The Human Gut Microbiome and Surgical Outcomes

Since 2011, The New York Times alone has published 10 articles on the human microbiome.  Tending to the Body’s Microbial Garden (NYT 6/18/12) by Carl Zimmer reminds us that study of this area of research can lead to major medical breakthroughs – but it will require considerable effort.  He quotes Michael A. Fischbach, a microbiologist at the University of California, San Francisco, “I cannot wait for this to become a big area of science.”  Similarly, “There is No Healthy Microbiome” (NTY 11/1/14) points out that, “In return, everything from the food we eat to the medicines we take can shape our microbial communities — with important implications for our health. Studies have found that changes in our microbiome accompany medical problems from obesity to diabetes to colon cancer.”  It is known that disruptions in the gut microbiome or pathogenic colonic bacteria can cause clinical disease (Cholera, Clostridium Difficile).  However, as molecular approaches have enabled us to more specifically characterize the microbiome, we have discovered that it has role in both health and disease.  Dysbiosis is the term used to describe a microbial imbalance within the body.

Recently, this topic was the subject of a well-attended panel discussion at The 2014 Annual meeting of the American College of Surgeons.  “The Gut Microbiome:  A Surgeon’s Hostile Adversary or Secret Savior” was delivered by a panel of researchers that included Michael Morowitz.  In his talk, Dr. Morowitz remarked that, “surgical patients are a setup for dysbiosis and may benefit from therapeutic modification of the microbiome.”  He too pointed out that,  “there are 4 known examples of surgical topics impacted by the microbiome:  cancer, wound healing, obesity  and inflammatory bowel disease.”

A deeper understanding of our microbiome will enable surgeons to improve surgical outcomes.

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Great Talks from 2014 ACS Meeting

Of the many topics covered at  The Annual Meeting of The American College of Surgeons, in San Francisco, CA, I found the following most interesting.  Many of the links below provide video interviews with the presenter.

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Thyroid Goiter

Iodine is an essential dietary component that is needed to maintain normal thyroid function. Typical sources of iodine include, breads, chesse, cow’s milk, eggs, frozen yogurt, ice cream, iodized table salt, saltwater fish, seaweed, shellfish, soy milk and soy sauce.(1) Iodine deficiency has been almost completely eradicated in the United States since the introduction of iodized salt in the 1920′s-30′s. In the US, the Recommended Daily Allowance (RDA) for Iodine is 150ug per day.

Approximately 40% of the world remains at risk for iodine deficiency.(1)

The thyroid gland is made up of follicular cells. Thyroxine (T4) and Triiodothyronie (T3) are thyroid homones that are made inside the follicular of the thyroid gland. Dietary iodine is absorbed through the gastrointestinal tract and is then concentrated within the thyroid. It is then used by the follicular cell as an essential component of the thyroid hormones.

T3 and T4 are secreted from the thyroid gland under the regulation of Thyroid Stimulating Hormone (TSH) that is made in the anterior pituitary gland. TSH is released in response to low plasma levels of T3 and T4.

The majority of thyroid hormone is released from the thyroid gland as T4; however, once release from the thyroid, T4 is converted to T3. T3 is the metabolically active form of the hormone. T3 is responsible for increasing the body’s Basal Metabolic Rate (BMR). The BMR is the amount of energy that is expended by a person at rest. An increase in BMR leads to an increase in oxygen and energy consumption. T3 acts on the majority of tissues within the body.

A dietary iodine deficiency results in a deficiency in thyroid hormones (T3 and T4). The result can be hypothyroidism in adults, cretinism in children and in some cases nodular goiter.

A goiter is any swelling of the thyroid gland. Endemic goiter is a type of goiter that is associated with dietary iodine deficiency. Typically endemic goiter can be treated medically, however, in advanced cases where the mass encroaches upon or compresses nearby structures such as the trachea, surgical intervention is necessary.

The Struma Classification of Goiters:

Class I – only found by palpation.

Class II – can be easily seen.

Class III – large, pressure results in compression marks.

