Efficacy and safety of percutaneous transhepatic biliary radiofrequency ablation in patients with malignant obstructive jaundice

BACKGROUND Percutaneous transhepatic cholangiodrainage(PTCD)and endoscopic retrograde cholangiopancreatography/endoscopic nasobiliary drainage are the most common clinical procedures for jaundice control in patients with unresectable malignant obstructive jaundice,yet the safety and effect of endobiliary radiofrequency ablation(EB-RFA)combined PTCD is rarely reported,in this article,we report our experience of EB-RFA combined PTCD in such patients.AIM To retrospectively study the efficacy and safety of EB-RFA combined PTCD in patients with unresectable malignant obstructive jaundice.METHODS Patients with unresectable malignant obstructive jaundice treated with EB-RFA under PTCD were selected,the bile ducts of the right posterior lobe was selected as the target bile ducts in all cases.The general conditions of all patients,preoperative tumour markers,total bilirubin(TBIL),direct bilirubin(DBIL),albumin(ALB),alkaline phosphatase(ALP),and glutamyl transferase(GGT)before and on the 7th day after the procedure,as well as perioperative complications,stent patency time and patient survival were recorded.RESULTS All patients successfully completed the operation,TBIL and DBIL decreased significantly in all patients at the 7th postoperative day(P=0.009 and 0.006,respectively);the values of ALB,ALP and GGT also decreased compared with the preoperative period,but the difference was not statistically significant.Perioperative biliary bleeding occurred in 2 patients,which was improved after transfusion of blood and other conservative treatments,pancreatitis appeared in 1 patient after the operation,no serious complication and death happened after operation.Except for 3 patients with loss of visits,the stent patency rate of the remaining 14 patients was 100%71%and 29%at the 1^(st),3^(rd),and 6^(th)postoperative months respectively,with a median survival of 4 months.CONCLUSION EB-RFA under PTCD in patients with unresectable malignant obstructive jaundice has a satisfactory therapeutic effect and high safety,which is worthy of further clinical practice.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic bile duct drainage in the management of malignant obstructive jaundice

BACKGROUND Malignant obstructive jaundice(MOJ)is a condition characterized by varying degrees of bile duct stenosis and obstruction,accompanied by the progressive development of malignant tumors,leading to high morbidity and mortality rates.Currently,the two most commonly employed methods for its management are percutaneous transhepatic bile duct drainage(PTBD)and endoscopic ultrasound-guided biliary drainage(EUS-BD).While both methods have demonstrated favorable outcomes,additional research needs to be performed to determine their relative efficacy.To compare the therapeutic effectiveness of EUS-BD and PTBD in treating MOJ.METHODS This retrospective analysis,conducted between September 2015 and April 2023 at The Third Affiliated Hospital of Soochow University(The First People’s Hospital of Changzhou),involved 68 patients with MOJ.The patients were divided into two groups on the basis of surgical procedure received:EUS-BD subgroup(n=33)and PTBD subgroup(n=35).Variables such as general data,preoperative and postoperative indices,blood routine,liver function indices,myocardial function indices,operative success rate,clinical effectiveness,and complication rate were analyzed and compared between the subgroups.RESULTS In the EUS-BD subgroup,hospital stay duration,bile drainage volume,effective catheter time,and clinical effect-iveness rate were superior to those in the PTBD subgroup,although the differences were not statistically significant(P>0.05).The puncture time for the EUS-BD subgroup was shorter than that for the PTBD subgroup(P<0.05).Postoperative blood routine,liver function index,and myocardial function index in the EUS-BD subgroup were significantly lower than those in the PTBD subgroup(P<0.05).Additionally,the complication rate in the EUS-BD subgroup was lower than in the PTBD subgroup(P<0.05).CONCLUSION EUS-BD may reduce the number of punctures,improve liver and myocardial functions,alleviate traumatic stress,and decrease complication rates in MOJ treatment.

