Obstructive jaundice and perioperative management

Obstructive jaundice treatment during the COVID-19 pandemic: retrospective cohort study at a single tertiary care center in Serbia

OBJECTIVE

We aimed to compare mortality and complication rates in patients treated for obstructive jaundice before and during the COVID-19 pandemic in a tertiary care center in Serbia.

METHODS

We conducted a retrospective cohort study among a first group of patients treated between 1 January 2017 and 1 January 2019. The second group was treated between 1 March 2020 and 1 March 2022.

RESULTS

The first group comprised 35 patients, and the second group (in which all patients were SARS-CoV-2 positive) included 18 patients; 37 and 16 patients were treated for malignant and benign diseases, respectively. The groups did not differ significantly regarding the diagnoses and treatment received. The second group showed significantly higher aspartate aminotransferase levels and lower white blood cell, C-reactive protein, and interleukin 6 levels. Mortality and complication rates did not differ significantly between groups. All deceased patients in the second group had significant radiologic findings associated with COVID-19 pneumonia.

CONCLUSIONS

COVID-19 infection is a risk factor in treating obstructive jaundice. This study illustrates the potential influence of COVID-19 on mortality after obstructive jaundice treatment. COVID-19 pneumonia may be a significant risk factor for mortality in patients treated for obstructive jaundice.

Omega-3 Polyunsaturated Fatty Acids Alleviate Intestinal Barrier Dysfunction in Obstructive Jaundice Rats

Obstructive jaundice (OJ) can cause multiple pathophysiological consequences including intestinal barrier dysfunction. Omega-3 has been indicated to have a promising therapeutic effect on OJ. This study aimed to further investigate the functions of omega-3 on OJ-induced intestinal injury. A rat OJ model was established by bile duct ligation with or without omega-3 administration. ELISA was utilized for measuring serum levels of inflammatory cytokines. Hematoxylin-eosin staining and TUNEL staining were employed for detecting the morphological changes and cell apoptosis in rat intestine. Western blotting was utilized for evaluating expression of tight junction proteins in the intestinal tissues. Omgea-3 offset the reduction in body weight of OJ rats. Omega-3 alleviated inflammatory response, pathological damages and cell apoptosis in the intestine of OJ rats. Additionally, omega-3 enhanced levels of tight junction proteins in the intestinal tissues of OJ rats. Omega-3 ameliorates OJ-triggered impairment of intestinal barrier function in rats.

Pathophysiological consequences and treatment strategy of obstructive jaundice

Obstructive jaundice (OJ) is a common problem in daily clinical practice. However, completely understanding the pathophysiological changes in OJ remains a challenge for planning current and future management. The effects of OJ are widespread, affecting the biliary tree, hepatic cells, liver function, and causing systemic complications. The lack of bile in the intestine, destruction of the intestinal mucosal barrier, and increased absorption of endotoxins can lead to endotoxemia, production of proinflammatory cytokines, and induce systemic inflammatory response syndrome, ultimately leading to multiple organ dysfunction syndrome. Proper management of OJ includes adequate water supply and electrolyte replacement, nutritional support, preventive antibiotics, pain relief, and itching relief. The surgical treatment of OJ depends on the cause, location, and severity of the obstruction. Biliary drainage, surgery, and endoscopic intervention are potential treatment options depending on the patient's condition. In addition to modern medical treatments, Traditional Chinese medicine may offer therapeutic benefits for OJ. A comprehensive search was conducted on PubMed for relevant articles published up to August 1970. This review discusses in detail the pathophysiological changes associated with OJ and presents effective strategies for managing the condition.

Mirizzi Syndrome: A Case Report

Mirizzi syndrome (MS) describes a rare complication of cholelithiasis resulting from extrinsic compression of the common hepatic duct by impacted gallstones in the cystic duct or Hartmann's pouch. MS is most commonly seen in adults and is more prevalent in the female population. Due to the pathophysiology of MS being similar to other causes of cholecystitis and biliary obstruction, the symptomatology is rather nonspecific. While ultrasound and magnetic resonance cholangiopancreatography are commonly used for diagnosis, treatment of this condition typically involves cholecystectomy. Identifying MS versus other more common causes of obstructive jaundice is paramount in limiting complications. In this report, we describe a case of MS diagnosed in a 32-year-old male who presented with nonspecific abdominal pain and other signs of obstructive jaundice. The goal of this study is to show how identifying a rare underlying cause of a common presentation can lead to improved patient outcomes.

