Objective To design and create a C/S-J type of biliary self-releasing stent,and to study its safety and efficacy in preventing post-ERCP complications.Methods 118 patients with common bile duct stones treated in our hospital were enrolled into this study from October 2013 to May 2015.These patients were randomly divided into two groups:the experimental group who underwent ERCP + EST + C/S-J type of self-releasing biliary stent drainage,while the control group underwent ERCP + EST + ENBD.The incidences of post-ERCP acute pancreatitis (PEP) and cholangitis in the two groups and the time the self-releasing stent was dislodged from the biliary system in the experimental group were recorded.Results The incidence of PEP was 6.4％ (5/78) and 7.5％ (3/40) in the experimental and the control group,respectively (P ＞ 0.05).There were no patients who developed postoperative acute cholangitis in the two groups.The stents were dislodged from the biliary system on the first day after the procedure in 2 patients in the experimental group without any complications.One stent failed in self-releasing but was removed successfully with endoscopy 3 months later.In the other 75 patients,the stents were successfully dislodged and were excreted outside the patient's body through the intestinal tract (mean 11.4,range 9 ～ 14) days,without any complications.Conclusion The C/S-J type of biliary self-releasing stents is safe and efficacious in preventing post-ERCP pancreatitis and cholangitis.

Objective To analyze and compare the clinical characteristics of primary sclerosing cholangitis (PSC) with IgG4-related sclerosing cholangitis (IgG4-SC).Methods The clinical data of 32 PSC patients and 72 IgG4-SC patients who were hospitalized in Peking Union Medical College Hospital (PUMCH) from January 2004 to December 2014 were retrospectively analyzed.Results Of the 32 PSC patients,there were 16 male and 16 female.Of the 72 IgG4-SC patients,there were 61 male and 11 female,(ratio =5.5∶ 1).The average ages were 44.9 (11 ～ 77) and 59.8 (28 ～ 83) years,respectively (P ＜0.05).The most common symptoms of PSC and IgG4-SC were abdominal pain and jaundice,and the incidences of abdominal pain and jaundice were 50.0％ and 68.1％,78.1％ and 81.9％,respectively.The serum IgG4 level of the IgG4-SC patients was significantly higher than the PSC patients (P ＜ 0.05).The total protein in serum of the IgG4-SC patients was higher than the PSC patients (P ＜ 0.05).The rate of bile duct wall thickening as detected on endoscopic ultrasonography (EUS) was higher than by abdominal ultrasound and abdominal CT,which were 91.2％,11.5％ and 33.3％,respectively (P ＜0.05).12 PSC patients were followed up for over 2 years,including 2 patients who underwent liver transplantation after failure of conservative treatment,5 patients who died from hepatic failure and infection,and 3 with stable condition.43 IgG4-SC patients were followed up for over 2 years,including 16 patients with relapse.The recurrence rate was 37.2％ (16/43).The more the extrabiliary organs or bile duct segments were involved,the higher was the recurrence rate.Conclusions Both PSC and IgG4-SC are cholestatic diseases,and they have many similarities in clinical and imaging manifestations.However,they still have unique features.IgG4-SC is sensitive to glucocorticoids therapy and has good prognosis.Thus,it is important to differentiate PSC from IgG4-SC.

Objective To investigate the risk factors of chylous leakage after pancreatioduodenectomy so as to find effective measures to prevent this complication.Methods A retrospective analysis was conducted on 230 patients who underwent pancreatioduodenectomy at the First Affiliated Hospital of Zhejiang University from Jun.2012 to Jun.2014.Patients with chylous leakage were identified and a 1 ∶ 2 patients in the study and the control groups were selected.The parameters for matching included tumor volume,vascular invasion,and extent of lymph node dissection.A logistic analysis was performed to identify independent risk factors of chylous leakage.Results 15 (6.5％) patients developed chylous leakage after pancreatioduodenectomy.The average hospital stay after surgery of the study group was 20.8 days,compared to 13.5 days in the control-group (P =0.004).In the study group,chylous leakage rate increased in patients with 14th and 16th group of lymph nodes dissection (80％ vs 36.7％,P =0.006).Logistic analysis showed that 14th and 16th lymph nodes dissection was an independent risk factor of chylous leakage after pancreatioduodenectomy (P ＜ 0.05,OR =6.909,95％ CI 1.593 ～ 29.958).Conclusions Chylous leakage prolonged hospitalization after pancreatioduodenectomy.Dissection of the 14th and 16th lymph node groups was an independent risk factor of chylous leakage after pancreatioduodenectomy.Careful ligation of the gastrocolic vein near the lymphatic trunk and dissection of 14th and 16th group of lymph nodes were effective interventions to reduce postoperative chylous leakage.

