Inflammatory response in patients with malignant obstructive jaundice

Preoperative controlling nutritional status score predicts systemic disease recurrence in patients with resectable biliary tract cancer

INTRODUCTION

This study aimed to evaluate the association between the preoperative Controlling Nutritional Status (CONUT) score, survival outcomes, and recurrence pattern in patients with resectable biliary tract cancer (BTC).

METHODS

A total of 224 BTC patients (gallbladder, n = 69; intrahepatic bile ducts, n = 26; perihilar bile ducts, n = 72; distal bile duct, n = 57) who underwent surgery with curative intent were enrolled. The best cutoff point of the preoperative CONUT score in discriminating survival was determined using χ² scores. The sites of recurrence were subclassified as locoregional or distant.

RESULTS

Patients were subdivided into the CONUT-low (score ≤ 3, n = 156) and the CONUT-high (score > 3; n = 68) groups. In-hospital mortality occurred more frequently in the CONUT-high group than in the CONUT-low group (7.4% vs. 1.3%; p = 0.028). A high preoperative CONUT score was independently associated with worse overall survival (hazard ratio [HR] 1.906, p = 0.001), worse disease-specific survival (HR 1.840, p = 0.006), and worse recurrence-free survival (HR 1.680, p = 0.005). Recurrence developed in 110 (49.1%) patients. A high preoperative CONUT score was independently associated with a higher risk of distant recurrence (HR 2.245, p = 0.001), but not locoregional recurrence. The incidences of distant recurrence at 5 years were 55.4% and 34.2% in the CONUT-high and CONUT-low groups, respectively (p = 0.001).

CONCLUSIONS

The preoperative CONUT score independently predicts survival outcomes and may serve as a surrogate marker of aggressive systemic disease recurrence in patients with resectable BTC.

Human skin dermis-derived fibroblasts are a kind of functional mesenchymal stromal cells: judgements from surface markers, biological characteristics, to therapeutic efficacy

Background

Human mesenchymal stromal cells (MSCs) have been widely advocated to clinical use. Human skin dermis-derived fibroblasts shared similar cellular morphology and biological characteristics to MSCs, while it still keeps elusive whether fibroblasts are functionally equivalent to MSCs for therapeutic use.

Methods

We isolated various fibroblasts derived from human foreskins (HFFs) and human double-fold eyelids (HDF) and MSCs derived from human umbilical cords (UC-MSCs), and then comprehensively investigated their similarities and differences in morphology, surface markers, immunoregulation, multilineage differentiation, transcriptome sequencing, and metabolomics, and therapeutic efficacies in treating 2,4,6-Trinitrobenzenesulfonic acid (TNBS) induced colitis and carbontetrachloride (CCL4) induced liver fibrosis.

Results

Fibroblasts and UC-MSCs shared similar surface markers, strong multilineage differentiation capacity, ability of inhibiting Th1/Th17 differentiation and promoting Treg differentiation in vitro, great similarities in mRNA expression profile and metabolites, and nearly equivalent therapeutic efficacy on TNBS-induced colitis and CCL4-induced hepatic fibrosis.

Conclusion

Human skin dermis-derived fibroblasts were a kind of functional MSCs with functionally equivalent therapeutic efficacy in treating specific complications, indicating fibroblasts potentially had the same lineage hierarchy of origin as MSCs and had a remarkable potential as an alternative to MSCs in the treatment of a variety of diseases.

Analysis of the Bacterial Spectrum and Key Clinical Factors of Biliary Tract Infection in Patients with Malignant Obstructive Jaundice after PTCD

Objective

To analyze the bacterial spectrum and key clinical factors associated with biliary tract infections following percutaneous transhepatic cholangial drainage (PTCD) for malignant obstructive jaundice (MOJ).

Methods

This retrospective study comprised patients with MOJ who were treated with PTCD from 1^st June 2016 to 31^st December 2020. Patient clinical data, development of postprocedure biliary tract infections, spectrum of pathogenic bacteria, and drug sensitivity were analyzed, focusing on antibiotic drug resistance and identifying key associated risk factors for postoperative biliary tract infections.

Results

Of the 528 study patients, 80 were diagnosed with postoperative biliary tract infections, 58 of whom had pathogenic bacteria detected in their bile samples. A total of 90 strains of pathogenic bacteria and 3 strains of fungi were detected; the top 4 were Escherichia coli, Klebsiella pneumoniae, Enterococcus faecium, and Pseudomonas aeruginosa. By univariate analysis, a positive bile culture following PTCD was closely correlated with both the location and degree of preoperative obstruction and the preoperative bilirubin level. Moreover, the results of logistic regression analysis concluded that complete obstruction and a high preoperative total bilirubin level prior to PTCD were independent risk factors for a positive bile culture following PTCD.

Conclusion

Biliary tract infections following PTCD for MOJ were principally due to Escherichia coli, and bacteria in the bile were statistically more likely to be detected in patients with complete obstruction and high preoperative bilirubin levels.

Vater's ampullary carcinoma increases the risk of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is a frequent complication after pancreaticoduodenectomy (PD). This study aimed to investigate the impact of Vater's ampullary carcinoma (VAC) on clinically relevant POPF (CR-POPF) in patients undergoing PD.

