Synbiotics reduce postoperative infectious complications: a randomized controlled trial in biliary cancer patients undergoing hepatectomy

Effect of probiotics on prognosis in patients with hepatectomy: a systematic review and meta-analysis of randomized controlled trial

OBJECTIVE

To investigate the effect of perioperative probiotics on prognosis in patients with hepatectomy.

METHOD

By conducting a computer-based search of electronic databases to collect randomized controlled trials (RCTs) on the use of probiotics in the perioperative period for patients undergoing liver resection. Two researchers independently screened the literature, extracted data, assessed bias risk, and performed a meta-analysis using RevMan 5.4 software.

RESULT

A total of 988 patients were enrolled across 14 studies. The results of the meta-analysis revealed that the probiotics group had lower rates of postoperative infectious complications (OR = 0.49; 95%CI 0.49 to 0.60; P < 0.01), serum endotoxin levels (SMD= -0.69; 95%CI -1.27 to -0.11; P = 0.02), white blood cell counts (SMD= -0.37; 95%CI -0.67 to -0.061.47; P = 0.02), hospital stays (SMD= -0.85; 95%CI -1.53 to -0.18; P = 0.01), and first postoperative exhaust times (SMD= -0.85; 95%CI -1.53 to -0.18; P = 0.01) compared to the control group. No significant differences in liver function indices (alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBiL) and international normalized ratio (INR)) or postoperative inflammatory markers (C-reactive protein (CRP), procalcitonin, interleukin-6 (IL-6)) were found between the two groups (all P > 0.05).

CONCLUSIONS

Probiotics used perioperatively can lower postoperative infection risk and shorten hospital stays for hepatectomy patients, but they do not appear to aid in liver function restoration or inflammation reduction.

CLINICAL TRIAL NUMBER

Not applicable.

Effect of Preoperative Autologous Blood Storage in Major Hepatectomy for Perihilar Malignancy: A Randomized Controlled Trial

OBJECTIVE

To reappraise whether preoperative autologous blood donation reduces post-hepatectomy liver failure (PHLF) in major hepatectomy for perihilar malignancy.

SUMMARY BACKGROUND DATA

Autologous blood storage and transfusion are carried out to reduce the use of allogeneic blood transfusion during hepatectomy and prevent postoperative complications. However, the clinical benefit of major hepatectomy has been controversial.

METHODS

This randomized clinical trial included patients who underwent major hepatectomy with extrahepatic bile duct resection for perihilar malignancy. Eligible patients were randomly assigned (1:1) to undergo surgery with or without the use of autologous blood transfusion. The primary outcome was the incidence of clinically relevant PHLF (grade B/C according to the International Study Group of Liver Surgery definition).

RESULTS

Between February 6, 2019, and May 12, 2023, 138 consecutive patients were enrolled in the study (blood storage group n=68, non-storage group n=70). Twenty-five patients who did not undergo resection were excluded; the remaining 113 patients were investigated as the full analysis set (blood storage group n=60, non-storage group n=53). Surgical procedures, operative time, and blood loss were not significantly different between the 2 groups. The incidence of PHLF was comparable [blood storage group n=10 (17%), non-storage group n=10 (19%); P =0.760]. There were also no between-group differences in other postoperative outcomes, including the incidence of Clavien-Dindo Grade Ⅲ or higher (72% vs 72%, P =0.997) and median duration of hospital stay (25 vs 29 days, P =0.277).

CONCLUSIONS

Autologous blood storage did not contribute to reducing the incidence of PHLF in patients undergoing major hepatectomy.

Enhancing Colorectal Cancer Treatment: The Role of Bifidobacterium in Modulating Gut Immunity and Mitigating Capecitabine-Induced Toxicity

Colorectal cancer (CRC) is the third leading cause of cancer-related mortality globally and presents significant challenges in treatment and patient care. Capecitabine, a widely used prodrug of 5-fluorouracil (5-FU), offers targeted delivery with reduced systemic toxicity compared to traditional chemotherapies. However, capacitabine is associated with adverse effects, such as hand-foot syndrome, gastrointestinal issues, and mucositis. Emerging evidence suggests that probiotics, particularly Bifidobacterium, play a pivotal role in gut microbiota modulation, promoting anti-inflammatory cytokines and short-chain fatty acids, such as butyrate, which possess both intestinal protective and anti-cancer properties. In this review, we explored the potential of Bifidobacterium to improve chemotherapy outcomes by mitigating inflammation and enhancing mucosal immunity in CRC patients. Furthermore, we demonstrated in silico approaches, including molecular docking and protein-protein interaction analysis, for Bifidobacterium and Toll-like receptor 2 (TLR-2), a key mediator of intestinal immunity. Docking results revealed strong binding affinity, suggesting the activation of anti-inflammatory pathways. Notably, this interaction enhanced IL-10 production while reducing pro-inflammatory cytokines, such as IL-6 and TNF-α, fostering gut homeostasis and mitigating chronic inflammation, a key driver of CRC progression. Therefore, future research should focus on personalized probiotics and validating their synergy with chemotherapy and immunotherapy to improve CRC treatment outcomes.

Impact of the ratio of fecal short-chain fatty acids to lactic acid concentration on postoperative infectious complications after pancreaticoduodenectomy

BACKGROUND

We previously reported that the balance of short-chain fatty acids and lactic acid in feces affects postoperative infectious complications after major hepatectomy. However, the effect remains unclear in pancreaticoduodenectomy.

METHODS

Preoperative fecal samples were collected from 210 patients who underwent pancreaticoduodenectomy at 2 institutions between January 2019 and June 2021. Organic acid concentrations were measured per 1 g of feces by high-performance liquid chromatography; the ratio, defined as the sum of acetic, propionic, and butyric acid divided by lactic acid, was calculated. The correlation between the acetic, propionic, and butyric acid divided by lactic acid ratio and postoperative infectious complications was determined using univariate and multivariate analyses.

RESULTS

Sixty-one patients (29%) had postoperative infectious complications, represented by intra-abdominal abscess, cholangitis, and surgical-site infection. Fecal lactic acid levels ranged from 0.13 to 36.98, with a median of 0.69; the median level was 1.10 μmol/g in the postoperative infectious complications group and 0.36 μmol/g in the nonpostoperative infectious complications group (P < .001). The acetic, propionic, and butyric acid divided by lactic acid ratio ranged from 1.65 to 1,753.4, with a median of 105.8; the median ratio was 59.1 in the postoperative infectious complications group and 198.6 in the nonpostoperative infectious complications group (P = .002). Multivariate analysis revealed that a low acetic, propionic, and butyric acid divided by lactic acid ratio (<75) in the preoperative feces was an independent risk factor for postoperative infectious complications, with an odds ratio of 3.5 and a 95% confidence interval of 1.8-7.0 (P < .001). Preoperative biliary drainage was significantly associated with a low acetic, propionic, and butyric acid divided by lactic acid ratio.

CONCLUSION

The preoperative fecal organic acid profile determined using the acetic, propionic, and butyric acid divided by lactic acid ratio clinically impacted the incidence of postoperative infectious complications in patients who underwent pancreaticoduodenectomy.

Strategies to Maximize the Benefits of Evidence-Based Enteral Nutrition: A Narrative Review

Enteral nutrition (EN) has been reported to have some physiological importance for critically ill patients. However, the advantage of EN over parenteral nutrition remains controversial in recent paradigms. To maximize the benefits and efficiency of EN, implementing measures based on comprehensive evidence is essential. Here, we systematically reviewed EN-related studies and integrated them into the best and most up-to-date EN practices. We extracted studies from 13 systematic reviews during the development of Japanese Critical Care Nutrition Guidelines, summarizing findings on the assessment of enteral feeding intolerance (EFI), the timing of EN, formula composition and nutrients, and method of administration in critically ill adult patients. Multifaceted EFI assessment may be needed in patients for high-risk patients. Early EN may reduce infectious complications, and initiating EN even earlier may offer an additional advantage. High protein intake (≥1.2 g/kg/day) could maintain muscle mass and physical function without increasing gastrointestinal complications. Probiotics, prebiotics, and synbiotics may serve as beneficial options for preventing infection and gastrointestinal complications, although their efficacy depends on the strains, types, and combinations used. For patients with EFI, post-pyloric feeding could be an effective approach, while intermittent feeding may be a safer approach. Both methods should be utilized to achieve nutritional targets. Integrating these nutritional interventions into EN strategies may help maximize their effectiveness and minimize complications. However, careful consideration regarding timing, dosage, nutrient selection, administration methods, and patient selection is required.

The effect of perioperative probiotics and synbiotics on postoperative infections in patients undergoing major liver surgery: a meta-analysis of randomized controlled trials

Objective

To evaluate the effect of perioperative probiotics or synbiotics on the incidence of postoperative infections following major liver surgery.

Design

Meta-analysis.

Data sources

PubMed, Embase, Scopus, and the Cochrane Library for relevant English-language studies published up to February 21st, 2024.

Eligibility criteria

Randomized controlled trials evaluating perioperative probiotics or synbiotics for preventing postoperative infections in patients undergoing major liver surgery.

Data extraction and synthesis

Outcomes included postoperative infection incidence, antibiotic therapy duration, length of stay in intensive care unit (ICU) and hospital. A random-effect model was adopted for the meta-analysis. The quality of included studies was evaluated using the Cochrane risk of bias tool.

