|
1
|
Speelman JP, Hui KL, Woodbridge NT, Pfeiffer S, Beatty JA, Taylor AH. Prognostic Factors in 26 Cats Undergoing Surgery for Extra-Hepatic Biliary Obstruction. Vet Sci 2024; 11:610. [PMID: 39728950 DOI: 10.3390/vetsci11120610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Revised: 11/13/2024] [Accepted: 11/27/2024] [Indexed: 12/28/2024] Open
Abstract
Surgical management of feline extra-hepatic biliary obstruction (EHBO) has poor survival rates with few prognostic factors reported in the literature. The etiology and clinical findings of feline EHBO and their influence on short-(2 weeks-6 months) and long-term (>6 months) survival and prognosis were examined in an observational clinical retrospective study of 26 client-owned cats undergoing surgery for biliary obstruction at one institution between 2012 and 2020. The etiology of EHBO was determined in 21/26 cats, which included inflammatory causes (14/21), neoplastic causes (6/21), and a duodenal foreign body (1/21). Pre-operative hyperbilirubinemia and post-extubation hypotension (mean arterial pressure < 60 mmHg) were statistically associated with reduced short- and long-term survival. Short-term survival was documented in 17/26 cats, and long-term survival in 13/26 cats. Median survival time (MST) was 86 days (range, 0-1497). An MST of 17 days (range, 2-520) in cats with malignancies was found compared to an MST of 1165 days (range, 61-2268) in EHBO resulting from inflammatory complexes. Pre-operative hyperbilirubinemia and immediate post-operative hypotension may represent prognostic factors for cats undergoing surgery for EHBO. Cats with inflammatory causes of EHBO carry a more favorable prognosis than neoplastic causes. Further studies are required to evaluate the validity of the observed associations.
Collapse
Affiliation(s)
| | - Ki-Lam Hui
- Pulse Veterinary Specialists and Emergency, 450 Ordze Road, Sherwood Park, AB T8B 0C5, Canada
| | - Nicolas T Woodbridge
- Dick White Referrals, Station Farm, London Road, Six Mile Bottom, Cambridgeshire CB8 0UH, UK
| | - Susanne Pfeiffer
- Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong SAR, China
| | - Julia A Beatty
- Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong SAR, China
- Centre for Animal Health and Welfare, City University of Hong Kong, Hong Kong SAR, China
- Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong SAR, China
| | - Alan H Taylor
- CityU VMC, Sham Shui Po, Kowloon, Hong Kong SAR, China
| |
Collapse
|
|
2
|
Thompson BJ, Sherman RA. Comprehensive Review of Biliary Peritonitis. Top Companion Anim Med 2021; 44:100532. [PMID: 33781985 DOI: 10.1016/j.tcam.2021.100532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/26/2022]
Abstract
Biliary peritonitis is a growing concern in the canine patient and a thorough understanding of the disease will lead to better treatment outcomes. This article reviews the human and veterinary literature pertaining to biliary peritonitis including both scientific reviews and original publications. Compared to human medicine, biliary peritonitis can be difficult to diagnose preoperatively. Multiple risk factors exist increasing the likelihood of development of biliary peritonitis. Treatment recommendations center on stabilization, surgical cholecystectomy, and postoperative supportive care. Clinically, further studies on treatment and prevention in veterinary medicine are warranted.
Collapse
|
|
3
|
Abstract
Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.
Collapse
|
|
4
|
Lagman C, Nagasawa DT, Azzam D, Sheppard JP, Chen CHJ, Ong V, Nguyen T, Prashant GN, Niu T, Tucker AM, Kim W, Kaldas FM, Pouratian N, Busuttil RW, Yang I. Survival Outcomes After Intracranial Hemorrhage in Liver Disease. Oper Neurosurg (Hagerstown) 2020; 16:138-146. [PMID: 29767779 DOI: 10.1093/ons/opy096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Survival outcomes for patients with liver disease who suffer an intracranial hemorrhage (ICH) have not been thoroughly investigated. OBJECTIVE To understand survival outcomes for 3 groups: (1) patients with an admission diagnosis of liver disease (end-stage liver disease [ESLD] or non-ESLD) who developed an ICH in the hospital, (2) patients with ESLD who undergo either operative vs nonoperative management, and (3) patients with ESLD on the liver transplant waitlist who developed an ICH in the hospital. METHODS We retrospectively reviewed hospital charts from March 2006 through February 2017 of patients with liver disease and an ICH evaluated by the neurosurgery service at a single academic medical center. The primary outcome was survival. RESULTS We included a total of 53 patients in this study. The overall survival for patients with an admission diagnosis of liver disease who developed an ICH (n = 29, 55%) in the hospital was 22%. Of those patients with an admission diagnosis of liver disease, 27 patients also had ESLD. Kaplan-Meier analysis found no significant difference in survival for ESLD patients (n = 33, 62%) according to operative status. There were 11 ESLD patients on the liver transplant waitlist. The overall survival for patients with ESLD on the liver transplant waitlist who suffered an in-hospital ICH (n = 7, 13%) was 14%. CONCLUSION ICH in the setting of liver disease carries a grave prognosis. Also, a survival advantage for surgical hematoma evacuation in ESLD patients is not clear.
Collapse
Affiliation(s)
- Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Daniel T Nagasawa
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Daniel Azzam
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Cheng Hao Jacky Chen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Vera Ong
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Tianyi Niu
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Alexander M Tucker
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Won Kim
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Fady M Kaldas
- Department of Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Nader Pouratian
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Ronald W Busuttil
- Department of Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California.,Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California.,Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California.,UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles, Los Angeles, California
| |
Collapse
|
|
5
|
Sriussadaporn S, Sriussadaporn S, Pak-art R, Kritayakirana K, Prichayudh S, Samorn P, Narueponjirakul N. Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study. ASIAN BIOMED 2019. [DOI: 10.1515/abm-2019-0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD).
Objectives
To determine whether PBD is associated with more complications after PD.
Methods
Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate.
Results
There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without.
Conclusions
PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.
Collapse
Affiliation(s)
- Suvit Sriussadaporn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Sukanya Sriussadaporn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Rattaplee Pak-art
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Kritaya Kritayakirana
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Supparerk Prichayudh
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Pasurachate Samorn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Natawat Narueponjirakul
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| |
Collapse
|
|
6
|
Parkanzky M, Grimes J, Schmiedt C, Secrest S, Bugbee A. Long-term survival of dogs treated for gallbladder mucocele by cholecystectomy, medical management, or both. J Vet Intern Med 2019; 33:2057-2066. [PMID: 31490022 PMCID: PMC6766501 DOI: 10.1111/jvim.15611] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/20/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Gallbladder mucoceles (GBM) typically are treated by cholecystectomy. Medical management rarely has been reported and medical and surgical management have not been compared. HYPOTHESIS/OBJECTIVES To compare survival of dogs treated for GBM by medical management or cholecystectomy or both. ANIMALS Eighty-nine client-owned dogs diagnosed with GBM that received cholecystectomy or medical treatment or both from 2011 to 2017. METHODS Potential cases were identified by searching the medical records database. Data collected included signalment, clinicopathologic results, treatments, and ultrasonographic images and reports. Dogs were grouped according to the treatment received (medical management, surgical treatment, or both) that was chosen at the discretion of the attending veterinarian. Survival analysis was performed and prognostic variables identified and compared between treatment groups. RESULTS Of dogs surviving at least 14 days after diagnosis, median survival times were 1802 (95% confidence interval [CI], 855-not reached) days, 1340 (95% CI, 444-1340) days, and 203 (95% CI, 18-525) days, for the surgical, medical, and medical then surgical treatment groups, respectively, and differed significantly (P < .0001). Gallbladder mucocele type (P = .05), serum alkaline phosphatase activity (P = .0001), and serum creatinine (P = .002) and phosphorus (P = .04) concentrations were associated with decreased survival across groups. Suspicion of biliary rupture on abdominal ultrasound (AUS) examination was correlated with increased survival in the surgical group (P = .02). CONCLUSIONS AND CLINICAL IMPORTANCE Cholecystectomy for the treatment of GBM results in the best long-term survival in dogs surviving the immediate postoperative period (14 days) compared to medical management. Although medical management is associated with shorter survival compared to surgical treatment, it is a reasonable alternative when surgery cannot be pursued.
Collapse
Affiliation(s)
- Max Parkanzky
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, Athens, Georgia
| | - Janet Grimes
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, Athens, Georgia
| | - Chad Schmiedt
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, Athens, Georgia
| | - Scott Secrest
- Department of Veterinary Biosciences and Diagnostic Imaging, University of Georgia College of Veterinary Medicine, Athens, Georgia
| | - Andrew Bugbee
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, Athens, Georgia
| |
Collapse
|
|
7
|
Ausania F, Senra P, Meléndez R, Caballeiro R, Ouviña R, Casal-Núñez E. Prehabilitation in patients undergoing pancreaticoduodenectomy: a randomized controlled trial. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:603-608. [PMID: 31232076 DOI: 10.17235/reed.2019.6182/2019] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION prehabilitation has been proposed as an effective tool to prevent postoperative complications in patients undergoing major abdominal surgery. However, no studies have demonstrated its effectiveness in pancreatic surgical patients. The aim of this study was to assess the impact of prehabilitation on postoperative complications in patients undergoing a pancreaticoduodenectomy (PD). METHODS this was a randomized controlled trial. Eligible candidates who accepted to participate were randomized to the control (standard care) or intervention (standard care + prehabilitation) group. All patients with pancreatic or periampullary tumors who were candidates for pancreaticoduodenectomy were included. Patients who received neoadjuvant treatment were excluded. Prehabilitation covered three actions: a) nutritional support; b) control of diabetes and exocrine pancreatic insufficiency; and c) physical and respiratory training. The main study outcome was the proportion of patients who suffered postoperative complications. Secondary outcomes included the occurrence of specific complications (pancreatic leak and delayed gastric emptying) and hospital stay. RESULTS forty patients were included in the analysis. Twenty-two patients were randomized to the control arm and 18, to the intervention group. No statistically significant differences were observed in terms of overall and major complications between the prehabilitation and standard care groups. Pancreatic leak was not statistically different between the groups (11% vs 27%, p = 0.204). However, DGE was significantly lower in the prehabilitation group (5.6% vs 40.9% in the standard care group, p = 0.01). CONCLUSION prehabilitation did not reduce postoperative complications following pancreaticoduodenectomy. However, a reduction in DGE was observed. Further studies are needed to validate the role and the timing of prehabilitation in high-risk patients.