METHODS

Clinical data were gathered retrospectively from January 2018 to December 2020 for all patients undergoing PD. The univariate and multivariate analysis were used to identify independent risk factors of CR-POPF. A propensity score-matched (PSM) analysis at a ratio of 1:1 was performed to minimize bias from baseline characteristics between VAC and non-VAC groups. Main postoperative complications were compared between the two groups after PSM.

RESULTS

In 263 patients, 94 (35.7%) patients were diagnosed as VAC. CR-POPF occurred in 99 (37.6%) patients and VAC was identified as an independent risk factor of CR-POPF in multivariate logistic regression analysis (OR = 0.548, 95% CI = 0.327-0.920, P = 0.023). After PSM, there were similar baseline characteristics between the VAC and non-VAC group. Moreover, VAC group had a higher rate of CR-POPF (P = 0.025) and intra-abdominal infection (P = 0.015) compared to the non-VAC group.

CONCLUSIONS

In patients undergoing PD, VAC increases the risk of CR-POPF and several other postoperative complications.

Retrospective analysis of T-lymphocyte subsets and cytokines in malignant obstructive jaundice before and after external and internal biliary drainage

Objective

To study changes in T lymphocyte subsets, cytokines, and liver enzymes in patients with malignant obstructive jaundice (MOJ) before and after external biliary drainage (percutaneous transhepatic cholangiography drainage, PTCD) and internal biliary drainage (percutaneous transhepatic insertion of biliary stents, PTIBS).

Methods

MOJ patients undergoing PTCD (n = 44) and PTIBS (n = 38) at our hospital were enrolled in the study from January 2017 until December 2019. Peripheral blood total bilirubin (TBIL), direct bilirubin (DBIL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), CD3⁺%, CD4⁺%, CD4⁺/CD8⁺ ratio, interleukin (IL)-2, IL-6, and tumor necrosis factor (TNF)-α were measured before and 1 week after biliary drainage.

Results

There was no significant difference in any parameter between the two groups before biliary drainage. TBIL, DBIL, AST and ALT following PTCD were significantly lower than before PTCD. By contrast, CD3⁺%, CD4⁺%, CD4⁺/CD8⁺ ratio, IL-2, IL-6 and TNF-α showed no significant difference before and 1 week after PTCD. TBIL, DBIL, AST, ALT, IL-6 and TNF-α were significantly lower following PTIBS than before PTIBS. CD3⁺%, CD4⁺%, CD4⁺/CD8⁺ ratio and IL-2 were significantly higher following PTIBS than before PTIBS.

Conclusion

Both PTCD and PTIBS were effective for treatment of MOJ, but PTIBS was more beneficial for recovery of immune function.

Effect of postoperative early enteral nutrition on clinical outcomes and immune function of cholangiocarcinoma patients with malignant obstructive jaundice

BACKGROUND

Most cholangiocarcinoma patients with malignant obstructive jaundice (MOJ) have varying degrees of malnutrition and immunodeficiency preoperatively. Therefore, perioperative nutritional support has important clinical significance in the treatment of cholangiocarcinoma.

AIM

To investigate the effects of postoperative early enteral nutrition (EEN) on immunity function and clinical outcomes of cholangiocarcinoma patients with MOJ.

METHODS

This prospective clinical study included 60 cholangiocarcinoma patients with MOJ who underwent surgery. The patients were randomly divided into an experimental group and a control group according to the nutrition support modes. The control group received postoperative total parenteral nutrition (TPN), whereas the experimental group received postoperative EEN and parenteral nutrition (PN; EEN + PN). The clinical outcomes, postoperative immune function, incidences of surgical site infection and bile leakage, intestinal function recovery time, average hospitalization days, and hospitalization expenses of the two groups were assessed on postoperative days (PODs) 1, 3, and 7.

RESULTS

The CD3+T, CD4+T, CD8+T, and CD4+T/CD8+T cell count and the immunoglobulin (Ig) G, IgM, and IgA levels in the EEN + PN group were significantly higher than those in the TPN group on PODs 3 and 7 (P < 0.05), whereas no significant differences in the CD3+T, CD4+T, CD8+T, and CD4+T/CD8+T cell counts and IgG, IgM, and IgA levels before operation and on POD 1 were found between the two groups (P > 0.05). The intestinal function recovery time and postoperative hospital stay were shorter (P < 0.001 for both) in the EEN + PN group than in the TPN group. The hospitalization expenses of the EEN + PN group were lower than those of the TPN group (P < 0.001). However, the incidence of abdominal distension was higher than in the EEN + PN group than in the TPN group (P < 0.05). The incidence rates of biliary leakage and surgical site infection were not significantly different between the two groups (P > 0.05).

CONCLUSION

A postoperative EEN program could reduce the incidence of postoperative complications and improve the clinical outcomes and immune functions of cholangiocarcinoma patients with MOJ and is thus beneficial to patient recovery.

