Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4-6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.

[Preoperative cognitive function in very old patients : Influence on the complication rate and length of hospitalization]

BACKGROUND

Gastrointestinal cancer is a frequent diagnosis in older patients. A curative resection, possibly in combination with radiotherapy and/or chemotherapy, is the standard therapy. The advanced age of the patients with an increasing number of comorbidities and often the presence of cognitive impairment represents a high risk for perioperative complications and a longer stay in hospital. The challenge in the clinical routine is to recognize a cognitive impairment in older patients and to prepare these patients for the operative intervention in the best possible way.

OBJECTIVE

This retrospective analysis was carried out to find out whether preoperative cognitive impairment is a prognostic factor for the postoperative outcome.

METHODS

In patients over the age of 75 years who were prepared for abdominal surgery of gastrointestinal cancer in the preoperative consultation, the mini mental state examination (MMSE) and the clock test were carried out. The results of the tests were retrospectively compared with the complication rate and the duration of hospital stay.

RESULTS

Low MMSE values were significantly associated with the complication rate and the development of a severe complication (Clavien-Dindo grade ≥ 3a). A cut-off value of 24 points in the MMSE was predictive for the development of complications and a longer hospital stay. The age of the patients was not associated with the MMSE.

CONCLUSION

Cognitive impairment is an important prognostic factor for the development of perioperative complications and the duration of the hospital stay in patients undergoing extensive abdominal surgery for gastrointestinal cancer. Therefore, a preoperative assessment, for example with the MMSE, is recommended in order to identify high-risk patients.

Isolation and Expansion of Hepatic Stem-like Cells from a Healthy Rat Liver and their Efficient Hepatic Differentiation of under Well-defined Vivo Hepatic like Microenvironment in a Multiwell Bioreactor

BACKGROUND

Currently, undifferentiated cells are found in all tissue and term as local stem cells which are quiescent in nature and less in number under normal healthy conditions but activate upon injury and repair the tissue or organs via automated activating mechanism. Due to very scanty presence of local resident somatic local stem cells in healthy organs, isolation and expansion of these adult stems is an immense challenge for medical research and cell based therapy. Particularly organ like liver, there is an ongoing controversy about existence of liver stem cells.

METHODS

Herein, Hepatic stem cells population was identified during culture of primary hepatocyte cells upon immediate isolation of primary hepatocyte cells. These liver stem cells has been expanded extensively and differentiated into primary hepatocytes under defined culture conditions in a nanostructured self assembling peptides modular bioreactor that mimic the state of art of liver microenvironment and compared with Matrigel as a positive control. Nanostructured self assembling peptides were used a defined extracellular matrix and Matrigel was used for undefined extracellular matrix. Proliferation of hepatic stem cells was investigated by two strategies. First strategy is to provide high concentration of hepatocyte growth factor (HGF) and second strategy is to evaluate the role of recombinant human erythropoietin (rHuEPO) in presence of trauma/ischemia cytokines (IL-6, TNF-α). Expansion to hepatic differentiation is observed by morphological analysis and was evaluated for the expression of hepatocyte-specific genes using RT-PCR and biochemical methods.

RESULTS

Hepatocyte-specific genes are well expressed at final stage (day 21) of differentiation period. The differentiated hepatocytes exhibited functional hepatic characteristics such as albumin secretion, urea secretion and cytochrome P450 expression. Additionally, immunofluorescence analysis revealed that hepatic stem cells derived hepatocytes exhibited mature hepatocyte markers (albumin, CK-19, CPY3A1, alpha 1-antitrypsin). Expansion and hepatic differentiation was efficiently in nanostructured self assembling peptides without such batch to batch variation while there was much variation in Matrigel coated bioreactor. In conclusion, the results of the study suggest that the nanostructured self assembling peptides coated bioreactor supports expansion as well as hepatic differentiation of liver stem cells which is superior than Matrigel.

CONCLUSION

This defined microenvironment conditions in bioreactor module can be useful for research involving bioartificial liver system, stem cell research and engineered liver tissue which could contribute to regenerative cell therapies or drug discovery and development.

