Biliary diseases are common and with many challenges in clinical practice.Even though some big progress appeared in recent years,there are still many hot topics and noanswer questions.Herein,this article summarized some novel achievements and put opening questions on biliary surgical diseases including biliary tract cancer (intrahepatic cholangiocarcinoma,gallbladder carcinoma and hilar cholangiocarcinoma) and cholelithiasis in order to discuss these issues with national colleagues.

Objective To introduce the mechanisms of graft injuries after small-for-size liver transplantation and protective measures.Methods Recently relevant literatures were reviewed and summarized.Results Portal hypertension after small-for-size liver transplantation induces mechanical injuries as well as hepatic sinusoidal microcirculation disturbance and cytokines release,which worsened the injuries.Decrease portal pressure by surgery or drug could improve grafts function.Conclusion Comprehending the mechanisms of graft injuries will contribute a lot for the living donor liver transplantation.

Objective To assess the role of combined use of laparoscopy with diagnostic peritoneal lavage (DPL) in the diagnosis of abdominal stab injury (ASI). Methods From March 2005 to June 2010,21 cases of abdominal and thoracoabdominal stab injuries were analyzed retrospectively.All the cases were diagnosed laparoscopically first.If no significant injury was detected,1 000 ml of normal saline was infused through the abdominal trocar into the peritoneal cavity and routine/regular study on RBCs,WBC,amylase and bile of the effluent fluid was made. ResultsLaparoscopic diagnosis was positive in five cases,including two cases of diaphragmatic injuries,one traumatic bleeding of liver capsule,one small intestinal perforation and one stomach wall perforation.Laparoscopic diagnosis was negative in 16 cases,of which two were detected as intestinal perforation and repaired by laparotomy.The operation time was (120 ± 35.6) min and the hospital stay was (5.3 ± 3.4) d.There were no major complications after operation. Conclusion Combining the visual advantage of laparoscopy with the sensitivity and specificity of DPL can effectively improve the diagnosis of ASI.

The prognosis of hepatocellular carcinoma (HCC)is poor,and tumor thrombus in the portal vein or in the bile duct is an important influencing factor.Approximately 30%of HCC patients are found to have portal vein tumor thrombus (PVTT)when diagnosed,and their median survival time is about 2.7-4.0 months if they do not receive any treatment.The incidence of HCC complicated with bile duct tumor thrombus (BDTT)is less than 10%,while the prognosis is dismal.Once tumor thrombus extends to the major bile ducts,obstructive jaundice and subsequent hepatic dysfunction are inevitable.The survival time of patients with HCC complicated with BDTT is less than 4 months if they only receive palliative biliary stenting.The management of HCC complicated with PVTT or BDTT is challenging with controversy at present.Different treatment approaches and their benefits for patients with HCC complicated with PVTT or BDTT are introduced in this paper.

As the change of concept of health,the aim of medicine is not only to prolong life and improve the function of organs,but also to help patients to integrate to social life.Previous studies always pay much attention to clinical outcomes ineluding mortality,morbidity,long-term or short-term survival,but patients with liver cancer usually have long disease history and with background diseases such as liver cirrhosis.Traditional liver transplantation and liver resection ale both effective modalities for liver cancer,but liver resection has disadvantages of hish recurrence rate and repeated hepatic artery interventional therapy,and liver transplantation is high-cost.So the health economics and life quality of patients should not be ignored when comparing liver transplantation and liver resection.

The management of hilar cholangiocarcinoma was challenging to the surgeons due to difficult operations and low resection rate.Recently,a new mode of multidisciplinary team (MDT) is applied to the diagnosis and treatment of hilar cholangiocarcinoma,which leads to significant changes and development of the diagnosis and treatment for hilar cholangiocarcinoma.In this article,the authors first introduced the recent application of MDT treatment for hilar cholangiocarcinoma on diagnostic methods,staging systems,evaluation for resectability,radical resection,application of liver transplantation and other systematic therapies.Considering the complexity of hilar cholangiocarcinoma,a surgery-centered MDT for hilar cholangiocarcinoma is important and should be promoted.

