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Huang Y, Xu L, Wang N, Wei Y, Wang W, Xu M, Jiang L. Preoperative dexamethasone administration in hepatectomy of 25-min intermittent Pringle's maneuver for hepatocellular carcinoma: a randomized controlled trial. Int J Surg 2023; 109:3354-3364. [PMID: 37526089 PMCID: PMC10651268 DOI: 10.1097/js9.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND A previous randomized controlled trial demonstrated that intermittent Pringle's maneuver (IPM) with a 25-min ischemic interval could be applied safely and efficiently in hepatectomy for patients with hepatocellular carcinoma (HCC). But prolonging the hepatic inflow clamping time will inevitably aggravate the ischemia-reperfusion injury. Therefore, we aimed to evaluate the effect of prophylactic dexamethasone on alleviating surgical stress for HCC patients with a 25-min ischemic interval. METHODS From December 2022 to April 2023, patients who met the inclusion criteria were randomly assigned to the dexamethasone group or control group. Perioperative data and short-term survival outcomes between the two groups were recorded and compared, and subgroup analysis was performed. RESULTS Two hundred and seventy patients were allocated to the dexamethasone group ( n =135) and control group ( n =135). Patients in the dexamethasone group had lower area under the curve of serial alanine aminotransferase (AUC ALT ) ( P =0.043) and aspartate aminotransferase (AUC AST ) ( P =0.009), total bilirubin (TB) ( P =0.018), procalcitonin (PCT) ( P =0.012), interleukin-6 (IL-6) ( P =0.006), incidence of major complication ( P =0.031) and shorter postoperative hospital stay ( P =0.046) than those in the control group. Subgroup analysis showed that the dexamethasone group experienced milder hepatocellular injury than the control group for patients with cirrhosis, and for patients without cirrhosis, the dexamethasone group experienced milder inflammatory response. Moreover, the dexamethasone group preserved better liver function and experienced milder inflammatory response for patients undergoing major hepatectomy, although the hepatocellular injury was not significantly improved. CONCLUSION Preoperative dexamethasone administration can help improve perioperative outcomes for HCC patients when applying IPM with a 25-min ischemic interval in hepatectomy.
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Affiliation(s)
| | | | | | | | | | - Mingqing Xu
- Department of General Surgery, Division of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Li Jiang
- Department of General Surgery, Division of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
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Effect of inferior vena cava respiratory variability-guided fluid therapy after laparoscopic hepatectomy: a randomized controlled clinical trial. Chin Med J (Engl) 2023:00029330-990000000-00327. [PMID: 36752804 DOI: 10.1097/cm9.0000000000002484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND After major liver resection, the volume status of patients is still undetermined. However, few concerns have been raised about postoperative fluid management. We aimed to compare gut function recovery and short-term prognosis of the patients after laparoscopic liver resection (LLR) with or without inferior vena cava (IVC) respiratory variability-directed fluid therapy in the anesthesia intensive care unit (AICU). METHODS This randomized controlled clinical trial enrolled 70 patients undergoing LLR. The IVC respiratory variability was used to optimize fluid management of the intervention group in AICU, while the standard practice of fluid management was used for the control group. The primary outcome was the time to flatus after surgery. The secondary outcomes included other indicators of gut function recovery after surgery, postoperative length of hospital stay (LOS), liver and kidney function, the severity of oxidative stress, and the incidence of severe complications associated with hepatectomy. RESULTS Compared with patients receiving standard fluid management, patients in the intervention group had a shorter time to anal exhaust after surgery (1.5 ± 0.6 days vs. 2.0 ± 0.8 days) and lower C-reactive protein activity (21.4 [95% confidence interval (CI): 11.9-36.7] mg/L vs. 44.8 [95%CI: 26.9-63.1] mg/L) 24 h after surgery. There were no significant differences in the time to defecation, serum concentrations of D-lactic acid, malondialdehyde, renal function, and frequency of severe postoperative complications as well as the LOS between the groups. CONCLUSION Postoperative IVC respiratory variability-directed fluid therapy in AICU was facilitated in bowel movement but elicited a negligible beneficial effect on the short-term prognosis of patients undergoing LLR. TRIAL REGISTRATION ChiCTR-INR-17013093.
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The Use of Newly Synthesized Composite Scaffolds for Bone Regeneration - A Review of Literature. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2021-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Abstract
At present, clamping of the portal triad is a widespread surgical procedure in hospitals. Such an operation can prevent pathological changes in the organs. However, the optimal time for clamping remains unclear. To determine the starting time of irreversible morphological changes in the small intestine due to the clamping of the portal triad. The study was carried out on rats (n=94). Animals were randomly subdivided into 4 groups based on the duration of clamping of the portal triad (PT): I control group (CG; without clamping the PT; n=10); II intervention group (6-IG; clamping PT for 6 min; n=28); III intervention group (12-IG; clamping time of the PT for 12 min; n=28); IV intervention group (24-IG; clamping time of the PT for 24 min; n=28). In groups 6- IG, 12-IG, 24-IG, after clamping the portal triad, animals were withdrawn from the experiment after 3 hours, 6 hours, 12 hours, 1 day, 3 days and 7 days. Morphological changes in the small intestine were assessed by measuring the diameter of the lumen of micro-vessels. In addition, the mortality in the groups was analysed as well. In the CG group, the diameter of the arterioles of the small intestine was 34±4 μm, the diameters of pre-capillaries were 15±2μm, the capillaries were 5.4±1 μm, the post-capillaries were 18±2 μm, and the diameter of the lumen of the venues was 40±3 μm. In the 6-IG group (on the 3rd day), the structure of the small intestine showed the recovery signs. By the 7th day, the indicators returned to their original values. In the 12-IG group, the parameters of the small intestine were restored on the seventh day that corresponds to the usual course of the disease. However, in the 24-IG group, changes in these organs persisted until the end of the study. No deaths were reported in the CG and 6-IG animal groups. Mortality among rats of the 12-IG group was 14.3%, while in the 24-IG group with PT clamping for 24 minutes it was 42.8%, respectively. The morphological changes in the microvasculature of the small intestine after 6-minute PT clamping showed a tendency to recover (back to the control parameters). Nevertheless, after 24 minutes of clamping, the changes in the intestinal tissue were irreversible.
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Sparrelid E, Olthof PB, Dasari BVM, Erdmann JI, Santol J, Starlinger P, Gilg S. Current evidence on posthepatectomy liver failure: comprehensive review. BJS Open 2022; 6:6840812. [PMID: 36415029 PMCID: PMC9681670 DOI: 10.1093/bjsopen/zrac142] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF. METHODS A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022. RESULTS Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited. DISCUSSION Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.
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Affiliation(s)
- Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pim B Olthof
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bobby V M Dasari
- Department of HPB Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jonas Santol
- Department of Surgery, HPB Center, Viennese Health Network, Clinic Favoriten and Sigmund Freud Private University, Vienna, Austria.,Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Patrick Starlinger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria.,Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, New York, USA
| | - Stefan Gilg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Optimal surgical sequence for colorectal cancer liver metastases patients receiving colorectal cancer resection with simultaneous liver metastasis resection: A multicentre retrospective propensity score matching study. Int J Surg 2022; 106:106952. [DOI: 10.1016/j.ijsu.2022.106952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
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Chen H, Lu D, Yang X, Hu Z, He C, Li H, Lin Z, Yang M, Xu X. One Shoot, Two Birds: Alleviating Inflammation Caused by Ischemia/Reperfusion Injury to Reduce the Recurrence of Hepatocellular Carcinoma. Front Immunol 2022; 13:879552. [PMID: 35634295 PMCID: PMC9130551 DOI: 10.3389/fimmu.2022.879552] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/15/2022] [Indexed: 12/12/2022] Open
Abstract
Inflammation is crucial to tumorigenesis and the development of metastasis. Hepatic ischemia/reperfusion injury (IRI) is an unresolved problem in liver resection and transplantation which often establishes and remodels the inflammatory microenvironment in liver. More and more experimental and clinical evidence unmasks the role of hepatic IRI and associated inflammation in promoting the recurrence of hepatocellular carcinoma (HCC). Meanwhile, approaches aimed at alleviating hepatic IRI, such as machine perfusion, regulating the gut-liver axis, and targeting key inflammatory components, have been proved to prevent HCC recurrence. This review article highlights the underlying mechanisms and promising therapeutic strategies to reduce tumor recurrence through alleviating inflammation induced by hepatic IRI.
