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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight new research findings in the complex bidirectional crosstalk that occurs between the intestinal microbiome and the host immune system in the context of surgical recovery and outcomes. RECENT FINDINGS Significant evidence has been generated emphasizing the central role of the intestinal microbiome on surgical outcomes such as wound healing, surgical site infections and anastomotic leak. Current preventive strategies, including the use of some parenteral antibiotics, may actually exacerbate the problem by selecting for drug-resistant pathogens. SUMMARY A delicate balance exists between the human host and its microbial counterparts that is directly related to postsurgical healing. This balance can be easily altered in favor of the pathogen through perioperative and surgical interventions leading to intestinal dysbiosis and loss of colonization resistance. Current strategies to prevent infectious complications with the escalating use of broader and more powerful antibiotics are not an evolutionarily stable strategy. A more complete understanding of the ecological and molecular interactions of the host with its microbiome is necessary to uncover new therapeutic strategies that preserve the composition and function of the intestinal microbiome and constrain virulent pathogens through the course of surgical injury.
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Affiliation(s)
- Monika A. Krezalek
- Center for Surgical Infection Research and Therapeutics Pritzker School of Medicine, University of Chicago, Department of Surgery, 5841 S. Maryland, Chicago, Illinois 60637
| | - John C. Alverdy
- Center for Surgical Infection Research and Therapeutics Pritzker School of Medicine, University of Chicago, Department of Surgery, 5841 S. Maryland, Chicago, Illinois 60637
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Mutanen A, Lohi J, Sorsa T, Jalanko H, Pakarinen MP. Features of liver tissue remodeling in intestinal failure during and after weaning off parenteral nutrition. Surgery 2016; 160:632-42. [DOI: 10.1016/j.surg.2016.04.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/15/2016] [Accepted: 04/18/2016] [Indexed: 12/12/2022]
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Demehri FR, Krug SM, Feng Y, Lee IFM, Schulzke JD, Teitelbaum DH. Tight Junction Ultrastructure Alterations in a Mouse Model of Enteral Nutrient Deprivation. Dig Dis Sci 2016; 61:1524-33. [PMID: 26685910 DOI: 10.1007/s10620-015-3991-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 12/08/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Total parenteral nutrition (TPN), a necessary treatment for patients who cannot receive enteral nutrition, is associated with infectious complications due in part to a loss of intestinal epithelial barrier function (EBF). Using a mouse model of TPN, with enteral nutrient deprivation, we previously demonstrated an increase in mucosal interferon-γ and tumor necrosis factor-α; these cytokine changes are a major mediator driving a reduction in epithelial tight junction (TJ) protein expression. However, the exact ultrastructural changes to the intestinal epithelial barrier have not been previously described. AIM We hypothesized that TPN dependence results in ultrastructural changes in the intestinal epithelial TJ meshwork. METHODS C57BL/6 mice underwent internal jugular venous cannulation and were given enteral nutrition or TPN with enteral nutrient deprivation for 7 days. Freeze-fracture electron microscopy was performed on ileal tissue to characterize changes in TJ ultrastructure. EBF was measured using transepithelial resistance and tracer permeability, while TJ expression was measured via Western immunoblotting and immunofluorescence staining. RESULTS While strand density, linearity, and appearance were unchanged, TPN dependence led to a mean reduction in one horizontal strand out of the TJ compact meshwork to a more basal region, resulting in a reduction in meshwork depth. These findings were correlated with the loss of TJ localization of claudin-4 and tricellulin, reduced expression of claudin-5 and claudin-8, and reduced ex vivo EBF. CONCLUSION Tight junction ultrastructural changes may contribute to reduced EBF in the setting of TPN dependence.
