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Barchi A, Massimino L, Mandarino FV, Vespa E, Sinagra E, Almolla O, Passaretti S, Fasulo E, Parigi TL, Cagliani S, Spanò S, Ungaro F, Danese S. Microbiota profiling in esophageal diseases: Novel insights into molecular staining and clinical outcomes. Comput Struct Biotechnol J 2024; 23:626-637. [PMID: 38274997 PMCID: PMC10808859 DOI: 10.1016/j.csbj.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/27/2024] Open
Abstract
Gut microbiota is recognized nowadays as one of the key players in the development of several gastro-intestinal diseases. The first studies focused mainly on healthy subjects with staining of main bacterial species via culture-based techniques. Subsequently, lots of studies tried to focus on principal esophageal disease enlarged the knowledge on esophageal microbial environment and its role in pathogenesis. Gastro Esophageal Reflux Disease (GERD), the most widespread esophageal condition, seems related to a certain degree of mucosal inflammation, via interleukin (IL) 8 potentially enhanced by bacterial components, lipopolysaccharide (LPS) above all. Gram- bacteria, producing LPS), such as Campylobacter genus, have been found associated with GERD. Barrett esophagus (BE) seems characterized by a Gram- and microaerophils-shaped microbiota. Esophageal cancer (EC) development leads to an overturn in the esophageal environment with the shift from an oral-like microbiome to a prevalently low-abundant and low-diverse Gram--shaped microbiome. Although underinvestigated, also changes in the esophageal microbiome are associated with rare chronic inflammatory or neuropathic disease pathogenesis. The paucity of knowledge about the microbiota-driven mechanisms in esophageal disease pathogenesis is mainly due to the scarce sensitivity of sequencing technology and culture methods applied so far to study commensals in the esophagus. However, the recent advances in molecular techniques, especially with the advent of non-culture-based genomic sequencing tools and the implementation of multi-omics approaches, have revolutionized the microbiome field, with promises of implementing the current knowledge, discovering more mechanisms underneath, and giving insights into the development of novel therapies aimed to re-establish the microbial equilibrium for ameliorating esophageal diseases..
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Affiliation(s)
- Alberto Barchi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luca Massimino
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Edoardo Vespa
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology & Endoscopy Unit, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Omar Almolla
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Sandro Passaretti
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ernesto Fasulo
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Tommaso Lorenzo Parigi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Stefania Cagliani
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Salvatore Spanò
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Federica Ungaro
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
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2
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Olson S, Welton L, Jahansouz C. Perioperative Considerations for the Surgical Treatment of Crohn's Disease with Discussion on Surgical Antibiotics Practices and Impact on the Gut Microbiome. Antibiotics (Basel) 2024; 13:317. [PMID: 38666993 PMCID: PMC11047551 DOI: 10.3390/antibiotics13040317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
Crohn's disease, a chronic inflammatory process of the gastrointestinal tract defined by flares and periods of remission, is increasing in incidence. Despite advances in multimodal medical therapy, disease progression often necessitates multiple operations with high morbidity. The inability to treat Crohn's disease successfully is likely in part because the etiopathogenesis is not completely understood; however, recent research suggests the gut microbiome plays a critical role. How traditional perioperative management, including bowel preparation and preoperative antibiotics, further changes the microbiome and affects outcomes is not well described, especially in Crohn's patients, who are unique given their immunosuppression and baseline dysbiosis. This paper aims to outline current knowledge regarding perioperative management of Crohn's disease, the evolving role of gut dysbiosis, and how the microbiome can guide perioperative considerations with special attention to perioperative antibiotics as well as treatment of Mycobacterium avium subspecies paratuberculosis. In conclusion, dysbiosis is common in Crohn's patients and may be exacerbated by malnutrition, steroids, narcotic use, diarrhea, and perioperative antibiotics. Dysbiosis is also a major risk factor for anastomotic leak, and special consideration should be given to limiting factors that further perturb the gut microbiota in the perioperative period.
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Affiliation(s)
- Shelbi Olson
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.O.); (L.W.)
| | - Lindsay Welton
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.O.); (L.W.)
| | - Cyrus Jahansouz
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN 55455, USA
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Scholten J, Reuvers JRD, Stockmann HBAC, van Stralen KJ, van Egmond M, Bonjer HJ, Kazemier G, Abis GSA, Oosterling SJ. Selective Decontamination with Oral Antibiotics in Colorectal Surgery: 90-day Reintervention Rates and Long-term Oncological Follow-up. J Gastrointest Surg 2023; 27:1685-1693. [PMID: 37407901 DOI: 10.1007/s11605-023-05746-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/25/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Oral antibiotics (OAB) in colorectal surgery have been shown to reduce surgical site infections (SSIs) and possibly anastomotic leakage. However, evidence on long-term follow-up, reintervention rates and 5-year oncological follow-up is lacking. The current study aims at elucidating this knowledge gap. METHODS This study evaluated the long-term effectiveness of perioperative 'Selective decontamination of the digestive tract' (SDD) in colorectal cancer surgery. The primary outcome was anastomotic leakage within 90 days, secondary outcomes included infectious complications, reinterventions, readmission, hospital stay, and 5-year overall and disease-free-survival. Statistical analysis including univariate and multivariate analysis was performed to identify predictors of 90-day outcomes, and Kaplan-Meier survival analysis was used for the 5-year survival outcomes. RESULTS In total 455 patients were analyzed, 228 participants in the SDD group and 227 in the control group. Anastomotic leakage rate was not statistically different between the SDD and control group (6.6% versus 9.7%). One or more infectious complications occurred in 15.4% of patients in the SDD group and in 28.2% in the control group (OR 0.46, 95% C.I. 0.29 - 0.73). In the SDD group 8,8% of patients required a reintervention compared to 16,3% of patients in the control group (OR 0.47, 95% C.I. 0.26 - 0.84). After multivariable analysis SDD remained significant in reducing both infectious complications and reinterventions after 90-days follow-up. There was no difference between SDD and control group in 5-year overall survival and disease-free-survival. CONCLUSION SDD as OAB is effective in reducing 90-days postoperative infectious complications and reinterventions. As such, SDD as standard OAB in elective colorectal surgery is highly recommended.
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Affiliation(s)
- J Scholten
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands.
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - J R D Reuvers
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081 HZ, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - H B A C Stockmann
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
| | - K J van Stralen
- Spaarne Gasthuis Academy, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
| | - M van Egmond
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081 HZ, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - H J Bonjer
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081 HZ, Amsterdam, The Netherlands
| | - G Kazemier
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081 HZ, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - G S A Abis
- Department of Surgery, Meander Medisch Centrum, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - S J Oosterling
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
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Boatman S, Kohn J, Jahansouz C. The Influence of the Microbiome on Anastomotic Leak. Clin Colon Rectal Surg 2023; 36:127-132. [PMID: 36844711 PMCID: PMC9946719 DOI: 10.1055/s-0043-1760718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anastomotic leak, defined by the International Study Group of Rectal Cancer as "a communication between the intra- and extraluminal compartments owing to a defect of the integrity of the intestinal wall at the anastomosis," is one of the most devastating complications in colorectal surgery. Much work has been done to identify causes of leak; however, despite advances in surgical technique, the prevalence of anastomotic leak has remained at around 11%. The potential causative role of bacteria in the etiopathology of anastomotic leak was established in the 1950s. More recently, alterations in the colonic microbiome have been shown to affect rates of anastomotic leak. Multiple perioperative factors that alter the homeostasis of the gut microbiota community structure and function have been linked to anastomotic leak after colorectal surgery. Here, we discuss the role of diet, radiation, bowel preparation, medications including nonsteroidal anti-inflammatory drugs, morphine, and antibiotics, and specific microbial pathways that have been implicated in anastomotic leak via their effects on the microbiome.
