Sustained methylene blue staining to guide anatomic hepatectomy for hepatocellular carcinoma: Initial experience and technical details.

BACKGROUND: The boundary of the target hepatic segment within the liver parenchyma cannot be marked by the use of a conventional anatomic hepatectomy approach. This study describes a novel methylene blue staining technique for guiding the anatomic resection of hepatocellular carcinoma (HCC). METHODS: Between February 2009 and February 2012, anatomic hepatectomy was performed in 106 patients with HCC via a novel, sustained methylene blue staining technique. Sustained staining was achieved by injecting methylene blue into the distal aspect of the portal vein after exposing Glisson's sheath. The hepatic pedicle was immediately ligated, and the hepatic parenchymal transection was performed along the interface between methylene blue stained tissue and unstained tissue. RESULTS: Anatomic hepatectomies included subsegmentectomy (n = 16), monosegmentectomy (n = 57), multisegmentectomy (n = 27), and hemihepatectomy (n = 6). The portal vein was injected successfully with methylene blue in 100% of cases, and complete staining of the target hepatic segment was achieved in 98 of 106 (92.5%) cases. Mean intraoperative bleeding was 360 ± 90 mL, and the postoperative complication rate was 24.5% (26/106). No perioperative mortality occurred. Operative margins were all negative on pathologic examination. Mean duration of postoperative follow-up was 40 months (range, 24-60). No local recurrence (around the operative margin) occurred. CONCLUSION: This novel technique of achieving sustained staining by injecting methylene blue then immediately ligating the hepatic pedicle is simple and feasible. It can guide the selection of the operative margin during hepatic parenchyma transection to improve the accuracy of anatomic hepatectomy for the treatment of HCC.

On perihilar surgery / 中国实用外科杂志

The anatomic relationship between bile duct and portal vein/hepatic artery is complicated in perihilar region. As perihilar surgery is technically demanding, both surgical safety and long-term outcome are not satisfactory. Under the guidance of precision surgery, three kinds of technique,including visualization, quantitation and controlization, are focused. Meanwhile, three principles including vessel priority,bleeding control and limit point control are introduced to improve the development of perihilar surgery. In addition,some new types of operation are potentially important and warranted in the near future.

Complete radio frequency ablation of hepatocellular carcinoma adjacent to the main bile duct and blood vessels between the first and the second hepatic portal.

In cases where hepatocellular carcinoma cannot be surgically removed either due to the capacity of hepatic functional reserve or the special location of the tumor, a radiofrequency ablation (RFA) is recognized to be an effective and minimally invasive treatment. However, when the tumor is adjacent to the main bile duct and blood vessels, it is feared that due to the "heat-sink effect" of the blood and the possible damage to the duct and blood vessels, complete tumor ablation is hard to achieve. We report here a case of complete RFA of hepatocellular carcinoma, adjacent to the main bile duct and blood vessels between the first and the second hepatic portal, with emphasis on the safety of the approach for complete ablation of the tumor.

A simple rat model of in situ reversible obstructive jaundice in situ reversible obstructive jaundice model

PURPOSE: To develop a simple and reliable rat model of in situ reversible obstructive jaundice with low morbidity and mortality rates. METHODS: Rats were divided into 4 groups with 8 rats each: the sham-operated (SH) group only underwent laparotomy, the control internal drainage (ID-C) group underwent choledochoduodenostomy, the new internal drainage (ID-N) group and the long-term internal drainage (ID-L) group underwent choledochocholedochostomy. Common bile duct ligation was performed in all the drainage groups 7 days before reversal procedures. All rats were sacrificed for samples 7 days after the last operation except rats of the ID-L group that survived 28 days before sacrifice. Body weight, liver function, histopathological changes, morbidity and mortality were assessed. RESULTS: One rat died and 2 rats had complications with tube blockage in the ID-C group. No death or complications occurred in the ID-N and ID-L groups. The drainage tube remained patent in the long-term observation ID-L group. Body weight showed no significant difference between the ID-C and ID-N groups after 7 days drainage. Liver function was not fully recovered in the ID-C and ID-N groups after 7 days drainage, but statistical differences were only observed in the ID-C group compared with the SH and ID-L groups. Periportal inflammation and bile duct proliferation showed severer in the ID-C group than in the ID-N group. CONCLUSION: The present study provided an efficient, simple, and reliable rat model that is especially suitable for long-term or consecutive studies of reversible obstructive jaundice.

