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Endotoxemia after relief of biliary obstruction by internal and external drainage in rats
Endotoxemia After Relief of Biliary Obstruction by Internal and External Drainage in Rats
Dirk J. Gouma, MD, Houston, Texas Julio C. U. Coelho, MD, PhD, Houston, Texas John D. Fisher, BS, Houston, Texas Jerry F. Schlegel, BS, Houston, Texas Yong F. Li, MD, Houston, Texas Frank G. Moody, MD, Houston, Texas
Endotoxemia has been demonstrated in experimental studies and in patients with obstructive jaundice. It has been associated with a high incidence of renal dysfunction and occasionally, hemorrhagic gastritis [1,2]. An increased mortality was observed after administration of Escherichia coli endotoxin in jaundiced rats [3]. Bailey [3] also demonstrated that intestinal absorption of endotoxin is increased after bile duct obstruction. This may explain why patients with obstructive jaundice requiring surgical intervention have a high incidence of septic complications and an increased mortality [4]. Preoperative external biliary drainage has been used widely during the past years to decrease the operative mortality and morbidity of patients with obstructive jaundice [5,6]. However, several controlled studies have reported no benefit from preoperative biliary drainage [ 7,8]. The failure to decrease the morbidity and mortality of operations after preoperative biliary drainage could be due to the persistence of endotoxemia. The effect of preoperative biliary drainage on endotoxemia has not been systematically evaluated. We postulate that endotoxemia may still be present after preoperative drainage, particularly after the loss of bile associated with external drainage. The purpose of this study, therefore, is to evaluate whether systemic and portal endotoxemia occur in rats with obstructive jaundice and to determine if there is a change in systemic and portal endotoxemia after relief of the obstruction by internal and external biliary drainage. Material and Methods All experiments were performed on Sprague-Dawley rats weighing between 175 and 230 g. The animals were subjected to a 12 hour artificial daylight cycle and allowed From the Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas. Requests for reprints should be addressed to Frank G. Moody, MD, Department of Surgery, The University of Texas Medical School at Houston, 6431 Fannin, Suite 4020, Houston, Texas 77030.
476
free access to food and water. Animals were housed in groups of five. After the placement of an external drainage catheter, which was brought to the outside as described below, they were housed in individual cages to protect the catheter. All surgical procedures were carried out under ether anesthesia and clean technique. Surgical procedures: A 2 cm laparotomy was performed, and the bile duct was ligated and divided according to the method of Lee [9]. The ligatures were placed at the same position in all animals. In rats having a sham operation, the bile duct was dissected but not ligated. External drainage. Two weeks after division of the bile duct, the abdomen was reopened through the previous incision, and the liver was mobilized to the anterior abdominal wall. The dilated bile duct was dissected and the bile was aspirated for culture. A Silastic@ tube (0.030 cm inside diameter, 0.065 cm outside diameter) to which a Silastic cuff was applied, was inserted into the bile duct and tied in position by two pursestring 6-O sutures. The Silastic tube, 8 cm in length, was passed through a subcutaneous tunnel to the lower abdominal wall and exteriorized through a 14 gauge tubing adapter which was fixed to the skin with a 9 mm Autoclip@. Internal drainage. After placement of the catheter in the bile duct as just described, the Silastic tube, 1.5 cm in length, was inserted into the duodenum and tied in position by pursestring suture as described by Ryan et al
[m
Endotoxin assay: Endotoxin in the blood was determined by the limulus lysate test as first described by Levin et al [II]. The method was modified by Prior and Spagna [12] using the microdilution procedure. The modified method was used in this study. Blood samples were aseptically collected during laparotomy by direct puncture of the portal vein and cardiac puncture using a pyrogen-free 1 ml syringe containing 100 units of sodium heparin. All samples were tested 1 hour after collection. Plasma samples were extracted initially with chloroform for 2 hours into a 37°C shaking bath. After centrifugation of the emulsion of plasma and chloroform, the cloudy middle layer was mixed with 0.050 ml of amebocyte lysate (Sigma, St. Louis, MO) and incubated at 37*C for 3 hours. Parallel control assays were performed for each sample with sterile pyrogen-free 0.9 percent sodium
The American
Journal of Surgery
Endotoxemia
TABLE I
and Drainage for Biliary Obstruction
Changes In Body Weight, Berum Albumin Level, and Creatlnine Clearance Afler Bile Duct Ligation (BDL), Internal, and External Dralnage’ Body Weight (g) After After BDL Drainage
Serum Albumin (g/dl) After After BDL Drainage
Creatinine Clearance (ml/h)t
Group
Basal
BDL(n = 15) BDL & internal drainage (n = 13) BDL & external I drainage (n = 14) Control (n = 14)
180 f 6
225f
187 f
224 f 23
245 f
19
2.1 f 0.9
2.7 f 0.4
56.1 f 29.4
231 f 22 239 f 26t
226 f
19t
2.2 f 0.6 3.1 zlz0.4t
2.1 f 0.5t
67.7 f 31.7 58.4 f 18.95
15
190 f 14 177 zt 7
12
2.4 f 0.2
. .