Results

Ten studies involving 588 patients were included. Pooled analyses revealed that perioperative probiotics or synbiotics significantly reduced postoperative infection incidence (RR 0.36, 95% CI [0.24-0.54], P < 0.0001, I2 = 6%) and antibiotic therapy duration (MD -2.82, 95% CI [-3.13 to -2.51], P < 0.001, I2 = 0%). No significant differences were observed in length of stay in ICU (MD -0.25, 95% CI [-0.84-0.34], P = 0.41, I2 = 64%) or length of stay in hospital (MD -1.25, 95% CI [-2.74-0.25], P = 0.10, I2 = 56%).

Conclusions

This meta-analysis suggests that perioperative administration of probiotics or synbiotics may reduce the incidence of postoperative infections and duration of antibiotic therapy. Their use as adjunctive therapy during the perioperative period could be considered for patients undergoing major liver surgery.

Impact of Fecal Organic Acid Profile Before Training on Athletic Performance Improvement After High-Intensity Interval Training

PURPOSE

This study sought to investigate the efficacy of Tabata-style high-intensity interval training (T-HIIT) on athletic performance in judoka and to determine the impact of the fecal organic acid profile before training on the improvement of athletic performance.

METHODS

Twenty males from Aichi University Judo Club (10 high-level competitors and 10 others) were included. Physical fitness tests such as the Uchikomi shuttle run, countermovement jump, squat jump, and chin-ups using a judo uniform were performed before and after T-HIIT. Fecal samples were collected before T-HIIT to measure the fecal concentration of organic acids. The fecal characteristics were categorized using the Bristol Stool Scale.

RESULTS

The mean number of repetitions of the Uchikomi shuttle run test significantly increased for all judoka following T-HIIT. However, improvements in other physical fitness tests varied, with some judoka showing improvements while others did not. The changes in countermovement jump (r = -.48, P = .029) and chin-ups using a judo uniform (r = -.45, P = .045) after T-HIIT were significantly negatively correlated with the fecal concentrations of succinic acid before T-HIIT. There was a significant correlation between the Bristol Stool Scale score and fecal concentrations of succinic acid (r = .45, P = .044). Compared with other compounds, the fecal concentrations of acetic acid and propionic acid were significantly greater in high-level competitors, while succinic acid concentrations tended to be lower.

CONCLUSIONS

T-HIIT effectively improved the specialized endurance of the judoka. Modifying the fecal organic acid profile, especially the fecal succinic acid concentration, may enhance the efficacy of athletic performance improvements achieved by T-HITT.

Narrative Review of Probiotic Use on the Recovery of Postoperative Patients with Esophageal Cancer

PURPOSE OF REVIEW

This narrative review discusses the significance of probiotic therapy in the postoperative care of patients with esophageal cancer and its role as an adjunct therapy to other treatment modalities for esophageal cancer.

RECENT FINDINGS

As such, there is an emerging need to address any malnutrition and gastrointestinal problems occurring in these patients which tend to have a strong negative impact on their prognosis. Probiotic effects on esophageal cancer biomarkers suggest that there is a positive correlation between these two factors. However, the beneficial effects remain controversial and warrant further investigation. Probiotics, now being widely utilized as postoperative therapy in some carcinomas of the gastrointestinal tract such as gastric cancer and colorectal cancer, have been shown in some clinical studies to positively impact the nutritional status of patients with esophageal cancer. Postoperative care among patients suffering from esophageal cancer is a very crucial aspect in the survival of these patients.

The Efficacy of Probiotics, Prebiotics, and Synbiotics in Patients Who Have Undergone Abdominal Operation, in Terms of Bowel Function Post-Operatively: A Network Meta-Analysis

BACKGROUND

Abdominal operations may lead to post-operative bowel dysfunction, while administration of probiotics, prebiotics and synbiotics may limit its manifestation. Τhe study aimed to assess the efficacy of probiotics, prebiotics and synbiotics in patients who undergone abdominal operation, in terms of bowel function post-operatively.

METHODS

PubMed, Scopus, Cochrane Central Register of Controlled Trials (Central), Embase, US Registry of clinical trials, and sources of grey literature were searched. The relative effect sizes were estimated, and we obtained the relative ranking of the interventions using cumulative ranking curves.

RESULTS

In total, 30 studies were included in the analysis. For the outcome of post-operative ileus, probiotics was superior to placebo/no intervention (relative risk, RR: 0.38; 95%CI: 0.14-0.98) with the highest SUCRA (surface under the cumulative ranking) value (92.1%). For time to first flatus, probiotics (MD: -0.47; 95%CI: -0.78 to -0.17) and synbiotics (MD: -0.53; 95%CI: -0.96 to -0.09) were superior to placebo/no intervention. For time to first defecation and for post-operative abdominal distension probiotics were superior to placebo/no intervention. For post-operative hospitalization days, synbiotics were superior to placebo/no intervention (MD: -3.07; 95%CI: -4.80 to -1.34).

CONCLUSIONS

Administration of probiotics in patients who had undergone abdominal surgery reduced the prevalence of post-operative ileus, time to first flatus, time to first defecation, and prevalence of post-operative abdominal distension. Synbiotics reduce time to first flatus and post-operative hospitalization days.

Gut microbiota associated with the mitigation effect of synbiotics on adverse events of neoadjuvant chemotherapy in patients with esophageal cancer: A retrospective exploratory study

Introduction. Our synbiotics (Lacticaseibacillus paracasei strain Shirota, Bifidobacterium breve strain Yakult, and galacto-oligosaccharides: LBG) helps mitigate serious adverse events such as febrile neutropenia (FN) and diarrhoea in oesophageal cancer patients receiving neoadjuvant chemotherapy (NAC). Unfortunately, LBG therapy does not benefit all patients.Hypothesis/Gap Statement. Identification of the gut microbiota species involved in adverse events during chemotherapy could help predict the onset of adverse events. Identification of the gut microbiota that influence the efficacy of LBG could also help establish a diagnostic method to identify patients who will respond to LBG before the initiation of therapy.Aim. To identify the gut microbiota involved in adverse events during NAC and that affect the efficacy of LBG therapy.Methodology. This study was ancillary to a parent randomized controlled trial in which 81 oesophageal cancer patients were recruited and administered either prophylactic antibiotics or LBG combined with enteral nutrition (LBG+EN). The study included 73 of 81 patients from whom faecal samples were collected both before and after NAC. The gut microbiota was analysed using 16S rRNA gene amplicon sequencing and compared based on the degree of NAC-associated adverse events. Furthermore, the association between the counts of identified bacteria and adverse events and the mitigation effect of LBG+EN was also analysed.Results. The abundance of Anaerostipes hadrus and Bifidobacterium pseudocatenulatum in patients with no FN or only mild diarrhoea was significantly higher (P<0.05) compared to those with FN or severe diarrhoea. Moreover, subgroup analyses of patients receiving LBG+EN showed that the faecal A. hadrus count before NAC was significantly associated with a risk of developing FN (OR, 0.11; 95 % CI, 0.01-0.60, P=0.019). The faecal A. hadrus count after NAC was positively correlated with intestinal concentrations of acetic acid (P=0.0007) and butyric acid (P=0.00005).Conclusion. Anaerostipes hadrus and B. pseudocatenulatum may be involved in the ameliorating adverse events and can thus be used to identify beforehand patients that would benefit from LBG+EN during NAC. These results also suggest that LBG+EN would be useful in the development of measures to prevent adverse events during NAC.

Novel Dietary Approach with Probiotics, Prebiotics, and Synbiotics to Mitigate Antimicrobial Resistance and Subsequent Out Marketplace of Antimicrobial Agents: A Review

Antimicrobial resistance (AMR) is a significant public health concern worldwide. The continuous use and misuse of antimicrobial agents have led to the emergence and spread of resistant strains of bacteria, which can cause severe infections that are difficult to treat. One of the reasons for the constant development of new antimicrobial agents is the need to overcome the resistance that has developed against existing drugs. However, this approach is not sustainable in the long term, as bacteria can quickly develop resistance to new drugs as well. Additionally, the development of new drugs is costly and time-consuming, and there is no guarantee that new drugs will be effective or safe. An alternative approach to combat AMR is to focus on improving the body's natural defenses against infections by using probiotics, prebiotics, and synbiotics, which are helpful to restore and maintain a healthy balance of bacteria in the body. Probiotics are live microorganisms that can be consumed as food or supplements to promote gut health and improve the body's natural defenses against infections. Prebiotics are non-digestible fibers that stimulate the growth of beneficial bacteria in the gut, while synbiotics are a combination of probiotics and prebiotics that work together to improve gut health. By promoting a healthy balance of bacteria in the body, these can help to reduce the risk of infections and the need for antimicrobial agents. Additionally, these approaches are generally safe and well tolerated, and they do not contribute to the development of AMR. In conclusion, the continuous development of new antimicrobial agents is not a sustainable approach to combat AMR. Instead, alternative approaches such as probiotics, prebiotics, and synbiotics should be considered as they can help to promote a healthy balance of bacteria in the body and reduce the need for antibiotics.