A simple rat model of in situ reversible obstructive jaundice in situ reversible obstructive jaundice model

PURPOSE: To develop a simple and reliable rat model of in situ reversible obstructive jaundice with low morbidity and mortality rates. METHODS: Rats were divided into 4 groups with 8 rats each: the sham-operated (SH) group only underwent laparotomy, the control internal drainage (ID-C) group underwent choledochoduodenostomy, the new internal drainage (ID-N) group and the long-term internal drainage (ID-L) group underwent choledochocholedochostomy. Common bile duct ligation was performed in all the drainage groups 7 days before reversal procedures. All rats were sacrificed for samples 7 days after the last operation except rats of the ID-L group that survived 28 days before sacrifice. Body weight, liver function, histopathological changes, morbidity and mortality were assessed. RESULTS: One rat died and 2 rats had complications with tube blockage in the ID-C group. No death or complications occurred in the ID-N and ID-L groups. The drainage tube remained patent in the long-term observation ID-L group. Body weight showed no significant difference between the ID-C and ID-N groups after 7 days drainage. Liver function was not fully recovered in the ID-C and ID-N groups after 7 days drainage, but statistical differences were only observed in the ID-C group compared with the SH and ID-L groups. Periportal inflammation and bile duct proliferation showed severer in the ID-C group than in the ID-N group. CONCLUSION: The present study provided an efficient, simple, and reliable rat model that is especially suitable for long-term or consecutive studies of reversible obstructive jaundice.

A stable rat model of obstructive jaundice reversed by internal bile drainage using microsurgical techniques / 中国现代普通外科进展

Objective:To better understand the pathogenesis of obstructive jaundice (O J),a variety of rat OJ and biliary drainage models have been tried;however,complications are still common.We aimed to establish a stable rat model of OJ using microsurgical techniques,and to assess its reversal by internal bile drainage(IBD).Methods:After the pilot study,we developed a standardized surgical procedure.All operations were carried out under an operating microscope.In the first laparotomy,the proximal common bile duct (CBD) of the rat was ligated and transected.A tube was introduced into the distal end of the duct,and the other end of the tube was sealed and fixed.In the second laparotomy,the drainage tube was inserted into the (by now markedly dilated) proximal CBD,and ligated into position.We evaluated the general condition of the rats,the status of the liver and pancreas before and after IBD.Results:Complications such as intestinal reflux and bile duct blockage,were not found.Pancreatic injury was not evident by day 4 after the first laparotomy.After biliary drainage,the serum glucose and albumin concentration rapidly returned to normal levels.Liver weight/body weight ratio increased.The biochemical indicators and ultrasonographic elastography results for the liver gradually returned to normal.Conclusion:Using microsurgical techniques,we have developed a stable rat model of OJ reversed by IBD.

Comparison of the Predictive Values of Eight Staging Systems for Primary Liver Cancer in Prognosis of Combined Hepatocellular-cholangiocellular Carcinoma Patients after Surgery / 中国医学科学院学报

