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PubMed1994

Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas.

OBJECTIVE: This study was set up to identify patient-related factors favoring the application of either surgery or endoprostheses in the palliation of obstructive jaundice in subsets of patients with cancer of the head of the pancreas or periampullary region. SUMMARY BACKGROUND DATA: In the palliation of obstructive jaundice, surgical biliodigestive anastomosis has traditionally been performed. Surgical biliary bypass is associated with high mortality (15% to 30%) and morbidity rates (20% to 60%) but little recurrent obstructive jaundice (0% to 15%). Biliary drainage with endoscopically placed endoprostheses has a lower complication rate, but recurrent obstructive jaundice is seen in up to 20% to 50% of patients. METHODS: Patients with advanced cancer of the head of the pancreas or periampullary region treated at the University Hospital Dijkzigt, Rotterdam, The Netherlands, between 1980 and 1990 were reviewed. In 148 patients, data were compared concerning the morbidity and hospital stay after the palliation of obstructive jaundice with endoscopic endoprostheses or surgical biliary bypasses. These patients were stratified for long (> 6 months) and short (< 6 months) survival times. RESULTS: In short-term survivors, the higher late morbidity rates after endoprostheses were offset by higher early morbidity rates and longer hospital stays after the surgical bypass. In long-term survivors, there was no difference in the hospital stay between the two groups, but the late morbidity rate was significantly higher in the endoprosthesis group. CONCLUSIONS: These data suggest that endoscopic endoprosthesis is the optimal palliation for patients surviving less than 6 months and surgical biliary bypass for those surviving more than 6 months. This policy necessitates the development of prognostic criteria, which were obtained by Cox proportional-hazards survival analysis. Advanced age, male sex, liver metastases, and large diameters of tumors were unfavorable prognostic factors. With these factors, the risk of short- or long-term survival can be predicted. It is hoped that the application of these data may allow a rational approach toward optimal palliative treatment of this form of malignant obstructive jaundice.

Aged↗

PubMedDate not supplied

Evaluation of functional liver reserve in patients with obstructive jaundice undergoing hepatectomy.

BACKGROUND/AIMS: In hepatectomy in patients with obstructive jaundice, correct evaluation of the functional liver reserve is sometimes difficult. This study examined whether the preoperative level of total bilirubin in the bile from a predicted remnant liver can be used as a predictor for safe hepatectomy in such patients. METHODOLOGY: Twenty consecutive patients with jaundice who underwent major hepatectomy and in whom all bile from the predicted remnant liver could be collected were included in this study. The level of total bilirubin in the bile was calculated by multiplying bile volume and density obtained by percutaneous transhepatic biliary drainage. Patients were divided into two groups, with (group 1) and without postoperative death due to liver failure (group 2). RESULTS: The level of total bilirubin in the bile from the predicted remnant liver was lower in group 1 than in group 2. Patients did not die of postoperative liver failure if the level of total bilirubin in the bile was maintained, even if the bile volume or density were low. CONCLUSIONS: The preoperative level of total bilirubin in the bile from the predicted remnant liver can be used as a predictor for safe hepatectomy in patients with obstructive jaundice.

Adult↗

PubMed1978

Sonographic "parallel channel" sign of biliary tree enlargement in mild to moderate obstructive jaundice.

The criteria for the diagnosis of minimal obstructive jaundice (i.e., bilirubin less than 11.0 mg/100 ml) using sonography have not been established. A reliable diagnosis of obstructive jaundice with mild dilation of the bile ducts can be made by sonography when the "parallel channel" sign is seen. This sign is due to the simultaneous imaging of the dilated right or left main hepatic duct and the adjacent contiguous main portal vein branch. A prospective study of 86 patients showed this to be a highly reliable means of differentiating obstructive from nonobstructive jaundice when minimal duct dilation is present.

Adult↗

PubMed1992

The effect of temporary hepatic artery or portal vein occlusion in obstructive jaundice.

