Abstract:Abstract:Objective:To observe the clinical results of laparoscopic cholecystectomy(LC) combined with endoscopic Oddi sphincterotomy(EST) in treating cholecystolithiasis and choledocholithiasis.Methods:The preoperative and postoperative clinical data of 20 cases that received LC & EST combined therapy for cholecystolithiasis and choledocholithiasis were analyzed retrospectively.Results:The success rate was 95.0%,with all the calculi removed completely;no complications occurred.The average hositpal stay was 7.5 days.Conclusions:Combined LC & EST procedure is a safe and effective method to treat patients suffering from cholecystolithiasis and choledocholithiasis.

Abstract:Abstract:Objective:To assess the therapeutic effect and opportune time of surgical treatment of hepaticolithiasis. Methods:The clinical data of 92 patients with hepaticolithiasis who underwent surgical treatment were analyzed retrospectively. Results:(1) The incidence of postoperative complications was 14.1%(13/92 cases), in choledochoscopy group it was 9.3%(4/43 cases) and in the noncholedochoscopy group 18.4%(9/49 cases) ; in the emergency operation group it was 36%(9/25 cases) and in selective operation group 5.97%(4/67 cases) . (2) The incidence of residual stones was 22.9%(21/92 cases); in choledochoscopy group it was 13.9%(6/43 cases) and the noncholedochoscopy group 30.6%(15/49 cases); in emergency surgery group it was 36%(9/25 cases) and in selective operation group 17.9%(12/67 cases).(3)One pationt died from ACST two days after operation. All of the patients were followed up for 4-10 years; there were 80 cases (86.9%) who had a good therapeutic outcome. Conclusions:Logical surgical procedure associated with choledochoscopy and appropriate timing of surgical intervention can markedly improve the effect of surgical treatment of hepaticolithiasis and reduce the incidence of postoperative complications.

Abstract:Abstract:Objective:To study the therapeutic methods of cholecystic duct stones. Methods:A retrospective analysis of the clinical data of 158 cases of cholecystic duct stones treated in the recent 6 years was made. Results:97 of the 158 cases of cholecystic duct stones were removed by open surgical operation and 61 cases by laparoscopic cholecystectomy(LC).In 49 of the 61 casestreated with LC,the cholecystic duct stones were removed together with removal of the gallbladder, and 12 by duodenoscopy after LC. Conclusions:One should strive to extract the cholecystic duct stones while removing the gallbladder. If the stones or stone fragments escape into the common bile duct, they could be removed through a choledochotomy at the time of the open operation,or by postoparative duodenoscopy in cases undergoing LC. The latter method of treatment is associated with minor trauma, quick recovery and definite therapeutic results.

Abstract:Abstract:Objective:To investigate the clinical treatment principles of asymptomatic cholecystolithiasis. Methods:136 cases of asymptomatic cholecystolithiasis, found on health check-up, were randomly divided into two groups :(1) Preventive cholecystectomy group,66 cases;(2)therapeutic cholecystectomy group,70 cases. The data of postoperative pathologic examination, complications and degree of operative difficulty between the two groups were compared. Results:The postoperative pathologic examination, complications and degree of operative difficulty between the two groups were significantly different(P<0.05~0.025). Conclusions:Preventive cholecystectomy should be selectively implemented for asymptomatic cholecystolithiasis patients,and the performance of surgical treatment should not routinely be undertaken only after the occurrence of one or more complications of cholecystolithiasis.

Abstract:Abstract:Objective: To explore an effective treatment for inflammatory hilar bile duct stricture. Methods: The clinical data with patients of intra-hepatic cholelithiasis complicated with hilar bile duct stricture that received plastic repair of hilar bile duct stricture(PHBDS) with pedicled cholecystic graft or Roux-en-Y cholangio-jejunostomy(RYCJ) in our hospital during recent 10 years were retrospectively analyzed. The peri-operative conditions, postoperative morbidity of cholangitis and recurrence of hepaticolithiasis were observed. Results:The peri-operative morbidity of biliary fistula and inflammatory ileus were not significantly different between the two groups. The postoperative morbidity rate of cholangitis was 5.66% and 21.88%,(P=0.010) and recurrence rate of hepaticolithiasis was 3.77% and 16.67%,(P=0.021) in PHBDS group and RYCJ group respectively. Conclusions:PHBDS is an easy and safe operation. RHBDS can preserve the physiologic function of Oddi′s spincter, so the reflux of intestinal contents to bile duct is avoided, and the results are better than the RVCJ.

