Abstract:

Objective：To discuss diagnosis and treatment of hepatolithiasis complicated with cholangiocarcinoma.
Methods：Fifty-four cases of hepatolithiasis complicated with cholangiocarcinoma from 1998 to 2009 treated in Zhongnan Hospital were collected and analysed.
Results：Cholangiocarcinoma occurred in 5.45% of patients with hepatolithiasis in our hospital group. The diagnosis was established preoperatively in 45 cases (83.3%). All of 54 cases underwent surgery. Among them, 21 cases (38.9%) of adenocarcinoma in bile duct underwent radically resected.  At followed up of 45 cases (83.3%), the average survival  time of patients that underwent radical resection was 23 months and that of patients who underwent drainage was 8.5 months.
Conclusions：The therapeutic effect of cholangiocarcinoma complicated with hepatolithiasis is poor and, when possible, radical resection of the tumor should be undertaken.

Abstract:

Objective：To explore the related factors that can influence the prognosis of patients with resectable hilar cholangiocarcinoma.
Methods：The clinical data and survival status of 44 cases of resected hilar cholangiocarcinoma,in our department in the latest 6 years, were analyzed retrospectively by univariate and multivariate analysis.
Results：Of all the 44patients, the R0, R1 and R2 resection was done in 38, 6 and 0 cases, respectively. A new technique of hepaticojejunostomy, in which the anterior edges of the jejunal end were sutured to the liver above the opening of bile duct stump after suturing of posterior edges, was used in 25 patients, and the traditional hepaticojejunostomy technique was used in the other 19 patients; the bile leakage rate of the former techniqne was significantly less than that of the latter (χ2=4.565, P=0.033). The clinical stage, extent of liver resection whether or not R0 resecion was done and lymph nodes metastasis were the factors that affected the survival with statistical difference by univariate analysis (P＜0.05); while the clinical stage and whether or not R0 resection was done were the independent prognosis factors that affected the survival by multivariate Cox regression analysis (P＜0.05).
Conclusions：The clinical stage and attainment of R0 resecion are the key factors that affect the prognosis of patients with resectable hilar cholangiocarcinoma; the new technique of hepaticojejunostomy is a useful measure which can decrease the resection extent of normal liver tissue while making sure that the tumor is completely resected.

Abstract:

Objective：To explore the diagnosis, surgical treatment and outcome of hepatocellular carcinoma(HCC) with tumor thrombus in bile duct (BDT).
Methods：The clinical data of  16 patients with hepatocellular carcinoma and tumor thrombus in bile duct treated in Henan Tumor Hospital from June 2006 to December 2008 were retrospectively analyzed.
Results：All 16 patients received surgical treatment. The operative procedures included left hemihepatectomy combined with tumor thrombectomy through choledochotomy (n=2), right hemihepatectomy with tumor thrombectomy through choledochotomy (n=3), segmental hepatectomy with  tumor thrombectomy through choledochotomy (n=4), left hemihepatectomy combined with hepatic hilar duct    resection and bilioenteric anastomosis (n=1), left lateral and right anterior segment ectomy combined with tumor thrombectomy through choledochotomy and potal vein  tumor thrombectomy (n=1), extended left hemihepatectomy with removal of tumor thrombus in left bile duct (n=1), right hemihepatectomy with removal of tumor thrombus in right bile duct (n=1), and Ⅴ, Ⅵ  segmentectomy with removal of left bile duct  tumor thrombus (n=1),  and tumor thrombectomy through choledochotomy (n=2).  In 1 patient,  bile leakage occurred and it healed after continuous drainage for 34 days. There were no other serious complications and no perioperative death. All patients were followed up; the average survival time was 23.6（4-63）months. Six patients have survived well now and 1 patient survived for over 5 years.
Conclusions：Patients with hepatocellular carcinoma and tumor thrombus of bile duct can obtain a good outcome after definitive diagnosis and aggressive surgical treatment.

