Research ArticleClinical Studies
Open Access

Prognostic Role of Bacterial Translocation, Serum Endotoxin, and ZO-1 in Postoperative Infections Following Colorectal Cancer Surgery

NIKOLAOS BENETATOS, DIMITRA GEORGAKOPOULOU, ANNE-LISE DE LASTIC, DIAMANTO ARETHA, GEORGIOS SKROUBIS, VASILEIOS LEIVADITIS, EFSTRATIOS KOLETSIS, FEVRONIA KOLONITSIOU, ATHANASIA MOUZAKI, IOANNIS MAROULIS and STELIOS F. ASSIMAKOPOULOS
In Vivo November 2025, 39 (6) 3394-3405; DOI: https://doi.org/10.21873/invivo.14136

Abstract

Background/Aim: Bacterial translocation (BT) is linked to increased postoperative infections in oncologic patients undergoing major abdominal surgery. This study evaluated the prognostic value of BT, serum endotoxin, and zonula occludens-1 (ZO-1) for postoperative infections in patients with colon cancer undergoing open or laparoscopic colectomy.

Patients and Methods: Seventy-one patients (40 open, 31 laparoscopic colectomy) were analyzed. Mesenteric lymph nodes (MLNs) and liver tissue were cultured for BT detection. Serum endotoxin and ZO-1 were measured preoperatively and 24 h post-operation and compared with 12 healthy controls. Postoperative infections and hospital length of stay (HLOS) were recorded.

Results: Postoperative infection rates did not differ between groups (p=0.16); however, open surgery patients had longer HLOS (p<0.001). BT rates were similar between groups. Endotoxin levels increased on Day 1 in both open (p=0.03) and laparoscopic (p=0.04) groups vs. controls. Serum ZO-1 was significantly higher preoperatively (p<0.001) and remained elevated postoperatively, with no group differences. BT was the only independent risk factor for infection [OR 95% confidence interval (CI)=17.45 (2.65-36.8), p=0.01], while endotoxin and ZO-1 showed low prognostic accuracy. Open surgery and infections were independent predictors of prolonged HLOS (p<0.001).

Conclusion: Open and laparoscopic colectomy show similar infection rates. Serum ZO-1 and endotoxin are not reliable infection predictors. BT, detected via MLN and liver cultures, is an independent infection risk factor and may aid in identifying high-risk patients for enhanced postoperative surveillance and early intervention.

Keywords:

Introduction

The symbiotic interaction between the intestinal microbiota and the intestinal immune system is imperative to maintain gut mucosal homeostasis (1). The disruption of this dynamic balance, resulting in bacterial translocation from the gut lumen into the systemic circulation, is often responsible for sepsis and infectious complications in surgical patients (2, 3).

Bacterial translocation (BT) is the process by which viable bacteria and/or their products (e.g., endotoxin) cross the gut epithelial barrier, reaching the mesenteric lymph nodes (MLNs), other normally sterile extraintestinal sites, and the systemic circulation (4, 5). BT has been implicated in postoperative complications, including systemic inflammatory response syndrome (SIRS), bloodstream infections, and multiorgan failure (2). In patients with cancer undergoing highly invasive abdominal surgeries–such as esophagectomy, major hepatectomy with extrahepatic bile duct resection, and pancreatoduodenectomy–BT has been associated with an increased risk of postoperative infectious complications (6-10). Previous studies have shown that patients with colon cancer subjected to open or laparoscopic colectomy present high rates of BT with no difference between surgical approaches (11, 12). However, the role of BT in postoperative infections complicating colon resections for colorectal cancer has not been fully elucidated.

Beyond the confirmation of BT by intraoperative MLN sampling, the use of appropriate biomarkers of BT and gut barrier integrity would be of great value for infectious risk stratification of these patients. Endotoxin, also known as lipopolysaccharide (LPS), is a structural component of the outer membrane of Gram-negative bacteria. Endotoxin has been extensively studied as a non-invasive marker of BT and gut permeability in diverse pathological states (13, 14). In addition, due to its role in systemic immune activation upon translocation from the gut lumen into the circulation, it has been extensively studied as a key pathophysiological link between BT and complications such as SIRS and sepsis (2). Another biomarker of gut barrier integrity is zonula occludens-1 (ZO-1), a cytoplasmic protein that connects tight junction (TJ) proteins to the cytoskeleton (15). ZO-1 serves as an indicator of tight junction stability and paracellular barrier integrity, the primary pathway for endotoxin translocation (14, 15).