Hepatic hemodynamics before vascular occlusion and the effect of transient hepatic artery or portal vein occlusion on the liver were investigated in normal dogs and dogs with experimentally induced obstructive jaundice by measurement of hepatic tissue blood flow (HTBF), index of hemoglobin concentration (IHb), oxygen saturation (ISO2), serum glutamic pyruvic transaminase (SGPT) concentration, and malonaldehyde (MDA) concentration in liver tissue. Livers with obstructive jaundice had increased blood flow and a lower hemoglobin concentration compared with normal livers at baseline before vascular occlusion. Percentage change of ISO2 from baseline was higher than percentage change of HTBF after reperfusion in both normal and obstructive jaundiced liver, although they were decreased to almost similar proportions during vascular occlusion. MDA concentration in obstructive jaundice after reperfusion following vascular occlusion was higher than in normal liver. Furthermore, MDA concentration after reperfusion following hepatic artery occlusion was increased compared with after reperfusion following portal venous occlusion in obstructive jaundice. There was no evidence of massive liver necrosis which was newly developed by transient vascular occlusion. These results represent the pathological condition in the liver before transient vascular occlusion and after reperfusion in obstructive jaundice.

Alanine Transaminase↗

PubMed2004

The effect of N-acetylcysteine (NAC) on liver and renal tissue inducible nitric oxide synthase (iNOS) and tissue lipid peroxidation in obstructive jaundice stimulated by lipopolysaccharide (LPS).

Morbidity and mortality rates are very high in obstructive jaundice when it is associated with sepsis and multiple organ failure. Nitric oxide (NO) formation and increased expression of inducible nitric oxide synthase (iNOS) also take place in obstructive jaundice (OJ). N-Acetylcysteine (NAC) has a beneficial effect by demonstrating anti-inflammatory activity such as inhibits cytokine expression/release, inhibiting the adhesion molecule expression and inhibiting nuclear factor kappa B (NFkappaB). The aim of this study was to investigate the effects of NAC on liver and renal tissue iNOS, and liver tissue lipid peroxidation in lipopolysaccharide (LPS) induced obstructive jaundice. We randomized 48 rats into six groups. Group A: Sham group; group B: OJ group; group C: OJ+NAC; group D: OJ+LPS (Escherichia coli LPS serotype L-2630, 100mg, Sigma) group E: OJ+NAC+LPS; group F: OJ+LPS+NAC. NAC was started subcutaneously 100mg/kg. LPS was injected intraperitoneally and then at the tenth day we sacrificed the rats. Liver malondialdehyde (MDA) increased and liver ATPase decreased in groups B-D when compared to group A. After the administration of NAC (groups C-E), liver MDA levels decreased, tissue ATPase levels increased as compared to other groups. The liver and renal tissue iNOS expression was increased in groups B, D, and F. After the administration of NAC (groups C-E) the liver and renal tissue iNOS expression were decreased. Our results indicated that NAC prevented the deleterious effects of LPS in OJ by reducing iNOS expression via lipid peroxidation in liver and renal tissue; if it was administrated before LPS. But NAC failed to prevent the iNOS expression and lipid peroxidation if there was established endotoxemia in OJ.

Acetylcysteine↗

PubMed1990

A model of reversible obstructive jaundice in the rat.

A model of reversible, extrahepatic biliary obstruction is described. Vessel loop blockade of the biliary tree results in obstructive jaundice while removal of the exteriorized vessel loop provides internal biliary drainage without subsequent laparotomy. This technique combined with a system for chronic venous infusion and arterial blood sampling in the unrestrained rat is ideal for long-term metabolic studies of obstructive jaundice. Male Fisher 344 rats (275-350 g) underwent either the combined procedure of total biliary tract blockade and vascular access or sham operation. Mean serum bilirubin was significantly elevated (12.7 +/- 8.9 mg/dl) in the experimental group and following relief of biliary obstruction significantly dropped below 1 mg/dl in all animals except one. Concomitant changes in alkaline phosphatase, glutamate oxaloacetate transaminase, and glutamate pyruvate transaminase were seen. Experimental and control rats initially lost weight following laparotomy; however, mean body weight stabilized by the 5th postoperative day and was similar in both groups on the 10th postoperative day. This combined procedure is a simple, effective and reproducible method of obstructive jaundice.

Alanine Transaminase↗

PubMed1986

Pancreatic hypersecretion in dogs with obstructive jaundice.

We examined the hypersecretory function of the isolated, blood-perfused pancreas of dogs with experimentally obstructive jaundice. There was no difference in basal pancreatic secretion between control dogs and obstructively jaundiced dogs. Secretin- or pancreozymin-stimulated increase in total values for pancreatic juice flow, bicarbonate, protein and amylase were greater in dogs with obstructive jaundice than in control dogs; however, concentrations of bicarbonate, protein and amylase were unchanged in each group. Acetylcholine-stimulated increase in total values and concentrations of these factors were the same in dogs with obstructive jaundice and controls. These data suggest that hypersensitivity of the pancreas to secretin and pancreozymin may be one of the main mechanisms of pancreatic hypersecretion.

