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Kastelijn JB, van de Pavert YL, Besselink MG, Fockens P, Voermans RP, van Wanrooij RLJ, de Wijkerslooth TR, Curvers WL, de Hingh IHJT, Bruno MJ, Koerkamp BG, Patijn GA, Poen AC, van Hooft JE, Inderson A, Mieog JSD, Poley JW, Bijlsma A, Lips DJ, Venneman NG, Verdonk RC, van Dullemen HM, Hoogwater FJH, Frederix GWJ, Molenaar IQ, Welsing PMJ, Moons LMG, van Santvoort HC, Vleggaar FP. Endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for palliation of malignant gastric outlet obstruction (ENDURO): study protocol for a randomized controlled trial. Trials 2023; 24:608. [PMID: 37749590 PMCID: PMC10518948 DOI: 10.1186/s13063-023-07522-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/17/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Malignant gastric outlet obstruction (GOO) is a debilitating condition that frequently occurs in patients with malignancies of the distal stomach and (peri)ampullary region. The standard palliative treatment for patients with a reasonable life expectancy and adequate performance status is a laparoscopic surgical gastrojejunostomy (SGJ). Recently, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) emerged as a promising alternative to the surgical approach. The present study aims to compare these treatment modalities in terms of efficacy, safety, and costs. METHODS The ENDURO-study is a multicentre, open-label, parallel-group randomized controlled trial. In total, ninety-six patients with gastric outlet obstruction caused by an irresectable or metastasized malignancy will be 1:1 randomized to either SGJ or EUS-GE. The primary endpoint is time to tolerate at least soft solids. The co-primary endpoint is the proportion of patients with persisting or recurring symptoms of gastric outlet obstruction for which a reintervention is required. Secondary endpoints are technical and clinical success, quality of life, gastroenterostomy dysfunction, reinterventions, time to reintervention, adverse events, quality of life, time to start chemotherapy, length of hospital stay, readmissions, weight, survival, and costs. DISCUSSION The ENDURO-study assesses whether EUS-GE, as compared to SGJ, results in a faster resumption of solid oral intake and is non-inferior regarding reinterventions for persistent or recurrent obstructive symptoms in patients with malignant GOO. This trial aims to guide future treatment strategies and to improve quality of life in a palliative setting. TRIAL REGISTRATION International Clinical Trials Registry Platform (ICTRP): NL9592. Registered on 07 July 2021.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yorick L van de Pavert
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Roy L J van Wanrooij
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Thomas R de Wijkerslooth
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Alderina Bijlsma
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frederik J H Hoogwater
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paco M J Welsing
- Division of Internal Medicine and Dermatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
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Kastelijn JB, Moons LMG, Kist JW, Prince JF, van Leeuwen MS, Koopman M, Vleggaar FP. Clinical Outcomes of Biliary Drainage in Patients with Malignant Biliary Obstruction Caused by Colorectal Cancer Metastases. J Gastrointest Cancer 2023; 54:564-573. [PMID: 35608755 PMCID: PMC10435637 DOI: 10.1007/s12029-022-00834-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Malignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC) that is challenging to solve. Biliary drainage can be performed to relieve symptoms of jaundice, treat cholangitis, or enable palliative systemic therapy. The aim of this study is to evaluate clinical outcomes of biliary drainage of malignant biliary obstruction in mCRC patients. METHODS Consecutive patients with malignant biliary obstruction due to mCRC who underwent endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography were included. Patient, disease, and procedural characteristics and outcomes were retrospectively collected from electronic medical records. Radiological data were prospectively reassessed. Main outcome was functional success, i.e. achievement of the intended goal of biliary drainage. Prognostic factors for functional success and survival were assessed. RESULTS Thirty-seven patients were included. Functional success was achieved in 18 (50%) patients. Seventeen (46%) patients experienced adverse events (suspected to be) related to the procedure. Median overall survival after biliary drainage was 61 days (IQR 31-113). No prognostic factors of functional success were identified. Performance status, presence of the primary tumor, ascites, ≥ 5 intrahepatic metastases, estimated hepatic invasion of > 50% and above-median levels of bilirubin and lactate dehydrogenase were significantly associated with poorer survival. Improved survival was seen in patients with technical, functional, or biochemical success, and with subsequent oncologic treatment. CONCLUSIONS Functional successful biliary drainage was achieved in half of the patients. Adverse events also occurred in nearly half of the patients. We observed a significantly longer survival in whom biliary drainage allowed palliative oncologic therapy.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jakob W Kist
