Efficacy of indocyanine green (ICG) angiography in reducing postoperative complications in oesophagectomy: systematic review and meta-analysis
Alexander A Dermanis, Dominic Thompson, Sivesh K Kamarajah, Ewen A GriffithsAbstract
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.