51
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Jacobson R, Terranella S, Booker C, Khalid S, Torquati A, Omotosho P. The Impact of Perioperative Antibiotic Prophylaxis on Weight Loss Following Laparoscopic Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A 2020; 30:998-1000. [DOI: 10.1089/lap.2020.0449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Richard Jacobson
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Samantha Terranella
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Connor Booker
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Syed Khalid
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Alfonso Torquati
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Philip Omotosho
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
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52
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Blanc MC, Slim K, Beyer-Berjot L. Best practices in bowel preparation for colorectal surgery: a 2020 overview. Expert Rev Gastroenterol Hepatol 2020; 14:681-688. [PMID: 32476518 DOI: 10.1080/17474124.2020.1775581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cohort studies have recently initiated a paradigm shift in the field of preoperative bowel preparation. Indeed, the adjunction of oral antibiotics (OAB) to mechanical bowel preparation (MBP) is now the gold standard for the American guidelines. However, this strategy is highly controverted. AREAS COVERED This review was an up-to-date analysis of literature on bowel preparation. We conducted a systematic review for randomized controlled trials (RCTs) and meta-analyses published since 2009. A non-exhaustive overview of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) cohort studies and the international guidelines was also given, and future leads were discussed. EXPERT OPINION The methodology of the ACS NSQIP studies did not allow a strong conclusion in favor of the association MBP+OAB. Besides, guidelines were not univocal, with non-American guidelines promoting no preparation at all. RCTs favored OAB alone: indeed, MBP+OAB showed no benefits in terms of surgical site infection (SSI) except when compared to MBP alone, while OAB alone seemed superior to no preparation. Likewise, the meta-analyses also favored OAB alone in terms of overall SSI and organ space infection. Large RCTs are currently running and may change these conclusions. Finally, microbiota is a future lead for personalized OAB.
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Affiliation(s)
- Marie-Caroline Blanc
- Department of Visceral Surgery, CHU de Marseille, Hôpital Nord , Marseille, France
| | - Karem Slim
- Department of Digestive Surgery, CHU Clermont-Ferrand , Clermont-Ferrand, France
| | - Laura Beyer-Berjot
- Department of Visceral Surgery, CHU de Marseille, Hôpital Nord , Marseille, France
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53
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Zhang J, Yu WQ, Chen W, Wei T, Wang CW, Zhang JY, Zhang Y, Liang TB. Systematic Review and Meta-Analysis of the Efficacy of Appropriate Empiric Anti-Enterococcal Therapy for Intra-Abdominal Infection. Surg Infect (Larchmt) 2020; 22:131-143. [PMID: 32471332 DOI: 10.1089/sur.2020.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Delayed treatment of seriously infected patients results in increased mortality. However, antimicrobial therapy for the initial 24 to 48 hours is mostly empirically provided, without evidence regarding the causative pathogen. Whether empiric anti-enterococcal therapy should be administered to treat intra-abdominal infection (IAI) before obtaining culture results remains unknown. We performed a meta-analysis to explore the effects of empiric enterococci covered antibiotic therapy in IAI and the risk factors for enterococcal infection in IAI. Methods: We searched multiple databases systematically and included 23 randomized controlled trials (RCTs) and 13 observational studies. The quality of included studies was assessed, and the reporting bias was evaluated. Meta-analysis was performed using random effects or fixed effects models according to the heterogeneity. The risk ratio (RR), odds ratio (OR), and 95% confidence interval (CI) were calculated. Results: Enterococci-covered antibiotic regimens provided no improvement in treatment success compared with control regimens (RR, 0.99; 95% CI, 0.97-1.00; p = 0.15), with similar mortality and adverse effects in both arms. Basic characteristic analysis revealed that most of the enrolled patients with IAI in RCTs were young, lower risk community-acquired intra-abdominal infection (CA-IAI) patients with a relatively low APACHE II score. Interestingly, risk factor screening revealed that malignancy, corticosteroid use, operation, any antibiotic treatment, admission to intensive care unit (ICU), and indwelling urinary catheter could predispose the patients with IAI to a substantially higher risk of enterococcal infection. "Hospital acquired" itself was a risk factor (OR, 2.81; 95% CI, 2.34-3.39; p < 0.001). Conclusion: It is unnecessary to use additional agents empirically to specifically provide anti-enterococcal coverage for the management of CA-IAI in lower risk patients without evidence of causative pathogen, and risk factors can increase the risk of enterococcal infection. Thus, there is a rationale for providing empiric anti-enterococcal coverage for severely ill patients with CA-IAI with high risk factors and patients with hospital-acquired intra-abdominal infection (HA-IAI).
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Affiliation(s)
- Jian Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China.,Innovation Center for the Study of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Wen-Qiao Yu
- Department of Surgical Intensive Care Unit, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wen Chen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China.,Innovation Center for the Study of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Tao Wei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China.,Innovation Center for the Study of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Chao-Wei Wang
- Affiliated Hospital of Stomatology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jing-Ying Zhang
- Department of General Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China.,Innovation Center for the Study of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Ting-Bo Liang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China.,Innovation Center for the Study of Pancreatic Disease, Hangzhou, Zhejiang, China
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54
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Schardey HM, Wirth U, Strauss T, Kasparek MS, Schneider D, Jauch KW. Prevention of anastomotic leak in rectal cancer surgery with local antibiotic decontamination: a prospective, randomized, double-blind, placebo-controlled single center trial. Int J Colorectal Dis 2020; 35:847-857. [PMID: 32103326 DOI: 10.1007/s00384-020-03544-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak and other infectious complications are septic complications of rectal cancer surgery caused by bacteria. Data from registry analysis show a beneficial effect of local antimicrobial administration on anastomotic leaks, but data are inconsistent in recent clinical trials. Therefore, our aim was to study the efficacy of topical antibiotic treatment on the incidence of anastomotic leaks in rectal cancer surgery. METHODS A prospective, randomized, double-blind and placebo-controlled, single center trial was conducted. Patients received either placebo and amphotericin B or decontamination with polymyxin B, tobramycin, vancomycin, and amphotericin B four times per day starting the day before surgery until postoperative day 7. If a protective ileostomy was created, a catheter was placed transanally and the medication was administered locally to the anastomotic site. All patients received an intravenous perioperative antibiotic prophylaxis. RESULTS The trial had to be stopped for ethical reasons after first interim analysis with 80 patients instead of the initially planned 280 patients. Of the 40 patients randomized to receive placebo, eight (20%) developed anastomotic leak compared to only 2 (5%) in the treatment group of 40 patients (decontamination) with significant difference in the χ2 test (p = 0.0425). Twenty percent of the placebo group and 12.5% in the treatment group developed infectious complications not associated with anastomotic leak (p = 0.5312). One patient (2.5%) in the placebo group died (p = 0.3141). CONCLUSION Local decontamination with polymyxin, tobramycin, vancomycin, and amphotericin B is safe and effective in the prevention of anastomotic leak in rectal cancer surgery.
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Affiliation(s)
- H M Schardey
- Department of General, Visceral, and Transplantion Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of General, Visceral and Vascular Surgery, Agatharied Hospital, Norbert-Kerkel-Platz, 83734, Hausham, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplantion Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - T Strauss
- Department of General, Visceral, and Transplantion Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
- AGAPLESION Diakonieklinikum Rotenburg, 27356, Rotenburg, Germany
| | - M S Kasparek
- Department of General, Visceral, and Transplantion Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of Visceral Surgery, Josephinum, Schönfeldstraße 16, 80539, Munich, Germany
| | - D Schneider
- Department of General, Visceral, and Transplantion Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - K W Jauch
- Department of General, Visceral, and Transplantion Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
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55
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Christley S, Shogan B, Levine Z, Koo H, Guyton K, Owens S, Gilbert J, Zaborina O, Alverdy JC. Comparative genetics of Enterococcus faecalis intestinal tissue isolates before and after surgery in a rat model of colon anastomosis. PLoS One 2020; 15:e0232165. [PMID: 32343730 PMCID: PMC7188289 DOI: 10.1371/journal.pone.0232165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 04/08/2020] [Indexed: 12/17/2022] Open
Abstract
We have recently demonstrated that collagenolytic Enterococcus faecalis plays a key and causative role in the pathogenesis of anastomotic leak, an uncommon but potentially lethal complication characterized by disruption of the intestinal wound following segmental removal of the colon (resection) and its reconnection (anastomosis). Here we hypothesized that comparative genetic analysis of E. faecalis isolates present at the anastomotic wound site before and after surgery would shed insight into the mechanisms by which collagenolytic strains are selected for and predominate at sites of anastomotic disruption. Whole genome optical mapping of four pairs of isolates from rat colonic tissue obtained following surgical resection (herein named “pre-op” isolates) and then 6 days later from the anastomotic site (herein named “post-op” isolates) demonstrated that the isolates with higher collagenolytic activity formed a distinct cluster. In order to perform analysis at a deeper level, a single pair of E. faecalis isolates (16A pre-op and 16A post-op) was selected for whole genome sequencing and assembled using a hybrid assembly algorithm. Comparative genomics demonstrated absence of multiple gene clusters, notably a pathogenicity island in the post-op isolate. No differences were found in the fsr-gelE-sprE genes (EF1817-1822) responsible for regulation and production of collagenolytic activity. Analysis of unique genes among the 16A pre-op and post-op isolates revealed the predominance of transporter systems-related genes in the pre-op isolate and phage-related and hydrolytic enzyme-encoding genes in the post-op isolate. Despite genetic differences observed between pre-op and post-op isolates, the precise genetic determinants responsible for their differential expression of collagenolytic activity remains unknown.
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Affiliation(s)
- Scott Christley
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
| | - Benjamin Shogan
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
| | - Zoe Levine
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
| | - Hyun Koo
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
| | - Kristina Guyton
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
| | - Sarah Owens
- Argonne National Laboratory, Argonne, IL, United States of America
| | - Jack Gilbert
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
- Argonne National Laboratory, Argonne, IL, United States of America
| | - Olga Zaborina
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
| | - John C. Alverdy
- Department of Surgery, University of Chicago, Chicago, IL, United States of America
- * E-mail:
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56
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van Praagh JB, Luo JN, Zaborina O, Alverdy JC. Involvement of the Commensal Organism Bacillus subtilis in the Pathogenesis of Anastomotic Leak. Surg Infect (Larchmt) 2020; 21:865-870. [PMID: 32310731 DOI: 10.1089/sur.2019.345] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: It is now well established that microbes play a key and causative role in the pathogenesis of anastomotic leak. Yet, in patients, determining whether a cultured pathogen retrieved from an anastomotic leak site is a cause or a consequence of the complication remains a challenge. The aim of this study was to test a methodology to invoke causality between a retrieved microbe from a leak site and its role in anastomotic leak. Methods: The commensal organism Bacillus subtilis was isolated from an esophagojejunostomy leak site in a 35-year-old patient with a CDH1 mutation after a prophylactic gastrectomy whose body mass index (BMI) was 35 kg/m2. The organism was screened for its ability to degrade collagen, shift human recombinant matrix metalloprotease-9 (MMP9) to its active form, and induce a clinical anastomotic leak when introduced to anastomotic tissues of mice fed their standard diet (SD) of chow or an obesogenic Western-type diet (WD). Results: The Bacillus subtilis strain retrieved from the anastomotic leak site displayed a high degree of collagenolytic activity and was able to activate human MMP9 consistent with other pathogens expressing this characteristic "leak phenotype." Exposure of the Bacillus subtilis to the anastomotic tissues of obese mice fed a WD led to dehiscence of the anastomosis, abscess formation with peritonitis, and mortality in 50% of mice (3/6). When anastomotic healing was evaluated by a validated anastomotic healing score (AHS), substantially worse healing was observed (i.e., higher AHS) in WD-fed mice exposed to Bacillus subtilis compared to SD-fed mice (analysis of variance [ANOVA], p = 0.0006). Conclusions: Microbial strains obtained from patients' anastomotic leak sites can be evaluated for their pathogenic in the leak process by assessing their ability to produce collagenase, activate MMP9 and cause clinical leaks in mice fed a WD. These studies may aid in identifying those bacterial strains that play a causal role in patients with an anastomotic leak.