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jip F Prince
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Kastelijn JB, Didden P, Bogte A, Moons LMG, Vleggaar FP. Digital single-operator cholangioscopy to guide selective cannulation of complex biliary strictures. Surg Endosc 2022; 36:9476-9480. [PMID: 36261641 PMCID: PMC9652227 DOI: 10.1007/s00464-022-09665-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Selective cannulation and stenting of complex, tight, and/or angulated biliary strictures under endoscopic retrograde cholangiopancreaticography (ERCP) can be challenging. Digital single-operator cholangioscopy (SOC) may facilitate guidewire advancement through the stricture with endoscopic visual guidance. We aimed to describe a case series on clinical outcomes of this technique for selective cannulation, when used after failed conventional ERCP attempts. METHODS Consecutive patients who underwent therapeutic digital SOC for selective cannulation of biliary strictures after failed conventional ERCP were retrospectively included. RESULTS Ten patients with a malignant (n = 6) or benign (n = 4) biliary stricture were included. Digital SOC-assisted selective guidewire insertion and stent placement across the biliary stricture were technically successful in five (50%) patients. Bilirubin levels improved in all patients with technical success. One (10%) patient developed a post-ERCP pancreatitis. CONCLUSIONS Technically successful cannulation of biliary strictures with digital SOC was achieved in half of patients in whom cannulation with conventional ERCP failed, sparing them more invasive interventions. Stricture opacification during the failed ERCP was seen in all technically successful SOCs.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
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Kastelijn JB, van der Loos MA, Welsing PM, Dhondt E, Koopman M, Moons LM, Vleggaar FP. Clinical outcomes of biliary drainage of malignant biliary obstruction due to colorectal cancer metastases: A systematic review. Eur J Intern Med 2021; 88:81-88. [PMID: 33931267 DOI: 10.1016/j.ejim.2021.03.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Malignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC). Biliary drainage is frequently performed to relieve symptoms of jaundice or enable palliative systemic therapy, but effective drainage can be difficult to accomplish. The aim of this study is to summarize literature on clinical outcomes of biliary drainage in mCRC patients with malignant biliary obstruction. METHODS We searched Medline and EMBASE for studies that included patients with malignant biliary obstruction secondary to mCRC, treated with endoscopic and/or percutaneous biliary drainage. We summarized available data on technical success, clinical success, adverse events, systemic therapy administration and survival after biliary drainage. RESULTS After screening 3584 references and assessing 509 full-text articles, seven cohort studies were included. In these studies, rates of technical success, clinical success and adverse events varied between 63%-94%, 42%-81%, and 19%-39%, respectively. Subsequent chemotherapy was administered in 17%-56% of patients. Overall survival varied between 40 and 122 days across studies (278-365 days in patients who received subsequent chemotherapy, 42-61 days in patients who did not). CONCLUSIONS Successful biliary drainage in mCRC patients can be challenging to achieve and is frequently associated with adverse events. Overall survival after biliary drainage is limited, but is significantly longer in patients treated with subsequent systemic therapy. Expected benefits of biliary drainage should be carefully weighed against its risks.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX 3584, the Netherlands
| | - Maria Atc van der Loos
- Department of Internal Medicine, Amsterdam University Medical Center, De Boelelaan 1117, Amsterdam, HV 1081, the Netherlands
| | - Paco Mj Welsing
- Division of Internal Medicine and Dermatology, Univeristy Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX 3584, the Netherlands
| | - Elisabeth Dhondt
- Department of Vascular and Interventional Radiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX 3584, the Netherlands
| | - Leon Mg Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX 3584, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX 3584, the Netherlands.