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Affiliation(s)
- Hao Chen
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
| | - Di Lu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
| | - Xinyu Yang
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
| | - Zhihang Hu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
| | - Chiyu He
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Huigang Li
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
| | - Zuyuan Lin
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
| | - Modan Yang
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China
| | - Xiao Xu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health Commission (NHC) Key Laboratory of Combined Multi-organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,Westlake Laboratory of Life Sciences and Biomedicine, Westlake University, Hangzhou, China
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Multidisciplinary surgical approach for renal cell carcinoma with inferior vena cava tumor thrombus. Surg Today 2021; 52:1016-1022. [PMID: 34786640 DOI: 10.1007/s00595-021-02415-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
PURPOSES The optimal surgical management of renal cell carcinoma with tumor thrombus within the inferior vena cava (IVC) remains to be clarified. METHODS Sixteen consecutive cases were reviewed. Incision, the IVC clamping position, and the venous drainage procedure were modified according to the tumor thrombus extension level: level I or II (below the hepatic vein, n = 8), level III (above the hepatic vein but below the right atrium, n = 5), and level IV (extending into the right atrium, n = 3). RESULTS For level I or II, resection could be simply achieved by clamping the IVC below the hepatic vein, without hemodynamic collapse. For level III, clamping the IVC above the hepatic vein and the hepatoduodenal ligament was required. Venous drainage from the lower body (cannulation to distal IVC) and portal system (cannulation to ileocolic vein) were applied. When opening the IVC, the significant backflow was controlled using cardiopulmonary bypass with drop-in suckers. For level IV, median sternotomy, exposure of the right atrium, and cardiopulmonary bypass were mandatory. With the combination of these approaches, the perioperative mortality rate was 0% and the 5-year overall survival rate was 52%. CONCLUSIONS A multidisciplinary surgical approach is essential, especially for level III and IV cases.
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Huang YQ, Wen RT, Li XT, Zhang J, Yu ZY, Feng YF. The Protective Effect of Dexmedetomidine Against Ischemia-Reperfusion Injury after Hepatectomy: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2021; 12:747911. [PMID: 34712138 PMCID: PMC8546301 DOI: 10.3389/fphar.2021.747911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Hepatic inflow occlusion proceeded to reduce blood loss during hepatectomy induces ischemia-reperfusion (IR) injury in the remnant liver. Dexmedetomidine, a selective α2-adrenoceptor agonist used as an anesthetic adjuvant, has been shown to attenuate IR injury in preclinical and clinical studies. However, a meta-analysis is needed to systematically evaluate the protective effect of perioperative dexmedetomidine use on IR injury induced by hepatectomy. Methods: A prospectively registered meta-analysis following Cochrane and PRISMA guidelines concerning perioperative dexmedetomidine use on IR injury after hepatectomy was performed via searching Cochrane Library, PubMed, EMBASE, ClinicalTrials.gov, Web of Science, CNKI, WanFang, and Sinomed for eligible randomized controlled trials up to 2021.3.31. The main outcome is postoperative liver function. Risk of bias was assessed by the Cochrane Risk of Bias tool. Review Manager 5.3 and Stata12.0 were applied to perform data analyses. Results: Eight RCTs enrolling 468 participants were included. Compared with 0.9% sodium chloride, dexmedetomidine decreased serum concentration of ALT (WMD = −66.54, 95% CI: −92.10–−40.98), AST (WMD= −82.96, 95% CI: −106.74–−59.17), TBIL (WMD = −4.51, 95% CI: −7.32–−1.71), MDA (WMD = −3.09, 95% CI: −5.17–−1.01), TNF-α (WMD = −36.54, 95% CI: −61.33–−11.95) and IL-6 (WMD = −165.05, 95% CI: −225.76–−104.34), increased SOD activity (WMD = 24.70, 95% CI: 18.09–31.30) within postoperative one day. There was no significant difference in intraoperative or postoperative recovery parameters between groups. Conclusions: Perioperative administration of dexmedetomidine can exert a protective effect on liver IR injury after hepatectomy. Additional studies are needed to further evaluate postoperative recovery outcomes of dexmedetomidine with different dosing regimens.
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Affiliation(s)
- Ya-Qun Huang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China.,Department of Pharmaceutical Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Rui-Ting Wen
- Department of Pharmacy, Peking University People's Hospital, Beijing, China.,Department of Pharmaceutical Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Xiao-Tong Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Jiao Zhang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China.,Department of Pharmaceutical Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhi-Ying Yu
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Yu-Fei Feng
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
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Wisén E, Almazrooa A, Sand Bown L, Rizell M, Ricksten S, Kvarnström A, Svennerholm K. Myocardial, renal and intestinal injury in liver resection surgery-A prospective observational pilot study. Acta Anaesthesiol Scand 2021; 65:886-894. [PMID: 33811772 DOI: 10.1111/aas.13823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Post-operative organ complications in liver resection surgery are not uncommon. This prospective observational pilot study was performed to evaluate the incidence, degree and timing of myocardial, renal and intestinal injury in patients undergoing liver resection surgery using the low central venous pressure (LCVP) technique and the Pringle manoeuvre. METHODS Blood samples were obtained before, during and after elective liver resection until post-operative day (POD) 5. High-sensitive troponin T (hs-TnT), serum creatinine, urea, intestinal fatty acid binding protein (I-FABP), D-lactate, arterial lactate, portal lactate, amylase, as well as urine N-acetyl-ß-D-glucosaminidase (NAG) were analysed. Systemic haemodynamics were measured intraoperatively. RESULTS Eighteen patients fulfilled the protocol. The Pringle manoeuvre was used in all but 1 patient. hs-TnT increased significantly over time (P < .001) and 5 patients (28%) developed myocardial injury. Five patients had a pre-operative elevation of hs-TnT, four of those developed myocardial injury. Serum creatinine increased significantly over time (P = .015). Acute kidney injury (AKI) occurred in 5 patients (28%), while NAG, as a marker of tubular injury, was not affected. I-FABP increased over time (P < .001) with a maximal 75% increase at 3 hours after resection. D-lactate was below detection level at all measuring points. CONCLUSIONS In patients undergoing liver resection surgery, using LCVP technique and Pringle manoeuvre, myocardial injury was seen in approximately 30% of the patients post-operatively and almost 30% developed transient AKI in the early post-operative period with no tubular injury. Furthermore, a transient increase of the enterocyte damage marker I-FABP was demonstrated with no signs of gut barrier dysfunction.
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Affiliation(s)
- Ellinor Wisén
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Abdulrahman Almazrooa
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Lena Sand Bown
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Magnus Rizell
- Department of Transplantation and Liver Surgery Sahlgrenska academyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Andreas Kvarnström
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care Medicine Sahlgrenska AcademyUniversity of GothenburgSahlgrenska University Hospital Gothenburg Sweden
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Hemorheological and Microcirculatory Factors in Liver Ischemia-Reperfusion Injury-An Update on Pathophysiology, Molecular Mechanisms and Protective Strategies. Int J Mol Sci 2021; 22:ijms22041864. [PMID: 33668478 PMCID: PMC7918617 DOI: 10.3390/ijms22041864] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 02/08/2023] Open
Abstract
Hepatic ischemia-reperfusion injury (IRI) is a multifactorial phenomenon which has been associated with adverse clinical outcomes. IRI related tissue damage is characterized by various chronological events depending on the experimental model or clinical setting. Despite the fact that IRI research has been in the spotlight of scientific interest for over three decades with a significant and continuous increase in publication activity over the years and the large number of pharmacological and surgical therapeutic attempts introduced, not many of these strategies have made their way into everyday clinical practice. Furthermore, the pathomechanism of hepatic IRI has not been fully elucidated yet. In the complex process of the IRI, flow properties of blood are not neglectable. Hemorheological factors play an important role in determining tissue perfusion and orchestrating mechanical shear stress-dependent endothelial functions. Antioxidant and anti-inflammatory agents, ischemic conditioning protocols, dynamic organ preservation techniques may improve rheological properties of the post-reperfusion hepatic blood flow and target endothelial cells, exerting a potent protection against hepatic IRI. In this review paper we give a comprehensive overview of microcirculatory, rheological and molecular–pathophysiological aspects of hepatic circulation in the context of IRI and hepatoprotective approaches.
