Endotoxemia after relief of biliary obstruction by internal and external drainage in rats

The impact of preoperative biliary drainage on postoperative healthcare-associated infections and clinical outcomes following pancreaticoduodenectomy: a ten-year retrospective analysis

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex procedure and easily accompanied by healthcare-associated infections (HAIs). This study aimed to assess the impact of PBD on postoperative infections and clinical outcomes in PD patients.

METHODS

The retrospective cohort study were conducted in a tertiary hospital from January 2013 to December 2022. Clinical and epidemiological data were collected from HAIs surveillance system and analyzed.

RESULTS

Among 2842 patients who underwent PD, 247 (8.7%) were diagnosed with HAIs, with surgical site infection being the most frequent type (n = 177, 71.7%). A total of 369 pathogenic strains were detected, with Klebsiella pneumoniae having the highest proportion, followed by Enterococcu and Escherichia coli. Although no significant association were observed generally between PBD and postoperative HAIs, subgroup analysis revealed that PBD was associated with postoperative HAIs in patients undergoing robotic PD (aRR = 2.174; 95% CI:1.011-4.674; P = 0.047). Prolonging the interval between PBD and PD could reduce postoperative HAIs in patients with cholangiocarcinoma (≥4 week: aRR = 0.292, 95% CI 0.100-0.853; P = 0.024) and robotic PD (≤2 week: aRR = 3.058, 95% CI 1.178-7.940; P = 0.022). PBD was also found to increase transfer of patients to ICU (aRR = 1.351; 95% CI 1.119-1.632; P = 0.002), extended length of stay (P < 0.001) and postoperative length of stay (P = 0.004).

CONCLUSION

PBD does not exhibit a significant association with postoperative HAIs or other outcomes. However, the implementation of robotic PD, along with a suitable extension of the interval between PBD and PD, appear to confer advantages concerning patients' physiological recuperation. These observations suggest potential strategies that may contribute to enhanced patient outcomes.

Preoperative biliary drainage in severely jaundiced patients with pancreatic head cancer: A retrospective cohort study

BACKGROUND

Guidelines recommend against preoperative biliary drainage (PBD) in patients with pancreatic head cancer if bilirubin levels are <250 μmol/l. However, patients with higher bilirubin levels undergo PBD, despite the lack of supporting evidence. This study aims to evaluate outcomes in patients with a bilirubin level ≥250 and < 250.

METHODS

Patients were identified from databases of 3 centers. Outcomes were compared in patients with a bilirubin level ≥250 versus <250 both at the time of diagnosis and directly prior to surgery.

RESULTS

244 patients were included. PBD was performed in 64% (123/191) with bilirubin <250 at diagnosis and 91% (48/53) with bilirubin ≥250. PBD technical success (83% vs. 81%, p = 0.80) and PBD related complications (33% vs. 29%, p = 0.60) did not differ between these groups. Analyzing bilirubin levels ≥250 versus <250 directly prior to surgery, no differences in severe postoperative complications and mortality were found.

CONCLUSIONS

In patients with a pancreatic head cancer, PBD technical success and complications, and severe postoperative complications did not differ between patients with a bilirubin level ≥250 and < 250. Our study does not support a different approach regarding PBD in patients with severe jaundice.

Fecal Microbes Associated with the Outcomes After Esophagectomy in Patients with Esophageal Cancer

BACKGROUND

Although accumulating evidence suggests that an imbalanced gut microbiota leads to cancer progression, few studies demonstrated the implication in patients who underwent oncologic esophagectomy. This study aimed to elucidate the association between gut microbes and the outcomes after oncologic esophagectomy, as well as the host's inflammatory/nutritional status.

METHODS

Overall, 783 consecutive patients who underwent oncologic esophagectomy were eligible. We investigated the microbiota detected by fecal culture tests and then assessed the association between the gut microbiota and patient characteristics, short-term outcomes, and long-term survival.

RESULTS

Seventeen different species could be cultivated. We comprehensively examined the impact of each detected microbe on survival. The presence of Bacillus species (Bacillus sp.; 26.8%) was associated with favorable prognosis on overall and cancer-specific survival (p = 0.02 and 0.02, respectively). Conversely, the presence of Proteus mirabilis (P. mirabilis; 3.4%) was associated with unfavorable overall and recurrence-free survivals (p = 0.02 and < 0.01, respectively). Multivariate analysis showed that the presence of P. mirabilis was one of the independent prognostic factors for poor recurrence-free survival (p < 0.01). Patients with Bacillus sp. had lower modified Glasgow prognostic score and better response to preoperative treatment than those without (p = 0.01 and 0.03, respectively). Meanwhile, patients with P. mirabilis were significantly associated with higher systemic inflammation scores and increased postoperative pneumonia incidence than those without (p = 0.01 and 0.02, respectively).

CONCLUSIONS

Preoperative fecal microbiota was associated with the host's inflammatory and nutritional status and may influence the outcomes after oncologic esophagectomy.

Efficacy and safety of preoperative biliary drainage in patients undergoing pancreaticoduodenectomy: an updated systematic review and meta-analysis

OBJECTIVES

This study aimed to evaluate the effect of preoperative biliary drainage (PBD) on outcomes of pancreaticoduodenectomy (PD) in patients with biliary obstruction.

METHODS

We searched PubMed, EMBASE, Cochrane library, and Web of Science from database inception to 11 March 2021. We used the ROBINS-I tool and Cochrane risk of bias tool 2.0 to assess the risk of bias. The data were statistically analyzed using the RevMan software (Version 5.4).

RESULTS

In all, 43 studies, including 23,076 patients, were analyzed, of which 13,922 patients were treated with PBD and 9154 were treated with no preoperative biliary drainage (NPBD). The morbidity     , infection morbidity      , and postoperative pancreatic fistulae (POPF)       in patients undergoing PBD, were significantly higher than those in patients undergoing NPBD. Further, PBD may lead to a significantly worse 2- and 3-year overall survival (OS) rates           . In subgroup meta-analysis, the differences in morbidity, POPF, and OS outcomes lost significance between the PBD and NPBD groups when the mean total serum bilirubin (TSB) concentration was below 15 mg/dl.

CONCLUSIONS

Routine PBD still cannot be recommended because it showed no beneficial effect on postoperative outcomes. However, in patients with < 15 mg/dl TSB concentration, PBD tends to be a better choice.

Bile is a promising gut nutrient that inhibits intestinal bacterial translocation and promotes gut motility via an interleukin-6-related pathway in an animal model of endotoxemia

OBJECTIVES

People who are critically ill have high rates of endotoxemia that can significantly decrease bile flow and increase bile cytokines, the latter of which might worsen their condition. Bile acids are nutrient-signaling hormones that have a significant impact on gut barrier function and motility, and the gut is considered the origin of systemic inflammation. Therefore, healthy exogenous bile could be a promising gut nutrient for critical illness, so the biomedical role of bile in endotoxemia was investigated in this study.

METHODS

Twelve rats were injected with lipopolysaccharide (LPS) and randomized into a group with sham operation) and a group with bile external drainage (n = 6 for each group); six rats with sham operation served as the control group. In addition, interleukin-6 (IL-6) knockout mice and macrophages were treated with LPS.

