Eloy Espin-Basany

Lactobacillus casei downregulates commensals' inflammatory signals in Crohn's disease mucosa

Background: The interaction of commensal bacteria with the intestinal immune system is an essential factor in the development of inflammatory bowel disease (IBD). The study of isolated commensal bacterias effects on the mucosal immune response might be relevant for a better understanding of pathophysiological mechanisms in IBD. Methods: We investigated the immune responses to signals from the commensal Escherichia coli ATCC 35345 and the probiotic Lactobacillus casei DN‐114 001 in Crohns disease (CD) mucosa. Ileal specimens were obtained during surgery from CD patients. Mucosal explants were incubated with L. casei or its genomic DNA; TNF‐&agr;, IFN‐&ggr;, IL‐2, IL‐6, IL‐8, and CXCL1 were measured in the supernatant. Second, tissue expression of key proinflammatory cytokines (IL‐6, TGF‐&bgr;, IL‐23p19, IL‐12p35, IL‐17F), and chemokines (IL‐8, CXCL1, CXCL2) was evaluated after incubation with L. casei or E. coli. Finally, combination experiments were carried out by incubating both strains with mucosal explants at different timepoints. Results: Live L. casei significantly decreased secretion of TNF‐&agr;, IFN‐&ggr;, IL‐2, IL‐6, IL‐8, and CXCL1 by CD mucosa, but the effect was not reproduced by L. casei DNA. Second, live L. casei downregulated expression of IL‐8, IL‐6, and CXCL1 and did not modify expression of IL‐23p19, IL‐12p35, and IL‐17F. In contrast, E. coli significantly upregulated expression of all these cytokines. Interestingly, combination experiments revealed the ability of L. casei to prevent and counteract the proinflammatory effects of E. coli. Conclusions: Live L. casei can counteract the proinflammatory effects of E. coli on CD inflamed mucosa by specific downregulation of key proinflammatory mediators.

Prospective, randomised study on antibiotic prophylaxis in colorectal surgery. Is it really necessary to use oral antibiotics?

Background and aimsThe use of prophylactic antibiotics in addition to mechanical cleansing is the current standard of care prior to colonic surgery. The question of whether the antibiotics should be administered intravenously or orally, or by both routes, remains controversial. Our aim was to compare three methods of prophylactic antibiotic administration in elective colorectal surgery.MethodsThree hundred consecutive elective colorectal resections were studied. All patients had preoperative mechanical colon cleansing with oral sodium phosphate and intravenous antibiotic prophylaxis with cefoxitin (one dose before skin incision and two postoperative doses). Patients were randomised to one of the following three groups: group A: three doses of oral antibiotic (neomycin and metronidazole) at the time of mechanical colon cleansing; group B: one dose of oral antibiotic; group C: no oral antibiotics. All patients were followed during their hospital stay and at 7, 14 and 30 days post-surgery.ResultsVomiting occurred in 31%, 11% and 9% of the studied patients (groups A, B and C, respectively) (p<0.001). Nausea was present in 44%, 18% and 13% of patients (p<0.001). Abdominal pain was recorded in 13%, 10% and 4% of patients (p: 0.077). Wound infection was present in 7%, 8% and 6% and suture dehiscence occurred in 2%, 2% and 3% of the patients in the three groups (no differences among them). Neither were differences found among the three groups in terms of urinary infections, pneumonia, postoperative ileus or intra-abdominal abscess.ConclusionThe addition of three doses of oral antibiotics to intravenous antibiotic prophylaxis is associated with lower patient tolerance in terms of increased nausea, vomiting and abdominal pain, and has shown no advantages in the prevention of postoperative septic complications. Therefore, we recommend that oral antibiotics should not be used prior to colorectal surgery.

Prosthetic Mesh in Parastomal Hernia Prevention. Laparoscopic Approach

ABSTRACT: The use of a sublay mesh in open surgery has been probed to be an efficient strategy for the prevention of parastomal hernia. Based on these previous reports, placing a composite mesh (polypropylene/cellulose) in an intraperitoneal fashion seems to be a good technique when a laparoscopic approach is performed. This technique is easy to perform. Mesh is kept in place with the help of tackers, normal intra-abdominal pressure, and the colon itself. We report the description of a laparoscopic technique for placing an intraperitoneal mesh for the prevention of a parastomal hernia.

