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Elderly Patients Benefit From Enhanced Recovery Protocols After Colorectal Surgery.
Liu, JY, Perez, SD, Balch, GG, Sullivan, PS, Srinivasan, JK, Staley, CA, Sweeney, J, Sharma, J, Shaffer, VO
The Journal of surgical research. 2021;:54-61
Abstract
BACKGROUND Enhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols. METHODS We queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile. RESULTS Two hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value < 0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value < 0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days. CONCLUSION Overall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.
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Sevelamer Use in End-Stage Kidney Disease (ESKD) Patients Associates with Poor Vitamin K Status and High Levels of Gut-Derived Uremic Toxins: A Drug-Bug Interaction?
Dai, L, Meijers, BK, Bammens, B, de Loor, H, Schurgers, LJ, Qureshi, AR, Stenvinkel, P, Evenepoel, P
Toxins. 2020;(6)
Abstract
Gut microbial metabolism is not only an important source of uremic toxins but may also help to maintain the vitamin K stores of the host. We hypothesized that sevelamer therapy, a commonly used phosphate binder in patients with end-stage kidney disease (ESKD), associates with a disturbed gut microbial metabolism. Important representatives of gut-derived uremic toxins, including indoxyl sulfate (IndS), p-Cresyl sulfate (pCS), trimethylamine N-oxide (TMAO), phenylacetylglutamine (PAG) and non-phosphorylated, uncarboxylated matrix-Gla protein (dp-ucMGP; a marker of vitamin K status), were analyzed in blood samples from 423 patients (65% males, median age 54 years) with ESKD. Demographics and laboratory data were extracted from electronic files. Sevelamer users (n = 172, 41%) were characterized by higher phosphate, IndS, TMAO, PAG and dp-ucMGP levels compared to non-users. Sevelamer was significantly associated with increased IndS, PAG and dp-ucMGP levels, independent of age, sex, calcium-containing phosphate binder, cohort, phosphate, creatinine and dialysis vintage. High dp-ucMGP levels, reflecting vitamin K deficiency, were independently and positively associated with PAG and TMAO levels. Sevelamer therapy associates with an unfavorable gut microbial metabolism pattern. Although the observational design precludes causal inference, present findings implicate a disturbed microbial metabolism and vitamin K deficiency as potential trade-offs of sevelamer therapy.
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Risk factors for ileocolic anastomosis dehiscence; a cohort study.
Golda, T, Lazzara, C, Zerpa, C, Sobrino, L, Fico, V, Kreisler, E, Biondo, S
American journal of surgery. 2020;(1):170-177
Abstract
BACKGROUND Anastomotic leak (AL) after ileocolic anastomosis influences morbidity, mortality, length of hospitalization and costs. This study analyzes risk and protective factors for AL on ileocolic anastomoses. METHODS We retrospectively analyzed our single institution patients' series undergoing elective ileocolic anastomosis for AL between 1/2008-12/2017. AL grade A/B (antibiotic treatment and/or radiological drainage) were summarized as mild, grade C (surgical re-intervention) corresponds to severe AL. RESULTS We included 470 patients (mean age 70.8 years, 43.2% females). Overall AL rate was 9.4% (44 patients) with 6.0% severe and 3.4% mild AL. There was no difference in AL between hand sewn and stapled anastomoses. Multivariate analysis revealed preoperative serum albumin (p = 0.004), smoking habits (p = 0.005) and perioperative blood transfusion (p = 0.038) as risk factors for AL. Suture oversewing as anastomotic reinforcement resulted as independent protective factor (p < 0.001). CONCLUSION Poor nutritional status, smoking habits and perioperative blood transfusion are negative factors influencing on AL. Suture oversewing as anastomotic reinforcement associates with significantly less AL.
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Dietary quality and the colonic mucosa-associated gut microbiome in humans.
Liu, Y, Ajami, NJ, El-Serag, HB, Hair, C, Graham, DY, White, DL, Chen, L, Wang, Z, Plew, S, Kramer, J, et al
The American journal of clinical nutrition. 2019;(3):701-712
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Abstract
BACKGROUND Despite tremendous interest in modulating the microbiome to improve health, the association between diet and the colonic mucosa-associated gut microbiome in healthy individuals has not been examined. OBJECTIVE To investigate the associations between Healthy Eating Index (HEI)-2005 and the colonic mucosa-associated microbiota. METHODS In this cross-sectional observational study, we analyzed bacterial community composition and structure using 16S rRNA gene (V4 region) sequencing of 97 colonic mucosal biopsies obtained endoscopically from different colon segments of 34 polyp-free participants. Dietary consumption was ascertained using an FFQ. Differences in α- and β-diversity and taxonomic relative abundances between the higher and lower score of total HEI and its components were compared, followed by multivariable analyses. RESULTS The structure of the microbiota significantly differed by the scores for total HEI, total and whole fruits (HEI 1 and HEI 2), whole grains (HEI 6), milk products and soy beverages (HEI 7), and solid fat, alcohol, and added sugar (HEI 12). A lower score for total HEI and HEIs 2, 7, and 12 was associated with significantly lower richness. A lower score for total HEI was associated with significantly reduced relative abundance of Parabacteroides, Roseburia, and Subdoligranulum but higher Fusobacterium. A lower score for HEI 2 was associated with lower Roseburia but higher Bacteroides. A lower score for HEI 7 was associated with lower Faecalibacterium and Fusobacterium but higher Bacteroides. A lower score for HEI 12 was associated with lower Subdoligranulum but higher Escherichia and Fusobacterium (false discovery rate-adjusted P values <0.05). The findings were confirmed by multivariate analysis. Less abundant bacteria such as Alistipes, Odoribacter, Bilophila, and Tyzzerella were also associated with dietary quality. CONCLUSIONS A lower score for total HEI-2005 was significantly associated with reduced relative abundance of potentially beneficial bacteria but increased potentially harmful bacteria in the colonic mucosa of endoscopically normal individuals.