Acetylcholine↗

PubMed1990

[Experimental and clinical studies on liver tissue blood flow in obstructive jaundice].

To clarify some pathologic aspects of obstructive jaundice before and after bile duct drainage, changes in liver tissue blood flow were observed using an electrolytic historheometer, in combination with the FITC-dextran method, during experimental bile duct obstruction and after its elimination. Clinical investigations were based on histologic findings in liver tissue specimens collected by wedge biopsy at the time of laparotomy following bile duct drainage. Rats with bile duct obstruction showed significantly (P less than 0.01) lower values for liver tissue blood flow, with sinusoid dilation, in comparison to control rats, at 2 and 4 weeks following the initiation of experimental bile duct obstruction. Liver tissue blood flow disturbance subsided 3 days after eliminating the obstruction, at 2 weeks following its initiation, while no improvement occurred even following elimination of obstruction after 4 weeks. Clinically, in cases with a high degree of sinusoid dilation the effect of postoperative bile duct drainage was poor, with a high incidence of postoperative complication. These findings suggest that liver tissue blood flow disturbance might causatively affect the pre- and postoperative course of obstructive jaundice.

Animals↗

PubMedDate not supplied

Cell biological evaluation of biliary drainage prior to hepatectomy in obstructive jaundice.

BACKGROUND/AIM: The necessity and efficacy of biliary drainage prior to major surgery in patients with obstructive jaundice have been reported in various clinical and experimental studies in Japan. However, it is not enough that Western countries understand the advantage of preoperative drainage. In this study, therefore, cytoprotective effect of preoperative biliary drainage drainage was evaluated using the cell biological technique. MATERIALS AND METHODS: Ten jaundiced dogs and 10 with drainage (after induction of jaundice) were each divided into two groups: those with and those without 40% hepatectomy. Using these four groups, the advantage of biliary drainage before hepatectomy in obstructive jaundice was studied, using isolated hepatocytes and Kupffer cells. RESULTS: In jaundiced dogs, isolated hepatocyte viability and intracellular cyclic AMP concentration were considerably reduced. The bleb formation rate, culture supernatant lipid peroxide and lactate dehydrogenase contents, and plasma thromboxane B2 and 6-keto-PGF1 alpha levels all markedly increased. These changes were more exaggerated in those after hepatectomy. In the dogs with drainage, all of these values were approximated to those in normal animals. The changes following hepatectomy in dogs with drainage were also less pronounced in comparison with jaundiced animals. CONCLUSIONS: These findings suggest that biliary drainage prior to hepatectomy in obstructive jaundice mitigates liver impairment, both at the cellular level and in terms of prostanoid metabolism. It was concluded that preoperative biliary drainage prior to hepatectomy ensures better results for obstructive jaundice.

Animals↗

PubMed2000

Improvement of portal flow and hepatic microcirculatory tissue flow with N-acetylcysteine in dogs with obstructive jaundice produced by bile duct ligation.

OBJECTIVE: To find out if N-acetylcysteine (NAC) would improve hepatic circulation in dogs with obstructive jaundice. DESIGN: Open laboratory study. SETTING: University hospitals, Japan and France. MATERIALS: 14 male beagle dogs and 10 male Wistar rats. INTERVENTIONS: Obstructive jaundice was produced by ligation of the common bile duct (CBD) for 7 days in both dogs and rats. Either 5% dextrose (control group, n = 7) or NAC (NAC group, n = 7) was given to dogs. Sinusoidal endothelial cells were obtained from rats after ligation by elutriation, and varying amounts of NAC were given. MAIN OUTCOME MEASURES: The volumes of portal blood flow and hepatic microcirculatory tissue flow were reduced after ligation of the CBD, but those increased after NAC had been given to dogs with obstructive jaundice. NAC increased the concentrations of plasma cyclic 3',5'-guanosine monophosphate (cGMP). It also increased concentrations of serum and hepatic-reduced glutathione, and hepatic adenosine triphosphate (ATP) in cholestatic dogs, and secretion of cGMP from sinusoidal endothelial cells from rats with obstructive jaundice. CONCLUSION: These results suggest that NAC given intravenously effectively improves hepatic circulation and hepatic function in dogs with obstructive jaundice.

Acetylcysteine↗

PubMed1994

[Experimental study on the metabolism of pancreatic hormone in obstructive jaundice].