The present study was undertaken to address the prognostic role of bacterial translocation, serum endotoxin and ZO-1 in postoperative infections in patients undergoing open or laparoscopic surgery for colorectal cancer.

Patients and Methods

This prospective non-randomized investigator initiated one-center study was approved by the Ethics Committee of our hospital (408/09.10.2020) in accordance with the Declaration of Helsinki as revised in 2000. Written informed consent was obtained from all patients and healthy controls who participated in the study. From September 2020 to October 2023, 71 consecutive patients who were scheduled to undergo open or laparoscopic colectomy for non-metastatic colorectal cancer at our department were studied. Patients were assigned to be treated with laparoscopic or open approach, according to surgeon’s preference.

Exclusion criteria included any condition with known impact on the integrity of intestinal barrier as any active infection, chronic hepatitis B or C, Human Immunodeficiency Virus (HIV) infection, liver cirrhosis, pulmonary or cardiac insufficiency, immunosuppression, underlying rheumatologic disease, chronic kidney disease [stages 3, 4 or 5 according to the National Kidney Foundation, estimated glomerular filtration rate (eGFR) <60 ml/min], diabetes mellitus type 1 or 2, obesity (body mass index ≥30), gastrointestinal disorders (celiac disease, inflammatory bowel disease, irritable bowel syndrome, gastrointestinal bleeding within 4 weeks), previous intestinal surgery, colonoscopy during the last 2 weeks. In addition, patients were excluded if there was alcohol abuse, or use of antibiotics, corticosteroids, nonsteroidal anti-inflammatory drugs, antioxidant substances (vitamin C or E, allopurinol, N-acetylcysteine), prokinetics or probiotics within one month (16).

The postoperative patients’ course was recorded up to 30 days post operation. Postoperative septic and infectious complications in patients undergoing colectomy were systematically monitored through a structured approach to febrile episodes and clinical assessment. Hospital length of stay (HLOS) was also recorded. After discharge patients were clinically assessed weekly, or earlier when indicated e.g., when fever had emerged, up to 30 days post operation. Fever was managed with appropriate microbiological cultures, including blood, urine, and wound cultures, alongside imaging studies when indicated, to identify the infectious source. Empirical antibiotic therapy was initiated promptly and subsequently adjusted based on antimicrobial susceptibility testing.

Surgical site infections (SSIs) were classified as incisional or involving the operated organ/space according to the 2023 Centers for Disease Control and Prevention (CDC) criteria 2023 (17). Intra-abdominal collections were defined as clinically relevant purulent output from abdominal drains or newly placed radiological drains in patients with leukocytosis, a positive computed tomography (CT) scan indicating anastomotic leakage, and positive fluid cultures. Pneumonia was diagnosed based on radiological criteria and clinical parameters, whereas catheter-related bloodstream infections were identified through paired blood cultures and catheter-tip cultures. Sepsis was defined according to the Sepsis-3 definition, established in 2016 by the Third International Consensus Definitions for Sepsis and Septic Shock (18). Clinical and microbiological outcomes, as well as the duration of antibiotic therapy and hospital stay, were systematically recorded to evaluate treatment efficacy and guide therapeutic decisions. This comprehensive surveillance strategy allowed for timely diagnosis and targeted management of postoperative infections.

Surgical technique. Laparoscopic colorectal surgery was performed after pneumoperitoneum was established using an open technique. Insufflation of CO2 with an intraperitoneal pressure of 12 to 15 mmHg was obtained. A four-trocar technique was the standard approach depending on the site of colectomy and a five-six cm mini laparotomy for specimen extraction was used. The colon was dissected with a medial to lateral approach with high vessel ligation as per oncological procedure with stapler anastomosis for the continuity restoration of the colon. Standard open colectomy was performed and a stapler anastomosis after resection was fashioned through midline incision. Histological findings were assessed using the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) system (19).

Sampling of mesenteric lymph node and liver tissue. Mesenteric lymph node retrieval was performed in all patients at the first steps of operation before bowel manipulation with fresh surgical instruments and before surgical mobilization. Small wedge resection of the liver was undertaken on the free edge of the left liver lobe. Finally, both liver and lymph nodes samples were obtained under sterile conditions and were sent to the microbiology department for tissue culture. At least 1 cm3 of tissue was obtained in all cases.