Chronological changes in the gut microbiota and intestinal environment in recipients and donors of living donor liver transplantation

BACKGROUND/PURPOSE

This prospective study aimed to investigate the dynamic changes in the gut microbiota (GM) and associated intestinal environment, which were assessed by measuring fecal organic acid (OA) concentrations, during the early period after liver transplantation (LT). To understand the fundamental characteristics of the human GM, data obtained from living donors were also analyzed.

METHODS

Fixed-point observation was performed in 23 recipients and 21 donors for up to 2 weeks after LT. The GM and OA concentrations were investigated using ribosomal RNA-targeted reverse-transcription quantitative polymerase chain reaction and high-performance liquid chromatography, respectively.

RESULTS

Before LT, the recipients exhibited remarkable dysbiosis and OA depletion, which were proportional to the model for end-stage liver disease score. Correlations between the abundances of some specific strains and OA concentrations were observed. After LT, while donor lobectomy caused only slight, transient and reversible changes in the GM and OA concentrations, recipients exhibited delayed recovery in these factors. However, no clear evidence of causality was observed between the GM or OA concentrations and LT outcomes.

CONCLUSIONS

The GM and intestinal environment in LT recipients exhibited characteristics that were clearly different from those in donors. LT did not normalize but rather disrupted the GM during the early post-LT period, but its negative clinical impact could be minimized with perioperative management.

Synbiotics and Surgery: Can Prebiotics and Probiotics Affect Inflammatory Surgical Outcomes?

PURPOSE OF REVIEW

Prebiotics, probiotics, and synbiotics have received increasing attention over the years for their beneficial impact on the gut microbiome and for their systemic anti-inflammatory effects. They have also been shown to improve surgical outcomes. Here, we review the inflammatory effects of surgery as well as the data which suggests a benefit of prebiotics, probiotics, and synbiotics taken in the perioperative period.

RECENT FINDINGS

Synbiotics and fermented foods may have an even greater anti-inflammatory effect than probiotics or prebiotics alone. Recent data suggest that the anti-inflammatory effects and microbiome changes brought on by prebiotics, probiotics, and synbiotics have the potential to improve surgical outcomes. We highlight the potential to alter systemic inflammation, surgical and hospital-acquired infections, colorectal cancer formation, recurrence, and anastomotic leak. Synbiotics could also impact metabolic syndrome. Prebiotics, probiotics, and especially synbiotics may be extremely beneficial when taken in the perioperative period. Even short-term gut microbiome pre-habilitation could alter surgical outcomes significantly.

The Role of Probiotics in Inflammation Associated with Major Surgery: A Narrative Review

Background: Gut microbiota is well-known for its ability to maintain intestinal homeostasis. However, the disruption of this homeostasis, known as dysbiosis, leads to multiple consequences, including local and systemic inflammation. Surgery-induced inflammation is a major concern for patients, as it leads to many infectious and non-infectious complications. Objective: The purpose of this review was to explore the role of probiotics and symbiotics in surgery-induced inflammation and to determine if their use is effective in combatting inflammation and its complications Methods and Materials: A literature search was conducted, and articles published only in English, until December 2022 were included. The results are reported in the form of a narrative review. Results: The perioperative use of probiotics and/or symbiotics results in lower risk of infectious complications, including reduced rates of surgical site infections, respiratory and urinary tract infections, shorter hospital stays, and fewer days of antibiotic administration. It also contributes to reducing non-infectious complications, as it mitigates systemic and local inflammation via maintenance of the intestinal barrier, improves intestinal mobility, and is associated with lower rates of postoperative pain and anastomotic leak. Conclusions: Restoring gut microbiota after disruptions caused by surgery may accelerate local healing processes, attenuate systemic inflammation, and may thus prove beneficial to certain populations.

Efficiency of probiotics in elderly patients undergoing orthopedic surgery for postoperative cognitive dysfunction: a study protocol for a multicenter, randomized controlled trial

BACKGROUND

Postoperative cognitive dysfunction (POCD) refers to a neurological dysfunction after a major surgery and anesthesia. It is common in elderly patients and is characterized by impairment in consciousness, orientation, thinking, memory, and executive function after surgical anesthesia. However, at present, there is no definite preventive or treatable strategy for it. Previous animal experiments showed that giving probiotics to mice before operation can prevent POCD, but there is a lack of clinical evidence. This study aims to intervene with the intestinal flora imbalance using probiotics during the perioperative period to reduce the incidence of POCD in elderly patients after orthopedic surgery and to provide new ideas and methods for the clinical prevention and treatment of POCD.

METHODS

A multicenter, double-blind, placebo-controlled clinical trial will be performed to evaluate the efficacy of probiotics in elderly patients undergoing orthopedic surgery. Participants (n = 220) will receive probiotics (Peifeikang, Live Combined Bifidobacterium, 210 mg per capsule, twice a day, four capsules each time, which contains Bifidobacterium longum, Lactobacillus acidophilus and Streptococcus faecalis no less than 1.0 × 10⁷ CFU viable bacteria respectively) or placebo from 1 day before surgery to 6 days after surgery. Neuropsychological tests will be performed 1 day before surgery and 1 week and 1 month after surgery. The main outcome of this study is the incidence of POCD 7 days after surgery. Our secondary objective is to assess the incidence of POCD 1 month after surgery; the cognitive status will be determined based on a telephone interview and will be evaluated via TICS-m; postoperative delirium will be assessed 7 days after surgery using the Confusion Assessment Method (CAM).

DISCUSSION

Discovering the correlation between the intestinal microbiota and POCD is an important breakthrough. Based on the key role of the intestinal microbiota in other cognitive disorders, we hope that probiotics can reduce its incidence in elderly orthopedic patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04017403. Registered on August 15, 2019.

Dysbiosis and Depletion of Fecal Organic Acids Correlate With the Severity of Rejection After Rat Liver Transplantation

The impact of T cell-mediated rejection (TCMR) after liver transplantation (LT) on the alterations in the gut microbiota (GM) and associated intestinal environment represented by fecal organic acids (OAs) require further elucidation. A rat allogeneic LT model was prepared without immunosuppressants or antibiotics, and a syngeneic model was used as a control. Qualitative and quantitative analyses of fecal samples at fixed time points were performed. Correlation analyses were also performed between liver function and GMs and OA levels. In the allogeneic TCMR group, the number of predominant obligate anaerobes decreased as liver function declined. Clostridioides difficile, Enterobacteriaceae, Enterococcus, Streptococcus, and Staphylococcus were significantly increased. Regarding fecal OA concentration, short-chain fatty acid (SCFA) concentrations were depleted as liver function declined. In contrast, in the syngeneic group, GM and OAs exhibited only slight, transient, and reversible disturbances. In addition, alanine aminotransferase and total bilirubin were positively correlated with the number of Enterobacteriaceae and Enterococcus, and negatively correlated with the fecal concentration of SCFAs. The allogeneic TCMR model demonstrated distinct dysbiosis and depletion of fecal OAs as TCMR progressed after LT. The degree of graft injury was closely related to the number of specific bacterial strains and the concentrations of fecal SCFAs.

Probiotics or Synbiotics for Preventing Postoperative Infection in Hepatopancreatobiliary Cancer Patients: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Postoperative infection of hepatopancreatobiliary cancer (HPBC) is a major cause of morbidity and mortality. Probiotics and synbiotics are potential prevention strategies, but evidence on the efficacy of probiotics or synbiotics in the prevention of postoperative infection for HPBC remains controversial. This study aimed to define the impact of probiotics or synbiotics on the incidence of postoperative infection in HPBC patients.

METHODS

A systematic search of the Cochrane Library, PubMed, Embase, and Web of Science databases was conducted from inception to February 2, 2021 to identify randomized controlled trials (RCTs) evaluating the efficacy of probiotics or synbiotics in HPBC. Data were pooled and expressed as the risk ratio (RR) and mean difference (MD) with 95% confidence intervals.

RESULTS

Eight RCTs involving 445 participants were included. Supplementation with probiotics or synbiotics significantly reduced the incidence of postoperative infection (RR 0.55) in HPBC patients, and both probiotics (RR 0.68) and synbiotics (RR 0.41) were effective in reducing the incidence of postoperative infection. In addition, probiotics or synbiotics can reduce duration of antibiotic use (MD -3.52) and length of hospital stay (MD -4.21).

CONCLUSION

Probiotics or synbiotics are effective strategies for the prevention of postoperative infection in HPBC patients.

Prophylactic effects of probiotics or synbiotics on postoperative ileus after gastrointestinal cancer surgery: A meta-analysis of randomized controlled trials

Background

Postoperative ileus is a major problem following gastrointestinal cancers surgery, several randomized controlled trials have been conducted investigating the use of probiotics or synbiotics to reduce postoperative ileus, but their findings are controversial.

Objective

We conducted a meta-analysis to determine the effect of probiotics or synbiotics on early postoperative recovery of gastrointestinal function in patients with gastrointestinal cancer.

Methods

The Embase, Cochrane Library, PubMed, and Web of Science databases were comprehensively searched for randomized controlled trials (RCTs) that evaluated the effects of probiotics or synbiotics on postoperative recovery of gastrointestinal function as of April 27, 2021. Outcomes included the time to first flatus, time to first defecation, days to first solid diet, days to first fluid diet, length of postoperative hospital stay, incidence of abdominal distension and incidence of postoperative ileus. The results were reported as the mean difference (MD) and relative risk (RR) with 95% confidence intervals (CI).

