BACKGROUND: The clinicopathological features of uncinate process pancreatic cancer (UPPC) are poorly described. Furthermore the anatomy of the uncinate process and its division during surgery are central to pancreaticoduodenectomy for UPPC. We set out to describe the embryology and anatomy of the uncinate process and the clinicopathological features of UPPC.
DATA SOURCES: All published case series of UPPC were reviewed and included in this review.
RESULTS: The true incidence of UPPC is difficult to quantify, with the reported incidence ranging from 2.5% to 10.7% of pancreatic cancer. There are 5 published series of UPPC including 117 patients, 72 males and 45 females, aged from 45-53 years to 61-84 years. The median survival was 5 or 5.5 months in 3 of the series, 12.1 months in another based only on potentially resectable lesions and 17 months in another based only on resected cases.
CONCLUSIONS: The number of reported series of UPPC is limited, with vague symptoms as the predominant presenting features of the disease. The prognosis is poor with synchronous venous resection demonstrating a survival advantage.

BACKGROUND: Hepatic artery (HA) reconstruction is one of the key steps for living donor liver transplantation (LDLT). The incidence of HA thrombosis has been reduced by the introduction of microsurgical techniques under a high resolution microscope or loupe.
METHODS: We report our experience in 101 cases of HA reconstruction in LDLTs using the graft-artery-unclamp and posterior-wall-first technique. The reconstructions were completed by either a plastic surgeon or a transplant surgeon.
RESULTS: The rate of HA thrombosis was 2% (2/101). The risk factors for failed procedures appeared to be reduced by participation of the transplant surgeon compared with the plastic surgeon. For a graft with duplicate arteries, we considered no branches should be discarded even with a positive clamping test.
CONCLUSIONS: HA reconstruction without clamping the graft artery is a feasible and simplified technique, which can be mastered by transplant surgeons with considerable microsurgical training.

BACKGROUND: Because of the shortage of deceased donors with livers fit for transplantation, living donor liver transplantation (LDLT) is becoming an attractive alternative. Attention should be paid to the donors, especially to those of the right lobe. In this study, we evaluated the risks faced by donors of the right lobe for adult-to-adult LDLT.
METHODS: The perioperative data from 105 consecutive living donors of the right lobe performed in West China Hospital from January 2002 to December 2007 were retrospectively studied. Preoperative evaluation included CT, MRCP, and intraoperative cholangiography, showing liver volume, hepatic vasculature and the biliary system. The standard liver volume (SLV) and the ratio of left lobe volume to SLV were calculated. The right lobe grafts were obtained by transecting the liver on the right side of the middle hepatic vein without inflow vascular occlusion, using an ultrasonic dissector. After operation the donors were monitored in the Intensive Care Unit for about three days. Each donor was followed up for at least 6 months.
RESULTS: There was no donor mortality. Major complications occurred in 14 donors (13.3%), of whom 3 received conservative treatment, 8 required invasive paracentesis, and 3 required further surgery. All donors were recovered well and resumed their previous occupations.
CONCLUSIONS: Donors of the right lobe face low risks. The preoperative evaluation, especially evaluation of the volume of the remnant liver, should be exact. During the operation, the patency of the remnant hepatic vasculature and bile duct must be preserved, and the extent of injury to the remnant liver should be limited as much as possible. The detection and treatment of postoperative complications should be diligently performed.

BACKGROUND: Ischemia-reperfusion injury occurs when ischemic tissues or organs suffer from further functional and structural damage when their blood supply recovers. This study aimed to contrast the protective effects of ischemic preconditioning and ischemic postconditioning in hepatic ischemia-reperfusion injury in rats.
METHODS: Thirty-two healthy male Wistar rats were randomly divided into four groups: sham-operated (SO), ischemia-reperfusion (IR), ischemic preconditioning (I-pre), and ischemic postconditioning (I-post). Blood samples and hepatic tissue were taken from all groups after the experiments.
RESULTS: There were significant differences between the IR, I-pre and I-post groups in alanine aminotransferase and aspartate aminotransferase levels, NF-κB p65 expression, apoptosis index and superoxide dismutase activity in hepatic tissue. There were no significant differences between the I-pre and I-post groups.
CONCLUSIONS: Ischemic postconditioning and ischemic preconditioning reduce hepatic ischemia-reperfusion injury, but in clinical practice the former is a more appropriate choice.

