Suppression of liver regeneration affects hepatic graft survival in small-for-size liver transplantation in rats.

AIM: Small-for-size liver transplantation (SFSLT) often results in hepatic graft failure and decreased survival. The present study was aimed to investigate the possible mechanism of hepatic graft failure in SFSLT in rats. METHODS: Rat models of full-size orthotopic liver transplantation, 50% partial liver transplantation and 30% partial liver transplantation were established. Proliferative responses of the hepatic graft were evaluated by immunohistochemical staining and western blotting. Apoptosis-, inflammatory-, anti-inflammatory- and growth factor-related genes were screened by quantitative reverse transcription polymerase chain reaction. Activities of transcription factors of AP-1 and nuclear factor (NF)-κB were analyzed by electrophoretic mobility shift assay. RESULTS: A 30% partial liver transplant not only resulted in marked structural damages to the hepatic graft, but also showed the lowest 7-day survival rate. In addition, sup pressed expressions of proliferating cell nuclear antigen (PCNA) and cyclin D1 by immunohistochemical staining and decreased expressions of cyclin D1 and p-c-Jun by western blotting were detected. Downregulated expressions of Bcl-2, Bcl-XL, interleukin (IL)-6, IL-10, IP-10 and CXCR2, upregulated expression of tumor necrosis factor-α, and decreased levels of AP-1 and NF-κB were also found following 30% partial liver transplantation after reperfusion. CONCLUSION: Liver regeneration is remarkably suppressed in SFSLT. The significant changes of intra-graft gene expression described above indicated that ischemia reperfusion injury would be severe in 30% partial liver transplantation. The capability of liver regeneration secondary to ischemia reperfusion injury might determine hepatic graft survival in SFSLT.

Multi-visceral resection of malignant tumors with left-sided portal hypertension.

BACKGROUND/AIMS: Left-sided portal hypertension (LSPH) is an uncommon clinical syndrome which may lead to bleeding from isolated gastric varices and pancreatitis is the most common etiology. Despite the particular rare incidence of LPSH caused by malignant tumor, the optimal management remains undefined. METHODOLOGY: From January 2006 to December 2009, a total of 8 patients of left-sided portal hypertension caused by malignancies were admitted into the department of surgery of our hospital. Medical records of those patients were retrieved and analyzed, including etiologies, clinical presentations, diagnostic methods and surgical approaches. RESULTS: Of current series, pancreatic tumors (5/8) and retroperitoneal tumors (3/8) were the primary etiologies. Those patients mainly presented with upper gastrointestinal bleeding or irregular left upper abdominal pain and isolated gastric varices became important clinical evidence. All those patients were performed multi-visceral resection. No recurrent upper gastrointestinal bleeding occurred during the follow-up period and three patients died 6, 18 and 21 months postoperatively. CONCLUSIONS: Although LSPH caused by malignant tumor is uncommon and difficult to deal with, deliberate evaluation of preoperative CT images will ensure the success of an aggressive multi-visceral resection and the prognoses in those patients are relatively promising.

Liver transplantation as a treatment for complicated bile duct injury.

BACKGROUND/AIMS: Bile duct injury during cholecystectomy can be successfully managed by biliary reconstruction in the majority of patients. However it can also lead to potentially severe complications with unpredictable long-term results and in fact a proportion of these cases may even require liver transplantation. METHODOLOGY: In recent years, two cases of complicated bile duct injury after the failure of traditional surgical interventions were admitted to our hospital. Both patients underwent liver transplantation successfully, and the detailed clinical data was analyzed retrospectively. RESULTS: Bile duct injury (Strasberg type E4) in one patient was caused by laparoscopic cholecystectomy associated with proper hepatic artery injury; after the failure of an initial Roux-en-Y hepaticojejunostomy, the patient underwent classical orthotopic liver transplantation. Bile duct injury (Strasberg type D) in the other patient was caused by abdominal trauma in his childhood. After several unsuccessful surgical interventions, the patient finally developed secondary biliary cirrhosis twelve years later. He therefore underwent a living related liver transplantation. The outcome of both patients was satisfactory. CONCLUSIONS: Liver transplantation should be considered when bile duct injury has occurs concomitant with severe vascular injury or secondary biliary cirrhosis appears after failure of surgical intervention.

