Relief Of Obstructive Jaundice Research Articles

The role of EUS-guided iodine-125 seed implantation in patients with unresectable ampullary cancer after relief of obstructive jaundice.

Few studies have focused on the management of inoperable ampullary carcinoma (AC), and patients with jaundice suffer from biliary stents replacement frequently. Iodine-125 (125I) brachytherapy has been used in the treatment of malignant tumors owing to its curative effect, minimal surgical trauma, and tolerable complications. The aim of the study was to investigate the role of 125I seed implantation in patients with unresectable ampullary carcinoma after relief of obstructive jaundice. A total of 44 patients with obstructive jaundice resulting from unresectable ampullary carcinoma from January 1, 2010 to October 31, 2020 were enrolled in the study. Eleven patients underwent implantation of 125I seeds under endoscopic ultrasound (EUS) after receiving biliary stent placement via endoscopic retrograde cholangiopancreatography (ERCP) (treatment group), and 33 patients received a stent alone via ERCP (control group). Cox regression model was applied in this single-center retrospective comparison study. The median maximum intervention interval for biliary obstruction was 381 days (interquartile range [IQR]: 204-419 days) in the treatment group and 175 days (IQR: 126-274 days) in the control group (p < 0.05). Stent occlusion rates at 90 and 180 days in the control group were 12.9% and 51.6%, respectively. No stent occlusion occurred in the treatment group. Patients in the treatment group obtained longer survival time (median, 26 vs. 13 months; p < 0.01) and prolonged duodenal obstruction (median, 20.5 vs. 11 months; p < 0.05). No brachytherapy-related grade 3 or 4 adverse events were observed. Longer intervention interval for biliary obstruction and survival as well as better stent patency and prolonged time to duodenal obstruction could be achieved by implanting 125I seeds combined with biliary stent in patients with unresectable ampullary cancer.

A Comparative Study of Self-Expandable Metallic Stent Combined with Double 125I Seeds Strands or Single 125I Seeds Strand in the Treatment of Advanced Perihilar Cholangiocarcinoma with Malignant Obstructive Jaundice.

PurposeThe purpose of this study was to compare the safety and effectiveness of a self-expandable metallic stent (SEMs) with a novel brachytherapy biliary drainage catheter (BBDC, double 125I seeds strands) or a single 125I seeds strand in the treatment of advanced perihilar cholangiocarcinoma (pCCA) with malignant obstructive jaundice (MOJ).MethodsFrom September 2016 to December 2018, we retrospectively enrolled patients with biliary stent implantation after receiving either BBDC loaded with 125I seeds (double-strands irradiation group) or an 125I seed strand treatment (single-strand irradiation group, control group). The outcomes were analyzed regarding the relief of obstructive jaundice, and interventional-related complications. Moreover, the Kaplan–Meier method was used to analyze stent patency and survival.ResultsThe success rate of interventional therapy in both groups was 100%, and all patients with MOJ were alleviated. According to the Common Terminology Criteria for Adverse Events (CTCAE 4.02), the grade 3 or 4 complications in the BBDC group and in the control group were 6/34 (17.65%) and 7/39 (17.95%), respectively (P > 0.05). The median and mean overall stent patency of the BBDC group and the control group were 207 days versus 180 days, 204.212 days versus 186.278 days (P = 0.043). The median and mean overall survivals in the BBDC group were higher than those in the control group (245 days versus 212 days, 244.883 days versus 221.844 days, P = 0.030).ConclusionThis interim analysis showed that BBDC (double-stranded irradiation) can prolong the stent patency time compared with 125I seed strand treatment (single-stranded irradiation) and had the advantage of reducing jaundice, which seemed to extend the survival period of advanced pCCA.

P-336 Clinical outcomes of 49 consecutive patients admitted with malignant obstructive jaundice

Biliary obstruction as a consequence of primary biliary malignancy or secondary metastatic disease from extrabiliary sites is often accompanied by significant symptoms, resulting in poor quality of life. Clinical symptoms vary depending upon the location of cancer but commonly include jaundice in up to 90%, pruritus in 66%, pain and malabsorption leading to weight loss in 30-50% patients. The relief of obstructive jaundice is a key aim in the palliation of biliary tract cancers and has been shown to prolong life, and equally importantly, quality of life.

