Laparoscopic versus open colorectal surgery for colon cancer: the effect of surgical trauma on the bacterial translocation. A prospective randomized study

Can Triclosan-Coated Sutures Reduce the Incidence of Surgical Site Infections and Intra-Abdominal Infection: A Double-Blinded Randomized Controlled Trial

Abstract Background: Surgical site infections (SSIs) are the most common nosocomial infections suffered by surgical patients. They increase medical costs and prolong hospital stay. With respect to gastrointestinal surgery, SSIs are reported to have an incidence of up to 30%, and they frequently cause morbidity. The aim of this study was to prospectively investigate whether use of triclosan-coated sutures for abdominal incision closure during colorectal surgery reduces the incidence of SSI. Patients and Methods: This was a double-blinded randomized controlled trial in a single academic surgical hospital. Patients who underwent laparoscopic or open colorectal surgery were included. Patients were pre-operatively randomly assigned to either the Vicryl^® Plus (VP) or Vicryl^® (Ethicon Inc., Somerville, NJ) group. The patients and medical staff were blinded. Results: The primary end point was overall SSI rate and SSI at 30 days. Over a six-year period, 811 patients who underwent colorectal surgery and provided informed consent were randomly assigned (VP group, 396 patients; Vicryl group, 415 patients). No differences in baseline demographics were observed between the groups. The overall incidence of SSI was 4.8% (39/811 patients). There were no statistically significant differences in mean length of post-operative hospital stay between the groups (VP group, 9.3 days; Vicryl group, 9.6 days; p = 0.587). Statistically significant differences in SSI rate after post-operative day 30 were observed between the groups (VP group, 1 patient [7.1%]; Vicryl group, 7 patients [28.0%]; p = 0.039). Conclusions: Although use of triclosan-coated sutures did not reduce incidence of SSI within 30 days post-operatively, it is associated with reduced SSI rate after post-operative day 30.

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.

Mid- and low-rectal cancer: laparoscopic vs open treatment-short- and long-term results. Meta-analysis of randomized controlled trials

BACKGROUND

The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce.

OBJECTIVE

The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer.

DATA SOURCES

A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words.

STUDY SELECTION

Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

INTERVENTION(S)

This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer.

MAIN OUTCOME MEASURES

Primary outcomes were oncological parameters.

RESULTS

Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group.

LIMITATIONS

There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique.

CONCLUSIONS

Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.

Surgery for Colorectal Cancer: A Trigger for Liver Metastases Development? New Insights into the Underlying Mechanisms

Surgery is a crucial intervention and provides the best chance of cure for patients with colorectal cancer. Experimental and clinical evidence, however, suggests that paradoxically surgery itself may precipitate or accelerate tumor recurrence and/or liver metastasis development. This review addresses the various aspects of surgery-induced metastasis formation and sheds light on the role of inflammation as potential trigger for metastasis development. Understanding these mechanisms may provide potential new perioperative interventions to improve treatment outcomes, and as such could transform the perioperative timeframe from a facilitator of metastatic progression to a window of opportunity to reduce the risk of liver metastasis development. Ultimately, this can potentially improve long-term survival rates and quality of life in patients with colorectal cancer.

A Population of Radio-Resistant Macrophages in the Deep Myenteric Plexus Contributes to Postoperative Ileus Via Toll-Like Receptor 3 Signaling

Postoperative ileus (POI) is triggered by an innate immune response in the muscularis externa (ME) and is accompanied by bacterial translocation. Bacteria can trigger an innate immune response via toll-like receptor (TLR) activation, but the latter's contribution to POI has been disproved for several TLRs, including TLR2 and TLR4. Herein we investigated the role of double-stranded RNA detection via TLR3 and TIR-domain-containing adapter-inducing interferon-β (TRIF) signaling pathway in POI. POI was induced by small bowel intestinal manipulation in wt, TRIF^-/-, TLR3^-/-, type I interferon receptor^-/- and interferon-β reporter mice, all on C57BL/6 background, and POI severity was quantified by gene expression analysis, gastrointestinal transit and leukocyte extravasation into the ME. TRIF/TLR3 deficiency reduced postoperative ME inflammation and prevented POI. With bone marrow transplantation, RNA-sequencing, flow cytometry and immunohistochemistry we revealed a distinct TLR3-expressing radio-resistant MHCII^hiCX3CR1^- IBA-1⁺ resident macrophage population within the deep myenteric plexus. TLR3 deficiency in these cells, but not in MHCII^hiCX3CR1⁺ macrophages, reduced cytokine expression in POI. While this might not be an exclusive macrophage-privileged pathway, the TLR3/TRIF axis contributes to proinflammatory cytokine production in MHCII^hiCX3CR1^- IBA-1⁺ macrophages during POI. Deficiency in TLR3/TRIF protects mice from POI. These data suggest that TLR3 antagonism may prevent POI in humans.