Robotic thyroidectomy via bilateral axillo-breast approach: Experience and learning curve through initial 220 cases.

OBJECTIVE: This study is aim to summarize the experience of robotic thyroidectomy via bilateral axillo-breast approach of our center and also to find out the learning curve of this technique. METHODS: In total 220 initial patients who have undergone robotic thyroidectomy via bilateral axillo-breast approach from May 2015 to September 2017 were involved in this study. The data of operation time, clinical characteristics, surgical outcomes and oncological outcomes were collected. The moving average method is use to explore the learning curve. RESULTS: All patients had undergone robotic thyroidectomy successfully without conversion to other surgical approaches. The mean age of the enrolled subjects was 34.4 ± 7.8 years old, while the sex ratio (male/female) was 38/182. There were 50 benign tumor cases and 170 malignant tumor cases. The mean total operation time was 105.3 ± 37.6 min. Lymph node metastasis was observed in 61 (35.9%) patients. The mean retrieved lymph node count was 5.1 ± 3.8 while the mean metastatic lymph node count was 0.7 ± 1.5. The operation time decreased significantly after about 30-35 cases and formed the plateau. After 80 cases, the operation time significantly decreased again. CONCLUSION: For skilled endocrine surgeons, robotic thyroidectomy has proved to be safe and feasible, which could be applied extensively in patients strictly selected in high-volume centers, with a relatively short learning curve of about 30-35 cases. While the surgeons getting more experienced, this technique would be more efficient.

Role of splanchnic hemodynamics in liver regeneration after living donor liver transplantation.

The aim of this study was to investigate the changes in splanchnic hemodynamics after LDLT and their relationship with graft regeneration. Eighteen patients with LDLT December 2006 and June 2008 were enrolled, and color Doppler ultrasonography was performed preoperatively and on postoperative days (PODs) 1, 3, 5, 7, 30, and 90 after transplantation. The changes in the portal blood flow mean velocity (PBV) and portal blood flow volume (PBF) were monitored, and their effects on hepatic function were observed simultaneously. Graft sizes were measured on PODs 7, 30, and 90 after the operation. The regeneration rates of grafts were calculated. PBF increased in the recipient group from 1081.17 +/- 277.50 to 2171.44 +/- 613.15 mL/minute, and PBV increased from 15.01 +/- 5.67 to 56.00 +/- 22.11 cm/s; they were both significantly higher than those in the donor group (P < 0.01). On POD 1, serum aspartic aminotransferase, alanine aminotransferase, and total bilirubin all peaked; however, these indices in patients with PBF/graft weight (GW) > 300 mL/minute . 100 g were significantly higher than those in patients with PBF/GW < 300 mL/minute . 100 g. Livers in the recipient group regenerated rapidly. The graft regeneration rate reached 119.40% +/- 28.21% as early as 1 month post-transplantation. PBF and PBV on PODs 1 and 3 were greatly related to liver regeneration at 30 days. The portal venous flow in patients with portal hypertension after LDLT showed a high perfusion state, which could promote graft regeneration, but PBF/GW after the operation should be controlled below 300 mL/minute . 100 g in order to protect grafts from hyperperfusion injury.

[The retrospective analysis of surgical outcome of portal hypertension].

