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Experimental and clinical studies on the effect of biliary drainage in obstructive jaundice
Experimental and Clinical Studies on the Effect of Biliary Drainage in Obstructive Jaundice Kenji Koyama, MD, Sendai, Japan Yasushi Takagi, MD, Sendai, Japan Kenji Ito, MD, Sendai, Japan Toshio Sato, MD, FACS, Sendai, Japan
Bile duct proliferation and hepatic fibrosis after cholestasis are typical findings in patients with obstructive jaundice, which is associated with deterioration of liver function and decreased metabolism of several substances that cause hepatic failure [1,2]. Hepatic impairment caused by biliary obstruction may be improved by relief of the obstruction. We have obtained good operative results in jaundiced patients with pancreaticoduodenal cancer by performing a two stage procedure consisting of external biliary drainage as the first operation, followed by radical operation after improvement of jaundice [3]. This report presents the results of experimental and clinical investigations on hepatic functional improvement after relief of biliary obstruction. Material
and Methods
In experimental studies, obstructive jaundice was induced in mongrel male dogs weighing 15 to 20 kg by ligating and dissecting the common bile duct. Animals were divided into three groups in which biliary obstruction was released by means of’cholecystogastrostomy after 4,6 and 12 weeks of biliary obstruction. Each group consisted of three dogs. Blood and approximately 5 g of liver tissue were sampled for examination at the time of cholecystogastrostomy, 3 and ‘7weeks after operation. Clinical studies were carried out in six patients with pancreaticoduodenal cancer with obstructive jaundice; three of the patients had had jaundice for less than 2 months and three for more than 2 months. Blood and liver tissue were sampled for investigation at the time of the first stage operation (external cholecystostomy) and at the second stage operation (pancreaticoduodenectomy or choledochojejunostomy), performed 4 or 6 weeks after the first stage operation. Serum hilirubin. glutamic oxalacetic transaminase, glutamic pyruvic transaminase, alkaline phosphatase, plasma protein content, and albumin content were measured in both experimental and clinical cases. The plasma disappearance rate of indocyanine green was measured in the clinical cases. Liver specimens obtained from dogs and patients with obstructive jaundice were used for biochemical and histologic studies as follows. From the Department of Surgery, Tohoku University School of Medlclne. Sendal. Japan This IS the sixth report of a senes of studies on obstructwe jaundice Requests for reprints should be addressed to Toshlo Sate, MD, Department of Surgery. Tohoku University School of Medicine, l-l Seryo-cho, Sendal. Japan
Volume 142, August 1981
Mitochondrial respiratory function: Mitochondria were fractionated by Hogeboom and Schneider’s method [4], and the mitochondrial respiratory curve, using succinate as a substrate, and recorded polarographically with a Hagihara’s oxygen consumption meter [5] as reported previously [6]. The respiratory control ratio, adenosine diphosphateloxygen ratio, oxygen consumption rate of state 3 respiration (respiration under the existence of respiratory substrate and adenosine diphosphate) and adenosine triphosphate synthesis were calculated from the mitochondrial respiratory curve. Activities of latent adenosine triphosphatase and dinitrophenol-stimulated adenosine triphosphatase in mitochondria were measured and their ratio (activation ratio of adenosine triphosphatase) was calculated. Ketogenesis of the liver: As reported previously, the liver specimens were sliced with a thickness less than 0.5 mm and were incubated in Eagle’s minimal essential medium (Nissui Seiyaku Co., Ltd., Tokyo) containing 10 pmol of sodium n-butyrate as a substrate for 2 hours. Ketogenesis was determined by measuring the increment of the ketone bodies in the medium [1,7]. Biochemical study of fibrosis of the liver: Liver slices were also incubated in minimal essential medium containing carbon-14 proline. The content of hepatic collagen was determined by Wossner’s method [8] and its synthetic activity was determined by means of a liquid scintillation counter as incorporation of proline into hydroxyproline. These details were reported previously [9].
Results Experimental Studies Standard liver function tests: Total plasma bilirubin, glutamic pyruvic transaminase and alkaline phosphatase reached maximum levels after 1 or 2 weeks of biliary obstruction and plateaued thereafter, whereas these values decreased rapidly after release of biliary obstruction (Figure 1). Although total bilirubin returned to a normal level 3 weeks after release of the obstruction, reduction of alkaline phosphatase and glutamic pyruvic transaminase was modest. However, plasma protein and albumin levels, which decreased markedly with the prolongation of biliary obstruction, decreased continuously after release of the obstruction. Histologic changes in the liver: Details of the histologic changes in the liver will he reported else293
Koyama et al
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where. In brief, there was evidence that distinct cholestasis, proliferation of bile ducts and fibrosis due to biliary obstruction were improved by relief of the obstruction (Figure 2). Mitochondrial respiratory function: Various parameters of mitochondrial function are illustrated in Figure 3. In a group of dogs with biliary obstruction for 4 weeks, a tendency toward improvement in the respiratory control ratio was found 3 weeks after release of the obstruction, recovering to 80 percent of control values after 7 weeks. A group with biliary obstruction for 6 weeks did not show significant improvement 3 weeks after release of the obstruction, but these values improved significantly after 7 weeks. In contrast, recovery of the respiratory control ratio after relief of biliary obstruction lasting for 12 weeks
294
Figure 1. Liver function tests in dogs during biliary obstruction and afterits relief (mean value in three dogs f standard deviation). Squares indicate control values; circles, triangles and x’s indicate billary obstruction for 4, 6 and 72 weeks, respectively. a = significant (p <0.05) 3 or 7 weeks after relief versus before relief; b = signlflcant (p < 0.05) 7 weeks after relief versus 3 weeks alter relief; c after 6 or 72 = significant (p <0.05) weeks of blliary obstruction versus 4 weeks of billary obstruction; d = signlficant (p < 0.05) after 72 weeks of biliary obstruction versus 6 weeks of biliary obstruction. AI-P. = alkallne phosphatase; GPT = gkdamfc pyruvic transaminase; W = weeks.
