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Aim: To study the feasibility and safety of middle segmental pancreatectomy (MSP) compared with pancreaticoduodenectomy (PD) and extended distal pancreatectomy (EDP)., Methods: We studied retrospectively 36 cases that underwent MSP, 44 patients who underwent PD, and 26 who underwent EDP with benign or low-grade malignant lesions in the mid-portion of the pancreas, between April 2003 and December 2009 in Ruijin Hospital. The perioperative outcomes and long-term outcomes of MSP were compared with those of EDP and PD. Perioperative outcomes included operative time, intraoperative hemorrhage, transfusion, pancreatic fistula, intra-abdominal abscess/infection, postoperative bleeding, reoperation, mortality, and postoperative hospital time. Long-term outcomes, including tumor recurrence, new-onset diabetes mellitus (DM), and pancreatic exocrine insufficiency, were evaluated., Results: Intraoperative hemorrhage was 316.1 ± 309.6, 852.2 ± 877.8 and 526.9 ± 414.5 mL for the MSP, PD and EDP groups, respectively (P < 0.05). The mean postoperative daily fasting blood glucose level was significantly lower in the MSP group than in the EDP group (6.3 ± 1.5 mmol/L vs 7.3 ± 1.5 mmol/L, P < 0.05). The rate of pancreatic fistula was higher in the MSP group than in the PD group (42% vs 20.5%, P = 0.039), all of the fistulas after MSP corresponded to grade A (9/15) or B (6/15) and were sealed following conservative treatment. There was no significant difference in the mean postoperative hospital stay between the MSP group and the other two groups. After a mean follow-up of 44 mo, no tumor recurrences were found, only one patient (2.8%) in the MSP group vs five (21.7%) in the EDP group developed new-onset insulin-dependent DM postoperatively (P = 0.029). Moreover, significantly fewer patients in the MSP group than in the PD (0% vs 33.3%, P < 0.001) and EDP (0% vs 21.7%, P = 0.007) required enzyme substitution., Conclusion: MSP is a safe and organ-preserving option for benign or low-grade malignant lesions in the neck and proximal body of the pancreas.

Objective: To investigate the mechanism of increase of serum bilirubin after hepatic ischemia-reperfusion., Methods: 104 SD rats were randomly divided into 2 groups: Group A (sham operation group) and Group B (undergoing 70% hepatic 35 min ischemia-reperfusion). Then the rats were subdivided into subgroups according the different time points (1 and 6 hours, and 1, 3, 5 days after reperfusion). Bile of the ischemic hepatic lobes and blood from the vena cava were collected to examine the conjugated bilirubin (CB) in the bile and serum, and total bilirubin (TB) and alanine aminotransferase (ALT) in serum, and the bile generation rate was calculated. Tissues of the left liver lobe were collected to undergo microscopy with hematoxiline and eosin staining. Real time fluorescence PCR was used to analyze the mRNA expression of multi-drug resistance-associated protein 2 (MRP2) and radixin, a cytoskeleton crosslinker protein. Laser confocal method was used to analyze the localization of MRP2 and radixin in canalicular membrane., Results: Pathological examination showed that there was only a mild inflammation in the liver tissues that had undergone ischemia-reperfusion, and no necrosis of hepatocytes was seen. 1 h approximately 3 d after reperfusion, the bile generation rate and CB level in bile were significant decreased, and the serum TB and CB levels were significantly increased 1 h approximately 5 d after reperfusion. Radixin expression was significantly reduced 6 h approximately 1 d after reperfusion, but down-regulation of MRP2 only occurred 6 h after reperfusion. Localization of MRP2 in the canalicular membrane was absent when the expression of radixin was missing., Conclusion: Absence of MRP2 localization in canalicular membrane resulted from missing of radixin expression may be the mechanism of an increase of serum bilirubin after hepatic ischemia-reperfusion.