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Kastelijn JB, Moons LM, Vleggaar FP. Reply to McDonald and colleagues: "Can endoscopic ultrasound-guided gastroenterostomy be used as first line modality for endoscopic management of malignant gastric outlet obstruction?". Endosc Int Open 2021; 9:E425-E426. [PMID: 33656494 PMCID: PMC7895661 DOI: 10.1055/a-1339-1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Janine B. Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P. Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Kastelijn JB, Van der Voort V, Bijlsma A, Moons LMG, Schwartz MP, Vleggaar FP. Early Lumen-Apposing Metal Stent Dysfunction Complicating Endoscopic Ultrasound-Guided Gastroenterostomy: A Report of Two Cases. Clin Endosc 2021; 54:603-607. [PMID: 33434963 PMCID: PMC8357596 DOI: 10.5946/ce.2020.201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022] Open
Abstract
Endoscopic ultrasonography-guided gastroenterostomy using a lumen-apposing metal stent has emerged as a novel technique in the palliative treatment of malignant gastric outlet obstruction. Endoscopic ultrasonography-guided gastroenterostomy seems to have the potential to provide long-lasting patency in a minimally invasive manner. Low reintervention rates have been described. We report two cases with early lumen-apposing metal stent dysfunction, compromising patency. One case showed food impaction after three weeks, and hyperplastic tissue overgrowth with a buried distal flange six weeks after stent placement. The latter was successfully treated by argon plasma coagulation, stent removal, and deployment of a larger-diameter lumen-apposing metal stent. The second case showed a narrowed luminal diameter of the stent and jejunal pressure ulcerations after three weeks. The narrowing was successfully treated by balloon dilation. Eight weeks later, hyperplastic tissue overgrowth at the distal flange of the stent and a gastro-colonic fistula were diagnosed, followed by extensive reconstructive surgery.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Veronique Van der Voort
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Alderina Bijlsma
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Kastelijn JB, Moons LM, Garcia-Alonso FJ, Pérez-Miranda M, Masaryk V, Will U, Tarantino I, van Dullemen HM, Bijlsma R, Poley JW, Schwartz MP, Vleggaar FP. Patency of endoscopic ultrasound-guided gastroenterostomy in the treatment of malignant gastric outlet obstruction. Endosc Int Open 2020; 8:E1194-E1201. [PMID: 32904815 PMCID: PMC7458745 DOI: 10.1055/a-1214-5659] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) is a novel, minimally invasive technique in the palliative treatment of malignant gastric outlet obstruction (GOO). Several studies have demonstrated feasibility and safety of EUS-GE, but evidence on long-term durability is limited. The aim of this study was to evaluate patency of EUS-GE in treatment of malignant GOO. Patients and Methods An international multicenter study was performed in seven centers in four European countries. Patients who underwent EUS-GE with a LAMS between March 2015 and March 2019 for palliative treatment of symptomatic malignant GOO were included retrospectively. Our main outcome was recurrent obstruction due to LAMS dysfunction; other outcomes of interest were technical success, clinical success, adverse events (AEs), and survival. Results A total of 45 patients (mean age 69.9 ± 12.3 years and 48.9 % male) were included. Median duration of follow-up was 59 days (interquartile range [IQR] 41-128). Recurrent obstruction occurred in two patients (6.1 %), after 33 and 283 days of follow-up. Technical success was achieved in 39 patients (86.7 %). Clinical success was achieved in 33 patients (73.3 %). AEs occurred in 12 patients (26.7 %), of which five were fatal. Median overall survival was 57 days (IQR 32-114). Conclusions EUS-GE showed a low rate of recurrent obstruction. The relatively high number of fatal AEs underscores the importance of careful implementation of EUS-GE in clinical practice.
