Cai Xj

Binding pancreaticojejunostomy is a new technique to minimize leakage.

Pancreaticoduodenectomy (Whipple procedure) has been the standard treatment for periampullary and pancreatic carcinoma. A leak or fistula from the pancreatic anastomosis is the leading cause of morbidity and mortality after pancreaticoduodenectomy. In order to effectively prevent the development of pancreatic fistulae, we designed a special technique called binding pancreaticojejunostomy, by which 3 cm of the serosa-muscular sheath of the jejunum was bound to the pancreatic remnant. We have performed this procedure in 105 consecutive patients; none of the cases developed pancreatic fistula. It is a safe, simple, and efficient technique.

Laparoscopic hepatectomy by curettage and aspiration : Experiences of 62 cases

BackgroundThis article introduces a new technique for hepatectomy. Its purpose is to describe the details of laparoscopic hepatectomy by curettage and aspiration (LHCA) and develop a new instrument for this technique.MethodsWe have performed laparoscopic hepatectomy by curettage and aspiration (LHCA) in 62 patients in our institute between 1998 and 2005: 34 men and 28 women, mean age 47.8 years (range: 26–71 years). Their diagnoses included 18 primary hepatic carcinoma, 2 metastatic carcinoma, 19 intrahepatic duct calculus, and 23 benign entities.ResultsThe LHCA operation was completed in 60 patients. In two, the procedure had to be converted to open operation. The mean operative time was 146 min and the mean operative blood loss was 458 ml. Complications occurred in two patients, one with bile leakage and the other with pneumothorax. All the patients were ambulatory within 24 hours of operation. The average length of hospital stay was 1 week.ConclusionsOur experience leads us to believe that laparoscopic hepatectomy by curettage and aspiration (LHCA) is a safe and effective technique for resection of liver lesions.

Binding pancreaticojejunostomy – a safe and reliable anastomosis procedure

BACKGROUNDnOver the past one hundred years, the development of pancreaticoduodenectomy (PD) has always involved the struggle against pancreatic leakage. Until now, leakage of the pancreatic anastomosis has remained a common and serious complication after PD. Various methods of dealing with the pancreatic stump for prevention of pancreatic anastomotic leakage have been described. No matter which method is used, however, pancreatic anastomotic leakage is still most likely to occur when anastomosis involves a normal and soft pancreas.nnnMETHODSnTo perform a safe and reliable pancreaticoenteric anastomosis, we investigated the risk factors and potential mechanisms of occurrence of pancreatic leakage, including leakage from the needle hole and from the seam between two anastomosed structures, blood supply to the anastomosis and tension at the anastomosis. Based on these findings, we established a new pancreaticoenteric anastomosis procedure - binding pancreaticojejunostomy. The unique aspects of this procedure are as follows. The sero-muscular sheath of jejunum is bound to the invaginated pancreatic stump, so as to seal the gap between them; mucosa of the segment of jejunum that would eventually be in contact with the pancreatic stump is destroyed either chemically or by electric coagulation to promote healing. There is no needle hole on the jejunal surface of the anastomotic site.nnnRESULTSnFrom 1996 to 2003, a total of 227 consecutive patients were treated with this type of pancreaticojejunostomy in this institution. None of the patients developed a pancreatic anastomotic leak.nnnDISCUSSIONnBinding pancreaticojejunostomy is a safe and reliable anastomotic procedure to effectively minimize leakage even when the texture of the pancreas is soft and normal.

Suppression of autophagy by chloroquine sensitizes 5-fluorouracil-mediated cell death in gallbladder carcinoma cells

Autophagy1 is a complex of adaptive cellular response that enhances cancer cell survival in the face of cellular stresses such as chemothery. Here we show that in human gallbladder carcinoma (GBC) cells lines, SGC-996 and GBC-SD, autophagy is induced by the DNA damaging agent 5-fluorouracil (5-FU). While in combination with the pre-treatment of chloroquine (CQ), a inhibitor of autophagy, the inhibition of 5-FU to the proliferation and viability of GBC cells was potentiated. Furthermore, 5-FU treatment resulted in a general increase of the apoptotic rate and G0/G1 arrest of GBC cells, and the effect was potentiated by CQ pre-treatment. Since 5-FU induced autophagy in GBC cells, and CQ inhibited autophagy, our findings suggest a possible mechanism that CQ inhibited 5-FU-induced autophagy, which modified the cytotoxicity of 5-FU. The combination therapy of CQ and 5-FU should be considered as an effective strategy for the treatment of gallbladder carcinoma.