Pretreatment C-reactive protein/albumin ratio for predicting overall survival in pancreatic cancer: A meta-analysis

BACKGROUND

Inconsistent findings have been reported regarding the association of C-reactive protein to albumin ratio (CAR) with survival outcome in patients with pancreatic cancer. We conducted the current meta-analysis to assess the prognostic utility of elevated baseline CAR in predicting overall survival (OS) in pancreatic cancer patients.

METHODS

A comprehensively literature search was performed in the PubMed and Embase database until February 10, 2019. Studies evaluating the association between pretreatment CAR and OS among pancreatic cancer were selected. Study quality was evaluated by using the Newcastle-Ottawa Scale.

RESULTS

Nine retrospective studies involving 1534 pancreatic cancer patients were identified. A meta-analysis using a random-effect model indicated that elevated CAR was associated with poor OS (hazard ratio 1.98; 95% confidence interval 1.58-2.48). Subgroup analysis produced similar prognostic values for OS in different geographical regions, sample sizes, thresholds of CAR, treating methods, and Newcastle-Ottawa Scale points.

CONCLUSION

Elevated pretreatment CAR may independently predict poor OS in pancreatic cancer patients. Pretreatment CAR is possibly a simple and cost-effective blood-derived indicator for predicting survival outcome in patients with pancreatic cancer.

Internal drainage versus external drainage in palliation of malignant biliary obstruction: a meta-analysis and systematic review

INTRODUCTION

Preoperative biliary drainage has been widely used to treat patients with malignant biliary obstruction. However, it is still unclear which method is more effective: internal drainage or external drainage. Thus, we carried out a meta-analysis to compare the safety and efficacy of the two drainage methods in treatment of malignant biliary obstruction in terms of preoperative and postoperative complications.

MATERIAL AND METHODS

We conducted a literature search of Medline, EMBASE, PubMed, Ovid journals and the Cochrane Library, and compared internal drainage and external drainage in malignant biliary obstruction patients. The pre- and postoperative complications, stent dysfunction rate and mortality were analyzed.

RESULTS

Ten published studies (n = 1464 patients) were included in this meta-analysis. We found that patients with malignant biliary obstruction who received external drainage showed reductions in the preoperative cholangitis rate (OR = 0.33, 95% CI: 0.24-0.44, p < 0.00001), the incidence of stent dysfunction (OR = 0.41, 95% CI: 0.30-0.57, p < 0.00001), and total morbidity (OR = 0.34, 95% CI: 0.23-0.50, p < 0.00001) compared with patients who received internal drainage.

CONCLUSIONS

The current meta-analysis indicates that external drainage is better than internal drainage for malignant biliary obstruction in terms of the preoperative cholangitis rate, the incidence of stent dysfunction and total morbidity, etc. However, the findings need to be confirmed by randomized controlled trials.

Retrograde installation of percutaneous transhepatic negative-pressure biliary drainage stabilizes pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective cohort study

BACKGROUND

Leakage from the pancreatoenteric anastomosis has been one of the major complications of pancreaticoduodenectomy (PD). The aim of this study was to investigate the feasibility of retrograde installation of percutaneous transhepatic negative-pressure biliary drainage (RPTNBD), as part of which the drainage tube is intraoperatively inserted into the bile duct and afferent loop by surgical guidance to reduce pancreaticoenteric leakage after PD.

METHODS

We retrospectively reviewed the medical records of the patients who underwent pylorus-preserving PD or Whipple's operation for a malignant disease between June 2012 and August 2016. We performed intraoperative RPTNBD to decompress the biliopancreatic limb in all patients and compared their clinical outcomes with those of internal controls.

RESULTS

Twenty-one patients were enrolled in this study. The operation time was 412.0 ± 92.8 min (range, 240-600 min). The duration of postoperative hospital stay was 39.4 ± 26.4 days (range, 13-105 days). Ten patients (47.6%) experienced morbidities of Clavien-Dindo grade > II, and 2 patients (9.5%) experienced pancreaticojejunostomy-related complications. The internal controls showed a higher incidence rate of pancreaticojejunostomy-related complications than the study participants (P = 0.020). Mortality occurred only in the internal controls.

CONCLUSION

For stabilizing the pancreaticoenteric anastomosis after PD for a malignant disease, RPTNBD is a feasible and effective procedure. When PD is combined with technically demanding procedures, including hepatectomy or vascular reconstruction, RPTNBD could prevent fulminant anastomotic failure.

Increased Intestinal Permeability and Decreased Barrier Function: Does It Really Influence the Risk of Inflammation?

Background

Increased intestinal permeability due to barrier dysfunction is supposed to cause microbial translocation which may induce low-grade inflammation in various diseases. However, this series of events has not been comprehensively evaluated yet.