Prediction of the effect of the photodynamic therapy on survival in patients with stage IV of pancreatic cancer

The article presents the results of a study of survival after complex palliative treatment of patients with malignant tumors of the pancreas stage IV in two comparable groups of patients. The aim of the study is to determine the prognostic factors affecting survival in patients with stage IV pancreatic cancer who received local and systemic photodynamic therapy. In the main group, which consisted of 19 patients with histologically veried stage IV pancreatic maligant tumor, palliative treatment was performed using photodynamic therapy. In the comparison group, consisting of 28 patients with histologically veried malignant tumor of the pancreas stage IV, palliative treatment was performed without the use of photodynamic therapy. On the background of the use of local and systemic photodynamic therapy in the main group it was observed a statistically significant increase in life expectancy compared with the comparison group. The three-month survival of patients who received local and systemic photodynamic therapy is affected by the level of brinogen before treatment. The level of brinogen above 3.4 g/l makes it possible to predict a decrease in the probability of three-month survival after photodynamic therapy. Thus, complex treatment with the use of photodynamic therapy for stage IV malignant tumors of the pancreas can increase the survival rate of patients.

[Minimally invasive technologies of lithotripsy and antegrade hydraulic lithoextraction in complex treatment of choledocholithiasis]

OBJECTIVE

To evaluate the effectiveness of minimally invasive technologies of lithotripsy and hydraulic antegrade lithoextraction in complex treatment of choledocholithiasis.

MATERIAL AND METHODS

In the main group, 74 patients with choledocholithiasis underwent complex treatment with minimally invasive lithotripsy and hydraulic antegrade lithoextraction. In the control group, 177 patients with choledocholithiasis complicated by obstructive jaundice underwent complex treatment without minimally invasive lithotripsy and hydraulic antegrade lithoextraction.

RESULTS

Both groups were characterized by significant decrease of serum bilirubin, markers of cytolysis and cholestasis with regression of clinical manifestations of obstructive jaundice. At the same time, early and delayed postoperative complications were significantly more common in the control group. Most of these complications accounted for interventions through laparotomy such as external drainage of the common bile duct and hepaticojejunostomy. There were no similar procedures in the main group due to the use of minimally invasive technologies of lithotripsy and antegrade hydraulic lithoextraction.

CONCLUSION

Minimally invasive lithotripsy and antegrade hydraulic lithoextraction are safe alternatives to traditional methods of lithoextraction and can be recommended in case of ineffective laparoscopic and retrograde endoscopic lithoextraction.

The value of endoscopic ultrasonography for differential diagnosis in obstructive jaundice of the distal common bile duct

INTRODUCTION

Obstructive jaundice is a common clinical disease of great significance; however, diagnosing it according to etiology, especially in patients with distal obstructive jaundice is difficult. The development of endoscopic ultrasonography has improved diagnostic methods. Endoscopic ultrasonography not only improves the accuracy of conventional endoscopic ultrasound technology in etiological diagnosis, but also offers several special endoscopic ultrasound technologies for diagnosing distal obstructive jaundice of the common bile duct. What's more, endoscopic ultrasonography can be used to treat distal obstructive jaundice of common bile duct.

AREAS COVERED

This review discusses the diagnostic value and applications of endoscopic ultrasonography for obstructive jaundice of the distal common bile duct.

EXPERT OPINION

This article summarizes the value of endoscopic ultrasonography in the etiological diagnosis, relevant treatment applications of distal obstructive jaundice and the limitations of endoscopic ultrasonography in some etiologies due to the lack of clear comparison with other imaging methods. We also provide new data for the future research direction of endoscopic ultrasonography in distal obstructive jaundice.

Comparative Study of the Results of Operations in Patients with Tumor and Non-Tumor Obstructive Jaundice Who Received and Did Not Receive Antioxidant Therapy for the Correction of Endotoxemia, Glycolysis, and Oxidative Stress