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Affiliation(s)
- Sonja Boatman
- Department of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Julia Kohn
- Department of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Cyrus Jahansouz
- Department of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
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Abstract
Striving to optimize surgical outcomes, the Enhanced Recovery After Surgery (ERAS) pathway mitigates patients' stress through the implementation of evidence-based practices during the pre-, intra-, and postoperative periods. Intestinal flora is a sophisticated ecosystem integrating with the host and the external environment, which serves as a mediator in diverse interventions of ERAS to regulate human metabolism and inflammation. This review linked gut microbes and their metabolites with ERAS interventions, offering novel high-quality investigative proponents for ERAS. ERAS could alter the composition and function of intestinal flora in patients by alleviating various perioperative stress responses. Modifying gut flora through multiple modalities, such as diet and nutrition, to accelerate recovery might be a complementary approach when exploring novel ERAS initiatives. Meanwhile, the pandemic of COVID-19 and the availability of promising qualitative evidence created both challenges and opportunities for the establishment of ERAS mode.
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Gaidarski III AA, Ferrara M. The Colorectal Anastomosis: A Timeless Challenge. Clin Colon Rectal Surg 2022; 36:11-28. [PMID: 36619283 PMCID: PMC9815911 DOI: 10.1055/s-0042-1756510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.
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Affiliation(s)
| | - Marco Ferrara
- Colon and Rectal Clinic of Orlando, Orlando, Florida,Address for correspondence Marco Ferrara, MD Colon and Rectal Clinic of Orlando110 West Underwood ST, Suite A, Orlando, FL 32806
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Martínez-Montoro JI, Martínez-Sánchez MA, Balaguer-Román A, Gil-Martínez J, Mesa-López MJ, Egea-Valenzuela J, Ruiz-Alcaraz AJ, Queipo-Ortuño MI, Ferrer M, Fernández-García JC, Ramos-Molina B. Dietary modulation of gut microbiota in patients with colorectal cancer undergoing surgery: A review. Int J Surg 2022; 104:106751. [PMID: 35803517 DOI: 10.1016/j.ijsu.2022.106751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022]
Abstract
Colorectal cancer (CRC) is the third most frequent malignancy and the second cause of cancer death worldwide. Several factors have been postulated to be involved in CRC pathophysiology, including physical inactivity, unhealthy dietary habits, obesity, and the gut microbiota. Emerging data suggest that the microbiome may play a key role in CRC prognosis and derived complications in patients undergoing colorectal surgery. On the other hand, dietary intervention has been demonstrated to be able to induce significant changes in the gut microbiota and related metabolites in different conditions; therefore, the manipulation of gut microbiota through dietary intervention may constitute a useful approach to improve perioperative dysbiosis and post-surgical outcomes in patients with CRC. In this article, we review the role of the gut microbiota in CRC surgery complications and the potential therapeutic modulation of gut microbiome through nutritional intervention in patients with CRC undergoing surgery.
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Affiliation(s)
- José Ignacio Martínez-Montoro
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Instituto de Investigacion Biomedica de Malaga (IBIMA), Faculty of Medicine, University of Malaga, Malaga, Spain
| | | | - Andrés Balaguer-Román
- Obesity and Metabolism Laboratory, Biomedical Research Institute of Murcia (IMIB), Murcia, Spain; Department of General and Digestive System Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - José Gil-Martínez
- Department of General and Digestive System Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - María José Mesa-López
- Department of Digestive Diseases- Unit of Gastrointestinal Endoscopy, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Juan Egea-Valenzuela
- Department of Digestive Diseases- Unit of Gastrointestinal Endoscopy, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Antonio José Ruiz-Alcaraz
- Department of Biochemistry, Molecular Biology B and Immunology, Faculty of Medicine, University of Murcia, Murcia, Spain
| | - María Isabel Queipo-Ortuño
- Department of Medical Oncology, Virgen de la Victoria and Regional University Hospitals-IBIMA, UMA-CIMES, Malaga, Spain
| | - Mercedes Ferrer
- Obesity and Metabolism Laboratory, Biomedical Research Institute of Murcia (IMIB), Murcia, Spain; Department of Endocrinology and Nutrition, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - José Carlos Fernández-García
- Department of Endocrinology and Nutrition, Regional University Hospital of Malaga, Instituto de Investigacion Biomedica de Malaga (IBIMA), Faculty of Medicine, University of Malaga, Malaga, Spain.
| | - Bruno Ramos-Molina
- Obesity and Metabolism Laboratory, Biomedical Research Institute of Murcia (IMIB), Murcia, Spain.
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Jalodia R, Antoine D, Braniff RG, Dutta RK, Ramakrishnan S, Roy S. Opioid-Use, COVID-19 Infection, and Their Neurological Implications. Front Neurol 2022; 13:884216. [PMID: 35677336 PMCID: PMC9169980 DOI: 10.3389/fneur.2022.884216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/25/2022] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an imminent threat to human health and public safety. ACE2 and transmembrane serine protease 2 proteins on host cells provide the viral entry point to SARS-CoV-2. Although SARS-CoV-2 mainly infects the respiratory system, there have been reports of viral neurotropism and central nervous system injury as indicated by plasma biomarkers, including neurofilament light chain protein and glial fibrillary acidic protein. Even with a small proportion of infections leading to neurological manifestation, the overall number remains high. Common neurological manifestations of SARS-CoV-2 infection include anosmia, ageusia, encephalopathy, and stroke, which are not restricted to only the most severe infection cases. Opioids and opioid antagonists bind to the ACE2 receptor and thereby have been hypothesized to have therapeutic potential in treating COVID-19. However, in the case of other neurotropic viral infections such as human immunodeficiency virus (HIV), opioid use has been established to exacerbate HIV-mediated central nervous system pathogenesis. An analysis of electronic health record data from more than 73 million patients shows that people with Substance Use Disorders are at higher risk of contracting COVID-19 and suffer worse consequences then non-users. Our in-vivo and in-vitro unpublished studies show that morphine treatment causes increased expression of ACE2 in murine lung and brain tissue as early as 24 h post treatment. At the same time, we also observed morphine and lipopolysaccharides treatment lead to a synergistic increase in ACE2 expression in the microglial cell line, SIM-A9. This data suggests that opioid treatment may potentially increase neurotropism of SARS-CoV-2 infection. We have previously shown that opioids induce gut microbial dysbiosis. Similarly, gut microbiome alterations have been reported with SARS-CoV-2 infection and may play a role in predicting COVID-19 disease severity. However, there are no studies thus far linking opioid-mediated dysbiosis with the severity of neuron-specific COVID-19 infection.