Bacterial translocation detection. The lymph nodes and liver were cut into small pieces (1 cm) and suspended in Trypticase soy broth (TSB) (Becton, Dickinson and Company, Sparks, MD, USA). The samples were incubated for 24 h at 37°C and then each sample (10 μl) was incubated on selective and non-selective media (MacConkey and blood agar, Oxoid Ltd, Basingstoke, Hampshire, UK). The aerobic agar plates were incubated for 24 h at 37°C. The identification of bacteria was made by using VITEK® 2 (bioMérieux, Lyon, France). The technicians performing the analysis were unaware of the patient’s study group (open or laparoscopic) or other relevant clinical information.

Serum endotoxin and ZO-1 measurements. Serum endotoxin and ZO-1 were tested preoperatively (Day 0) and 24 h postoperatively (Day 1) in all patients. Blood was collected in endotoxin-free vials via venipuncture from a peripheral vein and the serum was isolated from the blood after centrifugation and stored at −80°C until analysis. The concentrations of ZO-1 and endotoxin in patient samples were determined using ELISA (Enzyme-Linked Immunosorbent Assay) with commercially available kits, following the manufacturer’s instructions: ZO-1 (TJP1) cat# EH15434 (Finetest, Wuhan Fine Biotech Co, Wuhan, PR China), range=0.156-10 ng/ml, sensitivity=0.094 ng/ml and Human Endotoxin (ET) kit cat# abx051541 (Abbexa Ltd, Cambridge, UK), range=0.015-1 EU/ml, sensitivity <0.01 EU/ml. The samples were processed after appropriate dilution according to the manufacturer’s instructions.

The assay used in this study for endotoxin measurement was based on a competitive binding enzyme-linked immunosorbent technology with colorimetric output, a format that has been utilized extensively. The inherent limitations of all endotoxin assays remain, mainly the correlation of measured LPS levels to actual biological function due to its unstable form and multiple interactions in the plasma. Having repeatedly used and checked this assay in previous studies we are confident nonetheless that the measured endotoxin levels reflect the actual clinical state of the patients (20-22). The assay for ZO-1 was directed against the respective human protein, therefore, the sandwich ELISA format that was used did not pose the problems posed by LPS and as such had excellent specificity without known cross-reactivity, as per the manufacturer statement.

Statistics. The normality of the data was evaluated using the Shapiro-Wilk and the Kolmogorov-Smirnov tests with a significance level of 0.05. Categorical variables are presented as frequency matrices and percentages. Continuous variables with normal distribution are presented as mean and standard deviation (SD), and those without normal distribution are presented as the median and interquartile range (IQR). For the categorical variables, the analysis was performed using Fisher’s exact and Chi-square tests with Yates correction. Following a normal distribution, continuous variables were assessed with the Student’s t-test, while those without a normal distribution were tested with the Mann-Whitney U test. Endotoxin and ZO1 level differences among groups (open, laparoscopic and healthy controls) at different time points were evaluated with ANOVA Repeated Measures test (ordinary ANOVA test for variables with normal distribution and Kruskal-Wallis test for variables without normal distribution). Receiver operating characteristics (ROC) curves were used for the evaluation of the sensitivity and specificity of endotoxin and ZO1 in infection prognosis at Day 0 and Day 1.

To identify factors associated with postoperative infections and HLOS a univariate and multivariate analysis were conducted using linear or logistic regression with backward stepwise elimination. Variables with p-values <0.1 in the univariate regression were included in the multivariable model, while the choice of variables was also based on scientific knowledge and considered potential collinearity. Multicollinearity issues were assessed using the variance inflation factor (VIF). Independent factors contributing to HLOS are presented as regression coefficient and 95% confidence interval (CI), while independent factors contributing to postoperative infection are presented as Odds ratio (OR) and 95%CI. In all cases, p-values <0.05 were considered significant. Data were analyzed using the Statistical Package for the Social Sciences (SPSS, version 28.0; IBM, Armonk, NY, USA) and GraphPad Prism Software version 10.4.1 (La Jolla, CA, USA).

Results

Patient characteristics. A total of 71 patients, 40 patients in the open operation group, 31 in the laparoscopic operation group and 12 healthy controls were enrolled in the study. The characteristics of the two groups of patients (open vs. laparoscopic operation) and healthy controls are presented in Table I. The two groups of patients did not significantly differ in age and sex. Regarding the site and type of operation, patients subjected to laparoscopic operation were operated more often on the sigmoid colon (p=0.04) and anterior resection operations were more (p=0.04). No differences were noted in AJCC classification.

View this table:
Table I.

Characteristics of the two groups of patients (Open vs. Laparoscopic operation) and healthy controls.