Results

A total of 21 RCTs, involving 1776 participants, were included. Compared with the control group, probiotic and synbiotic supplementation resulted in a shorter first flatus (MD, -0.53 days), first defecation (MD, -0.78 days), first solid diet (MD, -0.25 days), first fluid diet (MD, -0.29 days) and postoperative hospital stay (MD, -1.43 days). Furthermore, Probiotic and synbiotic supplementation reduced the incidence of abdominal distension (RR, 0.62) and incidence of postoperative ileus (RR, 0.47).

Conclusion

Perioperative supplementation of probiotics or synbiotics can effectively promote the recovery of gastrointestinal function after gastrointestinal cancer surgery.

Bacterial Translocation in Gastrointestinal Cancers and Cancer Treatment

In recent years, there has been increasing evidence that gut microbiota is associated with the onset and exacerbation of various diseases, such as gastrointestinal cancer. For instance, it is well known that local inflammation of the intestinal tract in colorectal cancer that is caused by the increased number of Fusobacterium, due to changes in the intestinal bacterial flora, is involved in carcinogenesis. In contrast, gut bacteria or their products, pathogen-associated molecular patterns, not only cause intestinal inflammation but also invade the bloodstream through dysbiosis and gut barrier dysfunction, thereby leading to systemic inflammation, namely bacterial translocation. The involvement of bacterial translocation in the carcinogenesis of gastrointestinal cancers and their prognosis is increasingly being recognized. The Toll-like receptor signaling pathways plays an important role in the carcinogenesis of such cancers. In addition, bacterial translocation influences the treatment of cancers such as surgery and chemotherapy. In this review, we outline the concept of bacterial translocation, summarize the current knowledge on the relationship between gut bacteria and gastrointestinal cancer, and provide future perspectives of this field.

Update on perioperative management of patients undergoing surgery for liver cancer

Hepatocellular carcinoma is often accompanied by chronic hepatitis or cirrhosis. Preoperative evaluation of liver function and postoperative nutritional management are critical in patients with hepatocellular carcinoma who undergo liver surgery. Although the incidence of postoperative complications and death has declined in Japan over the last 10 years, postoperative complications have not been fully overcome. Therefore, surgical procedures and perioperative management must be improved. Accurate preoperative evaluations of liver function, nutrition, inflammation, and body skeletal muscle are required. Determination of the optimal surgical procedure should consider not only tumor characteristics but also the physical reserve of the patient. Nutritional management of chronic liver disorders, especially maintaining protein synthesis for postoperative protein/energy, is important. Prophylactic antibiotics are recommended for short‐term use within 24 hours after surgery. Abdominal drainage is recommended for patients with cirrhosis who may develop large amounts of ascites, who are at risk of postoperative bleeding, or who may have bile leakage due to a large resection area. Postoperative exercise therapy may improve insulin resistance in patients with chronic liver damage. Implementation of an early/enhanced recovery after surgery program is recommended to reduce biological invasive responses and achieve early independence of physical activity and nutrition intake. We review the latest information on the perioperative management of patients undergoing liver resection for hepatocellular carcinoma.

Probiotics Evaluation in Oncological Surgery: A Systematic Review of 36 Randomized Controlled Trials Assessing 21 Diverse Formulations

BACKGROUND

Objectives were to evaluate probiotics safety and efficacy in oncological surgery.

METHODS

Systematic review methodology guided by Cochrane, PRISMA, SWiM, and CIOMS. Protocol registered on PROSPERO (CRD42018086168).

RESULTS

36 RCTs (on 3305 participants) and 6 nonrandomized/observational studies were included, mainly on digestive system cancers. There was evidence of a beneficial effect on preventing infections, with 70% of RCTs' (21/30) direction of effect favoring probiotics. However, five RCTs (17%) favored controls for infections, including one trial with RR 1.57 (95% CI: 0.79, 3.12). One RCT that changed (balanced) its antibiotics protocol after enrolling some participants had mortality risk RR 3.55 (95% CI: 0.77, 16.47; 7/64 vs. 2/65 deaths). The RCT identified with the most promising results overall administered an oral formulation of Lactobacillus acidophilus LA-5 + Lactobacillus plantarum + Bifidobacterium lactis BB-12 + Saccharomyces boulardii. Methodological quality appraisals revealed an overall substantial risk-of-bias, with only five RCTs judged as low risk-of-bias.

CONCLUSIONS

This large evidence synthesis found encouraging results from most formulations, though this was contrasted by potential harms from a few others, thus validating the literature that "probiotics" are not homogeneous microorganisms. Given microbiome developments and infections morbidity, further high-quality research is warranted using those promising probiotics identified herein.

Influence of Probiotics Administration Before Liver Resection in Patients with Liver Disease: A Randomized Controlled Trial

BACKGROUND

By inhibiting the growth of pathogenic bacteria and modulating the local intestinal immune system, probiotics may reduce bacterial translocation and systemic endotoxaemia, factors partially responsible for post-operative complications following liver resection for hepatocellular carcinoma in patients with cirrhosis.

METHODS

Patients with resectable hepatocellular carcinoma developed in the setting of chronic liver disease were prospectively divided into two equal-sized groups: one receiving probiotic treatment 14 days prior to surgery and the other receiving placebo. The primary endpoint was the level of circulating endotoxins after hepatectomy. Secondary endpoints were systemic inflammation (inflammatory cytokine levels), post-operative liver function and overall post-operative complication rate.

RESULTS

From May 2013 to December 2018, 64 patients were randomized, and 54 patients were included in the analysis, 27 in each arm. No significant change in endotoxin levels was observed over time in either group (P = 0.299). No difference between the groups in terms of post-operative liver function and overall complication rates was observed. The only differences observed were significant increases in the levels of TNFalpha (P = 0.019) and interleukin 1-b (P = 0.028) in the probiotic group in the post-operative period.

CONCLUSION

Contrary to the modest data reported in the literature, the administration of probiotics before minor liver resection for hepatocellular carcinoma developed in the setting of compensated chronic liver disease does not seem to have an impact on circulating endotoxin levels or post-operative complication rates.

TRIAL REGISTRATION

Trial registration: NCT02021253.

Impact of synbiotics treatment on bacteremia induced during neoadjuvant chemotherapy for esophageal cancer: A randomised controlled trial

BACKGROUND & AIMS

To elucidate the impact of synbiotics on bacterial translocation and subsequent bacteremia during neoadjuvant chemotherapy for esophageal cancer.

METHODS

Patients requiring neoadjuvant chemotherapy for esophageal cancer were randomized to receive synbiotics (synbiotics group) or no synbiotics (control group) during chemotherapy. Blood and fecal samples were taken before and after every chemotherapy cycle, and 1 day before surgery. Mesenteric lymph nodes (MLNs) were harvested at laparotomy (MLN-1) and after resection of the tumor (MLN-2). Bacteria in each sample were detected. Fecal microbiota and organic acid concentrations were also determined. The primary endpoint was the detection of bacteria in the blood samples, as well as the incidence of side effects during chemotherapy. The secondary endpoint was the detection rate of bacteria in the MLN samples collected during surgery.

RESULTS

The study recruited a total of 42 patients (22 in the control group, 20 in the synbiotics group). Bacteria were detected in 16 of 101 blood samples in the control group, whereas those were detected only 2 of 100 blood samples in the synbiotics group (p < 0.001) during neoadjuvant chemotherapy. Additionally, bacteria were detected in 12 of 34 MLN samples in the control group, whereas no bacteria were detected in 38 MLN samples in the synbiotics group (p < 0.001). Suppression of bacterial translocation was at least partly associated with an increased fecal acetic acid concentration as well as a lowered fecal pH by synbiotics. The incidence rate of grade 3 gastrointestinal toxicity during chemotherapy was lower in the synbiotics group compared to the control group (8/22 vs. 1/20, p = 0.022).

CONCLUSIONS

Neoadjuvant chemotherapy for esophageal cancer may induce bacterial translocation and subsequent bacteremia, which can be prevented by synbiotics administration.

TRIAL REGISTRATION

The University Hospital Medical Information Network (http://www.umin.ac.jp; registration number ID 000007651).

Avoidance of milk and dairy products after oral surgery-is such a recommendation still valid? A cross-sectional study among German and international oral and maxillofacial surgeons and dental practitioners with review of the literature

PURPOSE

For prevention of wound-healing complications, patients in German-speaking countries are traditionally advised to avoid consumption of milk and dairy products after oral surgery. In the absence of national and international guidelines, this study investigates scientific evidence and compares international practice, frequency scale, and rationale behind such recommendation.

METHODS

Comparison of a German cross-sectional mono-center-questionnaire pilot study and a survey among international oral and maxillofacial surgeons (OMFS), specialized oral surgeons and general dentists, evaluating international practice regarding post-operative dietary and nutrition recommendations. Our literature review further assessed scientific evidence for relevant effects of probiotics, prebiotics, and/or synbiotics.

RESULTS

Among German study participants, 56% (n = 64/114) advise patients to avoid milk and dairy products, with 42% of OMFS (n = 38) and 65% (n = 76) of the general dentists recommending abstention (p = .027). In striking contrast, such recommendation could not be identified in our international survey (n = 143) (t test, p < .001) nor in the literature. There were significant differences between German and international study participants regarding the rationale for dietary recommendations, with dental schools and literature most frequently indicated as sources (Fisher's exact test, p < .001).

