Nan-Sheng Cheng

Prophylaxis Against Hepatitis B Recurrence Posttransplantation Using Lamivudine and Individualized Low-Dose Hepatitis B Immunoglobulin

Although the combination of lamivudine (LAM) and high‐dose intravenous (IV) hepatitis B immunoglobulin (HBIG) is very effective in preventing hepatitis B virus (HBV) recurrence after liver transplantation (LT), the major limitation of this regimen is its high cost. A more cost‐effective, convenient and widely accepted regimen is urgently needed. We evaluated the safety and efficacy of another strategy using LAM and individualized low‐dose intramuscular (IM) HBIG. Between May 2002 and December 2009, a total of 254 adult patients undergoing LT for HBV‐related benign end‐stage liver diseases received this regimen in our center. The mean follow‐up of these patients was 41.2 ± 22.7 months. Their 1‐, 3‐ and 5‐year survival rates were 85.3%, 77.4% and 76.4%, respectively, and 1‐, 3‐ and 5‐year HBV recurrence rates were 2.3%, 6.2% and 8.2%. Fourteen patients experienced posttransplant HBV recurrence. Pretransplant high viral load and posttransplant prednisone withdrawal time were observed to be associated with recurrence. In conclusion, combination therapy with LAM and individualized low‐dose IM HBIG provides a safe and effective prophylaxis against HBV recurrence after LT at about 5% of the cost of conventional high‐dose IV HBIG regimens.

Effectiveness of chemical biliary duct embolization for chemical hepatectomy.

Background and Aims:u2002 The high recurrence of hepatolithiasis and high operative trauma of hepatectomy necessitate new therapeutic approaches. Thus, this study was designed to (i) investigate the effectiveness of chemical biliary duct embolization (CBDE) for chemical hepatectomy; and (ii) to determine the mechanism of CBDE.

Bronchogenic cyst of the gastric fundus in a young woman

Most bronchogenic cysts (BCs) are found within the medistinum and lung [1]. Extrathoracic and subdiaphragmatic BCs are ery rare, and BCs of the stomach are even more rarely seen. A 25ear-old woman presented to our hospital with a 1-week history f epigastric pain. An upper gastrointestinal radiography revealed a harply demarcatedmass in the gastric fundus (Fig. 1a). An esophaogastroduodenoscopy revealed a 3.0 cm×2.5 cm×2.0 cm smooth ass with normal overlying mucosa in the gastric fundus (Fig. b), and simultaneously provided evidence of antral gastritis (Fig. c). Considering the uncertain diagnosis, computed tomography or ndoscopic ultrasonographywas suggested, but the patient refused ecause of financial issues. Gastrointestinal stromal tumour was onsidered preoperatively. Thus, proximal hemigastrectomy was lanned. At laparotomy, a soft mass, arising from the gastric fundus as felt and yellowmucous fluid gushed out after the correspondng stomach wall was opened. The frozen section analysis of the iopsy specimen indicated a gastric cyst but no malignant cells. ence, a wedge resection of the fundus containing the cyst was erformed. The postoperative course was uneventful and she was ischarged 7 days after surgery. Histological studies of the surgial specimen revealed a cyst lined with pseudostratified ciliated olumnar epithelium and surrounded by smooth muscle (Fig. 2), nd the final diagnosis was of a gastric bronchogenic cyst.

Compression Stockings for Prevention of Postthrombotic Syndrome A Systematic Review and Meta-Analysis

Objective: The present meta-analysis aimed to evaluate the efficacy and safety of compression stockings for postthrombotic syndrome (PTS) prevention in patients with deep venous thrombosis (DVT). Methods: Randomized controlled trials (RCTs) regarding the use of compression stockings for prevention of PTS were identified from the Medline, PubMed, and Embase databases as well as the Cochrane library. The resulting manuscripts were analyzed according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions. Results: Six RCTs involving 1465 patients with DVT were included. The meta-analysis indicated no statistical differences between the compression stocking and the control groups in PTS incidence, using either the Villalta scale (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.23-1.74) or the Ginsberg scale (OR, 1.13; 95% CI, 0.72-1.77). Based on the Villalta scale categorization, there were no differences in the incidence of mild–moderate PTS (OR, 0.71; 95% CI, 0.36-1.41) or incidence of severe PTS (OR, 0.68; 95% CI, 0.15-3.11). The difference in the recurrence of venous thromboembolism (OR, 0.89; 95% CI, 0.61-1.30) was also not significant. In the 3 RCTs that reported side effects of compression stockings, they were primarily related to discomfort, including itching, erythema, and rash. Conclusion: The present meta-analysis has indicated that compression stockings may not prevent PTS, as determined by either the Villalta or the Ginsberg scale, in patients with DVT. However, owing to the limited number of trials, the evidence is not strong enough to draw a reliable conclusion. Further larger, randomized, double-blind, placebo-controlled, multicenter trials are needed.

