Effect of early enteral combined with parenteral nutrition in patients undergoing pancreaticoduodenectomy

AIM:To investigate the effect of early enteral nutrition(EEN)combined with parenteral nutritional support in patients undergoing pancreaticoduodenectomy(PD).METHODS:From January 2006,all patients were given EEN combined with parenteral nutrition(PN)(EEN/PN group,n=107),while patients prior to this date were given total parenteral nutrition(TPN)(TPN group,n=67).Venous blood samples were obtained for a nutrition-associated assessment and liver function tests on the day before surgery and 6 d after surgery.The assessment of clinical outcome was based on postoperative complications.Follow-up for infectious and noninfectious complications was carried out for 30 d after hospital discharge.Readmission within 30 d afterdischarge was also recorded.RESULTS:Compared with the TPN group,a significant decrease in prealbumin(PAB)(P=0.023)was seen in the EEN/PN group.Total bilirubin(TB),direct bilirubin(DB)and lactate dehydrogenase(LDH)were significantly decreased on day 6 in the EEN/PN group(P=0.006,0.004 and 0.032,respectively).The rate of gradeⅠcomplications,gradeⅡcomplications and the length of postoperative hospital stay in the EEN/PN group were significantly decreased(P=0.036,0.028and 0.021,respectively),and no hospital mortality was observed in our study.Compared with the TPN group(58.2%),the rate of infectious complications in the EEN/PN group(39.3%)was significantly decreased(P=0.042).Eleven cases of delayed gastric emptying were noted in the TPN group,and 6 cases in the EEN/PN group.The rate of delayed gastric emptying and hyperglycemia was significantly reduced in the EEN/PN group(P=0.031 and P=0.040,respectively).CONCLUSION:Early enteral combined with PN can greatly improve liver function,reduce infectious complications and delayed gastric emptying,and shorten postoperative hospital stay in patients undergoing PD.

Establishment of a rat liver transplantation model with prolonged biliary warm ischemia time

AIM:To investigate the impact of different time points of secondary warm ischemia on bile duct in a rat autologous liver transplantation model with external bile drainage.METHODS:One hundred and thirty-six male inbred SD rats were randomly assigned to one of four groups(Ⅰ-Ⅳ) according to the secondary warm ischemia time of 0,10,20 and 40 min.A rat model of autologous liver transplantation with continuous external biliary drainage under ether anesthesia was established.Ten rats in each group were used to evaluate the one-week survival rate.At 6 h,24 h,3 d and 7 d after reperfusion of the hepatic artery,6 rats were killed in each group to collect the blood sample via the infrahepatic vena cava and the median lobe of liver for assay.Warm ischemia time of liver,cold perfusion time,anhepaticphase,operative duration for biliary external drainage and survival rates in the four groups were analyzed for the establishment of models.RESULTS:No significant difference was shown in warm ischemia time,anhepatic phase and operative duration for biliary external drainage among the four groups.Five of the 40 rats in this study evaluated for the one-week survival rate died,including three deaths of severe pulmonary infection in group Ⅳ.A significant decrease of one-week survival rate in group Ⅳ was noted compared with the other three groups.With the prolongation of the biliary warm ischemia time,the indexes of the liver function assessment were significantly elevated,and biliary epithelial cell apoptosis index also increased.Pathological examinations showed significantly aggravated inflammation in the portal area and bile duct epithelial cell injury with the prolonged secondary warm ischemia time.Microthrombi were found in the micrangium around the biliary tract in some sections from groups Ⅲ and Ⅳ.CONCLUSION:The relationship between secondary warm ischemia time and the bile duct injury degree is time-dependent,and 20 min of secondary warm ischemia time is feasible for the study of bile duct injury.

Effects of warm ischemia time on biliary injury in rat liver transplantation

AIM:To investigate the effect of different secondary warm ischemia time (SWIT) on bile duct injury in livertransplanted rats. METHODS:Forty-eight male inbred Sprague-Dawley rats were randomly assigned into four groups:a shamoperation group and three groups with secondary biliary warm ischemia time of 0 min, 10 min and 20 min. A rat model of autologous liver transplantation under ether anesthesia was established, and six rats were killed in each group and blood samples and the median lobe of the liver were collected for assay at 6 h and 24 h after hepatic arterial reperfusion. RESULTS:With prolongation of biliary warm ischemia time, the level of vascular endothelial growth factor-A was significantly decreased, and the value at 24 h was higher than that at 6 h after hepatic arterial reperfusion, but with no significant difference. The extended biliary SWIT led to a significant increase in bile duct epithelial cell apoptosis, and a decrease in the number of blood vessels, the bile duct surrounding the blood vessels and bile duct epithelial cell proliferation in the early postoperative portal area. Pathologic examinations showed that inflammation of the rat portal area was aggravated, and biliary epithelial cell injury was significantly worsened. CONCLUSION:A prolonged biliary warm ischemia time results in aggravated injury of the bile duct and the surrounding vascular plexus in rat autologous orthotopic liver transplantation.

Diagnosis and Treatment of Cholangiocarcinoma: A Consensus from Surgical Specialists of China

Cholangiocarcinoma refers to malignant tumors that develop in epithelial lining of biliary system, and it is divided into two categories according to tumor location, intrahepatic cholangiocarcinoma （ICC） and extrahepatic cholangiocarcinoma （ECC）. ICC occurs from the epithelial cells of the intrahepatic bile duct, its branches and interlobular biliary tree; and ECC is divided into hilar cholangiocarcinoma and distal cholangiocarcinoma by the circumscription at the confluence of cystic duct and the common hepatic duct.