七氟醚预处理在肝胆管手术联合胃造口术的肠保护作用研究

目的探讨七氟醚预处理在肝胆管手术联合胃造口术的肠保护作用。方法将2014年1月至2015年12月吴川市人民医院收治的肝胆管结石患者60例随机分为对照组与研究组，每组30例；对照组麻醉诱导采用丙泊酚2mg／kg＋芬太尼4～6μg／kg＋维库溴铵0．1mg／kg，麻醉维持采用丙泊酚6～10mg／（kg·h）；研究组在麻醉诱导成功后采用七氟醚混合氧吸入，保持七氟醚的体积分数为1．5％～2．0％，持续20～30min后洗出。结果两组患者在诱导前（T0）、气管插管时（T1）、手术10min（T2）、手术30min（T3）、拔管时（T4）、拔管5min后（T5）的SBP、DBP、HR、RR及SpO2比较，差异均无统计学意义（均P〉0．05）；两组患者术后24h的TNF-α、D乳酸盐及I-FABP水平均不同程度升高，研究组术后24h的TNF-α、D乳酸盐及I-FABP水平均显著低于对照组同期，均P〈0．001。结论七氟醚预处理可有效维持肝胆管手术联合胃造口手术中的血流动力学稳定，减轻机体的炎症反应，保护肠道黏膜的屏障作用，降低肠道损伤。

Diagnosis and Treatment of Liver Cystadenocarcinoma:Report of 18 Cases

Objective： To discuss the diagnosis and treatment of liver cystadenocarcinoma. Methods： The clinical, imaging, and pathological data of 18 patients with liver cystadenocarcinoma between January 2000 and December 2004 in our hospital were retrospectively analyzed. Results： The liver cystadeno- carcinoma was seen in males and females （m/f： 9/9）; mean age was 51 years. Ultrasonography revealed cystic parenchymatous mass echoes of fluid predominance with uneven margins. Nonenhanced CT revealed intrahepatic low-density space occupying shadows with nodular protrusions on the margins in all cases. Enhancement CT revealed that part of the nodular protrusions and tissues around the lesions were enhanced and the delayed phase disappeared. 66.67% （12/18） of the lesions were more than 10 cm in diameter. The diagnosis of liver cystadenocarcinoma was confirmed by postoperative pathology in all cases. Of these patients, 12 lesions were in the left lobe, 3 in the right lobe, 1 in the mid lobe, 1 in the right and left lobe, and 1 in the caudate lobe. Of tile 18 patients, 6 had completely resect the cystadenocarcinoma, 2 were surgically explored, one received TAE＋fine needle aspiration cytology＋injection of chemotherapy drugs, and 9 underwent radical hepatectomy＋choledochostomy or T-tube drainage, in which, one patient underwent choledochostomy＋left hepatectomy＋radical gastrectomy for cancer＋lymphadenectomy; one patient underwent resection of the cystadenocarcinoma, who had relapse 20 months after the initial procedure. The patient received repeat reseet for the recurrent cystadenoeareinoma＋eholangio-jejunostomy. Six months later she had another relapse and received repeat reseet （only PMCT） for the recurrent cystadenoearcinoma. The patient died from eholangiopleural fistula after third time operation （PMCT） was attempted perioperatively. Seven patients died of metastatic disease after operation. The remaining 10 patients were alive without cancer recurrence or metastasis （mean follow-up 20 months）. Conclusion： Liver eystadenocarcinoma is rarely seen and grows slowly. It shows some typical clinical and imaging features. The crux for diagnosing and treating liver cystadenoeareinoma is how familiar the surgeon is with the pathology and clinical features of the condition. Prolonged survival can be achieved by radical resection of the tumor.