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Affiliation(s)
- Farokh R Demehri
- Section of Pediatric Surgery, Department of Surgery, Mott Children's Hospital, University of Michigan Health System, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI, 48109-4211, USA.
| | - Susanne M Krug
- Institute of Clinical Physiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Yongjia Feng
- Section of Pediatric Surgery, Department of Surgery, Mott Children's Hospital, University of Michigan Health System, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI, 48109-4211, USA
| | - In-Fah M Lee
- Institute of Clinical Physiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Joerg D Schulzke
- Institute of Clinical Physiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Daniel H Teitelbaum
- Section of Pediatric Surgery, Department of Surgery, Mott Children's Hospital, University of Michigan Health System, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI, 48109-4211, USA
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Feng Y, Barrett M, Hou Y, Yoon HK, Ochi T, Teitelbaum DH. Homeostasis alteration within small intestinal mucosa after acute enteral refeeding in total parenteral nutrition mouse model. Am J Physiol Gastrointest Liver Physiol 2016; 310:G273-84. [PMID: 26635320 PMCID: PMC4754738 DOI: 10.1152/ajpgi.00335.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/24/2015] [Indexed: 01/31/2023]
Abstract
Feeding strategies to care for patients who transition from enteral nutrient deprivation while on total parenteral nutrition (TPN) to enteral feedings generally proceed to full enteral nutrition once the gastrointestinal tract recovers; however, an increasing body of literature suggests that a subgroup of patients may actually develop an increased incidence of adverse events, including death. To examine this further, we studied the effects of acute refeeding in a mouse model of TPN. Interestingly, refeeding led to some beneficial effects, including prevention in the decline in intestinal epithelial cell (IEC) proliferation. However, refeeding led to a significant increase in mucosal expression of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), as well as an upregulation in Toll-like receptor 4 (TLR-4). Refeeding also failed to prevent TPN-associated increases in IEC apoptosis, loss of epithelial barrier function, and failure of the leucine-rich repeat-containing G protein-coupled receptor 5-positive stem cell expression. Transitioning from TPN to enteral feedings led to a partial restoration of the small bowel microbial population. In conclusion, while acute refeeding led to some restoration of normal gastrointestinal physiology, enteral refeeding led to a significant increase in mucosal inflammatory markers and may suggest alternative strategies to enteral refeeding should be considered.
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Affiliation(s)
- Yongjia Feng
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan;
| | - Meredith Barrett
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,2General Surgery, Department of Surgery, the University of Michigan Medical School, Ann Arbor, Michigan;
| | - Yue Hou
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,3University of Michigan, Ann Arbor, Michigan; and
| | - Hong Keun Yoon
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,3University of Michigan, Ann Arbor, Michigan; and
| | - Takanori Ochi
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,4Department of Pediatric Surgery, Juntendo Hospital, Juntendo University, Tokyo, Japan
| | - Daniel H. Teitelbaum
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan;
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Lian J, Ma L, Yang J, Xu L. Aberrant Gene Expression Profile of Unaffected Colon Mucosa from Patients with Unifocal Colon Polyp. Med Sci Monit 2015; 21:3935-40. [PMID: 26675397 PMCID: PMC4687947 DOI: 10.12659/msm.895576] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background The aim of this study was to evaluate gene expression profiles in unaffected colon mucosa and polyp tissue from patients with unifocal colon polyp to investigate the potential mucosa impairment in normal-appearing colon mucosa from these patients. Material/Methods Colon polyp patients were prospectively recruited. We obtained colon biopsies from the normal-appearing sites and polyp tissue through colonoscopy. Gene expression analysis was performed using microarrays. Gene ontology and clustering were evaluated by bioinformatics. Results We detected a total of 711 genes (274 up-regulated and 437 down-regulated) in polyp tissue and 256 genes (170 up-regulated and 86 down-regulated) in normal-appearing colon mucosa, with at least a 3-fold of change compared to healthy controls. Heatmapping of the gene expression showed similar gene alteration patterns between unaffected colon mucosa and polyp tissue. Gene ontology analyses confirmed the overlapped molecular functions and pathways of altered gene expression between unaffected colon mucosa and polyp tissue from patients with unifocal colon polyp. The most significantly altered genes in normal-appearing tissues in polyp patients include immune response, external side of plasma membrane, nucleus, and cellular response to zinc ion. Conclusions Significant gene expression alterations exist in unaffected colon mucosa from patients with unifocal colon polyp. Unaffected colon mucosa and polyp tissue share great similarity and overlapping of altered gene expression profiles, indicating the potential possibility of recurrence of colon polyps due to underlying molecular abnormalities of colon mucosa in these patients.
