Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis: A systematic review and meta-analysis.

BACKGROUND: Common bile duct (CBD) stones may occur in up to 3%-14.7% of all patients with cholecystectomy. Various approaches of laparoscopic CBD exploration plus primary duct closure (PDC) are the most commonly used and the best methods to treat CBD stone. This systematic review was to compare the effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC for choledocholithiasis. DATA SOURCES: Randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) (case-control studies or cohort studies) were searched from Cochrane library (until Issue 2, 2015), Web of Science (1980-January 2016), PubMed (1966-January 2016), and Baidu search engine. After independent quality assessment and data extraction, meta-analysis was conducted using RevMan 5.1 software. RESULTS: Four RCTs and 18 NRCTs were included. When compared with choledochotomy exploration (CE) plus T-tube drainage (TTD) (CE + TTD), CE plus PDC (CE + PDC) and CE + PDC with biliary drainage (BD) (CE + PDC + BD) had a lower rate of postoperative biliary peritonitis (OR = 0.22; 95% CI: 0.06, 0.88; P < 0.05; OR = 0.27; 95% CI: 0.08, 0.84; P < 0.05; respectively) where T-tubes were removed more than 3 weeks. The operative time of CE + PDC was significantly shorter (WMD = -24.82; 95% CI: -27.48, -22.16; P < 0.01) than that of CE + TTD in RCTs. Cystic duct exploration (CDE) plus PDC (CDE + PDC) has a lower rate of postoperative complications (OR = 0.39; 95% CI: 0.23, 0.67; P < 0.01) when compared with CE + PDC. Confluence part micro-incision exploration (CME) plus PDC (CME + PDC) has a lower rate of postoperative bile leakage (OR = 0.17; 95% CI: 0.04, 0.74; P < 0.05) when compared with CE + PDC. CONCLUSION: PDC with other various approaches are better than TTD in the treatment of choledocholithiasis.

Differentiation between gastrointestinal schwannomas and gastrointestinal stromal tumors by computed tomography.

The aim of the present study was to identify computed tomography (CT) features to assist in differentiating gastrointestinal schwannomas from gastrointestinal stromal tumors (GISTs). CT images of gastrointestinal schwannomas (n=15) and GISTs (n=50) were analyzed. The absolute CT values of tumor/aorta during plain scan/arterial phase/venous phase were recorded as tumor plain scan (Tp)/aorta plain scan (Ap), tumor arterial phase (Ta)/aorta arterial phase (Aa) and tumor venous phase (Tv)/aorta venous phase (Av), respectively, and normalized CT values of the three phases were calculated as Sp=Tp/Ap, Sa=Ta/Aa and Sv=Tv/Av, respectively. The difference in tumor CT value between arterial and venous phases was calculated and recorded as Tv-a. CT data including tumor size, contour, margin, growth pattern, presence of calcification, cystic change, hemorrhage, ulceration, perilesional lymph nodes (PLNs), local invasion to surrounding structures, metastasis, ascites, vasculatures, enhancement pattern/degree, Tp/Ta/Tv and Sp/Sa/Sv were evaluated for each patient. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of the CT data to differentiate gastrointestinal schwannomas from GISTs. Compared with GISTs, gastrointestinal schwannomas more frequently demonstrated round contouring, relatively smaller tumor size, a homogeneous enhancement pattern, with the presence of PLNs and a higher level of vasculature (P<0.05), whilst the presence of cystic changes were more common in GISTs compared with gastrointestinal schwannomas (P<0.05). The Sa, Ta and Tv-a of gastrointestinal schwannomas were less compared with those of GISTs (P<0.05). The difference in margin, growth pattern, intra-tumoral calcifications and hemorrhage were insignificant (P>0.05). ROC analysis indicated that tumor size, cystic change, the presence of PLNs, tumor enhancement pattern and Sa demonstrated improved diagnostic potential compared with others [area under the curve (AUC) >0.7], amongst which cystic change demonstrated the best diagnostic ability (AUC=0.82). Size exhibited the highest sensitivity, 90%, and cystic change, Sa exhibited the best specificity, 87%. Quantitative analysis indicated that certain features aided the differentiation between gastrointestinal schwannomas and GISTs using CT imaging.

Screening of RB1 gene mutations in Chinese patients with retinoblastoma and preliminary exploration of genotype-phenotype correlations.