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Affiliation(s)
| | | | | | | | | | - Sabita Roy
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
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Lo BD, Zhang GQ, Canner JK, Stem M, Taylor JP, Atallah C, Efron JE, Safar B. Preoperative Opioid Dose and Surgical Outcomes in Colorectal Surgery. J Am Coll Surg 2022; 234:428-435. [PMID: 35290261 DOI: 10.1097/xcs.0000000000000109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The worsening opioid epidemic has led to an increased number of surgical patients with chronic preoperative opioid use. However, the impact of opioids on perioperative outcomes has yet to be fully elucidated. The purpose of this study was to assess the association between preoperative opioid dose and surgical outcomes among colectomy patients. METHODS Adult colectomy patients in the IBM MarketScan database (2010-2017) were stratified based on preoperative opioid dose, calculated as the average opioid dose in morphine milligram equivalents (MME) in the 90 days prior to surgery: 0 MME, 1 to 49 MME, and 50 or more MME. The association between preoperative opioid dose and anastomotic leak, the primary outcome of interest, as well as other postoperative complications, was assessed using multivariable regression. RESULTS Among 45,515 adult colectomy patients, 71.4% did not use opioids (0 MME), 27.4% had an opioid dose between 1 and 49 MME, and 1.2% had an opioid dose at or above 50 MME. Patients with preoperative opioid use exhibited a higher incidence of anastomotic leak (0 MME: 4.8%, 1-49 MME: 5.5%, ≥50 MME: 8.3%; p trend = 0.001). Multivariable analysis demonstrated a dose-response relationship between preoperative opioids and surgical outcomes, as the odds of anastomotic leak worsened with increasing opioid dose (1-49 MME: OR 1.19, 95% CI 1.08-1.31, p < 0.001; ≥50 MME: OR 1.64, 95% CI 1.20-2.24, p = 0.002). Similar dose-response relationships were seen after risk-adjustment for lung complications, pneumonia, delirium, and 30-day readmission (p < 0.05 for all). CONCLUSIONS Providers should exercise caution when prescribing opioids preoperatively, as increasing doses of preoperative opioids were associated with worse surgical outcomes and higher 30-day readmission among adult colectomy patients.
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Affiliation(s)
- Brian D Lo
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George Q Zhang
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Department of Surgery (Canner), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - James P Taylor
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- From the Colorectal Research Unit, Department of Surgery (Lo, Zhang, Stem, Taylor, Atallah, Efron, Safar), The Johns Hopkins University School of Medicine, Baltimore, MD
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10
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Abstract
Despite advances in surgical technique and the expanded use of antibiotics, anastomotic leak remains a dreaded complication leading to increased hospital length of stay, morbidity, mortality, and cost. Data continues to grow addressing the importance of a functional and diverse colonic microbiome to ensure adequate healing. Individual pathogens, such as Enterococcus faecalis and Pseudomonas aeruginosa , have been implicated in the pathogenesis of anastomotic leak. Yet how these pathogens proliferate remains unclear. It is possible that decreased microbial diversity promotes a shift to a pathologic phenotype among the remaining microbiota which may lead to anastomotic breakdown. As the microbiome is highly influenced by diet, antibiotic use, the stress of surgery, and opioid use, these factors may be modifiable at various phases of the surgical process. A large amount of data remains unknown about the composition and behavior of the "normal" gut microbiome as compared with an altered community. Therefore, targeting the gut microbiome as a modifiable factor in anastomotic healing may represent a novel strategy for the prevention of anastomotic leak.
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Affiliation(s)
| | - John C Alverdy
- Department of Surgery, University of Chicago, Chicago, Illinois
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11
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Plat VD, van Rossen TM, Daams F, de Boer NK, de Meij TGJ, Budding AE, Vandenbroucke-Grauls CMJE, van der Peet DL. Esophageal microbiota composition and outcome of esophageal cancer treatment: a systematic review. Dis Esophagus 2021; 35:6425236. [PMID: 34761269 PMCID: PMC9376764 DOI: 10.1093/dote/doab076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/24/2021] [Accepted: 10/10/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of esophageal microbiota in esophageal cancer treatment is gaining renewed interest, largely driven by novel DNA-based microbiota analysis techniques. The aim of this systematic review is to provide an overview of current literature on the possible association between esophageal microbiota and outcome of esophageal cancer treatment, including tumor response to (neo)adjuvant chemo(radio)therapy, short-term surgery-related complications, and long-term oncological outcome. METHODS A systematic review of literature was performed, bibliographic databases were searched and relevant articles were selected by two independent researchers. The Newcastle-Ottawa scale was used to estimate the quality of included studies. RESULTS The search yielded 1303 articles, after selection and cross-referencing, five articles were included for qualitative synthesis and four studies were considered of good quality. Two articles addressed tumor response to neoadjuvant chemotherapy and described a correlation between high intratumoral Fusobacterium nucleatum levels and a poor response. One study assessed surgery-related complications, in which no direct association between esophageal microbiota and occurrence of complications was observed. Three studies described a correlation between shortened survival and high levels of intratumoral F. nucleatum, a low abundance of Proteobacteria and high abundances of Prevotella and Streptococcus species. CONCLUSIONS Current evidence points towards an association between esophageal microbiota and outcome of esophageal cancer treatment and justifies further research. Whether screening of the individual esophageal microbiota can be used to identify and select patients with a predisposition for adverse outcome needs to be further investigated. This could lead to the development of microbiota-based interventions to optimize esophageal microbiota composition, thereby improving outcome of patients with esophageal cancer.
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Affiliation(s)
- Victor D Plat
- Address correspondence to: Mr Victor Dirk Plat, MD, Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, De Boelelaan 1117, ZH 7F020, 1081 HV Amsterdam, The Netherlands.
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Amsterdam UMC, VU University Medical Center Amsterdam, The Netherlands
| | - Tim G J de Meij
- Department of Pediatric Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Control, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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12
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Yan Y, Chen Y, Zhang X. The effect of opioids on gastrointestinal function in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:370. [PMID: 34689805 PMCID: PMC8543814 DOI: 10.1186/s13054-021-03793-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 12/31/2022]
Abstract
Gastrointestinal (GI) dysfunction is common in the critical care setting and is highly associated with clinical outcomes. Opioids increase the risk for GI dysfunction and are frequently prescribed to reduce pain in critically ill patients. However, the role of opioids in GI function remains uncertain in the ICU. This review aims to describe the effect of opioids on GI motility, their potential risk of increasing infection and the treatment of GI dysmotility with opioid antagonists in the ICU setting.
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Affiliation(s)
- Yun Yan
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yu Chen
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
| | - Xijing Zhang
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China. .,Department of Critical Care Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China.
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Agnes A, Puccioni C, D'Ugo D, Gasbarrini A, Biondi A, Persiani R. The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review. BMC Surg 2021; 21:83. [PMID: 33579260 PMCID: PMC7881582 DOI: 10.1186/s12893-021-01087-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery. METHODS We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics. RESULTS According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection. CONCLUSIONS The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.
