Disclosures. Reshape Medical Gusto LLC Applied Medical

Transcription

1 Disclosures Reshape Medical Gusto LLC Applied Medical

2 Alverdy Lab Olga Zaborina, PhD Alexander Zaborin, PhD Ben Shogan MD Neil Hyman MD Sanjiv Hyoju MD SURGICAL RESEARCH FELLOWS Sarah Gaines MD Ashley Williamson MD Richard Jacobson MD Eugene Chang, MD (director) Bana Jabri MD PhD (co-director) John Alverdy MD (associate co-director) National Institute of General Medical Sciences of the NIH NIH R01-GM (JCA) NIH 5R21AI Polyphosphate Loaded Nanoparticles for Suppression of Gut Pathogen Collagenase Activity and Promotion of Post-Surgical Intestinal Healing

3 Infusion of tetracycline (Achromycin) OR saline directly into intestine via tube X 3d Both groups of dogs received 600,000 units of Penicillin IM at beginning of study De-vascularize colon segment

4 Appearance of colon before closing the abdomen We have no idea if or which bacteria cause leak and whether the antibiotics we use today actually get rid of them 7 days later Antibiotics, delivered right to the site of the anastomosis reversed ischemia and prevented leak Saline 5/6 all developed leak/peritonitis Tetracylcline No leaks no peritonitis

5 Erythro/Kanamycin p.o. for 6 days postop 70% increase in tensile strength! Erythro/Kanamycin p.o. for 3 days postop? Erythro/Kanamycin p.o. for 1 day postop Conclusion: Bacteria have a major influence on anastomotic healing

6 We have ignored the relevance of the microbiome in surgical complications because >50% of the organisms in the human gut are uncultivatable Community structure and membership Community gene expression and function Can this community express the human phenotype in animals? Model human disease Intestinal contents of patients with ileus, leak-

7 The gut microbiome is the driving force behind postoperative ileus Gut, 2017 Postoperative Ileus starts here Normal movement Paralytic Ileus No contractionfunctional obstruction Macrophages are controlled by the microbiomedelayed gastric emptying following pancreaticoduodenectomy?

8 Bacterial information processing governs the occurrence, course and outcome of clinical infection Interkingdom signal exchange Host Factors (cytokines, opioids, ischemic end-products) are released during surgical stress Interspecies and intraspecies signal exchange Quorum Sensing Complex interactions produce emergent bacterial phenotypes unique to the environmental context a matchless web of dense dynamic interactions

9 The physiologic effects of major surgery are sensed by the colonizing microbiota who then respond accordingly I. 4-6 hour pancreaticoduodenectomy III. Bacterial information processing by colonizing microbes V. Bacterial-host engagement at the operated tissue site II. Release of host compensatory signals and local cues IV. Shift in phenotype ( virulence) IV. Activation of host tissue proteases I. MOLECULAR DÉTENTE II. MICROBE-MEDIATED PATHOLOGY

10 The molecular basis of bacterial information processing following surgical injury Local [Pi ] Quorum Sensing (QS) activation by host cues Intestine Phosphate Sensing Proteinconnects to QS Inhibition of QS Pseudomonas aeruginosa Science When bacteria 2005 get the nutrients PNAS 2009 they need, they Cell, do Host not Microbe respond 2010 to incoming Science Trans host Med activation 2015 cues Microbe-mediated pathology

11 Do Enhanced Recovery Programs (ERAS) improve outcomes via their influence on the microbiome?

12 Bacteria not technique cause anastomotic leak Are there unique environmental cues present at this site? Do they activate colonizing pathogens in a context dependent manner?

13 Anastomotic sites become shifted in their microbial community structure and phenotype 16s rrna genetic analysis of anastomotic tissues (NOT FECES) The 90% reduction in Bacteroidetes and a 500 fold bloom in Enterococcus is only seen in TISSUES NOT FECES

14 Enterococcus faecalis regulates its virulence via quorum sensing and produces the tissue destroying enzyme collagenase Host Factor recognition during surgery Collagenases Bacteria produce 1,000 V. Bacterial times more collagenase collagenase than intestinal degrades tissues Collagen I and IV VI. Bacterialmediated leak

15 Rat model of anastomotic leak using segmental devascularization (D vasc ) Skim Milk Why didn t these rats leak? Collagenase producing bacteria Selective Growth Agar Skim Milk Overlay on Selective Growth Agar A B C Non-collagenase producing bacteria Anastomosis Anastomosis + Devascularization Bacterial collagenase not ischemia discriminates between those that leak versus those that heal

16 High collagenase producing E. faecalis strains cause anastomotic leak in rats Introduce Pro-form E1 versus of E2 Active form of into the rat MMP9 rectum MMP9 WITHOUT devascularization E2 ( collagenase) Over-activation of host protease by a specific bacterial phenotype G Collagenase activity of E. faecalis strains RFU/OD600nm E. faecalis (E1 or E2) E faecalis, E1, E2 E1= collagenase E2= collagenase x Sham Primary E1 Anastomosis- NO Dvasc Is high collagenase producing E faecalis (E2) sufficient to cause leak? Heal Leak E2 breaks down collagen I directly via collagenase, and collagen IV indirectly via MMP9 activation E2 Anastomosis + Devascularization

17 Leaks after a Whipple- its all about the pancreatico-jejunostomy

18 Pseudomonas aeruginosa

19 collagenase + E. faecalis The presence of certain intestinal bacteria (i.e E faecalis, P. aeruginosa) drives overamplification of host proteases leading to pathoadaptive healing across all wounds elevated protease activity (EPA) is the hallmark of non-healing Trypsinogen collagenase + P. aeruginosa Trypsin

20 19 pts with a POPF

21 Antibiotics are NOT an evolutionarily stable strategy: more better Phosphate (Pi) doping to suppress bacterial virulence Intestine Local [Pi ] Phosphate Sensing Proteinconnects to QS Inhibition of QS Pseudomonas aeruginosa Quorum Sensing (QS) activation by host cues Science When bacteria 2005 get the nutrients PNAS 2009 they need, they Cell, do Host not Microbe respond 2010 to incoming Science Trans host Med activation 2015 cues Microbe-mediated pathology

22 Should we prep the bowel prior to pancreaticoduodenectomy and if so how should it be done? Purgatives + Oral + IV antibiotics with broader coverage against E. faecalis and P. aeruginosa? Embed key nutrients (i.e phosphate, Zn, glucose, etc) within pancreaticojejunostomy tissue site to suppress bacterial virulence expression There is no science on the pathobiology of leaks following a pancreaticoduodenectomy, just probability statistics We should generate the science first and let the results inform the best way to prepare the patient We have no idea if the antibiotics we use today actually decontaminate anastomotic tissues of the bacteria that cause leak