[Clinical analysis of inflatable video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopy].

Objective: To examine the safety and effectiveness of inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE). Methods: Totally 269 patients admitted to the Anhui Provincial Hospital of Anhui Medical University who underwent IVMTE (IVMTE group, n=47) or thoracoscopy combined with minimally invasive Mckeown esophageal cancer resection (MIME group, n=222) from September 2017 to December 2021 were analyzed retrospectively. There were 31 males and 16 females in IVMTE group, aged (68.6±7.5) years (range: 54 to 87 years). There were 159 males and 63 females in MIME group, aged (66.8±8.8) years (range: 42 to 93 years). A 1∶1 match was performed on both groups by propensity score matching, with 38 cases in each group. The intraoperative conditions and postoperative complication rates of the two groups were compared by t test, Wilcoxon rank, χ2 test, or Fisher exact probability method. Results: Patients in IVMTE group had less intraoperative bleeding ((96.0±39.2) ml vs. (123.8±49.3) ml, t=-2.627, P=0.011), shorter operation time ((239.1±47.3) minutes vs. (264.2±57.2) minutes, t=-2.086, P=0.040), and less drainage 3 days after surgery (85(89) ml vs. 675(573) ml, Z=-7.575, P<0.01) compared with that of MIME group. There were no statistically significant differences between the two groups in terms of drainage tube-belt time, postoperative hospital stay, and lymph node dissection stations and numbers (all P>0.05). The incidence of Clavien-Dindo grade 1 to 2 pulmonary infection (7.9%(3/38) vs. 31.6%(12/38), χ²=6.728, P=0.009), total complications (21.1%(8/38) vs. 47.4%(18/38), χ²=5.846, P=0.016) and total lung complications (13.2%(5/38) vs. 42.1%(16/38), χ²=7.962, P=0.005) in the IVMTE group were significantly lower. Conclusion: Inflatable video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopic esophagectomy is safe and feasible, which can reach the same range of oncology as thoracoscopic surgery.

[Impact of the examined number of lymph nodes at N1 station on the prognosis of patients with pT1-3N0M0 non-small cell lung cancer].

Objective: To investigate the relationship between the examined number of lymph nodes at the N1 station and the clinicopathological characteristics and prognosis of patients with pT1-3N0M0 non-small cell lung cancer (NSCLC). Methods: A total of 337 patients with pT1-3N0M0 NSCLC who underwent radical lung cancer surgery at the Provincial Hospital Affiliated to Anhui Medical University from January 2013 to March 2015 were selected. The receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value for predicting 5-year survival in pT1-3N0M0 NSCLC patients by the examined number of lymph nodes at the N1 station. The relationships between the examined number of lymph nodes at the N1 station and the clinicopathological characteristics and prognosis of patients with pT1-3N0M0 NSCLC were analyzed according to the optimal cut-off group. Results: A total of 1 321 lymph nodes at N1 station were examined in 337 patients, with a mean of 3.9 nodes per patient. The median survival time was 42.0 months, with 1-, 3- and 5-year survival rates of 82.2%, 57.1% and 24.9%, respectively. ROC curve analysis showed that the optimal cut-off value of 4.5 lymph nodes examined at the N1 station was used to predict 5-year survival in patients with pT1-3N0M0 NSCLC. After rounding off the number, the number of lymph nodes examined at the N1 station was 5 as the cut-off value, and the patients were divided into the group with <5 lymph nodes examined (212 cases) and the group with ≥5 lymph nodes examined (125 cases). The proportion of patients received adjuvant chemotherapy was 19.2% in the group with ≥5 lymph nodes examined, which was higher than 9.0% in the group with <5 lymph nodes examined (P=0.007), and the differences in other clinicopathological characteristics between the two groups were not statistically significant (P>0.05). The median survival time for patients in the group with <5 lymph nodes examined was 38.0 months, with 1-, 3- and 5-year survival rates of 80.1%, 52.5% and 15.6%, respectively. The median survival time for patients in the group with ≥5 lymph nodes examined was 48.0 months, and the 1-, 3- and 5-year survival rates were 85.6%, 64.0% and 36.0%, respectively. The survival rate of patients in the group with ≥5 lymph nodes examined was better than that in the group with <5 lymph nodes examined (P=0.002). Multifactorial Cox regression analysis showed that T stage (OR=1.408, 95% CI: 1.118-1.670) and the examined number of lymph nodes at N1 station (OR=0.670, 95% CI: 0.526-0.853) were independent influence factors for the prognosis of pT1-3N0M0 NSCLC patients. Conclusion: The examined number of lymph nodes at the N1 station is associated with the prognosis of patients with pT1-3N0M0 NSCLC, and the examination of at least 5 lymph nodes at N1 station at the time of postoperative pathological examination improves the 5-year survival rate of patients.