Purpose: To compare the results of surgical treatment and changes in biomarkers of cholestasis, endotoxicosis, cytolysis, lipid peroxidation, glycolysis disorders, and inflammation in patients with benign and malignant obstructive jaundice (OJ) in patients receiving and not receiving antioxidant pharmacotherapy (AOT). Patients and methods: The study included 113 patients (aged 21–90 years; 47 males and 66 females) who received surgical intervention for OJ due to non-malignant (71%) or malignant tumor (29%) etiologies. Patients were divided into two groups: Group I (n = 61) who did not receive AOT and Group II (n = 51) who received AOT (succinate-containing drug Reamberin) as part of detoxification infusion therapy. The surgical approach and scope of interventions in both groups were identical. Dynamic indicators of endotoxicosis, cholestasis, and cytolysis (total, direct, and indirect bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [AP] and gamma-glutamyltransferase [GGT]), kidney function (urea), lipid peroxidation (malonic dialdehyde, MDA), inflammation (leukocytosis), and glycolysis disorders (lactate dehydrogenase (LDH), glucose) were evaluated. Results: Tumor jaundice, unlike non-tumor jaundice, persisted and was characterized by a more severe course, a higher level of hyperbilirubinemia, and lipid peroxidation. The prognostic value of the direct (and total) bilirubin, MDA, glycemia, and leukocytosis levels on the day of hospitalization, which increased significantly in severe jaundice and, especially, in deceased patients, was established. Decompression interventions significantly reduced levels of markers of liver failure, cytolysis, cholestasis, and lipid peroxidation on day 3 after decompression by 1.5–3 times from initial levels; this is better achieved in non-tumor OJ. However, 8 days after decompression, most patients did not normalize the parameters studied in both groups. AOT favorably influenced the dynamics (on day 8 after decompression) of total and direct bilirubin, ALT, AST, MDA, and leukocytosis in non-tumor jaundice, as well as the dynamics of direct bilirubin, AST, MDA, glucose, and LDH in tumor jaundice. Clinically, in the AOT group, a two-fold reduction in the operative and non-operative complications was recorded (from 23% to 11.5%), a reduction in the duration of biliary drainage by 30%, the length of stay in intensive care units was reduced by 5 days, and even hospital mortality decreased, especially in malignancy-induced OJ. Conclusion: A mechanism for the development of liver failure in OJ is oxidative stress with the appearance of enhanced lipid peroxidation and accompanied by hepatocyte necrosis. Inclusion of AOT in perioperative treatment in these patients improves treatment outcomes.

Biliary Leakage Following Pancreatoduodenectomy: Experience from a High-Volume Center

Purpose: Hepaticojejunostomy leak and bile fistula after pancreaticoduodenectomy (PD) are less frequent than pancreatic leaks. Patients with biliary fistula (BF) have an increased risk of serious complications and an extended hospital stay. This study has investigated the occurrence and outcome of BF. Methods: All patients who underwent a PD from January 1st, 2015 to December 31st, 2019 were included. The significance of multiple risk factors was examined. Univariate analysis was used to identify predictive variables for postoperative BF. Results: Of the 552 patients who underwent PD, 38 patients (6.7%) developed a BF. Patients with nonmalignant diagnoses and malignancies without bile duct obstruction had a greater risk of developing BF. BF did not increase the mortality, though most patients had complications, including surgical site infections, intraabdominal abscesses, and an extended hospital stay. Conclusion: BF after PD leads to an increased risk of subsequent complications and an extended hospital stay but does not increase mortality. Patients with nonmalignant diagnoses and malignancies without bile duct obstruction have an increased risk of BF.

Percutaneous biliary stent combined with brachytherapy using 125I seeds for treatment of unresectable malignant obstructive jaundice: A meta-analysis

BACKGROUND

Malignant obstructive jaundice (MOJ) is a common pathologic manifestation of malignant biliary obstruction. Recently, several clinical trials have explored the clinical effectiveness of intraluminal ¹²⁵I seed-based brachytherapy for MOJ patients, and various outcomes have been reported.

AIM

To assess the efficacy and safety of percutaneous biliary stents with ¹²⁵I seeds compared to conventional metal stents in patients with unresectable MOJ.

METHODS

A systematic search of English-language databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed to identify studies published prior to June 2020 that compared stents with or without ¹²⁵I seeds in the treatment of unresectable MOJ. The outcomes analyzed included primary outcomes (stent patency and overall survival) and secondary outcomes (complications and liver function parameters).