.
37.9 f
17.2
All values expressed as the mean f SD. t Measure at time of endotoxin study (second to third postoperative week). t p < 0.05 compared with other groups in respective columns. g p < 0.05 compared with the BDL group in the same column. l
chloride solution. The assays were read after 2 and 3 hours. The presence or absence of gelation was determined by first adding 50 111of a 0.005 percent aqueous crystal violet stain solution into each well. The bottoms of the plates were then viewed at an oblique angle (30 to 45 degrees). Lack of gelation was noted in the wells in which the dye mixed and colored the contents completely. Positive gelation was recorded as a positive test result. All samples were coded and the assay results were interpreted by an independent observer who did not know the
source of the sample. Experimental groups: The animals were divided into four groups: Group 1 had bile duct ligation only. These 15 rats were sacrificed 14 days postoperatively for endotoxin study. Group 2 had bile duct ligation followed by an internal drainage procedure 14 days later. The 15 animals were sacrificed for endotoxin study 7 days after the drainage procedure. Group 3 (15 rats) had bile duct ligation followed by external drainage 14 days later and endotoxin study was performed 7 days later. Group 4 had a sham operation. These 14 rats were sacrificed 14 days postoperatively for endotoxin study. Results are reported as the mean f standard deviation, and differences were analyzed using the Student’s t test for unpaired data. The Fischer’s exact test was used to analyze differences in systemic and portal endotoxemia.
Result!i There were no deaths after the first operation in any of the groups. All rats in Groups 1,2, and 3 were extremely jaundiced by 14 days after bile duct ligation. After the drainage procedure, two animals, one from Group 2 and one from Group 3, died due to biliary peritonitis. The remaining rats were healthy. Jaundice disappeared in all except one animal in Group 3 which had an occluded drainage catheter. This animal was excluded from the analysis. The rats with external drainage had a daily subcutaneous injection of 10 ml of 0.9 percent sodium chloride solution to replace fluid loss due to bile drainage. There was no difference in weight gain after 2 weeks in the animals with a bile duct ligation; however, the sham animals gained more weight (p
Volume 151, April lSe6
CO.05) when compared with the other groups. There was a significant difference in weight after the two types of drainage procedures (Table I). Serum albumin levels in the sham group were higher (p <0.05) compared with the other groups at 2 weeks after bile duct ligation. An increase in the albumin level was observed after internal drainage (Table II). Renal function, evaluated by creatinine clearance, was decreased after bile duct ligation (p <0.05) but returned to normal 1 week after both internal and external drainage. In regard to liver function tests, the serum bilirubin levels were elevated 2 weeks after bile duct ligation and returned to normal levels after 1 week of internal and external drainage. There was a wide variation in the alkaline phosphatase level which persisted after drainage. However, serum glutamic oxalacetic transaminase and serum glutamic pyruvic transaminase levels decreased to normal values after either drainage procedure. Bile cultures were obtained in all animals after bile duct ligation, and a positive culture was found in four animals, two from Group 2 and two from Group 3. The limulus lysate test results indicated that endotoxemia was increased after bile duct ligation (p
Systemic endotoxemia has frequently been observed in patients with obstructive jaundice. Hunt et al [4] showed that patients with endotoxemia before surgical management for jaundice carry a poor prognosis with an increased mortality. Endotoxemia has also been associated with a high incidence of renal dysfunction [2,13]. Fletcher et al [14]
477
Gouma et al
TABLE II
Changes in Liver Function Test Results After Bile Duct Ligation (BDL) and Internal and External Drainage AP (U/liter) After After BDL Drainage
Bilirubin (mg/dl) After After Drainage BDL
Group BDL (n = 15) BDL & internal drainage (n = 13) BDL & external drainage (n = 14) Control (n = 14)
285f31
351flll
9.16 f 2
SGPT (U/liter) After After BDL Drainage
SGOT (U/liter) After After Drainage BDL
58f31
7.55 f 3.8
0.34 f 0.32
240 f
73
258 f
116
443 f
7.7 f 3 0.1*0.1+
0.13 f 0.05
290 f 32 177*59+
285 f
115
432 f 143 79*17+
All values expressed as the mean f SD. + p < 0.001 compared with other groups in respective columns. AP = alkaline phosphatase; SGOT = serum glutamic oxalacetic transaminase;
131
80 f 29 llOf43 ...
