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Mirzayeva Rafiqa Sahib, oncologist of the Oncological Clinic Azerbaijan Medical University
Kaziev Abuzer Yusif, professor, doctor of Medical Sciences, Department of Oncology, Azerbaijan Medical University
Jafarova Gulnara Alisa, Candidate of Biological Sciences, doctor-laboratory assistant of the Oncological Clinic Azerbaijan Medical University
E-mail: xeyalcafarov4@gmail.com
EVALUATION OF HEPATOPANKREATOBILIARY SYSTEM FUNCTIONAL ACTIVITIES IN POSTOPERATIV PERIOD IN GASTRIC CANCER PATIENTS
Abstract: Patients with gastric cancer (GC) have evaluated the hepatopancreatobiliar system disorders and their outcomes after surgery. For this purpose, activity of liver, gallbladder and enzymes (ALAT, ASAT, ALP, a-amylase, lipase, elastase-1) in liver, gallbladder and pelvic function in blood and coprofiltrates of patients with GC without complications with 51 malabsorption syndromes were studied. The role of some cytokines (IL-6 and TNF-a) and antimicrobial peptides (lactoferrin, calprotectin and zonuline) in the immune mechanisms ofthe inflammatory process in the intestines has been studied. The analysis and biochemical analyzes were performed prior to surgery and were followed in 3 and 6 months after surgery. It has been established that the enzyme activity of the pancreatobiliar zone after the procedure of postoperative surgery in patients with malabsorption GC was significantly decreased after 3 months and 6 months after the surgery: The activity ofALAT, ASAT and ALP enzymes was 39.5%, 19.9% and 58.4%, and the activity of a-amylase and lipase enzymes reflecting the secretory activity of the pancreas was 40.6% and 24.3%, respectively, compared with the preoperative predictors of fecal elastase-1 enzyme activity compared to 13.9% in comparison with the previous year. In these patients, cytokines and antimicrobial peptides concentrations increased significantly after 6 months of operation: concentration of zonuline, calprotectin and lactoferrin was 16.9%, 44.6% and 9.2% higher than the preoperateness indicators, IL-6 and TNF-a. The density of a increased by 52.9% and 26.5%, respectively.
Keywords: Gastric cancer, antimicrobial peptides, cytokine.
Gastric cancer (GC) is the most widespread tumor among post-operative death in GC patients are metabolic disorders the malignant tumors of the hepatopancreatobiliary system and associated with the structural-functional changes in different is one of the most important areas of clinical oncology in terms organic, especially those entering the pancreatobiliary system. of diagnosis and treatment. Although great success has been Disfunction of lungs, gallbladder and pancreatic secretory ac-achieved in the diagnosis and treatment of gastric cancer over tivity is observed in most patients in the early and late post-the past few decades, difficulties in early diagnostic, the inci- operative period [2; 5; 6; 7; 8] Investigating the biochemical dence of primary non-resectible tumors and, in some cases, mechanisms of digestive tract disorders in GC patients can patients' in advanced stages, create problems in adequate treat- lead to early and accurate diagnosis and also can be used to ment of this disease. GC is the second most common cause of provide effective treatment methods of this disease. Recently, diseaes related death rate after lung cancer in men, and takes the study of antimicrobial peptides (AMP) and cytokines is the 4th place in death rate women in menopause. Every year, in the focus of assessment of digestive system activity. This around 1 million new cases of GC and 700.000 deaths are re- method is feasible by its non-invasiveness and high sensitivported worldwide. Now days surgery is considered to be the ity [9; 10; 11]. The purpose of the present study is to study main radical treatment of gastric cancer [1; 3; 4]. the dynamics of some enzymes, antimicrobial peptides and
Although significant progress has been made in the treat- cytokines, which reflect the functional activity of hepatopan-ment and prophylaxis of GC in recent decades, the incidence creatobiliary system in postoperative period in GC patients. of perioperativ complications, requiring the identification of Materials and Methods. The study includes 51 patients
new areas and perspectives in treatment and diagnostic of with a diagnosis of stomach cancer not complicated by mal-the disease. It has been established that one of the causes of absorption syndrome at the age of 31-76 years treated at the
Oncology Clinic of Azerbaijan Medical University. The control group consisted of 17 elderly healthy people.
