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Smith HG, Nilsson PJ, Shogan BD, Harji D, Gambacorta MA, Romano A, Brandl A, Qvortrup C. Neoadjuvant treatment of colorectal cancer: comprehensive review. BJS Open 2024; 8:zrae038. [PMID: 38747103 PMCID: PMC11094476 DOI: 10.1093/bjsopen/zrae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Neoadjuvant therapy has an established role in the treatment of patients with colorectal cancer. However, its role continues to evolve due to both advances in the available treatment modalities, and refinements in the indications for neoadjuvant treatment and subsequent surgery. METHODS A narrative review of the most recent relevant literature was conducted. RESULTS Short-course radiotherapy and long-course chemoradiotherapy have an established role in improving local but not systemic disease control in patients with rectal cancer. Total neoadjuvant therapy offers advantages over short-course radiotherapy and long-course chemoradiotherapy, not only in terms of increased local response but also in reducing the risk of systemic relapses. Non-operative management is increasingly preferred to surgery in patients with rectal cancer and clinical complete responses but is still associated with some negative impacts on functional outcomes. Neoadjuvant chemotherapy may be of some benefit in patients with locally advanced colon cancer with proficient mismatch repair, although patient selection is a major challenge. Neoadjuvant immunotherapy in patients with deficient mismatch repair cancers in the colon or rectum is altering the treatment paradigm for these patients. CONCLUSION Neoadjuvant treatments for patients with colon or rectal cancers continue to evolve, increasing the complexity of decision-making for patients and clinicians alike. This review describes the current guidance and most recent developments.
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Affiliation(s)
- Henry G Smith
- Abdominalcenter K, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Dept. of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Benjamin D Shogan
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Deena Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Dipartimento di Scienze Radiologiche ed Ematologiche, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Angela Romano
- Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Andreas Brandl
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Camilla Qvortrup
- Department of Oncology, Rigshospital, University of Copenhagen, Copenhagen, Denmark
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Vierra M, Rouhani Ravari M, Soleymani Sardoo F, Shogan BD. Tailored Pre-Operative Antibiotic Prophylaxis to Prevent Post-Operative Surgical Site Infections in General Surgery. Antibiotics (Basel) 2024; 13:99. [PMID: 38275328 PMCID: PMC10812803 DOI: 10.3390/antibiotics13010099] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
The average American today undergoes three inpatient and two outpatient surgical procedures during one's life, each of which carries with it a risk of post-operative infection. It has long been known that post-operative infections cause significant morbidity in the immediate peri-operative period, but recent evidence suggests that they can have long-term consequences as well, increasing a patient's risk of infectious complications in unrelated surgeries performed months or even years later. While there are several theories on the origin of this association, including bacterial colonization of a post-operative infectious wound site, antimicrobial resistance from curative courses of antibiotics, subclinical immunosuppression, or the creation of an inflammatory "pathobiome" following an infectious insult, it is ultimately still unclear why patients who experience a single post-operative infection seem to be at a significantly higher risk of experiencing subsequent ones. Regardless, this association has significant implications for the routine use of pre-operative antibiotic prophylaxis. Indeed, while the prescription of antibiotics pre-operatively has dramatically reduced the rate of post-operative infections, the chosen prophylaxis regimens are typically standardized according to national guidelines, are facing increasing antimicrobial resistance patterns, and have been unable to reduce the risk of post-operative infection to acceptably low levels for certain surgeries. As a result, some clinicians have speculated that tailoring pre-operative antibiotic prophylaxis according to a patient's prior infectious and operative history could improve efficacy and further reduce the rate of post-operative infections. The purpose of this review is to describe the evidence for the link between multiple post-operative infections and explore the efficacy of individualized pre-operative prophylaxis.
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Affiliation(s)
- Mason Vierra
- Pritzker School of Medicine, The University of Chicago, Chicago, IL 60637, USA;
| | - Mohsen Rouhani Ravari
- Department of Surgery, The University of Chicago Medicine, Chicago, IL 60637, USA; (M.R.R.); (F.S.S.)
| | - Fatemeh Soleymani Sardoo
- Department of Surgery, The University of Chicago Medicine, Chicago, IL 60637, USA; (M.R.R.); (F.S.S.)
| | - Benjamin D. Shogan
- Department of Surgery, The University of Chicago Medicine, Chicago, IL 60637, USA; (M.R.R.); (F.S.S.)
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Vigneswaran J, Keskey RC, Morgan RB, Alverdy JC, Alpert L, Chang E, Weichselbaum R, Zaborina O, Shogan BD. Western Diet-induced Transcriptional Changes in Anastomotic Tissue Is Associated With Early Local Recurrence in a Mouse Model of Colorectal Surgery. Ann Surg 2023; 278:954-960. [PMID: 37522222 PMCID: PMC10775465 DOI: 10.1097/sla.0000000000006052] [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] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To determine the timeframe and associated changes in the microenvironment that promote the development of a diet-induced local-regional recurrence in a mouse model of colorectal surgery. BACKGROUND Postoperative recurrence and metastasis occur in up to 30% of patients undergoing attempted resection for colorectal cancer (CRC). The underlying mechanisms that drive the development of postoperative recurrences are poorly understood. Preclinical studies have demonstrated a diet and microbial-driven pathogenesis of local-regional recurrence, yet the precise mechanisms remain undefined. METHODS BALB/C mice were fed a western diet (WD) or standard diet (SD), underwent a colon resection and anastomosis, given an Enterococcus faecalis enema on postoperative day (POD) 1, and subjected to a CT26 cancer cell enema (mimicking shed cancer cells) on POD2. Mice were sacrificed between POD3 and POD7 and cancer cell migration was tracked. Dynamic changes in gene expression of anastomotic tissue that were associated with cancer cell migration was assessed. RESULTS Tumor cells were identified in mice fed either a SD or WD in both anastomotic and lymphatic tissue as early as on POD3. Histology demonstrated that these tumor cells were viable and replicating. In WD-fed mice, the number of tumor cells increased over the early perioperative period and was significantly higher than in mice fed a SD. Microarray analysis of anastomotic tissue found that WD-fed mice had 11 dysregulated genes associated with tumorigenesis. CONCLUSIONS A WD promotes cancer cells to permeate a healing anastomosis and migrate into anastomotic and lymphatic tissue forming viable tumor nodules. These data offer a novel recurrence pathogenesis by which the intestinal microenvironment promotes a CRC local-regional recurrence.
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Affiliation(s)
- Janani Vigneswaran
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Robert C. Keskey
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Ryan B. Morgan
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, United States
| | - John C. Alverdy
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Lindsay Alpert
- The University of Chicago Medicine, Department of Pathology, Chicago, Illinois, United States
| | - Eugene Chang
- The University of Chicago Medicine, Department of Medicine, Chicago, Illinois, United States
| | - Ralph Weichselbaum
- The University of Chicago Medicine, Department of Radiation and Cellular Oncology, Chicago, Illinois, United States
| | - Olga Zaborina
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Benjamin D. Shogan
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, United States
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Godley FA, Shogan BD, Hyman NH. Role of the Microbiome in Malignancy. Surg Infect (Larchmt) 2023; 24:271-275. [PMID: 37010971 PMCID: PMC10771884 DOI: 10.1089/sur.2023.028] [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] [Indexed: 04/04/2023] Open
Abstract
The conceptual underpinning of carcinogenesis has been strongly influenced by an expanded understanding of the human microbiome. Malignancy risks in diverse organs have been uniquely tied to aspects of the resident microbiota in different organs and systems including the colon, lungs, pancreas, ovaries, uterine cervix, and stomach; other organs are increasingly linked to maladaptive aspects of the microbiome as well. In this way, the maladaptive microbiome may be termed an oncobiome. Microbe-driven inflammation, anti-inflammation, and mucosal protection failure, as well as diet-induced microbiome derangement are all mechanisms that influence malignancy risk. Therefore, they also offer potential avenues of diagnostic and therapeutic intervention to modify malignancy risk, and to perhaps interrupt progression toward cancer in different sites. Each of these mechanisms will be explored using colorectal malignancy as a prototype condition to demonstrate the microbiome's role in carcinogenesis.
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Affiliation(s)
- Frederick A. Godley
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Benjamin D. Shogan
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Neil H. Hyman
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
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Affiliation(s)
- Benjamin D. Shogan
- Section of Colon & Rectal, Department of Surgery, The University of Chicago, Chicago, Illinois
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Rubio GA, Shogan BD, Umanskiy K, Hurst RD, Hyman N, Olortegui KS. Simple Diverting Colostomy for Sacral Pressure Ulcers: Not So Simple After All. J Gastrointest Surg 2023; 27:382-389. [PMID: 36400903 DOI: 10.1007/s11605-022-05522-7] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/19/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgeons are often asked to provide a diverting colostomy to enable healing or simplify management of sacral pressure ulcers. However, little evidence exists regarding the safety of a diversion in this often compromised patient population. We hypothesized that malnourished patients with sacral pressure ulcers have poor outcomes with fecal diversion. METHODS ACS-NSQIP (2012-2018) was used to identify patients who underwent elective diverting colostomy for sacral pressure ulcers. Demographics, comorbidities, and perioperative details were recorded. Postoperative complications and 30-day mortality were compared between patients with moderate/severe hypoalbuminemia (< 2.5 g/dL) vs those with albumin > 2.5 g/dL. RESULTS We identified a total of 863 patients who underwent elective diverting colostomy for sacral pressure ulcer. Mean age was 57.5 years old. Rate of associated comorbidities was high, with most patients classified as ASA class 3 or 4. Over 40% of patients had a preoperative albumin level < 2.5 g/dL. Thirty-day overall postoperative mortality was 6.7%. This was significantly higher in patients with hypoalbuminemia (11.4% vs. 3.5%, p < 0.001). On multivariable regression analysis, preoperative albumin < 2.5 g/dL was independently associated with mortality (OR 1.92, p = 0.039). Other factors associated with mortality included increased age (OR 1.04 per year, p < 0.001), preoperative sepsis (OR 1.66, p = 0.003), and Black race (OR 2.2, p = 0.01). CONCLUSIONS Diverting colostomy performed for patients with sacral pressure ulcers is associated with a substantial risk of postoperative death. Surgeons should carefully consider risks of diversion in this patient population, especially in malnourished patients with hypoalbuminemia.