Post-operative infections and HLOS. There was no significant difference in the incidence of postoperative infections between the open and the laparoscopic operation groups [14/40 (35%) vs. 6/31 (19.35%) respectively, p=0.16). Patients subjected to open operation had longer hospital stay as compared to patients subjected to laparoscopic operation [12 (9-14) days vs. 7 (6-8), p<0.001] (Table II).

View this table:
Table II.

Bacterial translocation, post-operative infections and hospital length of stay (HLOS) between the open and the laparoscopic group of patients.

Bacterial translocation incidence and microbiology. There was no difference in the incidence of bacterial translocation between the open and the laparoscopic groups of patients (p=0.60). There were no differences in the incidence of positive lymph nodes cultures (p=0.68) or positive liver cultures between the two groups (p=0.25) (Table II). The microbiology of translocated microorganisms is presented in Table III. Gram-negative bacteria were the most translocated microorganisms (53.96%), followed by gram-positive (39.68%) and fungi (6.24%). E. coli (30.15%) and enterococci (20.63%) were the main translocated microorganisms.

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Table III.

Translocated microorganisms detected in the mesenteric lymph nodes and liver.

Systemic endotoxin concentrations. In both groups of patients, endotoxin concentrations were not different from controls on Day 0 but were significantly increased on Day 1 (p=0.03 for open operation group vs. healthy controls and p=0.04 for laparoscopic group vs. healthy controls) (Figure 1). There were no statistically significant differences in endotoxin levels between open and laparoscopic operation groups both on Day 0 and Day 1 (p>0.99 for Day 0 and p=0.56 for Day 1, respectively).

Figure 1.
Figure 1.

Systemic endotoxin levels among operation groups (open vs. laparoscopic) and healthy controls on Day 0 and Day 1. Line/Brackets represent differences between bars while mean endotoxin values are presented at the bottom of the bars.

Serum ZO-1 levels. Serum ZO-1 levels were significantly higher in both open and laparoscopic operation groups as compared to healthy controls on Day 0 (p<0.001, respectively) (Figure 2). This significant difference remained on Day 1, while ZO-1 levels were similar between open and laparoscopic groups for both days (p=0.87 for Day 0 and p=0.88 for Day 1, respectively].

Figure 2.
Figure 2.

Serum ZO-1 levels among operation groups (open vs. laparoscopic) and healthy controls on Day 0 and Day 1. Line/Brackets represent differences between bars while mean endotoxin values are presented at the bottom of the bars.

Factors associated with postoperative infections. Table IV presents the results of univariate and multivariate regression analyses examining factors associated with postoperative infections. In the univariate regression model, bacterial translocation was identified as an independent risk factor for increased postoperative infection risk [OR 95%CI=17.45 (2.65-36.8), p=0.01]. After adjusting for age in the multivariable analysis, bacterial translocation continued to demonstrate an independent association with postoperative infection [OR 95%CI=18.73 (3.34-35.47), p=0.006]. Our multivariate model for infection prognosis revealed a positive predicted power of 67% and a negative predicted power of 83% (ROC: area under the curve (AUC)=83%, p=0.0001). Endotoxin and ZO1 levels on Day 0 and Day 1 were not associated with infection.

View this table:
Table IV.

Univariate and multivariate regression analyses of factors associated with postoperative infections.

The role of serum endotoxin and ZO-1 in infection prognosis. ROC curves for endotoxin and ZO1 on Day 0 and Day 1 are presented in Figure 3. Both endotoxin and ZO1 revealed low sensitivity and specificity for infection prognosis. ZO1 revealed AUC=0.62, p=0.12 and AUC=0.63, p=0.09 for Day 0 and Day 1, respectively (Figure 3A and B), while endotoxin revealed AUC=0.52, p=0.79 and AUC=0.52, p=0.55 for Day 0 and Day 1, respectively (Figure 3C and D).

Figure 3.
Figure 3.

Receiver operating characteristics curves of endotoxin and ZO-1 (at Days 0 and 1) for infection prognosis.

Factors associated with HLOS. Univariate and multivariate regression analyses of factors associated with the LOHS are presented in Table V. Open laparotomy operation and postoperative infections were independent risk factors associated with prolonged HLOS (p<0.001).

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Table V.

Univariate and Multivariate regression analyses of factors associated with hospital length of stay (HLOS).

