Microbiota transplantation from younger to older mice could restore lost immunity to effectively clear salmonella infection in Th2-biased BALB/c mice.

AIMS: The composition, overtly abundance, and diversity of gut microbiota, play a significant role in maintaining physiological homeostasis with age. Reports revealed that the gut microbial profile might be correlated with immunity and metabolism. It is, therefore, tantamount to know if an older individual can achieve the immunity and metabolic profile of a younger individual by receiving the gut microbiome of a younger individual. In the current report, we have studied the effects of cecal microbiota transplantation (CMT) from younger to older mice. MATERIALS AND METHODS: In this study, older BALB/c mice (23 weeks) received CMT from younger BALB/c mice (3 weeks). KEY FINDINGS: CMT recipient mice showed altered expressions of immune and tight junction protein genes in the colon of mice, while the non-CMT recipient mice did not. Older mice were treated with AVNM to make them compatible with CMT. Further data from metabolite studies revealed that AVNM treatment mainly affected the aromatic amino acid biosynthesis pathway while CMT mostly affected the metabolism of different carbohydrates. We repeated the analysis in C57BL/6 mice without any significant effects of CMT. SIGNIFICANCE: Results revealed that mice who received CMT showed more efficient restoration of gut microbiota than non-CMT recipient mice. CMT caused the alleviation of Salmonella infection and efficient recovery of the cecal index in the mice following antibiotics treatment.

Cecal Slurry Injection in Neonatal and Adult Mice.

Studying the pathophysiology of sepsis still requires animal models, and the mouse remains the most commonly used species. Here we discuss the "cecal slurry" (CS) model of polymicrobial, peritoneal sepsis and compare and contrast it to other commonly used methods. Among the different murine models of sepsis, cecal ligation and puncture (CLP), and not the CS, is often considered the "gold standard" to induce polymicrobial sepsis in laboratory animals. CLP is a well-described model involving a simple surgical procedure that closely mimics the clinical course of intra-abdominal sepsis. However, CLP may not be an option for experiments involving newborn pups, where the cecum is indistinguishable from small bowel, where differences in microbiome content may affect the experiment, or where surgical procedures/anesthesia exposure needs to be limited. An important alternative method is the CS model, involving the intraperitoneal injection of cecal contents from a donor animal into the peritoneal cavity of a recipient animal to induce polymicrobial sepsis. Furthermore, CS is an effective alternative model of intraperitoneal polymicrobial sepsis in adult mice and can now be considered the "gold standard" for experiments in neonatal mice.

Surgical strategy of esophageal resection and reconstruction for aortoesophageal fistula.

Aortoesophageal fistula is a critical and life-threatening disease. The cardiovascular strategy for graft replacement has been widely discussed. However, the surgical strategy of esophageal resection and reconstruction for aortoesophageal fistula has rarely been discussed. The objective of this study is to establish a surgical strategy and procedure of esophageal resection and reconstruction for aortoesophageal fistula. Eleven patients with aortoesophageal fistula who underwent aortic graft replacement and esophagectomy between 2008 and 2015 at Kobe University Hospital were enrolled in this study. Patient characteristics, operative methods, and clinical outcomes were obtained by retrospective chart review. All 11 patients underwent graft replacement, esophagectomy, and omental wrapping. Ten esophagectomies were simultaneously accomplished in the same operative field as aortic graft replacement. Seven patients underwent subtotal esophagectomy from a left thoracotomy, and three patients underwent upper hemiesophagectomy from a median sternotomy. The other patient underwent staged esophagectomy from a right thoracotomy. Seven of 11 patients (63.6%) successfully underwent staged esophageal reconstruction. Pedicled jejunal transfer with supercharge and superdrainage were performed in six patients, and ileocecal reconstruction was performed in one patient. Median survival time in the patients with esophageal reconstruction was 21 months while that in the patients without esophageal reconstruction was 10 months. Six of 7 patients (85.7%) who underwent esophageal reconstructions were alive. Our surgical strategy for aortoesophageal fistula, which includes simultaneous graft replacement and esophagectomy in the same operative field and staged reconstruction by pedicled jejunal transfer to ensure omental wrapping, is feasible and promising.