Pathophysiological consequences and treatment strategy of obstructive jaundice

Obstructive jaundice(OJ)is a common problem in daily clinical practice.However,completely understanding the pathophysiological changes in OJ remains a challenge for planning current and future management.The effects of OJ are widespread,affecting the biliary tree,hepatic cells,liver function,and causing systemic complications.The lack of bile in the intestine,destruction of the intestinal mucosal barrier,and increased absorption of endotoxins can lead to endotoxemia,production of proinflammatory cytokines,and induce systemic inflammatory response syndrome,ultimately leading to multiple organ dysfunction syndrome.Proper management of OJ includes adequate water supply and electrolyte replacement,nutritional support,preventive antibiotics,pain relief,and itching relief.The surgical treatment of OJ depends on the cause,location,and severity of the obstruction.Biliary drainage,surgery,and endoscopic intervention are potential treatment options depending on the patient's condition.In addition to modern medical treatments,Traditional Chinese medicine may offer therapeutic benefits for OJ.A comprehensive search was conducted on PubMed for relevant articles published up to August 1970.This review discusses in detail the pathophysiological changes associated with OJ and presents effective strategies for managing the condition.

Roux-en-Y choledochojejunostomy using novel magnetic compressive anastomats in canine model of obstructive jaundice

BACKGROUND:The traditional hand-sewn Roux-en-Y choledochojejunostomy is technically complicated,and the incidence of postoperative complications has remained high.A set of novel magnetic compressive anastomats was introduced to facilitate choledochojejunostomy and improve the prognosis of patients.METHODS:After ligating the common bile duct for 7 days,16 dogs were randomly divided into two groups (n=8 per group).Anastomats were used in the study group,and the traditional hand-sewn method was used in the control group for standard Roux-en-Y choledochojejunostomy.We compared the operation time,incidence of complications,gross appearance,and pathological disparity in stoma between the two groups in 1-month and 3-month follow-up examinations.RESULTS:The time spent on constructing the anastomosis for the study group was significantly shortened.Although no anastomotic stenosis occurred in the two groups,the narrowing rate of biliary-enteric anastomosis was much higher in the control group.There was one case of bile leakage in the control group,whereas no bile leakage occurred in the study group.A smoother surface,an improved layer apposition,and a lower local inflammatory response were identified in the anastomosis of the study group.CONCLUSION:The structures of the novel magnetic compressive anastomats are simple,and they are time-saving,safe and efficient for performing Roux-en-Y choledocho- jejunostomy procedures in a canine model of obstructive jaundice.

Application of endoscopic retrograde cholangiopancreatography for treatment of obstructive jaundice after hepatoblastoma surgery:A case report

BACKGROUND We aimed to investigate the effectiveness of endoscopic retrograde cholangiopan-creatography(ERCP)for treating obstructive jaundice(OJ)post hepatoblastoma(HB)surgery(post-HB OJ)by analyzing the data of a case and performing a literature review.CASE SUMMARY Clinical data of one patient with post-HB OJ treated by ERCP were retrospectively analyzed.Furthermore,clinical characteristics and insights into the diagnosis and treatment of post-HB OJ in children were summarized via searching various databases and platforms,such as China National Knowledge Infrastructure,Wanfang database,CQVIP database,PubMed,Ringer Link,and Google Scholar.The patient reported herein underwent five chemotherapy sessions after the diagnosis of HB and right hemihepatectomy after tumor size reduction;these were followed by two postoperative chemotherapy sessions.Three months postoperatively,the patient developed icteric sclera,strong tea-colored urine,and clay-like stools,and showed signs of skin itchiness;blood analysis showed significantly an increased conjugated bilirubin(CB)level(200.3μmol/L).Following the poor efficacy of anti-jaundice and hepatoprotective treatments,the patient underwent ERCP.Intraoperative imaging showed a dilated bile duct in the porta hepatis with significant distal stenosis.A 5 Fr nasopancreatic tube was placed in the dilated area through the stricture for external drainage,and the patient was extubated on postoperative day 6.Postoperatively,the patient’s stool turned yellow,and the CB level decreased to 78.2μmol/L.Fifteen days later,ERCP was repeated due to unrelieved jaundice symptoms,wherein a 7 Fr naso-biliary drainage tube was successfully placed.Three months post-ERCP,the jaundice symptoms resolved,and the CB level was reduced to 33.2μmol/L.A follow-up examination one year postoperatively revealed no jaundice symptoms and normal CB level.CONCLUSION Post-HB OJ is rare.Compared to biliary tract reconstruction,ERCP is less invasive and has a better therapeutic effect.

Pathophysiological consequences of obstructive jaundice and perioperative management

Background: Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management.Data sources: A Pub Med was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated.Results: The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier,the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production(TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders,nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma,albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.Conclusion: The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.