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Affiliation(s)
- Jasper B van Praagh
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA.,Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - James N Luo
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Olga Zaborina
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - John C Alverdy
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
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Synchronous genitourinary lichen sclerosus signals a distinct urinary microbiome profile in men with urethral stricture disease. World J Urol 2020; 39:605-611. [PMID: 32274566 DOI: 10.1007/s00345-020-03198-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/31/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Alterations in the urinary microbiome have been associated with urological diseases. The microbiome of patients with urethral stricture disease (USD) remains unknown. Our objective is to examine the microbiome of USD with a focus on inflammatory USD caused by lichen sclerosus (LS). METHODS We collected mid-stream urine samples from men with LS-USD (cases; n = 22) and non-LS USD (controls; n = 76). DNA extraction, PCR amplification of the V4 hypervariable region of the 16S rRNA gene, and sequencing was done on the samples. Operational taxonomic units (OTUs) were defined using a > 97% sequence similarity threshold. Alpha diversity measurements of diversity, including microbiome richness (number of different OTUs) and evenness (distribution of OTUs) were calculated and compared. Microbiome beta diversity (difference between microbial communities) relationships with cases and controls were also assessed. RESULTS Fifty specimens (13 cases and 37 controls) produced a 16S rRNA amplicon. Mean sample richness was 25.9 vs. 16.8 (p = 0.076) for LS-USD vs. non-LS USD, respectively. LS-USD had a unique profile of bacteria by taxonomic order including Bacillales, Bacteroidales and Pasteurellales enriched urine. The beta variation of observed bacterial communities was best explained by the richness. CONCLUSIONS Men with LS-USD may have a unique microbiologic richness, specifically inclusive of Bacillales, Bacteroidales and Pasteurellales enriched urine compared to those with non-LS USD. Further work will be required to elucidate the clinical relevance of these variations in the urinary microbiome.
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58
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Yan Y, Drew DA, Markowitz A, Lloyd-Price J, Abu-Ali G, Nguyen LH, Tran C, Chung DC, Gilpin KK, Meixell D, Parziale M, Schuck M, Patel Z, Richter JM, Kelsey PB, Garrett WS, Chan AT, Stadler ZK, Huttenhower C. Structure of the Mucosal and Stool Microbiome in Lynch Syndrome. Cell Host Microbe 2020; 27:585-600.e4. [PMID: 32240601 PMCID: PMC7453618 DOI: 10.1016/j.chom.2020.03.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 11/22/2019] [Accepted: 03/10/2020] [Indexed: 12/12/2022]
Abstract
The gut microbiota has been associated with colorectal cancer (CRC), but causal alterations preceding CRC have not been elucidated. To prospectively assess microbiome changes prior to colorectal neoplasia, we investigated samples from 100 Lynch syndrome patients using 16S rRNA gene sequencing of colon biopsies, coupled with metagenomic and metatranscriptomic sequencing of feces. Colectomy and CRC history represented the largest effects on microbiome profiles. A subset of Clostridiaceae were depleted in stool corresponding with baseline adenomas, while Desulfovibrio was enriched both in stool and in mucosal biopsies. A classifier leveraging stool metatranscriptomes resulted in modest power to predict interval development of preneoplastic colonic adenoma. Predictive transcripts corresponded with a shift in flagellin contributors and oxidative metabolic microenvironment, potentially factors in local CRC pathogenesis. This suggests that the effectiveness of prospective microbiome monitoring for adenomas may be limited but supports the potential causality of these consistent, early microbial changes in colonic neoplasia.
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Affiliation(s)
- Yan Yan
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - David A Drew
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Arnold Markowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason Lloyd-Price
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Galeb Abu-Ali
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Long H Nguyen
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Christina Tran
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel C Chung
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Katherine K Gilpin
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Dana Meixell
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melanie Parziale
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Madeline Schuck
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Zalak Patel
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter B Kelsey
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Wendy S Garrett
- Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Immunology & Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Immunology & Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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59
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Rink AD, Kienle P, Aigner F, Ulrich A. How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting. Langenbecks Arch Surg 2020; 405:223-232. [PMID: 32189067 DOI: 10.1007/s00423-020-01864-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/05/2020] [Indexed: 01/16/2023]
Abstract
AIMS Anastomotic leakage is one of the most worrisome complications in colorectal surgery. An expert meeting was organized to discuss and find a consensus on various aspects of the surgical management of colorectal disease with a possible impact on anastomotic leakage. METHODS A three-step Delphi-method was used to find consensus recommendations. RESULTS Strong consensus was achieved for the use of mechanical bowel preparation and oral antibiotics prior to colorectal resections, the abundance of non-selective NSAIDs, the preoperative treatment of severe iron deficiency anemia, and for attempting to improve the patients' general performance in the case of frailty. Concerning technical aspects of rectal resection, there was a strong consensus in regard to routinely mobilizing the splenic flexure, to dividing the inferior mesenteric vein, and to using air leak tests to check anastomotic integrity. There was also a strong consensus on not to oversew the stapled anastomoses routinely, to use protective ileostomies for low rectal and intersphincteric, but not for high-rectal anastomoses. Furthermore, a consensus was reached in regard to using CT-scans with rectal contrast enema to evaluate suspected anastomotic leakage as well as measuring C-reactive protein routinely to monitor the postoperative course after colorectal resections. No consensus was found concerning the indication and technique for testing bowel perfusion, the routine use of endoscopy to check the integrity of the anastomosis, the placement of transanal drains for rectal anastomoses and the management of anastomotic leakage with peritonitis. CONCLUSION Consensus could be found for several practice details in the perioperative management in colorectal surgery that might have an influence on anastomotic leakage.
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Affiliation(s)
- Andreas D Rink
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Leverkusen gGmbH, Am Gesundheitspark 11, 51375, Leverkusen, Germany.
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany.
| | - Peter Kienle
- Klinik für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und St. Hedwig-Klinik GmbH, Mannheim, Germany
| | - Felix Aigner
- Chirurgische Klinik Campus Charité Mitte/Campus Virchow, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexis Ulrich
- Chirurgische Klinik I, Rheinland Klinikum GmbH, Lukaskrankenhaus Neuss, Neuss, Germany
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Foppa C, Ng SC, Montorsi M, Spinelli A. Anastomotic leak in colorectal cancer patients: New insights and perspectives. Eur J Surg Oncol 2020; 46:943-954. [PMID: 32139117 DOI: 10.1016/j.ejso.2020.02.027] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 02/09/2020] [Accepted: 02/20/2020] [Indexed: 12/14/2022] Open
Abstract
Anastomotic leak (AL) remains a potentially life-threatening sequela of colorectal surgery impacting on mortality, short- and long-term morbidity, quality of life, local recurrence (LR) and disease-free survival. Despite technical improvements and the identification of several surgery- and patient-related factors associated to the risk of AL, its incidence has not significantly changed over time. In this context, the clarification of the mechanisms underlying anastomotic healing remains an important unmet need, crucial for improving patients' outcomes. This review concentrates on novel key findings in the etiopathogenesis of AL, how they can contribute in determining LR, and measures which may contribute to reducing its incidence. AL results from a complex, dynamic interplay of several factors and biological processes, including host genetics, gut microbiome, inflammation and the immune system. Many of these factors seem to act in concert to drive both AL and LR, even if the exact mechanisms remain to be elucidated. The next generation sequencing technology, including the microbial metagenomics, could lead to tailored bowel preparations targeting only those pathogens that can cause AL. Significant progress is being made in each of the reviewed areas, moving toward translational and targeted therapeutic strategies to prevent the difficult complication of AL.
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Affiliation(s)
- Caterina Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy.
| | - Siew Chien Ng
- Department of Medicine and Therapeutics, Division of Gastroenterology and Hepatology, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Marco Montorsi
- Division of General and Digestive Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
| | - Antonino Spinelli
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi) - Italy; Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy.
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61
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Mucus Microbiome of Anastomotic Tissue During Surgery Has Predictive Value for Colorectal Anastomotic Leakage. Ann Surg 2020; 269:911-916. [PMID: 29303807 DOI: 10.1097/sla.0000000000002651] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of the present study is to investigate the association of gut microbiota, depending on treatment method, with the development of colorectal anastomotic leakage (AL). BACKGROUND AL is a major cause for morbidity and mortality after colorectal surgery, but the mechanism behind this complication still is not fully understood. METHODS Bacterial DNA was isolated from 123 "donuts" of patients where a stapled colorectal anastomosis was made and was analyzed using 16S MiSeq sequencing. In 63 patients, this anastomosis was covered with a C-seal, a bioresorbable sheath stapled to the anastomosis. RESULTS In non-C-seal patients, AL development was associated with low microbial diversity (P = 0.002) and correspondingly with a high abundance of the dominant Bacteroidaceae and Lachnospiraceae families (P = 0.008 and 0.010, respectively). In C-seal samples, where AL rates were slightly higher (25% vs 17%), an association with the gut microbiota composition was almost undetectable. Only a few opportunistic pathogenic groups of low abundance were associated with AL in C-seal patients, in particular Prevotella oralis (P = 0.007). CONCLUSIONS AL in patients without a C-seal can be linked to the intestinal microbiota, in particular with a low microbial diversity and a higher abundance of especially mucin-degrading members of the Bacteroidaceae and Lachnospiraceae families. In C-seal patients, however, it seems that any potential protective benefits or harmful consequences of the gut microbiota composition in regard to wound healing are negated, as progression to AL is independent of the initially dominant bacterial composition.
