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With the popularity and development of minimally invasive surgery such as laparoscopic cholecystectomy, the incidence of iatrogenic biliary tract injury and biliary duct stenosis after injury has been increased significantly. The biliary duct injury of laparoscopic cholecystectomy is mainly heat damage, and the biliary duct tissue is prone to biliary duct stenosis after heat injury. Currently the treatment of complex iatrogenic biliary stricture has still been a difficult and unfinished problem. It’s necessary to explore the therapy options of iatrogenic biliary stricture based on animal models of biliary stricture. According to the literature at home and abroad, this article reviewed the methods and advantages and disadvantages of several models of benign biliary stricture.
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Objective:To construct a Nomogram model in predicting recurrence-free survival (RFS) and overall survival (OS) at six months, one year and two years after hepatocellular carcinoma (HCC) resection by using inflammatory markers combined with other routine clinical indicators.Methods:The data of 314 patients with HCC who underwent first time hepatectomy at Beijing Chaoyang Emergency Rescue Center and Air Force Characteristic Medical Center from January 2013 to January 2018 were analyzed. HCC patients who underwent hepatectomy at the First Medical Center of PLA General Hospital from January 2011 to January 2016 ( n=106) were used as the external validation group. Univariate and multivariate Cox proportional risk model was used to analyze independent risk factors of recurrence and death in HCC patients. A Nomogram model was constructed based on independent risk factors. Validation of the efficacy of the Nomogram model was done based on external data. Results:In the experimental group, 174 patients relapsed. The median RFS was 26 months. The 6 months, 1 year and 2 years RFS were 26.8%, 43.9%, and 68.8%, respectively. A total of 142 patients had died. The median survival time was 30 months. The 6 months, 1 year and 2 years OS were 5.9%, 23.6% and 63.1%, respectively. In the external validation group, 63 patients had developed recurrence, with a median RFS time of 28 months. The 6 months, 1 year and 2 years RFS were 26.4%, 45.3%, 54.7%, respectively. The median survival time was 31 months. The 6 months, 1 year and 2 years OS were 7.5%, 25.5%, 46.6%, respectively. Tumor size (>6.0 cm, HR: 1.447), vascular invasion ( HR: 1.408), TBil (>0.94 mg/dl, HR: 1.949), NLR (>2.54, HR: 2.843), AGR (≤0.88, HR: 2.447) were independent risk factors of HCC recurrence ( P<0.05). Tumor size (>6.0 cm, HR: 2.207), vascular invasion ( HR: 1.529), and NLR (>2.54, HR: 2.708) were independent risk factors of death for HCC patients ( P<0.05). The C-indexes of half-year, one-year and two-year RFS were 0.764 (95% CI: 0.677-0.854), 0.710 (95% CI: 0.615-0.824) and 0.673 (95% CI: 0.601-0.786), respectively. The C-indexes of half-year OS, one-year OS and two-year OS were 0.729 (95% CI: 0.648-0.841), 0.708 (95% CI: 0.608-0.813) and 0.664 (95% CI: 0.618-0.771), respectively. Conclusion:In this study, the construction of a Nomogram model in predicting prognosis of HCC patients was helpful to guide clinicians in improving preoperative treatment plans and in providing ideas for individualized treatment of patients.
