Objective To investigate the pathological characteristics of bile duct tumor thrombi (BDTT) and its inlfuence on the prognosis of patients with hepatocellular carcinoma (HCC) after surgical treatments. Methods Clinical data of 26 patients with HCC and BDTT (23 males, 3 females, age ranging from 23 to 78 years old and the median age of 52 years old) who underwent hepatectomy in Department of Hepatopancreatobiliary Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University from June 2007 to June 2012 were analyzed retrospectively. The informed consents of all patients were obtained and the ethical committee approval was received. The surgical procedures included regular hepatectomy (n=12), irregular hepatectomy (n=14). The treatments for BDTT included bile duct thrombectomy (n=13), extrahepatic bile duct resection (n=8), combined resection of BDTT and tumor (n=5). The pathological characteristics of BDTT were observed and its correlation with tumor recurrence was analyzed. The comparison of rates was conducted by Fisher's exact probability test. Results Two cases of pure small microscopic BDTT and 24 cases of big macroscopic BDTT (14 cases were combined with pure small microscopic BDTT) were observed. According to the Satoh's BDTT clinical classiifcation, there were 3 cases of typeⅠ, and 21 cases of type Ⅱin 24 cases of big macroscopic BDTT. In all 26 cases of BDTT, sub-epithelium spreading along the bile duct wall was observed in 23 cases, most of which were small microscopic BDTT or big macroscopic BDTT. Intraductal spreading was rare and was observed mostly at the end part of big macroscopic BDTT. During the follow-up, intrahepatic tumor recurrence was observed in 10 cases, in which 8 cases were combined with BDTT recurrence. The intrahepatic tumor recurrence rate was 3/9 in patients after regular hepatectomy, and was 58%(7/12) in patients after irregular hepatectomy. In the 13 cases receiving bile duct thrombectomy, 7 cases suffered from BDTT recurrence with the recurrence rate of 54%(7/13). In the 8 cases receiving extrahepatic bile duct resection, 1 case suffered from BDTT recurrence with the recurrence rate of 1/8, where signiifcant difference was observed (P<0.05). Conclusions BDTT of HCC includes macroscopic BDTT and microscopic BDTT. BDTT spreads mostly in sub-epithelium along the bile duct wall. Tumor recurrence rate may be reduced and the outcome may be improved by surgical treatments of regular hepatectomy combined with extrahepatic bile duct resection.

Objective To investigate the role of preoperative peripheral blood neutrophil to lymphocyte ratio (NLR) in the prognosis of patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) after operation. Methods Clinical data of 299 patients with HBV-related HCC who underwent radical liver resection in Department of Hepatobiliary Surgery, the Afifliated Hospital of Medical College, Qingdao University from January 2005 to December 2010 were analyzed retrospectively. The informed consents of all patients were obtained and the ethical committee approval was received. There were 258 males and 41 females with age ranging from 23 to 82 years old and median age of 54 years old. NLR was calculated according to the blood routine examination result of peripheral blood collected 3 days before operation. All patients were regularly followed up after operation and the survival and tumor recurrence were recorded. Receiver operating characteristic (ROC) curve of NLR for diagnosing tumor recurrence was plotted and the cut-off value was deifned. The patients were divided into low NLR group and high NLR group according to the cut-off value of NLR. The differences of cumulative survival rates and disease-free survival rates between two groups were compared. Clinical parameters were included as the factors influencing patients' 5-year cumulative survival rates and independent risk factors were analyzed. The survival analysis was conducted using Kaplan-Meier method and Log-rank test. Independent risk factor analysis was conducted using Cox proportional-hazards regression model. Results When the cut-off value of NLR for diagnosing tumor recurrence after operation was deifned at 1.71, the sensitivity was 0.49 and speciifcity was 0.73. The 1, 3, 5-year cumulative survival rates were 90.8%, 82.6%, 61.8%in low NLR group (n=173) and was 83.3%, 72.2%, 46.2% in high NLR group (n=126), and the 1, 3, 5-year disease-free survival rates were 82.8%, 66.7%, 44.9%and 62.7%, 36.2%, 24.8%respectively. There were signiifcant differences between two groups in cumulative survival rates and disease-free survival rates (χ2=6.987, 19.970;P<0.05). The independent risk factors for 5-year cumulative survival rate were preoperative NLR>1.71, gamma-glutamyl transpeptidase (GGT)>64 U/L, alpha fetal protein (AFP)≥400μg/L and tumor diameter>5 cm (RR=1.504, 0.590, 1.540, 0.982; P<0.05). Conclusions The preoperative NLR is an independent risk factor for influencing the prognosis of patients with HBV-related HCC. Patients with preoperative NLR>1.71 have poor prognosis.

