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ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. Am J Gastroenterol 2023; 118:405-426. [PMID: 36863037 DOI: 10.14309/ajg.0000000000002190] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/13/2022] [Indexed: 03/04/2023]
Abstract
A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.
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Bortolotti P, Delpierre C, Le Guern R, Kipnis E, Lebuffe G, Lenne X, Pruvot FR, Truant S, Bignon A, El Amrani M. High incidence of postoperative infections after pancreaticoduodenectomy: A need for perioperative anti-infectious strategies. Infect Dis Now 2021; 51:456-463. [PMID: 33853752 DOI: 10.1016/j.idnow.2021.01.001] [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: 09/03/2020] [Revised: 12/19/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Postoperative infections occur frequently after pancreaticoduodenectomy, especially in patients with bile colonization. Recommendations for perioperative anti-infectious treatment are lacking, and clinical practice is heterogenous. We have analyzed the effects of bile colonization and antibiotic prophylaxis on postoperative infection rates, types and therapeutic consequences. METHODS Retrospective observational study in patients undergoing pancreaticoduodenectomy with intraoperative bile culture. Data on postoperative infections and non-infectious complications, bile cultures and antibiotic prophylaxis adequacy to biliary bacteria were collected. RESULTS Among 129 patients, 53% had a positive bile culture and 23% had received appropriate antibiotic prophylaxis. Postoperative documented infection rate was over 40% in patients with or without bile colonization, but antibiotic therapy was more frequent in positive bile culture patients (77% vs. 57%, P=0,008). The median duration of antibiotic therapy was 11 days and included a broad-spectrum molecule in 42% of cases. Two-thirds of documented postoperative infections involved one or more bacteria isolated in bile cultures, which was associated with a higher complication rate. While bile culture yielded Gram-negative bacilli (57%) and Gram-positive cocci (43%), fungal microorganisms were scarce. Adequate preoperative antibiotic prophylaxis according to bile culture was not associated with reduced infectious or non-infectious complication rates. CONCLUSION Patients undergoing pancreaticoduodenectomy experience a high rate of postoperative infections, often involving bacteria from perioperative bile culture when positive, with no preventive effect of an adequate preoperative antibiotic prophylaxis. Increased postoperative complications in patients with bile colonization may render necessary a perioperative antibiotic treatment targeting bile microorganisms. Further prospective studies are needed to improve the anti-infectious strategy in these patients.
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Affiliation(s)
- P Bortolotti
- Pôle d'anesthésie-réanimation, CHU de Lille, 59000 Lille, France; Inserm, CNRS, institut Pasteur de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, University Lille, 59000 Lille, France.
| | - C Delpierre
- Pôle d'anesthésie-réanimation, CHU de Lille, 59000 Lille, France.
| | - R Le Guern
- Inserm, CNRS, institut Pasteur de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, University Lille, 59000 Lille, France; Institut de microbiologie, CHU de Lille, 59000 Lille, France.
| | - E Kipnis
- Pôle d'anesthésie-réanimation, CHU de Lille, 59000 Lille, France; Inserm, CNRS, institut Pasteur de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, University Lille, 59000 Lille, France.
| | - G Lebuffe
- Pôle d'anesthésie-réanimation, CHU de Lille, 59000 Lille, France; EA 7365 - GRITA - Groupe de recherche sur les formes injectables et les technologies associées, University Lille, 59000 Lille, France.
| | - X Lenne
- Département d'information médicale, CHU de Lille, 59000 Lille, France.
| | - F-R Pruvot
- Département de chirurgie digestive et transplantation, CHU de Lille, 59000 Lille, France; Inserm, CNRS, UMR9020 - UMR-S 1277 - Canther - Cancer Heterogeneity, Plasticity and Resistance to Therapies, CHU de Lille, University Lille, 59000 Lille, France.
| | - S Truant
- Département de chirurgie digestive et transplantation, CHU de Lille, 59000 Lille, France; Inserm, CNRS, UMR9020 - UMR-S 1277 - Canther - Cancer Heterogeneity, Plasticity and Resistance to Therapies, CHU de Lille, University Lille, 59000 Lille, France.
| | - A Bignon
- Pôle d'anesthésie-réanimation, CHU de Lille, 59000 Lille, France.
| | - M El Amrani
- Département de chirurgie digestive et transplantation, CHU de Lille, 59000 Lille, France; Inserm, CNRS, UMR9020 - UMR-S 1277 - Canther - Cancer Heterogeneity, Plasticity and Resistance to Therapies, CHU de Lille, University Lille, 59000 Lille, France.