Experimental study of colonic anastomosis with a degradable stent in a porcine model

BACKGROUNDnIntestinal anastomosis is a major technical component of gastrointestinal procedures. We have developed a new procedure of colonic anastomosis with a degradable stent. This article evaluates this procedure.nnnMETHODSnForty pigs were assigned randomly to a stent group (n = 20) and a control group (n = 20). A colonic anastomosis with a degradable stent was performed in the stent group, and hand-sewn anastomosis was performed in the control group. Pigs of each group were divided evenly into 4 subgroups according to time of death (days 3, 7, and 14, and month 10 postoperatively) to evaluate the healing of anastomosis.nnnRESULTSnAll procedures were completed successfully. The surgical time of the stent group was significantly less than the control group. No complications occurred in either group. Bursting pressure of the stent group was significantly higher than the control group on postoperative days 3 and 7. No significant difference of hydroxyproline content or microvessel density was found between the 2 groups.nnnCONCLUSIONSnThe procedure of colonic anastomosis with a degradable stent is a simple, feasible, and safe procedure in this porcine model.

Gastrointestinal stromal tumors of the duodenum: Surgical management and survival results

AIMnTo provide long-term survival results of operable duodenal gastrointestinal stromal tumors (DGISTs) in a tertiary center in China.nnnMETHODSnIn this retrospective study, the pathological data of 28 patients with DGISTs who had been treated surgically at the Second Department of General Surgery, Sir Run Run Shaw Hospital (SRRSH) from June 1998 to December 2006 were reviewed. All pathological slides were examined by a single pathologist to confirm the diagnosis. In patients whose diagnosis was not confirmed by immunohistochemistry at the time of resection, representative paraffin blocks were reassembled, and sections were studied using antibodies against CD117 (c-kit), CD34, smooth muscle actin (SMA), vimentin, S-100, actin (HHF35), and desmin. Operative procedures were classified as wedge resection (WR, local resection with pure closure, without duodenal transection or anastomosis), segmental resection [SR, duodenal transection with Roux-Y or Billroth II gastrojejunostomy (G-J), end-to-end duodenoduodenostomy (D-D), end-to-end or end-to-side duodenojejunostomy (D-J)], and pancreaticoduodenectomy (PD, Whipple operation with pancreatojejunostomy). R0 resection was pursued in all cases, and at least R1 resection was achieved. Regional lymphadenectomy was not performed. Clinical manifestations, surgery, medical treatment and follow-up data were retrospectively analyzed. Related studies in the literature were reviewed.nnnRESULTSnThere were 12 males and 16 females patients, with a median age of 53 years (20-76 years). Their major complaints were gastrointestinal bleeding (57.2%) and nonspecific discomfort (32.1%). About 14.3%, 60.7%, 17.9%, and 7.1% of the tumors originated in the first to fourth portion, respectively, with a median size of 5.8 cm (1.6-20 cm). Treatment was by WR in 5 cases (17.9%), SR in 13 cases (46.4%), and by PD in 10 cases (35.7%). The morbidity and mortality rates were 35.7% and 3.6%, respectively. The median post-operative stay was 14.5 d (5-47 d). During a follow-up of 61 (23-164) mo, the 2-year and 5-year relapse-free survival was 83.3% and 50%, respectively. Eighty-four related articles were reviewed.nnnCONCLUSIONnSurgeons can choose to perform limited resection or PD for operable DGISTs if clear surgical margins are achieved. Comprehensive treatment is necessary.

Meta-analysis of immunohistochemical expression of hypoxia inducible factor-1α as a prognostic role in gastric cancer.

AIMnTo conduct a meta-analysis to evaluate the prognostic role of hypoxia inducible factor-1α (HIF-1α) expression in gastric cancer.nnnMETHODSnThe PubMed, EMBASE, and Web of Science databases were searched systematically for all articles published in English before August, 2013. Pooled effect was calculated from the available data to evaluate the association between HIF-1α expression and 5-year overall survival and tumor clinicopathological features in gastric cancer patients. Pooled odds ratios (ORs) with 95%CIs were calculated using either a fixed-effects or a random-effects model.nnnRESULTSnNine studies matched the selection criteria, which reported on 1103 subjects, 548 of whom had HIF-1α positive expression (50%). This meta-analysis indicated that HIF-1α positive expression in gastric cancer correlated with lower 5-year overall survival (OR = 0.36; 95%CI: 0.21-0.64), worse tumor differentiation (OR = 0.38; 95%CI: 0.23-0.64), deeper invasion (OR = 0.42; 95%CI: 0.32-0.57), higher rates of lymph node metastasis (OR = 2.23; 95%CI: 1.46-3.40), lymphatic invasion (OR = 2.50; 95%CI: 1.46-4.28), and vascular invasion (OR = 1.80; 95%CI: 1.29-2.51), and higher TNM stage (III + IV) (OR = 0.31; 95%CI: 0.15-0.60).nnnCONCLUSIONnHIF-1α positive expression indicates a poor prognosis for patients with gastric cancer. Further studies are required to confirm these results.