Objective To discuss the surgical treatment and its effects for hepatocellular carcinoma (HCC) in late pregnancy. Methods Clinical data of 3 patients with HCC in late pregnancy who were admitted in Department Hepatobiliary Surgery, the First People's Hospital of Foshan from November 2011 to December 2011 were analyzed retrospectively. The age of the patients was 23, 33 and 26 years old respectively. Case 1 with 35 weeks pregnancy was admitted to hospital for 3+weeks of progressive jaundice in skin and sclera after caesarean, and the alpha-fetoproteins (AFP) was 49 096μg/L. Case 2 with 29+4 weeks pregnancy was admitted to hospital after 1 week of ifnding a giant occupying lesion in the right lobe of liver, and the AFP was 973μg/L. Case 3 with 30+6 weeks pregnancy was admitted to hospital for 1 month of right upper quadrant abdominal dull pain after 2 d of ifnding a giant occupying lesion in the right lobe of liver, and the AFP was>1 210μg/L. The patients who had a history of viral hepatitis B began to take obstetrical examinations from 3+month of pregnancy, but not including the upper abdomen ultrasonic scan. All of them were diagnosed with HCC by ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). The informed consents of 3 patients were obtained and the ethical committee approval was received. Case 1 underwent percutaneous transhepatic cholangial drainage (PTCD) to reduce jaundice, then underwent right hemihepatectomy by anterior approach+thrombectomy through choledochotomy+left hepatic duct-jejunum end-to-side anastomosis. Case 2 delivered a healthy baby girl by caesarean after 2 weeks of conservative treatment, then underwent right hemihepatectomy by anterior approach+hepatic segmentⅣnodulectomy. Case 3 delivered a healthy baby boy naturally after 1 week of conservative treatment, then underwent segmentⅥ,Ⅶ,Ⅷhepatectomy by anterior approach. Results Case 1 recovered well after operation and was found with multiple intrahepatic metastasis in January 2013. Then transcatheter arterial chemoembolization (TACE) was performed. Case 2 was discharged from hospital with improvement 10 d after operation. Multiple hepatic and pulmonary metastasis was found 4 months after operation, and then treatments of targeted therapy of sorafenib combined with local radiofrequency ablation were given to the patient. Case 3 suffered bile leakage, bile duct and right subphrenic infection, and pancreatic tail infection and necrosis after operation and was discharged from hospital with improvement 93 d after treatments of repeated anti-infection, percutaneous peritoneal drainage, enternal nutrition support and so on. And then multiple pulmonary metastasis was found in February 2013. All the patients survived till this article was submitted. Conclusions Once the diagnosis of HCC in late pregnancy is conifrmed, the patient is suggested to keep pregnant till 32 weeks in order to save baby’s life and undergo hepatectomy as early as possible. Most of the patients are late HCC and the curative effect is poor.

