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IntroductionAnastomotic leakage (AL) is one of the major complications after colorectal surgery. Compromised tissue perfusion at the anastomosis site increases the risk of AL. Several cohort studies have shown that indocyanine green (ICG) combined with fluorescent near-infrared imaging is a feasible and reproducible technique for real-time intraoperative imaging of tissue perfusion, leading to reduced leakage rates after colorectal resection. Unfortunately, these studies were not randomised. Therefore, we propose a randomised controlled trial to assess the value of ICG-guided surgery in reducing AL after colorectal surgery.Methods and analysisA multicentre, randomised controlled clinical trial will be conducted to assess the benefit of ICG-guided surgery in preventing AL. A total of 978 patients scheduled for colorectal surgery will be included. Patients will be randomised between the Fluorescence Guided Bowel Anastomosis group and the Conventional Bowel Anastomosis group. The primary endpoint is clinically relevant AL (defined as requiring active therapeutic intervention or reoperation) within 90 days after surgery. Among the secondary endpoints are 30-day clinically relevant AL, all-cause postoperative complications, all-cause and AL-related mortality, surgical and non-surgical reinterventions, total surgical time, length of hospital stay and all-cause and AL-related readmittance.Ethics and disseminationThis protocol has been approved by the Medical Ethical Committee Leiden-Den Haag-Delft (METC-LDD) and is registered at ClinicalTrials.gov and trialregister.nl. The results of this study will be reported through peer-reviewed publications and conference presentations.Trial registration numberNCT04712032; NL7502.

Background. With soft-tissue sarcoma of the extremity (ESTS) representing a heterogenous group of tumors, management decisions are often made in multidisciplinary team (MDT) meetings. To optimize outcome, nomograms are more commonly used to guide individualized treatment decision making. Purpose. To evaluate the influence of Personalised Sarcoma Care (PERSARC) on treatment decisions for patients with high-grade ESTS and the ability of the MDT to accurately predict overall survival (OS) and local recurrence (LR) rates. Methods. Two consecutive meetings were organised. During the first meeting, 36 cases were presented to the MDT. OS and LR rates without the use of PERSARC were estimated by consensus and preferred treatment was recorded for each case. During the second meeting, OS/LR rates calculated with PERSARC were presented to the MDT. Differences between estimated OS/LR rates and PERSARC OS/LR rates were calculated. Variations in preferred treatment protocols were noted. Results. The MDT underestimated OS when compared to PERSARC in 48.4% of cases. LR rates were overestimated in 41.9% of cases. With the use of PERSARC, the proposed treatment changed for 24 cases. Conclusion. PERSARC aids the MDT to optimize individualized predicted OS and LR rates, hereby guiding patient-centered care and shared decision making.

In wetlands, a distinct zonation of plant species composition occurs along moisture gradients, due to differential flooding tolerance of the species involved. However, \"flooding\" comprises two important, distinct stressors (soil oxygen demand [SOD] and partial submergence) that affect plant survival and growth. To investigate how these two flooding stressors affect plant performance, we executed a factorial experiment (water depth × SOD) for six plant species of nutrient-rich and nutrient-poor conditions, occurring along a moisture gradient in Dutch dune slacks. Physiological, growth, and biomass responses to changed oxygen availability were quantified for all species. The responses were consistent with field zonation, but the two stressors affected species differently. Increased SOD increased root oxygen deprivation, as indicated by either raised porosity or increased alcohol dehydrogenase (ADH) activity in roots of flood-intolerant species (Calamagrostis epigejos and Carex arenaria). While SOD affected root functioning, partial submergence tended more to reduce photosynthesis (as shown both by gas exchange and 13C assimilation), leaf dark respiration, 13C partitioning from shoots to roots, and growth of these species. These processes were especially affected if the root oxygen supply was depleted by a combination of flooding and increased SOD. In contrast, the most flood-tolerant species (Juncus subnodulosus and Typha latifolia) were unaffected by any treatment and maintained high internal oxygen concentrations at the shoot: root junction and low root ADH activity in all treatments. For these species, the internal oxygen transport capacity was well in excess of what was needed to maintain aerobic metabolism across all treatments, although there was some evidence for effects of SOD on their nitrogen partitioning (as indicated by δⁱ⁵N values) and photosynthesis. Two species intermediate in flooding tolerance (Carex nigra and Schoenus nigricans) responded more idiosyncratically, with different parameters responding to different treatments. These results show that partial submergence and soil flooding are two very different stressors to which species respond in different ways, and that their effects on physiology, survival, and growth are interactive. Understanding species zonation with water regimes can be improved by a better appreciation of how these factors affect plant metabolism independently and interactively.

The experience with restoring high water levels (i.e., rewetting) within restoration ecology is limited, and information on changes in soil nutrient supply is scarce. A reduction in nutrient supply is needed to restore the desired oligotrophic vegetation. We determined the effects of restoration of high water levels on decomposition and net carbon (C), nitrogen (N), and phosphorus (P) mineralization rates in wet dune slacks and its consequences for the relative abundance of eutrophic vs. oligotrophic species in the vegetation. This was done by analyzing these variables for valleys that experienced a large groundwater rise vs. valleys that had a small groundwater rise but the same current water level. In addition, the influences of underlying factors (waterlogging, vegetation dieback, and soil dynamics prior to groundwater rise) were separated in a transplantation experiment. Short-term effects of large groundwater rise were a massive dieback of vegetation, increased thickness of the fermentation layer, increased microbial decomposition activity, increased C mineralization, and decreased net N mineralization. Net P mineralization was not affected. The relative abundance of oligotrophic vs. eutrophic species was greater at large groundwater rise. Changes in decomposition and mineralization by large groundwater rise were, however, not caused by the vegetation dieback, but due to previous soil conditions. Soils experiencing waterlogged conditions for 3-4 years or more prior to large groundwater rise had lower C and higher net N mineralization rates at waterlogged conditions than soils that had experienced aerobic conditions, presumably due to differences in labile soil C contents. Contrary to expectations induced by previously determined nutrient pulses and measured vegetation dieback, large groundwater rise resulted in lower soil nutrient supply rates and more oligotrophic vegetation. If these trends continue on the longer term, restoration of high water levels may be effective in restoration ecology to establish oligotrophic, wet vegetation in dune slacks.