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Jacobson RA, Wienholts K, Williamson AJ, Gaines S, Hyoju S, van Goor H, Zaborin A, Shogan BD, Zaborina O, Alverdy JC. Enterococcus faecalis exploits the human fibrinolytic system to drive excess collagenolysis: implications in gut healing and identification of druggable targets. Am J Physiol Gastrointest Liver Physiol 2020; 318:G1-G9. [PMID: 31604031 PMCID: PMC6985841 DOI: 10.1152/ajpgi.00236.2019] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Perforations, anastomotic leak, and subsequent intra-abdominal sepsis are among the most common and feared complications of invasive interventions in the colon and remaining intestinal tract. During physiological healing, tissue protease activity is finely orchestrated to maintain the strength and integrity of the submucosa collagen layer in the wound. We (Shogan, BD et al. Sci Trans Med 7: 286ra68, 2015.) have previously demonstrated in both mice and humans that the commensal microbe Enterococcus faecalis selectively colonizes wounded colonic tissues and disrupts the healing process by amplifying collagenolytic matrix-metalloprotease activity toward excessive degradation. Here, we demonstrate for the first time, to our knowledge, a novel collagenolytic virulence mechanism by which E. faecalis is able to bind and locally activate the human fibrinolytic protease plasminogen (PLG), a protein present in high concentrations in healing colonic tissue. E. faecalis-mediated PLG activation leads to supraphysiological collagen degradation; in this study, we demonstrate this concept both in vitro and in vivo. This pathoadaptive response can be mitigated with the PLG inhibitor tranexamic acid (TXA) in a fashion that prevents clinically significant complications in validated murine models of both E. faecalis- and Pseudomonas aeruginosa-mediated colonic perforation. TXA has a proven clinical safety record and is Food and Drug Administration approved for topical application in invasive procedures, albeit for the prevention of bleeding rather than infection. As such, the novel pharmacological effect described in this study may be translatable to clinical trials for the prevention of infectious complications in colonic healing.NEW & NOTEWORTHY This paper presents a novel mechanism for virulence in a commensal gut microbe that exploits the human fibrinolytic system and its principle protease, plasminogen. This mechanism is targetable by safe and effective nonantibiotic small molecules for the prevention of infectious complications in the healing gut.
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Affiliation(s)
- Richard A. Jacobson
- 1Department of Surgery, Rush University Medical Center, Chicago, Illinois,2Pritzker School of Medicine, University of Chicago, Illinois,3Department of Surgery, John H. Stroger Hospital of Cook County, Chicago, Illinois
| | - Kiedo Wienholts
- 4Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Sara Gaines
- 2Pritzker School of Medicine, University of Chicago, Illinois
| | - Sanjiv Hyoju
- 2Pritzker School of Medicine, University of Chicago, Illinois
| | - Harry van Goor
- 4Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | | | - Olga Zaborina
- 2Pritzker School of Medicine, University of Chicago, Illinois
| | - John C. Alverdy
- 2Pritzker School of Medicine, University of Chicago, Illinois
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63
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Hyoju SK, Adriaansens C, Wienholts K, Sharma A, Keskey R, Arnold W, van Dalen D, Gottel N, Hyman N, Zaborin A, Gilbert J, van Goor H, Zaborina O, Alverdy JC. Low-fat/high-fibre diet prehabilitation improves anastomotic healing via the microbiome: an experimental model. Br J Surg 2019; 107:743-755. [PMID: 31879948 DOI: 10.1002/bjs.11388] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/20/2019] [Accepted: 09/11/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Both obesity and the presence of collagenolytic bacterial strains (Enterococcus faecalis) can increase the risk of anastomotic leak. The aim of this study was to determine whether mice chronically fed a high-fat Western-type diet (WD) develop anastomotic leak in association with altered microbiota, and whether this can be mitigated by a short course of standard chow diet (SD; low fat/high fibre) before surgery. METHODS Male C57BL/6 mice were assigned to either SD or an obesogenic WD for 6 weeks followed by preoperative antibiotics and colonic anastomosis. Microbiota were analysed longitudinally after operation and correlated with healing using an established anastomotic healing score. In reiterative experiments, mice fed a WD for 6 weeks were exposed to a SD for 2, 4 and 6 days before colonic surgery, and anastomotic healing and colonic microbiota analysed. RESULTS Compared with SD-fed mice, WD-fed mice demonstrated an increased risk of anastomotic leak, with a bloom in the abundance of Enterococcus in lumen and expelled stool (65-90 per cent for WD versus 4-15 per cent for SD; P = 0·010 for lumen, P = 0·013 for stool). Microbiota of SD-fed mice, but not those fed WD, were restored to their preoperative composition after surgery. Anastomotic healing was significantly improved when WD-fed mice were exposed to a SD diet for 2 days before antibiotics and surgery (P < 0·001). CONCLUSION The adverse effects of chronic feeding of a WD on the microbiota and anastomotic healing can be prevented by a short course of SD in mice. Surgical relevance Worldwide, enhanced recovery programmes have developed into standards of care that reduce major complications after surgery, such as surgical-site infections and anastomotic leak. A complementary effort termed prehabilitation includes preoperative approaches such as smoking cessation, exercise and dietary modification. This study investigated whether a short course of dietary prehabilitation in the form of a low-fat/high-fibre composition can reverse the adverse effect of a high-fat Western-type diet on anastomotic healing in mice. Intake of a Western-type diet had a major adverse effect on both the intestinal microbiome and anastomotic healing following colonic anastomosis in mice. This could be reversed when mice received a low-fat/high-fibre diet before operation. Taken together, these data suggest that dietary modifications before major surgery can improve surgical outcomes via their effects on the intestinal microbiome.
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Affiliation(s)
- S K Hyoju
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - C Adriaansens
- Department of Surgery, University of Chicago, Chicago, Illinois, USA.,Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - K Wienholts
- Department of Surgery, University of Chicago, Chicago, Illinois, USA.,Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - A Sharma
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - R Keskey
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - W Arnold
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - D van Dalen
- Department of Surgery, University of Chicago, Chicago, Illinois, USA.,Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - N Gottel
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - N Hyman
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - A Zaborin
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J Gilbert
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - H van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - O Zaborina
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J C Alverdy
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Prevention of Anastomotic Leak Via Local Application of Tranexamic Acid to Target Bacterial-mediated Plasminogen Activation: A Practical Solution to a Complex Problem. Ann Surg 2019; 274:e1038-e1046. [PMID: 31851007 DOI: 10.1097/sla.0000000000003733] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the role of bacterial- mediated plasminogen (PLG) activation in the pathogenesis of anastomotic leak (AL) and its mitigation by tranexamic acid (TXA). BACKGROUND AL is the most feared complication of colorectal resections. The pathobiology of AL in the setting of a technically optimal procedure involves excessive submucosal collagen degradation by resident microbes. We hypothesized that activation of the host PLG system by pathogens is a central and targetable pathway in AL. METHODS We employed kinetic analysis of binding and activation of human PLG by microbes known to cause AL, and collagen degradation assays to test the impact of PLG on bacterial collagenolysis. Further, we measured the ability of the antifibrinolytic drug TXA to inhibit this process. Finally, using mouse models of pathogen-induced AL, we locally applied TXA via enema and measured its ability to prevent a clinically relevant AL. RESULTS PLG is deposited rapidly and specifically at the site of colorectal anastomoses. TXA inhibited PLG activation and downstream collagenolysis by pathogens known to have a causal role in AL. TXA enema reduced collagenolytic bacteria counts and PLG deposition at anastomotic sites. Postoperative PLG inhibition with TXA enema prevented clinically and pathologically apparent pathogen-mediated AL in mice. CONCLUSIONS Bacterial activation of host PLG is central to collagenolysis and pathogen-mediated AL. TXA inhibits this process both in vitro and in vivo. TXA enema represents a promising method to prevent AL in high-risk sites such as the colorectal anastomoses.
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Li YD, He KX, Zhu WF. Correlation between invasive microbiota in margin-surrounding mucosa and anastomotic healing in patients with colorectal cancer. World J Gastrointest Oncol 2019; 11:717-728. [PMID: 31558976 PMCID: PMC6755102 DOI: 10.4251/wjgo.v11.i9.717] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Impaired anastomotic healing is one of the major complications resulting from radical resection in colorectal cancer (CRC). Accumulating evidence suggests that intestinal microbiota is correlated with anastomotic healing.
AIM To explore the microbiota structural shift in margin-surrounding mucosa and evaluate the predictive ability of selected bacterial taxa for impaired anastomotic healing.
METHODS Margin-surrounding mucosa samples derived from 37 patients were collected to characterize the microbial community structure by 16s rRNA gene sequencing. The patients were divided into two groups according to the healing status of anastomoses: well-healing group (n = 30) and impaired-healing group (n = 7). Statistic differences in bacteria taxa were compared by Wilcoxon test and chi-squared test. The predictive ability of the selected bacterial taxa for the healing status of anastomoses was evaluated by the area under the receiver operator characteristic curve.
RESULTS Community structure shifts were observed in the impaired-healing group and well-healing group. Six bacterial species were found to be significantly correlated with anastomotic healing, and among these species, Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis were considered as the predictive factors. Taking the known risk factor age into consideration, Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis improved predictive ability for the healing status of anastomoses.
CONCLUSION These data show that Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis could be considered as supplementary factors in the prediction of anastomosis healing status in patients after CRC radical resection.
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Affiliation(s)
- Yan-Dong Li
- Division of Colon and Rectal Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Kang-Xin He
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Wei-Fang Zhu
- Division of Dermatology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Meyer J, Naiken S, Christou N, Liot E, Toso C, Buchs NC, Ris F. Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges. World J Gastroenterol 2019; 25:5017-5025. [PMID: 31558854 PMCID: PMC6747296 DOI: 10.3748/wjg.v25.i34.5017] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.
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Affiliation(s)
- Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Surennaidoo Naiken
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Niki Christou
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Emilie Liot
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | | | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
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Oral Polyphosphate Suppresses Bacterial Collagenase Production and Prevents Anastomotic Leak Due to Serratia marcescens and Pseudomonas aeruginosa. Ann Surg 2019; 267:1112-1118. [PMID: 28166091 DOI: 10.1097/sla.0000000000002167] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective of this study was to determine the effect of polyphosphate on intestinal bacterial collagenase production and anastomotic leak in mice undergoing colon surgery. BACKGROUND We have previously shown that anastomotic leak can be caused by intestinal pathogens that produce collagenase. Because bacteria harbor sensory systems to detect the extracellular concentration of phosphate which controls their virulence, we tested whether local phosphate administration in the form of polyphosphate could attenuate pathogen virulence and prevent leak without affecting bacterial growth. METHODS Groups of mice underwent a colorectal anastomosis which was then exposed to collagenolytic strains of either Serratia marcescens or Pseudomonas aeruginosa via enema. Mice were then randomly assigned to drink water or water supplemented with a 6-mer of polyphosphate (PPi-6). All mice were sacrificed on postoperative day 10 and anastomoses assessed for leakage, the presence of collagenolytic bacteria, and anastomotic PPi-6 concentration. RESULTS PPi-6 markedly attenuated collagenase and biofilm production, and also swimming and swarming motility in both S. marcescens and P. aeruginosa while supporting their normal growth. Mice drinking PPi-6 demonstrated increased levels of PPi-6 and decreased colonization of S. marcescens and P. aeruginosa, and collagenase activity at anastomotic tissues. PPi-6 prevented anastomotic abscess formation and leak in mice after anastomotic exposure to S. marcescens and P. aeruginosa. CONCLUSIONS Polyphosphate administration may be an alternative approach to prevent anastomotic leak induced by collagenolytic bacteria with the advantage of preserving the intestinal microbiome and its colonization resistance.
