Jian-Ping Zeng

Surgical treatment of type IV-A choledochal cyst in a single institution: Children vs. adults

BACKGROUND The treatment of type IV-A choledochal cyst is particularly difficult and remains a challenge because of the rareness and the various presentations of the disease involving not only the extrahepatic but also the intrahepatic biliary tract. The purpose of this study is to analyze our clinical experience for surgical treatment of type IV-A choledochal cyst, and compare between children and adults. METHODS During a 10-year period of time (2000-2010), clinical data of 81 consecutive patients with type IV-A choledochal cyst were retrospectively analyzed. We divided these patients into two groups, the child group (age ≤ 18 years) and the adult group (age >18 years). According to whether the patient received additional liver resection, patients were divided into a extrahepatic cystectomy (EHC) group and an additional liver resection (LR) group. The long-term outcomes after surgery were evaluated in two groups. RESULTS Of all 81 patients, there were 17 children and 64 adults; 16 children and 35 adults belonged to EHC group, one child and 29 adults belonged to LR group. The morbidity of biliary stricture and/or lithiasis in the adults was significantly higher than that in the children (p = 0.041 < 0.05). In the EHC group, the reoperation rate of adults was significantly higher than that of children (p = 0.019 < 0.05). For adult patients, the morbidity of biliary stricture and/or lithiasis and the reoperation rate in EHC group was significantly higher than that in LR group (p = 0.037 < 0.05 and p = 0.026 < 0.05 respectively). Five adults were found to have cholangiocarcinoma within a follow-up period, while no child was found to. However, for adult patients, no significant discrepancy was observed between EHC group and LR group (p = 0.366 > 0.05). CONCLUSIONS The present study suggests that the children have better outcomes than adults for patients with type IV-A choledochal cyst after EHC, while LR brings better outcomes than EHC for adult patients.

Portal inflow preservation during portal diversion in small-for-size syndrome

AIM To investigate the impact of portal inflow on liver remnants in a stable pig model of small-for-size syndrome. METHODS Twenty pigs underwent mesocaval shunt (MCS) surgery followed by 85%-90% hepatectomy. The control group had no shunt placement; the S1 group had portal flow maintained at an average of 2.0 times the baseline values; and the S2 group had portal flow maintained at an average of 3.2 times the baseline flow. The effect of portal functional competition on the liver remnant was investigated for 48 h postoperatively. Data were presented as mean ± SD. Statistical significance was determined using Students t test (SPSS, Chicago, IL, United States). Values of P < 0.05 were considered statistically significant. RESULTS At 24 h after hepatectomy, biochemical and histological changes were not significantly different between the S1 and S2 groups, but changes in both sets of variables were significantly less than in the control group. At 48 h, biochemical and histological changes were significantly less in the S2 group than in the S1 or control group. The regeneration index was significantly higher in the S2 group than in the S1 group, and was similar to that in the control group. Apoptosis index, serum lipopolysaccharide, and bacterial DNA levels were significantly lower in the S2 group than in the other two groups. CONCLUSION Diversion of portal inflow using MCS reduces portal overflow injury. Excessive diversion of portal inflow inhibits liver regeneration following major hepatectomy. Maintaining portal inflow at an average of 3.2 times above baseline helps promote hypertrophy of the liver remnant and reduce apoptosis.

Sphincter of Oddi Dysfunction and the Formation of Adult Choledochal Cyst Following Cholecystectomy: A Retrospective Cohort Study.

AbstractTo determine the causes underlying the formation of adult choledochal cyst.Anomalous pancreaticobiliary junction is the most widely accepted theory regarding the etiology of choledochal cyst. However, choledochal cysts have been found in patients in the absence of this anomaly. Because the number of adult patients with choledochal cyst is increasing, it is important to address this controversy.Bile amylase levels in the cysts of 27 patients (8 males and 19 females) who had undergone cholecystectomy were retrospectively evaluated.The average age of the 27 patients was 45.8 ± 10.1 years and the majority (85.2%) were diagnosed with Todani type I cysts. None of the patients had dilatation of the common bile duct prior to surgery. There were 6 (22.2%) patients with anomalous pancreaticobiliary junction. However, amylase levels did not significantly differ between patients with and without this anomaly (P = 0.251). According to bile amylase levels, pancreatobiliary reflux was present in 21 (77.8%) patients. The mean amylase level significantly differed in patients with pancreatobiliary reflux (23,462 ± 11,510 IU/L) and those without (235 ± 103 IU/L) (P < 0.001). In patients with pancreatobiliary reflux, only 4 patients had anomalous pancreaticobiliary junction. That is, the majority of patients (17/21, 81%) having pancreatobiliary reflux did not have an anomalous junction of the pancreatic and biliary ducts.Since the only explanation for pancreatobiliary reflux in patients with a normal pancreaticobiliary junction is sphincter of Oddi dysfunction, we proposed that the formation of adult choledochal cyst is mainly due to sphincter of Oddi dysfunction.