BACKGROUND: Although hepatic resection is widely accepted as a proper modality for treating hepatocellular carcinoma (HCC), a majority of patients are unable to undergo surgical resection due to various tumor and patient factors. Radiofrequency ablation (RFA) has mostly been used as a therapeutic alternative to resection for treating HCC. The objective of this study was to evaluate the results of intraoperative RFA for HCCs in locations difficult for a percutaneous approach.
METHODS: Eight patients (male, seven; age, 49-67 years) with 8 HCCs in difficult locations were treated by intraoperative RFA. Six of the patients had local tumor progression after initial transarterial chemoembolization or ultrasound (US) guided percutaneous RFA. The locations of the tumors were hepatic dome in six patients, posterior subcapsule in one, and caudate lobe in one. The tumor size was 2.0 to 6.4 cm (mean, 3.9 cm). Intraoperative RFA was performed at the tumor itself and an anticipated resection line under US guidance with 3 cm monopolar single or clustered internally cooled electrodes. Tumor resection was performed in six patients. One month later, treatment response was assessed by contrast material-enhanced computed tomography (CT). CT studies were performed every 2 or 3 months after RFA.
RESULTS: RFA was technically successful in all tumors, and the contrast-enhanced CT images acquired one month later showed complete disappearance of tumor enhancement. One pneumothorax occurred. After a median follow-up of 18 months (range, 6-30 months), no tumors showed local progression. During the follow-up period, four new recurrent tumors were observed in three patients. Four patients were alive at the time of this report and the other four died of hepatorenal syndrome, liver failure, and progression of new recurrent tumors.
CONCLUSION: Intraoperative RFA with tumor resection can be an alterative treatment option for HCC in locations difficult for a percutaneous approach.

BACKGROUND: Intra-abdominal free fluid is commonly caused by injuries of solid or hollow organs in patients suffering from blunt abdominal trauma (BAT). However, it presents a diagnostic dilemma for surgeons when free fluid is unexplained, especially in stable BAT patients. This study was to analyze the incidence of such unexplained free fluid in BAT patients and its diagnostic value in abdominal organ injury.
METHODS: Altogether 597 patients with BAT who had been treated at our trauma center over a 10-year period were reviewed. Stable patients with free fluid but without free air or definite organ injury on abdominal computed tomography were studied. Clinical management and operative findings were analyzed.
RESULTS: Thirty-four (5.70%) of the 597 patients met the inclusion criteria: 24 (4.02%) underwent therapeutic exploratory laparotomy: bowel injuries were found in 13, hepatic rupture in 3, colon rupture in 3, duodenal rupture in 2, spleen rupture in 1, pancreas rupture in 1, and gallbladder perforation in 1. In 2 patients, laparotomy was nontherapeutic. Those with moderate or large amounts of free fluid were more likely to suffer from a hollow viscus injury and have a therapeutic procedure. The mean time of hospital stay for the delayed laparotomy group was longer than that for the emergency group (19±5.12 vs. 12±2.24 days; t=2.73, P<0.01).
CONCLUSIONS: There was a positive correlation between the amount of unexplained free fluid and the determination of intra-abdominal organ injury. The proportion of BAT patients who required surgical intervention was high, particularly those with a moderate or large amount of free fluid, and most of them suffered from a hollow organ injury. Emergency laparotomy is recommended for these patients.

