J Gastrointest Surg (2014) 18:2095–2104 DOI 10.1007/s11605-014-2674-2
ORIGINAL ARTICLE
Preoperative Bile Replacement Improves Immune Function for Jaundiced Patients Treated with External Biliary Drainage Yuko Yoshida & Tetsuo Ajiki & Kimihiko Ueno & Kenta Shinozaki & Sae Murakami & Taro Okazaki & Taku Matsumoto & Ippei Matsumoto & Takumi Fukumoto & Makoto Usami & Yonson Ku
Received: 18 June 2014 / Accepted: 5 October 2014 / Published online: 18 October 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Background Although preoperative biliary drainage in jaundiced patients is controversial, external biliary drainage (EBD) is beneficial for infection control in patients with biliary cancers. When EBD is performed, additional bile replacement (BR) has the benefit of improving impaired intestinal barrier function, but the detailed mechanism remains unknown. We examined the effect of bile replacement on immune functions over the duration of BR in jaundiced patients. Methods Fifteen patients were enrolled into this prospective study. BR was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was given two times orally (2×100 ml/day). Concanavalin A (Con A)- and phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and serum diamine oxidase (DAO) activity were measured before starting and during BR. Twenty patients with EBD and no BR were analyzed as a control group. Results Serum liver enzymes, prothrombin time–international normalized ratio (PT-INR), and responses to Con A and PHA gradually improved over the 14 days of BR, but percentages of lymphocytes and DAO levels did not. PT-INR, and Con A and PHA responses did not improve during EBD in the control group. PT-INR significantly decreased in patients with a greater fraction of their drained bile replaced. Conclusions Our results indicate that preoperative BR using as large a quantity of bile as possible is useful for improving blood coagulability and cellular immunity in patients with EBD. Keywords Bile replacement . Obstructive jaundice . Immune function
Introduction Biliary tumors have often caused obstructive jaundice by the time of presentation, and the relationship between jaundice No grant support was provided for this study. Y. Yoshida : T. Ajiki (*) : K. Ueno : K. Shinozaki : S. Murakami : T. Okazaki : T. Matsumoto : I. Matsumoto : T. Fukumoto : Y. Ku Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan e-mail: [email protected] M. Usami Division of Nutrition and Metabolism, Department of Biophysics, Kobe University Graduate School of Health Sciences, 7-10-2 Tomogaoka, Suma-ku, Kobe 654-0102, Japan
and operative risk is currently under discussion.1,2 The value of preoperative biliary drainage in jaundiced patients is controversial. Early studies showed decreased mortality and morbidity rates in patients with biliary drainage, but recent prospective studies have not confirmed any clear benefit of preoperative biliary drainage.3–6 In Western countries, biliary drainage for major hepatic resection is thought to be generally required, but pancreatoduodenectomy (PD) is suggested to need biliary drainage only in selected cases.2,7 In contrast, biliary drainage is routinely performed in Japan for patients with obstructive jaundice regardless of planned PD or hepatectomy.8,9 There are two different types of biliary drainage (BD): external (EBD) being percutaneous transhepatic biliary drainage (PTBD) and endoscopic nasobiliary drainage (ENBD), and internal (IBD) being endoscopic retrograde biliary drainage (ERBD). Although quality of life of patients treated with IBD appears superior to that with EBD, IBD (ERBD) is not always adequate because it quite often leads to infection (cholangitis).10,11 For bile duct cancers (especially hilar
2096
cholangiocarcinoma), EBD was recently recommended as the most suitable method for preoperative biliary drainage in jaundiced patients who are candidates for surgical resection in Asian countries,11–13 although this strategy has not been adopted worldwide. ENBD is an external drainage method, and the absence of intestinal bile is associated with certain problems. Our experimental studies indicated that IBD improved bacterial translocation in the gut immune system via reversal of chemokine expression.14,15 In addition, IBD is superior to EBD with respect to postoperative hepatic regeneration in experimental rat models.16,17 In humans, the value of preoperative bile replacement is demonstrated mainly by its impact on the impaired intestinal barrier function.18 Thus, when EBD is performed, bile replacement is possibly a better option for the preoperative management of jaundiced patients. However, to the best of our knowledge, the literature on bile replacement in humans is scarce and detailed changes of immune function are not clear to date. In the present study, we prospectively investigated the effect of bile replacement on immune functions over the time course of bile replacement in jaundiced patients.