Abstract:Abstract:Objective:To explore the pathological characteristics, diagnosis and operative treatment of Mirizzi Syndrome(MS). Methods:The clinical data of 95 cases of Mirizzi Syndrome admitted to our hospital in recent 12 years were reviewed retrospectively. Results:All of the 95 cases underwent operative therapy. In the 95 patients, simple cholecystectomy was performed in 2 patients, cholecystectomy and choledochotomy with T-tube drainage in 58 patients, cholecystectomy and choledoscopic bile duct examination via cystic duct in 15 patients, partial cholecystectomy plus repair of choledochal fistula in 18 patients, and cholecystectomy plus repair of the injured choledochus in 2 patients. 65 cases were folloned up for 1-5 years, and all of them have been in good health. Conclusions:Mirizzi Syndrome consists of varied pathology. The selection of rational operation for different types of Mirizzi Syndrome can give satisfactory results.

Abstract:Abstract:Objective:To summarize the clinical experience of laparoscopic cholecystectomy(LC) for acute cholecystitis.Methods:Clinical records of 58 cases of acute cholecystitis treated by LC from March 1998 to May 2004 were respectively reviewed.Results:Intraoperative cholangiography was conducted in 6 cases,5 of which were found to have common bile duct stones.Of the 5 cases,2 underwent LC combined with choledoscopic choledochotomy, stone removal and T-tube drainage; the other 3 cases had ill-defined relationship of Calot′s triangle and underwent conversion to open choledochotomy with stone removal and T-tube drainage.In 52 cases were diagnosed as simple gallbladder stones, LC was successfully accomplished in 50 cases and conversion to open surgery was required in 2 cases because of serious inflammatory adhesions.In this study 1 case had jaundice after operation and 3 cases had leakage of bile,and all recovered on conservative treatment. Conclusions:LC can be performed safely in the majority of cases of acute cholecystitis.

Abstract:Abstract:Objective:To investigate the preventive effects of 103Pd radioactive stent on stenosis after bile duct injury in dogs.Methods:Twelve healthy dogs (15~20kg) were randomly divided into 103Pd radioactive stent group (n=6) and control group (n=6). Immediately after balloon dilatation injury to the bile duct, the 103Pd radioactive stent(experiment group) or the ordinary stent(control group) was positioned into the target segment. The dogs were killed one month later. The injured bile duct segments were dissected free from the dogs, and were examined radionucleonically, immunohistochemically and pathologically. Muscular proliferation area and lumen area were determined by computer-assisted picture analysis system. Results:In the control group, 30 days after ductal injury, the mucosa of the bile duct was fractured, the mucosa was proliferated and the lumen stenosed.Compared with the control group, 103Pd radioactive stent significantly reduced muscular proliferation area (P＜0.01), decreased percentage of stenosis area ［(60±21.6)% vs (31.6±9.5)%］, and increased bile duct lumen area (P＜0.01). Conclusions:103Pd radioactive stent is feasible and effective in reducing muscular proliferation and preventing stenosis 30 days after balloon dilatation injury to the bile duct in dogs.

Abstract:Abstract:Objective:To investigate the myocardial injury induced by bile duct obstruction and the protective effects ulinastatin(UTI). Methods:Dynamic observation of of the levels of malondialdyhyde(MDA) and superoxide dismutase（SOD） of myocardial tissues, and the levels of serum TBil, alkaline phosphatase(ALP), MB isoenzyme of creatine kinase(CK-MB), endotoxin (ET), and tumor necrosis factor(TNF-α) in bile duct obstruction(BLD) rats and UIT treatment rats. The left ventricles of the rats were obtained for light and electronic microscopic observation. Immunohistochemical staining method of ABC used was to locate the expression and distribution of TNF-α in myocardial tissues. Results:After ligation of the common bile duct, serum TBIL, ALP, CK-MB, ET, TNF-α levels and myocardium MDA gradully increased, while SOD levels gradually decreased, and the expression of TNF-α in myocardium increased. As compared with BDL group at the same phase, in UIT group, serum TBIL, ALP, CK-MB, ET, TNFα levels and myocardium MDA in UTI-treated groups decreased, while myocardium SOD increased, and the expression of TNF-α in myocardium decreased．Myocardial injuries of bile duct obstruction were aggravated as time progressed, and there were less myocardial injuries in UTI-treated groups than in BDL groups at the same stage as shown with light and electronic microscopic observation．Conclusions:UTI can effectively protect the myocardium from ET,TNF-α and free radical injury in bile duct obstucion rats.