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Hamidi M, Dauch J, Watson R, O'Grady C, Hsu P, Arrington A, Riall TS, Khreiss M. Outcomes with Preoperative Biliary Stenting After Pancreaticoduodenectomy In the Modern Era. J Gastrointest Surg 2021; 25:162-168. [PMID: 33219497 DOI: 10.1007/s11605-020-04874-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have documented increased complications following pancreaticoduodenectomy in patients who undergo preoperative biliary stenting (PBS). However, in the modern era, the vast majority of patients with jaundice are stented. We hypothesized that there is no difference in short-term postoperative outcomes between PBS and no PBS in patient with obstructive jaundice undergoing pancreaticoduodenectomy. METHODS We performed an analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use file (2014-2017). Patients who received neoadjuvant chemotherapy and required stenting were excluded from the analysis. A propensity-matched analysis was performed to select obstructive jaundice patients who underwent PBS and those who did not with similar characteristics prior to pancreaticoduodenectomy. Short-term postoperative outcome measures included superficial surgical site infection (S-SSI), deep surgical site infection (D-SSI), hospital length of stay (LOS), postoperative pancreatic fistula (POF), hospital readmission, minor morbidity (Clavien-Dindo I-II), major morbidity (Clavien-Dindo III, IV, V), and 30-day mortality. RESULTS A total of 5851 patients with obstructive jaundice underwent pancreaticoduodenectomy without neoadjuvant chemotherapy. 81.6% underwent PBS. Based on the propensity-matched analysis, 927 patients who received PBS and 927 patients who did not were selected for comparing the outcomes between the two groups. There was no significant difference in outcome measures between the two groups with respect to S-SSI (OR 1.30 , 95% CI = 0.94-1.80, p = 0.12), D-SSI (OR 1.07, 95% CI = 0.81-1.41, p = 0.62), POF (OR 1.11, 95% CI = 0.87-1.42, p = 0.40), hospital readmission (OR 0.99, 95% CI = 0.77-1.27, p = 0.94), minor morbidity (OR 0.91, 95% CI = 0.76-1.11, p = 0.36), major morbidity (OR 0.84, 95% CI = 0.67-1.06, p = 0.14), and 30-day mortality (OR 1.05, 95% CI = 0.57-1.95, p = 0.87). Patients who underwent PBS were more likely to have shorter LOS (RR 0.87, 95% CI = 0.81-0.93, p < 0.0001). CONCLUSION Contrary to previously reported studies, there was no increased risk of short-term postoperative outcomes after pancreaticoduodenectomy between PBS and N-PBS in a propensity-matched analysis. Preoperative biliary stenting is safe and does not need to be avoided before surgical intervention in patients who present with obstructive jaundice.
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Affiliation(s)
- Mohammad Hamidi
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA
| | - Jacqueline Dauch
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA
| | - Raj Watson
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA
| | - Catherine O'Grady
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA
| | - Paul Hsu
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA
| | - Amanda Arrington
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA
| | - Taylor S Riall
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA
| | - Mohammad Khreiss
- Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA.
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Liu J, Qu J, Chen H, Ge P, Jiang Y, Xu C, Chen H, Shang D, Zhang G. The pathogenesis of renal injury in obstructive jaundice: A review of underlying mechanisms, inducible agents and therapeutic strategies. Pharmacol Res 2020; 163:105311. [PMID: 33246170 DOI: 10.1016/j.phrs.2020.105311] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/30/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022]
Abstract
Kidney injury is one of the main complications of obstructive jaundice (OJ) and its pathogenesis has not been clarified. As an independent risk factor for OJ associated with significant morbidity and mortality, it can be mainly divided into two types of morphological injury and functional injury. We called these dysfunctions caused by OJ-induced kidney injury as OJKI. However, the etiology of OJKI is still not fully clear, and research studies on how OJKI becomes a facilitated factor of OJ are limited. This article reviews the underlying pathological mechanism from five aspects, including metabolisms of bile acids, hemodynamic disturbances, oxidative stress, inflammation and the organic transporter system. Some nephrotoxic drugs and measures that can enhance or reduce the renal function with potential intervention in perioperative periods to alleviate the incidence of OJKI were also described. Furthermore, a more in-depth study on the pathogenesis of OJKI from multiple aspects for exploring more targeted treatment measures were further put forward, which may provide new methods for the prevention and treatment of clinical OJKI and improve the prognosis.
