139 Real-time intestinal perfusion assessment for anastomotic site selection using LSCI INTRODUCTION Anastomotic leakage (AL) is a major complication following gastrointestinal surgery and remains the foremost concern for gastrointestinal surgeons. The occurrence rate of AL varies between 1-19% depending on the anatomic location of the anastomosis 1, 2, 3, 4. The AL etiology is influenced by various factors, including patient characteristics, peroperative factors, and tissue perfusion 2, 5, 6, 7. Adequate blood perfusion is widely recognized as a crucial factor for successful healing of an anastomosis 1, 8, 9, 10. Insufficient perfusion can impair the natural healing of the body, compromising the repair process and increasing the risk of AL. In recent years, there has been growing interest in utilizing real-time perfusion assessment techniques to guide surgical decision-making to improve outcomes 11. By identifying tissue areas with compromised perfusion, surgeons can potentially avoid creating an anastomosis in those regions and opt for better-perfused tissue, thereby minimizing the risk of AL 12. Real-time identification of intestinal perfusion to guide surgeons towards creating a bowel anastomosis using tissue with optimal perfusion, can be achieved using laser speckle contrast imaging (LSCI) 13, 14, 15 with instantaneous and continuous 2D-perfusion maps 16, 17, 18. This imaging technique allows visualization of tissue perfusion in real-time, without the need for contrast agents 19. By integrating the LSCI system into current laparoscopic video systems and surgical workflow, surgeons can have immediate access to visual information on tissue perfusion during the procedure. This additional feedback may serve as a valuable tool to identify regions with compromised perfusion, prompting surgeons to select alternative tissue segments for anastomoses that exhibit better perfusion 20. If real-time identification of intestinal perfusion proves feasible and effective, it could serve as a valuable adjunct in surgical practice, providing surgeons with additional information used in better substantiated clinical decision making and optimize patient outcomes. We hypothesized that the use of LSCI will enable surgeons to make better informed decisions regarding anastomotic site selection prompting surgeons to select alternative tissue segments for anastomosis that exhibit better perfusion, and therefore potentially reduce AL rates in future patients. Therefore, the current study aimed to assess real-time identification of intestinal perfusion using laparoscopic LSCI, subsequent decision making based on this assessment, and the efficacy and feasibility of the used LSCI device. MATERIALS AND METHODS This study was performed at the animal facility of Maastricht University Medical Center, Maastricht, The Netherlands. The animal was treated in compliance with the regulations of the Dutch legislation concerning animal research and ARRIVE guidelines, and a protocol approved by the Local Experimental Animal Committee (DEC) (number 2017-021-001). 7
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