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Precision,minimal invasiveness,digitalization,information technology and integrative medicine were considered as the future driving force of hepatobiliary surgery progress in the era of precision medicine,especially in the comprehensive management for patients with hepatobiliary (HB) tumors.Given the encouraging outcomes in the genomic technology-based precision treatment of cancers,we believe that a paradigm shift is emerging in the surgical management for HB tumors with cumulative practice in precision medicine.The current practice would be changed in:(1) the precision neoadjuvant therapy for unresectable HB tumors would come into practice to improve the long-term survival or increase the resec-tability;(2) precision management may become a first-line strategy to prevent the postoperative disease recurrence;(3)patients with recurrent intractable HB tumors could be conversed to the chronic status of surviving with tumor.Given the large population of HB tumors and current status of precision,the precision-based paradigm shift is inevitable in the surgical management for HB tumors.It's therefore mandatory for the new generation of hepatobiliary surgeons to comprehend the concept and technology of precesion medicine into the current practice.We compose this article to emphasize the role of precision medicine in practice of surgical oncology for HB tumors
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Objective To investigate the difference of hepatic microvessel density, neovasculariza-tion of regenerating liver tissue after ablation of two ways of irreversible electroporation and radiofrequency ablation in rats. Methods 90 male Sprague-Dawley rats were randomly divided into 3 groups, including the control group ( n =30), the irreversible electroporation group ( n =30 ) and the radiofrequency ablation group (n=30). 3,7 and 10 days were executed after the operation and draw material, expression of vascu-lar endothelial growth factor(VEGF) and CD34 in tissue was studied by immunohistochemistry, and the mi-crovascular density of tissue and VEGF positive cells were measured. Results The microvascular density of 3, 7 and 10 days in the control group was 50. 3 ± 12. 5, 54. 6 ± 11. 9 and 58. 2 ± 14. 7, the microvascular density of the radiofrequency ablation group was 18. 4 ± 4. 7, 17. 3 ± 5. 1 and 18. 1 ± 5. 9, respectively. The microvascular density of the irreversible electroporation group was 42. 8 ± 10. 4, 45. 6 ± 10. 2 and 49. 2 ± 13. 8, respectively. The positive cells of VEGF in control group was 50, 56 and 57 at 3, 7 and 10 days, and 32, 30 and 33 at 3, 7 and 10 days in radiofrequency ablation group, 44, 43 and 45 at 3, 7 and 10 days in irreversible electroporation group; expression of VEGF and CD34 in 3, 7, 10 d and the microvascular density of ablation area in radiofrequency ablation group was significantly lower than those in control group after irreversible electroporation and radiofrequency ablation. No significant differences were found between irreversible electroporation group and control group. Conclusion The irreversible electroporation can effectively protect the microvessels in the ablation area, ensure the tissue’s blood supply after the ablation, and provide a guarantee for the repair and regeneration of the tissue.
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Objective To study the surgical treatment of hepatic hemangiomas and the timing of surgery.Methods A retrospective study was conducted on 908 patients with giant hemangiomas who underwent surgery between December 1997 and December 2017.The clinical data,surgical indications,surgical outcomes,lesion size,and the effect of TAE were compared.Results The diameter (mean + /-S.D.)of the resected hepatic cavernous hemangiomas was (11.1 ± 6.2) cm (the longest diameter was 60 cm).585 patients (64.4％) underwent enucleation of hepatic hemangiomas and 323 patients (35.6％) underwent anatomical hepatectomy.Six patients died perioperatively (mortality rate 0.7％).The incidence of severe complication (Clavien-Dindo grade 3 ～ 5) was 3.8％.The incidence of severe postoperative complication for enucleation (2.7％) was significantly less than anatomic liver resection (5.6％,P ＜0.05).When the lesion was more than 20 cm,the complication and mortality rates were significantly higher than those less than 20 cm (P ＜ 0.05).The complication and mortality rates in patients who underwent TAE before surgery were significantly higher than those without TAE (P ＜ 0.05).Conclusions Surgical enucleation of hemangiomas was superior to anatomical hepatectomy.With increase in tumor size,the risk of surgery increased.Surgical treatment was safe and effective for giant hepatic hemangiomas.For giant hepatic hemangiomas with significant increase in size,prompt surgical treatment is recommended.
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Objective To investigate the feasibility and realistic significance of different teaching methods in professional and scientific degree graduate students.Methods Twenty six graduate students (scientific 12,professional 14) were randomly selected as research object from Sep.2014 to Apr.2017,and the relationship between clinical or research outcome and type of degree,clinical or experiment time were analyzed.Results The experiment time of scientific degree graduate students was significantly longer than that of professional degree graduate students [(21.0 ± 1.6) vs.(11.0 ± 3.5) months],and professional degree graduate students paid more attention to clinical work,there was statistic difference between the two groups [(20.0 ±2.1) vs.(12.0 ±2.4) months,both P＜0.05].The qualification rate of basic clinical manipulation in the professional group was higher than that in the scientific group (85.7％ vs.75.0％,P ＜ 0.05).Conclusion Different type of teaching methods based on the type of student degree were feasible and proper for graduate students in surgery,and the terminal object of our teaching should be focus on the resolution of clinical problems.
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Objective To evaluate the overall survival in patients with locally advanced pancreatic cancer (LAC) treated with irreversible electroporation (IRE) and chemotherapy.Methods A retrospective study on the overall survival of 30 patients with LAC treated with IRE,and 30 patients with LAC treated with chemotherapy from July 2015 to October 2016 in the PLA General Hospital was conducted.Results For the 30 patients with LAC who underwent IRE successfully,there were 21 women and 9 men.The median age was 59 (36 ～81) years.Twenty-four patients had primary pancreatic head cancer and 6 had body cancer.Twelve (40.0％) of these patients had chemotherapy after the IRE ablation.The 90-day mortality in the IRE treated patients was 3 (10.0％).For the 30 patients with LAC who were treated with chemotherapy,the 90-day mortality was 6 (20.0％).In comparison of the IRE treated patients with the chemotherapy treated patients,improvements on disease-free survival (6 months vs.4 months,P ＜ 0.05) and overall survival (11 months vs.5.6 months,P ＜ 0.05) were observed.Conclusion IRE ablation of LAC was safe and could potentially improve overall survival when compared with the standard chemotherapy treatment.
