Anastomotic leakage, surgical site infections, and other infectious complications are still common complications in gastrointestinal surgery. The concept of perioperative antibiotic bowel ...decontamination demonstrates beneficial effects in single randomized controlled trials (RCTs), but data from routine clinical use are still sparse. Our aim was to analyze the data from the routine clinical use of perioperative antibiotic bowel decontamination in gastrointestinal surgery.
Based on 20 years' experience, we performed a retrospective analysis of all cases in oncologic gastrointestinal surgery with the use of antibiotic bowel decontamination in gastric, sigmoid, and rectal cancer. Clinical data and perioperative outcomes were analyzed, especially regarding anastomotic leakage, surgical site infections, and other infectious complications.
A total of
= 477 cases of gastrointestinal surgery in gastric cancer (
= 80), sigmoid cancer (
= 168), and rectal cancer (
= 229) using a perioperative regimen of antibiotic bowel decontamination could be included in this analysis. Overall, anastomotic leakage occurred in 4.4% (2.5% gastric cancer, 3.0% sigmoid cancer, 6.1% rectal cancer) and surgical site infections in 9.6% (6.3% gastric cancer, 9.5% sigmoid cancer, 10.9% rectal cancer). The incidence of all infectious complications was 13.6% (12.5% gastric cancer, 11.3% sigmoid cancer, 15.7% rectal cancer). Mortality was low, with an overall rate of 1.1% (1.3% gastric cancer, 1.8% sigmoid cancer, 0.4% rectal cancer). Antibiotic decontamination was completed in 98.5%. No adverse effects of antibiotic bowel decontamination could be observed.
Overall, in this large cohort, we can report low rates of surgery-related serious morbidity and mortality when perioperative antibiotic bowel decontamination is performed. The rates are lower than other clinical reports. In our clinical experience, the use of perioperative antibiotic bowel decontamination appears to improve patient safety and surgical outcomes during gastrointestinal oncologic procedures in a routine clinical setting.
Introduction
Crohn’s disease (CD) is a chronic inflammatory bowel disease of a multifactorial pathogenesis. Recently numerous genetic variants linked to an aggressive phenotype were identified, ...leading to a progress in therapeutic options, resulting in a decreased necessity for surgery. Nevertheless, surgery is often inevitable. The aim of the study was to evaluate possible risk factors for postoperative complications and disease recurrence specifically after colonic resections for CD.
Patients and methods
A total of 241 patients who underwent colonic and ileocaecal resections for CD at our instiution between 2008 and 2018 were included. All data was extracted from clinical charts.
Results
Major complications occurred in 23.8% of all patients. Patients after colonic resections showed a significantly higher rate of major postoperative complications compared to patients after ICR (
p
= < 0.0001). The most common complications after colonic resections were postoperative bleeding (22.2%), the need for revision surgery (27.4%) and ICU (17.2%) or hospital readmission (15%). As risk factors for the latter, we identified time interval between admission and surgery (
p
= 0.015) and the duration of the surgery (
p
= 0.001). Isolated distal resections had a higher risk for revision surgery and a secondary stoma (
p
= 0.019). Within the total study population, previous bowel resections (
p
= 0.037) were identified as independent risk factors for major perioperative complications.
Conclusion
The results indicate that both a complex surgical site and a complex surgical procedure lead to a higher perioperative morbidity in colonic resections for Crohn’s colitis.
Zusammenfassung
Das Risiko, an einem kolorektalen Karzinom (CRC) zu erkranken, ist sowohl bei der Colitis ulcerosa (CU) als auch bei Morbus Crohn (MC) deutlich erhöht. Der Hauptauslöser für die ...Entstehung von CRC bei chronisch-entzündlichen Darmerkrankungen (CED) ist die chronische und/oder rezidivierende Schleimhautentzündung, die dazu beizutragen scheint, dass diese mit einem aggressiveren klinisch-pathologischen Phänotyp und einer schlechteren Prognose einhergehen. Die wichtigste Methode zur Verringerung des CRC-Risikos bei CED ist die Koloskopie im Rahmen eines strukturierten endoskopischen Überwachungsprogramms, das neben der Detektion von möglichen Dysplasien eine kontinuierliche medizinische Behandlung der CED zur Therapie der Grunderkrankung umfasst. In den letzten beiden Jahrzehnten haben sich die endoskopischen Visualisierungs- und Resektionstechniken deutlich weiterentwickelt, weshalb die Indikationsbreite für die endoskopische Therapie und Überwachung zugenommen hat. Die chirurgische Therapieempfehlung der Patienten sollte in einem multidisziplinären Board abgegeben werden, wobei die operative Strategie von verschiedenen Faktoren abhängt und sorgfältig gewählt werden muss. Die teilweise sehr jungen Patienten müssen die Vor- und Nachteile der verschiedenen Therapieoptionen kennen und in die Entscheidungsfindung des geeigneten Operationsverfahrens miteinbezogen werden. Dabei sollten onkologische Prinzipien analog zu nicht CED-assoziierten Karzinomen beachtet werden.