69 IL 23
37f
11
62 f 27 22f 5+
30 f
7
l
t--p-l-,
PORTAL SYSTEMIC
IILE : DUCT 8
LIGATION n=15
SOL+
INT
DRAINAGE ” =13
BDL+
EXT
t
P’
f
P’
0.01
..
P’
0.001
0.05
CONTROL
DRAINAGE ” q 14
n =14
Figure 7. Results of the limulus tysate test on portat and systemic blood after bile duct ligation (BDL) and internal and external drainage. Asterisks indicate values stgniftcantly different from those of the animals with bile duct ligation only. The dagger indicates the significant difference between the animals with internal drainage and those with external drainage.
suggested that endotoxin-induced thromboxane AZ production could cause renal fibrin production in obstructive jaundice, thus contributing to the pathogenesis of renal impairment. Clemente et al [2] observed that endotoxemia is also occasionally associated with the development of hemorrhagic gastritis. Recently, Cahill [15] showed that preoperative administration of the bile salt, sodium deoxycholate, prevented postoperative endotoxemia in patients with obstructive jaundice. Significant mortality after administration of E. coli endotoxin has been reported in experimental studies [3,14]. It has also been shown that increased absorption of endotoxin in obstructive jaundice can be prevented by oral administration of bile salts [3]. In addition, a
470
SGPT = serum glutamic pyruvic transaminase.
direct influence of E. coli endotoxin on hepatic function was reported in the isolated rat liver by Utili et al [16], who demonstrated a decreased bile flow, probably caused by impairment of the hepatic excretory mechanism. Preoperative external biliary drainage in obstructive jaundice has been used widely during the past years to reduce morbidity and mortality; however, results of controlled trials indicate little or no reduction in mortality and morbidity after external drainage [7,8]. Possibly, the absence of bile in the intestinal tract secondary to external drainage has contributed to this negative result. This possibility has not been evaluated in the clinical situation. Previous studies in this laboratory have observed an increased mortality in rats with bile duct ligation after an abdominal infection induced by cecal ligation and puncture. Mortality was decreased after preoperative internal drainage but no reduction was found after external drainage. In the present study, a significant increase in portal and systemic endotoxemia was found after bile duct ligation. The high incidence of both portal and systemic endotoxemia after bile duct ligation supports previous findings that there is an increase in the absorption of endotoxins from the intestinal tract [3]. The increased absorption in combination with impaired clearance of endotoxins by the liver caused systemic endotoxemia [I 71. We have demonstrated in this study that both portal and systemic endotoxemia were significantly reduced after relief of the obstruction by internal drainage. These findings suggest that the absorption of endotoxin was reduced after the reestablishment of bile flow into the intestinal tract. The significantly higher incidence of portal and systemic endotoxemia observed after external drainage, despite serum bilirubin levels returning to normal units, indicate that absorption of endotoxin is still increased after external drainage. The limulus lysate test has been used as a semiquantitative measurement [5]. After adding the crystal violet stain, the difference between the presence of gelation (positive test result) and lack of
The American Journal of Surgery
Endotoxemia