[Clinical characteristics and efficacy analysis of secondary benign paroxysm positional vertigo after middle ear surgery].

Objective:To investigate the clinical characteristics and therapeutic effect of benign paroxysm positional vertigo（BPPV） secondary to middle ear surgery. Method:A total of 1 126 patients who underwent tympanoplasty or radical mastoidectomy due to chronic suppurative otitis media and middle ear cholesteatoma in our hospital from January 2014 to December 2018 were collected. Clinical data of BPPV within 1 month after surgery were collected, The incidence, incidence side, involved semicircular canal, onset time, age of onset, and duration of operation of secondary BPPV after middle ear surgery were analyzed. All patients with secondary BPPV were treated by manual reduction, and the efficacy was evaluated 1 day, 1 week, and 1 month after reduction. Result:2.13% （24 cases） of patients had secondary BPPV after operation, among which 2 cases were parietal incidence. 18 cases were involved in posterior semicircular canals and 6 cases were horizontal semicircular canals. The onset time was 1-12 days after the operation, with an average of （3.29±2.44） days. The mean age of onset was （51.62±10.15） years old, and there was no statistically significant difference between the age of patients without BPPV after middle ear surgery （P>0.05）. The average operating time was （97.29±14.78） minutes, showing no statistically significant difference compared with patients in the group without BPPV （P>0.05）. Fourteen cases （58.3%） were cured and 10 cases were improved after 1 day evaluation. Evaluated 1 week after treatment, 19 cases （79.17%） were cured and 5 cases were improved. Evaluated 1 month after treatment, all patients were cured without recurrence. Conclusion:BPPV secondary to middle ear surgery often appears 3 days after surgery, and the posterior semicircular canal of the operative ear is most commonly involved. Age and operation duration have no significant influence on the incidence of BPPV, and satisfactory therapeutic effect can be obtained through manipulative reduction.

[Analysis on CT in diagnosis of lymph node metastasis of thoracic esophageal cancer with minimum diameter greater than 1 cm].

Objectives: To evaluate the diagnostic value of CT for lymph node metastasis of thoracic esophageal carcinoma with a diameter of more than 1 cm, and to find the optimal diagnostic index by comparing relevant CT indexes. Methods: Totally 80 patients with pathologically proved thoracic esophageal cancer with preoperative CT examination revealed lymph node diameter greater than 1 cm admitted at Department of Thoracic Surgery, the First Affiliated Hospital of University of Science and Technology of China from January 2016 to January 2018 were enrolled in this study. There were 70 males and 10 females, aging of (60±14) years (range: 40-85 years). According to the pathological result of lymph nodes, all the patients and lymph nodes were divided into two groups (N+group: 47 patients, 62 lymph nodes; N-group: 33 patients, 39 lymph nodes). The average number of dissected lymph nodes were 21±4 and 101 lymph nodes' diameter were greater than 1 cm. The clinicopathologic factors, postoperative complications, lymph node dissection and relevant CT indexes like the minimum diameter of lymph nodes (Min D), the maximum diameter of lymph node (Max D), lymph node axial ratio(LAR), the enhancement of lymph node (ELN) and the boundary of lymph node (BLN) were compared. The clinicopathological data, lymph node dessection and CT parameters of the two groups were compared by t test, χ(2) test or Wilcoxon rank sum test. Receiver operating characteristic (ROC) curve analysis was used to compare the ability to predict lymph node metastasis between Min D, Max D, LAR, ELN and BLN. Multiple Logistic regression analysis were performed to determine the independent variables for prediction of lymph node metastasis. Results: The difference of tumor segmentation, pN stage, pTNM stage, total number of metastatic lymph nodes, total number of abdominal lymph node metastases, Min D, Max D, ELN and BLN between the two groups were statistically significant. The results of univariate and multivariate analyses showed that gender (OR=0.128, 95%CI: 0.019 to 0.858, P=0.034), pTNM stage (OR=1.514, 95%CI: 1.020 to 2.247, P=0.039), Min D (OR=0.102, 95%CI: 0.010 to 0.995, P=0.050) and LAR (OR=0.195, 95%CI: 0.052 to 0.731, P=0.015) were the independent relative factors. The area under the curve of ROC curve analysis of Min D, Max D, LAR, ELN and BLN were 0.679, 0.666, 0.561, 0.650 and 0.820, respectively. BLN was the best CT index to diagnosis lymph node metastasis, while the accuracy of dignosis of lymph node metastasis of BLN was 97.0%. The Youden index of Min D, Max D and LAR were 1.25 cm, 1.64 cm and 0.77, respectively. Combining the BLN and ELN had a higher diagnostic rate (97.0%) of lymph node metastasis. Conclusions: CT has high diagnostic value for lymph node metastasis in thoracic esophagel cancer when the lymph node diameter is greater than 1 cm. BLN is the best diagnostic index for lymph node metastasis.

