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PubMedDate not supplied

Endobiliary stents for palliation in patients with malignant obstructive jaundice.

BACKGROUND: Endobiliary drainage for malignant obstructive jaundice presents a viable palliative alternative. Its role and efficacy depend on factors related to the stent, procedure, and patient. GOALS: To review the evidence in the literature in which settings plastic or metal stents are cost-effective, and whether adjuvant measures or patient-related factors affect duration of stent patency. STUDY: Using databases a literature search was performed for papers published from 1979 to April 2004. All retrieved papers reporting experimental or clinical observations were rated according to strength of evidence, and carefully analyzed. RESULTS AND CONCLUSIONS: Metal stents (Wallstent) stay patent longer than plastic stents (large-bore polyethylene with side-holes), overall median 250 and 110 days, respectively, and seem cost-effective in patients with longer than about 6 months survival, which cannot be accurately predicted. Antibiotics or choleretic agents do not prolong stent patency in clinical settings. In case of stent occlusion, indicated stent exchanges and insertion of a plastic stent, respectively, seem cost-effective in patients initially treated with plastic and metal stents.

Bile Ducts↗
PubMed1985

Evaluation of percutaneous cholangiography and percutaneous biliary drainage in obstructive jaundice.

104 patients with obstructive jaundice were referred for percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD). The effects of PTBD on postoperative morbidity and mortality were evaluated as well as the occurrence of complications. The results were compared to a group of 33 patients with malignant bile duct obstruction operated without preoperative bile drainage. There was no significant difference in the rate of postoperative complications and mortality between these two groups.

Adult↗
PubMed1981

Evaluation of cholangeographic procedures in diagnosis of obstructive jaundice.

Endoscopic retrograde cholangiography, percutaneous transhepatic cholangiography with external bile drainage and a combined method utilizing both procedures were evaluated in 187 patients with obstructive jaundice. Ductal obstructive regions were located in 90 per cent of cases by endoscopic retrograde cholangiography, and 55 per cent of these were correctly diagnosed. Complications were observed in 7.9 per cent with a mortality rate of 2.9 per cent. The most serious complication was cholangitic sepsis. By percutaneous transhepatic cholangiography with external bile drainage, ductal obstructive regions were correctly located in 82 per cent, 37 per cent of these patients were correctly diagnosed. Complications occurred in 9.2 per cent with a mortality rate of 1.5 per cent. The most serious complication was massive bleeding. Successful external bile drainage could be obtained in most cases. The combined method overcomes the disadvantages of the single methods and the cause of obstructive jaundice can be diagnosed more precisely. The surgeon has a better knowledge of the type and the extent of the lesion prior to definitive surgery and can operate more safely on patients with obstructive jaundiced when the serum total bilirubin, has decreased to a level below 5 mg/dl.

Adult↗
PubMed1999

Increased neutrophil chemotaxis in obstructive jaundice: an in vitro experiment in rats.

BACKGROUND AND AIMS: Changes in neutrophil functions in obstructive jaundice have been poorly understood. An in vitro experimental study was performed to evaluate the effect of obstructive jaundice on the functions of macrophages (secretion of neutrophil chemoattractants) and neutrophils (chemotaxis and superoxide anion generation). METHODS: Obstructive jaundice was produced in rats by 7 day bile duct ligation. Peripheral neutrophils and peritoneal macrophages were harvested from either normal, sham-ligated or bile duct-ligated rats and supernatants of the monolayers of the respective macrophages were prepared after stimulation with lipopolysaccharide. Neutrophil chemotaxis was evaluated with a modified Boyden method. RESULTS: The supernatant of the bile duct-ligated rat macrophages showed a chemotactic effect on normal rat neutrophils with insignificant difference from the supernatant of the sham-ligated rat macrophages. Chemotaxis of the bile duct-ligated rat neutrophils towards the supernatant of the normal rat macrophages was significantly increased, compared with that of sham-ligated rat neutrophils. Similarly, neutrophils from bile duct-ligated rats showed significantly greater chemotaxis to formyl-methionyl-leucyl-phenylalanine than the sham-ligated rat neutrophils. Superoxide anion generation in response to formyl-methionyl-leucyl-phenylalanine or phorbol myristate acetate was significantly increased in the bile duct-ligated rats compared with the sham-ligated rats. CONCLUSIONS: The results suggest that the neutrophil is primed in terms of chemotaxis and superoxide anion generation in obstructive jaundice. How these activated neutrophils play a role in the inflammatory response to obstructive jaundice should be evaluated.