<p><b>OBJECTIVE</b>To compare the predictive values of eight staging systems for primary liver cancer in the prognosis of combined hepatocellular-cholangiocellular carcinoma (cHCC-CC) patients after surgery.</p><p><b>METHODS</b>The clinical data of 54 cHCC-CC patients who underwent hepatectomy or liver transplantation from May 2005 to Augest 2013 in Chinese PLA General Hospital were collected. We evaluated the prognostic value of the Okuda staging system, Cancer of the Liver Italian Program (CLIP) score, French staging system, Barcelona Clinic Liver Cancer (BCLC) staging system, 7th edition of tumour-node-metastasis (TNM) staging system for hepatocellular carcinoma and intrahepatic cholangiocarcinoma (ICC), Japan Integrated Staging (JIS) score, and Chinese University Prognostic Index. The distribution, Kaplan-Meier method, Log-rank test, and area under a receiver operating characteristic curve were used to compare the prognosis-predicting ability of these different staging systems in 54 cHCC-CC patients after surgery.</p><p><b>RESULTS</b>The TNM staging system for ICC and JIS score had a better distribution of cases. The 12-and 24-month survivals of the entire cohort were 65.5% and 56.3%, respectively. A Log-rank test showed that there was a significant difference existing in the cumulative survival rates of different stage patients when using TNM staging system for ICC (stage 1 vs. stage 2, P=0.012; stage 2 vs. stage 3-4, P=0.002), Okuda staging system (stage 1 vs. stage 2, P=0.025), and French staging system (stage A and stage B, P=0.045). The 12-and 24-month area under curve of TNM staging system for ICC, BCLC staging system, JIS score, and CLIP score were 0.836 and 0.847, 0.744 and 0.780, 0.723 and 0.764, and 0.710 and 0.786, respectively.</p><p><b>CONCLUSION</b>The 7th edition of TNM staging system for ICC has superior prognostic value to other seven staging systems in cHCC-CC patients undergoing surgical treatment.</p>

Transient hepatic venous occlusion induced liver hemodynamic change and reperfusion injury in rats / 中国医学科学院学报

<p><b>OBJECTIVE</b>To observe the hemodynamic change and reperfusion injury cause by transient hepatic venous occlusion and transient hepatic inflow occlusion in rats.</p><p><b>METHODS</b>The rat liver was divided into 3 different areas: the ischemia reperfusion (IR) area: the inflow of the right superior lobe was clamped for half an hour; the non-isolated lobe congestive reperfusion (NIL-CR) area: the outflow of the right median lobe was clamped for half an hour; and the isolated lobe congestive reperfusion (IL-CR) area: the outflow of the left lobe was clamped for half an hour. The flux value and the oxygen saturation of microcirculation were monitored before at clamping for 30 minutes, and on 1 day, 3 days ,and 7 days after reperfusion. The hepatic damage and Suzuki's score were evaluated.</p><p><b>RESULTS</b>After clamping for 30 minutes, the flux value in the IR area was significantly higher than in NIL-CR area (P<0.01) and IL-CR area (P<0.01), the oxygen saturation in the IR area was significantly higher than in NIL-CR area (P<0.01) and IL-CR area (P<0.05). Compared with IR area, both NIL-CR area and IL-CR area were found having more severe liver damage in terms of Suzuki's score in early postoperative period (at clamping for 30 minutes and on 1 day, P<0.01). However, there was no significant difference between NIL-CR area and IL-CR area in flux value, oxygen saturation, and Suzuki's score (P>0.05).</p><p><b>CONCLUSIONS</b>Hepatic venous occlusion can more effectively decrease the blood perfrusion and oxygen saturation; thus, compared to the IR, CR can result in more severe liver damage. The presence of normal liver tissue around the congestion area can not influence liver damage in transient hepatic venous occlusion.</p>

A meta-analysis of the long-term effects of chronic pancreatitis surgical treatments: duodenum-preserving pancreatic head resection versus pancreatoduodenectomy / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Surgery is regarded as the most effective treatment to relieve pain and reduce complications in chronic pancreatitis (CP). Two major strategies exist: duodenum-preserving pancreatic head resection (DPPHR) and pancreatoduodenectomy (PD). Many studies suggest that DPPHR offers advantages during surgery and in the short-term; however, the long-term effects have not been thoroughly investigated. We analyzed the long-term outcomes of DPPHR and PD, over follow-up times of at least 1 year, to determine the optimal surgical treatment for CP.</p><p><b>METHODS</b>We systemically reviewed all CP surgical treatment reports, and only included randomized controlled trials (RCT) comparing DPPHR and PD, excluding unqualified studies using several pre-specified criteria. When multiple publications of a single trial were found, the most comprehensive current data were selected. Characteristics of the study populations and long-term postoperative outcome parameters were collected. The quality of the studies and data was analyzed using RevMan 4.2 software.</p><p><b>RESULTS</b>Five trials were qualified for meta-analysis, with 261 participants in total (114 in the DPPHR group and 147 in the PD group). There were no significant differences in the age, gender, or indications for surgery of each group. At the mean of 5.7-year (1 - 14 years) follow-up examination, DPPHR and PD resulted in equally effective pain relief, exocrine and endocrine function, and similar mortality rates (P > 0.05); however, DPPHR patients had improved global quality of life and weight gain, and reduced diarrhea and fatigue (P < 0.05).</p><p><b>CONCLUSION</b>DPPHR and PD result in equal pain relief, mortality, and pancreatic function; however, DPPHR provides superior long-term outcomes.</p>