Collapse
|
|
8
|
Sha J, Dong Y, Niu H. A prospective study of risk factors for in-hospital mortality in patients with malignant obstructive jaundice undergoing percutaneous biliary drainage. Medicine (Baltimore) 2019; 98:e15131. [PMID: 30985679 PMCID: PMC6485810 DOI: 10.1097/md.0000000000015131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The in-hospital mortality rate in patients undergoing percutaneous transhepatic biliary drainage (PTBD) for malignant obstructive jaundice (MOJ) is high. There are few reports on the risk factors associated with hospital death after MOJ, with most of them being retrospective analyses of single factors. Therefore, this study aimed to assess pre-, intra-, and post-procedure risk factors that were independently associated with increased in-hospital mortality in MOJ patients who underwent PTBD. METHODS One-hundred fifty-five patients with MOJ who underwent initial PTBD were included in this study. A total of 25 pre-, 4 intra-, and 6 post-procedure factors potentially related to in-hospital mortality were assessed by univariate and multivariate analyses. RESULTS The in-hospital mortality rate was 16.8% (26/155). Of 25 pre-procedure variables analyzed, Child-Pugh classification C, creatinine level ≥6.93 μmol/L, and quality-of-life score (≤30) were found to be significant in univariate and multivariate analyses. Increased mortality was observed in patients with 2 or more risk factors, which was significantly different from patients with no risk factors or one risk factor (P < .01). None of the intra-procedure factors were important in identifying patients at risk of death. Multivariate analysis indicated post-PTBD cholangitis and unsuccessful drainage as post-procedure risk factors that correlated with in-hospital death. CONCLUSION It was identified that in-hospital mortality was associated with 3 pre-procedure and 2 post-procedure risk factors, such as the liver function classification, quality-of-life score of cancer patients, creatinine level, PTBD-associated biliary duct infection, and unsuccessful drainage.
Collapse
|
|
9
|
Youn G, Waschak MJ, Kunkel KAR, Gerard PD. Outcome of elective cholecystectomy for the treatment of gallbladder disease in dogs. J Am Vet Med Assoc 2019; 252:970-975. [PMID: 29595398 DOI: 10.2460/javma.252.8.970] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine mortality rates for dogs undergoing cholecystectomy and variables associated with failure to survive to hospital discharge. DESIGN Retrospective cohort study. ANIMALS 70 dogs that underwent cholecystectomy for biliary tract disease at a companion animal referral hospital from 2009 through 2015. PROCEDURES Medical records of dogs were reviewed and data collected; dogs with biliary diversion surgery were excluded. Included dogs were grouped by whether cholecystectomy had been elective (ie, dogs with no or mild clinical signs, with no indication of biliary obstruction, or that initially underwent surgery for a different procedure) or nonelective (ie, dogs with icterus and questionable patency of the biliary system). Mortality rates (proportions of dogs that failed to survive to hospital discharge) were compared between various groups. RESULTS 45 (64%) dogs were included in the elective group and 25 (36%) in the nonelective group. Group mortality rates were 2% (1/45) and 20% (5/25), respectively, and differed significantly. Overall mortality rate was 9% (6/70). Serum albumin concentration was significantly lower and serum alanine aminotransferase activity and total bilirubin concentration were significantly higher in nonsurviving versus surviving dogs. Dogs with vomiting, signs of lethargy or anorexia, icterus, or azotemia were less likely to survive than dogs without these signs. CONCLUSIONS AND CLINICAL RELEVANCE Dogs that underwent elective cholecystectomy had a considerably lower mortality rate than previously reported. Elective cholecystectomy may be an appropriate recommendation for dogs with early signs of biliary disease to avoid the greater mortality rate associated with more advanced disease and nonelective cholecystectomy.
Collapse
|
|
10
|
Hepatobiliary Hands of Hopkins. Ann Surg 2017; 267:S34-S39. [PMID: 29206676 DOI: 10.1097/sla.0000000000002606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This historical perspective documents the role that John L. Cameron played in advancing hepatobiliary research, education, and surgery at Johns Hopkins in the 1970s, 1980s, and 1990s. SUMMARY OF BACKGROUND DATA Dating back to William S. Halsted in the 19th century, leaders of the Department of Surgery at Johns Hopkins have been interested in hepatobiliary disease and surgery. John L. Cameron had broad hepato-pancreato-biliary (HPB) interests when he completed his surgical training. Over the next 3 decades, he focused on the pancreas. As a result, many faculty and trainee hepatobiliary careers were launched. METHODS This perspective is based on 18 years of service as a surgical resident and faculty member at Johns Hopkins. An extensive literature search on the hepatobiliary publications of Halsted, Trimble, Blalock, Longmire, Zuidema, and Cameron was undertaken for this manuscript. Numerous hepatobiliary publications from Johns Hopkins from the 1970s, 1980s, 1990s, and early 2000s were also reviewed. RESULTS John L. Cameron's early biliary interests included stones, infections, malignancies, and strictures. He was innovative with respect to portal hypertension and Budd-Chiari surgery and supportive when liver transplantation emerged in the 1980s. Volume-outcome studies in the 1990s included hepatic and complex biliary surgery. He supported and encouraged studies of biliary lithotripsy, laparoscopic cholecystectomy, clinical pathways, hepatobiliary cysts, and gallstone pathogenesis. CONCLUSION Lessons learned by many who worked with John L. Cameron included the importance of mentorship, innovation, friendship, and collaboration. He taught leadership and change management by example. He fostered a multidisciplinary approach and encouraged randomized controlled trials.
Collapse
|
|
11
|
Monticelli P, Stathopoulou TR, Lee K, Adami C. Life-threatening perianaesthetic complications in five cats undergoing biliary tract surgery: case series and literature review. J Feline Med Surg 2017; 19:717-722. [PMID: 27099297 PMCID: PMC11128805 DOI: 10.1177/1098612x16646152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Case series summary The aim of this case series was to describe the intra- and early postanaesthetic complications occurring in five cats undergoing major surgeries involving the gallbladder and the biliary tree. The five cases of this series were admitted to the Queen Mother Hospital for Animals between June and December 2015, and were all overseen by the same senior anaesthesist. Pre-existing pancreatitis was a common finding. Observed life-threatening events were persistent, unresponsive hypotension in the absence of major blood loss, which occurred mainly during surgical manipulation of the biliary tract, and postoperative renal failure. Relevance and novel information Biliary surgery carries the potential for life-threatening complications in cats. The pathogenesis of such morbidities is likely to be multifactorial. The perianaesthetic use of haemoglobin-based oxygen-carrying solution may be considered as an alternative treatment option when hypotension is unresponsive to fluids and traditional positive inotropes and vasopressors.
Collapse
Affiliation(s)
| | | | - Karla Lee
- Royal Veterinary College, University of London, Hatfield, UK
| | - Chiara Adami
- Royal Veterinary College, University of London, Hatfield, UK
| |
Collapse
|
|
12
|
Sauvanet A, Boher JM, Paye F, Bachellier P, Sa Cuhna A, Le Treut YP, Adham M, Mabrut JY, Chiche L, Delpero JR. Severe Jaundice Increases Early Severe Morbidity and Decreases Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma. J Am Coll Surg 2015. [PMID: 26206638 DOI: 10.1016/j.jamcollsurg.2015.03.058] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The influence of jaundice on outcomes after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to determine, in a large multicentric series, the influence of severe jaundice (serum bilirubin level ≥250 μmol/L and 300 μmol/L) on early severe morbidity and survival after PD. STUDY DESIGN From 2004 to 2009, twelve hundred patients (median age 66 years, 57% male) with resectable PDAC underwent PD. Patients who received preoperative biliary drainage for neoadjuvant treatment or cholangitis were excluded. Pre- and intraoperative data were collected by a standardized form. Serum bilirubin level and creatinine clearance were analyzed as categorical variables. Predictive factors of severe complications and poor survival (Kaplan-Meier method) were identified by univariate and multivariate analysis. RESULTS Median follow-up was 21 months (95% CI, 19-23). Operative mortality was 3.9% (n = 47), with no predictive factors in multivariate analysis. Severe complications (Dindo-Clavien grade III to IV) occurred in 22% (n = 268), with male sex (p = 0.025), America Society of Anesthesiologists score 3 to 4 (p = 0.022), serum bilirubin level ≥300 μmol/L (p = 0.034), and creatinine clearance <60 mL/min/1.73 m(2) (p = 0.013) identified as predictive factors in multivariate analysis. Overall 3-year survival rate was 41% (95% CI, 37-45%). In multivariate analysis, serum bilirubin level ≥300 μmol/L (p = 0.048), low-volume center (p < 0.001), venous resection (p = 0.014), N1 status (p < 0.01), R1 status (p < 0.001), and absence of adjuvant treatment (p < 0.001) negatively impacted survival. There was a negative relationship between survival at 12 months or later and higher rates of bilirubin. Presence of a biliary stent did not influence early or long-term results. CONCLUSIONS In this multicentric study, serum bilirubin level ≥300 μmol/L increased severe morbidity and decreased long-term survival after PD for PDAC. These findings suggest that biliary stenting is appropriately indicated before PD in patients with PDAC and severe jaundice.
Collapse
Affiliation(s)
- Alain Sauvanet
- Department of Hepato-Biliary and Pancreatic Surgery, Hôpital Beaujon, Clichy, France.
| | - Jean-Marie Boher
- Department of Biostatistics and Methodology, Institut Paoli Calmettes, Marseille, France; Unité Mixte de Recherche Institut de Recherche pour le Développement, Aix-Marseille University, Marseille, France
| | - François Paye
- Department of Digestive Surgery, Hôpital Saint Antoine, Paris, France
| | | | - Antonio Sa Cuhna
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
| | | | - Mustapha Adham
- Department of Surgery, Hôpital Edouard-Herriot, Lyon, France
| | | | - Laurence Chiche
- Department of Surgery, Maison du Haut-Levêque, Pessac, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli Calmettes, Marseille, France
| | | |
Collapse
|
|
13
|
Wu JQ, Wang H, Cui YF. Preoperative biliary drainage and pancreaticoduodenectomy. Shijie Huaren Xiaohua Zazhi 2015; 23:1592-1596. [DOI: 10.11569/wcjd.v23.i10.1592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the standard procedure in the surgical treatment of malignant obstructive jaundice (MOJ). However, the postoperative recovery of the patients remains unsatisfactory, due to the extensive surgical trauma and high morbidity. In this review we briefly discuss the positive effect of preoperative biliary drainage (PBD) in reducing the complications after pancreaticoduodenectomy, explain the rationality and necessity of this technique, and discuss some key issues, such as the selection and indications of PBD.
Collapse
|
|
14
|
Ahmad SR, Adler DG. Cancer of the ampulla of vater: current evaluation and therapy. Hosp Pract (1995) 2015; 42:45-61. [PMID: 25485917 DOI: 10.3810/hp.2014.12.1158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.