Abstract:

Objective：To evaluate the effectiveness of preoperative biliary drainage (PBD) in patients with obstructive jaundice resulting from malignant tumors.
Methods：According to the requirements of Cochrane systematic review, a thorough literature search was performed in Medline and Embase electronic databases between 1995 and 2009 in terms of the key words preoperative biliary drainage, restricted articles for the English language. Two reviewers independently screened the studies for eligibility, evaluated the quality and extracted the data from the eligible studies with confirmation by cross-checking. Data were processed for a meta-analysis by Stata 9.2 software. Comparison was performed between PBD patients and patients without PBD, who both subsequently underwent resection of the malignant tumors, including the indices such as postoperative mortality, the incidence of postoperative pancreatic leakage, bile leakage, abdominal abscess, delayed gastric emptying and incision infection.
Results：There were 14 papers with 1 826 malignant obstructive jaundice patients selected and analysed, The combined RR values of postoperative mortality, the incidence of pancreatic leakage, bile leakage, abdominal abscess, and delayed gastric emptying between PBD patients and patients without PBD were not statistically significant (P=0.986, 0.364, 0.786, 0.819, 0.265, respectively); but the incidence of postoperative incision infection was improved in PBD group versus that in non-PBD group (P=0.002）.
Conclusions：PBD did not significantly improve the postoperative efficacy and safety in patients with malignant obstructive jaundice. Therefore, PBD may not be regarded as a preoperative routine measure for patients with malignant obstructive jaundice.

Abstract:

Objective：To study the effect of LY294002, an inhibitor of PI3-Kinase, on human cholangiocarcinoma QBC939 cells.
Methods：The cell proliferation was detected by MTT assays. Apoptosis was analyzed by flow cytometry. The phosphorylation of Akt and expression of caspase9 were assessed by Western-blotting.
Results：LY294002 inhibited the proliferation and induced apoptosis in human cholangiocarcinoma QBC939 cells in a dose-dependent manner. Furthermore, Western-blotting showed that LY294002 attenuated the phosphorylatioin of Akt and up-regulated the expression of caspase3, 9.
Conclusions：LY294002 up-regulates the expression of caspase3, 9 by inhibition of the activity of PI3-K/Akt signaling pathway, induction of apoptosis and decreasing  cell proliferation.

Abstract:

Objective：To observe the change of drug resistance of QBC939 cells after treatment with verapamil, a competitive inhibitior of P-glycoprotein.
Methods：MMT was used to test the change of verapamil on cisplatin dose curves.
Results：The dose of cisplatin of 50% inhibition was 335.5 μg/L,it decreased to 73.20 μg/L,29.12 μg/L and 17.30 μg/L treated with 10 μg/mL, 20 μg/mL and 40 μg/mL verapamil, respectively.
Conclusions： Verapamil can inhibit cisplatin resistance of QBC939, and the inhibitory effect is related with the concentration of verapamil.

Abstract:

Objective：To evaluate the method and effect of combination treatment with duodenoscope and choledochoscope for impacted residual bile duct stones.
Methods：From March 1998 to May 2010, 98 cases of residual bile duct stones, including 20 cases of postoperative acute severe cholangitis, 66 cases of postoperative choledocholithiasis and 12 cases of postoperative hepatolithiasis, were treated by combination of duodenoscope and choledochoscope, and the clinical data were retrospectively analyzed.
Results：The technique of combination of duodenoscope and choledochoscope was implemented successfully in all patients. In 95 of the 98 patients, stones were extracted successfully in the first session of combined treatment procedure（96.9%）, and  in 3 cases stones were extracted successfully in a second session（3.1%）. The success rate of stone removal was 100%. The impacted stones of all patients were completely cleared without serious complications such as biliary tract perforation or hemorrhage.  Acute pancreatitis occurred in 1 case（1.0%） and 9 cases had hyperamylasemia（9.2%） after the procedures.
Conclusions：The technique of combination of duodenoscope and choledochoscope for treatment of impacted residual bile duct stones is safe, effective, simple and minimally invasive, which is an ideal choice for treatment of impacted residual bile duct stones.

Abstract:

Objective：To evaluate the feasibility of without using clips and harmonic scalpel and only using coagulation hook and absorbable suture to perform laparoscopic cholecystectomy(LC).
Methods：From December 2008 to June 2010, we performed  LC in  554 cases by using absorbable sutures instead of clips and harmonic scalpel to close the cystic duct and artery. First, we dissected the gallbladder by clamps and coagulation hook, and adopted an anterograde or retrograde LC according to the condition of Calot triangle. After the dissection of cystic duct and artery, their proximal ends were ligated with 10 cm long absorbable sutures, the knots were made intraperitonealy by clamps, and their distal ends were severed by coagulation hook.
Results：Except 2 cases, 1 case of gallbladder perforation making Calot triangle unclear and 1 case of gallbladder-colonic fistula formation, converted to open surgery, all the other cases successfully underwent LC. The mean operation time was 32 minutes (range 10 to 70 minutes). The blood loss ranged from 5 to 200 mL (mean,13 mL). there was no hemorrhage, biliary leakage or intra-abdominal infection post-operatvely. Among the patients, 503 cases were followed up for 1 month to 1.5 years (mean, 7 months), during which no abdominal pain, jaundice or fever occurred. 
Conclusions：Using absorbable sutures and coagulation hook  instead of clips and harmonic scalpel is a safe, reliable and more economical method for LC, and can avoid the complications caused by clips.

