Hepatocellular apoptosis after hepatectomy in obstructive jaundice in rats

Hepatoprotective effect of the hydroalcoholic extract of Cichorium intybus in a rat model of obstructive cholestasis

BACKGROUND AND STUDY AIMS

Obstructive cholestasis increases the levels of oxidants and inflammatory mediators, leading to liver damage. Previous studies have found that Cichorium intybus possesses anti-inflammatory effects. In the present study, the effects of the hydroalcoholic extract of C. intybus leaves were assessed in a rat model of obstructive cholestasis.

MATERIAL AND METHODS

Male Wistar rats were randomly divided into five groups (n = 6 rats per group): sham-operated, control [bile duct ligation (BDL) + vehicle)] and BDL + extract treatment (100, 200 and 400 mg/kg/day, i.p.) groups. Rats received treatments for 7 consecutive days. On the eighth day, prothrombin time (PT); serum albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and total and direct bilirubin levels and total antioxidant and paraoxonase activities were measured using colorimetric methods. In addition, tumour necrosis factor-α and nitric oxide (NO) levels were measured using enzyme-linked immunosorbent assay.

RESULTS

The hydroalcoholic extract of C. intybus significantly decreased PT and the serum levels of AST, ALT, TNF-α and NO compared with the control group (p < 0.05). On the other hand, the serum albumin levels were increased in the extract-treated groups compared with the control group (p < 0.05).

CONCLUSION

The hydroalcoholic extract of C. intybus protects the liver against injury induced by obstructive cholestasis.

Evaluation of liver function by means of serum cytokeratin 18 and hepatocyte growth factor levels in patients with obstructive jaundice

OBJECTIVE

To evaluate the serum levels of cytokeratin 18 (CK18) and hepatocyte growth factor (HGF) in obstructive jaundice patients before and after treatment and thereby to detect the possible role of CK18 and HGF in patients with obstructive jaundice.

PATIENTS AND METHODS

Forty patients who had obstructive jaundice and 40 healthy control subjects were included in the study. Patients were treated using percutaneous, endoscopic or surgical approaches. Blood samples were obtained at the day before and 7 days after the intervention for obstructive jaundice. Serum HGF and CK18 concentrations were determined by ELISA method.

RESULTS

There were statistically significant decreases in HGF, CK18, total bilirubin and direct bilirubin serum levels, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, and alkaline phosphatase activities and white blood cell count when compared with pre-treatment levels.

CONCLUSION

Evaluating pre- and post-treatment serum HGF and CK18 levels suggested that there was an apoptosis in obstructive jaundice patients and this apoptosis decreased after the decompression of the biliary tract. We also demonstrated that HGF levels were altered at biliary obstruction compared to healthy controls and the levels of this biomarker also decreased after decompression of biliary obstruction. We concluded that these biomarkers can be used as predictors of liver injury in biliary obstruction.

Management of large hepatocellular carcinoma in adult patients with Alagille syndrome: a case report and review of literature

BACKGROUND

Alagille syndrome is a multi-system developmental disorder associated with paucity of interlobular bile ducts and cholestasis, rarely associated with hepatocellular carcinoma. Associated syndromic co-morbidities may complicate surgical management. As such, we herein review the modern management of a large hepatocellular carcinoma in an adult patient with Alagille syndrome and review the literature of adult Alagille patients with hepatocellular carcinoma.

CASE PRESENTATION

A 29-year-old woman with a history of Alagille syndrome was referred with biopsy-proven 12 × 8 cm hepatocellular carcinoma replacing her right liver. Biopsy of the contralateral liver demonstrated findings consistent with Alagille syndrome, but no underlying cirrhosis. CT volumetrics demonstrated a future liver remnant of 40%. Extensive hematologic and cardiac work-up was performed pre-operatively, given the syndrome's associated bleeding dyscrasias and cardiac abnormalities. The patient underwent a margin-negative right hepatectomy using the "hanging" technique through a thoracoabdominal approach. The patient developed a transient hyperbilirubinemia but no hepatic insufficiency and did well post-operatively.

CONCLUSION

Since Alagille syndrome affects multiple organ systems, preoperative evaluation of cardiac, hematologic, and hepatic function should be considered. This case illustrates the peri-operative management of an Alagille patient, and highlights several key technical points that contributed to a successful resection.

