BACKGROUND: Liver transplantation is an effective treatment for end-stage liver disease, but a huge gap remains between the number of people who need a liver transplant and the number of organs available. In order to maximize donor organ access for adult and pediatric recipients, novel surgical and liver replacement procedures have evolved. Newer surgical techniques include split cadaveric liver transplantation and living donor liver transplantation (LDLT). With marginal and abnormal donor livers, despite tremendous advances in surgical technology, individual surgical procedure can not be completely brought into play unless effective measurements and basal studies are undertaken.
DATA SOURCES: A literature search of MEDLINE and the Web of Science database using "liver transplantation" and  "expanding donor pool" was conducted and research articles were reviewed.
RESULTS: Therapies directed toward scavenging O2-, inhibiting nicotinamide adenine dinucleotide phosphate oxidase, and/or immuno-neutralizing tumor necrosis factor-alpha may prove useful in limiting the liver injury induced by surgical procedures such as split liver transplantation or LDLT. Improved donor organ perfusion and preservation methods, modulation of inflammatory cytokines, energy status enhancement, microcirculation amelioration, and antioxidant usage can improve non-heart beating donor liver transplantation. Effective measures have been taken to improve the local conditions of donor cells with steatosis, including usage of fat-derived hormone and inflammatory mediators, ischemic preconditioning, depletion of Kupffer cells, and cytokine antibody and gene therapy. Double-filtration plasmapheresis can effectively reduce HCV viremia and prevent HCV recurrence in patient with high HCV RNA levels after LDLT.
CONCLUSIONS: Shortage of grafts and poor function of marginal and abnormal donor grafts put many patients at risk of death in waiting for liver transplantation. Advances in surgical technology, combined with improvement and breakthroughs in basic studies hold a promise in expanding the liver donor pool.

BACKGROUND: Ciliated foregut cysts of the liver are rare, with only 96 cases diagnosed since the first description in 1857. They are being increasingly diagnosed recently; the majority of the cases have been reported in the last 15 years. Although they bear a close resemblance to the simple cyst of the liver which has essentially a benign course, ciliated hepatic foregut cysts (CHFCs) can progress to malignancy with devastating consequences. It is imperative that this group of conditions be diagnosed and treated adequately.
DATA SOURCES: This review includes discussion of the data from all the 96 reported cases from English and non-English literature. Analysis of the incidence rates, embryogenesis, growth, clinical features, risk of malignancy and the prognosis are highlighted systematically. The roles of various diagnostic modalities including ultrasound, CT, MRI, fine needle aspiration cytology (FNAC), immunohistochemistry and surgery are further discussed.
RESULTS: The mean age of patients with CHFC was 48±12 years. The male/female ratio was 1.1:1. The majority of patients with CHFC (62%) were asymptomatic, and the common mode of presentation was right upper abdominal pain. The cysts occurred in the left lobe in 51 patients, with sole location in segment Ⅳ in 44, and in the right lobe in 26. The average size of the cysts was 3.6±2.12 cm. The majority of the cysts were unilocular, and only 7 cases were multilocular. Cyst contents were described as viscous or mucinous in 73 patients, whereas bilious fluid was noted in 3. Large cysts having squamous carcinoma were cited in 3 patients, and 2 had extensive squamous metaplasia without malignancy. Others had benign histopathology.
CONCLUSIONS: Clinicians have become increasingly aware of CHFC. Imaging alone is not diagnostic per se, but when considered in the context of the global picture does provide important clues to the diagnosis. FNAC is diagnostic by the presence of the ciliated columnar aspirate but lacks sensitivity. Infantile presentation is usually accompanied by biliary communication and mandates a different surgical approach. The demonstration of malignant transformation in 3 cases and its fatal course emphasizes the need for surgical resection in all cases once the diagnosis is made.