Squamous cell anal cancer: Management and therapeutic options

The incidence of anal cancer has increased during the second half of the 20th century, with an incidence rate over 2.9% greater than in the decade of 1992-2001. Yet, it still constitutes a small percentage, about 4%, of all anorectal tumours. Its risk factors are human papillomavirus infection, a history of sexually transmitted diseases, a history of vulvar or cervical carcinoma, immunosuppression related to human immunodeficiency virus infection or after organ transplantation, haematological or immunological disorders, and smoking. The most frequent symptom is rectal bleeding (45%), followed by anal pain, and sensation of a rectal mass. The diagnosis requires clinical examination, palpation of the inguinal lymph nodes, high resolution anoscopy followed by fine-needle aspiration biopsy or core biopsy. Subsequent histologic diagnosis is necessary, as well as computed tomography or magnetic resonance imaging evaluation of the pelvic lymph nodes. Since 1980, patients with a diagnosis of anal cancer have shown a significant improvement in survival. In Europe during the years 1983-1994, 1-year survival increased from 78% to 81%, and the improvement over 5 years was between 48% and 54%. Prior to 1974, patients with invasive cancer were routinely scheduled for abdominoperineal amputation, after which it was demonstrated that treatment with 5-fluorouracil and radiotherapy associated with mitomycin or capecitabine could be adequate to treat the tumour without surgery. Today, numerous studies have confirmed that combined multimodal treatment is effective and sufficient.

Comparison of robot-assisted surgery, laparoscopic-assisted surgery, and open surgery for the treatment of colorectal cancer: A network meta-analysis

BACKGROUND

The aim of this study was to find the better treatment for colorectal cancer (CRC) by comparing robot-assisted colorectal surgery (RACS), laparoscopic-assisted colorectal surgery (LACS), and open surgery using network meta-analysis.

METHODS

A literature search updated to August 15, 2017 was performed. All the included literatures were evaluated according to the quality evaluation criteria of bias risk recommended by the Cochrane Collaboration. All data were comprehensively analyzed by ADDIS. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were used to show the effect index of all data. The degree of convergence of the model was evaluated by the Brooks-Gelman-Rubin method with the potential scale reduction factor (PSRF) as the evaluation indicator.

RESULTS

The PSRF values of operation time, estimated blood loss, length of hospital stay, complication, mortality, and anastomotic leakage ranged from 1.00 to 1.01, and those of wound infection, bleeding, and ileus ranged from 1.00 to 1.02. Open surgery had the shortest operation time compared with LACS and RACS. Furthermore, compared with LACS, the amount of blood loss, complication, mortality, bleeding rate, and ileus rate for RACS were the least, and the length of hospital stay for RACS was the shortest. The anastomotic leakage rate for LACS was the least, but there was no significant difference compared with those of RACS and open surgery. The wound infection rate for LACS was the least, but there was no significant difference compared with that of RACS.

CONCLUSION

RACS might be a better treatment for patients with CRC.

Spillage of bacterial products during colon surgery increases the risk of liver metastases development in a rat colon carcinoma model

Surgical resection of the primary tumor provides the best chance of cure for patients with colorectal carcinoma (CRC). However, bacterial translocation during intestinal surgery has been correlated with poor long-term oncological outcome. Therefore, we investigated the influence of bacterial contamination during colon surgery on CRC liver metastases development. Blood and liver samples of patients undergoing resection of primary CRC or liver metastases were collected. Cell numbers, activation markers and inflammatory mediators were determined. Tumor cell adhesion and outgrowth after sham- or colectomy operations were determined in a rat model, in which tumor cells had been injected into the portal vein.

White blood cells and granulocytes were increased in per- and post-operative patient blood samples. IL-6 was also increased post-operatively compared to the preoperative level. Expression of NOX-2, NOX-4 and polymorphonuclear cells (PMNs) numbers were elevated in post-operative human liver samples. In vitro stimulation of macrophages with plasma of rats after colectomy resulted in production of reactive oxygen species (ROS). Colectomy in rats increased D-lactate levels in plasma, supporting bacterial translocation. Decreased expression of tight junction molecules and increased tumor cell adhesion and outgrowth was observed. Treatment with a selective decontamination of the digestive tract (SDD) cocktail decreased tumor cell adherence after colectomy.