Predicting liver failure following major hepatectomy

Pre-operative determination of the risk of liver dysfunction has come under criticism with regards to its usefulness in clinical practice. Opinion is split between centres which use such tests uniformly on all patients and those where clinical judgment alone is used. Published data would not suggest any difference in mortality, morbidity or liver failure rates between these groups. This review outlines and presents the evidence for pre-operative quantification of functional liver remnant volume.

Bacteribilia after preoperative bile duct stenting: a prospective study

STUDY DESIGN

A prospective analysis of intraoperative bile duct cultures in patients undergoing surgery for both, malignant or benign periampullary diseases at the Department of Surgery, St Josef Hospital, Bochum, Germany, during a period of 18 months, between January 2004 and June 2005.

GOALS

The goals of the presented study were to investigate the effects of preoperative bile duct stenting on intraoperative bile duct cultures and postoperative outcome in patients undergoing pancreatic surgery.

BACKGROUND

In pancreatic surgery, bile duct stenting is often aimed at improving postoperative outcome. As implantation of xenograft material in the main bile duct facilitates bacterial contamination and cholangitis, a critical evaluation of stenting is mandatory.

STUDY

In all patients with a hepaticojejunostomy (n=80), a bile duct culture was collected during the operation. All patients received antibiotic prophylaxis perioperatively and a retrograde flushing of bile ducts with warm saline after bile duct resection. Fifty-one percent (41/80) patients had biliary drainage before surgery, whereas 49% (39/80) were operated without preoperative draining procedures.

RESULTS

After bile duct stenting, 98% of patients had a positive bile culture, whereas only 21% of infected bile was seen in patients without drainage (P<0.001). Despite infected bile, only 2% stented patients developed acute cholangitis postoperatively, versus 13% patients in the group without stent (P=0.231). After stenting, major complications occurred in 12%, versus 8% in patients without stent (P=0.817).

CONCLUSIONS

Preoperative biliary drainage leads to an almost 100% bacterial contamination of bile ducts. With hospital-adjusted antibiotic prophylaxis and retrograde flushing of bile ducts, the postoperative rate of acute cholangitis and morbidity is not elevated. A critical evaluation of benefits from preoperative biliary drainage for each patient is necessary.

Liver failure after major hepatic resection

INTRODUCTION

The consequence of excessive liver resection is the inexorable development of progressive liver failure characterised by the typical stigmata associated with this condition, including worsening coagulopathy, hyperbilirubinaemia and encephalopathy. The focus of this review will be to investigate factors contributing to hepatocyte loss and impaired regeneration.

METHODS

A literature search was undertaken of Pubmed and related search engines, examining for articles relating to hepatic failure following major hepatectomy.

RESULTS

In spite of improvements in adjuvant chemotherapy and increasing surgical confidence and expertise, the parameters determining how much liver can be resected have remained largely unchanged. A number of preoperative, intraoperative and post-operative factors all contribute to the likelihood of liver failure after surgery.

CONCLUSIONS

Given the magnitude of the surgery, mortality and morbidity rates are extremely good. Careful patient selection and preservation of an obligate volume of remnant liver is essential. Modifiable causes of hepatic failure include avoidance of sepsis, drainage of cholestasis with restoration of enteric bile salts and judicious use of portal triad inflow occlusion intra-operatively. Avoidance of post-operative sepsis is most likely to be achieved by patient selection, meticulous intra-operative technique and post-operative care. Modulation of portal vein pressures post-operatively may further help reduce the risk of liver failure.

Improvement of the survival rate after rat massive hepatectomy due to the reduction of apoptosis by caspase inhibitor

BACKGROUND AND AIM

Acute liver failure after massive hepatectomy is caused by both necrosis and apoptosis in the remnant liver. We investigate the protective effect of the caspase inhibitor on apoptosis after massive hepatectomy in rats.