Animals↗
PubMed2001

Anti-inflammatory response in patients with obstructive jaundice caused by biliary malignancy.

BACKGROUND: Obstructive jaundice potentially modulates the host defense mechanism resulting in perioperative infection. It has been reported that a systemic inflammatory response occurs in patients with obstructive jaundice. An anti-inflammatory response was studied in 29 jaundiced patients undergoing biliary drainage. RESULTS: Plasma concentrations of interleukin (IL)-10, soluble tumor necrosis factor receptor (STNFR) p55, STNFR p75, IL-1 receptor antagonist (IL-1ra), IL-6 and soluble CD14 (sCD14) were measured by using immunoassay. Plasma concentrations of IL-10, STNFR p55, STNFR p75, IL-1ra, IL-6 and sCD14 were significantly higher in jaundiced patients than in the controls (P < 0.01). After biliary drainage, the concentrations of IL-10, the three cytokine antagonists, and IL-6 decreased significantly (P < 0.05). The sCD14 concentration did not decrease. At the time of drainage, the concentrations of STNFR p55 and STNFR p75 were significantly higher in 10 patients with positive bile cultures than in 19 patients with negative bile cultures (P < 0.05). Bile cultures became positive 14 days after drainage in 10 patients, and remained negative in nine. The concentration of STNFR p55 before drainage was significantly higher in the former group (P = 0.05). The plasma concentrations of IL-10 and STNFRs were significantly correlated with the IL-6 concentration, body temperature and the white blood cell count (P < 0.05). Serum total bilirubin levels did not affect plasma levels of anti-inflammatory mediators, and sCD14. CONCLUSION: Jaundiced patients exhibited an anti-inflammatory immune response that potentially modulates the host defense mechanism and results in anergy and increased susceptibility to infection. Biliary infection may be one of the major stimuli of the immune response.

Aged↗
PubMed1985

Effect of obstructive jaundice on amylase secretion in rat pancreatic acini.

The effect of obstructive jaundice on pancreatic amylase secretion was studied in isolated pancreatic acini prepared from bile duct ligated rats (7 days postoperatively), sham operated rats being used as control. Obstructive jaundice caused increase in pancreatic wet weight, pancreatic protein content and pancreatic amylase content by 27.9%, 40.1% and 33.2%, respectively. In acini prepared from obstructive jaundice group, compared with acini from sham operation group, responsiveness to cholecystokinin (CCK) and carbachol was decreased when amylase release was expressed as the percentage of total amylase activity initially present in acini. However, sensitivity to both secretagogues was unchanged when expressed as the percentage of maximally stimulated amylase release. The dose-response curves to Ca2+ ionophore for amylase release were similarly shaped in both groups. These results suggested that a pancreatico-trophic effect, compared with altered responsiveness of pancreatic acini, should play a major role in hypersecretion in obstructive jaundice.

Amylases↗
PubMed2005

Bombesin and neurotensin reduce endotoxemia, intestinal oxidative stress, and apoptosis in experimental obstructive jaundice.