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Affiliation(s)
- Jiayue Liu
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Jialin Qu
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China
| | - Haiyang Chen
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Peng Ge
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Yuankuan Jiang
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Caiming Xu
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Hailong Chen
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Dong Shang
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China; Institute (College) of Integrative Medicine, Dalian Medical University, No. 9, South Road of Lvshun, Dalian 116044, China; Department of General Surgery, Pancreatic-Biliary Center, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China
| | - Guixin Zhang
- Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, No. 222, Zhongshan Road, Dalian 116011, China.
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Biocompatible Polymer Materials with Antimicrobial Properties for Preparation of Stents. NANOMATERIALS 2019; 9:nano9111548. [PMID: 31683612 PMCID: PMC6915381 DOI: 10.3390/nano9111548] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/15/2019] [Accepted: 10/29/2019] [Indexed: 12/17/2022]
Abstract
Biodegradable polymers are promising materials for use in medical applications such as stents. Their properties are comparable to commercially available resistant metal and polymeric stents, which have several major problems, such as stent migration and stent clogging due to microbial biofilm. Consequently, conventional stents have to be removed operatively from the patient's body, which presents a number of complications and can also endanger the patient's life. Biodegradable stents disintegrate into basic substances that decompose in the human body, and no surgery is required. This review focuses on the specific use of stents in the human body, the problems of microbial biofilm, and possibilities of preventing microbial growth by modifying polymers with antimicrobial agents.
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Shin SH, Han IW, Ryu Y, Kim N, Choi DW, Heo JS. Optimal timing of pancreaticoduodenectomy following preoperative biliary drainage considering major morbidity and postoperative survival. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:449-458. [DOI: 10.1002/jhbp.652] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Sang Hyun Shin
- Division of Hepatobiliary‐Pancreatic Surgery Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine 81 Irwon‐Ro, Gangnam‐gu Seoul135-710South Korea
| | - In Woong Han
- Division of Hepatobiliary‐Pancreatic Surgery Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine 81 Irwon‐Ro, Gangnam‐gu Seoul135-710South Korea
| | - Youngju Ryu
- Division of Hepatobiliary‐Pancreatic Surgery Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine 81 Irwon‐Ro, Gangnam‐gu Seoul135-710South Korea
| | - Naru Kim
- Division of Hepatobiliary‐Pancreatic Surgery Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine 81 Irwon‐Ro, Gangnam‐gu Seoul135-710South Korea
| | - Dong Wook Choi
- Division of Hepatobiliary‐Pancreatic Surgery Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine 81 Irwon‐Ro, Gangnam‐gu Seoul135-710South Korea
| | - Jin Seok Heo
- Division of Hepatobiliary‐Pancreatic Surgery Department of Surgery Samsung Medical Center Sungkyunkwan University School of Medicine 81 Irwon‐Ro, Gangnam‐gu Seoul135-710South Korea
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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: 1.4] [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.
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Spironolactone rescues renal dysfunction in obstructive jaundice rats by upregulating ACE2 expression. J Cell Commun Signal 2018; 13:17-26. [PMID: 29882088 DOI: 10.1007/s12079-018-0466-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/17/2018] [Indexed: 12/31/2022] Open
Abstract
Postoperative acute renal failure in patients with obstructive jaundice is still a serious clinically complication, yet the mechanisms remain unclear. Renin-angiotensin-aldosterone system (RAAS) plays a central role in renal disease progression. Several lines of evidence shows that angiotensin-converting-enzyme-2 (ACE2), a main effector of RAAS acts as a local regulator for renal protection. This study aims to investigate the role of ACE2 and the effect of spironolactone treatment in obstructive jaundice(OJ) rats with renal injury. The rats with obstructive jaundice were established by bile duct ligation. Total bilirubin (TBil), serum creatinine (Scr) and the expression of ACE2 in kidney tissue of obstructive jaundice rats were detected. Comparatively, the expression of ACE2, renin, angiotensin II (AngII), angiotensin-(1-7)[Ang-(1-7)], aldosterone and intercellular adhesion molecule 1 (ICAM-1) in kidney tissues after spironolactone administration were measured by ELISA. Renal necrosis, inflammation and fibrosis induced by OJ were also measured by HE staining and Masson staining. The correlation between the expression of ACE2 and TBil, also the Scr level were investigated. With the time of common bile duct ligation prolonged, the TBil and Scr concentration increased while the expression of ACE2 in OJ rats' kidney tissues decreased. However, after spironolactone intervention, the expressions of ACE2, renin, AngII, Ang-(1-7), aldosterone and ICAM-1 in kidney tissue were changed, moreover, necrotic, inflammatory and fibrotic condition was also decreased. The relationship between the mRNA expression of ACE2 and TBil/Scr was observed to be moderately negatively correlated (r = -0.516, R2 = 0.292, P < 0.01), (r = -0.576, R2 = 0.332, P < 0.01), respectively. RAAS exerted an important effect in the renal damage caused by OJ. Spironolactone intervention not only improved the degree of renal fibrosis induced by OJ, but also upregulated the ACE2 expression in the kidney of OJ rats and rescued the renal function.