METHODS

Benzyloxycarbonyl-Val-Ala-Asp(OMe)-fluoromethylketone (ZVAD-fmk) is a general inhibitor of the caspase. Male Wister rats weighing 200-300 g were divided into three groups: 90Hx group undergoing 90% hepatectomy, 95Hx group undergoing 95% hepatectomy, 95Hx + ZVAD group undergoing 95% hepatectomy and administration of ZVAD-fmk. The 7-day survival rate was studied, and the rats were sacrificed at the 1, 2, 3, 5, and 7th day after hepatectomy. The remnant liver tissues were stained with hematoxylin-eosin, and with proliferating cell nuclear antigen (PCNA) for evaluation of liver regeneration, and with TdT-mediated dUTP-biotin nick end labeling (TUNEL) and in situ oligo ligation method (ISOL) for evaluation of apoptosis.

RESULTS

The 7-day survival rates were 100%, 0%, and 30%, in the 90Hx, 95Hx, and 95Hx + ZVAD groups, respectively. There was no significant difference in PCNA labeling index (LI) between the 95Hx and 95Hx + ZVAD groups. TUNEL and ISOL LI of 95Hx + ZVAD group were significantly lower than those of 95Hx group. Fatal liver failure after massive hepatectomy was characterized by more apoptosis and less mitosis of hepatocytes. ZVAD-fmk could significantly attenuate apoptosis of hepatocytes in the remnant liver and improve the survival rate after 95% hepatectomy in rats.

CONCLUSION

Caspase inhibitors such as ZVAD-fmk may provide a new adjuvant therapy to treat liver failure after massive hepatectomy.

Mechanism of impaired hepatic regeneration in cholestatic liver

The regenerative capacity of the liver is an important factor following liver surgery. The dramatic change in portal venous flow, due to either portal vein embolization or partial hepatectomy, induces a rapid change in liver volume. In response to these stresses, hepatocytes are primed, through the release of inflammatory cytokines, to increase the expression of immediate early genes and increase the activation of transcriptional factors. The primed hepatocytes then respond to growth factors, including hepatocyte growth factor, epidermal growth factor, and transforming growth factor-alpha. Several pathologic conditions have been shown to inhibit hepatic regeneration. These include diabetes mellitus, malnutrition, aging, infection, chronic ethanol consumption, and biliary obstruction. Impaired hepatic regeneration in the setting of biliary obstruction is an especially serious problem because it can be a major determinant in not considering surgical treatment. The mechanism responsible for impaired hepatic regeneration in patients with biliary obstruction includes decreased portal venous flow, attenuated production of liver proliferation-associated factors, an increased rate of apoptosis, and lack of enterohepatic circulation. Restoring these factors may lead to an improvement in regeneration in a cholestatic liver following portal vein embolization or partial hepatectomy. This review article summarizes the current understanding of the mechanism of hepatic regeneration, with particular emphasis on that in the cholestatic liver.

Compensatory recovery of liver mass by Akt-mediated hepatocellular hypertrophy in liver-specific STAT3-deficient mice

BACKGROUND/AIMS

Liver regeneration following hepatectomy is complicated and involves a variety of interacting factors. The present study was designed to study the roles of proliferation and hypertrophy of hepatocytes in liver regeneration following hepatectomy in liver-specific STAT3-knockout (LS3-KO) mice lacking mitogenic activity.

METHODS

Partial hepatectomy was performed in LS3-KO and control mice. Liver regeneration was estimated by the liver weight, cell proliferation and cell size, and the related cellular signals were analyzed.

RESULTS

Proliferation of hepatocytes following PH was markedly suppressed in LS3-KO mice with reduced cyclinD1 transcript. However, liver mass recovered sufficiently following PH in LS3-KO mice almost equal to that of control mice. Analysis of hepatocellular growth revealed that cell size following hepatectomy was significantly larger in LS3-KO mice than in control mice. Hepatectomy induced immediate but transient phosphorylation of Akt, p70S6K, mTOR and GSK-3beta in LS3-KO mice much more than in control mice. Additionally, adenoviral transfection of dominant negative mutant of Akt to control and LS3-KO mice led to insufficient liver regeneration following hepatectomy.

CONCLUSIONS

PI3-K/Akt-mediated responsive hepatocellular hypertrophy may be essential for liver regeneration following hepatectomy and sufficiently compensated liver regeneration even in STAT3-deficient liver, in which cell proliferation is impaired.