The role of seed implantation in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using ERCP

PurposeThe purpose of the study was to investigate the role of iodine-125 seed implantation, guided by endoscopic ultrasound (EUS) and/or percutanous ultrasound, in patients with unresectable pancreatic carcinoma after relief of obstructive jaundice using endoscopic retrograde cholangiopancreatography (ERCP). Methods and MaterialsA total of 101 patients with obstructive jaundice due to unresectable pancreatic carcinoma were enrolled between January 2010 and December 2017 in this retrospective study. Of these patients, 50 underwent implantation of iodine-125 seeds under EUS and/or percutaneous ultrasound guidance after receiving a stent via ERCP (treatment group), and 51 received a stent via ERCP without undergoing seed implantation (control group). The clinical data and therapeutic outcomes of these patients were analyzed. ResultsCompared with the control group, the treatment group obtained significant relief of abdominal pain at the 1-week, 1-month, and 3-month followup (p < 0.05), with a significantly lower visual analog scale pain score (p < 0.05). The treatment group obtained a longer median survival (8.8 vs. 6.5 months, p = 0.02), longer median duration of stent patency (10.8 ± 1.4 vs. 6.9 ± 0.8 months, p = 0.02), and prolonged average time to gastric outlet obstruction (6.8 ± 1.6 vs. 5.3 ± 1.3 months, p = 0.02). Differences between liver function and appetite for the two groups were not significant (p > 0.05 and p = 0.59, respectively). ConclusionsIodine-125 seed implantation after relief of obstructive jaundice via ERCP prolongs survival, biliary stent patency, and time to gastric outlet obstruction and improves patient quality of life by relieving pancreatic pain in patients with unresectable pancreatic carcinoma.

Mo2079 The Role of Iodine-125 Seed Implantation in Treatment of Patients With Unresectable Pancreatic Carcinoma Following Relief of Obstructive Jaundice By ERCP

Mo2079 The Role of Iodine-125 Seed Implantation in Treatment of Patients With Unresectable Pancreatic Carcinoma Following Relief of Obstructive Jaundice By ERCP

Effect of biliary drainage on inducible nitric oxide synthase, CD14 and TGR5 expression in obstructive jaundice rats

To investigate the effect of biliary drainage on inducible nitric oxide synthase (iNOS), CD14 and TGR5 expression in rats with obstructive jaundice (OJ). Male adult Sprague-Dawley rats were randomly assigned to four groups: OJ, sham operation (SH), internal biliary drainage (ID) and external biliary drainage (ED). Rat models were successfully established by two operations and succumbed for extraction of Kupffer cells (KCs) and liver tissue collection on the 8(th) and 15(th) day. KCs were isolated by in situ hepatic perfusion and digested with collagen IV, density gradient centrifuged by percoll reagent and purified by cell culture attachment. The isolated KCs were cultured with the endotoxin lipopolysaccharide (LPS) with and without the addition of ursodeoxycholic acid (UDCA). The expression of iNOS, CD14 and bile acid receptor-TGR5 protein in rat liver tissues was determined by immunohistochemistry. The expression of iNOS and CD14 messenger RNA (mRNA) on the isolated KCs was detected by reverse transcription polymerase chain reaction (PCR) and the TGR5 mRNA level in KCs was measured by real-time quantitative PCR. The iNOS protein was markedly expressed in the liver of OJ rats, but rare expressed in SH rats. After relief of OJ, the iNOS expression was decidedly suppressed in the ID group (ID vs OJ, P < 0.01), but obviously increased in rats of ED (ED vs OJ, P = 0.004). When interfered only with LPS, the expression of iNOS mRNA by KCs was increased in the OJ group compared with the SH group (P = 0.004). After relief of biliary obstruction, the iNOS mRNA expression showed slight changes in the ED group (ED vs OJ, P = 0.71), but dropped in the ID group (ID vs OJ, P = 0.001). Compared with the simple intervention with LPS, the expressions of iNOS mRNA were significantly inhibited in all four groups after interfered with both LPS and UDCA (P < 0.01, respectively). After bile duct ligation, the CD14 protein expression in rat liver was significantly strengthened (OJ vs SH, P < 0.01), but the CD14 mRNA level by KCs was not up-regulated (OJ vs SH, P = 0.822). After relieving the OJ, the expression of CD14 protein was reduced in the ID group (ID vs OJ, P < 0.01), but not reduced in ED group (ED vs OJ, P = 0.591). And then the CD14 mRNA expression was aggravated by ED (ED vs OJ, P < 0.01), but was not significantly different between the ID group and the SH and OJ groups (ID vs SH, P = 0.944; ID vs OJ, P = 0.513, respectively). The expression of TGR5 protein and mRNA increased significantly in OJ rats (OJ vs SH, P = 0.001, respectively). After relief of OJ, ID could reduce the expression of TGR5 protein and mRNA to the levels of SH group (ID vs SH, P = 0.22 and P = 0.354, respectively), but ED could not (ED vs SH, P = 0.001, respectively). ID could be attributed to the regulatory function of activation of KCs and release of inflammatory mediators.