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Distinct inflammatory profile underlies pathological increases in creatinine levels associated with Plasmodium vivax malaria clinical severity. PLoS Negl Trop Dis 2018; 12:e0006306. [PMID: 29596409 PMCID: PMC5875744 DOI: 10.1371/journal.pntd.0006306] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 02/08/2018] [Indexed: 11/22/2022] Open
Abstract
Background Although Plasmodium vivax infection is a frequent cause of malaria worldwide, severe presentations have been more regularly described only in recent years. In this setting, despite clinical descriptions of multi-organ involvement, data associating it with kidney dysfunction are relatively scarce. Here, renal dysfunction is retrospectively analyzed in a large cohort of vivax malaria patients with an attempt to dissect its association with disease severity and mortality, and to determine the role of inflammation in its progression. Methods A retrospective analysis of a databank containing 572 individuals from the Brazilian Amazon, including 179 patients with P. vivax monoinfection (161 symptomatic malaria, 12 severe non-lethal malaria, and 6 severe lethal disease) and 165 healthy controls, was performed. Data on levels of cytokines, chemokines, C-reactive protein (CRP), fibrinogen, creatinine, hepatic enzymes, bilirubin levels, free heme, and haptoglobin were analyzed to depict and compare profiles from patients per creatinine levels. Results Elevated creatinine levels were found predominantly in women. Vivax malaria severity was highly associated with abnormal creatinine increases, and nonsurvivors presented the highest values of serum creatinine. Indication of kidney dysfunction was not associated with parasitemia levels. IFN-γ/IL-10 ratio and CRP values marked the immune biosignature of vivax malaria patients, and could distinguish subjects with elevated creatinine levels who did not survive from those who did. Patients with elevated serum creatinine or severe vivax malaria displayed indication of cholestasis. Biomarkers of hemolysis did not follow increases in serum creatinine. Conclusion These findings reinforce the hypothesis that renal dysfunction is a key component in P. vivax malaria associated with clinical severity and mortality, possibly through intense inflammation and immune imbalance. Our study argues for systematic evaluation of kidney function as part of the clinical assessment in vivax malaria patients, and warrants additional studies in experimental models for further mechanism investigations. Severe clinical presentations of Plasmodium vivax malaria are not completely understood. Multi-organ involvement is described in severe vivax cases, however data associating it with kidney dysfunction are relatively scarce, in part because the clinical signs only appear late during kidney injury. We analyzed biomarkers of renal function in groups of patients from the Brazilian Amazon with different presentations of vivax malaria to determine its associations with disease progression. Inflammatory biomarkers were also analyzed to assess inflammation related to kidney dysfunction. The results indicate that severe disease presentation in these patients was associated with abnormal serum creatinine elevations and exacerbated systemic inflammatory response. The highest levels of creatinine were observed in nonsurvivors. Biomarkers of hemolysis did not directly follow increases in serum creatinine. These readouts suggest that kidney dysfunction probably influences vivax malaria severity and mortality. As P. vivax is a widely distributed species of Plasmodium in the world, and severe cases are increasingly being reported, it is important to better understand the role of kidney injury in these presentations, especially considering that it may affect clinical outcomes.