gelation was easily recognized. We did not express the positive endotoxin test result in terms of concentration because of the lack of absolute units and also because standard and test endotoxin were not from the same source [18]. Renal function returned to normal after both internal and external drainage, supporting the opinion that the combination of jaundice and endotoxemia is a significant factor in impaired renal function [f5]. Persistent systemic endotoxemia without jaundice did not affect renal function in this study. We conclude that internal biliary drainage is an effective method of decreasing the incidence of systemic and portal endotoxemia after biliary obstruction. These results also indicate that the systemic endotoxemia observed after relief of biliary obstruction by external biliary drainage may contribute to the increased mortality, as observed in our previous study. Further study is required to fully evaluate these findings clinically. Summary Systemic and portal endotoxemia were studied in rats with biliary obstruction and after relief of the obstruction by internal and external drainage. Endotoxemia was increased after bile duct ligation (p CO.001) compared with control values. The incidence of systemic and portal endotoxemia was significantly reduced after internal drainage (p
Volume 151, April 1986
and Drainage
for Biliary Obstruction
References 1. Allison MEM, Prentice CRM, Kennedy AC, Blumgart LH. Renal function and other factors in obstructive jaundice. Br J Surg 1979;66:392-7. 2. Clemente C, Bosch J, Rodes J, Arroyo V, Mas A. Maragall S. Functional renal failure and haemorrhagic gastritis associated with endotoxaemia in cirrhosis. Gut 1977;16:556-60. 3. Bailey ME. Endotoxin, bile salts and renal function in obstructive jaundice. Br J Surg 1976;63:774-8. 4. Hunt DR, Allison MEM, Prentice CRM, Blumgati LH. Endotoxemia, disturbance of coagulation, and obstructive jaundice. Am J Surg 1982;144:325-9. 5. Denning DA, Ellison EC, Carey LC. Preoperative percutaneous transhepatic biliary decompression lowers operative morbidity in patients with obstructive jaundice. Am J Surg 1981;141:61-5. 6. Gouma DJ, Wesdorp RIG, Oostenbroek RJ, Soeters PB, Greep JM. Percutaneous transhepatic drainage and insertion of an endoprosthesis for obstructive jaundice. Am J Surg 1983; 145~763-8. 7. Hatfield ARW, Terblanche J, Fataar S, et al. Preoperative external biliary drainage in obstructive jaundice. Lancet 1982;2:896-9. 8. McPherson GAD, Benjamin IS, Hodgson HJF, Bowley NB, Allison DJ, Blumgart LH. Preoperative percutaneous transhepatic biliary drainage. Br J Surg 1984:71:371-5. 9. Lee E. The effect of obstructive jaundice on the migration of reticula-endothelial cells and fibroblasts into early experimental granulomata. Br J Surg 1972;59:875. 10. Ryan CJ, Than T, Blumgart LH. Choledochoduodenostomy in the rat with obstructive jaundice. J Surg Res 1977;23: 321-31. 11. Levin J, Poore IE. Zauber NP, Oser RS. Detection of endotoxin in the blood of patients with sepsis due to gram-negative bacteria. New Engl J Med 1970;283: 13 13-6. 12. Prior RB, Spagna VA. Adaptation of a microdilution procedure to the limulus lysate assay for endotoxin. J Clin Microbial 1979:10:394-5. 13. Wardle EN. Endotoxinaemia and the pathogenesis of acute renal failure. Q J Med 1975;174:389-98. 14. Fletcher MS, Westwick J, Kakkar VV. Endotoxin, prostaglandins and renal fibrin deposition in obstructive jaundice. Br J Surg 1982;69:625-9. 15. Cahill CJ. Prevention of postoperative renal failure in patients with obstructive jaundice: the role of bile salts. Br J Surg 1983;70:590-5. 16. Utili R, Abernathy CO, Zimmerman HJ. Cholestatic effects of Escherichia coli endotoxin on the isolated perfused rat liver. Gastroenterology 1976;70:248-53. 17. Holman JM Jr, Rikkers LF. Biliary obstruction and host defense failure. J Surg Res 1982;32:208-13. 18. Harris RI, Stone PCW, Stuart J. An improved chromogenic substrate endotoxin assay for clinical use. J Clin Pathol 1983;36:1145-9.
