T lymphocyte function in patients with malignant biliary obstruction

Postoperative biological and clinical outcomes following uncomplicated pancreaticoduodenectomy

Backgrounds/Aims

The aim of this study was to describe clinical and biological changes in a group of patients who underwent pancreaticoduodenectomy (PD) without any complication during the postoperative period. These changes reflect the "natural history" of PD, and a deviation should be considered as a warning sign.

Methods

Between January 2000 and December 2009, 131 patients underwent PD. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. Postoperative variables were validated using an external prospective database of 158 patients.

Results

The mean postoperative length of hospital stay was 20.3±4 days. The mean number of days until removal of nasogastric tube was 6.3±1.6 days. The maximal fall in hemoglobin level occurred on day 3 and began to increase after postoperative day (POD) 5, in patients with or without transfusions. The white blood cell count increased on POD 1 and persisted until POD 7. There was a marked rise in aminotransferase levels at POD 3. The peak was significantly higher in patients with hepatic pedicle occlusion (866±236 IU/L versus 146±48 IU/L; p<0.001). For both γ-glutamyl transpeptidase and alkaline phosphatase, there was a fall on POD1, which persisted until POD 5, followed with a stabilization. Bilirubin decreased progressively from POD 1 onwards.

Conclusions

This study facilitates a standardized biological and clinical pathway of follow-up. Patients who do not follow this recovery indicator could be at risk of complications and additional exams should be made to prevent consequences of such complications.

Comparison of clinical outcome and cost-effectiveness after various preoperative biliary drainage methods in periampullary cancer with obstructive jaundice

The aim of this study was to compare the clinical outcome and cost-effectiveness of preoperative biliary drainage (BD) methods in periampullary cancer, and to suggest guidelines for selecting the appropriate preoperative BD method. Between October 2004 and August 2010, 211 patients underwent pancreatoduodenectomy after preoperative BD. Clinical outcome and cost-effectiveness of the preoperative BD methods were compared based on the final drainage method used and on intention-to-treat analysis. There was no significant difference in drainage duration between percutaneous transhepatic biliary drainage (PTBD) and endoscopic BD groups (14.2 vs 16.6 days, respectively; P = 0.121) but daily diminution of serum bilirubin level was higher in the PTBD group (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Based on intention-to-treat analysis, drainage duration was shorter (13.2 vs 16.5 days, respectively; P = 0.049), daily diminution of serum bilirubin level was higher (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Medical care cost was lower (14.2 vs 15.7 × 10(3) USD, respectively; P = 0.040) in the PTBD group than in the endoscopic BD group. When selecting the preoperative BD method, practitioners should consider that PTBD is more cost-effective and safer than endoscopic BD.

Effect of preoperative endoscopic biliary drainage on infectious morbidity after pancreatoduodenectomy: a case-control study

BACKGROUND

The utility of preoperative endoscopic biliary drainage (PEBD) in jaundiced patients before pancreatoduodenectomy (PD) is still debated. This is in part due to the heterogeneity of the studied population, including different tumor location, drainage techniques, and surgical procedures. The aim of the current study was to report the influence of PEBD on postoperative infectious morbidity of PD.

MATERIALS AND METHODS

Between January 1996 and December 2004, 124 patients underwent a PD and 28. Twenty-eight (22.6%) of these patients underwent a PEBD. This group of patients was matched to 28 control patients who underwent PD without PEBD during the same period. The 2 groups were matched for age, sex, indication of surgery, and serum bilirubin levels.

RESULTS

The specific morbidity of PEBD before surgery was 10.7% (n = 3). The postoperative overall morbidity, medical morbidity, and surgical morbidity rates were not different between the 2 groups. At the time of surgery, 89.3% (n = 25) of the patients in the PEBD group had positive bile culture in comparison to 19.4% (n = 4) in the control group (P < .001). The number of patients with 1 or more infectious complications was higher in the PEBD group (50%; n = 14) than in the control group (21.4%; n = 6) (P = .05).

CONCLUSIONS

Before PD, PEBD should be routinely avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. In patients with cholangitis, requiring extensive preoperative assessment (such as liver biopsy) or neoadjuvant treatment, PEBD might still be indicated.

