[Show abstract][Hide abstract] ABSTRACT: Hepatic ischaemia/reperfusion (I/R) injury is of primary concern during liver surgery. We propose a new approach for preserving low liver blood perfusion during hepatectomy either by occlusion of the portal vein (OPV) while preserving hepatic artery flow or occlusion of the hepatic artery while limiting portal vein (LPV) flow to reduce I/R injury. The effects of this approach on liver I/R injury were investigated. Rats were randomly assigned into 4 groups: sham operation, occlusion of the portal triad (OPT), OPV and LPV. The 7-day survival rate was significantly improved in the OPV and LPV groups compared with the OPT group. Microcirculatory liver blood flow recovered rapidly after reperfusion in the OPV and LPV groups but decreased further in the OPT group. The OPV and LPV groups also showed much lower ALT and AST levels, Suzuki scores, inflammatory gene expression levels, and parenchymal necrosis compared with the OPT group. An imbalance between the expression of vasoconstriction and vasodilation genes was observed in the OPT group but not in the OPV or LPV group. Therefore, preserving low liver blood perfusion by either the OPV or LPV methods during liver surgery is very effective for preventing hepatic microcirculatory dysfunction and hepatocyte injury.
[Show abstract][Hide abstract] ABSTRACT: To establish a scoring system to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).
The clinical records of 921 consecutive patients who underwent PD between 2008 and 2013 were reviewed retrospectively. Postoperative pancreatic fistula (POPF) was defined and classified by the international study group of pancreatic fistula (ISGPF). We used a logistic regression model to determine the independent risk factors of CR-POPF and developed a scoring system based on the regression coefficient of the logistic regression model. The optimal cut-off value to divide the risk strata was determined by the Youden index. The patients were divided into two groups (low risk and high risk). The independent sample t test was used to detect differences in the means of drain amylase on postoperative day (POD) 1, 2 and 3. The optimal cut-off level of the drain amylase to distinguish CR-POPF from non-clinical POPF in the two risk strata groups was determined using the receiver operating characteristic (ROC) curves.
Grade A POPF occurred in 106 (11.5%) patients, grade B occurred in 57 (6.2%) patients, and grade C occurred in 32 (3.5%) patients. A predictive scoring system for CR-POPF (0-6 points) was constructed using the following four factors: 1 point for each body mass index ≥ 28 [odds ratio (OR) = 3.86; 95% confidence interval (CI): 1.92-7.75, P = 0.00], soft gland texture (OR = 4.50; 95%CI, 2.53-7.98, P = 0.00), and the difference between the blood loss and transfusion in operation ≥ 800 mL (OR = 3.45; 95%CI, 1.92-7.75, P = 0.00); and from 0 points for a 5 mm or greater duct diameter to 3 points for a less than 2 mm duct (OR = 8.97; 95%CI: 3.70-21.77, P = 0.00). The ROC curve showed that the area under the curve of this score was 0.812. A score of 3 points was suggested to be the best cut-off value (Youden index = 0.485). In the low risk group, a drain amylase level ≥ 3600 U/L on POD3 could distinguish CR-POPF from non-clinical POPF (the sensitivity and specificity were 75% and 85%, respectively). In the high risk group, the best cut-off was a drain amylase level of 1600 (the sensitivity and specificity were 77 and 63%, respectively).
A 6-point scoring system accurately predicted the occurrence of CR-POPF. In addition, a drain amylase level on POD3 might be a predictor of this complication.
[Show abstract][Hide abstract] ABSTRACT: Background:
Post-pancreaticoduodenectomy (PD) hemorrhage (PPH) is an uncommon but serious complication. This retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH.
A total of 840 patients with PD between 2000 and 2010 were retrospectively analyzed. Among them, 73 patients had PPH: 19 patients had early PPH and 54 had late PPH. The assessment included the preoperative history of disease, pancreatic status and surgical techniques. Other postoperative complications were also evaluated.
The incidence of PPH was 8.7% (73/840). There were no independent risk factors for early PPH. Male gender (OR=4.40, P=0.02), diameter of pancreatic duct (OR=0.64, P=0.01), end-to-side invagination pancreaticojejunostomy (OR=5.65, P=0.01), pancreatic fistula (OR=2.33, P=0.04) and intra-abdominal abscess (OR=12.19, P<0.01) were the independent risk factors for late PPH. Four patients with early PPH received conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical therapy was 27.8% (15/54). Initial endoscopy was operated in 12 patients (22.2%), initial angiography in 19 (35.2%), and relaparotomy in 15 (27.8%). Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ failure, hemorrhagic shock, sepsis and uncontrolled rebleeding.
Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt management is necessary. Although endoscopy and angiography are the standard procedures for the management of PPH, surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.
No preview · Article · Oct 2014 · Hepatobiliary & pancreatic diseases international: HBPD INT
[Show abstract][Hide abstract] ABSTRACT: microRNAs (miRNAs) are short noncoding RNAs that negatively regulate gene expression. Although recent evidences have been indicated that their aberrant expression may play an important role in cancer stem cells, the mechanism of their deregulation in neoplastic transformation of liver cancer stem cells (LCSCs) has not been explored. In our study, the HCC model was established in F344 rats by DEN induction. The EpCAM(+) cells were sorted out from unfractionated fetal liver cells and liver cancer cells using the FACS analysis and miRNA expression profiles of two groups were screened through microarray platform. Gain-of-function studies were performed in vitro and in vivo to determine the role of miR-92b on proliferation and differentiation of the hepatic progenitors. In addition, luciferase reporter system and gene function analysis were used to predict miR-92b target. we found that miR-92b was highly downregulated in EpCAM(+) fetal liver cells in expression profiling studies. RT-PCR analysis demonstrated reverse correlation between miR-92b expression and differentiation degree in human HCC samples. Overexpression of miR-92b in EpCAM(+) fetal liver cells significantly increased proliferation and inhibited differentiation as well as in vitro and in vivo studies. Moreover, we verified that C/EBPß is a direct target of miR-92b and contributes to its effects on proliferation and differentiation. We conclude that aberrant expression of miR-92b can result in proliferation increase and differentiation arrest of hepatic progenitors by targeting C/EBPß.
[Show abstract][Hide abstract] ABSTRACT: To study the surgical management of solid-pseudopapillary tumor of the pancreas (SPTP) and its characteristics of outcome.
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 (rangeing 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.
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.
SPTP is found primarily in young women. Excellent prognosis would be achieved with surgical resection.
No preview · Article · Jul 2012 · Zhonghua wai ke za zhi [Chinese journal of surgery]
[Show abstract][Hide abstract] ABSTRACT: Hilar cholangiocarcinoma is a malignant tumor that is difficult to cure. The aim of this study was to observe the effects of flow-controlled partial portal vein arterializations (PPVA) on liver regeneration after hepatectomy in minipigs with chronic obstructive jaundice.
Eight minipigs were made into chronic obstructive jaundice models. United semi-hepatectomy, which imitates extended radical surgery for treatment of hilar cholangiocarcinoma, was then performed. The eight minipigs were randomly divided into groups A and B (n = 4 minipigs each). PPVA was performed in Group A but not in Group B. The effects of flow-controlled PPVA on live regeneration after hepatectomy were observed for 30 days after hepatectomy.
The portal vein PO(2) at the immediate time point and on postoperative day 30 was higher in Group A ((47.33 ± 2.43) and (48.50 ± 4.44) mmHg) than in Group B ((35.38 ± 4.06) and (35.55 ± 2.55) mmHg respectively, all P < 0.01). The mitotic index of liver cells on postoperative days 14 and 21 was higher in Group A (12.55% ± 2.85% and 15.25% ± 1.99% respectively) than in Group B (6.85% ± 2.10% and 11.88% ± 1.15% respectively, all P < 0.05). The regeneration rate of residual liver on postoperative days 14 and 21 was higher in Group A (24.56% ± 6.15% and 70.63% ± 9.83% respectively) than in Group B (11.96% ± 5.43% and 44.92% ± 7.42% respectively, P < 0.05 and P < 0.01 respectively).
Flow-controlled PPVA can promote liver regeneration after hepatectomy and prevent liver failure in minipigs with chronic obstructive jaundice.
No preview · Article · Jul 2012 · Chinese medical journal
[Show abstract][Hide abstract] ABSTRACT: 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).
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.
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.
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.
No preview · Article · Apr 2012 · Zhonghua wai ke za zhi [Chinese journal of surgery]
[Show abstract][Hide abstract] ABSTRACT: To summarize the clinical experience with diagnosis and treatment of intrahepatic biliary cystadenoma (IBCA).
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.
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.
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.
No preview · Article · Oct 2011 · Nan fang yi ke da xue xue bao = Journal of Southern Medical University
[Show abstract][Hide abstract] ABSTRACT: Liver revascularization is frequently required during the enlarged radical operation for hilar cholangiocarcinoma involving the hepatic artery. Researchers have carried out a number of experiments applying partial portal vein arterialization (PVA) in clinical practice. In this study we aimed to establish a theoretical basis for clinical application of partial PVA and to investigate the effects of partial PVA on rat hilar bile duct and hepatic functions.
