Excision of a part of the bile duct as an iatrogenic injury typical for laparoscopic cholecystectomy - characteristics, treatment and long-term results, based on own material.

INTRODUCTION: Cholecystectomy is associated with the risk of bile duct injury (BDI). The nature of the injury in laparoscopic cholecystectomy (LC) cases seems to be more serious. AIM: We present an analysis of long-term results of the treatment of patients who underwent operations at our department due to iatrogenic excision of a part of the bile duct (EPBD). MATERIAL AND METHODS: Out of all 120 patients treated for BDI in our department we selected a group of 40 with EPBD. In all cases the corrective operation was hepaticojejunostomy. The median follow-up time was 157 (56-249) months. We evaluated risk factors for EPBD during LC compared to open cholecystectomy (OC). RESULTS: Among bile duct injuries referred to our centre, EPBD occurred more frequently during LC (46.7%) compared to OC (11%), p < 0.001. Injuries located in the hepatic hilum occurred more often in the case of LC (68.6%) than OC (20%), p = 0.056. We did not find a difference in the frequency of EPBD between LC and OC groups depending on the presence of acute or chronic cholecystitis. The narrow common hepatic duct was reported more frequently in the LC (68.6%) vs. OC (20%) group, p = 0.056. Satisfactory long-term reconstructive treatment results were observed in 36 (90%) of 40 patients. CONCLUSIONS: Excision of a part of the bile duct occurs more often during LC than OC. It is often located in the hepatic hilum. Presence of a narrow common hepatic duct is a risk factor for EPBD during LC. Large diameter hepaticojejunostomy is a reconstructive procedure that promises good long-term results.

Spleen migrating dendritic cells primed with CC531 colon cancer antigen and LPS - is it a method to compromise liver metastases?

The anti-tumor vaccination is burdened by low recruitment rate of intravenously administered in vitro primed DC in liver metastases and lack of supplying them continuously in large numbers. Therefore, it seemed rational to create a model of in vivo vaccination with specifically primed splenic DC and cytotoxic T lymphocytes being continuously supplied to the liver vascular bed. The question we raised was whether anti-tumor immunized splenic DC flowing to liver metastases could adhere to and be cytotoxic to tumor cells. We immunized rats with CC531 tumor cells and stimulated them with Escherichia coli LPS. Subsequently, spleen DC-enriched population was isolated, its activation by LPS, adherence to CC531 cells and cytotoxicity were measured. Spleen cells home to the liver reaching it via splenic vein. These cells can be retrieved by simple washout of liver sinusoids (liver sinusoidal washout cells - LSWC). Their adherence to and cytotoxicity against CC531 cells were evaluated. Moreover, in vitro adherence of splenic DC-enriched cells and LSWC to CC531 liver tumor sections was measured. We found that in vivo immunization of splenic population containing DC, NK cells and lymphocytes with CC531 cells and stimulation with LPS activated these cells but did not significantly increase the cytotoxicity against CC531 cells. There was also no increase in cytotoxicity of LSWC. Adhesion of splenic DC and LWSC to liver CC531 metastases on cryosections was higher than to the adjacent liver tissue. However, it was more expressed on tumor stromal than neoplastic cells. The level of splenic Treg cells down-regulating immune response was found only slightly increased after immunization. Taken together, in the model of in vivo immunization against CC531 cells, low level of spleen DC and spleen-derived LSWC cytotoxicity as well as adherence rate to tumor cells were observed. More effective methods of immunizing splenic DC overcoming the suppressive mechanisms should be looked for.

A liver perfusion model for studies of selective adherence and transient halting of portal blood leukocytes in sinusoids.

Portal blood leukocytes play an important, but still poorly defined, role in the immune processes of the liver. In our previous studies, we showed that certain leukocyte subsets are selectively halted in the liver. These cells marginate in sinusoids and, together with resident Kupffer and endothelial sinusoidal cells, participate in antiviral and antitumor processes. The molecular mechanisms of margination and cooperation with resident sinusoidal cells require clarification. However, in vivo harvesting of portal blood leukocytes is associated with cumbersome cannulation of portal and hepatic veins and manipulation of the liver, causing major disturbances in splanchnic blood flow and liver blood supply, totally distorting sinusoidal blood perfusion and leukocyte margination. To overcome these difficulties, we have developed an in situ normothermic rat liver perfusion model permitting quantitative observations of blood leukocyte extraction in sinusoids. First, liver was flushed through the portal vein and the effluent leukocytes, named liver-associated leukocytes (LAL1), were collected from hepatic veins. Then, the liver was perfused for 60 min with 50 ml of blood using a semiclosed perfusion system. Upon completion of perfusion, the liver portal vasculature was flushed again to retrieve the leukocytes extracted from the perfusing blood (LAL2). These cells were characterized with respect to their phenotype and cytotoxicity. The mean leukocyte count of the washout before perfusion was 1.04+/-0.2x10(6)/g of liver tissue and 0.9+/-0.1x10(6)/g after 60 min of perfusion, indicating retention by the perfused liver, the live leukocyte extracting capacity. To further evaluate the efficiency of perfusion, FITC-labelled leukocytes were added to the perfusing leukocyte-free blood. Around 95% of the postperfusion washout LALs were FITC(+). Heat-killed leukocytes did not marginate in sinusoids. Preincubation of leukocytes with substances able to lower adhesion capacity, such as lidocaine, trypsin and AAGM1, significantly decreased the postperfusion LAL2 washout population. The numbers of extracted postperfusion LAL2 CD5(+), CD4(+), CD8(+), CD56(+) and class II(+) subsets did not differ statistically from those of preperfusion LAL1. Moreover, the cytotoxicity of LAL2 and LAL1 against CC531 and K562 remained at a similar level. Thus, perfused liver also retained its selective leukocyte extraction capacity. This model shows that the process of selective margination of portal blood cell subsets in the liver can be studied in an artificially perfused liver subject to physiological blood flow parameters, temperature, oxygenation and minimal ischemic time before connection to the perfusion device. Furthermore, it is suitable for studies of the selective recruitment of blood cells in sinusoids in a wide large of situations including liver tumors, infections, rejection after transplantation, graft vs. host disease, as well as in the investigation of the effect of drugs on these processes.