Phagocytosis and production of H2O2 by human peripheral blood mononuclear cells from patients with obstructive jaundice

BACKGROUND

The immune function is altered in jaundiced patients; here, the ability of their peripheral blood mononuclear cells to perform phagocytosis and to release H2O2 was analyzed.

METHODS

Cells from 53 patients before surgery for relief of cholestasis, from 38 patients 1 week and from 15 patients 2 weeks after surgery were separated and cultured for 1 h in the presence of phorbol myristate acetate. H2O2 release was evaluated colorimetrically and phagocytosis by the ingestion of Escherichia coli in vitro.

RESULTS

Before surgery for relief of cholestasis, the cells of the patients were unable to release H2O2, but, after surgery, an increasing percentage of patients had cells that were able to produce H2O2 (13% after 1 week; 33% after 2 weeks). This recovery did not correlate with bilirubinemia. When cultured for 1 week in the presence of normal or jaundiced plasma, regardless of collection time, cells of 12/12 patients released H2O2, but in lower levels if in the presence of jaundiced plasma. In contrast, H2O2 release by normal donor cells was enhanced in the presence of jaundiced plasma. Phagocytosis by cells of the patients was lower, but when present was associated with a significantly higher bactericidal activity.

CONCLUSION

These significant, but reversible alterations of monocyte function in jaundiced patients might contribute to their enhanced susceptibility to surgical complications.

The effect of jaundice on the generation of anti-gastrin antibodies in G17DT immunized patients with advanced pancreatic cancer

AIM

The aim of this study was to determine the ability of G17DT to generate anti-gastrin antibodies in jaundiced patients with biliary obstruction due to advanced pancreatic cancer.

METHODS

G17DT was administered to 41 patients with advanced pancreatic adenocarcinoma by intramuscular (i.m.) injection at a dose of 250mcg at weeks 0, 1 and 3 of the study.

RESULTS

Thirty-five of 41 patients participating in the study were categorized as responders in terms of their gastrin-17 antibody response. There was no correlation between the maximum G17 antibody response and the bilirubin level at either week 0 or week 12. The median survival of patients from the time of the first injection of G17DT was 204 days with 25% of patients surviving for <or=97 days and 25% of patients surviving for >or=305 days.

CONCLUSION

This study shows that G17DT administered to jaundiced patients with advanced pancreatic cancer is immunogenic and well tolerated.

A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice

OBJECTIVE

To review the effectiveness of preoperative biliary drainage (PBD) in patients with obstructive jaundice resulting from tumors.

SUMMARY BACKGROUND DATA

This was a systematic review, including a meta-analysis, of randomized controlled trials and comparative cohort studies conducted worldwide and published between 1966 and September 2001, classified on methodologic strength and subdivided into level 1 (randomized controlled trials) and level 2 (comparative cohort studies).

METHODS

Comparison was made of PBD versus no PBD in jaundiced patients undergoing resection of a tumor. Outcome measures were in-hospital death rate, overall complications resulting from the treatment modality (drainage- and surgery-related complications), and hospital stay. Effect sizes were calculated and combined in meta-analyses. Relative differences (%) were calculated to compare effects on outcome measures.

RESULTS

Five randomized controlled studies comprising 302 patients met the inclusion criteria for level 1 studies, and 18 cohort studies comprising 2,853 patients met the criteria for level 2 studies. Meta-analysis of level 1 studies showed no difference in the overall death rate between patients who had PBD and those who had surgery without PBD. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. At level 2, there was no difference in the death rate between the two treatment modalities. The overall complication rate, however, was significantly adversely affected by PBD compared with surgery without PBD. If PBD had been without complications, then complications would be in favor of drainage based on level 1 studies, and no difference based on level 2 studies. Further, PBD was not able to reduce the length of postoperative hospital stay compared with surgery without PBD; instead, it prolonged the stay.

CONCLUSIONS

This meta-analysis shows that PBD with current standards for patients with obstructive jaundice resulting from tumors carries no benefit and should not be performed routinely. The potential benefit of PBD in terms of postoperative rates of death and complications does not outweigh the disadvantage of the drainage procedure. Only if PBD-related complications could be reduced by 27% and consequently diminish hospital stay could PBD be beneficial. Further randomized controlled trials with improved PBD techniques are necessary.

