Abstract:Objective: To investigate the feasibility of “one-stop” surgical treatment for regional hepatolithiasis. Methods: The clinical data of 74 patients with regional hepatolithiasis admitted from January 2013 to August 2016 were retrospectively analyzed. All patients underwent “one-stop” surgical treatment, i.e., one-session performance of complete stone removal and resection of the biliary strictures and impaired portion of the liver based on regular liver resection and guided by intraoperative B-type ultrasonography and cholangioscopy. Results: In the 74 patients, the coincidence rate of stone distributions by preoperative imaging examinations was 94.6% (70/74). All patients underwent regular hepatectomy that included left hemihepatectomy in 21 cases, left lateral lobectomy in 8 cases, right hemihepatectomy in 17 cases, right posterior lobectomy in 16 cases, right anterior lobectomy in 4 cases, right posterior lobectomy plus left lateral lobectomy in 5 cases and extended right hemihepatectomy in 3 cases; anatomical hepatectomy was performed in 49 patients (66.2%); 5 of the 7 cases who had internal biliary-intestinal drainage previously underwent additional reconstruction of the anastomosis due to anastomotic stenosis; 71 cases underwent T-tube drainage, the other 3 cases did not undergo T-tube placement due to short length of the preserved common hepatic duct after reconstruction of the anastomosis; the average operative time was (235.7±35.6) min and the average of blood was (415.3±106.8) mL. No deaths occurred, and postoperative complications occurred in 11 patients, all of which were improved by conservative treatments; the average length of postoperative hospital stay was (9.2±4.1) d. Six patients with suspicious residual stones by postoperative T-tube cholangiography underwent outpatient cholangioscopy or stone extraction. All patients were followed-up for 3 to 24 months, biliary infection occurred once in the 2 cases who did not undergo reconstruction of the anastomosis of the previous biliary-intestinal drainage, and 21 patients had stone recurrence in the common bile duct and were treated by ERCP+EST. Conclusion: After rigorous preoperative evaluation and selection of suitable patients, “one-stop” surgical treatment for regional hepatolithiasis is safe and feasible, with favorable efficacy.

Abstract:Objective: To compare the clinical efficacy of laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE) versus endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) plus LC for cholecystolithiasis with choledocholithiasis in elderly patients. Methods: The clinical data of 94 elderly patients (over 60 years of age) with gallbladder and common bile duct stones undergoing minimally invasive therapy in China-Japan Union Hospital from October 2012 to April 2016 were retrospectively analyzed. Of the patients, 45 cases received LC plus LCBDE (LC+LCBDE group) and 49 cases had ERCP/EST plus LC (ERCP/EST+LC group), and the main clinical variables between the two groups of patients were compared. Results: In LC+LCBDE group versus ERCP/EST+LC group, the surgical success rate (93.3% vs. 89.8%, P=0.539) and incidence of postoperative complications (8.9% vs. 10.2%, P=0.892) showed no significant difference, but the hospitalization cost was significantly decreased (37 735 yuan vs. 48 260 yuan, P<0.001) and length of hospital stay was significantly shortened (11.51 d vs. 13.39 d, P=0.015). A total of 81 patients from both groups were followed up for 6 to 48 months; the incidence of stone recurrence and biliary tract infections showed no significant difference between the two groups of patients,and no cases of biliary stricture, pancreatitis or malignant transformation of the bile ducts occurred in either group of patients. Conclusion: LC+LCBDE approach has obvious advantages in reducing the cost and length of hospitalization, is not limited by the number and size of the choledocholithiasis, and further, it can preserve the function of the sphincter of Oddi. So, it should be considered as the first choice of option in most elderly patients. However, based on the individualization principle,this procedure should be selected flexibly according to the patients’ and technical conditions.

