DOI: 10.1097/js9.0000000000005638 ISSN: 1743-9159

Indocyanine green-guided lymphadenectomy in gastrectomy for gastric cancer: a systematic review and meta-analysis with trial sequential analysis and meta-regression

Fatma A. Rikabe, Abdelrhman H. Mohamed, Amr Khalid Abdallah, Alyaa Ahmed Ibrahim, Asmaa Soliman, Marina Takawy, Nesreen Alhamwi, Mohamed Alatfawy, Ahmed Eldefrawy, Abdelrahman Abdalla Mohamed, Nasim Abukaresh, Eman M. Ghawanmeh, Mohammed Hammad Jaber Amin, Rama Alawneh, Amro Ali, Mohamed Fawzi Hemida
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Background:

Indocyanine green (ICG) near-infrared fluorescence is increasingly used to guide lymphadenectomy during laparoscopic gastrectomy for gastric cancer, but its impact on oncologic outcomes and perioperative safety compared with conventional surgery remains unclear. This systematic review and meta-analysis evaluates whether ICG guidance improves long-term outcomes and surgical quality in adults undergoing laparoscopic radical gastrectomy for resectable gastric adenocarcinoma.

Methods:

We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library through October 2025 for randomized trials and comparative cohort studies comparing ICG-guided lymphadenectomy with conventional laparoscopic gastrectomy without ICG. Random-effects models were used to pool effect estimates, with subgroup analyses, meta-regression, sensitivity analyses, and trial sequential analysis employed to explore heterogeneity and assess robustness.

Results:

From 1457 records, 28 studies were included, of which 25 contributed to the meta-analysis. ICG guidance significantly increased total lymph node retrieval [mean difference (MD): 6.57 nodes; 95% confidence interval (CI): 5.09–8.04; P < 0.0001] without increasing metastatic lymph node yield (MD: 0.01; 95% CI: −0.53 to 0.56; P = 0.958). No significant differences emerged in 5-year overall survival [risk ratio (RR): 0.99; 95% CI: 0.87–1.12], 2-year overall survival (RR: 1.03; 95% CI: 0.95–1.12), or 30-day mortality (RR: 1.19; 95% CI: 0.34–4.25). ICG-guided surgery showed modest reductions in operative time (MD: −8.67 min), blood loss (MD: −11.84 mL), and hospital stay (MD: −0.54 days), though heterogeneity was substantial for several perioperative outcomes. No significant reductions were seen in overall complications, Clavien–Dindo grade-specific complications, time to first flatus or oral intake or affected resection margins.

Conclusion:

ICG fluorescence–guided lymphadenectomy provides meaningful technical benefits during laparoscopic gastrectomy, increasing lymph node yield and modestly improving perioperative efficiency without compromising survival or increasing harm. These findings support ICG as a safe, effective adjunct to standard gastrectomy, though standardized protocols and further large, high-quality trials are needed to confirm long-term oncologic benefit.

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