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Identification of Collagenolytic Bacteria in Human Samples: Screening Methods and Clinical Implications for Resolving and Preventing Anastomotic Leaks and Wound Complications. Dis Colon Rectum 2019; 62:972-979. [PMID: 31283593 PMCID: PMC6624086 DOI: 10.1097/dcr.0000000000001417] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Bacteria that produce collagen-digesting enzymes (collagenolytic bacteria) have been shown to play a critical and previously unappreciated role in anastomotic leak pathogenesis by breaking down host tissue extracellular matrix proteins. Detection of these bacteria is labor intensive, and no screening method currently exists. OBJECTIVES We evaluated a rapid screening method developed to detect the presence of these collagenolytic bacteria in clinical samples, such as drain fluid, anastomotic tissue, or feces. DESIGN We compared a new method of detecting collagenolytic bacterial species with a previously used technique using samples from a murine experimental model and then demonstrated the utility of this screening method in samples from patients with anastomotic complications. SETTINGS All of the laboratory work and previous murine experiments were performed in Dr Alverdy's laboratory at the University of Chicago under institutional review board-approved protocols. PATIENTS Samples from patients with challenging wound complications were provided by participating clinicians with verbal patient consent. Given the small number of patients, this was determined to be institutional review board exempt. MAIN OUTCOME MEASURES Whether this analysis can influence patient management and outcomes will require additional study. RESULTS This screening method detects numerous strains of bacteria with collagenolytic properties, including the collagenolytic species that have been implicated previously in anastomotic leak. Once collagenolytic strains are identified, they can be speciated and tested for antibiotic resistance using standard laboratory techniques. LIMITATIONS This study is limited by the small number of patient samples tested. CONCLUSIONS We demonstrated the potential applicability of this assay to evaluate rare and complex anastomotic complications that often require analysis beyond standard culture and sensitivity assays. Future applications of this method may allow the development of strategies to prevent anastomotic leak related to collagenolytic bacteria. See Video Abstract at http://links.lww.com/DCR/A962.
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69
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Hajjar R, Santos MM, Dagbert F, Richard CS. Current evidence on the relation between gut microbiota and intestinal anastomotic leak in colorectal surgery. Am J Surg 2019; 218:1000-1007. [PMID: 31320106 DOI: 10.1016/j.amjsurg.2019.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/29/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a major complication in colorectal surgery. It worsens morbidity, mortality and oncological outcomes in colorectal cancer. Some evidence suggests a potential effect of the intestinal microbiome on wound healing. This review aims to provide a comprehensive review on historical and current evidence regarding the relation between the gastrointestinal microbiota and AL in colorectal surgery, and the potential microbiota-modifying effect of some perioperative commonly used measures. DATA SOURCES A comprehensive search was conducted in Pubmed, Medline and Embase for historical and current clinical and animal studies addressing perioperative intestinal microbiota evaluation, intestinal healing and AL. CONCLUSIONS Evidence on microbes' role in AL is mainly derived from animal experiments. The microbiota's composition and implications are poorly understood in surgical patients. Elaborate microbiota sequencing is required in colorectal surgery to identify potentially beneficial microbial profiles that could lead to specific perioperative microbiome-altering measures and improve surgical and oncological outcomes.
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Affiliation(s)
- Roy Hajjar
- Digestive Surgery Service, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 rue Saint-Denis, Montréal, Québec, H2X 0C1, Canada; Department of Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.
| | - Manuela M Santos
- Nutrition and Microbiome Laboratory, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue Saint-Denis, Montréal, Québec, QC H2X 0A9, Canada; Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - François Dagbert
- Digestive Surgery Service, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 rue Saint-Denis, Montréal, Québec, H2X 0C1, Canada; Department of Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Carole S Richard
- Digestive Surgery Service, Centre Hospitalier de l'Université de Montréal (CHUM), 1000 rue Saint-Denis, Montréal, Québec, H2X 0C1, Canada; Department of Surgery, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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70
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Histologic changes in early colonic anastomotic healing using autologous platelet-rich fibrin matrix. Eur Surg 2019. [DOI: 10.1007/s10353-019-0578-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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71
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Felder S, Lee JT. Techniques for Colorectal Anastomotic Construction Following Proctectomy and Variables Influencing Anastomotic Leak. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00425-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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72
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Gershuni VM, Friedman ES. The Microbiome-Host Interaction as a Potential Driver of Anastomotic Leak. Curr Gastroenterol Rep 2019; 21:4. [PMID: 30684121 DOI: 10.1007/s11894-019-0668-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The goal of this paper is to review current literature on the gut microbiome within the context of host response to surgery and subsequent risk of developing complications, particularly anastomotic leak. We provide background on the relationship between host and gut microbiota with description of the role of the intestinal mucus layer as an important regulator of host health. RECENT FINDINGS Despite improvements in surgical technique and adherence to the tenets of creating a tension-free anastomosis with adequate blood flow, the surgical community has been unable to decrease rates of anastomotic leak using the current paradigm. Rather than adhere to empirical strategies of decontamination, it is imperative to focus on the interaction between the human host and the gut microbiota that live within us. The gut microbiome has been found to play a potential role in development of post-operative complications, including but not limited to anastomotic leak. Evidence suggests that peri-operative interventions may have a role in instigating or mitigating the impact of the gut microbiota via disruption of the protective mucus layer, use of multiple medications, and activation of virulence factors. The microbiome plays a potential role in the development of surgical complications and can be modulated by peri-operative interventions. As such, further research into this relationship is urgently needed.
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Affiliation(s)
- Victoria M Gershuni
- Department of Surgery, Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA. .,Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Elliot S Friedman
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Xie X, He Y, Li H, Yu D, Na L, Sun T, Zhang D, Shi X, Xia Y, Jiang T, Rong S, Yang S, Ma X, Xu G. Effects of prebiotics on immunologic indicators and intestinal microbiota structure in perioperative colorectal cancer patients. Nutrition 2018; 61:132-142. [PMID: 30711862 DOI: 10.1016/j.nut.2018.10.038] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The aim of the present study was to investigate the effects of prebiotics (containing fructooligosaccharides, xylooligosaccharides, polydextrose, and resistant dextrin) intake on immune function and intestinal microbiota structure in perioperative patients with colorectal cancer (CRC). METHODS A randomized, double-blind, no-treatment parallel control clinical trial involving 140 perioperative patients (90 men and 50 women, aged 40-75 y) with CRC was performed. Patients were randomly divided into two groups: an intervention group (prebiotic group, n = 70) that received prebiotic supplementation of 30 g/d for 7 d, and a control group (non-prebiotic group, n = 70) that received no prebiotic supplementation. The nutritional and immunologic indices were evaluated for both groups before and after operation and analyzed against baseline values. Moreover, fecal samples were collected from 40 patients randomly chosen from the two groups to study intestinal microbiota, which was analyzed by sequencing the V3-V4 region of 16S ribosomal DNA using the Illumina (San Diego, CA) MiSeq (PE 2 × 300 bp) platform. RESULTS Oral intake of prebiotics produced significant effects on immunologic indices in both the preoperative and postoperative periods, but the patterns of effects were different. In the preoperative period, prebiotics increased serum levels of immunoglobulin G (IgG; P = 0.02), IgM (P = 0.00), and transferrin (P = 0.027; all P < 0.05). In the postoperative period, enhanced levels of IgG (P = 0.003), IgA (P = 0.007), suppressor/cytotoxic T cells (CD3+CD8+; P = 0.043), and total B lymphocytes (CD19+; P = 0.012) were identified in the prebiotic group (all P < 0.05). The differences in the intestinal microbiota at the phylum level were not statistically significant between the intervention and control groups (P > 0.05). At the genus level, prebiotics increased the abundance of Bifidobacterium (P = 0.017) and Enterococcus (P = 0.02; both P < 0.05) but decreased the abundance of Bacteroides (P = 0.04) in the preoperative period (all P < 0.05). In the postoperative period, the abundance of Bacteroides (P = 0.04) was decreased, but the abundance of Enterococcus (P = 0.00), Bacillus (P = 0.01), Lactococcus (P = 0.00), and Streptococcus (P = 0.037) increased in the non-prebiotic group (all P < 0.05); however, no significant change was identified in the abundance of Enterococcus (P = 0.56), Lactococcus (P = 0.07), and Streptococcus (P = 0.56) as a result of prebiotic intervention in this period (all P > 0.05). The abundance of Escherichia-Shigella was increased after prebiotic intake in the postoperative period (P = 0.014, P < 0.05). There was a notable trend of decline in the abundance of intestinal microbiota from preoperative to postoperative in the non-prebiotic group. CONCLUSIONS Prebiotic intake is recommended to improve serum immunologic indicators in patients with CRC 7 d before operation. Prebiotics improved the abundance of four commensal microbiota containing opportunistic pathogens in patients with CRC. Surgical stress decreased the abundance of most intestinal microbiota in the intestinal tract but increased the abundance of some opportunistic pathogens and commensal microbiota. Bacteroides is a relevant bacterial species for further research on the mechanism of prebiotics.
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Affiliation(s)
- Xiaoliang Xie
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, China; College of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Yaqin He
- Surgical Department, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Hai Li
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Dong Yu
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Li Na
- Biobank of the General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ting Sun
- Biobank of the General Hospital of Ningxia Medical University, Yinchuan, China
| | - Dong Zhang
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xinrong Shi
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yuhan Xia
- Nutrition Department, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Tao Jiang
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Shikuo Rong
- College of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Shaoqi Yang
- Department of Gastroenterology, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Xiaoqiang Ma
- Department of Colorectal Surgery, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Guangxian Xu
- Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, General Hospital of Ningxia Medical University, Yinchuan, China.
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Siddharthan R, Chapek M, Warren M, Martindale R. Probiotics in Prevention of Surgical Site Infections. Surg Infect (Larchmt) 2018; 19:781-784. [PMID: 30394861 DOI: 10.1089/sur.2018.231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Despite significant improvements in peri-operative care, surgical site infections (SSIs) remain an important contributor to morbidity, cost, and death. The human gastrointestinal tract is a complex microenvironment linking host cells and the indigenous microflora or "microbiome," creating a "super-organism" that engages in macro-nutrient and micro-nutrient extraction for the host while serving as a barrier to toxins and other detrimental bacterial end-products. Maintaining a healthy microbiome in the peri-operative period may enable control of multi-drug resistance (MDR) organisms, whereas use of antibiotics simply resets the dysbiotic relation by eliminating multiple strains of bacteria. Such loss of microbial diversity or abundance can slow wound healing. Use of pro-biotics to prevent infection has been evaluated in several studies, but their utility is not yet clear. There is a clear need for randomized trials to draw firm conclusions about their efficacy and to make clinical recommendations.