Collapse
Affiliation(s)
- Sarah R Ahmad
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
| | | |
Collapse
|
|
15
|
Nugroho A, Lalisang TJ. Validation of simplified predictive score for postoperative mortality after pancreaticoduodenectomy. MEDICAL JOURNAL OF INDONESIA 2014. [DOI: 10.13181/mji.v23i2.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background: Pancreaticoduodenectomy has long been associated with high rates of morbidity and mortality. The key to a better postoperative outcome is a good patient selection. The aim of this study was to develop a simplified preoperative predictive score for postoperative mortality after pancreaticoduodenectomy.Methods: Patients who underwent elective pancreaticoduodenectomy from 1995 to 2012 were identified from the Division of Digestive Surgery database. Bivariate analysis and multivariate logistic regression analysis identified prediction of morbidity and mortality. ROC curve estimation is use to determined the cut-off value of the predictive score.Results: Of 138 patients who underwent pancreaticoduodenectomy, 27 patients (19.6%) died. The predictor of mortality are serum total bilirubin ≥ 10 mg/dL, serum creatinin ≥ 1.3 mg/dL, hematocrit ≤ 30%, serum albumin ≤ 3.0 g/dL and ASA status ≥ 3, with assign score 1, 1, 2, 1, 1, respectively. The cut-off value was 4 with 96% sensitivity and 91% specificity. The area under the receiver operator characteristic curve was 0.974 (SE 0.011; p < 0.001), which demonstrated a reasonable predictive value for the score.Conclusion: A total score of 4 or more is associated with increased postoperative mortality in patients underwent pancreaticoduodenectomy.
Collapse
|
|
16
|
Navaneethan U, Gutierrez NG, Jegadeesan R, Venkatesh PGK, Sanaka MR, Vargo JJ, Parsi MA. Factors predicting adverse short-term outcomes in patients with acute cholangitis undergoing ERCP: A single center experience. World J Gastrointest Endosc 2014; 6:74-81. [PMID: 24634711 PMCID: PMC3952163 DOI: 10.4253/wjge.v6.i3.74] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/10/2013] [Accepted: 11/12/2013] [Indexed: 02/05/2023] Open
Abstract
AIM To identify potential factors that can predict adverse short-term outcomes in patients with acute cholangitis undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS Retrospective analysis of consecutive patients admitted to our center for acute cholangitis and underwent ERCP from 2001 to 2012. Involvement of two or more organ systems was termed as organ failure (OF). Cardiovascular failure was defined based on a systolic blood pressure of < 90 mmHg despite fluid replacement and/or requiring vasopressor treatment; respiratory failure if the Pa02/Fi02 ratio was < 300 mmHg and/or required mechanical ventilation; coagulopathy if the platelet count was < 80; and renal insufficiency if serum creatinine was > 1.9 mg/dL. Variables associated with short term adverse clinical outcomes defined as persistent OF and/or 30-d mortality was determined. RESULTS A total of 172 patients (median age 62 years, 56.4% female) were included. The median door to ERCP time was 17 h. Bile duct stones were the most common etiology (n = 67, 39.2%). In multivariate analysis, factors that were independently associated with persistent OF and/or 30-d mortality included American Society of Anesthesiology (ASA) physical classification score > 3 (OR = 7.70; 95%CI: 2.73-24.40), presence of systemic inflammatory response syndrome (OR = 3.67; 95%CI: 1.34-10.3) and door to ERCP time greater than 72 h (OR = 3.36; 95%CI: 1.12-10.20). Door to ERCP time greater than 72 h was also associated with 70% increase in the mean length of stay (P < 0.001). Every one point increase in the ASA physical classification and every 1 mg/dL increase in the pre-ERCP bilirubin level was associated with a 34% and 2% increase in the mean length of hospital stay, respectively. Transfer status did not impact clinical outcomes. CONCLUSION Higher ASA physical classification and delays in ERCP are associated with adverse clinical outcomes and prolonged length of hospital stay in patients with acute cholangitis undergoing ERCP.
Collapse
|
|
17
|
Lv X, Song JG, Li HH, Ao JP, Zhang P, Li YS, Song SL, Wang XR. Decreased hepatic peroxisome proliferator-activated receptor-γ contributes to increased sensitivity to endotoxin in obstructive jaundice. World J Gastroenterol 2011; 17:5267-73. [PMID: 22219595 PMCID: PMC3247690 DOI: 10.3748/wjg.v17.i48.5267] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 08/25/2011] [Accepted: 09/02/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the role of hepatic peroxisome proliferator-activated receptor-γ (PPAR-γ) in increased susceptibility to endotoxin-induced toxicity in rats with bile duct ligation during endotoxemia.
METHODS: Male Sprague-Dawley rats were subjected to bile duct ligation (BDL). Sham-operated animals served as controls. DNA binding were determined by polymerase chain reaction, Western blotting analysis, and electrophoretic mobility shift assay, respectively. BDL and sham-operated rats received a non-lethal dose of intraperitoneal lipopolysaccharide (LPS) injection (3 mg/kg, i.p.). Additionally, the potential beneficial effects of the PPAR-γ agonist rosiglitazone were determined in BDL and sham-operated rats treated with a non-lethal dose of LPS. Survival was assessed in BDL rats treated with a non-lethal dose of LPS and in sham-operated rats treated at a lethal dose of LPS (6 mg/kg, i.p.).
RESULTS: PPAR-γ activity in rats undergoing BDL was significantly lower than in the sham-controls. Hepatic PPAR-γ gene expression was downregulated at both the mRNA and protein levels. In a parallel group, serum levels of pro-inflammatory cytokines were nearly undetectable in the sham-operated rats. When challenged with a non-lethal dose of LPS (3 mg/kg), the BDL rats had approximately a 2.4-fold increase in serum IL-6, a 2.7 fold increase in serum TNF-α, 2.2-fold increase in serum IL-1 and 4.2-fold increase in serum ALT. The survival rate was significantly lower as compared with that in sham-operated group. Additionally, rosiglitazone significantly reduced the concentration of TNF-α, IL-1β, IL-6 and ALT in sham-operated rats, but not in BDL rats, in response to LPS (3 mg/kg). Also, the survival was improved by rosiglitazone in sham-operated rats challenged with a lethal dose of LPS, but not in BDL rats, even with a non-lethal dose of LPS (3 mg/kg).
CONCLUSION: Obstructive jaundice downregulates hepatic PPAR-γ expression, which in turn may contribute to hypersensitivity towards endotoxin.
Collapse
|
|
18
|
Mehler SJ. Complications of the extrahepatic biliary surgery in companion animals. Vet Clin North Am Small Anim Pract 2011; 41:949-67, vi. [PMID: 21889694 DOI: 10.1016/j.cvsm.2011.05.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Surgery of the biliary tract is demanding and is associated with several potentially life-threatening complications. Veterinarians face challenges in obtaining accurate diagnosis of biliary disease, surgical decision-making, surgical hemostasis and bile peritonitis. Intensive perioperative monitoring is required to achieve early recognition of common postoperative complications. Proper treatment and ideally, avoidance of surgical complications can be achieved by gaining a clear understanding physiology, anatomy, and the indications for hepatobiliary surgery.
Collapse
Affiliation(s)
- Stephen J Mehler
- Veterinary Specialists of Rochester, 825 White Spruce Boulevard, Rochester, NY 14623, USA.
| |
Collapse
|
|
19
|
Hauptman K, Jekl V, Knotek Z. Extrahepatic biliary tract obstruction in two ferrets (Mustela putorius furo). J Small Anim Pract 2011; 52:371-5. [PMID: 21671943 DOI: 10.1111/j.1748-5827.2011.01068.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This report describes extrahepatic bile duct obstruction in two ferrets, which were presented with anorexia, chronic weight loss and general weakness. Physical examination revealed lethargy, cachexia, dehydration, abdominal pain and icterus. Marked haematological, serum chemistry and urinalysis abnormalities included hyperbilirubinaemia (65·5 and 114·2 μmol/L), high concentrations of alanine transaminase (1327·53 and 2578·88 IU/L) and biluribinuria. Abdominal ultrasonography revealed thickening of the bile duct together with the gall bladder wall. The common bile duct was obviously distended. Choledochotomy revealed inspissated bile with fragile green gelatinous plugs that was removed to allow the bile to flow into the duodenum. Cytology and culture of the biliary tract contents were negative for bacteria. Laboratory analyses of biliary plugs showed presence of only protein substances, without detectable mineral composition. Histopathological examination of the liver showed diffuse steatosis and non-specific cholangiohepatitis in both cases.
Collapse
Affiliation(s)
- K Hauptman
- Avian and Exotic Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Palackého 1-3, Brno, Czech Republic
| | | | | |
Collapse
|
|
20
|
Morris-Stiff G, Tamijmarane A, Tan YM, Shapey I, Bhati C, Mayer AD, Buckels JAC, Bramhall SR, Mirza DF. Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy. Int J Surg 2010; 9:145-9. [PMID: 21029795 DOI: 10.1016/j.ijsu.2010.10.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/11/2010] [Accepted: 10/17/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Whilst there are theoretical benefits from pre-operatively draining the biliary tree prior to pancreatoduodenectomy (PD), the current literature does not support this intervention. The aim of this study was to explore the relationship between pre-operative stenting, bactibilia and outcome in a large United Kingdom tertiary referral practice. METHODS Patients undergoing PD were identified from a prospectively maintained database. The presence or absence of a stent prior to PD, and the results of bile cultures taken at PD were related to the subsequent post-operative course and the development of complications. RESULTS 280 patients underwent PD for periampullary malignancies, all of whom presented with jaundice. 118 patients were stented prior to referral (98 ERCP, 20 PTC). Bile cultures were positive more frequently in the stent group (83% vs. 55%; p = 0.000002) and bactibilia was more common after ERCP than PTC (83% vs. 56%; p = 0.006). The overall prevalence of complications was 54% in the stented and 41% in the non-stented group (p = 0.03) with statistical significance achieved for pancreatic leak (p = 0.013) and haemorrhagic complications (p = 0.03). Comparing stent with no stent, there as no difference in the 30-day mortalities (8.5% vs. 6.8%; p = 0.6) or the 1-year mortality rates (35% vs. 28%; p = 0.21). Mortality rates in the infection versus no infection groups were comparable at 30 days (8.5% vs. 5.5%; p = 0.21), and at 1 year (30.7% vs. 26.4%; p = 0.25). CONCLUSIONS Pre-operative stent insertion prior to PD is associated with increased morbidity but not mortality and this is greatest for stents placed at ERCP.