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

AIM: To investigate the effect of biliary drainage on inducible nitric oxide synthase (iNOS), CD14 and TGR5 expression in rats with obstructive jaundice (OJ). METHODS: 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. RESULTS: 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).CONCLUSION: ID could be attributed to the regulatory function of activation of KCs and release of inflammatory mediators.

Protective effects of intravenous anesthetics on kidney tissue in obstructive jaundice

AIM:To evaluate the protective effects on kidney tissue of frequently used intravenous anesthetics(ketamine,propofol,thiopental,and fentanyl)in rats with obstructive jaundice.METHODS:There is an increased incidence of postoperative acute renal failure in patients with obstructive jaundice.Thirty-two Wistar-albino rats were randomly divided into four equal groups.Laparatomy was performed on each animal in the four groups and common bile ducts were ligated and severed on day 0.After 7 d,laparotomy was again performed using ketamine,propofol,thiopental,or fentanyl anesthesia whose antioxidative properties are well known in oxidative stress in a rat liver model of obstructive jaundice.After 2 h,the rats were sacrificed.Renal tissue specimens were analyzed for catalase,superoxide dismutase and malondialdehyde enzymes activities.All values are expressed as the mean±SD.P values less than 0.05 were considered statistically significant.RESULTS:All animals survived without complications until the end of the study.Enlargement in the bile duct and obstructive jaundice were observed in all rats.Catalase was found to be significantly lower in the fentanyl group than in the ketamine(P=0.039),propofol(P=0.012),and thiopental(P=0.001)groups.Superoxide dismutase activities were similar in all groups(P>0.05).Malondialdehyde was found to be significantly lower in the ketamine group than in the propofol(P=0.028),thiopental(P=0.002)and fentanyl(P=0.005)groups.Malondialdehyde was also lower in the fentanyl group than in the thiopental group(P=0.001).The results showed that obstructive jaundice sensitizes renal tissue to damage under the different anesthetics.CONCLUSION:Among the agents tested,ketamine and propofol generated the least amount of oxidative stres on renal tissues in this rat model of obstructive jaundice created by common bile duct ligation.The importance of free radical injury in renal tissue in obstructive jaundice under different intravenous anesthetics during hepatobiliary and liver transplant surgery should be considered for prevention of postoperative acute renal failure.

Obstructive jaundice in Iran:factors affecting early outcome

BACKGROUND:Understanding any factors which influence the morbidity and mortality in patients with obstructive jaundice in each society will better guide appropriate management and lead to improved survival This study aimed to assess baseline etiologies,clinical manifestations,diagnostic results,and morbidity and mortality related to obstructive jaundice in Iranian patients. METHODS:The hospital recorded files of 133 patients with the final diagnosis of obstructive jaundice who had been admitted to the Taleqhani Hospital in Tehran between January 2001 and September 2004 were reviewed. RESULTS:The most common etiologies of obstructive jaundices were neoplasia and then common bile duct stone in the two genders.The results of ultrasonography were positive in less than half of the patients.However,the most positive results were related to endoscopic retrograde cholangiopancreatography(ERCP).The in-hospital mortality rate in patients less than 50 years old and elderly patients was 0%and 6.76%,respectively.The in-hospital morbidity rate was 2.25%and 7.51%,respectively in both patients and it was commonly related to infection of ulcer (44.46%),pneumonia(14.75%),myocardial infarction (14.75%),and subdiaphragmatic abscess(11.29%).In patients with a diagnosis of benign obstruction,only one patient died of severe sepsis.In malignant group preoperative characteristics,such as weight loss(P=0.015) and serum bilirubin concentration more than 16 mg/dl and postoperative complications,such as sepsis(P<0.001) cardiac arrest(P<0.001),and hepatic coma(P<0.001)were main predictors for the in-hospital mortality rate.CONCLUSION:Although the mortality and morbidity of obstructive jaundice in our study are less than those in other studies,the determination of preoperative clinical and laboratory indices and postoperative complications of patients is needed for the control of mortality and morbidity rate.