Background: In the early period of orthotopic liver transplantation (OLT), initial poor graft function (IPGF) is one of the complications which leads to primary graft non-function (PGNF) in serious cases. This study set out to establish the clinical risk factors resulting in IPGF after OLT., Methods: Eighty cases of OLT were analyzed. The IPGF group consisted of patients with alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) above 1500 IU/L within 72 hours after OLT, while those in the non-IPGF group had values below 1500 IU/L. Recipient-associated factors before OLT analyzed were age, sex, primary liver disease and Child-Pugh classification; factors analyzed within the peri-operative period were non-heart beating time (NHBT), cold ischemia time (CIT), rewarming ischemic time (RWIT), liver biopsy at the end of cold ischemia; and factors analyzed within 72 hours after OLT were ALT and/or AST values. A logistic regression model was applied to filter the possible factors resulting in IPGF., Results: Donor NHBT, CIT and RWIT were significantly longer in the IPGF group than in the non-IPGF group; in the logistic regression model, NHBT was the risk factor leading to IPGF (P<0.05), while CIT and RWIT were possible risk factors. In one case in the IPGF group, PGNF appeared with moderate hepatic steatosis., Conclusions: Longer NHBT is an important risk factor leading to IPGF, while serious steatosis in the donor liver, CIT and RWIT are potential risk factors.

Background: The past several decades have witnessed increasingly successful rates of liver transplantation. However, retransplantation remains the only choice for patients with irreversible graft failure after primary transplantation. This article aimed to summarize our clinical experience in liver retransplantation., Methods: From June 2002 to December 2005, a total of 185 cases of liver transplantation including 8 cases of retransplantation were performed in our hospital. The clinical data were analyzed retrospectively., Results: The rate of liver retransplantation was 4.32%. Retransplantation was indicated for the following reasons: biliary complication (3 cases), chronic rejection (2), hepatic artery thrombosis (1), uncontrollable acute rejection (1) and hepatitis B recurrence (1). The mean model of end-stage liver disease (MELD) scores before primary transplantation and retransplantation were 15.6 and 23.9, respectively (P<0.05). The MELD score reflected the severity of liver disease more precisely than the Child classification. The mean interval between the first and second transplantation was 316 days (78-725 days). The first three patients, with mean interval of 101 days, died of severe infection combined with multiple organ failure after retransplantation. The patients who underwent retransplantation more than six months after the first transplant had better outcomes. The one-year survival rate for retransplantation in our group was 62.5%., Conclusions: Liver retransplantation is the only means of saving the patient with hepatic allograft failure. Understanding of the indications for retransplantation, careful selection of operation timing, excellent surgical skills and meticulous postoperative management all contribute to the success of each case of retransplantation.

Background: Multivisceral transplantation (MTX, or cluster transplantation) is defined as the transplantation of three or more abdominal organs en bloc, namely the liver together with the pancreatoduodenal complex, the stomach as well as the small bowel with/without the right hemicolon. Up to May 1999, only 72 cases were reported to the Intestinal Transplant Registry. Organ cluster transplantation may carry with complex hemodynamic alterations. Based on our experience in two cases of abdominal cluster transplantation, we describe the technical details of multivisceral transplantation and the management of hemodynamic changes., Methods: A Swan-Ganz catheter was placed to assist in monitoring the patients' hemodynamic status. After the transplantation, the 2 patients were closely observed in the intensive care unit in terms of vital signs;disseminated intravascular coagulation (DIC) including activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen (Fg) and D-dimer, and arterial blood gas; and quantity and characteristics of drainage. Additionally, intra-abdominal hemorrhage was supervised by bedside B-ultrasonography or enhanced computed tomography (CT) examination. Whole blood viscosity was monitored 2 weeks after transplantation. The blood flow of the hepatic artery and portal vein and arterial resistant index were assessed routinely by Doppler ultrasonography., Results: Hemodynamic changes were observed during perioperation. Liver and renal function recovered within one week after transplantation. Enteral feedings and oral intake were gradually increased with a reciprocal decrease in parenteral nutrition. Despite systemic antibiotics were given according to the results of frequent cultures, patient 1 died from cytomegalovirus (CMV) infection 4 months after transplantation and patient 2 died of a systemic sepsis 2 months after the operation., Conclusions: Many factors contribute to the success of multivisceral transplantation. In order to maintain hemodynamics stable during perioperation, preoperative coagulatory function should be corrected, and stable circulation, serum electrocyte balance, and normal body temperature should be kept during the operation in addition to the treatment of intra-abdominal hemorrhage and making up for the loss of body fluid. However, complications, infection and rejection are barriers for the improvement of graft survival.