To examine the mechanism of reduced tolerance to glucose in obstructive jaundice, insulin and glucagon metabolism was examined using mongrel dogs. Perfused pancreas isolated from obstructive jaundice dogs was used for this purpose, and the following results were obtained. Insulin release from the pancreas was decreased but glucagon was not changed by stimulation with cholecystokinin octapeptide. Extraction of insulin and glucagon in the liver was examined using the dogs which had cholestatic and non-cholestatic lobes in each individual. Insulin levels of the hepatic blood were significantly lower than those of the portal blood. In comparison of the insulin levels between the hepatic blood from cholestatic and non-cholestatic lobes, the value of the cholestatic hepatic blood was significantly higher than that of the non-cholestatic hepatic blood. Concerning on glucagon, however, there were no significant differences between the two blood samples. Therefore, the reduced tolerance to glucose in obstructive jaundice could not be attributed to the enhanced extraction of insulin in the liver but to the decrease of insulin production in the pancreas.

Animals↗

PubMedDate not supplied

Non-homogeneity of serum leucine arylamidase (LAP) activity in hepatocellular and obstructive jaundice.

In 40 patients with hepatocellular and obstructive jaundice and in 20 healthy subjects the pattern of serum leucine arylamidase (LAP) isoenzymes was determined. Polyacrylamide gel electrophoresis was used for demonstration of enzyme non-homogeneity. It was found that the main enzyme activity in healthy subjects was connected with postalbumins. In some healthy subjects and additional zone of activity was observed in beta lipoproteins. Only exceptionally 3- and 4-fraction enzymograms were found in healthy subjects. Additional activity zones were present in these subjects in the alpha2 macroglobulin region or in the region of slowly migrating haptoglobins. In hepatocellular jaundice, i.e. in viral hepatitis, the total serum LAP activity increased slightly. In the enzymogram this increase was localized in the postalbumin fraction and caused also appearance of additional, sporadically occurring isoenzymes migrating with rapidly moving haptoglobins. In obstructive jaundice of benign or malignant etiology the total serum enzyme activity rose strikingly. In most patients a 6-fraction enzymogram was found. The activity of postalbumin isoenzyme was particularly increased, while no changes were observed in the remaining activity zones sporadically occurring in healthy subjects and in hepatocellular jaundice.

Adult↗

PubMed2005

Randomized clinical trial of the effect of intravenous fluid administration on hormonal and renal dysfunction in patients with obstructive jaundice undergoing endoscopic drainage.

BACKGROUND: Renal dysfunction in patients with biliary obstruction is associated with extracellular water depletion. This study examined the effect of preoperative saline infusion before biliary drainage on hormonal and renal functional derangements in patients with obstructive jaundice. METHODS: In a randomized study, 49 patients with malignant obstructive jaundice were investigated at baseline, on the day of drainage, and at 24 h, 72 h and 7 days after internal endoscopic biliary drainage. Patients were randomized to receive (n = 22) or not to receive (n = 27) 3000 ml normal saline intravenously for 24 h before drainage. Variables analysed included extracellular water volume, creatinine clearance, and serum levels of aldosterone, renin, atrial natriuretic peptide (ANP), vasopressin and albumin. RESULTS: Preoperative saline infusion produced a rise in creatinine clearance, diuresis, ANP concentration and extracellular water volume but this did not translate into better recovery of renal function after operation. Drainage produced a fall in creatinine clearance in all patients, but hormonal and renal function had recovered by 2 days after restoration of bile flow, independently of preoperative hydration. CONCLUSION: Fluid administration expands the extracellular water compartment before drainage but fails to improve renal function after drainage. Definitive improvement in endocrine and renal function requires the restoration of bile flow into the duodenum.

Adult↗

PubMed1979

Afferent loop obstruction presenting as obstructive jaundice.

The first case of obstructive jaundice secondary to a chronic afferent loop obstruction has been reported. The cause of the obstructed afferent loop was found to be a carcinoma of the gastric pouch occurring 25 years after surgery for peptic ulcer disease. The failure to develop any evidence of pancreatitis despite marked dilatation of the biliary tree and gall bladder suggests the existence of an independent functioning pancreatic sphincter, perhaps the sphincter of Boyden.

Adenocarcinoma↗

PubMed1991

Contribution of portal systemic shunt to Kupffer cell dysfunction in obstructive jaundice.

