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For a set of five moderate disturbance events, we calculate the total number of He+ ions removed the plasmasphere using calibrated global EUV images. In each of the events, between ~0.6 and 2.2×1030 He+ ions are removed from a region of the inner magnetosphere from L=1.5 to 5.5. This loss constitutes between 20% and 42% of the initial He+ distribution. The lost percentage is correlated with the number of hours of strongly positive solar wind electric field (Ey>2.5 mV/m). Also, the total amount of material removed from the plasmasphere is estimated by using several values of the He+ to H+ number density ratio. The total mass lost is found to be in the range of 20 to 80 metric tons although for each individual case the estimate can vary by over 50% depending on assumed density ratio. We also attempt to distinguish between losses to the ionosphere and losses to the dayside boundary layers by estimating losses interior and exterior to the newly formed plasmapause boundary. For the events studied, losses inside the new plasmapause constitute between 24% to 54% of the total number of He+ ions lost.

Introduction The empty pelvis syndrome is a significant source of morbidity following pelvic exenteration surgery. It remains poorly defined with research in this field being heterogeneous and of low quality. Furthermore, there has been minimal engagement with patient representatives following pelvic exenteration with respect to the empty pelvic syndrome. ‘PelvEx—Beating the empty pelvis syndrome’ aims to engage both patient representatives and healthcare professionals to achieve an international consensus on a core outcome set, pathophysiology and mitigation of the empty pelvis syndrome.Methods and analysis A modified-Delphi approach will be followed with a three-stage study design. First, statements will be longlisted using a recent systematic review, healthcare professional event, patient and public engagement, and Delphi piloting. Second, statements will be shortlisted using up to three rounds of online modified Delphi. Third, statements will be confirmed and instruments for measurable statements selected using a virtual patient-representative consensus meeting, and finally a face-to-face healthcare professional consensus meeting.Ethics and dissemination The University of Southampton Faculty of Medicine ethics committee has approved this protocol, which is registered as a study with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of this study will increase the potential for comparative research to further understanding and prevent the empty pelvis syndrome.Trial registration number NCT05683795.

Drug delivery system is an amazing tool which is widely used for drug protection and its controlled release in order to enhance drug bioavailability, reduce side effects and therefore to improve overall therapy. Hydrogels have been attracted great attention as drug carriers due to their great physicochemical properties, similarity to the living tissues and biocompatibility. One group of pH sensitive hydrogels are based on poly(methacrylic acid) (PMAA). These non-toxic hydrogels are used as drug delivery system because they swell as a response to the change in pH of external environment and drug is being released during the process. In present study, in order to improve the control of drug release rate, caffeine was encapsulated in liposomes which were further embedded into PMC hydrogel (PMCL). It was investigated how the change in neutralization degree of methacrylic acid affect the swelling degree of PMCL hydrogels and caffeine release in two environments at 37 °C for 24 h: 0.1 M hydrochloride acid (pH 1) and phosphate buffer with pH value of 6.8 (pH 6.8), as a simulation of pH environment in human stomach and intestines, respectively. Obtained results show that PMCL hydrogels have great potential for controlled release of poorly water-soluble drugs in human intestines.

