ArticlePDF Available

The effect of immunonutrition on bacterial translocation after Pringle maneuverer in rats

Authors:
  • TC SAĞLIK BAKANLIĞI SAKARYA EĞİTİM VE ARAŞTIRMA HASTANESİ

Abstract

Introduction: Temporary clamping of the hepatoduodenal ligament (the Pringle manoeuvre) is the most commonly used method to prevent intraoperative blood loss in liver surgery. Some side effects of the Pringle manoeuvre (PM) can occur. Aim: To investigate the effectiveness of preoperative immunonutritional support to prevent bacterial translocation (BT) in rats due to PM. Material and methods: Forty Wistar albino rats were randomly divided into four groups. Groups 1 and 2 were fed with normal rat diet and water, and groups 3 and 4 were fed with enteral immunonutrition (Impact Glutamine) containing 1 g/kg/day amino acid in the preoperative period. Group 1 (n = 10) and 4 (n = 10) rats were treated only with laparotomy; group 2 (n = 10) and 3 (n = 10) rats were treated with PM for 30 min with laparotomy. After 30 min, relaparotomy was applied to all groups and portal blood, mesentery, spleen samples were taken for culture purposes. Results: Proliferation in portal blood cultures was significantly higher in the samples from the normally fed group (group 2) in whom PM was applied, compared to the other groups (p < 0.001). No proliferation was observed in the PM-treated group (group 3), who also received preoperative immunonutritional support. Conclusions: Preoperative immunonutritional support is effective in the prevention of BT due to PM in rats.
Original paper
The effect of immunonutrition on bacterial
translocation after Pringle maneuverer in rats
Ozkan Subasi1, Selim Yigit Yildiz1, Adem Yuksel2, Murat Coskun1, Hamdi Taner Turgut1, Eda Yildiz3
1Department of General Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
2Department of Gastrointestinal Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
3Department of Clinical Microbiology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
Gastroenterology Rev 2019; 14 (3): 178–182
DOI: https://doi.org/10.5114/pg.2019.88166
Key words: immunonutrition, Pringle manoeuvre, bacterial translocation.
Address for correspondence: Ozkan Subasi MD, Department of General Surgery, Kocaeli Derince Training and Research Hospital,
41900 Kocaeli, Turkey, phone: +90 262 317 80 00/+90 505 384 21 09, fax: +90 262 233 46 41, e-mail: osubasi25@hotmail.com
Abstract
Introduction: Temporary clamping of the hepatoduodenal ligament (the Pringle manoeuvre) is the most commonly used
method to prevent intraoperative blood loss in liver surgery. Some side effects of the Pringle manoeuvre (PM) can occur.
Aim: To investigate the effectiveness of preoperative immunonutritional support to prevent bacterial translocation (BT) in
rats due to PM.
Material and methods: Forty Wistar albino rats were randomly divided into four groups. Groups 1 and 2 were fed with nor-
mal rat diet and water, and groups 3 and 4 were fed with enteral immunonutrition (Impact Glutamine) containing 1 g/kg/day
amino acid in the preoperative period. Group 1 (n = 10) and 4 (n = 10) rats were treated only with laparotomy; group 2 (n = 10)
and 3 (n = 10) rats were treated with PM for 30 min with laparotomy. After 30 min, relaparotomy was applied to all groups and
portal blood, mesentery, spleen samples were taken for culture purposes.
Results: Proliferation in portal blood cultures was significantly higher in the samples from the normally fed group (group 2)
in whom PM was applied, compared to the other groups (p < 0.001). No proliferation was observed in the PM-treated group
(group 3), who also received preoperative immunonutritional support.
Conclusions: Preoperative immunonutritional support is effective in the prevention of BT due to PM in rats.