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Electroacupuncture Pretreatment Attenuates Intestinal Injury after Autogenous Orthotopic Liver Transplantation in Rats via the JAK/STAT Pathway. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:9187406. [PMID: 32832009 PMCID: PMC7424380 DOI: 10.1155/2020/9187406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/05/2020] [Accepted: 07/15/2020] [Indexed: 01/16/2023]
Abstract
Background Liver transplantation induces self-injury and affects remote organs, such as the lung, kidney, and intestine. Postoperative intestinal dysfunction has been associated with prolonged hospitalization and affects a patient's health and quality of life. Electroacupuncture (EA) has been proven effective in multiple organ protection. However, the potential mechanism underlying the protective effects of EA on intestinal injury after liver transplantation remains unclear. Methods After establishing an autogenous orthotopic liver transplantation (AOLT) model, we studied the effects of EA pretreatment on intestinal injury after AOLT. We used the JAK2-specific inhibitor AG490 to explore the underlying mechanism. Histological analysis and apoptosis assays were used to evaluate intestinal injury. Oxidative stress index and inflammatory response were also measured after AOLT. Furthermore, we detected the phosphorylation levels of JAK2, STAT1, and STAT3 by Western blot. Results We found that pretreatment with EA alleviated intestinal injury after AOLT, as shown by HE staining and TUNEL methods. EA pretreatment inhibited the expressions of p-JAK2, p-STAT1, and p-STAT3 in the intestines after AOLT. Upon treatment with JAK2-specific inhibitor AG490, intestinal injury was balanced. Conclusion The data indicated EA pretreatment alleviated intestinal injury after AOLT by inhibiting the JAK/STAT signaling pathway. These results provide basic evidence to support the potential therapeutic efficacy of EA.
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Ke J, Liu F, Liu Y. Glissonean Pedicle Transection with Hepatic Vein Exclusion for Hepatocellular Carcinoma: A Comparative Study with the Pringle Maneuver. J Laparoendosc Adv Surg Tech A 2020; 30:58-63. [PMID: 31573392 DOI: 10.1089/lap.2019.0484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Jianji Ke
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Feiqi Liu
- The Cancer Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
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13
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The effect of immunonutrition on bacterial translocation after Pringle maneuverer in rats. GASTROENTEROLOGY REVIEW 2019; 14:178-182. [PMID: 31649788 PMCID: PMC6807670 DOI: 10.5114/pg.2019.88166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 01/16/2019] [Indexed: 11/17/2022]
Abstract
Introduction Temporary clamping of the hepatoduodenal ligament (the Pringle manoeuvre) is the most commonly used method to prevent intraoperative blood loss in liver surgery. Some side effects of the Pringle manoeuvre (PM) can occur. Aim To investigate the effectiveness of preoperative immunonutritional support to prevent bacterial translocation (BT) in rats due to PM. Material and methods Forty Wistar albino rats were randomly divided into four groups. Groups 1 and 2 were fed with normal rat diet and water, and groups 3 and 4 were fed with enteral immunonutrition (Impact Glutamine) containing 1 g/kg/day amino acid in the preoperative period. Group 1 (n = 10) and 4 (n = 10) rats were treated only with laparotomy; group 2 (n = 10) and 3 (n = 10) rats were treated with PM for 30 min with laparotomy. After 30 min, relaparotomy was applied to all groups and portal blood, mesentery, spleen samples were taken for culture purposes. Results Proliferation in portal blood cultures was significantly higher in the samples from the normally fed group (group 2) in whom PM was applied, compared to the other groups (p < 0.001). No proliferation was observed in the PM-treated group (group 3), who also received preoperative immunonutritional support. Conclusions Preoperative immunonutritional support is effective in the prevention of BT due to PM in rats.
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Zhang Y, Liu M, Yang Y, Cao J, Mi W. Dexmedetomidine exerts a protective effect on ischemia-reperfusion injury after hepatectomy: A prospective, randomized, controlled study. J Clin Anesth 2019; 61:109631. [PMID: 31669050 DOI: 10.1016/j.jclinane.2019.109631] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/19/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE Dexmedetomidine, a highly selective α2-receptor agonist, has been widely used for protection against ischemia-reperfusion (IR) injury. We hypothesized that dexmedetomidine might exert a protective effect on IR injury after hepatectomy. DESIGN A prospective, randomized, single-blind study was conducted in 58 patients undergoing hepatectomy who were randomly assigned to two study groups. The dexmedetomidine group (D group) received a loading dose of 0.5 μg/kg for 10 min, and maintained it with 0.5 μg/kg/h until resection of the liver lobes. The control group (C group), received 0.9% sodium chloride administered in the same volume and infusion rate as D group. Eleven patients had hepatic inflow occlusion in D group as did 14 patients in C group. MEASUREMENTS The primary outcome was the serum concentration of α-glutathione S-transferase (α-GST), which reflects hepatic ischemic injury. Secondary outcomes included laboratory variables reflecting inflammatory responses, liver and kidney function, and blood coagulation, as well as hemodynamic changes, recovery variables, and complications related to anesthesia and surgery. RESULTS The concentration of α-GST at 0.5 h after resection was significantly lower in the dexmedetomidine group than the control group (9.1 ± 3.4 ng/mL vs 15.8 ± 6.5 ng/mL; p < .01), and was also significantly lower in the dexmedetomidine group in subgroup analyses of patients with and without hepatic inflow occlusion. While the concentrations of α-GST at 0.5 h after resection in patients with or without occlusion in D group were comparable, in C group the α-GST concentration without occlusion was significantly higher than that with occlusion. There was an interaction between dexmedetomidine and no occlusion (p < .01), and its concentration in D group without occlusion was the lowest of all subgroups. In addition, there were significant differences in interleukin (IL)-6 and tumor necrosis (TNF)-α concentrations at 24 h after hepatectomy between the two groups, and mean arterial pressure, heart rate, and the bispectral index were also significantly lower in D group than in C group (p < .05). There were significant differences between the two groups in ALT and AST at 2 h and 24 h after the resection of the liver lobe. However, there were no significant differences in renal function, recovery variables, blood coagulation. No severe complications related surgeries and anesthesia were found in both groups. CONCLUSION Dexmedetomidine exerts a protective effect on ischemia-reperfusion injury after hepatectomy.
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Affiliation(s)
- Yu Zhang
- Medical School of Chinese PLA, Beijing, China; Anesthesia and Operation Center, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Miao Liu
- Institute of Geriatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yu Yang
- Anesthesia and Operation Center, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiangbei Cao
- Anesthesia and Operation Center, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Weidong Mi
- Medical School of Chinese PLA, Beijing, China; Anesthesia and Operation Center, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
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van Gorp C, de Lange IH, Spiller OB, Dewez F, Cillero Pastor B, Heeren RMA, Kessels L, Kloosterboer N, van Gemert WG, Beeton ML, Stock SJ, Jobe AH, Payne MS, Kemp MW, Zimmermann LJ, Kramer BW, Plat J, Wolfs TGAM. Protection of the Ovine Fetal Gut against Ureaplasma-Induced Chorioamnionitis: A Potential Role for Plant Sterols. Nutrients 2019; 11:E968. [PMID: 31035616 PMCID: PMC6566982 DOI: 10.3390/nu11050968] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 01/29/2023] Open
Abstract
Chorioamnionitis, clinically most frequently associated with Ureaplasma, is linked to intestinal inflammation and subsequent gut injury. No treatment is available to prevent chorioamnionitis-driven adverse intestinal outcomes. Evidence is increasing that plant sterols possess immune-modulatory properties. Therefore, we investigated the potential therapeutic effects of plant sterols in lambs intra-amniotically (IA) exposed to Ureaplasma. Fetal lambs were IA exposed to Ureaplasma parvum (U. parvum, UP) for six days from 127 d-133 d of gestational age (GA). The plant sterols β-sitosterol and campesterol, dissolved with β-cyclodextrin (carrier), were given IA every two days from 122 d-131 d GA. Fetal circulatory cytokine levels, gut inflammation, intestinal injury, enterocyte maturation, and mucosal phospholipid and bile acid profiles were measured at 133 d GA (term 150 d). IA plant sterol administration blocked a fetal inflammatory response syndrome. Plant sterols reduced intestinal accumulation of proinflammatory phospholipids and tended to prevent mucosal myeloperoxidase-positive (MPO) cell influx, indicating an inhibition of gut inflammation. IA administration of plant sterols and carrier diminished intestinal mucosal damage, stimulated maturation of the immature epithelium, and partially prevented U. parvum-driven reduction of mucosal bile acids. In conclusion, we show that β-sitosterol and campesterol administration protected the fetus against adverse gut outcomes following UP-driven chorioamnionitis by preventing intestinal and systemic inflammation.