PURPOSE: Retinoblastoma (RB) sets the paradigm for hereditary cancer syndromes, for which medical care can change depending on the results of genetic testing. In this study, we screened constitutional mutations in the RB1 gene via a method combining DNA sequencing and multiplex ligation-dependent probe amplification (MLPA), and performed a preliminary exploration of genotype-phenotype correlations. METHODS: The peripheral blood of 85 retinoblastoma probands, including 39 bilateral and 46 unilateral, was collected, and genomic DNA was extracted. DNA sequencing was conducted first. MLPA analysis was applied for patients with bilateral RB with negative sequencing results and unilateral probands whose age at diagnosis was less than 1 year old. RESULTS: Thirty-four distinct mutations were identified in 40 (47.1%) of the 85 probands (36 bilateral and four unilateral), of which 20% (8/40) was identified by MLPA. The total detection rate in bilateral cases was 92.3% (36/39). Of the total mutations identified, 77.5% (31/40) probands with a mean age of 10.7 months at diagnosis had null mutations, and 22.5% (9/40) with a mean age of 13.5 months at diagnosis had in-frame mutations. Of the 31 probands with null mutations, bilateral RB accounted for 96.8% (30/31). Of the nine probands with in-frame mutations, 66.7% had bilateral RB. There were seven new mutations of RB1 identified in this report, including six null mutations and one missense mutation. Clinical staging of the tumor did not show obvious differences between patients with null mutations and in-frame mutations. CONCLUSIONS: Our results confirm that the type of mutation is related to age of onset and the laterality, but not staging of the retinoblastoma tumor. MLPA is a reliable method for detecting gross deletion or duplication of the RB1 gene. The combination of sequencing and MLPA improves the clinical diagnosis of RB.

[Characteristics of RB1 gene mutations in Chinese patients with retinoblastoma].

OBJECTIVE: To study the characteristics of RB1 gene mutations in Chinese patients with retinoblastoma. METHODS: Peripheral blood samples of 35 patients with retinoblastoma were collected and genomic DNA was extracted. Multiplex PCR sequencing was carried out to identify RB1 gene mutations. Parents of 6 probands with RB1 mutations were also enrolled to identify the origins of mutations. RESULTS: Fourteen patients were found to have carried germline mutations, among whom 11 had bilateral tumors and 3 had unilateral tumors. Sixteen germline mutations were identified, among which 13 were pathological, which included 5 nonsense mutations (c.1072C > T, c.1333C > T, c.1363C > T, c.1399C > T, c.2501C > A), 4 missense mutations (c.920C > T, c.1346G > A, c.1468G > A, c.1861C > A), 2 frameshift mutations (c.1947delG, c.2403delA) and 2 large fragment deletions (c.139_168 del30, exon 8 deletion). Three were non-pathological mutations, including 2 intronic mutations (c.540-23 dupT, c.2664-10T > A) and 1 silent mutation (c.2192T > A). One carrier was identified among the 6 parents of children carrying a RB1 mutation. CONCLUSION: Screening for RB1 gene mutations in patients with bilateral or unilateral retinoblastoma can help to identify heritable mutations and provide important clues for genetic counseling and clinical management.

Effect of endoscopic retrograde cholangiopancreatography combined with laparoscopy and choledochoscopy on the treatment of Mirizzi syndrome.

BACKGROUND: Mirizzi syndrome is often difficult to diagnose before surgery, and is often accompanied by extensive adhesions in the cystohepatic (Calot's) triangle and the difficulty of separating tissue can lead to bile duct injury and other intraoperative and postoperative complications. The aim of this study is to investigate minimally invasive means of treating different types of Mirizzi syndrome. METHODS: Fifty-four patients diagnosed with Mirizzi syndrome were enrolled between July 2004 and May 2012. The diagnosis was further refined according to the Csendes classification. Twenty-seven patients were treated with a combination of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopy, and choledochoscopy (tripartite approach group); type I in 16 cases, type II five cases, and type III in six cases. Twenty-seven patients were treated with laparotomy (routine approach group); type I in 19 cases, type II in six cases, and type III in two cases. The operation time, blood loss during operation, initiation of intake time of food, postoperative complications, and hospital stays were compared between two groups. RESULTS: All patients were successfully cured in surgical operation. The operation time was (49.7 ± 27.5) minutes, blood loss during operation was (21.1 ± 15.9) ml, initiation of intake time of food was (6.3 ± 2.7) hours, postoperative complications were with two cases (7%, 2/27), and hospital stay was (6.7 ± 1.8) days in the tripartite approach group. In the routine approach group, the operation time was (85.1 ± 20.3) minutes, blood loss during operation was (150.3 ± 20.5) ml, initiation of intake time of food was (36.6 ± 10.3) hours, postoperative complications were with three cases (11%, 3/27), and hospital stay was (10.9 ± 3.4) days. Except for postoperative complications, there were significant differences in the operation time, blood loss during operation, initiation of intake time of food, and hospital stays between two groups (P < 0.05). CONCLUSIONS: ERCP combined with laparoscopy and choledochoscopy is a safe and effective means of treating Mirizzi syndrome. The approach is minimally invasive and patients recover quickly requiring only brief hospitalization.

COX-2 inhibition improves immune system homeostasis and decreases liver damage in septic rats.