OBJECTIVE: To evaluate the effect of bombesin (BBS) and neurotensin (NT) on intestinal histopathology, intestinal oxidative stress, and endotoxemia in experimental obstructive jaundice. SUMMARY BACKGROUND DATA: Obstructive jaundice compromises gut barrier function, resulting in endotoxemia. BBS and NT, exerting various biologic actions on gastrointestinal tissues, preserve gut mucosal integrity in cases of injury or atrophy. METHODS: Seventy male Wistar rats were randomly divided into 5 groups: I = controls, II = sham operated, III = bile duct ligation (BDL), IV = BDL + BBS (30 microg/kg/d), V = BDL + NT (300 microg/kg/d). By the end of the experiment, on day 10, endotoxin was measured in portal and aortic blood. Tissue sections of the terminal ileum were examined histologically, and villus density, mucosal thickness, mitotic activity and apoptosis in crypts were assessed. In addition, ileal mucosa was analyzed for DNA and protein content. To estimate intestinal oxidant/antioxidant equilibrium, lipid peroxidation, protein oxidation, and thiol redox state (reduced glutathione [GSH], oxidized glutathione [GSSG], total nonprotein mixed disulfides [NPSSR], protein thiols [PSH], and protein disulfides [PSSP]) were determined on tissue homogenates from the terminal ileum. RESULTS: BBS or NT administration significantly reduced portal and systemic endotoxemia observed in obstructive jaundice. Both factors reversed obstructive jaundice-induced morphologic features of intestinal atrophy, increasing villus density and mucosal thickness. This effect was accompanied by induction of mitoses and reduction of apoptosis in intestinal crypts. Mucosal DNA and protein content were reduced, although not to significant levels, in BDL animals and restored to control levels after BBS or NT treatment. Moreover, BBS or NT administration protected the intestine in jaundiced rats against oxidative stress, as demonstrated by reduction of intestinal lipid peroxidation, increase of the antioxidant GSH, and decrease of the oxidized forms GSSG and NPSSR, while BBS additionally reduced protein oxidation as well. CONCLUSIONS: Administration of BBS or NT in bile duct-ligated rats exerts beneficial effects on intestinal oxidative stress, cell proliferation, apoptosis, and endotoxemia. This observation might be of potential value in patients with extrahepatic cholestasis.

Animals↗
PubMed1994

"Rendez-vous" procedure (RVP) for obstructive jaundice.

Seven patients with obstructive jaundice were palliatively treated with the "rendez-vous" procedure, which combines a percutaneous and an endoscopic approach to stent insertion into the biliary system. In six cases, pretreatment papillotomy was not needed. Endoscopy was also not really necessary for stenting in one patient. This procedure should be restricted for use in cases of endoscopic failure.

Aged↗
PubMed1996

Metastatic breast carcinoma presenting as obstructive jaundice.

A case of obstructive jaundice due to extrahepatic intraductal biliary metastasis from a breast carcinoma is reported. This clinical picture was a late manifestation and the first evidence of spread of the disease. The patient was treated by surgical decompression with relief of jaundice but died 5 months later. In patients with a history of carcinoma of the breast, the possibility of extrahepatic biliary metastasis should always be considered in the differential diagnosis of jaundice. Because this condition is amenable to palliation, it is important to differentiate it from jaundice due to hepatic involvement by this tumor.

Adenocarcinoma↗
PubMed2003

Endoscopic retrograde cholangiopancreatographic evaluation of patients with obstructive jaundice.

OBJECTIVE: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice. DESIGN: A retrospective, observational study. PLACE AND DURATION OF STUDY: The study was carried out at Valley Clinic, Rawalpindi, from January 1999 to January 2002. SUBJECTS AND METHODS: Two-hundred and twenty-six patients, who underwent ERCP for evaluation of obstructive jaundice were included. ERCP in each case was performed with standard technique and the findings were recorded. Therapeutic procedures like sphincterotomy, Dormia extraction for stone, and stent placements were performed whenever indicated. RESULTS: Of the 226 patients, 117 (51.8%) were males, and 109 (48.2%) females, their mean age being 51.8+/-16.6 years. Common bile and pancreatic ducts were visualized in 81.8% and 68.1% patients respectively. Growth/masses and stones were commonest causes of obstructive jaundice. Choledocholithias was common in males, while biliary channel related growth/masses were common in females (p-value=0.03). Common bile duct stone clearance rate was 88%, stenting was highly successful in patients with growth and strictures. ERCP related complications were noted in 11 (4.8%) patients. CONCLUSION: ERCP is an important diagnostic and therapeutic modality for evaluation of patients with obstructive jaundice. Growth/masses and stones are common causes of obstructive jaundice which can be diagnosed and treated with ERCP.