Abstract:Objective: To investigate the efficacy of laparoscopic common bile duct exploration (LCBDE) under the concept of fast-track surgery (FTS) in elderly patients. Methods: The clinical data of 35 elderly patients undergoing LCBDE under FTS perioperative management from September 2013 to September 2016 (FTS group) and 31 patients undergoing LCBDE with traditional perioperative management during September 2011 to August 2013 (traditional group) were retrospectively analyzed. The relevant clinical variables between the two groups of patients were compared. Results: In FTS group compared with traditional group, the time to postoperative ambulation (15.34 h vs. 26.94 h), and time to first anal gas passage (23.09 h vs. 36.65 h), defecation (53.83 h vs. 62.03 h) and food intake (22.91 h vs. 53.29 h) as well as the length of hospital stay (6.29 d vs. 9.42 d) and hospitalization costs (17 200 yuan vs. 25 400 yuan) were all significantly reduced (all P<0.05). In addition, the postoperative nutritional indexes, overall incidence of complications and analgesic effects in the FTS group were all superior to those in traditional group (all P<0.05). Conclusion: LCBDE under the FTS protocol is safe and effective for elderly patients. However, the principle of individuation should also be followed for improving the patients’ compliance, and the multi-disciplinary cooperation should be enhanced.

Abstract:Objective: To compare the effects between laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopic common bile duct exploration (LCBDE) with primary biliary suture in treatment of common bile duct stones. Methods: The clinical data of 104 patients undergoing minimally invasive therapy for common bile duct stones from January 2013 to December 2015 were retrospectively analyzed. Of the patients, 50 cases received LTCBDE treatment (LTCBDE group) and 54 cases had LCBDE plus primary biliary suture (LCBDE plus primary suture group). The main clinical variable between the two groups were compared. Results: In LCBDE compared with LCBDE plus primary suture group, the operative time (91.7 min vs. 110.9 min), intraoperative blood loss (15.5 mL vs. 17.4 mL), amount of postoperative drainage (28.4 mL vs. 44.6 mL), tube retention time (7.8 d vs. 9.7 d) and length of hospital stay (8.8 d vs. 10.6 d) were all significantly reduced (all P<0.05). The incidence of postoperative bile leakage in LTCBDE group was significantly lower than that in LCBDE plus primary suture group (2.0% vs. 13.0%, P=0.036), while no significant difference was noted in incidence of other postoperative complications between the two groups (all P>0.05). Conclusion: In treatment of common bile duct stones, LCBDE is safe and reliable, and more accurately reflect the requirements of minimal invasiveness than LCBDE plus primary biliary suture. So it is recommended to be the first choice for the conditions with indications for both procedures.

Abstract:Objective: To analyze the reasons for conversion from laparoscopic cholecystectomy (LC) to open surgery and the related factors. Methods: The clinical data of 3 849 patients undergoing LC from January 2010 to December 2015 were retrospectively analyzed. Results: Among the 3 849 patients, 39 cases (1.01%) were converted to open surgery, and there was no significant difference in conversion rates among years during 2010 to 2015 (P=0.982). The reasons for open conversion included unclear anatomy of Calot’s triangle in 16 cases, severe abdominal or pericholecystic adhesions in 14 cases, Mirrizi syndrome in 3 cases, cystic artery bleeding in 2 cases, and bile leakage, common bile duct injury, cholecystoduodenal fistula and gallbladder cancer in 1 case each. Thirty-three patients underwent early open conversion, and 6 patients underwent intermediate or late conversion, and the open conversions in 5 cases in the latter were performed due to intraoperative complications that included cystic artery bleeding in 2 cases, obscure Calot’s triangle after gallbladder rupture and resultant dense adhesions in 1 case, common bile duct injury in 1 case and bile leakage in 1 case. Gender, age and course of disease were influential factors for conversion of LC (all P<0.05). The incidence of short-term postoperative complications of conversion of LC by senior surgeons was significantly lower than that by junior surgeons (P=0.043). Conclusion: There is a certain conversion rate during LC, difficulties in dissection of Calot’s triangle and severe abdominal or pericholecystic adhesions are main reasons for open conversion, and early open conversion is recommended in those with relevant influential factors to ensure surgical safety.

