title: Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak.
abstract: Even under the most expert care, a properly constructed intestinal anastomosis can fail to heal, resulting in leakage of its contents, peritonitis, and sepsis. The cause of anastomotic leak remains unknown, and its incidence has not changed in decades. We demonstrate that the commensal bacterium Enterococcus faecalis contributes to the pathogenesis of anastomotic leak through its capacity to degrade collagen and to activate tissue matrix metalloproteinase 9 (MMP9) in host intestinal tissues. We demonstrate in rats that leaking anastomotic tissues were colonized by E. faecalis strains that showed an increased collagen-degrading activity and also an increased ability to activate host MMP9, both of which contributed to anastomotic leakage. We demonstrate that the E. faecalis genes gelE and sprE were required for E. faecalis-mediated MMP9 activation. Either elimination of E. faecalis strains through direct topical antibiotics applied to rat intestinal tissues or pharmacological suppression of intestinal MMP9 activation prevented anastomotic leak in rats. In contrast, the standard recommended intravenous antibiotics used in patients undergoing colorectal surgery did not eliminate E. faecalis at anastomotic tissues nor did they prevent leak in our rat model. Finally, we show in humans undergoing colon surgery and treated with the standard recommended intravenous antibiotics that their anastomotic tissues still contained E. faecalis and other bacterial strains with collagen-degrading/MMP9-activating activity. We suggest that intestinal microbes with the capacity to produce collagenases and to activate host metalloproteinase MMP9 may break down collagen in the intestinal tissue contributing to anastomotic leak.
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Shogan
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Natalia
authors.initials: N
authors.lastname: Belogortseva
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Preston M
authors.initials: PM
authors.lastname: Luong
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Zaborin
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Simon
authors.initials: S
authors.lastname: Lax
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Cindy
authors.initials: C
authors.lastname: Bethel
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: Ward
authors.affiliation: NorthShore University HealthSystem, Evanston, IL 60201, USA.
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Muldoon
authors.affiliation: NorthShore University HealthSystem, Evanston, IL 60201, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Singer
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Gary
authors.initials: G
authors.lastname: An
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Konstantin
authors.initials: K
authors.lastname: Umanskiy
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Vani
authors.initials: V
authors.lastname: Konda
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Baddr
authors.initials: B
authors.lastname: Shakhsheer
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: James
authors.initials: J
authors.lastname: Luo
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA. Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
authors.forename: Robin
authors.initials: R
authors.lastname: Klabbers
authors.affiliation: The University of Kansas, Lawrence, KS 66045, USA.
authors.forename: Lynn E
authors.initials: LE
authors.lastname: Hancock
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA. Argonne National Laboratory, Argonne, IL 60439, USA.
authors.forename: Jack
authors.initials: J
authors.lastname: Gilbert
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
authors.forename: Olga
authors.initials: O
authors.lastname: Zaborina
authors.affiliation: University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA. jalverdy@surgery.bsd.uchicago.edu.
authors.forename: John C
authors.initials: JC
authors.lastname: Alverdy
mesh_terms: D057868:Anastomotic Leak / Q000382:microbiology / Q000473:pathology*; D000818:Animals; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D017173:Caenorhabditis elegans; D002460:Cell Line; D003094:Collagen / Q000737:chemistry*; D013293:Enterococcus faecalis / Q000472:pathogenicity*; D006801:Humans; D007413:Intestinal Mucosa / Q000378:metabolism*; D007422:Intestines / Q000382:microbiology* / Q000473:pathology; D007511:Ischemia / Q000473:pathology; D008264:Macrophages / Q000378:metabolism; D008297:Male; D020780:Matrix Metalloproteinase 9 / Q000378:metabolism*; D051379:Mice; D012336:RNA, Ribosomal, 16S / Q000235:genetics; D051381:Rats; D017208:Rats, Wistar; D011994:Recombinant Proteins / Q000378:metabolism; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D012336:RNA, Ribosomal, 16S; D011994:Recombinant Proteins; D003094:Collagen; C579270:MMP9 protein, human; D020780:Matrix Metalloproteinase 9