Thirty-six years' experience with elective therapeutic portacaval shunt for bleeding esophagogastric varices due to cirrhosis

Thirty-six years' experience with elective therapeutic portacaval shunt for bleeding esophagogastric varices due to cirrhosis

A1236 SSAT ABSTRACTS • MULTIPLE ORGAN CYTOKINE GENE EXPRESSION INDUCED BY ACUTE PANCREATITIS. J Norman. G Fink_ G Carter, A Rosemur~,v. M ~ . Dept o...

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A1236

SSAT ABSTRACTS

• MULTIPLE ORGAN CYTOKINE GENE EXPRESSION INDUCED BY ACUTE PANCREATITIS. J Norman. G Fink_ G Carter, A Rosemur~,v. M ~ . Dept of Surgery, University of South Florida, Tampa, FL. Pro-inflammatory cytoklnes are elevated during acute pancreatitis and have been implicated in the progression of pauereatifis-assoeiated multiple organ dysfunction. Where these mediators are produced, however, is not known. This study was designed to examine pro-inflammatory eytokine gena expression in organs affected during panereatitis in order to investigate their role in propagating pancreatitis and multi-organ failure. Methods. Acute necrotizing pancreatitis was induced in adult male mice by IP injection of eaerulein (50 ~g/kg/hr x 4). Control mice received IP saline. Nine animals were sacrificed by exsanguination at 0, 0.5, 1, 2, 4, and 6 hours after the first caerulein injection. The pancreas, lungs, liver, kidneys, spleen, and gastroeaemius muscle were rapidly excised from all animals and prepared for mRNA and protein determination. The severity of pancreatitis was established by histologis grading and serum amylase and lipase. Serum IL-1, IL-6, and TNF-~ were determined by ELISA. The appearance of tissue cytoldnes was examined by Western blot analysis. Tissue cytokine mRNA was determined by rtPCR. Results. Caerulein injection was associated with histologie evidence of acute pancreatitis and elevation of serum amylase and lipase within the first hour (both p < 0.05 vs time 0; Student's t test), with the severity increasing through hour 6. There was no cytokine mRNA or protein detectable within serum, pancreas, liver, kidney, and muscle tissues prior to the induction of pancreatitis. TNF-~ mRNA was detected within the pancreas within one hour following the onset of panereatitis, with IL-1 and IL-6 mRNA appearing one and two hours later, respectively. The spleen demonstrated low constitutive expression of IL-1 and TNF-¢ n'LRNAwhich increased significantly by hour four (p<0,05). IL-1 and TNF-,~ mRNA became detectable within the lung and liver during the fourth hour ofpancreatitis with IL-6 mRNA following 2 hours later. Kidney and muscle failed to express cytokine mRNA at all times. Concomitant with mRNA prodnetion was the elevation of tissue levels of all three cytokines, detectable first within the pancreas, and then subsequently within the lung and liver (all p<0.05 vs Control). Similarly, IL-1, IL-6 and TNF-~ appeared in the serum beginning at hour 2 and increased through hour 6 (all p<0.005 vs Control). Conclusions. Pro-inflammatory cytokines are produced within the pancreas and within organs developing dysfunction during severe acute pancreatitis. The production of these cytokines appears to occur first within the pancreas and subsequently at distant sims. Serum IL-1, IL-6, and TNF-~z which correlate with pancreatitis severity are a result of systemic production at many sites.