CONCLUSION

The hypothesis of a harmful effect of the consumption of milk and dairy products after dentoalveolar surgery could not be supported by evidence. The recommendation to avoid dairy products post-surgery was identified as a specific phenomenon practiced almost exclusively in German-speaking countries. Corresponding recommendations, most probably based on a now irrelevant risk of contracting tuberculosis from milk products, can at present no longer be substantiated.

Synbiotic Therapy Prevents Nosocomial Infection in Critically Ill Adult Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials Based on a Bayesian Framework

Background: The efficacy of synbiotics, probiotics, prebiotics, enteral nutrition or adjuvant peripheral parenteral nutrition (EPN) and total parenteral nutrition (TPN) in preventing nosocomial infection (NI) in critically ill adults has been questioned. We conducted a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) to evaluate and rank the effectiveness of these therapies on NI amongst critically ill adults.

Methods: Four electronic databases were systematically searched up to June 30, 2019 for RCTs comparing the administration of probiotics, prebiotics, synbiotics, EPN and TPN in critically ill adults. The primary outcome was NI. The relative efficacy of all outcomes was determined by a Bayesian framework with random effects NMA. We estimated the odds ratio (OR) and mean difference (MD) and ranked the comparative effects of all regimens with the surface under the cumulative ranking probabilities. The study has been registered on PROSPERO (CRD42019147032).

Results: Fifty-five RCTs (7,119 patients) were identified. Primary outcome showed that synbiotics had the best effect in preventing NI than EPN (OR 0.37; 95% CrI 0.22–0.61), probiotics followed (OR 0.52; 95% CrI 0.34–0.77), whereas TPN significantly increased NI (OR 2.29; 95% CrI 1.48–3.67). Subgroup analysis showed that TPN significantly increased NI in intensive care unit (ICU) patients (OR 1.57; 95% CrI 1.01–2.56) and severe acute pancreatitis (SAP) patients (OR 3.93; 95% CrI 1.74–9.15). Secondary outcomes showed that synbiotics were more effective in preventing hospital-acquired pneumonia (HAP) (OR 0.34; 95% CrI 0.11–0.85), catheter-related bloodstream infection (OR 0.08; 95% CrI 0.01–0.80), urinary tract infection (OR 0.27; 95% CrI 0.08–0.71) and sepsis (OR 0.34; 95% CrI 0.16–0.70) than EPN. Amongst the treatments, probiotics were most effective for shortening the mechanical ventilation duration (MD −3.93; 95% CrI −7.98 to −0.02), prebiotics were most effective for preventing diarrhea (OR 0.24; 95% CrI 0.05–0.94) and TPN was the least effective in shortening hospital length of stay (MD 4.23; 95% CrI 0.97–7.33).

Conclusions: Amongst the five therapies, synbiotics not only prevented NI in critically ill adults but also demonstrated the best treatment results. By contrast, TPN did not prevent NI and ranked last, especially in ICU and SAP patients.

Take-Home Message: Nosocomial infection is a leading cause of mortality in critically ill patients in the ICU. However, the efficacy of synbiotics, probiotics, prebiotics, enteral nutrition or adjuvant peripheral parenteral nutrition and total parenteral nutrition in preventing nosocomial infection in critically ill adults has been questioned. The network meta-analysis provides evidence that amongst the five therapies, synbiotics not only prevented NI in critically ill adults but also demonstrated the best treatment results. By contrast, TPN did not prevent NI and ranked last, especially in ICU and SAP patients. The results of this study will provide a new scientific basis and a new idea for the debate on the efficacy of synbiotics and other treatments in the improvement of prognosis in critically ill adult patients.

Tweet: Synbiotic prevents nosocomial infection in critically ill adults, while total parenteral nutrition has the adverse curative.

Preoperative prognostic nutritional index predicts postoperative infectious complications and oncological outcomes after hepatectomy in intrahepatic cholangiocarcinoma

Background

In the surgical treatment of intrahepatic cholangiocarcinoma (ICC), postoperative complications may be predictive of long-term survival. This study aimed to identify an immune-nutritional index (INI) that can be used for preoperative prediction of complications.

Patients and methods

Multi-institutional data from 316 patients with ICC who had undergone surgical resection were retrospectively analysed, with a focus on various preoperative INIs.

Results

Severe complications (Clavien-Dindo grade III–V) were identified in 66 patients (20.8%), including Grade V complications in 7 patients (2.2%). Comparison of areas under the receiver operating characteristic curve (AUCs) among various INIs identified the prognostic nutritional index (PNI) as offering the highest predictive value for severe complications (AUC = 0.609, cut-off = 50, P = 0.008). Multivariate analysis revealed PNI <  50 (odds ratio [OR] = 2.22, P = 0.013), hilar lesion (OR = 2.46, P = 0.026), and long operation time (OR = 1.003, P = 0.029) as independent risk factors for severe complications. In comparing a high-PNI group (PNI ≥ 50, n = 142) and a low-PNI group (PNI <  50, n = 174), the low-PNI group showed higher rates of both major complications (27% vs. 13.4%; P = 0.003) and infectious complications (14.9% vs. 3.5%; P = 0.0021). Furthermore, median survival time and 1- and 5-year overall survival rates were 34.2 months and 77.4 and 33.8% in the low-PNI group, respectively, and 52.4 months and 89.3 and 47.5% in the high-PNI group, respectively (P = 0.0017).

Conclusion

Preoperative PNI appears useful as an INI correlating with postoperative severe complications and as a prognostic indicator for ICC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08424-0.

Probiotic-related bacteremia after major hepatectomy for biliary cancer: a report of two cases

Background

Probiotics have been reported to be beneficial for the prevention of postoperative complications and are often used during the perioperative period. Among the probiotic-related adverse events, bacteremia is rare. Here, we report two cases of probiotic-related bacteremia after major hepatectomy for biliary cancer.

Case presentation 1

A 74-year-old man was referred to our hospital to be treated for gallbladder cancer. Neoadjuvant chemotherapy, two courses of gemcitabine plus S-1 combination therapy, was administered. Extended right hepatectomy with caudate lobectomy, extrahepatic bile duct resection and biliary reconstruction were performed 3 weeks after chemotherapy. Probiotics, Clostridium butyricum (C. butyricum) MIYAIRI 588, were administered 6 days before surgery and continued after surgery. Sepsis of unknown origin occurred 17 days after surgery and developed into septic shock. C. butyricum was detected in blood cultures at postoperative day 26 and 45. After stopping the probiotic agent, C. butyricum was undetectable in the blood cultures. The patient died due to an uncontrollable sepsis 66 days after surgery.

Case presentation 2

A 63-year-old man with diabetes mellitus whose past history included total colectomy, papillectomy, and Frey’s operation at the age of 19, 34 and 48, respectively, was referred to our hospital to be treated for perihilar cholangiocarcinoma. Extended left hepatectomy with caudate lobectomy, extrahepatic bile duct resection and reconstruction of bile duct were performed. Probiotics were administered during the perioperative period. Combined probiotics that included lactomin, amylolytic bacillus and C. butyricum, were given before surgery. C. butyricum MIYAIRI 588 was given after surgery. Sepsis occurred 16 days after surgery and developed to respiratory failure 8 days later. Blood culture at postoperative day 25 revealed Enterococcus faecalis and C. butyricum. After the probiotics were stopped at postoperative day 27, C. butyricum was not detected in the blood culture. The general condition improved with intensive care. The patient was transferred to another hospital for rehabilitation at postoperative day 156.

Conclusion

It should be noted that the administration of probiotics in severe postoperative complications can lead to probiotic-related bacteremia.

The Surviving Sepsis Campaign: Basic/Translational Science Research Priorities

Objectives:

Expound upon priorities for basic/translational science identified in a recent paper by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.

Data Sources:

Original paper, search of the literature.

Study Selection:

By several members of the original task force with specific expertise in basic/translational science.

Data Extraction:

None.

Data Synthesis:

None.

Conclusions:

In the first of a series of follow-up reports to the original paper, several members of the original task force with specific expertise provided a more in-depth analysis of the five identified priorities directly related to basic/translational science. This analysis expounds on what is known about the question and what was identified as priorities for ongoing research. It is hoped that this analysis will aid the development of future research initiatives.

Bifidobacterium breve BBG-001 and intestinal barrier function in preterm babies: Exploratory Studies from the PiPS Trial

BACKGROUND

Uncertainty remains about the role of probiotics to prevent necrotising enterocolitis (NEC) some of which arises from the variety of probiotic interventions used in different trials, many with no prior evidence of potential efficacy. Mechanistic studies of intestinal barrier function embedded in a large probiotic trial could provide evidence about which properties of probiotics might be important for NEC prevention thus facilitating identification of strains with therapeutic potential.

METHODS

Intestinal permeability, stool microbiota, SCFAs and mucosal inflammation were assessed from the second postnatal week in babies enrolled to a randomised controlled trial of B. breve BBG-001 (the PiPS trial). Results were compared by allocation and by stool colonisation with the probiotic.

RESULTS

Ninety-four preterm babies were recruited across six nested studies. B. breve BBG-001 content was higher by allocation and colonisation; Enterobacteriaceae and acetic acid levels were higher by colonisation. No measure of intestinal barrier function showed differences. The PiPS trial found no evidence of efficacy to reduce NEC.