Objective To investigate the clinical value of sorafenib in preventing tumor recurrence in patients with hepatocellular carcinoma (HCC) after liver transplantation (LT). Methods A total of 41 patients with HCC beyond University of California, San Francisco (UCSF) criteria receiving LT in Department of Hepatobiliary Pancreatic Surgery, People's Hospital of Zhengzhou from March 2010 to July 2012 were enrolled in this prospective study. The informed consents of all patients were obtained and the ethical committee approval was received. There were 35 males and 6 females with age ranging from 34 to 61 years old and the median age of 49 years old. According to whether the patients chose sorafenib for  Objective To investigate the clinical value of sorafenib in preventing tumor recurrence in patients with hepatocellular carcinoma (HCC) after liver transplantation (LT). Methods A total of 41 patients with HCC beyond University of California, San Francisco (UCSF) criteria receiving LT in Department of Hepatobiliary Pancreatic Surgery, People's Hospital of Zhengzhou from March 2010 to July 2012 were enrolled in this prospective study. The informed consents of all patients were obtained and the ethical committee approval was received. There were 35 males and 6 females with age ranging from 34 to 61 years old and the median age of 49 years old. According to whether the patients chose sorafenib for treatment after operation, they were divided into sorafenib group (n=9) and control group (n=32). Patients were treated with sorafenib orally (400 mg) twice daily in sorafenib group, and half dose (200 mg) was given twice daily when the patients were intolerant to the adverse reactions. In control group, patients did not take sorafenib or changed to take sorafenib after tumor recurrence. Patients received follow-up after operation, and tumor recurrence and survival were recorded during the follow-up. The tumor recurrence rates after operation of two groups were compared using Chi-squane test. The postoperative 1-, 2-year disease-free survival and cumulative survival rates were compared using Kaplan-Meier method and Log-rank test. Results The tumor recurrence rate was 3/9 in sorafenib group including 2 cases of taking half dose sorafenib. The tumor recurrence rate was 47%(15/32) in control group including 3 cases with liver metastasis underwent radiofrequency ablation, 2 cases with pulmonary metastases underwent radiation therapy, 2 cases with pulmonary metastases took sorafenib, the other 8 cases with multiple metastases received no treatments. No signiifcant difference was observed in tumor recurrence rates between two groups (χ2=0.523, P>0.05). No death was observed in sorafenib group, while in control group, 12 cases died of tumor recurrence or metastasis. The postoperative 2-year disease-free survival rates were 67%, 53%in sorafenib group and control group respectively and no signiifcant difference was observed (χ2=2.226, P>0.05). The postoperative 2-year cumulative survival rates were 100%, 63%in sorafenib group and control group respectively and signiifcant difference was observed (χ2=5.126, P<0.05). Conclusion For patients with HCC beyond UCSF criteria after LT, sorafenib can improve the 2-year cumulative survival rate and has a certain value in preventing tumor recurrence after operation.

Objective To investigate the causes, prevention and treatment of seizures following liver transplantation (LT). Methods In the 772 patients undergoing LT in Organ Transplantation Center, the third Affiliated Hospital of Sun Yat-sen University from October 2003 to June 2009, clinical data of 8 patients who developed seizures during the follow-up after operation were analyzed retrospectively. The informed consents of all patients were obtained and the ethical committee approval was received. There were 5 males and 3 females with age ranging from 46 to 58 years old and median age of 54 years old. The patients received regular reexaminations of blood routine, liver function, renal function, electrolytes, blood concentration of immunosuppressant, infection related etiological examinations, etc. The examinations of electroencephalogram (EEG), computed tomography (CT), or magnetic resonance imaging (MRI) were completed for the suspicious patients of seizures. The causes of disease, diagnosis, treatments and outcome of the patients were analyzed, including the incidence, onset time, seizures types, etiological analysis, treatments and outcome. Results The incidence of seizures following LT was 1.0% (8/772), in which 1 case occurred in 1 week after operation, 2 cases within 5 to 6 weeks, 5 cases over 16 weeks and the longest case over 7 years after operation. Generalized tonic-clonic seizure was observed in 7 cases, including 2 cases developed to status epilepticus and 1 case of complex partial seizure. The etiological analysis revealed that 1 case had a history of seizures and 2 cases had hepatic encephalopathy before operation. Water-electrolyte imbalance occurred in 6 cases after operation including 2 cases complicated with hypoglycemia. And cerebral apoplexy occurred in 4 cases after operation including 1 case complicated with abnormally elevating blood concentration of tacrolimus (FK506), 1 case complicated with intracranial fungus and cytomegalovirus infections. Sedative and antiepileptic were given to all of 8 patients and various inducements were treated. Two cases recovered well and were discharged from hospital, and 6 cases died of multiple organ dysfunction syndrome or cerebral hemorrhage. Conclusions Seizures following LT may be related with many factors such as preoperative history of seizures and hepatic encephalopathy, immunosuppressant toxicity, water-electrolyte imbalance, cerebral apoplexy and intracranial infections after operation, etc. Once seizures are confirmed, sedative and antiepileptic should be given to the patients and various inducements should be treated. The prognosis of the patients is poor.