Biliary drainage for obstructive jaundice caused by unresectable hepatocellular carcinoma: the endoscopic versus percutaneous approach

BACKGROUND: For palliative treatment of the obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC), percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde biliary drainage (ERBD) has been performed. PTBD is preferred as an initial procedure. Little is known about the better option for patients with obstructive jaundice caused by unresectable HCC. METHODS: Sixty patients who had received ERBD or PTBD for the palliative treatment of obstructive jaundice caused by unresectable HCC between January 2006 and May 2010 were included in this retrospective study. Successful drainage, drainage patency, and the overall survival of patients were evaluated. RESULTS: Univariate analysis revealed that the overall frequency of successful drainage was higher in the ERBD group (22/29, 75.9%) than in the PTBD group (15/31, 48.4%) (P=0.029); but multivariate analysis showed marginal significance (P=0.057). The duration of drainage patency was longer in the ERBD group than in the PTBD group (82 vs 37 days, respectively, P=0.020). Regardless of what procedure was performed, the median survival time of patients who had a successful drainage was much longer than that of the patients who did not have a successful drainage (143 vs 38 days, respectively, P<0.001).CONCLUSION: Besides PTBD, ERBD may be used as the initial treatment option to improve obstructive jaundice in patients with unresectable HCC if there is a longer duration of drainage patency after a successful drainage.

Profile of hepatocyte apoptosis and bile lakes before and after bile duct decompression in severe obstructive jaundice patients

BACKGROUND:Excessive hepatocyte apoptosis and bile lakes in severe obstructive jaundice might impair liver functions.Although decompression of the bile duct has been reported to improve liver functions in animal studies,the mechanism of obstruction differs from that in humans.This study aimed to determine the profiles of hepatocyte apoptosis and bile lakes following bile duct decompression in patients with severe obstructive jaundice in the clinical setting.METHODS:We conducted a 'before and after study' on severe obstructive jaundice patients as a model of inhibition of the excessive process by bile duct decompression.Specimens of liver biopsies were taken before and after decompression of the bile duct and then stained by terminal deoxynucleotide transferase-mediated dUTP nick end-labeling(TUNEL) to identify hepatocyte apoptosis and by hematoxilin-eosin(HE) to identify bile lakes.All measurements were independently done by 2 observers.RESULTS:Twenty-one severe obstructive jaundice patients were included.In all patients,excessive hepatocyte apoptosis and bile lakes were apparent.After decompression,the hepatocyte apoptosis index decreased from 53.1(SD 105) to 11.7(SD 13.6)(P<0.05),and the bile lakes from 23.6(SD 14.8) to 10.9(SD 6.9)(P<0.05).CONCLUSION:Bile duct decompression improves hepatocyte apoptosis and bile lakes in cases of severe obstructive jaundice,similar to the findings in animal studies.

Decreased hepatic peroxisome proliferator-activated receptor-γ contributes to increased sensitivity to endotoxin in obstructive jaundice

AIM: To investigate the role of hepatic peroxisome proliferator-activated receptor-γ (PPAR-γ) in increased susceptibility to endotoxin-induced toxicity in rats with bile duct ligation during endotoxemia.METHODS: Male Sprague-Dawley rats were subjected to bile duct ligation (BDL). Sham-operated animals served as controls. DNA binding were determined by polymerase chain reaction, Western blotting analysis,and electrophoretic mobility shift assay, respectively.BDL and sham-operated rats received a non-lethal dose of intraperitoneal lipopolysaccharide (LPS) injection (3 mg/kg, i.p.). Additionally, the potential beneficial effects of the PPAR-γ agonist rosiglitazone were determined in BDL and sham-operated rats treated with a non-lethal dose of LPS. Survival was assessed in BDL rats treated with a non-lethal dose of LPS and in sham-operatedrats treated at a lethal dose of LPS (6 mg/kg, i.p.).RESULTS: PPAR-γ activity in rats undergoing BDL wassignificantly lower than in the sham-controls. Hepatic PPAR-γ gene expression was downregulated at both them RNA and protein levels. In a parallel group, serumlevels of pro-inflammatory cytokines were nearly unde-tectable in the sham-operated rats. When challenged with a non-lethal dose of LPS (3 mg/kg), the BDL ratshad approximately a 2.4-fold increase in serum IL-6,a 2.7 fold increase in serum TNF-α, 2.2-fold increasein serum IL-1 and 4.2-fold increase in serum ALT. Thesurvival rate was significantly lower as compared with that in sham-operated group. Additionally, rosiglitazone significantly reduced the concentration of TNF-α, IL-1β, IL-6 and ALT in sham-operated rats, but not in BDL rats, in response to LPS (3 mg/kg). Also, the survival was improved by rosiglita zone in sham-operated rats challenged with a lethal dose of LPS, but not in BDL rats, even with a non-lethal dose of LPS (3 mg/kg).CONCLUSION: Obstructive jaundice downregulates hepatic PPAR-γ expression, which in turn may contributeto hypersensitivity towards endotoxin.