RESULTS

Compared to the control animals, the group with LPS injection and sham operation had significantly increased levels of gut permeability, gut bacterial translocation, gut mucosal tumor necrosis factor α, IL-6 transcripts, and serum tumor necrosis factor α and IL-6. Compared to group with sham operation and LPS injection, bile external drainage (in LPS-challenged rats) increased gut bacterial translocation by 10 times, and this detrimental effect was associated with prolonged intestinal transit time, increased serum IL-6 concentration, and up-regulated gut mucosal IL-6 transcripts. Moreover, bile selectively inhibited LPS-stimulated macrophages in IL-6 release, which can activate gastrointestinal submucosal neurons to promote motility. Knocking out IL-6 significantly reduced gut bacterial translocation in endotoxemic mice.

CONCLUSIONS

Bile is a promising gut nutrient that inhibits gut bacterial translocation and promotes gut motility via an IL-6-related pathway in experimental endotoxemia.

The effect of preoperative biliary stents on outcomes after pancreaticoduodenectomy: A meta-analysis

BACKGROUND

Whether biliary drainage should be performed before surgery in jaundiced patients is a topic of debate. Published studies on the effect of preoperative biliary drainage show great discrepancies in their conclusions, and the use of different drainage methods is an important factor. The aim of the present study was to investigate the effect of preoperative biliary stents (PBS) on postoperative outcomes in patients following pancreaticoduodenectomy (PD).

METHODS

MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane database were searched up to October 2019 to identify all published articles related to the topic. A meta-analysis was performed to compare postoperative outcomes in patients with and without PBS. Quality assessment and data extraction from included studies were performed by 2 independent authors. Statistical analysis was performed using RevMan 5.2 software.

RESULTS

Twenty-seven studies involving 10,445 patients were included in the analysis. Biliary drainage was performed in 5769 patients (PBS group), and the remaining 4676 patients underwent PD directly (direct surgery [DS] group). Overall mortality, severe complications, abdominal hemorrhage, bile leakage, intra-abdominal abscess, and pancreatic fistula were not significantly different between the PBS and DS groups. However, overall morbidity, delayed gastric emptying, and wound infection were significantly higher in the PBS group compared to the DS group. Subgroup analysis indicated that the adverse effect of PBS on postoperative complications was more evident with increased stent proportion.

CONCLUSIONS

Preoperative biliary stenting increases overall morbidity, delayed gastric emptying, and wound infection rates in patients following PD. Thus, preoperative biliary drainage via stent placement should be avoided in patients waiting for PD.

Is radical resection of hilar cholangiocarcinoma plus partial resection of pancreatic head justified for advanced hilar cholangiocarcinoma?

BACKGROUND

To outline our experience with the radical resection of hilar cholangiocarcinoma (HCCA) combined with the partial resection of the pancreatic head (RRHCCAPRPH) as a treatment for HCCA with distal bile duct involvement and to appraise the feasibility of this challenging procedure.

METHODS

Between 2007 and 2017, 205 patients with HCCA who underwent curative surgery at our hospital were included. Among the patients, extrahepatic bile duct resection combined with hepatectomy (EBDRH), RRHCCAPRPH and hepatopancreaticoduodenectomy (HPD) was performed in 168, 21 and 16 patients, respectively. Clinical pathological factors, post-operative complications and survival were compared between the three groups.

RESULTS

There was a significant difference in operative blood loss, operative time, post-operative hospital stay and tumour size between EBDRH group, RRHCCAPRPH group and HPD group (P < 0.05). In terms of post-operative complications, there was no statistical difference between the three groups (P = 0.177). Further analysis showed that the incidence of pancreatic fistula (43.8%) and delayed gastric emptying (25%) after HPD were significantly higher than the other two groups. The median survival time and overall survival rate for 172 patients with R0 resection were 33 months and 85.5% at 1 year, 47.7% at 3 years, 28.4% at 5 years. Furthermore, the 1-, 3- and 5-year survival rates of patients with EBDRH, RRHCCAPRPH and HPD after R0 resection were 86.2%, 48.7%, 29.2%; 85.0%, 44.0%, 24.7% and 78.6%, 42.9%, 22.9%, respectively (P = 0.948).

CONCLUSION

The RRHCCAPRPH in some selected patients can actually replace HPD as a surgical treatment for HCCA with distal bile duct involvement.

Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis

OBJECTIVES

The influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice.

METHODS

Data were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups.

RESULTS

A total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63-5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21-4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67-8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group.

CONCLUSIONS

In this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.

Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study

Background

Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD).

Objectives

To determine whether PBD is associated with more complications after PD.

Methods

Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate.

Results

There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without.

Conclusions

PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.

Endoscopic versus Percutaneous Biliary Drainage in Palliation of Advanced Malignant Hilar Obstruction: A Meta-Analysis and Systematic Review

Background. Palliation in advanced unresectable hilar malignancies can be achieved by endoscopic (EBD) or percutaneous transhepatic biliary drainage (PTBD). It is unclear if one approach is superior to the other in this group of patients. Aims. Compare clinical outcomes of EBD versus PTBD. Methods. (i) Study Selection Criterion. Studies using PTBD and EBD for palliation of advanced unresectable hilar malignancies. (ii) Data Collection and Extraction. Articles were searched in Medline, PubMed, and Ovid journals. (iii) Statistical Method. Fixed and random effects models were used to calculate the pooled proportions. Results. Initial search identified 786 reference articles, in which 62 articles were selected and reviewed. Data was extracted from nine studies (N = 546) that met the inclusion criterion. The pooled odds ratio for successful biliary drainage in PTBD versus EBD was 2.53 (95% CI = 1.57 to 4.08). Odds ratio for overall adverse effects in PTBD versus EBD groups was 0.81 (95% CI = 0.52 to 1.26). Odds ratio for 30-day mortality rate in PTBD group versus EBD group was 0.84 (95% CI = 0.37 to 1.91). Conclusions. In patients with advanced unresectable hilar malignancies, palliation with PTBD seems to be superior to EBD. PTBD is comparable to EBD in regard to overall adverse effects and 30-day mortality.

Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review

BACKGROUND

In patients requiring surgical resection for malignant biliary jaundice, it is unclear if preoperative biliary drainage (PBD) would improve mortality and morbidity by restoration of biliary flow prior to operation. This is a meta-analysis to pool the evidence and assess the utility of PBD in patients with malignant obstructive jaundice. The primary outcome is comparing mortality outcomes in patients with malignant obstructive jaundice undergoing direct surgery (DS) versus PBD. The secondary outcomes include major adverse events and length of hospital stay in both the groups.

METHODS

Studies using PBD in patients with malignant obstructive jaundice were included in this study. For the data collection and extraction, articles were searched in MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, etc. Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model).

RESULTS

Initial search identified 2230 reference articles, of which 204 were selected and reviewed. Twenty-six studies (N = 3532) for PBD in malignant obstructive jaundice which met the inclusion criteria were included in this analysis. The odds ratio for mortality in PBD group versus DS group was 0.96 (95 % CI = 0.71 to 1.29). Pooled number of major adverse effects was lower in the PBD group at 10.40 (95 % CI = 9.96 to 10.83) compared to 15.56 (95 % CI = 15.06 to 16.05) in the DS group. Subgroup analysis comparing internal PBD to DS group showed lower odds for major adverse events (odds ratio, 0.48 with 95 % CI = 0.32 to 0.74).

CONCLUSIONS

In patients with malignant biliary jaundice requiring surgery, PBD group had significantly less major adverse effects than DS group. Length of hospital stay and mortality rate were comparable in both the groups.

