Indocyanine green–guided lymphadenectomy in gastrectomy for gastric cancer: A systematic review and meta-analysis.

e16098 Background: Indocyanine green (ICG) near-infrared fluorescence is increasingly used to guide lymphadenectomy during laparoscopic gastrectomy for gastric cancer, but its true impact on oncologic outcomes and perioperative safety compared with conventional surgery remains unclear. This systematic review and meta-analysis evaluated whether ICG guidance meaningfully improves long-term outcomes and surgical quality in adults undergoing laparoscopic radical gastrectomy for resectable gastric adenocarcinoma. Methods: We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library up to October 2025 for randomized trials and comparative cohort studies comparing ICG fluorescence–guided lymphadenectomy with conventional laparoscopic gastrectomy. Adults with resectable gastric adenocarcinoma undergoing laparoscopic radical gastrectomy were included. Random-effects models were used to pool effect estimates. Results: Across several randomized and non-randomized studies, including tens of thousands of patients overall, ICG-guided surgery achieved similar 5-year (RR 0.99, 95% CI 0.87–1.12) and 2-year (RR 1.03, 95% CI 0.95–1.12) overall survival compared with conventional surgery. Despite this, ICG was associated with clear oncologic advantages: overall recurrence was significantly reduced (RR 0.57, 95% CI 0.43–0.76), and primary tumor recurrence was markedly lower (RR 0.19, 95% CI 0.07–0.52). Early postoperative mortality was also reduced with ICG guidance (RR 0.60, 95% CI 0.40–0.90). From a surgical standpoint, ICG-guided lymphadenectomy retrieved more lymph nodes than standard surgery (MD – 5.41 nodes, 95% CI 3.38–7.43), without increasing the number of metastatic nodes, suggesting improved staging rather than stage inflation. ICG use was associated with a modest reduction in operative time and a shorter postoperative hospital stay (MD −0.63 days, 95% CI −0.97 to −0.30), while intraoperative/estimated blood loss, recovery of bowel function, conversion to open surgery, resection margins, and readmission rates were broadly similar between groups. Overall postoperative complications were slightly but significantly lower with ICG (RR 0.87, 95% CI 0.76–1.00), and there was no signal of increased major (Clavien–Dindo III–V) complications. Conclusions: ICG fluorescence–guided provides meaningful technical and clinical advantages: it increases lymph node yield, reduces recurrence and early postoperative mortality, and lowers overall complication risk, all without compromising overall survival or increasing perioperative harm. These findings support ICG guidance as a safe, effective adjunct to standard laparoscopic gastrectomy for gastric cancer. Standardized ICG protocols and further large, high-quality trials are still needed to confirm long-term oncologic benefits and define best practice.