Anatomical variations of the cystic duct: two case reports.

Anatomical variations of the cystic duct often occur and may be encountered during cholecystectomy. Knowledge of the variable anatomy of the cystic duct and cysticohepatic junction is important to avoid significant ductal injury in biliary surgery. Here, we present two unusual cases with an anomalous cystic duct, namely, low lateral insertion and narrow-winding of the cystic duct. The first case was a 64-year-old man with cholelithiasis and chronic cholecystitis. During surgery, the entrance of the cystic duct was misidentified as being short and leading into the right hepatic duct. Further exploration showed multiple calculi in the right and common hepatic ducts. Cholecystectomy was completed, followed by T-tube drainage of the common and right hepatic ducts. Postoperative T-tube cholangiography demonstrated that the two T tubes were respectively located in the cystic and common hepatic duct. Six weeks later, the retained stones in the distal choledochus were extracted by cholangioscopy through the sinus tract of the T-tube. The second case was a 41-year-old woman, in which, preoperative endoscopic retrograde cholangiopancreatography (ERCP) revealed a long cystic duct, with a narrow and curved-in lumen. The patient underwent open cholecystectomy. Both patients were cured. The authors propose that preoperative ERCP or magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography or cholangioscopy constitute a useful and safe procedure for determining anatomical variations of the cystic duct.

Prognostic significance of HIF-2alpha/EPAS1 expression in hepatocellular carcinoma.

AIM: To evaluate the prognostic significance of HIF-2alpha/EPAS1 expression in hepatocellular carcinoma (HCC). METHODS: Surgical specimens from 315 patients with HCC as well as 196 adjacent noncancerous lesions and 22 cases of normal liver tissue were investigated by immunohistochemistry (IHC) for HIF-2alpha/EPAS1 using a standard detection system. Correlations with clinicopathological factors, VEGF, microvessel density (MVD), and prognosis were analyzed. RESULTS: Immunoreactivity of HIF-2alpha/EPAS1 was positive in 69.5% of HCC, 55.6% of adjacent noncancerous tissue, and 0% of normal liver tissue. And it was significantly correlated with tumor grade, venous invasion, intrahepatic metastasis, necrosis, and capsule infiltration. Correlation analysis of HIF-2alpha/EPAS1 with angiogenic factor VEGF (P<0.001), and MVD (P=0.016) was also noted. HIF-2alpha/EPAS1 protein was less frequently expressed in low MVD cases, whereas a high rate of expression was noted in cases with both medium and high MVD (P=0.042). By Kaplan-Meier analysis, strong HIF-2alpha/EPAS1 staining (>50% of tumor cells) in HCC correlated with a shortened survival in patients (Cox's regression, P<0.001, r=3.699). CONCLUSION: We conclude that HIF-2alpha/EPAS1 expression may play an important role in tumor progression and prognosis of HCC. Assessment of HIF-2alpha/EPAS1 expression in HCC may be used as a diagnostic tool and possibly a target in the treatment of HCC.

Expression of HIF-2alpha/EPAS1 in hepatocellular carcinoma.

AIM: To investigate the expression of hypoxia-inducible factor (HIF)-2alpha/endothelial PAS domain protein1 (EPAS1) in hepatocellular carcinoma (HCC). METHODS: Expression of HIF-2alpha/EPAS1 was investigated immunohistochemically on paraffin-embedded sections from 97 patients with HCC. To further confirm that HIF-2alpha/EPAS1 in HCC tissues also correlated with angiogenesis, a parallel immunohistchemistry study of vascular endothelial growth factor (VEGF) was performed on these 97 cases. RESULTS: HIF-2alpha/EPAS1 could be detected in 50 of 97 cases (51.6%), including 19 weakly positive (19.8%), and 31 strongly positive (31.1%), the other 47 cases were negative (48.4%). The expression of HIF-2alpha/EPAS1was significantly correlated with tumor size, capsule infiltration, portal vein invasion, and necrosis. A parallel immunohistochemical analysis of VEGF demonstrated its positive correlation with capsule infiltration, portal vein invasion, and HIF-2alpha/EPAS1 overexpression, which supported the correlation of HIF-2alpha/EPAS1up-regulation with tumor angiogenesis. No apparent correlation was observed between HIF-2alpha/EPAS1 and capsular formation, presence of cirrhosis, and histological grade. CONCLUSION: HIF-2alpha/EPAS1 is expressed in most of HCC with capsular infiltration and portal vein invasion, which indicates a possible role of HIF-2alpha/EPAS1 in HCC metastasis.

Subtotal colectomy with antiperistaltic cecoproctostomy for selected patients with slow transit constipation-from Chinese report.

BACKGROUND AND AIMS: Total abdominal colectomy with ileorectal anastomosis (TAC-IRA) is recommended widely for the patients with severe, refractory slow transit constipation (STC). Subtotal colectomy with end-to-end antiperistaltic cecorectal anastomosis (Sarli procedure), an alternative for STC, has been paid particular attention. The purpose of this study was to retrospectively compare alterations of clinical functions and qualities of life between TAC-IRA and Sarli procedure. METHODS: Seventeen patients with STC who underwent Sarli procedure and 20 patients with STC who underwent TAC-IRA were chosen for this study. Patient characteristics, operative data, postoperative data, alterations of clinical function, and quality of life were compared. The gastrointestinal quality of life index (GIQLI) survey was used to evaluate postoperative qualities of life. RESULTS: At the mean 4-year follow-up (range 2-6 years), the frequency of daily bowel movement in the Sarli group was significantly less than that in the TAC-IRA group (2.4 +/- 0.9 vs. 3.4 +/- 0.8; P = 0.0014), and the Wexner continence scores were significantly lower in the Sarli group compared to the TAC-IRA group (4.3 +/- 1.8 vs. 5.8 +/- 1.9; P = 0.0223). However, the GIQLI score in Sarli group was higher than the TAC-IRA group (119.8 +/- 7.5 vs. 111.1 +/- 12.0, P = 0.0455). Post subtotal colectomy barium enema showed a sign of "reservoir" at the residual ascending colon and cecum. CONCLUSIONS: Compared to the TAC-IRA, subtotal colectomy with end-to-end antiperistaltic cecoproctostomy for appropriately selected patients with STC resulted in relief of constipation, satisfactory functional outcome, and improved qualities of life.