Objective To investigate the risk factors for reoperation after pancreaticoduodenectomy (Whipple). Methods Clinical data of 339 patients who underwent Whipple in the First Afifliated Hospital of Sun Yat-sen University from January 2000 to December 2009 were analyzed retrospectively. The informed consents of all patients or relatives were obtained and the ethical committee approval was received. There were 206 males and 133 females with age ranging from 1 to 86 years old and the median age of 55 years old. According to whether the patients received reoperation after operation, they were divided into reoperation group (n=24) and non-reoperation group (n=315). The reoperation of patients and its risk factors were analyzed. The relations between reoperation and clinical parameters were analyzed using Chi-square test and the risk factors for reoperation were analyzed using Logistic regression analysis. Results The reoperation rate of patients was 7.1%(24/339). The main causes of reoperation included abdominal bleeding (n=8, 5 cases were complicated with pancreatic fistula), upper gastrointestinal bleeding (n=7, 2 cases were complicated with pancreatic ifstula), pancreatic ifstula complicated with abdominal infection (n=2), biliary leakage (n=1) and wound rupture (n=6). In 24 patients receiving reoperation, 9 cases were related with pancreatic ifstula. Four out of 5 death cases were with pancreatic ifstula. The reoperation was related to preoperative diabetes, intraoperative blood loss (χ2=5.588, 4.565;P<0.05). Preoperative diabetes, intraoperative blood loss>400 ml were independent risk factors for reoperation after Whipple (OR=5.80, 2.74; P<0.05). Conclusions The main causes of reoperation after Whipple are pancreatic ifstula and wound rupture. Preoperative diabetes, intraoperative blood loss>400 ml are independent risk factors for reoperation after Whipple.

Objective To investigate the clinical value of contrast-enhanced ultrasound (CEUS) in evaluating the invasive area of hilar cholangiocarcinoma. Methods Clinical data of 103 patients with hilar cholangiocarcinoma who received conventional ultrasound and CEUS examination in Department of Medical Ultrasonics, the Third Affiliated Hospital of Sun Yat-sen University from January 2005 to March 2013 were analyzed retrospectively. The patients were conifrmed by contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) or surgical pathological examination. There were 70 males and 33 females with mean age of (59±13) years old. The informed consents of all patients were obtained and the ethical committee approval was received. The patients received conventional ultrasound and CEUS examination both. The display of invasive area of hilar cholangiocarcinoma by two methods was observed. The contrast-enhanced CT, MRI or surgical pathological examination were regarded as the gold standards. The diagnostic accordance rates of invasive area of hilar cholangiocarcinoma by two methods were calculated and compared using Chi-square test. Results For conventional ultrasound, 28 cases were with ill-deifned tumor borders and 75 cases were with well-deifned or poorly deifned tumor borders, in which 33%(25/75) of the tumor invasive areas were intraductal, 67%(50/75) were intraductal and extraductal. In arterial phase of CEUS, tumors in 51.4%(53/103) of patients were displayed hyper-enhanced, 28.2%(29/103) were homo-enhanced, and 20.4%(21/103) were hypo-enhanced. In venous phase, tumors in 100%(103/103) of patients were displayed hypo-enhanced. For CEUS, 16.5% (17/103) of the tumor invasive areas were intraductal, 83.5% (86/103) were intraductal and extraductal. The diagnostic accordance rate was 59.2%(61/103) by conventional ultrasound and was 99.0% (102/103) by CEUS. The diagnostic accordance rate of CEUS was signiifcantly higher than that of conventional ultrasound (χ2=17.611, P<0.05). Conclusion Compared with conventional ultrasound, CEUS can evaluate the invasive area of hilar cholangiocarcinoma more accurately.

