[Surgical treatment for hilar cholangiocarcinoma of Bismuth-Corlette type IV].

OBJECTIVE: To investigate the surgical treatment for hilar cholangiocarcinoma(HCCA) of Bismuth-Corlette type IV. METHODS: The clinical data of 73 HCCA patients admitted in Southwest Hospital, the Third Military Medical University from January 2002 to December 2008 were analyzed retrospectively. There were 41 males and 32 females, aged from 30 to 84 years old (averaged, 56.8 years old). All patients were diagnosed as hilar mass with hilar biliary obstruction by B-ultrasound, CT, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography or percutaneous transhepatic cholangiography, and confirmed by pathological examination in intra-operation and post-operation. Diagnosis of all patients were according to Bismuth-Corlette type IV. RESULTS: Fifteen cases underwent percutaneous transhepatic cholangial drainage, stents were implanted in 8 patients. Simple internal drainage was performed on 25 of the 73 patients and 4 with palliative resection. Radical resection was performed on 19 patients. The radical resection rate of HCCA were 26.0%. The 1, 3 years of survival rates were 36.8%, 10.5% respectively. The 1 year survival rate was 6.3% in drainage group. CONCLUSION: Radical resection is the potentially curative treatment for HCCA, a sufficient, reasonable use of internal and external drainage would improve the patient's quality of life.

Clinical analysis of surgical treatment of portal hypertension.

AIM: To review the experience in surgery for 508 patients with portal hypertension and to explore the selection of reasonable operation under different conditions. METHODS: The data of 508 patients with portal hypertension treated surgically in 1991-2001 in our centers were analyzed. Of the 508 patients, 256 were treated with portaazygous devascularization (PAD), 167 with portasystemic shunt (PSS), 62 with selective shunt (SS), 11 with combined portasystemic shunt and portaazygous devascularization (PSS+PAD), 9 with liver transplantation (LT), 3 with union operation for hepatic carcinoma and portal hypertension (HCC+PH). RESULTS: In the 167 patients treated with PSS, free portal pressure (FPP) was significantly higher in the patients with a longer diameter of the anastomotic stoma than in those with a shorter diameter before the operation (P < 0.01). After the operation, FPP in the former patients markedly decreased compared to the latter ones (P < 0.01). The incidence rate of hemorrhage in patients treated with PAD, PSS, SS, PSS+PAD, and HCC+PH was 21.09% (54/256), 13.77 (23/167), 11.29 (7/62), 36.36% (4/11), and 100% (3/3), respectively. The incidence rate of hepatic encephalopathy was 3.91% (10/256), 9.58% (16/167), 4.84% (3/62), 9.09% (1/11), and 100% (3/3), respectively while the operative mortality was 5.49% (15/256), 4.22% (7/167), 4.84% (3/62), 9.09% (1/11), and 66.67% (2/3) respectively. The operative mortality of liver transplantation was 22.22% (2/9). CONCLUSION: Five kinds of operation in surgical treatment of portal hypertension have their advantages and disadvantages. Therefore, the selection of operation should be based on the actual needs of the patients.

[Effects of portaazygous disconnection, portocaval shunt and selective shunts on experimental rat liver cirrhosis].

OBJECTIVE: To evaluate the effects of portaazygous disconnection (PAD), portacaval shunt (PCS) and distal splenocaval shunt (DSCS) on the portosytemic shunting (PSS), hepatic function (HF), hepatic mitochondrial respiratory function (HMRF), oral glucose tolerance test (OGTT) and arterial ketone body ratio (KBR) in order to provide a sound basis for selecting suitable operations for patients. METHODS: Using a cirrhotic portal hypertensive model induced by CCl4/ethanol in Wistar rats, the PSS, HF, HMRF, OGTT and KBR were determined three weeks after PCS, DSCS and PAD. RESULTS: It was revealed that: (1) In the cirrhotic portal hypertension rats, the PSS increased significantly, HMRF and hepatic reserve function (HRF) decreased significantly when compared with the control rats. (2) At the time of first postoperative week, the mean blood glucose value in the 120-minute OGTT in each PAD, PCS and DSCS groups had significant differences compared with the cirrhotic control group. But during the second and third postoperative weeks, the mean blood glucose values in the 120-minute OGTT in both PAD and DSCS groups had no significant differences compared with the cirrhotic control group except for the PCS group. The values of KBR in the three operative groups decreased significantly compared with the cirrhotic control group during the two postoperative weeks. In the third postoperative week, only the values of KBR in the PCS group had a significant difference compared with the cirrhotic control group. (3) After PCS, the PSS was further increased; HF and HMRF were significantly decreased. Little improvement was found in the third postoperative week. (4) After DSCS and PAD, the above mentioned indices were less influenced, and they were restored more quickly than those in the PCS group. CONCLUSION: We found that PAD and DSCS are more desirable than PCS.

Modified hepatic outflow tract reconstruction in piggyback liver transplantation.

OBJECTIVE: To summarize the experience in modified reconstruction of the hepatic outflow tract during piggyback liver transplantation at our hospital. METHODS: The clinical data on 67 patients undergoing piggyback liver transplantation with modified hepatic outflow tract reconstruction from January 1999 to October 2002 were analyzed retrospectively. RESULTS: In this group, 7 patients (10.45%) died perioperatively. Complications included: pulmonary infection (38 patients); multiple organ system failure (10), intraperitoneal bleeding (6), acute respiratory distress syndrome (14), thrombosis of the hepatic artery (1), and bile leakage (1). No hepatic outflow occluded. Two recipients survived for over 3 years, 8 over 2 years, and 19 over a year. CONCLUSION: Modified hepatic outflow reconstruction in piggyback liver transplantation may increase the success rate of liver transplantation and decrease technical complications.

Tolerance limit of rats to normothermic hepatic inflow occlusion under portal blood bypass.

OBJECTIVE: To evaluate the tolerance limit of rats to normothermic hepatic inflow occlusion under portal blood bypass. METHODS: A new rat model of normothermic hepatic inflow occlusion under portal blood bypass was established by clamping temporarily the pedicles of all liver lobes while the caudal lobe was kept as a passage of the portal blood flow. After hepatic blood flow restored, the caudal lobe was cut off. On the 7th postoperative day, survival rate, hepatic morphological changes, and the severity and reversibility of the injured energy metabolism of the liver were investigated. RESULTS: All rats that had been subjected to 30, 60 and 90 minutes of hepatic inflow occlusion under portal blood bypass survived on the 7th postoperative day. ischemia-reperfusion injury of the liver was reversible and compensatory in rats with hepatic inflow occlusion within 90 minutes. However, the survival rates of rats with 100, 110 and 120 minutes of hepatic inflow occlusion were 50%, 30% and 20% respectively. Liver injury of rats with 120 minutes of hepatic inflow occlusion was severe and Irreversible. CONCLUSIONS: The tolerance limit of rats to normothermic hepatic inflow occlusion is enhanced significantly under portal blood bypass and the upper limit is 90 minutes.