Assessment of hepatic reserve function of cirrhosis liver using dynamic SPECT (99m)Tc-galactosyl human serum albumin scintigraphy / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the effectiveness of dynamic SPECT (99m)Tc-galactosyl human serum albumin (GSA) scintigraphy on the assessment of reserve function of cirrhosis liver.</p><p><b>METHODS</b>From January 2010 to December 2011, 55 patients with cirrhosis liver were enrolled in this study. The case numbers of male and female were 43 and 12 respectively and the age was (51 ± 9) years (ranging from 35 to 69 years). After routine biochemistry test, CT scan and (99m)Tc-GSA dynamic SPECT scan were performed in turn using a juxtaposed SPECT/CT system. Then the morphologic volume of liver parenchyma (MLV), functional liver volume (FLV) and the hepatic cell absorption rate constant (GSA-K) were calculated. The correlations between GSA-K and routine biochemistry test, Child-Pugh score, indocyanine green clearance rate (ICG-K) were analyzed. The patients were further divided into 3 groups according to whether there was occlusion or stenosis in the main branch of left portal vein (group 1, n = 5), right portal vein (group 2, n = 13) or not (group 3, n = 37) and the regional hepatic functions index of the 3 groups were compared.</p><p><b>RESULTS</b>The value of FLV of the whole, left and right liver was (594 ± 152) ml, (244 ± 119) ml and (356 ± 171) ml, respectively. There were correlations between GSA-K and total bilirubin, prothrombintime, Child-Pugh score and ICG-K (r = -0.730--0.298, P < 0.05). The FLV and MLV ratios of involved hemiliver to uninvolved hemiliver were 0.09 ± 0.06 and 0.30 ± 0.14 in group 1, 0.57 ± 0.43 and 1.08 ± 0.63 in group 2, 0.71 ± 0.30 and 0.71 ± 0.48 in group 3. The difference in MLV-FLV ratio was signifcant between group 1 and group 3, between group 2 and group 3 (P = 0.000).</p><p><b>CONCLUSIONS</b>The dynamic SPCECT (99m)Tc-GSA scintigraphy can not only assess the whole liver function of cirrhosis liver effectively, but also evaluate the variation of regional liver function accurately.</p>

Ablation of segmental glissonian pedicle by ultrasound-guided radiofrequency in precision liver resection in a porcine model / 中华外科杂志

<p><b>OBJECTIVE</b>To demonstrate the ablation of segmental glissonian pedicle by ultrasound-guided radiofrequency in precision liver resection in porcine model.</p><p><b>METHODS</b>The study was carried out on 6 Bama miniature pigs. Coagulative desiccation of the vessels feeding the segment to be resected was induced by introduction of a "cooled-tip" radiofrequency electrode under intraoperative ultrasound guidance at the level of the vessels. Then, an area of marked discoloration on the surface of the liver became obvious. Liver parenchymal transection followed without any form of hepatic inflow occlusion. Three segments (segment 3, 5, and 6) were resected on each pig. The criteria studied the local and general tolerance, the change of blood flow parameters of each segmental arterial and portal branches, and the microscopic appearance of the segmental arterial, portal and biliary tract branches. Using t test as the statistical methods.</p><p><b>RESULTS</b>Postoperative mortality and morbidity were 0 and all serum parameters had normalized by 14 days. Demarcation area was obtained in 15 segments. The flow rate of the resected segmental portal branches was 0 cm/s after radiofrequency and the value of the arterial branches was (28 ± 18) cm/s which was significantly lower than pre-radiofrequency, which were (10.2 ± 3.0) cm/s and (60 ± 17) cm/s (t = 14.439, 5.502; P = 0.000). There was no significant difference in the flow rate of the remnant segmental arterial and portal branches among pre-radiofrequency, post-radiofrequency and 14 days after operation. On microscopic observation, the mean ablated length of segmental portal, arterial and biliary tract branches were (1.6 ± 0.4) cm, (1.2 ± 0.4) cm, and (1.7 ± 0.3) cm respectively.</p><p><b>CONCLUSIONS</b>The ablation of the segmental glissonian pedicle by ultrasound-guided radiofrequency is quick, safe and effective. The probe needs to be away from vessels feeding segments 1.5 cm at least to avoid thermal injuries.</p>