Changes of serum cytokines and expression of inducible nitric oxide synthase mRNA by Kupffer cells after relief from obstructive jaundice in rats

To investigate the changes of serum endotoxin, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and inducible nitric oxide synthase (iNOS) expression by Kupffer cells after relief of obstructive jaundice (OJ) by internal biliary drainage (ID) and external biliary drainage (ED) in rats. Forty eight adult Sprague Dawley rats were randomly assigned to four groups: OJ, ID, ED and sham operation (SH). Inducible nitric oxide synthase mRNA by the Kupffer cells was detected by reverse transcription polymerase chain reaction. The serum TNF-alpha and IL-6 were measured by enzyme linked immunosorbent assay and endotoxin by kinetic turbidimetric limulus tests. Serum endotoxin, IL-6 and TNF-alpha levels were significantly elevated in OJ rats compared to that of SH rats (P < 0.01). After relief from OJ, the elevated endotoxin, IL-6 and TNF-alpha levels could be significantly depressed by ID (P < 0.01). However, the serum IL-6 level was increased in ED rats (P < 0.05) and the TNF-alpha level was not depressed by ED. Expression of iNOS mRNA by Kupffer cells was markedly stronger in the OJ group than in the SH group (P = 0.005). After relief from OJ, the iNOS mRNA expression was suppressed by ID (P = 0.139, ID vs OJ). However, the iNOS mRNA expression was promoted by ED (P = 0.321 ED vs OJ; P = 0.016 ED vs SH). The levels of serum endotoxin, TNF-alpha and IL-6 and the expression of iNOS mRNA by Kupffer cells were increased in rats with obstructive jaundice. Internal biliary drainage could entirely reverse the changes, but external drainage only partially did.

A matrix metalloproteinase inhibitor to treat unresectable cholangiocarcinoma

Matrix metalloproteinases (MMPs) are implicated in tumour invasion and metastasis. We report the first use of an MMP inhibitor to treat unresectable cholangiocarcinoma. Four men with stage IV cholangiocarcinoma received oral Marimastat (10mg bd) indefinitely following relief of obstructive jaundice. Monthly measurements of the tumour marker CA 19‐9 were used as an indicator of disease response and activity. CA 19‐9 levels dropped sharply and stayed low in the two patients who appeared to respond. Mean survival of the four patients was 21.5 months (range 4–48 months). Side effects were well tolerated. A more extensive and detailed examination of MMP inhibitors to treat cholangiocarcinoma is indicated.

Percutaneous placement of metallic stents in the management of malignant biliary obstruction.

