Effectiveness of Indocyanine Green Fluorescence Angiography in Preventing Anastomotic Leakage: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Figure 1. Study selection process based on PRISMA 2020 flow diagram PRISMA 2020 flow diagram illustrating the process of literature search, screening, eligibility assessment, and final study inclusion. Adapted from the PRISMA 2020 statement [5]. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; n: number of records; RCT: randomised controlled trial.

Figure 2. Overall effect of ICG-FA versus standard visual assessment on anastomotic leakage Forest plot displaying the combined results of trials evaluating indocyanine green fluorescence angiography (ICG-FA) against conventional visual assessment for anastomotic leak rates in colorectal surgery. Each square corresponds to the odds ratio (OR) of an individual study, with its area reflecting the relative study weight. Horizontal lines represent the 95% confidence interval (CI) for each trial. The diamond depicts the overall pooled effect, with its span indicating the 95% CI. Values of OR below 1 favour the use of ICG-FA, consistent with a reduction in anastomotic leakage. References: Alekseev et al. [11]; De Nardi et al. [13]; Jafari et al. [12]; Rinne et al. [16]; Watanabe et al. [14]; Gach et al. [10]; Faber et al. [15].

Figure 3. Effect of ICG-FA versus standard visual assessment on anastomotic leak rates in left-sided resections Forest plot summarising the comparison of indocyanine green fluorescence angiography (ICG-FA) and conventional visual assessment for anastomotic leak rates in left-sided colorectal surgery. Each square corresponds to the odds ratio (OR) of a single trial, with its area scaled to represent the relative study weight, while horizontal lines mark the 95% confidence interval (CI). The diamond represents the combined OR with its CI, with values below 1 indicating a benefit of ICG-FA in lowering leak risk compared with standard assessment. References: Alekseev et al. [11]; De Nardi et al. [13]; Jafari et al. [12]; Rinne et al. [16]; Watanabe et al. [14]; Gach et al. [10]; Faber et al. [15]

Figure 4. Effect of ICG-FA versus standard visual assessment on anastomotic leak rates in right-sided resections Forest plot presenting outcomes from trials that assessed indocyanine green fluorescence angiography (ICG-FA) versus visual inspection in rectal resections. Individual study odds ratios (ORs) are shown as squares, with the square size indicating the contribution of each trial to the overall analysis. Horizontal lines display the 95% confidence interval (CI) for each study. The diamond represents the pooled effect estimate with its CI, where OR values less than 1 reflect a trend toward reduced anastomotic leak rates with ICG-FA. References: Faber et al. (2024) [15]; Rinne et al. (2025) [16].