Background
Inflammation is known to be an essential driver of various types of cancer. An increasing number of studies have suggested that the occurrence and development of colorectal cancer (CRC) ...are linked to the inflammatory microenvironment of the intestine. This assumption is further supported by the fact that patients with inflammatory bowel disease (IBD) are more likely to develop CRC. Multiple studies in mice and humans have shown that preoperative systemic inflammatory response is predictive of cancer recurrence after potentially curative resection. Lipopolysaccharides (LPS) are membrane surface markers of gram-negative bacteria, which induce gut barrier dysfunction and inflammation and might be significantly involved in the occurrence and development of CRC.
Methods
A selective literature search was conducted in Medline and PubMed, using the terms “Colorectal Cancer”, “Gut Barrier”, “Lipopolysaccharides”, and “Inflammation”.
Results
Disruption of intestinal homeostasis, including gut barrier dysfunction, is linked to increased LPS levels and is a critical factor for chronic inflammation. LPS can activate the diverse nuclear factor-κB (NF-κB) pathway via Toll-like receptors 4 (TLR4) to promote the inflammatory response, which aggravates gut barrier dysfunction and encourages CRC development. An intact gut barrier prevents antigens and bacteria from crossing the intestinal endothelial layer and entering circulation. In contrast, a damaged gut barrier triggers inflammatory responses and increases susceptibility to CRC. Thus, targeting LPS and the gut barrier might be a promising novel therapeutic approach for additional treatment of CRC.
Conclusion
Gut barrier dysfuction and bacterial LPS seem to play an important role in the pathogenesis and disease progression of colorectal cancer and therefore require further investigation.
Abstract
Background and Aims
Dysregulated T cell responses contribute to the pathogenesis of inflammatory bowel disease IBD. Because vitamin D vitD deficiency is a risk factor for adverse disease ...outcomes, we aimed to characterize the impact of vitD on intestinal and peripheral T cell profiles.
Methods
T cells were isolated from peripheral blood and intestinal biopsies of IBD patients, incubated with vitD and characterized by flow cytometry. To translate these in vitro findings to the clinic, serum vitD concentrations and clinical outcomes were correlated with T cell phenotype and function in a prospective patient cohort.
Results
Incubation of peripheral and intestinal T cells with 1,25(OH)2-vitD resulted in strongly reduced frequencies of pro-inflammatory CD4+ and CD8+ T cells producing interferon γ IFNγ, interleukin-17 IL-17, IL-22, IL-9 and tumour necrosis factor TNF. Univariable analysis of 200 IBD patients revealed associations of vitD deficiency with non-compliant vitD intake, season of the year and anaemia in Crohn’s disease CD as well as disease activity in ulcerative colitis UC. Ex vivo immunophenotyping revealed that CD4+ and CD8+ T cell subsets were not substantially altered in vitD-deficient vs vitD-sufficient patients while regulatory T cell frequencies were reduced in UC and non-smoking CD patients with vitD deficiency. However, normalization of serum vitD concentrations in previously deficient CD patients resulted in significantly reduced frequencies of CD4+ T cells producing IFNγ, IL-17 and IL-22.
Conclusion
vitD exerts profound anti-inflammatory effects on peripheral and intestinal CD4+ and CD8+ T cells of IBD patients in vitro and inhibits TH1 and TH17 cytokine production in CD patients in vivo.
Background and aims
Early-onset colorectal neoplasms (EoCRN) include both benign and malign colorectal tumors, which occur before the age of 50. The incidence of EoCRN is rising worldwide. Tobacco ...smoking has previously been proven to be related to the development of various tumor types. However, its relationship with EoCRN is not clearly defined. Hence, we carried out a systematic review and a meta-analysis to evaluate the relationship between smoking status and the risk of EoCRN.
Methods
A systematic search of PubMed, EMBASE, and Web of Science up to September 7, 2022, was performed for studies that evaluated the association of smoking status with EoCRN. The quality of the case–control study was evaluated with the Newcastle‒Ottawa Scale. The quality of the cross-sectional studies was evaluated with the American Health Care Research and Quality checklist. Fixed-effects models were used to pool odds ratios (ORs) to evaluate the relationship between the risk of developing EoCRN and smoking status. The meta-analyses were performed with Review Manager version 5.4, and funnel plots and publication bias tests were produced by STATA software.
Results
A total of six studies were included in this meta-analysis. After pooling the results of these six studies, we found that current smokers carry a relatively high risk of developing EoCRN (OR, 1.33; 95% confidence interval CI, 1.17–1.52) compared to never-smokers. Ex-smokers were not at a significantly increased risk for developing EoCRN (OR, 1.00; 95% CI, 0.86–1.18).
Discussion
Smoking behavior is significantly associated with an increased risk for developing EoCRN and might be one of the reasons for the increasing incidence. Ex-smokers who quit are not at significant risk of developing EoCRN.