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Affiliation(s)
- Charlotte van Gorp
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Ilse H de Lange
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands.
- Department of Surgery, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Owen B Spiller
- Cardiff University School of Medicine, Cardiff CF10 3AT, Wales, UK.
| | - Frédéric Dewez
- Maastricht Multimodal Molecular Imaging Institute (M4I), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Berta Cillero Pastor
- Maastricht Multimodal Molecular Imaging Institute (M4I), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Ron M A Heeren
- Maastricht Multimodal Molecular Imaging Institute (M4I), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Lilian Kessels
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Nico Kloosterboer
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Wim G van Gemert
- Department of Surgery, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Michael L Beeton
- Cardiff School of Health Sciences, Cardiff Metropolitan University, Cardiff CF14 4XN, UK.
| | - Sarah J Stock
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK.
| | - Alan H Jobe
- Division of Neonatology/Pulmonary Biology, The Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH 45229, USA.
| | - Matthew S Payne
- Division of Obstetrics and Gynecology, School of Medicine, The University of Western Australia, Crawley WA 6009, Australia.
| | - Matthew W Kemp
- School of Women's and Infant's Health, The University of Western Australia, Crawley WA 6009, Australia.
| | - Luc J Zimmermann
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Boris W Kramer
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Jogchum Plat
- Department of Nutrition and Movement Sciences, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6202 AZ Maastricht, The Netherlands.
| | - Tim G A M Wolfs
- Department of Pediatrics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands.
- Department of Biomedical Engineering (BMT), School for Cardiovascular Diseases (CARIM), Maastricht University, 6202 AZ Maastricht, The Netherlands.
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16
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Shen L, Uz Z, Ince C, van Gulik T. Alterations in intestinal serosal microcirculation precipitated by the Pringle manoeuvre. BMJ Case Rep 2019; 12:12/1/e228111. [PMID: 30610034 DOI: 10.1136/bcr-2018-228111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Lucinda Shen
- Department of Translational Physiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, Rotterdam, The Netherlands
| | - Zühre Uz
- Department of Translational Physiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Experimental Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Intensive Care, Erasmus MC, Rotterdam, The Netherlands
| | - Thomas van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Orci LA, Lacotte S, Delaune V, Slits F, Oldani G, Lazarevic V, Rossetti C, Rubbia-Brandt L, Morel P, Toso C. Effects of the gut-liver axis on ischaemia-mediated hepatocellular carcinoma recurrence in the mouse liver. J Hepatol 2018; 68:978-985. [PMID: 29331341 DOI: 10.1016/j.jhep.2017.12.025] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/06/2017] [Accepted: 12/22/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is growing evidence that liver graft ischemia-reperfusion (I/R) is a risk factor for hepatocellular carcinoma (HCC) recurrence, but the mechanisms involved are unclear. Herein, we tested the hypothesis that mesenteric congestion resulting from portal blood flow interruption induces endotoxin-mediated Toll-like receptor 4 (Tlr4) engagement, resulting in elevated liver cancer burden. We also assessed the role of remote ischemic preconditioning (RIPC) in this context. METHODS C57Bl/6j mice were exposed to standardized models of liver I/R injury and RIPC, induced by occluding the hepatic and femoral blood vessels. HCC was induced by injecting RIL-175 cells into the portal vein. We further evaluated the impact of the gut-liver axis (lipopolysaccharide (LPS)-Tlr4 pathway) in this context by studying mice with enhanced (lipopolysaccharide infusion) or defective (Tlr4-/- mice, gut sterilization, and Tlr4 antagonist) Tlr4 responses. RESULTS Portal triad clamping provoked upstream mesenteric venous engorgement and increased bacterial translocation, resulting in aggravated tumor burden. RIPC prevented this mechanism by preserving intestinal integrity and reducing bacterial translocation, thereby mitigating HCC recurrence. These observations were linked to the LPS-Tlr4 pathway, as supported by the high and low tumor burden displayed by mice with enhanced or defective Tlr4 responses, respectively. CONCLUSIONS Modulation of the gut-liver axis and the LPS-Tlr4 response by RIPC, gut sterilization, and Tlr4 antagonism represents a potential therapeutic target to prevent I/R lesions, and to alleviate HCC recurrence after liver transplantation and resection. LAY SUMMARY Cancer recurrence can occur after liver resection or liver transplantation for hepatocellular carcinoma (HCC). This study suggests that intestinal venous congestion, which often occurs during liver surgery, favors the translocation of gut-derived bacterial products in the portal vein, thereby facilitating cancer recurrence by enhancing the signaling of Toll-like receptor 4 in the liver. Using a mouse model of HCC recurrence, we show that strategies that (i) reduce bacterial translocation (by gut decontamination, or by protecting the intestine from venous ischemia damage) or (ii) inhibit Tlr4 signaling in the liver, could reduce cancer recurrence.
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Affiliation(s)
- Lorenzo A Orci
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Stéphanie Lacotte
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Vaihere Delaune
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Florence Slits
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Graziano Oldani
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Vladimir Lazarevic
- Genomic Research Laboratory, Geneva University Hospitals, Geneva, University of Geneva, Switzerland
| | - Carlo Rossetti
- Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell'Insubria, Varese, Italy
| | - Laura Rubbia-Brandt
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Division of Clinical Pathology, Department of Pathology and Immunology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Philippe Morel
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Toso
- Division of Abdominal and Transplantation Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Jansen-Winkeln B, Tagkalos E, Heimann A, Gaiser T, Hirsch D, Gockel I, Mittler J, Lang H, Heinrich S. Pringle maneuver increases the risk of anastomotic leakage after colonic resection in rats. HPB (Oxford) 2018; 20:392-397. [PMID: 29306581 DOI: 10.1016/j.hpb.2017.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 09/29/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many centers use the Pringle's maneuver during liver resections. Since this maneuver might impair healing of bowel anastomoses, we evaluated its influence on the healing of colonic anastomosis in rats. METHODS Male Wistar rats underwent median laparotomy and sigmoid resection with end-to-end anastomosis under inhalation anesthesia. Thereafter, rats received a 25 minutes Pringle's maneuver (PM, group 1) or were kept under anesthesia for the same period of time (group 2). The anastomotic bursting pressure (BP) was measured on postoperative days (POD) 3, 6 and 9. Hematoxylin and Eosin (H&E) staining was used for histopathological evaluation of the anastomosis. The Mann-Whitney U and χ2 -tests were used, p<0.05 values were considered significant. RESULTS All animals (n=48) lost body weight (BW) until POD3 (95.2% vs. 85.7%, p=0.003), and BW remained lower after PM (106.2% vs. 92.8%, p=0.001). The anastomotic BP was lower in group 1 compared to group 2 on POD 3 (116mmHg vs. 176.28mmHg, p=0.001), POD 6 (182.8mmHg vs. 213mmHg, p=0.029) and POD 9 (197.2mmHg vs. 251.7mmHg, p=0.009), and mortality was higher in group 1 (1 vs. 7, p=0.022). CONCLUSIONS Pringle's maneuver increases anastomotic complications in rats. Therefore, a Pringle's maneuver should be avoided during simultaneous liver and colorectal surgery.
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Affiliation(s)
- Boris Jansen-Winkeln
- Department of General, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Axel Heimann
- Institute for Neurosurgical Pathophysiology, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Timo Gaiser
- Department of Pathology, University Hospital Mannheim, Mannheim, Germany
| | - Daniela Hirsch
- Department of Pathology, University Hospital Mannheim, Mannheim, Germany
| | - Ines Gockel
- Department of General, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Jens Mittler
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany.
