Commensal and pathogenic microorganisms must resist the deleterious actions of bile in order to survive in the human gastrointestinal tract. Herein we review the current knowledge on the mechanisms by which Gram-positive and Gram-negative bacteria contend with bile stress. We describe the antimicrobial actions of bile, assess the variations in bile tolerance between bacterial genera and examine the interplay between bile stress and other stresses. The molecular mechanisms underlying bile tolerance are investigated and the relationship between bile and virulence is examined. Finally, the potential benefits of bile research are briefly discussed.

The interaction between bacteria and bile

Insulin and insulin-like growth factor (IGF) axes are major determinants of proliferation and apoptosis and thus may influence carcinogenesis. In various animal models, modulation of insulin and IGF-1 levels through various means, including direct infusion, energy excess or restriction, genetically induced obesity, dietary quality including fatty acid and sucrose content, inhibition of normal insulin secretion and pharmacologic inhibition of IGF-1, influences colonic carcinogenesis. Human evidence also associates high levels of insulin and IGF-1 with increased risk of colon cancer. Clinical conditions associated with high levels of insulin (noninsulin-dependent diabetes mellitus and hypertriglyceridemia) and IGF-1 (acromegaly) are related to increased risk of colon cancer, and increased circulating concentrations of insulin and IGF-1 are related to a higher risk of colonic neoplasia. Determinants and markers of hyperinsulinemia (physical inactivity, high body mass index, central adiposity) and high IGF-1 levels (tall stature) are also related to higher risk. Many studies indicate that dietary patterns that stimulate insulin resistance or secretion, including high consumption of sucrose, various sources of starch, a high glycemic index and high saturated fatty acid intake, are associated with a higher risk of colon cancer. Although additional environmental and genetic factors affect colon cancer, the incidence of this malignancy was invariably low before the technological advances that rendered sedentary lifestyles and obesity common, and increased availability of highly processed carbohydrates and saturated fatty acids. Efforts to counter these patterns are likely to have the most potential to reduce colon cancer incidence, as well as cardiovascular disease and diabetes mellitus.

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Insulin, Insulin-Like Growth Factors and Colon Cancer: A Review of the Evidence

Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases.

Hypothesis Experience with pancreatic resection for the last 10 years has resulted in new trends in patient characteristics and, for pancreaticoduodenectomy (PD), a decrease in the length of stay (LOS). This decrease is due in part to the implementation of case management and clinical pathways. Design Retrospective case series of patients undergoing pancreatic resection. Setting A university-affiliated, tertiary care referral center. Patients The study comprised 733 consecutive patients undergoing pancreatic resection for benign or malignant disease at the Massachusetts General Hospital in Boston from April 1990 to March 2000. Interventions Of the 733 pancreatic resections, 489 were PD; 190, distal pancreatectomy; 40, total pancreatectomy; and 14, middle-segment pancreatectomy. Main Outcome Measures Length of stay; occurrence of delayed gastric emptying, pancreatic fistula, reoperation, readmission, or other complications; mortality; and comparison of patients in 3 periods according to the implementation of case management (July 1995) and clinical pathways (September 1998). Results For PD, patients in group 1 (April 1990 to June 1995) were significantly younger (mean ± SD, 57 ± 15 years) than those in group 2 (July 1995 to August 1998; mean ± SD, 62 ± 13 years) and group 3 (September 1998 to October 2000; mean ± SD, 65 ± 13 years)( P P = .01), and the proportion of PD for chronic pancreatitis decreased from 23% to 10% ( P P P P P P P P = .06). Median LOS decreased from 9 days to 6. For total pancreatectomy, resections for cystic tumors increased from 18% to 43%. Median LOS decreased from 14.5 days to 11. For all resections, case volume increased from 4 resections per month in 1990 to 5.8 in 1995 and 12 in 2000 ( r = 0.83; P Conclusions Older patients are increasingly being selected for pancreatic resection. This reflects an increasing frequency of operations performed for cystic tumors and fewer for chronic pancreatitis. With the exception of delayed gastric emptying, complications and mortality have remained the same or decreased slightly during the past 10 years. However, there has been a significant decrease in LOS; this is the result of implementation of case management and clinical pathways, increasing case volume, decreasing incidence of delayed gastric emptying, and decreasing use of pylorus-preserving PD.

