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Ann Thorac Surg 1993;55:1080-1086
© 1993 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Hammersmith Hospital, London United Kingdom
b Department of Cardiothoracic Surgery, Harefield Hospital, Middlesex, United Kingdom
c Department of Clinical Biochemistry, Kings College Hospital, London, United Kingdom
d Department of Chemical Pathology, UMDS, St. Thomas's Hospital, London, United Kingdom
* Address reprint requests to Mr Ohri, Cardiothoracic Unit, Department of Surgery, Hammersmith Hospital, Royal Postgraduate Medical School, London, W12 OHS, United Kingdom.
Gastrointestinal damage occurs in 0.6% to 2% of patients after cardiopulmonary bypass (CPB), and carries a mortality of 12% to 67%. The incidence of subclinical gastrointestinal damage may be much greater. We examined the effects of nonpulsatile, hypothermic CPB on intestinal absorption and permeability in 41 patients. Bowel mucosal saccharide transport and permeation were evaluated using 100 mL of an oral solution containing 3-O-methyl-D-glucose (0.2 g), D-xylose (0.5 g), L-rhamnose (1.0 g), and lactulose (5.0 g) to assess active carrier-mediated, passive carrier-mediated, transcellular, and paracellular transport, respectively, with a 5-hour urine analysis. Patients were studied before, immediately after, and 5 days after CPB. Immediately after CPB there was a decrease in urinary excretion of 3-O-methyl-D-glucose (from 34% ± 2.2% to 5.2% ± 0.7%; p < 0.0001), D-xylose (from 25.4% ± 1.4% to 4.1% ± 0.8%;p < 0.0001), and L-rhamnose (from 8.3% ± 0.6% to 2.6% ± 0.4%;p < 0.0001). The permeation of 3-O-methyl-D-glucose and D-xylose returned to normal levels 5 days after CPB, but that of L-rhamnose remained significantly below pre-CPB values at 6.6% ± 0.5% (p = 0.004). However, the permeation of lactulose increased after CPB (from 0.35% ± 0.04% to 0.59% ± 0.1%; p = 0.018), and the lactulose/L-rhamnose gut permeability ratio increased markedly (from 0.045 ± 0.04 to 0.36 ± 0.08; normal = 0.06 to 0.08; p = 0.004). Patients who had a CPB time of 100 minutes or more had a greater increase in gut permeability (p = 0.049). In 10 patients, gastric mucosal blood flow was determined by laser Doppler flowmetry. A 48.7% ± 7% reduction in gastric mucosal laser Doppler flow was found 30 minutes after the institution of CPB (p = 0.0001). This study demonstrates that after CPB gut barrier function is impaired, with increases in gut permeability; patients undergoing longer (>100 minutes) bypass procedures sustain greater increases in gut permeability. There is reversible impairment of small bowel transcellular transport after CPB. The alterations in gut barrier function and mucosal transport are probably secondary to CPB-induced mucosal hypoperfusion. These findings have implications for the prevention of endotoxemia after CPB, as well as enteral nutrition and drug therapy in the immediate post-CPB period.
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