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Page 4 of 12 Hambright et al. Mini-invasive Surg 2024;8:19 https://dx.doi.org/10.20517/2574-1225.2024.08

Continuing, the role of ICG in esophagectomies can be further explored by analyzing published systematic
reviews. The systemic review and meta-analysis by Slooter et al., published in 2019, indicated that ICG
[14]
angiography significantly diminishes post-operative anastomotic leaks and graft necrosis . However, a
separate systematic review and meta-analysis of ICG use in MI-ILEs, conducted in 2021, opposed this. This
review found no discernible differences in anastomotic leak rates, mortality, or length of stay between the
ICG and non-ICG cohorts .
[15]

Interestingly, a 2023 single-institution study evaluating the efficacy of ICG in a sample of 181 (ICG n = 59,
non-ICG n = 122) patients undergoing MI-ILE found individuals in the ICG group exhibited significantly
higher rates of both anastomotic leakage (10.2% vs. 1.6%, P = 0.015) and 90-day mortality (8.5% vs. 1.6%, P =
0.038) in comparison to the non-ICG group. Notably, a subset of patients within the ICG group identified
with “abnormal perfusion” of the conduit experienced significantly elevated rates of anastomotic leak,
repeat interventions, and 30-day mortality compared to both the broader ICG group and the non-ICG
group .
[16]

There is also the question of how the use of ICG intraoperatively affects a surgeon’s decision-making. A
2022 study by De Groot et al. investigated this in the setting of RAMIE and found that the use of ICG
(7.5 mg) after anastomotic site selection led to a change in anastomotic location in 14% of cases . This
[17]
provides some evidence that the ability to visualize perfusion intraoperatively does exert an influence on
surgical decision-making. Of note, the cohort of 63 patients included in this study had an anastomotic leak
rate of 22%.

Furthermore, LeBlanc et al. published a similar article in 2023 that investigated this same question,
[18]
comparing two groups of RAMIE patients, 251 non-ICG patients to 61 ICG patients . In this study, time to
initial perfusion, time to maximum perfusion, and the surgeon’s initial line of demarcation (prior to ICG
injection) were used to assess ICG efficacy. They found no significant difference in anastomotic leak rates
between the groups (non-ICG, 5.2% vs. ICG, 5.6%). Additionally, there were no significant differences in 30-
and 90-day mortality between the groups. Intriguingly, of the patients within the ICG group who did
develop an anastomotic leak, all had extended time to initial perfusion, time to total perfusion, and time to
maximum perfusion. In terms of decision-making, a 15-patient cohort showed that a surgeon’s observed
line of demarcation of perfusion and the ICG-observed line of demarcation differed in 80% of cases by an
average of 0.77 cm .
[18]
ICG also has use in detecting regional lymph nodes separate from the esophagus during MIE. A study
published by Hachey et al. in 2016 showed that a mixture of ICG and human serum albumin was effective
in detecting and identifying regional lymph nodes intraoperatively . While this was done in a small cohort
[19]
of ten patients, it still provides evidence for the potentially multifaceted use of ICG within the scope of
neoplastic resection .
[19]

Due to the heterogeneity across the aforementioned studies, the use of ICG angiography and its efficacy
remain debated among surgeons. At worst, it serves as a low-risk tool to help assess perfusion during
conduit creation and locate an optimal anastomotic site on the conduit; thus, its use should be at the
discretion of the surgeon.