Repair of bile duct defect with degradable stent and autologous tissue in a porcine model

AIMnTo introduce and evaluate a new method to repair bile duct defect with a degradable stent and autologous tissues.nnnMETHODSnEight Ba-Ma mini-pigs were used in this study. Experimental models with common bile duct (CBD) defect (0.5-1.0 cm segment of CBD resected) were established and then CBD was reconstructed by duct to duct anastomosis with a novel degradable stent made of poly [sebacic acid-co-(1,3-propanediol)-co-(1,2-propanediol)]. In addition, a vascularized greater omentum was placed around the stent and both ends of CBD. Cholangiography via gall bladder was performed for each pig at postoperative months 1 and 3 to rule out stent translocation and bile duct stricture. Complete blood count was examined pre- and post-operatively to estimate the inflammatory reaction. Liver enzymes and serum bilirubin were examined pre- and post-operatively to evaluate the liver function. Five pigs were sacrificed at month 3 to evaluate the healing of anastomosis. The other three pigs were raised for one year for long-term observation.nnnRESULTSnAll the animals underwent surgery successfully. There was no intraoperative mortality and no bile leakage during the observation period. The white blood cell counts were only slightly increased on day 14 and month 3 postoperatively compared with that before operation, the difference was not statistically significant (P = 0.652). The plasma level of alanine aminotransferase on day 14 and month 3 postoperatively was also not significantly elevated compared with that before operation (P = 0.810). Nevertheless, the plasma level of γ-glutamyl transferase was increased after operation in both groups (P = 0.004), especially 2 wk after operation. The level of serum total bilirubin after operation was not significantly elevated compared with that before operation (P = 0.227), so did the serum direct bilirubin (P = 0.759). By cholangiography via gall bladder, we found that the stent maintained its integrity of shape and was still in situ at month 1, and it disappeared completely at month 3. No severe CBD dilation and stricture were observed at both months 1 and 3. No pig died during the 3-mo postoperative observation period. No sign of necrosis, bile duct stricture, bile leakage or abdominal abscess was found at reoperation at month 3 postoperatively. Pigs had neither fragments of stent nor stones formed in the CBD. Collagen deposit was observed in the anastomosis by hematoxylin and eosin (HE) and Massons trichrome stains. No severe cholestasis was observed in liver parenchyma by HE staining. Intestinal obstruction was found in a pig 4 mo after operation, and no bile leakage, bile duct stricture or biliary obstruction were observed in laparotomy. No sign of bile duct stricture or bile leakage was observed in the other two pigs.nnnCONCLUSIONnThe novel method for repairing bile duct defect yielded a good short-term effect without postoperative bile duct stricture. However, the long-term effect should be further studied.

Effect of fibulin-5 on adhesion, migration and invasion of hepatocellular carcinoma cells via an integrin-dependent mechanism.

AIMnTo elucidate the role of fibulin-5 (FBLN-5) as a suppressor of hepatocellular carcinoma (HCC) cell metastasis via integrin.nnnMETHODSnThe expression of FBLN-5 was determined by immunohistochemistry in 140 HCC samples and matched normal tissues, and was further confirmed by RT-PCR and Western blot analyses in various cell lines. Recombinant FBLN-5 was expressed in Escherichia coli BL21(DE3), purified and used in cell attachment assays. Expression of a specific plasmid or a specific siRNA in HCC cells resulted in the overexpression or knockdown of FBLN-5, respectively. Further, the migration and invasion of HCC cells were investigated using the Boyden chamber and transwell assays. The concentration of secreted matrix metalloproteinase 7 (MMP-7) was determined using ELISA.nnnRESULTSnFBLN-5 expression was found to be downregulated in HCC. Its expression was significantly correlated with advanced tumor metastasis; this was indicative of poor 5-year overall survival. Recombinant full-length human FBLN-5 promoted the attachment of HCC cells via integrins: it inhibited HCC cell adhesion and migration to fibronectin in a concentration-dependent manner. It also inhibited HCC cell migration and invasion through an integrin-binding arginine-glycine-aspartic acid (RGD) motif by downregulating MMP-7.nnnCONCLUSIONnThese results suggest that lower FBLN-5 expression is an important indicator of poor survival and that FBLN-5 inhibits HCC motility via an integrin-dependent mechanism. RGD-dependent suppression of MMP-7 by FBLN-5 might contribute to the development of new therapeutic strategies for HCC.

Evolution of associating liver partition and portal vein ligation for staged hepatectomy: Simpler, safer and equally effective methods

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently demonstrated as a method to induce rapid and extensive hypertrophy within a short time and has been employed for a variety of primary and metastatic liver tumors. However, controversies remain due to its high morbidity and mortality. To enable safer surgery, liver surgeons have searched for better technical modifications, such as partial ALPPS, mini-ALPPS, minimally invasive ALPPS, and Terminal branches portal vein Embolization Liver Partition for Planned hepatectomy (TELPP). It seems that TELPP is very promising, because it has the main advantage of ALPPS - the rapid increase of future liver remnant volume, but the morbidity and mortality are much lower because only one surgical operation is required.