was slight and showed significantly lower levels than with 6 weeks of biliary obstruction. In the adenosine diphosphateloxygen ratio and adenosine triphosphate synthesis, almost the same degree of improvement was found after relief of obstruction, but it was very slight in the oxygen consumption rate of state 3 respiration particularly in the groups with obstruction for 6 and 12 weeks. The adenosine triphosphatase activation ratio (latent adenosine triphosphatase/dinitrophenol stimulated adenosine triphosphatase) is illustrated in Figure 4. In groups with biliary obstruction for 4 and 6 weeks, this ratio was elevated moderately and returned to almost control values after release of the obstruction. However, the ratio became markedly elevated in a group with 12 weeks of obstruction and did not return to the control value after release of the ob-
The American Journal of Surgery
Biliary Drainage in Obstructive Jaundice
Figure 2. Histologic findings in the dog liver. Left, after 6 weeks of biiiary obstruction; right, 7 weeks after relief of biiiary obstruction in the same dog. (Hemafoxyitn-eosin stain; magnified X400, reduced 23 percent.)
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I Figure 3. Parameters of mitochondriai function in the dog liver during biiiary obstruction and after its relief (mean value in three dogs f standard deviation). ATP = adenosine triphosphate; P/O = adenosine diphosphateloxygen ratio: RC = respiratory control ratio; S, = oxygen consumption rate of stage 3 respiratkm. Other abbreviations and symbols as in Figure 1.
Volume
142,
August 1981
Cont ml
After relief obstruction
of biliary
ATPsynthesis
S3 (natomslmg
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3w
Biliary obstruction
(nmoles/mg
prot./min)
prot./minl
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295
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,-
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( I
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struction, but rather remained close to the values of the groups with 4 and 6 weeks of biliary obstruction. Ketogenesis of the liver: The synthetic ability of ketone bodies decreased markedly after biliary obstruction in some of the experimental animals (Figure 4). There was no significant improvement in ketogenesis after release of the obstruction. Hepatic fibrosis: Content of hydroxyproline and the synthetic ability of collagen in the liver are illustrated in Figure 4. The content of hydroxyproline increased in biliary obstruction and gradually decreased after the release of the obstruction, nearly reaching the control value after 7 weeks. The incorporation of carbon-14 proline into hydroxyproline in the liver with biliary obstruction increased to approximately 10 times the control value but decreased significantly after release of the obstruction and_returned to the control level after 3 weeks, even in animals with long-term obstruction.
296
obstruction
Flgure 4. Adenosine triphosphatase ( ATPase) actlvatkwt ratio in mltochondrial fraction, ketogenesis, collagen synthesis andcolkigencontentblhwsUcesofdcgs during b/Mary obstrucllon and after its relief. Numbers In parentheses btdlcate the number of experknental animals. Abbreviations and symbols as In Figure 1.
Clinical Studies Table I lists the results of investigation in patients with pancreaticoduodenal cancer who were classified as having either short- or long-term biliary obstruction. Similar to the experimental studies in the dog, clinical patients showed marked elevations of total bilirubin and alkaline phosphatase and marked reduction of indocyanine green values, although elevations in glutamic oxalacetic transaminase and glutamic pyruvic transaminase were slight. These changes in liver function tests did not correspond to the duration of biliary obstruction. Although these abnormalities improved after release of the obstruction, improvement of indocyanine green tended to proceed slowly. Figure 5 shows changes in liver function tests as well as mitochondrial function in a patient. While recovery of total bilirubin and alkaline phosphatase was rapid after release of the obstruction, that of indocyanine green was gradual. Pa-
The American Journal 01 Surgery
Biliary Drainage
in Obstructive
Jaundice
Bll 31 IX) AI-P
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ICGk (0)
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Flgure 5. Correlation of liver function tests and mltochondrlal fund/on In a 49 year old man with pancreatlcoduodenal cancer. Units as in Table 1. Numbers in boxes lndkate the respfratory control ratio/ adenoshe trlphosphate synthesis. GOT = g&tam/c oxalacetlc transaminase; ICGK = plasma disappearance rate of Indocyanlne green; T. Bll. = total bllkrrbht; other abbrevlatlons and symbols as In Flgure 1.
rameters of mitochondrial respiratory function decreased less markedly in patients with short-term biliary obstruction and showed marked improvement after relief of the obstruction. In contrast, severe mitochondrial respiratory dysfunction was evident in patients with long-term obstruction, improving only slightly 5 or 6 weeks after release of the obstruction. Both the synthesis of ketone bodies and the activation ratio of adenosine triphosphatase showed changes similar to those in experimental studies in dogs. The synthetic activity of hydroxyproline increased markedly in patients with jaundice and recovered promptly after release of the obstruction, particularly in patients with short-term biliary obstruction. On the other hand, the content of hydroxyproline tended to increase even after release of the obstruction in all patients except case 2.