Collapse
Affiliation(s)
- Gareth Morris-Stiff
- Hepato-biliary Pancreatic Surgery Unit, Nuffield House, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | | | | | | | | | | | | | | | | |
Collapse
|
|
21
|
Huang CY, Sheen-Chen SM, Ho HT, Tang RP, Eng HL. Antithrombin-III Attenuates Hepatocyte Apoptosis in Bile Duct Ligated Rat: A Striking Cellular Change. Surg Innov 2010; 17:132-5. [DOI: 10.1177/1553350610366716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and purpose: Retention and accumulation of toxic hydrophobic bile salts within hepatocyte may cause hepatocyte toxicity by inducing apoptosis. This study was designed with the purpose of evaluating the possible effect of antithrombin-III on hepatocyte apoptosis in bile duct ligated rat. Materials and methods: The rats were randomized to 3 groups: group 1 (control, C) underwent sham operation; group 2 (obstructive jaundice, OB) underwent common bile duct ligation; and group 3 (obstructive jaundice with antithrombin-III, OBAT-III) underwent common bile duct ligation and simultaneously were treated with antithrombin-III. Liver tissues were harvested on the fifth postoperative day. Results: Hepatocyte apoptosis was significantly increased in bile duct ligated group when compared with the sham operation group. The administration of antithrombin-III effectively attenuates such phenomenon in obstructive jaundice with antithrombin-III group. Conclusion: Bile duct ligation significantly increased hepatocyte apoptosis and the administration of antithrombin-III effectively attenuates such phenomenon.
Collapse
Affiliation(s)
- Chun-Ying Huang
- Dept. of Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, College of Medicine, Chang Gung University, Taiwan
| | - Shyr-Ming Sheen-Chen
- Dept. of Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, College of Medicine, Chang Gung University, Taiwan, , Dept. of Surgery, Xiamen Chang Gung Hospital, Xiamen, China
| | - Hsin-Tsung Ho
- Dept. of Laboratory Medicine, Mackay Memorial Hospital, Mackay Medicine, Nursing and Management College, Taiwan
| | - Rei-Ping Tang
- Dept. of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, College of Medicine, Chang Gung University, Taiwan
| | - Hock-Liew Eng
- Dept. of Pathology, Chang Gung Memorial Hospital, Kaohsiung, Medical Center, College of Medicine, Chang Gung University,Taiwan
| |
Collapse
|
|
22
|
Sheen-Chen SM, Ho HT, Eng HL. Z-LLY-FMK attenuates intestinal apoptosis after bile duct ligation in rats. Dig Dis Sci 2009; 54:2357-61. [PMID: 19093200 DOI: 10.1007/s10620-008-0652-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 11/21/2008] [Indexed: 12/14/2022]
Abstract
Apoptosis is an important process in a wide variety of different biological systems. In addition to caspases, recently, calpains, another family of proteases, have been found to be involved in apoptosis of many cell systems. This study is designed with the aims to evaluate the possible effect of Z-LLY-FMK (a calpain inhibitor) on intestine apoptosis after bile duct ligation in rats. Male Sprague-Dawley rats weighing 250-300 g were randomized to five groups (n = 6 in each group). Group 1 (CONTROL: C) underwent Sham operation and were simultaneously treated with the same amount of normal saline. Group 2 (CONTROL with DMSO: CDMSO) underwent Sham operation and were simultaneously treated with the same amount of dimethylsulfoxide (DMSO). Group 3 (Obstructive jaundice: OB) underwent common bile duct ligation without any other manipulation. Group 4 (Obstructive jaundice with Z-LLY-FMK: OBZLLY) underwent common bile duct ligation and were simultaneously treated with Z-LLY-FMK (dissolved in DMSO). Group 5 (Obstructive jaundice with ZFA-FMK: OBZFA) underwent common bile duct ligation and were simultaneously treated with ZFA-FMK (dissolved in DMSO). After 3 days, intestine tissue was harvested for apoptosis measurements. There was no significant difference between Sham operation group (C) and Sham operation with DMSO group (CDMSO) either in jejunum (P = 0.924) or in ileum (P = 0.996). When compared to Sham operation group (C), increased intestine apoptosis occurred in either jejunum (P < 0.001) or in ileum (P < 0.001) after common bile duct ligation (OB). After administration of Z-LLY-FMK (OBZLLY), the increased intestine apoptosis after common bile duct ligation (OB) was significantly diminished either in jejunum or in ileum (P < 0.001 and P < 0.001). Moreover, administration of ZFA (OBZFA) failed to show the same phenomenon in either jejunum (P = 0.993) or ileum (P = 0.485). There was a significant difference in intestine apoptosis in either jejunum (P < 0.001) or in ileum (P < 0.001) between OBZLLY group and OBZFA group. Significantly increased intestine apoptosis occurred after common bile duct ligation. The administration of Z-LLY-FMK could effectively diminish the intestine apoptosis after common bile duct ligation, whereas the administration of ZFA-FMK failed to show the same effect.
Collapse
Affiliation(s)
- Shyr-Ming Sheen-Chen
- Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, College of Medicine, Chang Gung University, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan.
| | | | | |
Collapse
|
|
23
|
|
|
24
|
Abstract
STUDY DESIGN A prospective analysis of intraoperative bile duct cultures in patients undergoing surgery for both, malignant or benign periampullary diseases at the Department of Surgery, St Josef Hospital, Bochum, Germany, during a period of 18 months, between January 2004 and June 2005. GOALS The goals of the presented study were to investigate the effects of preoperative bile duct stenting on intraoperative bile duct cultures and postoperative outcome in patients undergoing pancreatic surgery. BACKGROUND In pancreatic surgery, bile duct stenting is often aimed at improving postoperative outcome. As implantation of xenograft material in the main bile duct facilitates bacterial contamination and cholangitis, a critical evaluation of stenting is mandatory. STUDY In all patients with a hepaticojejunostomy (n=80), a bile duct culture was collected during the operation. All patients received antibiotic prophylaxis perioperatively and a retrograde flushing of bile ducts with warm saline after bile duct resection. Fifty-one percent (41/80) patients had biliary drainage before surgery, whereas 49% (39/80) were operated without preoperative draining procedures. RESULTS After bile duct stenting, 98% of patients had a positive bile culture, whereas only 21% of infected bile was seen in patients without drainage (P<0.001). Despite infected bile, only 2% stented patients developed acute cholangitis postoperatively, versus 13% patients in the group without stent (P=0.231). After stenting, major complications occurred in 12%, versus 8% in patients without stent (P=0.817). CONCLUSIONS Preoperative biliary drainage leads to an almost 100% bacterial contamination of bile ducts. With hospital-adjusted antibiotic prophylaxis and retrograde flushing of bile ducts, the postoperative rate of acute cholangitis and morbidity is not elevated. A critical evaluation of benefits from preoperative biliary drainage for each patient is necessary.
Collapse
|
|
25
|
Abstract
BACKGROUND Multifactor prognostic scoring systems have been developed for acute pancreatitis to identify those patients with a potentially poor prognosis. A similar system for patients with acute cholangitis is still lacking. GOALS To identify common clinical, biochemical, and etiologic variables that can be used to predict mortality and the need for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute cholangitis. STUDY A retrospective study of 108 patients with acute cholangitis was performed at a single center. Univariate analysis and logistic regression were used to identify variables that were significantly associated and predictive of mortality and need for early ERCP. RESULTS Univariate analysis identified 18 variables significantly associated with mortality and 15 variables that predicted the need for early ERCP. Through logistic regression total bilirubin (P<0.01), partial prothrombin time (P<0.01), and presence of a liver abscess (P<0.01) were found to be significant in predicting mortality. Alanine aminotransferase (P<0.01) and white blood cell count (P<0.01) were determined to be predictive of a need for early ERCP. The scoring systems for predicting mortality (93.9%, 80.7%) and early ERCP (98%, 91%) were both highly sensitive and specific, respectively. CONCLUSIONS Acute cholangitis is a disease that presents with varying severity. We report a scoring system that can be used to identify patients at high risk of early mortality and those that may benefit from earlier ERCP.
Collapse
|
|
26
|
Minter RM, Bi X, Ben-Josef G, Wang T, Hu B, Arbabi S, Hemmila MR, Wang SC, Remick DG, Su GL. LPS-binding protein mediates LPS-induced liver injury and mortality in the setting of biliary obstruction. Am J Physiol Gastrointest Liver Physiol 2009; 296:G45-54. [PMID: 18948440 PMCID: PMC2636928 DOI: 10.1152/ajpgi.00041.2008] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
It is generally accepted that low levels of lipopolysaccharide (LPS)-binding protein (LBP) augment the cell's response to LPS, whereas high levels of LBP have been shown to inhibit cell responses to LPS. Clinical studies and in vitro work by our group have demonstrated that, in the setting of liver disease, increased or acute-phase levels of LBP may actually potentiate rather than inhibit an overwhelming proinflammatory response. Therefore, in the present studies we sought to determine the role of acute-phase LBP in mediating morbidity and mortality in animals challenged with LPS in the setting of biliary obstruction. Using LBP-deficient mice and LBP blockade in wild-type mice, we demonstrate that high levels of LBP are deleterious in the setting of cholestasis. Following biliary obstruction and intraperitoneal LPS challenge, hepatic injury, hepatic neutrophil infiltration, and mortality were significantly increased in animals with an intact LBP acute-phase response. Kupffer cell responses from these animals demonstrated a significant increase in several inflammatory mediators, and Kupffer cell-associated LBP appears to be responsible for these differences, at least in part. Our results indicate that the role of LBP signaling in inflammatory conditions is complex and heterogeneous, and elevated levels of LBP are not always protective. Increased LBP production in the setting of cholestatic liver disease appears to be deleterious and may represent a potential therapeutic target for preventing overwhelming inflammatory responses to LPS in this setting.
Collapse
Affiliation(s)
- Rebecca M. Minter
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Xiaoming Bi
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Gal Ben-Josef
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Tianyi Wang
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Bin Hu
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Saman Arbabi
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Mark R. Hemmila
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Stewart C. Wang
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Daniel G. Remick
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| | - Grace L. Su
- Departments of Surgery, Pathology, and Internal Medicine, University of Michigan, Ann Arbor; and the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan
| |
Collapse
|
|
27
|
Papazoglou LG, Mann F, Wagner-Mann C, Song KJE. Long-term Survival of Dogs After Cholecystoenterostomy: A Retrospective Study of 15 Cases (1981–2005). J Am Anim Hosp Assoc 2008; 44:67-74. [DOI: 10.5326/0440067] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fifteen dogs with extrahepatic biliary tract disease underwent cholecystoenterostomy. Long-term survivors were significantly older at presentation (mean age 140.5 months) than dogs that survived the first 20 days after surgery but subsequently died from causes related to the surgery or hepatobiliary disease (mean age 72 months). Dogs that died during the first 20 days had significantly more complications in the hospital than dogs that survived this period. The type of underlying hepatobiliary disease (i.e., benign or malignant) was not associated with either short-term outcome or long-term survival. Eight dogs died from causes related to surgery or hepatobiliary disease. Long-term complications included hepatic abscesses, acquired portosystemic shunts, pancreatitis, and vomiting.