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Liver transplantation is one of the main treatments for acute and chronic liver failure currently.In recent years,with the lack of donor liver transplantation and the in creasing number of patients,the major donator of liver transplant is brain dead patients.In brain-dead state,organ functions de cline gradually.Changes in hemodynamics and immunity could lead to inflammation and alter hormone release.Organ survival and patients'prognosis can be unpredictable.The study of the above phenomenal mechanisms is still at an early stage.This article summarized the current liver transplant treatments by explai ning the pathophysiology of donor organ damage and reviewing the prognosis.The aim of this article was to provide a perspective for future study on this topic.
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Objective To investigate the effect of selective bowel decontamination (SBD) on prognosis of 90％ hepatectomy in rats.Methods We adopted rat model of subtotal hepatectomy(90％,SHx),gentamicin + polymyxin + nystatinor saline of the same amount was administrated preoperatively.Liver damage makers,portal and systemic lipopolysaccharide(LPS),mucosal damage,signaling pathways and liver regeneration were investigated.Results We found that SHx resulted in significantly enhancedsystemic LPS.Inhibition of gastrointestinal gram-negative bacteria by SBD significantly reduced LPS levels and improved survival after SHx.SBD protected intestinal mucosa barrier,alleviated liver parenchymal damage and inflammation and promoted liver regeneration.Conclusion SBD is beneficial and necessary for extended heptactomy.
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Objective To study the clinicopathological features and prognosis of Gastric hepatoid adenocarcinoma (GHA) and aims to guide future clinical practice.Method We retrospectively studied the clinical data of 25 patients with pathologically confirmed GHA who were admitted to our hospital from January 2003 to December 2015.Results There were 19 males and 6 females.The average age was 61.2 years.The clinical manifestations were non-specific.Pathologically,majority of GHA presented with ulcerative type,poor differentiation and extensive vascular cancerous embolus.Preoperative liver metastases were found in 12 patients,and postoperative liver metastases in 15 patients.Conclusions GHA is a special primary gastric adenocarcinoma which possesses both hepatocellular carcinoma-like and adenocarcinoma-like histology.GHA is characterized by a significantly elevated serum AFP and early hepatic metastasis.GHA is therefore often misdiagnosed as primary hepatocellular carcinoma.The main treatment option remains to be surgical resection,and the prognosis is poor.
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Objective To study the role of mesenchymal stem cells (MSC) in an animal model combining ischemia-reperfusion with 85％ liver resection.Methods Eight-week-old male SD rats received BM-MSC by tail vein and then underwent 30-min ischemia followed by 85％ liver resection.The survival rate was monitored for 7 days after surgery.Liver regeneration was assessed on day 2 after hepatectomy.Liver damage,liver cell apoptosis,and cytokine expression in the first 24 h after hepatectomy were also assessed.Results BM-MSC mostly homed to the spleen.Transplantation significantly inhibited myeloperoxidase [(19.9 ± 6.0) mg/g vs.(41.4 ± 10.2) mg/g] and downregulated proinflammatory cytokines.BM-MSC significantly reduced the ALT and AST levels [AST (1 475 ± 275) IU/L vs.(2 550 ± 441) IU/L,P ＜ 0.05;ALT (738 ± 101) IU/L vs.(1 113 ± 268) IU/L,P ＜ 0.05].The attenuation of liver injury was also verified histologically 24 h after surgery.Liver cell apoptosis was markedly reduced.Moreover,BM-MSC infusion significantly promoted remnant liver regeneration.As a result,the survival rate was improved by BM-MSC treatment in this model (95％ vs 70％,P ＜ 0.05).Conclusion In an animal model combining ischemia-reperfusion with 85％ liver resection,BM-MSC infusion attenuated liver injury and promoted hepatocyte regeneration,resulting in improved survival rate.