Incidence and risk factors of pancreatitis in obstructive jaundice patients after percutaneous placement of self-expandable metallic stents

Background:Percutaneous transhepatic biliary drainage is an alternative treatment for patients with malignant distal biliary obstruction.The aim of this study was to investigate the occurrence of pancreatitis in patients who had undergone percutaneous placement of a biliary stent and to assess the risk factors for pancreatitis and the treatment outcomes.Methods:From January 2010 to October 2016,980 patients in our hospital who underwent percutaneous placements of self-expandable metallic stents for obstructive jaundice were retrospectively analyzed.The incidence of pancreatitis and risk factors were assessed by univariate and multivariate logistic regression analysis.Therapeutics,such as somatostatin,which were also adminstrated to release the symptom and promote the restoration of normal function of pancreas,were also analyzed.Results:Pancreatitis occurred in 45(4.6%)patients.One patient died from severe acute pancreatitis.Multivariate logistic regression analysis showed that common bile duct stent placement was the only independent risk factor that related to pancreatitis(odds ratio=2.096,95%CI:1.248–5.379;P=0.002).By using somatostatin,the concentrations of serum amylase and lipase were decreased in 44 patients with pancreatitis.No major complications were found during the treatment.Conclusions:Pancreatitis is a relatively low complication of percutaneous placement of biliary stents.The common bile duct stent placement is the only independent risk factor that related to pancreatitis.In this case,the percutaneous transhepatic biliary drainage is a preferred method for treatment.Furthermore,somatostatin is a secure and efficacious method to release the symptom and promote the restoration of pancreatic function.

Protective effects of pLNCX-SOD gene transfection on hepatocyte injury induced by obstructive jaundice in rats

BACKGROUND: Hydrophobic bile acids lead to the generation of oxygen free radicals in mitochondria. Accordingly, this study is to investigate if gene delivery of superoxide dismutase (SOD) will reduce hepatocyte injury caused by experimental cholestasis. METHODS: The recombinant of pLNCX-SOD gene packaged with lipofection of AMINE was transfected into hepatocytes in vitro, which stably expressed the SOD gene. RESULTS: After transfection, hepatocytes enhanced the protective effect against injury to bile and the toxicity of serum in obstructive jaundice. The inhibition of bile at the concentration of 2% (v: v, bile: DMEM 1: 50) decreased obviously from (78.80 +/- 12.35)% to (43.35 +/- 9.69)% in 12 hours, from (82.55 +/- 11.27)% to (-26.64 +/- 7.66)% in 24 hours, and from (83.83 +/- 18.69)% to (-19.27 +/- 14.38)% in 48 hours, compared with that of the untransfected cells (P < 0.01). The inhibition of serum at the obstructive jaudice concentration of 2.5% was obviously decreased from (89.72 +/- 1.52)% to (14.68 +/- 14.33)% in 12 hours, from (92.2 +/- 11.27)% to (41.39 +/- 7.66)% in 24 hours, and from (94.25 +/- 8.96)% to (22.71 +/- 4.38)% in 48 hours (P < 0.01). CONCLUSION: Hepatocytes transfected with the pLNCX-SOD gene could obviously be resistant to the toxicity of bile and serum from rat with obstructive jaundice.