Patients were diagnosed using radiologic, endoscopic, histological and laboratory diagnostic methods. The diagnosis of gastric cancer, histological structure of the tumor and the stage of the disease have been confirmed by the morphological examination of biopsy of the tumor. All tumors were adenocarcinoma. In order to achieve the goal, the levels of some marker enzymes of the liver, gallbladder and pancreas (ALAT, ASAT, ALP, a-amylase, lipase enzymes and some cytokines a(lL-6, TNF-a), were investigated in parallel, the pancreatic elastase-1 enzymes, zonuline, calprotectin and lactoferrine antimicrobial peptides were analyzed in coprofiltrate of healthy individuals and patients included in the research contingent and the level of investigated biochemical parameters was investigated 3 and 6 months after surgery. The level of ALAT, ASAT, ALP, lipase and amylase in the blood of patients with gastric cancer were analyzed by reactives of "Human" (Germany) company.
The concentration of cytokines TNF-a and IL-6 in the blood serum was carried out by a "sandwich" method through a jet set of Vektor-Best (Russian Federation). The principle of an analysis of the amount of elastase-1 enzyme in coprofiltrate is based on the double-synthetic immunoferment reaction (Immun Diagnostics, Germany). Zonuline, calprotectin and lac-toferrine in coprofiltrate were determined by immunoferment method using a reactive kit of Immun Diagnostic (Germany).
All patients were followed up after surgery and data of 3 months later. Their complaints examination included clinical, laboratory and instrumental examinations.
The obtained results were statistically analyzed using the variation method. The non-parametric U-Wilcoxon (MannWhitney) criterion was applied to determine the difference between the groups.
Results of research and their discussion. The results showed that the activity of AlAT and ASAT enzymes in blood
serum of GC patients was (40.6 ± 1.4 U/l,p < 0.001; control: 29.6 ± 1.7U/l) and 17.9% (41.4 ± 1.8 U/I, p < 0.01; control: 32. 6 ± 1.4 U/l) increased by 37/2% compared to the control group and respectively. AlAT and ASAT enzymes are important in aminoacides metabolism. They enter the bloodstream during cells damage and destroyment. The activity of the ALP enzyme, one of the major enzymes of the bile ducts, was not significantly differ from the control group, and it was 203.5 ± ± 7.8 U/l (control: 188.8 ± 9.9 U/). The results showed that the concentration of ALAT, ASAT and ALP enzymes significantly rose 3 month after surgery compared to the preoperative data 17.9% (p < 0.01); 16.9% (p < 0.05) and 28.5% (p < 0.001) and 39.5% after 6 months (p < 0.001); 51.7% (p < 0.001) and 58.4% (p < 0.001) respectively.
Activity of a-amylase, lipase, and fecal elastase-1 enzymes is of great importance in detection of pancreatic secretion deficiency [12].
The activity of the a-Amylase enzyme increased by 24.5% (61.6 ± 2.4 U/l,p < 0.05, control: 49.5 ± 4.7 U/l) compared to the control group. The activity of lipase enzyme in this group was 29.9 ± 1.1 U/l and did not differ from the control group (28.7 ± 1.6 U/l). This result was not statistically significant/
a-Amylase and lipase activity rose by 18.2% (p < 0.01) and 13.3% (p < 0.05) within 3 months, respectively.After 6 months 40.6% (p < 0.001) and 24.3% (p < 0.001) increase was observed, respectively.
Since the pancreatic elastase-1 enzyme that is synthesized by the acinar cells of the pancreas don't destroyed in intestine, its concentration in the feces can be considered an objective criterion for assessiment of exocrine function of this gland [13]. The activity of the fecal elastase-1 enzyme was lower by 9% in the control group (203.0 ± 2.2 mkg/g, p < 0.001, control: 223.3 ± 5.2 mkg/g). There was a statistically significant decrease in fecal elastase-1 enzyme activity 6 months after surgery (p < 0.001) (Table 1).
