The effectiveness of intraoperative indocyanine green fluorescence imaging in preventing anastomotic leakage after minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis

Background Anastomotic leakage (AL) remains a major complication after minimally invasive esophagectomy (MIE) for esophageal cancer (EC), primarily due to inadequate perfusion at the anastomotic site. Conventional intraoperative assessment of gastric conduit blood supply is subjective and often fails to detect occult hypoperfusion. Although indocyanine green (ICG) fluorescence imaging provides real-time, objective evaluation of Intraoperative tissue perfusion, potentially guiding anastomotic decisions and reducing AL risk, robust evidence supporting its routine use in MIE remains limited. Methods A systematic literature search was conducted in PubMed, Embase, Cochrane Library, and Web of Science up to January 31, 2026, to identify studies evaluating intraoperative ICG fluorescence imaging in patients undergoing MIE for EC. Perioperative outcomes were independently extracted by two reviewers and synthesized using a random-effects model. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) served as the summary statistics. Subgroup analyses and sensitivity analyses were subsequently performed. Results A total of eight retrospective cohort studies with 1,314 patients were included. Patients were classified into the ICG fluorescence imaging group and the control group. The analysis demonstrated that ICG fluorescence imaging was associated with a significantly lower risk of AL (OR = 0.37; 95% CI: 0.18 to 0.76; p = 0.007). There were no significant between-group differences in operative time, intraoperative blood loss, cardiovascular complications, or postoperative length of stay (LOS), with a trend toward reduced postoperative pneumonia observed in the ICG group. Subgroup analyses revealed that the protective effect of ICG against AL was more pronounced in patients undergoing McKeown esophagectomy (OR = 0.31; 95% CI: 0.13 to 0.75; p = 0.009) and those with body mass index (BMI) <24 (OR = 0.35; 95% CI: 0.13 to 0.94; p = 0.04). Sensitivity analysis validated the reliability of the primary result on AL. Conclusion Intraoperative ICG fluorescence imaging is significantly associated with a lower risk of AL following MIE for EC, with no significant impact on operative time, blood loss, or perioperative complications. The association between ICG application and reduced AL risk is particularly prominent in patients undergoing McKeown esophagectomy and in those with a BMI <24. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261283021 , identifier: CRD420261283021