Nanostructured self-assembling peptides as a defined extracellular matrix for long-term functional maintenance of primary hepatocytes in a bioartificial liver modular device

Much effort has been directed towards the optimization of the capture of in vivo hepatocytes from their microenvironment. Some methods of capture include an ex vivo cellular model in a bioreactor based liver module, a micropatterned module, a microfluidic 3D chip, coated plates, and other innovative approaches for the functional maintenance of primary hepatocytes. However, none of the above methods meet US Food and Drug Administration (FDA) guidelines, which recommend and encourage that the duration of a toxicity assay of a drug should be a minimum of 14 days, to a maximum of 90 days for a general toxicity assay. Existing innovative reports have used undefined extracellular matrices like matrigel, rigid collagen, or serum supplementations, which are often problematic, unacceptable in preclinical and clinical applications, and can even interfere with experimental outcomes. We have overcome these challenges by using integrated nanostructured self-assembling peptides and a special combination of growth factors and cytokines to establish a proof of concept to mimic the in vivo hepatocyte microenvironment pattern in vitro for predicting the in vivo drug hepatotoxicity in a scalable bioartificial liver module. Hepatocyte functionality (albumin, urea) was measured at days 10, 30, 60, and 90 and we observed stable albumin secretion and urea function throughout the culture period. In parallel, drug metabolizing enzyme biomarkers such as ethoxyresorufin-O-deethylase, the methylthiazol tetrazolium test, and the lactate dehydrogenase test were carried out at days 10, 30, 60, and 90. We noticed excellent mitochondrial status and membrane stability at 90 days of culture. Since alpha glutathione S-transferase (GST) is highly sensitive and a specific marker of hepatocyte injury, we observed significantly low alpha GST levels on all measured days (10, 30, 60, and 90). Finally, we performed the image analysis of mitochondria-cultured hepatocytes at day 90 in different biophysical parameters using confocal microscopy. We applied an automatic algorithm-based method for 3D visualization to show the classic representation of the mitochondrial distribution in double hepatocytes. An automated morphological measurement was conducted on the mitochondrial distribution in the cultured hepatocytes. Our proof of concept of a scalable bioartificial liver modular device meets FDA guidelines and may function as an alternative model of animal experimentation for pharmacological and toxicological studies involving drug metabolism, enzyme induction, transplantation, viral hepatitis, hepatocyte regeneration, and can also be used in other existing bioreactor modules for long-term culture for up to 90 days or more.

Morphological and Functional Analysis of Hepatocyte Spheroids Generated on Poly-HEMA-Treated Surfaces under the Influence of Fetal Calf Serum and Nonparenchymal Cells

Poly (2-hydroxyethyl methacrylate) (HEMA) has been used as a clinical material, in the form of a soft hydrogel, for various surgical procedures, including endovascular surgery of liver. It is a clear liquid compound and, as a soft, flexible, water-absorbing material, has been used to make soft contact lenses from small, concave, spinning molds. Primary rat hepatocyte spheroids were created on a poly-HEMA-coated surface with the intention of inducing hepatic tissue formation and improving liver functions. We investigated spheroid formation of primary adult rat hepatocyte cells and characterized hepatic-specific functions under the special influence of fetal calf serum (FCS) and nonparencymal cells (NPC) up to six days in different culture systems (e.g., hepatocytes + FCS, hepatocytes – FCS, NPC + FCS, NPC – FCS, co-culture + FCS, co-culture – FCS) in both the spheroid model and sandwich model. Immunohistologically, we detected gap junctions, Ito cell/Kupffer cells, sinusoidal endothelial cells and an extracellular matrix in the spheroid model. FCS has no positive effect in the sandwich model, but has a negative effect in the spheroid model on albumin production, and no influence in urea production in either model. We found more cell viability in smaller diameter spheroids than larger ones by using the apoptosis test. Furthermore, there is no positive influence of the serum or NPC on spheroid formation, suggesting that it may only depend on the physical condition of the culture system. Since the sandwich culture has been considered a “gold standard” in vitro culture model, the hepatocyte spheroids generated on the poly-HEMA-coated surface were compared with those in the sandwich model. Major liver-specific functions, such as albumin secretion and urea synthesis, were evaluated in both the spheroid and sandwich model. The synthesis performance in the spheroid compared to the sandwich culture increases approximately by a factor of 1.5. Disintegration of plasma membranes in both models was measured by lactate dehydrogenase (LDH) release in both models. Additionally, diazepam was used as a substrate in drug metabolism studies to characterize the differences in the biotransformation potential with metabolite profiles in both models. It showed that the diazepam metabolism activities in the spheroid model is about 10-fold lower than the sandwich model. The poly-HEMA-based hepatocyte spheroid is a promising new platform towards hepatic tissue engineering leading to in vitro hepatic tissue formation.