Evolution of the neobladder: A critical review of open and intracorporeal neobladder reconstruction techniques.

Orthotopic neobladder is an attractive alternative to the ileal conduit following radical cystectomy. Robotic cystectomy is gaining popularity although the uptake of neobladder reconstruction is low, with the majority of cases being constructed extracorporeally via a mini-laparotomy. Minimally invasive cystectomy using the robotic platform facilitates intracorporeal neobladder reconstruction and several techniques have been described. This review discusses issues relating to patient selection, and describes existing techniques of open surgical neobladder reconstruction and their evolution to suit an intracorporeal approach. A Medline search for publications from January 1970 to September 2015 with the following keyword search criteria was performed: radical cystectomy, robotic cystectomy, intracorporeal, neobladder, orthotopic bladder reconstruction, surgical technique, patient selection and ureteric-ileal anastomosis.

Robotic-assisted laparoscopic catheterizable bladder augment: a novel approach to treat recurrent bladder neck contracture following radical prostatectomy.

INTRODUCTION: Bladder neck contractures (BNC) are an uncommon complication following radical prostatectomy. Occasionally, BNCs can be refractory to endoscopic approaches. We describe the effectiveness of a novel robotic-assisted laparoscopic catheterizable bladder augment in treating recalcitrant BNCs. MATERIALS AND METHODS: Patients undergoing robotic-assisted radical prostatectomy (RALP) between 2004-2014 who developed a postoperative BNC were identified. We documented our experience with robotic-assisted laparoscopic catheterizable bladder augment for recalcitrant BNCs. Total operative time, robotic time, estimated surgical blood, length of hospital stay, serum creatinine, complications, and postoperative course/upper tract imaging were recorded. RESULTS: Thirty-six of 2002 RALP patients (1.8%) experienced a post-surgical BNC at 182 days post-surgery. Twenty-two (61.1%) underwent a single dilation and/or transurethral incision. Eleven (30.6%) required = 1 procedure. Three patients (8.3%) had recalcitrant BNCs. One patient with normal bladder capacity elected open urethroplasty. The remaining two had reduced bladder capacity, detrusor over-activity and failed multiple incisions and self-catheterization. In one patient, the stricture was complete. The other patient experienced urethral leakage requiring bladder neck closure. In both patients, a robotic approach, utilizing an ileal-cecal segment as a catheterizable augment, was performed. At 16 and 89 months follow up, both are continent, with stable renal function and normal upper tracts. CONCLUSION: Robotic-assisted laparoscopic catheterizable bladder augment is a viable treatment for recurrent BNCs. This approach may be particularly well suited for patients with concurrent hyperreflexia or decreased bladder capacity.

Evidence for a link between gut microbiota and hypertension in the Dahl rat.

The gut microbiota plays a critical role in maintaining physiological homeostasis. This study was designed to evaluate whether gut microbial composition affects hypertension. 16S rRNA genes obtained from cecal samples of Dahl salt-sensitive (S) and Dahl salt-resistant (R) rats were sequenced. Bacteria of the phylum Bacteroidetes were higher in the S rats compared with the R rats. Furthermore, the family S24-7 of the phylum Bacteroidetes and the family Veillonellaceae of the phylum Firmicutes were higher in the S rats compared with the R rats. Analyses of the various phylogenetic groups of cecal microbiota revealed significant differences between S and R rats. Both strains were maintained on a high-salt diet, administered antibiotics for ablation of microbiota, transplanted with S or R rat cecal contents, and monitored for blood pressure (BP). Systolic BP of the R rats remained unaltered irrespective of S or R rat cecal transplantation. Surprisingly, compared with the S rats given S rat cecal content, systolic BP of the S rats given a single bolus of cecal content from R rats was consistently and significantly elevated during the rest of their life, and they had a shorter lifespan. A lower level of fecal bacteria of the family Veillonellaceae and increased plasma acetate and heptanoate were features associated with the increased BP observed in the S rats given R rat microbiota compared with the S rats given S rat microbiota. These data demonstrate a link between microbial content and BP regulation and, because the S and R rats differ in their genomic composition, provide the necessary basis to further examine the relationship between the host genome and microbiome in the context of BP regulation in the Dahl rats.