Summary

Intestinal epithelial barrier dysfunction and increased permeability have been described in patients with inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), alcoholic liver disease, nonalcoholic steatohepatitis (NASH), liver cirrhosis, acute pancreatitis, primary biliary cholangitis (PBC), type 1 and type 2 diabetes, chronic kidney disease, chronic heart failure (CHF), depression, and other diseases. Most clinical reports used either permeability assays of challenge tests or measurement of circulating bacterial markers like endotoxin for assessment of 'the leaky gut'. The intestinal permeability assessed by the challenge tests has often been related to the changes of tight junction proteins in the epithelium or circulating endotoxin levels. In patients with IBD, alcoholic liver disease, NASH, liver cirrhosis, PBC, obstructive jaundice, severe acute pancreatitis, and CHF, endotoxemia and proinflammatory cytokinemia have been found in addition to increased permeability. In the serum of patients with IBS and depression, antiflagellin antibodies and antilipid A antibodies were detected, respectively, together with increased permeability and proinflammatory cytokinemia. The site of infection, which is localized to the intestine in IBD and IBS, includes various extraintestinal organs in other diseases. The relation of gut dysbiosis to intestinal barrier dysfunction has gradually been clarified.

Key Messages

Although no direct cause-and-effect relationship has been confirmed, all clinical and experimental data suggest the importance of intestinal hyperpermeability in the inflammatory changes of various diseases. Increased intestinal permeability is a new target for disease prevention and therapy. Considering the close relationship of 'the leaky gut' and gut dysbiosis to the major diseases, we can conclude that meticulous dietetic and probiotic approaches to recover healthy microbiota have the potential to make a breakthrough in the management of these diseases tomorrow.

Increased Intestinal Permeability and Decreased Barrier Function: Does It Really Influence the Risk of Inflammation?

Background

Increased intestinal permeability due to barrier dysfunction is supposed to cause microbial translocation which may induce low-grade inflammation in various diseases. However, this series of events has not been comprehensively evaluated yet.

Summary

Intestinal epithelial barrier dysfunction and increased permeability have been described in patients with inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), alcoholic liver disease, nonalcoholic steatohepatitis (NASH), liver cirrhosis, acute pancreatitis, primary biliary cholangitis (PBC), type 1 and type 2 diabetes, chronic kidney disease, chronic heart failure (CHF), depression, and other diseases. Most clinical reports used either permeability assays of challenge tests or measurement of circulating bacterial markers like endotoxin for assessment of 'the leaky gut'. The intestinal permeability assessed by the challenge tests has often been related to the changes of tight junction proteins in the epithelium or circulating endotoxin levels. In patients with IBD, alcoholic liver disease, NASH, liver cirrhosis, PBC, obstructive jaundice, severe acute pancreatitis, and CHF, endotoxemia and proinflammatory cytokinemia have been found in addition to increased permeability. In the serum of patients with IBS and depression, antiflagellin antibodies and antilipid A antibodies were detected, respectively, together with increased permeability and proinflammatory cytokinemia. The site of infection, which is localized to the intestine in IBD and IBS, includes various extraintestinal organs in other diseases. The relation of gut dysbiosis to intestinal barrier dysfunction has gradually been clarified.

Key Messages

Although no direct cause-and-effect relationship has been confirmed, all clinical and experimental data suggest the importance of intestinal hyperpermeability in the inflammatory changes of various diseases. Increased intestinal permeability is a new target for disease prevention and therapy. Considering the close relationship of 'the leaky gut' and gut dysbiosis to the major diseases, we can conclude that meticulous dietetic and probiotic approaches to recover healthy microbiota have the potential to make a breakthrough in the management of these diseases tomorrow.

Effect of glutamine enriched nutrition support on gut barrier of rats with obstructive jaundice: A Meta-analysis

AIM: To systematically assess the effect of glutamine enriched enteral nutrition support on the gut barrier of rats with obstructive jaundice (OJ).

METHODS: Databases including PubMed, Embase, High Wire and Cochrane Central Register of Controlled Trials were searched using keywords "glutamine", "obstructive jaundice". Literature published before November 2014 was searched. Randomized controlled trials comparing conventional treatment and glutamine enriched nutrition support were enrolled in the study, and then the literature was screened and the data were extracted by two independent reviewers. The quality of the literature was assessed, and the data were analyzed using the RevMan4.2 software. Count data were analyzed using relative risk (RR) and 95% confidence interval (95%CI), and measurement data were analyzed using standard mean difference (SMD) or weighted mean difference (WMD) and 95%CI. The heterogeneity of the data was analyzed using the I² test.

RESULTS: Eight articles including 152 cases were enrolled in the study, and all of them were prospective randomized controlled studies. There were 76 rats treated by conventional methods (control group) and 76 rats receiving glutamine enriched nutrition support (experimental group). Compared with the control group, glutamine enriched nutrition support could decrease the rates of bacterial translocation (BT) to mesenteric lymph nodes (MLNs), the liver, spleen and blood (RR = 0.34, 0.36, 0.38, 0.30, P < 0.05), and enhance the antioxidant capacity of the intestinal mucosa (WMD_MPO = -0.44, WMD_MDA = -57.87; 95%CI: -0.85--0.03, -104.14--11.60; P < 0.05), but could not significantly improve the liver dysfunction and intestinal villi.

CONCLUSION: Glutamine enriched nutrition support has a protective effect on intestinal barrier function in rats with OJ in terms of reducing BT effectively and enhancing the antioxidant capacity of the intestinal mucosa significantly.