Risk-adjustment in hepatobiliarypancreatic surgery

AIM: The present study evaluates the performance of the POSSUM, the American Society of Anesthetists (ASA), APACHE and Childs classification in predicting mortality and morbidity in hepatopancreaticobiliary (HPB) surgery. We describe especially the limitations and advantages of risk in stratifying the patients. METHODS: We investigated 177 randomly chosen patients undergoing elective complex HPB surgery in a single institution with a total of 71 pre-operative and intra-operative risk factors. Primary endpoint was in-hospital mortality and morbidity. Ordered logistic regression analysis was used to identify individual predictors of operative morbidity and mortality. RESULTS: The operative mortality in the series was 3.95%. This compared well with the p-POSSUM and APACHE predicted mortality of 4.31% and 4.29% respectively. Postoperative complications amounted to 45% with 24 (13.6%) patients having a major adverse event. On multrvariate analysis the pre-operative POSSUM physiological score (OR = 1.18, P = 0.009) was superior in predicting complications compared to the ASA (P= 0.108), APACHE (P= 0.117) or Childs classification (P= 0.136). In addition, serum sodium, creatinine, international normalized ratio (INR), pulse rate, and intra-operative blood loss were independent risk factors. A combination of the POSSUM variables and INR offered the optimal combination of risk factors for risk prognostication in HPB surgery. CONCLUSION: Morbidity for elective HPB surgery can be accurately predicted and applied in everyday surgical practice as an adjunct in the process of informed consent and for effective allocation of resources for intensive and high-dependency care facilities.

Endoscopic therapy of benign biliary strictures

Benign biliary strictures are being increasingly treated with endoscopic techniques. The benign nature of the stricture should be first confirmed in order to ensure appropriate therapy. Surgery has been the traditional treatment, but there is increasing desire for minimally invasive endoscopic therapy. At present, endoscopy has become the first line approach for the therapy of post- liver transplant anastomotic strictures and distal （Bismuth ! and I） post-operative strictures. Strictures related to chronic pancreatitis have proven more difficult to treat, and endoscopic therapy is reserved for patients who are not surgical candidates. The preferred endoscopic approach is aggressive treatment with gradual dilation of the stricture and insertion of multiple plastic stents. The use of uncovered self expandable metal stents should be discouraged due to poor long-term results. Treatment with covered metal stents or bioabsorbable stents warrants further evaluation. This area of therapeutic endoscopy provides an ongoing opportunity for fresh research and innovation.

Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation

AIM: To investigate the possibilities and advantages of laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct compaired with traditional open operation.METHODS: Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation were performed in two groups of patients who had gallstones in the left lobe of liver and in the common bile duct. The hospitalization time, hospitalization costs, operation time, operative complications and post-operative liver functions of the two groups of patients were studied.RESULTS: The operation time and post-operative liver functions of the two groups of patients had no significant differences, while the hospitalization time, hospitalization costs and operative complications of the laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration in the common bile duct group were significantly lower than those in the traditional open operation group.CONCLUSION: For patients with gallstones in the left lobe of liver and in the common bile duct, laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct can significantly shorten the hospitalization time, reduce the hospitalization costs and the post-operative complications,without prolonging the operation time and bringing about more liver function damages compared with traditional open operation. This kind of operation has more advantages than traditional open operation.

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

AIM: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. METHODS: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively. RESULTS: Bile duct injury was caused by cholecys- tectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini- incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively. CONCLUSION: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.

Intrahepatic biliary cystadenoma:Is there really an almost exclusively female predominance?

Biliary cystic tumors,such as cystadenomas and cystadenocarcinomas,are rare cystic tumors of the liver,accounting for less than 5% of all intrahepatic cysts of biliary origin.Biliary cystadenomas have been known to occur predominantly in women (> 85%),and 38%-44% of biliary cystadenocarcinomas have occurred in males.We wrote this letter to comment on a brief article (World J Gasteroenterol 2011 January 21;17(3):361-365) regarding a case of intrahepatic biliary cystic neoplasm treated with surgery.The adenoma-carcinoma sequence is the possible mechanism of carcinogenesis.If the carcinogenesis of biliary cystadenocarcinoma occurs in the adenoma-carcinoma sequence,we believe that the male-to-female ratio of cystadenoma should be higher than the incidence rate that has been reported to date.