Effects on GLP-1, PYY, and leptin by direct stimulation of terminal ileum and cecum in humans: implications for ileal transposition.

BACKGROUND: We do not have a unified, scientifically tested theory of causation for obesity and its co-morbidities, nor do we have explanations for the mechanics of the metabolic/bariatric surgery procedures. Integral to proffered hypotheses are the actions of the hormones glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and leptin. The objective of this study was to obtain blood levels of GLP-1, PYY, and leptin after stimulation of the terminal ileum and cecum by a static infusion of a food hydrolysate in morbidly obese patients undergoing a duodenal switch procedure. SETTING: University Hospital. METHODS: Plasma levels of GLP-1, PYY, and leptin were obtained at 0, 30, 60, 90, and 120 minutes after instillation of 240 mL of a food hydrolysate into the ileum or cecum. RESULTS: The mean±SD GLP-1 values by cecal stimulation for 0, 30, 60, 90, and 120 minutes were: 41.3±23.2; 39.6±21.8; 38.9±19.1; 47.4±22.3; 51.7±27.3 pM, and by ileal stimulation: 55.0±32.8; 83.4±16.1; 78.7±23.8; 84.7±23.5; 76.4±25.6. The mean±SD PYY values by cecal stimulation were: 62.1±24.8; 91.1±32.8; 102.1±39.6; 119.6±37.5; 130.3±36.7, and by ileal stimulation: 73.8±41.6; 138.1±17.7; 149.5±23.3; 165.7±24.3; 155.5±29.1. Percent change in PYY levels increased ~150%, GLP-1 increased ~50%, and leptin decreased ~20%. CONCLUSION: Direct stimulation of the human terminal ileum and cecum by a food hydrolysate elicits significant plasma GLP-1 and PYY elevations and leptin decreases, peaking at 90-120 minutes. The ileal GLP-1 and PYY responses exceed those of the cecum, and the PYY effect is about 3-fold that of GLP-1. The results of this study question the satiety premise for ileal transposition.

Application of the HyperEye Medical System for esophageal cancer surgery: a preliminary report.

The HyperEye Medical System is a newly developed device that allows for the visualization of the fluorescent image of indocyanine green enhanced by near-infrared light among the surrounding vivid color images. We recently applied this system to confirm the blood flow of an esophageal substitute, and for sentinel node navigation during esophagectomy. Five consecutive patients with thoracic esophageal cancer who underwent a subtotal esophagectomy between June 2010 and May 2011 were enrolled in the study. The esophageal substitute used for reconstruction was the stomach and ileocecum in four and one cases, respectively. In all cases with a reconstructive stomach, fine arterial blood flow and venous perfusion were observed. The blood flow of the reconstructive colon was poor before microvascular anastomosis, however, it dramatically increased after anastomosis. Concerning the sentinel node navigation, the fluorescence of lymph nodes, lymphatic vessels, and the tumor site were detected. The postoperative courses of all cases were uneventful, with no mortalities or anastomotic leakage occurring.

Lymphotoxin regulates commensal responses to enable diet-induced obesity.

Microbiota are essential for weight gain in mouse models of diet-induced obesity (DIO), but the pathways that cause the microbiota to induce weight gain are unknown. We report that mice deficient in lymphotoxin, a key molecule in gut immunity, were resistant to DIO. Ltbr(-/-) mice had different microbial community composition compared to their heterozygous littermates, including an overgrowth of segmented filamentous bacteria (SFB). Furthermore, cecal transplantation conferred leanness to germ-free recipients. Housing Ltbr(-/-) mice with their obese siblings rescued weight gain in Ltbr(-/-) mice, demonstrating the communicability of the obese phenotype. Ltbr(-/-) mice lacked interleukin 23 (IL-23) and IL-22, which can regulate SFB. Mice deficient in these pathways also resisted DIO, demonstrating that intact mucosal immunity guides diet-induced changes to the microbiota to enable obesity.