BACKGROUND: Liver resection after liver transplantation is a relatively uncommon procedure. Indications for liver resection include hepatic artery thrombosis (HAT), non-anastomotic biliary stricture (ischemic biliary lesions), liver abscess, liver trauma and recurrence of hepatocellular carcinoma (HCC). Organ shortage and lower survival after re-transplantation have encouraged us to make attempts at graft salvage.
METHODS: Eleven resections at a mean of 59 months after liver transplantation were made over 18 years. Indications for liver resection included HCC recurrence in 4 patients, ischemic cholangiopathy, segmental HAT, sepsis and infected hematoma in 2 each, and ischemic segment Ⅳ after split liver transplantation in 1.
RESULTS: There was no perioperative mortality. Morbidity included one re-laparotomy for small bowel perforation, one bile leak treated conservatively, one right subphrenic collection, one wound infection and 5 episodes of Gram-negative sepsis. One patient underwent re-transplantation 4 months after resection for chronic rejection. There were 3 deaths, two from HCC recurrence and one from post-transplant lymphoproliferative disorder. The overall mean follow-up after resection was 48 months.
CONCLUSIONS: Liver resection in liver transplant recipients is safe, and has good outcome in selected patients and avoids re-transplantation in the majority of patients. Recipients with recurrent HCC in graft may benefit from resection, but cure is uncommon.

BACKGROUND: Hepatitis B virus (HBV) is encountered sporadically the year round in Bangladesh. It results in a wide range of liver diseases, with asymptomatic acute hepatitis at one end to hepatocellular carcinoma (HCC) at the other end of the spectrum.
METHODS: All 1018 individuals of different age groups and sex with varied religious, educational and social backgrounds were tested for HBsAg by ELISA. The positive samples were further tested by ELISA for HBeAg. Before testing, blood samples were preserved at -20 ℃. The study was conducted in a semi-urban location on the outskirts of Dhaka.
RESULTS: Of the 1018 individuals, 5.5% tested positive for HBsAg. None were tested positive for anti-HCV. Among the HBsAg-positive population, 58.93% were HBeAg-positive and the rest 41.07% HBeAg-negative. There was a male predominance and those who were tested positive were mostly between 16 and 50 years of age. Major risk factors for exposure to HBV appeared to be injudicious use of injectable medications, treatment by unqualified, traditional practitioners, mass-vaccination against cholera and smallpox, barbers and body piercing.
CONCLUSION: HBV remains a major cause of morbidity and mortality in Bangladesh and we have a long way to go before we may bid farewell to this deadly menace.

BACKGROUND: Small-for-size (SFS) syndrome is an important clinical problem after living donor liver transplantation, split liver transplantation or extended hepatectomy. The uncertainty of the mechanisms and treatments of SFS syndrome urges surgeons to establish effective models for SFS syndrome.
METHODS: A new porcine model for SFS syndrome based on extended hepatectomy was established. Portal pressure gradient was observed before and after the surgery, and venous sampling for estimation of alanine aminotransferase, total bilirubin, and international normalized ratio was continued on a daily basis.
RESULTS: Although the external morphology of the porcine liver differs from that of human being, segmental anatomy is remarkably similar in term of its vascularity and biliary tree. Extended hepatectomy with segments I and VII as resection remnant (about 20% of total liver volume) resulted in similar survival rates, blood liver function tests, and elevated portal pressure gradient as clinical SFS syndrome.
CONCLUSIONS: The extended hepatectomy based new model can easily be reproduced, with few costs and surgical complications. Clinical SFS syndrome can easily be simulated by this new model, which is a useful tool for studying SFS syndrome-related liver injuries, especially portal overperfusion and hypertension.