Introduction
In liver surgery, the most important factors affecting
morbidity and mortality are intraoperative blood loss
and septic complications [1]. Various techniques have
been used to prevent intraoperative blood loss. The old-
est and most commonly used of these techniques is the
Pringle manoeuvre (PM). The PM was first discovered in
1908 by J.H. Pringle, and it was proven that temporary
clamping of the hepatoduodenal ligament reduces in-
traoperative blood loss [2]. The PM causes portal, super-
ficial, and inferior mesenteric venous stasis, which leads
to a decrease in splanchnic blood flow [3]. Experimental
studies have shown that splanchnic hypoperfusion sec-
ondary to the PM causes intestinal mucosal injury and
bacterial translocation (BT) [4–7]. Intestinal mucosal in-
jury and BT have been shown to be predisposing factors
in the development of serious clinical conditions after
trauma, major surgery, and shock, such as sepsis, and
multiorgan failure [8, 9].
Immunonutrition is a nutritional product containing
high energy and protein, enriched with certain nutri-
ents, mostly arginine, glutamine, omega-3 fatty acids,
and nucleotides. The use of these products 5–7 days
prior to various surgical procedures has been shown
to reduce postoperative infectious complications [10].
It has also been shown to reduce BT in experimental
obstructive jaundice and intestinal obstruction models
[11, 12].
Aim
In this study, it was planned to investigate the ef-
fects of preoperative immunonutritional support against
development of BT due to PM, which is commonly used
in liver surgery.
Creative Commons licenses: This is an Open Access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 4.0 International (CC BY -NC -SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/).
179
The effect of immunonutrition on bacterial translocation after Pringle maneuverer in rats
Gastroenterology Review 2019; 14 (3)
Material and methods
The study protocol was made with the approval of
Kocaeli University Experimental Animal Ethics Commit-
tee. Forty Wistar albino rats weighing 200–250 g were
used in the study. Rats were housed in a 12-hour light/
dark cycle at constant temperature in accordance with
the standards of the National Institutes of Health Pub-
lication Guide for the Care and Use of Laboratory Ani-
mals (NIHPGC). Rats were randomly sampled and divid-
ed into four groups with 10 rats in each group (Table I).
All groups were fed for 5 days according to their charac-
teristics. Groups 1 and 2 were fed with standard rat diet
and water, and groups 3 and 4 were supplemented with
1 g/kg/day amino acid containing enteral nutritional
supplement (22% protein, 51% carbohydrate, 24% fat,
also containing L-arginine 14 g/l, L-glutamine 10 g/l)
and fed with a paediatric orogastric feeding probe in
addition to standard rat diet and water.
Surgical procedure
All subjects, kept under standard laboratory condi-
tions, were allowed to drink water while being fasted
on the day of operation at the end of the fifth day. An-
aesthesia was induced by administering intramuscular
100 mg/kg ketamine hydrochloride and 10 mg/kg xyla-
zine hydrochloride combination to all subjects in the
group.
After anaesthesia, the anterior abdominal wall was
cleansed with povidone-iodine and then the hepato-
duodenal ligament was released by exploration of the
abdomen through a 2 cm upper abdominal incision, as
standard. The hepatoduodenal ligament was occlud-
ed for 30 min in the subjects of groups 2 and 3 using
a vascular clamp. At the end of 30 min, reperfusion was
provided, and the sac was closed with 3/0 Vicryl. The
hepatoduodenal ligament was explored with laparoto-
my in group 3 and 4 subjects. After 30 min of waiting,
the abdomen was closed with 3/0 Vicryl. All subjects in
the groups underwent relaparotomy 30 min after the
closure of the abdomen. The portal vein was cannulated
with a gauge catheter and a 2-ml blood sample was
taken. Samples from the spleen and terminal ileum
were taken for microbiological examination. All surgical
procedures were performed using sterile instruments
in aseptic conditions. After the procedure, the rats were
sacrificed by cardiac incision.