Semaglutide, a glucagon-like peptide 1 receptor agonist, is an antidiabetic that has recently shown promising immunomodulatory and antitumor effects. Breast cancer is the most common type of cancer affecting women worldwide. The aim of this study was to analyze the effects of semaglutide on the antitumor immunity in a 4T1 mouse breast cancer model. After induction of breast cancer, BALB/C mice were treated intraperitoneally with semaglutide. Semaglutide administration decelerated tumor appearance, growth and progression. The antidiabetic drug showed neither a direct cytotoxic effect in vitro, nor an angiogenic effect. Furthermore, depletion of NK cells had no affect on tumor growth in semaglutide treated mice suggesting a non-NK cell-dependent mechanism. However, semaglutide increased the accumulation and maturation of CD11c + dendritic cell, while decreasing the percentage of FoxP3 + regulatory T cells in the spleen and primary tumor. In addition, semaglutide increased tumor infiltration and promoted the antitumor phenotype of T cells, in vivo. Furthermore, semaglutide enhanced the cytotoxic capacity of CD8 + T cells, in vitro. These results suggest that semaglutide enhances the acquired antitumor immune response and has potential for the future treatment of malignancies., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. Conflicts of Interest The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Background and Objectives: Peritoneal metastasis from colorectal cancer carries a high risk for relapse after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). A novel alpha-emitting radiopharmaceutical (Radspherin) has been designed to deliver short-range radiation to micrometastases and free-floating tumor cells., Methods: A Phase 1/2a study evaluated the safety, tolerability, and signal of efficacy of escalating doses of Radspherin injected intraperitoneally after CRS-HIPEC., Results: Eleven patients received 1-4 MBq (Group 1) whereas 12 patients received 7 MBq; nine patients single dose/three patients split-dose (Group 2). Median age was 66.5 and 61.5 years, and median peritoneal cancer index 6 and 7, respectively. One hundred and seventy-eight adverse events were reported, only seven were deemed related to Radspherin. Thirteen serious adverse events (SAEs) were reported in eight patients and no SAEs were related to Radspherin. At 18-months, none of the 12 patients receiving 7 MBq experienced peritoneal recurrences, however four had non-peritoneal recurrences. Across both groups (n = 22), 41% had recurrent disease, only 14% of them in the peritoneum., Conclusions: Radspherin was well tolerated. At 18 months, median disease-free survival has not been reached, and none of the patients receiving the recommended dose (7 MBq) had peritoneal recurrences. The results are encouraging and warrant further clinical evaluation., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

This study compares ultrasound to clinical and radiographic measurements for assessing tendon pathology associated with distal radial anterior locking plates. A total of 46 patients undergoing removal of a distal radial plate had a preoperative clinical examination, radiographs and ultrasound evaluation to detect evidence of tendon irritation. Gross changes to the tendon were assessed during plate removal. In total, 32 patients demonstrated clinical abnormality. Soong 2 position was noted in 13 patients. Ultrasound revealed tenosynovitis in nine patients, tendon fibrillation or thickening in four patients and a single case of partial discontinuity. Intraoperative assessment revealed tenosynovitis in 28 patients and tendon fibre discontinuity in eight patients. Ultrasound findings were not predictive of intraoperative tenosynovitis and discontinuity. A relationship was noted between higher Soong grade, especially grade 2, and intraoperative presence of tenosynovitis, as well as Soong grade and amount of soft-tissue coverage. This study negates our hypothesis that ultrasound is useful for identifying tendinopathy after distal radial anterior plate fixation. Level of evidence: II., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at midterm follow-up., Methods: Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3-year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via the Wrightington method by 3 independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Patient-Rated Elbow Evaluation (PREE), and EuroQoL-5 Dimensions (EQ-5D)., Results: Thirty-eight consecutive patients (22 female, 16 male) with a mean age of 67 years underwent TEA via a triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were as follows: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), and 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with 1 patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across 3 observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QuickDASH, PREE, and EQ-5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs., Conclusion: At midterm follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preoperative to final postoperative follow-up. Although promising, these results should be interpreted with some caution as long-term data regarding this prosthesis are still lacking., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Aim: Rectal cancers requiring beyond total mesorectal excision (bTME) are traditionally operated using an open approach, but the use of minimally invasive robot-assisted procedures is increasing. Introduction of minimal invasive surgery for complex cancer cases could be associated with compromised surgical margins or increased complication rates. Therefore, reporting results both clinical and oncological in large series is important. Since bTME procedure reports are heterogeneous, comparing results is often difficult. In this study, a magnetic resonance imaging (MRI) classification system was used to describe the bTME surgery according to pelvic compartments., Methods: Consecutive patients with primary rectal cancer operated with laparoscopic robot-assisted bTME were prospectively included for 2 years. All patients had tumors that threatened the mesorectal fascia, invaded adjacent organs, and/or involved metastatic pelvic lateral lymph nodes. Short-term clinical outcomes and oncological specimen quality were registered. Surgery was classified according to pelvic compartments resected., Results: Clear resection margins (R0 resection) were achieved in 95 out of 105 patients (90.5%). About 26% had Accordion Severity Grading System of Surgical Complications grade 3-4 complications and 15% required re-operations. About 7% were converted to open surgery. The number of compartments resected ranged from one to the maximum seven, with 83% having two or three compartments resected. All 10 R1 resections occurred in the lateral and posterior compartments., Conclusions: The short-term clinical outcomes and oncological specimen quality after robot-assisted bTME surgery were comparable to previously published open bTME surgery. The description of surgical procedures using the Royal Marsden MRI compartment classification was feasible., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ebbe B. Thorgersen is proctor for Intuitive Surgical.