Comments There have been many reports on hepatic dysfunction in obstructive jaundice [IO-121. We also investigated mitochondrial respiratory function, metabolism of short chain fatty acids and ammonia, fibrosis and morphologic findings in light and electron microscopy in rat liver with bihary obstruction [1,2,6,9,13]. On the other hand, there are only a few
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reports on the pathophysiology of the liver after relief of biliary obstruction [14,15]. In our investigation using dogs, the duration of jaundice and of the periods after its release were found to be similar to those frequently seen in man. In patients with pancreaticoduodenal cancer and jaundice, the same investigations were performed, and comparison was made between experimental and clinical data. It was found that hepatic mitochondrial respiratory function deteriorated in parallel with prolongation of biliary obstruction in dogs, as we reported previously [6] in experiments in rats. It was also observed that the degree of recovery after the relief of obstruction depended on both the duration of obstruction and of the period after relief of the obstruction. Mitochondrial respiratory inhibition is regulated not only by the concentration of toxic substances like bilirubin and bile acids but also by the period during which mitochondria exist in the unfavorable situation with cholestasis. It is unlikely that mitochondrial function recovers rapidly even if the toxic substances are removed after relief of biliary obstruction. Among the parameters of mitochondrial respiration, the oxygen consumption rate of state 3 respiration decreased easily in biliary obstruction and recovered slightly after its relief. Therefore, this change in the oxygen consumption rate of state 3 respiration was thought to cause a decrease in adenosine triphosphate synthesis. Ketogenesis in the substrate of short chain fatty acids was impaired by long-term obstruction and did not easily recover, which indicated that ketogenesis closely reflected reduced mitochondrial function. Since short chain fatty acids are also believed to be a cause of hepatic failure [16], their impaired metabolism in patients with prolonged obstruction is apt to induce hepatic failure even after relief of the obstruction. Considering the long-term prognosis for patients with obstructive jaundice, histologic findings in the liver, especially the degree of fibrosis, are important. After relief of the biliary obstruction, a decrease in collagen or at least a decrease in the rate of collagen synthesis could be expected biochemically and morphologically. The significance of standard liver function tests was also investigated since a simplified evaluation of liver function was desirable. In our experiments abnormalities in liver function tests were found to recover rapidly after release of the obstruction; most cases showed normal or near-normal values within 3 weeks after relief. However, as reported by Aronsen [14], decrease in serum protein and albumin content was found and recovery after relief of obstruction hardly occurred in our cases. The results of investigation in patients are fundamentally similar to those in the experimental studies except for the collagen content, which in-
298
creased at the second operation in the clinical cases. Simultaneous histologic examination, however, revealed reduction of the area of fibrosis in the liver. This discrepancy may be explained by localization of the large amount of collagen in Glisson’s sheaths. Consequently, there was an increase in the hepatic parenchyma proportional to the biliary obstruction, which was thought to be an important factor in the improvement of liver dysfunction. Based on these results, the critical duration of biliary obstruction in which nearly complete recovery from hepatic damage can be obtained after release of obstruction must be discussed. In terms of standard liver function tests and histologic findings of the liver in dogs, Aronsen [I41 reported that the complete recovery of liver dysfunction could be obtained after a maximum of 2 weeks of obstruction, which was thought to be a critical duration. We believe, however, that the measurement of mitochondrial functions is more appropriate for the evaluation of liver function, because electron transport and respiration are coupled and adenosine triphosphate is produced in mitochondria. Twelve weeks of biliary obstruction was considered the critical duration in dogs, when not only the improvement of the mitochondrial function was extremely slow and slight, but recovery of ketogenesis and regression of hepatic fibrosis were insufficient after relief of the obstruction. The critical duration in man is thought to be analogous to these experimental findings. In clinical cases with poor recovery of mitochondrial function, there was little tendency for improvement in serum bilirubin and alkaline phosphatase levels. Aronsen [14] showed that the recovery of the sodium sulfobromophthalein retention rate was slow after release of the long-term obstruction, and we also found poor recovery of indocyanine green values, which are thought to reflect the slow recovery from liver damage associated with an unfavorable improvement of mitochondrial function. It is therefore presumed that the slow reduction in total bilirubin or alkaline phosphatase levels, or the delayed improvement of indocyanine green values after relief of the biliary obstruction, are critical signs of poor recovery of mitochondrial dysfunction. In recent years, instead of operative relief of biliary nonsurgical percutaneous biliary obstruction, drainage has been performed [15], followed by a radical operation such as pancreaticoduodenectomy. In order to perform this radical operation safely, the interval between external biliary drainage and operation should be as long as possible, during which time the improvement of mitochondrial function could be obtained. However, it is possible that the chance for curative operation may be lost due to the growth of tumors during the period. Consequently, it is so difficult to wait until mitochondrial function recovers completely that the radical operation should
