328 Chapter 14 technical details of use, such as dose, concentration, distance of target organ, and timing of dye administration 23. The absence of standardization of these modifiable factors results in compromised outcomes and render the data incomparable. Therefore, it is important to standardize imaging protocols and validation and include more patients in future NIRF trials to compare AL outcomes. Despite both conflicting results and necessary improvement in standardization and quantification, there is growing believe that assessment of colorectal anastomoses with NIRF is likely to be associated with lower risk of AL compared to traditional white light assessment 36. The EssentiAL trail, which included 850 rectal cancer patients randomized to receive either ICG or standard care, showed that the incidence of AL was significant lower 37. Overall, ICG fluorescence imaging significantly reduced the AL rate by 4.2%. Another phase III randomized controlled trial (AVOID trial) using ICG for the prevention of AL but in all colorectal resections, has recently reached its sample size of 978 CRC patients 38. Preliminary results seem to be promising in reducing AL rates in case of left-sided resections when using ICG. Final outcomes from this trial are expected in the short term and could conclusively demonstrate the efficacy of NIRF in reducing AL rates. Subsequent, further investigation of the role of MB may be explored for simultaneous imaging during colorectal procedures and additionally reduce other complications like ureteral damage. For both MB and ICG, we demonstrated feasibility of performing quantified fluorescence imaging. A specific limitation chapter 6 is the lack of a golden standard for quantification. Although we followed a standardized protocol within our study, this protocol is not world widely adopted. As previously mentioned, not only consensus on quantification of NIRF is essential to draw evidence-based conclusions, but also procedural standardization 39. Several cohort studies have described quantified bowel perfusion using various methods, and most of these studies did not use a standardized imaging protocol (i.e., inconsistency in camera-totarget distance, angle of camera on target tissue, type of imaging system and its settings, etc.) 40-44. A recent Dutch prospective cohort study has demonstrated a quantification approach to distinguish between various perfusion patterns (well perfused, transition zone, and poorly perfused) using a standardized imaging protocol 45. By employing such a standardized imaging protocol, we expect to improve the reproducibility of quantification methods as suggested in this paper, which can also help to develop perfusion patterns for MB. Subsequent studies should further investigate the clinical significance of these perfusion patterns by correlating each pattern with the incidence of AL. Ideally, larger datasets can be used to develop prediction models providing risk rated of AL per tissue location in real-time. In addition to fluorescence angiography, innovative imaging approaches that do not rely on dyes are currently another pertinent focus of research. Laser Speckle Contrast Imaging (LSCI) emerges as a promising technique in this field. As described in the introduction, LSCI offers real-time blood flow data through the detection of the dynamic interference pattern created
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