[A comparative study of the short-term efficacy and long-term efficacy of systematic lymph node dissection and elective lymph node dissection in patients with early esophageal cancer].

Objective: To investigate the feasibility, safety, short-term efficacy and long-term efficacy of elective lymph node dissection in patients with early esophageal cancer. Methods: The study retrospectively evaluated 405 patients with cT1N0M0 esophageal carcinoma who received minimally invasive esophagectomy in the First Affiliated Hospital of University of Science and Technology of China between March 2007 and March 2013. Of those patients, 208 patients underwent systematic lymph node dissection (SLND) and 197 patients underwent elective lymph node dissection (ELND). The clinicopathologic factors, operational factors, postoperative complications, lymph node dissection and prognosis of patients were compared by independent sample t test, χ(2) test, or Mann-Whitney rank test. The 5-year overall survival was calculated by the Kaplan-Meier estimation method using the Log-rank test. Results: There was no significant difference in clinicopathological data between the SLND group and the ELND group. The incidence of pulmonary infection (8.2% vs. 2.9%, P=0.04) and arrhythmia (6.2% vs. 2.0%, P=0.03) of the minor postoperative complications in the SLND group were higher than the ELND group. The incidence of pulmonary infection (6.2% vs. 2.0%, P=0.03), Chylothorax (5.8% vs.1.5%, P=0.02), anastomotic or pleural hemorrhage requiring reoperation (2.9% vs.0.5%, P=0.04) of major postoperative complications in the SLND group were higher than the ELND group, the difference was statistically significant. In the perioperative data of two groups, the incidence of total postoperative complications, total pulmonary complications, operation time, intraoperative blood loss, postoperative hospitalization, postoperative thoracic drainage duration and postoperative thoracic drainage fluid volume of the SLND group were higher than the ELND group, the difference was statistically significant. The mean numbers and stations of dissected lymph node in the SLND were 30.2±4.2 and 12.1±2.7, the mean numbers and stations of dissected lymph node in the ELND were 25.7±3.8 and 8.4±3.6. The survival rates of 1, 3, 5 years of all patients were 100%, 95.9% and 82.5%, respectively. The median survival time was 87.4 months. Further analysis showed that the 1, 3 and 5 years survival rate of patients with stage Ⅰ esophageal cancer was 100%, 97.1% and 88.9%, respectively. The median survival time was 89.3 months. The 1, 3 and 5 years survival rate of patients with stage Ⅱa esophageal cancer was 100%, 93.2% and 76.8%, respectively. The median survival time was 77.2 months. There was no significant difference in survival rate between the SLND group and the ELND group in 1, 3 and 5 years. When taking a further analysis of stage Ⅰ esophageal cancer, the survival rates between 188 patients in the SLND group and 180 patients in the ELND group were no significant difference. When focus on the stage Ⅱa esophageal cancer, the 1, 3 and 5 years survival rate were higher in the SLND group than that in the ELND group (100%, 94.5%, 83.2% vs. 100%, 91.3%, 72.1%, P=0.047), the difference was statistically significant. Conclusion: ELND can be safely and effectively performed for early esophageal cancer with favorable short-term efficacy and long-term efficacy.

[Learning curve of uniportal video-assisted thoracoscopic surgery lobectomy for the treatment of resectable lung cancer].

Objective: To analyze the learning curve of uniportal video-assisted thoracoscopic surgery (VATS) lobectomy for the treatment of resectable lung cancer. Methods: The clinical data of 160 patients with resectable lung cancer who underwent uniportal VATS lobectomy by a single surgical team between May 2016 and April 2017 at Department of Thoracic Surgery, the First Affiliated Hospital of the University of Science and Technology of China were analyzed retrospectively. The study group consisted of 90 male and 70 female patients with age of 28 to 84 years (median: 62 years). The patients were divided into four groups from group A to D according to chronological order. The operation time, incision length, intraoperative blood loss, number of dissected lymph nodes and nodal stations, the proportion of changes in operation mode, postoperative complications, chest drainage duration and hospitalization time were individually compared among the four groups by variance analysis and χ(2) test. Results: The 4 groups were similar in terms of incision length, chest drainage duration, number of dissected lymph nodes and nodal stations and postoperative hospitalization time (P>0.05). The difference of the operation time ((185.9±17.9) minutes vs. (139.9±10.7) minutes vs.(128.7±7.8) minutes vs.(124.0±9.3) minutes, F=219.605, P=0.000), intraoperative blood loss ((233.9±135.8) ml vs. (126.8±18.1) ml vs. (116.4±22.6) ml vs.(112.8±25.3) ml, F=26.942, P=0.000), the proportion of changes in operation mode (17.5% vs.7.5% vs. 5.0% vs. 5.0%, χ(2)=8.300, P=0.040), and the incidence of postoperative complications (27.5% vs. 10.0% vs. 10.0% vs. 7.5%, χ(2)=8.643, P=0.034) among the 4 groups was statistically significant. Conclusions: Uniportal VATS lobectomy can be safely and feasibly performed for resectable lung cancer, learning curve for uniportal VATS lobectomy is approximately 40 cases. Operation time, intraoperative blood loss, postoperative complications and the proportion of changes in operation mode can be used as the main measures during surgery.