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Guibing R, Xiping Z, Xiaowen D, Dehong Z, Hongjiang Y, Xiaoru M, Wenju M, Xiangming H, Shuai Z. EFFECTS OF SALVIA MILTIORRHIZAE ON THE KIDNEY OF RATS WITH SEVERE ACUTE PANCREATITIS AND OBSTRUTIVE JAUNDICE. AFRICAN JOURNAL OF TRADITIONAL, COMPLEMENTARY, AND ALTERNATIVE MEDICINES : AJTCAM 2017; 14:103-124. [PMID: 28573227 PMCID: PMC5446434 DOI: 10.21010/ajtcam.v14i2.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Severe acute pancreatitis (SAP) and obstructive jaundice (OJ) are frequent recurring diseases that bring about huge threat to human health. Some reports have demonstrated that Salviae miltiorrhizae can protect multiple organs of SAP and OJ model animals or patients, but their related mechanisms were not clear. In this study, we observed the effects of Salvia miltiorrhizae injection on apoptosis and NF-κB expression in kidney and explored the protective effect and mechanism of Salvia miltiorrhizae on the kidney of SAP or OJ rats. The results obtained will provide a theoretical basis for clinical application of Salvia miltiorrhizae. Material and Methods: A total of 288 rats were used for SAP -and OJ-associated experiments. The mortality rates of rats, the contents of serum BUN and CREA, the expression levels of Bax, NF-κB proteins and the apoptosis index were observed, respectively. Results: The pathological changes in the kidney of SAP or OJ rats in treated group were mitigated to varying degrees. At 6 and 12 hours after operation in SAP rats or on 21 and 28 days after operation in OJ rats, the contents of serum CREA in treated group were significantly lower than those in model control group; At 3 and 6 hours after operation, the staining intensity of Bax protein of kidney in treated group was significantly lower than that in model control group; on 14 days after operation, the apoptosis index in the kidney of OJ rats in treated group was significantly lower than that in model control group. Conclusion: Salvia miltiorrhizae can exert protective effects on the kidney of SAP and OJ rats.
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Affiliation(s)
- Ren Guibing
- Department of Oncological Surgery, Affiliated Hospital, Logistics University of the Chinese People's Armed Police Force, Tianjin, 300162, PR China
| | - Zhang Xiping
- Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, PR China.,Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, Zhejiang Province, PR China
| | - Ding Xiaowen
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, Zhejiang Province, PR China
| | - Zou Dehong
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, Zhejiang Province, PR China
| | - Yang Hongjiang
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, Zhejiang Province, PR China
| | - Meng Xiaoru
- Department of Oncological Surgery, Affiliated Hospital, Logistics University of the Chinese People's Armed Police Force, Tianjin, 300162, PR China
| | - Mo Wenju
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, Zhejiang Province, PR China
| | - He Xiangming
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, Zhejiang Province, PR China
| | - Zhao Shuai
- Department of Breast Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, Zhejiang Province, PR China
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Dolejs S, Zarzaur BL, Zyromski NJ, Pitt HA, Riall TS, Hall BL, Behrman SW. Does Hyperbilirubinemia Contribute to Adverse Patient Outcomes Following Pancreatoduodenectomy? J Gastrointest Surg 2017; 21:647-656. [PMID: 28205125 DOI: 10.1007/s11605-017-3381-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/27/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Jaundice due to biliary obstruction leads to multiple physiologic derangements and a decline in performance status that may result in unfavorable intra- and postoperative outcomes following a Whipple procedure. While preoperative biliary decompression may improve synthetic function, this strategy has been reported to increase the incidence of infectious complications following surgery. We hypothesized that hyperbilirubinemia at the time of pancreatoduodenectomy (PD) would be a risk factor for increased morbidity and mortality postoperatively. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pancreatectomy Demonstration Project and the 2014 Procedure Targeted Pancreatectomy databases were queried for patients with a bilirubin level obtained within 7 days of PD. Results were compared among patients with bilirubin level percentiles <80th (0-2.9 mg/dL), 80-90th (3-7.3 mg/dL), and >90th (>7.3 mg/dL). Data were further evaluated between those with a bilirubin ≥10 mg/dL and those with a normal level and by utilizing bilirubin as a continuous variable. Outcomes included 30-day mortality and overall and serious morbidity as previously defined by ACS-NSQIP. Categorical variables were compared using chi-squared, Fisher's exact, Kruskal-Wallis, or Wilcoxon rank sum tests with a p = 0.05 considered significant. RESULTS The combined databases yielded 2556 patients who had PD and a preoperative bilirubin level for analysis. When comparing patients with bilirubin levels at the 80th (n = 2055), 80-90th (n = 273), and >90th percentiles (n = 228), no difference was observed among groups with respect to overall and serious morbidity or mortality. Similarly, no difference in postoperative outcomes was observed between the 147 patients who had a bilirubin ≥10 mg/dL and those with normal levels or when bilirubin increased when levels were analyzed as a continuous variable. CONCLUSION Modest degrees of hyperbilirubinemia were not shown to affect morbidity and mortality following pancreatoduodenectomy. The indication and need for preoperative biliary decompression should be reserved, and utilized selectively, only for those with symptomatic, elevated bilirubin levels.