Detection of nanolevel drug metabolites in an organotypic culture of primary human hepatocytes and porcine hepatocytes with special reference to a two-compartment model

The quantification of drug metabolites produced during drug metabolism is a growing concern for the pharmaceutical industry, regulatory agencies such as the US Food and Drug Administration, the European Medicines Agency, and others. As 70% of drugs are known reactive metabolites and have black box warnings, they are a major cause of drug-induced injury and lead to drug attrition in early or late clinical stages. According to a 2006 survey report of pharmaceutical companies, drug-induced liver injury was ranked first in terms of adverse events, and it remains the most common reason for restriction or withdrawal of a drug from the market by the Food and Drug Administration. Although there are many reasons underlying drug-induced liver injury, one of the most important is liver failure induced by drug metabolites. Generally, a drug produces metabolites that may bind to cellular molecules and trigger a toxicological effect, cause serious adverse drug reactions, or alter cellular functions. Experimental cellular models that attempt to qualify drug metabolites from cell cultures rely on human plasma and urine obtained from clinical trials and supernatant during early in vitro experiments. However, there is a lack of information about the quantification of drug metabolites inside human hepatocytes, where the drug is extensively metabolized. To overcome this limitation, we used the highly accepted, gold standard organotypic cellular model of primary human hepatocytes to investigate and quantify the parent drug, as well as drug metabolites inside human hepatocytes and outside human hepatocytes to evaluate the quantity of drug metabolites, which are assumed to have remained inside the primary human hepatocytes. We refer to this as a two-compartment model, where one compartment is supernatant compared with in vivo hepatic blood circulation, and the other is inside the hepatocyte cell compared with the inside of in vivo human liver. We detected the nanoconcentrations of all major metabolites (desmethyldiazepam, temazepam, and oxazepam) of the diazepam drug, both inside the cells (matrix) and outside the hepatocyte cells (supernatant) at different time points (primary human hepatocytes: 0, 1, 2, 4, 8, and 24 hours; primary porcine hepatocytes: 0, 1, 2, 5, and 24 hours) during biotransformation in an organotypic sandwich cellular model. Although it is difficult to detect tissue distribution of metabolites in humans, we strongly recommend testing in a two-compartment model of primary human hepatocytes, as nonhuman models may not reflect human metabolism. Preclinical drug screening assessment tests that use this two-compartment strategy may facilitate safer registration of new drug candidates.

Three dimensional cultures of rat liver cells using a natural self-assembling nanoscaffold in a clinically relevant bioreactor for bioartificial liver construction

Till date, no bioartificial liver (BAL) procedure has obtained FDA approval or widespread clinical acceptance, mainly because of multifactorial limitations such as the use of microscale or undefined biomaterials, indirect and lower oxygenation levels in liver cells, short-term undesirable functions, and a lack of 3D interaction of growth factor/cytokine signaling in liver cells. To overcome preclinical limitations, primary rat liver cells were cultured on a naturally self-assembling peptide nanoscaffold (SAPN) in a clinically relevant bioreactor for up to 35 days, under 3D interaction with suitable growth factors and cytokine signaling agents, alone or combination (e.g., Group I: EPO, Group II: Activin A, Group III: IL-6, Group IV: BMP-4, Group V: BMP4 + EPO, Group VI: EPO + IL-6, Group VII: BMP4 + IL-6, Group VIII: Activin A + EPO, Group IX: IL-6 + Activin A, Group X: Activin A + BMP4, Group XI: EPO + Activin A + BMP-4 + IL-6 + HGF, and Group XII: Control). Major liver specific functions such as albumin secretion, urea metabolism, ammonia detoxification, phase contrast microscopy, immunofluorescence of liver specific markers (Albumin and CYP3A1), mitochondrial status, glutamic oxaloacetic transaminase (GOT) activity, glutamic pyruvic transaminase (GPT) activity, and cell membrane stability by the lactate dehydrogenase (LDH) test were also examined and compared with the control over time. In addition, we examined the drug biotransformation potential of a diazepam drug in a two-compartment model (cell matrix phase and supernatant), which is clinically important. This present study demonstrates an optimized 3D signaling/scaffolding in a preclinical BAL model, as well as preclinical drug screening for better drug development.