BACKGROUND: Recent studies show that mesenchymal stem cells (MSCs) have immunomodulatory properties. They suppress the immune response to alloantigen and modify the proliferation of T cells. CD4⁺CD25⁺ regulatory T cells have strong immunomodulatory potential. However, little is known about the effects of rat MSCs (rMSCs) on the development of regulatory T cells.
METHODS: MSCs were obtained from bone marrow of male Sprague-Dawley rats, and co-cultured with CD3⁺ T cells from allogeneic spleen cells. The proportion of CD4⁺CD25⁺ regulatory T cells was analyzed by flow cytometry. To further confirm the immunosuppressive activity of rMSCs, we used MTT assay and flow cytometry of CD3⁺ T cells to investigate the proliferative responses of CD3⁺ T cells to mitogenic stimuli. Enzyme-linked immunosorbent assay was performed to detect alterations of the cytokines TNF-α, TGF-β and IL-10.
RESULTS: The proliferation of CD3⁺ T cells decreased when co-cultured with rMSCs, and the degree of inhibition was concentration-dependent. The percentage of CD4⁺CD25⁺ regulatory T cells increased when CD3⁺ T cells were co-cultured with different concentrations of rMSCs. The levels of pro-inflammatory cytokine (TNF-α) decreased while anti-inflammatory (TGF-β, IL-10) cytokines increased in mixed lymphocyte reaction.
CONCLUSIONS: rMSCs inhibit allogeneic T cell proliferation in mixed cell cultures. This immunosuppressive effect seems to be mediated by inducing the generation of CD4⁺CD25⁺ regulatory T cells and soluble factors.

BACKGROUND: Survivin is a new and important gene in the regulation of apoptosis. It is very important to explore the effect of the expression of survivin protein caused by ischemia-reperfusion (IR) injury. The effect of IR injury caused by ischemic preconditioning (IP) on the liver in rats and the relation between the protective effect of IP and the expression of survivin are unclear.
METHODS: One hundred and fifty male Wistar rats (weighing 190-210 g, aged 6-7 weeks) were divided into three groups at random: ischemic preconditioning (IP), ischemia-reperfusion (IR) and sham-operation (SO). Sample specimens were collected from each group at 6, 12, 24, 48, and 72 hours after reperfusion. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were measured by an automatic biochemical analyzer. Malondialdehyde (MDA) in liver tissue was measured. Pathological changes in the liver and immunohistochemical staining for survivin were determined with an optical microscope.
RESULTS: The ALT levels in the IP and IR groups after reperfusion at each time were higher than those in the SO group (P<0.05), whereas after reperfusion for 6 and 12 hours, the ALT levels in the IP group were lower than those in the IR group (P<0.05). The AST levels in all IP and IR groups were higher than those in the SO group (P<0.05), whereas after reperfusion for 12, 24, 48 and 72 hours, the AST levels in the IP group were lower than those in the IR group (P<0.05). The MDA concentrations after reperfusion in the IP group were lower than those in the IR group (P<0.05), though the MDA concentrations in the IP and IR groups increased in contrast to those in the SO group after reperfusion at each time (P<0.05). After reperfusion for 12, 24, 48 and 72 hours, the number of survivin-positive cells was larger in the IP and IR groups than in the SO group (P<0.05). After reperfusion for 12, 24, and 48 hours the number of survivin-positive cells in the IP group increased compared with that in the IR group (P<0.05).
CONCLUSIONS: IR increases the protein expression of survivin in liver tissue. IP inhibits the accumulation of MDA, advances the expressive phase of survivin protein in hepatic tissue, and improves liver function.