[Advances in research of exosomes and age-related macular degeneration].

Exosomes are small vesicles with a molecular diameter of 30 to 100 nm, which are secreted into the cell after the fusion of the multivesicular bodies with the plasma membrane. Exosomes contain various molecular constituents of their cell origin, including proteins, microRNAs and lipids. Different cell-derived exosomes have different biological functions. Exosomes play a very important role in the development and progression of age-related macular degeneration (AMD). The exosomes derived from the eye are involved in the processes of cell growth, metastasis, angiogenesis and immunosuppression by transferring contents to adjacent or distant cells. Some of the specific molecules may be used for early diagnosis and treatment of AMD. This article reviews the relationship between exosomes and AMD pathogenesis and treatment, which may provide a new insight into the pathogenesis and treatment strategy of AMD. (Chin J Ophthalmol, 2017, 53:786-790).

Detection and characterization of ciRS-7: a potential promoter of the development of cancer.

Circular RNAs (circRNAs) are a class of newly-identified non-coding RNA molecules. CircRNAs are conserved across different species and display specific organization, sequence, and expression in disease. Moreover, circRNAs' closed ring structure, insensitivity to RNase, and stability are advantages over linear RNAs in terms of development and application as a new kind of clinical marker. In addition, according to recent studies, circular RNA-7 (ciRS-7) acts as a sponge of miR-7 and thus inhibits its activity. Numerous evidences have confirmed expression of miR-7 is dysregulated in cancer tissues, however, whether ciRS-7 invovled in oncogenesis by acting as sponge of miR-7 remains unclear. Most recently, a study reported ciRS-7 acted as an oncogene in hepatocellular carcinoma through targeting miR-7 expression. This suggest ciRS-7/ miR-7 axis affects oncogenesis, and it provides a new perspective on the mechanisms of decreased miR-7 expression in cancer tissues. Discovery of sponge role of circRNAs caused researchers to more closely explore the underlying mechanism of carcinogenesis and has significant clinical implications, and may open a new chapter in research on the pathology and treatment of cancers. This review summarizes the structure and function of circRNAs and provides evidence for the impact of ciRS-7 in promoting the development of cancer by acting as sponge of miR-7.

High expression of long non-coding RNA ATB indicates a poor prognosis and regulates cell proliferation and metastasis in non-small cell lung cancer.

BACKGROUND AND AIM: Long non-coding RNAs (lncRNAs) have been demonstrated to act as a critical regulator in the processes of tumor biology. In this study, whether lncRNA-ATB is a potential indicator for non-small cell lung cancer (NSCLC) was investigated and its biological function in NSCLC was also determined. METHODS: The expression levels of lncRNA-ATB in NSCLC tissues and cell lines were measured. A549 cell line was explored to investigate the functions of lncRNA-ATB in NSCLC. RESULTS: Real-time PCR results showed that lncRNA-ATB expression was up-regulated in both in NSCLC tissues and cell lines. High lncRNA-ATB expression in tumor tissue was associated with larger tumor size, lymph node metastasis, and distant metastasis in patients with NSCLC, respectively. In addition, the patients with high expression of lncRNA-ATB presented a lower survival probability. In vitro experiments showed that down-regulation of lncRNA-ATB promoted the cell apoptosis, whereas inhibited the cell viability, cell migration, and cell invasion. CONCLUSION: High expression of lncRNA-ATB indicated a poor prognosis and led to the cell proliferation and metastasis in NSCLC.

Jujube leaf green tea extracts inhibits hepatocellular carcinoma cells by activating AMPK.