Microbiological analysis
Microbiological analyses of the study were carried out
in Kocaeli Derince Training and Research Hospital Micro-
biology Laboratory. During microbiological analysis, tissue
samples from the meso of small intestine were placed in
sterile tubes containing 2 ml Brain Heart Infusion Broth
(RTA Laboratories, Turkey). After homogenisation, direct
seeding was carried out for qualitative evaluation and for
quantitative evaluation, 100 µl was inoculated into 5%
Sheep Blood Agar (RTA Laboratories, Turkey ) and Eosine
Metilen Blue Agar (RTA Laboratories, Turkey), and then
the plates were incubated for 24 h at 37°C. Incubation of
plates without reproduction was extended to 48 h. Tissue
samples taken from the spleen were collected into sterile
tubes with 2 ml Brain Heart Infusion Broth (RTA Labora-
tories, Turkey). After homogenisation, direct seeding was
carried out for qualitative evaluation and for quantitative
evaluation, 100 µl was inoculated into 5% Sheep Blood
Agar (RTA Laboratories, Turkey) and Eosine Metilen Blue
Agar (RTA Laboratories, Turkey), and then the plates were
incubated for 24 h at 37°C. Incubation of plates without
reproduction was extended to 48 h. Two-millilitre blood
samples taken from the portal vein were incubated in
a BacT/ALERT®3D (bioMERIEUX, France) automated blood
culture device after being inoculated into BacT/ALERT®3D
(bioMERIEUX, France) blood culture bottles.
Reproducible microorganisms were identified by
a VITEK®2Compact (bioMERIEUX, France) automated
identification and antibiogram instrument.
Statistical analysis
Statistical evaluation was performed with IBM SPSS
20.0 (SPSS Inc., Chicago, IL, USA) package programme.
Categorical variables were given as frequencies (per-
centages). Differences between groups were assessed
by Monte Carlo c2 analysis. P < 0.05 was considered
sufficient for statistical significance in two-way tests.
Table I. Groups (n = 10)
Group Preoperative feeding (5 day) Operation
1 Standard rat diet Laparotomy
2 Standard rat diet Laparotomy + PM
3 Standard rat diet + enteral nutritional supplement Laparotomy + PM
4 Standard rat diet + enteral nutritional supplement Laparotomy
PM – Pringle manoeuvre.
180 Ozkan Subasi, Selim Yigit Yildiz, Adem Yuksel, Murat Coskun, Hamdi Taner Turgut, Eda Yildiz
Gastroenterology Review 2019; 14 (3)
Results
During the experiment, all subjects tolerated the
intervention, and no subjects were lost within the
estimated period or left out of the study. Growth in
blood cultures were detected in three samples (30%)
of group 2 (standard feed + PM), while no growth was
detected in the other groups. In the statistical analy-
sis of all groups, the proliferation in blood cultures of
group 2 was statistically higher than in the other groups
(p < 0.001) (Table II). All of the proliferation in blood
cultures occurred within the first 48 h after inoculation.
Enterococcus faecalis growth was seen in two samples
of portal vein culture of group 2 and Leuconostoc pseu-
domesenteroides growth was seen in one sample (Fig-
ure 1).
Growth in mesenteric lymph node specimens was
10% in group 2, and no growth was observed in other
groups (Figure 2). When compared with other groups,
there was no statistically significant difference, but
there was a proliferation in group 2 (p = 1.00). Entero-
coccus faecalis had proliferated in the mesenteric lymph
node samples of a rat from group 2. No spleen samples
were found to have any growth; no statistical compari-
son was made for this reason.
Discussion
BT is defined as the passage of microorganisms or
their products (endotoxin), which are localised in the
intestinal organs to extraintestinal areas that are nor-
mally sterile, such as mesenteric lymph nodes, other in-
testinal organs, and bloodstream, by crossing the intes-
tinal mucosal barrier [13]. There are different opinions
about the clinical importance of BT. There are opinions
suggesting that BT can be considered as a physiolog-
ical event in normal healthy individuals [14]. Howev-
er, contrary to this view, O’Boyle et al. [15] conducted
a study in which BT was found in 15% of patients un-
dergoing laparotomy, and 45% of the patients with BT
had postoperative sepsis, which was reported to be 19%
in the group without translocation. In addition, other
studies supporting this view have reported that BT is
a predisposing factor in the development of postoper-
ative infectious complications in patients undergoing
major abdominal surgery [16, 17].