479
Dirk J. Gouma, MD, Houston, Texas Julio C. U. Coelho, MD, PhD, Houston, Texas John D. Fisher, BS, Houston, Texas Jerry F. Schlegel, BS, Houston, Texas Yong F. Li, MD, Houston, Texas Frank G. Moody, MD, Houston, Texas
Endotoxemia has been demonstrated in experimental studies and in patients with obstructive jaundice. It has been associated with a high incidence of renal dysfunction and occasionally, hemorrhagic gastritis [1,2]. An increased mortality was observed after administration of Escherichia coli endotoxin in jaundiced rats [3]. Bailey [3] also demonstrated that intestinal absorption of endotoxin is increased after bile duct obstruction. This may explain why patients with obstructive jaundice requiring surgical intervention have a high incidence of septic complications and an increased mortality [4]. Preoperative external biliary drainage has been used widely during the past years to decrease the operative mortality and morbidity of patients with obstructive jaundice [5,6]. However, several controlled studies have reported no benefit from preoperative biliary drainage [ 7,8]. The failure to decrease the morbidity and mortality of operations after preoperative biliary drainage could be due to the persistence of endotoxemia. The effect of preoperative biliary drainage on endotoxemia has not been systematically evaluated. We postulate that endotoxemia may still be present after preoperative drainage, particularly after the loss of bile associated with external drainage. The purpose of this study, therefore, is to evaluate whether systemic and portal endotoxemia occur in rats with obstructive jaundice and to determine if there is a change in systemic and portal endotoxemia after relief of the obstruction by internal and external biliary drainage. Material and Methods All experiments were performed on Sprague-Dawley rats weighing between 175 and 230 g. The animals were subjected to a 12 hour artificial daylight cycle and allowed From the Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas. Requests for reprints should be addressed to Frank G. Moody, MD, Department of Surgery, The University of Texas Medical School at Houston, 6431 Fannin, Suite 4020, Houston, Texas 77030.
476
free access to food and water. Animals were housed in groups of five. After the placement of an external drainage catheter, which was brought to the outside as described below, they were housed in individual cages to protect the catheter. All surgical procedures were carried out under ether anesthesia and clean technique. Surgical procedures: A 2 cm laparotomy was performed, and the bile duct was ligated and divided according to the method of Lee [9]. The ligatures were placed at the same position in all animals. In rats having a sham operation, the bile duct was dissected but not ligated. External drainage. Two weeks after division of the bile duct, the abdomen was reopened through the previous incision, and the liver was mobilized to the anterior abdominal wall. The dilated bile duct was dissected and the bile was aspirated for culture. A Silastic@ tube (0.030 cm inside diameter, 0.065 cm outside diameter) to which a Silastic cuff was applied, was inserted into the bile duct and tied in position by two pursestring 6-O sutures. The Silastic tube, 8 cm in length, was passed through a subcutaneous tunnel to the lower abdominal wall and exteriorized through a 14 gauge tubing adapter which was fixed to the skin with a 9 mm Autoclip@. Internal drainage. After placement of the catheter in the bile duct as just described, the Silastic tube, 1.5 cm in length, was inserted into the duodenum and tied in position by pursestring suture as described by Ryan et al
[m
Endotoxin assay: Endotoxin in the blood was determined by the limulus lysate test as first described by Levin et al [II]. The method was modified by Prior and Spagna [12] using the microdilution procedure. The modified method was used in this study. Blood samples were aseptically collected during laparotomy by direct puncture of the portal vein and cardiac puncture using a pyrogen-free 1 ml syringe containing 100 units of sodium heparin. All samples were tested 1 hour after collection. Plasma samples were extracted initially with chloroform for 2 hours into a 37°C shaking bath. After centrifugation of the emulsion of plasma and chloroform, the cloudy middle layer was mixed with 0.050 ml of amebocyte lysate (Sigma, St. Louis, MO) and incubated at 37*C for 3 hours. Parallel control assays were performed for each sample with sterile pyrogen-free 0.9 percent sodium
The American
Journal of Surgery
Endotoxemia
TABLE I
and Drainage for Biliary Obstruction
Changes In Body Weight, Berum Albumin Level, and Creatlnine Clearance Afler Bile Duct Ligation (BDL), Internal, and External Dralnage’ Body Weight (g) After After BDL Drainage
Serum Albumin (g/dl) After After BDL Drainage
Creatinine Clearance (ml/h)t
Group
Basal
BDL(n = 15) BDL & internal drainage (n = 13) BDL & external I drainage (n = 14) Control (n = 14)
180 f 6
225f
187 f
224 f 23
245 f
19
2.1 f 0.9
2.7 f 0.4
56.1 f 29.4
231 f 22 239 f 26t
226 f
19t
2.2 f 0.6 3.1 zlz0.4t
2.1 f 0.5t
67.7 f 31.7 58.4 f 18.95
15
190 f 14 177 zt 7
12
2.4 f 0.2
. .