Effect of obstructive jaundice on hemodynamics in the liver and its clinical significance

BACKGROUND: Many diseases can cause obstructive jaundice and then lead to a series of pathologic disorders. Thus preoperative assessment of liver function is of utmost importance. Traditional assessment is to monitor related indicators of liver function, but it is invasive and needs to be performed repeatedly. Color Doppler flow imaging (CDFI) was used to monitor blood flow of the hepatic artery and portal vein, a non-invasive method which can be used repeatedly. METHODS: Twenty cases of obstructive jaundice were detected by CDFI and changes of liver function were measured after operation. The variables of hemodynamic monitoring included peak flow rate and mean blood flow in the hepatic artery proper at the peak of the contraction period; the inner diameter of blood vessels, the peak flow rate, and the congestion index, the blood flow in the main portal vein. RESULTS: The average peak flow rate in the hepatic artery of patients with obstructive jaundice was significantly higher than that of normal people; both the inner diameter and congestive index of the portal vein were significantly larger than those of normal people. But the mean blood flow and peak flow rate in the portal vein were lower than those of normal people. CONCLUSIONS: CDFI is an ideal and non-invasive method for evaluating liver hemodynamics in obstructive jaundice. If the increase of hepatic arterial flow is more significant than the decrease of the blood flow in the portal vein, hepatic functional recovery after operation is smoother, suggesting a better prognosis. If the increase of the hepatic arterial flow is less significant than the decrease of the blood flow in the portal vein, hepatic functional recovery after operation may not be smooth, suggesting a worse prognosis.

Biliary stent combined with iodine-125 seed strand implantation in malignant obstructive jaundice

BACKGROUND Malignant obstructive jaundice is mainly caused by cholangiocarcinoma.Only a few patients are indicated for surgical resection,and the 3-year survival rate is<50%.For patients who are not eligible for surgery,biliary stent placement can relieve biliary obstruction and improve liver function and quality of life.However,restenosis after biliary stents has a poor prognosis and is a clinical challenge.Biliary stent combined with iodine-125(125I)seed implantation can prolong stent patency and improve survival.AIM To evaluate the safety and efficacy of biliary stent combined with 125I seed strand implantation in malignant obstructive jaundice.METHODS We enrolled 67 patients between January 2016 and June 2018 with malignant obstructive jaundice and randomized them into a biliary stent combined with 125I seed strand treatment(combined)group(n=32)and biliary stent(control)group(n=35).All patients underwent enhanced computed tomography and magnetic resonance imaging and were tested for biochemical and cancer markers.Twelve patients underwent pathological examination before surgery.All patients were followed up by telephone or clinical visit.Postoperative liver function improvement,postoperative complications,stent patency time,and survival time were compared between the two groups.Prognostic risk factors were evaluated.RESULTS Technical success was achieved in all patients in both groups.Postoperative liver function improved significantly in all patients(total bilirubin,direct bilirubin,alanine aminotransferase,and aspartate aminotransferase decreased significantly in all patients,the P values were less than 0.05).There was no significant difference in preoperative or postoperative indexes between the two groups for changes in total bilirubin(P=0.147),direct bilirubin(P=0.448),alanine aminotransferase(P=0.120),and aspartate aminotransferase(P=0.387)between the two groups.The median stent patency time of the combined group was 9.0±1.4 mo[95%confidence interval(CI):6.3-11.8 mo],which was significantly longer than the that of the control group(6.0±0.3 mo,95%CI:5.5-6.5 mo,P=0.000).The median survival time of the combined group was 11.0±1.4 mo(95%CI:8.2-13.7 mo),which was significantly longer than that of the control group(7.0±0.3 mo,95%CI:6.4-7.6 mo,P=0.000).Location of obstruction and number of stents were independent risk factors affecting prognosis.CONCLUSION Biliary stent combined with 125I seed strand implantation is safe and effective in malignant obstructive jaundice and improves stent patency time and median survival time.

Effect of postoperative early enteral nutrition on clinical outcomes and immune function of cholangiocarcinoma patients with malignant obstructive jaundice