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Affiliation(s)
- Jingjing Lian
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Lili Ma
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Jiayin Yang
- Division of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Lili Xu
- Division of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
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Tan SJ, Yu C, Yu Z, Lin ZL, Wu GH, Yu WK, Li JS, Li N. High-fat enteral nutrition reduces intestinal mucosal barrier damage after peritoneal air exposure. J Surg Res 2015; 202:77-86. [PMID: 27083951 DOI: 10.1016/j.jss.2015.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/05/2015] [Accepted: 12/01/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Peritoneal air exposure is needed in open abdominal surgery, but long-time exposure could induce intestinal mucosal barrier dysfunction followed by many postoperative complications. High-fat enteral nutrition can ameliorate intestinal injury and improve intestinal function in many gastrointestinal diseases. In the present study, we investigated the effect of high-fat enteral nutrition on intestinal mucosal barrier after peritoneal air exposure and the underlying mechanism. METHODS Male adult rats were administrated saline, low-fat or high-fat enteral nutrition via gavage before and after peritoneal air exposure for 3 h. Rats undergoing anesthesia without laparotomy received saline as control. Twenty four hours after surgery, samples were collected to assess intestinal mucosal barrier changes in serum D-lactate levels, intestinal permeability, intestinal tight junction protein ZO-1 and occludin levels, and intestinal histopathology. The levels of malondialdehyde and the activity of superoxide dismutase in the ileum tissue were also measured to assess the status of intestinal oxidative stress. RESULTS High-fat enteral nutrition significantly decreased the serum D-lactate level and increased the intestinal tight junction protein ZO-1 level when compared to the group treated with low-fat enteral nutrition (P < 0.05). Meanwhile, histopathologic findings showed that the intestinal mucosal injury assessed by the Chiu's score and the intestinal epithelial tight junction were also improved much more in the high-fat enteral nutrition-treated group (P < 0.05). In addition, the intestinal malondialdehyde level was lower, and the intestinal superoxide dismutase activity was higher in the high-fat enteral nutrition-treated group than that in the low-fat enteral nutrition-treated group (P < 0.05). CONCLUSIONS These results suggest that high-fat enteral nutrition could reduce intestinal mucosal barrier damage after peritoneal air exposure, and the underlying mechanism may be associated with its antioxidative action. Perioperative administration of high-fat enteral nutrition may be a promising intervention to preserve intestinal mucosal barrier function in open abdominal surgery.
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Affiliation(s)
- Shan-Jun Tan
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chao Yu
- Department of Nephrology, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Zhen Yu
- Department of General Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Zhi-Liang Lin
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Guo-Hao Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Wen-Kui Yu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Jie-Shou Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
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Demehri FR, Barrett M, Teitelbaum DH. Changes to the Intestinal Microbiome With Parenteral Nutrition: Review of a Murine Model and Potential Clinical Implications. Nutr Clin Pract 2015; 30:798-806. [PMID: 26424591 DOI: 10.1177/0884533615609904] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Parenteral nutrition (PN) dependence, while life sustaining, carries a significant risk of septic complications associated with epithelial barrier dysfunction and translocation of gut-derived microbiota. Increasing evidence suggests that PN-associated changes in the intestinal microbiota play a central role in the breakdown of the intestinal epithelial barrier. This review outlines the clinical and experimental evidence of epithelial barrier dysfunction with PN, the role of gut inflammatory dysregulation in driving this process, and the role of the intestinal microbiome in modulating inflammation in the gut and systemically. The article summarizes the most current work of our laboratory and others and describes many of the laboratory findings behind our current understanding of the PN enteral environment. Understanding the interaction between nutrient delivery, the intestinal microbiome, and PN-associated complications may lead to the development of novel therapies to enhance safety and quality of life for patients requiring PN.