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Affiliation(s)
- Annamaria Agnes
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Caterina Puccioni
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
| | - Domenico D'Ugo
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Alberto Biondi
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy.
| | - Roberto Persiani
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
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Koliarakis I, Athanasakis E, Sgantzos M, Mariolis-Sapsakos T, Xynos E, Chrysos E, Souglakos J, Tsiaoussis J. Intestinal Microbiota in Colorectal Cancer Surgery. Cancers (Basel) 2020; 12:cancers12103011. [PMID: 33081401 PMCID: PMC7602998 DOI: 10.3390/cancers12103011] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/04/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023] Open
Abstract
Simple Summary The microbial communities of the intestine exist in a delicate balance with the human. Colorectal cancer is one of the most common gastrointestinal malignancies, and the microbiota seems to be related to it. The intestinal microbiota of patients after colorectal surgery is changed due to surgical stress and other perioperative factors. The occurrence of complications after colorectal cancer (CRC) surgery may depend on these bacterial shifts, which could also be associated with prognosis and survival in postoperative CRC patients. Abstract The intestinal microbiota consists of numerous microbial species that collectively interact with the host, playing a crucial role in health and disease. Colorectal cancer is well-known to be related to dysbiotic alterations in intestinal microbiota. It is evident that the microbiota is significantly affected by colorectal surgery in combination with the various perioperative interventions, mainly mechanical bowel preparation and antibiotic prophylaxis. The altered postoperative composition of intestinal microbiota could lead to an enhanced virulence, proliferation of pathogens, and diminishment of beneficial microorganisms resulting in severe complications including anastomotic leakage and surgical site infections. Moreover, the intestinal microbiota could be utilized as a possible biomarker in predicting long-term outcomes after surgical CRC treatment. Understanding the underlying mechanisms of these interactions will further support the establishment of genomic mapping of intestinal microbiota in the management of patients undergoing CRC surgery.
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Affiliation(s)
- Ioannis Koliarakis
- Laboratory of Anatomy, School of Medicine, University of Crete, 70013 Heraklion, Greece;
| | - Elias Athanasakis
- Department of General Surgery, University Hospital of Heraklion, 71110 Heraklion, Greece; (E.A.); (E.C.)
| | - Markos Sgantzos
- Laboratory of Anatomy, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece;
| | - Theodoros Mariolis-Sapsakos
- Surgical Department, National and Kapodistrian University of Athens, Agioi Anargyroi General and Oncologic Hospital of Kifisia, 14564 Athens, Greece;
| | - Evangelos Xynos
- Department of Surgery, Creta Interclinic Hospital of Heraklion, 71305 Heraklion, Greece;
| | - Emmanuel Chrysos
- Department of General Surgery, University Hospital of Heraklion, 71110 Heraklion, Greece; (E.A.); (E.C.)
| | - John Souglakos
- Laboratory of Translational Oncology, School of Medicine, University of Crete, 71003 Heraklion, Greece;
| | - John Tsiaoussis
- Laboratory of Anatomy, School of Medicine, University of Crete, 70013 Heraklion, Greece;
- Correspondence: ; Tel.: +30-2810-394716
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15
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Parker KE, Sugiarto E, Taylor AMW, Pradhan AA, Al-Hasani R. Pain, Motivation, Migraine, and the Microbiome: New Frontiers for Opioid Systems and Disease. Mol Pharmacol 2020; 98:433-444. [PMID: 32958571 DOI: 10.1124/mol.120.119438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022] Open
Abstract
For decades the broad role of opioids in addiction, neuropsychiatric disorders, and pain states has been somewhat well established. However, in recent years, with the rise of technological advances, not only is the existing dogma being challenged, but we are identifying new disease areas in which opioids play a critical role. This review highlights four new areas of exploration in the opioid field. The most recent addition to the opioid family, the nociceptin receptor system, shows promise as the missing link in understanding the neurocircuitry of motivation. It is well known that activation of the kappa opioid receptor system modulates negative affect and dysphoria, but recent studies now implicate the kappa opioid system in the modulation of negative affect associated with pain. Opioids are critical in pain management; however, the often-forgotten delta opioid receptor system has been identified as a novel therapeutic target for headache disorders and migraine. Lastly, changes to the gut microbiome have been shown to directly contribute to many of the symptoms of chronic opioid use and opioid related behaviors. This review summarizes the findings from each of these areas with an emphasis on identifying new therapeutic targets. SIGNIFICANCE STATEMENT: The focus of this minireview is to highlight new disease areas or new aspects of disease in which opioids have been implicated; this includes pain, motivation, migraine, and the microbiome. In some cases, this has resulted in the pursuit of a novel therapeutic target and resultant clinical trial. We believe this is very timely and will be a refreshing take on reading about opioids and disease.
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Affiliation(s)
- Kyle E Parker
- Department of Anesthesiology and Washington University Pain Center, Washington University in St. Louis, Missouri (K.E.P, R.A.-H.); Center for Clinical Pharmacology, Washington University School of Medicine, St. Louis, Missouri (K.E.P., R.A.-H.); Department of Pharmacology, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois (A.A.P.); and St. Louis College of Pharmacy, St. Louis, Missouri (R.A.-H.)
| | - Elizabeth Sugiarto
- Department of Anesthesiology and Washington University Pain Center, Washington University in St. Louis, Missouri (K.E.P, R.A.-H.); Center for Clinical Pharmacology, Washington University School of Medicine, St. Louis, Missouri (K.E.P., R.A.-H.); Department of Pharmacology, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois (A.A.P.); and St. Louis College of Pharmacy, St. Louis, Missouri (R.A.-H.)
| | - Anna M W Taylor
- Department of Anesthesiology and Washington University Pain Center, Washington University in St. Louis, Missouri (K.E.P, R.A.-H.); Center for Clinical Pharmacology, Washington University School of Medicine, St. Louis, Missouri (K.E.P., R.A.-H.); Department of Pharmacology, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois (A.A.P.); and St. Louis College of Pharmacy, St. Louis, Missouri (R.A.-H.)
| | - Amynah A Pradhan
- Department of Anesthesiology and Washington University Pain Center, Washington University in St. Louis, Missouri (K.E.P, R.A.-H.); Center for Clinical Pharmacology, Washington University School of Medicine, St. Louis, Missouri (K.E.P., R.A.-H.); Department of Pharmacology, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois (A.A.P.); and St. Louis College of Pharmacy, St. Louis, Missouri (R.A.-H.)
| | - Ream Al-Hasani
- Department of Anesthesiology and Washington University Pain Center, Washington University in St. Louis, Missouri (K.E.P, R.A.-H.); Center for Clinical Pharmacology, Washington University School of Medicine, St. Louis, Missouri (K.E.P., R.A.-H.); Department of Pharmacology, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada (E.S., A.M.W.T.); Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois (A.A.P.); and St. Louis College of Pharmacy, St. Louis, Missouri (R.A.-H.)