Abstract:Objective: To investigate the feasibility of Minilap-assisted single-port transumbilical laparoscopic cholecystectomy. Methods: Forty patients with gallbladder stones or gallbladder polyps admitted in the First Department of General Surgery of the First Affiliated Hospital, Baotou Medical College, between January and December of 2015 were randomly selected, and then divided into control group and observation group according to their preferences, with 20 cases in each group. Patients in control group underwent single-port transumbilical laparoscopic cholecystectomy and those in observation group received Minilap-assisted single-port transumbilical laparoscopic cholecystectomy. The main clinical variables between the two groups of patients were compared. Results: Laparoscopic surgery was successfully performed in all 40 patients, without any open conversion. In observation group compared with control group, the average operative time (29.90 min vs. 19.10 min, P=0.000) and intraoperative blood loss (4.90 mL vs. 8.05 mL, P=0.000) were significantly decreased, while other variables showed no significant difference (all P>0.05), including the length of postoperative hospital stay, postoperative pain scores, analgesic consumption, and degree of patient satisfaction for surgical scars. Postoperative follow-up was conducted for 10 to 18 months, all patients recovered uneventfully, and no obvious scar was noted in the puncture site of Minilap. Conclusion: Minilap-assisted single-port transumbilical laparoscopic cholecystectomy is safe and feasible, has favorable cosmetic results and it helps to reduce surgical difficulty, so it is recommended to be used in clinical practice.

Abstract:

Objective: To investigate the influence of TNF-α on activity of P311/TGF-β1/α-SMA signaling pathway in rabbit bile duct fibroblasts and the interventional effect of tetramethylpyrazine (TMP). Methods: Bile duct fibroblasts of rabbits were isolated and cultured, and then identified. The bile duct fibroblasts were exposed to TNF-α or TNF-α plus different concentrations (0.08, 0.4 and 2.0 mg/mL) of TMP respectively for 48 h, using untreated bile duct fibroblasts as blank control. Afterwards, the cell proliferation was determined by CCK-8 assay, mRNA expressions of P311, TGF-β1 and α-SMA were measured by real-time PCR, and protein expressions of TGF-β1 and α-SMA were examined by Western blot analysis. Results: In bile duct fibroblasts after TNF-α treatment, the cell proliferation significantly accelerated, and the mRNA expressions of P311, TGF-β1 and α-SMA as well as the protein expressions of TGF-β1 and α-SMA were significantly up-regulated compared with blank control cells (all P<0.05); TMP inhibited the above effects of TNF-α with a concentration-dependent tendency, and the inhibitions exerted by TMP at 0.4 and 2.0 mg/mL were significant (all P<0.05). Conclusion: TNF-α can promote proliferation of bile duct fibroblasts possibly via regulating P311/TGF-β1/α-SMA signaling pathway in fibroblasts, and TMP can inhibit the activation of this pathway induced by TNF-α, so it may have preventive and therapeutic effect on benign biliary stricture.

Abstract:

Objective: To investigate the role of Toll-like receptor 4 (TLR4) in the repairing process of bile duct injury. Methods: The TLR4 expressions in 12 specimens of bile duct tissue with biliary stricture and 4 specimens of normal bile duct tissue were determined by immunohistochemical staining. Biliary injury and repair model was established in TLR4 deficient (TLR4–/–) and wild-type (TLR4+/+) mice using clamping method, with their corresponding sham-operated mice as control, and the pathological changes and liver function status were observed in each group of mice 48 h after operation. Results: TLR4 was expressed mainly in the endothelial cells of the bile ducts, and its positive expression rate in bile duct wall with benign biliary stricture was significantly higher than that in bile duct wall of normal tissue (83.33% vs. 25.00%, P<0.01). No pathological changes were noted in the liver and bile duct tissues in the two groups of sham-operated mice, while obvious liver and bile duct injuries were seen in model groups of both TLR4–/– and TLR4+/+ mice, but the injuries were markedly milder in the former than those in the latter; compared with corresponding sham-operated control, the serum levels of alanine transaminase, and total or direct bilirubin in model groups of both TLR4–/– and TLR4+/+ mice were significantly increased (all P<0.05), but the increasing amplitudes of these parameters in the former were significantly slighter than those in the latter (all P<0.05). Conclusion: TLR4 contributes critically to benign bile duct stricture probably via participating in the natural immune responses of biliary epithelial cells, initiating the expressions of a range of inflammatory cytokines, and prompting fibroblast proliferation.

