Xin-Fu Song, Ming-Xu Luo, Yi-Hui Lei, Department of Gastrointestinal Surgery, Xiamen Humanity Hospital, Xiamen 361000, Fujian Province, China
Xiao-Qing Huang, Department of Gastroenterology, Xiamen Humanity Hospital, Xiamen 361000, Fujian Province, China
Yun-Ling Zhuang, Department of Anesthesiology, Xiamen Humanity Hospital, Xiamen 361000, Fujian Province, China
Author contributions: Song XF and Luo MX designed the research study; Song XF, Lei YH, Huang XQ, and Zhuang YL performed the research; Lei YH and Huang XQ collected and analyzed the data; Song XF and Luo MX have been involved in drafting the manuscript; all authors have been involved in revising the manuscript critically for important intellectual content; all authors give final approval of the version to be published; all authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to its accuracy or integrity.
AI contribution statement: No AI tools were used in the preparation of this manuscript.
Supported by Xiamen Natural Science Foundation Project, No. 3502Z202374080.
Institutional review board statement: The study was reviewed and approved by Xiamen Humanity Hospital Ethics Committee (approval No. HAXM-MEC-20230703-049-01).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at zyl901202@126.com.
Corresponding author: Yun-Ling Zhuang, Department of Anesthesiology, Xiamen Humanity Hospital, No. 3777 Xianyue Road, Xiamen 361000, Fujian Province, China. zyl901202@126.com
Received: June 23, 2026 Revised: July 29, 2026 Accepted: September 11, 2026 Published online: December 15, 2026 Processing time: 139 Days and 0.9 Hours
Abstract
BACKGROUND
Adequate lymph node (LN) retrieval is essential for accurate staging and treatment planning in gastric cancer. Conventional white-light laparoscopic D2 lymphadenectomy may miss small or fat-embedded LN. Preoperative endoscopic submucosal indocyanine green (ICG) injection combined with intraoperative near-infrared (NIR) fluorescence imaging may improve nodal visualization. However, its effects on metastatic node detection, pathological staging, and early survival remain unclear.
AIM
To evaluate whether ICG-NIR navigation improves nodal retrieval, staging metrics, and 12-month outcomes after laparoscopic radical gastrectomy.
METHODS
This single-center, retrospective cohort study included 280 patients with stage I-III gastric cancer who underwent curative-intent laparoscopic gastrectomy with D2 lymphadenectomy from July 2023 to December 2025. Patients were classified into the ICG-NIR and conventional white-light groups according to intraoperative fluorescence use. The ICG group received an endoscopic submucosal ICG injection 18-24 hours before surgery. Propensity score matching and multivariate Cox regression were used to reduce selection bias and assess survival outcomes.
RESULTS
The ICG group had higher total LN retrieval than the control group (42.2 ± 9.4 vs 31.4 ± 8.8, P < 0.001) and more metastatic LNs detected (12.8 ± 6.2 vs 7.4 ± 4.5, P < 0.001). The LN ratio and log odds of metastatic LNs were also higher in the ICG group (both P < 0.001). Pathological upstaging occurred more frequently with ICG-NIR navigation (73.9% vs 55.8%, P = 0.002). Twelve-month overall survival was 92.3% and 81.9% (P = 0.010), and the disease-free survival rates were 84.5% and 71.7%, respectively (P < 0.001). ICG was independently associated with an improved overall survival after adjustment. At a median follow-up of 16 months, these 12-month survival estimates should be regarded as early signals rather than mature oncological end points.
CONCLUSION
Preoperative endoscopic submucosal ICG injection with intraoperative NIR fluorescence imaging improved LN retrieval and pathological staging and was associated with better 12-month survival outcomes after laparoscopic radical gastrectomy. Longer follow-up is required before a survival benefit can be confirmed.
Core Tip: In 280 patients with stage I-III gastric cancer undergoing laparoscopic D2 gastrectomy, preoperative endoscopic submucosal indocyanine green injection with intraoperative near-infrared fluorescence navigation significantly improved total lymph node retrieval and metastatic node detection compared with white-light surgery. Pathological upstaging was more frequent. At 12 months, overall survival and disease-free survival were higher with indocyanine green; because follow-up was limited to a 12-month landmark, these survival findings should be interpreted as early signals that require confirmation with longer follow-up.