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Affiliation(s)
- Gustavo A Rubio
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, S217, Chicago, IL, 60637, USA
| | - Benjamin D Shogan
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, S217, Chicago, IL, 60637, USA
| | - Konstantin Umanskiy
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, S217, Chicago, IL, 60637, USA
| | - Roger D Hurst
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, S217, Chicago, IL, 60637, USA
| | - Neil Hyman
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, S217, Chicago, IL, 60637, USA
| | - Kinga Skowron Olortegui
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, S217, Chicago, IL, 60637, USA.
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Arshad M, Al-Hallaq H, Polite BN, Shogan BD, Hyman N, Liauw SL. ASO Visual Abstract: Intraoperative Radiation Therapy for Colorectal or Anal Cancer at Risk for Margin-Positive Resection: Initial Results of a Single-Institution Registry. Ann Surg Oncol 2023; 30:333-334. [PMID: 36224512 DOI: 10.1245/s10434-022-12654-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Muzamil Arshad
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, IL, USA
| | - Hania Al-Hallaq
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, IL, USA
| | - Blase N Polite
- Department of Hematology and Oncology, The University of Chicago Medicine, Chicago, IL, USA
| | - Benjamin D Shogan
- Section of Colon and Rectal Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Neil Hyman
- Section of Colon and Rectal Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, IL, USA.
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Arshad M, Al-Hallaq H, Polite BN, Shogan BD, Hyman N, Liauw SL. Intra-operative Radiation Therapy for Colorectal or Anal Cancer at Risk for Margin-Positive Resection: Initial Results of a Single-Institution Registry. Ann Surg Oncol 2023; 30:325-332. [PMID: 36255512 DOI: 10.1245/s10434-022-12564-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Pelvic recurrence of rectal or anal cancers is associated with considerable morbidity and mortality. We report our initial experience with an aggressive intra-operative radiotherapy (IORT) program. METHODS Patients with locally advanced or recurrent rectal or anal cancers considered to have a high likelihood of R1 or R2 resection after multi-disciplinary review underwent surgical excision and IORT using a high-dose-rate afterloader (Ir-192) and HAM applicator. Endpoints included local or distant recurrence, and acute and late toxicity graded using the American College of Surgeons (ACS) NSQIP and the LENT-SOMA scale. RESULTS Twenty-one patients, largely with prior history of both pelvic external beam radiotherapy (EBRT, median 50.4 Gy) and surgical resection, underwent excision with IORT (median dose 12.5 Gy, range 10-15). Median follow-up was 20 months. Twelve (57%) patients had failure at the IORT site. Freedom from failure (FFF) within the IORT field was associated with resection status (FFF at 1 year 75% for R0 vs 15% for R1/2, p = 0.0065) but not re-irradiation EBRT or IORT dose (p > 0.05). Twelve, 5, and 13 patients experienced local, regional, and distant failure, respectively; 3 (14%) patients were disease-free at last follow-up. The most frequent acute toxicity was sepsis/abscess (24%). One patient (5%) required a ureteral stent; no patients developed neuropathy attributable to IORT. CONCLUSIONS In patients treated with excision and IORT for locally recurrent cancer, R0 resection is a critical determinant of local control. For patients with R1/2 resection, poor disease-free outcomes warrant consideration of a different treatment strategy.
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Affiliation(s)
- Muzamil Arshad
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, IL, USA
| | - Hania Al-Hallaq
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, IL, USA
| | - Blase N Polite
- Department of Hematology and Oncology, The University of Chicago Medicine, Chicago, IL, USA
| | - Benjamin D Shogan
- Section of Colon and Rectal Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Neil Hyman
- Section of Colon and Rectal Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, IL, USA.
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Runde J, Erondu A, Akiyama S, Traboulsi C, Rai V, Glick LR, Yi Y, Ollech JE, Cohen RD, Skowron KB, Hurst RD, Umanskiy K, Shogan BD, Hyman NH, Rubin MA, Dalal SR, Sakuraba A, Pekow J, Chang EB, Rubin DT. Outcomes of Ileoanal Pouch Anastomosis in Pediatric Ulcerative Colitis Are Worse in the Modern Era: A Time Trend Analysis Outcomes Following Ileal Pouch-Anal Anastomosis in Pediatric Ulcerative Colitis. Inflamm Bowel Dis 2022; 28:1386-1394. [PMID: 35040964 PMCID: PMC9434476 DOI: 10.1093/ibd/izab319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Despite significant differences in surgical outcomes between pediatric and adult patients with ulcerative colitis (UC) undergoing colectomy, counseling on pediatric outcomes has largely been guided by data from adults. We compared differences in pouch survival between pediatric and adult patients who underwent total proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS This was a retrospective single-center study of patients with UC treated with IPAA who subsequently underwent pouchoscopy between 1980 and 2019. Data were collected via electronic medical records. We stratified the study population based on age at IPAA. Differences between groups were assessed using t tests and chi-square tests. Kaplan-Meier curves were used to compare survival probabilities. Differences between groups were assessed using a log-rank test. RESULTS We identified 53 patients with UC who underwent IPAA before 19 years of age and 329 patients with UC who underwent IPAA at or after 19 years of age. Subjects who underwent IPAA as children were more likely to require anti-tumor nerosis factor (TNF) postcolectomy compared with adults (41.5% vs 25.8%; P < .05). Kaplan-Meier estimates revealed that pediatric patients who underwent IPAA in the last 10 years had a 5-year pouch survival probability that was 28% lower than that of those who underwent surgery in the 1990s or 2000s (72% vs 100%; P < .001). Further, children who underwent IPAA and received anti-TNF therapies precolectomy had the most rapid progression to pouch failure when compared with anti-TNF-naive children and with adults who were either exposed or naive precolectomy (P < .05). CONCLUSIONS There are lower rates of pouch survival for children with UC who underwent IPAA following the uptake of anti-TNF therapy compared with both historical pediatric control subjects and contemporary adults.
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Affiliation(s)
- Joseph Runde
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Comer Children’s Hospital, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Amarachi Erondu
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Shintaro Akiyama
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Laura R Glick
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Yangtian Yi
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Jacob E Ollech
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Kinga B Skowron
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Roger D Hurst
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Konstatin Umanskiy
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Benjamin D Shogan
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Neil H Hyman
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Michele A Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sushila R Dalal
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Atsushi Sakuraba
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Eugene B Chang
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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13
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Akiyama S, Ollech JE, Traboulsi C, Rai V, Glick LR, Yi Y, Runde J, Olivas AD, Weber CR, Cohen RD, Olortegui KBS, Hurst RD, Umanskiy K, Shogan BD, Rubin MA, Dalal SR, Sakuraba A, Pekow J, Chang EB, Hart J, Hyman NH, Rubin DT. Histopathology of Colectomy Specimens Predicts Endoscopic Pouch Phenotype in Patients with Ulcerative Colitis. Dig Dis Sci 2022; 67:4020-4031. [PMID: 35288827 PMCID: PMC10966959 DOI: 10.1007/s10620-022-07405-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/29/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The endoscopic appearance in patients with "pouchitis" after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be quite heterogenous. Patients with an endoscopic phenotype resembling Crohn's disease (CD) are at high risk of pouch loss. AIMS We aimed to assess how the histopathology of colectomy specimens predicts endoscopic pouch phenotypes in UC. METHODS We retrospectively assessed pouchoscopies from patients with UC who underwent IPAA and classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted ≥ 6 months from ileostomy takedown. We assessed the clinical and pathological data including deep, focal inflammation, granulomas, and terminal ileal involvement in the colectomy specimens. Logistic regression analysis was performed to identify contributing factors to each phenotype. RESULTS This study included 1,203 pouchoscopies from 382 patients with UC. On multivariable analysis, deep inflammation was significantly associated with pouch fistulas (Odds ratio 3.27; 95% confidence interval 1.65-6.47; P = 0.0007). Of the 75 patients with deep inflammation, only two patients (2.7%) were diagnosed with CD based on pathology review. Terminal ileal involvement significantly increased the risk of afferent limb involvement (Odds ratio 2.96; 95% confidence interval 1.04-8.47; P = 0.04). There were no significant associations between other microscopic features and phenotypes. CONCLUSIONS We identify histologic features of colectomy specimens in UC that predict subsequent pouch phenotypes. Particularly, deep inflammation in the resected colon was significantly associated with pouch fistulas, a pouch phenotype with poor prognosis.