Effects of different hepatic inflow occlusion methods on liver regeneration following partial hepatectomy in rats / 中国医学科学院学报

<p><b>OBJECTIVE</b>To explore the effects of different hepatic inflow occlusion methods on liver regeneration in rats after partial hepatectomy (PH).</p><p><b>METHODS</b>Male Wistar-Furth rats were randomly assigned to three groups: control group, underwent 68% hepatectomy alone; occlusion of portal triad (OPT) group, subjected to occlusion of portal triad under portal blood bypass; and occlusion of portal vein (OPV) group, subjected to occlusion of portal vein under portal blood bypass. Blood flow was occluded for 20, 30, and 40 minutes before 68% hepatectomy. According to the 7-day survival of each group, a same occlusion time T was set. Each group was divided into two subgroups (n = 8), in which animals were killed 3 and 7 days later. Liver regeneration was calculated as a percent of initial liver weight. Immunohistochemistry for proliferating cell nuclear antigen (PCNA) and Ki-67 was performed to quantify proliferating cells. In addition, functional liver volume represented by 99Tc(m)-GSA radioactivity was assessed.</p><p><b>RESULTS</b>The safe tolerance limit time was 30 minutes for OPT group and 40 minutes for OPV group. At 3 days after PH, no significant difference was observed in the regeneration rate of each group (P > 0.05). However, liver radioactive activity, PCNA labeling index, and Ki-67 index of OPV group was significantly higher than those of OPT group (P < 0.05); the latter were similar to those of control group (P > 0.05). At 7 days after PH, no significant difference was observed in all indexes among three groups (P > 0.05).</p><p><b>CONCLUSION</b>Compared with Pringle maneuver, preserving the hepatic artery flow during portal triad blood inflow occlusion can promote remnant liver regeneration early after PH.</p>

Application of persistent methylene blue dyeing method for anatomic hepatectomy of hepatocellular carcinoma with bile duct tumor thrombi / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the role of anatomic hepatectomy of hepatocellular carcinoma with bile duct tumor thrombi by application of persistent methylene blue dyeing method.</p><p><b>METHODS</b>From January 2009 to February 2011, 11 hepatocellular carcinoma patients with bile duct tumor thrombi underwent anatomic hepatectomy with removal of the biliary tumor thrombus. There were 10 male and 1 female patients. The average age was 49 years (ranging from 31 to 67 years). The initial symptom of 9 out of the 11 patients was jaundice. After anatomy and ligation of Glissonean pedicle of pre-resection segment, methylene blue was injected into its far-end portal vein in order to dye the segment.</p><p><b>RESULTS</b>Persistent methylene blue dyeing method was successful in all patients. Primary foci were found in all patients. Hepatectomy were performed, including 4 patients of segmentectomy, 3 patients of subsegmentectomy, 2 patients of hemihepatectomy, and 2 patients of hepatic sectionectomy. The mean operation time and blood loss was 137 minutes and 246 ml respectively. Severe complications such as liver function failure and sub-diaphragm abscess was avoided in all patients. No perioperative death. Post-operation radiotherapy was performed on 2 patients . Over a mean follow-up time of 14.6 months, liver cancer recurrence occurred in 2 patients, abdomen seeding metastasis in 1 patient, bile duct tumor thrombi recurrence in 1 case, and 2 patients died.</p><p><b>CONCLUSIONS</b>Anatomic hepatectomy of hepatocellular carcinoma with bile duct tumor thrombi by application of persistent methylene blue dyeing method can make resection more precise and improve curative effect.</p>

