Abstract:Objective: To compare the efficacies of anatomic and nonanatomic hepatectomy for hepatolithiasis. Methods: The clinical data of 61 patients with hepatolithiasis undergoing hepatectomies were retrospectively analysed. Using a prospective, cohort-controlled design, 31 patients with hepatolithiasis underwent anatomic hepatectomy and the other 30 patients with hepatolithiasis underwent nonanatomic hepatectomy. The operative time, intraoperative blood loss, incidence of postoperative complications, postoperative aspartate transaminase (AST) level, postoperative drainage volume, time to flatus, length of postoperative hospitalization and residual stone rate of the two groups were compared. Results: There were no significant differences in the general condition, organs function, stone distribution, anatomic variation and scope of liver resection between the two groups before operation (all P>0.05). The intraoperative blood loss, incidence of postoperative complications, AST level and drainage volume were significantly reduced but the operative time was significantly prolonged in anatomic hepatectomy group compared with nonanatomic hepatectomy group (all P<0.05). No differences between the two groups were noted with regard to the time span for flatus, length of postoperative hospital stay and residual stone rate (all P>0.05). Conclusion: Anatomic hepatectomy has the advantages of minimum surgical trauma as well as reduced exudation and less complications. Although it currently requires longer operative time than nonanatomic procedure, its potentiality for improvement is possible. So it deserves to be widely performed.

Abstract:

Objective: To assess the clinical application value of biliary stent placement for hilar cholangiocarcinoma via percutaneous transhepatic biliary drainage (PTBD) or endoscopic retrograde cholangiopancreatography (ERCP). Methods: The clinical data of 75 patients with hilar cholangiocarcinoma undergoing metal biliary stent placement were retrospectively analyzed. Results: In PTBD group, stent placement was performed in 29 cases and stents were successfully placed in 26 of the 29 cases (89.7%), the incidence of complications was 6.5%, and the median survival time was 26 weeks respectively. In ERCP group, stents were successfully placed in 38 of the 44 cases (86.4%), the incidence of complications was 13.6%, and the median survival time was 28 weeks respectively. The median survival time of both the unilateral placement group (29 cases) and bilateral placement group (35 cases) was 28 weeks. Conclusion: Biliary stent placement for hilar cholangiocarcinoma can achieve demonstrable efficacy either by PTBD or ERCP. Unilateral placement is preferred when using PTBD, while bilateral placement is recommended when performing ERCP.

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Objective: To investigate the clinical value and safety of choledochoscopy combined with holmium laser lithotripsy through T-tube tract for treatment of retained stones in the intra- or extrahepatic bile ducts. Methods: The clinical data of 300 patients with retained stones in the intra- or extrahepatic bile ducts from February 2010 to June 2011, who underwent the combination treatment of choledochoscopy and holmium laser lithotripsy through the postoperative T-tube tract, were retrospectively analyzed. Results: Two hundred and ninety-two patients were completely stone-free after the holmium laser lithotripsy in combination with choledochoscopy. The lithotripsy procedures took 4 to 12 min and were performed one to 5 times. Thirteen patients underwent lithotripsy 5 times. Lithotripsy failed in 8 patients with stones in the hepatic grade III or IV bile ducts, of whom, stone extraction was successful in 6 cases and failed in 2 cases by plasma shock wave lithotripsy after 2 months of tube retention. A total of 568 stones were fragmented and the clearance rate was 95.2% (292/300). No severe complications, such as massive biliary bleeding, perforation, biliary wall burns or biliary fistula occurred during operation, and 15 cases experienced low grade fever after operation. Follow-up was performed in 268 patients for 6 to 18 months with an average period of 10 months, and no recurrent or residual stones or biliary strictures were noted. Conclusion: Choledochoscopy combined with holmium laser lithotripsy can significantly improve the therapeutic effect on retained intra- or extrahepatic stones, and is a simple, safe and effective technique which deserves to be widely used in clinical practice.