Background: In some surgical disciplines, navigation-assisted surgery has become standard of care, but in rectal cancer, indications for navigation and the utility of different technologies remain undetermined., Methods: The NAVI-LARRC prospective study (NCT04512937; IDEAL Stage 2a) evaluated feasibility of navigation in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC). Included patients had advanced tumours with high risk of incomplete (R1/R2) resection, and navigation was considered likely to improve the probability of complete resection (R0). Tumours were classified according to pelvic compartmental involvement, as suggested by the Royal Marsden group. The Brainlab TM navigation platform was used for preoperative segmentation of tumour and pelvic anatomy, and for intraoperative navigation with optical tracking. R0 resection rates, surgeons' experiences, and adherence to the preoperative resection plan were assessed., Results: Seventeen patients with tumours involving the posterior/lateral compartments underwent navigation-assisted procedures. Fifteen patients required abdominosacral resection, and 3 had resection of the sciatic nerve. R0 resection was obtained in 6/8 (75%) LARC and 6/9 (69%) LRRC cases. Preoperative segmentation was time-consuming (median 3.5 h), but intraoperative navigation was accurate. Surgeons reported navigation to be feasible, and adherence to the resection plan was satisfactory., Conclusions: Navigation-assisted surgery using optical tracking was feasible. The preoperative planning was time-consuming, but intraoperative navigation was accurate and resulted in acceptable R0 resection rates. Selected patients are likely to benefit from navigation-assisted surgery., (© 2023. The Author(s).)

Background: Peritoneal metastasis (PM) from colorectal cancer carries a dismal prognosis despite extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). With a median time to recurrence of 11-12 months, there is a need for novel therapies. Radspherin® consists of the α-emitting radionuclide radium-224 ( 224 Ra), which has a half-life of 3.6 days and is adsorbed to a suspension of biodegradable calcium carbonate microparticles that are designed to give short-range radiation to the serosal peritoneal surface linings, killing free-floating and/or tumor cell clusters that remain after CRS-HIPEC., Methods: A first-in-human phase 1 study (EudraCT 2018-002803-33) was conducted at two specialized CRS-HIPEC centers. Radspherin® was administered intraperitoneally 2 days after CRS-HIPEC. Dose escalation at increasing activity dose levels of 1-2-4-7-MBq, a split-dose repeated injection, and expansion cohorts were used to evaluate the safety and tolerability of Radspherin®. The aim was to explore the recommended dose and biodistribution using gamma-camera imaging. The results from the planned safety interim analysis after the completion of the dose-limiting toxicity (DLT) period of 30 days are presented., Results: Twenty-three patients were enrolled: 14 in the dose escalation cohort, three in the repeated cohort, and six in the expansion cohort. Of the 23 enrolled patients, seven were men and 16 were women with a median age of 64 years (28-78). Twelve patients had synchronous PM stage IV and 11 patients had metachronous PM [primary stage II; (6) and stage III; (5)], with a disease-free interval of 15 months (3-30). The peritoneal cancer index was median 7 (3-19), operation time was 395 min (194-515), and hospital stay was 12 days (7-37). A total of 68 grade 2 adverse events were reported for 17 patients during the first 30 days; most were considered related to CRS and/or HIPEC. Only six of the TEAEs were evaluated as related to Radspherin®. One TEAE, anastomotic leakage, was reported as grade 3. Accordion ≥3 grade events occurred in a total of four of the 23 patients: reoperation due to anastomotic leaks (two) and drained abscesses (two). No DLT was documented at the 7 MBq dose level that was then defined as the recommended dose. The biodistribution of Radspherin® showed a relatively even peritoneal distribution., Conclusion: All dose levels of Radspherin® were well tolerated, and DLT was not reached. No deaths occurred, and no serious adverse events were considered related to Radspherin®. Clinical Trial Registration: Clinicaltrials.gov, NCT03732781., Competing Interests: ØB is a clinical consultant to and holds ownership in Oncoinvent AS. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors declare that this study received funding from Oncoinvent AS. Oncoinvent AS was involved in the study design, collection, analysis, interpretation of data and the decision to submit this article for publication., (Copyright © 2023 Larsen, Graf, Mariathasan, Sørensen, Spasojevic, Goscinski, Selboe, Lundstrøm, Holtermann, Revheim and Bruland.)