Effect of resection following downstaging of unresectable hepatocelluar carcinoma by transcatheter arterial chemoembolization / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>This retrospective study was undertaken to analyze the outcome of hepatic resection in fifty-two patients with unresectable hepatocellular carcinoma (HCC) between January 2004 and December 2008.</p><p><b>METHODS</b>Among these fifty-two patients, the mean diameter of the tumor was 7.9 cm (4.4 - 15.5 cm, median 8.5 cm) prior to the first transcatheter arterial chemoembolization (TACE). After 1 - 6 times of TACE (median 2), the median tumor diameter was reduced to 4.2 cm (0 - 8.4 cm) prior to resection. The duration between the last TACE treatment and sequential resection varied from one to six months (median 2.7 months). Serum a-fetoprotein (AFP) levels were abnormal in thirty-eight out of the fifty-two patients. In AFP producing HCCs, AFP levels returned to normal (≤ 400 µg/L) in twenty-five out of thirty-eight patients. Hepatic segmentectomy, multiple hepatic segmentectomy or partial hepatic resection were performed in forty-five patients, two underwent extended left hemihepatectomy, and one underwent right posterior branch portal vein thrombectomy. One patient received a right hemihepatectomy and three had left hemihepatectomies.</p><p><b>RESULTS</b>Complete tumor radiological response (CR) occurred in five patients (9.6%). There were three cases of perioperative mortality in the fifty-two patients (5.8%). One patient underwent salvaged orthotopic liver transplantation, and twenty-one patients observed tumor recurrence within two years. The 1-, 3- and 5-year survival rates of the fifty-two patients were 77.0% (n = 40), 55.0% (n = 29), and 52.0% (n = 28), respectively. The median survival time after surgery was 49 months (95% confidence interval 7.5 - 52.7 months).</p><p><b>CONCLUSIONS</b>TACE treatment provides a better chance for HCC resection in patients initially diagnosed with unresectable HCC. Furthermore, liver resection should be performed once the tumor is downstaged to be compatible for successful resection.</p>

Influence of obstructive jaundice on postoperative complications and mortality after pancreaticoduodenectomy: analysis of the 25-year single-center data / 中华外科杂志

<p><b>OBJECTIVE</b>To study the influence of the depth of jaundice, the duration of jaundice and preoperative biliary drainage (PBD) on postoperative complications and mortality after pancreaticoduodenectomy (PD).</p><p><b>METHODS</b>A retrospective review was performed of the medical records of 1025 patients who underwent PD between June 1986 and December 2010. The patients comprised 659 men and 366 women, ranging from 4 to 81 years old with a mean age of (54 ± 12) years. The indications for PD were malignant disease in 869 patients (84.78%) and benign or borderline tumors in 156 patients (15.22%). The operative procedures performed were pylorus-preserving modification in 279 patients and conventional PD, i.e. Whipple's operation in 746 patients. Complications after PD were compared among the different groups which was classified according to the depth of obstructive jaundice, the duration of obstructive jaundice and whether undergoing preoperative biliary drain or not, and the analysis was made by variance analysis and χ(2) test respectively.</p><p><b>RESULTS</b>The depth of jaundice did not significantly affect the incidence of complications after PD except for the hemorrhage complication (χ(2) = 11.06, P = 0.03). The duration of jaundice had no much influence on the postoperative complications and mortality. PBD could not reduce the postoperative complications and mortality, however, it would increase the incidence of postoperative incision infection (χ(2) = 9.84, P = 0.01). No significant relationship was observed between the duration of PBD and the postoperative complications and mortality.</p><p><b>CONCLUSIONS</b>Either the depth or duration of obstructive jaundice has no relationship with the postoperative complications and mortality after PD but the postoperative hemorrhage. Patients undergoing PD can not be benefited from PBD. Consequently, PBD should not be performed routinely, but it can be used in some serious patients with severe depth of jaundice who can not received surgery at once.</p>

