Efficacy of indocyanine green fluorescence imaging-guided lymphadenectomy in radical gastrectomy for gastric cancer: A systematic review and meta-analysis

Abstract

BackgroundIndocyanine green (ICG) imaging-guided lymphadenectomy has been introduced in gastric cancer (GC) surgery and its clinical value remains controversial. The aim of this study is to evaluate the efficacy of ICG fluorescence imaging-guided lymphadenectomy in radical gastrectomy for GC.MethodsStudies comparing lymphadenectomy in radical gastrectomy between use and non-use of ICG fluorescence imaging up to July 2022 were systematically searched from PubMed, Web of Science, Embase and Cochrane Library. A pooled analysis was performed for the available data regarding the baseline features, the number of retrieved lymph nodes (LNs), the number of metastatic LNs and surgical outcomes as well as oncological outcomes. RevMan 5.3 software was used to perform the statistical analysis. Quality evaluation and publication bias were also conducted.Results17 studies with a total of 2274 patients (1186 in the ICG group and 1088 in the control group) undergoing radical gastrectomy and lymphadenectomy were included. In the pooled analysis, the baseline features were basically comparable. However, the number of retrieved LNs in the ICG group was significantly more than that in the control group (MD = 7.41, 95% CI = 5.44 to 9.37, P < 0.00001). No significant difference was found between the ICG and control groups in terms of metastatic LNs (MD = -0.05, 95% CI = -0.25 to 0.16, P = 0.65). In addition, the use of ICG could reduce intraoperative blood loss (MD = -17.96, 95% CI = -27.89 to -8.04, P = 0.0004) without increasing operative time (P = 0.14) and overall complications (P = 0.10). In terms of oncological outcomes, the use of ICG could reduce the overall recurrence rate (OR = 0.50; 95% CI 0.28-0.89; P = 0.02) but could not increase the 2-year overall survival rate (OR = 1.25; 95% CI 0.72-2.18; P = 0.43).ConclusionsICG imaging-guided lymphadenectomy is valuable for complete LNs dissection in radical gastrectomy for GC. However, more high-quality randomized controlled trials are needed to confirm this benefit.

Impact of Indocyanine Green Fluorescence Imaging on Lymphadenectomy Quality During Laparoscopic Distal Gastrectomy for Gastric Cancer (Greeneye): An Adaptative, Phase 2, Clinical Trial

“…The median number of additional nodes that were retrieved after NIR visualization was approximately 1, resulting in an increase of only 2.3% in the total number of nodes retrieved. This result is in contrast with the previously cited meta-analysis (mean 7.4 additional LNs with ICG guidance) 16 and with the two available, randomized, controlled trials that respectively reported a mean number of 8.5 and 7.9 additional LNs. 12 , 17 As said before, this difference can be partially explained by the fact that in our study fluorescence was used only at the end of lymphadenectomy, when the procedure had already been judged as adequate by the operating surgeon.…”

“…Several studies, and a recent meta-analysis, suggest that fluorescence guided LND allows for a higher number of LNs harvested with respect to standard LND, possibly reducing intraoperative blood loss and without impact on operative time and postoperative complications. 16 Most of these studies (mainly comparative retrospective, only two randomized trials) compare ICG-guided LND to standard LND; allocation to either group is clearly not blinded, and the reasons for a better performance of ICG-guided LND in terms of number of retrieved LNs might be related to different factors that are not necessarily related to the effectiveness of fluorescence guidance. In this study, to overcome this potential bias, LND was performed as per local standards and NIR visualization was used after specimen extraction, in order to appreciate its crude effectiveness.…”

“…The time spent for the NIR-guided retrieval of additional nodal stations was 12 (range 8–16) minutes, which appeared to minimally impact on the total operative time as observed in most studies. 16 However, studies targeted to evaluate the intention to treat risks of this procedure, and the economic justification, are still needed. Finally, this study was targeted to assess the clinical benefit of NIR in distal gastrectomy, and its magnitude in total gastrectomy might be different.…”

Global trends in indocyanine green fluorescence navigation in the field of gastric cancer: bibliometrics and knowledge atlas analysis

“…The actual clinical value of ICG remains a matter of debate due to the current lack of confirmation from clinical studies. Additional high-quality randomized controlled tests to substantiate such benefits are urgently required ( 54 ). Although several studies have shown a markedly larger average count of lymph nodes detected for an ICG group than for a non-ICG group ( 55 ), some scholars reported the opposite result.…”