Background: Patients referred to public orthopaedic clinics can experience long waiting times before assessment. This study aims to evaluate the effectiveness of a collaborative Shoulder/Elbow Triage and Assessment (SHELTA) model of care involving orthopaedic surgeons and physiotherapists to reduce the waitlist and improve service and clinical outcomes for patients on an orthopaedic shoulder/elbow clinic waitlist., Methods: Patients on the waitlist were triaged by surgeons and physiotherapists and invited to an assessment by experienced physiotherapists. Patients were treated nonoperatively or transferred to orthopaedic management based on clinical discussion. The primary outcome was the number of patients on the waitlist. Secondary outcomes included adverse events, patient satisfaction, re-referral and conversion to surgery rates. Pain, function and patient global impression of change were recorded for participants managed nonoperatively., Results: From July 2019 to December 2019, the waitlist reduced from 451 to 298 patients with no adverse events. Seventy-nine patients could not be contacted and 25 no longer required assessment, and were removed from the waitlist. Nonoperatively managed participants reported satisfaction with the service, a median score of 6 on a 7-point Patient Global Impression of Change scale, change in pain of -2.5/10 (95% CI -3.3, -1.7; P < 0.001) on a numerical pain rating scale, and change in function of -17.4/100 (95% CI: -24.1, -10.8; P < 0.001) on the QuickDASH, indicating improvement., Conclusions: The SHELTA model of care effectively reduced the number of patients on an orthopaedic shoulder/elbow clinic waitlist with good service and clinical outcomes., (© 2023 Royal Australasian College of Surgeons.)

Distal clavicle excision (DCE) for acromioclavicular (AC) joint primary osteoarthritis and post-traumatic arthritis has been shown to have good to excellent outcomes. However, there are studies that report significant rates of residual AC joint pain and distal clavicle instability after open and arthroscopic techniques. We describe a surgical technique for management of AC joint primary osteoarthritis, post-traumatic arthritis, and revision DCE that involves DCE with ligament reconstruction and tendon interposition arthroplasty. It provides distal clavicle stability and can theoretically reduce residual AC joint pain secondary to acromial abutment after DCE., Competing Interests: Conflicts of Interest and Source of Funding: J.S.H. has the following disclosures: Mathys Ltd: Paid presenter or speaker; Research support. Medartis: Paid presenter or speaker. Zimmer: IP royalties; Paid consultant; Paid presenter or speaker. For the remaining authors none were declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The scope of the present study was to prepare fully bio-based unsaturated polyester resins (UPRs) with comparable properties to the commercial formulations. The focus was set on the determination of the optimal prepolymer formulation using the same set of diacids (itaconic and succinic acid) and different diols (propylene glycol, isosorbide and neopentyl glycol) or its equimolar mixtures, keeping the fixed molar ratio of 1:1:2.1 in all feed compositions. Instead of commonly used styrene, bio-based dimethyl itaconate was used as a reactive diluent (RD). The rheology of the obtained resins was studied in detail. The effect of the used diol on structural (FTIR), thermal (DSC), thermomechanical (DMA), and mechanical (tensile) properties was explained. The properties of UPRs were found to be highly dependent on the diol used in the prepolymer formulation. The UPR with an equimolar ratio of propylene glycol and neopentyl glycol was shown to be the most promising candidate to compete with the commercial petroleum-based resins.

