Elizabeth C. Wick

A human colonic commensal promotes colon tumorigenesis via activation of T helper type 17 T cell responses.

The intestinal flora may promote colon tumor formation. Here we explore immunologic mechanisms of colonic carcinogenesis by a human colonic bacterium, enterotoxigenic Bacteroides fragilis (ETBF). ETBF that secretes B. fragilis toxin (BFT) causes human inflammatory diarrhea but also asymptomatically colonizes a proportion of the human population. Our results indicate that whereas both ETBF and nontoxigenic B. fragilis (NTBF) chronically colonize mice, only ETBF triggers colitis and strongly induces colonic tumors in multiple intestinal neoplasia (Min) mice. ETBF induces robust, selective colonic signal transducer and activator of transcription-3 (Stat3) activation with colitis characterized by a selective T helper type 17 (TH17) response distributed between CD4+ T cell receptor-αβ (TCRαβ)+ and CD4–8–TCRγδ+ T cells. Antibody-mediated blockade of interleukin-17 (IL-17) as well as the receptor for IL-23, a key cytokine amplifying TH17 responses, inhibits ETBF-induced colitis, colonic hyperplasia and tumor formation. These results show a Stat3- and TH17-dependent pathway for inflammation-induced cancer by a common human commensal bacterium, providing new mechanistic insight into human colon carcinogenesis.

Readmission rates and cost following colorectal surgery

BACKGROUND: Hospital readmission is emerging as a quality indicator by the state, federal, and private payors with the goal of denying payment for select readmissions. OBJECTIVE: We designed a study to measure the rate, cost, and risk factors for hospital readmission after colorectal surgery. STUDY DESIGN/SETTING: We reviewed commercial health insurance records of 10,882 patients who underwent colorectal surgery over a 7-year period (2002–2008). PATIENTS: All patients undergoing colon and/or rectal resection ages 18 to 64 were included. MAIN OUTCOME MEASURE: The 30-day and 90-day readmission rates, the number of readmissions per patient, the median cost, length of stay, and risk factors for readmission were analyzed. RESULTS: Thirty-day readmission occurred in 11.4% (1239/10,882) of patients. Readmission between 31 and 90 days occurred in an additional 11.9% (1027/10,882) of patients for a total 90-day readmission rate of 23.3%. Two or more readmissions occurred in 1.4% (155) and 5.2% (570) of patients in the first 30 and 90 days. Mean readmission length of stay was 8 days, and the median cost per stay was

Microbiota organization is a distinct feature of proximal colorectal cancers

8885. Initial hospitalization risk factors for readmission were the diagnosis of a surgical site infection (OR 1.2), creation of a stoma (OR 1.2), discharge to nursing home (OR 1.2), index admission length of stay >7 days (OR 1.2), proctectomy (OR 1.1), and severity of illness score (severity of illness 3 = OR 1.1; severity of illness 4 = OR 1.3). CONCLUSIONS: Readmission after colorectal surgery occurs frequently and is associated with a cost of approximately

Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections

9000 per readmission. Nationwide these findings account for

The Bacteroides fragilis toxin gene is prevalent in the colon mucosa of colorectal cancer patients

300 million in readmission costs annually for colorectal surgery alone. Clinical and systems-based prevention strategies are needed to reduce readmission.