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SELECTIVE DO~GULATION OF G L U T A M I N E T R A N S P O R T AFTER JEJUNOILEAL AUTOTRANSPLANTATION. A.J. Oishi*, Y. Inoue#, W.W. Scuba#, M.G. Sarr*. Dept. of Surgery, M a y o Clinic, Rochester, MN* and M a s s a c h u s e t t s G e n e r a l Hospital, Boston, MAt. Gut t r a n s p l a n t a t i o n is c o m p l i c a t e d by w e i g h t loss a n d diarrhea. L i t t l e is known, however, about a b s o r p t i o n of glutamine, an i m p o r t a n t s u b s t r a t e for e n t e r o c y t e metabolism. Aim: To d e t e r m i n e ileal t r a n s p o r t of g l u t a m i n e iF vitro a n d in v i v o a f t e r intestinal transplantation. Methods: B r u s h - b o r d e r m e m b r a n e v e s i c l e s (BBMV) from the ileum of 6 d o g s b e f o r e and 2 and 8 w k a f t e r a m o d e l of j e j u n o i l e a l a u t o t r a n s p l a n t a t i o n w e r e c o m p a r e d to 6 o p e r a t e d c o n t r o l s who had p r o x i m a l a n d distal small bowel t r a n s e c t i o n and r e a n a s t o m o s i s to c o n t r o l for d i s r u p t i o n of e n t e r i c neural continuity. U s i n g a rapid mixing/ f i l t r a t i o n technique, c a r r i e r - m e d i a t e d transport of 100~M 3H-L-glutamine, g l u c o s e and other amino acids was assayed. In 6 other dogs, ileal absorption of g l u t a m i n e w a s d e t e r m i n e d in v i v e before and at 2 and 8 w k a f t e r this m o d e l u s i n g a triple lumen t e c h n i q u e w i t h i s o s m o l a r e l e c t r o l y t e solut i o n c o n t a i n i n g 20 m M glutamine. Results: D i a r r h e a o c c u r r e d a f t e r this model of jejunoileal autotransplantation. B B M V t r a n s p o r t of g l u t a m i n e (but not glucose) d e c r e a s e d at 2 w k and remained d e c r e a s e d at 8 w k (113±6 vs 82±4 a n d 92±5 pmol/mg p r o t e i n / 1 0 sec, resp; each p<0.05) s e c o n d a r y to a d e c r e a s e in V~x b u t n o t ~ . A b s o r p t i o n of w a t e r and e l e c t r o l y t e s d e c r e a s e d at 2 w k b u t returned to b a s e l i n e at 8 wk. G l u t a m i n e a b s o r p t i o n in vivo d e c r e a s e d at 2 and 8 w k (185±20 vs 121±27 and 151±22 ~mol/cm/min, resp; pc0.06; ANOVA). Conclusions: J e j u n o i l e a l a u t o t r a n s p l a n t a t i o n downr e g u l a t e d c a r r i e r - m e d i a t e d g l u t a m i n e transport and in v i v o g l u t a m i n e a b s o r p t i o n (but not glucose) by d e c r e a s i n g the n u m b e r of transporters and not by c h a n g i n g t r a n s p o r t e r affinity. This e f f e c t a p p e a r s to be m e d i a t e d by e x t r i n s i c denervation. Support: N I H DK39337 (MGS).

GASTROENTEROLOGY, Vol. 1 0 8 , No. 4

THE INCREASED PRODUCTION OF INFLAMMATORY CYTOKINES BY DIFFERENT POPULATIONS OF ENTEROCYTES A F T E R T H E R M A L INJURY. C.K. Oqle,PhD., J. Mao,MD,

P-O H a s s e l q r e n , M D , P h D , J.W. A l e x a n d e r , M . D . , S c . D . U n i v e r s i t y of Cincinnati, D e p a r t m e n t of Surgery and Shriners Burns Institute, Cincinnati, Ohio. Purpose: To d e t e r m i n e if d i s t i n c t p o p u l a t i o n s of normal and burn enterocytes respond d i f f e r e n t l y to s t i m u l a t i o n w i t h LPS. Methods: G u i n e a p i g s r e c e i v e d a 30% flame b u r n and w e r e sacrificed 24 hours after injury. Three populations of e n t e r o c y t e s w e r e o b t a i n e d b y 3 extractions with EDTA (designated Fraction I (closest to the lumen), II, and III). The cells w e r e i n c u b a t e d w i t h LPS (10~g/ml) for 24 hours and s u p e r n a t a n t s w e r e a n a l y z e d for IL-I and IL-6. Cell a s s o c i a t e d (ca)TNF w a s also d e t e r m i n e d since supernatant TNF values were negligible. Statistics: A N O V A (one b e t w e e n a n d two within) followed b y N e w m a n Keulls s i g n i f i c a n c e at p<0.05. Results (Values in u/ml):