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16
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Bartolini I, Risaliti M, Ringressi MN, Melli F, Nannini G, Amedei A, Muiesan P, Taddei A. Role of gut microbiota-immunity axis in patients undergoing surgery for colorectal cancer: Focus on short and long-term outcomes. World J Gastroenterol 2020; 26:2498-2513. [PMID: 32523307 PMCID: PMC7265137 DOI: 10.3748/wjg.v26.i20.2498] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/27/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Human body is colonized by a huge amount of microorganisms mostly located in the gastrointestinal tract. These dynamic communities, the environment and their metabolites constitute the microbiota. Growing data suggests a causal role of a dysbiotic microbiota in several pathologies, such as metabolic and neurological disorders, immunity dysregulations and cancer, especially the well-studied colorectal cancer development. However, many were preclinical studies and a complete knowledge of the pathogenetic mechanisms in humans is still absent. The gut microbiota can exert direct or indirect effects in different phases of colorectal cancer genesis. For example, Fusobacterium nucleatum promotes cancer through cellular proliferation and some strains of Escherichia coli and Bacteroides fragilis produce genotoxins. However, dysbiosis may also cause a pro-inflammatory state and the stimulation of a Th17 response with IL-17 and IL-22 secretion that have a pro-oncogenic activity, as demonstrated for Fusobacterium nucleatum. Microbiota has a crucial role in several stages of postoperative course; dysbiosis in fact seems related with surgical site infections and Enterococcus faecalis (and other collagenase-producers microbes) are suggested as a cause of anastomotic leak. Consequently, unbalanced presence of some species, together with altered immune response may also have a prognostic role. Microbiota has also a substantial role in effectiveness of chemotherapy, chemoresistance and in the related side effects. In other words, a complete knowledge of the fine pathological mechanisms of gut microbiota may provide a wide range of new diagnostic tools other than therapeutic targets in the light of tailored medicine.
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Affiliation(s)
- Ilenia Bartolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Matteo Risaliti
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Maria Novella Ringressi
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Filippo Melli
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Giulia Nannini
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Paolo Muiesan
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Antonio Taddei
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
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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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18
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El Bairi K, Jabi R, Trapani D, Boutallaka H, Ouled Amar Bencheikh B, Bouziane M, Amrani M, Afqir S, Maleb A. Can the microbiota predict response to systemic cancer therapy, surgical outcomes, and survival? The answer is in the gut. Expert Rev Clin Pharmacol 2020; 13:403-421. [PMID: 32308061 DOI: 10.1080/17512433.2020.1758063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The gut microbiota seems to play a key role in tumorigenesis, across various hallmarks of cancer. Recent evidence suggests its potential use as a biomarker predicting drug response and adding prognostic information, generally in the context of immuno-oncology. AREAS COVERED In this review, we focus on the modulating effects of gut microbiota dysbiosis on various anticancer molecules used in practice, including cytotoxic and immune-modulating agents, primarily immune-checkpoint inhibitors (ICI). Pubmed/Medline-based literature search was conducted to find potential original studies that discuss gut microbiota as a prognostic and predictive biomarker for cancer therapy. We also looked at the US ClinicalTrials.gov website to find additional studies particularly ongoing human clinical trials. EXPERT COMMENTARY Sequencing of stool-derived materials and tissue samples from cancer patients and animal models has shown a significant enrichment of various bacteria such as Fusobacterium nucleatum and Bacteroides fragilis were associated with resistant disease and poorer outcomes. Gut microbiota was also found to be associated with surgical outcomes and seems to play a significant role in anastomotic leak (ATL) after surgery mainly by collagen breakdown. However, this research field is just at the beginning and the current findings are not yet ready to change clinical practice.
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Affiliation(s)
- Khalid El Bairi
- Cancer Biomarkers Working Group, Mohamed Ist University , Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohamed Ist University , Oujda, Morocco
| | - Rachid Jabi
- Faculty of Medicine and Pharmacy, Mohamed Ist University , Oujda, Morocco
- Department of Visceral Surgery, Mohamed VI University Hospital , Oujda, Morocco
| | - Dario Trapani
- Department of Haematology and Oncology, European Institute of Oncology, IEO, IRCCS, University of Milano , Milan, Italy
| | - Hanae Boutallaka
- Department of Gastroenterology and Digestive Endoscopy, Mohamed V Military Teaching Hospital of Rabat, Mohamed V University , Rabat, Morocco
| | | | - Mohammed Bouziane
- Faculty of Medicine and Pharmacy, Mohamed Ist University , Oujda, Morocco
- Department of Visceral Surgery, Mohamed VI University Hospital , Oujda, Morocco
| | - Mariam Amrani
- Department of Pathology, National Institute of Oncology, Faculty of Medicine and Pharmacy, Mohamed V University , Rabat, Morocco
| | - Said Afqir
- Cancer Biomarkers Working Group, Mohamed Ist University , Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohamed Ist University , Oujda, Morocco
- Department of Medical Oncology, Mohamed VI University Hospital , Oujda, Morocco
| | - Adil Maleb
- Faculty of Medicine and Pharmacy, Mohamed Ist University , Oujda, Morocco
- Department of Microbiology, Mohamed VI University Hospital , Oujda, Morocco
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19
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Pimentel MB, Borges FTP, Teymour F, Zaborina OY, Alverdy JC, Fang K, Hong SH, Staneviciute A, He YJ, Papavasiliou G. An in vitro tissue model for screening sustained release of phosphate-based therapeutic attenuation of pathogen-induced proteolytic matrix degradation. J Mater Chem B 2020; 8:2454-2465. [PMID: 32108210 PMCID: PMC7183213 DOI: 10.1039/c9tb02356a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tissue response to intestinal injury or disease releases pro-inflammatory host stress signals triggering microbial shift to pathogenic phenotypes. One such phenotype is increased protease production resulting in collagen degradation and activation of host matrix metalloproteinases contributing to tissue breakdown. We have shown that surgical injury depletes local intestinal phosphate concentration triggering bacterial virulence and that polyphosphate replenishment attenuates virulence and collagenolytic activity. Mechanistic studies of bacterial and host protease expression contributing to tissue breakdown are difficult to achieve in vivo necessitating the development of novel in vitro tissue models. Common techniques for screening in vitro protease activity, including gelatin zymography or fluorogenic protease-sensitive substrate kits, do not readily translate to 3D matrix degradation. Here, we report the application of an in vitro assay in which collagenolytic pathogens are cultured in the presence of a proteolytically degradable poly(ethylene) glycol scaffold and a non-degradable phosphate and/or polyphosphate nanocomposite hydrogel matrix. This in vitro platform enables quantification of pathogen-induced matrix degradation and screening of sustained release of phosphate-based therapeutic efficacy in attenuating protease expression. To evaluate matrix degradation as a function of bacterial enzyme levels secreted, we also present a novel method to quantify hydrogel degradation. This method involves staining protease-sensitive hydrogels with Sirius red dye to correlate absorbance of the degraded gel solution with hydrogel weight. This assay enables continuous monitoring and greater accuracy of hydrogel degradation kinetics compared to gravimetric measurements. Combined, the proposed in vitro platform and the presented degradation assay provide a novel strategy for screening efficacy of therapeutics in attenuating bacterial protease-induced matrix degradation.
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Affiliation(s)
- Marja B Pimentel
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA.
| | - Fernando T P Borges
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL, USA
| | - Fouad Teymour
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL, USA
| | - Olga Y Zaborina
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - John C Alverdy
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Kuili Fang
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL, USA
| | - Seok Hoon Hong
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL, USA
| | - Austeja Staneviciute
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA.
| | - Yusheng J He
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA.
| | - Georgia Papavasiliou
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA.