Abstract:Objective: To investigate the techniques and efficacy of the combined laparoscopic and endoscopic procedures in management of gallstones accompanied with common bile duct stones. Methods: The clinical data of 168 patients with concomitant gallbladder and common bile duct stones undergoing the combined treatment involving two procedures (laparoscopy plus choledochoscopy or duedenoscopy) or three procedures (laparoscopy plus choledochoscopy and duodenoscopy) during recent 6 years were retrospectively analyzed. Results: One hundred and twenty-six patients underwent the two combined procedures and three of them were converted to open surgery. Forty-two patients underwent the three combined procedures and two of them were comverted to open operation. There were no residual stones or serious complications, such as bleeding, biliary fistula or intra-abdominal infection, and no death occurred after operation. One hundred and twenty-four patients were followed up for 6 months, and no long-term complications, such as biliary stricture, were seen. Conclusion: The combined laparoscopic-endoscopic procedures are safe and feasible for concomitant gallstones and common bile duct stones, and reflect the minimally invasive orientation in modern surgical practice.

Abstract:Objective: To investigate the diagnosis and treatment of adult congenital bile duct cysts (BDC). Methods: The clinical data of 53 adult patients with congenital BDC admitted from January 1996 to May 2012 were retrospectively analyzed. Results: All patients underwent operation. Of the patients, total cyst excision with Roux-en-Y hepaticojejunostomy was performed in 39 cases with types Ia, Ib and Ic BDC as well as in 4 cases with type II BDC, while another 3 cases with type Ia BDC underwent partial cyst excision plus Roux-en-Y hepaticojejunostomy; one case with type IVa BDC underwent left lateral hepatic lobectomy, total cyst excision, hepatic ducts plasty and Roux-en-Y hepaticojejunostomy, and another case of type IVa BDC underwent total cyst excision plus Roux-en-Y hepaticojejunostomy; one case with type V BDC underwent left intrahepatic bile duct cyst excision. Of the two patients who showed malignant change, one case underwent resection of the malignant cysts and dissection of local metastatic lymph nodes, and another underwent cyst excision and left intrahepatic bile duct tumor resection. Forty-two of the 53 patients were followed-up for 6 months to 3 years. All patients with benign disease were in excellent condition after surgery. Of the two cancer patients, one case died of tumor recurrence and multi-system organ failure 26 months after peration, and the other case had tumor recurrence and liver metastasis after 26 months and then underwent re-operation that included left hemihepatectomy, S5 resection and Roux-en-Y hepaticojejunostomy, but finally died two months after re-operation due to the tumor progression and multi-system organ failure. Conclusion: For adult congenital BDC, the selection of surgical procedure may significantly influence the final results, and the different clinical types require different surgical methods.

Abstract:Objective: To explore the clinical efficacy and safety of laparoscopic surgery for acute cholecystitis (AC) in elderly patients. Methods: From January 2006 to May 2012, 138 elderly patients with acute cholecystitis were randomly assigned to undergo laparoscopic cholecystectomy (laparoscopic group, n=70) or open cholecystectomy (open surgery group, n=68). The operative time, time span for bowel function recovery, length of postoperative hospital stay and incidence of complications of the two groups were compared. Results: Except for the similarity in the intraoperative blood loss (P>0.05), the operative time, time to intestinal function recovery and length of postoperative hospital stay were all significantly reduced in laparoscopic group compared with open surgery group (all P<0.05). The incidence of complications of laparoscopic group was also significantly lower than that of open surgery group (P<0.05). Conclusion: Laparoscopic surgery has ideal effect for acute cholecystitis in the elderly, and the successful treatment depends on the choice of the surgery timing and surgical expertise.

Abstract:

Objective: To investigate the morbidity and clinical features of cholelithiasis in recent years in Tangshan region. Methods: The clinical data of 6 417 patients with cholelithiasis confirmed by surgery between June 2005 and June 2011 were retrospectively analyzed. Results: The total number of cholelithiasis patients showed an increasing trend over the years (P<0.01), in which cholecystolithiasis accounted for 85.29%. For the entire group of cholelithiasis patients, the male to female ratio was 1:1.65, and cholecystolithiasis was predominant in both sexes. The peak age in the cases of gallbladder stones was 41–50 years, and in those of extrahepatic as well as those of intrahepatic bile duct stones it was 51–60 years. As for the occupational composition ratio, farmers (34.19%) and office staffs (36.82%) were the main sufferers of gallbladder stones at the time of this survey, and farmers accouted for the majority of intrahepatic bile duct stones (80.00%). The proportion of farmers in the cholecystolithiasis population showed a rising tendency (P<0.01). Conclusion: Cholecystolithiasis is the most important type of cholelithiasis in Tangshan, and farmer and office staffs are the main sufferers of this disease.

