Translocation of Enterococcus in jaundiced and anergic rats

Background

Translocation of bacteria from the gut to other organs is one cause of systemic complications in obstructive jaundice. Furthermore, hyperbilirubinaemia appears to cause anergy. This study investigated whether these responses (translocation of gut bacteria and anergy) increase the postoperative mortality rate in rats in which obstructive jaundice is induced surgically by ligature of the bile duct.

Methods

Some 88 male Wistar rats were divided into six groups. All rats except those in group 1 received gentamicin by the oral route (0·7 mg in 1 ml water, daily for 6 days) to ensure intestinal decontamination. On day 7, all rats except those in groups 1 and 2, which had vehicle only, received Enterococcus. Statistical analysis was by Student's test and Fishers's exact test.

All animals underwent standard blood testing, delayed hypersensitivity tests, haematimetry and serum endotoxin determinations. Flow cytometry was used to count CD3-, CD4- and CD8-positive lymphocytes. On the day 5 after surgery, these assays were repeated and, in addition, the rats were killed for microbiological analysis of gut and viscera contents (liver, spleen, mesentery and lung).

Results

Five days after surgery, mean bilirubin levels in groups 5 and 6 were greater than 14 mg dl−1. In addition, all rats in groups 5 and 6 showed absence of the delayed hypersensitivity response, indicating anergy. Lymphocyte counts in each group are shown in the Table.

The mean proportion of CD8-positive lymphocytes in rats that had received Enterococcus (groups 3–6) was 16 per cent compared with 25 per cent in groups 1 and 2 (P < 0·05). The mean percentage of CD3-positive lymphocytes in groups 5 and 6 was 51 per cent, but 71 per cent in all other groups (P < 0·05). Likewise, the mean percentage of CD4-positive lymphocytes in groups 5 and 6 was 32 per cent, but 47 per cent in all other groups (P < 0·05). The postoperative mortality rate in group 4 (17 per cent) was significantly lower than that in the obstructive jaundice groups 5 and 6 (62 per cent) (P < 0·01). Post-mortem microbiological analyses revealed translocation of Enterococcus only in groups 5 (80 per cent) and 6 (70 per cent). Enterococci were most frequently present in the mesentery (80 and 70 per cent respectively), followed by the liver (40 and 40 per cent), spleen (20 and 20 per cent) and lungs (10 and 10 per cent).

Conclusion

(1) Obstructive jaundice in rats leads to immunological alterations including anergy. (2) Obstructive jaundice in rats favours translocation of enterococci from the gut to other organs. (3) The postoperative mortality rate in jaundiced rats was much higher than that in sham-operated rats.

Immunological surrogate parameters in a prognostic model for multi-organ failure and death

OBJECTIVE

To assess the ability of clinical or biochemical parameters to predict outcome (survival or non-survival; severe or moderate/no complication) using multiple regression analyses.

DESIGN

Prospective, descriptive cohort study with no interventions

SETTING

12 surgical intensive care units of university hospitals and large community hospitals; four medical school research laboratories in eight European countries

PATIENTS

128 surgical patients with major intra-abdominal surgery admitted for at least two days to an intensive care unit

MAIN OUTCOME MEASURES

Prediction of complications or survival based on analysis of clinical (Multiple Organ Dysfunction Score, Multi-Organ-Failure Score, Acute Physiology and Chronic Health Evaluation II scores) and immunological (plasma levels of endotoxin, endotoxin neutralizing capacity, IL-6, IL-8, cell associated IL-8, Fc-receptor polymorphism, soluble CD-14) parameters, with comparison of predicted and actual outcomes.

RESULTS

APACHE II, MODS score, MOF score, platelets, IL-6, IL-8, ENC, cell ass. IL-8 were significantly different between survivors and non-survivors and patients with/without severe complications by univariate analysis. By multivariate analysis only MOF, MODS score, IL-6, platelets, comorbidity predicted complications with a sensitivity of 82% and a specificity of 87%. Multivariate analysis demonstrated that only APACHE II score, plasma IL-8 and complications predicted death (sensitivity 84%; specificity 90%).

CONCLUSION

Immunological surrogate parameters may predict complications and death of surgical ICU patients. The use of several parameters may add to increase sensitivity and specificity in a prognostic model.