The placement of metallic stents is now a well-established method in the management of malignant biliary obstruction. This study evaluated the long-term clinical efficacy of percutaneous transhepatic insertion of metallic stents in the management of malignant biliary obstruction. From January 1999 to December 2002, 102 consecutive patients with malignant biliary obstruction were treated with percutaneous transhepatic placement of metallic stents at a medical center in Taipei. The level of obstruction was at the hepatic hilum in 44 patients, and common bile duct (CBD) in 58 patients. Memotherm stents were used in 78 patients and Wallstents in 38. Among the 44 patients with hilar obstruction, 30 received a single stent and 14 received bilateral stents. Among the 58 patients with CBD obstruction, the stents were placed across the ampulla of Vater in 27. Patient survival rates and stent patency rates were compared using the Kaplan-Meier method. Placement of stents was successful in all patients. The mean (range) serum bilirubin level before, 1 week after, and 1 month after stent insertion was 15.1 mg/dL (4.2-32.4 mg/dL), 7.8 mg/dL (0.5-19.4 mg/dL), and 1.8 mg/dL (0.2-8.2 mg/dL), respectively. The mean survival in all patients was 66.0 weeks (1-130 weeks) and the mean stent patency period (MSPP) in all patients was 59.9 weeks (1-130 weeks). The MSPP was 71.4 versus 49.9 weeks in hilar type versus CBD type patients (p = 0.047). The MSPP was 53.9 versus 73.0 weeks in patients who received Memotherm stents versus Wallstents (p = 0.115). In the hilar obstruction group, the MSPP was 82.1 versus 58.0 weeks in patients receiving bilateral versus a single stent (p = 0.039). In the CBD obstruction group, the MSPP was 46.3 versus 45.5 weeks in stents placed across versus not placed across the ampulla of Vater (p = 0.338). The efficacy and patency period of percutaneous transhepatic insertion of metallic stents in the management of malignant biliary obstruction is satisfactory in the relief of obstructive jaundice. Both types of metallic stents performed well in relieving malignant biliary obstruction. Bilateral stenting was more effective than single stenting in treating patients with hilar obstruction. In patients with CBD obstruction, no significant difference in the stent patency period was found between stents placed across or not across the ampulla of Vater.

Initial Experience with Laparoscopic Bypass for Upper Gastrointestinal Malignancy: A New Option for Palliation of Patients with Advanced Upper Gastrointestinal Tumors

The majority of patients with upper gastrointestinal (UGI) tract malignancy present at a stage where cure of disease is not possible. The aim of treatment in these patients is effective palliation. Various interventions have been described for the palliation of biliary and gastric outlet obstruction including open surgery, endoscopic and transparietal stent placement. Laparoscopic bypass appears to have the advantage of decreased postoperative pain and shorter hospital stay as well as offer effective palliation. The aim of this study was to assess the safety and efficacy of laparoscopic bypass in patients with incurable UGI tract malignancy. Between August 2000 and April 2002 laparoscopic gastric and biliary bypass concurrently or alone was attempted in 19 consecutive patients with unresectable carcinoma of the head of the pancreas, adenocarcinoma of the stomach, cholangiocarcinoma of the distal common bile duct, or adenocarcinoma of the duodenum. The operative time, length of postoperative stay, complications, and the effectiveness of the procedure in terms of the ability to sustain oral nutrition and or the relief of obstructive jaundice were recorded and used as outcome measures. Laparoscopic bypass was successful in 18 out of 19 cases. The mean operative time for a single bypass was 164 minutes while the average postoperative hospital stay was 11 days. All patients were able to sustain oral nutrition during the course of their hospital stay and or had effective relief from their obstructive jaundice. Two patients died from procedure unrelated causes within 30 days of the operation. Laparoscopic bypass appears to be a safe and effective means of palliation for patients with unresectable UGI tract tumors and should replace open surgical palliation in this group of patients.

Safe and permissible limits of hepatectomy in obstructive jaundice patients.