Fraction Units/ml

TNF(ca)

I -LPS

+ LPS

II -LPS

NO.15(a) O.30(a) 0.72

III

+ LPS

-LPS

+ LPS

0.46(a)

1.04

2.80(a)

B 0.42

3.74

0.88

2.98

1.81

14.2(b)(c)

IL-1

N 232

268

184

289(a)

2

987(c}

B 318 N8.12

596 441 688 8.70(a} 6.15(a} 9.38

471

1,371(b}(c)

IL-6

10.71(al 12.22(a)

B 10.7 16.1 12.7 13.2 14.1 19.7(b}(c) S i g n i f i c a n t differences: (a) n o r m a l N vs b u r n B; (b) -LPS vs +LPS; (c) fraction I vs II vs IlI. Conclusions: E n t e r o c y t e s furthest from the lumen (fraction III) p r o d u c e d m o r e IL-I in r e s p o n s e t o LPS b e f o r e or after and m o r e TNF a n d IL-6 after thermal injury. T h e r m a l injury p r i m e d enterocytes to p r o d u c e m o r e TNF, IL-I, a n d IL-6 in r e s p o n s e to LPS. The increase in cell a s s o c i a t e d TNF after thermal i n j u r y c o u l d l e a d to i n c r e a s e d c y t o t o x i c i t y for enterocytes. The gut has the potential to become a potent source of i n f l a m m a t o r y c y t o k i n e s after thermal injury.

THIRTY-SIX YEARS' EXPERIENCE WITH ELECTIVE THERAPEUTIC PORTACAVAL SHUNT FOR BLEEDING ESOPHAGOGASTRIC VARICES DUE TO CIRRHOSIS. M,J. 0rloff. M.S. Orloff, S,L. Orloff. M. Rambotti B. Girard. Department of Surgery, UCSD Medical Center, San Diego CA. Since 1958 we have performed elective therapeutic portacaval shunt (PCS) (side-to-side in 92%, end-to-side in 8%) in 824 patients with biopsy-proven cirrhosis (alcoholic in 89%) who were usually referred to us from other hospitals after they recovered from bleeding esophagogastric varices (BEV). All patients have had at least 5 yr of follow-up. Age ranged from 27-79 yr, 67% were male, and 55% had had >i bleeding episode. Quantitative Child's risk classes were A-10%, B-58%, C-32%. BEV were proven in all patients by endoscopy and/or contrast radiography. Incidence of serious risk factors on admission or in past history was: ascites 62%; jaundice 55%; severe muscle wasting 40%; encephalopathy 33%; hyperdynamic state (CO~6L/min) 78%; past delirium tremens 15%. Mean PV-IVC pressure gradient (ram saline) pre-PCS was 251 and post-PCS was 22. Mean operative blood transfusions was 2.2u, and mean operative time was 3,2 hr (96%~4 hr). Survival to leave the hospital was 98.4% (operative mortality 1.6%). SuhseQuent survival rates were: i yr 95%, 5 yr 68%, i0 yr (actuarial) 62%, 15 yr (actuarial) 57%. Continued alcoholism caused 2/3 of the deaths. Encephalopathy occurred transiently in 10% and recurrently in 7%, compared to 33% pre-shunt. Long-term shunt patency was 99.6% by angiography and/or Doppler ultrasonography every 1-2 yr. Only 3 patients (0.4%) had recurrent varieeal bleeding, all due to shunt occlusion. 62% abstained from alcohol, and 89% of the abstainers survived 5 yr. LFT after 1 yr were improved in 72%, unchanged in 21%, and worse in only 7%. 67% resumed fullor part-time work. Conclusion: In the largest and longest experience reported to date, elective therapeutic PCS for BEV resulted in prolonged survival and life of satisfactory quality in 2/3 of cirrhotic patients. Liver transplantation is being done with increasing frequency in bleeding alcoholic cirrhotics who practice abstinence, but PCS in abstainers results in substantially greater 5-yr survival (89%), with much lower morbidity and cost.