Abstract
Preoperative biliary drainage may improve the cytokine and acute-phase response derangements observed in patients with obstructive jaundice. We conducted a prospective longitudinal, before-after trial in our 600-bed teaching hospital. Twenty-four patients with obstructive jaundice were investigated, 11 with benign obstruction and 13 with malignant disease. Endoscopic internal biliary drainage was performed in all patients (7 by papillotomy and 17 by endoprostheses). Endotoxin, tumor necrosis factor alpha (TNF-α), interIeukin-6 (IL-6), nitric oxide production, and C-reactive protein (CRP) were determined at admission and on days 2 and 7 after internal biliary drainage was accomplished. Bile cultures were obtained before and at the time of drainage. Endotoxin, IL-6, TNF-α, and CRP were significantly higher in patients with cancer. After internal drainage, endotoxin (11.4 vs. 2 EU/L; p<0.05), TNF-α (87.5 vs. 48 pg/ml; p=0.03), and IL-6 (324 vs. 232 pg/ml;/ p<0.05) plasma levels decreased significantly in the early postdrainage period in patients with cancer. Endotoxin, cytokines, as well as the CRP plasma values, however, increased again on day 7 after drainage. This trend was less marked in patients with benign obstruction. Patients with positive bile cultures after drainage displayed higher levels of CRP (115 vs. 62 mg/L; p=0.03), IL-6 (598 vs. 330 pg/ml; p=0.04), and endotoxin (10.6 vs. 4.8 EU/L; p=0.02) than those with negative bile cultures. Biliary tract obstruction is associated with an increase in endotoxin levels, a positive acute-phase response, and plasma cytokine elevation. After biliary drainage a transitory improvement of these alterations was observed, although values remained high 1 week postdrainage. These findings were associated with positive bile cultures.
Résumé
Le drainage biliaire préopératoire peut améliorer les perturbations des cytokines et celles observées dans la réponse de la phase aiguë chez les patients atteints d’ictère obstructif. Cette étude, prospective, longitudinale, a consisté à étudier 24 patients atteints d’ictère obstructif, 11 d’origine bénigne, 13 d’origine maligne, avant et après traitement dans un Hôpital Universitaire de 600 lits. Les interventions comportaient toujours un drainage endoscopique interne (7 papillotomies et 17 endoprothèses). On a mesuré l’endotoxine, le facteur TNF-α, l’IL-6, la production en oxyde nitrique et la C-réactive protéine (CRP) au moment de l’admission et aux jours 2 et 7 après drainage biliaire interne. Des cultures ont été obtenues avant et au moment du drainage. Les taux d’endotoxine, de l’IL-6, du TNF-α et de la CRP étaient significativement plus élevés chez les patients atteints de cancer. Après drainage interne, les taux plasmatiques de l’endotoxine (11.4 vs. 2 EU/L; p<0.05), de TNF-α (87.5 vs. 48 pg/ml; p=0.03) et d’IL-6 (324 vs. 232 pg/ml; p<0.05) ont diminué de façon significative après drainage chez les patients atteints de cancer. Les taux d’endotoxine et des cytokines tout comme les taux plasmatiques de la CRP ont cependant augmenté au jour sept. Cette tendance a été moins marquée chez les patients porteurs d’obstruction bénigne. Les patients ayant des cultures de bile positives après drainage avaient un taux postdrainage plus élevé de CRP (115 vs. 62 mg/L; p=0.03), d’IL-6 (598 vs. 330 pg/ml; p=0.04) et d’endotoxine (10.6 vs. 4.8 EU/L; p=0.02) que ceux ayant des cultures de bile négatives. L’obstruction biliaire est associée à une augmentation des taux d’endotoxines, à une réponse de phase aiguë positive et à une élévation des cytokines plasmatiques. Après drainage biliaire, on observe une amélioration transitoire de ces altérations, même si les valeurs restaient élevées une semaine après le drainage, surtout en cas de cultures de bile positives.
Resumen
En pacientes ictéricos, el drenaje biliar preoperatorio parece mejorar las atocinas y las alteraciones de respuesta de la fase aguda. En un Hospital Universitario de 600 camas, se diseñó un estudio clínico prospectivo longitudinal. Se estudiaron 24 pacientes con ictericia obstructiva: La obstrucción era benigna en 11 y maligna en 13. El drenaje biliar interno se realizó por vía endoscópica (7 papilotomías y 17 endoprótesis). El día del ingreso y a los 2 y 7 días del drenaje biliar interno se determinaron: endotoxina, TNF-α, IL-6, producción de óxido nítrico y proteína C reactiva (CRP). Las endotoxina, IL-6, TNF-α y CRP estaban significativamente más elevadas en pacientes con cáncer. En pacientes cancerosos, tras drenaje interno, los niveles plasmáticos descendieron inmediata y significativamente: endotoxina (11.4 vs. 2 EU/L; p<0.05) TNF-α (87.5 vs. pg/ml; p=0.03), y IL-6 (324 vs. 232 pg/ml; p<0.05). Sin embargo, la citocina, endotoxina y los valores plasmáticos de la CRP volvieron ha elevarse al 7° día post-drenaje. Estas modificaciones fueron menores en pacientes con ictericia obstructiva benigna. Tras el drenaje, los pacientes con cultivos biliares positivos, mostraron mayores elevaciones de la CRP (115 vs. 62 mg/L; p=0.03), IL-6 (598 vs. 330 pg/ml; p=0.04) y de la endotoxina (10.6 vs. 4.8 EU/L; p=0.02), que aquellos cuyos cultivos fueron negativos. La obstrucción del colédoco se acompaña de: un incremento de los niveles de endotoxina, respuesta positiva de la fase aguda y elevación de las citocinas plasmáticas. Tras drenaje biliar se produce una mejora transitoria de las alteraciones observadas, aunque los parámetros persisten elevados transcurrida una semana del drenaje biliar. Este hecho se observó en pacientes con cultivos positivos en la bilis.
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Published Online: September 26, 2002
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Padillo, F.J., Muntane, J., Montero, J.L. et al. Effect of internal biliary drainage on plasma levels of endotoxin, cytokines, and C-reactive protein in patients with obstructive jaundice. World J. Surg. 26, 1328–1332 (2002). https://doi.org/10.1007/s00268-002-6232-9
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DOI: https://doi.org/10.1007/s00268-002-6232-9