Abstract:

Objective: To investigate the expression of paired-related homeobox 1 protein (Prrx-1) in gallbladder cancer tissue and its significance. Methods: The Prrx-1 expressions in 45 specimens of gallbladder cancer tissues and 35 specimens of gallbladder tissues with benign diseases were determined by immunohistochemical staining, and the relations of Prrx-1 expression with clinicopathologic profiles of gallbladder cancer were analyzed. Results: The expression rate of Prrx-1 was 55.6% (25/45) in gallbladder cancer tissue, and was 5.7% (2/35) in gallbladder tissue with benign diseases, and the difference between them had statistical significance (χ2=21.87, P<0.05). Statistical analysis indicated that the Prrx-1 expression was closely associated with the degree of differentiation and clinical stage of gallbladder cancer (both P<0.05), but irrelevant to the sex and age of the patients and histological type of gallbladder cancer (all P>0.05). Conclusion: Prrx-1 expression is increased in gallbladder cancer and its expression may be closely connected to the occurrence and development of gallbladder cancer.

Abstract:

Objective: To investigate the expressions of annexin A2 and the epithelial-mesenchymal transition (EMT) markers E-cadherin and vimentin in hepatolithiasis-associated intrahepatic cholangiocarcinoma and their significance. Methods: The expressions of annexin A2, E-cadherin and vimentin in tumor tissues from 46 patients with hepatolithiasis-associated intrahepatic cholangiocarcinoma (tumor group), bile duct tissues with chronic inflammation from 50 patients with simple hepatolithiasis (inflammation group) and normal bile duct tissues form 35 patients undergoing surgical resection for hepatic hemangioma or liver injury (normal group) were determined by immunohistochemical staining. The expressions of the three proteins among the groups were compared and their relations with clinicopathologic factors and prognosis of the patients with hepatolithiasis-associated intrahepatic cholangiocarcinoma were analyzed. Results: The positive expression rates of both annexin A2 and vimentin were presented in descending order as tumor group>inflammation group>normal group (69.6% vs. 36.0% vs. 11.4%; 54.3% vs. 28.0% vs. 8.6%, all P<0.05), while the opposite pattern was seen in that of E-cadherin (21.7% vs. 48.0% vs. 71.4%, all P<0.05). In cholangiocarcinoma tissues, there was a positive correlation between the annexin A2 and vimentin expression (r=0.627, P<0.05), and negative correlation between the E-cadherin expression and either the annexin A2 or vimentin expression (r=–0.682; r=–0.575, both P<0.05). The expressions of annexin A2 and vimentin were significantly associated with the degree of tumor differentiation, lymph node metastasis and TNM stage, and E-cadherin expression was significantly associated with the degree of tumor differentiation and lymph node metastasis (all P<0.05). Among the patients with hepatolithiasis-associated intrahepatic cholangiocarcinoma, the survival rate in cases with positive annexin A2 or vimentin expression was significantly lower than that in their corresponding negative ones, and the survival rate in cases with negative E-cadherin expression was significantly lower than that in those with its positive expression (all P<0.05). Conclusion: The annexin A2/EMT pathway may probably play an important role in the development and progression of hepatolithiasis-associated intrahepatic cholangiocarcinoma. The expressions of annexin A2, E-cadherin and vimentin are closely related to the degree of malignancy of the tumor and prognosis of the patients.

Abstract:

Objective: To investigate the Snail expression in intrahepatic cholangiocarcinoma (ICC) and its relations with clinicopathologic features and prognosis of the patients. Methods: The clinical and follow-up data of 55 ICC patients undergoing surgical treatment between December 1999 and January 2010 were retrospectively analyzed. The Snail expressions in specimens of tumor and adjacent tissues from these patients were determined by immunohistochemical staining, and the relations of Snail expression with the clinicopathologic characteristics and prognosis of the patients were statistically analyzed. Results: In tumor tissues compared with their adjacent tissues, both the expression level (2.764 vs. 0.914) and high expression rate of Snail (48.6% vs. 18.0%) were significantly increased (both P<0.05), and Snail expression was significantly associated with the tumor differentiation (χ2=4.231, P=0.040), TNM stage (χ2=6.631, P=0.010), lymphatic metastasis (χ2=4.134, P=0.042), microvascular invasion (χ2=10.197, P=0.001) and recurrence (χ2=4.610, P=0.032); the postoperative overall survival rate was decreased (P=0.018) and accumulative recurrence rate was increased (P=0.032) in patients with high Snail expression compared with those with low expression. Results of univariate and multivariate Cox regression analysis revealed that microvascular invasion, lymphatic metastasis and Snail expression were independent influential factors for prognosis of the patients (all P<0.05). Conclusion: Snail expression is increased in ICC tissue, and its overexpression is closely related to malignant pathological profiles and dismal prognosis of the ICC patients.

