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.

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.

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.

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.

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.

ObjectiveTo evaluate the expression of heat shock genes and acute phase genes and to examine the hepatic ultrastracture under the stress of intermittent Pringle manoeuvre. MethodsRT-PCR was used to detect the expression of HSP70A, HSC70, TNF-? and IL-6,and electronic microscopy examination was taken to document the ultrastructural change in patients with hepatocellular carcinoma, with or without, Pringle manoeuvre, during the operations. ResultsHeat shock gene family-HSP70A and HSC70, which is related to intracellular repair and cell protection, was on higer expression after liver transection in Pringle manoenvre group than that of control group. Normal ultrastructure were also found in liver parenchymal cells and nonparenchymal cells in Pringle manoeuvre group after liver resection. ConclusionIntermittent Pringle manoeuvre induced relatively higher expression of heat shock genes, which are related to intracellular homestasis, and was consistent with the well maintenance of liver ultrastructure.

ObjectiveTo verify the effect of comprehensive therapy for primary liver cancer (PLC). MethodsThe clinical data of 420 cases admitted to our hospital from Jan. 1994 to Jun. 2000 was analyzed retrospectively. Patients received hepatectomy and transarterial chemoembolization (TACE), drug delivery system (DDS) on case-to-case basis.Results Three hundred and twenty-seven patients were followed-up from 3 days to 81 months. The overall 1-, 3-, 5-year survival rates were 40.9%、19.1%、12.4%, respectively. 75.9%,47.3%,40.1% for patients undergoing radical resection and 39.6%,22.1%,17.5% in patients with palliative resection. TACE or DDS implantation after palliative resection was effective to enhance the survival rate. Conclusion The rational and scientific combination of multiple modality is important to prolong survival time of the patients with PLC.

Hepatolithiasis is still a common biliary disease in China with unknown pathogenesis and poor long-term outcomes.Surgery is probably the only curative treatment to hepatolithiasis.However,surgeons and patients cannot keep trouble from high recurrence and reoperation rates after surgery.Hepatolithiasis is a serious disease,which can cause cholangitis,liver abscess,liver cirrhosis,and even cholangiocarcinoma.Sphincter of Oddi,which controls the unidirectional outflow of bile and separates the bile duct from the bacteria-filled intestinal tract,is thought to be a gatekeeper of the almost-sterile biliary tract.Dysfunction of sphincter of Oddi,including stenosis,spasm and laxity,is closely associated with biliary disease,A lax sphincter of Oddi will aggravate bilioenteric reflux,leading to biliary infection and calculi development eventually.This issue has gradually gained enough attention.How to evaluate sphincter of Oddi function reliably and restore or replace its function,which is key to treat hepatolithiasis and prevent its recurrence,remain unclear.