Surgical treatment of hepatocellular carcinoma with bile duct tumor thrombi

AIM: To study the surgical treatment effect and outcome of hepatocellular carcinoma (HCC) with bile duct tumor thrombi (BDTT). METHODS: Fifty-three consecutive HCC patients with BDTT admitted in our department from July 1984 to December 2002 were reviewed retrospectively. The clinical data, diagnostic methods, surgical procedures and outcome of these patients were collected and analyzed. RESULTS: One patient rejected surgical treatment, 6 cases underwent percutaneous transhepatic cholangial drainage (PTCD) for unresectable primary disease, and the other 46 cases underwent surgical operation. The postoperative mortality was 17.6%, and the morbidity was 32.6%. Serum total bilirubin levels of these patients with obstructive jaundice decreased gradually after surgery. The survival time of six cases who underwent PTCD ranged from 2 to 7 mo (median survival of 3.7 mo). The survival time of the patients who received surgery was as follows: 2 mo for one patient who underwent laparotomy, 5-46 mo (median survival of 23.5 mo, which was the longest survival in comparison with patients who underwent other procedures, P=0.0024) for 17 cases who underwent hepatectomy, 5-17 mo (median survival of 10.0 mo) for 5 cases who underwent HACE, 3-9 mo (median survival of 6.1 mo) for 11 cases who underwent simple thrombectomy and biliary drainage, and 3-8 mo (median survival of 4.3 mo) for four cases who underwent simple biliary drainage. CONCLUSION: Jaundice caused by BDTT in HCC patients is not a contraindication for surgery. Only curative resection can result in long-term survival. Early diagnosis and surgical treatment are the key points to prolong the survival of patients.

Prognostic analysis of patients suffering from intrahepatic cholangiocarcinoma

Objective： The outcome of surgical treatment of patients with intrahepatic cholangiocarcinoma （ICC） is poor. This study was designed to analyze prognostic factors after surgical procedure for ICCs. Methods： A retrospective clinical analysis was made in 183 cases of ICC, admitted to Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China, from December 1996 to July 2003. Fifteen clinicopathologic factors that could possibly influence survival were selected. A multivariate analysis of these individuals was performed using the Cox Proportional Hazards Model. Results： The accumulative 1-, 3-and 5-year survival rates of the patients were 51.3%, 21.6% and 11.8% respectively. The statistical analysis showed that surgical procedure, lymph node metastasis, serum level of CA19-9 and pathological differentiation grade affected postoperative survival significantly, but transfusion, postoperative radiotherapy and chemotherapy, diameter of tumor, serum level of AFP, cirrhosis, preoperative total serum bilirubin level （TBIL）, ratio of albumin to globulin （A/G）, sex and age were not significant factors influencing postoperative survival. Conclusion： Major hepatectomy with systematic lymph node dissection may be recommended for the surgical treatment of ICC. Aggressive treatment and prevention on postoperative intrahepatic recurrence and lymph node metastasis are important strategy to improve the survival for ICC.

Role of Kasai procedure in surgery of hilar bile duct strictures

AIM:To assess the application of the Kasai procedure in the surgical management of hilar bile duct strictures.METHODS:Ten consecutive patients between 2005 and 2011 with hilar bile duct strictures who underwent the Kasai procedure were retrospectively analyzed.Kasai portoenterostomy with the placement of biliary stents was performed in all patients.Clinical characteristics,postoperative complications,and long-term outcomes were analyzed.All patients were followed up for 2-60 mo postoperatively.RESULTS:Patients were classified according to the Bismuth classification of biliary strictures.There were two Bismuth Ⅲ and eight Bismuth Ⅳ lesions.Six lesions were benign and four were malignant.Of the benign lesions,three were due to post-cholecystectomy injury,one to trauma,one to inflammation,and one to inflammatory pseudotumor.Of the malignant lesions,four were due to hilar cholangiocarcinoma.All patients underwent Kasai portoenterostomy with the placement of biliary stents.There were no perioperative deaths.One patient experienced anastomotic leak and was managed conservatively.No other complications occurred perioperatively.During the follow-up period,all patients reported a good quality of life.CONCLUSION:The Kasai procedure combined with biliary stents may be appropriate for patients with hilar biliary stricture that cannot be managed by standard surgical methods.