BACKGROUND Most cholangiocarcinoma patients with malignant obstructive jaundice(MOJ)have varying degrees of malnutrition and immunodeficiency preoperatively.Therefore,perioperative nutritional support has important clinical significance in the treatment of cholangiocarcinoma.AIM To investigate the effects of postoperative early enteral nutrition(EEN)on immunity function and clinical outcomes of cholangiocarcinoma patients with MOJ.METHODS This prospective clinical study included 60 cholangiocarcinoma patients with MOJ who underwent surgery.The patients were randomly divided into an experimental group and a control group according to the nutrition support modes.The control group received postoperative total parenteral nutrition(TPN),whereas the experimental group received postoperative EEN and parenteral nutrition(PN;EEN+PN).The clinical outcomes,postoperative immune function,incidences of surgical site infection and bile leakage,intestinal function recovery time,average hospitalization days,and hospitalization expenses of the two groups were assessed on postoperative days(PODs)1,3,and 7.RESULTS The CD3+T,CD4+T,CD8+T,and CD4+T/CD8+T cell count and the immunoglobulin(Ig)G,IgM,and IgA levels in the EEN+PN group were significantly higher than those in the TPN group on PODs 3 and 7(P<0.05),whereas no significant differences in the CD3+T,CD4+T,CD8+T,and CD4+T/CD8+T cell counts and IgG,IgM,and IgA levels before operation and on POD 1 were found between the two groups(P>0.05).The intestinal function recovery time and postoperative hospital stay were shorter(P<0.001 for both)in the EEN+PN group than in the TPN group.The hospitalization expenses of the EEN+PN group were lower than those of the TPN group(P<0.001).However,the incidence of abdominal distension was higher than in the EEN+PN group than in the TPN group(P<0.05).The incidence rates of biliary leakage and surgical site infection were not significantly different between the two groups(P>0.05).CONCLUSION A postoperative EEN program could reduce the incidence of postoperative complications and improve the clinical outcomes and immune functions of cholangiocarcinoma patients with MOJ and is thus beneficial to patient recovery.

Effects of recombinant human growth hormone on intestinal translocation of bacteria and endotoxin in rats with obstructive jaundice

Extrahepatic biliary obstruction promotes intestinal translocation of bacteria and endotoxin and this process is an important cause of morbidity and mortality in patients with jaundice. This study was undertaken to investigate the effect and mechanism of recombinant human growth hormone (rhGH) and to alleviate intestinal translocation of bacteria and endotoxin in murine obstructive jaundice. METHODS:A group of 42 Wistar rats were divided into 3 groups:sham operation (SO), bile duct ligation (BDL), and BDL and rhGH treatment (rhGH). By the end of the experiment,on day 7, the animals were killed, and their liver function and serum endotoxin were measured, bacterial cultures of the liver, kidney and mesenchymal lymph were made. Terminal ileum mucosa was observed under an electron microscope. RESULTS:Liver function was improved more significantly in the rhGH group than in the BDL group. The value of endotoxin in the rhGH group was 0.38±0.03 EU/ml, significantly lower than that in the BDL group (0.65±0.04 EU/ml, P【0.01), and similar to that in the SO group (0.30±0.02 EU/ml, P】0.05). The rate of bacteria translocation in the liver, kidney and mesenteric lymph was much higher in the BDL group than in other two groups. The rate of bacteria translocation in mesenteric lymph was 64.29%,significantly higher than that in the SO group and the rhGH group (P【0.05). There was no significant difference in bacteria translocation rate between the SO group and the rhGH group (P】0.05). Under an electron microscope , ileum mucosa epithelial cells in the BDL group were necrotic, and organelle were markedly metamorphic. In the rhGH group, ultrastructural changes were less evident or similar to those in the SO group. CONCLUSION:rhGH has significant protective effects on intestinal mucosa barrier in obstructive jaundice, and reduces intestinal translocation of bacteria and endotoxin.

Effect of Danshen on apoptosis and NF-кB protein expression of the intestinal mucosa of rats with severe acute pancreatitis or obstructive jaundice

BACKGROUND:Intestinal mucosa injury in cases of severe acute pancreatitis(SAP) or obstructive jaundice(OJ) is one of the main reasons for the accelerated aggravation of these diseases.Besides being an organ to digest and absorb nutrients,the intestine is also a unique immune organ.When SAP and OJ develop,the destruction of the intestinal mucosa barrier is an important contributing factor for the development of bacterial translocation,systemic inflammatory response syndrome,and multiple organ dysfunction syndrome.It is important to protect the intestinal mucosa in the therapy for SAP and OJ.In this study,we determined the effect of Radix Salviae Miltiorrhizae(Danshen) injection on apoptosis and NF-κB P65 protein expression in the intestinal mucosa of rats with SAP or OJ,and explored the protective mechanism of Danshen in their mucosa.METHODS:Sprague-Dawley rats were used in the SAP and OJ experiments.These rats were randomly divided into shamoperated,model control,and treated groups.At various times after operation,the mortality rates were calculated.Subsequently,the rats were killed to assess the pathological changes,the expression levels of Bax and NF-κB proteins,and the apoptosis indices in the intestinal mucosa.RESULTS:Compared to the corresponding model control group,the number of SAP or OJ rats that died in the treated group decreased but showed no statistically significant difference.At all time points after operation,there was no significant difference between the treated and model control groups in the staining intensity as well as the product of staining intensity and positive staining rate of Bax protein in the intestinal mucosa of SAP and OJ rats.At 3 hours after operation,the apoptosis index of the intestinal mucosa of SAP rats in the treated group was lower than that in the model control group(P【0.01).At 12 hours after operation in SAP rats and 28 days after operation in OJ rats,the staining intensity as well as the product of staining intensity and positive staining rate of NF-κB protein of the intestinal mucosa in the treated group were lower than those in the model control group(P【0.01).CONCLUSION:Danshen exerts protective effects on the intestinal mucosa of SAP and OJ rats perhaps by inhibiting apoptosis and down-regulating NF-κB protein.