Objective To investigate the clinical outcomes of radical surgery for pancreatic body and tail tumors accompanied with sinistral portal hypertension (SPH).Method The clinicopathological data of 35 patients with pancreatic body and tail tumors accompanied with SPH operated from January 2004 to December 2014 were retrospectively analyzed.Results Of 35 patients,22 patients had body and tail pancreatic carcinomas,10 patients had malignant solid pesudopaillary tumors and 1 patients had a neuroendocrine tumor.All these patients developed splenomegaly and varices in the gastric fundus with normal hepatic function.The splenic vein pressure was (27.3 ±3.8)cmH2O (1 cmH2O =0.098 kPa),its average diameter was (1.3 ± 0.3) cm,and the speed of splenic vein blood flow was (8.9 ± 0.8) cm/s.Of the 35 patients with pancreatic body and tail tumors who underwent radical resectional operations,22 patients in addition underwent devascularization.There were 13 of these 22 patients who underwent pericardical devascularization and the remaining 9 underwent total or proximal gastrectomy.The main complications were pancreatic fistula (n =5,14.2％),intra-abdominal infection (n =4,11.5％),delayed gastric emptying (n =1,2.8％),lymphatic fistula (n =1,2.8％) and gastric perforation (n =1,2.8％).The post-complication morbidity rate was 34％.All these patients were followed-up for 6 to 60 months after operations.There was no upper gastrointestinal bleeding which occurred within 6 months of operation.Conclusion Multi-disciplinary treatment,complete preoperative evaluation,correct perioperative and individualized management enhanced efficacy in the surgical treatment of patients with pancreatic body and tail tumors with SPH.

Objective To investigate the effects of celastrol on the cell growth and apoptosis of human gallbladder cancer NOZ cells,and explore its potential molecular mechanism.Methods NOZ cell were cultured in vitro.And CCK-8 assay,Annexin V-FITC/PI staining method,cell cycle analysis were conducted to investigate the effects of celastrol on the growth and apoptosis of NOZ cells after being treated with drugs.The mitochondrial membrane potential and Bax and Bcl-2 protein expression level were determined by Rhodamine 123 and Western blot,respectively.Results Celastrol could inhibit NOZ cell growth,and the IC50 value was 5.3 μmol/L.Annexin-V/PI staining showed that cell apoptosis of NOZ cells were induced as the celastrol concentration increased,and the apoptosis ratio of control group was 4.4％,while the apoptosis rates of the test groups (2,5,10 p mol/L) were 7.4％,27.1％ and 43.4％,respectively.In addition,cell cycle analysis revealed that celastrol could induce G1-phase arrest.The G1-phase rate of control group was 25.6％,while the G1-phase rates of the test groups (2,5,10 μmol/L) were 36.5％,45.7％ and 92.5％,respectively.The mitochondrial membrane potential was measured after treatment with celastrol and the results indicated that the mitochondrial membrane potential was significantly decreased.Western Blot showed that the protein expression of Bax increased and Bcl-2 decreased in a time-dependent manner after treatment with celastrol.Conclusions Celastrol may inhibit cell proliferation of human gallbladder cancer NOZ cells and induce cell apoptosis partly by inducing the loss of mitochondrial membrane potential.