OBJECTIVE: To retrospectively analyze the surgical outcome of portal hypertension and explore the risk-factors of long-term survival after operation. METHODS: The data of 149 patients (male 119, female 30, aged from 19 to 73 years old) with portal hypertension treated surgically from January 1996 to October 2007 was collected. Among these patients, there were 110 patients for Child A and 39 patients for Child B according to Child-Pugh classification. According to different surgical modality, all patients were divided into devascularization group (n = 85) and shunting group (n = 64). RESULTS: The follow-up rate was 78.8% and the average follow-up time was (46.3 +/- 30.4) months. The overall survival rates of 1-, 3-, 5- and 10-years were 95.6%, 88.7%, 83.4% and 65.1% respectively. Meanwhile the survival rates of 1-, 3-, 5- and 10-years in devascularization group and in shunting group were 95.4%, 87.7%, 80.6%, 56.3% and 95.8%, 90.1%, 86.8%, 72.6% respectively. There was no significant difference in survival rate between these two groups (P > 0.05). Child-Pugh classification has been the most important risk-factor that could influence long-term survival after operation by analysis of COX regression and it showed that the long-term survival time in Child A was longer than in Child B. The re-hemorrhage rates of 1-, 3- and 5-years in shunting group would be much better than in devascularization group. The rate of postoperative encephalopathy in devascularization group and shunting group was 6.9% and 6.1% respectively and there was no significant difference (P > 0.05). The portal venous pressure and flow of portal vein decreased significantly after shunting operation (P < 0.05). CONCLUSIONS: The mainly sole risk-factor of long-term survival for portal hypertension has been the classification of Child-Pugh, not surgical procedure. The individualized proximal splenorenal shunt is much better than devascularization in controlling variceal hemorrhage.

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury.

AIM: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. METHODS: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively. RESULTS: Bile duct injury was caused by cholecystectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini-incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively. CONCLUSION: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.

Preliminary clinical experience in liver retransplantation.

BACKGROUND: The past several decades have witnessed increasingly successful rates of liver transplantation. However, retransplantation remains the only choice for patients with irreversible graft failure after primary transplantation. This article aimed to summarize our clinical experience in liver retransplantation. METHODS: From June 2002 to December 2005, a total of 185 cases of liver transplantation including 8 cases of retransplantation were performed in our hospital. The clinical data were analyzed retrospectively. RESULTS: The rate of liver retransplantation was 4.32%. Retransplantation was indicated for the following reasons: biliary complication (3 cases), chronic rejection (2), hepatic artery thrombosis (1), uncontrollable acute rejection (1) and hepatitis B recurrence (1). The mean model of end-stage liver disease (MELD) scores before primary transplantation and retransplantation were 15.6 and 23.9, respectively (P<0.05). The MELD score reflected the severity of liver disease more precisely than the Child classification. The mean interval between the first and second transplantation was 316 days (78-725 days). The first three patients, with mean interval of 101 days, died of severe infection combined with multiple organ failure after retransplantation. The patients who underwent retransplantation more than six months after the first transplant had better outcomes. The one-year survival rate for retransplantation in our group was 62.5%. CONCLUSIONS: Liver retransplantation is the only means of saving the patient with hepatic allograft failure. Understanding of the indications for retransplantation, careful selection of operation timing, excellent surgical skills and meticulous postoperative management all contribute to the success of each case of retransplantation.

Surgical experience in splitting donor liver into left lateral and right extended lobes.

AIM: To outline the surgical experience with donor liver splitting in split liver transplantation. METHODS: From March 1 to September 1 in 2004, 10 donor livers were split ex situ into a left lateral lobe (segments II and III) and a right extended lobe (segments I, IV-VIII) in Medical School of Hannover, and thereafter split liver transplantation was performed successfully in 19 cases. The average age, weight and ICU staying period of the donors were 32.7 years (15-51 years), 64.5 kg (45-75 kg) and 2.4 d (1-8 d) respectively. RESULTS: The average weight of the whole graft and the left lateral lobe was 1,322.6 g (956-1,665 g) and 281.8 g (198-373 g) respectively, and the average ratio of left lateral lobe to the whole graft was 0.215 (0.178-0.274). The average graft to recipient weight ratio (GRWR) of the left lateral lobe and the right extended lobe reached 2.44% (1.22-5.41%) and 1.73% (1.31-2.30%) respectively. On average it took approximately 105 min (85-135 min) to split the donor liver. Five donor organs showed anatomic variation including the left hepatic vein variation in two cases, the left hepatic artery variation in two cases and the bile duct variation in one case. CONCLUSION: Split liver transplantation has become a mature surgical technique to expand the donor pool with promising results. In the process of graft splitting, close attention needs to be paid to potential anatomic variations, especially to variations of the left hepatic vein, the left hepatic artery, and the bile duct.

