Efficacy of near-infrared indocyanine green imaging in D2 lymphadenectomy for gastric cancer: A systematic review and meta-analysis comparing eastern and western cohorts.

BACKGROUND

Accurate D2 lymphadenectomy is the cornerstone of curative gastric cancer surgery. Near-infrared indocyanine green (NIR-ICG) fluorescence imaging has emerged as an adjunctive technology that enhances lymphatic visualization, potentially improving node retrieval and supporting intraoperative assessment of D2 lymphadenectomy. However, the global reproducibility of these results and their applicability across surgical settings remain uncertain.

METHODS

A systematic review and meta-analysis were performed according to PRISMA guidelines (PROSPERO registration: CRD420251166824). Electronic databases and clinical trial registries were searched for studies comparing NIR-ICG-guided versus conventional D2 lymphadenectomy for gastric cancer. Random-effects models using the Knapp-Hartung adjustment were applied. Subgroup analyses assessed surgical volume and geographical region. Risk of bias was evaluated with Cochrane RoB 2 and ROBINS-I tools.

RESULTS

Eleven studies were included, with seven meeting quality thresholds for the main analysis (992 patients). NIR-ICG guidance significantly increased lymph node yield compared with conventional surgery (mean difference = 9.08; 95% CI 7.70-10.46; p < 0.001) without prolonging operative time or increasing major complications. Subgroup analyses revealed greater benefits in low-volume centers (dhigh volume = 0.66 vs dlow volume = 1.68; p = 0.01) and comparable outcomes between Chinese and Italian cohorts. No significant heterogeneity or publication bias was detected.

CONCLUSIONS

NIR-ICG fluorescence imaging markedly improves lymph node yield and potentially supports completeness of D2 lymphadenectomy in selected settings without compromising safety. The technique demonstrates consistent efficacy across different surgical settings and may be particularly advantageous for standardization and training in lower-volume institutions. Despite promising results, findings require careful interpretation and more detailed analysis of surgical outcomes.