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Impact of change in the surgical plan based on indocyanine green fluorescence angiography on the rates of colorectal anastomotic leak: a systematic review and meta-analysis

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In the present study, patients with colorectal anastomoses that were assessed with indocyanine green (ICG) fluorescence angiography (FA) were compared to patients who had only white light visual inspection of their anastomosis. The impact of change in surgical plan guided by ICG-FA on anastomotic leak (AL) rates was assessed.


PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried for eligible studies. Studies included were comparative cohort studies and randomized trials that compared perfusion assessment of colorectal anastomosis with ICG-FA and inspection under white light. Main outcome measures were change in surgical plan guided by ICG-FA and rates of AL. Risk of bias was assessed using RoB-2 and ROBINS-1 tools. Differences between the two groups in categorical and continuous variables were expressed as odds ratio (OR) with 95% confidence interval (CI) and weighted mean difference.


This systematic review included 27 studies comprising 8786 patients (48.5% males). Using ICG-FA was associated with significantly lower odds of AL (OR 0.452; 95% CI 0.366–0.558) and complications (OR 0.747; 95% CI 0.592–0.943) than the control group. The weighted mean rate of change in surgical plan based on ICG-FA was 9.6% (95% CI 7.3–11.8) and varied from 0.64% to 28.75%. A change in surgical plan was associated with significantly higher odds of AL (OR 2.73; 95% CI 1.54–4.82).


Technical heterogeneity due to using different dosage of ICG and statistical heterogeneity in operative time and complication rates.


Assessment of colorectal anastomoses with ICG-FA is likely to be associated with lower odds of anastomotic leak than is traditional white light assessment. Change in plan based on ICG-FA may be associated with higher odds of AL.

PROSPERO registration number: CRD42021235644.

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Steven D. Wexner is a paid consultant for Stryker, Intuitive Surgical, Olympus, and Medtronic and receives royalty payments from Karl Storz Endoscopy America, Medtronic, and Intuitive Surgical.

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Authors and Affiliations



SE designed the study, collected the data, assessed the quality of the studies, conducted data analysis, and wrote the manuscript. SK contributed to data collection and interpretation, quality assessment of studies, and revision of the manuscript. SW contributed to data interpretation and critically revised the manuscript.

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Correspondence to Sameh Hany Emile.

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Sameh Emile and Sualeh Khan have no conflict of interests or financial ties to disclose.

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Supplementary Information

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Supplementary file1 (DOCX 30 kb)


Supplementary file2 Supp Figure 1. Funnel plot for assessment of publication bias in outcome “impact of change in surgical plan on leak rate” (PNG 7 kb)


Supplementary file3 Supp Figure 2. Funnel plot for assessment of publication bias in outcome “Rate of anastomotic leak in ICG versus control group” (JPG 27 kb)


Supplementary file4 Supp Figure 3. Funnel plot for assessment of publication bias in outcome “Rate of Ileus in ICG versus control group” (PNG 7 kb)


Supplementary file5 Supp Figure 4. Funnel plot for assessment of publication bias in outcome “Rate of complications in ICG versus control group” (PNG 7 kb)


Supplementary file6 Supp Figure 5. Funnel plot for assessment of publication bias in outcome “operation time in ICG versus control group” (PNG 6 kb)

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Emile, S.H., Khan, S.M. & Wexner, S.D. Impact of change in the surgical plan based on indocyanine green fluorescence angiography on the rates of colorectal anastomotic leak: a systematic review and meta-analysis. Surg Endosc 36, 2245–2257 (2022).

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