Background: Tranexamic acid (TXA) is commonly used in upper and lower limb arthroplasty to limit blood loss and postoperative hematoma formation. The role of TXA in rotator cuff repair (RCR) surgery is less defined. This trial assessed the effect of preoperative TXA on early postoperative pain scores., Methods: A randomized double-blind trail was conducted in 89 patients undergoing RCR. Patients were randomized to either 2 g of intravenous TXA or placebo at induction. The primary outcome was visual analog scale (VAS)-pain score at day 3 postoperation, with secondary outcomes including VAS-pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores at 2, 8, 24, and 52 weeks., Results: There was no significant difference in VAS-pain scores between groups at day 3 postoperation. Pain scores were significantly better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at 6 months with a reduced rate of secondary adhesive capsulitis., Conclusion: TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated greater range of motion at 6 months with lower rates of secondary adhesive capsulitis., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Commercially available wrist-mounted exercise monitors may offer objective data on disease and recovery. This study is the first to evaluate the potential of such devices in the assessment of frozen shoulder and the effects of treatment., Methods: Twenty-one patients with isolated, unilateral frozen shoulder wore a wrist-mounted accelerometer (Fitbit Fire II, Fitbit Inc. 2007, California, USA) on each wrist for two separate seven-day periods, one week before and six months after treatment. The monitors produced an activity count for each 24-hour period, accounting for all movements of the upper limb. Three values were calculated for each time period: (1) the mean activity count for each limb, (2) the total activity count for both limbs, and (3) an activity count ratio calculated by dividing the activity of the frozen limb by the unaffected limb. Constant score, American Shoulder and Elbow Surgeons, visual analog scale-pain, and range of movement were recorded before and after treatment., Results: Mean activity counts were significantly lower in the frozen shoulder limb than those in the unaffected limb over the initial seven-day period (6066 vs. 7516; P  = .04). The activity count ratio significantly improved after treatment (0.83 vs. 096; p 0.01), whereas the mean total activity count remained similar before and after treatment (14915 vs. 12371; P  = .18), demonstrating that activity transferred from the unaffected limb back to the previously frozen limb. Range of movement ( P  < .01), Constant ( P  < .01), American Shoulder and Elbow Surgeons ( P  < .01), and visual analog scale-pain ( P  < .01) scores all significantly improved after treatment, but there was no correlation with the data from the activity monitor., Discussion: Wrist-mounted accelerometers are sufficiently sensitive to detect a difference in limb activity in patients affected by frozen shoulder. The movement deficit between the affected and unaffected limbs improved by 14% after treatment. These data could be used in conjunction with subjective scores to offer a clearer insight into patient disease burden and recovery., (© 2021 The Author(s).)

For locally advanced soft tissue sarcomas and metastases from melanoma located in the extremities, mutilating surgery or amputation may be necessary to achieve local control. Isolated limb perfusion with high-dose chemotherapy may represent an alternative to amputation for this patient group.

Nowadays, unsaturated polyester resins (UPR) are mainly obtained from non-renewable resources. The ever-increasing regulations and the continuous demand for more sustainability have led to extensive research towards more environmentally suitable alternatives to petroleum-based materials. However, one of the main disadvantages of bio-based UPR is their relatively high viscosity compared to petrochemical ones. In order to overcome this drawback, in this work, we investigated the possibility to lower the resin viscosity utilizing a mixture of dimethyl itaconate (DMI) and methyl methacrylate (MMA) as a reactive diluent. The effect of the DMI and MMA ratio on resin rheological properties was investigated. The optimal curing parameters were determined and all UPRs had a high gel content, which was shown to be dependent on the DMI and MMA ratio in the formulation. Furthermore, thermomechanical and mechanical properties of the resulting network were also found to be affected by the used reactive diluent mixture. A small substitution of DMI by MMA proved to be advantageous since it offers lower resin viscosity and improved mechanical properties.

