Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.

Single-incision laparoscopic appendectomy vs conventional laparoscopic appendectomy:Systematic review and meta-analysis

AIM: To assess the differences in clinical benefits and disadvantages of single-incision laparoscopic appendectomy(SILA) and conventional laparoscopic appendectomy(CLA).METHODS: The Cochrane Library,MEDLINE,Embase,Science Citation Index Expanded,and Chinese Biomedical Literature Database were electronically searched up through January 2013 to identify randomized controlled trails(RCTs) comparing SILA with CLA.Data was extracted from eligible studies to evaluate the pooled outcome effects for the total of 1068 patients.The meta-analysis was performed using Review Manager 5.2.0.For dichotomous data and continuous data,the risk ratio(RR) and the mean difference(MD) were calculated,respectively,with 95%CI for both.For continuous outcomes with different measurement scales in different RCTs,the standardized mean difference(SMD) was calculated with 95%CI.Sensitivity and subgroup analyses were performed when necessary.RESULTS: Six RCTs were identified that compared SILA(n = 535) with CLA(n = 533).Five RCTs had a high risk of bias and one RCT had a low risk of bias.SILA was associated with longer operative time(MD = 5.68,95%CI: 3.91-7.46,P < 0.00001),higher conversion rate(RR = 5.14,95%CI: 1.25-21.10,P = 0.03) and better cosmetic satisfaction score(MD = 0.52,95%CI: 0.30-0.73,P < 0.00001) compared with CLA.No significant differences were found for total complications(RR = 1.15,95%CI: 0.76-1.75,P = 0.51),drain insertion(RR = 0.72,95%CI: 0.41-1.25,P = 0.24),or length of hospital stay(SMD = 0.04,95%CI:-0.08-0.16,P = 0.57).Because there was not enough data among the analyzed RCTs,postoperative pain was not calculated.CONCLUSION: The benefit of SILA is cosmetic satisfaction,while the disadvantages of SILA are longer operative time and higher conversion rate.

Prognostic value of lymphovascular invasion in Bismuth-Corlette type Ⅳ hilar cholangiocarcinoma

AIM To assess the prognostic value of lymphovascular invasion(LVI)in Bismuth-Corlette typeⅣhilar cholangiocarcinoma(HC)patients. METHODS A retrospective analysis was performed on 142consecutively recruited typeⅣHC patients undergoing radical resection with at least 5 years of followup.Survival analysis was performed by the KaplanMeier method,and the association between the clinicopathologic variables and survival was evaluated by log-rank test.Multivariate analysis was adopted to identify the independent prognostic factors for overall survival(OS)and disease-free survival(DFS).Multiple logistic regression analysis was performed to determine the association between LVI and potential variables. RESULTS LVI was confirmed histopathologically in 29(20.4%)patients.Multivariate analysis showed that positive resection margin(HR=6.255,95%CI:3.485-11.229,P<0.001),N1 stage(HR=2.902,95%CI:1.132-7.439,P=0.027),tumor size>30 mm(HR=1.942,95%CI:1.176-3.209,P=0.010)and LVI positivity(HR=2.799,95%CI:1.588-4.935,P<0.001)were adverse prognostic factors for DFS.The independent risk factors for OS were positive resection margin(HR=6.776,95%CI:3.988-11.479,P<0.001),N1 stage(HR=2.827,95%CI:1.243-6.429,P=0.013),tumor size>30 mm(HR=1.739,95%CI:1.101-2.745,P=0.018)and LVI positivity(HR=2.908,95%CI:1.712-4.938,P<0.001).LVI was associated with N1 stage and tumor size>30 mm.Multiple logistic regression analysis indicated that N1 stage(HR=3.312,95%CI:1.338-8.198,P=0.026)and tumor size>30 mm(HR=3.258,95%CI:1.288-8.236,P=0.013)were associated with LVI. CONCLUSION LVI is associated with N1 stage and tumor size>30mm and adversely influences DFS and OS in typeⅣHC patients.

Effect of peroxisome proliferator-activated receptor-gamma ligand on inflammation of human gallbladder epithelial cells

AIM: To investigate the effect of peroxisome proliferatoractivated receptor gamma (PPAR-γ,) and its ligand,ciglitazone, on inflammatory regulation of human gallbladder epithelial cells (HGBECs) and to assess the effect of human epithelial growth factor (hEGF) on growth of HGBECs.METHODS: HGBECs were cultured in media containing hEGF or in hEGF-free media. HGBECs were divided into normal control group, inflammatory control group and ciglitazone group (test group). Inflammatory control group and ciglitazone group were treated with 5 μg/L of human interleukin-1β (hIL-1β) to make inflammatory model of HGBECs. The ciglitazone group was treated with various concentrations of ciglitazone, a potent ligand of PPAR-γ.Subsequently, interleukin-8 (IL-8), IL-6, and tumor necrosis factor-α (TNF-α) concentrations in all groups were measured. The data were analyzed statistically.RESULTS: HGBECs were cultured in medium successfully.The longevity of HGBECs in groups containing hEGF was longer than that in hEGF-free groups. So was the number of HGBECs. The longest survival time of HGBEC was 25 d.The inflammatory model of HGBECs was obtained by treating with hIL-1β. The concentrations of IL-6 and IL-8 in ciglitazone group were lower than those in inflammatory control group (P＜0.05). The secretion of IL-6 in inflammatory control group was higher (350.31±37.05 μg/L) than that in normal control group (50.0±0.00 μg/L, P＜0.001).Compared to normal control group, IL-8 concentration in inflammatory control was higher (P＜0.05).CONCLUSION: hEGF improves the growth of HGBECsin vitro. Ciglitazone inhibits the inflammation of HGBECs in vitroand has potential therapeutic effect on cholecystitis in vivo.

Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography:A meta-analysis and systematic review

AIM:To assess the safety and efficacy of carbon dioxide (CO2) insufflation during endoscopic retrograde cholangiopancreatography (ERCP). METHODS:The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO2 insufflation with air insufflation during ERCP. The trials were included in the review irrespec-tive of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes.Sensitivity and subgroup analyses were performed if necessary. R ESULTS:Seven double-blind RCTs involving a total of 818 patients were identified that compared CO2 insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-random- ization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO2 insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insuf-flation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI:0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO2 level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI:-14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI:-0.26-0.17, P = 0.67) between the two groups. C ONCLUSION:CO2 insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.

Repair of a common bile duct defect with a decellularized ureteral graft

AIM To evaluate the feasibility of repairing a common bile duct defect with a decellularized ureteral graft in a porcine model.METHODS Eighteen pigs were randomly divided into three groups. An approximately 1 cm segment of the common bile duct was excised from all the pigs. The defect was repaired using a 2 cm long decellularized ureteral graft over a T-tube(T-tube group, n = 6) or a silicone stent(stent group, n = 6). Six pigs underwent bile duct reconstruction with a graft alone(stentless group). The surviving animals were euthanized at 3 mo. Specimens of the common bile ducts were obtained for histological analysis.RESULTS The animals in the T-tube and stent groups survived until sacrifice. The blood test results were normal in both groups. The histology results showed a biliary epithelial layer covering the neo-bile duct. In contrast, all the animals in the stentless group died due to biliary peritonitis and cholangitis within two months post-surgery. Neither biliary epithelial cells nor accessory glands were observed at the graft sites in the stentless group.CONCLUSION Repair of a common bile duct defect with a decellularized ureteral graft appears to be feasible. A T-tube or intraluminal stent was necessary to reduce postoperative complications.

Histological examination of frozen sections for patients with acute cholecystitis during cholecystectomy

BACKGROUND： Unexpected gallbladder cancer may present with acute cholecystitis-like manifestat/ons. Some authors rec- ommended that frozen section analysis should be performed during laparoscopic cholecystectomy for all cases of acute cholecystitis. Others advocate selective use of frozen section analysis based on gross examination of the specimen by the surgeon. The aim of the present study was to evaluate whether surgeons could effectively identify suspected gallbladder with macroscopic examination alone. If not, is routine frozen sec- tion analysis worth advocating？

Efficacy of ursodeoxycholic acid as an adjuvant treatment to prevent acute cellular rejection after liver transplantation: a meta-analysis of randomized controlled trials

BACKGROUND： Acute cellular rejection（ACR） after liver transplantation（LT） is one of the most common problems faced by transplant recipients in spite of advances in immunosuppressive therapy. Recently, clinical trials reported that ursodeoxycholic acid（UDCA） reduced the incidence of ACR significantly.However, others have shown contradictory conclusion. Therefore,we performed a meta-analysis of rigorous randomized controlled trials（RCTs） to determine the efficacy of UDCA in reducing ACR after LT.DATA SOURCES： All RCTs that evaluated efficacy of UDCA as an adjuvant treatment to prevent ACR after LT were searched from PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ScienceDirect databases and Web of Science（from January 1981 to March 2012）. There was no language limitation in these searches. Relevant abstracts of international meetings were also searched. References of each included study were searched manually.RESULTS： A total of 234 patients from four high-quality RCTs（Jadad score 4 to 5） were included in this meta-analysis.Prophylactic use of UDCA did not decrease the incidence of ACR（RR： 0.94, 95% CI： 0.77-1.16, P0.05）, steroid-resistant rejection（RR： 0.77, 95% CI： 0.47-1.27, P0.05） and the number of patients with the multiple episodes of ACR（RR： 0.60, 95% CI：0.28-1.30, P0.05）. Different intervention programs（high-dose vs low-dose UDCA; early vs delayed UDCA treatment） also did not alter the outcomes.CONCLUSIONS： UDCA, as an adjuvant treatment, was not ableto prevent ACR and steroid-resistant rejection after LT. Further trials should be done to determine whether higher dose of UDCA will be beneficial.

一种预测Bismuth–Corlette IV型肝门部胆管癌患者术后早期复发的简易评分系统

背景:肝门部胆管癌(pCCA)患者术后早期复发提示预后不佳。本研究旨在建立一个有效预测Bismuth-Corlette IV型pCCA患者术后早期复发的评估系统,并探讨该系统在指导术后随访和辅助治疗中的价值。方法:共计244例行根治性切除术的IV型pCCA患者纳入研究,分析其临床病理资料、围手术期参数及生存结果。采用Kaplan-Meier方法绘制生存曲线;通过单因素和多因素逻辑回归模型筛选早期复发的影响因素。结果:将术后21个月作为判定早期复发与晚期复发的界值。单因素和多因素分析显示,CA19-9>200 U/mL、R1切除术、淋巴结转移和脉管浸润是术后早期复发的独立预测因素。据此建立预测术后早期复发的评分系统,得分为0、1、2、3、4、5分的患者术后早期复发率分别为23.9%、38.7%、60.0%、78.6%、83.4%和100%。辅助治疗能明显提高早期复发患者的总体生存率,但对晚期复发患者则无明显改善作用。对于评分≥2分的患者,术后行辅助治疗可显著改善预后。结论:我们基于CA19-9、N分期、切缘情况和脉管浸润四项参数建立的这一简易评分系统,能有效预测IV型pCCA患者的术后早期复发风险,从而指导术后随访方案的制定和辅助治疗的实施。