Here we evaluated the anti-hepatocellular carcinoma activity by the Jujube leaf green tea extracts (JLGTE). We showed that JLGTE exerted anti-proliferative, cytotoxic and pro-apoptotic activities against HepG2 and primary human hepatocellular carcinoma cells. It was however non-cytotoxic to the normal hepatocytes. JLGTE activated AMP-activated protein kinase (AMPK) signaling, which was required for its cytotoxicity against hepatocellular carcinoma cells. Silence of AMPKα1, via targeted short hairpin RNAs or CRISPR-Cas9 genome editing, inhibited JLGTE-induced AMPK activation and HepG2 cell apoptosis. Further, in-activation of AMPK by a dominant negative AMPKα1 (T172A) also alleviated JLGTE's cytotoxicity against HepG2 cells. On the other hand, forced-activation of AMPK by introduction of a constitutively-active AMPKα1 (T172D) mimicked JLGTE's actions and led to HepG2 cell apoptosis. These results suggest that JLGTE inhibits human hepatocellular carcinoma cells possibly via activating AMPK.

[Short-term outcomes of minimally invasive Sweet esophagectomy for Siewert type â ¡ esophagogastric junction adenocarcinoma].

Objective: To describe the technique for minimally invasive Sweet esophagectomy and to evaluate the feasibility, safety and the short-term clinical outcomes of this approach in the treatment of Siewert type Ⅱ esophagogastric junction adenocarcinoma. Methods: The clinical data of 122 patients with Siewert type Ⅱ esophagogastric junction adenocarcinoma who received Sweet esophagectomy between October 2013 and June 2015 in Department of Thoracic Surgery, Anhui Provincial Hospital Affiliated with Anhui Medical University was analyzed retrospectively. The study group consisted of 87 men and 35 women, and the ages ranged from 48 to 78 years (median: 67 years). Of those 122 patients, 47 underwent minimally invasive approach and 75 underwent open left transthoracic sweet esophagectomy. This study included 16 stage Ⅰa patients, 35 stage Ⅰb patients, 32 stage Ⅱa patients, 28 stage Ⅱb patients, and 11 stage Ⅲa patients. The clinicopathologic factors, operational factors and postoperative complications of the two groups were compared by t test and χ2 test. Results: The two groups were similar in terms of gender, age, American Society of Anesthesiologists grade, preoperative staging and incidence of comorbidities (P>0.05). The minimally invasive approach was associated with significant increase in the number of total lymph nodes dissected or the stations of the total lymph nodes dissected (18.1±2.7 vs. 15.0±2.5, t= 6.612, P=0.001; 8.9±1.1 vs. 6.7±1.2, t=9.960, P=0.003), significant decrease in surgical blood loss ((88±32) ml vs. (120±34) ml, t=5.052, P=0.001), chest tube duration ((8±4) d vs. (10±4) d, t=3.110, P=0.002) and postoperative stay ((9±5) d vs. (12±4) d, t=3.167, P=0.002) relative to the open approach. The postoperative in-hospital mortality and total morbidity did not differ between the two groups (P>0.05). The minimally invasive approach was associated with significantly fewer respiratory complications than the open approach (8.5% vs. 22.7%, χ2=4.063, P=0.044). Conclusion: Minimally invasive technique for Siewert type Ⅱ esophagogastric junction adenocarcinoma can be safely and effectively performed for intrathoracic anastomosis with favorable early outcomes.

Immediate radical therapy or conservative treatments when meeting the Milan criteria for advanced HCC patients after successful TACE.

BACKGROUND AND AIMS: Many advanced hepatocellular carcinoma (HCC) cases can be successfully downstaged into the Milan criteria; however, immediate radical therapy cannot be applied to all such patients for various reasons. Of the patients who are not eligible for immediate radical therapy, some accept repeated downstaging therapies and some undergo persistent observation. The aim of the present study was to compare long-term survival between these two groups of patients. PATIENTS AND METHODS: Between August 2003 and October 2008, 156 HCC patients successfully received downstaging therapy resulting in compliance with the Milan criteria. Of those, 98 cases accepted radical therapies, including liver transplantation (LT), resection, or radiofrequency ablation (RFA) (group 1), and 58 cases underwent repeated transcatheter arterial chemoembolization (TACE) or persistent observation (group 2). The baseline characteristics, demographic data, downstaging protocol, and information on long-term outcomes were collected and compared. RESULTS: No significant differences were observed in the patient demographic data, downstaging protocols, or tumor characteristics between the two groups. The 1-, 3-, and 5-year overall survival rates were 92.9, 82.7, and 78.6 %, respectively, in group 1, whereas these rates were 82.8, 65.5, and 48.3 %, respectively, in group 2 (P = 0.046). Among the 58 patients in group 2, the 1-, 3-, and 5-year overall survival rates were 92.3, 65.4, and 46.2 %, respectively, in the repeated TACE group, and 81.3, 65.6, and 50 %, respectively, in the persistent observation group (P = 0.783). CONCLUSION: Immediate radical therapy should be the first choice for advanced HCC patients who undergo successful TACE, and repeated TACE is unnecessary.

A significant expansion of CD8+ CD28- T-suppressor cells in adult-to-adult living donor liver transplant recipients.