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Gastric hepatoid adenocarcinoma (GHA) is a rare but important sub-type of gastric adenocarcinoma characterized by high serum α-fetoprotein,early lymphatic and hepatic metastasis,and poor prognosis.Clinically,the presentation could be atypical,liver neoplasm could be the initial finding.With similar clinicopathological presentation as hepatocellular carcinoma (HCC),prompt and correct diagnosis can be a challenge,especially in endemic areas with a high incidence of HCC.Once diagnosed,surgical removal remains the treatment of choice.This review focus on advancement on the biological,histological and immunohistological features,and the clinicopathological presentation of GHA.
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Objective To evaluate the perioperative safety and effect of irreversible electroporation (IRE) in the treatment of locally advanced pancreatic carcinoma (LAPC).Methods Twenty patients with imaging and cytohystological diagnosis of unresectable locally advanced pancreatic carcinoma were enrolled to undergo IRE treatment.The perioperative IRE-related complications were primarily analyzed to evaluate the safety of the procedure.The tumor reduction and biological response were analyzed through CT/MRI imaging and serous level of CA19-9.Results All patients were successfully treated with an average tumor size of(4.2 ± 0.6) cm and an average procedure time of (52.0 ± 23.3) minutes.Three intraoperative procedure-related complications were observed (15.0％) including two transient hypertension and one transient superventricular tachycardia.Six postoperative complications were described including two Grade A pancreatic fistula,one infection of incision,one portal vein thrombosis,one gastrointestinal hemorrhage and two functional delayed gastric emptying.The symptom remission rate was 73.7％ and lower serum CA19-9 level was recorded in all patients at discharge.Conclusions IRE is a safe and feasible procedure in the treatment of LAPC, and a reasonable operation strategy of IRE is helpful to consolidate the safety and efficacy.
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Radical resection is crucial in the surgical treatment of adenocarcinoma of the body and tail of pancreas.It usually refers to negative resection margin and dissection of regional lymph nodes.In recent reports,the definition of R0 margin has been updated,and radical antegrade modular pancreatosplenectomy (RAMPS),which was first described by Strasberg et al,contributes to achieving negative tangential margins.In some cases,extended radical resections were adopted in an attempt to achieve R0 margin.However,it would increase operation related morbidity and mortality,which should be taken into account before the procedure.Lymph nodes metastasis is an important prognostic factor.Extended lymph nodes dissection does not seem to bring survival benefits,while itg helpful in assessing the tumor stages and patients' prognosis.Laparoscopic distal pancreatectomy (LDP) has been applied in the treatment of ductal adenocarcinoma of the pancreas in reports with small sample sizes.But it remains controversial whether LDP is superior comparing to conventional open methods in regards to oncological outcomes.Curently,surgery is the promising method that may cure adenocarcinoma of the body and tail of pancreas.Highlighting radical resection will bring more survival benefits to patients.
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Objective To analyze the perioperative complications and prognosis of surgical treatment of pancreatic ductal stones.Methods 60 patients diagnosed to have pancreatic ductal stones and were admitted into our hospital from January 2009 and December 2014 were enrolled into this retrospective study.There were 47 males and 13 females.The average age was (44.1 ± 12.0).Results All patients underwent surgical operation and there was no perioperative death.Perioperative complications occurred in 7 patients (11.7％), including pancreatic fistula in 4 patients, delayed gastric emptying in 1 patient, abdominal infection in 1 patient, anastomotic bleeding in 1 patient.Eight patients developed elevated amylase levels.The fasting time was 3.4 ± 1.2 days and the hospital stay was 10.0 ±4.0 days.The follow-up rate was 88.3％ (53/60), at a mean follow-up of 27 months.In 51 patients who presented with abdominal pain, 43 patients (84.3％) had complete pain relief and 7 patients (13.7％) had partial pain relief.In 14 patients with preoperative diabetes mellitus, 1 patient had improvement and 2 patients recovered from diabetes.Two additional patients were diagnosed to have diabetes two years after the operation.Of the 2 patients who were shown to have pancreatic cancer on histopathological study, 1 patient was lost to follow-up while another patient died at 27 months after the operation.The patients diagnosed to have epithelial dysplasia were followed-up and none developed pancreatic cancer.Conclusions The relationship between chronic pancreatitis and pancreatic ductal stones was very close.Chronic pancreatitis also caused exocrine and endocrine dysfunction.Surgical operation plays an important role in symptomatic relief and in delaying pancreatic dysfunction.
