146 Chapter 7 LSCI is still seen as a less commonly used perfusion imaging technique, although its clinical applications seem promising. In contrast to other imaging techniques such as near-infrared fluorescence imaging (NIRF), there is no need for any pharmaceuticals or dyes. Additionally, LSCI captures the possibility for continued perfusion evaluation, without difficulties such as residual signals or wash-out effects 26. Future validation and exploration are necessary to assess the exact value of this current red flag technique in colorectal surgery. In the current study the surgeons were asked to draw conclusions based on LSCI images (verification). Although, for clinical setting it may be interesting to perform the current study in opposite direction and investigate if LSCI provides additional information compared to the white light images (validation). Additionally, it is interesting to compare these outcomes with other imaging technique such as fluorescence angiography as previous research has already shown the complemental role of LSCI compared to NIRF in parenchymal perfusion assessment 27. Yet, it may also be interesting to deeper evaluate inter-observer variability of experienced surgeons as used in this study, compared to less experienced residents. LSCI could emerge as a more direct, real-time, and repeatable approach in providing quantitative information on tissue perfusion 27, 28, 29. Developing additional methods to quantify the LSCI output can extra enhance the accuracy and reliability of LSCI. Given that this research exclusively focusses on establishing the practicability of measuring perfusion and identifying perfusion discrepancies at the anastomosis, future studies should focus on evaluating the device’s performance in clinical trials and investigate surgical clinical consequences such as AL rates and overall patient recovery. The results from the survey indicated that the senior surgeons were overall very satisfied with PerfusiX-Imaging® as a perfusion imager and its use during the surgical procedure. The system’s ability to accurately represent blood flow patterns, high display quality of data, ease of use, efficient setup, minimal latency, and real-time visualization of tissue perfusion were positively acknowledged. However, it is important to note that this study was conducted in an animal model, and further research is needed to validate the efficacy and feasibility of the LSCI device in clinical settings. Besides, while anastomotic perfusion is commonly required during colorectal anastomotic creation, we used small bowel loops in our experiment. This decision was based on the difficult curly nature of a pig’s colon, making the small bowel a more suitable choice for illustrative and surgical technical purposes. Consequently, the generalizability of our findings to human patients should be further investigated. Yet, previous research has shown good results using the same device for colonic perfusion assessment in a human population20. Also, for this experiment we conducted numerous experiments with separate bowel loops, however, it is essential to note that these observations were derived from a single animal. Consequently, it is imperative to be cautious when interpreting the data presented in this study, given its limited sample size. For our animal studies, we consider it of paramount importance to adhere to the principles of the 3R’s: replacement, reduction, and refinement 30. As such, the current experimental design was considered adequate for assessing the hypothesis.
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