Abstract:Objective: To analyze the indications, surgical techniques and complications of laparoscopic transcystic common bile duct exploration (LTCBDE). Methods: The literature related to LTCBDE from January 2000 to January 2012 was retrieved using Chinese Biomedical Journal Literature Database, Academic Dissertation Database and Meeting Papers Database were collected and analyzed. Results: Seventeen papers (1 186 cases) were selected, in which the operations were successfully performed in 1 142 (96.29%) cases, the average operative time was (114.59±29.11) min, average length of hospital stay was (5.17±1.8) d, and postoperative complications occurred in 21 (1.84%) cases. Conclusion: As a minimally invasive surgery, LTCBDE has the advantages of being safe, effective, convenient and economical. Indications for LTCBDE should be expanded in clinical practice and it is the first choice for secondary cholangiolithiasis with number of stones less than three, diameter of cystic duct larger than 4 mm and diameter of stone less than 5 mm.

Abstract:

Objective: To investigate the relations of vascular endothelial growth factor C (VEGF-C) expression and micro-lymphatic vessel density (MLVD) in cholangiocarcinoma tissues with the clinicopathologic features and prognosis of cholangiocarcinoma. Methods: The VEGF-C expression and D2-40 positive MLVD in 47 cases of cholangiocarcinoma tissues, 40 cases of adjacent non-tumor biliary tissues and 15 cases of normal biliary tissues were detected by immunohistochemical staining. The correlation between VEGF-C and their relations with clinicopathological characteristics and prognosis were analyzed. Results: The positive expression rate of VEGF-C in cholangiocarcinoma tissues was significantly higher than those in adjacent non-tumor and normal biliary tissues (both P<0.05), and the MLVD in both cholangiocarcinoma and adjacent non-tumor biliary tissues were significantly higher than that in normal biliary tissues (both P<0.05). The VEGF-C expression and MLVD were closely related to the depth of invasion, TNM stage and lymphatic metastasis of cholangiocarcinoma (all P<0.05), moreover, MLVD was also relevant to the differentiation degree of cholangiocarcinoma (P<0.05). MLVD in the VEGF-C positive cholangiocarcinoma tissues was significantly higher than that of the negative ones (P<0.05), and the VEGF-C expression was positively correlated with MLVD (r=0.615, P<0.05). The patients with negative VEGF-C expression had better prognosis than those with positive VEGF-C expression (P<0.05), and MLVD in the cholangiocarcinoma tissues of the recurrent cases was significantly higher than that of the non-recurrent ones (P<0.05); further, MLVD showed a negative correlation with the survival time of the patients (r=–0.542, P<0.05). Conclusion: VEGF-C expression and MLVD are closely related to the lymphatic metastasis and prognosis of cholangiocarcinoma. VEGF-C may potentially become one of the effective indicators for predicting lymphatic metastasis in patients with cholangiocarcinoma.

Abstract:Objective: To investigate the effect of octreotide on the subcutaneously implanted tumor mass derived from human cholangiocarcinorma QBC939 cells in nude mice and its possible mechanism. Methods: Twelve nude mice bearing tumor mass composed of human cholangiocarcinorma cancer QBC939 cells were equally randomized into the experimental group and control group. Mice were given respectively octreotide of 100 μg/(kg·d) or normal saline of the same volume by subcutaneous injection with a once-daily regimen for 4 weeks. Mice were sacrificed 24 h after the last dose injection and the tumor masses were resected en bloc. The volumes and weights of the tumors were measured, and tumor inhibition rate of the experiment group was calculated. The expression of hypoxia-inducible factor 1α (HIF-1α) and microvessel density (MVD) in tumor tissues of both groups were detected by immunohistochemical method. The apoptosis in tumor tissues of both groups was detected by TUNEL assay. Results: The size and weight of the implanted tumor in experiment group were significantly reduced compared with control group [(1934.85±272.88) mm3 vs. (2834.63±521.86) mm3; (1.77±0.23) g vs. (2.44±0.65) g] (both P<0.05), and the tumor inhibition rate of experiment group was 29.20%. The expression level of HIF-1α and MVD in the tumor tissues of experiment group were significantly less than those of control group [(0.2605±0.0406) vs. (0.3284±0.1008); (13.61±1.87) vs. (17.44±2.24)] (both P<0.05). The apoptotic index (AI) of tumor issues in experiment group was significantly higher than that in control group (P<0.05). Conclusion: Octreotide has inhibitory effect on the growth of implanted tumor of human cholangiocarcinoma in nude mice. The mechanism may be relevant to induction of apoptosis and inhibition of antiangiogenesis in tumor cells.

