Summary, discussion and future perspectives The combination of these two factors will allow for an expansion of potential applications for NIRF imaging, by improving the maximum penetration depth of fluorophores and the contrast‐to‐background‐ratio (CBR) through better optics6. Regarding sentinel lymph node detection in cancer surgery, the use of combined radioactive and fluorescent imaging agents has the potential to improve both preoperative (i.e. by planning of the surgical procedure) and intraoperative (i.e., by real‐time fluorescence detection) image‐guidance36. Next, extending the range of available clinically approved fluorescent dyes is another point that needs attention. To date, only ICG and MB are FDA approved for clinical use. The preclinical fluorescent dyes CW800‐CA (investigated in Chapter 5 and Chapter 6 of this thesis), CW800‐NHS and ZW800‐1 have been reported as promising new fluorophores due to their excretion through bile (CW800) and/or urine (both CW800 and ZW800‐1), high extinction coefficient, high quantum yield, rapid onset of NIR fluorescent signal and the ability for prolonged imaging when compared to ICG and MB23,30. Furthermore, ICG only has a poor binding capacity, whereas this is an area in which fluorophores such as CW800‐NHS and ZW800‐1 perform very well37,38. Unfortunately, it will take some time before these dyes can be included in human trials in order to prove their true potential30. The timing of dye administration is another point of attention. Various strategies have been reported with as many outcomes in terms of performance. For example, in laparoscopic fluorescence cholangiography, twenty‐four hours preoperative administration has shown to provide a better CBR compared to two hours preoperative administration39. However, logistically this strategy might prove difficult to incorporate for procedures performed in day‐care. Future studies are necessary to determine a standard protocol for fluorophore administration in combination with NIRF imaging. This should be performed per type of application. The implementation of NIRF imaging in standard clinical practice will take time and randomized clinical trials are needed to prove its true benefit compared to current intraoperative imaging techniques6. Optimization of both imaging systems and dyes for NIRF imaging (e.g., improving the quality of fluorescence images in terms of higher CBR) can help to reach this goal. For intraoperative bile duct imaging during laparoscopic cholecystectomy, a multicenter randomized controlled trial is currently being prepared. This study aims to evaluate whether earlier establishment as well as improved visualization of Critical View of Safety can be obtained during laparoscopic cholecystectomy, by applying NIRF laparoscopic imaging as an adjunct to conventional laparoscopic imaging versus conventional laparoscopic imaging alone. 173
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