Objective:

To describe the institutional experience in selecting between sphincter-saving surgery and abdominoperineal resection (APR) for low rectal tumors and evaluate the influence of ICG perfusion assessment on intraoperative decision-making and its potential impact on postoperative outcomes.

Approach:

• Study Design: Prospective, single-center, descriptive cohort study conducted from January 2021 to December 2025 involving over 400 patients with colorectal cancer, focusing on 70 patients with low rectal cancer, of which 27 underwent sphincter-saving surgery.
• ICG-FA Implementation: Indocyanine green fluorescence angiography (ICG-FA) was performed in 22 patients (81.5%) to assess bowel perfusion at the colonic stump, with modifications made to the resection line based on fluorescence results.

Key Findings:

• ICG-FA prompted modification of the resection line in 9 of 22 patients (40%), primarily proximally.
• The decision between sphincter preservation and APR was not altered by ICG-FA.
• A radical (R0) resection was achieved in 19 of 21 patients with recorded margin status.
• Postoperative complications occurred in 15 of 27 patients (56%), mostly Clavien–Dindo grade I–II.

Interpretation:

ICG-FA is a reproducible adjunct that aids intraoperative decision-making, though its impact on reducing anastomotic complications requires further randomized studies.

Limitations:

• The study was descriptive and not designed to establish a causal effect of ICG-FA on outcomes.
• Limited sample size of patients undergoing sphincter-saving surgery.

Conclusion:

ICG-FA may enhance surgical decision-making in sphincter-saving procedures, but its effect on postoperative complications needs further investigation.