Augmentation cystoplasty in children without preoperative mechanical bowel preparation.

OBJECTIVE: To retrospectively assess early postoperative complications in augmentation cystoplasty without preoperative mechanical bowel preparation (MBP). MATERIAL AND METHODS: Between May 1987 and May 2006, 162 cystoplasties were performed in 158 children. The segments used were: sigmoid colon (81.5%), ileum (13%), and ileocecum (5.5%). The mean age was 8.65 years (range 2.1-22.7 years). No preoperative MBP of any kind was used in any of the patients and all of them received antibiotics preoperatively and postoperatively. RESULTS: No intraoperative complications related to the procedure were reported. The mean hospital stay was 9.48 days (range 4-30 days). The mean time to intake of oral fluids was 94.77 h (range 48-288 h). Postoperative complications occurred in 9.87%: urinary fistula was the most common (2.4%); only 3 patients presented wound infection (1.85%); 5 patients required reoperative surgery (hemoperitoneum, patch necrosis and 3 cases of urinary peritonitis); 1 patient presented an intra-abdominal abscess that resolved with antibiotic treatment. CONCLUSIONS: Preoperative MBP can be omitted in children that require augmentation cystoplasty without an increased risk of infectious or anastomotic complications. Further prospective, randomized clinical trials should be carried out in order to validate our findings in the pediatric population.

Bridging the gap with an ileocolonic graft after extensive colorectal resections.

BACKGROUND: Ileocecal interposition (ICI) for first-line reconstruction after low anterior colorectal resection was introduced by von Flüe and Harder in 1994 (Dis Colon Rectum 37:1160-1162, 1994). We report our experience using this technique to bridge colonic gaps after significant loss of bowel length. PATIENTS AND METHODS: Between 1999 and 2009 the left-sided colon was too short for traditional isoperistaltic reconstruction in six patients treated in our hospital. Reasons for extensive bowel loss were a deficient (n = 3) or torn (n = 1) marginal artery with ischemia or repeat colorectal resections (n = 2). An ICI was done to bridge the gap and enable restoration of intestinal continuity. RESULTS: No patient died. Whenever performing a coloanal anastomosis (4/6) a loop ileostomy was raised. One patient with colonic diversion experienced graft-related complications: ischemic colitis of the interposed colonic segment, anastomotic stenosis, and a presacral sinus were observed and managed nonoperatively. Subsequent closure of the stoma was possible in all cases. A median Vaizey incontinence score of 9 (range: 4-14) was recorded in the patient with coloanal anastomosis. The average number of bowel movements per day was 1.5 (range: 0.5-6). CONCLUSIONS: When the descending colon does not reach the rectal stump or anal canal in reoperative cases or after vascular complication, ICI is a useful salvage procedure resulting in good bowel function.

Application of appendicular-based cecal flap for less invasive augmentation cystoplasty: a novel technique.

OBJECTIVES: To evaluate the use of a new modified technique for augmentation cystoplasty on selected cases, both in terms of improvements in bladder urodynamics and creating an ideal conduit for clean intermittent catheterization. METHODS: Ten patients suffering from intractable low-compliance bladder and reasonable capacity underwent appendicular-based cecal flap augmentation cystoplasty. The procedure comprised the isolation of a 10 to 12 x 3 to 5-cm cecal flap on the base of the appendicular pedicle, by which the bladder was augmented and the appendix was brought out through the abdominal wall for catheterization. Without any bowel anastomosis, the cecal anterior wall was repaired. RESULTS: After a mean follow-up of 23.8 months, 9 of 10 patients became continent. Postoperative urodynamic study revealed a 53.8% increase in mean maximal cystometric capacity (from 171.4 to 263.7 ml; p = 0.012) and a 7.7-fold increase in mean bladder compliance (from 3.39 to 26.66 ml/cm H(2)O; p = 0.012). Mean maximal detrusor filling pressure decreased by 79% (from 62.2 to 13 cm H(2)O; p = 0.012). Renal function remained stable in all patients. Appendicular stoma was easy to catheterize, and no stomal stenosis occurred during the follow-up period. CONCLUSIONS: Early results of this less invasive technique could be promising in patients with high filling pressure and acceptable maximum bladder capacity.