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Affiliation(s)
- Scott Dolejs
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ben L Zarzaur
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University School of Medicine, Philadelphia, PA, USA
| | - Taylor S Riall
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Bruce L Hall
- Department of Surgery, Washington University School of Medicine, Olin Business School, and Center for Health Policy, St. Louis, MO, USA.,Department of Surgery, American College of Surgeons, Chicago, IL, USA.,Department of Surgery, BJC Healthcare, St. Louis, MO, USA
| | - Stephen W Behrman
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue #203, Memphis, TN, 38163, USA.
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Song TJ, Lee JH, Lee SS, Jang JW, Kim JW, Ok TJ, Oh DW, Park DH, Seo DW, Lee SK, Kim MH, Kim SC, Kim CN, Yun SC. Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection. Gastrointest Endosc 2016; 84:814-821. [PMID: 27109456 DOI: 10.1016/j.gie.2016.04.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 04/07/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Preoperative biliary drainage (PBD) with stent placement has been commonly used for patients with malignant biliary obstruction. In PBD, the placement of fully covered self-expandable metal stents (FCSEMSs) may provide better patency duration and a lower incidence of cholangitis compared with plastic stents. We aimed to evaluate which type of stent showed better outcomes in PBD. METHODS In this multicenter, prospective randomized trial, we compared PBD with FCSEMSs versus plastic stents in 86 patients with malignant biliary obstruction between January 2012 and December 2014. Patients with obstructive jaundice were randomly assigned to undergo PBD either with plastic stents or FCSEMS placement. RESULTS Baseline characteristics were not significantly different between the 2 groups. Endoscopic stent placement was technically successful in all patients. Procedure-related adverse events were not significantly different between the 2 groups (plastic vs FCSEMS group; 16.3% vs 16.3%, P = 1.0). Reintervention was required in 16.3% of the plastic stent group and 14.0% of the FCSEMS group (P = .763). The interval to surgery after PBD (plastic vs FCSEMS group; 14.2 ± 8.3 vs 12.3 ± 6.9 days, P = .426) was not significantly different between groups. Surgery-related adverse events occurred in 43.6% of the plastic stent group and 40.0% of the FCSEMS group (P = .755). CONCLUSIONS In patients with resectable malignant biliary obstruction, the outcomes of PBD with plastic stents and FCSEMSs were similar. Considering the cost-effectiveness, PBD with plastic stents may be preferable to FCSEMS placement. (Clinical trial registration number: NCT01789502.).
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Affiliation(s)
- Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Hoon Lee
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Woong Jang
- Department of Internal Medicine, Eulgi University College of Medicine, Daejeon, Korea
| | - Jung Wook Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Tae Jin Ok
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Wook Oh
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Song Cheol Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chul Nam Kim
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sung Cheol Yun
- Department of Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Martínez-Cecilia D, Reyes-Díaz M, Ruiz-Rabelo J, Gomez-Alvarez M, Villanueva CM, Álamo J, Muntané J, Padillo FJ. Oxidative stress influence on renal dysfunction in patients with obstructive jaundice: A case and control prospective study. Redox Biol 2015; 8:160-4. [PMID: 26774750 PMCID: PMC4731952 DOI: 10.1016/j.redox.2015.12.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 12/20/2022] Open
Abstract
Background: Obstructive Jaundice (OJ) is associated with a significant risk of developing acute renal failure (ARF). The involvement of oxidative stress in the development of cholestasis has been demonstrated in different experimental models. However, its role in the morbidity of human cholestasis is far to be elucidated. The aim of the study was the evaluation of oxidative stress markers in blood from patients with OJ and its relation to complications and benign/malignant evolution of cholestasis. Methods: A prospective cross-sectional study of 105 patients with OJ and 34 control subjects were included. Several markers of liver function and oxidative stress, such as lipoperoxides (LPO), as well as reduced glutathione (GSH), catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities were assessed. Results: The patients with OJ showed a marked increase in plasma levels of LPO, SOD and GSH, while GSH-Px levels were decreased. The increase in lipid peroxidation products and the depletion of SOD activity in blood were also related to renal dysfunction. The highest level of LPO was associated with malignant etiology of the disease. The logistic regression analysis showed that the age of the patient and the levels of LPO in blood were predictors of renal dysfunction in OJ patients. Conclusions: This study demonstrates a correlation between oxidative stress and renal dysfunction patients with OJ. Obstructive jaundice was associated to a decreased glomerular filtration rate. Renal impairment was more frequent in jaundiced patients than in healthy subjects. LPO levels were higher in jaundiced patients than in healhy subjects, with highest levels related to malignant ethiology. Renal function was affected by the intensity of the biliary obstruction, and the balance between LPO and antioxidant defenses
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Affiliation(s)
- David Martínez-Cecilia
- General and Digestive Surgery Service, Complejo Hospitalario de Toledo, Av de Barber, 30, 45071 Toledo, Spain.