Split liver transplantation: a reliable approach to expand donor pool.

BACKGROUND: Orthotopic liver transplantation as a successful treatment of end-stage liver disease is hampered by a persistent lack of cadaveric organs. Split liver transplantation, which was first successfully performed by Medical School of Hannover in 1988, has become a mature surgical technique to expand the donor pool. Between 1993 and 1999, split liver transplantation activities have increased in Europe from 1.2% to 10.4% in all performed liver transplantations. Current data have strongly supported that the survival rate of patients after split liver transplantation is not significantly different from that of patients after whole-size orthotopic liver transplantation. The most important step of donor graft selection is surgeon's observation judged by the experience of individual transplant center. The paper aims to provide the guideline of donor selection, hepatic graft splitting, and recipient management as well. DATA SOURCES: Medical School of Hannover has accumulated plentiful experience of split liver transplantation for more than 10 cases ever since 1998. Besides that, we also reviewed a variety of literatures from other famous European and American centers specialized in this field for many years. RESULTS: According to our experience combined with the view points of others, the donor should meet the following criteria as well: (1) age less than 50 years; (2) hemodynamics stable; (3) ICU less than 5 days; (4) Na less than 170 mmol/L or better if less than 150 mmol/L. In 1996 and 1997, the Hamburg group and the UCLA group separately introduced a breakthrough technique performing split liver transplantation in situ. Evidently, the in situ technique has been limited by prolonged time of donor organ procurement, coordination with other organ procurement teams, and even extra burden on donor hospital. Some groups, therefore, have restored the ex situ or bench splitting technique, and fortunately the transplant outcomes of the ex situ technique are equivalent to those of the in situ one. Recently some new techniques have been introduced to split the liver for two adult patients, including the split-cava technique. CONCLUSIONS: It is clear that the most important factor for determining the prognosis of the patient is the time of receiving liver transplantation, not the type of liver transplantation. We still need to pay close attention to the graft to recipient weight ratio (GRWR) and the UNOS classification or MELD score before the patient is subjected to split liver transplantation.

Surgical treatment for Nevin stage IV and V gallbladder carcinoma: report of 70 cases.

BACKGROUND: The role of aggressive surgery for end-stage gallbladder carcinoma is controversial. This retrospective study was designed to evaluate the outcome of surgical treatment for Nevin stage IV and V gallbladder carcinoma at a single institution. METHODS: A retrospective analysis was made on 70 patients with Nevin stage IV and V gallbladder carcinoma undergoing surgical treatment from January 1993 to June 2004. RESULTS: There were 22 cases of stage IV and 48 of stage V. Cholecystectomy was performed in 37 cases with a resection rate of 53%, 9 cases received radical resection, 13 extended radical resection, and 15 palliative resection. The curative resection rate was 31% and the morbidity rate was 36%. Postoperative 1-, 3-, 5-year survival rates of curative and palliative resection were 69%, 33%, 8% and 27%, 13%, 0, respectively (P<0.01). The 1- and 3-year survival rates of patients undergoing exploratory laparotomy only were 3% and 0, respectively. CONCLUSIONS: Nevin stage IV and V gallbladder carcinoma should be treated by aggressive surgery. Curative resection is promising in the improvement of long-term survival rate.

Liver biopsy in evaluation of complications following liver transplantation.

