Preoperative Internal Biliary Drainage Is Superior to External Biliary Drainage in Liver Regeneration and Function After Hepatectomy in Obstructive Jaundiced Rats

Abstract

ObjectiveTo examine the differences in regeneration rates and functions of the liver at the time of and after hepatectomy in obstructive jaundiced rats with preoperative external and internal biliary drainage. Summary Background DataThe significance of biliary drainage before surgery is controversial in patients with obstructive jaundice. MethodsAfter biliary obstruction for 7 days, rats were randomly divided into three groups: obstructive jaundice and hepatectomy (OJHx), external biliary drainage and hepatectomy (ED-Hx), and internal biliary drainage and hepatectomy (ID-Hx). The OJ-Hx group underwent hepatectomy without biliary drainage; the other two groups underwent hepatectomy after biliary drainage for 7 days. At the time of hepatectomy, all rats were provided with internal biliary drainage. On days 0, 1, 2, 3, and 7 after hepatectomy, the DNA synthesis rate and the concentrations of adenine nucleotides and malondialdehyde in the liver were determined as markers of the hepatic regeneration rate, energy status, and lipoperoxide concentration, respectively. Portal endotoxin concentrations were measured and serum hyaluronic acid concentrations were determined as an indicator of hepatic endothelial function. ResultsThe relative liver weight was significantly higher in the ID-Hx group than in the OJ-Hx group on days 1, 3, and 7 after hepatectomy and than in the ED-Hx group on days 1 and 2. The rate of hepatic DNA synthesis was significantly higher in the ID-Hx group than in the OJ-Hx and ED-Hx groups on day 1. The rate was similar in the ED-Hx and ID-Hx groups on day 2 but was significantly higher than in the OJ-Hx group. The hepatic malondialdehyde concentration was significantly higher on day 1 in the ED-Hx group than in the other two groups. It was lowest in the ID-Hx group throughout the study. Both biliary drainage procedures lowered the portal endotoxin concentration and serum hyaluronic acid concentration at the time of hepatectomy. The serum hyaluronic acid concentration was lowest in the ID-Hx group. Hepatic adenine triphosphate concentrations and energy charge levels were similar among the three groups. ConclusionAlthough both external and internal biliary drainage before hepatectomy improved serum liver function tests, portal endotoxin concentration, and serum hyaluronic acid concentration at the time of surgery, preoperative internal biliary drainage was superior to external drainage, as evidenced by the better liver regeneration and function after hepatectomy.

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

“…34,39,40 In jaundiced rats undergoing hepatectomy, both external and internal PBD improved serum liver function tests; however, a better liver regeneration and function after hepatectomy was observed after internal drainage. 41 A negative side-effect of biliary drainage is the associated complications of the procedure itself. In dogs, insertion of biliary endoprostheses resulted in bile contamination and severe chronic inflammation of the bile duct.…”

“…[61][62][63] As mentioned earlier, animal studies concerning PBD are convincing in terms of complication reduction; clinical studies report conflicting results. [64][65][66][67] Two randomized controlled trials, in which a PBD strategy was compared to early-surgery strategy in jaundiced patients, including patients with proximal lesions, did not display a difference in perioperative mortality; however, they encountered a high rate of PBD-procedure-related complications. 68,69 Cautious interpretation is warranted as these studies used outdated techniques; included a variety of causes of biliary obstruction; and, moreover, comprised only a limited number of patients with proximal CCA.…”

Preoperative Biliary Drainage before Resection in Obstructive Jaundice

“…Restoration of bile into the normal enterohepatic circulation resulted in reduced rates of postoperative death [8], endotoxaemia [9], and renal impairment [10], more rapid recovery of cell-mediated immunity [11], and better regeneration rate of liver cells after hepatectomy [12]. …”

Percutaneous management of malignant biliary disease: factors that influence ability to overcome the stricture.

“…The major aims of percutaneous management are to direct the bile into the small intestine to achieve a drainage resembling normal physiological drainage and to maintain a normal enterohepatic circulation (3,4). In previous experimental studies in rats, improved liver function and nutritional status, reduced systemic endotoxemia and improved immunity have been observed with internal biliary drainage as compared to external biliary drainage or non-biliary drainage (13)(14)(15)(16)(17)(18)(19)(20). It is not easy to cross biliary obstructions in all patients.…”