Septic complications after biliary tract stone surgery: a review and report of the European prospective study

We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery. This study included a total of 280 patients operated on in eight hospitals in various European countries. In this study the computer program "Surgery" was used. Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female. The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin. Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections. The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02). In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs. 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively. The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03). The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001). Two patients died, one of them (0.4%) caused by sepsis. In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.

Acute abdomen caused by torsion of the pedicle in a wandering spleen

A case of acute abdomen caused by acute torsion of a wandering spleen in a 20-year-old female patient is presented. It underscores the efficiency of the ultrasonic examination in the diagnosis of this type of pathology.

Hyperbilirubinemia, jaundice and anergy

A prospective study of delayed hypersensitivity response was carried out in jaundiced patients. One hundred and seventy-seven subjects were studied. Fifty-nine were controls and one hundred and eighteen were patients with hepato-pancreato-biliary pathology and biliary tract obstruction. A multitest technique was used to evaluate the delayed hypersensitivity response, classifying the subjects into one of three groups: immunocompetent, relatively anergic and anergic. In the control group 76.3 per cent of the subjects were immunocompetent as opposed to 16.1 per cent of the patients (p less than 0.0001). Twenty-four per cent of the control subjects and eighty-four per cent of the patients presented anergy or relative anergy (p less than 0.0001). Among the patients no difference could be found in the index of anergy between malignant and benign pathology. We have found, moreover, that patients with a mean bilirubin level of 12 mg/dl showed a change in the delayed hypersensitivity response, with development of anergy or relative anergy.

Anergy in patients with gastric cancer

A prospective study of delayed hypersensitivity was carried out in gastric cancer patients. One hundred and fifty-six subjects were studied. Fifty-nine were controls and ninety-nine patients with gastric neoplasm. A multitest technique was used to evaluate the delayed hypersensitivity response, classifying the subjects into one of three groups: immunocompetent, relatively anergic, and anergic. In the control group, 76% per cent of the subjects were immunocompetent; of the patients, only 43% showed an adequate cell-mediated immune response (p less than 0.001). Fourteen control subjects (24%) and 54 patients (56%) presented with either anergy or relative anergy (p less than 0.001). Of the ninety-four patients that underwent surgery, five (11.9%) of the immunocompetent group developed major postoperative septic complications, as did seven (22%) of the relative anergic and seven (35%) of the anergic patients (immunocompetent vs. anergic, p less than 0.05). Our study indicates a relationship between anergy and postoperative septic complications.

[Cancer of the gallbladder]

A retrospective study was made of cancer of the gallbladder over a 10-year period, during which 874 operations of the biliary tract were performed, 26 for gallbladder neoplasm (2.97%). Of the 26 patients studied, 22 (84.6%) were women, mean age at appearance of the tumor being 63.9 years. In 77% of the patients the time of evolution of the symptoms was less than a year, a men of 3.6 months. The principal symptom was abdominal pain, encountered in 96% of patients, followed by nausea and vomiting (65.4%). Fifty-eight percent of patients had gallstones and 46% had metastases at the time of operation. In 23% of the patients only laparotomy and biopsy could be performed, 42% underwent cholecystectomy and 34% cholecystectomy and drainage of the biliary tract. Of the 26 patients in our study, 24 (92%) had adenocarcinoma.

Anergy in jaundiced patients

A prospective study of delayed hypersensitivity was carried out in jaundiced patients. One hundred and nineteen subjects were studied. Fifty-nine were controls and sixty were patients with pancreatobiliary pathology and biliary tract obstruction. A Multitest technique was used to evaluate the delayed hypersensitivity response, classifying the subject into one of three groups: immunocompetent, relatively anergic and anergic. In the control group, 76 per cent of the subjects were immunocompetent as opposed to 17 per cent of the patients (P less than 0.001). Ten per cent of the control subjects and fifty-five per cent of the patients presented anergy (P less than 0.001). Amongst the patients no difference could be found in the index of anergy between malignant or benign pathology. A greater incidence of postoperative septic complications in anergic and relatively anergic patients was found. Our study indicates a relationship between jaundice and anergy.