Dexamethasone pretreatment attenuates lung and kidney injury in cholestatic rats induced by hepatic ischemia/reperfusion

Hepatic ischemia followed by reperfusion (IR) results in mild to severe organ injury, in which tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) seem to be involved. Thus, we aim to assess the influence of hepatic ischemia/reperfusion injury on remote organs in addition to cholestasis and consider the possible efficacy of steroid pretreatment in reducing the injury. A common bile duct ligation model was done on 24 male Sprague-Dawley rats. After 7 days, the rats were divided randomly into control group, IR group, and dexamethasone (DEX) group. The IR group showed significant increases in serum alanine aminotransferase, aspartate aminotransferase, and creatinine levels compared with the control and DEX groups. By ELISA techniques, higher levels of TNF-α and IL-1β in lung and kidney tissues were measured in the IR group than in the control and DEX groups, these were verified by immunohistochemistry. The lung histology of the IR group rats showed neutrophil infiltration, interstitial edema, and alveolar wall thickening. Kidney histology of the IR group rats showed vacuolization of the proximal tubular epithelial cells and tubular dilatation with granular eosinophilic casts. Better morphological aspects were observed in the DEX-pretreated animals. Minimal lesions were observed in the control. The results suggest that hepatic ischemia/reperfusion injury in cholestatic rats induced lung and kidney injuries. Pretreatment with dexamethasone reduced the IR-induced injury in addition to cholestasis.

Evaluation of the uptake function of liver in rats with obstructive jaundice before and after relief from obstruction by superparamagnetic iron oxide-enhanced magnetic resonance imaging

The aim of this study was to investigate the changes in the uptake function of the liver in rats with obstructive jaundice prior to and following relief from obstructive jaundice, and to investigate whether superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) could be used to assess liver uptake function. In total, 40 male Sprague Dawley rats were randomly assigned into four groups: Obstructive jaundice, internal drainage, external drainage and sham surgery. The common bile ducts in the obstructive jaundice group were ligated. Internal drainage (ID) and external drainage (ED) groups were ligated, followed by internal drainage or external drainage, respectively. The T2 and T2* values of the liver parenchyma were measured. Liver sections were stained with Perls' Prussian blue, and hematoxylin and eosin. The number of SPIO-nanoparticle clusters was counted manually using a microscope. Total bilirubin of the blood was measured. Results showed that the T2 and T2* values and total bilirubin of the obstructive jaundice group were significantly higher compared to the other three groups. The number of SPIO-nanoparticle clusters in the obstructive jaundice group was significantly lower compared to the other three groups. In conclusion, obstructive jaundice suppresses liver uptake function in rats, which may be reversed by internal and external biliary drainage. However, no significant difference was found between the therapeutic effect of ID and ED on liver uptake function. Thus, SPIO-enhanced MRI may be used to evaluate the uptake function of the liver.

What is appropriate procedure for preoperative biliary drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy?

PURPOSE

The aims of this study were to compare the clinical outcomes of the preoperative drainage methods in patients with obstructive jaundice awaiting panreaticoduodenectomy and to determine, which procedure would be more effective for preoperative drainage.

METHODS

Among 239 patients undergoing pancreaticoduodenectomy for periampullary cancer, 77 with obstructive jaundice underwent percutaneous transhepatic biliary drainage (PTBD, n=34) or endoscopic biliary drainage (EBD, n=43).

RESULTS

Median rate of decrease in bilirubin was 0.65 mg/d in PTBD group and 0.34 mg/d in EBD group (P=0.003). Median interval from preoperative drainage to pancreaticoduodenectomy were 11 days in PTBD group and 18 days in EBD group (P=0.009). Overall indwelling catheter-related complication rates were higher in "EBD" group compared with "PTBD" group (23.3% vs. 2.9%, P=0.019). No catheter occlusion developed in "PTBD" group, but 6 stent occlusions (13.3%) developed in "EBD" group (P=0.031). The mortality rate was not significantly different between the 2 groups.

CONCLUSIONS

Percutaneous biliary drainage may be preferred for preoperative drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy due to rapid biliary decompression and lower frequency of catheter-related complications.

Cytokine response to portal endotoxaemia and neutrophil stimulation in obstructive jaundice

INTRODUCTION

An exaggerated proinflammatory response to endotoxaemia can occur in obstructive jaundice. The aims of this study were to determine the hepatic proinflammatory and anti-inflammatory cytokine response to endotoxaemia in experimental biliary obstruction and to determine the source of interleukin-6 (IL-6) using immunohistochemistry.

METHODOLOGY

Male Wistar rats were randomized into three groups: bile duct ligation (BDL), sham operation, and control groups. They were weighed before surgery and after 1 week. On day 8, hepatic perfusion was performed with endotoxin (Escherichia coli 0111:B4). Serial samples of blood, effluent, and influent perfusate were analyzed for proinflammatory and anti-inflammatory cytokines. Ultrastructural assessment of sections of the liver was performed.