J Gastrointest Surg (2014) 18:2095–2104
The patients were composed of 11 men and 4 women, with a mean age of 65 years (Table 1). Seven patients had bile duct cancer, six had pancreatic cancer, one had both, and the remaining patient had benign biliary stricture as a final diagnosis. One patient with pancreatic cancer did not complete the study because of rapid progression, and one patient was also excluded because of benign disease. Thus, finally we analyzed data from 13 patients. Blood samples for standard laboratory tests were obtained in the morning just before beginning bile replacement (day 0), and days 1, 3, 5, 7, and 14 after bile replacement. White blood cell (WBC) counts, lymphocyte fraction, prothrombin time– international normalized ratio (PT-INR), albumin, C-reactive protein (CRP), blood urea nitrogen (BUN), creatinine, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were quantified. Measurements of serum diamine oxidase (DAO) activity, as well as T cell responses to concanavalin A (Con A) and phytohemagglutinin (PHA), were performed on day 0 and day 3, 7, and 14 after bile replacement. Blood samples were centrifuged at 3,000g for 10 min at 4 °C and the sera were stored at −80 °C until measurement. Cellular Immunity
Methods Patients and Protocols This study was a prospective clinical trial at our institute. The inclusion criteria were age between 18 and 80 years in good general condition (Eastern Cooperative Oncology Group (ECOG) performance status 0–1) with obstructive jaundice (T-bil >5.0, D-bil >3.0 mg/dl). Written informed consent for participation was obtained from each patient before enrollment. This study was approved by the institutional ethics committee of the Kobe University Hospital (No. 1194, UMIN ID 000006645). Between October 2011 and January 2013, 15 consecutive patients with obstructive jaundice were enrolled. All patients received a regular diet preoperatively. None of them received preoperative parenteral or enteral nutritional supplementation. Eleven patients underwent ENBD, three underwent PTBD, and the remaining one patient underwent both ENBD and PTBD. Bile replacement was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was percolated through gauze and cooled before ingestion. Each patient received 100 ml of the drained bile orally two times per day (total 200 ml/day). Surgery was performed after the serum total bilirubin concentration reached 2.0 mg/dl. Time between starting initial biliary drainage and surgery was a median of 48 days (range, 28–122 days).
Cellular immunity was examined by assessing T cell proliferative responses to the plant mitogens Con A and PHA, taken as indicators of cell-mediated immunity. Stimulation indices were calculated by dividing the counts per minute (cpm) of Table 1 Patient characteristics
ENBD endoscopic nasobiliary drainage, PTBD percutaneous transhepatic biliary drainage
Median age, years (range) Gender, n Male Female Disease, n Bile duct cancer Pancreatic cancer Bile duct cancer + Pancreatic cancer Bile duct injury Method of biliary drainage, n ENBD PTBD ENBD + PTBD Operative procedure, n Pancreatoduodenectomy Choledocojejunostomy Bile duct resection Probe laparotomy No operation
65 (52–80) 11 4 7 6 1 1 11 3 1 7 1 1 2 4
J Gastrointest Surg (2014) 18:2095–2104
2097
nuclear3 H-thymidine incorporation in mitogen-stimulated cells by the cpm in cells cultured without mitogens.19
Enterococcus spp. (n=2), and Bacillus cereus, Corynebacterium spp., and Aeromonas hydrophila (n=1 of each).
Serum DAO Activity
Standard Laboratory Test Results
Serum DAO activity was used as a marker of intestinal integrity. It was determined using the modified method of Takagi et al. 20,21 In brief, a colorimetric assay based on a coupled reaction with peroxidase and the novel chromogen 10-(carboxymethyl-aminocarbonyl)-3,7-bis(dimethylamino) phenothiazine sodium salt (DA-67; Wako Pure Chemical Industries, Osaka, Japan) was performed. Previous reports showed that the serum activity averaged 4.9–6.25 U/l in healthy controls.20,22
Table 2 shows changes in laboratory tests for all patients. Serum total bilirubin, AST, and ALT levels decreased over time. Serum albumin, BUN, and creatinine levels did not change significantly during bile replacement. PT-INR increased on the first day after starting bile replacement, then gradually decreased, and was significantly lower at day 14 than at day 0 (p=0.022). The lymphocyte fraction did not change during bile replacement (p=0.511) (Fig. 1). Changes of Con A and PHA Responsiveness
Analysis of a Control Group of Patients Undergoing External Biliary Drainage, but No Bile Replacement In order to clarify the role of bile replacement, we have retrospectively analyzed 20 patients with pancreatic or biliary cancers who had obstructive jaundice and were treated with external biliary drainage without bile replacement. The patients were composed of 13 men and 7 women, with a mean age of 68 years. After serum total bilirubin concentration fell below 5.0 mg/dl, we analyzed total bilirubin, AST and ALT, albumin, BUN, creatinine, and PT-INR levels at days 0, 3, 7, and 14. Con A and PHA responses on days 0 and 7 were available in 6 of these 20 patients. Statistical Analysis Results are expressed as mean ± standard deviation (SD). Statistical analysis was performed using Fisher’s exact test, Student’s t test, and the Wilcoxon signed rank test using the StatView program (Abacus Concepts Inc., Berkeley, CA), as appropriate. A P value