Collapse
Affiliation(s)
- Lysimachos G. Papazoglou
- Department of Clinical Sciences (Papazoglou), Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, 11 S. Voutyra Street, 54627, Thessaloniki, Greece and the
- Department of Veterinary Medicine and Surgery (Mann, Wagner-Mann, Song), College of Veterinary Medicine, University of Missouri-Columbia, Columbia, Missouri 65211
- From the
| | - F.A. Mann
- Department of Clinical Sciences (Papazoglou), Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, 11 S. Voutyra Street, 54627, Thessaloniki, Greece and the
- Department of Veterinary Medicine and Surgery (Mann, Wagner-Mann, Song), College of Veterinary Medicine, University of Missouri-Columbia, Columbia, Missouri 65211
- From the
| | - Colette Wagner-Mann
- Department of Clinical Sciences (Papazoglou), Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, 11 S. Voutyra Street, 54627, Thessaloniki, Greece and the
- Department of Veterinary Medicine and Surgery (Mann, Wagner-Mann, Song), College of Veterinary Medicine, University of Missouri-Columbia, Columbia, Missouri 65211
- From the
| | - Kug Ju Eddie Song
- Department of Clinical Sciences (Papazoglou), Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, 11 S. Voutyra Street, 54627, Thessaloniki, Greece and the
- Department of Veterinary Medicine and Surgery (Mann, Wagner-Mann, Song), College of Veterinary Medicine, University of Missouri-Columbia, Columbia, Missouri 65211
- From the
| |
Collapse
|
|
28
|
Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RCN, Jiao LR. Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery. Surgery 2007; 142:313-8. [PMID: 17723881 DOI: 10.1016/j.surg.2007.04.022] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2006] [Revised: 04/12/2007] [Accepted: 04/15/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although previously examined, the potential relationship between preoperative biliary drainage (PBD), intraoperative bile culture (IBC), and postoperative morbidity and mortality rate for pancreatic surgery remains unclear. METHODS Two hundred twenty patients underwent operation for either benign pancreatic disease or malignant periampullary and pancreatic neoplasms, consisting of pylorus-preserving proximal pancreatoduodenectomy (n = 180), biliary bypass (n = 31), and total pancreatectomy (n = 9). An intraoperative bile specimen was prospectively collected immediately after division of the bile duct and sent for bacteriologic evaluation for both aerobic and anaerobic microorganisms. Morbidity and mortality rates were evaluated. RESULTS Of 220 patients evaluated, 113 patients (51.4%) had a positive IBC. Factors associated with a positive IBC were age >70 years (odds ratio [OR], 5.9;95% confidence interval, [CI]: 1.6-22.1; P = .007), history of coronary artery disease (OR, 0.08; 95% CI, 0.01-0.5; P = .007), diagnosis of neoplasia (OR, 0.3; 95% CI, 0.1-0.9; P =. 03), and PBD (OR, 0.1; 95% CI, 0.06-0.2; P = .0001). Infectious complications (OR, 1.8; 95% CI, 1-3; P = .03), and wound infection (OR, 2.8; 95% CI,1.4-5.3; P = .002) were greater in patients with positive IBC. CONCLUSIONS PBD predisposes to a positive IBC. Patients with a positive IBC have a clinically important increased risk of developing both infectious complications and wound infection after pancreatic surgery.
Collapse
Affiliation(s)
- Paolo Limongelli
- HPB unit, Hammersmith Campus, Hammersmith Hospital, London, England
| | | | | | | | | | | | | | | | | |
Collapse
|
|
29
|
IKEDA S, TANAKA M, YOSHIMOTO H, MAESHIRO K, MATSUMOTO S. Endoscopic Biliary Drainage for Acute Obstructive Cholangitis: Analysis of 100 Consecutive Patients. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1990.tb00345.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Seiyo IKEDA
- *Department of Surgery I, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Masao TANAKA
- **Kyushu University Faculty of Medicine, Fukuoka, Japan
| | - Hideo YOSHIMOTO
- *Department of Surgery I, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Kensei MAESHIRO
- *Department of Surgery I, Fukuoka University School of Medicine, Fukuoka, Japan
| | | |
Collapse
|
|
30
|
van der Gaag NA, de Castro SMM, Rauws EAJ, Bruno MJ, van Eijck CHJ, Kuipers EJ, Gerritsen JJGM, Rutten JP, Greve JW, Hesselink EJ, Klinkenbijl JHG, Rinkes IHMB, Boerma D, Bonsing BA, van Laarhoven CJ, Kubben FJGM, van der Harst E, Sosef MN, Bosscha K, de Hingh IHJT, Th de Wit L, van Delden OM, Busch ORC, van Gulik TM, Bossuyt PMM, Gouma DJ. Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial). BMC Surg 2007; 7:3. [PMID: 17352805 PMCID: PMC1828149 DOI: 10.1186/1471-2482-7-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 03/12/2007] [Indexed: 01/11/2023] Open
Abstract
Background Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life. Methods/design Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8). Discussion The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.
Collapse
Affiliation(s)
| | - Steve MM de Castro
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
| | - Erik AJ Rauws
- Department of Gastroenterology, Amsterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Amsterdam, the Netherlands
| | | | - Ernst J Kuipers
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Jan-Paul Rutten
- Department of Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Jan Willem Greve
- Department of Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Erik J Hesselink
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | | | | | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | | | - Frank JGM Kubben
- Department of Gastroenterology, Medical Center Rijnmond Zuid, Rotterdam, the Netherlands
| | - Erwin van der Harst
- Department of Surgery, Medical Center Rijnmond Zuid, Rotterdam, the Netherlands
| | - Meindert N Sosef
- Department of Surgery, Atrium Medical Center, Heerlen, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | | | - Laurens Th de Wit
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Otto M van Delden
- Department of Radiology, Academic Medical Center Amsterdam, The Netherlands
| | - Olivier RC Busch
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
| | - Patrick MM Bossuyt
- Department of clinical epidemiology and biostatistics, Academic Medical Center Amsterdam, the Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
| |
Collapse
|
|
31
|
SCHMIDT C, LILLEMOE K. Infections in Hepatic, Biliary, and Pancreatic Surgery. SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS 2007:125-135. [DOI: 10.1016/b978-1-4160-3256-4.50019-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
32
|
Sheen-Chen SM, Ho HT, Chia-Pei L, Hung KS, Eng HL. The effect of insulin-like growth factor-I on hepatocyte apoptosis after bile duct ligation in rat. Dig Dis Sci 2006; 51:2220-4. [PMID: 17103039 DOI: 10.1007/s10620-006-9127-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2005] [Accepted: 01/22/2006] [Indexed: 12/14/2022]
Abstract
Obstructive jaundice may promote bacterial overgrowth and altered intestinal barrier function, with resultant increased translocation of endotoxin to the liver, amd thus may potentiate the phenomenon of hepatocyte apoptosis. Exogenous administration of insulin-like growth factor-I (IGF-I) has been shown to enhance mucosal adaptation after small bowel resection in rats and also to accelerate repair of small intestinal mucosa after damage by the chemotherapy drug methotrexate. The aim of the current study was to determine the effect of exogenous IGF-I administration on hepatocyte apoptosis after bile duct ligation in rat. Male Sprague-Dawley rats weighing 250-300 g were randomized to three groups (n=6 in each group). Group 1 (control; C) underwent sham operation and was simultaneously treated with the same amount of normal saline. Group 2 (obstructive jaundice; OB) underwent common bile duct ligation without other manipulation. Group 3 (obstructive jaundice with IGF-I; OBIGF-I) underwent common bile duct ligation and simultaneous treatment with recombinant human IGF-I (a total dose of 1 mg in each rat, divided into six administrations; about 1 mg/kg/day). After 3 days, liver tissue was harvested and immediately snap-frozen in liquid nitrogen for histopathologic analysis and apoptosis measurements. Compared with the sham operation group (C), increased hepatocyte apoptosis (P < 0.001) and ductular proliferation (P < 0.001) occurred after common bile duct ligation (OB). After administration of IGF-I (OBIFG-I), the increased hepatocyte apoptosis and ductular proliferation after common bile duct ligation (OB) were significantly diminished (P < 0.001 and P < 0.001, respectively). There was no significant difference in hepatocyte apoptosis (P=0.925) or ductular proliferation (P=0.385) between the sham control group (C) and the OBIGF-I group. Increased hepatocyte apoptosis (P < 0.001) and ductular proliferation (P < 0.001) occurred after common bile duct ligation (OB). After administration of IGF-I (OBIFG-I), the increased hepatocyte apoptosis and ductular proliferation after common bile duct ligation (OB) were significantly diminished (P < 0.001 and P < 0.001, respectively).
Collapse
Affiliation(s)
- Shyr-Ming Sheen-Chen
- Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
| | | | | | | | | |
Collapse
|
|
33
|
Amsellem PM, Seim HB, MacPhail CM, Bright RM, Twedt DC, Wrigley RH, Monnet E. Long-term survival and risk factors associated with biliary surgery in dogs: 34 cases (1994–2004). J Am Vet Med Assoc 2006; 229:1451-7. [PMID: 17078808 DOI: 10.2460/javma.229.9.1451] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine factors associated with long-term survival after biliary surgery in dogs. DESIGN Retrospective case series. ANIMALS 34 dogs that underwent biliary surgery. PROCEDURES Data extracted from medical records included sex, breed, body weight, age at surgery, history and clinical examination findings, preoperative and postoperative CBC, serum biochemical panel and coagulation profiles results, abdominal ultrasonographic findings, results of bacteriologic culture and histologic examination, surgical findings, postoperative complications, and survival time. Follow-up information was obtained from medical records or phone conversations with owners and referring veterinarians. RESULTS Primary biliary findings included gallbladder mucocele (n = 20 dogs), inflammatory diseases (4), trauma (3), and neoplasia (1). Secondary biliary diseases included pancreatitis (n = 4), pancreatic neoplasia (1), and duodenal perforation (1). One- and 2-year survival rates were both 66%. Increasing age; gamma-glutamyltransferase activity; preanesthetic heart rate; BUN, phosphorus, and bilirubin concentrations; and the use of biliary diversion procedures were risk factors for death, although pancreatitis was not. However, poor long-term survival was associated with pancreatitis. CONCLUSIONS AND CLINICAL RELEVANCE Long-term prognosis was guarded after biliary surgery in dogs. However, dogs that survived the early postoperative period had good long-term prognosis. Dogs with pancreatitis had poor prognosis. Overall, the prognosis was worse for dogs that underwent a biliary diversion, compared with dogs that did not.
Collapse
Affiliation(s)
- Pierre M Amsellem
- Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | | | | | | | | | | | | |
Collapse
|
|
34
|
Abstract
AIM: To evaluate clinical presentation, etiology, compli-cations and response to treatment in elderly patients with acute cholangitis.
METHODS: Demographics, etiology of biliary obstruc-tion, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated.