BACKGROUND: Currently, one of the tough problems for the application of bioartificial liver (BAL) is the shortage of suitable hepatocytes. There are reports on different types of BAL assistance developed with porcine hepatocytes and HepG2 C3A cells, but their defects are obvious. In recent years, some studies focus more on liver cells with features of human origin and improved detoxification. In this study, a hepatocyte line with high expression of human glutamine synthetase (hGS) was raised and its capacity for ammonia metabolism was investigated. 
METHODS: hGS cDNA and alpha-fetoprotein transcription regulatory element (AFP-TRE) were cloned with the designed primers. The eukaryotic expression vectors, pLNChGS and pLNAFhGS, were constructed and transfected into PA317 cells. Recombinant retroviruses (Retro-hGS and Retro-AFhGS) were produced and then infected into HepG2 cells. G418-resistant cell clones, HepG2/pLNChGS and HepG2/pLNAFhGS, were selected and amplified. Then hGS mRNA was measured by semi-quantitative RT-PCR; hGS enzymatic activity and ammonia metabolism analysis in different concentration of NH₄⁺ were detected with a quantitative biochemistry kit. The cell proliferation was also detected by MTT chromatometry.
RESULTS: The expression of hGS mRNA in HepG2/pLNChGS cells (8.306±0.336) and HepG2/pLNAFhGS cells (21.358±1.716) was much stronger than in control cells (P<0.05), and that in HepG2/pLNAFhGS cells was markedly stronger than in HepG2/pLNChGS cells (P<0.05). The hGS enzymatic activities of HepG2/pLNChGS cells (3.279±0.328 U/mg prot) and HepG2/pLNAFhGS cells (4.557±0.253 U/mg prot) were higher than those of control cells (P<0.05), and those of HepG2/pLNAFhGS cells were also higher than the activities of HepG2/pLNChGS cells (P<0.05). In addition, the effect of hGS introduction on HepG2 cell proliferation was not significant. The amount of glutamine synthesis in HepG2/pLNChGS or HepG2/pLNAFhGS cells in three different concentrations of NH₄⁺ was higher than in the two control cells (P<0.05). The amount of glutamine synthesis and cell proliferation in the higher concentrations of NH₄⁺ (5 or 10 mmol/L) in HepG2/pLNAFhGS cells increased more than those in HepG2/pLNChGS cells (P<0.05). NH₄⁺ at a high concentration (10 mmol/L) was toxic to HepG2 and HepG2/pLNCX cells, but less toxic to HepG2/pLNChGS and HepG2/pLNAFhGS cells.
CONCLUSION: The constructed hepatocytes (HepG2 cells) with specific high-expression of hGS have a powerful ability to degrade ammonia in vitro, and provide necessary experimental data for the selection of biomaterials in BAL.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) with placement of a biliary stent or nasobiliary (NB) drain is the procedure of choice for treatment of post-cholecystectomy bile duct leaks. The aim of this study was to compare the effect of NB drainage versus internal biliary stenting on rates of leak closure, time elapsed until drain or stent removal, length of hospital stay and number of required endoscopic procedures.
METHODS: Charts were reviewed on 20 patients who underwent laparoscopic cholecystectomy complicated by Luschka or cystic duct leak. Ten patients were treated with NB drains connected to low intermittent suction and repeat NB cholangiograms were performed until leak closure was observed. Ten patients were treated with internal biliary stents. Biliary sphincterotomies were performed for stone extraction or a presumed papillary stenosis. Large bilomas were drained percutaneously prior to stenting.
RESULTS: In all 20 patients, a cholangiogram and successful placement of a NB drain or internal stent was achieved. Four patients (20%) were found to have bile duct stones, which were extracted following a sphincterotomy. Sixteen patients required percutaneous drains to evacuate large bilomas prior to biliary instrumentation. Fifteen cystic duct leaks and 5 Luschka duct leaks were reviewed. There were no complications related to ERCP. Closure of the leak was documented within 2 to 11 days (mean 4.7±0.9 days) in patients receiving a NB drain. The drains were removed non-endoscopically following leak closure. The internal stent group required stenting for 14 to 53 days (mean 29.1±4.4 days). The stent was then removed endoscopically after documentation of leak closure. Bile leaks following laparoscopic cholecystectomy closed rapidly after NB drainage and did not require repeat endoscopy for removal of the NB drain, resulting in fewer ERCPs required for treatment of biliary leaks. Internal biliary stents were in place longer owing to the nature of this intermittent endoscopic approach but an accurate comparison of time to leak closure could not be determined. Leak closure resulted once the bile flow was re-established, regardless of the technique, but removal of the NB drains was performed earlier than removal of the biliary stents. The number of ERCPs required per patient was 1.0±0 in the NB group and 2.2±0.1 (range 2-3) in the internal stent group. The length of hospitalization was 8.7±3.3 days for the NB group and 7.5±2.3 days for the internal stent group. Biliary stent placement resulted in an insignificant decrease in hospitalization at the expense of generating twice as many endoscopic procedures.
CONCLUSIONS: Our data suggest that NB drainage may be advantageous in patients requiring a prolonged hospital admission or in patients in whom repeat endoscopy is undesirable. Internal biliary stenting appears preferable when early discharge is anticipated or when expertise in placement and management of NB drains is lacking.