PM, which is commonly used for intraoperative
bleeding control in liver surgeries, has been shown to
lead BT in mesenteric lymph nodes and portal blood
specimens in various experimental and clinical studies
[18–21]. Our study also showed that PM causes bacte-
rial growth in portal blood and mesenteric tissue cul-
tures in rats. Although there is sufficient information in
the literature about the clinical conditions that cause
BT, information about the anatomic pathway (lymphat-
ic-hematogenous) that is effective in BT development
and when it first developed is insufficient [22]. In our
study, it was observed that there was growth in more
rats in the portal blood cultures taken at the first hour
after PM application, compared to the mesenteric cul-
ture samples. In a study done to explain the anatomic
pathway in BT, it was shown that portal blood cultures
in the early period had a higher rate of growth than
mesenteric cultures, and the hematogenous pathway
was the main pathway of BT [23].
Table II. Distribution of microorganism species isolated from blood cultures
Microorganism species Group 1 Group 2 Group 3 Group 4
Enterococcus faecalis 0 2 (20%) 0 0
Leuconostoc pseudomesenteroides 0 1 (10%) 0 0
1 2 3 4
Group
Figure 1. Blood culture
1 2 3 4
Group
Figure 2. Mesenteric lymph node culture
3.0
2.5
2.0
1.5
1.0
0.5
0
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
181
The effect of immunonutrition on bacterial translocation after Pringle maneuverer in rats
Gastroenterology Review 2019; 14 (3)
There are few experimental studies to prevent BT
after PM. In these few experimental studies, it has been
shown that the use of prophylactic antibiotics, preoper-
ative bowel cleansing, and the use of low-dose dexa-
methasone prevent BT after PM [18, 24].
It has been reported that the use of enteral immu-
nonutrition products containing glutamine, arginine,
nucleotide, and omega-3 fatty acids in different combi-
nations and doses prior to surgery regulates the inflam-
matory response in the early period and strengthens
the immune response and bowel function [25]. Gluta-
mine has been shown to inhibit intestinal atrophy by
increasing epithelial cell proliferation, to decrease bac-
terial adhesion to the intestinal mucosal surface by
increasing levels of secretory immunoglobulin A and
mucin, and to prevent BT by helping to preserve the
integrity of the intestinal wall [26]. In a study conduct-
ed by Zou et al. in a severe acute pancreatitis model,
enteral immunonutrition was reported to enhance the
intestinal mucosa barrier system and the immune sys-
tem [27]. In an obstructive jaundice model, the use of
enteral immunonutrition products in preoperative and
postoperative periods has been shown to reduce BT and
intestinal villus atrophy [11]. Although histopathological
examination was not included in our study, preoperative
immunonutrition support was shown to prevent BT af-
ter PM, according to microbiologic studies.
Conclusions
In this study, based on microbiological findings, it
was shown that PM leads to BT, and preoperative im-
munonutrition support prevents BT due to PM. However,
uncertainties remain about how much BT is responsible
for the development of postoperative septic complica-
tions. In light of our study and previous studies, the ef-
fect of immunonutritional support on BT and infectious
complications in patient groups who undergo a surgical
technique with a high risk of BT, such as PM, and other
groups with risk of BT (burn, trauma, pancreatitis, cir-
rhosis) should be investigated in future clinical trials.
Conflict of interest
The authors declare no conflict of interest.
References
1. Katz SC, Shia J, Liau KH, et al. Operative blood loss inde-
pendently predicts recurrence and survival after resection of
hepatocellular carcinoma. Ann Surg 2009; 249: 617-23.
2. Pringle JH. V. Notes on the arrest of hepatic hemorrhage due
to trauma. Ann Surg 1908; 48: 541-9.
3. Belghiti J, Marty J, Farges O. Techniques, hemodynamic moni-
toring, and indications for vascular clamping during liver resec-
tions. J Hepatobiliary Pancreat Surg 1998; 5: 69-76.
4. Ochiai H, Nakamura S, Suzuki S, Baba S. Pancreatic damage re-
sulting from temporary portal triad interruption during partial
hepatectomy: protective effect of a prostaglandin I2 analogue.
J Surg Res 1997; 73: 129-36.