Objective A classification for hepatic venous outflow obstruction after piggyback liver transplantation (PBLT) and its clinical significance.Methods We conducted a retrospective study on 248 patients who underwent liver transplantation from May 2000 to August 2006.The aims were to elucidate the causes and treatment of postoperative venous outflow obstruction.Results Venous outflow obstruction occurred in 38 patients after transplantation.Among those,2 (5.26％) had superior hepatic inferior vena cava (IVC) stenosis,13 (34,21％) had the hepatic vein anastomosis twisted at an angle,7 (18.42％) had IVC stenosis at the posthepatic segment,and 16 (42.10％) had outflow obstruction at the hepatic veins.In these 38 patients,34 underwent PBLT,2 underwent APBLT,and 2 COLT.Most patients with hepatic venous outflow obstruction improved with surgical treatment and interventional therapy.Conclusions Hepatic vein outflow obstruction was associated with the technique of hepatic vein anastomosis,the type of cavocaval anastomosis and graft size mismatch between the donor and the recipient.Performing piggyback liver transplantation according to the classification of hepatic vein and appropriate treatments could improve the prognosis of venous outflow obstruction in clinical practice.

Objective To evaluate the safety of mesohepatectomy for centrally located large hepatic tumors.Methods The clinical data of 37 patients who underwent hepatectomy for centrally located large liver tumors in our hospital from October 2010 to August 2015 were retrospectively analyzed.During the operation,the left and right hemilivers were mobilized.Slings for the improved liver hanging maneuver and for selective hepatic vascular occlusion were placed.These slings were used when necessary in order to minimize occlusion and ischemia time to the residual liver,and to maximize the volume of functional liver remnant.Mesohepatectomy was carried out using a microwave hemostatic separator.The feasibility,its effects on preventing hemorrhage,the degree of liver damage and the postoperative complications were evaluated.Results The mean diameter of the neoplasms was (12.6 ± 7.2) cm.The vascular inflow occlusion time of the left and right hemilivers were (12.2 ±3.5) min and (18.5 ±7.1) min,respectively.The blood loss was (487 ± 352) ml.The amount of red blood cell transfusion was (2.7 ± 1.9) U.The operation time was (215 ± 72) min.TBIL,ALT and AST reached their peak levels on the 1 st day after operation and they were higher than before surgery (P ＜ 0.01).The levels were then significantly decreased on the 3rd day after operation.However,the TBIL (P ＜ 0.05),ALT (P ＜ 0.01) and AST (P ＜ 0.05) were higher than the preoperative level,and only returned to normal or were close to the preoperative value on the 7th day after operation (P ＞ 0.05).The initial increase in ALT was quick and then it slowed down,while the initial increase in AST was slow but it decreased quickly.Conclusions Mesohepatectomy for centrally located large hepatic tumors could safely be carried out using the liver hanging maneuver combined with selective hepatic vascular occlusion and a microwave hemostatic separator.This method has the advantages of causing less bleeding,liver damage and rapid recovery.

Objective To analyze our experience on laparoscopic and Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection and reconstruction,and to expand the indications of surgery for patients with pancreatic cancer.Methods From December 2013 to January 2016,67 patients underwent laparoscopic and Da Vinci robotic pancreaticoduodenectomy in our department.The resection was combined with major vein resection in 5 patients.We retrospectively analyzed the clinical data of these patients who had laproscopic or Da Vinci robotic pancreaticoduodenectomy with major vascular resection and reconstruction.Results The mean operation time was 378 (360 ～ 480) minutes,and the mean estimated blood loss was 360 (120 ～450) ml.4 patients underwent laparoscopic wedge-resection of PV/SMV without interruption of blood flow.After pancreaticoduodenectomy using the superior mesentery artery first approach,one patient underwent resection of a segment of portal vein and superior mesenteric vein followed by an end to end anastomosis using the Da Vinci robotic system.The total blood flow occlusion time was 35 minutes.Intraoperative frozen section biopsy and postoperative pathological results were chronic pancreatitis with pancreatic cancer in all these patients.The veins were invaded by tumor in 3 patients.In the remaining 2 patients,the vascular wall showed chronic inflammation.All the surgical resection margins were tumor negative.Postoperative complications included one patient with bile leakage,one patient with upper gastrointestinal bleeding and one patient with a grade A pancreatic fistula (PF).The patient with upper gastrointestinal bleeding was managed successfully using hemostatic treatment under gastroscopy,and the other patients all recovered well after conservative therapy.There was no death in this study.The mean postoperative hospitalization stay was 14 (9 ～35) days.Conclusions Laparoscopic or Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection is safe and feasible in selected patients with pancreatic cancer.However,surgeons need to be experienced at both open pancreaticoduodenectomy combined with vascular resection and at standard laparoscopic pancreaticoduodenectomy.