ORIGINAL ARTICLE
Preoperative Bile Replacement Improves Immune Function for Jaundiced Patients Treated with External Biliary Drainage Yuko Yoshida & Tetsuo Ajiki & Kimihiko Ueno & Kenta Shinozaki & Sae Murakami & Taro Okazaki & Taku Matsumoto & Ippei Matsumoto & Takumi Fukumoto & Makoto Usami & Yonson Ku
Received: 18 June 2014 / Accepted: 5 October 2014 / Published online: 18 October 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Background Although preoperative biliary drainage in jaundiced patients is controversial, external biliary drainage (EBD) is beneficial for infection control in patients with biliary cancers. When EBD is performed, additional bile replacement (BR) has the benefit of improving impaired intestinal barrier function, but the detailed mechanism remains unknown. We examined the effect of bile replacement on immune functions over the duration of BR in jaundiced patients. Methods Fifteen patients were enrolled into this prospective study. BR was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was given two times orally (2×100 ml/day). Concanavalin A (Con A)- and phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and serum diamine oxidase (DAO) activity were measured before starting and during BR. Twenty patients with EBD and no BR were analyzed as a control group. Results Serum liver enzymes, prothrombin time–international normalized ratio (PT-INR), and responses to Con A and PHA gradually improved over the 14 days of BR, but percentages of lymphocytes and DAO levels did not. PT-INR, and Con A and PHA responses did not improve during EBD in the control group. PT-INR significantly decreased in patients with a greater fraction of their drained bile replaced. Conclusions Our results indicate that preoperative BR using as large a quantity of bile as possible is useful for improving blood coagulability and cellular immunity in patients with EBD. Keywords Bile replacement . Obstructive jaundice . Immune function
Introduction Biliary tumors have often caused obstructive jaundice by the time of presentation, and the relationship between jaundice No grant support was provided for this study. Y. Yoshida : T. Ajiki (*) : K. Ueno : K. Shinozaki : S. Murakami : T. Okazaki : T. Matsumoto : I. Matsumoto : T. Fukumoto : Y. Ku Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan e-mail: [email protected] M. Usami Division of Nutrition and Metabolism, Department of Biophysics, Kobe University Graduate School of Health Sciences, 7-10-2 Tomogaoka, Suma-ku, Kobe 654-0102, Japan
and operative risk is currently under discussion.1,2 The value of preoperative biliary drainage in jaundiced patients is controversial. Early studies showed decreased mortality and morbidity rates in patients with biliary drainage, but recent prospective studies have not confirmed any clear benefit of preoperative biliary drainage.3–6 In Western countries, biliary drainage for major hepatic resection is thought to be generally required, but pancreatoduodenectomy (PD) is suggested to need biliary drainage only in selected cases.2,7 In contrast, biliary drainage is routinely performed in Japan for patients with obstructive jaundice regardless of planned PD or hepatectomy.8,9 There are two different types of biliary drainage (BD): external (EBD) being percutaneous transhepatic biliary drainage (PTBD) and endoscopic nasobiliary drainage (ENBD), and internal (IBD) being endoscopic retrograde biliary drainage (ERBD). Although quality of life of patients treated with IBD appears superior to that with EBD, IBD (ERBD) is not always adequate because it quite often leads to infection (cholangitis).10,11 For bile duct cancers (especially hilar
2096
cholangiocarcinoma), EBD was recently recommended as the most suitable method for preoperative biliary drainage in jaundiced patients who are candidates for surgical resection in Asian countries,11–13 although this strategy has not been adopted worldwide. ENBD is an external drainage method, and the absence of intestinal bile is associated with certain problems. Our experimental studies indicated that IBD improved bacterial translocation in the gut immune system via reversal of chemokine expression.14,15 In addition, IBD is superior to EBD with respect to postoperative hepatic regeneration in experimental rat models.16,17 In humans, the value of preoperative bile replacement is demonstrated mainly by its impact on the impaired intestinal barrier function.18 Thus, when EBD is performed, bile replacement is possibly a better option for the preoperative management of jaundiced patients. However, to the best of our knowledge, the literature on bile replacement in humans is scarce and detailed changes of immune function are not clear to date. In the present study, we prospectively investigated the effect of bile replacement on immune functions over the time course of bile replacement in jaundiced patients.