The safe and permissible limits of hepatectomy in obstructive jaundice patients and the usefulness of preoperative portal embolization (PE) for increasing the limit for safe hepatectomy were examined. We classified 416 patients with hepatectomy performed over 9 years under the following headings: normal liver function (n = 242); chronic hepatitis (n = 71); liver cirrhosis (n = 64); and liver after relief of obstructive jaundice (n = 39). Hepatectomy was done after the total bilirubin level was reduced below 3 mg/dl by preoperative biliary drainage. Factors influencing the maximum total bilirubin level measured within 2 weeks after hepatectomy were investigated, and this level was taken to reflect the degree of surgical stress. PE was carried out in 18 patients with obstructive jaundice. The maximum total bilirubin, expressed as a logarithm, was significantly correlated with the percent of liver resected in all groups. Hepatectomy followed by a maximum total bilirubin of less than 8.5 mg/dl was accepted as safe, and hepatectomy followed by a bilirubin level of 14.4 mg/dl was deemed the maximum permissible resection. On the basis of these results, the safe and permissible limits of hepatectomy in patients with obstructive jaundice were 48.7% and 71.6%, respectively. PE decreased the maximum total bilirubin from 8.5 mg/dl to 3.9 mg/dl when 48.7% of the liver (a safe proportion in all cases) was resected; PE increased the safe limit of hepatectomy from 48.7% to 67.4% when a maximum posthepatectomy total bilirubin level of 8.5 mg/dl was accepted as safe.

Relation of biliary bile acid output to hepatic adenosine triphosphate level and biliary indocyanine green excretion in humans.

We have previously demonstrated that there are two subgroups of patients with different types of biliary bile acid output after relief of obstructive jaundice by percutaneous transhepatic biliary drainage (PTBD). The reason for two groups is not clear but is possibly the difference in hepatic reserve function. The aim of this study was to examine the relation of biliary bile acid output to the hepatic ATP level and biliary excretion rate of indocyanine green (ICG) in humans. Patients whose bile could be collected through a PTBD tube participated in this study. The mean serum total bilirubin concentration was 12.7 mg/dl at the time of PTBD, decreasing to 1.1 mg/dl before surgery. These patients underwent curative resection for cancer of the bile duct, duodenal papilla, or pancreatic head after the relief of hyperbilirubinemia. Bile was collected at 1-hour intervals for 5 hours after intravenous administration of ICG (0.5 mg/kg) within a few days before surgery, and a small liver tissue sample was obtained immediately after laparotomy without using ischemic procedures. The concentrations of total bile acid and ICG in bile, the bile flow rate, and the bile acid output and ICG excretion rate in bile over 5 hours were determined. ATP concentrations in liver tissue were determined by high performance liquid chromatography. Results of hepatic ATP levels were correlated with the bile acid output and ICG excretion rate into bile. Both the biliary bile acid output (micromoles per 5 hours) and ICG excretion rate (percent of injected dose of ICG) over 5 hours were significantly correlated with the hepatic ATP level (p = 0.0190 and p = 0.0084, respectively). Neither the bile flow rate nor the serum liver function tests were related to the hepatic ATP level. Significant correlation was found between the bile acid output and the ICG excretion rate (p = 0.0127). Biliary bile acid output reflects the hepatic ATP level. Determination of the biliary bile acid output and ICG excretion may provide useful parameters for evaluating the hepatic energy status, which is essential for organ viability.

Open cholecystojejunostomy for biliary obstruction

Summary A well-constructed cholecystojejunostomy provides lasting relief of obstructive jaundice in patients with benign or malignant biliary obstruction. The operation is safe and expedient, but appropriate patient selection is of paramount importance, and careful analysis of factors influencing patency of the cholecystojejunostomy warrants scrutiny.

