Objective:To explore the mechanism of biliary fibrosis after end to end anastomosis of bile duct.Methods:12 Neijiang miniature pigs (6-8 months old, weight 30-40 kg) were divided into experimental group ( n=6) and control group ( n=6). The model of end to end anastomosis after transection of the common bile duct was established in experimental group. Control group was a sham operation group, and only T tube was placed. After 9 months, Masson staining, fluorescence quantitative PCR and immunohistochemistry were used to analyze the expressing changes of pro-fibrotic factor transforming growth factor-β1 (TGF-β1), connective tissue growth factor (CTGF) and epithelial-mesenchymal transition (EMT) markers, including cytokeratin-19 (CK19), E-cadherin (E-Cad) and fibroblast specific protein-1 (S100A4), α-smooth muscle actin (α-SMA) and collagen components Collagen I (COL-1), collagen III (COL-3) and fibronectin (FN) in the anastomotic bile duct tissues. Results:Masson staining showed that the submucosal collagen fibers increased significantly in the experimental group. Compared with the control group, the mRNA expression of TGF-β1 [(3.482±0.313) vs. (1.000±0.102), t=18.43, P<0.001], CTGF [(2.160±0.287) vs. (1.000±0.103), t=9.32, P<0.001] were increased, the difference was statistically significant. Compared with control group, the mRNA and protein expression of CK19 and E-Cad were decreased in the experimental group, while the mRNA and protein expression of S100A4 and α-SMA were increased in the experimental group (all P<0.01). Conclusion:It was feasible in the short term to perform an end-to-end anastomosis after transection of the common bile duct, but there was an obvious fibrosis in the anastomotic bile duct tissue at later time.

Objective:To explore the necessity of transitional ICU care for patients with liver cancer after major hepatectomy.Methods:The clinical data of 548 liver cancer patients with major hepatectomy were retrospectively analyzed. According to whether by way of transitional ICU care was used or not, patients were divided into ICU group(92 cases) and none-ICU group(456 cases). The clinical data, postoperative complications and mortality were compared.Results:There were no difference in the incidence of major complications(ascites, liver failure, bile leakage, infection and bleeding), mortality and length of hospital stay between the two groups( P>0.05). But the total hospitalization costs of patients in the ICU group were significantly higher than those in the non-ICU group [(72 019±24 516) yuan vs. (67 002±21 374) yuan, t=2.004, P=0.046]. Multivariate analysis showed that intraoperative blood loss and transfusion were independent risk factors for patients undergoing transitional ICU care. Conclusion:Transitional ICU care does not reduce the incidence of postoperative complications and mortality for major hepatectomy patients, only increase the hospitalization costs.

Objective:To evaluate liver quadrate lobectomy combined with large-bore cholangio-jejunostomy for the treatment of benign biliary-enteric anastomotic stricture.Methods:The clinical data of 32 patients undergoing liver quadrate lobectomy combined with large-caliber cholangio-jejunostomy were retrospectively analyzed. The bile drainage effect and postoperative complications were analyzed. And the clinical effects of different size of biliary-enteric anastomosis were compared.Results:The most common short-term complications were cholangitis (9.4%) and bile leakage (9.4%), and the most common long-term complications were reflux cholangitis (15.6%). No anastomotic restenosis, stone formation or canceration were found. During the follow-up period, the total bilirubin ( t=19.455, P=0.000), direct bilirubin ( t=18.479, P=0.000), alkaline phosphatase ( t=3.229, P=0.002) and γ-glutamyltranspeptidase ( t=3.057, P=0.003) level were significantly improved. The effect of bile drainage in patients with 2-3 cm diameter of biliary-enteric anastomosis was similar to that in patients with >3 cm diameter ( t=0.284, P=0.778). The incidences of cholangitis (χ 2=0.121, P=0.728), bile leakage (χ 2=0.121, P=0.728) and reflux cholangitis (χ 2=0.205, P=0.652) were no statistical difference in both groups. Conclusion:Liver quadrate lobectomy combined with large-caliber cholangio-jejunostomy is effective in the treatment of benign biliary-enteric anastomotic stricture. More than 2cm in diameter of the biliary-enteric anastomosis is enough.