Abstract:Objective: To investigate the protective effect of sinomenine against liver injury caused by obstructive jaundice in rats. Methods: Thirty-two rats were equally randomized into sham operation group, model group, and low- and high-dose sinomenine treatment group. Except for the sham operation group, rats in all other groups underwent 1igation of the common bile duct. From the first day after surgery, rats of the two sinomenine treatment groups were given sinomenine (40 or 80 mg/kg) daily by gavage administration, and rats of the sham operation group and model group were given normal saline of the same volume instead. All rats were sacrificed on the postoperative day 8, the serum levels of total bilirubin (TBIL), direct bilirubin (DBIL), alanine aminotransferase (AST) and aspartate aminotransferase (ALT) were measured in blood samples drawn from their abdominal aortas, their right hemi-livers were used for determination of the contents of malondialdehyde (MDA) and myeloperoxidase (MPO), and total antioxidant capacity (T-AOC) by using commercial kits, as well as the gene expression of transforming growth factor β1 (TGF-β1) by real-time PCR technique; left hemi-livers were used for histopatological examination and detection of TGF-β1 protein expression through H&E and histoimmunochemical staining, respectively. Results: Except for the sham operation group, the rats’ liver tissues of all other groups presented varying degrees of pathological changes, and among them, the pathological changes of both sinomenine treatment groups were milder than those of the model group. Compared with the sham operation group, in all other groups, the serum levels of TBIL, DBIL, ALT and AST increased significantly, the liver tissue contents of MDA and MPO increased but T-AOC decreased significantly, and both gene and protein expression of TGF-β1 in liver tissues increased significantly (all P<0.05). The changes of above listed parameters were all more evident in model group than those in the two sinomenine treatment groups (all P<0.05), but all had no significant differences between the two sinomenine treatment groups (all P>0.05). Conclusion: Sinomenine has protective effect against liver damage caused by obstructive jaundice, and the mechanism may be probably related to its reducing the expression of TGF-β1.

Abstract:Objective: To investigate the photodynamic effect of photosensitizer PsD-007 on human hepatocellular HepG2 cells in vitro and its mechanism. Methods: HepG2 cells were divided into three photodynamic treatment groups, which were incubated with 10, 20 and 30 μg/mL PsD-007 respectively, and were all irradiated with visible light at 630 nm (energy density was 6.0 J/cm2 and exposure time was 2 min) during incubation. Meanwhile, three control groups were used, namely, the blank control group, irradiation alone group and dark cytotoxic group (treated with 30 μg/mL PsD-007 alone without irradiation). Twenty-four hours after experiment, the cell survival rates of each group were detected by MTT assay, and their apoptosis cells were observed by using apoptosis detection kit and fluorescence microscopy. The gene and protein expression of caspase-3, caspase-8 and P53 in cells of the two photodynamic treatment groups (20 and 30 μg/mL PsD-007) and three control groups were determined by Real-time PCR and Western blot method, respectively. Results: Compared with the blank control group, the cell survival rates of the three photodynamic treatment groups significantly decreased in a concentration-dependent manner (all P<0.05), while those of the irradiation alone group and dark cytotoxic group showed no obvious change (P>0.05). The fluorescence microscopic observation revealed that the late apoptotic and necrotic cells remarkably increased in each photodynamic treatment group compared with the three control groups. The Real-time PCR and Western blot results showed that both gene and protein expression levels of caspase-3, caspase-8 and P53 in the cells of the two photodynamic treatment groups were significantly higher than those of the three control groups. Conclusion: PsD-007 has photodynamic cytotoxic effect on HepG2 cells in vitro, and the mechanism is probably related to the regulation of caspase and p53 expression that thereby induces the cell apoptosis and necrosis.