Modified ileocecal interposition. The final sphincter-saving solution after failed salvage surgery for anastomotic complications of low anterior resection.

INTRODUCTION: Reversal of low Hartmann's procedures can be a challenging operation. We report on the successful treatment of patients who have already had prior salvage surgery for complications of a low colorectal anastomosis presenting with active fistulas from the rectal remnant. METHODS: An ileocolic segment was mobilized with the neurovascular pedicle of the ileocolic artery and turned counterclockwise into the pelvis. The fistulas were cured and a hand-sutured colo-anal anastomosis was performed at the level of the dentate line. Almost the entire length of the remnant colon was preserved. RESULTS: There was no morbidity. The functional outcome was good or reasonable and the subjective satisfaction with the outcome was very high. CONCLUSION: We conclude that an ileocolic segment is an excellent substitute for reversal of low Hartmann's procedures even in patients in whom prior salvage surgery has failed. As the functional outcome is slightly inferior to other alternatives for rectal replacement, its use should be restricted to patients with complex local situations or in whom alternative reconstructions would result in significant loss of bowel length.

A new technique using free ileocaecal patch transplantation for secondary voice restoration after total laryngectomy.

SUMMARY: We introduce our newly designed voice restoration technique, which uses free ileocaecal patch transplantation for patients who have undergone prior total laryngectomy. Two women received ileocaecal patch transplantation for secondary voice restoration after total laryngectomy. In order to make the tracheoesophageal shunt for speech, a new orifice on the anterior wall of the hypopharynx had to be opened, which was closed at the time of laryngectomy. The hypopharyngeal orifice was covered by a free caecal patch harvested from an ileocaecal segment. Then, a tracheoesophageal shunt was created by anastomosing the terminal ileum of the patch and the remnant of the cervical trachea. Expiratory air was diverted into the pharynx through the ileum of the transplanted graft when the tracheostoma was closed by digital occlusion. Aspiration through an oesophagotracheal shunt in swallowing was prevented by the ileocaecal valve on the patch. Both patients began to speak up to 4 weeks after surgery without requiring training or difficult practice to achieve initial phonation and to be able to swallow without aspiration. The advantages of our procedure are (1) it can be carried out at the time of laryngectomy and also at secondary voice restoration after earlier laryngectomy; (2) the graft contains an ileocaecal valve that prevents aspiration through the shunt and also functions as a vibrating device to produce voice; (3) our procedure can be adapted to individuals whose tracheostoma is detached from the oesophagus and becomes contraindicated for a voice prosthesis. We believe that our newly designed procedure is a unique and useful alternative, especially for secondary voice restoration after prior total laryngectomy.

Reconstruction of bladder and urethra using ileocecal segment and appendix in patients with exstrophy-epispadias complex: the first report of a new surgical approach.

OBJECTIVE: We aimed to describe our experience in administering an innovative surgical technique to treat pediatric cases of exstrophy-epispadias complex. MATERIAL AND METHODS: Between 1995 and 2004, seven consecutive patients (six males) with exstrophy-epispadias complex were treated using ileocecal segment for bladder augmentation and appendix for urethral reconstruction. In a single-stage operation, the exstrophied bladder was dissected- and a segment of cecum, ascending colon, terminal ileum, and the corresponding appendix were isolated. Using the opened colon to augment the bladder, the ileal segment was fashioned to skin as temporary stoma, and the appendix was laid in the urethral lumen as the neourethra following urethral demucosation. This technique was used as a secondary surgery in one case and as a primary surgery in six neonates. Evaluation of the urinary tract status was performed by cystograms and ultrasonograms. RESULTS: Renal function was saved in all cases and continence was achieved by clean intermittent catheterization every two hours either via the neourethra (n = 6) or through the temporary stoma (n = 1). The patients did not experience any metabolic complications in their follow-ups. Moreover, no one had vesicourethral reflux, dehiscence, or fistula. CONCLUSIONS: The technique was deemed safe with acceptable outcomes even when secondary repair of previously failed operation was intended. Experiencing the technique in larger cohorts as well as longer follow-ups might be necessary to assess probable long-term complications.