Current status of preoperative biliary drainage

Preoperative biliary drainage (PBD) has been thought to be preferable regardless of the site of biliary strictures, e.g., distal or proximal strictures because PBD by endoscopy or interventional radiology decreases postoperative mortality and morbidity rates. However, recently, several studies have revealed that PBD strategy showed an increased mortality rate or a high frequency of surgical site infection. Herein, we reviewed reports in the literature regarding the current status of PBD and investigated the effects of PBD on patients with distal and proximal biliary obstructions due to potentially resectable pancreatobiliary cancers. Our summary demonstrated that there is as yet no optimal PBD method regardless of the distal and proximal biliary strictures because of the small sample size and the lack of better control groups in previous studies. Thus, prospective randomized studies with a large sample size are needed to establish the optimal mode of PBD and to evaluate the potential benefits of PBD in patients with both distal and proximal biliary obstructions.

Endoscopic treatment of malignant biliary strictures

Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.

Preoperative biliary drainage in patients with distal obstruction due to pancreatic head cancer

A total of 77% of pancreatic head cancers manifest with obstructive jaundice. Hyperbilirubinemia impairs immunity and nutrition and is responsible for systemic toxicity. Several studies have attempted to investigate the impact of biliary drainage prior to duodenopancreatectomy (preoperative biliary drainage [PBD]) on jaundice resolution, morbidity, mortality and infectious complications, conferring high controversy. One large randomized controlled trial concluded that PBD should not be recommended in patients with distal obstructive jaundice owing to high infection rates. However, this work has been extensively criticized due to the exclusion of severely jaundiced patients, lack of information regarding antimicrobial agents used and employment of plastic instead of metal stents. However, proponents of PBD favor its application in selected cases. This work aims to review the literature on PBD for jaundice due to pancreatic head malignancy, to outline the controversy pertaining to this modality and to identify the indications of PBD in selected patients with malignant distal obstruction.

Should preoperative biliary drainage be routinely performed for obstructive jaundice with resectable tumor?

Obstructive jaundice is a common clinical manifestation of malignant lesions adjacent to extrahepatic bile duct, ampulla or pancreatic head. Animal experiments and some clinical observations have demonstrated that preoperative biliary drainage could improve liver function as well as reduce endotoxemia, thereby reducing the incidence of perioperative complications. However, a number of randomized, controlled studies have found that preoperative biliary drainage failed to improve prognosis or reduce the incidence of perioperative complications; in contrast, it might increase the incidence of complications and cause extra financial burden on patients. Thus, whether preoperative biliary drainage should be performed or not is controversial. Since clinical randomized controlled studies are more relevant in clinical setting, we believe that preoperative biliary drainage should not be routinely performed for obstructive jaundice with resectable tumors. More randomized, controlled, prospective studies should be conducted for further exploration.

The current status of preoperative biliary drainage for patients who receive pancreaticoduodenectomy for periampullary carcinoma: a comprehensive review

BACKGROUND

Surgery on patients with malignant obstructive jaundice carries increased risks of postoperative morbidity and mortality. Preoperative biliary drainage has been developed to reduce this procedure-related risks, but its role in patients who are going to receive pancreaticoduodenectomy for periampullary carcinoma is still controversial.

METHODS

This article aimed at reviewing the current status of preoperative biliary drainage for patients with peri-ampullary tumors who were candidates for pancreaticoduodenectomy. A MEDLINE and PubMed database search from 1980 to 2013 was performed to identify relevant articles using the keywords "pancreaticoduodenectomy", "preoperative biliary drainage", "jaundice", "peri-ampullary neoplasm" and "carcinoma of pancreas". Additional papers were identified by a manual search of the references from the key articles.

RESULTS

There were six randomized controlled trials (RCTs) and 5 meta-analyses on preoperative biliary drainage for patients with malignant obstructive jaundice. Most of the results of these studies could not be used to define the role of preoperative biliary drainage for patients who received pancreaticoduodenectomy for periampullary carcinoma because: first, the majority of these studies were on bypass or palliative resections; second, various pathologies with both proximal and distal biliary obstruction were included; third, there were different forms of percutaneous or endoscopic drainage procedures; fourth, there were different durations of preoperative drainage; and finally, there were variations in the definition of events and outcomes. There was only one RCT which included a homogeneous group of patients with carcinoma of pancreas who underwent pancreaticoduodenectomy. For patients with periampullary tumor, the RCTS and meta-analyses showed no benefit of preoperative biliary drainage. Instead, there were some concerns about the drainage-related complications and the increase in positive intraoperative bile culture rate and the associated infective complication rate postoperatively.

CONCLUSION

Routine preoperative biliary drainage showed no beneficial effect on the surgical outcome for patients with periampullary tumor. A selective approach of preoperative biliary drainage should be adopted for these patients. The optimal duration and modality of preoperative biliary drainage remain unclear.

Bile salt inhibition of host cell damage by Clostridium difficile toxins

Virulent Clostridium difficile strains produce toxin A and/or toxin B that are the etiological agents of diarrhea and pseudomembranous colitis. Treatment of C. difficile infections (CDI) has been hampered by resistance to multiple antibiotics, sporulation, emergence of strains with increased virulence, recurrence of the infection, and the lack of drugs that preserve or restore the colonic bacterial flora. As a result, there is new interest in non-antibiotic CDI treatments. The human conjugated bile salt taurocholate was previously shown in our laboratory to inhibit C. difficile toxin A and B activities in an in vitro assay. Here we demonstrate for the first time in an ex vivo assay that taurocholate can protect Caco-2 colonic epithelial cells from the damaging effects of the C. difficile toxins. Using caspase-3 and lactate dehydrogenase assays, we have demonstrated that taurocholate reduced the extent of toxin B-induced apoptosis and cell membrane damage. Confluent Caco-2 cells cultured with toxin B induced elevated caspase-3 activity. Remarkably, addition of 5 mM taurocholate reduced caspase-3 activity in cells treated with 2, 4, 6, and 12 µg/ml of toxin B by 99%, 78%, 64%, and 60%, respectively. Furthermore, spent culture medium from Caco-2 cells incubated with both toxin B and taurocholate exhibited significantly decreased lactate dehydrogenase activity compared to spent culture medium from cells incubated with toxin B only. Our results suggest that the mechanism of taurocholate-mediated inhibition functions at the level of toxin activity since taurocholate did not affect C. difficile growth and toxin production. These findings open up a new avenue for the development of non-antibiotic therapeutics for CDI treatment.

The quandary of preresection biliary drainage for pancreatic cancer

Surgery in patients with obstructive jaundice caused by a tumor in the pancreatic head area is associated with a higher risk of postoperative complications. Preoperative biliary drainage was introduced in an attempt to improve the general condition and reduce morbidity and mortality. Extensive experimental studies have been performed to analyze the beneficial effect of biliary drainage and showed improvement in liver function, nutritional status, and cell-mediated immune function as well as reduction in mortality. However, despite the results seen in the experimental studies, clinical studies reported both beneficial and adverse effects, and most studies advised against routinely performing preoperative biliary drainage. To add clarity to the ongoing controversy, a recent randomized controlled trial was performed and reported more overall complications in patients with jaundice who underwent preoperative biliary drainage followed by surgery compared to those who underwent surgery alone. Many of these complications were stent related. Like most clinical studies, a plastic stent was used to initiate biliary drainage. Patients with jaundice because of a tumor in the pancreatic head area without locoregional irresectability or metastases should be candidates for early surgery. Preoperative biliary drainage should not be performed routinely. However, some selected patients might benefit from preoperative biliary drainage, in cases of severe jaundice, neoadjuvant therapy, or postponed surgery due to logistics. In these cases, the use of metal biliary stents is indicated.

Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma

Hilar cholangiocarcinoma (HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia-Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio-frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia-Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation.

Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis. Eur J Surg Oncol. 2013;39:213-223. [PMID: 23294533 DOI: 10.1016/j.ejso.2012.12.010]

BACKGROUND

The clinical risk factors of delayed gastric emptying (DGE) in patients after pancreaticoduodenectomy (PD) remains controversial. Herein, we conducted a systematic review to quantify the associations between clinical risk factors and DGE in patients after conventional PD or pylorus preserving pancreaticoduodenectomy (PPPD).

METHODS

A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to 2012 was performed. Cohort, case-control studies, and randomized controlled trials that examined clinical risk factors of DGE were included.

RESULTS

Eighteen studies met final inclusion criteria (total n = 3579). From the pooled analyses, preoperative diabetes (OR 1.49, 95% CI, 1.03-2.17), pancreatic fistulas (OR 2.66, 95% CI, 1.65-4.28), and postoperative complications (OR 4.71, 95% CI, 2.61-8.50) were significantly associated with increased risk of DGE; while patients with preoperative biliary drainage (OR 0.68, 95% CI, 0.48-0.97) and antecolic reconstruction (OR 0.17, 95% CI, 0.07-0.41) had decreased risk of DGE development. Gender, malignant pathology, preoperative jaundice, intra-operative transfusion, PD vs. PPPD and early enteral feeding were not significantly associated with DGE development (all P > 0.05).

CONCLUSIONS

Our findings demonstrate that preoperative diabetes, pancreatic fistulas, and postoperative complications were clinical risk factors predictive for DGE. Antecolic reconstruction and preoperative biliary drainage result in a reduction in DGE. Knowledge of these risk factors may assist in identification and appropriate referral of patients at risk of DGE.

The alterations in hepatic microcirculation and Kupffer cell activity after biliary drainage in jaundiced mice

BACKGROUND/PURPOSE

The aim of this study is to examine the effects of biliary drainage on hepatic microcirculation and Kupffer cell activity in the liver with obstructive jaundice.

METHODS

Common bile duct ligation and division was performed on C57BL/6 mice to induce obstructive jaundice. Seven or 14 days after surgery, some mice underwent biliary drainage. Three days after biliary drainage, sinusoidal perfusion, leukocyte rolling and sticking in the postsinusoidal venules, and the diameters of sinusoids containing blood flow were evaluated using intravital microscopy. Kupffer cell phagocytic activity was estimated as the ratio of Kupffer cells that phagocytosed fluorescent-labeled particles to sinusoids containing blood flow.

RESULTS

Sinusoidal perfusion after biliary drainage was significantly increased compared with that in livers with obstructive jaundice, but remained decreased compared with controls. Although the number of rolling leukocytes and sticking leukocytes was significantly decreased, the diameters of sinusoids remained reduced, associated with an increase in Kupffer cell phagocytic activity compared with controls even after biliary drainage.

CONCLUSIONS

Leukocyte-endothelial cell interaction is ameliorated but sinusoids remain narrowed due to swelling of activated Kupffer cells; this might cause deterioration of hepatic microcirculation during the early phase of biliary drainage.

Value of preoperative biliary drainage in a consecutive series of resectable periampullary lesions. From randomized studies to real medical practice. Langenbecks Arch Surg. 2013;398:295-302. [PMID: 23007383 DOI: 10.1007/s00423-012-1000-2]

BACKGROUND

In cases with periampullary tumors, the practice of preoperative biliary drainage (PBD) is still debated without clear uniform indications. Our study focused on resectable cases with an obstructive jaundice candidate for curative surgery. Main endpoints were overall complication and mortality rates between patients treated with and without PBD.

METHODS

From January 2008 to November 2010, 100 consecutive patients with periampullary lesion underwent pancreatectomy. The rates of postoperative complications and mortality were compared between PBD and non-PBD patients.

RESULTS

The two groups were well matched for demographics, clinical, and operative characteristics. In patients who completed preoperative PBD protocol, biliary stent was placed systematically in 45 % of these cases without any clear indication. Post-PBD complication delayed surgery in 24 % of cases. Postoperative complications did not differ significantly between the two groups except for a significantly higher positive bile culture in PBD group (p = 0.001). There were seven cases of hospital mortality, four in PBD and three in non-PBD group. DFS was equal (32 months) in both groups (p = 0.55), and OS was 43 vs 32 months (p = 0.45).

CONCLUSION

PBD did not significantly increase the risk of overall postoperative complications, although it was associated to higher rate of biliary infections. PBD was not associated with any advantages in patients with a resectable periampullary lesion by reducing operative morbidity. PBD should be considered in selected patients when surgery has to be delayed.

What is appropriate procedure for preoperative biliary drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy? Surg Laparosc Endosc Percutan Tech. 2011;21:344-348. [PMID: 22002271 DOI: 10.1097/sle.0b013e3182318d2f]

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mechanism of Liver Injury during Obstructive Jaundice: Role of Nitric Oxide, Splenic Cytokines, and Intestinal Flora

To elucidate the roles of enteric bacteria and immunological interactions among liver, spleen and intestine in the pathogenesis of liver injury during obstructive jaundice, we studied the effects of antibiotics and splenectomy on bile-duct-ligated C57BL mice. When animals were subjected to bile-duct-ligation (BDL), plasma levels of bilirubin, alanine aminotransferase and aspartate aminotransferase increased markedly. However, the increases in plasma transaminases were significantly lower in splenectomized or antibiotics-treated groups than in the control BDL group. Histological examination revealed that liver injury was also low in the two groups. BDL markedly increased plasma level of interferon-γ (IFN-γ) and the expression of inducible nitric oxide synthase (iNOS) in liver and spleen. These changes were suppressed either by splenectomy or administration of antibiotics. Kinetic analysis revealed that BDL-induced liver injury and the increase of interleukin-10 (IL-10) and INF-γ were lower in iNOS^−/− than in wild type animals. BDL markedly increased the expression of IgA in colonic mucosa. These observations suggest that enteric bacteria, nitric oxide and cytokines including IFN-γ and IL-10 derived from spleen and intestines form a critical network that determines the extent of liver injury during obstructive jaundice.

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

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

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

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

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

Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy

OBJECTIVES

Whilst there are theoretical benefits from pre-operatively draining the biliary tree prior to pancreatoduodenectomy (PD), the current literature does not support this intervention. The aim of this study was to explore the relationship between pre-operative stenting, bactibilia and outcome in a large United Kingdom tertiary referral practice.

METHODS

Patients undergoing PD were identified from a prospectively maintained database. The presence or absence of a stent prior to PD, and the results of bile cultures taken at PD were related to the subsequent post-operative course and the development of complications.

