Efficacy of indocyanine green (ICG) angiography in reducing postoperative complications in oesophagectomy: systematic review and meta-analysis
In brief
Indocyanine green imaging was linked to 56% lower odds of leaks after esophagectomy
Across 23 studies involving 2,845 patients, indocyanine green imaging was associated with lower odds of anastomotic leak; the estimated number needed to treat was 13. Conduit necrosis was also less frequent, but mortality and reoperation did not differ. Evidence certainty was low or very low, and image interpretation remains operator-dependent.
- Journal
- The British journal of surgery (Q1)
- Published
- 5 October 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Alexander A Dermanis, Dominic Thompson, Sivesh K Kamarajah, Ewen A Griffiths
- PMID
- 42929024
- DOI
- 10.1093/bjs/znag134
Why clinicians should know about it
- Picked for Surgery (paper of the day, 31 October 2026): ICG perfusion guidance and anastomotic outcomes in oesophagectomy
Abstract
BACKGROUND: Anastomotic leakage after oesophagectomy is common, and associated with significant morbidity and mortality. Indocyanine green (ICG) fluorescence angiography has emerged as a promising intraoperative adjunct for perfusion assessment at the anastomotic site. This study aims to assess the impact of ICG use on anastomotic leakage rates and postoperative outcomes. METHODS: A PRISMA-compliant systematic search of Medline, PubMed, EMBASE, and the Cochrane Library was performed. The primary outcome was anastomotic leakage. Key secondary outcomes were conduit necrosis, mortality, and reoperation; all secondary outcomes were reported. The Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) and Risk of Bias 2 (RoB 2) tools were used for investigating risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence. A random-effects meta-analysis and meta-regression as well as subgroup and sensitivity analyses were performed. RESULTS: From 902 identified studies, 23 met the inclusion criteria (including 4 RCTs; 2845 patients, of whom 1154 underwent ICG assessment). ICG use was associated with reduced anastomotic leakage rates (OR 0.44 (95% c.i. 0.29 to 0.65), P < 0.001; number needed to treat = 13) and conduit necrosis rates (OR 0.32 (95% c.i. 0.12 to 0.85), P = 0.022). Mortality (OR 1.43 (95% c.i. 0.69 to 2.97), P = 0.335), reoperation (OR 0.84 (95% c.i. 0.51 to 1.39), P = 0.500), severe anastomotic leakage, overall morbidity, readmission, operating time, and length of stay did not differ between groups. Certainty of evidence was low or very low across all outcomes (GRADE), predominantly driven by the observational study design of many of the studies. CONCLUSION: Use of ICG appears to be associated with reduced anastomotic leak in oesophagectomy, although certainty of evidence is low. Assessment remains qualitative and operator-dependent.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.