RESULTS: Of 175 patients, 52 aged ≥ 60 years (groupI, age < 60 years; group II, age ≥ 60 years) and 105 were men. Fever was present in 38 of 52 patients of group II compared to 120 of 123 in groupI. High fever (fever ≥ 38.0°C) was more common in groupI(118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group II. Biliopancreatic malignancy was a common cause of biliary obstruction in group II (n = 34) and benign diseases in groupI(n = 120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of ≥ 38.0°C (n = 136), hypotension (n = 18), peritonism (n = 36), altered sensorium (n = 22), and failure to improve within 72 h of conservative management (n = 22). High grade fever was more common indication of biliary drainage in groupIand hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group II. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 groupI, 24 group II, stent: 64 groupI, 28 group II) without any significant age related difference in the success rate. Abdominal pain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in groupI(2-15 d) compared to 10 d in 47 patients of group II (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in groupIcompared to 15 d (5-26 d) in 47 patients in group II. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n = 3, CBD stones n = 2) died in group II and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group II despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group II patients (16.4 ± 5.6, 7-30 d) than in groupIpatients (8.2 ± 2.4, 7-20 d).
CONCLUSION: Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.
Collapse
Affiliation(s)
- Naresh Agarwal
- Department of Gastroenterology, GB Pant Hospital, New-Delhi-110002, India
| | | | | |
Collapse
|
|
35
|
Ara C, Esrefoglu M, Polat A, Isik B, Aladag M, Gul M, Ay S, Tekerleklioglu MS, Yilmaz S. The effect of caffeic acid phenethyl ester on bacterial translocation and intestinal damage in cholestatic rats. Dig Dis Sci 2006; 51:1754-60. [PMID: 16983503 DOI: 10.1007/s10620-006-9130-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Accepted: 11/07/2005] [Indexed: 01/03/2023]
Abstract
We investigated the effect of caffeic acid phenethyl ester in rat ileum injury induced by chronic biliary obstruction. Swiss albino rats were divided into three groups: Group 1, sham (n = 7); Group 2, common bile duct ligation (n = 7); and Group 3, common bile duct ligation plus caffeic acid phenethyl ester (n = 7). In the caffeic acid phenethyl ester-treated rats, ileum tissue levels of malondialdehyde and myeloperoxidase were significantly lower than those of the bile duct-ligated rats (P < 0.001). The levels of tumor necrosis factor-alpha, interleukin-6, and interleukin-1alpha in the caffeic acid phenethyl ester group were significantly lower than those in the bile duct ligation group (P < 0.03, P < 0.01, and P < 0.02 respectively). The present study demonstrates that intraperitoneal administration of caffeic acid phenethyl ester in bile duct-ligated rats reduces intestinal oxidative stress. This effect may be useful in the preservation of intestinal damage in cholestasis.
Collapse
Affiliation(s)
- Cengiz Ara
- Department of General Surgery, Inonu University School of Medicine, 44069 Malatya, Turkey.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
36
|
Buote NJ, Mitchell SL, Penninck D, Freeman LM, Webster CRL. Cholecystoenterostomy for treatment of extrahepatic biliary tract obstruction in cats: 22 cases (1994–2003). J Am Vet Med Assoc 2006; 228:1376-82. [PMID: 16649942 DOI: 10.2460/javma.228.9.1376] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify factors associated with outcome in cats with extrahepatic biliary tract obstruction (EHBTO) that undergo biliary diversion surgery. DESIGN Retrospective case series. ANIMALS 22 cats. PROCEDURES Medical records of cats with surgically confirmed EHBTO that underwent cholecystoenterostomy were reviewed. RESULTS Clinical signs and physical examination findings included vomiting, anorexia, icterus, lethargy, weakness, and weight loss. Common clinicopathologic abnormalities included high serum hepatic enzyme activities and serum bilirubin concentration. Abdominal ultrasonography was performed in 21 cats, and all 21 had findings consistent with EHBTO. Eleven of 15 cats in which blood pressure was monitored had intraoperative hypotension. Eighteen cats had anemia following surgery, and 14 cats had persistent hypotension. Extrahepatic biliary tract obstruction was a result of neoplasia in 9 cats and chronic inflammatory disease in 13. Fourteen cats survived long enough to be discharged from the hospital, but only 6 survived > 6 months after surgery, all of which had chronic inflammatory disease. Median survival time for cats with neoplasia (14 days) was significantly shorter than that for cats with inflammatory disease (255 days). No other variable was associated with outcome. CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that cats with EHBTO secondary to neoplasia have a poorer prognosis than cats with EHBTO secondary to chronic inflammatory disease. However, the overall prognosis for cats with EHBTO undergoing cholecystoenterostomy must be considered guarded to poor, and the incidence of perioperative complications is high.
Collapse
Affiliation(s)
- Nicole J Buote
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA 01536, USA
| | | | | | | | | |
Collapse
|
|
37
|
Treglia-Dal Lago M, Jukemura J, Machado MCC, da Cunha JEM, Barbuto JAM. Phagocytosis and production of H2O2 by human peripheral blood mononuclear cells from patients with obstructive jaundice. Pancreatology 2006; 6:273-8. [PMID: 16636599 DOI: 10.1159/000092688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Accepted: 11/23/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND The immune function is altered in jaundiced patients; here, the ability of their peripheral blood mononuclear cells to perform phagocytosis and to release H2O2 was analyzed. METHODS Cells from 53 patients before surgery for relief of cholestasis, from 38 patients 1 week and from 15 patients 2 weeks after surgery were separated and cultured for 1 h in the presence of phorbol myristate acetate. H2O2 release was evaluated colorimetrically and phagocytosis by the ingestion of Escherichia coli in vitro. RESULTS Before surgery for relief of cholestasis, the cells of the patients were unable to release H2O2, but, after surgery, an increasing percentage of patients had cells that were able to produce H2O2 (13% after 1 week; 33% after 2 weeks). This recovery did not correlate with bilirubinemia. When cultured for 1 week in the presence of normal or jaundiced plasma, regardless of collection time, cells of 12/12 patients released H2O2, but in lower levels if in the presence of jaundiced plasma. In contrast, H2O2 release by normal donor cells was enhanced in the presence of jaundiced plasma. Phagocytosis by cells of the patients was lower, but when present was associated with a significantly higher bactericidal activity. CONCLUSION These significant, but reversible alterations of monocyte function in jaundiced patients might contribute to their enhanced susceptibility to surgical complications.
Collapse
Affiliation(s)
- Marisa Treglia-Dal Lago
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
|
38
|
Fernández JA, Parrilla P. ¿Cuáles son los principales errors que cometemos los cirujanos en el tratamiento del cáncer de páncreas? Cir Esp 2006; 79:215-23. [PMID: 16753101 DOI: 10.1016/s0009-739x(06)70856-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The present review identifies two major conceptual errors. Therapeutic nihilism, which should be discounted in view of the results currently achieved by surgery, and noncentralization, since better results have been demonstrated, both in terms of morbidity and mortality and in survival, in high-volume centers than in low volume centers. The present review also identifies errors in management, the most important of which are: undervaluing the medical record, which is of great utility and continues to be the pillar on which the entire diagnostic process is based; the systematic use of preoperative biliary drainage, which used to be considered mandatory but should be used highly selectively in patients with severe jaundice or biliary tract infections, and viewing preoperative imaging tests as unreliable, when current radiological techniques, particularly helical computed tomography (CT), are highly reliable in establishing tumor resectability and consequently they should be used in all treatment planning. Moreover, because radiological tests are highly reliable, laparoscopic staging has lost diagnostic value; obtaining a preoperative histological diagnosis, which is not mandatory except when neoadjuvant therapy is planned or when tumors requiring nonsurgical treatment are suspected; undervaluing the use of surgical palliation, since this technique provides better long-term results than nonsurgical palliation, and consequently still plays a role in patients with good general health status and prolonged life expectancy; systematically performing gastrojejunostomy with bilio-enteric bypass, as this procedure should only be performed in tumors of the uncus or when there is imminent biliary or gastroduodenal obstruction; the use of supraradical surgical techniques such as regional, total or extensive pancreatectomy, since these techniques do not prolong survival after resection. Furthermore, the use of vascular resections would only be justified if resection with disease-free margins could be performed; undervaluing close postoperative monitoring within specialized units since this is the key to reducing morbidity and mortality rates in this type of surgery; and lastly when an intraoperative pancreatic incidentaloma is present, performing diagnostic maneuvers such as biopsy or pancreatic mobilization, since these procedures hamper subsequent radiological interpretation and possible surgical intervention.
Collapse
Affiliation(s)
- Juan Angel Fernández
- Servicio de Cirugía General y Digestiva I, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain.
| | | |
Collapse
|
|
39
|
Abstract
The role of preoperative biliary drainage in malignant obstructive jaundice has been controversial. Laboratory studies suggest that relief of jaundice prior to major pancreatic resection would be associated with improved morbidity and mortality. However, clinical experience has not supported the laboratory results. Obstructive jaundice can be relieved preoperatively via an endoprosthesis introduced either percutaneously or endoscopically. Cohort studies have not shown any clinical benefit and in some the endoprostheses have been implicated in postoperative complications. The only randomized study has shown no benefit in preoperative drainage, but one recent study has confirmed that endoscopic drainage, whilst not conferring an advantage, did no harm. Hence, whilst preoperative drainage is not recommended, if for any reason operation needs to be delayed, endoscopic drainage via an endoprosthesis can be used without fear of adversely influencing the outcome.