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Barbeiro HV, Machado MAC, de Souza HP, da Silva FP, Machado MCC. Reduction of venous pressure during the resection of liver metastases compromises enteric blood flow: IGFBP-1 as a novel biomarker of intestinal barrier injury. Clinics (Sao Paulo) 2017; 72:645-648. [PMID: 29160429 PMCID: PMC5666439 DOI: 10.6061/clinics/2017(10)10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/12/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Disruption of the intestinal barrier and bacterial translocation commonly occur when intestinal blood flow is compromised. The aim of this study was to determine whether liver resection induces intestinal damage. METHODS We investigated intestinal fatty-acid binding protein and insulin-like growth factor binding protein levels in the plasma of patients who underwent liver resection. RESULTS We show that liver resection is associated with significant intestinal barrier injury, even if the Pringle maneuver is not performed. CONCLUSION We propose the use of insulin-like growth factor binding protein-1 as a novel biomarker of intestinal damage in such situations.
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Affiliation(s)
- Hermes Vieira Barbeiro
- Departamento de Emergencias Clinicas, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Heraldo Possolo de Souza
- Departamento de Emergencias Clinicas, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabiano Pinheiro da Silva
- Departamento de Emergencias Clinicas, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marcel Cerqueira César Machado
- Departamento de Emergencias Clinicas, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Sirio Libanes, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Freitas SH, Dória RGS, Bueno RS, Rocha WB, Filho JRE, Moraes JRE, Vidane AS, Ambrósio CE. Evaluation of potential changes in liver and lung tissue of rats in an ischemia-reperfusion injury model (modified pringle maneuver). PLoS One 2017; 12:e0178665. [PMID: 28604841 PMCID: PMC5467837 DOI: 10.1371/journal.pone.0178665] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/09/2017] [Indexed: 01/12/2023] Open
Abstract
In surgical procedures involving the liver, such as transplantation, resection, and trauma, a temporary occlusion of hepatic vessels may be required. This study was designed to analyze the lesions promoted by ischemia and reperfusion injury of the hepatic pedicle, in the liver and lung, using histopathological and immunohistochemical techniques. In total, 39 Wistar rats were divided into four groups: control group (C n = 3) and ischemia groups subjected to 10, 20, and 30 minutes of hepatic pedicle clamping (I10, n = 12; I20, n = 12; I30, n = 12). Each ischemia group was subdivided into four subgroups of reperfusion (R15, n = 3; R30, n = 3; R60, n = 3; R120, n = 3), after 15, 30, 60, and 120 minutes of reperfusion, respectively. Significant differences were observed in the liver parenchyma (P < 0.05) between the values of microvesicles and hydropic degeneration at different times of ischemia and reperfusion. However, the values of vascular congestion, necrosis, and pyknotic nuclei showed no significant differences (P > 0.05). In the lung parenchyma, a significant difference was observed (P < 0.05) between the values of alveolar septal wall thickening and inflammatory infiltration at different times of ischemia and reperfusion. However, there was no significant difference (P < 0.05) between the values of vascular congestion, bronchial epithelial degeneration, interstitial edema, and hemorrhage. The positive immunoreactivity of caspase-3 protein in the liver parenchyma (indication of ongoing apoptosis), showed no significant differences (P > 0.05) at different times of ischemia and reperfusion. In the pulmonary parenchyma, the immunoreactivity was not specific, and was not quantified. This study demonstrated that the longer the duration of ischemia and reperfusion, the greater are the morphological lesions found in the hepatic and pulmonary parenchyma.
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Affiliation(s)
- Silvio Henrique Freitas
- Faculty of Veterinary Medicine, University of Cuiaba, Cuiabá, Mato Grosso, Brazil
- Department of Veterinary Medicine, Faculty of Animal Sciences and Food Engineering, University of São Paulo, Pirassununga, São Paulo, Brazil
| | - Renata G. S. Dória
- Department of Veterinary Medicine, Faculty of Animal Sciences and Food Engineering, University of São Paulo, Pirassununga, São Paulo, Brazil
| | - Rachel S. Bueno
- Department of Basic Sciences, Faculty of Animal Sciences and Food Engineering, University of São Paulo, Pirassununga, São Paulo, Brazil
| | - William B. Rocha
- Faculty of Veterinary Medicine, University of Cuiaba, Cuiabá, Mato Grosso, Brazil
| | - Jair R. E. Filho
- Graduate Program in Animal Science, School of Agricultural Sciences and Veterinary Medicine - Pontifícia Universidade Católica do Paraná (PUCPR), São José dos Pinhais, Paraná, Brazil
| | - Julieta R. E. Moraes
- Department of Pathology, Faculty of Agriculture and Veterinary Sciences, São Paulo State University Júlio de Mesquita Filho, Jaboticabal, São Paulo, Brazil
| | | | - Carlos E. Ambrósio
- Department of Veterinary Medicine, Faculty of Animal Sciences and Food Engineering, University of São Paulo, Pirassununga, São Paulo, Brazil
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Abstract
Historically, the 5-year survival rates for patients with stage 4 (metastatic) colorectal cancer were extremely poor (5%); however, with advances in systemic chemotherapy combined with an ability to push the boundaries of surgical resection, survival rates in the range of 25–40% can be achieved. This multimodal approach of combining neo-adjuvant strategies with surgical resection has raised a number of questions regarding the optimal management and timing of surgery. For the purpose of this review, we will focus on the treatment of stage 4 colorectal cancer with synchronous liver metastases.
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Affiliation(s)
- Danielle Collins
- Department of Colon and Rectal surgery, Mayo Clinic, Rochester, MN, USA
| | - Heidi Chua
- Department of Colon and Rectal surgery, Mayo Clinic, Rochester, MN, USA
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Anatomic trisegmentectomy: An alternative treatment for huge or multiple hepatocellular carcinoma of right liver. Biomed Pharmacother 2017; 88:684-688. [PMID: 28152477 DOI: 10.1016/j.biopha.2016.12.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 12/26/2016] [Accepted: 12/31/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The patients with huge (≥10cm) or multiple hepatocellular carcinoma (HCC) in the right liver and insufficient size of the remnant left liver can not be performed an operation of right hemihepatectomy because of that liver failure will occur post operation. We designed anatomic trisegmentectomy in right liver to increase the ratio of future liver remnant volume (%FLRV), thus increasing resectability of huge or multiple HCC. METHODS Thirteen patients were analyzed by preoperative CT scan for liver and tumor volumetries. If the right hemihepatectomy was done, %FLRV would be at the range of 29.6%-37.5%. However, if trisegmentectomy was done, %FLRV would increase by an average of 14.0%. So patients will not undergo postoperative liver failure due to sufficient %FLRV. Therefore, we designed anatomic trisegmentectomy, with retention of segment 5 or segment 8, to increase %FLRV and increase the resectability for huge or multiple HCC. RESULTS After trisegmentectomy, the inflow and outflow of remnant liver were maintained well. Severe complications and mortality were not happened post operation. Of the 13 patients, 10 survived up to now. Of the 10 living cases, postoperative lung metastasis was found in 2 and intrahepatic recurrence was found in 1. These 3 patients survive with tumor after comprehensive therapies including oral administration of Sorafenib. CONCLUSION Compared to right hemihepatectomy, anatomic trisegmentectomy in right liver guarantees the maximum preservation of %FLRV to increase the resectability of huge or multiple HCC, thus improving the overall resection rate.
