Safety and Efficacy of Indocyanine Green in Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis of 11,047 Patients

Abstract

Despite the technological advances and improved surgical skills, the incidence of anastomotic leakage following colorectal cancer surgery still ranges from 4% to 19%. Therefore, we performed a systematic review and meta-analysis to evaluate the efficacy and safety of indocyanine green (ICG) use in colorectal cancer surgery. An online search of the Embase, MEDLINE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases (from inception to 10 November 2021) was performed, in addition to manual screening. Thirty-two studies involving 11,047 patients were considered eligible for the meta-analysis. The anastomotic leak rate in the ICG and non-ICG groups varied and amounted to 3.7% vs. 7.6%, respectively (RR = 0.46; 95% CI: 0.39–0.56; p < 0.001). The rate in randomized controlled trials (RCTs) was 8.1% in the ICG group compared with 12.1% in the non-ICG group (RR = 0.67; 95% CI: 0.46–0.98; p = 0.04). In non-RCTs, it equaled 3.1% vs. 7.3%, respectively (RR = 0.43; 95% CI: 0.35–0.52; p < 0.001). Although the publications encompassed in our meta-analysis present different patients, with different factors influencing the results, a pooled analysis revealed a lower incidence of anastomotic leak in cases with ICG use. There are several other convincing advantages: safety, simplicity, and short time of the method adjustment. The presented meta-analysis indicates ICG perfusion assessment as a tool worth considering to decrease the rate of complications following colorectal surgery—valuable in the context of other, well-known risk factors.

Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery

“…Unfortunately, due to the low recruitment rate it was deemed underpowered and thus terminated early [ 12 ]. Two recent meta-analyses [ 13 , 14 ] concluded that the intraoperative use of ICG for perfusion assessment was associated with significantly lower odds for AL (OR 0.52, 95% CI 0.304–0.98, I2 = 0). One of these metanalyses [ 14 ] reported that the weighted mean rate of change in the surgical plan due to ICG imaging was 9.6% (95% CI 7.3–11.8).…”

“…Anastomotic Perfusion [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 26 , 27 , 28 , 29 ]…”

Intestinal Anastomotic Healing: What do We Know About Processes Behind Anastomotic Complications

“…Lacking new information, the frequent research goal is to develop means both for perioperative evaluation of the quality of blood circulation and means to improve the regional blood supply to the anastomosed intestinal tissues. In the first of these, great progress has been made with the introduction of protocols involving the intravenous administration of indocyanine green (ICG) ( 15 ). Depending on the quality and speed of ICG distribution to the tissues of the anastomotic intestine, it is then possible to decide on a modification of the resection line.…”

All-cause 30- and 90-day inpatient readmission costs associated with 4 minimally invasive colon surgery approaches: A propensity-matched analysis using Medicare and commercial claims data

“…Anastomotic leaks have serious clinical-economic and health care utilization implications. This complication has a reported incidence between 1.5% and 23% and leads to significant morbidity and mortality, longer hospital stays, and significantly increased cost of care [ [10] , [11] , [12] , [13] ]. These findings reinforce a previous claims analysis of 99,879 records which determined that patients with anastomotic leaks had 1.3 times higher 30-day readmission rates and incurred additional average length of stay increases of 7.3 days and additional hospital costs of $24,129 for hospitalization alone compared to patients without anastomotic leaks ( P < .001 for all) [ 14 ].…”

“…Numerous publications report that this technique enables improved visualization, allows confirmation of adequate perfusion of the anastomosis, and empowers surgeons to more accurately determine whether a change in the resection margin is warranted in an effort to significantly reduce costly postindex anastomotic failures [ 20 , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] ]. For example, a recent systematic review and meta-analysis including 32 studies involving 11,047 patients revealed a lower incidence of anastomotic leaks in cases with fluorescence use (3.7% vs 7.6%, P < .001) [ 10 ]. Additionally, a recently published cost analysis determined the routine use of intraoperative near-infrared fluorescence imaging using indocyanine green to be cost saving [ 41 ].…”