5. Filos KS, Kirkilesis I, Spiliopoulou I, et al. Bacterial transloca-
tion, endotoxaemia and apoptosis following Pringle manoeu-
vre in rats. Injury 2004; 35: 35-43.
6. Unno N, Uchiyama T, Yamamoto N, et al. Portal triad occlusion
induces endotoxin tolerance: role of portal congestion. J Surg
Res 2006; 135: 213-7.
7. Dello SA, Reisinger KW, van Dam RM, et al. Total intermittent
Pringle maneuver during liver resection can induce intestinal
epithelial cell damage and endotoxemia. PLoS One 2012; 7:
e30539.
8. Derikx JP, Poeze M, van Bijnen AA, et al. Evidence for intesti-
nal and liver epithelial cell injury in the early phase of sepsis.
Shock (Augusta, Ga) 2007; 28: 544-8.
9. Holland J, Carey M, Hughes N, et al. Intraoperative splanchnic
hypoperfusion, increased intestinal permeability, down-regu-
lation of monocyte class II major histocompatibility complex
expression, exaggerated acute phase response, and sepsis. Am
J Surg 2005; 190: 393-400.
10. Mariette C. Immunonutrition. J Visceral Surg 2015; 152 Suppl 1:
S14-7.
11. Zulfikaroglu B, Zulfikaroglu E, Ozmen MM, et al. The effect
of immunonutrition on bacterial translocation, and intestinal
villus atrophy in experimental obstructive jaundice. Clin Nutr
2003; 22: 277-81.
12. Quirino IE, Correia MI, Cardoso VN. The impact of arginine on
bacterial translocation in an intestinal obstruction model in
rats. Clin Nutr 2007; 26: 335-40.
13. Berg RD. Translocation of enteric bacteria in health and dis-
ease. Curr Stud Hematol Blood Transfus 1992; 59: 44-65.
14. Sedman PC, Macfie J, Sagar P, et al. The prevalence of gut
translocation in humans. Gastroenterology 1994; 107: 643-9.
15. O’Boyle CJ, MacFie J, Mitchell CJ, et al. Microbiology of bacterial
translocation in humans. Gut 1998; 42: 29-35.
16. Deitch EA. Gut-origin sepsis: evolution of a concept. Surgeon
2012; 10: 350-6.
17. MacFie J, O’Boyle C, Mitchell CJ, et al. Gut origin of sepsis:
a prospective study investigating associations between bac-
terial translocation, gastric microflora, and septic morbidity.
Gut 1999; 45: 223-8.
18. Erenoglu B, Gokturk HS, Kucukkartallar T, et al. Mechanical
intestinal cleansing and antibiotic prophylaxis for preventing
bacterial translocation during the Pringle maneuver in rabbits.
Surg Today 2011; 41: 824-8.
19. Yeh DC, Wu CC, Ho WM, et al. Bacterial translocation after
cirrhotic liver resection: a clinical investigation of 181 patients.
J Surg Res 2003; 111: 209-14.
20. Ferri M, Gabriel S, Gavelli A, et al. Bacterial translocation
during portal clamping for liver resection. A clinical study. Arch
Surg 1997; 132: 162-5.
21. Su Y, Pan H, Guo Z, et al. Bacterial translocation and endo-
toxemia after pringle maneuver in cirrhotic rats. Dig Dis Sci
2015; 60: 414-9.
22. Wiest R, Lawson M, Geuking M. Pathological bacterial translo-
cation in liver cirrhosis. J Hepatol 2014; 60: 197-209.
182 Ozkan Subasi, Selim Yigit Yildiz, Adem Yuksel, Murat Coskun, Hamdi Taner Turgut, Eda Yildiz
Gastroenterology Review 2019; 14 (3)
23. Mainous MR, Tso P, Berg RD, Deitch EA. Studies of the route,
magnitude, and time course of bacterial translocation in
a model of systemic inflammation. Arch Surg 1991; 126: 33-7.
24. Karaman K, Tirnaksiz MB, Ulusu N, et al. Effects of dexametha-
sone on ischemia reperfusion injury following pringle maneu-
ver. Hepatogastroenterology 2011; 58: 465-71.