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Affiliation(s)
- Ragavan Siddharthan
- Department of Surgery, Oregon Health and Science University , Portland, Oregon
| | - Michael Chapek
- Department of Surgery, Oregon Health and Science University , Portland, Oregon
| | - Malissa Warren
- Department of Surgery, Oregon Health and Science University , Portland, Oregon
| | - Robert Martindale
- Department of Surgery, Oregon Health and Science University , Portland, Oregon
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75
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Armstrong G, Croft J, Corrigan N, Brown JM, Goh V, Quirke P, Hulme C, Tolan D, Kirby A, Cahill R, O'Connell PR, Miskovic D, Coleman M, Jayne D. IntAct: intra-operative fluorescence angiography to prevent anastomotic leak in rectal cancer surgery: a randomized controlled trial. Colorectal Dis 2018; 20:O226-O234. [PMID: 29751360 PMCID: PMC6099475 DOI: 10.1111/codi.14257] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 05/02/2018] [Indexed: 02/06/2023]
Abstract
AIM Anastomotic leak (AL) is a major complication of rectal cancer surgery. Despite advances in surgical practice, the rates of AL have remained static, at around 10-15%. The aetiology of AL is multifactorial, but one of the most crucial risk factors, which is mostly under the control of the surgeon, is blood supply to the anastomosis. The MRC/NIHR IntAct study will determine whether assessment of anastomotic perfusion using a fluorescent dye (indocyanine green) and near-infrared laparoscopy can minimize the rate of AL leak compared with conventional white-light laparoscopy. Two mechanistic sub-studies will explore the role of the rectal microbiome in AL and the predictive value of CT angiography/perfusion studies. METHOD IntAct is a prospective, unblinded, parallel-group, multicentre, European, randomized controlled trial comparing surgery with intra-operative fluorescence angiography (IFA) against standard care (surgery with no IFA). The primary end-point is rate of clinical AL at 90 days following surgery. Secondary end-points include all AL (clinical and radiological), change in planned anastomosis, complications and re-interventions, use of stoma, cost-effectiveness of the intervention and quality of life. Patients should have a diagnosis of adenocarcinoma of the rectum suitable for potentially curative surgery by anterior resection. Over 3 years, 880 patients from 25 European centres will be recruited and followed up for 90 days. DISCUSSION IntAct will rigorously evaluate the use of IFA in rectal cancer surgery and explore the role of the microbiome in AL and the predictive value of preoperative CT angiography/perfusion scanning.
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Affiliation(s)
| | - J. Croft
- Clinical Trials Research UnitLeeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - N. Corrigan
- Clinical Trials Research UnitLeeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - J. M. Brown
- Clinical Trials Research UnitLeeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - V. Goh
- School of Biomedical Engineering and Imaging SciencesKing's College London and Honorary Consultant RadiologistGuy's and St Thomas’ Hospitals NHS Foundation TrustLondonUK
| | | | - C. Hulme
- Academic Unit of Health EconomicsLeeds Institute of Health SciencesUniversity of LeedsLeedsUK
| | - D. Tolan
- Leeds Teaching Hospital TrustLeedsUK
| | | | - R. Cahill
- University College DublinDublinIreland
| | | | | | - M. Coleman
- Derriford HospitalPlymouth NHS TrustPlymouthUK
| | - D. Jayne
- Leeds Institute of Biological and Clinical SciencesSt James's University HospitalLeedsUK
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Parker KD, Albeke SE, Gigley JP, Goldstein AM, Ward NL. Microbiome Composition in Both Wild-Type and Disease Model Mice Is Heavily Influenced by Mouse Facility. Front Microbiol 2018; 9:1598. [PMID: 30079054 PMCID: PMC6062620 DOI: 10.3389/fmicb.2018.01598] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/27/2018] [Indexed: 12/12/2022] Open
Abstract
Murine models have become essential tools for understanding the complex interactions between gut microbes, their hosts, and disease. While many intra-facility factors are known to influence the structure of mouse microbiomes, the contribution of inter-facility variation to mouse microbiome composition, especially in the context of disease, remains under-investigated. We replicated microbiome experiments using identical mouse lines housed in two separate animal facilities and report drastic differences in composition of microbiomes based upon animal facility of origin. We observed facility-specific microbiome signatures in the context of a disease model [the Ednrb (endothelin receptor type B) Hirschsprung disease mouse] and in normal C57BL/6J mice. Importantly, these facility differences were independent of cage, sex, or sequencing-related influence. In addition, we investigated the reproducibility of microbiome dysbiosis previously associated with Ednrb-/- (knock-out; KO) mice. While we observed genotype-based differences in composition between wild-type (WT) and KO mice, these differences were inconsistent with the previously reported conclusions. Furthermore, the genotype-based differences were not identical across animal facilities. Despite this, through differential abundance testing, we identified several conserved candidate taxa and candidate operational taxonomic units that may play a role in disease promotion or protection. Overall, our findings raise the possibility that previously reported microbiome-disease associations from murine studies conducted in a single facility may be heavily influenced by facility-specific effects. More generally, these results provide a strong rationale for replication of mouse microbiome studies at multiple facilities, and for the meticulous collection of metadata that will allow the confounding effects of facility to be more specifically identified.
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Affiliation(s)
- Kristopher D. Parker
- Department of Molecular Biology, University of Wyoming, Laramie, WY, United States
| | - Shannon E. Albeke
- Wyoming Geographic Information Science Center, University of Wyoming, Laramie, WY, United States
| | - Jason P. Gigley
- Department of Molecular Biology, University of Wyoming, Laramie, WY, United States
| | - Allan M. Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Naomi L. Ward
- Department of Botany, University of Wyoming, Laramie, WY, United States
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77
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Skowron KB, Shogan BD, Rubin DT, Hyman NH. The New Frontier: the Intestinal Microbiome and Surgery. J Gastrointest Surg 2018; 22:1277-1285. [PMID: 29633119 DOI: 10.1007/s11605-018-3744-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 03/12/2018] [Indexed: 01/31/2023]
Abstract
The microbiome exerts a remarkable effect on human physiology. The study of the human-microbiome relationship is a burgeoning field with great potential to improve our understanding of health and disease. In this review, we address common surgical problems influenced by the human microbiome and explore what is thus far known about this relationship. These include inflammatory bowel disease, colorectal neoplasms, and diverticular disease. We will also discuss the effect of the microbiome on surgical complications, specifically anastomotic leak. We hope that further research in this field will enlighten our management of these and other surgical problems.
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Affiliation(s)
- Kinga B Skowron
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 5095, Chicago, IL, 60637, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 5095, Chicago, IL, 60637, USA.
| | - David T Rubin
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Neil H Hyman
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 5095, Chicago, IL, 60637, USA
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78
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Zhu CS, Grandhi R, Patterson TT, Nicholson SE. A Review of Traumatic Brain Injury and the Gut Microbiome: Insights into Novel Mechanisms of Secondary Brain Injury and Promising Targets for Neuroprotection. Brain Sci 2018; 8:brainsci8060113. [PMID: 29921825 PMCID: PMC6025245 DOI: 10.3390/brainsci8060113] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 06/15/2018] [Accepted: 06/17/2018] [Indexed: 12/16/2022] Open
Abstract
The gut microbiome and its role in health and disease have recently been major focus areas of research. In this review, we summarize the different ways in which the gut microbiome interacts with the rest of the body, with focus areas on its relationships with immunity, the brain, and injury. The gut–brain axis, a communication network linking together the central and enteric nervous systems, represents a key bidirectional pathway with feed-forward and feedback mechanisms. The gut microbiota has a central role in this pathway and is significantly altered following injury, leading to a pro-inflammatory state within the central nervous system (CNS). Herein, we examine traumatic brain injury (TBI) in relation to this axis and explore potential interventions, which may serve as targets for improving clinical outcomes and preventing secondary brain injury.
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Affiliation(s)
- Caroline S Zhu
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
| | - Ramesh Grandhi
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
- Department of Neurosurgery, The University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
- Department of Neurosurgery, The University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
| | - Thomas Tyler Patterson
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
| | - Susannah E Nicholson
- Division of Trauma and Emergency Surgery, Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive (MC 7740), San Antonio, TX 78229, USA.
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Wiegerinck M, Hyoju SK, Mao J, Zaborin A, Adriaansens C, Salzman E, Hyman NH, Zaborina O, van Goor H, Alverdy JC. Novel de novo synthesized phosphate carrier compound ABA-PEG20k-Pi20 suppresses collagenase production in Enterococcus faecalis and prevents colonic anastomotic leak in an experimental model. Br J Surg 2018; 105:1368-1376. [PMID: 29658991 DOI: 10.1002/bjs.10859] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous work has demonstrated that anastomotic leak can be caused by collagenolytic bacteria such as Enterococcus faecalis via an effect on wound collagen. In humans, E. faecalis is the organism cultured most commonly from a leaking anastomosis, and is not routinely eliminated by standard oral or intravenous antibiotics. Novel strategies are needed to contain the virulence of this pathogen when present on anastomotic tissues. METHODS Polyphosphorylated polymer ABA-PEG20k-Pi20 was tested in mice for its ability to prevent anastomotic leak caused by collagenolytic E. faecalis. The study design included a distal colonic resection and anastomosis followed by introduction of E. faecalis to anastomotic tissues via enema. Mice were assigned randomly to receive either ABA-PEG20-Pi20 or its unphosphorylated precursor ABA-PEG20k in their drinking water. The development of anastomotic leak was determined after the animals had been killed. RESULTS Overnight incubation of two different E. faecalis collagenolytic strains with 2 mmol/l of ABA-PEG20k-Pi20 led to near complete inhibition of collagenase production (from 21 000 to 1000 and from 68 000 to 5000 units; P < 0·001; 6 samples per group) without suppressing bacterial growth. In mice drinking 1 per cent ABA-PEG20k-Pi20, the phosphate concentration in the distal colonic mucosa increased twofold and leak rates decreased from eight of 15 to three of 15 animals (P < 0·001). In mice drinking ABA-PEG20k-Pi20, the percentage of collagenolytic colonies among E. faecalis populations present at anastomotic tissue sites was decreased by 6-4800-fold (P = 0·008; 5 animals). CONCLUSION These data indicate that oral intake of ABA-PEG20k-Pi20 may be an effective agent to contain the virulence of E. faecalis and may prevent anastomotic leak caused by this organism. Clinical relevance Progress in understanding the pathogenesis of anastomotic leak continues to point to intestinal bacteria as key causative agents. The presence of pathogens such as Enterococcus faecalis that predominate on anastomotic tissues despite antibiotic use, coupled with their ability to produce collagenase, appears to alter the process of healing that leads to leakage. Further antibiotic administration may seem logical, but carries the unwanted risk of eliminating the normal microbiome, which functions competitively to exclude and suppress the virulence of pathogens such as E. faecalis. Therefore, non-antibiotic strategies that can suppress the production of collagenase by E. faecalis without affecting its growth, or potentially normal beneficial microbiota, may have unique advantages. The findings of this study demonstrate that drinking a phosphate-based polymer can achieve the goal of preventing anastomotic leak by suppressing collagenase production in E. faecalis without affecting its growth.