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Affiliation(s)
- Shintaro Akiyama
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Jacob E Ollech
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Laura R Glick
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Yangtian Yi
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Joseph Runde
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Andrea D Olivas
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Christopher R Weber
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Kinga B Skowron Olortegui
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Roger D Hurst
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Konstantin Umanskiy
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Benjamin D Shogan
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Michele A Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Sushila R Dalal
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Atsushi Sakuraba
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Eugene B Chang
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - John Hart
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Neil H Hyman
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
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14
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Williamson AJ, Jacobson R, van Praagh J, Gaines S, Koo HY, Lee B, Chan WC, Weichselbaum R, Alverdy JC, Zaborina O, Shogan BD. Enterococcus faecalis promotes a migratory and invasive phenotype in colon cancer cells. Neoplasia 2022; 27:100787. [PMID: 35366466 PMCID: PMC8971311 DOI: 10.1016/j.neo.2022.100787] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 02/05/2023] Open
Abstract
Much about the role of intestinal microbes at the site of colon cancer development and tumor progression following curative resection remains to be understood. We have recently shown that collagenolytic bacteria such as Enterococcus faecalis predominate within the colon postoperatively, particularly at the site of the colon reconnection (i.e. anastomosis) in the early period of post-surgical recovery. The presence of collagenolytic bacteria at this site correlates with the tumor progression in a mouse model of post-surgical tumor development. In the present study we hypothesized, that collagenolytic bacteria, such as E. faecalis, play an important yet to be discovered role in tumor formation and progression. Therefore the aims of this study were to assess the role of collagenolytic E. faecalis on the migration and invasion of a murine colon cancer cell line. Results demonstrated that both migration and invasion were induced by E. faecalis with collagenolytic activity being required for only invasion. Bidirectional signaling in the E. faecalis-cancer cell interaction was observed by the discovering that the expression of gelE in E. faecalis, the gene required for collagenase production, is expressed in response to exposure to CT26 cells. The mechanism by which migration enhancement via E. faecalis occurs appears to be dependent on its ability to activate pro-uPA, a key element of the urokinase-plasminogen system, a pathway that is well - known to be important in cancer cell invasion and migration. Finally, we demonstrated that collagenase producing microbes preferentially colonize human colon cancer specimens.
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Affiliation(s)
- Ashley J. Williamson
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - Rick Jacobson
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - J.B. van Praagh
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - Sara Gaines
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - Hyun Y. Koo
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - Brandon Lee
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - Wen-Ching Chan
- The University of Chicago, Center for Research Informatics, Chicago, IL, United States
| | - Ralph Weichselbaum
- The University of Chicago Medicine, Department of Radiation and Cellular Oncology, Chicago, IL, United States
| | - John C. Alverdy
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - Olga Zaborina
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States
| | - Benjamin D. Shogan
- The University of Chicago Medicine, Department of Surgery, Chicago, IL, United States,Corresponding author at: University of Chicago, Room J557F, MC 5095, Chicago, IL 60637, United States.
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15
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Liauw SL, Son CH, Shergill A, Shogan BD. Circulating tumor-tissue modified HPV DNA analysis for molecular disease monitoring after chemoradiation for anal squamous cell carcinoma: a case report. J Gastrointest Oncol 2021; 12:3155-3162. [PMID: 35070439 PMCID: PMC8748062 DOI: 10.21037/jgo-21-300] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/29/2021] [Indexed: 07/30/2023] Open
Abstract
Squamous cell carcinoma (SCC) of the anus typically arises after human papillomavirus (HPV) infection. We report on the use of molecular disease monitoring using a novel blood test measuring circulating tumor-tissue -modified HPV DNA in two patients with anal cancer. Two patients with anal SCC received concurrent chemotherapy and radiation therapy (chemoRT) with curative intent, one with a T2N0 anal margin squamous cell carcinoma with a history of AIDS, and one with a T3N0 anal squamous cell carcinoma and a history of concurrent prostate cancer. HPV genotyping at diagnosis confirmed the presence of HPV16 DNA in both cases. Circulating, tumor-tissue-modified HPV DNA (TTMV-HPV DNA) was measured in the peripheral blood utilizing digital PCR at baseline and in follow-up. Disease burden was assessed post-treatment with standard anoscopy, biopsy, and PET/CT. Plasma TTMV-HPV DNA levels were elevated at diagnosis, and decreased during and after chemoRT completion in both cases. During post treatment surveillance, TTMV-HPV DNA levels correlated with disease status including one case with progressive local recurrence within 2 months, and one case with 12 months of local control both confirmed by biopsy. These case studies present the first use of circulating tumor-tissue-modified HPV DNA as a biomarker for anal cancer. Further study of this blood test an adjunct to standard treatment and monitoring is warranted in HPV-positive anal cancer.
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Affiliation(s)
- Stanley L. Liauw
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Christina H. Son
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
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16
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Brajcich BC, Benson AB, Gantt G, Eng OS, Marsh RW, Mulcahy MF, Polite BN, Shogan BD, Yang AD, Merkow RP. Management of colorectal cancer during the COVID-19 pandemic: Recommendations from a statewide multidisciplinary cancer collaborative. J Surg Oncol 2021; 125:560-563. [PMID: 34820843 PMCID: PMC9015333 DOI: 10.1002/jso.26758] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/13/2021] [Indexed: 11/09/2022]
Abstract
COVID‐19 has resulted in significant disruptions in cancer care. The Illinois Cancer Collaborative (ILCC), a statewide multidisciplinary cancer collaborative, has developed expert recommendations for triage and management of colorectal cancer when disruptions occur in usual care. Such recommendations would be applicable to future outbreaks of COVID‐19 or other large‐scale disruptions in cancer care.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gerald Gantt
- Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Oliver S Eng
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Robert W Marsh
- Department of Medical Oncology, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois, USA
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Blase N Polite
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
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17
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Yamada A, Komaki Y, Komaki F, Haider H, Micic D, Pekow J, Dalal S, Cohen RD, Cannon L, Umanskiy K, Smith R, Shogan BD, Hurst R, Hyman N, Rubin DT, Sakuraba A. The Correlation between Vitamin D Levels and the Risk of Postoperative Recurrence in Crohn's Disease. Digestion 2021; 102:767-775. [PMID: 33556932 DOI: 10.1159/000513589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/04/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Vitamin D deficiency has been associated with disease activity in Crohn's disease (CD). We assessed whether there is a correlation between vitamin D levels and the risk of postoperative recurrence in CD. METHODS CD patients who underwent surgery were identified from a prospectively maintained database at the University of Chicago. The primary endpoint was the correlation of serum 25-hydroxy vitamin D levels measured at 6-12 months after surgery and the proportion of patients in endoscopic remission, defined as a simple endoscopic score for CD of 0. Clinical, biological (C-reactive protein), and histologic recurrences were also studied. RESULTS Among a total of 89 patients, 17, 46, and 26 patients had vitamin D levels of <15, 15-30, and >30 ng/mL, respectively. Patients with higher vitamin D levels were significantly more likely to be in endoscopic remission compared to those with lower levels (23, 42, and 67% in ascending tertile order; p = 0.028). On multivariate analysis, vitamin D >30 ng/mL (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.07-0.66, p = 0.006) and anti-tumor necrosis factor agent treatment (OR 0.25, 95% CI 0.08-0.83, p = 0.01) were associated with reduced risk of endoscopic recurrence. Rates of clinical, biological, and histologic remission trended to be higher in patients with higher vitamin D levels (p = 0.17, 0.55, 0.062, respectively). CONCLUSION In the present study, higher vitamin D level was associated with lower risk of postoperative endoscopic CD recurrence. Further, studies are warranted to assess the role of vitamin D in postoperative CD recurrence.
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Affiliation(s)
- Akihiro Yamada
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Section of Gastroenterology, Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Yuga Komaki
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Fukiko Komaki
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Haider Haider
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Dejan Micic
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sushila Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Lisa Cannon
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Konstantin Umanskiy
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Radhika Smith
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Benjamin D Shogan
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Roger Hurst
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Neil Hyman
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA,
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18
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Zhang LM, Schuitevoerder D, White MG, Feldt S, Krishnan P, Hyman N, Shogan BD. Combined mechanical and oral antibiotic bowel preparation is associated with prolonged recurrence-free survival following surgery for colorectal cancer. J Surg Oncol 2021; 124:1106-1114. [PMID: 34310702 DOI: 10.1002/jso.26619] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/26/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent studies suggest that bacteria influence the pathogenesis of primary colorectal cancer (CRC), yet their role in recurrence after resection is largely unknown. We have discovered that collagenase-producing bacteria promote cancer recurrence in mice, and that antibiotic bowel decontamination decreases colonization of these same organisms in humans. We hypothesized that preoperative combined mechanical and oral antibiotic bowel preparation would improve disease-free survival (DFS) in patients undergoing surgery for CRC. METHODS We reviewed a cancer registry of patients treated for CRC at a tertiary center. Patients who received bowel preparation were compared to those that did not via a 1:1-propensity score matched for follow-up, age, sex, BMI, stage, location, chemoradiation, infection, anastomotic leak, and blood transfusion. RESULTS One thousand two hundred and seventy-nine patients met inclusion criteria. Following propensity score matching, 264 patients receiving bowel prep were matched to 264 patients who did not. Kaplan-Meier estimates showed that patients who received bowel prep had a significantly improved 5-year DFS compared to those that did not (76.3% vs. 64.2%; p < .01). Cox regression demonstrated that bowel prep was associated with improved DFS (HR, 0.57; 95% CI, 0.37-0.89; p < .01). CONCLUSION Combined mechanical and oral antibiotic bowel preparation is independently associated with improved recurrence-free survival in patients undergoing surgery for CRC.