CONCLUSIONS

That the negative results of the PiPS trial were associated with failure of this probiotic to modify intestinal barrier function supports the possibility that the tests described here have the potential to identify strains to progress to large clinical trials.

IMPACT

Uncertainty about the therapeutic role of probiotics to prevent necrotising enterocolitis is in part due to the wide range of bacterial strains with no previous evidence of efficacy used in clinical trials. We hypothesised that mechanistic studies embedded in a probiotic trial would provide evidence about which properties of probiotics might be important for NEC prevention. The finding that the probiotic strain tested, Bifidobacterium breve BBG-001, showed neither effects on intestinal barrier function nor clinical efficacy supports the possibility that these tests have the potential to identify strains to progress to large clinical trials.

Impact of Preoperative Occult-Bacterial Translocation on Surgical Site Infection in Patients Undergoing Pancreatoduodenectomy

BACKGROUND

Occult-bacterial translocation (O-BT) has been reported as the condition in which microorganisms are detected in blood or lymph nodes by a highly sensitive method. However, the clinical impact of preoperative O-BT on postoperative complication is unclear.

STUDY DESIGN

A prospective observational study with patients undergoing pancreatoduodenectomy for periampullary diseases was conducted. Blood samples were collected immediately after induction of anesthesia. The status of O-BT was investigated using bacterium-specific ribosomal RNA-targeted reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR). The impact of O-BT on surgical site infection (SSI) was analyzed.

RESULTS

A total of 155 patients were included. The positive rate in preoperative blood samples detected by RT-qPCR was significantly higher than that obtained by the culture method (32 of 155 vs 4 of 155, p < 0.001). Preoperative blood samples were contaminated with 1.0 to 19.2 bacterial cells/mL in positive patients, and 30 of the 41 detected microorganisms were obligate anaerobes. No differences in preoperative factors were observed between patients with positive and negative RT-qPCR results. The incidence of any SSI was significantly higher in patients with contaminated preoperative blood (≥1.2 bacterial cells/mL) than in other patients (14 of 27 vs 35 of 128, p = 0.013). Multivariable analysis indicated that contaminated preoperative blood was identified as one of the independent risk factors for SSI (odds ratio 2.71, 95% CI 1.04 to 7.24, p = 0.041).

CONCLUSIONS

O-BT, predominantly with obligate anaerobes, was commonly observed in preoperative blood samples. In addition to the previously known risk factors, O-BT may be one of the risk factors for SSI after pancreatoduodenectomy.

Importance of "muscle" and "intestine" training before major HPB surgery: A review

Major hepato-pancreato-biliary (HPB) surgery is one of the most invasive abdominal surgeries. Through the experiences of several clinical trials, including those involving patients undergoing major HPB surgery, we have recognized the importance of "muscle" and "intestine" training before surgery. This review article summarizes the results of our clinical trials, specifically focusing on the importance of "muscle" and "intestine". The patients with low skeletal muscle mass or those with low functional exercise capacity showed a significantly worse postoperative course and poor long-term survival after surgery for HPB malignancy. The introduction of prehabilitation (preoperative physical and nutritional support) improved nutritional status and functional exercise capacity, even in patients with malignancy. Daily physical activity was correlated with nutritional status before surgery. These results indicated the usefulness of prehabilitation. The intestinal microenvironment, which is extrapolated from the fecal concentrations of short-chain fatty acids (SCFAs), showed a significant association with the incidence of surgery-induced bacterial translocation and postoperative infectious complications (POICs). The use of perioperative synbiotics not only increased the fecal levels of SCFAs but also prevented the incidence of POICs. A recent study also indicated that there are correlations between muscle mass and the intestinal microenvironment. Further investigation is required to determine the best "muscle" and "intestine" training protocol to improve the outcomes of major HPB surgeries.

Perioperative Enteral Nutrition Improves Postoperative Recovery for Patients with Primary Liver Cancer: A Randomized Controlled Clinical Trial

OBJECTIVE

The role of perioperative protein-enriched enteral nutrition for patients with primary liver cancer is unclear. We investigated the efficacy of perioperative protein-enriched enteral nutrition for patients with primary liver cancer followed hepatectomy.

METHODS

Patients with primary liver cancer that underwent hepatectomy between January 2016 and 2018 were enrolled. Patients in the treatment group was given enteral nutrition (TP-MCT) in addition to the regular diet. The primary outcome measures were duration of hospital stay and length of postoperative hospital stay. Secondary outcome measures included time to first flatus and time to first defecation.

RESULTS

There was a significant reduction of time to first flatus and time to first defecation in the treatment group, when compared with the control group (time to first flatus: P = 0.001, time to first defecation: P < 0.001).

CONCLUSIONS

It is found that addition of protein-enriched enteral nutrition (TP-MCT) improved postoperative recovery for patients with primary liver cancer following hepatectomy, with a significant reduction in time to first flatus and time to first defecation.

Clinical importance of "occult-bacterial translocation" in patients undergoing highly invasive gastrointestinal surgery: A review

In the clinical setting, mild bacteremia cannot be detected by conventional culture methods, only by a highly sensitive bacterial detection system. One of the major causes of mild bacteremia is bacterial translocation (BT) induced by a dysregulated intestinal microenvironment and increased intestinal epithelial permeability. This condition is called "occult-bacterial translocation (O-BT)"; however, the concept of O-BT is not yet fully recognized. In our previous studies, done using a highly sensitive bacterial detection system such as bacterium-specific ribosomal RNA-targeted reverse transcriptase quantitative polymerase chain reaction (RT-qPCR), O-BT was commonly observed in patients who underwent highly invasive surgery. We collected blood and mesenteric lymph node (MLN) samples from patients undergoing esophagectomy for esophageal cancer, before and after they were subjected to surgical stress. The detection rate of bacteria in these samples increased from approximately 20% before surgical stress to more than 50% after surgical stress. Moreover, positivity for bacteria in the blood or MLN samples was associated with the incidence of postoperative infectious complications (POICs). Using the RT-qPCR system, it is possible to detect the specific bacteria that cause O-BT immediately after surgery. This may allow us to select the exact antibiotic that targets possible pathogenic bacteria of POICs.

Effects of both Pro- and Synbiotics in Liver Surgery and Transplantation with Special Focus on the Gut-Liver Axis-A Systematic Review and Meta-Analysis

The gut-liver axis is of upmost importance for the development of infections after surgery. Further bacterial translocation due to surgery-related dysbiosis is associated with limited detoxification function of the liver compromising outcome of surgical therapy. After liver surgery, about 30% of patients develop a bacterial infection, with the risk of bacteremia or even sepsis-associated liver failure and mortality in >40%. The potential benefit of pro-/synbiotics given before surgery is still under debate. Thus, a systematic literature search on trials comparing patients with or without supplementation and outcome after liver resection or transplantation was performed. Our search strategy revealed 12 relevant studies on perioperative administration of pro-/synbiotics in liver surgery. The pro-/synbiotic combinations and concentrations as well as administration timeframes differed between studies. Five studies were performed in liver transplantation and 7 in liver resection. All studies but one reported lower infection rates (pooled RR: 0.46, 95% CI: 0.31-0.67) with pro-/synbiotics. Liver function was assessed after LT/LR in 3 and 5 studies, respectively. Pro-/synbiotics improved function in 1/3 and 2/5 studies, respectively. Concluding, perioperative pro-/synbiotics clearly reduce infection after liver surgery. However, standard protocols with both well-defined probiotic strain preparations and administration timeframes are pending.

The surviving sepsis campaign: basic/translational science research priorities

Objectives

Expound upon priorities for basic/translational science identified in a recent paper by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.

Data sources

Original paper, search of the literature.

Study selection

This study is selected by several members of the original task force with specific expertise in basic/translational science. Data extraction and data synthesis are not available.

Conclusions

In the first of a series of follow-up reports to the original paper, several members of the original task force with specific expertise provided a more in-depth analysis of the five identified priorities directly related to basic/translational science. This analysis expounds on what is known about the question and what was identified as priorities for ongoing research. It is hoped that this analysis will aid the development of future research initiatives.

Impact of Perioperative Steroid Administration in Patients Undergoing Major Hepatectomy with Extrahepatic Bile Duct Resection: A Randomized Controlled Trial

BACKGROUND

To date, five randomized controlled trials have assessed the clinical benefit of perioperative steroid administration in hepatectomy; however, all of these studies involved a substantial number of 'minor' hepatectomies. The benefit of steroid administration for patients undergoing 'complex' hepatectomy, such as major hepatectomy with extrahepatic bile duct resection, is still unclear. This study aimed to evaluate the clinical benefit of perioperative steroid administration for complex major hepatectomy.

METHODS

Patients with suspected hilar malignancy scheduled to undergo major hepatectomy with extrahepatic bile duct resection were randomized into either the control or steroid groups. The steroid group received hydrocortisone 500 mg immediately before hepatic pedicle clamping, followed by hydrocortisone 300 mg on postoperative day (POD) 1, 200 mg on POD 2, and 100 mg on POD 3. The control group received only physiologic saline. The primary endpoint was the incidence of postoperative liver failure.