RESULTS

BDL animals lost weight in the first week compared with the sham and the control animals that gained weight. Liver function tests were elevated in the BDL group. Effluent biochemistry did not reveal liver injury as a result of perfusion. Ultrastructurally, there was no evidence of liver injury, with only active Kupffer cells, preservation of liver architecture, and minimal liver injury being detected. Serum tumor necrosis factor-α was not detected in any group before perfusion; however, serum IL-6 was higher in the BDL group. Portal endotoxaemia resulted in an increase in tumor necrosis factor-α, IL-6, and IL-10 in the BDL group. Fluorescence immunohistochemistry demonstrated IL-6 in the sinusoidal spaces and the cytoplasm of Kupffer cells.

CONCLUSION

There is an exaggerated proinflammatory and anti-inflammatory cytokine response to portal endotoxaemia in animals with jaundice compared with the sham group.

Effect of preoperative biliary drainage on malignant obstructive jaundice: A meta-analysis

AIM: To evaluate the effect of preoperative biliary drainage (PBD) on obstructive jaundice resulting from malignant tumors.

METHODS: According to the requirements of Cochrane systematic review, studies in the English language were retrieved from MEDLINE and Embase databases from 1995 to 2009 with the key word “preoperative biliary drainage”. Two reviewers independently screened the eligible studies, evaluated their academic level and extracted the data from the eligible studies confirmed by cross-checking. Data about patients with and without PBD after resection of malignant tumors were processed for meta-analysis using the Stata 9.2 software, including postoperative mortality, incidence of postoperative pancreatic and bile leakage, abdominal abscess, delayed gastric emptying and incision infection.

RESULTS: Fourteen retrospective cohort studies involving 1826 patients with malignant obstructive jaundice accorded with our inclusion criteria, and were included in meta-analysis. Their baseline characteristics were comparable in all the studies. No significant difference was found in combined risk ratio (RR) of postoperative mortality and incidence of pancreatic and bile leakage, abdominal abscess, delayed gastric emptying between patients with and without PBD. However, the combined RR for the incidence of postoperative incision infection was improved better in patients with PBD than in those without PBD (P < 0.05).

CONCLUSION: PBD cannot significantly reduce the postoperative mortality and complications of malignant obstructive jaundice, and therefore should not be used as a preoperative routine procedure for malignant obstructive jaundice.

Effects of glutamine and curcumin on bacterial translocation in jaundiced rats

AIM: To investigate the effect of curcumin on bacterial translocation and oxidative damage in an obstructive jaundice model and compare the results to glutamine, an agent known to be effective and clinically used.

METHODS: Twenty-four female Wistar-Albino rats, weighing 200-250 g, were randomly divided into three groups (8 in each group). After ligation of the common bile duct in all animals, Group I received oral normal saline, Group II received oral glutamine and Group III received oral curcumin for seven days. Blood samples via cardiac puncture, tissue samples (terminal ileum, liver and mesenteric lymph node) and peritoneal fluid were obtained from the animals at the time of death to investigate bacterial translocation and oxidative damage.

RESULTS: We observed that both glutamine and curcumin reduced bacterial translocation in blood, hepatocellular damage, plasma cytokine levels, oxidative tissue damage and apoptosis significantly compared to the control group. Additionally, glutamine showed protective effects on ileal epithelium and reduced villus atrophy.

CONCLUSION: On the basis of these findings, both curcumin and glutamine are thought to be effective in preventing or reducing bacterial translocation and oxidative damage in obstructive jaundice.

Evidence for tight junction protein disruption in intestinal mucosa of malignant obstructive jaundice patients

OBJECTIVE

Experimental and clinical studies have shown that obstructive jaundice results in increased intestinal permeability. The mechanisms implicated in this phenomenon remain obscure. Integrated tight junctions (TJs) are essential for normal gut barrier function. TJ proteins, such as zonula occludens (ZO)-1, claudins and occludin, are indispensable to maintain the function of TJs. This study was undertaken to investigate whether TJ protein disruption occurs in the intestinal mucosa of malignant obstructive jaundice (MOJ) patients.

MATERIAL AND METHODS

Three groups were involved: Group A, MOJ patients whose bilirubin level was >or= 43 microM; Group B, MOJ patients without jaundice; and Group C, patients who underwent gastroscopy with negative findings (controls). Biopsy was done in all participants at the second part of the duodenum, distal to the ampulla of Vater. The morphological and ultrastructural changes of intestinal mucosa were observed. The distributions and expressions of the TJ proteins occludin, ZO-1, claudin-1 and claudin-4 in intestinal mucosa were evaluated by immunohistochemistry and Western blotting.

RESULTS

Histological examination showed a mild infiltration of the lamina propria by chronic inflammatory cells in Group A compared with Groups B and C. Duodenal architecture showed that the microvillus of Group A patients was loose, the structures of junctional complexes were disrupted and the gaps between cell junctions were wider. As shown by immunohistochemical staining and Western blotting, greatly reduced expressions of occludin, ZO-1 and claudin-1 protein were detected in Group A, whereas claudin-4 expression was significantly increased.

CONCLUSIONS

TJs in MOJ patients with jaundice were disrupted in the intestinal epithelium, which may have resulted from the alterations in TJ-related protein expression. TJ interruption may be a key factor contributing to intestinal mucosal barrier injury and increased intestinal permeability.