Abstract:

Objective: To investigate the growth inhibitory and apoptosis-inducing effect of icariin on hepatocellular carcinoma SMMC-7721 cells. Methods: The proliferation of SMMC-7721 cells after exposure to different concentrations of icariin (0, 6.25, 12.5, 25, 50, 100, 200, 400 and 800 μg/mL) for different time periods (24, 48 and 72 h) was determined by MTT assay. The cell cycle and apoptotic changes as well as the protein expression of PCNA, Bcl-2 and Bax in SMMC-7721 cells after incubation with different concentrations of icariin for 48 h were detected by using flow cytometry and Western blot analysis, respectively Results: Compared with the control group (0 μg/mL), each concentration of icariin significantly inhibited the proliferation of SMMC-7721 cells, and this effect acted in a time- and concentration-dependent manner (all P<0.05). In a concentration-dependent manner, icariin showed the effects of G0/G1 cell cycle arrest and apoptosis induction, up-regulating PCNA and Bcl-2 expression, and down-regulating Bax expression (all P<0.05). Conclusion: Icariin has proliferation inhibitory and apoptosis-inducing effect on SMMC-7721 cells.

Abstract:Objective: To establish a mice model of liver cancer suitable for microwave ablation. Methods: C57BL/6J mice were randomly divided into 4 groups (n=10 in each group) and subcutaneously injected with Hepa1-6 cells of different numbers (5×105, 1×106, 2×106 and 5×106) respectively, and then the tumor formation rates in the 4 groups were compared. Next, the ideal cell number for tumor formation was selected to establish the mouse models once again. When mean tumor diameter reached 8–10 mm, the tumor-bearing mice were randomly divided into 4 groups (n=10 in each group) to undergo microwave thermal tumor ablation. The temperature at the edge of the tumor was maintained at 60, 55, 50, and 45℃ respectively, and the ablation time was 3 min. The complete ablation rate and pathological changes of tumor among the 4 groups were compared. Results: The group with 2×106 Hepa1-6 subcutaneous injection had a high tumor formation rate and was suitable for ablation. Except for 60℃ ablation group, in other 3 groups, the 55℃ ablation group had the highest complete ablation rate and the lowest recurrence compared with the other two groups (P<0.05). Conclusion: 55℃× 3 min microwave ablation is feasible and effective for Hepa1-6 cells subcutaneously implanted model of liver cancer in mice.

Abstract:Objective: To summarize the recent clinical experience of liver transplantation using liver donated after cardiac death (DCD). Methods: The clinical data of 4 patients with end-stage liver disease undergoing DCD liver transplantation from September 2011 to February 2012 were retrospectively analyzed. Results: All 4 patients underwent successful liver transplantation without delayed liver function recovery. There were no complications such as bile leakage, acute rejection, stress ulcer bleeding, renal function damage or fulminant hepatitis. Only one patient developed wound infection, partial necrosis of segment VII and VIII, and right subdiaphragmatic haematocele, which were cured through the enhanced anti-infection treatment, frequent dressing changes and percutaneous drainage. Conclusion: DCD orthotropic liver transplantation has proven effectiveness, and offers a potential solution to the donor shortage in China. The effective implementation of DCD liver transplantation still needs vigorous promotion, as well as multi-sectoral and multidisciplinary cooperation.

Abstract:Objective: To investigate the diagnosis and treatment of cardiac achalasia in children. Methods: The clinical data of 34 pediatric patients with achalasia admitted between September 2001 and September 2011 were retrospectively analyzed. All patients presented with typical manifestations, such as dysphagia, vomiting after feeding and “bird’s beak” narrowing of the distal esophagus on barium esophagogram. All patients underwent modified transabdominal Heller’s myotomy plus Dor’s fundoplication. Results: All the 34 patients were discharged from hospital 7 to 14 days after surgery and were able to tolerate semi-liquid diet before discharge. One patient was lost to follow-up while the other 33 patients were followed up for 2 months to 9 years and 7 months. The symptoms such as dysphagia, vomiting after feeding and gastroesophageal reflux were not present in any of the patients. The postoperative barium meal examination results showed that esophageal lumen in all patients were smooth, the narrow segment expanded and the barium passed easily into the stomach. Except for one child with trisomy 21, the growth and development of all the other cases were similar to their age-matched peers. Conclusion: Modified Heller’s myotomy has noticeable effectiveness on cardiac achalasia in children, and the additional Dor’s fundoplication is an important procedure for prevention of gastroesophageal reflux after esophagocardiomyotomy.

