Background: The cause of AL in rectal cancer surgery is multifactorial. The impact of indocyanine green fluorescence angiography (ICG-FA)-based assessment of blood flow on anastomotic leakage (AL) prevention in low- and mid-rectal cancer surgery is unclear. The aim of this meta-analysis was to evaluate that impact. Methods: The MEDLINE, Cochrane Library, and Scopus databases were searched for articles published up to September 19, 2025 in which the association between ICG-FA and outcomes of rectal cancer surgery was assessed. Data were pooled for meta-analysis. The primary outcome was the AL rate in mid- and low-rectal cancer surgery. Secondary outcomes included severity of AL, diverting-stoma construction rates, and changes in surgical plans based on ICG-FA. Subgroup analysis for low-rectal cancer surgery was performed on the AL rate. Results: Eight studies (1286 patients) met the eligibility criteria, comprising 1 randomized controlled trial, 1 before-and-after prospective study, and 6 retrospective studies. The analysis involved 560 patients in the ICG-FA group and 726 in the control group. ICG-FA was associated with a significantly lower AL rate in mid- and low-rectal cancer surgeries (odds ratio OR, 0.34; 95% confidence interval CI, 0.22–0.51; P < .001), grade-A AL rate (OR, 0.17; 95% CI, 0.07–0.41; P < .001), and grade-B and grade C AL rate (OR, 0.41; 95% CI, 0.18–0.91; P = .03) compared to the control group. The diverting-stoma construction rate was comparable between the ICG-FA and control groups. The weighted mean rate of change in the surgical plan based on ICG-FA was 17.0% (95% CI, 10%–29%). In the subgroup analysis, ICG-FA was associated with a significantly lower AL rate in low-rectal cancer surgeries compared to that in the control group (OR, 0.36; 95% CI, 0.21–0.62; P < .001). Conclusion: In surgery for mid- and low- rectal cancer, ICG-FA-based blood-flow assessment is an important factor in reducing AL. Further randomized controlled trials that are focused on mid- and low-rectal cancer are warranted to confirm these benefits and establish the role of ICG-FA in clinical practice.
Kojima et al. (2025) studied this question.