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Affiliation(s)
- Janine B. Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Manuel Pérez-Miranda
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Viliam Masaryk
- Department of Gastroenterology and General Internal Medicine, SRH Wald-Klinikum, Gera, Germany
| | - Uwe Will
- Department of Gastroenterology and General Internal Medicine, SRH Wald-Klinikum, Gera, Germany
| | - Ilaria Tarantino
- Gastroenterology and Endoscopy Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy
| | - Hendrik M. van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Rina Bijlsma
- Department of Gastroenterology and Hepatology, Martini Hospital Groningen, Groningen, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Matthijs P. Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Frank P. Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Zakharkina T, Martin-Loeches I, Matamoros S, Povoa P, Torres A, Kastelijn JB, Hofstra JJ, de Wever B, de Jong M, Schultz MJ, Sterk PJ, Artigas A, Bos LDJ. The dynamics of the pulmonary microbiome during mechanical ventilation in the intensive care unit and the association with occurrence of pneumonia. Thorax 2017; 72:803-810. [PMID: 28100714 DOI: 10.1136/thoraxjnl-2016-209158] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 12/07/2016] [Accepted: 12/10/2016] [Indexed: 11/03/2022]
Abstract
RATIONALE Ventilator-associated pneumonia (VAP) is the most common nosocomial infections in patients admitted to the ICU. The adapted island model predicts several changes in the respiratory microbiome during intubation and mechanical ventilation. OBJECTIVES We hypothesised that mechanical ventilation and antibiotic administration decrease the diversity of the respiratory microbiome and that these changes are more profound in patients who develop VAP. METHODS Intubated and mechanically ventilated ICU-patients were included. Tracheal aspirates were obtained three times a week. 16S rRNA gene sequencing with the Roche 454 platform was used to measure the composition of the respiratory microbiome. Associations were tested with linear mixed model analysis and principal coordinate analysis. MEASUREMENTS AND MAIN RESULTS 111 tracheal aspirates were obtained from 35 patients; 11 had VAP, 18 did not have VAP. Six additional patients developed pneumonia within the first 48 hours after intubation. Duration of mechanical ventilation was associated with a decrease in α diversity (Shannon index; fixed-effect regression coefficient (β): -0.03 (95% CI -0.05 to -0.005)), but the administration of antibiotic therapy was not (fixed-effect β: 0.06; 95% CI -0.17 to 0.30). There was a significant difference in change of β diversity between patients who developed VAP and control patients for Bray-Curtis distances (p=0.03) and for Manhattan distances (p=0.04). Burkholderia, Bacillales and, to a lesser extent, Pseudomonadales positively correlated with the change in β diversity. CONCLUSION Mechanical ventilation, but not antibiotic administration, was associated with changes in the respiratory microbiome. Dysbiosis of microbial communities in the respiratory tract was most profound in patients who developed VAP.
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Affiliation(s)
| | | | | | - Pedro Povoa
- Intensive Care, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic i Provincial, Barcelona, Spain
| | | | - Jorrit J Hofstra
- Clinical Microbiology, Academic Medical Center, Amsterdam, Netherlands
| | - B de Wever
- Clinical Microbiology, Academic Medical Center, Amsterdam, Netherlands
| | - Menno de Jong
- Department of Microbiology, Academic Medical Center, Amsterdam, Netherlands
| | | | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Antonio Artigas
- Critical Care Centre, Corporació Sanitària I Universitaria Parc Taulí-Hospital De Sabadell-Ciber Enfermedades Respiratorias, Sabadell, Spain
| | - Lieuwe D J Bos
- Intensive Care, Academic Medical Center, Amsterdam, Netherlands.,Department of Respiratory Medicine, Academic Medical Center, Amsterdam, Netherlands
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Bos LDJ, Martin-Loeches I, Kastelijn JB, Gili G, Espasa M, Povoa P, Kolk AHJ, Janssen HG, Sterk PJ, Artigas A, Schultz MJ. The volatile metabolic fingerprint of ventilator-associated pneumonia. Intensive Care Med 2014; 40:761-2. [DOI: 10.1007/s00134-014-3260-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2014] [Indexed: 11/25/2022]
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