BACKGROUND: The appearance of human regulatory CD8(+) CD28(-) T-suppressor (Ts) cells has been associated with a reduced need for maintenance immunosuppression in cadaveric heart- kidney transplant recipients and pediatric liver-intestine transplant recipients. However, few data are available in adult-to-adult living donor liver transplantation (A-A LDLT). MATERIALS AND METHODS: To study the population of CD8(+) CD28(-) Ts cells in A-A LDLT, we performed flow cytometry on whole blood specimens obtained from 20 transplant recipients, 18 end-stage liver disease patients, and 20 normal controls. Meanwhile, we measured the trough levels of immunosuppressants and monitored graft function in transplant recipients. We retrospectively reviewed the clinical data of the 20 recipients. RESULTS: A significant expansion of CD8(+) CD28(-) Ts cells was observed among recipients of A-A LDLT as compared with a disease control group (P = .000) or healthy individuals (P = .000). All recipients were free of acute cellular rejection episodes. During the follow-up period, no grafts were lost due to acute or chronic rejection. CONCLUSION: Expansion of CD8(+) CD28(-) Ts cells in A-A LDLT seemed to be associated with a decreased occurrence of acute or chronic rejection and sustained good graft function. Based on our low dosages of immunosuppressants for recipients of A-A LDLT, we suggest that this strategy may promote expansion of CD8(+) CD28(-) Ts cells, which can conversely maintain the low immunosuppressant dosages.

Body mass index evaluating donor hepatic steatosis in living donor liver transplantation.

INTRODUCTION: Evaluation of graft hepatic steatosis is important for the safety of the donor and the recipient in living donor liver transplantation. It is necessary to establish a noninvasive evaluation method to avoid performing a liver biopsy for donor safety. The aim of this study was to identify independent factors that correlated with hepatic steatosis to create a noninvasive method to evaluate hepatic steatosis. METHODS: We retrospectively collected data from 105 living donors. No prisoners were used to obtain the grafts, all of which underwent postoperative histological evaluation for hepatic steatosis. Preoperative clinical and biochemical variables were examined with univariate analyses, and filtered variables further examined with ordinal regression analysis. RESULTS: Eighty (76.2%) donors showed no hepatic steatosis, 15 (14.3%), mild steatosis, and 10 (9.5%), moderate steatosis. In ordinal stepwise regression analysis, body mass index (BMI; P = .000) was the only independent factor that correlated with the grade of hepatic steatosis. Preoperative biochemical parameters were not significantly correlated with hepatic steatosis. A regression model based on BMI was created to evaluate hepatic steatosis grade. Furthermore, individuals with a BMI > 27.5 were most likely to show moderate steatosis, and those with BMI < 23 likely to display no or mild steatosis. CONCLUSION: BMI can help to identify the grade of hepatic steatosis among living donors. BMI is also useful to select living donors for a preoperative liver biopsy before liver transplantation.

Initial clinical effect of intraportal insulin administration on liver graft regeneration in adult patients underwent living donor right lobe liver transplantation.

OBJECTIVE: Insulin is one factor responsible for hepatotrophic regeneration in animal models. This study assessed the clinical effects of intraportal administration of insulin on liver graft regeneration in adult patients undergoing right lobe living donor liver transplantation (LDLT). METHODS: Between July 2005 and September 2007, 19 right lobe LDLT adult recipients voluntarily received posttransplant intraportal insulin administration. The present study describes 15 patients without postoperative vascular and bile duct complications, with more than 1 month survival and with complete clinical data who were enrolled to receive intraportal insulin therapy (group I; n = 15). Another consecutive 15 right lobe LDLT adult recipients without any stimulation regeneration who met the same criteria were enrolled in as noninsulin therapy control group (group NI; n = 15). Group I recipients were treated postoperatively with intraportal insulin infusion, as follows. An 18-gauge catheter was inserted into right gastro-omental vein during surgery, to administer regular insulin just after the operation at the rate of 2 U/h for 1 week. Graft volume (GV) was measured by computed tomography on postoperative days (POD) 7 and 30. Liver functions and serum insulin levels were also measured at POD 7 and POD 30. The liver graft regeneration rate was defined as ratio of posttransplant GV/harvested GV and posttransplant graft-to-recipient weight ratio (GRWR)/operative GRWR. RESULTS: The rate defined as ratio of POD 7 GV/harvested GV among group I was significantly greater than that of group NI (186.07 +/- 35.40% vs 160.61 +/- 22.11%; P < .05). The rate defined as ratio of POD 7 GRWR/operation GRWR was also significantly higher in group I than group NI (178.95 +/- 35.84% vs 156.56 +/- 18.53%; P < .05), whereas there was no significant difference in terms of regeneration rates at 1 month post-LDLT. Intraportal insulin administration may significantly downregulate POD 7 total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels (P < .05). These results suggested that intraportal insulin administration augmented liver regeneration during the first postoperative week by improving hepatic function in LDLT recipients.