AIM: To analyze the role of liver biopsies in differential diagnosis after liver transplantation. METHODS: A total of 50 biopsies from 27 patients with liver dysfunction out of 52 liver transplantation cases were included. Biopsies were obtained 0-330 d after operation, in which, 44 were fine needle biopsies, another 6 were wedge biopsies during surgery. All tissues were stained with haemotoxylin-eosin. Histochemical or immunohistochemical stain was done. RESULTS: The rate of acute rejection in detected cases and total transplantation cases was 48.2% and 25.0%, chronic rejection rate in detected cases and total transplantation cases was 14.8% and 7.7%, preservation-reperfusion injury in detected cases and total transplantation cases was 25.9% and 13.5%, hepatic artery thrombosis rate in detected cases and total transplantation cases was 11.1% and 5.8%, intrahepatic biliary injury rate in detected cases and total transplantation cases was 7.4 % and 3.8%, CMV infection rate in detected cases and total transplantation cases was 3.7% and 1.9%, hepatitis B recurrence rate in detected cases and total transplantation cases was 3.7% and 1.9%, the ratio of suspicious drug-induced hepatic injury in detected cases and total transplantation cases was 11.1% and 5.8%. CONCLUSION: Acute rejection and preservation-reperfusion injury are the major factors in early liver dysfunction after liver transplantation. Hepatic artery thrombosis and prolonged cold preservation may result in intrahepatic biliary injury. Acute rejection and viral infection may involve in the pathogenesis of chronic rejection. Since there are no specific lesions in drug-induced hepatic injury, the diagnosis must closely combine clinical history and rule out other possible complications.

Long-term results of small-diameter proximal splenorenal venous shunt: a retrospective study.

AIM: To investigate recurrent variceal hemorrhage and long-term survival rates of patients treated with partial proximal splenorenal venous shunt. METHODS: Patients with variceal hemorrhage who were treated with small-diameter proximal splenorenal venous shunt in Ruijin Hospital between 1996 and 2009 were included in this study. Shunt diameter was determined before operation using Duplex Doppler ultrasonography. Peri-operative and long-term results in term of rehemorrhage, encephalopathy and mortality were followed up. RESULTS: Ninety-eight patients with Child A and B variceal hemorrhage received small-diameter proximal splenorenal venous shunt with a diameter of 7-10 mm. After operation, the patients' mean free portal pressure (P < 0.01) and the flow rate of main portal vein (P < 0.01) decreased significantly compared with that before operation. The rates of rebleeding and mortality were 6.12% (6 cases) and 2.04% (2 cases), respectively. Ninety-one patients were followed up for 7 mo-14 years (median, 48.57 mo). Long-term rates of rehemorrhage and encephalopathy were 4.40% (4 cases) and 3.30% (3 cases), respectively. Thirteen patients (14.29%) died mainly due to progressive hepatic dysfunction. Five- and ten-year survival rates were 82.12% and 71.24%, respectively. CONCLUSION: Small-diameter proximal splenorenal venous shunt affords protection against variceal rehemorrhage with a low occurrence of encephalopathy in patients with normal liver function.

Surgical management of benign duodenal tumours.

BACKGROUND: While benign duodenal tumours are rare compared with malignant tumours, they comprise a wide variety of pathologies. Despite their diagnostic challenge, the optimal management of benign duodenal tumours remains undefined. We aimed to review the diagnosis and surgical treatment of benign duodenal tumours. METHODS: Records of all patients with post-operative pathological diagnosis of benign duodenal tumour were retrieved. Information on clinical presentations, diagnostic methods, tumour locations, surgical approaches, pathological results and patient outcomes were analysed. RESULTS: The operative spectrum included local resection in 8 cases, segmental duodenectomy in 1 case, subtotal gastrectomy in 1 case, papilla resection with sphincteroplasty in 3 cases and pancreaticoduodenectomy in 5 cases. The post-operative pathology results indicated 5 cases of adenoma, 2 cases of tubular adenoma, 2 cases of villous adenoma, 2 cases of tubulovillous adenoma, 2 cases of hamartoma and 1 case each of hamartomatous polyp, Brunner's adenoma, adenomyoma, fibromatosis and ectopic pancreas. Post-operatively, one patient died of unrelated disease, one case was lost in follow-up and the remaining patients survived recurrence-free with a good quality of life. CONCLUSION: The presentation of benign duodenal tumours is non-specific, with upper abdominal discomfort and upper gastrointestinal bleeding as common symptoms. Surgical resection is the preferable therapeutic choice with satisfactory prognosis.