Adult↗
PubMedDate not supplied

Renal failure in obstructive jaundice.

BACKGROUND/AIMS: The optimal preoperative management of patients with acute obstructive jaundice is still a matter of debate. Reduction in effective plasma volume and systemic endotoxemia are major consequences both in experimental acute bile duct ligation and in patients with acute obstructive jaundice (AOJ). The objective of this study is to show the necessity for adequate preoperative hydration and lactulose administration for the prevention of postoperative renal dysfunction in patients with AOJ. METHODOLOGY: Fifty-five patients (35 male, 20 female) with a mean age of 62 years were entered into the study. There were 23 benign and 32 malignant strictures in this group. All patients received oral lactulose (30-45mL per day) and IV cefazoline (3-4g/day) before surgery. Fluid and electrolyte balance was precisely maintained throughout the hospitalization via daily body weight calculations. High-risk elderly patients with left ventricular systolic dysfunction were assessed by echocardiography and therapeutic measures were undertaken. Renal function was assessed by creatinine clearance (ClCr) measurements and impairment of renal function was defined as a >20% fall in ClCr value post-surgery. RESULTS: Mean preoperative bilirubin level was 11.05mg/dL (range: 3.45-27.0mg/dL). None of the patients developed postoperative renal failure. The difference between pre- and postoperative ClCr value (104.02mL/min vs. 101.0mL/min respectively) was not significant (t=0.698, P=0.489). One patient with mild renal function impairment before surgery (ClCr=45.4mL/min) successfully recovered with 60% rise in creatinine clearance (ClCr=78.1mL/min) after the operation. Three patients with normal functioning kidneys died within 30 days of operation. The principle cause of death was carcinomatosis and pulmonary embolus in two and intraoperative hemorrhagic shock in one patient. CONCLUSIONS: These results further substantiated the importance of adequate preoperative hydration and endotoxin inactivation in terms of acute renal failure prophylaxis in patients with AOJ. This regimen obviates the afferent events in obstructive jaundice and provides prevention of acute renal failure even in high-risk elderly patients.

Acute Disease↗
PubMedDate not supplied

Relative merits of ultrasonography, computed tomography and cholangiography in patients of surgical obstructive jaundice.

Fifty consecutive patients with surgical obstructive jaundice were evaluated prospectively with ultrasonography (US), computed tomographic scans (CT scan) and cholangiography-percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangio-pancreaticography (ERCP). The diagnostic accuracy of ultrasound in defining the level of obstruction was 86% as compared to 86% and 94.8% for CT scan and cholangiography, respectively. To measure the etiology of the obstruction, the accuracy of ultrasound, CT scan and cholangiography were 84%, 86% and 75%, respectively. The sensitivity of CT scans and cholangiography in the diagnosis of choledocholithiasis was 100%, 81.8% and 90%, respectively, whereas specificity was 97%, 100% and 100%, respectively. Sensitivity for a diagnosis of malignant disease was 100% for both US and CT scans whereas specificity was 90% and 81%, respectively. Ultrasonography as a single radiological investigation is sufficient in the evaluation of the majority of patients with surgical obstructive jaundice. CT scan and cholangiography should be done only when US gives equivocal findings or if concomitant therapeutic procedures like basketing and stenting are also planned.

Adolescent↗
PubMedDate not supplied

Preoperative biliary drainage in obstructive jaundice.