RESULTS

280 patients underwent PD for periampullary malignancies, all of whom presented with jaundice. 118 patients were stented prior to referral (98 ERCP, 20 PTC). Bile cultures were positive more frequently in the stent group (83% vs. 55%; p = 0.000002) and bactibilia was more common after ERCP than PTC (83% vs. 56%; p = 0.006). The overall prevalence of complications was 54% in the stented and 41% in the non-stented group (p = 0.03) with statistical significance achieved for pancreatic leak (p = 0.013) and haemorrhagic complications (p = 0.03). Comparing stent with no stent, there as no difference in the 30-day mortalities (8.5% vs. 6.8%; p = 0.6) or the 1-year mortality rates (35% vs. 28%; p = 0.21). Mortality rates in the infection versus no infection groups were comparable at 30 days (8.5% vs. 5.5%; p = 0.21), and at 1 year (30.7% vs. 26.4%; p = 0.25).

CONCLUSIONS

Pre-operative stent insertion prior to PD is associated with increased morbidity but not mortality and this is greatest for stents placed at ERCP.

Splanchnic Th(2) and Th(1) cytokine redistribution in microsurgical cholestatic rats

BACKGROUND

Long-term extrahepatic cholestasis in the rat induces ductular proliferation and fibrosis in the liver, portal hypertension, splenomegaly, portosystemic collateral circulation, and ascites. These splanchnic alterations could have an inflammatory pathophysiology.

MATERIAL AND METHODS

We measured serum levels of hepatobiliary injury markers and the acute phase proteins, alpha-1-major acid protein (alpha(1)-MAP) and alpha-1-acid glycoprotein (alpha(1)-GPA) in rats 6 wk after microsurgical extrahepatic cholestasis. We also assayed Th(1) (TNF-alpha and IL-1beta) and Th(2) (IL-4 and IL-10) cytokine levels in the liver, ileum, spleen, and mesenteric lymph complex by enzyme-linked immunosorbent assay (ELISA) techniques. Liver fibrosis was measured by Sirius red stain and by using an image system computer-assisted method and mast cell liver infiltration by Giemsa stain.

RESULTS

The cholestatic rats showed an increase (P<0.001) in serum levels of bile acids, total and direct bilirubin, AST, ALT, AST/ALT index, gamma-GT, alkaline phosphatase, alpha(1)- MAP, alpha(1)-GPA, and LDH (P<0.05) in relation to sham-operated rats. TNF-alpha, IL-1beta, IL-4, and IL-10 increased in the ileum (P<0.01) and mesenteric lymph complex (P<0.001), and decreased in the liver (P<0.001). A marked bile proliferation associated with fibrosis (P<0.001) and mast cell infiltration was also shown in the liver of cholestatic rats.

CONCLUSION

The splanchnic redistribution of cytokines, with an increase of Th(1) and Th(2) production in the small bowel and in the mesenteric lymph complex, supports the key role of inflammatory mechanisms in rats with secondary biliary fibrosis.

Percutaneous transhepatic insertion of self-expanding short metal stents for biliary obstruction before resection of pancreatic or duodenal malignancy proves to be safe and effective

BACKGROUND

The British Society of Gastroenterology guidelines for the management of malignant obstructive jaundice state: "If a stent is placed prior to surgery, this should be of the plastic type and it should be placed endoscopically. Self-expanding metal stents should not be inserted in patients who are likely to proceed to resection." In 2003, a small series of complications after endoscopic intervention caused a change in the authors' practice. Currently, all patients requiring relief of biliary obstruction before surgical resection undergo attempted insertion of a short metal biliary stent.

METHODS

Retrospective analysis of the authors' prospective database containing all patients presenting with periampullary and pancreatic tumors between January 2004 and May 2008 was performed.

RESULTS

The authors have attempted percutaneous placement of internal metal stents in 67 patients with resectable malignancies and biliary obstruction. Stenting was successful for 53 patients (79%), and 5 patients (9.4%) experienced complications. These five patients were successfully managed conservatively, and all proceeded to trial dissection. The mean bilirubin level was 253 mg/dl before intervention and 33 mg/dl before surgery for the stented patients compared with 308 mg/dl before intervention and 102 mg/dl before surgery for those who needed external drainage.

CONCLUSIONS

Percutaneous insertion of short metal stents provides a safe and effective alternative to endoscopic stent placement for treating jaundice preoperatively in patients with potentially resectable tumors around the pancreatic head.

Ampullary carcinoma: Effect of preoperative biliary drainage on surgical outcome

AIM: To evaluate the influence of preoperative biliary drainage on morbidity and mortality after surgical resection for ampullary carcinoma.

METHODS: We analyzed retrospectively data for 82 patients who underwent potentially curative surgery for ampullary carcinoma between September 1993 and July 2007 at the Singapore General Hospital, a tertiary referral hospital. Diagnosis of ampullary carcinoma was confirmed histologically. Thirty-five patients underwent preoperative biliary drainage (PBD group), and 47 were not drained (non-PBD group). The mode of biliary drainage was endoscopic retrograde cholangiopancreatography (n = 33) or percutaneous biliary drainage (n = 2). The following parameters were analyzed: wound infection, intra-abdominal abscess, intra-abdominal or gastrointestinal bleeding, septicemia, biliary or pancreatic leakage, pancreatitis, gastroparesis, and re-operation rate. Mortality was assessed at 30 d (hospital mortality) and also long-term. The statistical endpoint of this study was patient survival after surgery.

RESULTS: The groups were well matched for demographic criteria, clinical presentation and operative characteristics, except for lower hemoglobin in the non-PBD group (10.9 ± 1.6 vs 11.8 ± 1.6 in the PBD group). Of the parameters assessing postoperative morbidity, incidence of wound infection was significantly less in the PBD than the non-PBD group [1 (2.9%) vs 12 (25.5%)]. However, the rest of the parameters did not differ significantly between the groups, i.e. sepsis [10 (28.6%) vs 14 (29.8%)], intra-abdominal bleeding [1 (2.9%) vs 5 (10.6%)], intra-abdominal abscess [1 (2.9%) vs 8 (17%)], gastrointestinal bleeding [3 (8.6%) vs 5 (10.6%)], pancreatic leakage [2 (5.7%) vs 3 (6.4%)], biliary leakage [2 (5.7%) vs 3 (6.4%)], pancreatitis [2 (5.7%) vs 2 (4.3%)], gastroparesis [6 (17.1%) vs 10 (21.3%)], need for blood transfusion [10 (28.6%) vs 17 (36.2%)] and re-operation rate [1 (2.9%) vs 5 (10.6%)]. There was no early mortality in either group. Median survival was 44 mo (95% CI: 34.2-53.8) in the PBD group and 41 mo (95% CI: 27.7-54.3; P = 0.86) in the non-PBD group.

CONCLUSION: Biliary drainage before surgery for ampullary cancer significantly reduced postoperative wound infection. Overall mortality was not influenced by preoperative drainage.