Surgical management and outcome of solid-pseudopapillary tumor of pancreas: a series of 58 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To study the surgical management of solid-pseudopapillary tumor of the pancreas (SPTP) and its characteristics of outcome.</p><p><b>METHODS</b>Fifty-eight patients with SPTP of the pancreas admitted from January 2001 to December 2010 were retrospectively analyzed. There were 7 male and 51 female patients, with an average age of 30 years (ranging 9 to 70 years). Most patients were symptomatic before admission; the most common symptom was abdominal pain. Of the 58 patients, 21 patients underwent pancreaticoduodenectomy, 30 patients underwent distal pancreatectomy, 6 patients underwent central pancreatectomy, 1 patient underwent simple tumor enucleation, and 1 patients underwent duodenum-preserving pancreatic head resection.</p><p><b>RESULTS</b>The average length of stay in hospital was 23.8 days (ranging 12 to 64 days). Thirteen patients (22.4%) developed postoperative complications, including grade A postoperative pancreatic fistula of 8 cases, gastrointestinal tract bleeding of 1 case, pleural effusion of 2 cases, wound infection and fat liquefaction of 2 cases. Two patients underwent reoperation due to gastrointestinal tract bleeding or wound infection. There was no hospital death. Forty-four patients were followed-up for 7 to 136 months with an average of 41 months. All the 44 patients were alive, while 8 patients developed dyspepsia and 4 patients developed diabetes mellitus. There were no tumor recurrences or metastasis.</p><p><b>CONCLUSIONS</b>SPTP is found primarily in young women. Excellent prognosis would be achieved with surgical resection.</p>

Intrahepatic biliary cystadenoma: experience with 10 consecutive cases at a single center / 南方医科大学学报

<p><b>OBJECTIVE</b>To summarize the clinical experience with diagnosis and treatment of intrahepatic biliary cystadenoma (IBCA).</p><p><b>METHODS</b>We retrospectively analyzed the data of 10 consecutive IBCA cases treated in our department in light of the characteristics of the epidemiology, radiology, lab tests, pathology and prognostic.</p><p><b>RESULTS</b>The patients are all female with an average age of 48.9 (16-73) years. The number of asymptomatic, slightly symptomatic and severe symptomatic patients was 4, 4 and 2, respectively. Radiological examination showed segmented cystic lesions in all the cases with an average diameter is 13.3∓4.9 cm. The incidence of segmentation, papillary or nodular hyperplasia, and calcification within the lesions was 90%, 60% and 20%, respectively. Macroscopic examination of the specimen showed compartmentation in the lesions, and microscopically, the lesions all showed lining of cubic or columnar epithelium on the inner wall with ovary-like or fibrous stroma. Complete resection of the tumor was achieved in 8 cases and partial resection was performed in 2 cases. The patients were followed up for a mean of 55.3 (12-164) months, and none of the patients with complete tumor resection showed recurrence, while both of the two patients with partial resection had postoperative recurrence.</p><p><b>CONCLUSION</b>IBCA is a rare cystic lesion occurring primarily in middle-aged women. The preoperative diagnosis of this disease relies primarily on radiological evidences, and a complete resection of IBCA may prolong the patient survival.</p>