25. Braga M. Perioperative immunonutrition and gut function. Curr
Opin Clin Nutr Metab Care 2012; 15: 485-8.
26. van der Hulst RR, van Kreel BK, von Meyenfeldt MF, et al. Gluta-
mine and the preservation of gut integrity. Lancet 1993; 341:
1363-5.
27. Zou XP, Chen M, Wei W, et al. Effects of enteral immunonutri-
tion on the maintenance of gut barrier function and immune
function in pigs with severe acute pancreatitis. J Parenter En-
teral Nutr 2010; 34: 554-66.
Received: 3.11.2018
Accepted: 16.01.2019
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
The intermittent Pringle maneuver (IPM) is frequently applied to minimize blood loss during liver transection. Clamping the hepatoduodenal ligament blocks the hepatic inflow, which leads to a non circulating (hepato)splanchnic outflow. Also, IPM blocks the mesenteric venous drainage (as well as the splenic drainage) with raising pressure in the microvascular network of the intestinal structures. It is unknown whether the IPM is harmful to the gut. The aim was to investigate intestinal epithelial cell damage reflected by circulating intestinal fatty acid binding protein levels (I-FABP) in patients undergoing liver resection with IPM. Patients who underwent liver surgery received total IPM (total-IPM) or selective IPM (sel-IPM). A selective IPM was performed by selectively clamping the right portal pedicle. Patients without IPM served as controls (no-IPM). Arterial blood samples were taken immediately after incision, ischemia and reperfusion of the liver, transection, 8 hours after start of surgery and on the first post-operative day. 24 patients (13 males) were included. 7 patients received cycles of 15 minutes and 5 patients received cycles of 30 minutes of hepatic inflow occlusion. 6 patients received cycles of 15 minutes selective hepatic occlusion and 6 patients underwent surgery without inflow occlusion. Application of total-IPM resulted in a significant increase in I-FABP 8 hours after start of surgery compared to baseline (p<0.005). In the no-IPM group and sel-IPM group no significant increase in I-FABP at any time point compared to baseline was observed. Total-IPM in patients undergoing liver resection is associated with a substantial increase in arterial I-FABP, pointing to intestinal epithelial injury during liver surgery. ClinicalTrials.gov NCT01099475.
Article
Full-text available
Gut translocation of bacteria has been shown in both animal and human studies. Evidence from animal studies that links bacteria translocation to the development of postoperative sepsis and multiple organ failure has yet to be confirmed in humans. To examine the spectrum of bacteria involved in translocation in surgical patients undergoing laparotomy and to determine the relation between nodal migration of bacteria and the development of postoperative septic complications. Mesenteric lymph nodes (MLN), serosal scrapings, and peripheral blood from 448 surgical patients undergoing laparotomy were analysed using standard microbiological techniques. Bacterial translocation was identified in 69 patients (15.4%). The most common organism identified was Escherichia coli (54%). Both enteric bacteria, typical of indigenous intestinal flora, and non-enteric bacteria were isolated. Postoperative septic complications developed in 104 patients (23%). Enteric organisms were responsible in 74% of patients. Forty one per cent of patients who had evidence of bacterial translocation developed sepsis compared with 14% in whom no organisms were cultured (p < 0.001). Septic morbidity was more frequent when a greater diversity of bacteria resided within the MLN, but this was not statistically significant. Bacterial translocation is associated with a significant increase in the development of postoperative sepsis in surgical patients. The organisms responsible for septic morbidity are similar in spectrum to those observed in the mesenteric lymph nodes. These data strongly support the gut origin hypothesis of sepsis in humans.
