Background: Neoadjuvant chemoradiotherapy (nCRT) is key for low rectal cancer but raises the risk of anastomotic leakage (AL). This study examines how fluorescence laparoscopic (FL) surgery reduces AL after intersphincteric resection (ISR), especially in nCRT patients. This real-world multicentre cohort study included 533 patients undergoing laparoscopic ISR for ultra-low rectal adenocarcinoma from January 2012 to July 2023. Patients were categorized into FL and non-FL groups. The primary endpoint was the incidence of AL within 6 months postoperatively. Secondary endpoints included anastomotic site perfusion, intraoperative blood loss, lymph node retrieval, perioperative complications, and postoperative recovery metrics. Subgroup analyses were conducted on the basis of nCRT status. The FL group showed a significantly lower AL incidence (3.1% versus 11.5%, P = 0.005), with fewer severe symptomatic AL cases (0.8% versus 6.1%, P = 0.014). Intraoperative blood loss was reduced (45.2 ± 58.9 mL versus 65.3 ± 73.1 mL, P = 0.004), and lymph node yield was higher (21.2 ± 11.4 versus 16.6 ± 7.3, P < 0.001) in the FL group. Postoperative recovery was accelerated, with earlier return of bowel function and shorter hospital stays (9.5 ± 3.1 versus 10.7 ± 3.8 days, P = 0.012). In subgroup analyses, FL significantly reduced AL rates in patients without nCRT (1.9% versus 7.2%, P = 0.045) and demonstrated a strong trend toward reduction in AL for patients receiving nCRT (13.0% versus 35.9%, P = 0.051). FL also increased the proportion of patients achieving benchmark lymph node retrieval, including those post-nCRT.
Conclusions: Fluorescence-guided laparoscopic surgery reduces anastomotic leakage and improves outcomes in low rectal cancer, especially after chemoradiotherapy, by enhancing surgical precision and recovery.