Influence of Rescrubbing Before Laparotomy Closure on Abdominal Wound Infection After Colorectal Cancer Surgery: Results of a Multicenter Randomized Clinical Trial

OBJECTIVE To test the hypothesis that strict asepsis in closing wounds following laparotomy reduces the risk for surgical wound infection in elective colorectal cancer surgery. DESIGN Multicenter randomized clinical trial conducted from June 1, 2009, through June 1, 2010. SETTINGS Colorectal surgery units of 9 Spanish hospitals. PATIENTS A total of 969 patients who underwent elective colorectal cancer surgery were eligible for randomization. In closing the laparotomy wound, the patients were randomized to 2 groups: conventional (n=516) and new operation (n=453). In the conventional group, a new set of instruments was used, surgical staff changed their gloves, and the surgical drapes surrounding the laparotomy were covered by a new set of drapes. The new operation group involved removing all drapes, the surgical staff scrubbed again, and a new set of drapes and instruments was used. MAIN OUTCOME MEASURES Incisional (superficial and deep) surgical site infection 30 days after the operation and risk factors for postoperative wound infections. RESULTS A total of 146 incisional surgical site infections (15.1%) were diagnosed. Of these, 96 (9.9%) were superficial and 50 (5.1%) were deep infections. On an intent-to-treat basis, significant differences were found between both groups (66 [12.8%] in the conventional group vs 80 [17.7%] in the new operation group [P=.04]). CONCLUSION This study does not support the use of rescrubbing to reduce the incidence of incisional surgical site infection. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN19463413

Factors associated with low anterior resection syndrome after surgical treatment of rectal cancer

The aim was to assess factors independently associated with low anterior resection syndrome (LARS) following resection for rectal cancer.

Double Barreled Wet Colostomy: Initial Experience and Literature Review

Background. Pelvic exenteration and multivisceral resection in colorectal have been described as a curative and palliative intervention. Urinary tract reconstruction in a pelvic exenteration is achieved in most cases with an ileal conduit of Bricker, although different urinary reservoirs have been described. Methods. A retrospective and observational study of six patients who underwent a pelvic exenteration and urinary tract reconstruction with a double barreled wet colostomy (DBWC) was done, describing the preoperative diagnosis, the indication for the pelvic exenteration, the complications associated with the procedure, and the followup in a period of 5 years. A literature review of the case series reported of the technique was performed. Results. Six patients had a urinary tract reconstruction with the DBWC technique, 5 male patients and one female patient. Age range was from 20 to 77 years, with a medium age 53.6 years. The most frequent complication presented was a pelvic abscess in 3 patients (42.85%); all complications could be resolved with a conservative treatment. Conclusion. In the group of our patients with pelvic exenteration and urinary tract reconstruction with a DBWC, it is a safe procedure and well tolerated by the patients, and most of the complications can be resolved with conservative treatment.

Exenteración pélvica con resección rectal por neoplasias de distinto origen en dos centros de referencia

INTRODUCTION Pelvic exenteration (PE) offers the best chance of cure for locally advanced primary or recurrent pelvic organ malignancies invading adjacent organs. The aims of this study were to analyse results for any pelvic exenteration that includes rectal resection and the analysis of results of fecal and urinary reconstruction. METHOD From January 2000 to April 2014, 111 PE with rectal resection for any pelvic cancer were analysed retrospectively at two national tertiary referral centers. RESULTS Thirty-six colorectal anastomosis were performed. Urologic reconstructions performed were 30 double barrelled wet colostomy (DBWC), 14 Bricker ileal conduit (BIC), and 2 ureterocutaneostomies. Postoperative complications occurred in 71 patients (64%). Six deaths (5.4%) occurred within 30 postoperative days. Five-year overall survival following R0 resection was 62.6%; R1: 42.7%; R2: 24.2% (P=.018). The resection margin status was associated with overall survival, local recurrence and distant recurrence. CONCLUSION Pelvic exenterations for any cause need to be performed in referral centers and by specialized surgeons. Anastomosis after modified supralevator pelvic exenteration for ovarian cancer, is safe. DBWC can be considered a valid option for urologic reconstruction. The most important prognostic factor after pelvic exenteration for malignant pelvic tumors is the status of surgical margins.