12 Chapter 1 for the formation of a strong and durable anastomosis. Insufficient perfusion can lead to tissue ischemia, delayed wound healing, and ultimately an increased risk of anastomotic breakdown and leakage 18. Hence, there is a rising interest in employing real-time perfusion assessment techniques to aid in surgical decision-making and enhance outcomes. Through the identification of tissue areas exhibiting compromised perfusion, surgeons can potentially steer clear of establishing an anastomosis in those regions, opting instead for tissues with more favorable perfusion. The most common intraoperative adjunct to assess bowel perfusion is by using near-infrared fluorescence angiography (NIRF). In short, a fluorophore is intravenously injected and, upon excitation at a specific wavelength, emits light at another specified wavelength (typically infrared) immediately following vessel division and/or completion of the anastomosis 17. Using an optic dye like indocyanine green (ICG) have proved to be effective for bowel perfusion assessment and AL reduction after colorectal surgery 19-22. As this technology enhances intraoperative decision-making by guiding surgeons to optimize perfusion and minimize the risk of AL, optimalisation of fluorescence imaging with new and better camera systems, development new optical dyes, quantification methods and assessing outcomes in large trials, is very popular in fluorescence-guided surgery research. Besides, near infrared fluorescence imaging can be used to visualize other structures too, like lymph nodes and the ureter, and might be helpful for multiple purposes during surgery. Another technique that has emerged as promising modality for real-time assessment of bowel perfusion is laser speckle contrast imaging (LSCI). It is a non-invasive imaging technique that assesses blood flow dynamics by exploiting the speckle pattern created when coherent light interacts with moving objects, in particular red blood cells 23. Previous research indicates that LSCI can achieve real-time intraoperative visualization of intestinal micro perfusion deficits, allowing for accurate prediction postoperative ischemic complications 24, 25. Therefore, LSCI can be a useful tool to mitigate ischemia-related complications such as AL and improve patients’ outcomes after CRC surgery. With this revealing capacity, it is important to perform additional preclinical validation, quantification, and feasibility assessment of LSCI to facilitate its potential in surgical decision-making when constructing colorectal anastomoses. Long-term oncological outcomes Already 15 years ago, an analysis of patients who did develop AL after lower anterior resections (LAR) for rectal cancer, showed that overall survival was reduced, but oncologic outcomes were not significantly influences by AL 26. Later, a meta-analysis on this topic concluded that AL was associated with high local recurrence and poor survival (both overall and cancer-specific), but not with distant recurrence after anterior resections 27. More recent studies showed that rectal cancer patients who developed AL after anterior resection or laparoscopic total mesorectal excisions (TME) had an increased risk of local recurrence, and even a decrease in overall survival, cancer-specific survival, and disease-free survival 2-4. In
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