J Gastrointest Surg (2014) 18:2095–2104
The patients were composed of 11 men and 4 women, with a mean age of 65 years (Table 1). Seven patients had bile duct cancer, six had pancreatic cancer, one had both, and the remaining patient had benign biliary stricture as a final diagnosis. One patient with pancreatic cancer did not complete the study because of rapid progression, and one patient was also excluded because of benign disease. Thus, finally we analyzed data from 13 patients. Blood samples for standard laboratory tests were obtained in the morning just before beginning bile replacement (day 0), and days 1, 3, 5, 7, and 14 after bile replacement. White blood cell (WBC) counts, lymphocyte fraction, prothrombin time– international normalized ratio (PT-INR), albumin, C-reactive protein (CRP), blood urea nitrogen (BUN), creatinine, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were quantified. Measurements of serum diamine oxidase (DAO) activity, as well as T cell responses to concanavalin A (Con A) and phytohemagglutinin (PHA), were performed on day 0 and day 3, 7, and 14 after bile replacement. Blood samples were centrifuged at 3,000g for 10 min at 4 °C and the sera were stored at −80 °C until measurement. Cellular Immunity
Methods Patients and Protocols This study was a prospective clinical trial at our institute. The inclusion criteria were age between 18 and 80 years in good general condition (Eastern Cooperative Oncology Group (ECOG) performance status 0–1) with obstructive jaundice (T-bil >5.0, D-bil >3.0 mg/dl). Written informed consent for participation was obtained from each patient before enrollment. This study was approved by the institutional ethics committee of the Kobe University Hospital (No. 1194, UMIN ID 000006645). Between October 2011 and January 2013, 15 consecutive patients with obstructive jaundice were enrolled. All patients received a regular diet preoperatively. None of them received preoperative parenteral or enteral nutritional supplementation. Eleven patients underwent ENBD, three underwent PTBD, and the remaining one patient underwent both ENBD and PTBD. Bile replacement was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was percolated through gauze and cooled before ingestion. Each patient received 100 ml of the drained bile orally two times per day (total 200 ml/day). Surgery was performed after the serum total bilirubin concentration reached 2.0 mg/dl. Time between starting initial biliary drainage and surgery was a median of 48 days (range, 28–122 days).
Cellular immunity was examined by assessing T cell proliferative responses to the plant mitogens Con A and PHA, taken as indicators of cell-mediated immunity. Stimulation indices were calculated by dividing the counts per minute (cpm) of Table 1 Patient characteristics
ENBD endoscopic nasobiliary drainage, PTBD percutaneous transhepatic biliary drainage
Median age, years (range) Gender, n Male Female Disease, n Bile duct cancer Pancreatic cancer Bile duct cancer + Pancreatic cancer Bile duct injury Method of biliary drainage, n ENBD PTBD ENBD + PTBD Operative procedure, n Pancreatoduodenectomy Choledocojejunostomy Bile duct resection Probe laparotomy No operation
65 (52–80) 11 4 7 6 1 1 11 3 1 7 1 1 2 4
J Gastrointest Surg (2014) 18:2095–2104
2097
nuclear3 H-thymidine incorporation in mitogen-stimulated cells by the cpm in cells cultured without mitogens.19
Enterococcus spp. (n=2), and Bacillus cereus, Corynebacterium spp., and Aeromonas hydrophila (n=1 of each).
Serum DAO Activity
Standard Laboratory Test Results
Serum DAO activity was used as a marker of intestinal integrity. It was determined using the modified method of Takagi et al. 20,21 In brief, a colorimetric assay based on a coupled reaction with peroxidase and the novel chromogen 10-(carboxymethyl-aminocarbonyl)-3,7-bis(dimethylamino) phenothiazine sodium salt (DA-67; Wako Pure Chemical Industries, Osaka, Japan) was performed. Previous reports showed that the serum activity averaged 4.9–6.25 U/l in healthy controls.20,22
Table 2 shows changes in laboratory tests for all patients. Serum total bilirubin, AST, and ALT levels decreased over time. Serum albumin, BUN, and creatinine levels did not change significantly during bile replacement. PT-INR increased on the first day after starting bile replacement, then gradually decreased, and was significantly lower at day 14 than at day 0 (p=0.022). The lymphocyte fraction did not change during bile replacement (p=0.511) (Fig. 1). Changes of Con A and PHA Responsiveness
Analysis of a Control Group of Patients Undergoing External Biliary Drainage, but No Bile Replacement In order to clarify the role of bile replacement, we have retrospectively analyzed 20 patients with pancreatic or biliary cancers who had obstructive jaundice and were treated with external biliary drainage without bile replacement. The patients were composed of 13 men and 7 women, with a mean age of 68 years. After serum total bilirubin concentration fell below 5.0 mg/dl, we analyzed total bilirubin, AST and ALT, albumin, BUN, creatinine, and PT-INR levels at days 0, 3, 7, and 14. Con A and PHA responses on days 0 and 7 were available in 6 of these 20 patients. Statistical Analysis Results are expressed as mean ± standard deviation (SD). Statistical analysis was performed using Fisher’s exact test, Student’s t test, and the Wilcoxon signed rank test using the StatView program (Abacus Concepts Inc., Berkeley, CA), as appropriate. A P value