RESULTS

A total of 94 patients were randomized to either the control (n = 46) or steroid (n = 48) groups. The two groups had similar baseline characteristics; however, there were no significant differences between the groups in the incidence of grade B/C postoperative liver failure (control group, n = 8, 17%; steroid group, n = 4, 8%; p = 0.188) and other complications. Serum bilirubin levels on PODs 2 and 3 were significantly lower in the steroid group than those in the control group; however, these median values were within normal limits in both groups.

CONCLUSION

Perioperative steroid administration did not reduce the risk of postoperative complications, including liver failure following major hepatectomy with extrahepatic bile duct resection.

Perioperative Probiotics or Synbiotics in Adults Undergoing Elective Abdominal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To define the impact of perioperative treatment with probiotics or synbiotics on postoperative outcome in patients undergoing abdominal surgery.

BACKGROUND

Postoperative surgical infection accounts for a third of all cases of sepsis, and is a leading cause of morbidity and mortality. Probiotics, prebiotics, and synbiotics (preparations that combine probiotics and prebiotics) are nutritional adjuncts that are emerging as novel therapeutic modalities for preventing surgical infections. However, current evidence on their effects is conflicting.

METHODS

A comprehensive search of the PubMed, Embase, and WHO Global Index Medicus electronic databases was performed to identify randomized controlled trials evaluating probiotics or synbiotics in adult patients undergoing elective colorectal, upper gastrointestinal, transplant, or hepatopancreaticobiliary surgery. Bibliographies of studies were also searched. The primary outcome measure was incidence of postoperative infectious complications. Secondary outcomes included incidence of noninfectious complications, mortality, length of hospital stay, and any treatment-related adverse events. Quantitative pooling of the data was undertaken using a random effects model.

RESULTS

A total of 34 randomized controlled trials reporting on 2723 participants were included. In the intervention arm, 1354 patients received prebiotic or symbiotic preparations, whereas 1369 patients in the control arm received placebo or standard care. Perioperative administration of either probiotics or synbiotics significantly reduced the risk of infectious complications following abdominal surgery [relative risk (RR) 0.56; 95% confidence interval (CI) 0.46-0.69; P < 0.00001, n = 2723, I = 42%]. Synbiotics showed greater effect on postoperative infections compared with probiotics alone (synbiotics RR: 0.46; 95% CI: 0.33-0.66; P < 0.0001, n = 1399, I = 53% probiotics RR: 0.65; 95% CI: 0.53-0.80; P < 0.0001, n = 1324, I = 18%). Synbiotics but not probiotics also led to a reduction in total length of stay (synbiotics weighted mean difference: -3.89; 95% CI: -6.60 to -1.18 days; P = 0.005, n = 535, I = 91% probiotics RR: -0.65; 95% CI: -2.03-0.72; P = 0.35, n = 294, I = 65%). There were no significant differences in mortality (RR: 0.98; 95% CI: 0.54-1.80; P = 0.96, n = 1729, I = 0%) or noninfectious complications between the intervention and control groups. The preparations were well tolerated with no significant adverse events reported.

CONCLUSIONS

Probiotics and synbiotics are safe and effective nutritional adjuncts in reducing postoperative infective complications in elective abdominal surgery. The treatment effects are greatest with synbiotics.

Impact of Qualitative and Quantitative Biliary Contamination Status on the Incidence of Postoperative Infection Complications in Patients Undergoing Pancreatoduodenectomy

BACKGROUND

Bacterial contamination status may differ under different biliary drainage conditions. The purpose of this study was to determine the impact of qualitative and quantitative biliary bacterial contamination on the incidence of infection complications in patients undergoing pancreatoduodenectomy.

METHODS

Patients undergoing pancreatoduodenectomy for periampullary diseases with different biliary drainage conditions, such as external drainage (ED), internal drainage (ID), and no drainage (ND), were included. Bile was collected intraoperatively, and biliary contamination status was qualified and quantified using bacterium-specific ribosomal RNA-targeted reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The impact of biliary contamination status on infection complications was analyzed.

RESULTS

A total of 152 patients were included (38 with ED, 40 with ID, and 74 with ND). The positive rate of microorganisms in bile was higher in the ID group (98%) compared with the ED group (82%, p = 0.021) and the ND group (65%, p < 0.001). The number of microorganisms detected in bile samples was higher in the ID group compared with the ED group (median 489,788 vs. 5375 bacteria/mL of bile, p < 0.001). With multivariate analysis, soft pancreas, intraoperative bleeding (> 600 mL), and biliary contamination by Atopobium cluster were identified as independent risk factors for infection complications. Biliary contamination by Atopobium cluster was significantly higher in the ID group compared with the other groups.

CONCLUSIONS

Biliary bacterial contamination is more frequently induced by ID than either ED or ND. In addition to the previously known risk factors, biliary contamination with Atopobium cluster may be one of the risk factors of infection complications following pancreatoduodenectomy.

Perioperative probiotic treatment decreased the incidence of postoperative cognitive impairment in elderly patients following non-cardiac surgery: A randomised double-blind and placebo-controlled trial

BACKGROUND

Given that population aging is a global health challenge, the high prevalence of postoperative neurocognitive impairment in elderly patients necessitates the development of novel simple and effective prevention methods.

OBJECTIVE

To evaluate the effects of perioperative application of oral probiotic as a prophylaxis for cognitive impairment in elderly patients following non-cardiac surgery.

METHODS

This randomised double-blind and placebo-controlled trial included 120 elderly patients (in a modified intention-to-treat analysis) scheduled for elective orthopaedic or colorectal surgery. Patients were assigned to receive either probiotics or a placebo from hospital admission until discharge. The primary endpoint was the incidence of postoperative cognitive impairment, defined as a decrease of ≥3 points in the Mini-Mental State Examination (MMSE) scores from admission baseline to the 7th day post-surgery. Secondary endpoints included changes in plasma interleukin-6 (IL-6) and cortisol, postoperative pain intensity, postoperative sleep quality, gastrointestinal function recovery, and faecal microbiota composition.

RESULTS

The incidence of postoperative cognitive impairment in the probiotic group was significantly lower than in the control group (3 of 59 patients [5.1%] vs. 10 of 61 patients [16.4%], P = 0.046). In addition, compared to pre-surgery, the levels of plasma IL-6 and cortisol in the probiotic group decreased more than in the control group 5-7 days after surgery (IL-6: -117.90 ± 49.15 vs. -14.93 ± 15.21, P = 0.044; cortisol: -158.70 ± 53.52 vs. 40.98 ± 72.48, P = 0.010). Relative abundance at the genus level in the faeces of the probiotic group also changed more than in that of the control group during the perioperative period. In contrast, postoperative pain intensity, sleep quality, and gastrointestinal function recovery did not differ significantly between the two groups.

CONCLUSION

Perioperative application of oral probiotic prevents postoperative cognitive impairment in elderly patients following non-cardiac surgery, possibly via the limitation of peripheral inflammation and the stress response.

Postoperative infectious complications caused by multidrug-resistant pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection

BACKGROUND

Few reports have addressed postoperative infectious complications caused by multidrug-resistant pathogens. The aim of this study was to review the surgical outcomes of patients undergoing major hepatectomy with extrahepatic bile duct resection and to clarify the incidence of and the risk factors for postoperative infectious complications caused by multidrug-resistant pathogens.

METHODS

Medical records of consecutive patients who underwent major hepatectomy with extrahepatic bile duct resection between 2006 and 2017 were retrospectively reviewed.

RESULTS

Among 620 study patients, 219 had postoperative infectious complications, including 62 (10.0%) with postoperative infectious complications caused by multidrug-resistant pathogens. The mortality of the 62 patients with postoperative infectious complications caused by multidrug-resistant pathogens was higher (n = 8, 12.9%) than that in the 157 patients with postoperative infectious complications caused by non-multidrug-resistant pathogens(n = 2, 1.3%) (P < .001). With multivariate analysis, the presence of preoperative cholangitis, the extent of liver resection more than 50%, operative time longer than 600 minutes, the amount of blood loss more than 1500 mL, and the presence of postoperative infectious complications caused by multidrug-resistant pathogens were identified as independent risk factors for postoperative death. The presence of multidrug-resistant pathogens in preoperative bile culture, the amount of blood loss greater than 1500 mL, the presence of bile leakage, and pancreatic fistula were identified as independent risk factors for postoperative infectious complications caused by multidrug-resistant pathogens.

CONCLUSION

The incidence of postoperative infectious complications caused by multidrug-resistant pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection is high, approximately 10%. This troublesome complication is closely associated with postoperative death. Thus, preventing postoperative infectious complications caused by multidrug-resistant pathogens is an urgent task to improve surgical outcome after major hepatectomy with extrahepatic bile duct resection.

Impact of preoperative fecal short chain fatty acids on postoperative infectious complications in esophageal cancer patients

Background

The intestinal epithelial barrier allows absorption of dietary nutrients and prevents passage of pathogens and toxins into the body. Severe insults have a negative impact on the intestinal environment, which may decrease intestinal barrier function and cause bacterial translocation. Bacterial translocation, which can cause infectious complications, is defined as the passage of microbes from the gastrointestinal tract across the mucosal barrier to extraintestinal sites. The aim of this study was to investigate the correlation between concentrations of preoperative fecal organic acids and the occurrence of postoperative infectious complications in patients with esophageal cancer.