Surgical possibilities for bile duct cancer: Standard surgical treatment

There is no consensus on the surgical treatment of bile duct cancer, which varies from total nihilism to an extremely aggressive resectional policy. This paper describes the adoption of a 'middle road' approach to these difficult cancers, and suggests that selective use of stenting, bypass and resection with judicious application of adjunctive chemotherapy is an appropriate attitude until controlled studies of the alternatives are available. The main aims of treatment are (a) relief of obstructive jaundice, (b) prevention and treatment of future recurrent obstruction and cholangitis, and (c) eradication of tumour when possible. Local resection carries a low morbidity and mortality and is always a reasonable option in patients fit for surgery, but the relative value of non-radical resection and stenting with chemotherapy remains to be determined. Extended resections, including major hepatectomy and radical lymph node dissection, are only justified when the intent is curative, and some patients may not be suitable for such extensive surgery. In patients who are explored and determined to be unsuitable for major resection, surgical bypass is an option, but there is little evidence that this produces better palliation or quality of survival than optimal percutaneous or endoscopic stenting. Of 76 patients referred to the author over 7 years, 27 (35%) underwent surgical resection, and 23 (30%) had no operation. In patients followed up for more than 1 year, median survival following curative resection (9 patients) was 26 months, and after palliative resection (15 patients) it was 11 months. Median survivals after palliative biliary-enteric bypass (11), exploration alone (9), or no operation (20) were 2, 4, and 5 months respectively. A cautious and selective approach to surgery for these tumours is advocated.

Enhanced endothelial cell injury by activated neutrophils in patients with obstructive jaundice

Background/Aims: A high incidence of complications has been documented in patients with obstructive jaundice after operations. Recent reports have revealed that neutrophils are involved in the mechanism causing postoperative complications. However, there are few reports investigating the interaction between neutrophils and endothelial cells in obstructive jaundice. The aim of this study was to evaluate neutrophil-mediated endothelial cell injury in patients with obstructive jaundice. Methods: Patients were divided into three groups: those with normal liver, obstructive jaundice, and relief of obstructive jaundice. Neutrophils were isolated from patients individually. Human umbilical vein endothelial cells and neutrophils were co-cultured after addition of phorbol myristate acetate. The release of lactate dehydrogenase and thrombomodulin was measured in the medium. Results: Lactate dehydrogenase and thrombomodulin were released in the co-culture medium, and Eglin C, which is an elastase inhibitor, reduced the release of lactate dehydrogenase and thrombomodulin in a dose-dependent manner. The release of lactate dehydrogenase and thrombomodulin in the group with relief of obstructive jaundice was significantly higher than in the group with normal liver. There was no significant difference between the group with obstructive jaundice and the group with normal liver. The elastase activity in neutrophil suspension was similarly higher in the group with relief of obstructive jaundice than in the group with normal liver. Conclusions: This study suggests that neutrophils in patients with obstructive jaundice are not activated before its relief. After relief of obstructive jaundice, neutrophils are strongly primed and have the potential to cause endothelial cell injury. The neutrophil “priming” in patients with obstructive jaundice may be associated wtih the frequent occurrence of postoperative complications.

Assessment of liver function by prognostic score after relief of obstructive jaundice

To evaluate liver function reserve after relief of obstructive jaundice, we investigated the correlation between outcome after hepatectomy and 16 perioperative clinical factors in 13 patients with hilar bile duct carcinoma. The patients were classified into two groups according to the presence or absence of postoperative hepatic failure, defined as serum total bilirubin level exceeding 10mg/dl. A prognostic score formula was then created retrospectively. Total bilirubin, plasma retention rate of indocyanine green at 15 min (ICGR15), bilirubin decrease rate (b value), and duration of operation showed significant inter-group relationships on univariate analysis. By stepwise logistic regression we proposed the following discriminant formula: Prognostic score=−16.155+2.223×(ICGR15) +1.492×(liver resection ratio) +0.807×(b value ×103) With this formula, scores for patients without hepatic failure were 33 or less while those for hepatic failure patients were 68 or more, showing a clear distinction between the groups. Preoperative portal embolization (PE) decreased the mean prognostic score from 101.2 to 81.2, but 3 of 4 patients survived the operation without hepatic failure despite their high prognostic scores. This prognostic score is useful for predicting postoperative hepatic failure in patients with obstructive jaundice. However, further prospective studies are required to confirm the reliability of this formula, and some other mode of prognostic assessment is needed for patients who have preoperative PE.