Collapse
Affiliation(s)
- Mayank Bhandari
- Department of General & Digestive Surgery, Flinders University, Flinders Medical CentreBedford Park South Australia
| | - James Toouli
- Department of General & Digestive Surgery, Flinders University, Flinders Medical CentreBedford Park South Australia
| |
Collapse
|
|
40
|
Minter RM, Fan MH, Sun J, Niederbichler A, Ipaktchi K, Arbabi S, Hemmila MR, Remick DG, Wang SC, Su GL. Altered Kupffer cell function in biliary obstruction. Surgery 2005; 138:236-45. [PMID: 16153432 DOI: 10.1016/j.surg.2005.04.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2005] [Revised: 03/10/2005] [Accepted: 04/08/2005] [Indexed: 12/27/2022]
Abstract
BACKGROUND An altered Kupffer cell (KC) response is thought to be responsible for the characteristic phenotype observed after biliary obstruction: a phenotype marked by a defect in the hepatic reticuloendothelial system and a hypersensitivity to endotoxin. Few studies, however, have directly examined KC function. We have sought to define the specific alterations in function and phenotype that occur in the KC after biliary obstruction. METHODS KCs were isolated from female C57BL/6 mice 4 days after a sham or common bile duct ligation (CBDL) operation. Phagocytosis, oxidative burst potential, and intracellular bacterial killing were measured as markers of reticuloendothelial system function. The KC response to endotoxin was assessed by measuring tumor necrosis factor alpha and interleukin 6 levels in the media after stimulation with lipopolysaccharide (LPS) or with LPS plus LPS-binding protein (LBP). RESULTS CBDL KCs demonstrated a significant increase in phagocytic ability and significantly decreased baseline oxidative stress, compared with Shams. The oxidative burst potential, however, was equivalent or higher for CBDL KCs. CBDL KCs also demonstrated increased numbers of viable intracellular bacteria after infection; however, it is unclear if this finding represents impaired intracellular bacterial killing or increased phagocytosis of bacteria. With respect to the KC response to endotoxin, CBDL KCs were found to be less sensitive to the stimulatory effects of LPS alone but were exquisitely sensitive to the effects of LBP. LBP levels were found to be significantly elevated in CBDL animals, and CBDL KCs demonstrated a dose-dependent, exaggerated tumor necrosis factor alpha and interleukin 6 response to LPS administered with LBP. CONCLUSIONS KC function is clearly altered after biliary obstruction. Phagocytic ability is actually increased, although the ability of CBDL KCs to kill bacteria within the phagosome remains ill defined. CBDL KCs are exquisitely sensitive to the effects of LBP, and LBP levels are elevated after biliary obstruction. LBP may be responsible for the increased proinflammatory response observed after endotoxin challenge in animals with biliary obstruction.
Collapse
Affiliation(s)
- Rebecca M Minter
- Veterans Administration Ann Arbor Healthcare Systems, Department of Surgery, University of Michigan Medical School, 48109-0331, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
41
|
Yang R, Harada T, Li J, Uchiyama T, Han Y, Englert JA, Fink MP. Bile modulates intestinal epithelial barrier function via an extracellular signal related kinase 1/2 dependent mechanism. Intensive Care Med 2005; 31:709-17. [PMID: 15782315 DOI: 10.1007/s00134-005-2601-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2004] [Accepted: 02/18/2005] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Obstructive jaundice is frequently complicated by infections and has been associated with increased bacterial translocation and gut mucosal hyperpermeability in animal models. Proper expression of the tight junction (TJ) proteins ZO-1 and occludin is important for normal gut barrier function. We tested whether bile modulates intestinal epithelial ZO-1 and occludin expression. ANIMALS (a) Male C57BL/6 mice; (b) male Sprague-Dawley rats. INTERVENTIONS (a) Mice were subjected to common bile duct ligation (CBDL) or a sham procedure, and 96 h later all surviving animals were killed for measurement of ileal mucosal permeability to FITC-labeled dextran (everted gut sac technique), bacterial translocation to mesenteric lymph nodes, and ileal epithelial ZO-1 and occludin expression (western blots). (b) Rat IEC-6 enterocytic monolayers were incubated in the presence or absence of graded concentrations of rat bile and/or U0126, an inhibitor of extracellular signal related kinase (ERK) 1/2 activation. RESULTS (a) Compared to sham-treated controls, CBDL significantly increased gut mucosal permeability and bacterial translocation and markedly decreased ileal epithelial expression of ZO-1 and occludin. In a follow-up in vivo experiment, gavaging mice with fresh rat bile twice daily significantly ameliorated the deleterious effects of CBDL on gut barrier function. (b) Addition of 1% (v/v) bile to media enhanced phosphorylation of ERK1/2, increased the expression of ZO-1 and occludin and decreased permeability to FITC-dextran. All of these bile-mediated effects were blocked by 10 microM U0126. CONCLUSIONS These data support the view that the presence of bile in the intestinal lumen is essential for normal gut barrier function, possibly because compounds present in bile initiate ERK1/2-dependent signaling that is essential for normal expression of key TJ proteins.
Collapse
Affiliation(s)
- Runkuan Yang
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | | | | | | | | | | | | |
Collapse
|
|
42
|
Pitiakoudis M, Mimidis K, Tsaroucha AK, Papadopoulos V, Karayiannakis A, Simopoulos C. Predictive value of risk factors in patients with obstructive jaundice. J Int Med Res 2004; 32:633-638. [PMID: 15587757 DOI: 10.1177/147323000403200608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Clinical and laboratory parameters that may affect post-operative mortality and morbidity were studied in 215 patients operated on for obstructive jaundice. The cause of the bile duct obstruction was benign disease in 56.7% of patients and malignant disease in 43.3%. Overall postoperative mortality and morbidity rates were 21.9% and 33.5%, respectively. Eight risk factors were shown to be associated with increased mortality: age > 70 years; malignancy; leucocytosis > 15 000 cells/microl and fever > 38.5 degrees C; haematocrit < or = 30%; creatinine > 1.3 mg/dl; albumin < or = 3 g/dl; bilirubin > 20 mg/dl; and serum alkaline phosphatase > 100 IU/l. The simultaneous presence of less than three risk factors was always associated with post-operative survival, but concomitant existence of seven or more risk factors indicated 100% mortality. Understanding the factors related to post-operative morbidity and mortality in patients with obstructive jaundice will better guide appropriate surgical or non-surgical management and lead to improved survival.
Collapse
Affiliation(s)
- M Pitiakoudis
- Second Department of Surgery, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | | | | | | | | | | |
Collapse
|
|
43
|
Mehler SJ, Mayhew PD, Drobatz KJ, Holt DE. Variables Associated with Outcome in Dogs Undergoing Extrahepatic Biliary Surgery: 60 Cases (1988-2002). Vet Surg 2004; 33:644-9. [PMID: 15659021 DOI: 10.1111/j.1532-950x.2004.04087.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To report clinical findings and define clinical variables associated with outcome in dogs undergoing extrahepatic biliary surgery. STUDY DESIGN Retrospective study. ANIMALS Sixty dogs that had extrahepatic biliary tract surgery. RESULTS Primary diagnoses included necrotizing cholecystitis (36 dogs, 60%), pancreatitis (12 dogs, 20%), neoplasia (5 dogs, 8%), trauma (4 dogs, 7%), and gallbladder rupture from cholelithiasis without necrotizing cholecystitis (3 dogs, 5%). Bile peritonitis occurred in 19 (53%) dogs with necrotizing cholecystitis, 4 dogs with trauma, and 3 dogs with cholelithiasis without evidence of necrotizing cholecystitis. Cholecystectomy (37 dogs, 62%) and cholecystoduodenostomy (14 dogs, 23%) were the 2 most commonly performed procedures. Median hospitalization for survivors was 5 days (range, 1-15 days). There were 43 surviving dogs (72%) and 17 nonsurvivors (28%, 4 died, 13 euthanatized). Presence of septic bile peritonitis (P=.038), elevation in serum creatinine concentration (P=.003), prolonged partial thromboplastin times (PTTs; P=.003), and lower postoperative mean arterial pressures (P=.0001) were significantly associated with mortality. CONCLUSIONS Extrahepatic biliary surgery is associated with high mortality and a relatively long hospitalization time for survivors. Cholecystectomy and cholecystoduodenostomy were the most common surgical procedures to treat the 4 major biliary problems (necrotizing cholecystitis, pancreatitis, neoplasia, and trauma) observed in this cohort of dogs. The relatively high mortality rate likely reflects the underlying diseases and their effects on the animal (septic bile peritonitis, higher serum creatinine, prolonged PTT, and lower postoperative mean arterial pressure) rather than complications of surgery. CLINICAL RELEVANCE Septic bile peritonitis, preoperative elevated creatinine concentration, and immediate postoperative hypotension in dogs undergoing extrahepatic biliary tract surgery are associated with a poor clinical outcome. Adequate supportive care and monitoring in the perioperative period is critical to improve survival of dogs with extrahepatic biliary disease.
Collapse
Affiliation(s)
- Stephen J Mehler
- Department of Clinical Studies, Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA.
| | | | | | | |
Collapse
|
|
44
|
Sheen-Chen SM, Eng HL, Hung KS. Altered serum transforming growth factor-beta1 and monocyte chemoattractant protein-1 levels in obstructive jaundice. World J Surg 2004; 28:967-70. [PMID: 15573249 DOI: 10.1007/s00268-004-7354-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Impaired immune function has long been documented in patients with obstructive jaundice, and those with jaundice due to extrahepatic biliary obstruction still experience a high rate of postoperative complications and death. Transforming growth factor-beta1 (TGFbeta1) appears to be an important regulator of both normal and pathologic conditions in the liver. Monocyte chemoattractant protein-1 (MCP-1) is an important mediator of monocyte recruitment to inflammatory sites. We hypothesize that obstructive jaundice may alter serum TGFbeta1 and MCP-1 expressions in the rat and that oral bile acid or glutamine (or both) can restore the altered serum TGFbeta1 and MCP-1 expression in rats with obstructive jaundice. Male Sprague-Dawley rats weighing 250 to 300 g were randomized to four groups (n = 10 in each group). Group 1 underwent a sham operation with oral normal saline administration. Group 2 underwent common bile duct ligation (CBDL) with oral normal saline administration. Group 3 underwent CBDL with oral bile acid replacement. Group 4 underwent CBDL with oral glutamine administration. Animals were sacrificed after 3 days (n = 5) and 7 days (n = 5), and blood samples were collected. Serum was obtained after centrifugation for measurement of TGFbeta1 and MCP-1 levels by an enzyme-linked immunosorbent assay. The serum TGFbeta1 level was significantly elevated (p = 0.006) 3 days after CBDL. Oral glutamine administration prevented this elevation, but oral bile acid replacement did not. The serum MCP-1 level showed similar changes. After 3 days of obstructive jaundice, the TGFbeta1 and MCP-1 levels were altered in the rat. Oral glutamine administration, not oral bile acid replacement, was able to prevent these alterations.
Collapse
Affiliation(s)
- Shyr-Ming Sheen-Chen
- Department of Surgery, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital, Kaohsiung, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan.
| | | | | |
Collapse
|
|
45
|
Hodul P, Creech S, Pickleman J, Aranha GV. The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy. Am J Surg 2003; 186:420-5. [PMID: 14599600 DOI: 10.1016/j.amjsurg.2003.07.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Preoperative biliary drainage (PBD) in jaundiced patients undergoing pancreaticoduodenectomy remains controversial. METHODS Patients presenting with obstructive jaundice who subsequently underwent pancreaticoduodenectomy from January 1996 to June 2002 were included in the study (n = 212). Patients with preoperative biliary stents (n = 154) were compared with patients without preoperative drainage (n = 58). RESULTS Patients in the stented group required a longer operative time (mean 6.8 hours versus 6.5 hours) and had greater intraoperative blood loss (mean 1207 mL versus 1122 mL) compared with the unstented group, (P = 0.046 and 0.018). No differences were found with respect to operative mortality (2%), incidence of pancreatic fistula (10% versus 14%), or intraabdominal abscess (7% versus 5%). Wound infection occurred more often in the stented group (8% versus 0%, P = 0.039). CONCLUSIONS PBD was associated with increased operative time, intraoperative blood loss, and incidence of wound infection. Although PBD did not increase major postoperative morbidity and mortality, it should be used selectively in patients undergoing pancreaticoduodenectomy.
