Morphine Promotes Colonization of Anastomotic Tissues with Collagenase - Producing Enterococcus faecalis and Causes Leak

BackgroundDespite ever more powerful antibiotics, newer surgical techniques, and enhanced recovery programs, anastomotic leaks remain a clear and present danger to patients. Previous work from our laboratory suggests that anastomotic leakage may be caused by Enterococcus faecalis strains that express a high collagenase phenotype (i.e., collagenolytic). Yet the mechanisms by which the practice of surgery shifts or selects for collagenolytic phenotypes to colonize anastomotic tissues remain unknown.MethodsHere, we hypothesized that morphine, an analgesic agent universally used in gastrointestinal surgery, promotes tissue colonization with collagenolytic E. faecalis and causes anastomotic leak. To test this, rats were administered morphine in a chronic release form as would occur during routine surgery or vehicle. Rats were observed for 6 days and then underwent exploratory laparotomy for anastomotic inspection and tissue harvest for microbial analysis. These results provide further rationale to enhanced recovery after surgery (i.e., ERAS) programs that suggest limiting or avoiding the use of opioids in gastrointestinal surgery.ResultsResults demonstrated that compared to placebo-treated rats, morphine-treated rats demonstrated markedly impaired anastomotic healing and gross leaks that correlated with the presence of high collagenase-producing E. faecalis adherent to anastomotic tissues. To determine the direct role of morphine on this response, various isolates of E. faecalis from the rats were exposed to morphine and their collagenase activity and adherence capacity determined in vitro. Morphine increased both the adhesiveness and collagenase production of four strains of E. faecalis harvested from anastomotic tissues, two that were low collagenase producers at baseline, and two that were high collagenase producers at baseline.ConclusionThese results provide further rationale to enhanced recovery after surgery (i.e., ERAS) programs that suggest limiting or avoiding the use of opioids in gastrointestinal surgery.

[1]  C. Cerletti,et al.  Chronic morphine administration: Plasma levels and withdrawal syndrome in rats , 1976, Pharmacology Biochemistry and Behavior.

[2]  C. Mcintosh,et al.  Chronic naltrexone treatment of rats: effects on gastrointestinal opioid peptide content. , 1992, European journal of pharmacology.

[3]  B. Bayer,et al.  Acute immunosuppressive effects of morphine: lack of involvement of pituitary and adrenal factors. , 1994, The Journal of pharmacology and experimental therapeutics.

[4]  T. Eisenstein,et al.  Morphine induces sepsis in mice. , 1997, The Journal of infectious diseases.

[5]  G. Weinstock,et al.  Enterococcus faecalis Adhesin, Ace, Mediates Attachment to Extracellular Matrix Proteins Collagen Type IV and Laminin as well as Collagen Type I , 2000, Infection and Immunity.

[6]  Rebecca L. Cali,et al.  Effect of morphine and incision length on bowel function after colectomy , 2000, Diseases of the colon and rectum.

[7]  Sabita Roy,et al.  The immunosuppressive effects of chronic morphine treatment are partially dependent on corticosterone and mediated by the μ‐opioid receptor , 2002, Journal of leukocyte biology.

[8]  K. Pang,et al.  Route-Dependent Metabolism of Morphine in the Vascularly Perfused Rat Small Intestine Preparation , 2000, Pharmaceutical Research.

[9]  L. Rue,et al.  The contribution of opiate analgesics to the development of infectious complications in burn patients. , 2006, American journal of surgery.

[10]  P. Sacerdote.  Opioids and the immune system , 2006, Palliative medicine.

[11]  J. Lavigne,et al.  Virulent Synergistic Effect between Enterococcus faecalis and Escherichia coli Assayed by Using the Caenorhabditis elegans Model , 2008, PloS one.

[12]  Jonathan A. Eisen,et al.  Human gut microbiome adopts an alternative state following small bowel transplantation , 2009, Proceedings of the National Academy of Sciences.

[13]  B. Scheller,et al.  INTERLEUKIN-22 DETECTED IN PATIENTS WITH ABDOMINAL SEPSIS , 2010, Shock.

[14]  Arnaud H. Muller,et al.  Endogenous Morphine Levels Are Increased in Sepsis: A Partial Implication of Neutrophils , 2010, PloS one.

[15]  Robert C. Edgar,et al.  BIOINFORMATICS APPLICATIONS NOTE , 2001 .

[16]  B. Haas,et al.  Chimeric 16S rRNA sequence formation and detection in Sanger and 454-pyrosequenced PCR amplicons. , 2011, Genome research.

[17]  C. Dejong,et al.  Collagen fleeces do not improve colonic anastomotic strength but increase bowel obstructions in an experimental rat model , 2011, International Journal of Colorectal Disease.

[18]  A. Rawlinson,et al.  A systematic review of enhanced recovery protocols in colorectal surgery. , 2011, Annals of the Royal College of Surgeons of England.

[19]  A. Zaborin,et al.  Intestinal Tissues Induce an SNP Mutation in Pseudomonas aeruginosa That Enhances Its Virulence: Possible Role in Anastomotic Leak , 2012, PloS one.

[20]  A. Zaborin,et al.  Pseudomonas aeruginosa Virulence Expression Is Directly Activated by Morphine and Is Capable of Causing Lethal Gut-Derived Sepsis in Mice During Chronic Morphine Administration , 2012, Annals of surgery.

[21]  T. Hendriks,et al.  Diclofenac causes more leakage than naproxen in anastomoses in the small intestine of the rat , 2013, International Journal of Colorectal Disease.

[22]  B. Murray,et al.  Library Screen Identifies Enterococcus faecalis CcpA, the Catabolite Control Protein A, as an Effector of Ace, a Collagen Adhesion Protein Linked to Virulence , 2013, Journal of bacteriology.

[23]  Robert C. Edgar,et al.  UPARSE: highly accurate OTU sequences from microbial amplicon reads , 2013, Nature Methods.

[24]  B. Shakhsheer,et al.  Membership and Behavior of Ultra-Low-Diversity Pathogen Communities Present in the Gut of Humans during Prolonged Critical Illness , 2014, mBio.

[25]  Pelin Yilmaz,et al.  The SILVA and “All-species Living Tree Project (LTP)” taxonomic frameworks , 2013, Nucleic Acids Res..

[26]  S. Christley,et al.  Intestinal anastomotic injury alters spatially defined microbiome composition and function , 2014, Microbiome.

[27]  K. Shirouzu,et al.  Effect of surgical stress on endogenous morphine and cytokine levels in the plasma after laparoscopoic or open cholecystectomy , 2000, Surgical Endoscopy.

[28]  H. van Goor,et al.  Systematic review of experimental studies on intestinal anastomosis , 2015, The British journal of surgery.

[29]  Calcium alginate as a rectal bulking agent. Experimental pilot study to determine its migratory trend and locoregional reaction , 2016, International Journal of Colorectal Disease.

[30]  M. Schwacha,et al.  The contribution of opiate analgesics to the development of infectious complications in trauma patients. , 2015, International journal of burns and trauma.

[31]  Lixia Yuan,et al.  Lactobacillus protects the integrity of intestinal epithelial barrier damaged by pathogenic bacteria , 2015, Front. Cell. Infect. Microbiol..

[32]  James N. Luo,et al.  Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak , 2015, Science Translational Medicine.

[33]  H. van Goor,et al.  Diclofenac causes anastomotic leakage in the proximal colon but not in the distal colon of the rat. , 2015, American journal of surgery.