Bile high-mobility group box 1 contributes to gut barrier dysfunction in experimental endotoxemia

Lipopolysaccharide (LPS) is an important factor in sepsis. LPS given by intraperitoneal injection induces intestinal hyperpermeability and bacterial translocation in animals and stimulates hepatic Kupffer cells to release TNF-alpha into the bile. This study aims to test the hypothesis that in response to LPS stimulation, hepatic Kupffer cells and extrahepatic macrophages release a large amount of the inflammatory cytokine high-mobility group box 1 (HMGB1) into the bile and that bile containing HMGB1 contributes to gut barrier dysfunction in experimental endotoxemia. To test this, rat common bile ducts were catheterized and bile flow rate was monitored before and during the LPS administration. Eight hours after LPS challenge, anti-HMGB1 neutralizing antibody or nonimmune (sham) IgG was injected into the duodenal lumen of endotoxemic rats; normal mice were also gavaged with normal or endotoxemic rat bile (bile collected from LPS-treated rats). We found that after LPS challenge, the bile flow rate in rats was significantly decreased at the 4- to 12-h time points, TNF-alpha concentration in the bile was markedly elevated at the 3- to 4-h time points, and bile HMGB1 levels were significantly increased at the 8- to 12-h time points. Duodenal injection with anti-HMGB1 antibody reversed LPS-induced gut barrier dysfunction in rats. In addition, feeding endotoxemic rat bile to normal mice significantly increased both mucosal permeability and bacterial translocation. The increase in permeability and bacterial translocation was reversible following removal of HMGB1 from the endotoxemic rat bile. These findings document that bile HMGB1 mediates gut barrier dysfunction in experimental endotoxemia.

Preoperative biliary drainage in patients with obstructive jaundice: history and current status

RATIONALE

Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results.

FINDINGS

For distal obstruction, currently the "best-evidence" available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits.

CONCLUSION

The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.

Preoperative biliary drainage before resection for cholangiocarcinoma (Pro)

Three types of preoperative biliary drainage (BD): percutaneous transhepatic (PTBD), endoscopic (EBD), and endoscopic nasobiliary (ENBD) can be indicated before resection of cholangiocarcinoma. However, three randomized controlled trials (RCTs) have revealed that preoperative PTBD does not improve perioperative results. Other RCTs have revealed that preoperative EBD for malignant obstructive jaundice has no demonstrable benefit and after EBD for hilar cholangiocarcinoma there are highly developed infectious complications. Most patients with distal cholangiocarcinoma undergo pancreatoduodenectomy (PD) without preoperative BD. However, no RCTs have been performed to clarify the safety of major hepatectomy without preoperative BD for cholestatic patients with hilar cholangiocarcinoma. Furthermore, preoperative intrahepatic segmental cholangitis is a prognostic factor in the outcome of major hepatectomy for biliary cancer. Preoperative BD has another purpose in the preoperative management of patients with hilar cholangiocarcinoma. Selective cholangiography via ENBD and/or PTBD catheters provides precise information about the complicated segmental anatomy of the intrahepatic bile ducts and extent of cancer along the separated segmental bile ducts, which contributes toward designing a type of resective procedure. RCTs in biliary cancer patients undergoing major hepatectomy have revealed that bile replacement during external biliary drainage and perioperative synbiotic treatment can prevent postoperative infectious complications. Although preoperative EBD increases the risk of cholangitis, major hepatectomy combined with preoperative biliary drainage, preferably PTBD and/or ENBD, followed by portal vein embolization has been established as a safer management strategy for perihilar cholangiocarcinoma.

Preoperative biliary drainage for hilar cholangiocarcinoma

Hilar cholangiocarcinomas grow slowly, and metastases occur late in the natural history. Surgical cure and long-term survival have been demonstrated, when resection margins are clear. Preoperative biliary drainage has been proposed as a way to improve liver function before surgery, and to reduce post-surgical complications. Percutaneous transhepatic biliary drainage (PTBD) with multiple drains was previously the preferred method for the preoperative relief of obstructive jaundice. However, the introduction of percutaneous transhepatic portal vein embolization (PTPE) and wider resection has changed preoperative drainage strategies. Drainage is currently performed only for liver lobes that will remain after resection, and for areas of segmental cholangitis. Endoscopic biliary drainage (EBD) is less invasive than PTBD. Among EBD techniques, endoscopic nasobiliary drainage (ENBD) is preferable to endoscopic biliary stenting (EBS), because secondary cholangitis (due to the retrograde flow of duodenal fluid into the biliary tree) does not occur. ENBD needs to be converted to PTBD in patients with segmental cholangitis, those with a prolonged need for drainage, or when the extent of longitudinal tumor extension is not sufficiently well characterized.

Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial)

Background

Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life.

Methods/design

Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8).

Discussion

The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.

Stent versus surgery

Following the introduction of percutaneous and endoscopic biliary drainage there has been an ongoing debate about the indications and outcomes of endoscopic versus surgical drainage in a variety of bilio-pancreatic disorders. The evidence-based literature concerning four different areas of pancreatobiliary diseases have been reviewed. Preoperative endoscopic biliary drainage in patients with obstructive jaundice should not be used routinely but only in selected patients. For patients with biliary leakage and bile duct strictures after a laparoscopic cholecystectomy, endoscopic stent therapy might be first choice and surgery should be used for failures of endoscopic treatment. Surgery is the treatment of choice after transection of the bile duct (the major bile duct injuries). The majority of patients with obstructive jaundice due to advanced pancreatic cancer will undergo endoscopic drainage but for relatively fit patients with a prognosis of more than 6 months, surgical drainage or even palliative resection might be considered. For patients with persistent pain due to chronic pancreatitis surgical drainage combined with limited pancreatic head resection might be first choice for pain relief. Most importantly, the management of patients with these pancreatobiliary diseases should be performed by a multidisciplinary HPB approach and teamwork consisting of gastroenterologists, radiologists and surgeons.

Perioperative synbiotic treatment to prevent postoperative infectious complications in biliary cancer surgery: a randomized controlled trial

SUMMARY BACKGROUND DATA

Use of synbiotics has been reported to benefit human health, but clinical value in surgical patients remains unclear.

OBJECTIVE

To investigate the effect of perioperative oral administration of synbiotics upon intestinal barrier function, immune responses, systemic inflammatory responses, microflora, and surgical outcome in patients undergoing high-risk hepatobiliary resection.

METHODS

Patients with biliary cancer involving the hepatic hilus (n = 101) were randomized before hepatectomy, into a group receiving postoperative enteral feeding with synbiotics (group A); or another receiving preoperative plus postoperative synbiotics (group B). Lactulose-mannitol (L/M) ratio, serum diamine oxidase (DAO) activity, natural killer (NK) cell activity, interleukin-6 (IL-6), fecal microflora, and fecal organic acid concentrations were determined before and after hepatectomy. Postoperative infectious complications were recorded.

RESULTS

Of 101 patients, 81 completed the trial. Preoperative and postoperative changes in L/M ratio and DAO activity were similar between groups. Preoperatively in group B, NK activity, and lymphocyte counts increased, while IL-6 decreased significantly (P < 0.05). Postoperative serum IL-6, white blood cell counts, and C-reactive protein in group B were significantly lower than in group A (P < 0.05). During the preoperative period, numbers of Bifidobacterium colonies cultured from and total organic acid concentrations measured in feces increased significantly in group B (P < 0.05). Postoperative concentrations of total organic acids and acetic acid in feces were significantly higher in group B than in group A (P < 0.05). Incidence of postoperative infectious complications was 30.0% (12 of 40) in group A and 12.1% (5 of 41) in group B (P < 0.05).

CONCLUSIONS

Preoperative oral administration of synbiotics can enhance immune responses, attenuate systemic postoperative inflammatory responses, and improve intestinal microbial environment. These beneficial effects likely reduce postoperative infectious complications after hepatobiliary resection for biliary tract cancer.