Collapse
Affiliation(s)
- Pamela Hodul
- Divisions of Surgical Oncology, Surgical Service Hines VA Hospital, Hines, IL, USA
| | | | | | | |
Collapse
|
|
46
|
Ogata Y, Nishi M, Nakayama H, Kuwahara T, Ohnishi Y, Tashiro S. Role of bile in intestinal barrier function and its inhibitory effect on bacterial translocation in obstructive jaundice in rats. J Surg Res 2003; 115:18-23. [PMID: 14572768 DOI: 10.1016/s0022-4804(03)00308-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Our previous study using genetically labeled Escherichia coli strain JNW14 revealed that obstructive jaundice promotes bacterial translocation in rats and that the absence of bile in the intestinal tract is considered to be a factor inducing bacterial translocation. The aim of this study was to investigate the role of bile and bile acids in intestinal barrier function against bacterial translocation. MATERIALS AND METHODS Eight-week-old male specific-pathogen-free Wistar rats were subjected to ligation of their common bile ducts (CBDL). The CBDL rats were treated with bacitracin, neomycin sulfate, and streptomycin sulfate, and the intestinal tract was colonized with E. coli strain JNW14, which was genetically labeled with resistant markers against the above three antibiotics, to monitor the bacterial translocation. The rats were then administered saline, cholic acid (20 mg/100 g BW), taurocholic acid (TCA: 5-50 mg/100 BW), or bile (1.5-6 mL/day) via a duodenal catheter. The degree of bacterial translocation of E. coli strain JNW14 to the mesenteric lymph nodes was compared. Histopathological examination of the terminal ileum and intestinal permeability test using phenolsulfonphthalein was also performed. RESULTS Both cholic acid and TCA showed no inhibitory effect on bacterial translocation at any of the doses tested in CBDL rats, although TCA significantly decreased the numbers of E. coli strain JNW14 in the cecum. However, bile administration reduced the numbers of E. coli strain JNW14 in the cecum and mesenteric lymph nodes in CBDL rats although the inhibitory effect was weak. The integrity and permeability of the intestinal mucosa were kept at normal levels by bile administration in CBDL rats whereas the morphological changes, such as villous atrophy, villous edema, and lacteal canal dilatation, were observed in other CBDL rats. CONCLUSION Bile plays an important role in maintaining the intestinal barrier function to prevent the invasion of enteric bacteria to the underlying tissues, suggesting that the intestinal administration of bile to patients with obstructive jaundice is a useful way to reduce infectious complications by inhibiting bacterial translocation from the intestine to other organs.
Collapse
Affiliation(s)
- Yorihiko Ogata
- Department of Digestive Surgery, Graduate School of Medicine, University of Tokushima, Tokushima, Japan
| | | | | | | | | | | |
Collapse
|
|
47
|
Sewnath ME, van der Poll T, van Noorden CJF, ten Kate FJW, Gouma DJ. Cholestatic interleukin-6-deficient mice succumb to endotoxin-induced liver injury and pulmonary inflammation. Am J Respir Crit Care Med 2003; 169:413-20. [PMID: 14604838 DOI: 10.1164/rccm.200303-311oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Circulating and hepatic interleukin (IL)-6 levels are strongly increased during clinical and experimental cholestasis. Cholestatic liver injury is associated with increased susceptibility to endotoxin-induced toxicity. To determine the role of IL-6 herein, extrahepatic cholestasis was induced by bile duct ligation (BDL) in IL-6-gene deficient (IL-6(-/-)) and normal (IL-6(+/+)) mice. BDL elicited increased levels of hepatic IL-6 mRNA and protein in normal mice. Hepatocellular injury 2 weeks after BDL was similar in IL-6(-/-) and IL-6(+/+) mice as demonstrated by clinical chemistry and histopathology. Administration of endotoxin to cholestatic mice 2 weeks after BDL was associated with enhanced cytokine release, severe liver damage, and death when compared with sham-operated mice. Effects of endotoxin were largely similar in sham-operated IL-6(-/-) and IL-6(+/+) mice, but cholestatic IL-6(-/-) mice were more susceptible to the toxic effects of endotoxin, as reflected by increased cytokine release, more profound liver injury and lung inflammation, and higher mortality. Although endogenous IL-6 is not important in the development of liver injury after experimentally induced obstructive jaundice, this cytokine plays an important role in decreasing hypersensitivity to endotoxin in cholestatic mice.
Collapse
Affiliation(s)
- Miguel E Sewnath
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
|
48
|
Sheen-Chen SM, Ho HT, Chen WJ, Eng HL. Obstructive jaundice alters proliferating cell nuclear antigen expression in rat small intestine. World J Surg 2003; 27:1161-4. [PMID: 12917765 DOI: 10.1007/s00268-003-6992-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Translocation of bacteria and endotoxin has long been documented in obstructive jaundice, and altered intestinal barrier function is considered to be one of the important mechanisms for this phenomenon. Proliferating cell nuclear antigen (PCNA), also known as cyclin, is an auxiliary protein of DNA polymerase-delta, and the level of synthesis correlates directly with rates of cellular proliferation and DNA synthesis. This study was designed with the aim of evaluating the effect of obstructive jaundice on PCNA expression in small bowel epithelium. Male Sprague-Dawley rats were randomized to four groups. Group A (n = 10, control group) underwent a sham operation. Group B (n = 9, obstructive jaundice group for 1 week) underwent common bile duct ligation. Group C (n = 8, obstructive jaundice group for 2 weeks) underwent common bile duct ligation. Group D (n = 8, obstructive jaundice group for 2 weeks) underwent common bile duct ligation with oral glutamine intake. After periods of 7 days and 2 weeks, segments of small bowel were harvested from groups A & B and groups C & D, respectively. Nuclear immunohistochemical expression of PCNA in small bowel was evaluated. The PCNA-labeling index [(PCNA-positive cells/500 cells) x 100] was quantified. Comparisons among the four groups were performed. The PCNA-labeling index in small bowel of group B was significantly higher than that of group A (29.0% vs 21.2%, p = 0.001). After 2 weeks of common bile duct ligation, the PCNA-labeling index in small bowel of group C was significantly lower than that of group A (19.4% vs 21.2%, p = 0.045). With oral glutamine intake daily, the PCNA-labeling index in small bowel of Group D was restored and was significantly higher than that of group A (24.5% vs 21.2%, p = 0.002). Obstructive jaundice for 1 week upgraded PCNA expression in rat small intestine. PCNA expression in rat small intestine later became depressed after obstructive jaundice for 2 weeks. Oral glutamine intake daily could effectively restore the PCNA expression in small bowel of rats subjected to obstructive jaundice for 2 weeks.
Collapse
Affiliation(s)
- Shyr-Ming Sheen-Chen
- Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung College of Medicine, Chang Gung University, 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan.
| | | | | | | |
Collapse
|
|
49
|
Brown KM, Brems JJ, Moazzam FN, Hartman GG, Gamelli RL, Ding JW. The nitric oxide donor molsidomine improves survival and reduces hepatocyte apoptosis in cholestasis and endotoxemia. J Am Coll Surg 2003; 197:261-9. [PMID: 12892810 DOI: 10.1016/s1072-7515(03)00386-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cholestasis and endotoxemia have been demonstrated to cause hepatocyte apoptosis through caspase-mediated pathways. In vitro nitric oxide (NO) donors reduce hepatocyte apoptosis and caspase activation in several models. The nitric oxide donor molsidomine improves survival in an in vivo model of endotoxemia. We tested the effect of molsidomine on survival and hepatocyte apoptosis in a model of obstructive jaundice and endotoxemia. STUDY DESIGN Sprague-Dawley rats underwent common bile duct ligation on day 1. On day 3, animals were given either 100 mg/kg of molsidomine or an equivalent volume of saline, and 30 minutes later they were given endotoxin 3 mg/kg or 10 mg/kg intravenously. Animals were sacrificed 4 or 16 hours after endotoxin injection. Serum samples were analyzed for alanine aminotransferase and frozen liver samples were analyzed for caspase 3 activity. Paraffin-embedded liver sections were assayed for apoptosis using the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling assay. Survival was measured in a separate experiment in which animals underwent the same protocol, but were given three different doses of endotoxin and were observed for 72 hours before sacrifice. RESULTS At endotoxin 3 mg/kg, the 72-hour survival in saline-treated animals was 92%, which decreased to 45% at 10 mg/kg and to 29% at 15 mg/kg. All of the molsidomine-treated animals survived all endotoxin doses. Alanine aminotransferase was reduced in molsidomine-treated animals compared with those treated with saline. Apoptosis was attenuated in molsidomine-treated animals. Caspase 3 activity was decreased in molsidomine-treated animals compared with those given saline. CONCLUSIONS Molsidomine attenuates caspase activation and hepatocyte apoptosis and improves survival after cholestatic endotoxic injury.
Collapse
Affiliation(s)
- Kimberly M Brown
- Department of Surgery, Burn and Shock Trauma Institute; Loyola University Medical Center, Maywood, IL 60607, USA
| | | | | | | | | | | |
Collapse
|
|
50
|
Mayhew PD, Holt DE, McLear RC, Washabau RJ. Pathogenesis and outcome of extrahepatic biliary obstruction in cats. J Small Anim Pract 2002; 43:247-53. [PMID: 12074289 PMCID: PMC7167133 DOI: 10.1111/j.1748-5827.2002.tb00067.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Extrahepatic biliary obstruction (EHBO) was confirmed at surgery or necropsy in 22 cats. Biliary or pancreatic adenocarcinoma was diagnosed by histopathology in six cats and one cat had an undiagnosed mass in the common bile duct. The remaining 15 cats had at least one of a complex of inflammatory diseases including pancreatitis, cholangiohepatitis, cholelithiasis and cholecystitis. The most common clinical signs were jaundice, anorexia, lethargy, weight loss and vomiting. Hyperbilirubinaemia was present in all cases. Distension of the common bile duct and gall bladder was the most commonly observed finding on abdominal ultrasound. Nineteen cats underwent exploratory laparotomy for biliary decompression and diversion. Mortality in cats with underlying neoplasia was 100 per cent and, in those with non-neoplastic lesions, was 40 per cent. Long-term complications, in those that survived, included recurrence of cholangiohepatitis, chronic weight loss and recurrence of obstruction. Based on these findings, the prognosis for EHBO in cats must be considered guarded.
Collapse
Affiliation(s)
- P D Mayhew
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia 19104-6010, USA
| | | | | | | |
Collapse
|