Abstract
The purpose of this study was to assess the association of intraoperative indocyanine green (ICG) fluorescence angiography with anastomotic leakage and surgical decision-making after colorectal resection. The systematic review and meta-analysis were conducted in accordance with PRISMA guidance. PubMed, Scopus, Web of Science, and Embase were searched for randomized and observational comparative studies reporting anastomotic leakage after colorectal surgery with or without ICG fluorescence assessment. Fourteen studies involving 5264 patients were included. The pooled risk ratio (RR) for anastomotic leakage was 0.59 (95% CI: 0.47-0.73; p < 0.001), corresponding to a 41% relative reduction but an unadjusted absolute difference of approximately 3.2 percentage points. Design-stratified sensitivity analyses remained significant in randomized trials (RR 0.65, 95% CI: 0.50-0.84) and observational studies (RR 0.43, 95% CI: 0.28-0.67), with no statistically significant subgroup interaction (p = 0.12). Surgical strategy was modified in approximately 7% of patients, whereas evidence for reoperation was inconclusive and underpowered. No universally validated qualitative or quantitative threshold was identified, assessment timing varied, and visual interpretation remained operator-dependent. ICG fluorescence angiography should therefore be considered an adjunct to comprehensive surgical assessment rather than an independent predictor of anastomotic integrity.