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Affiliation(s)
- Lindsey M Zhang
- Division of Colon and Rectal Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Michael G White
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan Feldt
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Pranav Krishnan
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Neil Hyman
- Division of Colon and Rectal Surgery, University of Chicago, Chicago, Illinois, USA
| | - Benjamin D Shogan
- Division of Colon and Rectal Surgery, University of Chicago, Chicago, Illinois, USA
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19
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Anderson DI, Keskey R, Ackerman MT, Zaborina O, Hyman N, Alverdy JC, Shogan BD. Enterococcus faecalis Is Associated with Anastomotic Leak in Patients Undergoing Colorectal Surgery. Surg Infect (Larchmt) 2021; 22:1047-1051. [PMID: 34255574 DOI: 10.1089/sur.2021.147] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Anastomotic leak is among the most dreaded complications in patients undergoing colorectal surgery. We have discovered that in rodents, collagenase-producing bacteria, particularly Enterococcus faecalis, promotes anastomotic leak by degrading healing anastomotic tissue. Yet, it is unclear if these organisms play a role in humans. Patients and Methods: Patients undergoing colorectal resection at the University of Chicago from July 2014 through June 2019 who developed a post-operative infection were stratified into infections that resulted from an anastomotic leak, a Hartmann pouch stump leak, or a deep infection without an associated staple line leak. Results: Forty-two patients had available culture data. Of these patients, 19 were found to have an anastomotic leak, 7 had a stump leak, and 16 had a deep infection that was not associated with a staple line. Enterococcus faecalis was identified in 24% of all infections and was associated with the development of anastomotic leak (p = 0.029). When the organisms were classified into their known ability to produce collagenase, 74% of patients with an anastomotic leak were colonized with collagenase-producing organisms, compared with only 28% of patients with a deep infection or stump leak (p = 0.022). Antibiotic-resistant organisms were more common in patients with anastomotic leak (p = 0.01). Conclusions: Collagenase-producing and antibiotic-resistant organisms are more prevalent in anastomotic leak infections compared with other deep or organ/space infections. This lends evidence to a bacterial driven pathogenesis of leak and suggests that targeting these organisms may be a novel strategy to reduce this complication.
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Affiliation(s)
- Dana I Anderson
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Robert Keskey
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, USA
| | - Max T Ackerman
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Olga Zaborina
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, USA
| | - Neil Hyman
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, USA
| | - John C Alverdy
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, USA
| | - Benjamin D Shogan
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois, USA
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20
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Miller MO, Kashyap PC, Becker SL, Thomas RM, Hodin RA, Miller G, Hundeyin M, Pushalkar S, Cohen D, Saxena D, Shogan BD, Morris-Stiff GJ. SSAT State-of-the-Art Conference: Advancements in the Microbiome. J Gastrointest Surg 2021; 25:1885-1895. [PMID: 32989690 DOI: 10.1007/s11605-020-04551-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The microbiome plays a major role in human physiology by influencing obesity, inducing inflammation, and impacting cancer therapies. During the 60th Annual Meeting of the Society of the Alimentary Tract (SSAT) at the State-of-the-Art Conference, experts in the field discussed the influence of the microbiome. This paper is a summary of the influence of the microbiome on obesity, inflammatory bowel disease, pancreatic cancer, cancer therapies, and gastrointestinal optimization. This review shows how the microbiome plays an important role in the development of diseases and surgical complications. Future studies are needed in targeting the gut microbiome to develop individualized therapies.
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Affiliation(s)
- Miquell O Miller
- Department of General Surgery, Stanford University, 300 Pasteur Dr, Stanford, CA, 94305, USA.
| | - Purna C Kashyap
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Sarah L Becker
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Ryan M Thomas
- Departments of Surgery, Molecular Genetics and Microbiology, University of Florida, Gainesville, FL, 32610, USA
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - George Miller
- Departments of Surgery and Cell Biology, New York University School of Medicine, New York, NY, 10016, USA
| | - Mautin Hundeyin
- Departments of Surgery and Cell Biology, New York University School of Medicine, New York, NY, 10016, USA
| | - Smruti Pushalkar
- Department of Medicine, New York University School of Medicine, New York, NY, 10016, USA
| | - Deirdre Cohen
- Department of Basic Science and Craniofacial Biology, New York University College of Dentistry, New York, NY, 10010, USA
| | - Deepak Saxena
- Department of Basic Science and Craniofacial Biology, New York University College of Dentistry, New York, NY, 10010, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago, Chicago, IL, 60637, USA
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21
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Gaines S, Hyoju S, Williamson AJ, van Praagh JB, Zaborina O, Rubin DT, Alverdy JC, Shogan BD, Hyman N. Infliximab Does Not Promote the Presence of Collagenolytic Bacteria in a Mouse Model of Colorectal Anastomosis. J Gastrointest Surg 2020; 24:2637-2642. [PMID: 31898107 PMCID: PMC7931774 DOI: 10.1007/s11605-019-04486-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous work from our group has suggested a pivotal role for collagenolytic bacteria in the development of anastomotic complications. Tumor necrosis factor antagonists are a mainstay of treatment for patients with inflammatory bowel disease. The reported impact of these agents on key surgical outcomes such as anastomotic leak has been inconsistent. The objective of this study is to assess the impact of infliximab on the anastomotic microbiome in a mouse model of colon resection. DESIGN BALB/c mice underwent colon resection with primary anastomosis. Mice were randomly assigned to receive either an intraperitoneal dose of saline (control) or 10 mg/kg of infliximab for 8 weeks prior to surgery. On postoperative day 7, the animals were sacrificed. Anastomotic tissues were analyzed by histology with TUNNEL staining as a marker of epithelial apoptosis. In order to assess compositional and functional changes of the local microbiome, anastomotic tissues were further analyzed by 16S rRNA V4 region sequencing and for the presence of collagenolytic strains that may impair anastomotic healing. The main outcome measures were microbiome community structure and the presence of collagenolytic bacteria. RESULTS Infliximab-treated mice demonstrated an increase in epithelial apoptosis, consistent with the expected drug effect. Although infliximab modified the perianastomotic microbiome, no increase in the presence of collagenolytic bacteria was observed. CONCLUSIONS Infliximab did not promote the emergence of collagenolytic bacteria or demonstrably impair anastomotic healing in a mouse model of colon resection and anastomosis.
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Affiliation(s)
- Sara Gaines
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Sanjiv Hyoju
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | | | - Jasper B. van Praagh
- University of Chicago, Pritzker School of Medicine, Chicago, IL.,University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Olga Zaborina
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - David T. Rubin
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - John C. Alverdy
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | | | - Neil Hyman
- University of Chicago, Pritzker School of Medicine, Chicago, IL.,To whom correspondence should be addressed: Neil Hyman MD, 5841 S. Maryland Ave, MC 5095, Chicago, IL, 60637, Phone: 773-702-6142 Fax: 773-834-1995,
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22
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Twohig K, Ajith A, Mayampurath A, Hyman N, Shogan BD. Abnormal vital signs after laparoscopic colorectal surgery: More common than you think. Am J Surg 2020; 221:654-658. [PMID: 32847687 DOI: 10.1016/j.amjsurg.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/15/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Anastomotic leak is a feared complication. The presence of abnormal vital signs is often cited as an important overlooked predictive clue in retrospective settings once the diagnosis of leak has already been established. We aimed to determine the prevalence of abnormal vital signs following colorectal resection and assess its predictive value. METHODS We retrospectively studied patients undergoing colorectal resection. The performance of vital signs in predicting anastomotic leak was assessed using discrete-time survival analysis and receiver operator characteristic curve. RESULTS 1662 patients (841 laparoscopic, 821 open) were included. Clinical anastomotic leak was diagnosed in 50 patients (3.1%). 96.8% of patients of the entire cohort had at least one abnormal vital sign during their postoperative course. No individual vital sign was a strong predictor of anastomotic leak in either laparoscopic or open cohorts. CONCLUSION Vital sign abnormalities are extremely common following open and laparoscopic colorectal surgery and alone are poor predictors of anastomotic leak.
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Affiliation(s)
- Kelly Twohig
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Aswathy Ajith
- Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | | | - Neil Hyman
- Division of Colon and Rectal Surgery, University of Chicago, Chicago, IL, USA
| | - Benjamin D Shogan
- Division of Colon and Rectal Surgery, University of Chicago, Chicago, IL, USA.
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23
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Berger M, Yamada A, Komaki Y, Komaki F, Cohen RD, Dalal S, Hurst RD, Hyman N, Pekow J, Shogan BD, Umanskiy K, Rubin DT, Sakuraba A, Micic D. Low Skeletal Muscle Index Adjusted for Body Mass Index Is an Independent Risk Factor for Inflammatory Bowel Disease Surgical Complications. Crohns Colitis 360 2020; 2:otaa064. [PMID: 36776498 PMCID: PMC9802466 DOI: 10.1093/crocol/otaa064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 05/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background This study aims to evaluate sarcopenia defined by skeletal muscle index (SMI) with cutoffs adjusted for sex and body mass index as a predictive marker for postoperative outcomes among individuals with inflammatory bowel disease. Methods The SMI was measured using the cross-sectional computed tomography images at the lumbar spine. Multivariate logistic regression was performed to identify independent risk factors of postoperative complications. Results Ninety-one patients were included in the study. In multivariate analysis, sarcopenia (odds ratio = 5.37; confidence interval: 1.04-27.6) was predictive of infectious postoperative complications. Conclusions Sarcopenia as defined by the SMI is a predictor for 30-day postoperative infection complications in inflammatory bowel disease surgeries.