Interspecies difference in liver-specific functions and biotransformation of testosterone of primary rat, porcine and human hepatocyte in an organotypical sandwich culture

Interspecies difference is an important issue in toxicology research. We compared the potential in vitro metabolism of human, porcine and rat hepatocytes over 2 weeks in culture in an organotypical culture model which reflects the in vivo situation. All three species show similar LDH-rates. Albumin measurements showed that rat cells are about twice as active as human and porcine hepatocytes. The ethoxyresorufin-O-deethylase (EROD) activity of the rat hepatocytes is with about 14 microU/10(6)cells distinctly higher than those of porcine and human cells (1.8 and 0.5 microU/10(6)cells respectively), furthermore, the activity of the rat EROD increases slightly during the prolonged time in culture, whereas those of porcine and human enzymes slightly decrease. Concerning ethoxycoumarin-O-deethylase (ECOD), the enzyme activities are found to be in three different ranges where rat cells show the highest activity with 66 microU/10(6)cells, porcine hepatocytes exhibit an activity of about 23 microU/10(6)cells, and human activity is lowest with 0.7 microU/10(6)cells. All three species show a similar decreasing trend of ECOD during the period of study. Regarding the biotransformation of testosterone, human and porcine liver cells form three major metabolites whereas rat cells form a mixture of all measured metabolites. Hence, in vitro metabolism using porcine hepatocytes would be much more scientific sense than one using rat hepatocytes since the metabolic pathways are much closer to human metabolism.

The influence of medium composition and matrix on long-term cultivation of primary porcine and human hepatocytes

The differentiated hepatocyte phenotype remains difficult to maintain in culture. The duration over which phenotypically stable hepatocytes can be cultured ranges from a couple of days to a few weeks. Shortcomings in medium formulation may be a factor in this lack of success. We have investigated effects of medium formulation on primary porcine and human hepatocyte cultures. We tested seven culture medium compositions (DMEM, ExCell 400, HepatoZYME-SFM, L-15 Leibovitz, SF-3, Waymouth, and Williams' E) and the effects of serum, fibronectin and biomatrix in a sandwich culture configuration. Albumin, urea, cholesterol, GOT, GPT, LDH and triglyceride concentrations were measured over 14 days. For both human and porcine cultures, the best results were obtained with SF-3 medium. Cells cultivated with Williams' E medium and FCS had good morphology and synthetic function during the first days of culture. However, continued addition of serum, was associated with a subsequent loss of differentiated phenotype. Addition of fibronectin was associated with improved function in cultures maintained in SF-3 medium whilst biomatrix had no effect. In contrast, addition of fibronectin did not influence cultures maintained in Williams' E medium, but cultures with biomatrix were associated with improved function at longer time points.

A calcineurin antagonist-free induction/maintenance strategy for immunosuppression in elderly recipients of renal allografts from elderly cadaver donors: long-term results from a prospective single centre trial

BACKGROUND

With the aim to improve the inferior outcomes in elderly recipients of kidneys from elderly cadaver donors, we applied and investigated a therapeutic regimen consisting of calcineurin inhibitor (CNI)-free, mycophenolate mofetil (MMF)-based immunosuppressive (i.s.) induction/maintenance protocol. In this article, we report the long-term results of this clinical trial.

METHODS

A total of 89 recipients (mean age: 63.8 yr) of kidneys from cadaver donors (mean age: 66.8 yr) were consecutively recruited for this 5-yr, prospective, open, single centre, pilot trial. Induction therapy consisted of MMF and steroids in conjunction with a short course (4-10 d) of rabbit antithymocyte globulin (ATG). Maintenance treatment was performed with MMF/steroids or MMF alone under strict therapeutic drug monitoring by aiming target mycophenolic acid (MPA)-trough levels between 2 and 6 mg/mL.

RESULTS

Cumulative 5-year patient and renal allograft survival was 87.69% and 69.81%, respectively. Acute rejection episodes occurred in 23.6% (21 patients). Long-term function of the old renal allografts proved to be satisfactory as reflected by serum creatinine-values of 1.53 mg/dL and urea-values of 57.9 mg/dL at 5 yr.

CONCLUSION

Application of a nephrotoxicity- and atherogenicity-free, MMF-based i.s. induction/maintenance protocol in elderly recipient of kidneys from elderly cadaver donors leads to improved long-term outcomes which are comparable with data from young recipients who have received allografts from young cadaver donors.