Abstract:

Objective：To explore the relationship between preopertive abdominal ultrasonic features of acute cholecystitis and conversion from laparoscopic to open cholecystectomy.
Methods：A total of 226 patients with acute cholecystitis received ultrasonic examination before LC. The parameters  measured pre-operatively included the gallbladder volume, cholecystic wall thickness, gallbladder fossa fluid, stone impaction in gallbladder neck, adhesions of gallbladder to arourd tissue or adhensions of Calot′s triangle. The relationship between the imaging results and conversion to laparotomy in LC were analyzed.
Results：LC was successfully performed in 208 patients, but 18 were converted to open surgery. Univariate analysis showed that enlarged gallbladder, cholecystic wall thickness, stone impaction in gallbladder neck and adhesions of Calot′s triangle were significantly correlated with the conversion to open cholecystectomy (P＜0.05). Multivariate analysis showed that cholecystic wall thickness and adhesion of Calot′s triangle were independent risk factors for conversion from laparoscopic cholecystectomy to open surgery.
Conclusions：Preoperative ultrasonography for predicting conversion from laparoscopic to open cholecystectomy in acute cholecystitis is simple, and has  important significance for selection of laparoscopic operation in acute cholecystitis.

Abstract:

Objective：To study the value and feasibility of fast track surgery (FTS) in laparoscopic common bile duct exploration.
Methods：Sixty cases undergoing simple laparoscopic common bile duct exploration were selected for the perioperative therapy of fast track surgery(n=28)or conventional surgery(n=32). The time for bowel flatus and food intake and ambulation,hospital stay and cost, and incidence of complications  after operation were compared.
Results：After operation,the time of bowel flatus, food intake, ambulation and hospital stay in fast track surgery group were significantly shorter than those in conventional surgery group(P<0.05).Hospital cost was also less(P<0.05) in FTS group; while the postoperative complications of the two groups showed no significant difference(P>0.05).
Conclusions：Fast track surgery in laparoscopic common bile duct exploration patients is safe,economical,effective,and has very high clinical value.

Abstract:

Objective：To investigate the effect of arterio-portal shunt (APS) on intrahepatic bile duct and peribiliary plexus (PBP).
Methods：Sixty rats were divided into three groups: SHAM group,hepatic artery ligation (HAL) group and HAL+APS group. Serum biochemical tests, histological and immunohistochemical analyses were performed to evaluate the pathological changes in portal area on d1,d7 and d30.
Results：(1)The serum biochemical test showed no significant difference between the three groups at 3 time points. (2) HAL induced inflammatory response in portal area, which was characterized by infiltration of inflammatory cells, thickening of the wall of interlobular portal vein and degenerative changes of cholangiocytes, but the pathological changes returned to normal by day 30. The APS group showed a transient inflammatory response which was milder than that of the HAL group. (3)Microvessel count, apoptosis index and PCNA index of cholangiocyte showed no significant difference between the three groups.
Conclusions：APS can improve portal area inflammation caused by HAL and promote early recovery of liver damage.

Abstract:

Objective：To construct survivin shRNA expression vector and investingate the effect of survivin shRNA on chemotherapy resistance of GBC-SD cells.
Methods：The siRNA sequence targeting survivin mRNA was synthesized and cloned into pEGFP-H1. The constructed plasmid and pEGFP-H1 were transfected into GBC-SD cells respectively via liposome. Then the transfected cells were selected with G418. GBC-SD cells were divided into three groups: GBC-SD, GBC-SD/EGFP and GBC-SD/survivin groups. Survivin mRNA was tested by RT-PCR. Then cells of the 3 groups were treated with adequate concentration of DDP（3.0 μg/mL） for similar periods of time, cell survival rate was detected with MTT and apoptosis was observed by TUNEL.
Results：The recombinant plasmid, pEGFP-survivin, was successfully constructed.  Compared to the other 2 groups, the level of  survivin expression in GBC-SD/survivin group was obviously decreased (74.7%, 71.5%). After DDP treatment, cell survival rate was obviously decreased in GBC-SD/survivin group compared with other 2 groups. There were brownly apopotosis nucleuses in the three groups.
Conclusions：Survivin shRNA expression vector has been constructed successfully and GBC-SD cells with stable expression shRNA has been obtained. The survivin shRNA could significantly down-regulate the expression of survivin in GBC-SD cells and improve the sensibility to chemotherapy.

