Guiding role of indocyanine green fluorescence lymphography compared to standard techniques in lymphadenectomy for gastric cancer during minimally invasive surgery: a systematic review and meta-analysis

Real-time indocyanine-green (ICG) fluorescence lymphography in gastric cancer (GC) surgery is gaining traction for its potential to enhance lymphadenectomy during minimally-invasive procedures. This systematic review and meta-analysis evaluated efficacy and safety of ICG-guided lymphadenectomy versus standard techniques. Following PRISMA and Cochrane guidelines, this review (PROSPERO: CRD42024628572) included randomized controlled trials (RCTs) and non-randomized controlled studies (n-RCTs) comparing ICG-guided versus standard minimally-invasive lymphadenectomy in GC patients undergoing gastrectomy. Primary outcome was number of retrieved lymph-nodes (LNs). Secondary outcomes included ideal (≥ 30 LNs) and proper (≥ 16 LNs) lymphadenectomy rates, postoperative outcomes, recurrence, and mortality. Meta-analyses used a random-effects model; evidence quality was assessed via GRADE. 21 studies involving 8633 patients were included. ICG-guided surgery retrieved significantly more LNs (MD 6.91; 95%CI 5.47–8.35; p < 0.00001; I2 68%). Subgroup analyses showed greater benefit in patients receiving neoadjuvant therapy (MD 9.3; 95%CI 6.73–11.88; p < 0.00001; I2 0%) and in overweight/obese patients (MD 10.94; 95%CI 3.25–18.64; p = 0.005; I2 79%). ICG significantly improved ideal lymphadenectomy rate (RR 1.29; 95%CI 1.15–1.45; p < 0.0001; I2 74%), though proper lymphadenectomy rates were similar. ICG reduced operative time (MD − 6.56; 95%CI − 12.31 to − 0.81; p = 0.03; I2 75%) and blood loss (MD − 10.13; 95%CI − 17.44 to − 2.82; p = 0.007; I2 83%). No significant differences emerged for postoperative complication, recurrence, or mortality. ICG lymphography significantly improves nodal yield and ideal lymphadenectomy rates in minimally-invasive GC surgery, enhancing efficiency and reducing blood loss, without increasing complications. Broader implementation is supported, especially in challenging subgroups, like obese or neoadjuvantly treated patients.