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Affiliation(s)
- Farokh R Demehri
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Meredith Barrett
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Daniel H Teitelbaum
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
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Barrett M, Demehri FR, Teitelbaum DH. Intestine, immunity, and parenteral nutrition in an era of preferred enteral feeding. Curr Opin Clin Nutr Metab Care 2015; 18:496-500. [PMID: 26154279 PMCID: PMC4589176 DOI: 10.1097/mco.0000000000000208] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW To review the benefits of enteral nutrition in contrast to the inflammatory consequences of administration of parenteral nutrition and enteral deprivation. To present the most recent evidence for the mechanisms of these immunologic changes and discuss potential areas for modification to decrease infectious complications of its administration. RECENT FINDINGS There is significant data supporting the early initiation of enteral nutrition in both medical and surgical patients unable to meet their caloric goals via oral intake alone. Despite the preference for enteral nutrition, some patients are unable to utilize their gut for nutritious gain and therefore require parenteral nutrition administration, along with its infectious complications. The mechanisms behind these complications are multifactorial and have yet to be fully elucidated. Recent study utilizing both animal and human models has provided further information regarding parenteral nutrition's deleterious effect on intestinal epithelial barrier function along with the complications associated with enterocyte deprivation. SUMMARY Changes associated with parenteral nutrition administration and enteral deprivation are complex with multiple potential areas for modification to allow for safer administration. Recent discovery of the mechanisms behind these changes present exciting areas for future study as to make parenteral nutrition administration in the enterally deprived patient safer.
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Affiliation(s)
- Meredith Barrett
- aDepartment of General Surgery, University of Michigan Hospital bDepartment of Pediatric Surgery, University of Michigan, Mott Children's Hospital, Ann Arbor, Michigan, USA
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Wojda TR, Mohammed O, Evans DC. Perioperative Nutrition Support for Surgical Patients: Aspects and Commentary. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0106-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Pakarinen MP. Autologous intestinal reconstruction surgery as part of comprehensive management of intestinal failure. Pediatr Surg Int 2015; 31:453-64. [PMID: 25820764 DOI: 10.1007/s00383-015-3696-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 12/21/2022]
Abstract
Pediatric intestinal failure (IF) remains to be associated with significant morbidity and mortality, the most frequent underlying etiologies being short bowel syndrome (SBS), and primary motility disorders. Management aims to assure growth and development, while preventing complications and facilitating weaning off parenteral support (PS) by fully utilizing adaptation potential of the remaining gut. Probability of survival and weaning off PS is improved by coordinated multidisciplinary intestinal rehabilitation combining individualized physiological enteral and parenteral nutrition (PN), meticulous central line care and medical management with carefully planned surgical care. Increasing evidence suggests that autologous intestinal reconstruction (AIR) surgery is effective treatment for selected short bowel patients. Bowel lengthening procedures normalize pathological adaptation-associated short bowel dilatation with potential to support intestinal absorption and liver function by various mechanisms. Although reversed small intestinal segment, designed to prolong accelerated intestinal transit, improves absorption in adult SBS, its feasibility in children remains unclear. Controlled bowel obstruction to induce dilatation followed by bowel lengthening aims to gain extra length in patients with the shortest duodenojejunal remnant. Reduced PS requirement limits the extent of complications, improving prognosis and quality of life. The great majority of children with SBS can be weaned from PS while prognosis of intractable primary motility disorders remains poor without intestinal transplantation, which serves as a salvage therapy for life-threatening complications such as liver failure, central vein thrombosis or recurrent bloodstream infections.
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Affiliation(s)
- Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 11, Po Box 281, 00029 HUS, Helsinki, Finland,
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