The American Journal of Surgery
Biliary
be performed 4 to 6 weeks after biliary drainage, when mitochondrial functions apparently improve to 40 to 50 percent of the control values. However, in cases with jaundice lasting more than 12 weeks or with critical signs such as high glutamic oxalacetic transaminase and alkaline phosphatase and low indocyanine green values even after biliary drainage, the operation should be delayed until at least 6 weeks after biliary drainage. In patients in whom a curative operation appears impossible, it is desirable to perform the operation of palliative internal fistula after a long enough period for improvement of mitochondrial function. Moreover, to obtain fast and complete recovery from hepatic dysfunction after relief of biliary obstruction, further investigations into the various supplementary procedures including administration of drugs are required. Summary Mitochondrial respiratory function, ketogenesis and collagen metabolism of the liver in biliary obstruction and after its relief were investigated in dogs and patients with obstructive jaundice. In dogs, it was found that hepatic mitochondrial respiratory function decreased significantly with prolongation of biliary obstruction, but recovered to varying degrees depending on both the duration of obstruction and of the period after the relief of obstruction. Ketogenesis was also impaired by biliary obstruction and its recovery was found in a slight degree only in cases with short-term obstruction. Hepatic collagen content and the synthetic ability significantly increased in biliary obstruction, and returned to normal levels within a relatively short period after the relief. Analogous results were obtained in clinical cases, but the decrease in serum bilirubin was somewhat delayed and increased hepatic collagen content continued after relief of the obstruction. When major surgery is required in patients with obstructive jaundice, biliary drainage should be carried out first 4 to 6 weeks before the performance of major operations. In cases with biliary obstruction for 12 weeks or more, it is desirable to wait for more than 6 weeks
Volume 142, August 1981
Drainage
in Obstructive
Jaundice
after biliary drainage since recovery of hepatic function, especially mitochondrial function, will be extremely slow. References 1. Koyama K, Kashimura S, Yamauchi H, Takagi Y, Owada Y, Sato T. Metabolism of short chain fatty acid in rat liver in biliary obstruction. Tohoku J Exp Med 1975; 117:335-41. 2 Koyama K, Owada Y, Yamauchi H, Ito K, Watabe S, Sato T. Ammonia metabolism in the rat liver in biliary obstruction. Tohoku J Exp Med 1979; 127:379-87 3. Maki T, Sato T, Kakizaki G. Pancreatoduodenectomy for periampullary carcinomas. Appraisal of two-stage procedure. Arch Surg 1966;92:825-33. 4. Hogeboom GH, Schneider WC Isolation of intact mitochondria from rat liver. J Biol Chem 1948;172:619-30 5. Hagihara B Techniques for the applicatron of polarography to mitochondrial respiration. Biochim Biophys Acta 1961; 46: 134-42. 6. Koyama K, Ito K, Ouchi K, Matsubara S, Sato T Mitochondrial function of rat liver in biliary obstruction. Tohoku J Exp Med 1980;131:59-69. 7 Lyon JB, Bloom WL. The use of furfural for the determination of acetone bodies in biological fluids. Can J Biochem Physiol 1958;36,1047-56. 8. Wossner JF Jr. The determination of hydroxyproline in tissue and protein samples containing small proportions of this amino acid. Arch Biochim Biophys 1961;93:440-7. 9. Koyama K. Muto I, Yamauchi H, Takagi Y, Anezaki T, Sato T. Biochemical study of fibrosis in the rat liver in biliary obstruction. Tohoku J Exp Med 1975;116:161-72. IO. Cameron GR, Hasan SM. Disturbances of structure and function in the liver as the result of biliary obstruction. J Pathol Bacteriol 1958;75:333-49. 11 Ozawa K, Takasan H, Kitamura 0, et al. Alteration of liver mitochondrial metabolism in a patient with biliary obstruction due to liver carcinoma. Am J Surg 1973;126:653-7 12 Trams EG, Symenoidis A. Morphologic and functional changes in the livers of rats after ligation or excision of the common bile duct. Am J Pathol 1957;33.13-27 13. Yamauchi H, Koyama K, Otowa T, Ouchi K, Anezakl T, Sato T Morphometric studies on the rat liver in biliary obstruction Tohoku J Exp Med 1976; 119:9-25. 14. Aronsen KF. Liver function studies during and after complete extrahepatic biliaty obstruction in the dog. Acta Chir Stand 1961;275:Suppl I-114. 15 Hansson JA, Hoevel J, Simert G, Tylen U, Vang J. Clintcal aspects of nonsurgical percutaneous transhepatic bile drainage in obstructive lesions of the extrahepatic bile ducts. Ann Surg 1979; 18958-6 1, 16 Recant L. Diminished ketogenesis in liver injury. J Lab Clin Med 1956;48:165-70.