BACKGROUND: Few studies have assessed microflora and their antibiotic sensitivity in normal bile and lithogenic bile with different types of gallstones. 
METHODS: We performed a case control study of 70 bile samples (35 cholesterol and 35 pigment stones from 51 females and 19 males, aged 21-72 years with a median age of 37 years) from patients who underwent laparoscopic cholecystectomy for uncomplicated cholelithiasis, and 20 controls (14 females and 6 males, aged 33-70 years with a median age of 38 years) who underwent laparotomy and had no gallbladder stone shown by ultrasound scan. The bile samples were aerobically cultured to assess microflora and their antibiotic susceptibility. The procedures were undertaken under sterile conditions. 
RESULTS: Thirty-eight (54%) of the 70 patients with gallstones had bacterial isolates. Nine isolates (26%) were from cholesterol stone-containing bile and 29 isolates (82%) from pigment stone-containing bile (P=0.01, t test). Twenty-eight of these 38 (74%) bile samples were shown positive only after enrichment in brain heart infusion medium (BHI) (P=0.02, t test). The overall bacterial isolates from bile samples revealed E. coli predominantly, followed by P. aeruginosa, Enterococcus spp., Klebsiella spp. and S. epidermidis. There were no bacterial isolates in the bile of controls after either direct inoculation or enrichment in BHI. 
CONCLUSIONS: Bacterial isolates were found in pigment stone-containing bile. Non-lithogenic bile revealed no bacteria, showing an association between gallstone formation and the presence of bacteria in bile. Antibiotic sensitivity patterns of isolated organisms were similar irrespective of the type of stone.

BACKGROUND: Some patients with chronic pancreatitis (CP) may require surgery mainly because of intractable pain, suspicion of malignancy, or complications related to CP. This study aimed to analyze the efficacy of surgical treatment for patients with CP in terms of pain relief, control of local complications, and pancreatic endocrine/exocrine function.
METHODS: Twenty-six patients with CP were treated surgically at our hospital from June 1985 to November 2005. The clinical data of these patients were analyzed retrospectively.
RESULTS: The follow-up time ranged from 8 to 130 months with a median of 60.6 months. No patients were lost to follow-up. All patients had improvement of clinical symptoms such as abdominal pain, steatorrhea and weight loss, to some degree, especially pain relief in patients with good dilation and high pressure of the main pancreatic duct. The endocrine and exocrine functions were not alleviated in all patients, otherwise the impaired glucose tolerance was improved in 8 (30.8%), 15 (57.7%) maintained the same body weight, one (3.8%) had an acute attack of CP, and 2 (7.7%) developed pancreatic carcinoma in the 16th and 28th month postoperatively and died within 3 years after operation for CP. The 1-, 3-, 5-year pain-free rates of CP patients were 96.2% (25/26), 88.5% (23/26) and 84.6% (22/26), respectively.
CONCLUSIONS: In selected patients with CP, surgical treatment is a safe procedure and can effectively relieve pain and control local complications; also, it is helpful to improve the quality of life for patients with pancreatitis, and to control the development of this disease.