Abstract:Objective: To discuss the diagnosis and treatment of incidental gallbladder cancer (IGC) during laparoscopic cholecystectomy. Methods: The clinical data of 23 patients with IGC admitted to our hospital from January 1998 through January 2007 were retrospectively analyzed. Results: Fifteen patients were identified as gallbladder cancer by intraoperative frozen-section examination, 13 of them were converted to open radical resection; 8 patients were diagnosed by postoperative pathology, 7 of whom underwent a secondary open surgery. The postoperative 5-year survival rate of the entire group was 78.3%, and the prognosis of IGC was closely related to the TNM stages. Conclusion: Incidental gallbladder cancer is often in early stage, attention should be paid to the specimen examination and intraoperative fast frozen-section in the high-risk patients. The extended radical operation is preferred for patients with T1b–T2 tumors, and for the advanced stage cases, whether to perform radical operation or palliative procedures may depend on the individual’s condition.

Abstract:Objective: To investigate the common difficulties and solutions in transumbilical single-port laparoscopic appendectomy. Methods: The clinical data of 86 patients with appendicitis undergoing transumbilical single-port laparoscopic treatment in Leliu Hospital from June 2009 to February 2012 were retrospectively analyzed. Results: The difficulties encountered during operation included 15 cases of intra-abdominal abscess, 6 cases with difficulties in appendix exposure, 5 cases with difficulties in appendiceal stump treatment and 3 cases of abdominal adhesions. Single-port laparoscopic appendectomy was successfully performed in 78 cases, 8 cases were converted to conventional laparoscopic operation and there was no open conversion. The average operative time was (41.39±13.76) min and the length of postoperative hospital stay was (4.82±2.16) d. No complications such as postoperative hemorrhage and wound infection occurred in any of the patients. Conclusion: Transumbilical single-port laparoscopic appendectomy is safe and feasible. The appropriate methods and techniques should be taken according to the appendiceal lesions when it is difficult to perform single-port laparoscopic appendectomy, so as to effectively prevent complications.

Abstract:

Objective: To investigate the serum level of serum high mobility group protein 1 (HMGB1) in patients with acute appendicitis and its diagnostic significance. Methods: The serum HMGB1 levels of 40 subjects undergoing health maintenance examination (group A) and 129 suspected acute appendicitis patients were detected by using quantitative ELISA kit, and their white blood cell (WBC) count and C-reactive protein (CRP) level were also determined. According to the surgical findings and postoperative pathological results, the 129 suspected cases were distinguished into group B (15 cases without appendicitis), group C (63 cases of simple acute appendicitis) and group D (51 cases of acute suppurative, gangrenous, perforated appendicitis or periappendiceal abscess). The differences in above mentioned indexes among the groups were compared and the receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic efficiency of each index for acute appendicitis. Results: The WBC count, serum level of HMGB1 and CRP markedly increased in group C and group D compared with group A or group B, and all differences had statistical significance (all P<0.05); further, all the values of the indexes in group D were significantly higher than those in group C (all P<0.05). ROC curve analysis showed that area under the curve (AUC) of WBC, CRP and HMGB1 were 0.729, 0.811 and 0.850 respectively, and HMGB1 had the highest diagnostic efficiency (both P<0.05). Conclusion: Patients with acute appendicitis have a pronounced elevation of serum HMGB1 level, thus it could be reasonably expected to become an important assistant diagnostic index for acute appendicitis and severity of this disease.

Abstract:

Patients with obstructive jaundice are at increased risk for perioperative complications and mortality due to a general immune dysfunction. This paper, based on the recent literature, is intended to provide an overview of the alterations in immune function of the patients with obstructive jaundice and their clinical relevance.

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