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Moggia E, Rouse B, Simillis C, Li T, Vaughan J, Davidson BR, Gurusamy KS. Methods to decrease blood loss during liver resection: a network meta-analysis. Cochrane Database Syst Rev 2016; 10:CD010683. [PMID: 27797116 PMCID: PMC6472530 DOI: 10.1002/14651858.cd010683.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver resection is a major surgery with significant mortality and morbidity. Specialists have tested various methods in attempts to limit blood loss, transfusion requirements, and morbidity during elective liver resection. These methods include different approaches (anterior versus conventional approach), use of autologous blood donation, cardiopulmonary interventions such as hypoventilation, low central venous pressure, different methods of parenchymal transection, different methods of management of the raw surface of the liver, different methods of vascular occlusion, and different pharmacological interventions. A surgeon typically uses only one of the methods from each of these seven categories. The optimal method to decrease blood loss and transfusion requirements in people undergoing liver resection is unknown. OBJECTIVES To assess the effects of different interventions for decreasing blood loss and blood transfusion requirements during elective liver resection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Science Citation Index Expanded to September 2015 to identify randomised clinical trials. We also searched trial registers and handsearched the references lists of identified trials. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of decreasing blood loss and blood transfusion requirements in people undergoing liver resection. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and collected data. We assessed the risk of bias using Cochrane domains. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4, following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) for the binary outcomes, mean differences (MD) with 95% CrI for continuous outcomes, and rate ratios with 95% CrI for count outcomes, using a fixed-effect model or random-effects model according to model-fit. We assessed the evidence with GRADE. MAIN RESULTS We identified 67 randomised clinical trials involving a total of 6197 participants. All the trials were at high risk of bias. A total of 5771 participants from 64 trials provided data for one or more outcomes included in this review. There was no evidence of differences in most of the comparisons, and where there was, these differences were in single trials, mostly of small sample size. We summarise only the evidence that was available in more than one trial below. Of the primary outcomes, the only one with evidence of a difference from more than one trial under the pair-wise comparison was in the number of adverse events (complications), which was higher with radiofrequency dissecting sealer than with the clamp-crush method (rate ratio 1.85, 95% CrI 1.07 to 3.26; 250 participants; 3 studies; very low-quality evidence). Among the secondary outcomes, the only differences we found from more than one trial under the pair-wise comparison were the following: blood transfusion (proportion) was higher in the low central venous pressure group than in the acute normovolemic haemodilution plus low central venous pressure group (OR 3.19, 95% CrI 1.56 to 6.95; 208 participants; 2 studies; low-quality evidence); blood transfusion quantity (red blood cells) was lower in the fibrin sealant group than in the control (MD -0.53 units, 95% CrI -1.00 to -0.07; 122 participants; 2; very low-quality evidence); blood transfusion quantity (fresh frozen plasma) was higher in the oxidised cellulose group than in the fibrin sealant group (MD 0.53 units, 95% CrI 0.36 to 0.71; 80 participants; 2 studies; very low-quality evidence); blood loss (MD -0.34 L, 95% CrI -0.46 to -0.22; 237 participants; 4 studies; very low-quality evidence), total hospital stay (MD -2.42 days, 95% CrI -3.91 to -0.94; 197 participants; 3 studies; very low-quality evidence), and operating time (MD -15.32 minutes, 95% CrI -29.03 to -1.69; 192 participants; 4 studies; very low-quality evidence) were lower with low central venous pressure than with control. For the other comparisons, the evidence for difference was either based on single small trials or there was no evidence of differences. None of the trials reported health-related quality of life or time needed to return to work. AUTHORS' CONCLUSIONS Paucity of data meant that we could not assess transitivity assumptions and inconsistency for most analyses. When direct and indirect comparisons were available, network meta-analysis provided additional effect estimates for comparisons where there were no direct comparisons. However, the paucity of data decreases the confidence in the results of the network meta-analysis. Low-quality evidence suggests that liver resection using a radiofrequency dissecting sealer may be associated with more adverse events than with the clamp-crush method. Low-quality evidence also suggests that the proportion of people requiring a blood transfusion is higher with low central venous pressure than with acute normovolemic haemodilution plus low central venous pressure; very low-quality evidence suggests that blood transfusion quantity (red blood cells) was lower with fibrin sealant than control; blood transfusion quantity (fresh frozen plasma) was higher with oxidised cellulose than with fibrin sealant; and blood loss, total hospital stay, and operating time were lower with low central venous pressure than with control. There is no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements (very low-quality evidence). Radiofrequency dissecting sealer should not be used outside the clinical trial setting since there is low-quality evidence for increased harm without any evidence of benefits. In addition, it should be noted that the sample size was small and the credible intervals were wide, and we cannot rule out considerable benefit or harm with a specific method of liver resection.
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Affiliation(s)
- Elisabetta Moggia
- IRCCS Humanitas Research HospitalDepartment of General and Digestive SurgeryVia Manzoni 5620089 RozzanoMilanItalyItaly20089
| | - Benjamin Rouse
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Constantinos Simillis
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Tianjing Li
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Jessica Vaughan
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Muangkaew P, Cho JY, Han HS, Yoon YS, Choi Y, Jang JY, Choi H, Jang JS, Kwon SU. Outcomes of Simultaneous Major Liver Resection and Colorectal Surgery for Colorectal Liver Metastases. J Gastrointest Surg 2016; 20:554-63. [PMID: 26471363 DOI: 10.1007/s11605-015-2979-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal surgical strategy for treating colorectal cancer liver metastases (CRLM) in patients requiring major liver resection (MLR) is controversial, especially in rectal cancer patients. METHOD Between March 2004 and January 2015, 103 patients underwent MLR for CRLM and underwent MLR simultaneously with colorectal surgery (simultaneous group; n = 55) or MLR after colorectal surgery (liver-only group; n = 48). RESULTS There were no significant differences in sex, age, ASA score, BMI, size and number of liver metastases, liver resection margin, surgical outcomes, and estimated blood loss. The rates of postoperative complications (simultaneous group vs. liver-only group; 76.4 % vs. 62.5 %; P = 0.126) and major complications (29.0 % vs. 25.0 %; P = 0.513) were also similar in both groups. The time to starting a soft diet was longer in the simultaneous group (6.0 days vs. 3.4 days; P < 0.001), but the length of hospital stay was similar (14.9 days vs. 13.3 days; P = 0.345). There were no perioperative deaths, anastomotic leakage, or septic complications. Among patients who underwent rectal surgery, the frequency of complications was greater in the simultaneous group (87.0 % vs. 56.2 %; P = 0.031), but there was no difference in major complications (34.7 % vs. 25.0 %; P = 0.822). The postoperative morbidity index was 0.204 and 0.180 in the simultaneous and liver-only groups, respectively, in all patients, and was 0.227 and 0.136, respectively, in the rectal surgery subgroup. CONCLUSION Simultaneous MLR is feasible and safe in synchronous CRLM patients, including rectal cancer patients.
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Affiliation(s)
- Paramin Muangkaew
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea.,Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea.
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Jae Yool Jang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Hanlim Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Jae Seong Jang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
| | - Seong Uk Kwon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea
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Dimitroulis D, Moris D, Pikoulis E, Spartalis E, Kontadakis G, Vrugt B, Valsami S, Kouraklis G. Variable Pringle Maneuvers and Effect on Intestinal Epithelium in Rats. A Pilot Experimental Study in Rats. PLoS One 2015; 10:e0140707. [PMID: 26496481 PMCID: PMC4619866 DOI: 10.1371/journal.pone.0140707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/28/2015] [Indexed: 02/07/2023] Open
Abstract
Background It is observed that combined liver and colon surgery especially when this includes major liver resection with Pringle maneuver (PM) performance does not have a favorable outcome. Aim of our experimental study is to investigate the impact of portal triad occlusion on the large bowel and intra-abdominal inflammation and potent protective effects of the variants of (PM) in the combined surgical cases. Materials and Methods Forty-four rats were divided into four groups. In group A (control group), 1cm of the left partial colon was resected and then an end-to-end anastomosis was performed. In group B, a continuous PM for 30 minutes was performed followed by resection of 1cm of the left colon and an end-to-end anastomosis. In group C, the left colonic resection and anastomosis was performed after intermittent PM (IPM), which was 10 minutes PM followed by 5 minutes reperfusion repeated for three circles. In group D, an ischemic preconditioning for 10 minutes was initially performed followed by 5 minutes reperfusion and then continuous PM for 30 minutes. Finally the rats in group D underwent a 1cm left colonic resection and an end-to-end anastomosis. Results The percentage of colitis was higher in the B group (P = 0,19). The percentage of inflammation was not significantly higher even when we compared all “occlusion” groups (B+C+D) with the sham group. No evidence of pancreatitis was found in the sham group whereas amylase and lipase levels were higher in Groups B, C and D together (P = 0,0267). The comparison of group A to group B showed a significant difference (P = 0,0014) caused by continuous PM for 30 minutes, but there was no such result after IPM. Conclusions Major liver resections are performed with PM in order to minimize intra-operative blood loss. In the combined cases of colon surgery and major liver resections where PM is needed our results showed that IPM presents with better outcome and could be preferred compared with the other PM variants.