RESULTS

Six randomized controlled trials and four retrospective studies involving 875 patients were eligible for the analysis. Of the 875 included patients, 404 were treated with ¹²⁵I seed stents, while 471 were treated with conventional stents. Unadjusted pooled analysis demonstrated that compared to conventional stents, ¹²⁵I seed stents extended the stent patency time [hazard ratio (HR) = 0.36, 95% confidence interval (CI) = 0.28-0.45, P < 0.0001] and overall survival period (HR = 0.52, 95%CI = 0.42–0.64, P < 0.00001). Subgroup analyses based on the type of ¹²⁵I seed stent and type of study design showed consistent results. However, there were no significant differences in the occurrence of total complications [odds ratio (OR) = 1.12, 95%CI = 0.75-1.67, P = 0.57], hemobilia (OR = 1.02, 95%CI = 0.45-2.3, P = 0.96), pancreatitis (OR = 1.79, 95%CI = 0.42-7.53, P = 0.43), cholangitis (OR = 1.13, 95%CI = 0.60-2.13, P = 0.71), or pain (OR = 0.67, 95%CI = 0.22-2, P = 0.47). In addition, there were no reductions in the levels of serum indices, including total bilirubin [mean difference (MD) = 10.96, 95%CI = -3.56-25.49, P = 0.14], direct bilirubin (MD = 7.37, 95%CI = -9.76-24.5, P = 0.4), alanine aminotransferase (MD = 7.52, 95%CI = -0.71-15.74, P = 0.07), and aspartate aminotransferase (MD = -4.77, 95%CI = -19.98-10.44, P = 0.54), after treatment. Publication bias was detected regarding the outcome overall survival; however, the conclusions were not changed after the adjustment.

CONCLUSION

Placement of stents combined with brachytherapy using ¹²⁵I seeds contributes to a longer stent patency and higher overall survival than placement of conventional stents without extra complications or severe liver damage. Thus, it can be considered an effective and safe treatment for unresectable MOJ.

The effect of Farnesoid X receptor agonist tropifexor on liver damage in rats with experimental obstructive jaundice

Purpose:

To investigate experimentally the effects of Tropifexor, a farnesoid X receptor agonist, on liver injury in rats with obstructive jaundice.

Methods:

Forty healthy Wistar albino female rats were divided randomly in selected groups. These groups were the sham group, control group, vehicle solution group, Ursodeoxycholic acid group and Tropifexor group. Experimental obstructive jaundice was created in all groups, except the sham one. In the blood samples obtained, aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), total bilirubin and direct bilirubin levels were established and recorded. Additionally, liver malondialdehyde, myeloperoxidase and catalase enzyme activity in the tissue samples were studied. Histopathological analysis was also performed.

Results:

No statistical difference was found between the control group and the Tropifexor group when AST, ALT and ALP values were compared. However, it was found that the Tropifexor group had statistically significant decreases in the values of GGT, total bilirubin and direct bilirubin (p < 0.05). Additionally, Tropifexor decreased the median values of malondialdehyde and myeloperoxidase, but this difference was not statistically significant compared to the control group. Finally, the Tropifexor group was statistically significant in recurring histopathological liver damage indicators (p < 0.05).

Conclusions:

Tropifexor reduced liver damage due to obstructive jaundice.

Palliative Biliary Drainage Has No Effect on Survival in Pancreatic Cancer: Medical Oncology Perspective

PURPOSE

Removal of obstructive jaundice in metastatic pancreatic cancer is an important part of palliative therapy. However, it is not known whether invasive procedures reduce cancer-related mortality. In this study, the effect of palliative biliary drainage on survival outcomes in pancreatic cancer patients was evaluated.

METHODS

Patients diagnosed with pancreatic cancer and undergoing biliary drainage in two different centers between 2010 and 2019 were evaluated retrospectively.

RESULTS

Biliary drainage was applied to 73 patients, constituting 20.6% of 355 patients included in the study. The median progression-free survival (PFS) of patients with biliary stent was 5 months, while the median PFS of patients without stenting was 5.5 months and the median overall survival (OS) was 11.1 and 11.5 months, respectively (p: 0.424, p: 0.802).

CONCLUSIONS

A positive effect of palliative biliary drainage on median PFS and OS could not be demonstrated in our study group. In pancreatic cancer, predictive markers are needed to select patients who can derive a survival benefit from biliary drainage.