Article
Full-text available
Hepatic ischemia reperfusion injury induced by Pringle maneuver leads to bacterial translocation, endotoxemia and apoptosis. Our aim was to compare the effects of low and high dose dexamethasone pretreatment on antioxidant enzyme activities, bacterial translocation, endotoxemia and apoptosis, following Pringle maneuver. Thirty-two rats were randomized into four groups; sham, control and two treatment groups; low dose dexamethasone (0.1 mg/kg) and high dose dexamethasone (1 mg/kg). In the treatment groups dexamethasone was administered intraperitoneally one hour before Pringle maneuver. Twenty-four hours after closing rats' abdomen, re-laparotomy was performed and tissue samples were taken from the mesenteric lymph nodes, liver, ileum and spleen and 1 mL of blood was drawn from the aorta. Bacterial translocation, endotoxemia, apoptosis and enzyme activities of G6PD, 6-PGD, GR, GST, GPx and CAT were evaluated. Low dose dexamethasone significantly decreased bacterial translocation to mesenteric lymph nodes, and reduced liver and enterocyte apoptosis, whereas high dose dexamethasone caused only a significant reduction in enterocyte apoptosis (p<0.05). Dexamethasone both in low and high doses significantly reduced the decrease in antioxidant enzyme levels (p<0.05). Low dose dexamethasone pretreatment caused constructive therapeutic effects after Pringle maneuver, whereas these effects were seen partially with a high dose.
Article
Résumé Sur la base d’un grade A de recommandations, l’immunonutrition doit être proposée en préopératoire pendant 5 à 7 jours chez tous les patients devant bénéficier d’une chirurgie digestive carcinologique qu’ils soient dénutris ou non dénutris. L’immunonutrition doit être poursuivie en postopératoire chez les patients dénutris en préopératoire (i) pendant 5 à 7 jours en l’absence de complications ou (ii) jusqu’à reprise d’une alimentation orale assurant au moins 60 % des besoins nutritionnels.
Article
Background: Pringle maneuver (Pm) is advocated for the reduction of blood loss during liver surgery, while postoperative infections continue to be a frequent complication after hepatic resection and liver transplantation. Aim: To investigate the effect of the Pringle maneuver on systemic bacterial translocation and endotoxemia in cirrhotic rats and cirrhotic rats with selective intestinal decontamination. Methods: A total of 100 male Sprague-Dawley cirrhotic rats were randomly divided into five equal groups: sham operation, Pm of 10 min, Pm of 20 min, Pm of 30 min, and pretreatment. Tissue samples from mesenteric lymph nodes, liver, lungs, portal, and vena cava vein blood were obtained for culture after 30 min and 24 h of the operation. Endotoxin levels were measured in portal vein and vena cava blood. Results: Portal vein and vena cava blood endotoxin concentrations increased significantly after 30 min, especially 24 h of operation in the Pm of 20 min and Pm of 30 min groups. A significant increase in contaminated mesenteric lymph nodes, liver, portal, and vena cava blood was noted 24 h later. The incidence of gut bacterial translocation increased with the duration extension of Pm. Escherichia coli was the most common bacteria isolated from the tissues. There was a significant decrease of portal vein and vena cava blood endotoxin concentrations and the incidence of bacterial translocation by selective intestinal decontamination. Conclusions: There is endotoxemia immediately after Pringle maneuver and gut bacteria translocation 24 h later. The incidence of gut bacterial translocation increases with the duration extension of Pm. Selective intestinal decontamination can decrease bacteria translocation and endotoxemia.
Article
In the last year, several meta-analyses focused on the potential clinical benefits of perioperative immunonutrition in surgical patients. Purpose of this review is to summarize their results and to draw recommendations about the current indication of immunonutrition in surgery. Standard enteral preparations have been modified by adding specific nutrients, such as arginine, omega-3 fatty acids and others, which have been shown to upregulate immune response, to control inflammatory response, and to improve gut function after surgery. The majority of the randomized trials found that perioperative immunonutrition improved short-term outcome in patients, who underwent elective major gastrointestinal (GI) surgery. Four meta-analyses including a large number of randomized clinical trials reported that perioperative immunonutrition is associated with a substantial reduction in both infection rate and length of hospital stay. These results have been found in both upper and lower GI patients, regardless of their baseline nutritional status. Promising results have been found also in head and neck surgery. In the light of these findings the use of perioperative immunonutrition should be implemented in patients undergoing elective major GI surgery. This should result in a considerable reduction in both postoperative morbidity and costs for healthcare systems.Larger trials are required before recommending immunonutrition as a routine practice in head and neck surgery.