Background: Despite its rare incidence, few cases of left-side gallbladder have been already published., Methods: We reported herein the case of a 29-year-old man with a left liver tumor in whom left lateral bisegmentectomy was mandatory. It represents the first description of a sinistroposition of both gallbladder and common bile duct., Results: Surgical exploration revealed a left-side gallbladder, located under the left lobe of the liver. During hepatic parenchyma dissection at the left side of the round ligament and the Rex recessus, the common bile duct was injured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the Rex recessus before reaching the hepatoduodenal ligament., Conclusion: Only careful dissection of the hepatoduodenal ligament up to Rex recessus level prior to liver parenchyma resection could avoid biliary tract injury during left lobectomy.

Aim: To analyze the role of liver biopsies in differential diagnosis after liver transplantation., Methods: A total of 50 biopsies from 27 patients with liver dysfunction out of 52 liver transplantation cases were included. Biopsies were obtained 0-330 d after operation, in which, 44 were fine needle biopsies, another 6 were wedge biopsies during surgery. All tissues were stained with haemotoxylin-eosin. Histochemical or immunohistochemical stain was done., Results: The rate of acute rejection in detected cases and total transplantation cases was 48.2% and 25.0%, chronic rejection rate in detected cases and total transplantation cases was 14.8% and 7.7%, preservation-reperfusion injury in detected cases and total transplantation cases was 25.9% and 13.5%, hepatic artery thrombosis rate in detected cases and total transplantation cases was 11.1% and 5.8%, intrahepatic biliary injury rate in detected cases and total transplantation cases was 7.4 % and 3.8%, CMV infection rate in detected cases and total transplantation cases was 3.7% and 1.9%, hepatitis B recurrence rate in detected cases and total transplantation cases was 3.7% and 1.9%, the ratio of suspicious drug-induced hepatic injury in detected cases and total transplantation cases was 11.1% and 5.8%., Conclusion: Acute rejection and preservation-reperfusion injury are the major factors in early liver dysfunction after liver transplantation. Hepatic artery thrombosis and prolonged cold preservation may result in intrahepatic biliary injury. Acute rejection and viral infection may involve in the pathogenesis of chronic rejection. Since there are no specific lesions in drug-induced hepatic injury, the diagnosis must closely combine clinical history and rule out other possible complications.

Objective: To investigate the causes of hemorrhage from the gallbladder bed during laparoscopic cholecystectomy., Methods: 617 patients who had received laparoscopic cholecystectomy from September, 2000 to March, 2001 at this hospital were reviewed retrospectively. Ninety-one of these patients were selected randomly for prospective observation. Color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy and to examine the anatomic relationship between the gallbladder bed and the branches of the middle hepatic vein in 91 patients preoperatively., Results: A large branch of the middle hepatic vein extended closely behind the gallbladder bed in all 91 patients. The mean distance between the closest point (C point) of this branch to the gallbladder bed was 5.0+/-4.6 mm. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 14 (15.38%) of the 91 patients. The distance between this branch and the gallbladder bed was within 1 mm in 10 (10.99%) of the 91 patients. The inside diameter at C point of this branch was 3.2+/-1.1 mm. The C point was found on the left side of the longitudinal axis of the gallbladder in 31 (34.66%) of the 91 patients, on the right side in 39 patients (42.86%), just on the axis in 21 patients (23.08%). The venous blood flow rate at the C point was 9.9+/-3.3 cm/s., Conclusions: A large branch of the middle hepatic vein passes behind the gallbladder. The inside diameter of this branch is relatively larger. The bleeding of this branch during operation can only be stopped by transfixion. The closest point of this vein to the gallbladder is mostly situated on the right side of the longitudinal axis of the gallbladder. Patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholecystectomy and should be identified preoperatively with ultrasound.

Objective: To assess the relevant factors of prognosis and the proper treatment of recurrent hepatocellular carcinoma (HCC)., Methods: From January 1983 to January 1997, 135 patients with recurrent HCC were analyzed in terms of host condition, tumor characteristics, and surgical procedures. Surgical treatments of these patients were compared., Results: Alpha-fetoprotein (AFP) level >1000 microg/L in the initial operation, tumor size larger than 5 cm in diameter, tumor embolization in the portal veins, 0 surgical margin, and no chemoembolization before the operation were the main factors directly affecting the prognosis in a year after recurrence. Repeat hepatectomy and liver transplantation were performed to obtain better results., Conclusions: Tumor characteristics and surgical treatment are the main factors affecting the prognosis after the recurrence of HCC. Liver transplantation plays an important role in patients with poor liver function or multi-recurrent sites.