The effect of caffeic acid phenethyl ester on bacterial translocation and intestinal damage in cholestatic rats

We investigated the effect of caffeic acid phenethyl ester in rat ileum injury induced by chronic biliary obstruction. Swiss albino rats were divided into three groups: Group 1, sham (n = 7); Group 2, common bile duct ligation (n = 7); and Group 3, common bile duct ligation plus caffeic acid phenethyl ester (n = 7). In the caffeic acid phenethyl ester-treated rats, ileum tissue levels of malondialdehyde and myeloperoxidase were significantly lower than those of the bile duct-ligated rats (P < 0.001). The levels of tumor necrosis factor-alpha, interleukin-6, and interleukin-1alpha in the caffeic acid phenethyl ester group were significantly lower than those in the bile duct ligation group (P < 0.03, P < 0.01, and P < 0.02 respectively). The present study demonstrates that intraperitoneal administration of caffeic acid phenethyl ester in bile duct-ligated rats reduces intestinal oxidative stress. This effect may be useful in the preservation of intestinal damage in cholestasis.

Reversible cholestasis and cholangitis induced by biliary drainage and infusion in the rat

To develop a rat model of ascending cholangitis, we constructed a controllable and accessible biliary drainage and infusion system. We first modified a reversible cholestasis model of the rat and then induced ascending cholangitis by administration of Escherichia coli into the proximal choledochostomy tube. After biliary infusion of E. coli, the liver, choledochostomy tube and bile were all positive for E. coli, but no bacteria grew in rats receiving biliary infusion of normal saline. Retrograde cholangiography of the initial choledochostomy ensured that the tube end was in the right position in the proximal common bile duct. The patency of the tube-tube choledochocholedochostomy was confirmed by a cholangiogram on day 90. Thirty days after the tube-tube choledochocholedochostomy, the livers of the experimental animals did not differ from the control livers. The tube-tube choledochocholedochostomy model not only provides reproducible, reliable, reversible cholestasis, but creates a sustainable and accessible biliary infusion system. This can be used for long-term investigations of repeated cholangitis and recurrent cholestasis.

Preoperative biliary drainage (stenting) for treatment of obstructive jaundice

The role of preoperative biliary drainage in malignant obstructive jaundice has been controversial. Laboratory studies suggest that relief of jaundice prior to major pancreatic resection would be associated with improved morbidity and mortality. However, clinical experience has not supported the laboratory results. Obstructive jaundice can be relieved preoperatively via an endoprosthesis introduced either percutaneously or endoscopically. Cohort studies have not shown any clinical benefit and in some the endoprostheses have been implicated in postoperative complications. The only randomized study has shown no benefit in preoperative drainage, but one recent study has confirmed that endoscopic drainage, whilst not conferring an advantage, did no harm. Hence, whilst preoperative drainage is not recommended, if for any reason operation needs to be delayed, endoscopic drainage via an endoprosthesis can be used without fear of adversely influencing the outcome.

THE SEVERITY OF CHOLESTATIC INJURY IS MODULATED BY THE GENETIC BACKGROUND

Common bile duct ligation (CBDL) compromises the hepatic reticuloendothelial system by impairing the clearing of endotoxin and triggering an overwhelming inflammatory response. The response to endotoxin at the level of cytokine release and subsequent mortality depends on the genetic background in experimental mouse models. We hypothesized that the genetic make-up modulates the inflammatory responses after CBDL. The CBD was ligated in male A/J and B6 mice (8 weeks old). At 7 days post-CBDL, the presence of ascites was observed in 80% of B6 mice but in none of the A/J mice (P < 0.001). B6 mice showed higher mortality than A/J mice (P < 0.05). Both strains had marked cholestatic injury documented histologically. Liver chemistries were markedly elevated in both strains after injury. Plasma levels of the anti-inflammatory cytokine IL-10 were significantly higher in A/J than B6 mice at the 4- and 12-h time points (P < 0.05), whereas proinflammatory cytokine TNF-alpha levels were significantly higher in B6 than A/J mice at 2 h (P < 0.05). Both strains displayed activation of NF-kappaB after CBDL. In conclusion, the contrasting response observed after CBDL between A/J and B6 mice is largely attributable to genetic differences. Survival after CBDL was correlated with an increase in anti-inflammatory cytokines.

The value of bile replacement during external biliary drainage: an analysis of intestinal permeability, integrity, and microflora

OBJECTIVE

To investigate the effect of bile replacement following percutaneous transhepatic biliary drainage, ie, external drainage, on intestinal permeability, integrity, and microflora in a clinical setting.

SUMMARY BACKGROUND DATA

Several authors have reported that internal biliary drainage is superior to external drainage. However, it is unclear whether bile replacement following external drainage is beneficial.

METHODS

Twenty-five patients with biliary cancer underwent percutaneous transhepatic biliary drainage (PTBD) as a part of presurgical management. All externally drained bile was replaced either per os or by administration through a nasoduodenal tube. The interval between PTBD and the beginning of bile replacement was 21.3 +/- 19.7 days, and the length of bile replacement was 20.7 +/- 9.6 days. The lactulose-mannitol test, measurement of serum diamine oxidase (DAO) activity, and analyses of fecal microflora and organic acids were performed before and after bile replacement.

RESULTS

The volume of externally drained bile varied widely from patient to patient, ranging from 220 +/- 106 mL/d to 1616 +/- 394 mL/d (mean, 714 +/- 346 mL/d). Biliary concentrations of bile acids, cholesterol, and phospholipids increased significantly after bile replacement. The lactulose-mannitol (L/M) ratio decreased from 0.063 +/- 0.060 before bile replacement to 0.038 +/- 0.032 after bile replacement (P < 0.05). Serum DAO activity increased from 3.9 +/- 1.4 U/L before bile replacement to 5.1 +/- 1.6 U/L after bile replacement (P < 0.005), and the magnitude of change in serum DAO activity correlated with the length of bile replacement (r = 0.483, P < 0.05). Neither the L/M ratios nor serum DAO activities before bile replacement correlated with the interval between PTBD and the beginning of bile replacement. Fecal microflora and organic acids were unchanged.

CONCLUSION

Impaired intestinal barrier function does not recover by PTBD without bile replacement. Bile replacement during external biliary drainage can restore the intestinal barrier function in patients with biliary obstruction, primarily due to repair of physical damage to the intestinal mucosa. Our results support the hypothesis that bile replacement during external drainage is beneficial.

Host immune responses and intestinal permeability in patients with jaundice

BACKGROUND

Systemic endotoxaemia is implicated in the development of complications associated with obstructive jaundice. The aims of these studies were to assess the systemic immune response to intervention in patients with jaundice and to compare the effects of surgical and non-surgical biliary drainage on host immune function and gut barrier function.

METHODS

In the first study, 18 jaundiced and 12 control patients were studied to assess systemic immune responses before and after intervention. In the second study, immune responses and gut barrier function were assessed following surgical and non-operative biliary decompression in 45 patients with jaundice.

RESULTS

Endotoxin antibody concentrations fell significantly in patients with jaundice immediately after surgical intervention, but not after non-operative biliary drainage. This decrease was associated with a significant increase in serum P(55) soluble tumour necrosis factor (sTNF) receptor concentration (5.3 versus 10.5 ng/ml; P < 0.001), urinary excretion of P(55) TNF receptors (21.4 versus 78.8 ng/ml; P = 0.002) and intestinal permeability (lactulose : mannitol ratio 0.032 versus 0.082; P = 0.048). Intestinal permeability was significantly increased in patients with jaundice compared with controls (0.033 versus 0.015; P = 0.002).