.
37.9 f
17.2
All values expressed as the mean f SD. t Measure at time of endotoxin study (second to third postoperative week). t p < 0.05 compared with other groups in respective columns. g p < 0.05 compared with the BDL group in the same column. l
chloride solution. The assays were read after 2 and 3 hours. The presence or absence of gelation was determined by first adding 50 111of a 0.005 percent aqueous crystal violet stain solution into each well. The bottoms of the plates were then viewed at an oblique angle (30 to 45 degrees). Lack of gelation was noted in the wells in which the dye mixed and colored the contents completely. Positive gelation was recorded as a positive test result. All samples were coded and the assay results were interpreted by an independent observer who did not know the
source of the sample. Experimental groups: The animals were divided into four groups: Group 1 had bile duct ligation only. These 15 rats were sacrificed 14 days postoperatively for endotoxin study. Group 2 had bile duct ligation followed by an internal drainage procedure 14 days later. The 15 animals were sacrificed for endotoxin study 7 days after the drainage procedure. Group 3 (15 rats) had bile duct ligation followed by external drainage 14 days later and endotoxin study was performed 7 days later. Group 4 had a sham operation. These 14 rats were sacrificed 14 days postoperatively for endotoxin study. Results are reported as the mean f standard deviation, and differences were analyzed using the Student’s t test for unpaired data. The Fischer’s exact test was used to analyze differences in systemic and portal endotoxemia.
Result!i There were no deaths after the first operation in any of the groups. All rats in Groups 1,2, and 3 were extremely jaundiced by 14 days after bile duct ligation. After the drainage procedure, two animals, one from Group 2 and one from Group 3, died due to biliary peritonitis. The remaining rats were healthy. Jaundice disappeared in all except one animal in Group 3 which had an occluded drainage catheter. This animal was excluded from the analysis. The rats with external drainage had a daily subcutaneous injection of 10 ml of 0.9 percent sodium chloride solution to replace fluid loss due to bile drainage. There was no difference in weight gain after 2 weeks in the animals with a bile duct ligation; however, the sham animals gained more weight (p
Volume 151, April lSe6
CO.05) when compared with the other groups. There was a significant difference in weight after the two types of drainage procedures (Table I). Serum albumin levels in the sham group were higher (p <0.05) compared with the other groups at 2 weeks after bile duct ligation. An increase in the albumin level was observed after internal drainage (Table II). Renal function, evaluated by creatinine clearance, was decreased after bile duct ligation (p <0.05) but returned to normal 1 week after both internal and external drainage. In regard to liver function tests, the serum bilirubin levels were elevated 2 weeks after bile duct ligation and returned to normal levels after 1 week of internal and external drainage. There was a wide variation in the alkaline phosphatase level which persisted after drainage. However, serum glutamic oxalacetic transaminase and serum glutamic pyruvic transaminase levels decreased to normal values after either drainage procedure. Bile cultures were obtained in all animals after bile duct ligation, and a positive culture was found in four animals, two from Group 2 and two from Group 3. The limulus lysate test results indicated that endotoxemia was increased after bile duct ligation (p
Systemic endotoxemia has frequently been observed in patients with obstructive jaundice. Hunt et al [4] showed that patients with endotoxemia before surgical management for jaundice carry a poor prognosis with an increased mortality. Endotoxemia has also been associated with a high incidence of renal dysfunction [2,13]. Fletcher et al [14]
477
Gouma et al
TABLE II
Changes in Liver Function Test Results After Bile Duct Ligation (BDL) and Internal and External Drainage AP (U/liter) After After BDL Drainage
Bilirubin (mg/dl) After After Drainage BDL
Group BDL (n = 15) BDL & internal drainage (n = 13) BDL & external drainage (n = 14) Control (n = 14)
285f31
351flll
9.16 f 2
SGPT (U/liter) After After BDL Drainage
SGOT (U/liter) After After Drainage BDL
58f31
7.55 f 3.8
0.34 f 0.32
240 f
73
258 f
116
443 f
7.7 f 3 0.1*0.1+
0.13 f 0.05
290 f 32 177*59+
285 f
115
432 f 143 79*17+
All values expressed as the mean f SD. + p < 0.001 compared with other groups in respective columns. AP = alkaline phosphatase; SGOT = serum glutamic oxalacetic transaminase;
131
80 f 29 llOf43 ...