Previous animal models of biliary tract obstruction have shown that hepatic phagocytic activity is impaired secondary to Kupffer cell dysfunction. Biliary tract obstruction leads to portal hypertension and an associated portal systemic shunt. Forty-eight Sprague-Dawley rats were studied to determine the contribution of portal systemic shunt to Kupffer cell dysfunction after 21 days of obstructive jaundice or sham operation. Liver uptake of radiolabeled Escherichia coli decreased from 76.1 +/- 1.4% (sham) to 63.1 +/- 6.1% in the common duct ligation (CDL) rats (P less than 0.05); lung uptake increased from 4.0 +/- 0.6% (sham) to 20.2 +/- 4.5 (CDL) (P less than 0.05). Portal systemic shunt, determined using radioactive microspheres, increased from 2.0 +/- 1.0% (sham) to 46.6 +/- 13.1% (CDL), P less than 0.05. Although a significant portal systemic shunt does exist in this 21-day model of obstructive jaundice, it does not appear to be the only mechanism underlying Kupffer cell dysfunction.

Animals↗

PubMed1993

Immunological status of patients with obstructive jaundice and immunostimulatory effect of arginine.

Sepsis is a major factor in the high mortality and morbidity following diagnostic and therapeutic procedures in patients with obstructive jaundice. The reasons for this increased susceptibility to infection are not fully understood. We therefore observed prospectively changes in immunological status of patients with obstructive jaundice in the perioperative period and studied immunological effects of perioperative arginine therapy. The results showed that there was a significant reduction in interleukin 2 (IL-2) production, interleukin 2 receptor (IL-2R) expression and lymphocyte response to phytohemagglutinin (PHA) mitogen in patients with obstructive jaundice compared with normal controls. After operation, the immune suppression in patients with obstructive jaundice was more significant. Arginine is a known T lymphocyte stimulator. Perioperative supplement with arginine significantly enhanced the immune function of patients with obstructive jaundice, the mechanism being related to increased IL-2 production and IL-2R expression.

Adjuvants, Immunologic↗

PubMed2006

[The diagnosis and treatment for chronic pancreatitis complicated by non-calculous obstructive jaundice].

OBJECTIVE: To study the characters of chronic pancreatitis complicated by non-calculous obstructive jaundice, and discuss the methods for differentiation and treatment. METHOD: Twenty cases selected from January 1985 to December 2004 were analysed in the fields of differentiation and treatment. RESULTS: All cases didn't present with typical clinical presentations and radiological features. Jaundice was presented as the main complaint. Stricture of the intra-pancreatic common bile duct was the symbolic radiological feature. Pancreatic disseminated inflammation was verified pathologically in these cases. CT, ultrasound, EUS, ERCP, MRCP and antigen-marker of neoplasm failed to offer the data for differentiation. The diagnosis could only be determined by pathological exam. The obstructive jaundice could be solved by biliary-enteric anastomoses successfully. CONCLUSIONS: The patients with sole complaint of obstructive jaundice account for 15% of all inpatients with chronic pancreatitis. There exists a direct relationship between the jaundice and the pancreatic inflammation. This disorder should be differentiated from total pancreatic carcinoma, but few differentiated material could be offered by preoperative studies. Pathological result derived from the tissue sample obtained within the exploration would be reliable for diagnosis. The bypass between biliary tract and intestine would be a safe and economical treatment method.

Adult↗

PubMed2000

Management of patients with malignant obstructive jaundice. Nursing perspective from the interventional radiology room.

Most patients with obstructive jaundice caused by primary pancreaticobiliary malignancies and metastatic disease cannot be cured by surgical resection when diagnosed. Biliary drainage in the management of obstructive jaundice therefore represents one of the most important issues in the palliative treatment of these patients. For more than 20 years, percutaneous transhepatic biliary drainage procedures have allowed a nonsurgical approach to the management of malignant biliary obstruction. Improvements in radiologic access systems have extended the use of the percutaneous biliary approach, especially since the advent of metallic stents. Nursing care of these patients before, during, and after the percutaneous biliary intervention is challenging. Patient and family need to be educated about the aim and consequences of the procedure as well as its complications. To care for these patients, the nurse must understand the techniques of percutaneous transhepatic biliary drainage. The purpose of this article is briefly to review the etiology of biliary obstruction, the current treatments to relieve obstructive jaundice, and the basic steps of biliary intervention techniques. The nursing management throughout the procedure, the patient preparation before the procedure, and most importantly, the postprocedural nursing care are discussed.

Biliary Tract Neoplasms↗