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Affiliation(s)
- M Wiegerinck
- Department of Surgery, University of Chicago, Chicago, Illinois, USA.,Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S K Hyoju
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J Mao
- Institute for Molecular Engineering, University of Chicago, Chicago, Illinois, USA
| | - A Zaborin
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - C Adriaansens
- Department of Surgery, University of Chicago, Chicago, Illinois, USA.,Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - E Salzman
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - N H Hyman
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - O Zaborina
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - H van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J C Alverdy
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Lee JA, Chico TJA, Renshaw SA. The triune of intestinal microbiome, genetics and inflammatory status and its impact on the healing of lower gastrointestinal anastomoses. FEBS J 2018; 285:1212-1225. [PMID: 29193751 PMCID: PMC5947287 DOI: 10.1111/febs.14346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/07/2017] [Accepted: 11/24/2017] [Indexed: 12/11/2022]
Abstract
Gastrointestinal resections are a common operation and most involve an anastomosis to rejoin the ends of the remaining bowel to restore gastrointestinal (GIT) continuity. While most joins heal uneventfully, in up to 26% of patients healing fails and an anastomotic leak (AL) develops. Despite advances in surgical technology and techniques, the rate of anastomotic leaks has not decreased over the last few decades raising the possibility that perhaps we do not yet fully understand the phenomenon of AL and are thus ill-equipped to prevent it. As in all complex conditions, it is necessary to isolate each different aspect of disease for interrogation of its specific role, but, as we hope to demonstrate in this article, it is a dangerous oversimplification to consider any single aspect as the full answer to the problem. Instead, consideration of important individual observations in parallel could illuminate the way forward towards a possibly simple solution amidst the complexity. This article details three aspects that we believe intertwine, and therefore should be considered together in wound healing within the GIT during postsurgical recovery: the microbiome, the host genetic make-up and their relationship to the perioperative inflammatory status. Each of these, alone or in combination, has been linked with various states of health and disease, and in combining these three aspects in the case of postoperative recovery from bowel resection, we may be nearer an answer to preventing anastomotic leaks than might have been thought just a few years ago.
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Affiliation(s)
- Jou A. Lee
- Department of Infection Immunity and Cardiovascular DiseaseThe Bateson CentreUniversity of SheffieldUK
| | - Timothy J. A. Chico
- Department of Infection Immunity and Cardiovascular DiseaseThe Bateson CentreUniversity of SheffieldUK
| | - Stephen A. Renshaw
- Department of Infection Immunity and Cardiovascular DiseaseThe Bateson CentreUniversity of SheffieldUK
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81
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Yeh A, Morowitz MJ. Probiotics and fecal microbiota transplantation in surgical disorders. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2017.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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82
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Krezalek MA, Alverdy JC. The influence of intestinal microbiome on wound healing and infection. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2017.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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83
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Shao C, Gaines S, Alverdy JC. Influence of the intestinal microbiome on anastomotic healing in the colon and rectum. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2017.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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84
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Trotter J, Onos L, McNaught C, Peter M, Gatt M, Maude K, MacFie J. The use of a novel adhesive tissue patch as an aid to anastomotic healing. Ann R Coll Surg Engl 2018; 100:230-234. [PMID: 29484939 PMCID: PMC5930107 DOI: 10.1308/rcsann.2018.0003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction One of the most feared complications of colorectal surgery is anastomotic leak. Numerous techniques have been studied in the hope of decreasing leakage. This study was designed to assess the handling characteristics of a novel adhesive tissue patch (TissuePatch™; Tissuemed, Leeds, UK) applied to colorectal anastomoses in a pilot study. This was with a view to assessing its potential role in aiding anastomotic healing in subsequent trials. Methods A patch was applied to colorectal anastomoses after the surgeon had completed the anastomosis and prior to abdominal closure. Handling characteristics and patient outcomes were recorded prospectively. Results Nine patients were recruited before the study was prematurely terminated. In one patient, the patch fell off and in another patient, the surgeon omitted to apply it. Six patients had significant postoperative problems (1 confirmed leak necessitating return to theatre and excision anastomosis, 3 suspicious of leak on computed tomography delaying discharge, 2 perianastomotic collections). One patient had an uneventful recovery. Conclusions Although the handling characteristics of this novel tissue patch were deemed satisfactory, it appears that wrapping a colorectal anastomosis with an adhesive hydrophilic patch has significant deleterious effects on anastomotic healing. This could be a consequence of the creation of a microenvironment between the patch and the anastomosis that impairs healing. Further research is required to better understand the mechanisms involved. At present, the use of such patches on colorectal anastomoses should be discouraged outside the confines of a well monitored trial.
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Affiliation(s)
- J Trotter
- York Teaching Hospital NHS Foundation Trust, UK
| | - L Onos
- York Teaching Hospital NHS Foundation Trust, UK
| | - C McNaught
- York Teaching Hospital NHS Foundation Trust, UK
| | - M Peter
- York Teaching Hospital NHS Foundation Trust, UK
| | - M Gatt
- York Teaching Hospital NHS Foundation Trust, UK
| | - K Maude
- York Teaching Hospital NHS Foundation Trust, UK
| | - J MacFie
- York Teaching Hospital NHS Foundation Trust, UK
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Abstract
Short-bowel syndrome represents the most common cause of intestinal failure and occurs when the remaining intestine cannot support fluid and nutrient needs to sustain adequate physiology and development without the use of supplemental parenteral nutrition. After intestinal loss or damage, the remnant bowel undergoes multifactorial compensatory processes, termed adaptation, which are largely driven by intraluminal nutrient exposure. Previous studies have provided insight into the biological processes and mediators after resection, however, there still remains a gap in the knowledge of more comprehensive mechanisms that drive the adaptive responses in these patients. Recent data support the microbiota as a key mediator of gut homeostasis and a potential driver of metabolism and immunomodulation after intestinal loss. In this review, we summarize the emerging ideas related to host-microbiota interactions in the intestinal adaptation processes.
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Key Words
- Adaptive Responses
- CONV, conventional
- ENS, enteric nervous system
- Enteric Flora
- GF, germ-free
- GI, gastrointestinal
- GLP-2, glucagon-like peptide 2
- IBD, inflammatory bowel disease
- ICR, ileocecal resection
- IF, intestinal failure
- IL, interleukin
- Immune System
- Intestinal Failure
- Microbial Metabolites
- NEC, necrotizing enterocolitis
- PN, parenteral nutrition
- SBR, small bowel resection
- SBS, short-bowel syndrome
- SCFA, short-chain fatty acid
- SFB, segmented filamentous bacteria
- TGR5, Takeda-G-protein-receptor 5
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Local antibiotic decontamination to prevent anastomotic leakage short-term outcome in rectal cancer surgery. Int J Colorectal Dis 2018; 33:53-60. [PMID: 29119289 DOI: 10.1007/s00384-017-2933-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Anastomotic leakage still presents an issue in rectal cancer surgery with rates of about 11%. As bacteria play a critical role, there is the concept of perioperative local decontamination to prevent anastomotic leakage. METHODS To ascertain the effectiveness of this treatment, we performed a retrospective analysis on 206 rectal resections with primary anastomosis and routine use of a selective decontamination of the digestive tract (SDD) regimen for local decontamination. SDD medication was administered every 8 h from the day before surgery to the seventh postoperative day. All patients were treated according to the fast-track protocol without mechanical bowel preparation; instead, a laxative was used. RESULTS Overall morbidity was 30%, overall mortality 0.5%. In our data, overall rate of anastomotic leakage (AL) was 5.8%, with 3.9% in anterior rectal resection and 6.5% in low anterior rectal resection group. In 75% of cases, anastomotic leakage was grade "C" and needed re-laparotomy. Surgical site infection rate was 19.9%. No serious adverse events were related to decontamination. CONCLUSION Local antibiotic decontamination appears to be safe and effective to decrease the rate of anastomotic leakage in rectal cancer surgery. Further focus should be on perioperative management including bowel preparation and choice of antimicrobial agents for local decontamination.
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Postoperative symbiotic in patients with head and neck cancer: a double-blind randomised trial. Br J Nutr 2017; 119:190-195. [PMID: 29277158 DOI: 10.1017/s0007114517003403] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Studies on the 'gut origin of sepsis' have suggested that stressful insults, such as surgery, can affect intestinal permeability, leading to bacterial translocation. Symbiotics have been reported to be able to improve gut permeability and modulate the immunologic system, thereby decreasing postoperative complications. Therefore we aimed to evaluate the postoperative use of symbiotics in head and neck cancer surgical patients for intestinal function and permeability, as well as the postoperative outcomes. Patients were double-blind randomised into the symbiotic (n 18) or the control group (n 18). Samples were administered twice a day by nasoenteric tube, starting on the 1st postoperative day until the 5th to 7th day, and comprised 109 colony-forming units/ml each of Lactobacillus paracasei, L. rhamnosus, L. acidophilus, and Bifidobacterium lactis plus 6 g of fructo-oligosaccharides, or a placebo (6 g of maltodextrin). Intestinal function (day of first evacuation, total stool episodes, stool consistency, gastrointestinal tract symptoms and gut permeability by diamine oxidase (DAO) enzyme) and postoperative complications (infectious and non-infectious) were assessed. Results of comparison of the pre- and postoperative periods showed that the groups were similar for all outcome variables. In all, twelve patients had complications in the symbiotic group v. nine in the control group (P>0·05), and the preoperative-postoperative DAO activity ranged from 28·5 (sd 15·4) to 32·7 (sd 11·0) ng/ml in the symbiotic group and 35·2 (sd 17·7) to 34·1 (sd 12·0) ng/ml in the control group (P>0·05). In conclusion, postoperative symbiotics did not impact on intestinal function and postoperative outcomes of head and neck surgical patients.