CONCLUSION

These data suggest that obstructive jaundice is associated with impaired gut barrier function and activation of host immune function that is exacerbated by intervention. Surgery causes an exaggerated pathophysiological disturbance not seen with non-operative biliary drainage procedures.

An improved rat model of obstructive jaundice and its reversal by internal and external drainage

BACKGROUND

A simple and reproducible rat model that allows studies of the reversal of obstructive jaundice (OJ) by internal (ID) and external (ED) drainage is not available at present.

METHODS

OJ was induced in rats by double ligation and division of the common bile duct. To minimize tissue handling and dissection the duodenum was extracted with a ophthalmic muscle hook and the common bile duct isolated using very fine forceps. One week after bile duct ligation, ID was accomplished by implanting a length of infant feeding tube between the dilated bile duct and the duodenum. ED was achieved by placing a PVC tube into the dilated bile duct and exteriorizing the other end at the nape of the neck.

RESULTS

Minimal adhesions were found around the dilated common bile duct, which made relaparotomy for drainage easy. Alanine transaminase, total bilirubin, alkaline phosphatase, and gamma-glutamyltransferase were significantly raised after bile duct ligation. All parameters returned to control levels after ID for 7 days. In the ED group plasma albumin was significantly decreased and alkaline phosphatase remained marginally elevated.

CONCLUSIONS

We have developed a simple and reproducible rat model that allows for the study of reversal of OJ by ID or ED. We also demonstrated that ID is superior to ED in reversing impaired liver function in OJ.

Selective versus total drainage for biliary obstruction in the hepatic hilus: an experimental study

BACKGROUND

Controversy exists as to whether selective biliary drainage (SBD) or total biliary drainage (TBD) is preferable as a preoperative procedure before extended hemihepatectomy for hilar cholangiocarcinoma, especially with regard to the functional reserve of the future remnant liver.

METHODS

SBD or TBD was performed after 1 week of total biliary obstruction in rats. In SBD, the biliary trees of the left lobes (approximately 70% of the liver) were kept obstructed, whereas the right lobes were drained selectively. Mitochondrial function and microsomal cytochrome content were examined before and 1, 2, and 4 weeks after drainage.

RESULTS

The right lobes weighed significantly more after SBD than after TBD. There were no significant differences in mitochondrial function between the two groups. The microsomal cytochrome content per milligram of microsomal protein significantly decreased 1 week after biliary obstruction and then recovered to a similar extent after SBD and TBD in the right lobes. However, the total microsomal cytochrome content (nanomoles per 100 g body weight) and the overall rate of mitochondrial adenosine triphosphate synthesis (mmoles per minute per 100 g of body weight) in the right lobes 4 weeks after SBD were significantly greater than those after TBD.

CONCLUSIONS

SBD is superior to TBD with regard to the functional reserve of the future remnant liver.

The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy

BACKGROUND

The benefit of preoperative biliary drainage in jaundiced patients undergoing pancreaticoduodenectomy for a suspected malignancy of the periampullary region is still under debate. This study evaluated preoperative biliary drainage in relation to postoperative outcomes.

STUDY DESIGN

At the Academic Medical Center, Amsterdam, the Netherlands, a cohort of 311 patients undergoing pancreaticoduodenectomy from June 1992 up to and including December 1999 was studied. Of this cohort 21 patients with external or surgical biliary drainage were excluded and 232 patients who had received preoperative internal biliary drainage were divided into three groups corresponding with severity of jaundice according to preoperative plasma bilirubin levels: < 40 microM (n = 177), 40 to 100 microM (n = 32), and > 100 microM (n = 23) were designated as groups 1, 2, and 3, respectively. These groups were compared with patients who underwent immediate surgery (n = 58) without preoperative drainage.

RESULTS

The median number of stent (re)placements was 2 (range 1 to 6) with a median drainage duration of 41 days (range 2 to 182 days) and a stent dysfunction rate of 33%. Although patients in group 1 were better drained than patients in groups 2 and 3 (median reduction of bilirubin levels 82%, 57%, and 37%, respectively, p < 0.01), there was no difference in overall morbidity among the drained groups (50%, 50%, and 52%, respectively). There was no significant difference in overall morbidity between patients with and without preoperative biliary drainage (50% and 55%, respectively).

CONCLUSIONS

Preoperative biliary drainage did not influence the incidence of postoperative complications, and although it can be performed safely in jaundiced patients it should not be used routinely.

Endotoxin-induced mortality in bile duct-ligated rats after administration of reconstituted high-density lipoprotein

Cholestatic patients have substantial morbidity because of increased susceptibility to endotoxin (lipopolysaccharide [LPS]). Although reconstituted high-density lipoprotein (rHDL) can bind and neutralize LPS, cholestasis is associated with a near complete absence of HDL. Effects of rHDL infusion on the outcome of LPS-induced inflammatory responses in cholestatic rats were determined. Bile duct-ligated (BDL) and sham rats were treated with rHDL or saline and challenged with LPS. Distribution of cholesterol over the lipoprotein subclasses changed by ligation: levels in low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL) were increased 2-fold and 5-fold, respectively, and were decreased in HDL 2-fold. rHDL treatment did not affect cholesterol distribution. LPS was mainly found in the HDL fraction, and ligation affected only levels of HDL-bound LPS (50% decrease; P<.05). Although rHDL infusion effectively normalized the lipoprotein-bound LPS distribution, it resulted in increased sensitivity (mortality: 88% in the ligation + rHDL group versus 44% in the ligation + saline group, 25% in the sham + saline group, and 0% in the sham + rHDL group, P <.05). In accordance with these results, plasma tumor necrosis factor (TNF) was significantly highest in the BDL + rHDL group at several hours after LPS challenge as well as the accumulation of LPS in the liver (P<.05). rHDL infusion leads to increased LPS-induced mortality in cholestatic rats. These results sharply contrast with the protective effects of rHDL suppletion in experimental endotoxemia in animals and human volunteers without biliary obstruction and suggest that there may be danger in administration of rHDL to cholestatic patients.

The effect of oral sodium taurocholate on endotoxemia and intestinal anastomotic wound healing in rats with obstructive jaundice

The effect of sodium taurocholate (ST) on endotoxemia and intestinal anastomotic wound healing in obstructive jaundice was evaluated in a rat model. A total of 108 Wistar rats were divided into three main groups. Thus, 36 animals were given ileal anastomosis (IA) alone (IA group), 36 were given IA with bile duct ligation (BDL) (IA + BDL group), and 36 were given IA with BDL and oral sodium taurocholate (ST) (IA + BDL + ST group). These three main groups were then divided into three equal subgroups, A, B, and C, which were killed on postoperative days (POD) 3, 5, and 9, respectively. In the IA + BDL + ST group, ST was administrated perioperatively and ceased from POD 5 onwards. The anastomotic hydroxyproline level and bursting pressure were significantly lower in the IA + BDL animals compared with the others on POD 3, 5, and 9 (P < 0.008). Endotoxemia was prominent in the IA + BDL group from POD 3 (P = 0.011). After ST was stopped, 42% of the AI + BDL + ST animals developed endotoxemia by POD 9 (P = 0.008). Anastomotic wound healing was better in the IA + BDL + ST group (P < 0.01). These findings suggest that endotoxemia and its adverse effects on wound healing in obstructive jaundice can be prevented by the oral administration of ST.