Efficacy and safety of indocyanine green fluorescence imaging in colorectal cancer: a systematic review and meta-analysis of randomized controlled trials

Abstract Background The primary treatment for colorectal cancer, which is very prevalent, is surgery. Anastomotic leaking poses a significant risk following surgery. Intestinal perfusion can be objectively and instantly assessed with indocyanine green fluorescence imaging, which may lower leakage rates and enhance surgical results. Methods PubMed, Embase, and Web of Science databases were systematically searched using relevant keywords from inception until 5th of March 2025. Eight studies were included after final screening. Outcomes were reported as overall anastomotic leakage, wound infection, paralytic ileus, mechanical ileus, and post-operative hospital stay. Interstudy heterogeneity was assessed using I 2 and X 2 statistics (I 2 > 50% = significant heterogeneity). Statistical calculations were performed using Review Manager 5.4.1 (The Cochrane Collaboration, Copenhagen, Denmark), with a p-value of < 0.05 indicating statistical significance. Results This meta-analysis includes 4047 patients from eight investigations (2026 indocyanine green (ICG) group, 2021 non-ICG group). Overall anastomotic leak risk was considerably decreased with ICG use (risk ratio (RR) = 0.66; 95% CI: 0.54–0.81; p < 0.0001) and showed no heterogeneity (I 2 = 0%). There was no heterogeneity (I 2 = 0%) in the Grade A leakage occurrence, which was considerably lower in the ICG group (RR = 0.34; 95% CI: 0.16–0.72; p = 0.005). With little heterogeneity (I 2 = 8.6%), combined leakage grades also supported ICG use (RR = 0.54; 95% CI: 0.35–0.84; p = 0.006). ICG was associated with a substantial decrease in Clavien–Dindo Grade I complications (RR = 0.67; 95% CI: 0.49–0.92; p = 0.01) without heterogeneity (I 2 = 0%). Initial postoperative hospital stays, mechanical ileus, paralytic ileus, and abdominal bleeding did not differ significantly. Although there was no heterogeneity (I 2 = 0%), sensitivity analysis showed that the ICG group had a substantially longer postoperative stay (MD = 0.27; 95% CI 0.05–0.49; p = 0.02) and significantly fewer wound infections (RR = 0.17; 95% CI 0.04–0.76; p = 0.02). With noteworthy heterogeneity (I 2 = 70%), the ICG group’s operating time was significantly longer (MD = 8.26 min; 95% CI 0.52–16.00; p = 0.04). Conclusion Although indocyanine green fluorescence imaging may marginally lengthen the recovery period and duration of operation, it dramatically lowers anastomotic leakage and wound infections following colorectal surgery, enhancing results.