Patient Satisfaction as a Possible Indicator of Quality Surgical Care

Significance We demonstrate, to our knowledge for the first time, that bacterial biofilms are associated with colorectal cancers, one of the leading malignancies in the United States and abroad. Colon biofilms, dense communities of bacteria encased in a likely complex matrix that contact the colon epithelial cells, are nearly universal on right colon tumors. Most remarkably, biofilm presence correlates with bacterial tissue invasion and changes in tissue biology with enhanced cellular proliferation, a basic feature of oncogenic transformation occurring even in colons without evidence of cancer. Microbiome profiling revealed that biofilm communities on paired normal mucosa cluster with tumor microbiomes but lack distinct taxa differences. This work introduces a previously unidentified concept whereby microbial community structural organization exhibits the potential to contribute to disease progression. Environmental factors clearly affect colorectal cancer (CRC) incidence, but the mechanisms through which these factors function are unknown. One prime candidate is an altered colonic microbiota. Here we show that the mucosal microbiota organization is a critical factor associated with a subset of CRC. We identified invasive polymicrobial bacterial biofilms (bacterial aggregates), structures previously associated with nonmalignant intestinal pathology, nearly universally (89%) on right-sided tumors (13 of 15 CRCs, 4 of 4 adenomas) but on only 12% of left-sided tumors (2 of 15 CRCs, 0 of 2 adenomas). Surprisingly, patients with biofilm-positive tumors, whether cancers or adenomas, all had biofilms on their tumor-free mucosa far distant from their tumors. Bacterial biofilms were associated with diminished colonic epithelial cell E-cadherin and enhanced epithelial cell IL-6 and Stat3 activation, as well as increased crypt epithelial cell proliferation in normal colon mucosa. High-throughput sequencing revealed no consistent bacterial genus associated with tumors, regardless of biofilm status. However, principal coordinates analysis revealed that biofilm communities on paired normal mucosa, distant from the tumor itself, cluster with tumor microbiomes as opposed to biofilm-negative normal mucosa bacterial communities also from the tumor host. Colon mucosal biofilm detection may predict increased risk for development of sporadic CRC.

Surgical Site Infections and Cost in Obese Patients Undergoing Colorectal Surgery

BACKGROUND Surgical site infections (SSI) are a common and costly problem, prolonging hospitalization and increasing readmission. Adherence to well-known infection control process measures has not been associated with substantial reductions in SSI. To date, the global burden of preventable SSI continues to result in patient harm and increased health care costs on a broad scale. STUDY DESIGN We designed a study to evaluate the association between implementation of a surgery-based comprehensive unit-based safety program (CUSP) and postoperative SSI rates. One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program (July 2009 to July 2011). The CUSP group met monthly and consisted of a multidisciplinary team of front-line providers (eg, surgeons, nurses, operating room technicians, and anesthesiologists) who were directly involved in the care of colorectal surgery patients. Surgical Care Improvement Project process measure compliance was monitored using standard methods from the Centers for Medicare and Medicaid Services. RESULTS In the 12 months before implementation of the CUSP and interventions, the mean SSI rate was 27.3% (76 of 278 patients). After commencement of interventions, the rate was 18.2% (59 of 324 patients) for the subsequent 12 months--a 33.3% decrease (95% CI, 9-58%; p < 0.05). The interventions included standardization of skin preparation; administration of preoperative chlorhexidine showers; selective elimination of mechanical bowel preparation; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for skin and fascial closure; addressing previously unrecognized lapses in antibiotic prophylaxis. There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period. CONCLUSIONS Formation of small groups of front-line providers to address patient harm using local wisdom and existing evidence can improve patient safety. We demonstrate a surgery-based CUSP intervention that might have markedly decreased SSI in a high-risk population.

Metabolism Links Bacterial Biofilms and Colon Carcinogenesis

BACKGROUND Enterotoxigenic Bacteroides fragilis (ETBF) produces the Bacteroides fragilis toxin, which has been associated with acute diarrheal disease, inflammatory bowel disease, and colorectal cancer (CRC). ETBF induces colon carcinogenesis in experimental models. Previous human studies have demonstrated frequent asymptomatic fecal colonization with ETBF, but no study has investigated mucosal colonization that is expected to impact colon carcinogenesis. METHODS We compared the presence of the bft gene in mucosal samples from colorectal neoplasia patients (cases, n = 49) to a control group undergoing outpatient colonoscopy for CRC screening or diagnostic workup (controls, n = 49). Single bacterial colonies isolated anaerobically from mucosal colon tissue were tested for the bft gene with touch-down polymerase chain reaction. RESULTS The mucosa of cases was significantly more often bft-positive on left (85.7%) and right (91.7%) tumor and/or paired normal tissues compared with left and right control biopsies (53.1%; P = .033 and 55.5%; P = .04, respectively). Detection of bft was concordant in most paired mucosal samples from individual cases or controls (75% cases; 67% controls). There was a trend toward increased bft positivity in mucosa from late- vs early-stage CRC patients (100% vs 72.7%, respectively; P = .093). In contrast to ETBF diarrheal disease where bft-1 detection dominates, bft-2 was the most frequent toxin isotype identified in both cases and controls, whereas multiple bft isotypes were detected more frequently in cases (P ≤ .02). CONCLUSIONS The bft gene is associated with colorectal neoplasia, especially in late-stage CRC. Our results suggest that mucosal bft exposure is common and may be a risk factor for developing CRC.