BACKGROUND: Autoimmune hepatitis (AIH) is a chronic inflammatory disease of the liver. Data on the disease remain scarce in the Southeast Asia region. This study was undertaken to assess the profiles of AIH in Brunei Darussalam.
METHODS: Nineteen patients with AIH treated at the hepatology clinic, RIPAS Hospital (up until December 2008) were reviewed. Demographic, laboratory, histologic, clinical, and therapeutic data of the patients were collected. 
RESULTS: The median age of the 19 patients at diagnosis was 52 years (range 33-70) with a male to female ratio of 1:3.75. All patients were diagnosed with type Ⅰ AIH. The prevalence rate of the disease was 5.61/100 000 and was higher in the Chinese than in Malays and Indigenous people. Commonly seen presentations were abnormal liver function (52.6%), icteric hepatitis (36.8%), and decompensated liver disease (10.5%). Histologically advanced fibrosis was found in 47.4% and cirrhosis in 21.1% of the patients. Immune-mediated diseases were present in 36.8%. In a follow-up for 31 months (range 0.25-102), three patients died, 2 had progressive liver failure and 1 had lymphoma. Complete biochemical response was seen in 75% of the patients, partial response in 12.5%, and no response in 12.5%. HLA DRB1*03 (DR3) was detected in 18.2% of the patients and DRB1*04 (DR4) in 45.5%. There were significant associations between HLA Cw7 (P=0.038) and DQB1*04 (P=0.007).
CONCLUSIONS: The data of the 19 patients were comparable to those reported in the literature. Most of the patients were found to have abnormal biochemistry. There were significant associations between HLA Cw7 and DQB1*04, but not between DRB1*03 (DR3) and DRB1*04 (DR4).

BACKGROUND: Currently adopted diagnostic methods for duodenal-biliary and pancreaticobiliary refluxes carry many flaws, so the incidence of the two refluxes demands further larger sample size studies. This study aimed to evaluate Western blotting for the diagnosis of refluxes in biliary diseases.
METHODS: An oral radionuclide 99mTc-DTPA test (radionuclide, RN) was conducted for the observation of duodenal-biliary reflux prior to measuring bile radioactivity and Western blotting for detecting bile enterokinase (EK). Pancreaticobiliary reflux was assessed by biochemical and Western blotting tests for biliary amylase activity and trypsin-1, respectively. In accordance with bile sample origin, our samples were classified into ductal bile and gall bile groups; based on each individual biliary disease, we further classified the ductal bile group into five sub-groups, and the gall bile group into four sub-groups. Western blotting was conducted to assess the two refluxes in biliary diseases.
RESULTS: Consistencies were noted between EK and RN tests when diagnosing duodenal-biliary reflux (P<0.001). The amylase and trypsin-1 tests also showed consistency in diagnosing pancreaticobiliary reflux (P<0.001). Amylase and lipase levels within gall and ductal bile were strongly correlated (P<0.05). In the common bile duct pigment stone group, the EK and trypsin-1 positive rates were found to be insignificant (P>0.05); in the common bile duct cyst group, the EK positive rate was significantly lower than the trypsin-1 positive rate (P<0.05).
CONCLUSIONS: Western blotting can accurately reflect duodenal-biliary and pancreaticobiliary refluxes. EK has greater sensitivity than RN for duodenal-biliary reflux. The majority of biliary amylase and lipase comes from the pancreas in all biliary diseases; pancreaticobiliary reflux is the predominant source in the common bile duct cyst group and duodenal-biliary reflux is responsible for the ductal pigment stone group.

BACKGROUND: Defective contractile motility of the gallbladder is an important factor for gallstone formation. Estrogen might increase the risk of gallstones and cholecystitis, and estradiol inhibits the contractile activity of isolated strips of guinea pig gallbladder. The potential risks associated with hormone replacement therapy (HRT) include symptomatic gallstones. Phytoestrogen have been used to treat menopause syndromes by replacing traditional estrogen. This experiment aimed to determine the effects of the phytoestrogen genistein on the contractile response of smooth muscle strips isolated from guinea pig gallbladder and its possible mechanism of action.
METHODS: Guinea pigs were sacrificed to remove the whole gallbladder. Two or three smooth muscle strips were cut longitudinally. Each strip was suspended in a tissue chamber containing Krebs solution. After 2 hours of equilibration, contractile response indexes were recorded. Different concentrations of genistein were added to the chamber and the contractile responses were measured. Each antagonist was added 2 minutes before genistein to study possible mechanisms. The effect of genistein on calcium-dependent contraction curves and biphasic contraction in calcium-free Krebs solution were measured.
RESULTS: Genistein decreased the resting tension dose-dependently, and reduced the mean contractile amplitude and frequency in gallbladder strips. Ranitidine partly inhibited the effect of genistein, but methylene blue, Nω-nitro-L-arginine, and propranolol hydrochloride did not influence this action. Genistein had no significant effects on calcium-dependent contraction. Genistein reduced the first contraction induced by acetylcholine chloride, but did not affect the second contraction caused by CaCl2.
CONCLUSIONS: Genistein relaxed smooth muscle isolated from the gallbladder of guinea pigs and this might contribute to the formation of gallstones. The inhibitory action might be related to H2 receptors and the release of intracellular Ca2+ from sarcoplasmic reticulum. Replacing traditional estrogen with phytoestrogen to treat menopause syndromes may increase the risk of gallstone formation.