  1. The American Thyroid Association (
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Thyroid Cancer

 The Rising Incidence of Thyroid Cancer in The New York Times. (October 14, 2010). The article, written by Carolyn Sayre points out,“…that the incidence has more than doubled since the early 1970s, and for women, it is the cancerwith the fastest-growing number of new cases.”(1)Similarly, Sabiston’s textbook of surgery agrees by saying, “Several studies have shown that the incidence of well-differentiated thyroid carcinoma has increased perhaps as much as 50% since 1990.”

And goes on to point out, that…“Whether this increase is due to enhanced sophistication in screening and diagnostic techniques or possible exposure to environmental factors such as radiation or environmental mutagenic chemicals is not clear.” (2)

Types of thyroid cancer include: Papillary (70-80%), Follicular (10%), Medullary (6%), Anaplastic (< 1%). Let’s concentrate on papillary:

  • Commonly associated with previous ionizing radiation
  • 3x more common in women
  • Typically present as asymptomatic nodule
  • Treatment:
    • <1cm: lobectomy & isthmectomy
    • 1-2cm: Controversial. total thyroidectomy vs. lobectomy & isthmectomy
    • 2cm: total thyroidectomy
    • Can metastasize to local lymph node
      • Spread to lymph nodes of the neck present in more than 50% of cases
      • Stage II-IV patients also undergo lymph node resection
  1. Sayre C. The Rising Incidence of Thyroid Cancer. The New York Times. October 14, 2010. FULL ARTICLE
  2. Hanks JB, Salomone LG. Thyroid. Townsend: Sabiston’s Textbook of Surgery. 18th Edition. Saunders. 2008. Chapter 36.
  3. Miccoli et al. Modified lateral neck lymphadenectomy: Prospective randomized study comparing harmonic scalpel with clamp-cut-tie technique. Otolaryngology-Head and Neck Surgery. 2009; 140; 61-64. (Abstract)
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Yes, Chef. From Ethiopia to NYC

YesChef_TP_300x250_FINALGreat book that starts out with a little boy in Ethiopia….

It begins with a simple ritual: Every Saturday afternoon, a boy who loves to cook walks to his grandmother’s house and helps her prepare a roast chicken for dinner. The grandmother is Swedish, a retired domestic. The boy is Ethiopian and adopted, and he will grow up to become the world-renowned chef Marcus Samuelsson. This book is his love letter to food and family in all its manifestations. Yes, Chef chronicles Samuelsson’s journey, from his grandmother’s kitchen to his arrival in New York City…

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Required Reading on The Obesity Epidemic

saltsugarfatSalt, Sugar, Fat is a must read book for anyone who has ever wondered why we are getting bigger.  Michael Moss explains the reasons behind the obesity epidemic.  

Every year, the average American eats thirty-three pounds of cheese and seventy pounds of sugar. Every day, we ingest 8,500 milligrams of salt, double the recommended amount, almost none of which comes from the shakers on our table. It comes from processed food, an industry that hauls in $1 trillion in annual sales. In Salt Sugar Fat, Pulitzer Prize–winning investigative reporter Michael Moss shows how we ended up here. Featuring examples from Kraft, Coca-Cola, Lunchables, Frito-Lay, Nestlé, Oreos, Capri Sun, and many more, Moss’s explosive, empowering narrative is grounded in meticulous, eye-opening research. He takes us into labs where scientists calculate the “bliss point” of sugary beverages, unearths marketing techniques taken straight from tobacco company playbooks, and talks to concerned insiders who make startling confessions. Just as millions of “heavy users” are addicted to salt, sugar, and fat, so too are the companies that peddle them. You will never look at a nutrition label the same way again.

How to Read a Label

How the Government Got You To Eat More Cheese

You Really Can’t Eat Just One and Here’s the Reason

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Senate Passes Food Allergies Awareness Bill in Md.

Senate Passes Food Allergies Awareness Bill in Md.  ANNAPOLIS, Md. — County governments may soon have authority to make restaurants accommodate customers with food allergies.

A new bill would let counties require each restaurant to have a staff member trained on food allergens, ready to advise customers. The bill would also require restaurants statewide to encourage customers to notify servers about their food allergies.

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