Extrahepatic cyst excision and partial hepatectomy for Todani type IV-A cysts

BACKGROUND Extrahepatic cyst excision and Roux-en-Y hepaticojejunostomy is not satisfactory in many patients with complex Todani type IV-A choledochal cysts. AIMS To report the results of combined extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts. METHODS The records of patients who received extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts from January 2002 to December 2011 were retrospectively reviewed, and surgical outcomes analysed. RESULTS 59 patients (30.5% males; mean age, 43.2 ± 18.4 years) were included. Radical excision of cystically dilated bile ducts was achieved in 53 patients (89.8%). Bile leakage, delayed wound healing, and abdominal infection occurred in 5 (8.47%), 7 (11.86%), and 3 (5.08%) patients, respectively. Forty-nine patients (83.1%) were followed for an average of 42.6 ± 15.3 months. During the follow-up, 6 patients (12.2%) experienced recurrent cholangitis. Long-term biliary function was excellent in 33 (67.4%), good in 9 (18.4%), fair in 5 (10.2%), and poor in 2 (4.1%) patients. CONCLUSION Combined extra-hepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy is effective for the treatment of complex Todani type IV-A choledochal cysts with substantial intrahepatic bile duct involvement and hilar bile duct stenosis.

Expression of scFv‐Mel‐Gal4 triple fusion protein as a targeted DNA‐carrier in Escherichia Coli

Liver‐directed gene therapy has become a promising treatment for many liver diseases. In this study, we constructed a multi‐functional targeting molecule, which maintains targeting, endosome‐escaping, and DNA‐binding abilities for gene delivery. Two single oligonucleotide chains of Melittin (M) were synthesized. The full‐length cDNA encoding anti‐hepatic asialoglycoprotein receptor scFv C1 (C1) was purified from C1/pIT2. The GAL4 (G) gene was amplified from pSW50‐Gal4 by polymerase chain reaction. M, C1 and G were inserted into plasmid pGC4C26H to product the recombinant plasmid pGC‐C1MG. The fused gene C1MG was subsequently subcloned into plasmid pET32c to product the recombinant plasmid C1MG/pET32c and expressed in Escherichia coli BL21. The scFv‐Mel‐Gal4 triple fusion protein (C1MG) was purified with a Ni2+ chelating HiTrap HP column. The fusion protein C1MG of roughly 64 kD was expressed in inclusion bodies; 4.5 mg/ml C1MG was prepared with Ni2+ column purification. Western blot and immunohistochemistry showed the antigen‐binding ability of C1MG to the cell surface of the liver‐derived cell line and liver tissue slices. Hemolysis testing showed that C1MG maintained membrane‐disrupting activity. DNA‐binding capacity was substantiated by luciferase assay, suggesting that C1MG could deliver the DNA into cells efficiently on the basis of C1MG. Successful expression of C1MG was achieved in E. coli, and C1MG recombinant protein confers targeting, endosome‐escaping and DNA‐binding capacity, which makes it probable to further study its liver‐specific DNA delivery efficacy in vivo. Copyright

Ultrathin choledochoscope improves outcomes in the treatment of gallstones and suspected choledocholithiasis

ABSTRACT Background: We aimed to compare laparoscopic cholecystectomy (LC) and simultaneous laparoscopic transcystic common bile duct exploration (LTCBDE) using an ultrathin choledochoscope with LC followed by endoscopic retrograde cholangiopancreatography (ERC) and endoscopic sphincterotomy (ES) when indicated. Methods: We retrospectively reviewed the records of patients seen between 2004 and 2014 and treated with LC+LTCBDE or LC for gallstones and suspected choledocholithiasis. Postoperative complications and surgical outcomes were compared using t-test, Mann-Whitney U test, or chi-square test. Results: 115 patients underwent successful LC+LTCBDE and 112 LC; follow-up data was available for 103 and 106 patients, respectively. Seventeen patients (16.5%) in the LC+LTCBDE group and 10 (28.6%) in the LC+ERC+ES group developed complications (P = 0.114). The LC+LTCBDE group had a significantly higher rate of satisfactory biliary function outcomes than the LC+ERC+ES group (98.1% vs. 85.7%, respectively) (P = 0.017). Conclusions: Single-step LC+LTCBDE using an ultrathin choledochoscope may provide better outcomes in patients with gallstones and suspected choledocholithiasis.

Role of the Surgical Method in Development of Postoperative Cholangiocarcinoma in Todani Type IV Bile Duct Cysts

Background. Our purpose was to investigate the association between the surgical approach for Todani type IV cysts and subsequent malignancy rate. Methods. The records of patients who received cyst excision from 1994 to 2013 were analyzed retrospectively for the following data: demographics, presenting symptoms, postoperative outcomes, malignant transformation, and follow-up reexaminations, including imaging, laboratory, and tumor marker tests. Results. Seven of the 196 patients initially treated at our hospital developed postoperative biliary malignancy, and the surgical approaches were extrahepatic bile duct cyst resection combined with hilar cholangioplasty and Roux-en-Y cystojejunostomy (n = 5), and intra- and extrahepatic bile duct cyst resection and Roux-en-Y hepaticojejunostomy (n = 2). The overall malignancy rate was 3.6% (7/196). Forty-eight patients initially treated at other hospitals developed malignancy postoperatively: 15 (31.2%) remained untreated and 33 (68.8%) had undergone incomplete resection procedures. Because Todani type IV cysts were seen in 268 patients, the postoperative malignancy rate of this group of patients was 12.3% (33/268). Conclusions. Radical resection of both intra- and extrahepatic cysts combined with hepatic resection and Roux-en-Y hepaticojejunostomy is associated with a reduced risk of subsequent cancer development. Procedures in which radical cyst excision is not performed are associated with a greater risk of subsequent malignancy.