The Role of Indocyanine Green Fluorescence Angiography in Reducing Anastomotic Leaks after Esophagectomy - A Comprehensive Meta-Analysis of Comparative Studies.

Abstract

Anastomotic leaks (AL) after esophagectomy contribute to significant morbidity (up to 30%) and mortality (5-10%). Indocyanine green (ICG) fluorescence angiography offers real-time perfusion assessment, potentially reducing AL compared to conventional methods. This meta-analysis evaluates ICG's efficacy in reducing AL after esophagectomy with gastric pull-up, focusing on cervical versus intrathoracic anastomoses. This systematic review and meta-analysis followed PRISMA guidelines. A comprehensive search of PubMed and Google Scholar from 2005 to the present was performed using MeSH terms to identify comparative studies of esophagectomy with gastric conduit reconstruction. Study quality was evaluated using the MINORS criteria. Statistical analyses included forest plots, random-effects models, leave-one-out sensitivity analysis, and Trial Sequential Analysis (TSA) to assess robustness. Harbord's test evaluated publication bias of binary outcomes. Fifteen studies (2,263 patients) were included. Overall, ICG significantly reduced odds of AL by 58% (9% vs. 15.5%; OR 0.42, 95% CI: 0.26-0.70; I²=42%), with an absolute risk difference (ARD) of 6.5% (95% CI: 3.3-9.7) and a number needed to treat (NNT) of 15 (10-30). In McKeown esophagectomy (MKE) with cervical anastomosis (10 studies, 1,768 patients), ICG reduced odds of AL by 62% (9.5% vs. 17.0%; OR 0.38, 95% CI: 0.26-0.57; I²=0%), corresponding to an ARD of 7.5% (95% CI: 4.8-10.2) and NNT of 13 (10-21), with TSA and leave-one-out sensitivity analysis confirming robust evidence. In contrast, in Ivor Lewis esophagectomy (ILE) with intrathoracic anastomosis (3 studies, 302 patients), ICG showed no benefit (8.0% vs. 6.9%; OR 1.70, 95% CI: 0.12-25.01; I²=70.6%), with an ARD of - 1.1% (95% CI: -8.0 to + 5.8). ICG fluorescence angiography significantly reduces AL after esophagectomy, particularly in cervical anastomosis after MKE, with a 62% odds reduction. No significant benefit was observed in intrathoracic anastomosis after ILE. These findings support the use of ICG as a valuable tool in cervical anastomosis, while further studies are needed to clarify its role in intrathoracic anastomosis.