Plant traits-the morphological, anatomical, physiological, biochemical and phenological characteristics of plants-determine how plants respond to environmental factors, affect other trophic levels, and influence ecosystem properties and their benefits and detriments to people. Plant trait data thus represent the basis for a vast area of research spanning from evolutionary biology, community and functional ecology, to biodiversity conservation, ecosystem and landscape management, restoration, biogeography and earth system modelling. Since its foundation in 2007, the TRY database of plant traits has grown continuously. It now provides unprecedented data coverage under an open access data policy and is the main plant trait database used by the research community worldwide. Increasingly, the TRY database also supports new frontiers of trait-based plant research, including the identification of data gaps and the subsequent mobilization or measurement of new data. To support this development, in this article we evaluate the extent of the trait data compiled in TRY and analyse emerging patterns of data coverage and representativeness. Best species coverage is achieved for categorical traits-almost complete coverage for 'plant growth form'. However, most traits relevant for ecology and vegetation modelling are characterized by continuous intraspecific variation and trait-environmental relationships. These traits have to be measured on individual plants in their respective environment. Despite unprecedented data coverage, we observe a humbling lack of completeness and representativeness of these continuous traits in many aspects. We, therefore, conclude that reducing data gaps and biases in the TRY database remains a key challenge and requires a coordinated approach to data mobilization and trait measurements. This can only be achieved in collaboration with other initiatives., (© 2019 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Background: Radiotherapy (RT) and subsequent abdominoperineal resection (APR) for locally advanced rectal cancer (LARC) is associated with significant perineal wound morbidity. The aim of the present study was to investigate if vertical rectus abdominis musculocutaneous (VRAM) flap repair after APR in LARC patients improves perineal wound healing compared with direct perineal wound closure (non-VRAM)., Methods: LARC patients (n = 329) operated with APR between January 2006 and December 2015 after neoadjuvant RT of ≥ 25 Gy were identified, including 260 and 69 patients in the non-VRAM and VRAM groups, respectively. Perineal wound healing was assessed 3 months postoperatively, and risk factors for perineal wound complications and associations with short- and long-term outcome were analyzed., Results: Delayed perineal wound healing after 3 months was more frequent in the non-VRAM group (31.5%) compared with the VRAM group (10.4%) (p < 0.01). In the non-VRAM group, 26.9% of patients developed pelvic abscess, compared with 10.1% in the VRAM group (p < 0.01). Significant risk factors for perineal wound morbidity were non-VRAM (odds ratio [OR] 3.94, 95% confidence interval [CI] 1.72-9.00; p = 0.02), positive circumferential resection margin (R1; OR 3.64, 95% CI 1.91-6.93; p < 0.01), pelvic abscess (OR 3.27, 95% CI 1.90-5.63; p < 0.01), and short-course RT (OR 3.81, 95% CI 1.75-8.30; p < 0.01). Perineal wound morbidity was not associated with impaired long-term oncologic outcome., Conclusions: VRAM flap reconstruction of the perineum is associated with an increased wound healing rate and may protect against pelvic abscess development. However, procedure-related long-term morbidity is incompletely studied and the procedure should be reserved for selected patients.

Background: High morbidity, increased mortality, and impaired long-term oncologic outcome have been reported after deep surgical site infection (SSI) in rectal cancer surgery. The rate, risk factors and consequences of deep SSI after (chemo)radiotherapy [(C)RT], and surgery for locally advanced rectal cancer (LARC) in a tertiary university hospital single centre cohort of 540 patients are presented., Methods: Patients with LARC, operated between January 1, 2007 and December 31, 2015, were identified in the institutional prospective database. All patients had tumours threatening the mesorectal fascia or invading adjacent organs, with a high rate of T4 tumours (60 %), and all received (C)RT. Risk factors for deep SSI were calculated by multivariable logistic regression analysis. Morbidity data were assessed. Overall survival (OS) and disease-free survival (DFS) between patients with or without deep SSI were estimated., Results: Of 540 patients, 104 (19 %) experienced a deep SSI, with the highest rate in the abdominoperineal resection (APR) group with 25 %. APR, good response to (C)RT (low tumour regression grade), age, and operative blood loss were identified as significant (P < 0.05) risk factors for deep SSI in multivariable analysis. No difference was found in OS (P = 0.995) or DFS (P = 0.568). Hospital stay increased with 5 days (P < 0.001), and complete wound healing at the 3-month follow-up decreased from 86 to 45 % (P < 0.001) after deep SSI., Conclusions: Deep SSI is a frequent and major complication after rectal surgery for LARC, with high morbidity, increased hospital stay and protracted wound healing. Interestingly, deep SSI did not influence long-term oncologic outcome.