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Affiliation(s)
- Matthew Berger
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Akihiro Yamada
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA,Section of Gastroenterology, Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Fukiko Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Russell D Cohen
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sushila Dalal
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Roger D Hurst
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Neil Hyman
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Joel Pekow
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Benjamin D Shogan
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Konstantin Umanskiy
- Section of Colon and Rectal Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - David T Rubin
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Dejan Micic
- Section of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA,Address correspondence to: Dejan Micic, MD, 5841 South Maryland Avenue, MC4076, Chicago, IL 60637 ()
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24
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Shogan BD, Chen J, Duchalais E, Collins D, Chang M, Krull K, Krezalek MA, Larson DW, Walther-Antonio MR, Chia N, Nelson H. Alterations of the Rectal Microbiome Are Associated with the Development of Postoperative Ileus in Patients Undergoing Colorectal Surgery. J Gastrointest Surg 2020; 24:1663-1672. [PMID: 32323252 DOI: 10.1007/s11605-020-04593-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The most common complications after colorectal surgery, postoperative ileus, surgical site infections, and anastomotic leaks continue to occur despite advances in surgical technique and enhanced recovery pathways. Preclinical studies have documented that intestinal bacteria play a role in the development of these complication, yet human data is lacking. Here we hypothesized that patients that develop ileus, surgical site infection, and/or anastomotic leak following colorectal surgery harbor a specific preoperative gut microbiome. METHODS We performed a prospective cohort study on 101 patients undergoing colon or rectal resection at the Mayo Clinic. Rectal samples were collected preoperatively and on the ward on postoperative day two. The bacterial community from each sample was characterized by 16S rRNA and associated with the development of complications. RESULTS The rectal microbiome collected from patients in the operating room (p = .003) and on postoperative day two (p = .001) was significantly difference in patients whom later developed postoperative ileus compared with patients that had a normal return of bowel function. Patients whom developed ileus showed increased abundance of Bacteroides spp., Parabacteroides spp., and Ruminococcus spp., bacteria that are associated with promoting intestinal inflammation. There were no differences in the microbiome in patients that developed surgical site infections or anastomotic leaks. CONCLUSIONS In this pilot study, patients that develop postoperative ileus harbor a specific gut microbiome during the perioperative period. These findings demonstrate that the preoperative bacterial composition may predispose patients to the development of ileus and that perioperative manipulation of the gut bacteria may provide a novel method to promote normal return of bowel function.
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Affiliation(s)
- Benjamin D Shogan
- Division of Colon and Rectal Surgery, University of Chicago, Room J557F, MC 5095, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| | - Jun Chen
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Emilie Duchalais
- Department of Digestive and Endocrine Surgery, CHU de Nantes, Nantes, France
| | | | - Melissa Chang
- Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Kimberly Krull
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Monika A Krezalek
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Nicholas Chia
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Heidi Nelson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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25
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Wang J, Prenner J, Wang W, Sakuraba A, Hyman N, Dalal S, Hurst R, Cohen RD, Umanskiy K, Shogan BD, Alpert L, Rubin DT, Colwell J, Pekow J. Risk factors and treatment outcomes of peristomal pyoderma gangrenosum in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2020; 51:1365-1372. [PMID: 32383278 DOI: 10.1111/apt.15766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/12/2020] [Accepted: 04/13/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Insufficient data exist for peristomal pyoderma gangrenosum (PPG), which primarily affects patients with inflammatory bowel disease (IBD). AIMS To evaluate the risk factors and treatment response of PPG in IBD patients in a real-life cohort. METHODS Cases of PPG were identified retrospectively using ICD-9/10 codes in patients with IBD who had an ostomy at a tertiary care centre. Disease-specific characteristics were compared between groups with and without PPG, and response to therapy was evaluated in patients with PPG. RESULTS The cohort included 41 IBD patients with PPG and 123 IBD controls with an ostomy who never developed PPG. Patients with PPG were more likely to be female (76% vs 51%, P = 0.006), had higher BMIs (29.78 ± 0.89 vs 23.53 ± 0.51, P < 0.0001) and had increased usage of pouch belts (97% vs 71%, P = 0.0008) compared to controls. There were no differences in age at surgery (41.76 ± 2.60 vs 43.49 ± 1.50, P = 0.57) or IBD diagnosis (63% vs 54% Crohn's disease, P = 0.28) between PPG and controls. 85% of PPG patients achieved complete resolution with different treatments, including surgery. Complete resolution with topical corticosteroids and calcineurin inhibitors alone were low (14% and 13% respectively). Higher rates of complete resolution were reported with anti-tumour necrosis factor (TNF) agents (63%) and surgical interventions (80%). CONCLUSIONS Female gender, higher BMI and pouch belts were associated with increased risk of developing PPG. Most PPG cases resolved after treatment with the highest rates of complete resolution seen with anti-TNF agents and surgical intervention.
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Affiliation(s)
- Jingzhou Wang
- Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Joshua Prenner
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Wenfei Wang
- Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Neil Hyman
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Sushila Dalal
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Roger Hurst
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Russell D Cohen
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | | | | | - Lindsay Alpert
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - David T Rubin
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
| | - Janice Colwell
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Joel Pekow
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL, USA
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26
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Gaines S, van Praagh JB, Williamson AJ, Jacobson RA, Hyoju S, Zaborin A, Mao J, Koo HY, Alpert L, Bissonnette M, Weichselbaum R, Gilbert J, Chang E, Hyman N, Zaborina O, Shogan BD, Alverdy JC. Western Diet Promotes Intestinal Colonization by Collagenolytic Microbes and Promotes Tumor Formation After Colorectal Surgery. Gastroenterology 2020; 158:958-970.e2. [PMID: 31655031 PMCID: PMC7062578 DOI: 10.1053/j.gastro.2019.10.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 09/24/2019] [Accepted: 10/20/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The Western diet, which is high in fat, is a modifiable risk factor for colorectal recurrence after curative resection. We investigated the mechanisms by which the Western diet promotes tumor recurrence, including changes in the microbiome, in mice that underwent colorectal resection. METHODS BALB/c male mice were fed either standard chow diet or Western-type diet (characterized by high fat, no fiber, and decreased minerals and vitamins) for 4 weeks; some mice were given antibiotics or ABA-PEG20k-Pi20 (Pi-PEG), which inhibits collagenase production by bacteria, but not bacterial growth, in drinking water. Colorectal resections and anastomoses were then performed. The first day after surgery, mice were given enemas containing a collagenolytic rodent-derived strain of Enterococcus faecalis (strain E2), and on the second day they were given mouse colon carcinoma cells (CT26). Twenty-one days later, distal colons were removed, and colon contents (feces, distal colon, and tumor) were collected. Colon tissues were analyzed by histology for the presence of collagenolytic colonies and by 16S ribosomal RNA sequencing, which determined the anatomic distribution of E faecalis at the site of the anastomosis and within tumors using in situ hybridization. Mouse imaging analyses were used to identify metastases. RESULTS Colorectal tumors were found in 88% of mice fed the Western diet and given antibiotics, surgery, and E faecalis compared with only 30% of mice fed the standard diet followed by the same procedures. Colon tumor formation correlated with the presence of collagenolytic E faecalis and Proteus mirabilis. Antibiotics eliminated collagenolytic E faecalis and P mirabilis but did not reduce tumor formation. However, antibiotics promoted emergence of Candida parapsilosis, a collagenase-producing microorganism. Administration of a Pi-PEG reduced tumor formation and maintained diversity of the colon microbiome. CONCLUSIONS We identified a mechanisms by which diet and antibiotic use can promote tumorigenesis by colon cancer cells at the anastomosis after colorectal surgery. Strategies to prevent emergence of these microbe communities or their enzymatic activities might be used to reduce the risk of tumor recurrence in patients undergoing colorectal cancer surgery.
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Affiliation(s)
- Sara Gaines
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Jasper B. van Praagh
- University of Chicago, Pritzker School of Medicine, Chicago, IL.,University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Richard A. Jacobson
- University of Chicago, Pritzker School of Medicine, Chicago, IL.,Rush University Medical Center, Chicago, IL
| | - Sanjiv Hyoju
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | | | - Jun Mao
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Hyun Y. Koo
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Lindsay Alpert
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | | | | | - Jack Gilbert
- University of Chicago, Pritzker School of Medicine, Chicago, IL.,University of California San Diego, Department of Pediatrics, La Jolla, CA
| | - Eugene Chang
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Neil Hyman
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Olga Zaborina
- University of Chicago, Pritzker School of Medicine, Chicago, IL
| | | | - John C. Alverdy
- University of Chicago, Pritzker School of Medicine, Chicago, IL.,To whom correspondence should be addressed: John C. Alverdy, 5841 S. Maryland Ave, MC 6090, Chicago, IL, 60637, Phone: 773-702-4876 Fax: 773-834-0201,
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27
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Jacobson RA, Wienholts K, Williamson AJ, Gaines S, Hyoju S, van Goor H, Zaborin A, Shogan BD, Zaborina O, Alverdy JC. Enterococcus faecalis exploits the human fibrinolytic system to drive excess collagenolysis: implications in gut healing and identification of druggable targets. Am J Physiol Gastrointest Liver Physiol 2020; 318:G1-G9. [PMID: 31604031 PMCID: PMC6985841 DOI: 10.1152/ajpgi.00236.2019] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Perforations, anastomotic leak, and subsequent intra-abdominal sepsis are among the most common and feared complications of invasive interventions in the colon and remaining intestinal tract. During physiological healing, tissue protease activity is finely orchestrated to maintain the strength and integrity of the submucosa collagen layer in the wound. We (Shogan, BD et al. Sci Trans Med 7: 286ra68, 2015.) have previously demonstrated in both mice and humans that the commensal microbe Enterococcus faecalis selectively colonizes wounded colonic tissues and disrupts the healing process by amplifying collagenolytic matrix-metalloprotease activity toward excessive degradation. Here, we demonstrate for the first time, to our knowledge, a novel collagenolytic virulence mechanism by which E. faecalis is able to bind and locally activate the human fibrinolytic protease plasminogen (PLG), a protein present in high concentrations in healing colonic tissue. E. faecalis-mediated PLG activation leads to supraphysiological collagen degradation; in this study, we demonstrate this concept both in vitro and in vivo. This pathoadaptive response can be mitigated with the PLG inhibitor tranexamic acid (TXA) in a fashion that prevents clinically significant complications in validated murine models of both E. faecalis- and Pseudomonas aeruginosa-mediated colonic perforation. TXA has a proven clinical safety record and is Food and Drug Administration approved for topical application in invasive procedures, albeit for the prevention of bleeding rather than infection. As such, the novel pharmacological effect described in this study may be translatable to clinical trials for the prevention of infectious complications in colonic healing.NEW & NOTEWORTHY This paper presents a novel mechanism for virulence in a commensal gut microbe that exploits the human fibrinolytic system and its principle protease, plasminogen. This mechanism is targetable by safe and effective nonantibiotic small molecules for the prevention of infectious complications in the healing gut.