HMGB1: An overview of its roles in the pathogenesis of liver disease

High-mobility group box 1 (HMGB1) is an abundant architectural chromosomal protein that has multiple biologic functions: gene transcription, DNA replication, DNA-damage repair, and cell signaling for inflammation. HMGB1 can be released passively by necrotic cells or secreted actively by activated immune cells into the extracellular milieu after injury. Extracellular HMGB1 acts as a damage-associated molecular pattern to initiate the innate inflammatory response to infection and injury by communicating with neighboring cells through binding to specific cell-surface receptors, including Toll-like receptors (TLRs) and the receptor for advanced glycation end products (RAGE). Numerous studies have suggested HMGB1 to act as a key protein mediating the pathogenesis of chronic and acute liver diseases, including nonalcoholic fatty liver disease, hepatocellular carcinoma, and hepatic ischemia/reperfusion injury. Here, we provide a detailed review that focuses on the role of HMGB1 and HMGB1-mediated inflammatory signaling pathways in the pathogenesis of liver diseases.

Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

The pathogenesis of renal injury in obstructive jaundice: A review of underlying mechanisms, inducible agents and therapeutic strategies

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.

Defining the Safety Profile for Performing Pancreatoduodenectomy in the Setting of Hyperbilirubinemia

BACKGROUND

Hyperbilirubinemia is commonly observed in patients requiring pancreatoduodenectomy (PD). Thus far, literature regarding the danger of operating in the setting of hyperbilirubinemia is equivocal. What remains undefined is at what specific level of bilirubin there is an adverse safety profile for undergoing PD. The aim of this study is to identify the optimal safety profile of patients with hyperbilirubinemia undergoing PD.

PATIENTS AND METHODS

The present work analyzed 803 PDs from 2004 to 2018. A generalized additive model was used to determine cutoff values of total serum bilirubin (TB) that were associated with increases in adverse outcomes, including 90-day mortality. Subgroup comparisons and biliary stent-specific analyses were performed for patients with TB below and above the cutoff.

RESULTS

TB of 13 mg/dL was associated with an increase in 90-day mortality (P = 0.043) and was the dominant risk factor on multivariate logistic regression [odds ratio (OR) 8.193, P = 0.001]. Increased TB levels were also associated with reoperations, number of complications per patient, and length of stay. Patients with TB greater than or equal to 13 mg/dL (TB ≥ 13) who received successful biliary decompression through stenting had less combined death and serious morbidity (P = 0.048).

CONCLUSIONS

Preoperative TB ≥ 13 mg/dL was associated with increased 90-day mortality after PD. Reducing a TB ≥ 13 is generally recommended before proceeding to surgery.

Dexmedetomidine activates the PI3K/Akt pathway to inhibit hepatocyte apoptosis in rats with obstructive jaundice

Obstructive jaundice (OJ) is a common disease in clinical surgery. The present study aimed to determine the effects of dexmedetomidine (Dex) on hepatocyte apoptosis in rats with OJ and also to explore the underlying mechanism. A total of 30 adult male Sprague Dawley rats were randomly divided into 3 groups: Sham group, bile duct ligation (BDL) group, and BDL+Dex group. The serum liver function index, expression levels of serum inflammatory factor interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), and the liver pathological changes were compared amongst groups. The serum liver function index and expression levels of inflammatory factors in the BDL group and BDL+Dex group were higher compared with the sham group. The serum liver function index and expression levels of inflammatory factors were lower in the BDL+Dex group compared with the BDL group. The severity of hepatic injury was diminished in the BDL+Dex group compared with the BDL group. Compared with the sham group, the hepatocyte apoptosis rate increased significantly in the BDL group and BDL+Dex group. The present findings suggested that Dex improved the liver function of rats with OJ, reduced the production of inflammatory factors and inhibited the apoptosis of hepatocytes. Dex demonstrated a protective effect on liver damage potentially via activation of the phosphoinositide 3-kinase/protein kinase B signaling pathway.

Effect of clinical signs, endocrinopathies, timing of surgery, hyperlipidemia, and hyperbilirubinemia on outcome in dogs with gallbladder mucocele