| | - María Reyes-Díaz
- Department of General Surgery, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Juan Ruiz-Rabelo
- General and Digestive Surgery Service, Hospital Universitario Reina Sofía, Cordoba, Spain
| | - Manuel Gomez-Alvarez
- General and Digestive Surgery Service, Hospital Universitario Reina Sofía, Cordoba, Spain
| | | | - José Álamo
- Department of General Surgery, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Jordi Muntané
- Department of General Surgery, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Francisco Javier Padillo
- Department of General Surgery, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Sevilla, Spain
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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: 80] [Impact Index Per Article: 8.9] [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.
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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
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16
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Abstract
Hepatobiliary surgery outcomes have significantly improved since the early 1970s. Surgical and anesthetic advances related to patient selection, alternative surgical management options, and reduction of operative blood loss have been important. Postoperative analgesic regimens are being modified to include intrathecal opiates and to embrace enhanced recovery regimens.
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17
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Son JH, Kim J, Lee SH, Hwang JH, Ryu JK, Kim YT, Yoon YB, Jang JY, Kim SW, Cho JY, Yoon YS, Han HS, Woo SM, Lee WJ, Park SJ. The optimal duration of preoperative biliary drainage for periampullary tumors that cause severe obstructive jaundice. Am J Surg 2013; 206:40-6. [PMID: 23706545 DOI: 10.1016/j.amjsurg.2012.07.047] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/13/2012] [Accepted: 07/24/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite routine preoperative biliary drainage (PBD) with periampullary cancer, its optimal duration has not been established. The objective of this study was to investigate PBD in severely jaundiced patients. METHODS A total of 120 patients with periampullary tumors who underwent surgery with intent to cure after PBD for severe obstructive jaundice were enrolled. According to the duration of PBD, 66 and 54 patients were classified into the long-term (≥2 weeks) and short-term (<2 weeks) groups. RESULTS PBD-related complications occurred in 6 (9.1%) and 14 (25.9%) patients in the short-term and long-term groups, respectively (P = .014). Rates of surgery-related complications and mortalities were not significantly different between the 2 groups. The R0 resection rate tended to be lower (P = .054) and the mean length of hospital stay was significantly longer (P = .039) in the long-term group. CONCLUSIONS PBD duration <2 weeks is more appropriate in severely jaundiced patients with periampullary cancer.
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Affiliation(s)
- Jun Hyuk Son
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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18
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Rafat C, Burbach M, Brochériou I, Zafrani L, Callard P, Rondeau E, Hertig A. Bilirubin-Associated Acute Tubular Necrosis in a Kidney Transplant Recipient. Am J Kidney Dis 2013; 61:782-5. [DOI: 10.1053/j.ajkd.2012.11.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 11/19/2012] [Indexed: 11/11/2022]
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Pancreatectomy for adenocarcinoma in elderly patients: postoperative outcomes and long term results: a study of the French Surgical Association. Eur J Surg Oncol 2012; 39:171-8. [PMID: 22999411 DOI: 10.1016/j.ejso.2012.08.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 07/26/2012] [Accepted: 08/20/2012] [Indexed: 12/18/2022] Open
Abstract
AIM To determine the benefit of surgery for resectable pancreatic adenocarcinomas (PAs) in elderly patients. METHODS From 2004 to 2009, 932 patients with resectable PAs underwent pancreatectomies without neoadjuvant treatment in 37 institutions. The patients were divided into three groups according to age: <70 years (control group; n = 580); 70-79 years (70s group, n = 288), and ≥ 80 years (80s group; n = 64). Preoperative, intraoperative, postoperative, and histological data were recorded to assess the postoperative course and survival. RESULTS Preoperative or intraoperative characteristics, and the histological findings were comparable in the three groups. Postoperative mortality and morbidity rates did not differ in the three groups. Adjuvant therapies were more frequently used in younger patients than in elderly patients (p < 0.01). The overall 1-year, 3-year, and 5-year survival rates of control group/70's group/80's group were 82.2%/75.7%/75.7%, 49.9%/41.8%/31%, and 38.7%/33.2%/0%, respectively (p = 0.16). The median survival of the control, 70s, and 80s groups was 24 months, 35.3 months, and 30 months, respectively. Four independent prognostic indicators were identified by multivariate analysis: venous invasion (hazard ratio (HR) = 2.12), arterial invasion (HR = 2.96), positive lymph nodes (HR = 2.25), and adjuvant treatment (HR = 0.65). CONCLUSIONS Fit elderly patients with resectable PAs should not be excluded from surgical resection of PA solely because of their real age. Moreover, elderly patients seem to obtain similar advantages from pancreatectomies than younger patients.
