The impact of bacterial DNA translocation on early postoperative outcomes in Crohn's patients undergoing abdominal surgery

Microbiota DNA Translocation Into Mesentery Lymph Nodes Is Associated With Early Development of Pouchitis After IPAA for Ulcerative Colitis

BACKGROUND

The role of bacterial translocation in Crohn's disease has been extensively studied. However, data regarding bacterial translocation into the mesentery in patients with ulcerative colitis were scarce.

OBJECTIVE

This study aimed to explore the relationship between bacterial translocation and postoperative outcome by comparing the microbiome profile of different anatomical sites in patients with ulcerative colitis who underwent proctocolectomy and IPAA.

DESIGN

A prospective study.

SETTING

This study was conducted at the Jinling Hospital from August 2017 to May 2018.

PATIENTS

Samples of 27 patients with ulcerative colitis who had IPAA and 15 healthy controls who underwent routine colonoscopy were collected.

MAIN OUTCOME MEASURES

The microbiome profile of different tissue sites and short- and long-term outcomes after IPAA in patients with ulcerative colitis.

RESULTS

Bacterial DNA was detected in mesenteric lymph nodes of 51.9% of patients with ulcerative colitis (14/27) and in mesenteric adipose tissue of 66.7% of patients (18/27). The microbiome in mesenteric lymph nodes and mesenteric adipose tissue resembled the mucosal microbiome to a greater extent than the fecal microbiome. Positive bacterial DNA in mesenteric lymph nodes (8/14 vs 0/13; p = 0.002) was associated with pouchitis within 12 months after IPAA, whereas Bray-Curtis distance in mesenteric lymph nodes was significantly different between patients with pouchitis and without ( p = 0.009).

LIMITATIONS

This study was limited by its small sample size and lacked situ experiment to confirm the true bacterial translation.

CONCLUSIONS

Bacterial translocation was highly prevalent in patients with ulcerative colitis. The translocated bacteria DNA in mesenteric adipose tissue and mesenteric lymph nodes was highly correlated and more likely to originate from mucosal than fecal microbiome. Also, the extent of bacterial translocation and translocation of certain bacteria might be associated with the early development of pouchitis after IPAA. This might represent an unprecedented technique to predict pouchitis using mesenteric lymph node bacterial profiles. See Video Abstract at http://links.lww.com/DCR/C119 .

LA TRANSLOCACIN DEL ADN DE LA MICROBIOTA EN LOS GANGLIOS LINFTICOS DEL MESENTERIO SE ASOCIA CON EL DESARROLLO TEMPRANO DE POUCHITIS DESPUS DE IPAA PARA LA COLITIS ULCEROSA

ANTECEDENTES:El papel de la translocación bacteriana en la enfermedad de Crohn se ha estudiado ampliamente en los últimos años. Sin embargo, los datos sobre la translocación bacteriana en el mesenterio en pacientes con colitis ulcerosa fueron escasos.OBJETIVO:El objetivo de este estudio fue explorar la relación entre la translocación bacteriana y el resultado postoperatorio comparando el perfil del microbioma de diferentes sitios anatómicos en pacientes con colitis ulcerosa que se sometieron a proctocolectomía y anastomosis ileoanal con bolsa.DISEÑO:Estudio prospectivo.AJUSTE:Este estudio se realizó en el Hospital Jinling desde agosto de 2017 hasta mayo de 2018.PACIENTES:Se recogieron muestras de 27 pacientes con colitis ulcerosa que tenían anastomosis de bolsa ileoanal y 15 controles sanos que se sometieron a una colonoscopia de rutina.PRINCIPALES MEDIDAS DE RESULTADO:El perfil del microbioma de diferentes sitios de tejido y los resultados a corto y largo plazo después de la anastomosis ileoanal con bolsa en pacientes con colitis ulcerosa.RESULTADOS:Se detectó ADN bacteriano en los ganglios linfáticos mesentéricos del 51,9 % (14/27) de los pacientes con colitis ulcerosa y en el tejido adiposo mesentérico del 66,7 % (18/27) de los pacientes, respectivamente. El microbioma en los ganglios linfáticos mesentéricos y el tejido adiposo mesentérico se parecía más al microbioma de la mucosa que al microbioma fecal. El ADN bacteriano translocado en los ganglios linfáticos mesentéricos y el tejido adiposo mesentérico estaban altamente correlacionados. El ADN bacteriano positivo en los ganglios linfáticos mesentéricos (8/14 frente a 0/13, p = 0,002) se asoció con reservoritis dentro de los 12 meses posteriores a la anastomosis ileoanal con reservorio, mientras que la distancia de Bray-Curtis en los ganglios linfáticos mesentéricos fue significativamente diferente entre reservoritis y no reservorios. -pacientes con reservorio (p = 0,009). Ruminococcus, Bacteroides y Clostridiales se encontraron exclusivamente en los ganglios linfáticos mesentéricos de pacientes con reservoritis.LIMITACIÓN:Este estudio estuvo limitado por el pequeño tamaño de la muestra y la falta de un experimento in situ para confirmar la verdadera traducción bacteriana.CONCLUSIÓN:La translocación bacteriana fue altamente prevalente en pacientes con colitis ulcerosa. El ADN bacteriano translocado en el tejido adiposo mesentérico y los ganglios linfáticos mesentéricos estaba altamente correlacionado y era más probable que se originara en el microbioma de la mucosa que en el fecal. Además, la extensión de la translocación bacteriana y la translocación de ciertas bacterias podría estar asociada con el desarrollo temprano de reservoritis después de la anastomosis del reservorio ileoanal. Esto podría representar una técnica sin precedentes para predecir la reservoritis utilizando perfiles bacterianos de los ganglios linfáticos mesentéricos. Consulte Video Resumen en. http://links.lww.com/DCR/C119(Traducción-Dr. Felipe Bellolio ).

Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review

Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Post-operative pain after laparoscopic right hemicolectomy for Crohn's disease: a case control study

AIM

Surgery for Crohn's disease (CD) is characterized by an enhanced inflammatory response. While inflammation can induce hyperalgesia, post-operative pain following surgery for CD has not been characterized. This retrospective study compared a consecutive series of patients undergoing laparoscopic right hemicolectomy for CD and neoplasia performed by a single surgeon.

METHOD

Elective resections performed between Jan-2016 and Aug-2017 managed in an enhanced recovery pathway were eligible for inclusion. Patients were excluded if open surgery was performed, an ileostomy was fashioned, no patient-controlled analgesia (PCA) was used or data were incomplete. Results : 38 cases were included, 20 for neoplasia and 18 for ileocolonic CD. There was no difference in patient gender (P=0.520). CD patients were younger (39.8±2.8 Vs 77.2±2.1 years, P<0.001) but had an equivalent length of resection (312.9±43.5 Vs 283.3±71.7 mm, P=0.915). CD patients had higher pain scores on post-operative day 1 (6.8±0.8 Vs 2.6±1.0, P<0.001), day 2 (5.0±0.5 Vs 1.6±0.9, P<0.001) and day 3 (4.1±0.6 Vs 1.3±0.7, P=0.008). CD patients used their PCA for longer (85.7±16.3 Vs 47.7±4.2 hours, P=0.017) and used a greater total amount of morphine (148.6±33.8 Vs 37.0±7.8 mg, P<0.001). Post-operative CRP was higher in patients with CD on day 1 (P=0.011), day 2 (P=0.001), day 3 (P=0.001) and day 4 (P=0.007), but no leak or intra-abdominal abscess occurred in either group.

RESULTS

38 cases were included, 20 for neoplasia and 18 for ileocolonic CD. There was no difference in patient gender (P=0.520). CD patients were younger (39.8±2.8 Vs 77.2±2.1 years, P<0.001) but had an equivalent length of resection (312.9±43.5 Vs 283.3±71.7 mm, P=0.915). CD patients had higher pain scores on post-operative day 1 (6.8±0.8 Vs 2.6±1.0, P<0.001), day 2 (5.0±0.5 Vs 1.6±0.9, P<0.001) and day 3 (4.1±0.6 Vs 1.3±0.7, P=0.008). CD patients used their PCA for longer (85.7±16.3 Vs 47.7±4.2 hours, P=0.017) and used a greater total amount of morphine (148.6±33.8 Vs 37.0±7.8 mg, P<0.001). Post-operative CRP was higher in patients with CD on day 1 (P=0.011), day 2 (P=0.001), day 3 (P=0.001) and day 4 (P=0.007), but no leak or intra-abdominal abscess occurred in either group.

CONCLUSIONS

CD patients experience increased post-operative pain, require more post-operative analgesia and have an enhanced post-operative inflammatory response. Further studies to elucidate the mechanism of this hyperalgesia and strategies to obviate it are required.