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Affiliation(s)
- Dimitrios Dimitroulis
- Second Department of Propedeutic Surgery, "Laikon" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Demetrios Moris
- First Department of Surgery, "Laikon" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
- * E-mail:
| | - Emmanouil Pikoulis
- First Department of Surgery, "Laikon" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- Second Department of Propedeutic Surgery, "Laikon" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Kontadakis
- Second Department of Propedeutic Surgery, "Laikon" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Bart Vrugt
- Laboratory of Molecular Oncology, Clinic of Oncology, University Hospital Zürich, Zürich, Switzerland
| | - Serena Valsami
- Second Department of Propedeutic Surgery, "Laikon" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kouraklis
- Second Department of Propedeutic Surgery, "Laikon" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Propofol Attenuates Small Intestinal Ischemia Reperfusion Injury through Inhibiting NADPH Oxidase Mediated Mast Cell Activation. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2015; 2015:167014. [PMID: 26246867 PMCID: PMC4515292 DOI: 10.1155/2015/167014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 09/07/2014] [Indexed: 12/14/2022]
Abstract
Both oxidative stress and mast cell (MC) degranulation participate in the process of small intestinal ischemia reperfusion (IIR) injury, and oxidative stress induces MC degranulation. Propofol, an anesthetic with antioxidant property, can attenuate IIR injury. We postulated that propofol can protect against IIR injury by inhibiting oxidative stress subsequent from NADPH oxidase mediated MC activation. Cultured RBL-2H3 cells were pretreated with antioxidant N-acetylcysteine (NAC) or propofol and subjected to hydrogen peroxide (H2O2) stimulation without or with MC degranulator compound 48/80 (CP). H2O2 significantly increased cells degranulation, which was abolished by NAC or propofol. MC degranulation by CP further aggravated H2O2 induced cell degranulation of small intestinal epithelial cell, IEC-6 cells, stimulated by tryptase. Rats subjected to IIR showed significant increases in cellular injury and elevations of NADPH oxidase subunits p47(phox) and gp91(phox) protein expression, increases of the specific lipid peroxidation product 15-F2t-Isoprostane and interleukin-6, and reductions in superoxide dismutase activity with concomitant enhancements in tryptase and β-hexosaminidase. MC degranulation by CP further aggravated IIR injury. And all these changes were attenuated by NAC or propofol pretreatment, which also abrogated CP-mediated exacerbation of IIR injury. It is concluded that pretreatment of propofol confers protection against IIR injury by suppressing NADPH oxidase mediated MC activation.
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Ren W, Wang X, Zhang A, Li C, Chen G, Ge X, Pan K, Dong JH. Selective bowel decontamination improves the survival of 90% hepatectomy in rats. J Surg Res 2015; 195:454-64. [DOI: 10.1016/j.jss.2015.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/12/2014] [Accepted: 01/13/2015] [Indexed: 12/23/2022]
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Yamaguchi N, Yokoyama Y, Ebata T, Igami T, Sugawara G, Asahara T, Nomoto K, Nagino M. Intermittent Pringle maneuver is unlikely to induce bacterial translocation to the portal vein: a study using bacterium-specific ribosomal RNA-targeted reverse transcription-polymerase chain reaction. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:491-7. [PMID: 25782012 DOI: 10.1002/jhbp.239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/12/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND The occurrence of bacterial translocation (BT) to the mesenteric lymph nodes following the Pringle maneuver is well established; however, the incidence of BT to the portal circulation remains unclear. METHODS Portal blood of patients with suspected hilar malignancy who underwent major hepatobiliary resection with cholangiojejunostomy was sampled three times during surgery: immediately after laparotomy (PV-1); before liver transection and after skeletonization of the hepatoduodenal ligament (PV-2); and after completion of the liver transection (PV-3). The samples were analyzed for microbes with a bacterium-specific ribosomal RNA-targeted reverse transcription-polymerase chain reaction method. RESULTS Fifty patients were enrolled in the study, with a mean total Pringle time of 86 min. Microbes in the portal blood were detected in 11 (22%) of the 50 patients. The occurrence of microbes was not different among the PV-1 samples (8% = 4/50), PV-2 samples (14% = 7/50), and PV-3 samples (14% = 7/50) (P = 0.567). Obligate anaerobes were predominantly detected. The positivity of the PV-3 samples showed no correlation with the total Pringle time or with the occurrence of postoperative infectious complications. The total Pringle time did not affect the surgical outcomes, including infectious complications, liver failure, or mortality. The concentrations of aspartate aminotransferase and alanine aminotransferase on postoperative day 1 significantly correlated with the total Pringle time. CONCLUSIONS The intermittent Pringle maneuver is unlikely to induce BT to the portal circulation and is safe, even in difficult, complicated hepatobiliary resections requiring long clamping times.
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Affiliation(s)
- Naoya Yamaguchi
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yukihiro Yokoyama
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsuyoshi Igami
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Gen Sugawara
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Asahara
- Yakult Central Institute for Microbiological Research, Tokyo, Japan
| | - Koji Nomoto
- Yakult Central Institute for Microbiological Research, Tokyo, Japan
| | - Masato Nagino
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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Intermittent clamping of the hepatic pedicle in simultaneous ultrasonography-guided liver resection and colorectal resection with intestinal anastomosis: is it safe? Int J Colorectal Dis 2014; 29:1517-25. [PMID: 25185843 DOI: 10.1007/s00384-014-2004-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE In patients with colorectal cancer (CRC) and synchronous colorectal liver metastases (CRLM) potentially candidates to combined liver (LR) and colorectal resection (CRR), the extent of LR and the need of hepatic pedicle clamping (HPC) in selected cases are considered risk factors for the outcome of the intestinal anastomosis. This study aimed to determine whether intermittent HPC is predictive of anastomotic leakage (AL) and has an adverse effect on the clinical outcome in patients undergoing combined restorative CRR and LR. METHODS One hundred six LR have been performed for CRLM in our unit from July 2005. Patients who received CRR with anastomosis and simultaneous intraoperative ultrasonography (IOUS)-guided LR/ablation for resectable CRLM were included in this study. CRR was performed first. Intermittent HPC was decided at the discretion of the liver surgeon. The perioperative outcome was evaluated according to occurrence of AL and overall postoperative morbidity and mortality. RESULTS Thirty-eight patients underwent simultaneous IOUS-guided LR/ablation and CRR with intestinal anastomosis; 19 underwent intermittent HPC (group ICHPY) while 19 did not (group ICHPN); the mean ± SD (range) duration of clamping in group ICHPY was 58.6 ± 32.2 (10.0-125.0) min. Postoperative results were similar between groups. One asymptomatic AL occurred in group ICHPY (5.2 %). Major postoperative complications were none in group ICHPY and one (5.2 %) in group ICHPN, respectively. One patient in group ICHPY died postoperatively (5.2 %). CONCLUSIONS This study suggests that intermittent HPC during LR is not predictive of AL and has no adverse effect on the overall clinical outcome in patients undergoing combined restorative colorectal surgery and hepatectomy for advanced CRC.
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Li BC, Xia ZQ, Li C, Liu WF, Wen SH, Liu KX. The incidence and risk factors of gastrointestinal complications after hepatectomy: a retrospective observational study of 1329 consecutive patients in a single center. J Surg Res 2014; 192:440-6. [DOI: 10.1016/j.jss.2014.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 05/04/2014] [Accepted: 06/06/2014] [Indexed: 12/20/2022]
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Wang ZX, Huang CY, Hua YP, Huang WQ, Deng LH, Liu KX. Dexmedetomidine reduces intestinal and hepatic injury after hepatectomy with inflow occlusion under general anaesthesia: a randomized controlled trial. Br J Anaesth 2014; 112:1055-64. [PMID: 24771805 DOI: 10.1093/bja/aeu132] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We compared intestinal, hepatic, and other organ function after hepatic portal occlusion with or without dexmedetomidine administration under general anaesthesia. METHODS In this prospective, randomized double-blind investigation, 44 patients undergoing elective hepatectomy with inflow occlusion were randomized into a dexmedetomidine group or a control group. The dexmedetomidine group received an initial dexmedetomidine loading dose of 1 μg kg(-1) over 10 min followed by a maintenance dose of 0.3 μg kg(-1) h(-1). In the control group, 0.9% sodium chloride was administered. The primary outcome was serum diamine oxidase (DAO) activity reflecting intestinal injury. The secondary outcomes included variables reflecting intestinal, hepatic, kidney, and cardiopulmonary function, and biomarkers of oxidative stress and systemic inflammatory response. RESULTS DAO activity was lower in the dexmedetomidine group than in the control group at 6 and 24 h after liver reperfusion [9.77 (1.07) vs14.29 (1.43) units ml(-1), P=0.021; 9.67 (0.98) vs 13.97 (1.31) units ml(-1), P=0.017]. d-lactate acid levels were lower during 1-72 h after liver reperfusion compared with the control group (all P<0.05). Also, the intestinal injury severity grade was decreased by dexmedetomidine (P=0.038). The biomarkers reflecting liver injury increased over time, but were lower in the dexmedetomidine group (all P<0.05), while the variables reflecting cardiopulmonary and renal function showed no differences between the groups (all P>0.05). CONCLUSIONS Dexmedetomidine administered perioperatively attenuates intestinal and hepatic injury in patients undergoing elective liver resection with inflow occlusion without any potential risk. CLINICAL TRIAL REGISTRATION ChiCTR-TRC-11001530, September 2011.