69 IL 23
37f
11
62 f 27 22f 5+
30 f
7
l
t--p-l-,
PORTAL SYSTEMIC
IILE : DUCT 8
LIGATION n=15
SOL+
INT
DRAINAGE ” =13
BDL+
EXT
t
P’
f
P’
0.01
..
P’
0.001
0.05
CONTROL
DRAINAGE ” q 14
n =14
Figure 7. Results of the limulus tysate test on portat and systemic blood after bile duct ligation (BDL) and internal and external drainage. Asterisks indicate values stgniftcantly different from those of the animals with bile duct ligation only. The dagger indicates the significant difference between the animals with internal drainage and those with external drainage.
suggested that endotoxin-induced thromboxane AZ production could cause renal fibrin production in obstructive jaundice, thus contributing to the pathogenesis of renal impairment. Clemente et al [2] observed that endotoxemia is also occasionally associated with the development of hemorrhagic gastritis. Recently, Cahill [15] showed that preoperative administration of the bile salt, sodium deoxycholate, prevented postoperative endotoxemia in patients with obstructive jaundice. Significant mortality after administration of E. coli endotoxin has been reported in experimental studies [3,14]. It has also been shown that increased absorption of endotoxin in obstructive jaundice can be prevented by oral administration of bile salts [3]. In addition, a
470
SGPT = serum glutamic pyruvic transaminase.
direct influence of E. coli endotoxin on hepatic function was reported in the isolated rat liver by Utili et al [16], who demonstrated a decreased bile flow, probably caused by impairment of the hepatic excretory mechanism. Preoperative external biliary drainage in obstructive jaundice has been used widely during the past years to reduce morbidity and mortality; however, results of controlled trials indicate little or no reduction in mortality and morbidity after external drainage [7,8]. Possibly, the absence of bile in the intestinal tract secondary to external drainage has contributed to this negative result. This possibility has not been evaluated in the clinical situation. Previous studies in this laboratory have observed an increased mortality in rats with bile duct ligation after an abdominal infection induced by cecal ligation and puncture. Mortality was decreased after preoperative internal drainage but no reduction was found after external drainage. In the present study, a significant increase in portal and systemic endotoxemia was found after bile duct ligation. The high incidence of both portal and systemic endotoxemia after bile duct ligation supports previous findings that there is an increase in the absorption of endotoxins from the intestinal tract [3]. The increased absorption in combination with impaired clearance of endotoxins by the liver caused systemic endotoxemia [I 71. We have demonstrated in this study that both portal and systemic endotoxemia were significantly reduced after relief of the obstruction by internal drainage. These findings suggest that the absorption of endotoxin was reduced after the reestablishment of bile flow into the intestinal tract. The significantly higher incidence of portal and systemic endotoxemia observed after external drainage, despite serum bilirubin levels returning to normal units, indicate that absorption of endotoxin is still increased after external drainage. The limulus lysate test has been used as a semiquantitative measurement [5]. After adding the crystal violet stain, the difference between the presence of gelation (positive test result) and lack of
The American Journal of Surgery
Endotoxemia
gelation was easily recognized. We did not express the positive endotoxin test result in terms of concentration because of the lack of absolute units and also because standard and test endotoxin were not from the same source [18]. Renal function returned to normal after both internal and external drainage, supporting the opinion that the combination of jaundice and endotoxemia is a significant factor in impaired renal function [f5]. Persistent systemic endotoxemia without jaundice did not affect renal function in this study. We conclude that internal biliary drainage is an effective method of decreasing the incidence of systemic and portal endotoxemia after biliary obstruction. These results also indicate that the systemic endotoxemia observed after relief of biliary obstruction by external biliary drainage may contribute to the increased mortality, as observed in our previous study. Further study is required to fully evaluate these findings clinically. Summary Systemic and portal endotoxemia were studied in rats with biliary obstruction and after relief of the obstruction by internal and external drainage. Endotoxemia was increased after bile duct ligation (p CO.001) compared with control values. The incidence of systemic and portal endotoxemia was significantly reduced after internal drainage (p
Volume 151, April 1986
and Drainage
for Biliary Obstruction
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