Intestinal homeostasis is a crucial factor for complication-free short- and long-term postoperative recovery. The brush border enzyme intestinal alkaline phosphatase (IAP) is an important regulator ...of gut barrier function and intestinal homeostasis and prevents endotoxemia by detoxifying lipopolysaccharides (LPSs). As IAP is predominantly secreted by enterocytes in the duodenum, we hypothesized that pancreaticoduodenectomy (PD) leads to a significantly stronger decrease in IAP than other major abdominal surgery.
Pre- and postoperative blood, stool, and intestinal samples were collected from patients undergoing PD, as well as other major surgical procedures without duodenectomy. The samples were analyzed using enzyme histochemistry, the para -nitrophenyl phosphate method for IAP, and the limulus amebocyte lysate assay for LPS.
Overall, 88 patients were prospectively enrolled in the study. Fecal IAP activity negatively correlated with serum LPS (r = -0.3603, p = 0.0006). PD led to a significant decline in IAP compared to preoperative baseline levels (p < 0.0001). The decline in IAP correlated with the length of proximal small intestinal resection (r = 0.4271, p = 0.0034). Compared to controls, PD was associated with a much more pronounced reduction in IAP-also after adjusting for surgical trauma (operative time, blood loss; r = 0.4598, p = 0.0086). Simultaneously, PD triggered a clearly more prominent increase in serum LPS compared to controls (p = 0.0001). Increased postoperative LPS was associated with an elongated hospitalization (r = 0.7534, p = 0.0062) and more prominent in pancreatic cancer (p = 0.0009).
Based upon the functional roles for IAP, supplementation with exogenous IAP might be a new treatment option to improve short- and long-term outcome after PD.
Zusammenfassung
Einleitung
Die neue, vermehrt kompetenzbasierte Weiterbildungsordnung für die chirurgische Weiterbildung (WBO) trat in Bayern im August 2022 in Kraft.
Methoden
Von Mai bis Juli 2022 ...führten wir eine anonymisierte Onlineumfrage unter den bayerischen Allgemein- und Viszeralchirurginnen und -cChirurgen sowie den Ärzt*innen in Weiterbildung (ÄiW) durch. Ziel war die Erfragung der Erwartungen an die Effekte der neuen WBO.
Ergebnisse
Die Rücklaufquote betrug 35 %; insgesamt konnten Daten von 80 Personen erhoben werden: 36 ÄiW (45 %), 30 Fach- und Oberärzt*innen (37,5 %) und 14 Chefärzt*innen (17,5 %). Die Mehrheit der Befragten arbeitete an einem Universitätsklinikum (38,8 %) oder Regelversorger (35 %). Eine Stärkung der Handlungskompetenz durch Umsetzung der neuen WBO erwarten 41,3 % und 55,7 % sehen als Ziel ein „selbstständiges Operieren unter teilweiser Aufsicht durch den Ausbilder“. 50 % sehen die geforderten Richtzahlen als nicht erreichbar an, bzw. 55,1 % verneinen ein Erreichen derselben im Zeitraum von 6 Jahren. Etwa 60 % erwarten, nicht die gleiche Anzahl an ÄiW in der gleichen Zeit ausbilden zu können. Fast 75 % der Befragten geben an, dass aus ihrer Sicht eine gute Weiterbildung mit Erreichen einer soliden Handlungskompetenz ohne Überstunden nicht funktioniere. Etwa 44 % der Befragten erwarten, dass die volle Weiterbildung an ihrem Haus auch weiterhin möglich sei.
Schlussfolgerung
Sowohl unter den Weiterbilder*innen als auch unter den ÄiW besteht tendenziell die Sorge, dass eine realistische Weiterbildung – insbesondere das Erreichen der Richtzahlen in der bisher üblichen Weiterbildungszeit – nicht möglich sein wird. Notwendig ist daher die konsequente Umsetzung einer strukturierten Weiterbildung mit hoher Transparenz der Ausbildung.
The new competency-based continuing education regulations for surgical training (WBO) came into effect in Bavaria in August 2022.
From May to July 2022, we conducted an anonymized online survey among ...Bavarian general and visceral surgeons and surgical residents (ÄiW). The aim was to survey expectations of the effects of the new WBO.
The response rate was 35%. In total data could be collected from 80 persons, 36 ÄiW (45%), 30 specialists and senior physicians (37.5%) and 14 chief physicians (17.5%). The majority of respondents worked at a university hospital (38.8%) or a regular provider (35%). A strengthening of the competence to act through implementation of the new WBO is seen by 41.3% and 55.7% see independent operating under partial supervision by the instructor as a goal. Of the respondents 50% see the required case numbers as not achievable and 55.1% deny reaching them in the expected period of 6 years. About 60% do not expect to be able to train the same number of ÄiWs in the same amount of time. Almost 75% of the respondents state that from their point of view, a good continuing education with the achievement of a solid competence to act would not work without overtime hours. About 44% of the respondents expect that a full surgical training would continue to be possible at their institution.
Both among the instructors and among the trainees there is a tendency to fear that realistic training, in particular the achievement of the guideline figures, will no longer be possible in the usual further training time. This necessitates the consistent implementation of structured continuing education with a high degree of transparency in training.