Gallbladder mucocele (GBM) is a common extra-hepatic biliary syndrome in dogs with death rates ranging from 7 to 45%. Therefore, the aim of this study was to identify the association of survival with variables that could be utilized to improve clinical decisions. A total of 1194 dogs with a gross and histopathological diagnosis of GBM were included from 41 veterinary referral hospitals in this retrospective study. Dogs with GBM that demonstrated abnormal clinical signs had significantly greater odds of death than subclinical dogs in a univariable analysis (OR, 4.2; 95% CI, 2.14-8.23; P<0.001). The multivariable model indicated that categorical variables including owner recognition of jaundice (OR, 2.12; 95% CI, 1.19-3.77; P=0.011), concurrent hyperadrenocorticism (OR 1.94; 95% CI, 1.08-3.47; P=0.026), and Pomeranian breed (OR, 2.46; 95% CI 1.10-5.50; P=0.029) were associated with increased odds of death, and vomiting was associated with decreased odds of death (OR, 0.48; 95% CI, 0.30-0.72; P=0.001). Continuous variables in the multivariable model, total serum/plasma bilirubin concentration (OR, 1.03; 95% CI, 1.01-1.04; P<0.001) and age (OR, 1.17; 95% CI, 1.08-1.26; P<0.001), were associated with increased odds of death. The clinical utility of total serum/plasma bilirubin concentration as a biomarker to predict death was poor with a sensitivity of 0.61 (95% CI, 0.54-0.69) and a specificity of 0.63 (95% CI, 0.59-0.66). This study identified several prognostic variables in dogs with GBM including total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, and the Pomeranian breed. The presence of hypothyroidism or diabetes mellitus did not impact outcome in this study.

Relevance of Preoperative Hyperbilirubinemia in Patients Undergoing Hepatobiliary Resection for Hilar Cholangiocarcinoma

Preoperative hyperbilirubinemia is known to increase the risk of mortality and morbidity in patients undergoing resection for hilar cholangiocarcinoma. The aim of this study was to characterize the associations between the preoperative bilirubin concentration and the risk of postoperative mortality and severe complications to guide decision-making regarding preoperative biliary drainage. Eighty-one patients undergoing liver and bile duct resection for hilar cholangiocarcinoma between 2005 and 2015 were analyzed retrospectively. Postoperative mortality and severe complications, defined as a Clavien⁻Dindo grade of ≥III, were the primary and secondary outcome measures, respectively. The severe postoperative complications and mortality rates were 28.4% (23/81) and 11.1% (9/81), respectively. Patients with preoperative biliary drainage had significantly lower bilirubin concentrations (p = 0.028) than did those without. The preoperative bilirubin concentration was a risk factor of postoperative mortality (p = 0.003), with an optimal cut-off of 6.20 mg/dL (c-statistic = 0.829). The preoperative bilirubin concentration was a risk factor of severe morbidity (p = 0.018), with an optimal cut-off of 2.48 mg/dL (c-statistic = 0.662). These results indicate that preoperative hyperbilirubinemia is a major risk factor of negative early postoperative outcomes of patients who undergo surgical treatment for hilar cholangiocarcinoma and may aid in decision-making with respect to preoperative biliary drainage.

[Outcomes of minimally invasive biliary decompression in obstructive jaundice]

AIM

To study postoperative complications and mortality after minimally invasive biliary decompression in patients with mechanical jaundice.

MATERIAL AND METHODS

Prospective analysis included 2.072 patients with mechanical jaundice who underwent differential biliary decompression depending on the cause, level of obstruction, severity of jaundice and patient's condition.

RESULTS

Relief of bilirubinemia and stabilization of the state were achieved in 1696 patients of the main group (98,6%) and in 328 (93.18%) patients of the control group. Mortality was similar in both groups: 8 (0.46%) and 2 (0.56%) patients. The best results were obtained in the main group for in-hospital and post-hospital complications after retrograde interventions (χ²=4.440821; df=0.891435; p<0.05) and post-hospital complications after antegrade interventions (χ²=35.52869; df= 1; p<0.05).

CONCLUSION

Differentiated approach to minimally invasive biliary decompression is followed by reduced postoperative morbidity.

Pathophysiological consequences of obstructive jaundice and perioperative management

BACKGROUND

Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management.

DATA SOURCES

A PubMed was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated.

RESULTS

The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier, the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production (TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders, nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.

CONCLUSION

The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.