Ileocecal with teniamyotomies and ileal detubularized neobladders: considerations about a videourodynamic study after a long-term follow-up.

OBJECTIVE: To evaluate the functionality of ileal detubularized reservoir and ileocecal neobladder with multiple teniamyotomies after a long term follow-up. MATERIAL AND METHODS: Eight patients with ileal detubularized reservoir (IR) and 10 with ileocecal neobladder with multiple teniamyotomies (ICUS) with an average follow-up of 95 months, were submitted to a videourodynamic digital fluorongiographic examination. The patients had the longest disease-free follow-up of our series. RESULTS: Urodynamic data collected were almost good and comparable between IR and ICUS. Anyway the exams showed that the smooth intestinal muscles remain active both in non-detubularized and detubularized bladders even after years. Continence is mostly assured by the striated sphincter, which can withstand transient high pressure peaks but is less effective when facing prolonged pressure increases. While in some cases a valid micturition was achieved simply relaxing the perineal floor, in other cases micturition was obtained by an abdominal straining against the resistance of a contracted urethral sphincter/pelvic floor even after a long follow-up. CONCLUSIONS: Detubularization and teniamyotomies can equally help the striated sphincter function by increasing the neobladder compliance. Moreover we observed that a non-spherical neobladder was compatible with good clinical results as well, proving that neobladder shape was less important in achieving good functional performance. Furthermore, in some cases the optimal relaxation of the perineal floor made abdominal straining superfluous especially when neobladders had physiological capacity. Thus a perineal floor musculature training and its co-ordination with abdominal muscles may improve the quality of micturition.

[Bladder augmentation cystoplasty with continent urinary diversion by ileo-caeco-appendicular graft in children]. / Agrandissement vésical avec dérivation étanche par bloc iléo-caeco-appendiculaire chez l'enfant (technique ARDE: Agrandissement Réimplantation Dérivation Etanche).

OBJECTIVE: Description of augmentation cystoplasty combined with continent urinary diversion using an ileo-caeco-appendicular graft in children. MATERIAL AND METHOD: Augmentation cystoplasty combined with Mitrofanoff appendicostomy and reimplantation of the ureters into the ileal stump was performed during a single operation in two patients (a 3-year-old girl and an 8-year-old boy). The indications were a pseudoneurogenic bladder with major dilatation of the upper tract due to high-grade reflux in one case and a small scarred bladder after repeated failure of repeated surgery for duplicated ureterocele in another case. RESULTS: A bladder capacity of about 300 ml was obtained in the 2 children. Incontinence was managed by intermittent catheterization via the abdominal stoma. Upper urinary tract dilatation had resolved after one year. CONCLUSION: This technique is useful in certain complex urological situations combining a small, poorly compliant bladder, destruction of continence and severe upper tract dilatation. In these situations, it constitutes a conservative alternative to salvage diversion.

New surgical technique for primary and secondary voice restoration using a free ileocecal patch graft after total laryngectomy.

PURPOSE: We devised a new surgical technique to restore the voice after laryngectomy. This procedure is designed to repair the hypopharyngeal defect by using a free ileocecal patch for voice rehabilitation. METHODS: We performed this procedure in seven patients; for primary voice restoration in six and for secondary voice restoration in one. The technique involved resecting an ileocecal segment containing the ileocecal valve and cutting a patch from the cecum, the size of which was equalized with the hypopharyngeal defect. After patch repair of the defect, the tracheopharyngeal shunt was completed by an anastomosis between the ileum and trachea. RESULTS: One patient died from sudden rupture of the carotid artery, but all six survivors were able to speak and swallow without aspiration, achieving fair to good articulation. CONCLUSIONS: The advantages of our method are as follows. (1) The operative procedure is simple and does not require complicated remodeling of the intestinal graft for voice production. (2) The ileocecal valve can prevent aspiration. (3) The patch expands the pharynx and prevents narrowing. (4) Using this procedure, it is possible to achieve voice restoration even in patients who have undergone total laryngectomy in the past.