The trend of C-Reactive protein allows a safe early discharge after surgery for Crohn's disease

Postoperative C-reactive protein (CRP) level allows to rule out infectious complications ensuring safe hospital discharge in colorectal cancer surgery. Since its clinical significance in Crohn's disease (CD) has not been studied yet, we investigated whether CRP can guide decision-making on hospital discharge in this population. Only consecutive CD patients undergoing resections with primary anastomosis and without covering stoma (2013-2017) were analysed. Pre- and post-operative CRP values, measured daily until discharge, were correlated with postoperative complications including anastomotic leakage (AL), infectious and non-infectious complications. The diagnostic accuracy of CRP in predicting AL was evaluated according to the area under the curve (AUC), using the receiver-operating characteristic (ROC) methodology. Two-hundred and fifty-one consecutive patients undergoing elective surgery for CD were selected. AL was diagnosed in 10 patients (4%). High CRP level was associated with AL on postoperative day (POD) 3-5 (p = 0.002, AUC 0.825) with a positive predictive value of 60%. CRP linear difference of 140 between POD 1 and 3 (AUC 0.800) maximizes sensitivity and specificity with a NPV of 98.6%. CRP trend, measured with the linear difference between POD 1 and 3, is able to rule out anastomotic complications with a high NPV and may allow a safe early hospital discharge after surgery for CD.

The Prognostic Value of the Detection of Microbial Translocation in the Blood of Colorectal Cancer Patients

Dysbiosis has been associated with various diseases and is of major health importance. Dysbiosis leads to microbial translocation, which is the passage of microorganisms, their fragments, or their metabolites from the intestinal lumen into the blood circulation and other sites. The aim of the study was to determine whether microbial translocation occurs in stage II/III-IV colorectal cancer (CRC) patients. The aim was also to evaluate the usefulness of blood PCR for diagnosis of such translocation and correlate the presence of toll-like receptor/vitamin D receptor (TLR/VDR) gene polymorphisms with microbial DNA fragments detected in the blood of CRC patients. Three hundred and ninety-seven CRC patients enrolled in the study. Peripheral blood DNA was analyzed using PCR for the amplification of genomic DNA encoding 16S rRNA, the β-galactosidase gene of Escherichia coli, glutamine synthase gene of Bacteroides fragilis, and 5.8S rRNA of Candida albicans. Significantly higher rates of all microbial fragments, but E. coli, detected were observed in the CRC patients (p < 0.001); such detection of all four microbial fragments was also significantly associated with the metastatic disease (p < 0.001), leading to shorter survival rates (p < 0.001). Tumor location in the right colon also significantly correlated with shorter survival (p = 0.016). Individuals with homozygous mutant alleles of TLR/VDR polymorphisms had significantly higher detection rates of microbial DNA fragments. The detection of microbial DNA fragments in CRC patients highlighted the role of these microbes in cancer development, progression, and patients' survival.

Large retroperitoneal abscess extended to the inferior right limb secondary to a perforated ileal Crohn's disease: the importance of the multidisciplinary approach

The typical complications of Crohn's disease concerns small and large bowel. The full thickness inflammation of the intestinal wall develops in strictures, fistulas and abdominal abscesses. Nowadays the most accepted therapeutic for intra-abdominal abscess option is antibiotic therapy and, in case of need, percutaneous drainage of the abscess. If the abscess passes through the pelvic foramen the abscess can involve the inferior limbs. We report a case a perforation of terminal ileum in Crohn's disease complicated by a large abscess of the right iliac fossa reaching the spaces between the anterior lateral muscles of the right thigh as far as the anterior lateral pre-tibial region. We discuss the diagnostic and therapeutic options in a multidisciplinary context.

Postoperative Inflammatory Response in Crohn's Patients: A Comparative Study

BACKGROUND AND AIMS

Surgery for Crohn's disease [CD] can be complicated by an enhanced inflammatory response. This retrospective study aims to compare the inflammatory response measured by C-reactive protein [CRP] in patients operated for CD with patients undergoing similar surgery for colorectal cancer [CRC].

METHODS

All CD patients undergoing an ileocaecal resection between February 2001 and December 2013 were retrieved from a prospectively maintained database. The same number of patients with a CRC of the ascending colon, undergoing a laparoscopic right hemicolectomy between March 2009 and June 2014, were retrieved from a CRC database. CRP level during the first 7 postoperative days was used as primary outcome.

RESULTS

Totals of 112 consecutive CD patients (male 40.2%; median age: 32.3 yrs; interquartile range [IQR]: 25.2-45.1) and 112 consecutive CRC patients [male 53.6%; median age 71.6 yrs; IQR: 64.7-77.5] were included. Postoperative CRP level in the CD group was on average 27% higher compared with the CRC group [p = 0.02]. The day-specific differences in CRP values were 21% (p = 0.021, 95% confidence interval [CI]: 3% 41%), 41% [p = 0.005, 95% CI: 11%-79%], 49% [p = 0.007, 95% CI: 11%-96%], and 49% [p = 0.006, 95% CI: 12%-100%] higher for CD patients at Days 1, 4, 5, and 6 respectively. The difference in postoperative CRP level was partially due to differences in preoperative CRP level.

CONCLUSION

CD patients develop a higher postoperative CRP level, probably reflecting an enhanced postoperative inflammatory response, which may be triggered by a higher preoperative inflammatory state.