BACKGROUND: CA19-9 is a carbohydrate tumor-associated antigen which is frequently upregulated in pancreatobiliary neoplasia. However, it may also be elevated in patients with jaundice in the absence of a tumor due to biliary obstruction, and in other non-hepato-pancreatico-biliary conditions. This study aimed to evaluate whether CA19-9 levels could accurately differentiate between benign and malignant pancreatobiliary disease.
METHODS: All patients referred to a single surgeon for investigation of pancreaticobiliary disease in 2003 in whom a firm diagnosis had been established were included. For malignant disease, a histological diagnosis was required but for benign disease a firm radiological diagnosis was deemed adequate. The patients were divided into 4 categories: pancreatic adenocarcinoma (PCa); cholangiocarcinoma (CCa); chronic pancreatitis (CP) and biliary calculous disease (Calc). Bilirubin and alkaline phosphatase levels corresponding to the point of assessment of CA19-9 were also noted.
RESULTS: Final diagnoses were made of pancreatic adenocarcinoma (PCa, n=73), cholangiocarcinoma (CCa, n=19), ampullary carcinoma (Amp, n=7), neuroendocrine carcinoma (Neu, n=4), duodenal carcinoma (Duo, n=3), chronic pancreatitis (CP, n=115), and biliary calculous disease (Calc, n=27). Median CA19-9 levels (U/ml) were: PCa, 653; CCa, 408; Duo, 403; Calc, 27; CP, 19; Neu, 10.5; Amp, 8 (reference range: 0-37). The CA19-9 levels were significantly greater for malignant than for benign disease, could differentiate PCa from CCa/Duo, and were significantly higher in unresectable than in resectable PCa. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for CA19-9 were 84.9%, 69.7%, 67.7% and 86.1%, respectively. A ROC analysis provided an area under the curve for CA19-9 of 0.871 (0.820-0.922), giving an optimal CA19-9 of 70.5 U/ml for differentiating benign from malignant pathology. Using this cut-off, the sensitivity was 82.1%, while specificity, PPV and NPV improved to 85.9%, 81.3% and 86.5%, respectively. When standard radiology was included (US/CT/MRCP) in the decision process, the results improved to 97.2%, 88.7%, 86.6%, and 97.7%. For benign disease, the CA19-9 correlated directly with the serum bilirubin, but for malignant disease, CA19-9 levels were elevated independent of the bilirubin level.
CONCLUSIONS: CA19-9 is useful in the differentiation of pancreatobiliary disease and when using an optimized cut-off and combining with routine radiology, the diagnostic yield is improved significantly, thus stressing the importance of a multi-disciplinary approach to pancreatobiliary disease.

BACKGROUND: Myeloperoxidase (MPO) has been implicated in promoting tissue damage in various inflammatory diseases. However, MPO blood levels in relation to the severity of acute pancreatitis (AP) and its time-course have not been studied. The present study aimed to determine the role of MPO in AP.
METHODS: We studied 86 patients with AP (48 patients with mild and 38 with severe pancreatitis) and 18 controls (volunteers). The relations of serum MPO levels to cytokine level, severity, and time-course of pancreatitis were studied. The serum level of MPO and cytokines were measured by MPO-EIA and cytokines ELISA, respectively.
RESULTS: The highest level of MPO was noted at the first day in patients with severe AP. A decrease of MPO blood level occurred during the first three days in all patients with necrotizing pancreatitis. The development of pancreatitis-associated lung injury and purulent complications was accompanied by increased MPO levels. Administration of pentoxifylline significantly reduced the MPO blood level, which was clearly correlated with the levels of proinflammatory cytokines in the two groups of patients.
CONCLUSIONS: The results of the present study showed the MPO blood level is dependent on the severity of AP and on cytokine blood levels. Pentoxifylline in the complex management of severe AP may improve the results of treatment.

