Post-operative outcomes and predictors of mortality after colorectal cancer surgery in the very elderly patients

Unraveling the relationship between gut microbiota and site-specific endometriosis: a Mendelian randomization analysis

Background

Although numerous studies have illustrated the connection between gut microbiota and endometriosis, a conspicuous gap exists in research focusing on the pathogenesis of endometriosis at various sites and its linkage with infertility.

Methods

In this study, we used a two-sample Mendelian randomization analysis to investigate the effect of gut microbiota on the development of endometriosis in different regions, including the uterus, ovary, fallopian tube, pelvic peritoneum, vagina, and rectovaginal septum, as well as the intestine. Additionally, we explored the correlation between gut microbiota and endometriosis-induced infertility. Genetic associations with gut microbes were obtained from genome-wide association study (GWAS) datasets provided by the MiBioGen consortium, whereas endometriosis-related GWAS data were sourced from the FinnGen dataset. In our analysis, single-nucleotide polymorphisms were used as instrumental variables, with the primary estimation of the causal effect performed via the inverse variance weighting method. Our sensitivity analyses incorporated heterogeneity tests, pleiotropy tests, and the leave-one-out method.

Results

We identified associations at the genus level between four bacterial communities and endometriosis. Subsequently, several associations between the gut microbiota and various subtypes of endometriosis at different anatomical sites were recognized. Specifically, three genera were linked with ovarian endometriosis, six genera were associated with tubal endometriosis, four genera showed links with pelvic peritoneum endometriosis, five genera were connected with vaginal and rectovaginal septum endometriosis, and seven genera demonstrated linkages with intestinal endometriosis. Additionally, one genus was associated with adenomyosis, and three genera exhibited associations with endometriosis-induced infertility.

Conclusion

Our study elucidates associations between gut microbiota and site-specific endometriosis, thereby augmenting our understanding of the pathophysiology of endometriosis. Moreover, our findings pave the way for potential therapeutic strategies targeting gut microbiota for individuals grappling with endometriosis-related infertility.

Long-term outcomes in elderly patients after elective surgery for colorectal cancer within an ERAS protocol: a retrospective analysis

PURPOSE

The number of elderly patients with a diagnosis of colorectal cancer (CRC) is increasing. Considering short life expectancy and multiple comorbidities, surgery may not always be the best treatment option.

METHODS

We included all consecutive patients aged 80 years and older who underwent elective resection for CRC following Enhanced Recovery after Surgery (ERAS) protocol between January 2011 and May 2021. The primary endpoint was overall survival, secondary endpoints were 30-day morbidity, and the rate of return to pre-operative living conditions 3 months after surgery.

RESULTS

Ninety-four patients were included. Mean age was 84.6 ± 3.6 years, 49 patients (52%) were female. Most patients (77.6%) were ASA score ≥ 3. Laparoscopic resections were performed in 85 patients (90.4%), involving 69 (73.4%) colonic and 25 (26.6%) rectal resections. A stoma was constructed in 22 patients (23%), and reversed in 12 (54.5%). Twenty-two patients (23.4%) experienced a Clavien-Dindo ≥ 3 complication, and 2 patients (2.1%) died. The median length of hospital stay was 8 (interquartiles: 6-15) days. Sixty-six patients (70.2%) were discharged home directly and 26 (27.7%) to rehabilitation or postacute care institutes. At three months after surgery, eighty-two patients (96.5%) returned to their pre-operative living conditions directly or after short-term rehabilitation. Mean follow-up was 53 ± 33 months, estimated 5-year overall survival was 60.3% (95%CI 49.5-71.1%), and disease-free survival was 86.3% (95%CI 78.1-94.4%).

CONCLUSIONS

Our study suggests that elderly patients undergoing elective surgery have a high potential to return to preoperative living conditions and good overall- and disease-free survivals, despite significant postoperative morbidity.

Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review

Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.

Focal Active Colitis: What Are Its Clinical Implications? A Narrative Review

Focal active colitis (FAC) is described as a histolopathological term indicating the isolated finding of focal neutrophil infiltration in the colonic crypts. Currently, there exist numerous debates regarding the clinical significance of diagnosing FAC, which may or may not have clinical relevance as it is frequently detected in colorectal biopsies without any other microscopic abnormalities. The objective of this narrative review is to provide an overview of the available evidence concerning the clinical implications of FAC, both in the adult population (among five studies available in the scientific literature) and in the pediatric context (based on two available studies).