Translational medicine is a new concept in China.It sets up a bridge between basic research and clinical work,and aims to transfer the basic study results to clinical practice as soon as possible.It is necessary for a surgeon to master the research idea of translational medicine in order to be expert in science and technique.Many unsolved clinical problems could be found in routine work,which is an advantage for translational medicine research.How to raise questions in routine clinical work and get these questions resolved in laboratory,and then apply the results to clinical work is a demand for surgeons nowadays.In this article,the research idea of translational medicine is introduced based on an example of the research on the relationship between rapamycin and hepatocellular carcinoma.

Objective To study the protective effects of hydrocortisone on glycocalyx in the vascular endothelium after trauma-hemorrhagic shock (T/HS) because the role of glycocalyx in maintaining the permeability of vascular endothelium intact,and in turn to identify the hydrocortisone protecting intestinal microcirculation.Methods Studies were carried out,in vivo,on a model of rats with induced T/HS.Intestinal perfusion and changes in endothelial glycocalyx and the associated molecular mechanism were assessed by using laser-Doppler velocimetry and electron microscopy,and the measurements of heparan sulfate,syndacan-1,and TNF-α in the superior mesenteric vein (SMV) with ELISA and Western-blot,and the expression of NF-κB in the vascular endothelium.Protective effects of hydrocortisone on the intestinal microcirculation after T/HS were evaluated.Results Degradation of the glycocalyx in intestinal vascular endothelium occurred 1-3 hours after T/HS in rats (P ＜0.05).By 3 hours later,significant reduction in intestinal perfusion was observed (P ＜ 0.05).The level of TNF-α in the SMV and the expression of NF-κB in the vascular endothelium increased.With the use of hydrocortisone,intestinal perfusion was improved,and the degradation of glycocalyx was attenuated.Conclusions The degradation of glycocalyx is associated with the malfunction of intestinal microcirculation after T/HS.The NF-κB/TNF-α system in vascular endothelium participates in this process of glycocalyx degradation.Hydrocortisone may be a good agent to interrupt the course of glycocalx degradation.

Objective To evaluate liver transplantation for patients with hepatocellular carcinoma (HCC).Methods From Feb,1999 to Mar,2002 a total of 95 cases underwent liver transplantation(LTX) in our centre, among them there were 23 cases of HCC.SPSS 10 0 software was used to evaluate the risk factors on the tumor recurrence after LTX.Results The tumor recurrence rate was 65% during the period of follow up. The patients' tumor free survival rate at 6 and 12 months was 75 0% and 58 3%, respectively. Multi variants analysis revealed that there was a statistical relationship between pretransplant tumor size and tumor recurrence( P =0 024).Statistical relations between preoperative demograplaic, clinical features and post LTX recurrence were not found.Conclusion Large hepatocellular carcinoma is a relative contraindication for LTX.

ObjectiveTo sum up the clinical experience in recent 10 years in our organ transplantation center. Methods We retrospectively reviewed clinical data of 120 patients receiving liver transplantation from April 1993 to October 2002. The patients′ clinical characteristics, surgical techniques, complications and survival rates were compared between the periods of 1993～1997 (phase Ⅰ), 1999 (phase Ⅱ), and 2000～2002 (phase Ⅲ). ResultsMalignant liver diseases were major indications for liver transplantation in phase Ⅰ (100%) and Ⅱ (53%), and phase Ⅲ (34%), respectively. The survival rate of recipients with benign liver diseases in phase Ⅲ significantly improved with the 3-month, 6-month and 1-year survival rates of 86%, 85% and 83.1%, respectively. For patients with malignant liver diseases, the 3-month, 6-month and 1-year survival rates were 87%, 81% and 46%, respectively. The recurrence of hepatitis B was 24% in 12 months after transplantation. The incidence of postransplantation vascular complications decreased significantly (from 29% in phase Ⅰ and Ⅱ to 4.9% in phase Ⅲ).Biliary complications remained one of the major problems for long-term survival. No veno-venous bypass was applied in phase Ⅲ. ConclusionStrict selection of candidate recipients, technical refinement, appropriate management of vascular and biliary complications, and prevention of recurrence of hepatitis B and malignant liver diseases are important for long-term survival.