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Lederer AK, Pisarski P, Kousoulas L, Fichtner-Feigl S, Hess C, Huber R. Postoperative changes of the microbiome: are surgical complications related to the gut flora? A systematic review. BMC Surg 2017; 17:125. [PMID: 29202875 PMCID: PMC5715992 DOI: 10.1186/s12893-017-0325-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The purpose of this review was to identify the relationship between the gut microbiome and the development of postoperative complications like anastomotic leakage or a wound infection. Recent reviews focusing on underlying molecular biology suggested that postoperative complications might be influenced by the patients' gut flora. Therefore, a review focusing on the available clinical data is needed. METHODS In January 2017 a systematic search was carried out in Medline and WebOfScience to identify all clinical studies, which investigated postoperative complications after gastrointestinal surgery in relation to the microbiome of the gut. RESULTS Of 337 results 10 studies were included into this analysis after checking for eligibility. In total, the studies comprised 677 patients. All studies reported a postoperative change of the gut flora. In five studies the amount of bacteria decreased to different degrees after surgery, but only one study found a significant reduction. Surgical procedures tended to result in an increase of potentially pathogenic bacteria and a decrease of Lactobacilli and Bifidobacteria. The rate of infectious complications was lower in patients treated with probiotics/symbiotics compared to control groups without a clear relation to the systemic inflammatory response. The treatment with synbiotics/probiotics in addition resulted in faster recovery of bowel movement and a lower rate of postoperative diarrhea and abdominal cramping. CONCLUSIONS There might be a relationship between the gut flora and the development of postoperative complications. Due to methodological shortcomings of the included studies and uncontrolled bias/confounding factors there remains a high level of uncertainty.
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Affiliation(s)
- Ann-Kathrin Lederer
- Center for Complementary Medicine, Department of Environmental Health Sciences and Hospital Infection Control, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 115b, 79106 Freiburg im Breisgau, Germany
| | - Przemyslaw Pisarski
- Department for General and Visceral Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lampros Kousoulas
- Department for General and Visceral Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department for General and Visceral Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carolin Hess
- Department for Thoracic Surgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roman Huber
- Center for Complementary Medicine, Department of Environmental Health Sciences and Hospital Infection Control, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 115b, 79106 Freiburg im Breisgau, Germany
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Belmouhand M, Krohn PS, Svendsen LB, Henriksen A, Hansen CP, Achiam MP. The occurrence of Enterococcus faecium and faecalis Is significantly associated With anastomotic leakage After pancreaticoduodenectomy. Scand J Surg 2017; 107:107-113. [PMID: 28980499 DOI: 10.1177/1457496917731188] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Enterococcus has emerged as a virulent species; Enterococcus faecium especially has arisen as a source of nosocomial infections. Furthermore, specific Enterococcus faecalis species are significantly associated with anastomotic leakage in rodent studies. The objective of this study was to investigate whether the occurrence of Enterococci ( E. faecium and E. faecalis) obtained from drain samples was associated with leakage in humans undergoing pancreaticoduodenectomy. MATERIALS AND METHODS All patients undergoing pancreaticoduodenectomy had a peritoneal drain sample sent for culturing between postoperative days 3 and 10. Postoperative pancreatic fistulas were defined and classified according to the International Study Group of Pancreatic Fistula. Bile leakage was radiologically verified. Postoperative complications were classified according to the Dindo-Clavien classification. RESULTS A total of 70 patients were eligible and enrolled in this study. Anastomosis leakage was observed in 19 patients; 1 leakage corresponding to the hepaticojejunostomy and 18 pancreatic fistulas were identified. In total, 10 patients (53%) with leakage had Enterococci-positive drain samples versus 12 patients (24%) without leakage [odds ratio (OR) = 5.1, 95% confidence interval (CI) = 1.4-19.4, p = 0.02]. Preoperative biliary drainage with either endoscopic stenting or a percutaneous transhepatic cholangiography catheter was associated with the occurrence of Enterococci in drain samples (OR = 5.67, 95% CI = 1.8-12.9, p = 0.003), but preoperative biliary drainage was not associated with leakage (OR = 0.45, 95% CI = 0.1-1.7, p = 0.23). CONCLUSION Enterococci in drain sample cultures in patients undergoing pancreaticoduodenectomy occurs significantly more among patients with anastomotic leakage compared to patients without leakage.
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Affiliation(s)
- M Belmouhand
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - P S Krohn
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - L B Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - A Henriksen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - C P Hansen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M P Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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90
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Mima K, Ogino S, Nakagawa S, Sawayama H, Kinoshita K, Krashima R, Ishimoto T, Imai K, Iwatsuki M, Hashimoto D, Baba Y, Sakamoto Y, Yamashita YI, Yoshida N, Chikamoto A, Ishiko T, Baba H. The role of intestinal bacteria in the development and progression of gastrointestinal tract neoplasms. Surg Oncol 2017; 26:368-376. [PMID: 29113654 DOI: 10.1016/j.suronc.2017.07.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/09/2017] [Accepted: 07/20/2017] [Indexed: 12/12/2022]
Abstract
More than 100 trillion microorganisms inhabit the human intestinal tract and play important roles in health conditions and diseases, including cancer. Accumulating evidence demonstrates that specific bacteria and bacterial dysbiosis in the gastrointestinal tract can potentiate the development and progression of gastrointestinal tract neoplasms by damaging DNA, activating oncogenic signaling pathways, producing tumor-promoting metabolites such as secondary bile acids, and suppressing antitumor immunity. Other bacterial species have been shown to produce short-chain fatty acids such as butyrate, which can suppress inflammation and carcinogenesis in the gastrointestinal tract. Consistent with these lines of evidence, clinical studies using metagenomic analyses have shown associations of specific bacteria and bacterial dysbiosis with gastrointestinal tract cancers, including esophageal, gastric, and colorectal cancers. Emerging data demonstrate that intestinal bacteria can modulate the efficacy of cancer chemotherapies and novel targeted immunotherapies such as anti-CTLA4 and anti-CD274 therapies, the process of absorption, and the occurrence of complications after gastrointestinal surgery. A better understanding of the mechanisms by which the gut microbiota influence tumor development and progression in the intestine would provide opportunities to develop new prevention and treatment strategies for patients with gastrointestinal tract cancers by targeting the intestinal microflora.
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Affiliation(s)
- Kosuke Mima
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Shuji Ogino
- Division of MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Oncologic Pathology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Sawayama
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Koichi Kinoshita
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Ryuichi Krashima
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takatsugu Ishimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Daisuke Hashimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yasuo Sakamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takatoshi Ishiko
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.
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91
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Zhang Y, Ma C, Zhao J, Xu H, Hou Q, Zhang H. Lactobacillus casei Zhang and vitamin K2 prevent intestinal tumorigenesis in mice via adiponectin-elevated different signaling pathways. Oncotarget 2017; 8:24719-24727. [PMID: 28445967 PMCID: PMC5421882 DOI: 10.18632/oncotarget.15791] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/15/2017] [Indexed: 12/11/2022] Open
Abstract
The incidence of colon cancer has increased considerably and the intestinal microbiota participate in the development of colon cancer. We showed that the L. casei Zhang or vitamin K2 (Menaquinone-7) intervention significantly alleviated intestinal tumor burden in mice. This was associated with increased serum adiponectin levels in both treatments. But osteocalcin level was only increased by L. casei Zhang. Furthermore, the anti-carcinogenic actions of L. casei Zhang were mediated by hepatic Chloride channel-3(CLCN3)/Nuclear Factor Kappa B(NF-κB) and intestinal Claudin15/Chloride intracellular channel 4(CLIC4)/Transforming Growth Factor Beta(TGF-β) signaling, while the vitamin K2 effect involved a hepatic Vitamin D Receptor(VDR)-phosphorylated AMPK signaling pathway. Fecal DNA sequencing by the Pacbio RSII method revealed there was significantly lower Helicobacter apodemus, Helicobacter mesocricetorum, Allobaculum stercoricanis and Adlercreutzia equolifaciens following both interventions compared to the model group. Moreover, different caecum acetic acid and butyric acid levels and enrichment of other specific microbes also determined the activity of the different regulatory pathways. Together these data show that L. casei Zhang and Vitamin K2 can suppress gut risk microbes and promote beneficial microbial metabolites to reduce colonic tumor development in mice.
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Affiliation(s)
- Yong Zhang
- Key Laboratory of Dairy Biotechnology and Engineering, Education Ministry of P. R. China, Department of Food Science and Engineering, Inner Mongolia Agricultural University, Hohhot 010018, P. R. China
| | - Chen Ma
- Key Laboratory of Dairy Biotechnology and Engineering, Education Ministry of P. R. China, Department of Food Science and Engineering, Inner Mongolia Agricultural University, Hohhot 010018, P. R. China
| | - Jie Zhao
- Key Laboratory of Dairy Biotechnology and Engineering, Education Ministry of P. R. China, Department of Food Science and Engineering, Inner Mongolia Agricultural University, Hohhot 010018, P. R. China
| | - Haiyan Xu
- Key Laboratory of Dairy Biotechnology and Engineering, Education Ministry of P. R. China, Department of Food Science and Engineering, Inner Mongolia Agricultural University, Hohhot 010018, P. R. China
| | - Qiangchuan Hou
- Key Laboratory of Dairy Biotechnology and Engineering, Education Ministry of P. R. China, Department of Food Science and Engineering, Inner Mongolia Agricultural University, Hohhot 010018, P. R. China
| | - Heping Zhang
- Key Laboratory of Dairy Biotechnology and Engineering, Education Ministry of P. R. China, Department of Food Science and Engineering, Inner Mongolia Agricultural University, Hohhot 010018, P. R. China
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92
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Bachmann R, Leonard D, Delzenne N, Kartheuser A, Cani PD. Novel insight into the role of microbiota in colorectal surgery. Gut 2017; 66:738-749. [PMID: 28153961 DOI: 10.1136/gutjnl-2016-312569] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/21/2016] [Accepted: 12/24/2016] [Indexed: 12/12/2022]
Abstract
Recent literature undeniably supports the idea that the microbiota has a strong influence on the healing process of an intestinal anastomosis. Understanding the mechanisms by which the bacterial community of the gut influences intestinal healing could open the door for new preventive and therapeutic approaches. Among the different mechanisms, data have shown that the production of specific reactive oxygen species (ROS) and the activation of specific formyl peptide receptors (FPRs) regulate intestinal wound healing. Evidence suggests that specific gut microbes such as Lactobacillus spp and Akkermansia muciniphila help to regulate healing processes through both ROS-dependent and FPR-dependent mechanisms. In this review, we will discuss the current knowledge and future perspectives concerning the impact of microbiota on wound healing. We will further review available evidence on whether mechanical bowel preparation and the use of specific antibiotics are beneficial or harmful procedures, an ongoing matter of debate. These practices have a profound effect on the gut microbiota composition at the level of both the mucosal and the luminal compartments. Therefore, a key question remains unanswered: should we continue to prepare the gut before surgical intervention? Current knowledge and data do not clearly support the use of one technique or another to avoid complications such as anastomotic leak. There is an urgent need for appropriate interventions with a deep microbiota analysis to investigate both the surgical technical benefits of a proper anastomosis compared with the potential effect of the gut microbes (beneficial vs harmful) on the processes of wound healing and anastomotic leakage reduction.