Abstract:Abstract:Objective:To study the action of death signal receptor pathway of apoptosis in the development of gallbladder carcinoma. Methods:Streptavidin-biotin-peroxidase immunohistochemistry technique was used to study the expression of Fas L in gallbladder carcinoma tissues,and TUNEL method for in situ detection of the number of apoptotic infiltrating lymphocytes around the tumor. Results:The positive rates of Fas L in gallbladder carcinoma, gallbladder adenoma, dysplasia of gallbladder epithelium and chronic cholecystis were 84.6%(22/26), 83.3%(15/18) ,100%(3/3) and 55%(11/20), respectively. The positive rate of Fas L in gallbladder carcinoma was significantly higher than in chronic cholecystis (P<0.05). The number of apoptotic infiltrating lymphocytes in gallbladder carcinoma of Fas L(+) was significantly higher than in gallbladder carcinoma of Fas L(-)(P<0.01). The number of apoptotic infiltrating lymphocytes in poorly-differentiated gallbladder carcinoma of Fas L(+) was significantly higher than in poorly-differentiated gallbladder carcinoma of Fas L(-)( P<0.05). The number of apoptotic infiltrating lymphocytes in NevinI、II、III gallbladder carcinoma of Fas L(+) was significantly higher than in NevinI,II,III gallbladder carcinoma of Fas L(-)(P<0.01). Conclusions:The death signal receptor pathway of apoptosis plays a role in the development of gallbladder carcinoma.

Abstract:Abstract:Objective:To explore an ideal method of establishing a rat acute hepatic failure (AHF) model. Methods:36 Sprague-Dawley rats were randomly divided into three groups. In modified operation induction group, rat AHF model was established by modified 95% hepatectomy. In the operation, 10ml 5% glucose saline solution per kilogram of body weight was injected into the median lobe hepatic vein of the rat. In traditional operation induction group, 95% liver was resected, but no glucose saline solution was injected. In drug induction group, AHF model was established by injecting 1.2g D-gal per kilogram of body weight intraperitoneally. Operative mortality and 24h survival rate after establishment of models were observed. ALT, total bilirubin (TB), NH3 and blood sugar (BG) were monitored. Results:The operation mortality in traditional operation induction group was higher than that in modified operation induction group (33.3% vs 0%). Survival rate was 0%, 0%and 25% in modified operation induction group, traditional operation induction group and D-gal group 24h later, respectively. ALT and NH3 in the modified operation induction group were significantly higher than those of D-gal group (P<0.05). TBIL and BG levels in the modified operation group were lower than those in the D-gal group, but the difference was not significant (P>0.05). Conclusions:The AHF model established by modified 95% hepatectomy is an ideal one. Injection of 5% glucose saline solution through median lobe hepatic vein at operation can reduce operative mortality.

Abstract:Abstract:Objective:To investigate the protective effect of ischemic preconditioning on extracelluar matrix of intestinal graft in rats. Methods:SD rats were randomly assigned to the following study groups: sham operation group (S group, n=6), small bowel transplantation group (SBT group, n=12), ischemic preconditioning plus small bowel transplantation group (IPSBT group, n=12). Heterotopic segmental SBT model was established.
When the graft was preserved and reperfused for 1h, samples were obtained from each group. Expression of laminin was studied by immunohistochemical means. The changes of epithelial basement membrane structure were examined by traversing electron microscopy. Results:The mean gray value of laminin positive products was 39.52±2.60,13.53±0.44,25.40±1.79, respectively, in S, SBT and IPSBT group. The mean gray value of laminin positive products in SBT group was markedly lower than that in S group
(P<0.05). However, The mean gray value of laminin positive products in IPSBT group was markedly higher than that in SBT group (P<0.05). Electron microscopically,the epithelial basement membrane in S group was linear and remained intact, but in SBT group it became disrupted,or even was absent. The degree of destruction of the epithelial basement membrane in IPSBT group was less than that in SBT group. Conclusions: Extracelluar matrix of intestinal graft is the target of cold preservation/reperfusion injury, and ischemic preconditioning has a protective effect on this injury of the extracelluar matrix.

Abstract:Abstract:Objective:To establish and assess a model of abdominal postoperative fatigue syndrome (POFS) in rats. Methods:After 70% hepatectomy was performed, the following observations of the animals were made:general condition, rat tail suspension test,weight-carrying swim fatigue test,serum levels of albumin,ferrition,and iron,pathologic assessment of injury of small intestinal mucosa and hepatic albumin gene expression.Results:After 70% hepatectomy of the rats,their general candition was poor,the level of physical tolerance decreased,they showed a certain amount of depression,and marked changes were found in nutritional index,stress injury of small intestinal mucosa and hepatic albumin gene expression.Conclusions:A 70% hepatectomy rat model has the basic characteristics of clinical abdominal POFS, and can be used as an experimental animal model for the study of abdominal POFS.