Yinchenhao decoction attenuates obstructive jaundice-induced liver injury and hepatocyte apoptosis by suppressing protein kinase RNA-like endoplasmic reticulum kinase-induced pathway

BACKGROUND Chronic biliary obstruction results in ischemia and hypoxia of hepatocytes,and leads to apoptosis.Apoptosis is very important in regulating the homeostasis of the hepatobiliary system.Endoplasmic reticulum(ER)stress is one of the signaling pathways that induce apoptosis.Moreover,the protein kinase RNA-like endoplasmic reticulum kinase(PERK)-induced apoptotic pathway is the main way;but its role in liver injury remains unclear.Yinchenhao decoction(YCHD)is a traditional Chinese medicine formula that alleviates liver injury and apoptosis,yet its mechanism is unknown.We undertook this study to investigate the effects of YCHD on the expression of ER stress proteins and hepatocyte apoptosis in rats with obstructive jaundice(OJ).AIM To investigate whether YCHD can attenuate OJ-induced liver injury and hepatocyte apoptosis by inhibiting the PERK-CCAAT/enhancer-binding protein homologous protein(CHOP)-growth arrest and DNA damage-inducible protein 34(GADD34)pathway and B cell lymphoma/leukemia-2 related X protein(Bax)/B cell lymphoma/leukemia-2(Bcl-2)ratio.METHODS For in vivo experiments,30 rats were divided into three groups:control group,OJ model group,and YCHD-treated group.Blood was collected to detect the indicators of liver function,and liver tissues were used for histological analysis.For in vitro experiments,30 rats were divided into three groups:G1,G2,and G3.The rats in group G1 had their bile duct exposed without ligation,the rats in group G2 underwent total bile duct ligation,and the rats in group G3 were given a gavage of YCHD.According to the serum pharmacology,serum was extracted and centrifuged from the rat blood to cultivate the BRL-3A cells.Terminal deoxynucleotidyl transferase mediated dUTP nick end-labelling(TUNEL)assay was used to detect BRL-3A hepatocyte apoptosis.Alanine aminotransferase(ALT)and aspartate transaminase(AST)levels in the medium were detected.Western blot and quantitative real-time polymerase chain reaction(qRT-PCR)analyses were used to detect protein and gene expression levels of PERK,CHOP,GADD34,Bax,and Bcl-2 in the liver tissues and BRL-3A cells.RESULTS Biochemical assays and haematoxylin and eosin staining suggested severe liver function injury and liver tissue structure damage in the OJ model group.The TUNEL assay showed that massive BRL-3A rat hepatocyte apoptosis was induced by OJ.Elevated ALT and AST levels in the medium also demonstrated that hepatocytes could be destroyed by OJ.Western blot or qRT-PCR analyses showed that the protein and mRNA expression levels of PERK,CHOP,and GADD34 were significantly increased both in the rat liver tissue and BRL-3A rat hepatocytes by OJ.The Bax and Bcl-2 levels were increased,and the Bax/Bcl-2 ratio was also increased.When YCHD was used,the PERK,CHOP,GADD34,and Bax levels quickly decreased,while the Bcl-2 levels increased,and the Bax/Bcl-2 ratio decreased.CONCLUSION OJ-induced liver injury and hepatocyte apoptosis are associated with the activation of the PERK-CHOP-GADD34 pathway and increased Bax/Bcl-2 ratio.YCHD can attenuate these changes.