Preliminary experience with indications for liver transplantation for hepatolithiasis.

OBJECTIVE: The aim of this study was to explore the indications for liver transplantation among patients with hepatolithiasis. PATIENTS AND METHODS: Data from 1,431 consecutive patients who underwent surgical treatment from January 2000 to December 2006 were retrospectively collected for analysis. Surgical procedures included T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones, hepatectomy, cholangiojejunostomy, and liver transplantation. RESULTS: Nine hundred sixty-one patients who had a stone located in the left or right intrahepatic duct underwent hepatectomy or T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones. The rate of residual stones was 7.5%. Four hundred seventy patients who had a stone located in the bilateral intrahepatic ducts underwent surgical procedures other than liver transplantation; the rate of residual stones was 21.7%. Only 15 patients with hepatolithiasis underwent liver transplantation; they all survived. According to the degree of biliary cirrhosis, recipients were divided into 2 groups: a group with biliary decompensated cirrhosis (n = 7), or group with compensated cirrhosis or no cirrhosis (n = 8). There were significant differences in operative times, transfusion volumes, and blood losses between the 2 groups (P < .05). In the first group, 6 of 7 patients experienced surgical complications, and in the second, 8 recipients recovered smoothly with no complications. Health status, disability, and psychological wellness of all recipients (n = 15) were significantly improved at 1 year after transplantation compared with pretransplantation (P < .05). CONCLUSIONS: Liver transplantation is a possible method to address hepatolithiasis and secondary decompensated biliary cirrhosis or difficult to remove, diffusely distributed intrahepatic duct stones unavailable by hepatectomy, cholangiojejunostomy, and choledochoscopy.

University of California at San Francisco criteria can be applied to living donor liver transplantation for hepatocellular carcinoma: single-center preliminary results in 27 patients.

BACKGROUND: Living donor liver transplantation (LDLT) can provide life-saving therapy for many patients with hepatocellular carcinoma (HCC), who otherwise would succumb due to tumor progression. However, donor risk must be balanced against potential recipient benefit. METHODS: From January 2002 to December 2006, a total of 27 LDLT were performed for HCC patients in our center, including 25 right lobe grafts, and 2 dual grafts. Twenty-four (88.89%) met the University of California at San Francisco (UCSF) criteria, whereas 3 (11.11%) did not. RESULTS: Of our 29 donors, the overall complication rate was 17.24%. Two (6.90%) experienced major complications including intra-abdominal bleeding and portal vein thrombosis in 1, respectively; 3 (10.34%) experienced minor complications: wound steatosis, pleural effusion, and transient chyle leakage in 1, respectively. We did not observe any donor mortality; all donors fully recovered and returned to their previous occupations. No recipient developed small-for-size syndrome. The overall HCC patient survival rates at 1- and 3-years were 84.01% and 71.40%, respectively, similar to those of patients undergoing LDLT for various nonmalignant diseases during the same period (P > .05). CONCLUSIONS: Although further study is needed to fully assess the risks and benefits of LDLT for both HCC patients and donors, our preliminary results suggested that LDLT offered an acceptable chance and duration of survival for HCC patients. It was not only a relatively safe procedure provided that every effort was taken to minimize donor morbidities, but also beneficial for HCC recipients.

Arterial complications after living-related liver transplantation: single-center experience from West China.

Vascular complications after liver transplantation remain a major source of morbidity and mortality for recipients. In particular, patients receiving living-related liver transplantation (LRLT) experience a higher rate of vascular complications owing to the complex vascular reconstruction. Between July 2001 and December 2005, LRLTs were performed in our center on 33 patients with end-stage liver diseases. The 23 men and 10 women had a mean age of 32.6 +/- 11.3 years (range = 5 to 58 years). Of the 33 patients, the percentage of vascular complications was 9.09% (3 cases), including hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), or hepatic artery pseudoaneurysm (HAP) in one patient, respectively. No portal vein or hepatic vein complication occurred in our patients. Thrombectomy was performed in the patient with thrombosis. The patient with stenosis was treated with balloon angioplasty and endoluminal stent placement. The pseudoaneurysm was also successfully embolized to restore the blood flow toward the donor liver. Mean follow-up for all patients after LRLT was 18.0 +/- 5.4 months. The overall postoperative 30-day mortality rate was 6.06% (2/33). The 1-year survival rate was 86.36% in 22 patients with benign diseases and 72.73% in 11 patients with malignant diseases. However, no death was associated with vascular complications. Careful preoperative evaluation and intraoperative microsurgical technique for hepatic artery reconstructions are the keys to prevent vascular complications following LRLT. Immediate surgical intervention is required for acute vascular complications, whereas late complications may be treated by balloon angioplasty and endoluminal stent placement. Embolization may be a safe and effective approach in the treatment of a pseudoaneurysm of the hepatic artery.