Abstract:Objective: To assess the feasibility and safety of using a novel intravascular stent in clinical practice through animal experiment. Methods: Thirty intravascular stents prepared by metal powder injection molding were implanted into the aorta of 30 experimental dogs, respectively. After implantation, the intra-aortic conditions were observed by computed tomography angiography, and the neointimal formations on the stent surface at different postoperative times were observed by gross visual inspection and microscopic and electron microscopic evaluation as well as immunohistochemical staining. Results: All intravascular stents were successfully implanted into the aorta of the dogs. All stents were patent without any evidence of stent displacement, distortion or fracture and intrastent infection or thrombosis as well as intraluminal stenosis or occlusion; the longitudinal and radial shrinkage rates of the stents were less than 2% and 4%, respectively. At one week after implantation, the luminal surface of the stent was rapidly covered by a thin layer of semi-transparent membrane-like structure; at one month after implantation, neointimal formations were seen on most of the luminal surface of the stent which connected with the surrounding intima; at 2 months after implantation, nearly the complete luminal surface of the stent (98.83%) was covered by the neointima, and its thickness reached a peak value (350.00 μm); at 3 to 6 months after implantation, the thickness of the neointima was gradually reduced, its inside diameter was gradually increased to almost the initial size before implantation, and finally, the neointimal surface was covered by a single layer of fully mature endothelial cells. In the neointimal tissues on the luminal surface of the stent, positive staining of smooth muscle α-actin was detected at each time point except one week after immplantaion, while positive staining of vascular endothelial growth factor was detected at any time point after immplantaion. Conclusion: The novel intravascular stent prepared by metal powder injection molding can maintain stable form and structure with fast endothelialization of the luminal surface of stent, and keep long-term patency. It shows favorable structural, physical and chemical stability and biocompatibility, and may have a promising application prospect in clinical practice.

Abstract:Objective: To investigate the feasibility, safety and efficacy of total laparoscopic choledochal cyst excision with Roux-en-Y hepatoenterostomy for congenital choledochal cysts in adult patients. Methods: The clinical data of 12 patients who underwent laparoscopic choledochal cysts excision from May 2014 to May 2016 in the First Affiliated Hospital of Kunming Medical University were analyzed retrospectively. Results: Of the patients, total laparoscopic choledochal cyst excision with Roux-en-Y hepatoenterostomy was successfully performed in 11 cases, and one case had extra-abdominal manual enteroenterostomy to reduce surgical cost. The operative time was 240 to 310 min, with an average of 280 min, the intraoperative blood loss was 20 to 150 mL, with an average of 60 mL and the length of postoperative hospital stay was 5 to 7 d, with an average of 6.5 d. Postoperative follow-up was conducted for 2 to 12 months, and no surgical complications or death occurred. Conclusion: Total laparoscopic choledochal cyst excision with Roux-en-Y hepatoenterostomy is safe and feasible in treatment of adult congenital choledochal cysts, and has obvious minimally invasive advantage. So, it is recommended to be used.

Abstract:Objective: To investigate the advantages of using enhanced recovery after surgery (ERAS) in perioperative management of hepatectomy for primary liver cancer. Methods: Eighty-one patients with primary liver cancer admitted from July 2015 to June 2016 were designated to ERAS group (n=40) and control group (n=41) by using a random number table. Patients in ERAS group received perioperative management directed by ERAS concept, while those in control group underwent conventional perioperative management. The main clinical variables between the two groups of patients were compared. Results: The general perioperative data of the two groups of patients showed no significant difference (all P>0.05). There were no significant differences in surgical types, operative time, intraoperative blood loss and postoperative complications between the two groups of patients, but the time to postoperative bowel function recovery, NRS scores, time to drainage tube removal, and length of postoperative hospital stay in ERAS group were all significantly superior to those in control group (all P<0.05). All patients were followed up for one month to two months, and there was no hospital readmission or reoperation in any of them within 30 d after surgery. Conclusion: Using ERAS concept in perioperative management of liver cancer resection is safe and effective, and it can accelerate the postoperative recovery of the patients.

