Title : Effectiveness of indocyanine green fluorescence angiography in preventing anastomotic leakage in colorectal resections: A systematic review and meta analysis of randomized controlled trials
Abstract:
Background: Anastomotic leakage is a major complication following colorectal resections. Perfusion of bowel ends at the anastomotic site found to be one of the most important modifiable risk factors in preventing anastomotic leakage. Fluorescence angiography (FA) using indocyanine green (ICG) with Near Infra-red (NIR) Imaging offers real time visualisation of tissue perfusion and has been proposed as a tool to reduce the incidence of anastomotic leakage. Several clinical studies have proven ICG FA to be beneficial in assessment of tissue perfusion, but the strength of high-quality evidence from randomized controlled trials (RCTs) are found to be lacking.
Objective: The systematic review aimed to assess whether ICG FA reduces anastomotic leakage rates in colorectal resections, based only on RCTs including latest available evidence, to evaluate whether outcomes differ between left and right sided resections.
Methods: Systematic research of PubMed, Embase and Cochrane CENTRAL was conducted within last 10 years, identifying RCTs comparing FA with standard intraoperative assessment. The primary outcome was the rate of anastomotic leakage in patients undergoing colorectal resections for benign and malignant conditions. Subgroup analyses were performed for left-and-right sided resections. Risk of bias assessed using the Cochrane Risk of Bias 2.0 tool. Meta analysis was conducted using random-effects model, and heterogeneity was evaluated using I2 statistic.
Results: Seven RCTs involving 3,887 patients were included. FA was associated with a statistically significant reduction in the overall anastomotic leakage rate compared to standard assessment, with a combined odds ratio (OR) of 0.66 (95% CI:0.53-0.82; p = 0.003; I2 = 0 %), indicating no heterogeneity. Subgroup analyses for left-sided resections demonstrated a more pronounced benefit, with combined OR of 0.59 (95% CI:0.46- 0.75; p = 0.002; I 2 = 0%). In contrast, the benefit in right-sided resections was less marked and not statistically significant in most trials.
Conclusion: Indocyanine Green Fluorescence Angiography with Near Infra-Red imaging significantly reduces anastomotic leakage rates in colorectal resections, particularly in left-side. Given its real-time assessment capabilities, safety profile and ease of use, it can be considered as a valuable adjunct to standard surgical techniques. Its selective use in high risk or technically challenging cases may be valuable in intraoperative decision making and postoperative outcomes.