Methods

Fifty-five patients with esophageal cancer who underwent esophagectomy were enrolled in this study. Perioperative synbiotics were administered to all patients. Perioperative clinical characteristics and concentrations of preoperative fecal organic acids were compared between patients with and without postoperative infectious complications.

Results

Postoperative infectious complications occurred in 10 patients. In patients with complications, the concentrations of acetic acid and propionic acid were significantly lower than in patients without complications (p = 0.044 and 0.032, respectively). The concentration of butyric acid was nonsignificantly lower in patients with complications, while the concentration of lactic acid was nonsignificantly higher. The calculated gap between the concentrations of fecal acetic acid plus propionic acid plus butyric acid minus lactic acid was significantly lower in patients with complications. Multivariate analysis revealed that a low gap between acetic acid plus propionic acid plus butyric acid minus lactic acid was an independent risk factor for postoperative infectious complications (p = 0.027).

Conclusions

Preoperative fecal concentrations of organic acids had a clinically important impact on the occurrence of postoperative infectious complications in patients with esophageal cancer. To reduce postoperative infectious complications, it may be useful to modulate the intestinal environment and maintain concentrations of fecal organic acids before surgery.

The effect of preoperative synbiotic treatment to prevent surgical-site infection in hepatic resection

We aimed to clarify the influence of preoperative synbiotic therapy on surgical-site infections (SSIs) after hepatic resection. Between January 2011 and December 2017, 284 patients who underwent hepatic resection without biliary tract reconstruction and resection of other organs were included. We prospectively administered Clostridium butyricum and partially hydrolyzed guar gum before hepatic resection between April 2016 and December 2017 (synbiotic group). One-hundred-fifteen patients of the synbiotic group and 169 patients (conventional group) treated between January 2011 and the end of March 2016 were compared using propensity score matching. The frequency of laparoscopic resection was significantly larger in the synbiotic group (conventional group; 28% vs synbiotic group; 55%, p<0.001) and the amount of intraoperative bleeding was significantly smaller in the synbiotic group (median; conventional group, 700 ml vs synbiotic group, 200 ml; p<0.001). The postoperative SSI was significantly lower in the synbiotic group of six patients (5.2%) than in the conventional group of 30 patients (17.8%) (p = 0.002). Sixty patients in each group remained after propensity score matching. There was no significant difference in the incidence of SSI between the groups (conventional group, 15% vs synbiotic group, 6.7%; p = 0.239). In conclusion, preoperative synbiotic treatment did not reduce SSIs after hepatic resection.

The International Scientific Association for Probiotics and Prebiotics (ISAPP) consensus statement on the definition and scope of synbiotics

In May 2019, the International Scientific Association for Probiotics and Prebiotics (ISAPP) convened a panel of nutritionists, physiologists and microbiologists to review the definition and scope of synbiotics. The panel updated the definition of a synbiotic to "a mixture comprising live microorganisms and substrate(s) selectively utilized by host microorganisms that confers a health benefit on the host". The panel concluded that defining synbiotics as simply a mixture of probiotics and prebiotics could suppress the innovation of synbiotics that are designed to function cooperatively. Requiring that each component must meet the evidence and dose requirements for probiotics and prebiotics individually could also present an obstacle. Rather, the panel clarified that a complementary synbiotic, which has not been designed so that its component parts function cooperatively, must be composed of a probiotic plus a prebiotic, whereas a synergistic synbiotic does not need to be so. A synergistic synbiotic is a synbiotic for which the substrate is designed to be selectively utilized by the co-administered microorganisms. This Consensus Statement further explores the levels of evidence (existing and required), safety, effects upon targets and implications for stakeholders of the synbiotic concept.

Efficacy of Using Probiotics with Antagonistic Activity against Pathogens of Wound Infections: An Integrative Review of Literature

The skin and its microbiota serve as physical barriers to prevent invasion of pathogens. Skin damage can be a consequence of illness, surgery, and burns. The most effective wound management strategy is to prevent infections, promote healing, and prevent excess scarring. It is well established that probiotics can aid in skin healing by stimulating the production of immune cells, and they also exhibit antagonistic effects against pathogens via competitive exclusion of pathogens. Our aim was to conduct a review of recent literature on the efficacy of using probiotics against pathogens that cause wound infections. In this integrative review, we searched through the literature published in the international following databases: PubMed, ScienceDirect, Web of Science, and Scopus using the search terms “probiotic” AND “wound infection.” During a comprehensive review and critique of the selected research, fourteen in vitro studies, 8 animal studies, and 19 clinical studies were found. Two of these in vitro studies also included animal studies, yielding a total of 39 articles for inclusion in the review. The most commonly used probiotics for all studies were well-known strains of the species Lactobacillus plantarum, Lactobacillus casei, Lactobacillus acidophilus, and Lactobacillus rhamnosus. All in vitro studies showed successful inhibition of chosen skin or wound pathogens by the selected probiotics. Within the animal studies on mice, rats, and rabbits, probiotics showed strong opportunities for counteracting wound infections. Most clinical studies showed slight or statistically significant lower incidence of surgical site infections, foot ulcer infection, or burn infections for patients using probiotics. Several of these studies also indicated a statistically significant wound healing effect for the probiotic groups. This review indicates that exogenous and oral application of probiotics has shown reduction in wound infections, especially when used as an adjuvant to antibiotic therapy, and therefore the potential use of probiotics in this field remains worthy of further studies, perhaps focused more on typical skin inhabitants as next-generation probiotics with high potential.

Predictive Factors and Microbial Spectrum for Infectious Complications after Hepatectomy with Cholangiojejunostomy in Perihilar Cholangiocarcinoma

Background: Despite advances in surgical techniques and peri-operative management, post-operative infectious complications still are common after perihilar cholangiocarcinoma (PHCC). This study investigated the predictive factors and microbial spectrum for infections after hepatectomy with cholangiojejunostomy performed to treat PHCC. Methods: A total of 70 consecutive patients, who underwent hepatectomy with cholangiojejunostomy by the same surgeons at a tertiary referral medical center between September 2010 and January 2019, were enrolled. Clinical data were reviewed for multivariable analysis to find independent risk factors for infectious complications. Microorganisms isolated from bile and infection sites were counted to explore the microbial spectrum. Results: A total of 43 patients (61.4%) suffered post-operative infections (33 with surgical site infection [SSI], four with bacteremia, three with pneumonia, 10 with cholangitis, and two with fungus infectious stomatitis), and 28 of them (65.1%) had a positive bile culture. Four independent risk factors were identified: male sex (odds ratio [OR] 12.737; 95% confidence interval [CI] 2.298-70.611; p = 0.004), red blood cell (RBC) count <3.8 × 10¹²/L (OR 5.085; 95% CI 1.279-20.211; p = 0.021), total cholesterol (TC) <2.90 mmol/L (OR 5.715; 95% CI 1.534-21.299; p = 0.009), and serum Na⁺ >145 mmol/L (OR 10.387; 95% CI 1.559-69.201; p = 0.016) on post-operative day (POD) 1. A total of 217 and 196 microorganisms were cultured from 311 and 627 specimens, respectively, collected from pre-/intra-operative bile and possible infection sites. Staphylococcus, Enterococcus, Acinetobacter, Streptococcus, and Escherichia were the most common findings of bile culture. The first five organisms most frequently isolated from infection sites were Enterococcus, Staphylococcus, Klebsiella, Acinetobacter, and Candida. A total of 18 patients (64.3%) had at least one species isolated from infection sites that had appeared in a previous bile culture. Conclusions: Male sex, erythrocytopenia, hypocholesterolemia, and hypernatremia on POD 1 are independent risk factors for infectious complications. For patients without positive bile cultures, third-generation cephalosporins could be considered as the prophylactic antibiotic. It is important to monitor the pathogens throughout the hospital stay.

Survey of preoperative management protocol for perihilar cholangiocarcinoma at 10 Japanese high-volume centers with a combined experience of 2,778 cases

BACKGROUND

In Japan, strategies for preoperative management of perihilar cholangiocarcinoma (PHC) have evolved over the last decade; the operative mortality has significantly reduced to <5%.

METHODS

A questionnaire was sent to 10 institutions based on their case volume. Questionnaire was based on: (1) preoperative biliary drainage, (2) bile replacement, (3) role of synbiotics, (4) remnant liver volume enhancement, (5) predicted remnant liver function, (6) imaging, (7) nutrition, and (8) role of Inchinkoto.

RESULTS

The median case volume was 226 (range 105-889) cases, respectively. Eight institutions preferred endoscopic nasobiliary drainage and two preferred endoscopic biliary stenting for biliary drainage. Nine used bile replacement within 2-3 days of biliary drainage. Four used synbiotics preoperatively. The median cutoff value for future remnant liver volume and serum total bilirubin, at which portal vein embolization (PVE) is done, is <40% and <4 mg/dl. The median interval between PVE and surgery was 3-4 weeks. To predict remnant liver function, indocyanine green retention (n = 8) and clearance rate (n = 2) were mainly used. Five used Inchinkoto to improve liver function. Nine used multidetector computed tomography and direct cholangiography for surgical planning.

CONCLUSION

With appropriate preoperative management of PHC, surgical morbidity and mortality can be reduced. This survey can provide recommendations to improve PHC perioperative outcomes.