Table 1. - Dynamics of changes in liver, gallbladder and pancreas enzymes in the serum of the stomach cancer patients without malabsorption syndrome, (M ± m)
Indicators Groups
Before surgery 3 months after surgery 6 months after surgery
1 2 3 4
ALAT, U/L 40.6 ± 1.4*** 47.8 ± 2.0***.AA 56.6 ± 2.7***.AAA
(23.2-60.3) (21.4-69.9) (22.6-83.2)
ASAT, U/L 41.4 ± 1.8** 48.4 ± 2.2***.A 62.8 ± 2.8***.AAA
(21.5 ± 65.1) (25.3-78.4) (25.8-96.7)
ALP, U/L 203.5 ± 7.8 261.4 ± 12.2**.AAA 322.3 ± 13.2)***.AAA
(103-299) (113-386) (158-482)
a - Amylase, U/L 61.6 ± 2.4* (30.9-91.3) 72.8 ± 3.0***.AA (33.4-107) 86.6 ± 4.2***.AAA (36-134)
1 2 3 4
Lipaza, U/L 29.9 ± 1.1 (17-43.2) 33.9 ± 1.4. A (17.5-52.5) 37.2 ± 1.8)*. AAA (17.6-58.8)
Elastaza, mkg/g 203.0 ± 2.2*** (183-237) 188.1 ± 4.4***. AA (107-247) 174.9 ± 5.5)***. AAA (83.3-229)
Note: By control:*** - p < 0.001, ** - p < 0.01, * - p < 0.05; According to pre-operative data: AAA - p < 0.001, AA - p < 0.01, A - p < 0.05
Thus, our results showed, serious changes in functional activity of the hepatobiliary digestive system after surgery in GC patients with included in this study.
Recently, research has been carried out to improve noninvasive methods for the early diagnosis and treatment of malabsorption syndrome and to detect new biomarkers. In this regard, it is of particular interest to study antimicrobial peptides such as lactoferrine, calprotectin and zonuline in patients with gastrointestinal disorders. Due to the resection of a certain part of the stomach, the reduction of chloride acid production leads to the massive increase of conditional-pathogenic bacteria in the upper gastrointestinal tract, resulting in acceleration of inflammatory processes in the intestine. It is well-known that AMP plays an important role in observation of inflammatory reactions and determination of their severity level. AMP is considered to be the main
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component of the organism's immune system and plays an important role in immune system [13; 14]
Calprotectin is a calcium regulations related protein het-erocomplex, which release from activated neutrophils and tissue macrophages and invoered in inflamation. Calprotectin has antibacterial, antifungicidal, immunomodulatory and antiproliferative effect, and is capable to induce apoptosis by weakening the growth of fibroblasts. In the digestive tract inflammation can be detected in feces couse of migration granulocytes from the intestinal wall.The elavation calprotectin in the feces is a key indicator of gastrointestinal tract the inflammation [15]. The consentration calprotectin in coprofil-trates of GC patients without malabsorption syndrome was 1.6 times higher than in the control group (±; control: 17,2 ± ± 1.2 mkg/g)
Figure 1. Change of antimicrobial peptide levels 3 and 6 months after surgery in GC patients without malabsorption syndrome
One of the important representatives of antimicrobial peptides is zonulin. It belongs to the group of haptoglobulin proteins and is synthesized in liver and inner epithelial tissues. Zonuline molecules provide tight contact between the mucous membrane cells of the small intestine wall. In study, it was determined that the level of zonuline in the coprofiltrates of GC patient without malabsorption syndrome was 1.5 times higher than in the control group (1.265 ± 0.043 m mkg/g, p < 0.001; 0.858 ± 0.094 mkg/g). Hyperproduction of zonuline activates
the chain of reactions that expands intercellular contacts and so causes the intestinal perfusion (transfusion) [16].