Objective To investigate the clinical value of magnetic resonance cholangiopancreatography (MRCP) in the preoperative evaluation of patients with biliary calculus. Methods Clinical data of 70 patients with biliary calculus in Sun Yat-sen Memorial Hospital and the Third Afifliated Hospital of Sun Yat-sen University from June 2012 to June 2013 were retrospectively analyzed. There were 38 males and 32 females with age ranging from 18 to 87 years old and the median age of 52 years old. The informed consents of all patients were obtained and the ethical committee approval was received. The patients underwent ultrasound examination and MRCP before operation. The surgical procedures were cholecystectomy+bile duct exploration and the intraoperative exploration result was the gold standard of diagnosis for biliary calculus and biliary tract variations. The detectable rate of biliary calculus and biliary tract variations by two methods were compared using Chi-square test and Fisher's exact probability test. Results The detectable rate of gallstones was 93%(62/67) by ultrasound and was 79%(53/67) by MRCP, where signiifcant difference was observed (χ2=4.968, P<0.05). The detectable rate of common bile duct stones was 61%(17/28) by ultrasound and was 86%(24/28) by MRCP, where signiifcant difference was observed (χ2=4.462, P<0.05). The detectable rate of the left and right hepatic duct stones was 2/5 by ultrasound and was 4/5 by MRCP, where no signiifcant difference was observed (P>0.05). The detectable rate of intrahepatic bile duct stones was 36%(4/11) by ultrasound and was 73%(8/11) by MRCP, where no signiifcant difference was observed (P>0.05). The detectable rate of biliary tract variations was 2/8 by ultrasound and was 7/8 by MRCP, where signiifcant difference was observed (P<0.05). Conclusions MRCP is superior to ultrasound examination in the detection of common bile duct stones and biliary tract variations. It can be a common practice in the preoperative evaluation of patients with biliary calculus when circumstances allow.

Objective To study the biological behavior of human liver cancer stem cells. Methods Human liver cancer MHCC97H cells in logarithmic growth phase were inoculated in the serum free medium for suspension cultivation and human liver cancer MHCC97H stem cells with stable propagation were acquired. Human liver cancer MHCC97H stem cell microspheres and human liver cancer MHCC97H cells were collected. Messenger ribonucleic acid (mRNA) of cell markers including cluster of differentiation (CD) 133, CD90, epithelial cell adhesion molecule (EpCAM) was detected by reverse transcription polymerase chain reaction (RT-PCR). Colony formation assay, tumor cell invasion assay (Transwell assay) and nude mouse tumorigenicity assay were performed respectively to observe the colony formation, cell invasion and tumorigenicity of two kinds of cells. The experimental data of two kinds of cells were compared by t test or t′test. Results The mean contents of CD133, CD90, EpCAM mRNA in human liver cancer MHCC97H stem cells (32.70±0.20, 66.30±0.32, 115.40±4.00) were significantly higher than those in human liver cancer MHCC97H cells (1.27±0.29, 13.60±1.36, 1.34±0.40) (t′=117.8, 53.97, 83.37;P<0.05). The colony forming efifciency was (213±10)%in human liver cancer MHCC97H stem cells and was (54±11)%in human liver cancer MHCC97H cells, where signiifcant difference was observed (t=13.11, P<0.05). Through the Transwell assay, the membrane permeating cell count was (587±120)/visual ifelds in human liver cancer MHCC97H stem cells, and was (97±13)/visual ifelds in human liver cancer MHCC97H cells, where signiifcant difference was observed (t=6.38, P<0.05). In the nude mouse tumorigenicity assay, subcutaneous transplanted tumors were observed in nude mouse 4 weeks after inoculating 2×103 human liver cancer MHCC97H stem cells and the tumor formation rate was 1/6. Subcutaneous transplanted tumors were observed in all nude mice by inoculating 2×105 human liver cancer MHCC97H stem cells, and the tumor formation rate was 6/6. Subcutaneous transplanted tumors were observed in nude mice by inoculating at least 2×105 human liver cancer MHCC97H cells, and the tumor formation rate was 2/6. Conclusion Compared with the human liver cancer MHCC97H cells, human liver cancer MHCC97H stem cells possess stronger invasion and higher tumor formation rate.