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Affiliation(s)
- Richard A. Jacobson
- 1Department of Surgery, Rush University Medical Center, Chicago, Illinois,2Pritzker School of Medicine, University of Chicago, Illinois,3Department of Surgery, John H. Stroger Hospital of Cook County, Chicago, Illinois
| | - Kiedo Wienholts
- 4Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Sara Gaines
- 2Pritzker School of Medicine, University of Chicago, Illinois
| | - Sanjiv Hyoju
- 2Pritzker School of Medicine, University of Chicago, Illinois
| | - Harry van Goor
- 4Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | | | - Olga Zaborina
- 2Pritzker School of Medicine, University of Chicago, Illinois
| | - John C. Alverdy
- 2Pritzker School of Medicine, University of Chicago, Illinois
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28
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Wang Y, Wang J, Pekow J, Dalal S, Cohen RD, Ollech J, Israel A, Shogan BD, Micic D, Cannon L, Umanskiy K, Hurst R, Hyman N, Rubin DT, Sakuraba A. Outcome of elective switching to vedolizumab in inflammatory bowel disease patients under tumor necrosis factor antagonist-maintained clinical remission. J Gastroenterol Hepatol 2019; 34:2090-2095. [PMID: 31169926 DOI: 10.1111/jgh.14751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/03/2019] [Accepted: 05/27/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Vedolizumab (VDZ) has been used in inflammatory bowel disease (IBD) patients who failed anti-tumor necrosis factor (TNF) therapy. This study was to examine long-term outcome of IBD patients switching to VDZ from anti-TNF agents for reasons other than failure of therapy. METHODS Inflammatory bowel disease patients at the University of Chicago IBD center who were in clinical remission with anti-TNF therapy and then electively changed to VDZ due to reasons other than loss of response were retrospectively analyzed. The primary outcome was the durability of clinical remission maintained by VDZ as assessed by Kaplan-Meier survival analysis. The proportion of patients in clinical and endoscopic remission at 6-12 months after switching to VDZ therapy was analyzed. RESULTS A total of 41 patients (36 with Crohn's disease and 5 with ulcerative colitis) met the inclusion criteria and were in clinical remission at the time of switch. The majority of patients switched therapy due to adverse effects (56.1%) or infections (14.6%). During a median duration of 30 months (range 7-52) of VDZ therapy, 34 (82.9%) were in VDZ-maintained clinical remission. One (2.4%) and four (9.8%) patients discontinued VDZ due to flare and adverse effects, respectively. Endoscopic remission was present in 25 of 30 patients (83.3%) who had a follow-up colonoscopy. CONCLUSIONS Vedolizumab was effective and safe in maintaining remission in IBD patients who switched from anti-TNF agents due to reasons other than failure of therapy. Our results suggest that switching anti-TNF remitters to VDZ treatment is a safe practice in specific patient populations.
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Affiliation(s)
- Yunwei Wang
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jennifer Wang
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sushila Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jacob Ollech
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Amanda Israel
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Benjamin D Shogan
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Dejan Micic
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Lisa Cannon
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Konstantin Umanskiy
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Roger Hurst
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Neil Hyman
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
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29
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Abstract
Whether to administer purgative cleansing and oral antibiotics before colon surgery as a method to prevent postoperative infections, once standard of care, is now being considered unnecessary with today’s advancements of care. A new study questions the efficacy of this bowel preparation approach with a prospective randomized trial.
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30
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Abstract
The microbiome exerts a remarkable effect on human physiology. The study of the human-microbiome relationship is a burgeoning field with great potential to improve our understanding of health and disease. In this review, we address common surgical problems influenced by the human microbiome and explore what is thus far known about this relationship. These include inflammatory bowel disease, colorectal neoplasms, and diverticular disease. We will also discuss the effect of the microbiome on surgical complications, specifically anastomotic leak. We hope that further research in this field will enlighten our management of these and other surgical problems.
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Affiliation(s)
- Kinga B Skowron
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 5095, Chicago, IL, 60637, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 5095, Chicago, IL, 60637, USA.
| | - David T Rubin
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Neil H Hyman
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 5095, Chicago, IL, 60637, USA
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31
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Lax S, Sangwan N, Smith D, Larsen P, Handley KM, Richardson M, Guyton K, Krezalek M, Shogan BD, Defazio J, Flemming I, Shakhsheer B, Weber S, Landon E, Garcia-Houchins S, Siegel J, Alverdy J, Knight R, Stephens B, Gilbert JA. Bacterial colonization and succession in a newly opened hospital. Sci Transl Med 2018; 9:9/391/eaah6500. [PMID: 28539477 DOI: 10.1126/scitranslmed.aah6500] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 02/27/2017] [Indexed: 11/02/2022]
Abstract
The microorganisms that inhabit hospitals may influence patient recovery and outcome, although the complexity and diversity of these bacterial communities can confound our ability to focus on potential pathogens in isolation. To develop a community-level understanding of how microorganisms colonize and move through the hospital environment, we characterized the bacterial dynamics among hospital surfaces, patients, and staff over the course of 1 year as a new hospital became operational. The bacteria in patient rooms, particularly on bedrails, consistently resembled the skin microbiota of the patient occupying the room. Bacterial communities on patients and room surfaces became increasingly similar over the course of a patient's stay. Temporal correlations in community structure demonstrated that patients initially acquired room-associated taxa that predated their stay but that their own microbial signatures began to influence the room community structure over time. The α- and β-diversity of patient skin samples were only weakly or nonsignificantly associated with clinical factors such as chemotherapy, antibiotic usage, and surgical recovery, and no factor except for ambulatory status affected microbial similarity between the microbiotas of a patient and their room. Metagenomic analyses revealed that genes conferring antimicrobial resistance were consistently more abundant on room surfaces than on the skin of the patients inhabiting those rooms. In addition, persistent unique genotypes of Staphylococcus and Propionibacterium were identified. Dynamic Bayesian network analysis suggested that hospital staff were more likely to be a source of bacteria on the skin of patients than the reverse but that there were no universal patterns of transmission across patient rooms.
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Affiliation(s)
- Simon Lax
- Department of Ecology and Evolution, University of Chicago, 1101 East 57th Street, Chicago, IL 60637, USA.,Division of Biosciences, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
| | - Naseer Sangwan
- Division of Biosciences, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA.,Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Daniel Smith
- Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Peter Larsen
- Division of Biosciences, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
| | - Kim M Handley
- Department of Ecology and Evolution, University of Chicago, 1101 East 57th Street, Chicago, IL 60637, USA
| | - Miles Richardson
- Department of Ecology and Evolution, University of Chicago, 1101 East 57th Street, Chicago, IL 60637, USA
| | - Kristina Guyton
- Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Monika Krezalek
- Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Benjamin D Shogan
- Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Jennifer Defazio
- Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Irma Flemming
- Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Baddr Shakhsheer
- Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Stephen Weber
- Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Emily Landon
- Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Sylvia Garcia-Houchins
- Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Jeffrey Siegel
- Department of Civil Engineering, University of Toronto, 35 St. George Street, Toronto, Ontario M5S 1A4, Canada.,Dalla Lana School of Public Health, University of Toronto, 223 College Street, Toronto, Ontario M5T 1R4, Canada
| | - John Alverdy
- Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
| | - Rob Knight
- Department of Pediatrics, University of California, San Diego, San Diego, CA 92037, USA.,Department of Computer Science and Engineering, University of California, San Diego, San Diego, CA 92037, USA
| | - Brent Stephens
- Department of Civil, Architectural and Environmental Engineering, Illinois Institute of Technology, 3201 South Dearborn Street, Chicago, IL 60616, USA
| | - Jack A Gilbert
- Department of Ecology and Evolution, University of Chicago, 1101 East 57th Street, Chicago, IL 60637, USA. .,Division of Biosciences, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA.,Microbiome Center, Department of Surgery, University of Chicago, A27 South Maryland Avenue, Chicago, IL 60637, USA
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Shogan BD, Belogortseva N, Luong PM, Zaborin A, Lax S, Bethel C, Ward M, Muldoon JP, Singer M, An G, Umanskiy K, Konda V, Shakhsheer B, Luo J, Klabbers R, Hancock LE, Gilbert J, Zaborina O, Alverdy JC. Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak. Sci Transl Med 2016; 7:286ra68. [PMID: 25947163 DOI: 10.1126/scitranslmed.3010658] [Citation(s) in RCA: 250] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Even under the most expert care, a properly constructed intestinal anastomosis can fail to heal, resulting in leakage of its contents, peritonitis, and sepsis. The cause of anastomotic leak remains unknown, and its incidence has not changed in decades. We demonstrate that the commensal bacterium Enterococcus faecalis contributes to the pathogenesis of anastomotic leak through its capacity to degrade collagen and to activate tissue matrix metalloproteinase 9 (MMP9) in host intestinal tissues. We demonstrate in rats that leaking anastomotic tissues were colonized by E. faecalis strains that showed an increased collagen-degrading activity and also an increased ability to activate host MMP9, both of which contributed to anastomotic leakage. We demonstrate that the E. faecalis genes gelE and sprE were required for E. faecalis-mediated MMP9 activation. Either elimination of E. faecalis strains through direct topical antibiotics applied to rat intestinal tissues or pharmacological suppression of intestinal MMP9 activation prevented anastomotic leak in rats. In contrast, the standard recommended intravenous antibiotics used in patients undergoing colorectal surgery did not eliminate E. faecalis at anastomotic tissues nor did they prevent leak in our rat model. Finally, we show in humans undergoing colon surgery and treated with the standard recommended intravenous antibiotics that their anastomotic tissues still contained E. faecalis and other bacterial strains with collagen-degrading/MMP9-activating activity. We suggest that intestinal microbes with the capacity to produce collagenases and to activate host metalloproteinase MMP9 may break down collagen in the intestinal tissue contributing to anastomotic leak.
