Postoperative hepatic catabolic stress response in patients with cirrhosis and chronic hepatitis.

Open (OC) or laparoscopic (LC) cholecystectomy is considered a relative contraindication in patients with liver cirrhosis. The effect of LC and OC on the hepatic catabolic stress response was studied in patients with postnecrotic liver cirrhosis and chronic hepatitis to define the most suitable procedure from a metabolic point of view. Altogether 14 patients with cirrhosis and 14 with chronic hepatitis were randomized to LC or OC (n = 7 in each group). The increase in the functional hepatic nitrogen clearance (FHNC) was quantified. Changes in glucose, insulin, glucagon, cortisol, epinephrine, norepinephrine, and prostaglandin E(2) (PGE(2)) were observed. There was no difference in FHNC between LC and OC in any of the patients. Among cirrhotic patients OC caused a 132% increase in FHNC (p < 0.05) and among the hepatitis patients a 69% increase (p < 0.05). In contrast, there was no significant increase following LC in any of the patients. OC increased fasting glucose and insulin in the hepatitis patients (p < 0.01 and p < 0.001, respectively) and in the cirrhosis group (p < 0.01 and p < 0.05, respectively). Alanine stimulation increased glucose in hepatitis patients after OC (p < 0.05) and after LC (p < 0.01). Stimulated glucagon increased after OC in the hepatitis group (p < 0.05). During stimulation cortisol was higher following LC in hepatitis patients (p < 0.01) and cirrhotic patients (p < 0.05). Fasting PGE(2) was down-regulated after LC in hepatitis patients (p < 0.05) and cirrhotic patients (p < 0.01) and after OC in the hepatitis group (p < 0.001). FHNC is similar after LC and OC. Thus from a metabolic point of view, LC has no advantage over OC.

Systemic and cell-mediated immune response after laparoscopic and open cholecystectomy in patients with chronic liver disease. A randomized, prospective study.

BACKGROUND: As impaired immune function observed in cirrhotic patients is known to increase the risk of postoperative complications, the immunological response to surgery was investigated. METHODS: Twenty-eight patients with postnecrotic liver cirrhosis or chronic hepatitis C and symptomatic gallstone disease were randomly allocated to laparoscopic (LC) or open cholecystectomy (OC). Changes in concentrations of cytokines (TNF-alpha, IL-1beta, IL-6, IL-8 and IL-10) were followed and the effect of surgical trauma on the distribution of lymphocyte subpopulations (CD3, CD4, CD8, CD16 and CD19) and NK cell cytotoxicity were measured. RESULTS: After OC a decrease in circulating CD3 (p < 0.05) and CD4 (p < 0.05) and an increase in CD19 (p < 0.05) cells were detected in contrast to LC after which only CD16 cells decreased (p = 0.05). The number of CD3 cells was higher after LC than after OC (p < 0.01), whereas the number of CD19 cells was higher after OC than after LC (p < 0.01). NK cell cytotoxicity was reduced after LC (p < 0.05). In cirrhotic patients circulating cytokines were unaffected by OC, whereas TNF-alpha (p < 0.05) and IL-1beta (p < 0.05) were reduced after LC. In chronic hepatitis IL-1beta decreased after OC (p = 0.05) and IL-10 was significantly higher after LC than following OC (p < 0.05). CONCLUSION: The immune response is less pronounced after a laparoscopic procedure compared to a conventional approach in patients with chronic liver disease.

Biliary parasites.

Parasitic diseases of the biliary tract occur frequently in tropical and subtropical areas and cause high morbidity and mortality. In general, neither the clinical presentation nor the general laboratory findings are sufficiently unique to raise the possibility of a parasitic biliary infestation in the mind of the surgeon. Once considered, however, the presence of a parasitic biliary infestation is easily confirmed. Most commonly this is accomplished by the identification of the parasite in stools or duodenal contents. Ultrasonography, CT and MRI are not only important in the diagnosis of parasitic biliary diseases but also in the follow-up and surveillance. ERCP is an excellent diagnostic tool for demonstrating the presence of parasites in the biliary tree. Furthermore, ERCP is also used in the therapy of biliary parasitic infestations and carries less morbidity and mortality than the surgical approach. Surgery is only indicated in complicated cases. Mechanisms that may be effective against parasites include: antibodies; cytotoxic T cells; T-cell-induced activated macrophages; natural killer cells, and a variety of cells that mediate antibody-dependent cell-mediated cytotoxicity and modulators of the immune system such as cytokines. Future research has to focus on the importance of these mechanisms for the immune evasion by parasites.

Sodium fusidate and the cytokine response in an experimental model of acute pancreatitis.

BACKGROUND: New therapies designed to downregulate the aberrant immune response associated with severe acute necrotizing pancreatitis (ANP) are being increasingly investigated in different experimental models of ANP. The aim of this study was to test the potential effects of sodium fusidate on the course of severe ANP in rabbits. METHODS: ANP was induced in 20 rabbits by retrograde injection of 5 per cent chenodeoxycholic acid into the pancreatic duct followed by duct ligation. The rabbits were allocated to pretreatment with intravenous physiological saline or sodium fusidate 80 mg/kg 30 min before the induction of ANP. Levels of serum amylase, lipase, tumour necrosis factor (TNF) alpha, interleukin (IL) 8, glucose and calcium, and leucocyte count were measured every 3 h for a total of 12 h. At the end of the experiment, ascitic fluid was collected and the pancreatic, lung and kidney tissues were obtained for histological examination. RESULTS: Pretreatment with sodium fusidate reduced the mortality rate from six of ten to three of ten (P < 005) and reduced the output of ascitic fluid from 5 2 to 2.0 ml/h (P < 0001). Serum levels of TNF-alpha and IL-8 were reduced significantly in the treated group from 5 min up to 9 h after induction of ANP. The leucopenia observed after 3 h in the untreated group was not significantly improved in the group treated with sodium fusidate (P = 0.055). By contrast, both treated and untreated rabbits had similar biochemical changes including levels of amylase, lipase, glucose and calcium as well as similar histological changes in the pancreas and lungs. CONCLUSION: Pretreatment with sodium fusidate resulted in a considerable reduction in mortality rate and ascitic fluid output in rabbits with bile-induced ANP, probably by lowering the TNF-alpha and IL-8 blood levels. However, pretreatment with sodium fusidate did not alter the local or systemic manifestations of ANP. Thus, cytokines other than TNF-alpha and IL-8 are likely to mediate the local and systemic symptoms of ANP.