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Bile duct proliferation and hepatic fibrosis after cholestasis are typical findings in patients with obstructive jaundice, which is associated with deterioration of liver function and decreased metabolism of several substances that cause hepatic failure [1,2]. Hepatic impairment caused by biliary obstruction may be improved by relief of the obstruction. We have obtained good operative results in jaundiced patients with pancreaticoduodenal cancer by performing a two stage procedure consisting of external biliary drainage as the first operation, followed by radical operation after improvement of jaundice [3]. This report presents the results of experimental and clinical investigations on hepatic functional improvement after relief of biliary obstruction. Material
and Methods
In experimental studies, obstructive jaundice was induced in mongrel male dogs weighing 15 to 20 kg by ligating and dissecting the common bile duct. Animals were divided into three groups in which biliary obstruction was released by means of’cholecystogastrostomy after 4,6 and 12 weeks of biliary obstruction. Each group consisted of three dogs. Blood and approximately 5 g of liver tissue were sampled for examination at the time of cholecystogastrostomy, 3 and ‘7weeks after operation. Clinical studies were carried out in six patients with pancreaticoduodenal cancer with obstructive jaundice; three of the patients had had jaundice for less than 2 months and three for more than 2 months. Blood and liver tissue were sampled for investigation at the time of the first stage operation (external cholecystostomy) and at the second stage operation (pancreaticoduodenectomy or choledochojejunostomy), performed 4 or 6 weeks after the first stage operation. Serum hilirubin. glutamic oxalacetic transaminase, glutamic pyruvic transaminase, alkaline phosphatase, plasma protein content, and albumin content were measured in both experimental and clinical cases. The plasma disappearance rate of indocyanine green was measured in the clinical cases. Liver specimens obtained from dogs and patients with obstructive jaundice were used for biochemical and histologic studies as follows. From the Department of Surgery, Tohoku University School of Medlclne. Sendal. Japan This IS the sixth report of a senes of studies on obstructwe jaundice Requests for reprints should be addressed to Toshlo Sate, MD, Department of Surgery. Tohoku University School of Medicine, l-l Seryo-cho, Sendal. Japan
Volume 142, August 1981
Mitochondrial respiratory function: Mitochondria were fractionated by Hogeboom and Schneider’s method [4], and the mitochondrial respiratory curve, using succinate as a substrate, and recorded polarographically with a Hagihara’s oxygen consumption meter [5] as reported previously [6]. The respiratory control ratio, adenosine diphosphateloxygen ratio, oxygen consumption rate of state 3 respiration (respiration under the existence of respiratory substrate and adenosine diphosphate) and adenosine triphosphate synthesis were calculated from the mitochondrial respiratory curve. Activities of latent adenosine triphosphatase and dinitrophenol-stimulated adenosine triphosphatase in mitochondria were measured and their ratio (activation ratio of adenosine triphosphatase) was calculated. Ketogenesis of the liver: As reported previously, the liver specimens were sliced with a thickness less than 0.5 mm and were incubated in Eagle’s minimal essential medium (Nissui Seiyaku Co., Ltd., Tokyo) containing 10 pmol of sodium n-butyrate as a substrate for 2 hours. Ketogenesis was determined by measuring the increment of the ketone bodies in the medium [1,7]. Biochemical study of fibrosis of the liver: Liver slices were also incubated in minimal essential medium containing carbon-14 proline. The content of hepatic collagen was determined by Wossner’s method [8] and its synthetic activity was determined by means of a liquid scintillation counter as incorporation of proline into hydroxyproline. These details were reported previously [9].
Results Experimental Studies Standard liver function tests: Total plasma bilirubin, glutamic pyruvic transaminase and alkaline phosphatase reached maximum levels after 1 or 2 weeks of biliary obstruction and plateaued thereafter, whereas these values decreased rapidly after release of biliary obstruction (Figure 1). Although total bilirubin returned to a normal level 3 weeks after release of the obstruction, reduction of alkaline phosphatase and glutamic pyruvic transaminase was modest. However, plasma protein and albumin levels, which decreased markedly with the prolongation of biliary obstruction, decreased continuously after release of the obstruction. Histologic changes in the liver: Details of the histologic changes in the liver will he reported else293
Koyama et al
2000 Al-f?
(King- Armstrong
unit
I
1000 -
500 -
100 -
50 -
P I
10 Cont rol
I
7w
3w
Siliary sbstruction
Biliarf ,bstructlon
After
relief
of biliar?
obstruction
obstruction
16.0 Total Rilirubin (mg/dl
i
14.0 -
12.0 -
\ _,
10.0 -
\ 8.0 -
$ Cant roi
t <,
1.0 1
where. In brief, there was evidence that distinct cholestasis, proliferation of bile ducts and fibrosis due to biliary obstruction were improved by relief of the obstruction (Figure 2). Mitochondrial respiratory function: Various parameters of mitochondrial function are illustrated in Figure 3. In a group of dogs with biliary obstruction for 4 weeks, a tendency toward improvement in the respiratory control ratio was found 3 weeks after release of the obstruction, recovering to 80 percent of control values after 7 weeks. A group with biliary obstruction for 6 weeks did not show significant improvement 3 weeks after release of the obstruction, but these values improved significantly after 7 weeks. In contrast, recovery of the respiratory control ratio after relief of biliary obstruction lasting for 12 weeks
294
Figure 1. Liver function tests in dogs during biliary obstruction and afterits relief (mean value in three dogs f standard deviation). Squares indicate control values; circles, triangles and x’s indicate billary obstruction for 4, 6 and 72 weeks, respectively. a = significant (p <0.05) 3 or 7 weeks after relief versus before relief; b = signlflcant (p < 0.05) 7 weeks after relief versus 3 weeks alter relief; c after 6 or 72 = significant (p <0.05) weeks of blliary obstruction versus 4 weeks of billary obstruction; d = signlficant (p < 0.05) after 72 weeks of biliary obstruction versus 6 weeks of biliary obstruction. AI-P. = alkallne phosphatase; GPT = gkdamfc pyruvic transaminase; W = weeks.