Objective To investigate the predictive value of preoperative Aspartate Transaminase and Platelet Ratio Index (APRI) for postoperative complications in patients with hepatocellular carcinoma after liver resection.Methods The clinical data of 278 patients who underwent hepatic resection for hepatocellular carcinoma from January 2010 to December 2013 were retrospectively analyzed.The receiver operating characteristic (ROC) curve was used to determine the cutoff value of APRI.Based on this preoperative APRI,patients were divided into the low-risk group (APRI ≤ 0.37) and the high-risk group (APRI ＞ 0.37).Using univariate analysis and multivariate logistic regression,21 risk factors that might be relevant to postoperative complications were analyzed.Results 159 patients (57.2％) developed postoperative complications.The AUC for APRI in predicting complications was 0.677 (0.615-0.740,P ＜ 0.05).At a cutoff value of APRI at 0.37,the sensitivity was 0.616 and the specificity was 0.697.Univariate analysis and logistic regression analysis showed that APRI (P ＜ 0.05,OR =2.138),degree of ASA (P ＜ 0.05,OR =1.864),prognostic nutritional index (PNI) (P ＜ 0.05,OR =0.354) and volume of blood loss during operation (P ＜ 0.05,OR =2.836) were independent risk factors of postoperative complications.Conclusions A high APRI (＞ 0.37) was a simple and practicable preoperative index to predict postoperative complications in patients with hepatocellular carcinoma after hepatectomy.

Objective To investigate the correlation between immediate postoperative platelet count with liver failure after partial hepatectomy in patients with hepatocellular carcinoma.Methods The clinical data of 71 patients with hepatocellular carcinoma who underwent liver resection at the Hepatopancreatobiliary Surgery Department of Nanjing Drum Tower Hospital from July 2013 to August 2015 were retrospectively analyzed.The clinical diagnosis was confirmed by pathology of the resected specimens.Based on postoperative platelet count within 2 h,the patients were divided into the low platelet count (PLT ＜ 100 × 109/L) group (n =24,33.8％) and the normal platelet count (PLT ≥ 100 × 109/L) group (n =47,66.2％).The correlations between immediate postoperative platelet count with serum indexes including serum alanine aminotransferase (ALT),aspartate aminotransferase (AST),total bilirubin (TBil) and direct bilirubin (DBil) were analyzed,and the incidences of posthepatectomy liver failure was also evaluated in these two groups.Results There was no re-operation and perioperative death in this study.Among the 71 patients,25 patients (35.2％) developed postoperative complications (grade Ⅰ to Ⅲ),and 8 patients (11.3％) suffered from postoperative liver failure (grade A).When compared with the normal platelet count group,the low platelet count group had significantly increased risks of postoperative liver failure (29.2％ vs 2.1％,X2 =11.618,P ＜ 0.05),increased postoperative peaks of ALT,AST,TBil and DBil levels [(462.5 ±135.7)U/L vs (307.9 ± 192.6) U/L,(440.0 ± 163.3) U/L vs (265.8 ± 155.8) U/L,(29.5 ±9.1) μmol/L vs (17.9 ±8.8) μ mol/L,t =3.507,4.385,5.129,P ＜0.05,respectively] and longer normalization time of liver function.Multiple Logistic regression analyses revealed that an immediate postoperative low platelet count was an independent risk factor of posthepatectomy liver failure.Conclusions The platelet count was associated with the incidence of postoperative liver failure after partial liver resection in patients with hepatocellular carcinoma.Patients with an immediate postoperative low platelet count suffered from a high incidence of posthepatectomy liver failure and delayed liver function recovery.