Role of interventional therapy in hepatic artery stenosis and non-anastomosis bile duct stricture after orthotopic liver transplantation

AIM： To analyze the clinical manifestations and the effectiveness of therapy in patients with orthotopic liver bansplantation （OLT）-associated hepatic artery stenosis （HAS） and non-anastomosis bile duct stricture.METHODS： Nine cases were diagnosed as HAS and non-anastomosis bile duct stricture. Percutaneous transluminal angioplasty （PTA） was performed in four HAS cases, and expectant treatment in other five HAS cases, percutaneous transhepatic bile drainage, balloon dilation, stent placement were performed in all nine cases.RESULTS： Diffuse intra- and extra-bile duct stricture was observed in nine cases, which was associated with bile mud siltation and biliary infection. Obstruction of the bile duct was improved obviously or removed. Life span/ follow-up period was 13-30 mo after PTA of four HAS cases, 6-23 mo without PTA of other five cases.CONCLUSION： Progressive, non-anastomosis, and diffuse bile duct stricture are the characteristic manifestations of HAS and non-anastomosis bile duct stricture after OLT. These are often associated with bile mud siltation, biliary infection, and ultimate liver failure. Interventional therapy is significantly beneficial.

Postoperative radiotherapy in locally advanced hepatic hilar cholangiocarcinoma

Objective: To evaluate the outcome of radiotherapy (RT) in locally advanced hepatic hilar cholangiocarcinoma. Methods: During March 1992 to December 1997, 47 patients who had positive microscopic surgical margins after surgery were treated by postoperative radiotherapy (S+RT, 28 patients, with a median dose of 50 Gy, 45–62 Gy) and surgery alone (S, 19 patients). The median follow-up was 30 months (4–113 months). Results: The overall 5-year survival rate was 28%, with a median survival length of 19.6 months while 5-year survival rates of S+RT group and S group were 34% and 14%, with median survival lengths of 29 and 10 months respectively (P=0.015). The occurrence rate of complications was 11% in either group. Conclusion: Postoperative radiotherapy significantly prolongs survival lengths in patients with hepatic hilar cholangio- carcinoma who had positive microscopic surgical margins. Radiation toxicities are tolerable.

A special recurrent pattern in small hepatocellular carcinoma after treatment:Bile duct tumor thrombus formation

AIM:To investigate the clinicopathologic features of bile duct tumor thrombus(BDTT) occurrence after treatment of primary small hepatocellular carcinoma(sHCC) .METHODS:A total of 423 patients with primary sHCC admitted to our hospital underwent surgical resection or local ablation.During follow-up,only six patients were hospitalized due to obstructive jaundice,which occurred 5-76 mo after initial treatment.The clinicopathologic features of these six patients were reviewed.RESULTS:Six patients underwent hepatic resection(n=5) or radio-frequency ablation(n=1) due to primary sHCC.Five cases had an R1 resection margin,and one case had an ablative margin less than 5.0 mm.No vascular infiltration,microsatellites or bile duct/canaliculus affection was noted in the initial resected specimens.During the follow-up,imaging studies revealed a macroscopic BDTT extending to the common bile duct in all six patients.Four patients had a concomitant intrahepatic recurrent tumor.Surgical re-resection of intrahepatic recurrent tumors and removal of BDTTs(n=4) ,BDTT removal through choledochotomy(n= 1) ,and conservative treatment(n=1) was performed.Microscopic portal vein invasion was noted in three of the four resected specimens.All six patients died,with a mean survival of 11 mo after BDTT removal or conservative treatment.CONCLUSION:BDTT occurrence is a rare,special recurrent pattern of primary sHCC.Patients with BDTTs extending to the common bile duct usually have an unfavorable prognosis even following aggressive surgery.Insufficient resection or ablative margins against primary sHCC may be a risk factor for BDTT development.