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Affiliation(s)
- Z X Wang
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan II Road, Guangzhou 510080, China
| | - C Y Huang
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan II Road, Guangzhou 510080, China
| | - Y P Hua
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan II Road, Guangzhou 510080, China
| | - W Q Huang
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan II Road, Guangzhou 510080, China
| | - L H Deng
- Department of Laboratory Medicine, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan II Road, Guangzhou 510080, China
| | - K X Liu
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan II Road, Guangzhou 510080, China
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Jia CK, Weng J, Chen YK, Fu Y. Anatomic resection of liver segments 6-8 for hepatocellular carcinoma. World J Gastroenterol 2014; 20:4433-4439. [PMID: 24764684 PMCID: PMC3989982 DOI: 10.3748/wjg.v20.i15.4433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 12/25/2013] [Accepted: 02/20/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To report the devised anatomic liver resection of segments 6, 7 and 8 to improve the resection rate for patients with right liver tumors.
METHODS: We performed anatomic liver resection of segments 6, 7 and 8 to guarantee the maximum preservation of the remaining normal liver tissue. Segment 5 was determined by two steps of Glissonean pedicle occlusion. And a “┏┛” shaped broken resection line was marked upon the diaphragmatic surface of the liver. Selective right hemihepatic inflow occlusion was used to reduce blood loss during parenchymal transection between segments 6 and 5 and between segments 8 and 5. If needed, total hepatic Glissonean pedicle occlusion was used during parenchymal transection between segment 8 and the left liver.
RESULTS: Compared to right hemihepatectomy, the percentage of future liver remnant volume was increased by an average of 13.9% if resection of segments 6, 7 and 8 was performed. Resection of segments 6, 7 and 8 was completed uneventfully. After hepatectomy, the inflow and outflow of segment 5 were maintained. There was no perioperative mortality, postoperative abdominal bleeding or bile leakage in this group. Alpha-fetoprotein (AFP) returned to the normal range within 2 mo after the operation in all the patients. One patient died 383 d postoperatively due to obstructive suppurative cholangitis. One patient suffered from severe liver dysfunction shortly after surgery and had intrahepatic recurrence 4 mo postoperatively. Postoperative lung metastasis was found in one patient. No tumor recurrence was found in the other patients and the parameters including liver function and AFP level were in the normal range.
CONCLUSION: Anatomic liver resection of segments 6, 7 and 8 can be a conventional operation to improve the overall resection rate for hepatocellular carcinoma.
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Wolfs TGAM, Kramer BW, Thuijls G, Kemp MW, Saito M, Willems MGM, Senthamarai-Kannan P, Newnham JP, Jobe AH, Kallapur SG. Chorioamnionitis-induced fetal gut injury is mediated by direct gut exposure of inflammatory mediators or by lung inflammation. Am J Physiol Gastrointest Liver Physiol 2014; 306:G382-93. [PMID: 24458021 PMCID: PMC3949018 DOI: 10.1152/ajpgi.00260.2013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intra-amniotic exposure to proinflammatory agonists causes chorioamnionitis and fetal gut inflammation. Fetal gut inflammation is associated with mucosal injury and impaired gut development. We tested whether this detrimental inflammatory response of the fetal gut results from a direct local (gut derived) or an indirect inflammatory response mediated by the chorioamnion/skin or lung, since these organs are also in direct contact with the amniotic fluid. The gastrointestinal tract was isolated from the respiratory tract and the amnion/skin epithelia by fetal surgery in time-mated ewes. Lipopolysaccharide (LPS) or saline (controls) was selectively infused in the gastrointestinal tract, trachea, or amniotic compartment at 2 or 6 days before preterm delivery at 124 days gestation (term 150 days). Gastrointestinal and intratracheal LPS exposure caused distinct inflammatory responses in the fetal gut. Inflammatory responses could be distinguished by the influx of leukocytes (MPO(+), CD3(+), and FoxP3(+) cells), tumor necrosis factor-α, and interferon-γ expression and differential upregulation of mRNA levels for Toll-like receptor 1, 2, 4, and 6. Fetal gut inflammation after direct intestinal LPS exposure resulted in severe loss of the tight junctional protein zonula occludens protein 1 (ZO-1) and increased mitosis of intestinal epithelial cells. Inflammation of the fetal gut after selective LPS instillation in the lungs caused only mild disruption of ZO-1, loss in epithelial cell integrity, and impaired epithelial differentiation. LPS exposure of the amnion/skin epithelia did not result in gut inflammation or morphological, structural, and functional changes. Our results indicate that the detrimental consequences of chorioamnionitis on fetal gut development are the combined result of local gut and lung-mediated inflammatory responses.
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Affiliation(s)
- Tim G. A. M. Wolfs
- 1Division of Neonatology, the Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio; ,2Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, Maastricht, the Netherlands; and
| | - Boris W. Kramer
- 2Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, Maastricht, the Netherlands; and
| | - Geertje Thuijls
- 1Division of Neonatology, the Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio;
| | - Matthew W. Kemp
- 3School of Women's and Infants Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Masatoshi Saito
- 3School of Women's and Infants Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Monique G. M. Willems
- 2Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, Maastricht, the Netherlands; and
| | - Paranthaman Senthamarai-Kannan
- 1Division of Neonatology, the Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio;
| | - John P. Newnham
- 3School of Women's and Infants Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Alan H. Jobe
- 1Division of Neonatology, the Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio; ,3School of Women's and Infants Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Suhas G. Kallapur
- 1Division of Neonatology, the Perinatal Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio; ,3School of Women's and Infants Health, The University of Western Australia, Crawley, Western Australia, Australia
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Antenatal ureaplasma infection impairs development of the fetal ovine gut in an IL-1-dependent manner. Mucosal Immunol 2013; 6:547-56. [PMID: 23149664 DOI: 10.1038/mi.2012.97] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Ureaplasma infection of the amniotic cavity is associated with adverse postnatal intestinal outcomes. We tested whether interleukin-1 (IL-1) signaling underlies intestinal pathology following ureaplasma exposure in fetal sheep. Pregnant ewes received intra-amniotic injections of ureaplasma or culture media for controls at 3, 7, and 14 d before preterm delivery at 124 d gestation (term 150 d). Intra-amniotic injections of recombinant human interleukin IL-1 receptor antagonist (rhIL-1ra) or saline for controls were given 3 h before and every 2 d after Ureaplasma injection. Ureaplasma exposure caused fetal gut inflammation within 7 d with damaged villus epithelium and gut barrier loss. Proliferation, differentiation, and maturation of enterocytes were significantly reduced after 7 d of ureaplasma exposure, leading to severe villus atrophy at 14 d. Inflammation, impaired development and villus atrophy of the fetal gut was largely prevented by intra-uterine rhIL-1ra treatment. These data form the basis for a clinical understanding of the role of ureaplasma in postnatal intestinal pathologies.
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Machado MCC, Barbeiro HV, Pinheiro da Silva F, de Souza HP. Circulating fatty acid binding protein as a marker of intestinal failure in septic patients. Crit Care 2012; 16:455. [PMID: 23130611 PMCID: PMC3672560 DOI: 10.1186/cc11653] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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