Surgical procedures for management of right portal venous branching in right lobe living donor liver transplantation.

OBJECTIVE: This study sought to describe the surgical management of right portal venous (PV) branches encountered among 104 cases of right lobe living donor liver transplantation (LDLT). METHODS: From January 2002 to September 2007, we performed 104 cases of right-lobe LDLT including 11-donors who had anomalous right portal venous branches (APVB). One recipient had PV sponginess hemangioma. The donor right PV branches were type I in 93 cases, type II (trifurcation) in nine cases, and type III in two cases. Except one narrow bridge of tissue excision, the PV branches were transected on the principal of donor priority: PV branches were excised approximately 2 to 3 mm from the confluence while leaving the donor's main portal vein and confluence intact. In type II APVB, donor PV branches were obtained with two separate openings in six cases; with two separate openings joined as a common orifice at the back table in two cases, with one common opening with a narrow bridge of tissue in one case. In type III APVB, the donor right anterior and posterior PV branches were obtained with separate openings. The donor right PV branches with one common opening in 92 cases of type I PV branches and a joined common orifice in three cases of type II APVB were anastomosed to the recipient's main portal vein or to right branching. As the unavailable recipient PV for sponginess hemangioma, one case of type I right PV branches was end-to-end anastomosed to one of the variceal lateral veins of about 1 cm diameter in a pediatric patient. The PV were reconstructed as double anastomoses in six type II APVB and in one type III APVB obtained with two separate PV openings. In the another type III APVB reconstruction, we successfully utilized a novel U-shaped vein graft interposition. RESULTS: The type II APVB donor receiving a narrow bridge of portal vein tissue excision developed portal vein thrombosis on the third postoperative day and underwent reexploration for thrombectomy. There were no vascular complications, such as portal vein thrombosis or stricture among other donors or all recipients. The velocity of blood flow in the U-graft was normal. The anastomosis between the type I donor right portal vein and recipient variceal lateral vein was unobstructed. CONCLUSION: Right PV branches should be excised on the principal of donor priority while leaving the donor's main portal vein and confluence intact. Single anastomoses was the fundamental procedure of right branch reconstruction. Double anastomoses could be used as the main management for type II and type III APVB reconstruction. U-graft interposition may be a potential procedure for type III APVB reconstruction. Single anastomoses between the donor right portal vein and the recipient variceal lateral vein may be performed when recipient portal vein is unavailable. These innovations for excision and reconstruction of right PV branches were feasible, safe, and had good outcomes.

Linkage exclusion and mutational analysis of the noggin gene in patients with fibrodysplasia ossificans progressiva (FOP).

Fibrodysplasia ossificans progressiva (FOP) is an extremely rare and disabling genetic disorder characterized by congenital malformation of the great toes and by progressive heterotopic endochondral ossification in predictable anatomical patterns. Although elevated levels of bone morphogenetic protein 4 (BMP4) occur in lymphoblastoid cells and in lesional cells of patients with FOP, mutations have not been identified in the BMP4 gene, suggesting that the mutation in FOP may reside in a BMP4-interacting factor or in another component of the BMP4 pathway. A powerful antagonist of BMP4 is the secreted polypeptide noggin. A recent case report described a heterozygous 42-bp deletion in the protein-coding region of the noggin gene in a patient with FOP. In order to determine if noggin mutations are a widespread finding in FOP, we examined 31 families with 1 or more FOP patients. Linkage analysis with an array of highly polymorphic microsatellite markers closely linked to the noggin gene was performed in four classically-affected multigenerational FOP families and excluded linkage of the noggin locus to FOP (the multipoint lod score was -2 or less throughout the entire range of markers). We sequenced the noggin gene in affected members of all four families, as well as in 18 patients with sporadic FOP, and failed to detect any mutations. Single-strand conformation polymorphism (SSCP) analysis of 4 of these patients plus an additional 9 patients also failed to reveal any mutations. Among the samples analyzed by SSCP and DNA sequencing was an independently obtained DNA sample from the identical FOP patient previously described with the 42-bp noggin deletion; no mutation was detected. Examination of the DNA sequences of 20 cloned noggin PCR products, undertaken to evaluate the possibility of a somatic mutation in the noggin gene which could be carried by a small subset of white blood cells, also failed to detect the presence of the reported 42-bp deletion. We conclude that mutations in the coding region of noggin are not associated with FOP.