Abstract:

Objective：To study the relevant differential expression proteins of GBC-SD cell line after treatment with thalidomide and the molecular mechanism.
Methods：Proteomic techniques and methods were used to separate the  differential expression proteins in GBC-SD cells after treated wiht that idomide (experiment group) and control group.
Results：The  differential expression proteins in experiment group and control group, whose spots variance was over 2-fold, were analysed  with PDQuest software,and found out 36 protein spots at difference level of expression（P＜0.05）, including 13 spots decreasing and 23 spots increasing  in experiment group. Then, 10 spots with more than 3-fold difference of  expression level were selected for anslysis, and 7 protein spots were identified.
Conclusions：Thalidomide has some effect on GBC-SD cells. Study on the function of differential protein can be as a basis for research on the mechanism of thalidomide treatment of gallbladder cancer.

Abstract:

Objective：To investigate the expression of DNA dependent protein kinases catalytic subunit (DNApkcs) and Ku70 in gallbladder adenocarcinoma,peritumoral tissues,adenomatous polyp and chronic cholecystitis, and explore its clinicopathological significance.
Methods：EnVisionTM immunohistochemical method was used to detect the expression of DNApkcs and Ku70 in the routinely paraffin embedded sections of samples of gallbladder adenocarcinoma(n=108),peritumoral tissues(n=46), adenomatous polyp(n=15) and chronic cholecystitis(n=35).
Results：The positive rates of DNApkcs and Ku70 were significantly lower in gallbladder adenocarcinoma(50.0%，51.9%)than in peritumoral tissues(82.6%，82.6%)and chronic cholecystitis(91.4%，88.6%)(P＜0.05 or P＜0.01).The positive rates were significantly higher in the cases of well-differentiated adenocarcinoma, non-metastasis of lymph node and non-infilatrated regional tissues or organs than in those of low-differentiated adenocarcinoma,metastasis of lymph node and infilated regional tissues or organs (P＜0.05 or P＜0.01).A high consistence was found between DNApkcs and Ku70 expression in gallbladder adenocarcinoma.
Conclusions：The expression of DNApkcs and Ku70 might be important biological markers reflecting the carcinogenesis，progression，biological behaviors and prognosis of gallbladder adenocarcinoma.The cases with positive expression of DNApkcs and Ku70 might have better prognosis.

Abstract:

Objective：To evaluate the hemostasis efficacy of selective artery embolization for treatment of patients with massive hemobilia.
Methods：Adopting the Seldinger technique, transcatheter selective arterial embolization was performed in twenty-three patients with massive hemobilia caused by liver trauma, hepatic calculus and hepatocellular carcinoma.
Results：Of the 23 cases, 12 cases had bleeding from right hepatic artery branch, 5 from left hepatic artery branch and 6 from both right and left hepatic artery branches as shown by digital subtraction angiography (DSA). Hepatic artery break off, false aneurysm，contrast medium overflow and bile duct display were the typical angiographic signs of the patients with massive hemobilia. There were twelve patients with single bleeding focus and eleven with multi-bleeding foci of hepatic artery branch. All patients successfully underwent selective artery embolization and the bleeding stopped immediately.  There were no cases of rebleeding, no cases were converted to laparotomy and no mortality caused by hepatic artery embolization in this series; and all the 23 patients are well in a half to three years of follow-up.
Conclusions：Selective arterial embolization is an effective and simple hemostasis method for patients with massive hemobilia.

Abstract:

Objective：To investigate the causes of reoperations for patients with biliary diseases so as to decrease the reoperative rates.
Methods：The clinical data of 152 patients with repeated biliary tract operations from January 2007 to August 2010 were analysized retrosepectively to study the causes, initial operative methods,and causes and methods of reoperations.
Results：Residual (n=36) and recurrent (n=80) bile duct stones were the main causes of reoperations for patients with biliary tract diseases(116/152, 76%).Other reasons were infection of biliary tract and bile duct injuries.
Conclusions：The causes for reoperation of extrahepatic biliay tract are multifactorial; main causes of reoperations were residual and recurrent bile duct stones, however, bile duct injuries and refluxing cholangitis should also be given special attention.