Thirty rats were randomly and equally assigned into 3 groups: control (group A), hepatic artery ligation+bile duct recanalization (group B), and partial PVA+bile duct recanalization (group C). Proliferation and apoptosis of rat hilar bile duct epithelial cells, arteriolar counts of the peribiliary plexus (PBP) of the bile duct wall, changes in serum biochemistry, and pathologic changes in the bile duct were assessed 1 month after operation.
The proliferation of hilar bile duct epithelial cells in group B was greater than in groups A and C (P<0.01). No apoptotic hilar bile duct epithelial cells were detected in any of the groups. The PBP arteriolar counts of the hilar bile duct wall were similar in groups A and C (P>0.05), but the count was lower in group B than in group A (P<0.01). No statistically significant differences in alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and albumin were found in the 3 groups. The gamma-glutamyltransferase value was higher in group B than in groups A and C (P<0.01). The hepatic tissues of groups A and C showed no significant abnormality. Chronic inflammatory changes in the hilar bile duct walls were observed only in group B.
Partial PVA can restore the arterial blood supply of the hilar bile duct and significantly extenuate the injury to hilar bile duct epithelial cells resulting from hepatic artery ligation.
No preview · Article · Oct 2011 · Hepatobiliary & pancreatic diseases international: HBPD INT
[Show abstract][Hide abstract] ABSTRACT: 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.
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).
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.
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.
Preview · Article · Nov 2010 · Chinese medical journal
[Show abstract][Hide abstract] ABSTRACT: To investigate the determinants of long-term survival for ampulla of Vater carcinoma treated by pancreaticoduodenectomy.
A total of 77 patients with ampulla of Vater carcinoma undergoing pancreaticoduodenectomy were reviewed. Kaplan-Meier method was used to analyze the survival rate. Independent t test was used for statistical comparison and COX regression model for multivariate analysis.
No patient died as a result of surgery. The overall 5-year survival was 40.7%. Univariate analysis showed that perioperative serum carcinoembryonic antigen (CEA) level (P = 0.012), tumor invasion depth (P = 0.000), UICC stage (P = 0.000) and tumor size (P = 0.001) were significant prognostic factors of ampulla of Vater carcinoma; in multivariate analysis, only the tumor size (P = 0.000) was an independent prognostic factor of ampulla of Vater carcinoma.
Pancreaticoduodenectomy is associated with significant survival. Tumor size is the most important influencing factor of outcome after pancreaticoduodenectomy; in addition, perioperative serum CEA level, tumor invasion depth and UICC stage may also influence the survival rate, there exists a need for further follow-up studies.
No preview · Article · Dec 2009 · Zhonghua yi xue za zhi
[Show abstract][Hide abstract] ABSTRACT: To explore the influence of portal vein hemo-dynamic changes after portal venous arterialization (PVA) on peribiliary vascular plexus (PVP) morphological structure and hepatic pathology, and to establish a theoretical basis for the clinical application of PVA.
Sprague-Dawley rats were randomly divided into control and PVA groups. After PVA, hemodynamic changes of the portal vein and morphological structure of hepatohilar PVP were observed using Doppler ultrasound, liver function tests, ink perfusion transparency management and three-dimensional reconstruction of computer microvisualization, and pathological examination was performed on tissue from the bile duct wall and the liver.
After PVA, the cross-sectional area and blood flow of the portal vein were increased, and the increase became more significant over time, in a certain range. If the measure to limit the flow in PVA was not adopted, the high blood flow would lead to dilatation of intrahepatic portal vein and its branches, increase in collagen and fiber degeneration in tunica intima. Except glutamic pyruvic transaminase (GPT), other liver function tests were normal.
Blood with a certain flow and oxygen content is important for filling the PVP and meeting the oxygen requirement of the bile duct wall. After PVA, It is the anatomic basis to maintain normal morphology of hepatohilar bile duct wall that the blood with high oxygen content and high flow in arterialized portal vein may fill PVP by collateral vessel reflux. A adequate measure to limit blood flow is necessary in PVA.
Preview · Article · Dec 2008 · World Journal of Gastroenterology
[Show abstract][Hide abstract] ABSTRACT: A fatal complication after liver transplantation is anastomotic embolization of the hepatic artery. In order to solve this problem, the portal venous arterialization (PVA) is used to reconstruct the hepatic arterial blood flow. The purpose of this study was to investigate the influence of PVA on rats with acute occlusion of hepatic artery.
Rat PVA models were established and then randomly divided into Group 1 (control group), Group 2 (jaundice group), Group 3 (bile duct recanalization group), and Group 4 (portal vein arterilization group). Recanalization of the common bile duct and PVA were performed 5 days after bile duct ligation in the rats. The influence of the PVA on general conditions, hepatic changes of structure and function, portal vein pressure and hepatic micrangium were observed for one month.
