Abstract 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; I 2 68%). Subgroup analyses showed greater benefit in patients receiving neoadjuvant therapy (MD 9.3; 95%CI 6.73–11.88; p < 0.00001; I 2 0%) and in overweight/obese patients (MD 10.94; 95%CI 3.25–18.64; p = 0.005; I 2 79%). ICG significantly improved ideal lymphadenectomy rate (RR 1.29; 95%CI 1.15–1.45; p < 0.0001; I 2 74%), though proper lymphadenectomy rates were similar. ICG reduced operative time (MD − 6.56; 95%CI − 12.31 to − 0.81; p = 0.03; I 2 75%) and blood loss (MD − 10.13; 95%CI − 17.44 to − 2.82; p = 0.007; I 2 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.
Deidda et al. (Mon,) studied this question.