. [66] under the Creative Commons CC BY-NC-ND license.

Fig. 3. Representative images of the quantitative fluorescence endoscopy (QFE) procedure after neoadjuvant chemoradiotherapy of a patient with (A) residual tumor, (B) submucosal tumor, (C) mucosal high-grade dysplasia (HGD) and (D) a pathological complete response. Arrows and dotted circles indicate the tumor. From left to right: a high-definition white-light video endoscope image of the rectal tumor; a white-light image from the QFE fiberoptic; the corresponding near-infrared (NIR) fluorescence image captured with an exposure time of 100 msec; the composite image of both modalities; and a hematoxylin-eosin (HE) staining of the surgical specimen in which the pathological TNM stage is indicated. The maximum quantified fluorescence value is depicted on the NIR fluorescence image. Reproduced from Tjalma et al. [71] under the Creative Commons CC BY license.

Fig. 1.

Fig. 2.

Fig. 3.

Fluorescence-guided surgery in colorectal cancer: current evidence, quantitative advances, and future perspectives

Study	Trial	Study design	No. of subjects	AL	Outcome
Jafari et al. [2] (2015)	PILLAR II	Prospective, multicenter, open label	139	1.4%	Change of surgical plan: 8% (AL, 0%)
De Nardi et al. [12] (2020)	-	Multicenter, randomized	240 (118 vs. 122)	5% vs. 9% (P=NS)	Extended bowel resection: 11%
Alekseev et al. [16] (2020)	FLAG trial	Single center, randomized	377 (187 vs. 190)	9.1% vs. 16.3% (P=0.04)	High anastomosis: 1.3% vs. 4.6% (P=0.37)
Alekseev et al. [16] (2020)	FLAG trial	Single center, randomized	377 (187 vs. 190)	9.1% vs. 16.3% (P=0.04)	Low anastomosis: 14.4% vs. 25.7% (P=0.04)
Jafari et al. [13] (2021)	PILLAR III	Multicenter, randomized	347 (178 vs. 169)	9.0% vs 9.6% (P=0.37)	Postop abscess: 5.7% vs. 4.2% (P=0.75)
Watanabe et al. [14] (2023)	EssentiAL	Multicenter, randomized, open label, phase 3	839 (422 vs. 417)^a	Grade A+B+C: 7.6% vs. 11.8% (P=0.041)	Reoperation rate: 0.5% vs. 2.4% (P=0.021)
Watanabe et al. [14] (2023)	EssentiAL	Multicenter, randomized, open label, phase 3	839 (422 vs. 417)^a	Grade B+C: 4.7% vs. 8.2% (P=0.044)	Reoperation rate: 0.5% vs. 2.4% (P=0.021)
Faber et al. [18] (2024)	AVOID	Multicenter, randomized, phase 3	982 (490 vs. 492)	90-Day clinical AL: 7% vs. 9% (P=0.24)	90-Day serious adverse events: 25% vs. 24%
Jayne et al. [19] (2025)	IntAct	Unblinded, randomized	698 (343 vs 355)	90-Day clinical AL: 10% vs. 15% (P=0.087)	Grade A: 3% vs 6%
					Grade B: 3% vs 9%
					Grade C: 7% vs 6%
Rinne et al. [20] (2025)	ICG-COLORAL	Randomized	1,136 (567 vs. 569)	5.8% vs. 7.9% (P=0.16)	Right colon: 5.9% vs. 6.7%
Rinne et al. [20] (2025)	ICG-COLORAL	Randomized	1,136 (567 vs. 569)	5.8% vs. 7.9% (P=0.16)	Left colon: 5.2% vs. 9.5%

Study	Study design	No. of subjects	Inclusion criteria	Total no. of harvested LN	Outcome	Oncologic outcome
Park et al. [35] (2020)	Retrospective, 1:2 matched case-control	75 (25 vs. 50)	Right colon cancer (cT3–T4)	39 vs. 30 (P=0.003)	Central LN: 14 vs. 7 (P<0.001)	-
Wan et al. [37] (2022)	Randomized	66	Sigmoid and rectal cancer	28 vs. 19 (P=0.001)	D3 LN: 7 vs. 5 (P=0.003)	-
Wan et al. [37] (2022)	Randomized	66	Sigmoid and rectal cancer	28 vs. 19 (P=0.001)	No difference in positive LN	-
Son et al. [36] (2023)	Prospective, case-control	291	RHC	-	D3 area FLM > control (P<0.001)	-
Son et al. [36] (2023)	Prospective, case-control	291	RHC	-	No difference in metastatic D3 LN (P=0.730)
Daibo et al. [39] (2024)	Multicenter, retrospective, PSM	462 (231 vs. 231)	RHC	31 vs. 27 (P=0.047)	Central LN: 6 vs. 4 (P<0.001)	3Y RFS: 88.8 vs 89.4 (P=0.721)
Daibo et al. [39] (2024)	Multicenter, retrospective, PSM	462 (231 vs. 231)	RHC	31 vs. 27 (P=0.047)	Intermediate LN: 7 vs. 6 (P=0.03)	3Y OS: 94.5 vs 94.7 (P=0.300)
Guo et al. [40] (2024)	Systematic review and meta-analysis	1,552 (922 vs. 630)	Colorectal cancer (stage II/III)	23.5 vs. 18.9 (P<0.00001)	Overall detection rate of SLN: 86.8	3Y OS: 94.1 vs 93.1 (P=0.61)
					Metastatic rate of ICG+ LN: 22.8	3Y RFS: 85.1 vs 86.2 (P=0.72)
						3Y LR 7.6 vs 9.7 (P=0.38)
Chen et al. [42] (2025)	Multicenter, retrospective, PSM	282 (141 vs. 141)	Rectal cancer	21 vs. 17 (P<0.001)	Metastatic IMA LN: 15.6 vs. 5.7 (P=0.007)	-
Panaiotti et al. [45] (2025)	Prospective, single-center, single-arm, phase 2 interventional	101	Colon cancer	-	FLM sensitivity 95.6% (not met the predefined sensitivity threshold 99%)	-
Qiu et al. [43] (2025)	Nonrandomized, controlled, prospective	64 vs. 65	Mid-low rectal cancer	20 vs. 17 (P=0.407)	Station 253 LN: 2.0 vs. 1.0 (P=0.0007)	-
					Station 252 LN: 6.0 vs. 5.0 (P=0.369)
					Station 251 LN: 10.0 vs. 11.0 (P=0.872)

Table 1. Clinical evidence on fluorescence-guided perfusion assessment

AL, anastomotic leakage; NS, not significant.

Expected reduction rate of AL, 6%.

Table 2. Clinical evidence on fluorescence-guided LN dissection