BACKGROUND: Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting. Although there are some procedures to retrieve the migrated stent, including surgical, percutaneous, and endoscopic approaches, endoscopy should be attempted first because it is least invasive. This study set out to evaluate the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents.
METHODS: Plastic stents that migrated in the bile duct (35 patients) or pancreatic duct (2) were retrieved with endoscopic retrograde cholangiopancreatography. Devices used were snare forceps, a basket catheter, grasping forceps, biopsy forceps, a balloon catheter, and the Soehendra stent retriever.
RESULTS: Endoscopic retrieval of migrated stents was performed successfully in 36 (97.0%) of the 37 patients. The devices utilized for successful treatment were basket catheter (13 patients), grasping forceps (10), snare forceps (8), balloon catheter (3), biopsy forceps (1), and the Soehendra stent retriever (1). The unsuccessfully treated patient with chronic pancreatitis underwent surgery since the guide wire did not move forward due to bile duct stenosis, and there was also duodenal stenosis. One patient developed mild pancreatitis after withdrawal of the stent; the pancreatitis was relieved with conservative treatment.
CONCLUSIONS: Endoscopic retrieval of migrated biliary and pancreatic stents appears to be useful because of its safety and low invasiveness. However, various forceps should be prepared for the retrieval of a migrated stent.

Echinococcosis is a severe helminthic zoonosis largely caused by Echinococcus granulosus and frequently encountered in endemic areas. The liver and lung are the most frequently involved organs. Cyst rupture into the peritoneal cavity represents a rare but serious complication. Herein, we describe an acute occurrence of anaphylactic shock due to a spontaneous rupture of hydatid cyst in a 21-year-old Turkish patient unwittingly infected by Echinococcosis. Resection surgery of the perforated cyst in combination with cleaning of the abdominal cavity was performed. The patient rapidly improved and no relapse occurred during a follow-up of 8 months. Anaphylaxis is a serious complication of hydatid cyst rupture and needs to be promptly diagnosed. The main objective of our report is to underscore this life-threatening complication that should be considered when anaphylactic shock of unknown origin occurs, even in non-endemic regions. Moreover, we emphasize the need for a radical surgical approach to avoid widespread dissemination.

BACKGROUND: Carcinoid tumors of the extrahepatic biliary tree are extremely rare malignancies, accounting for 0.2%-2% of all gastrointestinal carcinoid tumors, while carcinoids of the cystic duct are an uncommon entity and an extremely unusual cause of bile duct obstruction.
METHODS: After an extensive literature review, we retrospectively analysed 61 cases of carcinoid tumor of the biliary tree as well as one additional case of a 60-year-old female with symptoms and laboratory/imaging examination findings compatible with those of a malignant biliary tract obstruction. At laparotomy, resection of the gallbladder and common bile duct was performed. Histological study revealed a well-differentiated neuro-endocrine carcinoma of the cystic duct. The patient remained disease-free at 16 months.
RESULTS: Our presentation is the seventh case reported in the world literature. Compared to cholangiocarcinoma, analysis of the reviewed group indicates an increased incidence of extrahepatic carcinoid tumors in younger persons along with a slight female predominance. Statistically, the most common anatomic location is the common bile duct, followed by the perihilar region and the cystic duct. Jaundice is the most common finding. Curative surgery was realized in the majority of cases and long-term disease-free survival was achieved when surgery was curative.
CONCLUSIONS: Carcinoid tumors obstructing the biliary tree are extremely difficult to diagnose preoperatively, and nearly impossible to differentiate from non-neuroendocrine tumors. As surgery offers the only potential cure for both biliary carcinoids and cholangiocarcinoma, we recommend aggressive surgical therapy as the treatment of choice in every case of potentially resectable biliary tumor.