Altered expression of differential gene and lncRNA in the lower thoracic spinal cord on different time courses of experimental obstructive jaundice model accompanied with altered peripheral nociception in rats

The spinal origin of jaundice-induced altered peripheral nociceptive response poorly understood. In the current study, we aimed to first validate rats with bile duct ligation (BDL) as a jaundice model accompanied by altered peripheral nociceptive response, and then to analyze differential gene and lncRNA expression patterns in the lower thoracic spinal cord on different time courses after BDL operation by using high-throughput RNA sequencing. The differentially expressed genes (DEGs) identified using reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis, followed by clustering analysis, Gene Ontology analysis and pathway analysis. As a result, a total of 2033 lncRNAs were differentially expressed 28d after BDL, in which 1545 probe sets were up-regulated and 488 probe sets were down-regulated, whereas a total of 2800 mRNAs were differentially expressed, in which 1548 probe sets were up-regulated and 1252 probe sets were down-regulated. The RNAseq data of select mRNAs and lncRNAs was validated by RT-qPCR. 28d after BDL, the expressions of lncRNA NONRATT002335 and NONRATT018085 were significantly up-regulated whereas the expression of lncRNA NONRATT025415, NONRATT025388 and NONRATT025409 was significantly down-regulated. 14d after BDL, the expressions of lncRNA NONRATT002335 and NONRATT018085 were significantly up-regulated; the expression of lncRNA NONRATT025415, NONRATT025388 and NONRATT025409 was significantly down-regulated. In conclusion, the present study showed that jaundice accompanied with decreased peripheral nociception involved in the changes of gene and lncRNA expression profiles in spinal cord. These findings extend current understanding of spinal mechanism for obstructive jaundice accompanied by decreased peripheral nociception.

Prognostic value of inflammation-based markers in patients with recurrent malignant obstructive jaundice treated by reimplantation of biliary metal stents: A retrospective observational study

We aimed to assess the therapeutic effect of reimplantation of biliary metal stents by percutaneous transhepatic cholangial drainage (PTCD) in patients with recurrent malignant obstructive jaundice (MOJ). Furthermore, we explored the prognostic value of inflammation-based markers in these patients.We reviewed 33 cases of recurrent MOJ after implantation of biliary metal stents by PTCD, all of which underwent reimplantation of stents under digital subtraction angiography guidance. Levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin were compared between before and after reimplantation (1 week, 1 month, and 3 months postoperatively). Preoperative clinical data were collected to calculate the inflammation-based markers, including systemic immune-inflammation index (SII, neutrophil × platelets/ lymphocyte), platelets-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and monocyte-to-lymphocyte ratio (MLR). The primary outcome was overall survival (OS), which was estimated by the Kaplan-Meier method and Cox regression analysis.The levels of ALT, AST, total bilirubin, and direct bilirubin significantly reduced after the reimplantation operation. During a median follow-up time of 10 months, 18 (54.5%) patients died. Gender, albumin, SII, PLR, NLR, and MLR were found to be associated with OS by the log-rank test and univariate analysis. Multivariate Cox analysis identified elevated levels of SII and PLR as significant factors for predicting poor OS.Reimplantation is clinically feasible in patients with recurrent MOJ after implantation of biliary metal stents. SII and PLR are independent, useful inflammation-based prognostic models for predicting outcomes in these patients.

Choosing the appropriate strategy in managing malignant biliary obstruction

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) have shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, EUS guided biliary drainage, percutaneous transhepatic biliary drainage or surgical treatments are appropriate.

Bilirubin modulates acetylcholine receptors in rat superior cervical ganglionic neurons in a bidirectional manner

Autonomic dysfunction as a partial contributing factor to cardiovascular instability in jaundiced patients is often associated with increased serum bilirubin levels. Whether increased serum bilirubin levels could directly inhibit sympathetic ganglion transmission by blocking neuronal nicotinic acetylcholine receptors (nAChRs) remains to be elucidated. Conventional patch-clamp recordings were used to study the effect of bilirubin on nAChRs currents from enzymatically dissociated rat superior cervical ganglia (SCG) neurons. The results showed that low concnetrations (0.5 and 2 μM) of bilirubin enhanced the peak ACh-evoked currents, while high concentrations (3 to 5.5 µM) of bilirubin suppressed the currents with an IC₅₀ of 4 ± 0.5 μM. In addition, bilirubin decreased the extent of desensitization of nAChRs in a concentration-dependent manner. This inhibitory effect of bilirubin on nAChRs channel currents was non-competitive and voltage independent. Bilirubin partly improved the inhibitory effect of forskolin on ACh-induced currents without affecting the action of H-89. These data suggest that the dual effects of enhancement and suppression of bilirubin on nAChR function may be ascribed to the action mechanism of positive allosteric modulation and direct blockade. Thus, suppression of sympathetic ganglionic transmission through postganglionic nAChRs inhibition may partially contribute to the adverse cardiovascular effects in jaundiced patients.