Ex vivo liver resection followed by autotransplantation for end-stage hepatic alveolar echinococcosis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>For patients with end-stage hepatic alveolar echinococcosis (AE), in vivo resection of the involved parts of the liver is usually very difficult, therefore, allogenic liver transplantation is indicated. However, we hypothesize that for selected patents, ex vivo liver resection for thorough elimination of the involved tissues and liver autotransplantation may offer a chance for clinical cure.</p><p><b>METHODS</b>We presented a 24-year-old women with a giant hepatic AE lesion who was treated with hepatectomy, ex vivo resection of the involved tissue and hepatic autotransplantation. The patient had moderate jaundice and advanced hepatic AE lesion which involved segments I, IV, V, VI, VII, VIII and retrohepatic inferior vena cava. The lateral segments (II and III) of the left liver remained normal with over 1000 ml in its volume. No extrahepatic metastases (such as to the lung or brain) could be found. As the first step of treatment, X-ray guided percutaneous transhepatic cholangiodrainage (PTCD) was performed twice for bile drainage in segment III and II separately until her serum total bilirubin decreased gradually from 236 to 88 µmol/L. Total liver resection was then performed, followed by extended right hepatic trisegmentectomy and the entire retrohepatic vena cava was surgically removed en bloc while her hemodynamics parameters were stable. Neither veino-veinous bypass nor temporary intracorporeal cavo-caval or porto-caval shunt was used during the 5.7-hour anhepatic phase. The remained AE-free lateral segments of the left liver were re-implanted in situ. The left hepatic vein was directly anastomosed end-to-end to the suprahepatic inferior vena cava due to the lack of the retrohepatic inferior vena cava with AE total infiltration. Because compensatory retroperitoneal porto-caval collateral circulation developed, we enclosed remained infrahepatic inferior vena cava at renal vein level without any haemodynamics problems.</p><p><b>RESULTS</b>During a 60-day following-up after operation, the patient had a good recovery except for a mildly elevated serum total bilirubin.</p><p><b>CONCLUSIONS</b>As a radical approach, ex vivo liver resection and liver autotransplantation in a case has shown a optimal potential for treatment of the end-stage hepatic AE. Strict compliance with its indications, evaluation of vessels of patients pre-operatively, and precise surgical techniques are the keys to improve the prognosis of patients.</p>

Role of hepatic arterial ischaemia in biliary fibrosis following liver transplantation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>In clinical liver transplantation, whether the delay of hepatic arterial ischaemia increases biliary fibrosis or not is controversial. We designed a liver transplantation model to test this controversy and explore its mechanism.</p><p><b>METHODS</b>Twelve dogs were divided into two groups randomly: hepatic arterial ischaemia (HAI) and control groups. In HAI group, hepatic artery was perfused 60 minutes after portal perfusion, but in control group, hepatic arterial perfusion was simultaneous with portal perfusion. The pathological changes of intrahepatic bile ducts were observed. Transforming growth factor beta 1 (TGF-beta1), expressed in epithelial cells of intrahepatic bile duct, was detected by immunohistochemical streptoadividin-biotin complex method. Expressions of Smad3, P-Smad3 and the transcriptional levels of alpha smooth muscle actin (alpha-SMA) mRNA in intrahepatic bile ducts were detected by Western blotting and RT-PCR respectively.</p><p><b>RESULTS</b>Compared with the control group, more collagen deposition and leucocytic infiltration could be seen in biliary vessel walls. Significantly more buffy particles, which are the proteins of TGF-beta1, could be seen in biliary epithelial cells. P-Smad3 and alpha-SMA mRNA (as ratio to corresponding beta-actin) in intrahepatic bile ducts were 1.82 +/- 0.18 and 1.86 +/- 0.73 respectively in HAI group, significantly higher than those in control group (0.59 +/- 0.09 and 0.46 +/- 0.18, respectively).</p><p><b>CONCLUSIONS</b>Hepatic arterial ischaemia could increase the deposition of collagen fibres, trigger the transdifferentiation of myofibroblasts in intrahepatic bile duct and might result in biliary fibrosis by activating the TGF-beta1 signalling pathway.</p>

Effect of arterioportal shunting in radical resection of hilar cholangiocarcinoma / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The resection and reconstruction of the hepatic artery is often required in radical surgery for hilar cholangiocarcinoma. In this study, we report our experience in performing arterioportal shunting as an alternative for the arterial reconstruction.</p><p><b>METHODS</b>Four patients with hilar cholangiocarcinoma underwent extended left hepatectomy and caudate lobectomy combined with en bloc resection of the hepatic artery and arterioportal shunting with restriction of the arterial caliber. The efficacy of arterioportal shunting was assessed by computed tomography angiography (CTA).</p><p><b>RESULTS</b>All the four patients recovered uneventfully without any complications. CTA showed a patent shunt and normal liver regeneration. No signs of portal hypertension were found at one year of follow-up.</p><p><b>CONCLUSIONS</b>Arterioportal shunting with restriction of the arterial caliber appears to be a feasible and safe alternative for the microvascular reconstruction after hepatic artery resection in radical surgery for hilar cholangiocarcinoma.</p>