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Fungal Dysbiosis in Mucosa-associated Microbiota of Crohn's Disease Patients.
Liguori, G, Lamas, B, Richard, ML, Brandi, G, da Costa, G, Hoffmann, TW, Di Simone, MP, Calabrese, C, Poggioli, G, Langella, P, et al
Journal of Crohn's & colitis. 2016;(3):296-305
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Abstract
BACKGROUND AND AIMS Gut microbiota is involved in many physiological functions and its imbalance is associated with several diseases, particularly with inflammatory bowel diseases. Mucosa-associated microbiota could have a key role in induction of host immunity and in inflammatory process. Although the role of fungi has been suggested in inflammatory disease pathogenesis, the fungal microbiota has not yet been deeply explored. Here we analysed the bacterial and fungal composition of the mucosa-associated microbiota of Crohn's disease patients and healthy subjects. METHODS Our prospective, observational study evaluated bacterial and fungal composition of mucosa-associated microbiota of 23 Crohn's disease patients [16 in flare, 7 in remission] and 10 healthy subjects, using 16S [MiSeq] and ITS2 [pyrosequencing] sequencing, respectively. Global fungal load was assessed by real time quantitative polymerase chain reaction. RESULTS Bacterial microbiota in Crohn's disease patients was characterised by a restriction in biodiversity. with an increase of Proteobacteria and Fusobacteria. Global fungus load was significantly increased in Crohn's disease flare compared with healthy subjects [p < 0.05]. In both groups, the colonic mucosa-associated fungal microbiota was dominated by Basidiomycota and Ascomycota phyla. Cystofilobasidiaceae family and Candida glabrata species were overrepresented in Crohn's disease. Saccharomyces cerevisiae and Filobasidium uniguttulatum species were associated with non-inflamed mucosa, whereas Xylariales order was associated with inflamed mucosa. CONCLUSIONS Our study confirms the alteration of the bacterial microbiota and is the first demonstration of the existence of an altered fungal microbiota in Crohn's disease patients, suggesting that fungi may play a role in pathogenesis.
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Diffusion-weighted magnetic resonance imaging without bowel preparation for detection of ulcerative colitis.
Yu, LL, Yang, HS, Zhang, BT, Lv, ZW, Wang, FR, Zhang, CY, Chen, WB, Zhang, HM
World journal of gastroenterology. 2015;(33):9785-92
Abstract
AIM: To evaluate the accuracy of diffusion-weighted imaging (DWI) without bowel preparation, the optimal b value and the changes in apparent diffusion coefficient (ADC) in detecting ulcerative colitis (UC). METHODS A total of 20 patients who underwent 3T magnetic resonance imaging (MRI) without bowel preparation and colonoscopy within 24 h were recruited. Biochemical indexes, including C-reactive protein (CRP), erythrocyte sedimentation rate, hemoglobin, leucocytes, platelets, serum iron and albumin, were determined. Biochemical examinations were then performed within 24 h before or after MR colonography was conducted. DWI was performed at various b values (b = 0, 400, 600, 800, and 1000 s/mm(2)). Two radiologists independently and blindly reviewed conventional- and contrast-enhanced MR images, DWI and ADC maps; these radiologists also determined ADC in each intestinal segment (rectum, sigmoid, left colon, transverse colon, and right colon). Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic performance of DWI hyperintensity from various b factors, ADC values and different radiological signs to detect endoscopic inflammation in the corresponding bowel segment. Optimal ADC threshold was estimated by maximizing the combination of sensitivity and specificity. MR findings were correlated with endoscopic results and clinical markers; these findings were then estimated by ROC analysis. RESULTS A total of 100 segments (71 with endoscopic colonic inflammation; 29 normal) were included. The proposed total magnetic resonance score (MR-score-T) was correlated with the total modified Baron score (Baron-T; r = 0.875, P < 0.0001); the segmental MR score (MR-score-S) was correlated with the segmental modified Baron score (Baron-S; r = 0.761, P < 0.0001). MR-score-T was correlated with clinical and biological markers of disease activity (r = 0.445 to 0.831, P < 0.05). MR-score-S > 1 corresponded to endoscopic colonic inflammation with a sensitivity of 85.9%, a specificity of 82.8% and an area under the curve (AUC) of 0.929 (P < 0.0001). The accuracy of DWI hyperintensity was significantly greater at b = 800 than at b = 400, 600, or 1000 s/mm(2) (P < 0.05) when endoscopic colonic inflammation was detected. DWI hyperintensity at b = 800 s/mm(2) indicated endoscopic colonic inflammation with a sensitivity of 93.0%, a specificity of 79.3% and an AUC of 0.867 (P < 0.0001). Quantitative analysis results revealed that ADC values at b = 800 s/mm(2) differed significantly between endoscopic inflamed segment and normal intestinal segment (1.56 ± 0.58 mm(2)/s vs 2.63 ± 0.46 mm(2)/s, P < 0.001). The AUC of ADC values was 0.932 (95% confidence interval: 0.881-0.983) when endoscopic inflammation was detected. The threshold ADC value of 2.18 × 10(-3) mm(2)/s indicated that endoscopic inflammation differed from normal intestinal segment with a sensitivity of 89.7% and a specificity of 80.3%. CONCLUSION DWI combined with conventional MRI without bowel preparation provides a quantitative strategy to differentiate actively inflamed intestinal segments from the normal mucosa to detect UC.