Objective:To investigate the efficacy of two different percutaneous transhepatic biliary drainage (PTBD) procedures for malignant obstructive jaundice.Methods:The clinical data of 132 patients with malignant obstructive jaundice who underwent PTBD were retrospectively analyzed. According to whether the tip of the catheter was placed in the intestine, 132 patients were divided into the external drainage group and the internal-external drainage group. The effect on decrease in jaundice (total bilirubin, direct bilirubin levels), postoperative complications, and hospitalization costs of the two drainage methods were compared.Results:Of the 132 patients who were included in this study, there were 91 males and 41 females, aged 18 to 85 years. The external drainage group included 81 patients, and the internal and external drainage group included 51 patients. The total bilirubin [(190.2±41.8)μmol/L vs. (294.9±38.3) μmol/L] and direct bilirubin [(155.4±30.9)μmol/L vs. (242.1±39.6) μmol/L] levels in the external drainage group and the total bilirubin [(179.3±37.1)μmol/L vs. (288.1±35.4)μmol/L] and direct bilirubin [(147.7±32.5)μmol/L vs. (233.7±36.1)μmol/L] levels in the internal-external drainage group were significantly decreased after surgery (all P<0.05). The incidences of reoperation, re-intubation or bilateral catheterization [15.6%(8/51) vs. 3.7%(3/81)] and biliary tract infection [50.9%(26/51) vs. 27.1%(22/81)] in the internal-external drainage group was significantly higher than that in the external drainage group (all P<0.05). The mortality rate due to biliary tract infection in the internal-external drainage group was significantly higher than that of the external drainage group [7.8%(4/51) vs. 0, P<0.05]. Intestinal-derived bacteria such as Escherichia coli, Enterococcus faecium, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the main bacteria in the biliary tract infections of the two groups. The hospitalization cost of patients in the internal-external drainage group was significantly higher than that in the external drainage group [(34 928.0±3 693.0) yuan vs. (29 360.0±3 219.0) yuan, P<0.05]. Conclusion:Both PTBD external drainage and internal and external drainage could alleviate the symptoms of jaundice quickly and effectively.

Objective:To investigate the effect of local antibiotics irrigation on chronic proliferative cholangitis (CPC).Methods:CPC model of rabbits was established. Rabbits were divided into CPC group (without local antibiotics irrigation, n=20) and experimental group (with local antibiotics irrigation, n=20). Only the gallbladder was removed, and 20 rabbits with free bile duct (sham operation) were used as normal control. The inflammatory conditions, proliferation of cholangiocytes, biliary fibrosis and biliary stones formation ability were analyzed. Results:Compared with CPC group, the relative expression of inflammation index lipopolysaccharide and interleukin-6 [(1.21±0.13) vs. (3.24±0.21), (1.52±0.22) vs. (3.10±0.23)], biliary cell proliferation index cyclooxygenase-2 and vascular endothelial growth factor [(2.15±0.12) vs. (4.07±0.22), (2.44±0.14) vs. (3.22±0.21)], fibrosis index transforming growth factor-β and Collagen-I [(2.44±0.28) vs. (4.36±0.44), (1.54±0.13) vs. (2.22±0.18)] and biliary stones formation index β-glucuronidase and Mucin 5AC [(1.74±0.20) vs. (3.42±0.31), (1.47±0.15) vs. (2.81±0.22)] were significantly decreased in experimental group (all P<0.05). Conclusion:Local antibiotics irrigation could inhibit CPC by inhibiting the chronic inflammation of the biliary tract and excessive proliferation of cholangiocytes and biliary fibrosis, and reducing the probability of biliary stone formation.

Objective:To study the impact of additional resection of an intraoperative proximal bile duct positive margin on the survival rate of patients with hilar cholangiocarcinoma (HCCA).Methods:The clinical data of 214 patients with HCCA treated at the First Affiliated Hospital of Zhengzhou University from January 2000 to January 2017 were analyzed. There were 126 males and 88 females, aged (62.3±17.1) years. These patients were divided into three groups according to the pathological status of bile duct margins and whether the proximal bile duct was further resected. Group A consisted of patients with negative margins without additional resection (161 cases). Group B consisted of patients with negative margins after additional resection (21 cases). Group C consisted of patients with R 1 resections (32 cases). The Kaplan-Meier method was used for survival analysis and log-rank test was used for inter-group comparison. Univariate and multivariate Cox regression analysis were used to analyze prognostic factors. Results:The 3-year and 5-year survival rates of patients in groups A, B, and C were 37.1%, 28.6%, 0 and 18.5%, 10.7%, 0, respectively. The cumulative survival rates of patients in group A and group B were significantly higher than that in group C (all P<0.05). Multivariate Cox regression analysis showed that R 1 proximal bile duct margin ( HR=3.728, 95% CI: 2.531-4.936), margin width >5 mm ( HR=0.534, 95% CI: 0.224-0.857), and T 3-4 staging ( HR=5.655, 95% CI: 3.174-8.203) were independent influencing factors for overall survival of patients with HCCA after attempted radical surgery. Conclusion:The survival rate of patients with HCCA with a positive proximal bile duct margin was significantly improved by further resecting the bile duct to obtain a negative margin. The R 1 proximal bile duct margin was an independent risk factor for prognosis in patients with HCCA after attempted radical resection.