Article
The concept of bacterial translocation and gut-origin sepsis as a cause of systemic infectious complications and the multiple organ dysfunction syndrome (MODS) in surgical and ICU patients has emerged over the last several decades, although the exact clinical relevance of these phenomenon continue to be debated. Thus, the goal of this review will be to trace the evolution of gut-origin sepsis and gut-induced MODS and put these disorders and observations into clinical perspective. Additionally, the mechanisms leading to gut-derived complications will be explored as well as therapeutic options to limit or prevent these complications. From this work, several major conclusions emerge. First, that bacterial translocation occurs clinically and is responsible for increased infectious complications in patients undergoing major abdominal surgery. However, the phenomenon of bacterial translocation is not sufficient to explain the development of MODS in ICU patients. Instead, the development of MODS in these high-risk patients is likely due to gut injury and the systemic spread of non-microbial, tissue-injurious factors that reach the systemic circulation via the intestinal lymphatics. These observations have resulted in the gut-lymph hypothesis of MODS.
Article
We investigated the effectiveness of mechanical intestinal cleansing and antibiotic prophylaxis in preventing bacterial translocation (BT) during the Pringle maneuver in rabbits. Forty-eight rabbits were allocated to one of the following four groups: a control group (group 1); an antibiotic group, given 100 mg/kg intravenous ceftizoxime (group 2); a mechanical intestinal cleansing group, given a Fleet enema (group 3); and a mechanical intestinal cleansing plus antibiotic group (group 4). After performing laparotomy, we dissected the portal region and turned the portal triad, using tape. Pringle maneuver was applied for 30 min in all groups. Blood samples were collected from the portal vein for blood culture before the Pringle maneuver. All groups underwent relaparotomy 30 min after the Pringle maneuver, to obtain portal blood, mesenteric lymph nodes (MLNs), and splenic tissue for culture. All cultures from the portal vein specimens taken before the Pringle maneuver were negative. The rate of bacterial isolation in the portal vein (P < 0.001), MLNs (P < 0.01), and splenic (P < 0.001) cultures was significantly lower in group 4 than in the other groups. It was also lower in group 3 than in groups 1 and 2 (P < 0.05 for all). The combination of mechanical intestinal cleansing and preoperative broad-spectrum antibiotics was most effective for preventing BT during the Pringle maneuver.
Article
This study evaluated the effects of enteral immunonutrition (EIN) supplemented with glutamine, arginine, and probiotics on gut barrier function and immune function in pigs with severe acute pancreatitis (SAP). The model was induced by retrograde injection of 5% sodium taurocholate and trypsin via the pancreatic duct. After induction of SAP, 18 pigs were randomly divided into 3 groups, in which either parenteral nutrition (PN), control enteral nutrition (CEN), or EIN was applied for 8 days. Serum and pancreatic fluid amylase concentration was determined. Intestinal permeability (lactulose to mannitol ratio) was measured by high-performance liquid chromatography, and plasma endotoxin was quantified by the chromogenic limulus amebocyte lysate technique. Samples of venous blood and organs were cultured using standard techniques. Pancreatitis severity and villi of ileum were scored according to histopathologic grading. Plasma T-lymphocyte subsets were measured by flow cytometry, and immunoglobulins (Igs) were determined via enzyme-linked immunosorbent assay. There were no significant differences in serum and pancreatic fluid amylases concentrations or in pancreatitis severity between any 2 of the 3 groups. Compared with PN and CEN, EIN significantly decreased intestinal permeability, plasma endotoxin concentration, and the incidence and magnitudes of bacterial translocation, but increased ileal mucosal thickness, villous height, crypt depth, and percentage of normal intestinal villi. Significant differences were found in CD3+, CD4+ lymphocyte subsets, the ratio of CD4+: CD8+ lymphocyte subsets, and serum IgA and IgG, but not IgM, between any 2 of the 3 groups. EIN maintained gut barrier function and immune function in pigs with SAP.