Comparison of the results between investigation and control group revealed that the level of lactoferrine was 4.6 times higher in control group than in GC patients without malabsorption (4.56 ± 0.31 mkg/g, p < 0.001; control: 0.98 ± 0.16 mkg/g). Lactoferrin is a glycoprotein found in specific granules of neutrophils, refers to acute phase proteins, participates in non-specific humoral immune responses, and
has the ability to affect the activity of immunocompetent cells. Along with iron combining and transport functions, it provides antibacterial, antivirus, antifungicide, antiparasitic and antioxidant activity and encure microbalance of the gastrointestinal tract [13].
Located at the end of the "n" part of lactoferrin the specific peptide of lactoferrisin combines with the receptors of the immunocompotent cells with the participation, to perform an immunomodulatory effect. In this way, lactoferrin provides
the releasing of some cytokines: IL-6 and TNF-a from mono-nucleated cells.
Cytokines perform a special immunomodulatory function in progression of inflammation in GC. The deepest studied cytokines are IL-6 and TNF-a. Cytokines are polypeptide mediators that participate in formation and regulation of defense response of the organism by establishing connection among immune, nerve, endocrine, gonadotropic and other systems [17]. Density of IL-6 (3.4 ± 0.2 pq/ml, control: 3.0 ± 0.3 pq/ml) was slightly different in the control group (Figure 2).
Figure 2. Change of cytokine indexes in patients with non-complicated GC after 3 and 6 months postoperatively without malabsorption syndrome
As can be seen from the presented data, the blood concentration of TNF-a was 1.5 times more than in the control group (7.1 ± 0.5 pq/ml,p < 0.05; control: 4.9 ± 0.6 pq/ml). It stimulates the synthesis of various pathogenic molecules and acute phase mediators (TNF-a and IL-1) and IL-6.
The level of IL-6 and TNF- a 3 months after surgery were 37% (1.4 times, p < 0.001) and 18.2% (1.2 times) higher respectively compared to the preoperative indicators (the result was inaccurate).
The level IL-6 rose up to was 5.2 ± 0.3 pg / ml of markers above became higher and the TNF-a rose up to 9.0 ± 0.5 pg/ml 6 months after surgery.What is more than the previous figures, IL-6 was respectively 1.5 times thick, p < 0.001 and 1.3 times of TNF-a (p < 0.01).
IL-6 and TNF-a are important is synthesized by cytokines involved in immunological and inflammatory responses. IL-6 macrophages, T-cells, vascular endothelial cells, fibro-blasts, epithelial cells and so on. The IL-6 participates in im-munological reactions and haemopoesis. In inflammation, IL-6 accelerates the chronic inflammation and synthesis of active phase proteins in hepatocytes [18; 19]. TNF-a is syn-
thesized mainly by activated macrophages, and its prodrugs include endothelial cells, CD4-lymphocytes, NK-cells, dysplasia cells, mastocytes, myeloid, LAC, neuroglia cells and activated T-lymphocytes. TNF- a is an adipocytokine, participates in a systemic inflammatory processes, activates acute phase reactions. In healthy persons, TNF-a is founded in very small concentrations its synthesis is induced by microorganisms and endotoxins [20].
IL-1j8, IL-6 and TNF-a are known as proangiogenic factors of malignant processes, such as gastrointestinal tumors, play a great role in vascularization of the tumor, its development, progression, and proliferation. IL-6 and TNF-a stimulate the migration of tumor infiltrating leucocytes. It has been established that TNF-a, IL-1^ and IL-18 increase the expression of cell adhesion molecules in endothelium stimulate migration of immunocompetent cells to the tumor. Tumor infiltrating leucocytes begin to synthesize inflamatory and prooncogenic factors, thus creating pathological circulation [18; 19; 20; 21].
The results showed that after surgery in GC patients without malabsorption syndrome, serious irregularities in liver,
gallbladder and pancreatic secretory activity was observed that Postoperative disorders in GC patients affect the patient's life
is accompanied by progression of inflammation in the bowl. quality and requires adequate medication correction.
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