Use of indocyanine green in the prevention of anastomotic leak in colorectal surgeries
a systematic review
Keywords:
Anastomotic leak, Colorectal surgery, Disease Management, Fluorescence, Indocyanine greenAbstract
Anastomotic leak is a serious complication in colorectal surgery, with an incidence of up to 19% and significant mortality. Indocyanine green (ICG) allows intraoperative assessment of bowel perfusion through fluorescence imaging, but its effectiveness in reducing leaks remains controversial. This systematic review aimed to evaluate whether ICG use reduces anastomotic leak rates in colorectal surgery compared to conventional visual inspection. The search was performed in PubMed using MeSH terms, identifying 198 articles. After applying inclusion and exclusion criteria, 7 randomized controlled trials were analyzed. Two studies demonstrated significant leak reduction with ICG (Alekseev et al., 2020: 16.3% vs 9.1%, p=0.04; Watanabe et al., 2023: 11.8% vs 7.6%, p=0.041), while five studies showed no statistically significant difference, although with a numerical trend favoring ICG. Subgroup analyses suggest ICG benefit in low anastomoses (rectal). No serious adverse events were reported. ICG is safe, but its clinical efficacy remains uncertain. Routine use for all colorectal surgeries is not recommended, although it may be promising in high-risk scenarios, such as low rectal surgery.
References
Soares AS, Bano S, Clancy NT, Stoyanov D, Lovat LB, Chand M. Intraoperative bowel perfusion assessment methods and their effects on anastomotic leak rates: meta-analysis. Surgery. 2022;172(1):69-73. doi: 10.1016/j.surg.2021.12.021.
De Nardi P, Elmore U, Maggi G, Maggiore R, Boni L, Cassinotti E, Fumagalli U, Gardani M, De Pascale S, Parise P, Vignali A, Rosati R. Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc. 2020;34(1):53-60. doi: 10.1007/ s00464-019-06730-0.
Borg L, Portelli M, Testa L, Andrejevic P. The use of indocyanine green for colorectal anastomoses: a systematic review and meta analysis. Ann R Coll Surg Engl. 2025 Jul;107(6):390-396. doi: 10.1308/rcsann.2024.0002.
Alekseev MV, Rybakov EG, Achkasov SI. Fluorescence angiography in colorectal surgery. Khirurgiia (Mosk). 2023;(9 Vyp 2):58-62. doi: 10.17116/hirurgia202309258.
Kazi M, Ajith A, Bhoyar A, Yelamanchi R. Fluorescence imaging in reducing anastomotic leak after left-sided colorectal resections: a systematic review and updated meta-analysis. ANZ J Surg. 2024;94(12):2128-2136. doi: 10.1111/ans.19201.
Xia S, Wu W, Luo L, Ma L, Yu L, Li Y. Indocyanine green fluorescence angiography decreases the risk of anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis. Front Med (Lausanne). 2023;10:1157389. doi: 10.3389/fmed.2023.1157389.
Alekseev M, Rybakov E, Shelygin Y, Chernyshov S, Zarodnyuk I. A study investigating the perfusion of colorectal anastomoses using fluorescence angiography: results of the FLAG randomized trial. Colorectal Dis. 2020;22(9):1147-1153. doi: 10.1111/codi.15037.
Watanabe J, Takemasa I, Kotake M, Noura S, Kimura K, Suwa H, Tei M, Takano Y, Munakata K, Matoba S, Yamagishi S, Yasui M, Kato T, Ishibe A, Shiozawa M, Ishii Y, Yabuno T, Nitta T, Saito S, Saigusa Y, Watanabe M. Blood Perfusion Assessment by Indocyanine Green Fluorescence Imaging for Minimally Invasive Rectal Cancer Surgery (EssentiAL trial): A Randomized Clinical Trial. Ann Surg. 2023;278(4):e688-e694. doi: 10.1097/SLA.0000000000005907.
Faber RA, Meijer RPJ, Droogh DHM, Jongbloed JJ, Bijlstra OD, Boersma F, Braak JPBM, Meershoek-Klein Kranenbarg E, Putter H, Holman FA, Mieog JSD, Neijenhuis PA, van Staveren E, Bloemen JG, Burger JWA, Aukema TS, Brouwers MAM, Marinelli AWKS, Westerterp M, Doornebosch PG, van der Weijde A, Bosscha K, Handgraaf HJM, Consten ECJ, Sikkenk DJ, Burggraaf J, Keereweer S, van der Vorst JR, Hutteman M, Peeters KCMJ, Vahrmeijer AL, Hilling DE. Indocyanine green near-infrared fluorescence bowel perfusion assessment to prevent anastomotic leakage in minimally invasive colorectal surgery (AVOID): a multicentre, randomised, controlled, phase 3 trial. Lancet Gastroenterol Hepatol. 2024;9(10):924-934. doi: 10.1016/S2468-1253(24)00198-5.
Jayne D, Croft J, Corrigan N, Quirke P, Cahill RA, Ainsworth G, Meads DM, Kirby A, Tolan D, Gordon K, Hompes R, Spinelli A, Foppa C, Wolthuis AM, D’Hoore A, Vignali A, Tilney HS, Moriarty C, Vargas-Palacios A, Young C, Kelly R, Stocken D. Intraoperative fluorescence angiography with indocyanine green to prevent anastomotic leak in rectal cancer surgery (IntAct): an unblinded randomised controlled trial. Lancet Gastroenterol Hepatol. 2025;10(9):806-817. doi: 10.1016/S2468-1253(25)00101-3.
Haddaway NR, Page MJ, Pritchard CC, McGuinness LA. PRISMA2020: An R package and Shiny app for producing PRISMA 2020-compliant flow diagrams, with interactivity for optimised digital transparency and Open Synthesis. Campbell Systematic Reviews. 2022;18(2):e1230. doi: 10.1002/cl2.1230.
Rinne JKA, Huhta H, Pinta T, Turunen A, Mattila A, Tahkola K, Helminen O, Ohtonen P, Rautio T, Kössi J. Indocyanine Green Fluorescence Imaging in Prevention of Colorectal Anastomotic Leakage: A Randomized Clinical Trial. JAMA Surg. 2025;160(5):486-493. doi: 10.1001/jamasurg.2025.0006.
Jafari MD, Pigazzi A, McLemore EC, Mutch MG, Haas E, Rasheid SH, Wait AD, Paquette IM, Bardakcioglu O, Safar B, Landmann RG, Varma MG, Maron DJ, Martz J, Bauer JJ, George VV, Fleshman JW Jr, Steele SR, Stamos MJ. Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection. Dis Colon Rectum. 2021;64(8):995-1002. doi: 10.1097/DCR.0000000000002007.
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