Objective:To investigate the effects of ulinastatin on liver function in patients with liver cancer after major hepatectomy.Methods:The clinical data of 232 patients with major liver resection due to liver cancer were retrospectively analyzed. According to whether ulinastatin was applied after operation, patients were divided into treatment group (105 cases) and control group (127 cases). The postoperative inflammatory factors, liver function, postoperative complications and hospital stay were compared.Results:The levels of CRP、IL-6 and TBIL、ALT、AST were significantly lower than the control group 3 days after surgery (CRP: t=4.520, P=0.000; IL-6: t=17.982, P=0.000; TBIL: t=9.843, P=0.000; ALT: t=11.913, P=0.000; AST: t=4.520, P=0.000). The incidence of massive ascites in the treatment group (χ 2=4.212, P=0.040) and the average postoperative hospital stay ( t=9.994, P=0.000) were significantly lower than that in the control group. Conclusion:Early application of ulinastatin effectively inhibits the inflammatory process, protects liver function, reduces the incidence of massive ascites, and shortens the postoperative hospital stay.

Objective:To investigate the effect of expanded lymphadenectomy on the survival rate of the patients with hilar cholangiocarcinoma(HC).Methods:The clinical data of 129 patients undergoing radical resection of HC were retrospectively analyzed. According to the range of lymphadenectomy, they were divided into regional group(91 cases) and expanded group(38 cases). The clinical data, survival rate and postoperative complications in two groups were compared and analyzed.Results:The 3-year and 5-year survival rates of metastasis free(M0) patients in the regional group and expanded group were 44.1%, 24.8% and 47.0%, 33.6%, respectively; there were no statistically significant difference in survival rates between the two groups(χ 2=0.662, P=0.416). Compared with patients in the regional group, the average number of harvested lymph nodes in the expanded group was significantly increased and the difference was statistically significant( t=14.678, P=0.000), while the incidence of severe complications and mortality does not increase significantly. Conclusion:Expanded lymphadenectomy did not improve the survival rate of M0 HC patients, which while yielding more lymph nodes does not increase the incidence of postoperative complications and mortality in resectable HC patients.

Objective This study aimed to evaluate the impact of Intensive Care Unit (ICU)admission on patients with malignant liver tumors after elective major hepatectomy,and to analyze the relevant factors relating to ICU admission.Method 1 044 liver cancer patients who underwent elective hepatectomy were included into this study.Using the length of extubation time (＞ 5 h) and/or treatment time (＞ 24 h) in ICU,the patients were divided into the ICU group and the general group.The age,gender,underlying disease and operative time,intraoperative blood loss,blood transfusion,as well as postoperative complications,mortality,hospital stay and hospitalization costs were compared between the two groups.The relative factors of the ICU group were evaluated using univariate and multivariate analysis.Results Compared to the general group,the mean age (57.4 ± 3.7 vs.53.2 ± 3.2),and the proportions of patients with associated lung diseases (33.7％ vs.10.0％),chronic kidney diseases (9.6％ vs 2.0％),anemia (50.6％ vs.5.3％),as well as the amounts of intraoperative blood loss (816 ml vs.635 ml) and blood transfusion (4.3 U vs.1.4 U) in the ICU group were significantly higher.The differences were significant (P ＜0.05).Furthermore,the ICU group of patients had a significantly longer hospital stay (21.6 days vs.10.1 days,P ＜ 0.05) and more hospital costs (76 751 yuan vs.42 069 yuan,P ＜ 0.05).Multivariate analysis showed that age,blood loss and transfusion were associated with ICU admission.Conclusions It is not necessary to admit every patient with malignant liver tumors to ICU after elective major hepatectomy.ICU admission resulted in prolonged hospital stay and elevated hospital costs.Age (OR =1.077,95％ CI:1.030 ～ 1.127),amount of blood loss (OR =3.211,95％ CI:1.038 ～ 9.929) and blood transfusion (OR =1.330,95％ CI:1.113 ～ 1.589) were associated with ICU admission.There are still many potentially influencing factors which need further studies to determine.

Objective To explore the clinical significance of intraoperative frozen sections for the diagnosis of unexpected gallbladder neoplasm during cholecystectomy for acute cholecystitis.Methods We retrospectively analyzed the clinical data of acute cholecystitis patients who underwent cholecystectomy at the First Affiliated Hospital of Zhengzhou University,from Dec 2012 to Dec 2017.Results In the 1 386 acute cholecystitis patients,19 patients were found to have concurrent gallbladder neoplasm.Surgeons accurately recognized 9 gallbladder neoplasms by general observation alone,including 2 T2 and 2 T3 gallbladder neoplasms,but missed 10 gallbladder neoplasms.At the same time,we found that 3 Tis and 1 T1a gallbladder neoplasms were missed by frozen sections from 10 gallbladder neoplasms diagnosed by definitive histopathological examination.The sensitivity of frozen sections diagnosis was 60％ and the specificity was 100％.Conclusions During cholecystectomy for acute cholecystitis,the accuracy of surgeons' diagnosis with general observation in unexpected gallbladder neoplasm is poor.The accuracy of frozen sections to diagnose advanced gallbladder neoplasm is high,so we advocate frozen sections of every cholecystectomy sample in acute cholecystitis patients.