Five days after common bile duct ligation the serum bilirubin, transaminase and alkaline phosphatase levels were significantly increased. Compared with group 1, there was a statistically significant difference (P < 0.01). These rats then underwent bile duct recanalization and PVA. After a month, the liver functions and microscopic structures completely returned to normal and, compared with group 1, there was no statistically significant difference in portal vein pressure (P > 0.05). Vascular casting samples showed that hepatic sinusoids were slightly thicker and more filled than normal ones and although they had some deformations, the hepatic sinusoids were still distributed around the central vein in radial form.
Within a month after operation, bile duct recanalization and PVA do not show obvious adverse effects on liver hemodynamics and hepatic micrangium, and the liver function and microscopic structure can return to normal.
Full-text · Article · Jul 2008 · Chinese medical journal
[Show abstract][Hide abstract] ABSTRACT: AIM: To investigate intraoperative blood coagulation variation and correlative influential factors in liver transplantation. METHODS: Twenty-nine cases undergoing orthotopic liver transplantation from cadaveric livers from 2006-06 to 2007-05 and 15 cases undergoing living-donor liver transplantation in the same period were studied retrospectively. We assessed prothrombin time (PT), activated partial thromboplastin time (APPT), international normalizing ratio (INR), fibrinogen (FIB), platelet (PLT), hemoglobin concentration(Hb), albumin (ALB) and total carbon dioxide (TCO2) during the pro-operation period, dissection period, anhepatic period, early and late neohepatic period, respectively. Changes of every value reflecting blood coagulation function and acid-base metabolism condition were observed in all groups, and fluctuation patterns of all values were studied between periods and groups. Perioperative influential factors were also analyzed. In addition, we compared values of living-donor liver transplantation with orthotopic liver transplantation from cadaveric livers in the same period and studied their correlations. RESULTS: The average blood coagulation condition of CHC group was between the HCC group and FLF group. In the reperfusion 30 min reperfusion period, PT, APTT and INR were more abnormal than in any other period of the operation, while FIB level reached its lowest point in the anhepatic stage (Living-donor liver transplantation: 0.68 ± 0.17 g/L vs 0.93 ± 0.37 g/L, 0.77 ± 0.19 g/L, 0.83 ± 0.27 g/L, 0.72±0.31 g/L; Orthotopic liver transplantation: 0.65 ± 0.14 g/L vs 0.89 ± 0.10 g/L, 0.71 ± 0.26 g/L, 0.69 ± 0.16 g/L, 0.70 ± 0.23 g/L, P < 0.05). In the hepatocelluar carcinoma (HCC) group, their relative parameters were almost normal before LDLT and the change span during LDLT was less than those in the other two groups (P < 0.05). Patients in the FLF group were in the worst coagulation state with prolonged PT, APTT, INR and reduced FIB (P < 0.05). However, these patients recovered in the shortest time after reperfusion. The MELD score was negatively correlated with intraoperative blood loss and blood transfusion (r = 0.619, P < 0.05). Compared with liver transplantation from cadaveric liver, the change span of blood coagulation function and acid-base metabolism balance was wider than the frontier, especially in the coagulation function's aggravation aspect in the dissection and anhepatic periods. However, after reperfusion all parameters pertaining to blood coagulation function and acid-base metabolism balance recovered in a shorter time (P < 0.05). CONCLUSION: Coagulopathy therapy should be individualized according to the perioperative condition of patients to aid the operation and reduce intraoperative blood loss.
No preview · Article · Dec 2007 · World Chinese Journal of Digestology
[Show abstract][Hide abstract] ABSTRACT: To investigate the clinical characteristics of primary gallbladder carcinoma.
The data of clinical manifestations, image characteristics, diagnosis and treatment of 110 patients with primary gallbladder carcinoma were analyzed.
The rate of diagnosis as early primary gallbladder carcinoma was only 8.2% (9/110) in this series. The majority of the patients were females (63/110) with an age ranging from 31 to 80 years. Clinical manifestations were not specific, and diagnosis was made mainly on image examination. Radical resection was performed for 57 patients, palliative resection for 41, the rest 12 patients failed to receive operation on reasons of distant metastasis, age or other reasons. Only 88 patients were followed with a mean survival time of 196 days ranging from 15 days to 5 years and 11 months.
The primary gallbladder carcinoma is quite difficult to diagnose at the early stage, and its prognosis is usually poor. The diagnosis is made mainly depending on the medical history and image examinations.
No preview · Article · Oct 2007 · Zhonghua zhong liu za zhi [Chinese journal of oncology]