Epidermal Growth Factor Receptor as a Target for Anti-Proliferative Treatment of Proliferative Cholangitis in Hepatolithiasis

BACKGROUNDnIn recent years, with a deeper understanding of pathologic changes in hepatolithiasis, more and more attention has been paid to the relationship of postoperative remnant proliferative cholangitis (PC) with stone recurrence and biliary restenosis, but effective management strategies have not yet been developed. Thus, the aim of this study was to determine whether epidermal growth factor receptor inhibitor (AG-1478) could inhibit hyperplasia and lithogenic potentiality of PC.nnnMETHODSnThe PC animal model was established via retrograde insertion of a 5-0 nylon thread into the common bile duct through Vaters papilla. The common bile duct in the therapeutic group received a single intraluminal administration of AG-1478, followed by weekly intraperitoneal injections of AG-1478. Subsequently, influence of EGFR inhibitor on hyperplasia, apoptosis, and lithogenic potential of PC were evaluated via histology, expression changes of EGFR, BrdU, Ki-67, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL), Fas, mucin 5 AC, and collagen I.nnnRESULTSnEGFR inhibitor AG-1478 was effective not only in inhibiting the mRNA and protein expression of EGFR, BrdU, and Ki-67, but also in increasing Fas mRNA expression and TUNEL-positive cells, as a result leading to the inhibition of hyperplasia of the biliary epithelium, submucosal gland, and collagen fibers in the diseased bile duct. Additionally, collagen I expression and fibrous thickness of the bile duct wall was significantly reduced, thereby reducing the incidence of biliary tract stricture secondary to PC. Also of note, treatment with AG-1478 could efficiently decrease the lithogenic potential of PC via inhibition of mucin 5AC expression and mucoglycoprotein secretion, hereby facilitating prevention of stone recurrence.nnnCONCLUSIONnEGFR antagonist AG-1478 had a potent anti-proliferative and anti-fibrotic effectiveness on PC and, therefore, holds promise as a candidate of PC treatment.

Infected primary retroperitoneal teratoma presenting as a subhepatic abscess in a postpartum woman

It is highly unusual for a 20-cm retroperitoneal teratoma to present as a subhepatic abscess with septic shock in a postpartum woman. We present a case of a multilocular cystic teratoma densely adherent to adjacent viscera and vessels. Because of the complexity of the case and the clinical condition of the patient, a 2-stage operation was employed for this special case. An initial emergency drainage effectively relieved symptoms of acute infection and facilitated the 2nd-stage resection of the tumor.

Hepatobiliary and pancreatic: Traumatic neuroma of the ampulla of Vater

A 56 year old man was investigated because of a two week history of jaundice, abdominal pain and weight loss. There was no history of alcohol abuse. His past history included two biliary operations; a cholecystectomy for gall stones 13 years previously and exploration of the bile duct for choledocholithiasis three years previously. On physical examination, he had mild jaundice. Blood tests revealed a mild elevation of serum bilirubin (87 μmol/L) and a mild elevation of alkaline phosphatase and alanine aminotransferase. Serum levels of CA 19-9 were within the reference range. An abdominal ultrasound study showed dilatation of both the extrahepatic bile duct and intrahepatic ducts. Magnetic resonance cholangiopancreatography showed dilatation of the extrahepatic bile duct and a filling-defect in the distal bile duct (Figure 1 left). The magnetic resonance imaging scan also showed a thickened biliary wall around the ampulla of Vater (Figure 1 right). Endoscopic retrograde cholangiopancreatography was attempted but failed. The patient was thought to have an ampullary or periampullary carcinoma and was treated by pancreaticoduodenectomy. There was a firm, grey mass, approximately 1.0 cm in diameter, in the region of the ampulla of Vater. Histological evaluation revealed a traumatic neuroma involving both the lower bile duct (Figure 2, left, H&E x 200) and main pancreatic duct (Figure 2, right, H&E x 200) with the presence of hyperplastic nerve fibres and fibrous connective tissue. Traumatic neuromas (also known as amputation neuromas) are benign lesions that represent a reparative response to nerve injury. There is disordered proliferation of nerve fibres and connective tissue as nerves try to re-establish continuity after injury or transection. Most patients with traumatic neuromas have had previous surgery, trauma or chronic inflammation. The lesion is usually found as a small, firm nodule that may be responsible for pain at the neuroma site. Traumatic neuromas of the bile duct and pancreas are rare and, to our knowledge, this is the first report of a traumatic neuroma of the ampulla of Vater. As pancreatic and biliary neuromas are similar to other benign and malignant lesions, they are difficult to diagnose prior to surgery. At operation, a frozen section examination is often helpful to support the presence of a benign lesion and avoid a more extensive surgical resection.