In conclusion, postoperative bacterial translocation may activate liver macrophages and PMNs, resulting in ROS production. As we previously showed that ROS release led to liver vasculature damage, circulating tumor cells may adhere to exposed extracellular matrix and grow out into liver metastases. This knowledge is pivotal for development of therapeutic strategies to prevent surgery-induced liver metastases development.

The Influence of Carbon Dioxide Pneumoperitoneum on Systemic Inflammatory Response Syndrome and Bacterial Translocation in Patients With Bacterial Peritonitis Caused by Acute Appendicitis

OBJECTIVE

To explore the influence of carbon dioxide pneumoperitoneum (CDP) on system inflammatory response syndrome (SIRS) and bacterial translocation (BT) in patients with bacterial peritonitis (BP) caused by acute appendicitis (AA).

METHODS

Eighty-six consecutive subjects were randomly divided into the laparoscopy and laparotomy groups (n = 44 and n = 42, respectively). The levels of white blood cells (WBC), C-reactive protein (CRP), tumor necrosis factor α (TNF-α), and interleukin 6 (IL-6) of the 2 groups were tested preoperatively and at days 1, 2, and 4 after surgery. Blood and secretion culture was performed to verify whether septicemia or incision infection occurred, respectively. And the abdominal ultrasound or computed tomography scanning was used to diagnose peritoneal abscess for the suspected patients. The essential risk factors related to the aggravation of SIRS were analyzed through analysis of variance and binary logistic regression.

RESULTS

The postoperative blood levels of WBC, CRP, TNF-α, and IL-6 on day 4 in the laparoscopy group were significantly lower than those in the control group (all Ps < .05). The differences in incidence rates of septicemia and peritoneal abscess between the CDP and control groups were not statistically significant ( P > .05). Nevertheless, the incision infection rate in the laparoscopy group was apparently lower than that in the control group (4.55% vs 19.04%, P = .047). Analysis of variance and binary logistic regression showed that the non-pneumoperitoneum, pathological type of appendicitis, and multidrug resistant infections were the 3 major risk factors for SIRS (the P values were .001, .019, and .012, respectively).

CONCLUSION

It was found that CDP is safe for BP and could be a potential protective factor to mitigate BP effectively, indicating that the performance of laparoscopy operation under CDP is feasible to control SIRS; at the same time, CDP would not raise the incidence rate of BT.

Intestinal permeability changes, systemic endotoxemia, inflammatory serum markers and sepsis after Whipple's operation for carcinoma of the pancreas head

POURPOSE

The aim was to evaluate the relationship between failure of gut barrier function, inflammatory markers and septic complications after pancreatoduodenectomy for pancreatic adenocarcinoma.

METHODOLOGY

44 patients were enrolled in this prospective observational clinical study and underwent curative open pancreatoduodenectomy for adenocarcinoma of the head of the pancreas. All patients underwent assessment of intestinal permeability using the lactulose/manitol excretions ratios (L/M ratio), endotoxemia, IL-1β, IL-6, CRP, and elastase levels before surgery and on postoperative days 1, 3 and 7. Septic complication was defined as a specific clinical condition related to infection by bacterium, virus, or fungus in a specific organ/compartment with positive culture.

RESULTS

Septic complications developed in 25% of patients. There were no significant differences in preoperative L/M ratio, endotoxine, CRP, IL-1β, IL-6, and elastase levels between sepsis-positive and sepsis-negative groups. All patients showed a significant increase in intestinal permeability, endotoxemia, IL-1, IL-6, CRP and elastase on the first postoperative day. At postoperative day 7, the sepsis-positive group continued to demonstrate an increase in intestinal permeability, endotoxemia and elastase; a significant difference was observed between the two groups (P = 0.02), whereas there was no significant difference in IL-1, IL-6, and CRP levels.

CONCLUSION

The pattern of change of intestinal permeability, systemic endotoxemia, and elastase concentration in the postoperative period is significantly higher in patients in whom sepsis develops, while the concentration of IL-1β, IL-6 and CRP do not permit to distinguish infection from inflammation.

Biological modeling of mucus to modulate mucus barriers

A recent study using a transgenic mouse, whose intestinal mucus contains a molecule made of 12 copies of a domain found in many gelling mucins, demonstrates that it is possible to strengthen mucus properties in situ, leading to promising new treatment strategies in diseases in which the mucosal barrier is impaired.