Hemobilia: presentation, diagnosis, and management.

OBJECTIVES: Hemobilia is defined as hemorrhage into the biliary tract. To define a rational approach toward this rare entity, we performed a retrospective study on the presentation, diagnosis, and management of hemobilia. METHODS: During the past 3 yr, eight patients suffering from severe hemobilia presented to our departments. Jaundice, right-sided upper abdominal pain, and hematemesis were the most frequent symptoms. Hemobilia originated from iatrogenic injury in three patients, malignant hepatic or biliary tumors in three, parasitic infestation (ascariasis) in one, and coagulopathy due to end-stage liver cirrhosis in one. Duodenoscopy revealed bleeding from the papilla in all patients. Diagnosis was confirmed by endoscopic retrograde cholangiopancreatography and angiography in seven patients. RESULTS: In three patients, major liver resections were performed that definitively controlled the bleeding and the underlying tumor. Angiographic occlusion of an arterial lesion was successfully achieved in two patients. In two patients, operative ligation of the supplying artery was required. The patient suffering from end-stage liver disease was treated by substitution of coagulation factors but died due to progressive metabolic liver failure. CONCLUSION: Angiographic occlusion is recommended as initial treatment to control hemobilia and to render the patient stable in preparation for elective and definitive surgery. Surgery becomes necessary when nonoperative attempts to stop the bleeding fail and is required for tumors and parasitic disease.

Systemic plus local metronidazole and cephazolin in complicated appendicitis: a prospective controlled trial.

Appendicectomy was performed on 100 patients with complicated appendicitis through a grid-iron incision. All patients received systemic metronidazole and cephazolin sodium which started preoperatively and continued postoperatively for 5 days. At operation, patients were allocated randomly to receive either local instillation of metronidazole and cephazolin intraperitoneally and interparietally (group A) or no local antibiotic therapy (group B). All wounds were closed primarily without drainage. Postoperative wound sepsis occurred in four (8%) of the 50 patients in group A and in 17 (34%) of the 50 patients in group B. One patient in group B developed pelvic abscess in addition to wound sepsis. The mean duration of postoperative hospital stay was 6.6 days (s.d. 2.98) in group A and 8.7 days (s.d. 5.55) in group B. These differences were statistically significant. No adverse reaction was noted. The conclusion of this study is that a single peroperative instillation of metronidazole and cephazolin into the peritoneum and wound layers is a safe and valuable adjunct to the perioperative systemic administration of these drugs in significantly reducing postoperative sepsis and duration of hospital stay in complicated appendicitis.

Prophylactic appendicectomy during elective cholecystectomy: effects on morbidity. A prospective controlled study.

Prophylactic appendicectomy was performed on 56 consenting patients undergoing elective cholecystectomy. The control group consisted of 60 patients. Both groups were well matched in respect of age, sex, build and type of incision. All patients received a single i.v. dose of 1 g Cefazolin sodium and 500 mg Metronidazole at induction of anaesthesia. Postoperative wound sepsis occurred in 5.4% of the appendicectomy group and in 6.7% of the control group. Residual intra-abdominal sepsis did not occur in either group. The mean duration of postoperative hospital stay was 9.1 days (SD +/- 1.63) in the appendicectomy group and 8.5 days (SD +/- 1.85) in the control group. These differences were not statistically significant. Six (10.7%) of the appendices removed were abnormal, including two with inflammation. The conclusion of this study is that prophylactic appendicectomy can be performed safely during elective cholecystectomy provided that it is done without undue manipulation and the patient is protected with an effective prophylactic antibiotic regimen.

The place of antibiotics in the prevention of post-appendicectomy sepsis: a prospective study of 400 cases.

Post-appendicectomy sepsis still causes considerable morbidity and prolongs hospital stay. A large amount of recent work has gone into attempts to reduce such problems using various topical and systemic agents in differing regimes, with wide variation in their results. The aim of our study was to examine further the effectiveness of those different lines of prophylaxis against placebo in reducing post-appendicectomy sepsis. It is a comparative study of 400 cases of uncomplicated appendicitis operated upon by three senior Surgeons. The cases were allocated randomly in equal number to four groups according to the prophylactic antibiotic regime used: (a) Placebo; (b) Metronidazole alone; (c) Metronidazole and cefazolin; (d) Metronidazole and tobramycin. Antibiotics were given preoperatively with premedication and continued postoperatively for three days. The patients were checked for signs of sepsis during hospital stay and weekly up to a minimum of four weeks after discharge. They were also compared as far as their hospital stay is concerned. The conclusion of this study is that a combination of an antibiotic aimed at aerobes (cefazolin or tobramycin) with another aiming at anaerobes (metronidazole) is the best prophylactic regime against post-appendicectomy sepsis.