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Affiliation(s)
- Benjamin D Shogan
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | | | - Preston M Luong
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Alexander Zaborin
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Simon Lax
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Cindy Bethel
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Marc Ward
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | | | - Mark Singer
- NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Gary An
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | | | - Vani Konda
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Baddr Shakhsheer
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - James Luo
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Robin Klabbers
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA. Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - Jack Gilbert
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA. Argonne National Laboratory, Argonne, IL 60439, USA
| | - Olga Zaborina
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - John C Alverdy
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
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Lax S, Smith DP, Hampton-Marcell J, Owens SM, Handley KM, Scott NM, Gibbons SM, Larsen P, Shogan BD, Weiss S, Metcalf JL, Ursell LK, Vázquez-Baeza Y, Van Treuren W, Hasan NA, Gibson MK, Colwell R, Dantas G, Knight R, Gilbert JA. Longitudinal analysis of microbial interaction between humans and the indoor environment. Science 2014; 345:1048-52. [PMID: 25170151 DOI: 10.1126/science.1254529] [Citation(s) in RCA: 575] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The bacteria that colonize humans and our built environments have the potential to influence our health. Microbial communities associated with seven families and their homes over 6 weeks were assessed, including three families that moved their home. Microbial communities differed substantially among homes, and the home microbiome was largely sourced from humans. The microbiota in each home were identifiable by family. Network analysis identified humans as the primary bacterial vector, and a Bayesian method significantly matched individuals to their dwellings. Draft genomes of potential human pathogens observed on a kitchen counter could be matched to the hands of occupants. After a house move, the microbial community in the new house rapidly converged on the microbial community of the occupants' former house, suggesting rapid colonization by the family's microbiota.
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Affiliation(s)
- Simon Lax
- Department of Ecology and Evolution, University of Chicago, 1101 E 57th Street, Chicago, IL 60637, USA. Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
| | - Daniel P Smith
- Department of Ecology and Evolution, University of Chicago, 1101 E 57th Street, Chicago, IL 60637, USA. Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA. Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jarrad Hampton-Marcell
- Department of Ecology and Evolution, University of Chicago, 1101 E 57th Street, Chicago, IL 60637, USA. Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
| | - Sarah M Owens
- Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA. Computation Institute, University of Chicago, Chicago, IL 60637, USA
| | - Kim M Handley
- Department of Ecology and Evolution, University of Chicago, 1101 E 57th Street, Chicago, IL 60637, USA. Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
| | - Nicole M Scott
- Department of Ecology and Evolution, University of Chicago, 1101 E 57th Street, Chicago, IL 60637, USA. Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
| | - Sean M Gibbons
- Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA. Graduate Program in Biophysical Sciences, University of Chicago, Chicago, IL 60637, USA
| | - Peter Larsen
- Department of Bioscience, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA. Department of Bioengineering, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Sophie Weiss
- Biofrontiers Institute, University of Colorado, 3415 Colorado Avenue, Boulder, CO 80304, USA. Department of Chemical and Biological Engineering, University of Colorado at Boulder, Boulder, CO 80304, USA
| | - Jessica L Metcalf
- Biofrontiers Institute, University of Colorado, 3415 Colorado Avenue, Boulder, CO 80304, USA
| | - Luke K Ursell
- Biofrontiers Institute, University of Colorado, 3415 Colorado Avenue, Boulder, CO 80304, USA. Department of Chemistry and Biochemistry, University of Colorado at Boulder, Boulder, CO 80304, USA
| | - Yoshiki Vázquez-Baeza
- Biofrontiers Institute, University of Colorado, 3415 Colorado Avenue, Boulder, CO 80304, USA. Department of Chemistry and Biochemistry, University of Colorado at Boulder, Boulder, CO 80304, USA. Department of Computer Science, University of Colorado at Boulder, Boulder, CO 80304, USA
| | - Will Van Treuren
- Biofrontiers Institute, University of Colorado, 3415 Colorado Avenue, Boulder, CO 80304, USA
| | - Nur A Hasan
- CosmosID, 387 Technology Drive, Suite 3119, College Park, MD 20742, USA. Center for Bioinformatics and Computational Biology, University of Maryland Institute for Advanced Computer Studies, University of Maryland College Park, College Park, MD 20742, USA
| | - Molly K Gibson
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63108, USA. Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA. Department of Biomedical Engineering, Washington University, St. Louis, MO 63130, USA
| | - Rita Colwell
- CosmosID, 387 Technology Drive, Suite 3119, College Park, MD 20742, USA. Center for Bioinformatics and Computational Biology, University of Maryland Institute for Advanced Computer Studies, University of Maryland College Park, College Park, MD 20742, USA
| | - Gautam Dantas
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63108, USA. Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA. Department of Biomedical Engineering, Washington University, St. Louis, MO 63130, USA
| | - Rob Knight
- Biofrontiers Institute, University of Colorado, 3415 Colorado Avenue, Boulder, CO 80304, USA. Department of Chemistry and Biochemistry, University of Colorado at Boulder, Boulder, CO 80304, USA. Howard Hughes Medical Institute, Boulder, CO 80309, USA
| | - Jack A Gilbert
- Department of Ecology and Evolution, University of Chicago, 1101 E 57th Street, Chicago, IL 60637, USA. Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA. Graduate Program in Biophysical Sciences, University of Chicago, Chicago, IL 60637, USA.
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Shogan BD, An GC, Schardey HM, Matthews JB, Umanskiy K, Fleshman JW, Hoeppner J, Fry DE, Garcia-Granereo E, Jeekel H, van Goor H, Dellinger EP, Konda V, Gilbert JA, Auner GW, Alverdy JC. Proceedings of the first international summit on intestinal anastomotic leak, Chicago, Illinois, October 4-5, 2012. Surg Infect (Larchmt) 2014; 15:479-89. [PMID: 25215465 DOI: 10.1089/sur.2013.114] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The first international summit on anastomotic leak was held in Chicago in October, 2012 to assess current knowledge in the field and develop novel lines of inquiry. The following report is a summary of the proceedings with commentaries and future prospects for clinical trials and laboratory investigations. BACKGROUND Anastomotic leakage remains a devastating problem for the patient, and a continuing challenge to the surgeon operating on high-risk areas of the gastrointestinal tract such as the esophagus and rectum. Despite the traditional wisdom that anastomotic leak is because of technique, evidence to support this is weak-to-non-existent. Outcome data continue to demonstrate that expert high-volume surgeons working in high-volume centers continue to experience anastomotic leaks and that surgeons cannot predict reliably which patients will leak. METHODS A one and one-half day summit was held and a small working group assembled to review current practices, opinions, scientific evidence, and potential paths forward to understand and decrease the incidence of anastomotic leak. RESULTS RESULTS of a survey of the opinions of the group demonstrated that the majority of participants believe that anastomotic leak is a complicated biologic problem whose pathogenesis remains ill-defined. The group opined that anastomotic leak is underreported clinically, it is not because of technique except when there is gross inattention to it, and that results from animal models are mostly irrelevant to the human condition. CONCLUSIONS A fresh and unbiased examination of the causes and strategies for prevention of anastomotic leak needs to be addressed by a continuous working group of surgeons, basic scientists, and clinical trialists to realize a real and significant reduction in its incidence and morbidity. Such a path forward is discussed.