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Portal vein thrombosis is a common though serious complication after splenectomy in patients with liver cirrhosis and portal hypertension.Its pathogenesis may be primarily associated with the coagulation mechanism and the changes of hemorheology.The clinical presentations of portal vein thrombosis after splenectomy depend on the course of disease,as well as site and degree of obstruction.The principle of treatment is to improve microcirculation,relieve the platelet aggregation and prevent further progress of the thrombosis.But in clinical settings,signs and symptoms of portal vein thrombosis were generally atypical.Any misdiagnosis or delayed treatment may expose the patients under risk.This article focuses on the risk factors,potential mechanisms and recent progress on the prevention of post-splenectomy portal vein thrombosis.
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Objective Nanoknife,also called irreversible electroporation,is a new technique of tissue ablation.Short,microsecond electrical pulses with high voltage are applied to the cell membrane,causing pores to form within the membrane and finally leading to cell death.The current study was to investigate the efficacy and safety of the nanoknife in the ablation of the healthy pig pancreas.Methods Three healthy pigs underwent open pancreatic tissue ablation with nanoknife,and blood leukocytes and amylase were detected before and after treatment.Three pigs were sacrificed and gross specimens were collected on day 5,day 10 and day 15 after the procedure,respectively.HE staining and TUNEL staining were conducted and tissue,cellular and subcellular structures were observed under the ordinary microscope and transmission electron microscopy.Results Three experimental pigs recovered well after the procedure.No significant adhesions were found surrounding the pancreatic tissue,and the ablation zone was slightly harder.Transiently increased leukocyte count and amylase level were observed after the ablation,which decreased to the normal level on day 3 after treatment.Under light microscope,the pancreatic tissues in ablation zone appeared to be significantly different from the normal surrounding regions,with more cell death and more apoptotic cells detected by TUNEL staining.The subcellular structure changes also changed under electron microscope.But the main pancreatic duct and its large branches,together with arteriovenous distributions did not change much.Conclusions Nanoknife pancreatic tissue ablation can induce irreversible damage.In the ablation area,pancreatic duct and vascular structures are kept intact.Within a reasonable voltage range and appropriate electrical pulses setting,nanoknife ablation is safe in vivo experiment.
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Objective To investigate the feasibility and outcome of resection and reconstruction of hepatic artery in hilar cholangiocacinoma (HCC).Methods The data of 29 patients with HCC with hepatic artery reconstruction carried out from March 2009 to August 2013 in our center were retrospectively analyzed.23 right hepatic arteries and 6 common hepatic arteries were involved.In-situ anastomosis was carried out in 20 patients and a double anastomosis using gastrodoudenal artery grafts was carried out in 9 patients.Results There were no arterial thrombosis or other related complications on prolonged follow-up.Conclusion Hepatic artery resection and reconstruction should be carried out if the artery was invaded by a hilar cholangiocarcinoma to produce a high resection rate and a better outcome.
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The technique of Radiofrequency ablation (RFA) has been widely applied as alternative treatment for non resectable hepatocellular carcinoma (HCC) and has equivalent efficacy in prognosis.However,because of the restriction of current heat ablation technique and tumor's special location in liver,it is difficult for some physicians to obtain the ideal of one-off complete ablation.Therefore,incomplete destruction of tumor and multiple ablation processes resulted in miserable consequence in prognosis.So,to achieve one-off complete ablation,it is essential to evaluate the anatomy location of the tumor before RFA procedure and to establish the specified approach and adjuvant method.This article is to systematically analyze the theoretical hypothesis of this technique and to explore possible strategy for a safe approach based on characteristics of liver anatomy and combined with the professional advantages of hepatobiliary surgery.
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Objective To explore more safe and effective method for the treatment of common bile duct stones combined with cavernous transformation of the portal vein (CTPV).Methods We report 2 cases of post-treated patients in this series.In order to avoid severe bleeding caused by dissection of bile duct,we applied different methods to remove common bile duct stones compared with traditional operation.We removed common bile duct stones in one patient through cystic duct approach during operation.Two years later,we performed endoscopic duodenal incision (endoscopic sphincterotomy,EST) for him because of lower common bile duct stenosis with sand like stone.Another patient,on the other hand,we conducted the duodenal papilla incision during operation and removed common bile duct stones with choledochoscope through the bottom of common bile duct.Result Of the two patients,all of the three kinds of operation had good curative effects.Conclusions For the patients with common bile duct stones combined with CTPV,we should select appropriate treatments to avoid dissection of bile duct in front of the dilated and tortuous collateral veins during the operation,which is the key to guarantee the safety and success of the operation.EST is the preferred method of the treatment.Open operation with choledochoscopy via cystic duct approach or duodenal papilla incision through distal common bile duct to perform stone extraction also appears to be effective and safe.