Abstract:

Objective：To investigate the diagnosis and treatment of congenital choledochal cysts in adults.
Methods：The records of 78 cases of congenital choledochal cyst in adults seen in the last 10 years were retrospectively analysed.
Results：Among the 78 cases, 74 patients under went operation: (1)52 cases had total cyst excision and Roux-en-Y hepatojejunostomy; (2)9 cases had partial cyst excision and Roux-en-Y hepatojejunostomy; (3)2 cases had duodenopancreatectomy; (4)Among 11 cases with cancer, 1 case underwent duodenopancreatectomy, 7 cases had radical resection of cholangiocarcinoma and 3 cases had palliative external drainage; (5)1 case had external drainage for bleeding and  rupture of choledochal cyst. Among the 74 cases, 54 patients were followed-up, the rate of follow-up was 73.0%. Follow-up period was 2 months to 7 years, mean 39 months. Patients with benign disease were in excellent condition. Among malignant disease patients, 1 case had duodenopancreatectomy, was lost to follow-up; 5 of the 7 cases with radical correction of cholangiocarcinoma were followed up and the survival time was  2-5 years, with the median survival time of 2.3 years. Three cases,  who had palliative external drainage, had a survival of 2-16 months, with the median survival time of 7.8 months.
Conclusions：Adult congenital choledochal cyst is prone to develop cancer. Early diagnosis and early treatment of congenital choledochal cyst is the key, and surgical excision of the cyst and bilioenterostomy are the basic principles of treatment.

Abstract:

Objective：To study the experience in diagnosis, management and prevention of iatrogenic bile duct injury(IBDI) with hepatic pedicle vascular injury.
Methods：A total of six patients with iatrogenic bile duct injury and hepatic pedicle vascular injury treated from Jan 1990 to Dec 2007 were involved in this retrospective analysis.
Results： In the six cases of iatrogenic bile duct injury, three of them were Type Ⅲ and the other three were TypesⅥ. Pedicle vascular injury included left hepatic artery injury, right hepatic artery, left-portal vein and right-portal vein injury. Two cases died on the third day and five months after surgery, respectively. The other four cases suffered a series of serious complications, but were cured by surgical treatment. All the four cases underwent follow-up survey; they were all well for 6 months to 17 years.
Conclusions：Iatrogenic bile duct injury(IBDI) with hepatic pedicle vascular injury is difficult to deal with, and is one of the fatal complications of cholecystectomy. The key to prevention of IBDI with hepatic pedicle vascular injury lies on properly dealing with bleeding from hepatic pedicle.

Abstract:

Objective：To investigate the feasibility and indications of primary closure of the common bile duct (CBD) after choledochal exploration.
Methods：From January 2006 to January 2009, 149 patients with CBD stone(s) received primary closure of the common bile duct (group A) and were compared with 356 patients  with CBD stone(s) who received T-tube drainage (group B) after choledochal exploration. Intraoperative choledochoscopy was performed routinely to rule out the possibility of retained stones. The CBD was meticulously stitched using 5-0 monocryl absorbent sutures for primary closure. Following primary closure of the CBD, a drainage tube  was placed in the subhepatic space.
Results：Postoperative bile leakage was observed in 2 patients in group A and 13 in group B respectively (P＞0.05), but no reoperations were necessary. After surgery, the average volume of transfusion, normal eating time and postoperative hospital stay was 5.2 liters, 2.2 days and 7.2 days, respectively, in group A, versus 11.1 liters, 6 days and 16.7 days, respectively, in group B (P＜0.05). At 1-3 years follow-up，5 patients were found to have biliary stricture in group B, but none in group A.
Conclusions：Primary closure of the CBD after choledochal exploration in selected patients with common bile duct calculi is safe, effective and inexpensive, and could be regarded as an alternative procedure.

Abstract:

Objective：To explore the diagnosis and surgical treatment of gallstone ileus.
Methods：We retrospectively analysed the diagnosis,treatment and follow-up outcome of 18 patients with gallstone ileus. 
Results：There were 18 patients with mean age of 64.3 years and a male to female ratio of 1∶5. Preoperative diagnosis rate was 77.8%. All 18 patients underwent laparotomy.Three patients underwent enterolithotomy alone,eight had two-stage procedure and six had one-stage procedure; 1 patient, who undergoing biliary enteric drainage before, underwent one-stage enterolithotomy, plastic surgery of biliary-enteric anastomosis and lithotomy. The perioperative complication rate was 38.9% and the main complications were wound infection and pulmonary infection. One patient died from myocardial infarction,  the perioperative mortality rate was 5.5%.
Conclusions：Elderly female patients are more susceptible to gallstone ileus. Effective use of imaging techniques can provide a timely diagnosis and reliable basis for the treatment of gallstone ileus. Surgical intervention should be adopted as soon as possible and must be individualized.