Localization of calcitonin receptor‐like receptor and receptor activity modifying protein 1 in enteric neurons, dorsal root ganglia, and the spinal cord of the rat

IMPORTANCE In 2010, national payers announced they would begin using patient satisfaction scores to adjust reimbursements for surgical care. OBJECTIVE To determine whether patient satisfaction is independent from surgical process measures and hospital safety. DESIGN We compared the performance of hospitals that participated in the Patient Satisfaction Survey, the Centers for Medicare & Medicaid Services Surgical Care Improvement Program, and the employee Safety Attitudes Questionnaire. SETTING Thirty-one US hospitals. PARTICIPANTS Patients and hospital employees. INTERVENTIONS There were no interventions for this study. MAIN OUTCOMES AND MEASURES Hospital patient satisfaction scores were compared with hospital Surgical Care Improvement Program compliance and hospital employee safety attitudes (safety culture) scores during a 2-year period (2009-2010). Secondary outcomes were individual domains of the safety culture survey. RESULTS Patient satisfaction was not associated with performance on process measures (antibiotic prophylaxis, R = -0.216 [P = .24]; appropriate hair removal, R = -0.012 [P = .95]; Foley catheter removal, R = -0.089 [P = .63]; deep vein thrombosis prophylaxis, R = 0.101 [P = .59]). In addition, patient satisfaction was not associated with a hospitals overall safety culture score (R = 0.295 [P = .11]). We found no association between patient satisfaction and the individual culture domains of job satisfaction (R = 0.327 [P = .07]), working conditions (R = 0.191 [P = .30]), or perceptions of management (R = 0.223 [P = .23]); however, patient satisfaction was associated with the individual culture domains of employee teamwork climate (R = 0.439 [P = .01]), safety climate (R = 0.395 [P = .03]), and stress recognition (R = -0.462 [P = .008]). CONCLUSIONS AND RELEVANCE Patient satisfaction was independent of hospital compliance with surgical processes of quality care and with overall hospital employee safety culture, although a few individual domains of culture were associated. Patient satisfaction may provide information about a hospitals ability to provide good service as a part of the patient experience; however, further study is needed before it is applied widely to surgeons as a quality indicator.

Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes.

OBJECTIVES To measure the effect of obesity on surgical site infection (SSI) rates and to define the cost of SSIs in patients undergoing colorectal surgery. DESIGN, SETTING, AND PATIENTS This is a retrospective cohort study of 7020 colectomy patients using administrative claims data from 8 Blue Cross and Blue Shield insurance plans. Patients who had a total or segmental colectomy for colon cancer, diverticulitis, or inflammatory bowel disease between January 1, 2002, and December 31, 2008, were included. MAIN OUTCOME MEASURES We compared 30-day SSI rates among obese and nonobese patients and calculated total costs from all health care claims for 90 days following surgery. Multivariate logistic regression was performed to identify risk factors for SSIs. RESULTS Obese patients had an increased rate of SSI compared with nonobese patients (14.5% vs 9.5%, respectively; P < .001). Independent risk factors for these infections were obesity (odds ratio = 1.59; 95% confidence interval, 1.32-1.91) and open operation as compared with a laparoscopic procedure (odds ratio = 1.57; 95% confidence interval, 1.25-1.97). The mean total cost was