was slight and showed significantly lower levels than with 6 weeks of biliary obstruction. In the adenosine diphosphateloxygen ratio and adenosine triphosphate synthesis, almost the same degree of improvement was found after relief of obstruction, but it was very slight in the oxygen consumption rate of state 3 respiration particularly in the groups with obstruction for 6 and 12 weeks. The adenosine triphosphatase activation ratio (latent adenosine triphosphatase/dinitrophenol stimulated adenosine triphosphatase) is illustrated in Figure 4. In groups with biliary obstruction for 4 and 6 weeks, this ratio was elevated moderately and returned to almost control values after release of the obstruction. However, the ratio became markedly elevated in a group with 12 weeks of obstruction and did not return to the control value after release of the ob-
The American Journal of Surgery
Biliary Drainage in Obstructive Jaundice
Figure 2. Histologic findings in the dog liver. Left, after 6 weeks of biiiary obstruction; right, 7 weeks after relief of biiiary obstruction in the same dog. (Hemafoxyitn-eosin stain; magnified X400, reduced 23 percent.)
2.C l-
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I Figure 3. Parameters of mitochondriai function in the dog liver during biiiary obstruction and after its relief (mean value in three dogs f standard deviation). ATP = adenosine triphosphate; P/O = adenosine diphosphateloxygen ratio: RC = respiratory control ratio; S, = oxygen consumption rate of stage 3 respiratkm. Other abbreviations and symbols as in Figure 1.
Volume
142,
August 1981
Cont ml
After relief obstruction
of biliary
ATPsynthesis
S3 (natomslmg
7w
3w
Biliary obstruction
(nmoles/mg
prot./min)
prot./minl
60
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(
7w of biliary
295
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ATPase, Actwatmn ratlo (%
1 Ketogenesis i~moles/lOOmgllver/2hri I-
,-
(3) Bilmry >bstructlon
13) (31 7w 3w After rehef of bkw obstruction
( I
1500 “C
Hydroxyproline (/Ig/g hver)
Hydroxyprolme
1000 -
X X
500 P
I51 Cont rol ’
struction, but rather remained close to the values of the groups with 4 and 6 weeks of biliary obstruction. Ketogenesis of the liver: The synthetic ability of ketone bodies decreased markedly after biliary obstruction in some of the experimental animals (Figure 4). There was no significant improvement in ketogenesis after release of the obstruction. Hepatic fibrosis: Content of hydroxyproline and the synthetic ability of collagen in the liver are illustrated in Figure 4. The content of hydroxyproline increased in biliary obstruction and gradually decreased after the release of the obstruction, nearly reaching the control value after 7 weeks. The incorporation of carbon-14 proline into hydroxyproline in the liver with biliary obstruction increased to approximately 10 times the control value but decreased significantly after release of the obstruction and_returned to the control level after 3 weeks, even in animals with long-term obstruction.
296
obstruction
Flgure 4. Adenosine triphosphatase ( ATPase) actlvatkwt ratio in mltochondrial fraction, ketogenesis, collagen synthesis andcolkigencontentblhwsUcesofdcgs during b/Mary obstrucllon and after its relief. Numbers In parentheses btdlcate the number of experknental animals. Abbreviations and symbols as In Figure 1.
Clinical Studies Table I lists the results of investigation in patients with pancreaticoduodenal cancer who were classified as having either short- or long-term biliary obstruction. Similar to the experimental studies in the dog, clinical patients showed marked elevations of total bilirubin and alkaline phosphatase and marked reduction of indocyanine green values, although elevations in glutamic oxalacetic transaminase and glutamic pyruvic transaminase were slight. These changes in liver function tests did not correspond to the duration of biliary obstruction. Although these abnormalities improved after release of the obstruction, improvement of indocyanine green tended to proceed slowly. Figure 5 shows changes in liver function tests as well as mitochondrial function in a patient. While recovery of total bilirubin and alkaline phosphatase was rapid after release of the obstruction, that of indocyanine green was gradual. Pa-
The American Journal 01 Surgery
Biliary Drainage
in Obstructive
Jaundice
Bll 31 IX) AI-P
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fA) 60
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J
Flgure 5. Correlation of liver function tests and mltochondrlal fund/on In a 49 year old man with pancreatlcoduodenal cancer. Units as in Table 1. Numbers in boxes lndkate the respfratory control ratio/ adenoshe trlphosphate synthesis. GOT = g&tam/c oxalacetlc transaminase; ICGK = plasma disappearance rate of Indocyanlne green; T. Bll. = total bllkrrbht; other abbrevlatlons and symbols as In Flgure 1.
rameters of mitochondrial respiratory function decreased less markedly in patients with short-term biliary obstruction and showed marked improvement after relief of the obstruction. In contrast, severe mitochondrial respiratory dysfunction was evident in patients with long-term obstruction, improving only slightly 5 or 6 weeks after release of the obstruction. Both the synthesis of ketone bodies and the activation ratio of adenosine triphosphatase showed changes similar to those in experimental studies in dogs. The synthetic activity of hydroxyproline increased markedly in patients with jaundice and recovered promptly after release of the obstruction, particularly in patients with short-term biliary obstruction. On the other hand, the content of hydroxyproline tended to increase even after release of the obstruction in all patients except case 2.