Abstract:Objective: To investigate the safety and feasibility of complete resection of the hepatic caudate lobe with ruptured hepatocellular carcinoma (HCC) via right-side approach combined with reverse staining. Methods: The clinical data of one patient with spontaneous rupture of caudate lobe HCC was retrospectively analysed and combined with relevant literature review. Results: The liver function and tumor characteristics of the patient were rigorously evaluated before operation. After exclusion of contraindications for surgery, complete resection of the caudate lobe of the patient was successfully performed via right-side approach combined with reverse staining (distinguishing the border of the caudate lobe by dyeing the posterior right hepatic lobe). No occlusion of hepatic inflow and outflow or inferior vena cava was performed during operation. Liver function of the patient recovered well after operation. No recurrence was noted in a review visit 6 months after operation. Conclusion: Complete resection of caudate lobe with spontaneous rupture of HCC via simple right-side approach combined with reverse staining is safe and feasible.

Abstract:

Objective: To investigate the clinical value of contrast-enhanced ultrasonography (CEUS) immediately after radiofrequency ablation (RFA) for malignant hepatic tumors. Methods: Sixty consecutive patients with malignant hepatic tumors (76 lesions) admitted between October 2014 and December 2015 in Xiangya Hospital were randomly designated to study group and control group with 30 cases in each group (41 lesions in study group, 35 lesions in control group). All patients underwent percutaneous RFA under real time ultrasound guidance. In patients in study group, CEUS was performed immediately (within 5-10 min) after RFA, and supplementary ablation was conducted immediately for the tumor residues until no residue was detected by contrast examination, while immediate CEUS was not performed in those in control group. Patients in study group underwent CEUS again at 36-48 h after RFA, and patients in both groups underwent CEUS together with contrast-enhanced CT or MRI as well as detection of liver function parameters and tumor markers at 1 month after the RFA. Results: A total of 5 tumor residues were found by immediate CEUS in 5 patients of study group , and supplementary treatments were performed. By review examinations for the two groups at 1 month after RFA, one tumor residual (1/41) was found in study group and 7 tumor residuals (7/35) were found in control group, and the complete ablation rates between study group and control group were statistically different (96.7% vs. 80.0%, P<0.05). In study group, the thickness of the hematoma or edema around the ablation zone detected by CEUS in arterial phase examination immediately after RFA and 36–48h later was (6.89±2.73) mm and (4.68±2.05) mm respectively, and the difference had statistically significant (P<0.05). Conclusion: CEUS immediately after RFA can timely detect the tumor residuals and direct supplementary therapy, and effectively increase the complete ablation rate.

Abstract:

Hepatolithiasis is one of the common hepatobiliary diseases. It has been confirmed that biliary infection, cholestasis and epithelial mesenchymal transformation are important factors for the occurrence and the development of this condition, and recent studies found that inflammation mediated by LPS/TLR4 pathway plays a crucial role in the pathogenic processes of these factors. Here, the authors address the potential actions and relevant mechanisms of LPS/TLR4 signaling pathway in hepatolithasis, so as to provide new paths to the mechanism research as well as prevention and treatment of hepatolithiasis.

Abstract:Cholangiocarcinoma (CCA) is a very heterogeneous group of neoplasms, for which the early diagnosis is difficult, present treatment methods are inadequate and the treatment effects are also limited. Thus, a detailed knowledge of the molecular pathological profiles of CCA is important for improving its diagnosis, treatment and outcomes. With the development of molecular biological technologies, the molecular pathological mechanisms of CCA will gradually be revealed and clarified, which may provide new ideas and approaches for early diagnosis and targeted therapy of CCA. Here, the authors present the current research progress in molecular pathology of CCA.

Abstract:Although the prevalence of hilar cholangiocarcinoma (HC) is relatively low, it is associated with dismal prognosis, and surgical resection remains the only curative treatment for this condition. Over more than half a century, considerable achievements have been made in surgical treatment of HC, meanwhile, the accompanied controversies still exist. The authors, in this paper, discuss the issues concerning the preoperative staging and management, and surgical resection scope, combined vascular resection with reconstruction, number and scope of lymph node dissection, laparoscopic procedure and liver transplantation for HC, so as to provide helpful guidance for surgical management of HC.