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Affiliation(s)
- Radu Bachmann
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - Daniel Leonard
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - Nathalie Delzenne
- Université catholique de Louvain, Louvain Drug Research Institute, Metabolism and Nutrition research group, Brussels, Belgium
| | - Alex Kartheuser
- Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Cliniques des Pathologies Tumorales du Colon et de Rectum (CPTCR), Institut Roi Albert II, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - Patrice D Cani
- Université catholique de Louvain, Louvain Drug Research Institute, Metabolism and Nutrition research group, Brussels, Belgium.,WELBIO (Walloon Excellence in Life sciences and BIOtechnology), Brussels, Belgium
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93
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Afshinnekoo E, Chou C, Alexander N, Ahsanuddin S, Schuetz AN, Mason CE. Precision Metagenomics: Rapid Metagenomic Analyses for Infectious Disease Diagnostics and Public Health Surveillance. J Biomol Tech 2017; 28:40-45. [PMID: 28337072 DOI: 10.7171/jbt.17-2801-007] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Next-generation sequencing (NGS) technologies have ushered in the era of precision medicine, transforming the way we treat cancer patients and diagnose disease. Concomitantly, the advent of these technologies has created a surge of microbiome and metagenomic studies over the last decade, many of which are focused on investigating the host-gene-microbial interactions responsible for the development and spread of infectious diseases, as well as delineating their key role in maintaining health. As we continue to discover more information about the etiology of infectious diseases, the translational potential of metagenomic NGS methods for treatment and rapid diagnosis is becoming abundantly clear. Here, we present a robust protocol for the implementation and application of "precision metagenomics" across various sequencing platforms for clinical samples. Such a pipeline integrates DNA/RNA extraction, library preparation, sequencing, and bioinformatics analyses for taxonomic classification, antimicrobial resistance (AMR) marker screening, and functional analysis (biochemical and metabolic pathway abundance). Moreover, the pipeline has 3 tracks: STAT for results within 24 h; Comprehensive that affords a more in-depth analysis and takes between 5 and 7 d, but offers antimicrobial resistance information; and Targeted, which also requires 5-7 d, but with more sensitive analysis for specific pathogens. Finally, we discuss the challenges that need to be addressed before full integration in the clinical setting.
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Affiliation(s)
- Ebrahim Afshinnekoo
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, New York 10065, USA;; The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, New York, New York 10021, USA;; School of Medicine, New York Medical College, Valhalla, New York 10595, USA
| | - Chou Chou
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, New York 10065, USA;; The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, New York, New York 10021, USA
| | - Noah Alexander
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, New York 10065, USA;; The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, New York, New York 10021, USA
| | - Sofia Ahsanuddin
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, New York 10065, USA;; The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, New York, New York 10021, USA
| | - Audrey N Schuetz
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota 55905, USA; and
| | - Christopher E Mason
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, New York 10065, USA;; The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, New York, New York 10021, USA;; Feil Family Brain & Mind Research Institute, New York, New York 10065, USA
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94
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Alverdy JC, Luo JN. The Influence of Host Stress on the Mechanism of Infection: Lost Microbiomes, Emergent Pathobiomes, and the Role of Interkingdom Signaling. Front Microbiol 2017; 8:322. [PMID: 28303126 PMCID: PMC5332386 DOI: 10.3389/fmicb.2017.00322] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/15/2017] [Indexed: 01/10/2023] Open
Abstract
Mammals constantly face stressful situations, be it extended periods of starvation, sleep deprivation from fear of predation, changing environmental conditions, or loss of habitat. Today, mammals are increasingly exposed to xenobiotics such as pesticides, pollutants, and antibiotics. Crowding conditions such as those created for the purposes of meat production from animals or those imposed upon humans living in urban environments or during world travel create new levels of physiologic stress. As such, human progress has led to an unprecedented exposure of both animals and humans to accidental pathogens (i.e., those that have not co-evolved with their hosts). Strikingly missing in models of infection pathogenesis are the various elements of these conditions, in particular host physiologic stress. The compensatory factors released in the gut during host stress have profound and direct effects on the metabolism and virulence of the colonizing microbiota and the emerging pathobiota. Here, we address unanswered questions to highlight the relevance and importance of incorporating host stress to the field of microbial pathogenesis.
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Affiliation(s)
- John C Alverdy
- Sarah and Harold Lincoln Thompson Professor of Surgery, Pritzker School of Medicine, The University of Chicago Chicago, IL, USA
| | - James N Luo
- Pritzker School of Medicine, The University of Chicago Chicago, IL, USA
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95
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Sind Darmbakterien an der Entstehung der Anastomoseninsuffizienz beteiligt? COLOPROCTOLOGY 2017. [DOI: 10.1007/s00053-017-0145-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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96
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Jackrel SL, Owens SM, Gilbert JA, Pfister CA. Identifying the plant-associated microbiome across aquatic and terrestrial environments: the effects of amplification method on taxa discovery. Mol Ecol Resour 2017; 17:931-942. [PMID: 27997751 DOI: 10.1111/1755-0998.12645] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 11/09/2016] [Accepted: 12/14/2016] [Indexed: 11/26/2022]
Abstract
Plants in terrestrial and aquatic environments contain a diverse microbiome. Yet, the chloroplast and mitochondria organelles of the plant eukaryotic cell originate from free-living cyanobacteria and Rickettsiales. This represents a challenge for sequencing the plant microbiome with universal primers, as ~99% of 16S rRNA sequences may consist of chloroplast and mitochondrial sequences. Peptide nucleic acid clamps offer a potential solution by blocking amplification of host-associated sequences. We assessed the efficacy of chloroplast and mitochondria-blocking clamps against a range of microbial taxa from soil, freshwater and marine environments. While we found that the mitochondrial blocking clamps appear to be a robust method for assessing animal-associated microbiota, Proteobacterial 16S rRNA binds to the chloroplast-blocking clamp, resulting in a strong sequencing bias against this group. We attribute this bias to a conserved 14-bp sequence in the Proteobacteria that matches the 17-bp chloroplast-blocking clamp sequence. By scanning the Greengenes database, we provide a reference list of nearly 1500 taxa that contain this 14-bp sequence, including 48 families such as the Rhodobacteraceae, Phyllobacteriaceae, Rhizobiaceae, Kiloniellaceae and Caulobacteraceae. To determine where these taxa are found in nature, we mapped this taxa reference list against the Earth Microbiome Project database. These taxa are abundant in a variety of environments, particularly aquatic and semiaquatic freshwater and marine habitats. To facilitate informed decisions on effective use of organelle-blocking clamps, we provide a searchable database of microbial taxa in the Greengenes and Silva databases matching various n-mer oligonucleotides of each PNA sequence.
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Affiliation(s)
- Sara L Jackrel
- Department of Ecology and Evolution, The University of Chicago, 1101 E 57th Street, Chicago, IL, 60637, USA
| | - Sarah M Owens
- Biosciences Division, Argonne National Laboratory, 9700 S. Cass Avenue, Lemont, IL, 60439, USA
| | - Jack A Gilbert
- Biosciences Division, Argonne National Laboratory, 9700 S. Cass Avenue, Lemont, IL, 60439, USA
- The Microbiome Center, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Catherine A Pfister
- Department of Ecology and Evolution, The University of Chicago, 1101 E 57th Street, Chicago, IL, 60637, USA
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97
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Schardey HM, Rogers S, Schopf SK, von Ahnen T, Wirth U. Are gut bacteria associated with the development of anastomotic leaks? COLOPROCTOLOGY 2017. [DOI: 10.1007/s00053-016-0136-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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98
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Abstract
Surgery involving the gastrointestinal tract continues to prove challenging because of the persistence of unpredictable complications such as anastomotic leakage and life-threatening infections. Removal of diseased intestinal segments results in substantial catabolic stress and might require complex reconstructive surgery to maintain the functional continuity of the intestinal tract. As gastrointestinal surgery necessarily involves a breach of an epithelial barrier colonized by microorganisms, preoperative intestinal antisepsis is used to reduce infection-related complications. The current approach to intestinal antisepsis varies widely across institutions and countries with little understanding of its mechanism of action, effect on the gut microbiota and overall efficacy. Many of the current approaches to intestinal antisepsis before gastrointestinal surgery run counter to emerging concepts of intestinal microbiota contributing to immune function and recovery from injury. Here, we review evidence outlining the role of gut microbiota in recovery from gastrointestinal surgery, particularly in the development of infections and anastomotic leak. To make surgery safer and further reduce complications, a molecular, genetic and functional understanding of the response of the gastrointestinal tract to alterations in its microbiota is needed. Methods can then be developed to preserve the health-promoting functions of the microbiota while at the same time suppressing their harmful effects.
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Affiliation(s)
- Kristina Guyton
- MC-6040, Department of Surgery, University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, Illinois 60637, USA
| | - John C Alverdy
- MC-6090, Department of Surgery, University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, Illinois 60637, USA
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99
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Vallance A, Wexner S, Berho M, Cahill R, Coleman M, Haboubi N, Heald RJ, Kennedy RH, Moran B, Mortensen N, Motson RW, Novell R, O'Connell PR, Ris F, Rockall T, Senapati A, Windsor A, Jayne DG. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis 2017; 19:O1-O12. [PMID: 27671222 DOI: 10.1111/codi.13534] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.
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Affiliation(s)
- A Vallance
- Royal College of Surgeons of England, London, UK
| | - S Wexner
- Cleveland Clinic Florida, Weston, Florida, USA
| | - M Berho
- Cleveland Clinic Florida, Weston, Florida, USA
| | - R Cahill
- University College Dublin, Dublin, Ireland
| | | | - N Haboubi
- University Hospital of South Manchester, Manchester, UK
| | - R J Heald
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - B Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - R W Motson
- The ICENI Centre, Colchester University Hospital, Colchester, UK
| | - R Novell
- The Royal Free Hospital, London, UK
| | | | - F Ris
- Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - T Rockall
- Royal Surrey County Hospital, Guildford, UK
| | | | - A Windsor
- University College Hospital, London, UK
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100
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Stavrou G, Giamarellos-Bourboulis EJ, Kotzampassi K. The role of probiotics in the prevention of severe infections following abdominal surgery. Int J Antimicrob Agents 2016; 46 Suppl 1:S2-4. [PMID: 26686273 DOI: 10.1016/j.ijantimicag.2015.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Administration of probiotics has been proposed for various medical and surgical conditions. Their effect has been largely attributed to their ability to maintain the integrity of the intestinal mucosal barrier as well as to modulate the innate immune response. Multiple studies have demonstrated their effect in reducing infectious complications in critically ill patients, minimising bacterial translocation and increasing the secretion of anti-inflammatory cytokines. Furthermore, they have been shown to be effective in reducing infections following colorectal surgery, while at the same time preventing overgrowth of bacterial species such as Pseudomonas aeruginosa that has been implicated in the pathogenesis of anastomotic leak. Recent experimental studies have demonstrated that probiotics may decrease expression of the SOCS3 gene, which encodes the protein SOCS3 that suppresses cytokine production, implying a direct interaction of probiotics with the innate immune system. These results hold high promises for the development of new therapeutic strategies.
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Affiliation(s)
- George Stavrou
- 1st Department of Propaedeutic Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Katerina Kotzampassi
- 1st Department of Propaedeutic Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
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