Comments There have been many reports on hepatic dysfunction in obstructive jaundice [IO-121. We also investigated mitochondrial respiratory function, metabolism of short chain fatty acids and ammonia, fibrosis and morphologic findings in light and electron microscopy in rat liver with bihary obstruction [1,2,6,9,13]. On the other hand, there are only a few
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reports on the pathophysiology of the liver after relief of biliary obstruction [14,15]. In our investigation using dogs, the duration of jaundice and of the periods after its release were found to be similar to those frequently seen in man. In patients with pancreaticoduodenal cancer and jaundice, the same investigations were performed, and comparison was made between experimental and clinical data. It was found that hepatic mitochondrial respiratory function deteriorated in parallel with prolongation of biliary obstruction in dogs, as we reported previously [6] in experiments in rats. It was also observed that the degree of recovery after the relief of obstruction depended on both the duration of obstruction and of the period after relief of the obstruction. Mitochondrial respiratory inhibition is regulated not only by the concentration of toxic substances like bilirubin and bile acids but also by the period during which mitochondria exist in the unfavorable situation with cholestasis. It is unlikely that mitochondrial function recovers rapidly even if the toxic substances are removed after relief of biliary obstruction. Among the parameters of mitochondrial respiration, the oxygen consumption rate of state 3 respiration decreased easily in biliary obstruction and recovered slightly after its relief. Therefore, this change in the oxygen consumption rate of state 3 respiration was thought to cause a decrease in adenosine triphosphate synthesis. Ketogenesis in the substrate of short chain fatty acids was impaired by long-term obstruction and did not easily recover, which indicated that ketogenesis closely reflected reduced mitochondrial function. Since short chain fatty acids are also believed to be a cause of hepatic failure [16], their impaired metabolism in patients with prolonged obstruction is apt to induce hepatic failure even after relief of the obstruction. Considering the long-term prognosis for patients with obstructive jaundice, histologic findings in the liver, especially the degree of fibrosis, are important. After relief of the biliary obstruction, a decrease in collagen or at least a decrease in the rate of collagen synthesis could be expected biochemically and morphologically. The significance of standard liver function tests was also investigated since a simplified evaluation of liver function was desirable. In our experiments abnormalities in liver function tests were found to recover rapidly after release of the obstruction; most cases showed normal or near-normal values within 3 weeks after relief. However, as reported by Aronsen [14], decrease in serum protein and albumin content was found and recovery after relief of obstruction hardly occurred in our cases. The results of investigation in patients are fundamentally similar to those in the experimental studies except for the collagen content, which in-
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creased at the second operation in the clinical cases. Simultaneous histologic examination, however, revealed reduction of the area of fibrosis in the liver. This discrepancy may be explained by localization of the large amount of collagen in Glisson’s sheaths. Consequently, there was an increase in the hepatic parenchyma proportional to the biliary obstruction, which was thought to be an important factor in the improvement of liver dysfunction. Based on these results, the critical duration of biliary obstruction in which nearly complete recovery from hepatic damage can be obtained after release of obstruction must be discussed. In terms of standard liver function tests and histologic findings of the liver in dogs, Aronsen [I41 reported that the complete recovery of liver dysfunction could be obtained after a maximum of 2 weeks of obstruction, which was thought to be a critical duration. We believe, however, that the measurement of mitochondrial functions is more appropriate for the evaluation of liver function, because electron transport and respiration are coupled and adenosine triphosphate is produced in mitochondria. Twelve weeks of biliary obstruction was considered the critical duration in dogs, when not only the improvement of the mitochondrial function was extremely slow and slight, but recovery of ketogenesis and regression of hepatic fibrosis were insufficient after relief of the obstruction. The critical duration in man is thought to be analogous to these experimental findings. In clinical cases with poor recovery of mitochondrial function, there was little tendency for improvement in serum bilirubin and alkaline phosphatase levels. Aronsen [14] showed that the recovery of the sodium sulfobromophthalein retention rate was slow after release of the long-term obstruction, and we also found poor recovery of indocyanine green values, which are thought to reflect the slow recovery from liver damage associated with an unfavorable improvement of mitochondrial function. It is therefore presumed that the slow reduction in total bilirubin or alkaline phosphatase levels, or the delayed improvement of indocyanine green values after relief of the biliary obstruction, are critical signs of poor recovery of mitochondrial dysfunction. In recent years, instead of operative relief of biliary nonsurgical percutaneous biliary obstruction, drainage has been performed [15], followed by a radical operation such as pancreaticoduodenectomy. In order to perform this radical operation safely, the interval between external biliary drainage and operation should be as long as possible, during which time the improvement of mitochondrial function could be obtained. However, it is possible that the chance for curative operation may be lost due to the growth of tumors during the period. Consequently, it is so difficult to wait until mitochondrial function recovers completely that the radical operation should