Microbiota in Irritable Bowel Syndrome and Endometriosis: Birds of a Feather Flock Together-A Review

Endometriosis and irritable bowel syndrome (IBS) are chronic conditions affecting up to 10% of the global population, imposing significant burdens on healthcare systems and patient quality of life. Interestingly, around 20% of endometriosis patients also present with symptoms indicative of IBS. The pathogenesis of both these multifactorial conditions remains to be fully elucidated, but connections to gut microbiota are becoming more apparent. Emerging research underscores significant differences in the gut microbiota composition between healthy individuals and those suffering from either endometriosis or IBS. Intestinal dysbiosis appears pivotal in both conditions, exerting an influence via similar mechanisms. It impacts intestinal permeability, triggers inflammatory reactions, and initiates immune responses. Furthermore, it is entwined in a bidirectional relationship with the brain, as part of the gut-brain axis, whereby dysbiosis influences and is influenced by mental health and pain perception. Recent years have witnessed the development of microbiota-focused therapies, such as low FODMAP diets, prebiotics, probiotics, antibiotics, and fecal microbiota transplantation, designed to tackle dysbiosis and relieve symptoms. While promising, these treatments present inconsistent data, highlighting the need for further research. This review explores the evidence of gut dysbiosis in IBS and endometriosis, underscoring the similar role of microbiota in both conditions. A deeper understanding of this common mechanism may enable enhanced diagnostics and therapeutic advancements.

Imaging in Gastroparesis: Exploring Innovative Diagnostic Approaches, Symptoms, and Treatment

Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.

Five-year follow-up mortality prognostic index for colorectal patients

PURPOSE

To identify 5-year survival prognostic variables in patients with colorectal cancer (CRC) and to propose a survival prognostic score that also takes into account changes over time in the patient's health-related quality of life (HRQoL) status.

METHODS

Prospective observational cohort study of CRC patients. We collected data from their diagnosis, intervention, and at 1, 2, 3, and 5 years following the index intervention, also collecting HRQoL data using the EuroQol-5D-5L (EQ-5D-5L), European Organization for Research and Treatment of Cancer's Quality of Life Questionnaire-Core 30 (EORTC-QLQ-C30), and Hospital Anxiety and Depression Scale (HADS) questionnaires. Multivariate Cox proportional models were used.

RESULTS

We found predictors of mortality over the 5-year follow-up to be being older; being male; having a higher TNM stage; having a higher lymph node ratio; having a result of CRC surgery classified as R1 or R2; invasion of neighboring organs; having a higher score on the Charlson comorbidity index; having an ASA IV; and having worse scores, worse quality of life, on the EORTC and EQ-5D questionnaires, as compared to those with higher scores in each of those questionnaires respectively.

CONCLUSIONS

These results allow preventive and controlling measures to be established on long-term follow-up of these patients, based on a few easily measurable variables.

IMPLICATIONS FOR CANCER SURVIVORS

Patients with colorectal cancer should be monitored more closely depending on the severity of their disease and comorbidities as well as the perceived health-related quality of life, and preventive measures should be established to prevent adverse outcomes and therefore to ensure that better treatment is received.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02488161.

Pulmonary Complications Are a Strong Independent Predictor of 30-Day Mortality Following Elective Bariatric Surgery

OBJECTIVE

Pulmonary complications in patients with obesity carry a high morbidity and mortality. An analysis of the MBSAQIP database was performed to determine the effect of post-operative pulmonary complications on patients undergoing elective bariatric surgery, with the primary outcome of 30-day mortality.

METHODS

We extracted data from the MBSAQIP database from 2015 to 2019 on patients who underwent elective Roux-en-Y gastric bypass or sleeve gastrectomy. Pulmonary complications were defined as prolonged ventilation, pneumonia, unplanned intubation, pulmonary embolism, and coma past 24 h (with the assumption of this being due to hypercapnia). Data on post-operative complications and 30-day mortality was extracted. To determine the effect of pulmonary complications on 30-day mortality, a multivariable logistic regression model was developed.

RESULTS

Pulmonary complications were associated with a near 50-fold increased odds of 30-day mortality (OR 47.1; 95%, 38.6-57.5; p < 0.0001). Pulmonary complications were also associated with higher rates of anastomotic leaks (9.5% vs. 0.3%; p < 0.0001), post-operative bleeding (13.7% vs. 0.9%; p < 0.0001), cardiac complications (6.6% vs. 0.0%; p < 0.0001), post-operative AKIs (9.6% vs. 0.1%; p < 0.0001), incidence of deep SSI (9.4% vs. 0.2%; p < 0.0001), incidence of post-operative sepsis (6.2% vs. 0.1%; p < 0.0001), and incidence of Clostridioides difficile (2.0% vs. 0.1%; p < 0.0001).

CONCLUSION

Pulmonary complications after elective bariatric surgery are a strong predictor of 30-day mortality. Patients who experience pulmonary complications have a higher incidence of co-morbidities and unfavorable baseline patient characteristics, and thus, likely form a unique subset of the bariatric patient population.