Objective To study the role of garlicin, vitamin C and vitamin B6 and the mechanism in preventing and treating non-alcoholic fatty liver disease (NAFLD) in mouse. Methods Eighteen C57BL/6 mice were randomly divided into 3 groups according to the random number table:preventing group, treating group and control group with 6 mice in each group. In preventing group, the mice were fed with high fatty diet and were infused intragastrically with garlicin (0.02 mg/g), vitamin C (0.50 mg/g) and vitamin B6 (0.02 mg/g) by weight everyday at the same time for 4 weeks. In treating group, the mice were infused intragastrically with the above drugs for 1 week after 4 weeks of feeding with high fatty diet. In control group, the mice were fed with high fatty diet and were infused intragastrically with equivalent normal saline at the same time for 4 weeks. After processing, the levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), free fatty acids (FFA), levels of superoxide dismutase (SOD), malondialdehyde (MDA), expression of inducible nitric oxide synthase (iNOS), content of messenger ribonucleic acid (mRNA) of iNOS, pathological changes and inifltration of Kupffer cells of liver tissues in 3 groups were observed. The differences of measurement data in 3 groups were compared using one-way analysis of variance and LSD-t test. Results The mean levels of serum ALT were (30±7), (34±7), (44±6) U/L in preventing group, treating group and control group respectively, which were signiifcantly lower in preventing group and treating group than that in control group (LSD-t=3.815, 2.748; P<0.05). The levels of serum AST were (46±6), (43±8), (103±7) U/L in preventing group, treating group and control group respectively, which were significantly lower in preventing group and treating group than that in control group (LSD-t=12.400, 16.371; P<0.05). The levels of serum FFA were (196±10), (223±12), (254±31) mmol/L in preventing group, treating group and control group respectively, which were signiifcantly lower in preventing group and treating group than that in control group (LSD-t=4.335, 2.271; P<0.05), and it was significantly lower in preventing group than that in treating group (LSD-t=4.154;P<0.05). The levels of serum SOD were (128±17), (119±30), (82±13) kU/L in preventing group, treating group and control group respectively, which were signiifcantly higher in preventing group and treating group than that in control group (LSD-t=5.413, 2.850; P<0.05). The levels of serum MDA were (5.5±1.9), (5.7±1.9), (7.9±0.9)μmol/L in preventing group, treating group and control group respectively, which were signiifcantly lower in preventing group and treating group than that in control group (LSD-t=2.818, 2.527; P<0.05). The expression of iNOS protein in liver tissues of mice in control group signiifcantly increased, compared with that in preventing group and treating group. The mRNA contents of iNOS in liver tissues of mice were (3.6±0.5)×10-4, (3.3±0.5)×10-4, (7.5±0.3)×10-4, which were signiifcantly lower in preventing group and treating group than that in control group (LSD-t=13.273, 13.976; P<0.05). Obvious fatty liver was observed in mice of control group, while it was milder in preventing group and treating group. The activated Kupffer cells in liver tissues significantly decreased in preventing group and treating group, compared with that in control group. Conclusions Combined use of garlicin, vitamin C and vitamin B6 is effective in preventing and treating NAFLD. The mechanism may be related with alleviating lipid peroxidation damage, enhancing the oxidation resistance of liver, suppressing cytoactive of Kupffer cells and decreasing the levels of serum FFA.