BACKGROUND: Choledochal cysts in adults are more commonly associated with complications such as cystolithiasis, recurrent cholangitis, portal hypertension and malignancy, than in the pediatric age group.
METHOD: We report a case of adult choledochal cyst with long-term complication of large stone cast and portal hypertension due to secondary biliary cirrhosis.
RESULTS: A 50-year-old patient presented with obstructive jaundice and hepatosplenomegaly. On investigation, she was diagnosed as having a choledochal cyst with large stone cast and portal hypertension. Single stage resection of the choledochal cyst with Roux-en-Y hepaticojejunostomy was done by meticulous dissection and ligation of collaterals.
CONCLUSION: Single stage resection of a choledochal cyst is possible in spite of associated portal hypertension, if the portal vein is patent.

BACKGROUND: Obstructive jaundice caused by an intraductal hepatocellular carcinoma is a rare initial symptom. We report a rare case of an extrahepatic icteric type hepatocellular carcinoma.
METHODS: A 75-year-old patient was admitted to our hospital because of obstructive jaundice 3 months after resection of multilocular hepatocellular carcinoma. A postoperative bile leakage was treated by placement of a decompressing stent in the common bile duct. Endoscopic retrograde choledochoscopy showed extended blood clots filling the bile duct system and computed tomography revealed a local swelling in the common extrahepatic bile duct. The level of alpha-fetoprotein (AFP) was only slightly elevated but that of CA19-9 was dramatically increased. Cholangiography showed an intraductal filling defect typical of a cholangiocellular carcinoma.
RESULTS: Bile duct brushing cytology showed no cholangiocellular carcinoma but hepatocellular carcinoma cells in the extrahepatic bile duct. An extrahepatic bile duct resection was performed. Histological examination confirmed the diagnosis of extrahepatic intraductal growth of hepatocellular carcinoma.
CONCLUSION: Ectopic hepatocellular carcinoma is a rare but important differentially diagnosed of extrahepatic bile duct filling defect.

BACKGROUND: Autoimmune pancreatitis (AIP) is a unique chronic inflammation of the pancreas in which autoimmune mechanisms are involved in the pathogenesis. It is characterized by clinical, histopathological, radio-graphic, serologic and therapeutic features. Since it was first described in 1995, increasing numbers of AIP patients have been diagnosed.
METHODS: In this study, the data from 2 patients with AIP who had elevation of serum immunoglobulin G, positive autoantibody, swelling of the pancreas and narrowing of the main pancreatic duct on imaging were analyzed retrospectively.
RESULTS: With the initial diagnosis of AIP, both patients underwent regular prednisone therapy, which was initiated at a dose of 40 mg per day with a tapering schedule of 5 mg every 2 weeks. The patients responded very well to treatment with prednisone.
CONCLUSIONS: AIP is a relatively new disease entity. Although it is diagnosed by distinct characteristics of the clinical, radiologic, histopathologic, and serologic findings, many questions require further clarification, including its relationship to other autoimmune diseases and misdiagnosis as pancreaticobiliary malignancies.

BACKGROUND: Viral hepatitis B accounts for over 80% of acute hepatic failures in China and the patients die mainly of its complications. A patient with hepatic failure and fever is not uncommon, whereas repeated fever is rare.
METHODS: A 32-year-old female was diagnosed with subacute hepatic failure and hepatitis B viral infection because of hyperbilirubinemia, coagulopathy, hepatic encephalopathy, serum anti-HBs-positive without hepatitis B vaccination, and typical intrahepatic pathological features of chronic hepatitis B. Plasma exchange was administered twice and she awoke with hyperbilirubinemia and discontinuous fever.
RESULTS: Urethritis was confirmed and medication-induced fever and/or spontaneous bacterial peritonitis (Gram-negative bacillus infection) was suspected. The patient was treated with antibiotics, steroids and a Chinese herbal medicine, matrine, for three months and she recovered.
CONCLUSION: The survival rate of patients with hepatic failure might be improved with comprehensive supporting measures and appropriate, timely management of com-plications.