The Pre-Operative GRADE Score Is Associated with 5-Year Survival among Older Patients with Cancer Undergoing Surgery

We aimed to assess the prognostic value of the pre-operative GRADE score for long-term survival among older adults undergoing major surgery for digestive or non-breast gynaecological cancers. Between 2013 and 2019, 136 consecutive older adults with cancer were prospectively recruited from the PF-EC cohort study before major cancer surgery and underwent a geriatric assessment. The GRADE score includes weight loss, gait speed at the threshold of 0.8 m/s, cancer site and cancer extension. The primary outcome was post-operative 5-year mortality. Patients were classified as low risk (GRADE ≤ 8) or high risk (GRADE > 8) on the basis of the median score. A Cox multivariate proportional hazards regression model was performed to assess the association between pre-operative factors and 5-year mortality expressed by adjusted hazard ratio (aHR) and 95% CI. The median age was 80 years, 52% were men, 73% had colorectal cancer. The 30-day post-operative severe complication rate (Clavien-Dindo ≥ 3) was 37%. The 5-year post-operative mortality rate was 34.5%. A GRADE score ≥ 8 (aHR = 2.64 [1.34-5.21], p = 0.0002) was associated with post-operative mortality after adjustment for Body Mass Index < 21 kg/m² and Instrumental Activities of Daily Living <3/4. By combining very simple geriatric and cancer parameters, the pre-operative GRADE score provides a discriminant prognosis and could help to choose the most suitable treatment strategy for older cancer patients, avoiding under or over-treatment.

Laparoscopic distal pancreatectomy in patients with poor physical status

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is advantageous over open surgery in the treatment of benign pancreatic lesions and low-grade malignancies. Yet the evidence on the relationship between comorbidities and the outcomes of LDP remains scarce.

METHODS

Patients who had undergone LDP for all indications between April 1997 and December 2019 were included. Preoperative physical status was defined according to the American Society of Anesthesiology (ASA) criteria. Perioperative outcomes were compared between the patients with high (ASA III-IV) and low/moderate anesthetic risk (ASA I-II).

RESULTS

A total of 605 patients were eligible for analysis including 190 with ASA III-IV and 415 with ASA I-II. The former was associated with older age, male gender, preexisting medical conditions, greater total number of comorbidities and red blood cell transfusion. The rate of medical complications was significantly higher in high-risk patients. Multivariable analysis identified ASA III-IV and operative time as independent predictors for medical complications. Overall/severe morbidity, surgical complications and mortality rates were similar.

CONCLUSIONS

Poor physical status defined as ASA grades III-IV predicts medical complications, but has a limited impact on surgical complications and severe morbidity of LDP. Thus, it should not be considered as a contraindication for LDP.

EHD2 Overexpression Suppresses the Proliferation, Migration, and Invasion in Human Colon Cancer

Background: To investigate how EHD2 influences the development of colon cancer.Methods: Immunohistochemistry of 90 colon cancer tissue specimens were determined the expression of EHD2. The lentivirus-EHD2-transfected colon cancer cells were conducted to evaluate the biological behaviors.Results: EHD2 was closely associated with clinic pathological parameters (p < 0.001). EHD2 upregulation was relative with a longer overall survival. The results of the univariate and multivariate analyses indicated that EHD2 could be an independent prognosis marker. EHD2 overexpression suppressed cell invasion and proliferation, but enhanced cell apoptosis and cell cycle arrest.Conclusions: EHD2 might represent a therapeutic target of colon cancer.IMPACT STATEMENTWhat is already known on this subject? Membrane trafficking is crucial for cell proliferation, differentiation and apoptosis, especially tumorigenesis and development. EHD2 proteins play an important role in the regulation of membrane trafficking in endocytosis. EHD2 has been suggested to participate in the occurrence of some malignancies.What are the new findings? EHD2 could be an independent prognosis marker in colon cancer. EHD2 overexpression suppressed cell invasion and proliferation, but enhanced cell apoptosis and cell cycle arrest in vitro. EHD2 overexpression markedly increased the expression of EMT marker E-cadherin in colon cancer.How might it impact on clinical practice in the foreseeable future? EHD2 overexpression may inhibit tumorigenesis in colon cancer through the modulation of E-cadherin, the critical marker of EMT which is closely related to invasion and distant metastasis of tumor cells.

The Usefulness of Inflammation-based Prognostic Scores for the Prediction of Postoperative Mortality in Patients Who Underwent Intestinal Resection for Acute Intestinal Ischemia

Objective

The current study was conducted to clarify whether the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are clinically useful in predicting postoperative mortality among patients undergoing surgery for acute intestinal ischemia (AII).

Materials and methods

The study was conducted as a retrospective investigation of 37 consecutive patients operated for AII between January 2014 and September 2019. Data regarding potential prognostic factors, including age, sex, preoperative white blood cell count (WBC), C-reactive protein (CRP), neutrophil, lymphocyte, and platelet counts were obtained from medical records.

Results

Univariate analysis revealed that age, WBC, and neutrophil count were predictors of postoperative mortality. In multivariate analysis, age (OR =1.14; 95% CI, 1.005-1.303; P=0.02) was found to be the only independent variable predicting postoperative mortality.

Conclusions

Preoperative NLR and PLR cannot be used as independent variables to predict postoperative 30-day mortality in patients with AII who underwent surgery.