Effects of Epidermal Growth Factor Receptor Inhibitor Genistein on Proliferative Cholangitis in Rats

BACKGROUNDnMany strategies for treating hepatolithiasis neglect the therapy for associated proliferative cholangitis (PC), which is the root cause of residual and recurrent stones and biliary strictures, resulting in an unsatisfactory therapeutic outcome. Epidermal growth factor receptor (EGFR) expression is a dominant component in cell proliferation. The aim of this study was to investigate the effect of EGFR inhibitor genistein on PC in rats.nnnMETHODSnThe rat PC model was established by introducing a nylon thread into the bile duct. Different doses of genistein were administered directly into the bile duct. The effectiveness of genistein on PC was assessed by histology, immunohistochemistry for EGFR, and RT-PCR for EGFR mRNA.nnnRESULTSnThe proliferation of biliary epithelium, and fibrous tissue, and the hyperplasia of peribiliary gland in PC were indeed suppressed by genistein, and this antiproliferative effect presented a significant dose-response relationship. The structure of biliary tissue in the high-dose group (genistein 6.0mg/kg) had approached that of the normal bile duct. Compared with the PC model, the levels of expression of EGFR mRNA and protein in the genistein-treated groups were reduced gradually with the increase of genistein dosage, and the level of expression of EGFR mRNA and protein in the high-dose group had neared that of the normal bile duct.nnnCONCLUSIONSnDirect administration of genistein into the bile duct suppressed PC in a rat model, and may provide a novel strategy towards improving the prognosis of patients with hepatolithiasis.

Hepatobiliary and pancreatic: coexisting cancers: Hepatic neuroendocrine carcinomas with gall bladder adenocarcinoma.

A woman, aged 67, was investigated because of intermittent pain in the epigastrium for one month. There was no relevant past history and no abnormalities were detected on physical examination. Routine blood tests, including liver function tests, were within the reference range but she had a mild elevation of CA 19-9 (55 U/ml). Serological tests for hepatitis B and C were negative. A contrastenhanced computed tomography (CT) scan of the upper abdomen showed irregular thickening of the gallbladder wall (Figure 1, left). She also had low-density tumors with ring enhancement in segments 4 and 5 of the liver (Figure 1, right). These lesions had a maximum diameter of 5.0 cm. She was thought to have gallbladder adenocarcinoma with liver metastases and was treated by an extended resection that included gallbladder, mid-segments of the liver and regional lymph nodes. The gallbladder wall was diffusely thickened while the hepatic tumors were greyishwhite, hard and well-circumscribed. Histological evaluation of the galbladder specimen revealed adenocarcinoma while the hepatic tumors had sheets of neoplastic cells with round to oval hyperchromatic nuclei and eosinophilic cytoplasm (Figure 2, left). Immunohistochemical studies revealed strong expression for Syn (Figure 2, right) and CD6 supporting the diagnosis of an hepatic neuroendocrine tumor (neuroendocrine carcinoma). Under most circumstances, liver tumors associated with known or strongly suspected primary tumors are liver metastases. Occasionally, however, known or suspected primary tumors may coexist with a second tumor causing liver metastasis or with a primary liver tumor. In the above case, a neuroendocrine tumor involving the liver coexisted with a primary adenocarcinoma of the gallbladder. The possibility of the coexistence of two tumors might have been suspected because of ring enhancement of the liver tumors on a contrast-enhanced CT scan. This radiological finding is common in patients with neuroendocrine tumors but uncommon in patients with typical liver metastases. Other investigations that might have differentiated the tumors include magnetic resonance imaging, somatostatinreceptor scintigraphy and positron emission tomography (PET)-CT using a variety of tracers to identify neuroendocrine tumours. In the above case, a post-operative PET-CT failed to identify any extrahepatic tumors, thus raising the possibility of a primary neuroendocrine tumor of the liver. Primary hepatic tumors of this type appear to be rare with fewer than 150 cases in the medical literature.