Embolization and Percutaneous Aspiration of Hepatic Artery Aneurysm for Relief of Obstructive Jaundice

Embolization and Percutaneous Aspiration of Hepatic Artery Aneurysm for Relief of Obstructive Jaundice

Insulin metabolism after relief of obstructive jaundice: Intravenous glucose tolerance test with portal blood sampling

Glucose intolerance and impaired insulin secretion are often associated with obstructive jaundice. Our objective was to determine whether such abnormalities would be ameliorated after jaundice was relieved by biliary drainage. Twenty-four patients with hepatobiliary malignancy prospectively underwent intravenous glucose tolerance test with femoral and portal blood sampling, and the kinetics of insulin release were determined. Sixteen patients had obstructive jaundice (group A) that had been completely relieved by percutaneous transhepatic biliary drainage by the time of intravenous glucose tolerance testing, and eight patients exhibited no jaundice (group B). Integrated immunoreactive insulin (sigmaIRI, 10 muU min/ml; mean +/- SD) and integrated C-peptide (sigmaCPR, 10 ng min/ml) in the portal blood in group A were significantly lower than those values in group B (sigmaIRI: group A, 436.0 +/- 260.6; group B, 714.3 +/-287.2; p< 0.01; sigmaCPR; group A, 26 +/- 10.1; group B 49.5 +/- 18.8; p<0.005). The hepatic insulin extraction ratio (portal-femoral difference of sigmaIRI divided by portal sigmaIRI) in group A was significantly higher than that in group B (group A, 0.75 +/- 0.06; group B, 0.55 +/- 0.05; p<0.001), whereas the hepatic CPR extraction ratio did not differ significantly between the two groups (group A, 0.37 +/- 0.10; group B, 0.39 +/- 0.05). The impaired insulin secretion caused by obstructive jaundice is not fully reversed after percutaneous transhepatic biliary drainage. The high hepatic extraction ratio of insulin in patients who had been treated with percutaneous transhepatic biliary drainage may compensate for the impaired insulin secretion, although its mechanism is still unclear.

Insulin metabolism after relief of obstructive jaundice; intravenous glucose tolerance test with portal blood sampling: M Nagino, Y Nimura, H Yamamoto, N Hayakawa, T Kato, 1st Department of Surgery, Nagoya University School of Medicine, Nagoya 466, Japan

Insulin metabolism after relief of obstructive jaundice; intravenous glucose tolerance test with portal blood sampling: M Nagino, Y Nimura, H Yamamoto, N Hayakawa, T Kato, 1st Department of Surgery, Nagoya University School of Medicine, Nagoya 466, Japan

Endotoxemia and Intestinal Mucosal Dysfunction after the Relief of Obstructive Jaundice by Internal and External Drainage in Rats

We studied the effects of external and internal biliary drainage on the development of endotoxemia in a rat model of obstructive jaundice. Male Donryu rats were allocated to four groups: sham operation, common hepatic bile duct ligation (BDL), internal or external biliary drainage after BDL, and biliary drainage after BDL with oral endotoxin administration. Portal and systemic blood endotoxin concentrations were measured and the histomorphology of the intestinal mucosa was examined. Portal endotoxemia was observed 7 days after BDL and both portal and systemic endotoxemia were observed after 14 days. Portal endotoxemia was reversed by both internal and external biliary drainage and systemic endotoxemia was prevented. The ratio of villous height to crypt depth in the mucosa of the terminal ileum was decreased in rats with external drainage. Oral administration of endotoxin induced marked disruption of the mucosal epithelium in rats with external biliary drainage, but not in rats with internal biliary drainage. Significant increases in portal and systemic blood endotoxin concentrations were observed only in the external drainage group after oral endotoxin administration. The relief of biliary obstruction effectively relieved portal endotoxemia. External biliary drainage, however, has the potentially deleterious effect of disrupting the intestinal mucosa, which may promote the development of endotoxemia. These findings have implications for the use of biliary drainage procedures to reduce postoperative complications in jaundiced patients.