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Shogan BD, Smith DP, Christley S, Gilbert JA, Zaborina O, Alverdy JC. Intestinal anastomotic injury alters spatially defined microbiome composition and function. Microbiome 2014; 2:35. [PMID: 25250176 PMCID: PMC4171717 DOI: 10.1186/2049-2618-2-35] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 08/04/2014] [Indexed: 05/06/2023]
Abstract
BACKGROUND When diseased intestine (i.e., from colon cancer, diverticulitis) requires resection, its reconnection (termed anastomosis) can be complicated by non-healing of the newly joined intestine resulting in spillage of intestinal contents into the abdominal cavity (termed anastomotic leakage). While it is suspected that the intestinal microbiota have the capacity to both accelerate and complicate anastomotic healing, the associated genotypes and functions have not been characterized. RESULTS Using 16S rRNA amplicon sequencing of samples collected on the day of surgery (postoperative day 0 (POD0)) and the 6th day following surgery (postoperative day 0 (POD6)), we analyzed the changes in luminal versus tissue-associated microbiota at anastomotic sites created in the colon of rats. Results indicated that anastomotic injury induced significant changes in the anastomotic tissue-associated microbiota with minimal differences in the luminal microbiota. The most striking difference was a 500-fold and 200-fold increase in the relative abundance of Enterococcus and Escherichia/Shigella, respectively. Functional profiling predicted the predominance of bacterial virulence-associated pathways in post-anastomotic tissues, including production of hemolysin, cytolethal toxins, fimbriae, invasins, cytotoxic necrotizing factors, and coccolysin. CONCLUSION Taken together, our results suggest that compositional and functional changes accompany anastomotic tissues and may potentially accelerate or complicate anastomotic healing.
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Affiliation(s)
- Benjamin D Shogan
- Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
| | - Daniel P Smith
- Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
- Current address: Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX 77030, USA
| | - Scott Christley
- Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
| | - Jack A Gilbert
- Institute for Genomic and Systems Biology, Argonne National Laboratory, 9700 South Cass Avenue, Argonne, IL 60439, USA
- Department of Ecology and Evolution, University of Chicago, Chicago, IL 60637, USA
| | - Olga Zaborina
- Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
| | - John C Alverdy
- Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
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Abstract
INTRODUCTION Colorectal anastomotic leak, a feared complication, results in significantly increased patient morbidity, mortality, and hospital resource utilization. The overall incidence of colorectal anastomotic leak is approximately 11% with increasing rate the closer the anastomosis is to the anal verge. Because surgeons are unable to reliably predict which anastomosis would fail, most will construct a diverting ileostomy for low colorectal anastomosis to circumvent the devastating complications of anastomotic failure. Despite extensive investigations on technical considerations of anastomosis construction, anastomotic leaks continue to occur at an unacceptably high rate. DISCUSSION In this review, we examine the major known risk factors and technical considerations that have been implicated as factors in leakage. Although surgical technique has evolved over the past several decades with the advent of newer surgical staplers, laparoscopy, and robotics, we have not witnessed a decrease in the incidence of colorectal anastomotic leaks suggesting that the fundamental pathogenesis of anastomotic leak remains unknown. Among the factors contributing to anastomotic healing, intestinal bacteria remains largely overlooked even though compelling evidence exist that intraluminal microbes could play a major role in pathogenesis of anastomotic leak. Further investigation focusing on intestinal microbes could be one such avenue for uncovering the elusive cause of colorectal anastomotic leak.
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Affiliation(s)
- Benjamin D Shogan
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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Shogan BD, Smith DP, Packman AI, Kelley ST, Landon EM, Bhangar S, Vora GJ, Jones RM, Keegan K, Stephens B, Ramos T, Kirkup BC, Levin H, Rosenthal M, Foxman B, Chang EB, Siegel J, Cobey S, An G, Alverdy JC, Olsiewski PJ, Martin MO, Marrs R, Hernandez M, Christley S, Morowitz M, Weber S, Gilbert J. The Hospital Microbiome Project: Meeting report for the 2nd Hospital Microbiome Project, Chicago, USA, January 15(th), 2013. Stand Genomic Sci 2013; 8:571-9. [PMID: 24501640 PMCID: PMC3910697 DOI: 10.4056/sigs.4187859] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Benjamin D Shogan
- Department of Surgery, University of Chicago Medicine, Chicago, IL, 60637, USA
| | | | - Aaron I Packman
- Department of Civil and Environmental Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Scott T Kelley
- Department of Biology, San Diego State University, San Diego, CA, 92182, USA
| | - Emily M Landon
- Department of Medicine, Section of Infectious Diseases & Global Health, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Seema Bhangar
- Department of Civil and Environmental Engineering, University of California, Berkeley, CA 94720, USA
| | - Gary J Vora
- Center for Bio/Molecular Science and Engineering, Naval Research Laboratory, Washington DC, 20375, USA
| | - Rachael M Jones
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Kevin Keegan
- Argonne National Laboratory, Argonne, IL, 60439, USA
| | - Brent Stephens
- Department of Civil, Architectural and Environmental Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Tiffanie Ramos
- Department of Civil, Architectural and Environmental Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Benjamin C Kirkup
- Department of Wound Infections, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA ; Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Hal Levin
- Building Ecology Research Group, Santa Cruz, California, 95060, USA
| | - Mariana Rosenthal
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48109
| | - Betsy Foxman
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48109
| | - Eugene B Chang
- Department of Medicine, University of Chicago Medicine, Chicago, IL, 60637, USA
| | - Jeffrey Siegel
- Department of Civil Engineering, University of Toronto, Ontario, Canada
| | - Sarah Cobey
- Department of Ecology and Evolution, University of Chicago, Chicago, IL, 60637, USA
| | - Gary An
- Department of Surgery, University of Chicago Medicine, Chicago, IL, 60637, USA
| | - John C Alverdy
- Department of Surgery, University of Chicago Medicine, Chicago, IL, 60637, USA
| | | | - Mark O Martin
- Department of Biology, University of Puget Sound, Tacoma, Washington, 98416, USA
| | - Rachel Marrs
- Department of Medicine, Section of Infectious Diseases & Global Health, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Mark Hernandez
- Department of Civil, Environmental and Architectural Engineering, University of Colorado, Boulder, CO, 80309, USA
| | - Scott Christley
- Department of Surgery, University of Chicago Medicine, Chicago, IL, 60637, USA
| | - Michael Morowitz
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224
| | - Stephen Weber
- Department of Medicine, Section of Infectious Diseases & Global Health, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Jack Gilbert
- Argonne National Laboratory, Argonne, IL, 60439, USA ; Department of Ecology and Evolution, University of Chicago, Chicago, IL, 60637, USA
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Olivas AD, Shogan BD, Valuckaite V, Zaborin A, Belogortseva N, Musch M, Meyer F, L.Trimble W, An G, Gilbert J, Zaborina O, Alverdy JC. Intestinal tissues induce an SNP mutation in Pseudomonas aeruginosa that enhances its virulence: possible role in anastomotic leak. PLoS One 2012; 7:e44326. [PMID: 22952955 PMCID: PMC3432121 DOI: 10.1371/journal.pone.0044326] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 08/01/2012] [Indexed: 12/14/2022] Open
Abstract
The most feared complication following intestinal resection is anastomotic leakage. In high risk areas (esophagus/rectum) where neoadjuvant chemoradiation is used, the incidence of anastomotic leaks remains unacceptably high (∼10%) even when performed by specialist surgeons in high volume centers. The aims of this study were to test the hypothesis that anastomotic leakage develops when pathogens colonizing anastomotic sites become in vivo transformed to express a tissue destroying phenotype. We developed a novel model of anastomotic leak in which rats were exposed to pre-operative radiation as in cancer surgery, underwent distal colon resection and then were intestinally inoculated with Pseudomonas aeruginosa, a common colonizer of the radiated intestine. Results demonstrated that intestinal tissues exposed to preoperative radiation developed a significant incidence of anastomotic leak (>60%; p<0.01) when colonized by P. aeruginosa compared to radiated tissues alone (0%). Phenotype analysis comparing the original inoculating strain (MPAO1- termed P1) and the strain retrieved from leaking anastomotic tissues (termed P2) demonstrated that P2 was altered in pyocyanin production and displayed enhanced collagenase activity, high swarming motility, and a destructive phenotype against cultured intestinal epithelial cells (i.e. apoptosis, barrier function, cytolysis). Comparative genotype analysis between P1 and P2 revealed a single nucleotide polymorphism (SNP) mutation in the mexT gene that led to a stop codon resulting in a non-functional truncated protein. Replacement of the mutated mexT gene in P2 with mexT from the original parental strain P1 led to reversion of P2 to the P1 phenotype. No spontaneous transformation was detected during 20 passages in TSB media. Use of a novel virulence suppressing compound PEG/Pi prevented P. aeruginosa transformation to the tissue destructive phenotype and prevented anastomotic leak in rats. This work demonstrates that in vivo transformation of microbial pathogens to a tissue destroying phenotype may have important implications in the pathogenesis of anastomotic leak.
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Affiliation(s)
- Andrea D. Olivas
- Department of Surgery, University of Chicago, Illinois, United States of America
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago, Illinois, United States of America
| | - Vesta Valuckaite
- Department of Surgery, University of Chicago, Illinois, United States of America
- Bioengineering Institute for Advanced Surgery and Endoscopy, Chicago, Illinois, United States of America
| | - Alexander Zaborin
- Department of Surgery, University of Chicago, Illinois, United States of America
| | - Natalya Belogortseva
- Department of Surgery, University of Chicago, Illinois, United States of America
| | - Mark Musch
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Folker Meyer
- Institute for Genomic and Systems Biology, Argonne National Laboratory, Argonne, Illinois, United States of America
| | - William L.Trimble
- Institute for Genomic and Systems Biology, Argonne National Laboratory, Argonne, Illinois, United States of America
| | - Gary An
- Department of Surgery, University of Chicago, Illinois, United States of America
| | - Jack Gilbert
- Institute for Genomic and Systems Biology, Argonne National Laboratory, Argonne, Illinois, United States of America
| | - Olga Zaborina
- Department of Surgery, University of Chicago, Illinois, United States of America
| | - John C. Alverdy
- Department of Surgery, University of Chicago, Illinois, United States of America
- Bioengineering Institute for Advanced Surgery and Endoscopy, Chicago, Illinois, United States of America
- * E-mail:
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