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20
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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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21
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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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22
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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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Abstract
PURPOSE OF REVIEW The host-microbiota relationship is integral in human health and can be rapidly disrupted in ways that may contribute to poor recovery from surgery or acute illness. We review key studies by organ system to understand the effect of perioperative and critical illness stress on the microbiota. Throughout the review, our focus is on potential interventions that may be mediated by the microbiome. RECENT FINDINGS Although any perioperative intervention can have a profound impact on the gut microbiota, it is less clear how such changes translate into altered health outcomes. Preoperative stress (anxiety, lack of sleep, fasting), intraoperative stress (surgery itself, volatile anesthetics, perioperative antibiotics, blood transfusions), and postoperative stress (sepsis, surgical site infections, acute respiratory distress syndrome, catecholamines, antibiotics, opioids, proton pump inhibitors) have all been associated with alterations of the commensal microflora. These factors (e.g. administration of antibiotics or opioids) can create a favorable environment for emergence of pathogen virulence and development of serious infections and multiorgan failure. Data to recommend therapies aimed at restoring a disrupted microbiota, such as probiotics/prebiotics and fecal microbiota transplants is currently scarce. SUMMARY The microbiome is likely to play an important role in the perioperative and ICU setting but existing data is largely descriptive. There is an expanding number of mechanistic studies that attempt to disentangle the complicated bi-directional relationship between the host and the resident microbiota. When these results are combined with ongoing clinical studies, we should be able to offer better therapies aimed at restoring the microbiota in the future.
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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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25
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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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26
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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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27
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Nichols D, Pimentel MB, Borges FTP, Hyoju SK, Teymour F, Hong SH, Zaborina OY, Alverdy JC, Papavasiliou G. Sustained Release of Phosphates From Hydrogel Nanoparticles Suppresses Bacterial Collagenase and Biofilm Formation in vitro. Front Bioeng Biotechnol 2019; 7:153. [PMID: 31297368 PMCID: PMC6607000 DOI: 10.3389/fbioe.2019.00153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 06/10/2019] [Indexed: 11/13/2022] Open
Abstract
Intestinal disease or surgical intervention results in local changes in tissue and host-derived factors triggering bacterial virulence. A key phenotype involved in impaired tissue healing is increased bacterial collagenase expression which degrades intestinal collagen. Antibiotic administration is ineffective in addressing this issue as it inadvertently eliminates normal flora while allowing pathogenic bacteria to "bloom" and acquire antibiotic resistance. Compounds that could attenuate collagenase production while allowing commensal bacteria to proliferate normally would offer major advantages without the risk of the emergence of resistance. We have previously shown that intestinal phosphate depletion in the surgically stressed host is a major cue that triggers P. aeruginosa virulence which is suppressed under phosphate abundant conditions. Recent findings indicate that orally administered polyphosphate, hexametaphosphate, (PPi) suppresses collagenase, and biofilm production of P. aeruginosa and S. marcescens in animal models of intestinal injury but does not attenuate E. faecalis induced collagenolytic activity (Hyoju et al., 2017). Systemic administration of phosphates, however, is susceptible to rapid clearance. Given the diversity of collagenase producing bacteria and the variation of phosphate metabolism among microbial species, a combination therapy involving different phosphate compounds may be required to attenuate pathogenic phenotypes. To address these barriers, we present a drug delivery approach for sustained release of phosphates from poly(ethylene) glycol (PEG) hydrogel nanoparticles. The efficacy of monophosphate (Pi)- and PPi-loaded NPs (NP-Pi and NP-PPi, respectively) and a combination treatment (NP-Pi + NP-PPi) in mitigating collagenase and biofilm production of gram-positive and gram-negative pathogens expressing high collagenolytic activity was investigated. NP-PPi was found to significantly decrease collagenase and biofilm production of S. marcescens and P. aeruginosa. Treatment with either NP-Pi or NP-Pi + NP-PPi resulted in more prominent decreases in E. faecalis collagenase compared to NP-PPi alone. The combination treatment was also found to significantly reduce P. aeruginosa collagenase production. Finally, significant attenuation in biofilm dispersal was observed with NP-PPi or NP-Pi + NP-PPi treatment across all test pathogens. These findings suggest that sustained release of different forms of phosphate confers protection against gram-positive and gram-negative pathogens, thereby providing a promising treatment to attenuate expression of tissue-disruptive bacterial phenotypes without eradicating protective flora over the course of intestinal healing.
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Affiliation(s)
- Dylan Nichols
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - Marja B. Pimentel
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - Fernando T. P. Borges
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - Sanjiv K. Hyoju
- Department of Surgery, University of Chicago, Chicago, IL, United States
| | - Fouad Teymour
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - Seok Hoon Hong
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - Olga Y. Zaborina
- Department of Surgery, University of Chicago, Chicago, IL, United States
| | - John C. Alverdy
- Department of Surgery, University of Chicago, Chicago, IL, United States
| | - Georgia Papavasiliou
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, United States
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Wilson RB. Morpheus and the Underworld-Interventions to Reduce the Risks of Opioid Use After Surgery: ORADEs, Dependence, Cancer Progression, and Anastomotic Leakage. J Gastrointest Surg 2019; 23:1240-1249. [PMID: 30937715 DOI: 10.1007/s11605-019-04167-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative pain management is a key element of enhanced recovery after surgery (ERAS) programs. A multimodal approach to analgesia as part of a coordinated ERAS includes the reduction of opioid use. This review aims to discuss opioid-related adverse events, strategies to reduce opioid use after surgery, and the relevance to the present "opioid crisis" in North America. METHODS A literature review of the pharmacology of opioid drugs, perioperative opioid reduction strategies, and the potential public health benefit was performed. This included current ERAS guidelines on multimodal analgesia, randomized controlled trials on perioperative analgesia, and intervention studies to decrease opioid use, misuse, and diversion in North America. RESULTS Reduction of perioperative opioid usage has been endorsed by joint clinical practice guidelines on the management of postoperative pain from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists. Interventions as part of an "opioid bundle" that can be incorporated into ERAS protocols include multimodal analgesia, regional anesthesia, opioid sparing drugs, carbon dioxide humidification during laparoscopy, changing opioid prescription practices, patient and physician education, and proper disposal of unused opioid medications. CONCLUSION There are substantial benefits in incorporating opioid reduction strategies into ERAS and clinical practice guidelines. These include faster return of function and mobility, and decreased opioid-related adverse drug events (ORADEs), postoperative morbidity and mortality, and length of hospital stay. Improved oncological outcomes after cancer surgery may be an additional benefit. Evidence-based interventions can also reduce opioid abuse and diversion in the community.
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Affiliation(s)
- Robert Beaumont Wilson
- Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Suite 6, Level 2, 171 Bigge St, Liverpool, Sydney, NSW, 2170, Australia.
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29
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Zhan SH, French L. Sequence similarity searches for morphine biosynthesis enzymes in bacteria yield putative targets for understanding associations between infection and opiate administration. J Med Microbiol 2019; 68:952-956. [PMID: 31107204 PMCID: PMC7423160 DOI: 10.1099/jmm.0.001001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Exploiting the immunosuppressive, analgesic and highly addictive properties of morphine could increase the success of a bacterial pathogen. Therefore, we performed sequence similarity searches for two morphine biosynthesis demethylases in bacteria. For thebaine 6-O-demethylase and codeine O-demethylase, we found strong alignments to three (Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii) of the six ESKAPE pathogens (Enterococcus faecalis, Staphylococcus aureus, K. pneumoniae, A. baumannii, P. aeruginosa and Enterobacter species) that are commonly associated with drug resistance and nosocomial infections. Expression of the aligned sequence found in P. aeruginosa (NP_252880.1/PA4191) is upregulated in isolates obtained from cystic fibrosis patients. Our findings provide putative mechanistic targets for understanding the role of morphine in pathogenicity.