Discussion

Infectious complications in the postoperative period following colectomy for colon cancer not only increase morbidity in this vulnerable patient population but may also adversely impact long-term cancer outcomes by delaying the initiation of adjuvant therapy (10). Therefore, identifying patients at high risk for infectious complications is crucial for close monitoring and the timely implementation of preventive and therapeutic strategies. Previous studies have established a strong association between postoperative infections and BT, while prophylactic measures targeting BT have been linked to improved survival of patients with colon cancer undergoing surgery, underscoring the clinical relevance of this phenomenon (23, 24). The present study demonstrated that bacterial translocation is an independent risk factor associated with postoperative infectious complications in colorectal surgery for cancer.

In the present study, we used MLN and liver cultures as markers of BT (13). While peripheral blood cultures have also been investigated as potential BT markers during major abdominal surgery, they are neither particularly reliable nor sensitive. This limitation arises because bacterial translocation does not always lead to systemic bacteremia detectable in blood cultures, as the immune system often captures bacteria locally before they reach the bloodstream. Additionally, blood cultures may fail to detect low-level or transient translocation, and there is also the possibility that bacteremia originates from a source other than the gut (13, 25). In contrast, MLN cultures have been widely used in both animal and human studies and are considered highly specific for detecting BT. This is because bacteria that translocate across the intestinal mucosa typically follow the lymphatic route and become sequestered in MLNs (25). Furthermore, we also utilized liver cultures as a BT marker to detect translocation via the portal vein, where bacteria are subsequently trapped by the hepatic reticuloendothelial system.

The main factors implicated in the pathogenesis of BT are (a) the physical disruption of the integrity of the epithelial barrier, (b) disturbances in gut microbiota and (c) compromised of the immune function (4). Cancer-related immunosuppression is well established and is further exacerbated by the additional impact of surgical stress (26). Additionally, multiple studies have demonstrated a dysbiotic gut microbiota profile in patients with colon cancer (27, 28). However, intestinal barrier dysfunction-induced increased permeability appears to be a key factor facilitating the translocation of intraluminal bacteria and endotoxins into normally sterile extraintestinal tissues in patients with colon cancer (29). Surgical trauma, through mechanisms such as visceral vasoconstriction, intestinal ischemia, anesthetic exposure, blood loss, and the release of proinflammatory mediators, can compromise the integrity of enterocytes and their tight junctions (24).

Laparoscopic surgery, associated with reduced surgical trauma, theoretically offers an advantage in minimizing gut barrier injury compared to open surgery. However, in the present study, no significant differences were observed in BT or postoperative infection rates between open and laparoscopic procedures, consistent with previously reported findings (11, 12). Although the laparoscopic approach may favorably influence the inflammatory response to surgery, this benefit is likely offset by the effects of increased intra-abdominal pressure and prolonged procedural duration (3, 11, 12, 30).

In our study, we aimed to evaluate the prognostic value of biomarkers related to gut barrier integrity and BT in predicting postoperative infections. Specifically, we assessed two biomarkers: ZO-1, a cytoplasmic protein that anchors tight junction proteins to the cytoskeleton and serves as an indicator of tight junction stability and paracellular barrier integrity, and endotoxin, a structural component of the outer membrane of Gram-negative bacteria commonly used as a marker of BT. Previous studies by our group have shown that serum ZO-1 is a reliable biomarker of gut barrier dysfunction in sepsis, regardless of the infection site (abdominal or extra-abdominal), with prognostic value for patient outcomes (14). The present findings confirm that both ZO-1 and endotoxin are indicators of intestinal barrier disruption and BT in our surgical patients, with no significant differences observed between open and laparoscopic approaches. The early elevation of serum ZO-1 levels preoperatively, followed by a significant increase in endotoxemia 24 h postoperatively, suggests that surgical stress, bowel manipulation, disturbances in peristalsis, and potential alterations in microbiota may exacerbate BT in an already compromised gut barrier due to the underlying malignancy (31, 32). Previous studies have shown that gut barrier dysfunction in patients with colorectal cancer contributes to both local and systemic inflammation, which can further destabilize the tight junctions of enterocytes (31). In the present study, the absence of a further increase in ZO-1 levels postoperatively may suggest that additional mechanical barrier disruption from surgery occurs at a later stage (after 24 h) or that surgery-induced BT is primarily driven by alternative mechanisms, such as procedure-related immunosuppression (3). Although the selected biomarkers effectively identified gut barrier dysfunction and BT, neither was associated with postoperative infections nor demonstrated predictive value for infection risk. This might be attributed to several factors: (i) postoperative infections are multifactorial, influenced by variables beyond gut barrier dysfunction; (ii) the timing of ZO-1 and endotoxin measurements may not coincide with the period of highest susceptibility to infection; or (iii) there may be a critical threshold beyond which ZO-1 elevation and endotoxemia significantly contribute to infection risk, which was not reached in this cohort. These considerations highlight the complexity of postoperative infection pathophysiology and suggest that while gut barrier dysfunction and endotoxin translocation may play a role, they do not serve as independent predictors of infection risk. In contrast, BT, as determined by MLN and liver cultures, was an independent risk factor for postoperative infections. The identification of viable translocated microbes appears to be the most accurate predictor of infection risk, as it reflects both the virulence of the translocating pathogens and the patient’s net immunological status.