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20
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Chronic Kidney Disease. Perioper Med (Lond) 2011. [DOI: 10.1007/978-0-85729-498-2_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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van der Gaag NA, Kloek JJ, de Castro SMM, Busch ORC, van Gulik TM, Gouma DJ. Preoperative biliary drainage in patients with obstructive jaundice: history and current status. J Gastrointest Surg 2009; 13:814-20. [PMID: 18726134 DOI: 10.1007/s11605-008-0618-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 07/15/2008] [Indexed: 01/31/2023]
Abstract
RATIONALE Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results. FINDINGS For distal obstruction, currently the "best-evidence" available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits. CONCLUSION The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.
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Affiliation(s)
- N A van der Gaag
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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Abstract
AIM Multiorgan dysfunction is often encountered in jaundiced patients and may compromise the postoperative outcome after liver resection for cholangiocarcinoma (CCA). The aim of the present study was to elucidate evidence-based medicine regarding the benefit of the available preoperative treatments currently used for the preparation of patients before surgery for hilar CCA. MATERIAL AND METHODS An electronic search using the Medline database was performed to identify relevant articles relating to renal dysfunction, bacterial translocation, hemostasis impairment, malnutrition, liver failure, and postoperative outcome in jaundiced patients undergoing liver resection for CCA. RESULTS There is grade B evidence to expand the extracellular water volume and to administer oral synbiotic supplements. Intravenous vitamin K administration is an effective treatment. Perioperative nutritional support should be administered preferably by the enteral route in severely malnourished patients with compromised liver function undergoing extended liver resection (grade A evidence). There is only grade C evidence to recommend a portal vein embolization in patients with CCA when the future remnant liver volume is <40%. CONCLUSIONS A simplified scheme that might be useful in the management of patients presenting with obstructive jaundice was presented. Despite surgical technique improvements, preparation of patients for surgery will continue to be one of the major determinants for the postoperative prognosis of jaundiced patients.
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Affiliation(s)
- E. Oussoultzoglou
- Centre de Chirurgie Viscérale et de Transplantation – Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Université Louis PasteurStrasbourgFrance
| | - D. Jaeck
- Centre de Chirurgie Viscérale et de Transplantation – Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Université Louis PasteurStrasbourgFrance
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Wang Y, Chen WM, Gao LL, Liu JG. Dopamine modulates perioperative renal medulla aquaporin 2 expression in experimental obstructive jaundice. Shijie Huaren Xiaohua Zazhi 2007; 15:2714-2717. [DOI: 10.11569/wcjd.v15.i25.2714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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
AIM: To investigate the changes in aquaporin 2 expression after bile duct recanalization and the effects of low-dose dopamine on perioperative renal aquaporin 2 expression.
METHODS: Seventy wistar rats were randomly allocated to 4 groups. Sixty rats underwent common bile duct ligation, while the other 10 underwent sham operation. The common duct was ligated on a silicon tube of 2 mm external diameter. Seven days later, the experimental rats were randomly allocated into another 3 groups. Rats in the obstructive jaundice group were injected with 9 g/L normal saline (NS), while those in the other 2 groups were injected with dopamine at 5 or 10 µg/(kg•min), respectively. After 2 h treatment, half in each group were killed and the others were killed 24 h later. Serum was collected from each rat to assess hepatic and renal functions. The right renal medulla was separated and kept at -80℃ until used to measure aquaporin 2 expressions by Western blotting.
RESULTS: In the early period of bile duct recanalization, serum bilirubin levels decreased. There were no significant changes in blood urine or creatine. Renal aquaporin 2 expression was detected by Western blotting. Aquaporin 2 expression in the experimental group treated with dopamine 5 µg/(kg•min) was nearly the same as that in the normal group, both at 0 and 24 h (16 010 ± 646 and 22 715 ± 575 vs 21 966 ± 1544 and 21 917 ± 2661), and better than the group treated with dopamine 10 µg/(kg•min).
CONCLUSION: Low-dose dopamine injection appears to modulate expression of aquaporin 2 in the renal collective tubule epithelium, and to have a positive effect on perioperative renal function in obstructive jaundice.
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