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Affiliation(s)
- Shing Hei Zhan
- 1 Department of Zoology, University of British Columbia, Vancouver, Canada
| | - Leon French
- 4 Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,5 Institute for Medical Science, University of Toronto, Toronto, ON, Canada.,2 Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, ON, Canada.,3 Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
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30
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Long DR, Friedrich S, Eikermann M. High intraoperative opioid dose increases readmission risk in patients undergoing ambulatory surgery. Br J Anaesth 2018; 121:1179-1180. [PMID: 30336864 DOI: 10.1016/j.bja.2018.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 11/19/2022] Open
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Bhutiani N, Schucht JE, Miller KR, McClave SA. Technical Aspects of Fecal Microbial Transplantation (FMT). Curr Gastroenterol Rep 2018; 20:30. [PMID: 29886561 DOI: 10.1007/s11894-018-0636-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Fecal microbial transplantation (FMT) has become established as an effective therapeutic modality in the treatment of antibiotic-refractory recurrent Clostridium difficile colitis. A number of formulations and methods of delivery of FMT are currently available, each with distinct advantages. This review aims to review donor and patient selection for FMT as well as procedural aspects of FMT to help guide clinical practice. RECENT FINDINGS FMT can be obtained in fresh, frozen, lyophilized, and capsule-based formulations for delivery by oral ingestion, nasoenteric tube, colonoscopy, or enema (depending on the formulation used). Choosing the optimal method relies heavily on patient-related factors, including underlying pathology and severity of illness. As potential applications for FMT expand, careful donor screening and patient selection are critical to minimizing risk to patients and physicians. FMT represents an excellent therapeutic option for treatment of recurrent Clostridium difficile colitis and holds promise as a possible treatment modality in a variety of other conditions. The wide array of delivery methods allows for its application in various disease states in both the inpatient and outpatient setting.
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Affiliation(s)
- N Bhutiani
- Department of Surgery, Division of Trauma and Critical Care, University of Louisville, Louisville, KY, USA
| | - J E Schucht
- Department of Surgery, Division of Trauma and Critical Care, University of Louisville, Louisville, KY, USA
| | - K R Miller
- Department of Surgery, Division of Trauma and Critical Care, University of Louisville, Louisville, KY, USA
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, University of Louisville, 550 S. Jackson St., Ambulatory Care Building 3nd Floor, Louisville, KY, 40202, USA.
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32
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Tagkalos E, Heimann A, Gaiser T, Hirsch D, Gockel I, Lang H, Jansen-Winkeln B. Cecal Resection with Bipolar Sealing Devices in a Rat Model. J INVEST SURG 2018; 33:59-66. [PMID: 29775392 DOI: 10.1080/08941939.2018.1469698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Background: Bipolar sealing devices are routinely used to seal blood vessels. The aim of the study is to evaluate the feasibility and safety of colonic sealing with the use of the bipolar energy devices in rats as model for experimental appendectomy. Methods: Seventy-five male Wistar rats underwent a cecal resection with four different bipolar sealing devices or a linear stapler. The harvesting procedure was performed immediately or at postoperative day (POD) 7. The sealing front bursting pressure (BP) was measured in both groups. At POD7, the resection line was clinically examined and the hydroxyproline (HDP) levels were determined. Hematoxylin and Eosin (H&E) staining was used for histopathological evaluation of the sealing front as well. Results: There was no mortality and no insufficiency. The BPs between the bipolar sealing devices showed no statistical differences. The early phase of the seal (POD 0) provides a low BP with an 30.8% increase until POD 7. The BPs in the stapler group showed significant better values. The hydroxyproline levels did not differ statistically between the groups. Histopathologically, there were more signs of ischemic necrosis in the stapler group than in the sealing devices groups. Conclusion: The resection and sealing of the cecum as an experimental appendectomy model with the use of bipolar energy devices proved feasible and safe in rats. The different energy devices in this study produce comparable results. To justify clinical practice in humans, several studies on the underlying mechanisms of early stage wound healing are needed.
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Affiliation(s)
- E Tagkalos
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - A Heimann
- Institute for Neurosurgical Pathophysiology, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - T Gaiser
- Department of Pathology, University Hospital Mannheim, Mannheim, Germany
| | - D Hirsch
- Department of Pathology, University Hospital Mannheim, Mannheim, Germany
| | - I Gockel
- Department of Visceral, Transplant-, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - H Lang
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - B Jansen-Winkeln
- Department of Visceral, Transplant-, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
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33
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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: 33] [Impact Index Per Article: 5.5] [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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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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Reddy RM, Weir WB, Barnett S, Heiden BT, Orringer MB, Lin J, Chang AC, Carrott PW, Lynch WR, Beer DG, Fenno JC, Kapila Y. Increased Variance in Oral and Gastric Microbiome Correlates With Esophagectomy Anastomotic Leak. Ann Thorac Surg 2018; 105:865-870. [PMID: 29307454 DOI: 10.1016/j.athoracsur.2017.08.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leak after esophagectomy remains a significant source of morbidity and mortality. The gastrointestinal (GI) microbiome has been found to play a significant role in tumor oncogenesis and postoperative bowel anastomotic leak. We hypothesized that the GI microbiome could differentiate between esophageal cancer histologies and predict postoperative anastomotic leak. METHODS A prospective study of esophagectomy patients was performed from May 2013 to August 2014, with the collection of oral saliva, intraoperative esophageal and gastric mucosa, and samples of postoperative infections (neck swab or sputum). The presence and level for each bacterial probe as end points were used to analyze correlations with tumor histology, tumor stage, and presence of postoperative complications by unequal variances t tests for multiple comparisons and principal coordinate analysis. RESULTS Esophagectomy was successful in 55 of 66 patients who were enrolled. Among those, the diagnosis was adenocarcinoma in 44 (80%) squamous cell carcinoma in (13%), and benign disease in 4 (7%). The 30-day mortality was 1.8% (1 of 55). Complications included anastomotic leak requiring local drainage in 18% (10 of 55) and postoperative pneumonia in 2% (1 of 55). No correlation was noted between GI microbiome flora and tumor histology or tumor stage. A significant difference (p = 0.015) was found when the variance in bacterial composition between the preoperative oral flora was compared with intraoperative gastric flora in patients who had a leak but not in patients with pneumonia. CONCLUSIONS Patients with anastomotic leaks had increased variance in their preoperative oral and gastric flora. Microbiome analysis could help identify patients at higher risk for leak after esophagectomy.