Abstract:Abstract:Objective:To discuss the diagnosis and surgical treatment of hilar cholangiocarcinoma(HCC). Methods:The clinical data of 36 cases of HCC undergoing surgical treatment in the recent 5 years were analysed and summarized retrospectivly. Results:All of the patients in this group underwent operation. Postoperative complications occurred in 8 patients, included biliary fistula in 5, intra-abdominal infection in 2 and upper gastrointestinal bleeding in 1; all of the patients recovered with conservative treatment. There was no operative mortality.Of 20 patients who had received tumor resection , 15 were followed up.The median survival time was 1 year and 9 months, and the 1- and 3-year survival rate was 86.7%(13/15) and 13.3%(2/15) respectively. The shortest survival time was 11 months and the longest survuval time was 3 years and 2 month.Survival time was from 5 to 12 months and jaundice was relieved and life quality was improved in 16 and patients who received internal or external drainage. Conclusions:HCC should be resected energetically,and,whenever possible,internal or external drainage should be done in unresectable patients.

Abstract:Abstract:Objective:To summarize the experiences and lessons drawn from iatrogenic bile duct injury. Methods:The clinical records of 52 patients with iatrogenic bile duct injuries were studied retrospectively. Results:The injuries of 48 cases were resulted from extrahepatic bile duct operation,2 cases from partial gastrectomy and 2 cases from hepatectomy.The locations of injuries were at the juncture of common hepatic duct and common bile duct in 34 cases, the common hepatic duct in 6 cases,the common bile duct in 6 cases,the juncture of left and right hepatic duct in 4 cases，and the left and right hepatic duct each in 1 case respectively.Complete bile duct injuries were seen in 30 cases,and partial injuries in 22 cases .All patients were treated by operation. 8 cases were immediately discovered at the time of the initial operation and direct repair or end-to-end anastomosis with T-tube stent was done in 5 of the cases,direct insertion of T-tube drain in 1 case and Roux-en-Y hepaticojejunostomy in 1 case, all with good results;and in the another, a choledo choduodenostomy was performed,but re-operation by Roux-en-Y hepaticojejunostomy was done 3 years later,due to stricture of the anastomosis.For the 44 cases in which the bile duct injury was detected after the initial operation,Roux-en-Y hepaticojunostomy was done in 31 cases,hepaticoduodenostomy in 8 cases,drainage of common bile duct in 2 cases,plastic repair of common bile duct defect with jejunal flap in 1 case,hepaticojejunostomy(Longmire) in 1 case,and removal of stitches between the anterior and posterior wall of the common bile duct in 1 case.In the whole series,4 patients died,and 41 of 48 surviving patients were followed up.The excellent result rate was 82.9%,and 7 cases with poor results were cured by reoperation with Roux-en-Y cholangiojejunal anastomosis 2 months to 5 years after operation.Conclusions:The key to improvenment of treatment results of iatrogenic bile duct injury is awareness of its acurrence,early diagnosis, and eraly repair of the bile duct.The method of surgical therapy depends on the location and type of injury,and the time of detection after the injury.Roux-en-Y cholangiojejunal anastomosis gives the best results.

Abstract:Abstract:Objective:To summarize the experience of multiple primary colorectal carcinoma(MPCRC),to improve the level of diagnosis and treatment of MPCRC.Methods:The clinical data of 14 cases of MPCRC seen over a 23-year period were retrospectively analysed.Results:Amomg the 14 cases,9 cases were synchronous carcinomas and 5 cases were metachronous carcinomas.In the 14 patients,there were 37 carcinoma lesions and they were located as follows;8 lesions in the sigmoid colon,6 in the splenic flexure,6 in the transverse colon,5 in the hepatic flexure,3 in the ascending colon,9 in the desending colon,4 in the rectum and 3 in the cecum.Pathologic classification:19 were adenocarcinoma,7 were tubular adencarcinoma,7 were mucous adenocarcinoma,2 were papillary adenocarcinoma,1 was undifferentiated carcinoma,and 1 was polyp with malignant change.Duckes staging:stage B in 26 cancer lesions;stage C in 10 cancer lesions and stage D in 1 cancer lesion. A total of 21 operations were performed in the 14 patients,including hemicolectomy in 11 instances,extended hemicolectomy in 5,subtotal colectomy in 2,total colectomy in 2,and palliative resection in 1.There was no operative mortality.All 14 cases were followed up for 1~19 years;3 died of cerebral hemorrhage or natural causes.At present,11 patients have survived for 4~17 years.Conclusions:The prognosis of MPCRC is good,provided that it is detected early and operation is zealous.Metachronous carcinoma has a better result compared to synchronous carcinoma.The main operation of choice is hemicolectomy or extended hemicolectomy.Total colectomy is considered only when absolutely necessary.Regular postoperative colonoscopy followup should be done.