BACKGROUND/AIM: Although the role of preoperative percutaneous transhepatic biliary drainage in obstructive jaundice has been the subject of controversy in many other countries, in Japan, almost all surgeons agree that biliary decompression should be performed prior to the surgical treatment in obstructive jaundice. This study was performed in order to determine the role of preoperative percutaneous transhepatic biliary drainage in obstructive jaundice. PATIENTS AND METHODS: We evaluated 238 patients with preoperative obstructive jaundice, and also studied its pathophysiology in experimental animal models. RESULTS: Both of these studies demonstrated that this procedure should be performed if the value of total bilirubin is more than 5 mg/dl, the ICG Rmax value of the future remnant liver is less than 0.4 mg/kg/min, and the duration of jaundice is more than 3 weeks. Preoperative biliary drainage improves the liver function, so that major operations can be safely performed without major complications. CONCLUSIONS: It therefore seems preferable that patients undergo preoperative biliary decompression to reduce serum total bilirubin to below 5 mg/dl, and to improve hepatic and reticuloendothelial functions and hepatic reserve prior to any major surgical operation.

Adult↗
PubMed2004

Reversibility of leukocyte dysfunction in rats with obstructive jaundice.

BACKGROUND: The role of leukocytes in obstructive jaundice is obscure and the effect of relieving cholestasis on leukocyte function is unclear. We postulated that cholestasis affects systemic polymorphonuclear leukocyte function by deranging phagocytosis and hydrogen peroxide release and the leukocyte dysfunction is reversible by internal and external biliary drainage. MATERIALS AND METHODS: Sixty male Sprague Dawley rats were randomly assigned to four groups: obstructive jaundice (OJ), sham operation (SH), OJ with internal drainage (ID), and OJ with external drainage (ED). The phagocytic functions of neutrophils and monocytes in whole blood were measured with flow cytometry using fluorescent microspheres. Intracellular hydrogen peroxide production by leukocytes was assessed with flow cytometry using dihydrorhodamine-123 as probes. RESULTS: Leukocyte count and percentage of monocytes in rats with OJ was significantly increased compared with SH rats (P < 0.001). These elevations could be reversed by both ID and ED method (P < 0.001). The phagocytic function of neutrophils and monocytes was significantly depressed in OJ rats compared with that in SH rats (P < 0.001). After relief of the OJ, the suppressed phagocytic function of neutrophils and monocytes was completely improved in ID rats (ID versus OJ, P < 0.001), but only partially reversed in ED rats. The hydrogen peroxide production by monocytes and lymphocytes was significantly increased in OJ rats (P < 0.05). ID reversed the increased hydrogen peroxide generation (P < 0.05), but ED only partially did. CONCLUSIONS: In our rodent model of biliary obstruction, deranged phagocytosis, and hydrogen peroxide generation by leukocytes was found. Internal drainage is superior to external drainage for reversal of the distorted leukocyte function.

Animals↗
PubMed1992

Hepatic macrophage malfunction in rats with obstructive jaundice and its biological significance.

The present study was designed to investigate the pathophysiology of obstructive jaundice by analyzing the function of hepatic macrophages and their role in immune responses and homeostasis in rats. The phagocytic index, determined by the rate of disappearance of 51Cr-endotoxin from the peripheral blood after intravenous injection, was increased in obstructive jaundice 2 weeks after bile duct ligation. The superoxide production of isolated hepatic macrophages and peripheral blood monocytes, measured by the superoxide dismutase inhibitable ferricytochrome c reduction method, was increased. Prostaglandin E2 release, measured by RIA, was markedly increased in rats with obstructive jaundice, but there was no significant difference in interleukin-1 release between jaundiced and control rats. The flow-cytometric analysis of surface molecules of hepatic macrophages showed decreased expression of interleukin-2 receptor in rats with obstructive jaundice. Thus, the functions of hepatic macrophages in rats with obstructive jaundice were impaired. This malfunction may disturb the immunoregulatory network and metabolism, although the exact implications of the altered function of hepatic macrophages have not yet been clarified.

Animals↗