OBJECTIVE: To evaluate cyclooxygenase-2 (COX-2) inhibition by NS-398 in septic rats with respect to immunologic derangements and hepatic damage. METHODS: Six sham rats (Sham), 24 rats that underwent experimentally induced sepsis using cecal ligation and puncture (CLP), and 24 rats that underwent induced sepsis after treatment with NS-398 (NS-398), were compared. Sham rats were immediately sacrificed. Six each of CLP and NS-398 animals were sacrificed at 3, 6, 12, and 24 h after induction of sepsis. From each rat was obtained liver for COX-2 mRNA copy number determination and blood for quantification of alanine transaminase (ALT), aspartate aminotransferase (AST), interleukin 10 (IL-10), interleukin 6 (IL-6), and tumor necrosis factor alpha (TNFalpha) levels, and CD4:CD8 ratios. RESULT: Sham rats had a lower COX-2 mRNA copy number than NS-398 rats, which had a lower copy number than CLP rats. CLP and NS-938 rats had IL-10 and IL-6 levels above Sham levels. NS-938 rat IL-10 levels were greater and IL-6 levels less than those of CLP rats. For CLP rats, TNF production sharply declined and then increased above Sham levels; NS-398 rat TNF production was consistently mildly elevated above Sham levels. CD4:CD8 ratios sharply dropped over time; NS-398 showed a more modest decline. CLP rats showed unrelenting climbs in AST and ALT values; NS-398 rat levels peaked at 6 h and returned to normal after 12 h; the biochemical evidence of protection against septic liver damage was also seen morphologically, with ultrastructural and histologic normalization of nuclear appearances 12 h after sepsis induction with NS-398 pretreatment. CONCLUSION: Septic rats given the COX-2 inhibitor NS-398 showed amelioration of cytokine and cellular immunologic imbalances and decreased liver injury.

Treatment of patients with severe sepsis using ulinastatin and thymosin alpha1: a prospective, randomized, controlled pilot study.

BACKGROUND: Tradition treatment of sepsis and new therapies, including high dose corticosteroids and non-steroidal anti-inflammatory drugs, have proven unsuccessful in improving survival. This study aimed to evaluate the potential efficacy of immunomodulating therapy using Ulinastatin (UTI) plus Thymosin alpha1 (Talpha1) for improving organ function and reducing mortality in patients with severe sepsis. METHODS: A prospective study was carried out with randomized and controlled clinical analysis of 114 patients conforming to the enrollment standard. All patients had severe sepsis and received standard supportive care and antimicrobial therapy. Fifty-nine patients were also administered UTI plus Talpha1 (defined as Group A), 55 patients were given a placebo (defined as Group B). Clinical parameters were determined by evaluation with the Acute Physiology and Chronic Health Evaluation II (APACHE II), multiple organ failure (MOF) and the Glasgow Coma Scores (GCS) on entry and after therapy on the 3rd, 8th, and 28th day. By flow cytometery and ELISA lymphocyte subsets and cytokines were analyzed. Survival analysis was determined by the Kaplan-Meier method at 28, 60, and 90 days. RESULTS: Based on comparison of the two groups, patients in Group A exhibited a better performance in organ failure scores which was noticeable soon after initiation of treatment. Patients in Group A also demonstrated a better resolution of pre-existing organ failures during the observation period. After initiation of treatment, significant improvements in the CD(4)(+)/CD(8)(+) ratio, a quicker balance between proinflammatory mediators such as tumor necrosis factor alpha, interleukin 6 and anti-inflammatory cytokines including interleukin 4 and interleukin 10 were found. This was followed by cumulative survival increases of 17.3% at 28 days, 28.9% at 60 days, and 31.4% at 90 days in Group A. The reduction in mortality was accompanied by a considerably shorter stay in the ICU and a shorter length of supportive ventilation, antimicrobial and dopamine therapy. CONCLUSION: UTI plus Talpha(1) has a beneficial role in the treatment of severe sepsis.

[Over 55 years-old live-related donor kidney transplants: a report of 12 cases].

OBJECTIVE: To evaluate the risk factors of the over 55-year-old donor and the safety and efficacy of the donor, and the recipient with the immediate and long-term of the kidney. METHODS: The living-related donor kidney transplantation in 15 cases was performed in our unit from October 1999 to April 2002. Of these, 12 donors were over 55 with age ranging from 55 to 73 years-old and mean age of 62, 75 years. 5 donors were male and 7 were female. Father in 5 cases and 6 and 1 were mother and grandmother, respectively. The donors were evaluated depending on general state of health, hypertension, diabate and important organa in condition; and renal function by creatinine (Cre), creatinine clearance (Ccr), Glomerular filtration rate (GFR), B ultrasound and renal arteriograph prior to operation. The all receipients with ages ranging from 14 to 46 years with end-stage renal diseases (ESRD) from and their mean age was 32.9 years. The donor' left nephrectomy was performed in 10 cases and right nephrectomy in 2. Warm-ischemia time was from 70 s to 170 s (mean time, 92 s). Cold-ischemia time was from 60 minutes to 120 minutes and mean 84 minutes. The follow-up is from 12 to 42 months and mean 20, 84 months. RESULTS: All the 12 donors were perfectly recovered during operation and postoperation. During their 11-day stay in the hospital no complications was observed. The donor' creatinine was raised to about 12 to 34 micro mol/L (mean, 22 micro mol/L). One recipient died from lung infection at 28 days postoperative and 1 died due to liver failure with normal graft function after transplanted 6 months and yet one recipient with delayed graft function had recovered by 12 times dialysis. The remain recipient had a better recovered. CONCLUSION: Aged (>or= 55 years-old) donor renal transplantation can be carried out as the poor supply of can be used kidney but must to controled the indication and the prepare to be accomplished seriously.