https://jamanetwork.com/journals/jamasurgery/articlepdf/391232/sne0006.pdf

Ten-Year Experience With 733 Pancreatic Resections: Changing Indications, Older Patients, and Decreasing Length of Hospitalization

PURPOSE: Identification of prognostic factors is a primary basis for planning the treatment and predicting the outcome of patients with colorectal cancer. Reviewing studies from the literature performed using univariate and multivariate analyses and their own study, the authors critically discuss the prognostic value of the clinicopathologic parameters of the tumor. METHODS: Among 853 patients with colorectal tumors seen at the Department of Clinical Surgery of the Catholic University of Rome, Italy, 690 cases that were curatively resected entered the study. Overall survival rate, related to the clinicopathologic variables, was calculated, and univariate and multivariate analyses were performed. RESULTS: Five-year and ten-year overall survival rates were 70 and 55 percent, respectively. Univariate and multivariate analyses showed that node involvement, distant metastases, bowel obstruction, and patient gender are factors independently related to outcome. CONCLUSIONS: Data from the literature and the present study suggest that only a few clinical parameters, particularly bowel obstruction, and some pathologic factors (tumor stage, vessels invasion, and tumor ploidy) are related to patient survival rate and are the most reliable prognostic criteria. In prospective clinical studies, any other new pathologic or molecular factors should be matched with these parameters to confirm their value in outcome prediction.

Prognostic factors in colorectal cancer : Literature review for clinical application

In the 46-year period from September 1, 1932 to September 1, 1978, 11,808 patients were operated on for nonmalignant biliary tract disease. In 80.1% of these patients, the disease was considered chronic, and in 19.9%, acute inflammation was superimposed on the existing condition. There were 207 postoperative deaths, a mortality rate of 1.7%. Advanced age, acute cholecystitis and common duct stones were the principal determinants of operative mortality. Cholecystectomy for chronic cholecystitis was performed in 7,413 patients with an operative mortality of 0.5%. Choledochotomy in search of residual or recurrent common duct calculi was performed in 341 patients with a mortality of 2.1%. Detailed analysis of the causes of death in 105 patients who died during the years 1962 through 1978 revealed that cardiovascular disease, especially myocardial infarction, was the most frequent cause of death. Liver disease, most commonly cirrhosis, was also a major factor in operative mortality.

The incidence and causes of death following surgery for nonmalignant biliary tract disease.

A case of intra-atrial myxoma manifested clinically by evidences of mitral stenosis and peripheral emboli is presented in detail. The diagnosis was made during life and confirmed by angiocardiography. The surgical procedure, attempted as a last resort, is described, as are the postmortem findings. This case points the way to possible surgical cure in similar lesions.

Myxoma of the left atrium; diagnosis made during life with operative and post-mortem findings.

Carcinoma of the pancreas.

Percutaneous transhepatic cholangiography.

From 1932 to 1978, 105 patients with biliary enteric fistulas are reported upon from The New York Hospital-Cornell Medical Center. During this 46 year period, 11,808 patients were operated upon for nonmalignant biliary tract disease, representing an incidence of biliary enteric fistulas of 0.9 per cent. The most common location of the fistula was cholecystoduodenal in 77 per cent and cholecystocolic in 15 per cent. Ninety-eight of the 105 patients underwent 109 surgical procedures for symptoms and complications associated with the fistula. The operative mortality was 6 per cent. The recommended definitive procedure includes cholecystectomy, excision of the fistula, common bile duct exploration and operative cholangiography. Among the 105 patients were 22 who presented with intestinal obstruction or ileus due to gallstones. The operative mortality in this group was 4.5 per cent. The recommended treatment for this condition is operative relief of the obstruction with correction of the biliary enteric fistula at an elective second stage operation.

Frank Glenn

Papers

The incidence and causes of death following surgery for nonmalignant biliary tract disease.

Myxoma of the left atrium; diagnosis made during life with operative and post-mortem findings.

Carcinoma of the pancreas.

Percutaneous transhepatic cholangiography.

Biliary enteric fistula.