Study limitations. First, it is a single-center study with a relatively small sample size and a limited panel of biomarkers. Additional promising biomarkers of gut barrier integrity, such as citrulline, intestinal fatty acid-binding protein, and diamine oxidase, or markers of BT, including lipopolysaccharide-binding protein and bacterial DNA, could have provided a more comprehensive assessment (33, 34). Second, our analysis did not account for other key factors influencing gut barrier dysfunction and BT, such as gut microbiota alterations or the patients’ immunological profiles, which could have been evaluated through pro- and anti-inflammatory cytokine measurements. Third, the prognostic value of biomarkers was evaluated at only two time points (preoperatively and 24 hours postoperatively), whereas additional time points could have provided a more comprehensive assessment. However, this study has notable strengths. Its prospective design, the comparison of open and laparoscopic surgical approaches, the use of the gold-standard method for BT detection, and the comprehensive follow-up for infectious complications enhance its validity and clinical relevance.

Conclusion

In conclusion, open and laparoscopic colectomy for colorectal cancer do not differ in terms of postoperative infection rates or the incidence of BT. Serum ZO-1 and endotoxin levels, measured preoperatively and 24 h postoperatively, failed to predict postoperative infections. In contrast, BT, as detected by MLN and liver cultures, emerged as an independent risk factor for postoperative infections and may serve as a valuable tool for identifying high-risk patients. This could facilitate targeted postoperative monitoring and early therapeutic interventions. In high-risk patients, various pathophysiologically driven preventive strategies could be considered, including selective gut decontamination, close hemodynamic monitoring to prevent visceral micro-circulatory disturbances, enteral nutrition to support gut microcirculation, and carefully individualized probiotic administration to restore gut microbiota balance (2, 24). While routine prophylactic antibiotic use poses challenges, particularly from an antimicrobial stewardship perspective, vigilant infection surveillance and prompt initiation of antimicrobial therapy, when necessary, remain essential.

Footnotes

  • Authors’ Contributions

    NB: Conceptualization, Methodology, data acquisition, writing original draft; DG: data acquisition, laboratory sample analyses; ALdL: laboratory sample analyses, curation and data validation; DA: Statistical analyses and interpretation of data; GS: Data acquisition, draft revisions; VL: Data acquisition, draft revisions; EK: Data acquisition, draft revisions; FK: Data acquisition, interpretation; AM: Conceptualization, methodology, Supervision; IM: Conceptualization, editing, Supervision; SFA: Conceptualization, methodology, interpretation of data, supervision, draft revisions, final draft approval; All Authors significantly contributed to the article and approved the submitted version.

  • Conflicts of Interest

    On behalf of all Authors, the corresponding Author states that there are no conflicts of interest in relation to this study.

  • Funding

    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  • Artificial Intelligence (AI) Disclosure

    No artificial intelligence (AI) tools, including large language models or machine learning software, were used in the preparation, analysis, or presentation of this manuscript.

  • Received September 7, 2025.
  • Revision received September 23, 2025.
  • Accepted September 24, 2025.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).

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Prognostic Role of Bacterial Translocation, Serum Endotoxin, and ZO-1 in Postoperative Infections Following Colorectal Cancer Surgery
NIKOLAOS BENETATOS, DIMITRA GEORGAKOPOULOU, ANNE-LISE DE LASTIC, DIAMANTO ARETHA, GEORGIOS SKROUBIS, VASILEIOS LEIVADITIS, EFSTRATIOS KOLETSIS, FEVRONIA KOLONITSIOU, ATHANASIA MOUZAKI, IOANNIS MAROULIS, STELIOS F. ASSIMAKOPOULOS
In Vivo Nov 2025, 39 (6) 3394-3405; DOI: 10.21873/invivo.14136
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