Protective effects of Salvia miltiorrhizae on multiple organs of rats with obstructive jaundice

PURPOSE

we aim to explore the protective effects of Salvia miltiorrhizae injection on multiple organs of obstructive jaundice (OJ) rats through observing the impact of this injection on the pathological alterations in these organs and the contents of endotoxin, PLA(2), and TNF-alpha in the blood.

METHODS

A total of 90 mice were randomly divided into sham-operated group, model-control group, and Salvia miltiorrhizae-treated group (n = 30). According to the duration of postoperative administration, each group was further divided into two subgroups, namely, 21 d subgroup (consecutive administration for 21 d, n = 15) and 28 d subgroup (consecutive administration for 28 d, n = 15). After administration, the pathological alterations in multiple organs were observed and the contents of endotoxin, PLA(2), and TNF-alpha in the blood were determined.

RESULTS

Compared to model control group, the number of dead rats in treated group decreased though there was no statistical difference between the two groups. The pathological alterations in the liver, kidney, and spleen in treated group showed varying degrees of mitigation. At all time points, the contents of plasma endotoxin declined significantly. On day 28, plasma PLA(2) content in treated group was significantly lower than that in model-control group.

CONCLUSION

Salvia miltiorrhizae injection is able to obviously reduce the contents of inflammatory mediators in the blood of OJ rats and exert some protective effects on multiple organs of these rats.

Protective effect of Radix Astragali injection on immune organs of rats with obstructive jaundice and its mechanism

AIM: To observe the protective effect of Radix Astragali injection on immune organs (lymph nodes, spleen and thymus) of rats with obstructive jaundice (OJ) and its mechanism.

METHODS: SD rats were randomly divided into sham-operation group, model control group and Radix Astragali treatment group. On days 7, 14, 21 and 28 after operation, mortality rate of rats, pathological changes in immune organs, expression levels of Bax and nuclear factor (NF)-κB p65 proteins, apoptosis indexes and serum tumor necrosis factor (TNF)-α level in spleen and thymus were observed, respectively.

RESULTS: Compared to model control group, the number of dead OJ rats in Radix Astragali treatment group decreased (P > 0.05). The TNF-α level (27.62 ± 12.61 vs 29.55 ± 18.02, 24.61 ± 9.09 vs 31.52 ± 10.95) on days 7 and 21, the pathological severity score for spleen [0.0 (0.0) vs 0.0 (2.0) on days 7 and 14 and for lymph nodes [0.0 (1.0) vs 1.0 (2.0), 1.0 (0.0) vs 2.0 (1.0)] on days 21 and 28, the product staining intensity and positive rate of Bax protein in spleen [0.0 (0.0) vs 1.0 (2.0), 0.0 (1.0) vs 2.0 (1.5) and thymus [0.0 (0.0) vs 1.0 (2.0), 0.0 (1.0) vs 2.0 (1.5)] on days 14 and 28, the apoptotic indexes [0.0 (0.0) vs 0.0 (0.01)] in spleen and thymus [0.0 (0.0) vs 0.0 (0.01) on days 14 and 21 were significantly lower in Radix Astragali treatment group than in model control group (P < 0.05).

CONCLUSION: Radix Astragali has protective effects on immune organs of OJ rats by relieving the pathological changes in immune organs, reducing TNF-α level and inhibiting Bax expression and apoptosis in spleen and thymus.

Influence of rhGH on postoperative immune function of patients with obstructive jaundice

AIM: To observe the clinical significance and changes of cytoimmunity, humoral immunity and immune regulatory factors after the administration of rhGH on patients with obstructive jaundice (OJ).

METHODS: A prospective, randomized and controlled clinical study was performed, and 36 OJ cases were randomly divided into control group (A group, n = 18) and rhGH group (B group, n = 18). rhGH were added in group B. A dynamic investigation of cytoimmunity indices (CD3⁺, CD4⁺ and CD4⁺/CD8⁺), humoral immunity indices (IgA, IgG and IgM) and serum immune regulatory factors (IL-2, IL-6 and TNF-α) were conducted and mortality rate and complication rate of patients of two groups before therapy and at 1, 8 d after operation were evaluated.

RESULTS: Indexes of cytoimmunity indices (CD3⁺, CD4⁺ and CD4⁺/CD8⁺) in B group were obviously improved than A (42.32% ± 4.19% vs 31.51% ± 4.42%; 26.36% ± 4.25% vs 19.29% ± 4.27%; 1.22 ± 0.20 vs 0.95 ± 0.12, all P < 0.05). Humoral immunity indices (IgA, IgG and IgM) in B group were obviously improved than group A 8 days after treatment (2.42 ± 0.11 g/L vs 1.41 ± 013 g/L; 6.88 ± 0.18 g/L vs 4.89 ± 0.15 g/L; 1.84 ± 0.18 g/L vs 1.28 ± 0.24 g/L, all P < 0.05). Erum immune regulatory factors (IL-6 and TNF-α) were significantly decreased in B group (0.42 ± 0.11 mg/L vs 0.86 ± 0.10 mg/L; 11.04 ± 1.52 pmol/L vs 18.24 ± 1.22 pmol/L, both P < 0.05), IL-2 was obviously improved in group B (1.92 ± 0.15 mg/L vs 1.14 ± 0.12 mg/L, P < 0.05), and mortality rate and complication rate in group B were obviously lower than group A (22.22% vs 44.44%, 0.00% vs 5.56%, both P < 0.05).