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Affiliation(s)
- Rishindra M Reddy
- University of Michigan Medical School, Ann Arbor, Michigan; Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan.
| | - William B Weir
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Shari Barnett
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brendan T Heiden
- University of Michigan Medical School, Ann Arbor, Michigan; Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark B Orringer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew C Chang
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Philip W Carrott
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - William R Lynch
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - David G Beer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Yvonne Kapila
- Division of Periodontology, Department of Orofacial Sciences, University of California, San Francisco, San Francisco, California
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Kverneng Hultberg D, Angenete E, Lydrup ML, Rutegård J, Matthiessen P, Rutegård M. Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer. Eur J Surg Oncol 2017; 43:1908-1914. [PMID: 28687432 DOI: 10.1016/j.ejso.2017.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/03/2017] [Accepted: 06/08/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in colorectal surgery due to their opioid-sparing effect. However, several studies have indicated an increased risk of anastomotic leakage following NSAID treatment, although conflicting results exist. The primary goal of this study was to further examine whether postoperative NSAIDs are independently associated with anastomotic leakage after anterior resection for rectal cancer. METHODS Patients who underwent anterior resection for rectal cancer during 2007-2013 in 15 different hospitals in three healthcare regions in Sweden were included in the study. Registry data and information from patient records were retrieved. The association between NSAID treatment (for at least two days in the first postoperative week) and symptomatic anastomotic leakage (within 90 days) was evaluated with multiple logistic regression, with adjustment for pertinent confounding factors. RESULTS Some 1495 patients were included in the study. Of these, 27% received postoperative NSAIDs for at least two days in the first postoperative week. Symptomatic anastomotic leakage occurred in 11% and 14% in the NSAID and non-NSAID group, respectively. With adjustment for confounders, the odds ratio for leakage among patients who received NSAIDs compared with those who did not was 0.88 (95% CI 0.65-1.20). No differences were seen between non-selective and COX-2-selective NSAIDs. CONCLUSION Postoperative NSAID treatment does not seem to increase the risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. NSAID use appears to be safe, but a well-powered randomized clinical trial is warranted.
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Affiliation(s)
- D Kverneng Hultberg
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
| | - E Angenete
- Department of Surgery, Institute of Clinical Sciences, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - M-L Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Alverdy JC, Hyoju SK, Weigerinck M, Gilbert JA. The gut microbiome and the mechanism of surgical infection. Br J Surg 2017; 104:e14-e23. [PMID: 28121030 DOI: 10.1002/bjs.10405] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/20/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since the very early days of surgical practice, surgeons have recognized the importance of considering that intestinal microbes might have a profound influence on recovery from surgical diseases such as appendicitis and peritonitis. Although the pathogenesis of surgical diseases such as cholelithiasis, diverticulosis, peptic ulcer disease and cancer have been viewed as disorders of host biology, they are emerging as diseases highly influenced by their surrounding microbiota. METHODS This is a review of evolving concepts in microbiome sciences across a variety of surgical diseases and disorders, with a focus on disease aetiology and treatment options. RESULTS The discovery that peptic ulcer disease and, in some instances, gastric cancer can now be considered as infectious diseases means that to advance surgical practice humans need to be viewed as superorganisms, consisting of both host and microbial genes. Applying this line of reasoning to the ever-ageing population of patients demands a more complete understanding of the effects of modern-day stressors on both the host metabolome and microbiome. CONCLUSION Despite major advances in perioperative care, surgeons today are witnessing rising infection-related complications following elective surgery. Many of these infections are caused by resistant and virulent micro-organisms that have emerged as a result of human progress, including global travel, antibiotic exposure, crowded urban conditions, and the application of invasive and prolonged medical and surgical treatment. A more complete understanding of the role of the microbiome in surgical disease is warranted to inform the path forward for prevention.
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Affiliation(s)
- J C Alverdy
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - S K Hyoju
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - M Weigerinck
- Department of Surgery, Radboud University, Nijmegen, The Netherlands
| | - J A Gilbert
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
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Shakhsheer BA, Lec B, Zaborin A, Guyton K, Defnet AM, Bagrodia N, Kandel JJ, Zaborina O, Hernandez SL, Alverdy J. Lack of evidence for tissue hypoxia as a contributing factor in anastomotic leak following colon anastomosis and segmental devascularization in rats. Int J Colorectal Dis 2017; 32:539-547. [PMID: 27999936 DOI: 10.1007/s00384-016-2737-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Current surgical dogma dictates that tissue ischemia and hypoxia are major contributing factors in anastomotic leak despite scant evidence. The aim of this study was to determine if tissue hypoxia is a feature of anastomotic leakage in rats following colon resection and segmental devascularization. METHODS Rats were randomly assigned to undergo sham operation, segmental colon devascularization alone, colectomy alone, or segmental devascularization plus colectomy. Tissue hypoxia present at the colon anastomosis site across the various treatment groups was determined at sacrifice on postoperative day 6. Pimonidazole HCl was injected 30 min prior to sacrifice. Anastomotic tissues were examined and scored for healing versus leakage using an anastomotic healing score (AHS). Collagen content, hypoxia, enteric smooth muscle and periendothelial stromal patterning, and apoptosis were evaluated histologically. RESULTS No differences in tissue hypoxia were noted in the 16% of anastomotic tissues with poor healing compared to the remaining 84% of rats whose anastomoses healed well. No significant changes were found in cell death in the submucosa of any group. Consistent with previous findings, poor healing was associated with lower collagen content. Submucosal thickness correlated with increased arteriole diameter (R 2 = 0.25, p < 0.005). CONCLUSIONS These results demonstrate that tissue hypoxia is not a distinctive feature of anastomotic tissues that fail to heal and leak, even when their blood supply is interrupted. These findings suggest that compensatory factors may mitigate the effects of ischemia and hypoxia during healing of anastomotic tissues and that the process of leakage involves factors beyond their acute effects.
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Affiliation(s)
- B A Shakhsheer
- Department of Surgery, Center for Surgical Infection Research, Pritzker School of Medicine, 5841 S Maryland Ave, MC 6040, Chicago, IL, 60605, USA
| | - B Lec
- Department of Surgery, Section of Pediatric Surgery, The University of Chicago, Chicago, IL, USA
| | - A Zaborin
- Department of Surgery, Center for Surgical Infection Research, Pritzker School of Medicine, 5841 S Maryland Ave, MC 6040, Chicago, IL, 60605, USA
| | - K Guyton
- Department of Surgery, Center for Surgical Infection Research, Pritzker School of Medicine, 5841 S Maryland Ave, MC 6040, Chicago, IL, 60605, USA
| | - A M Defnet
- Department of Surgery, Section of Pediatric Surgery, The University of Chicago, Chicago, IL, USA
| | - N Bagrodia
- Department of Surgery, Section of Pediatric Surgery, The University of Chicago, Chicago, IL, USA
| | - J J Kandel
- Department of Surgery, Section of Pediatric Surgery, The University of Chicago, Chicago, IL, USA
| | - O Zaborina
- Department of Surgery, Center for Surgical Infection Research, Pritzker School of Medicine, 5841 S Maryland Ave, MC 6040, Chicago, IL, 60605, USA
| | - S L Hernandez
- Department of Surgery, Section of Pediatric Surgery, The University of Chicago, Chicago, IL, USA
| | - J Alverdy
- Department of Surgery, Center for Surgical Infection Research, Pritzker School of Medicine, 5841 S Maryland Ave, MC 6040, Chicago, IL, 60605, USA.
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Holubar SD, Hedrick T, Gupta R, Kellum J, Hamilton M, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper Med (Lond) 2017; 6:4. [PMID: 28270910 PMCID: PMC5335800 DOI: 10.1186/s13741-017-0059-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/11/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections. METHODS With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients. DISCUSSION As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).
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Affiliation(s)
- Stefan D. Holubar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Traci Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - John Kellum
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Mark Hamilton
- Department of Intensive Care Medicine and Anaesthesia, St. George’s Hospital and Medical School, London, UK
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - Monty G. Mythen
- Department of Anesthesia, UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D. Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, TN USA
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC USA
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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: 28] [Impact Index Per Article: 4.0] [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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