The American Journal of Surgery
Biliary
be performed 4 to 6 weeks after biliary drainage, when mitochondrial functions apparently improve to 40 to 50 percent of the control values. However, in cases with jaundice lasting more than 12 weeks or with critical signs such as high glutamic oxalacetic transaminase and alkaline phosphatase and low indocyanine green values even after biliary drainage, the operation should be delayed until at least 6 weeks after biliary drainage. In patients in whom a curative operation appears impossible, it is desirable to perform the operation of palliative internal fistula after a long enough period for improvement of mitochondrial function. Moreover, to obtain fast and complete recovery from hepatic dysfunction after relief of biliary obstruction, further investigations into the various supplementary procedures including administration of drugs are required. Summary Mitochondrial respiratory function, ketogenesis and collagen metabolism of the liver in biliary obstruction and after its relief were investigated in dogs and patients with obstructive jaundice. In dogs, it was found that hepatic mitochondrial respiratory function decreased significantly with prolongation of biliary obstruction, but recovered to varying degrees depending on both the duration of obstruction and of the period after the relief of obstruction. Ketogenesis was also impaired by biliary obstruction and its recovery was found in a slight degree only in cases with short-term obstruction. Hepatic collagen content and the synthetic ability significantly increased in biliary obstruction, and returned to normal levels within a relatively short period after the relief. Analogous results were obtained in clinical cases, but the decrease in serum bilirubin was somewhat delayed and increased hepatic collagen content continued after relief of the obstruction. When major surgery is required in patients with obstructive jaundice, biliary drainage should be carried out first 4 to 6 weeks before the performance of major operations. In cases with biliary obstruction for 12 weeks or more, it is desirable to wait for more than 6 weeks
Volume 142, August 1981
Drainage
in Obstructive
Jaundice
after biliary drainage since recovery of hepatic function, especially mitochondrial function, will be extremely slow. References 1. Koyama K, Kashimura S, Yamauchi H, Takagi Y, Owada Y, Sato T. Metabolism of short chain fatty acid in rat liver in biliary obstruction. Tohoku J Exp Med 1975; 117:335-41. 2 Koyama K, Owada Y, Yamauchi H, Ito K, Watabe S, Sato T. Ammonia metabolism in the rat liver in biliary obstruction. Tohoku J Exp Med 1979; 127:379-87 3. Maki T, Sato T, Kakizaki G. Pancreatoduodenectomy for periampullary carcinomas. Appraisal of two-stage procedure. Arch Surg 1966;92:825-33. 4. Hogeboom GH, Schneider WC Isolation of intact mitochondria from rat liver. J Biol Chem 1948;172:619-30 5. Hagihara B Techniques for the applicatron of polarography to mitochondrial respiration. Biochim Biophys Acta 1961; 46: 134-42. 6. Koyama K, Ito K, Ouchi K, Matsubara S, Sato T Mitochondrial function of rat liver in biliary obstruction. Tohoku J Exp Med 1980;131:59-69. 7 Lyon JB, Bloom WL. The use of furfural for the determination of acetone bodies in biological fluids. Can J Biochem Physiol 1958;36,1047-56. 8. Wossner JF Jr. The determination of hydroxyproline in tissue and protein samples containing small proportions of this amino acid. Arch Biochim Biophys 1961;93:440-7. 9. Koyama K. Muto I, Yamauchi H, Takagi Y, Anezaki T, Sato T. Biochemical study of fibrosis in the rat liver in biliary obstruction. Tohoku J Exp Med 1975;116:161-72. IO. Cameron GR, Hasan SM. Disturbances of structure and function in the liver as the result of biliary obstruction. J Pathol Bacteriol 1958;75:333-49. 11 Ozawa K, Takasan H, Kitamura 0, et al. Alteration of liver mitochondrial metabolism in a patient with biliary obstruction due to liver carcinoma. Am J Surg 1973;126:653-7 12 Trams EG, Symenoidis A. Morphologic and functional changes in the livers of rats after ligation or excision of the common bile duct. Am J Pathol 1957;33.13-27 13. Yamauchi H, Koyama K, Otowa T, Ouchi K, Anezakl T, Sato T Morphometric studies on the rat liver in biliary obstruction Tohoku J Exp Med 1976; 119:9-25. 14. Aronsen KF. Liver function studies during and after complete extrahepatic biliaty obstruction in the dog. Acta Chir Stand 1961;275:Suppl I-114. 15 Hansson JA, Hoevel J, Simert G, Tylen U, Vang J. Clintcal aspects of nonsurgical percutaneous transhepatic bile drainage in obstructive lesions of the extrahepatic bile ducts. Ann Surg 1979; 18958-6 1, 16 Recant L. Diminished ketogenesis in liver injury. J Lab Clin Med 1956;48:165-70.
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