CONCLUSION: RhGH has a direct immunoregulatory effect on patients with obstructive jaudice, which improves immunity of patients with obstructive jaundice and is good for their recovery.

Changes of serum cytokines and expression of inducible nitric oxide synthase mRNA by Kupffer cells after relief from obstructive jaundice in rats

AIMS

To investigate the changes of serum endotoxin, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and inducible nitric oxide synthase (iNOS) expression by Kupffer cells after relief of obstructive jaundice (OJ) by internal biliary drainage (ID) and external biliary drainage (ED) in rats.

MATERIALS AND METHODS

Forty eight adult Sprague Dawley rats were randomly assigned to four groups: OJ, ID, ED and sham operation (SH). Inducible nitric oxide synthase mRNA by the Kupffer cells was detected by reverse transcription polymerase chain reaction. The serum TNF-alpha and IL-6 were measured by enzyme linked immunosorbent assay and endotoxin by kinetic turbidimetric limulus tests.

RESULTS

Serum endotoxin, IL-6 and TNF-alpha levels were significantly elevated in OJ rats compared to that of SH rats (P < 0.01). After relief from OJ, the elevated endotoxin, IL-6 and TNF-alpha levels could be significantly depressed by ID (P < 0.01). However, the serum IL-6 level was increased in ED rats (P < 0.05) and the TNF-alpha level was not depressed by ED. Expression of iNOS mRNA by Kupffer cells was markedly stronger in the OJ group than in the SH group (P = 0.005). After relief from OJ, the iNOS mRNA expression was suppressed by ID (P = 0.139, ID vs OJ). However, the iNOS mRNA expression was promoted by ED (P = 0.321 ED vs OJ; P = 0.016 ED vs SH).

CONCLUSIONS

The levels of serum endotoxin, TNF-alpha and IL-6 and the expression of iNOS mRNA by Kupffer cells were increased in rats with obstructive jaundice. Internal biliary drainage could entirely reverse the changes, but external drainage only partially did.

Pancreaticoduodenectomy with preoperative obstructive jaundice: drainage or not

OBJECTIVES

In this study, we determined whether preoperative biliary drainage should be routinely performed in patients with jaundice.

METHODS

The 342 patients undergoing pancreaticoduodenectomy between June 2004 and June 2008 were analyzed. Of these patients, 303 without biliary drainage were divided into 4 groups: (1) no jaundice, (2) mild jaundice, (3) moderate jaundice, and (4) severe jaundice. Multiple preoperative, intraoperative, and postoperative variables were examined. Postoperative complications were stratified by severity according to the modified Clavien classification.

RESULTS

Patients with jaundice had a higher incidence in subsequent complications than those with no jaundice. The complications were stratified by severity. Compared with those in group 1, patients in groups 2, 3, and 4 had more complications just in grade 2 (15.6%, 23.1%, 28.3%, and 40.0%, respectively, P = 0.046), but not other more severe grades including 3a, 3b, 4a, 4b, and 5; all of the complications in this grade could be conservatively treated and cured without requiring surgical, endoscopic, or radiological intervention. The incidences of infection and overall complications were higher in patients with drainage than those without, but neither difference was statistically significant.

CONCLUSIONS

Preoperative drainage should not routinely be performed in patients with jaundice scheduled for pancreaticoduodenectomy, and immediate surgery is preferable.

Effects of Salvia miltiorrhiza on intercellular adhesion molecule 1 protein expression in the lungs of rats with severe acute pancreatitis or obstructive jaundice

OBJECTIVE

The objective of the study was to observe the effects of Salvia miltiorrhiza on intercellular adhesion molecule 1 (ICAM-1) protein expression in the lungs of rats with severe acute pancreatitis (SAP) or obstructive jaundice (OJ).

METHODS

A total of 288 rats were used for SAP- and OJ-associated experiments. The rats were randomly divided into sham-operated, model control, and treated group. According to the difference of time points after operation, the SAP rats of each group were subdivided into 3-, 6-, and 12-hour groups, whereas the OJ rats were divided into 7-, 14-, 21-, and 28-day groups. The contents of interleukin (IL) 6, IL-18, nitric oxide, malondialdehyde, and superoxide dismutase in serum were determined, and pathological changes and ICAM-1 protein expression in the lungs were observed.

RESULTS

Compared with the respective model control groups, in treated groups of SAP and OJ rats, the numbers of dead rats declined; serum superoxide dismutase content significantly increased, and serum IL-18, IL-6, and malondialdehyde contents were significantly decreased; the positive staining intensity of ICAM-1 protein in the lungs decreased significantly (P < 0.05, P < 0.01, or P < 0.001); and pathological changes in the lungs were relieved.

CONCLUSIONS

Salvia miltiorrhiza plays a positive role in the protection of the lungs of SAP and OJ rats.