Characterization of the Kupffer cell response to exogenous endotoxin in a rodent model of obstructive jaundice

BACKGROUND

Sepsis and endotoxaemia occur frequently in biliary obstruction. Impaired Kupffer cell endocytosis is implicated in these events. Tumour necrosis factor and interleukin 6, secreted by Kupffer cells, are important mediators of sepsis. Kupffer cell clearance of endotoxin and secretion of cytokines in experimental obstructive jaundice were investigated.

METHODS

Wistar rats were randomized to bile duct ligation, sham operation or control. Groups (n = 8) were studied 1 and 3 weeks after operation. Kupffer cell function was assessed using in situ hepatic perfusion.

RESULTS

Clearance of endotoxin was significantly depressed 1 week (median (interquartile range) 20.3 (10.5-27.1) per cent) and 3 weeks (22.1 (20.2-23.2) per cent) after bile duct ligation compared with that in respective sham animals (35.5 (29.9-41.6) and 40.9 (37.7-47.0) per cent) and controls (39.5 (37.3-46.8) per cent). Secretion of tumour necrosis factor was significantly greater 1 week (1113.7 (706.5-1436. 8) pg/ml) and 3 weeks (1118.2 (775.7-1484.1) pg/ml) following bile duct ligation compared with that in respective sham animals (114.3 (0-178.5) and 107.6 (63.7-166.4) pg/ml) and controls (0 (0-20.7) pg/ml). Interleukin 6 was not secreted by sham or control animals but was present in the perfusate from jaundiced animals at 1 and 3 weeks (52.5 (9.9-89.5) and 66.2 (60.2-193.1) pg/ml).

CONCLUSION

These data demonstrate simultaneous impairment of Kupffer cell clearance of endotoxin and increased secretion of proinflammatory cytokines in experimental obstructive jaundice. These diverse responses may contribute to the development of sepsis-related complications in biliary obstruction.

Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma

BACKGROUND

Resection of hepatocellular carcinoma is associated with high rates of morbidity and mortality. Since intensive nutritional support can reduce the catabolic response and improve protein synthesis and liver regeneration, we performed a prospective study to investigate whether perioperative nutritional support could improve outcome in patients undergoing hepatectomy for hepatocellular carcinoma.

METHODS

We studied 124 patients undergoing resection of hepatocellular carcinoma. Sixty-four patients (39 with cirrhosis, 18 with chronic active hepatitis, and 7 with no associated liver disease) were randomly assigned to receive perioperative intravenous nutritional support in addition to their oral diet, and 60 patients (33 with cirrhosis, 12 with chronic active hepatitis, and 15 with no associated liver disease) were randomly assigned to a control group. The perioperative nutritional therapy consisted of a solution enriched with 35 percent branched-chain amino acids, dextrose, and lipid emulsion (50 percent medium-chain triglycerides) given intravenously for 14 days perioperatively.

RESULTS

There was a reduction in the overall postoperative morbidity rate in the perioperative-nutrition group as compared with the control group (34 percent vs. 55 percent; relative risk, 0.66; 95 percent confidence interval, 0.45 to 0.96), predominantly because of fewer septic complications (17 percent vs. 37 percent; relative risk, 0.57; 95 percent confidence interval, 0.34 to 0.96). There were also a reduction in the requirement for diuretic agents to control ascites (25 percent vs. 50 percent; relative risk, 0.57; 95 percent confidence interval, 0.37 to 0.87), less weight loss after hepatectomy (median loss, 0 kg vs. 1.4 kg, P = 0.01), and less deterioration of liver function as measured by the change in the rate of clearance of indocyanine green (-2.8 percent vs. -4.8 percent at 20 minutes, P = 0.05). These benefits were seen predominantly in the patients with underlying cirrhosis who underwent major hepatectomy. There were five deaths during hospitalization in the perioperative-nutrition group, and nine in the control group (P not significant).

CONCLUSIONS

Perioperative nutritional support can reduce complications after major hepatectomy for hepatocellular carcinoma associated with cirrhosis.