BACKGROUND: Appropriate palliation for unresectable pancreatic head cancer is most important. This study was undertaken to compare the survival of patients with biliary obstruction caused by unresectable pancreatic head cancer after surgical and non-surgical palliation.
METHODS: We retrospectively reviewed 69 patients who underwent palliative treatment for unresectable pancreatic head cancer. Fifty-two patients with locally advanced disease (local vascular invasion) and 17 with distant metastatic disease were included. The patients were divided into two groups, surgical and non-surgical palliation.
RESULTS: Thirty-eight patients underwent biliary bypass surgery and 31 had percutaneous transhepatic biliary drainage (PTBD). There was no significant difference in the early complications, successful biliary drainage, recurrent jaundice, and 30-day mortality between surgical palliation and PTBD. However, in 52 patients whose tumor was unresectable secondary to local vascular invasion, the rate of recurrent jaundice after successful surgical biliary palliation was lower than that in patients who had non-surgical palliation (P<0.05). The patients who underwent surgical palliation had a longer hospital-free survival rate (P<0.001), although they had a longer postoperative hospital stay (P=0.004) during the first admission period.
CONCLUSIONS: In patients with preoperative evaluations showing potentially resectable tumors and/or no metastatic lesions, surgical exploration should be performed. Thus, in patients who have unresectable cancer or limited metastatic disease on exploration, surgical palliation should be performed for longer survival and better quality of survival.

BACKGROUND: Ampullary carcinoma is a neoplasia with a good prognosis compared to pancreatic cancer. But it is difficult to early diagnose because it lacks clear clinical symptoms. This study aimed to evaluate the efficacy of abdominal ultrasonography (US), enhanced computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in detecting ampullary carcinoma.
METHODS: Forty-one patients with ampullary carcinoma who had been confirmed pathologically among the inpatients at the First Affiliated Hospital of Zhejiang University School of Medicine from February 2003 to March 2007 were analyzed retrospectively. The accuracy of US, CT, MRCP and ERCP were compared in the diagnosis of ampullary carcinoma.
RESULTS: The accurate rate for detection of ampullary carcinoma with US was 26.83%. The accuracy of CT and ERCP in detection of ampullary tumors was 84.62% and 100%, respectively, which were significantly higher than that of US (P<0.05). The accuracy of MRCP in detection of ampullary tumors was similar to that of US in spite of visualization of obstruction and dilatation of the pancreaticobiliary duct with MRCP.
CONCLUSIONS: Because of the obscure and late onset of symptoms, ampullary carcinoma is difficult to diagnose early. Multiple imaging techniques should be carried out appropriately in order to early diagnose the disease and improve the prognosis.

BACKGROUND: In right liver living donor liver trans-plantation, hepatic venous anastomosis is performed using the recipients right hepatic vein orifice. There may be situations that the portal vein is short or the right liver graft is small, leading to difficulty in portal vein, hepatic artery or duct-to-duct anastomosis.
METHODS: The recipients right hepatic vein orifice is closed partially for 2 cm at the cranial end or totally, and a new venotomy is made caudal to the right hepatic vein orifice. Hepatic vein anastomosis is performed with the new venotomy.
RESULTS: The distance between the liver graft hilum and hepatoduodenal ligament is reduced. Portal vein, hepatic artery and biliary anastomosis could be performed without tension or conduit.
CONCLUSION: Caudal shifting of hepatic vein anasto-mosis facilitates implantation of a right liver living donor graft.

BACKGROUND: An intussusception is the invagination of one segment of the intestine into another. It is more common in children, but a rare clinical entity in adults, where the condition is almost always caused by tumors.
METHODS: A 51-year-old female presented with symptoms of gastric outlet obstruction associated with significant weight loss, but no jaundice. Routine hematological and biochemical investigation, including tumor markers, were normal. Abdominal ultrasound revealed duodenojejunal intussusception, and subsequent CT of the abdomen confirmed it.
RESULTS: She underwent a laparotomy, which confirmed duodenojejunal intussusception. On reducing the intussusception and performing a duodenotomy, a periampullary mass was confirmed. Hence, she underwent a pylorus-preserving pancreaticoduodenectomy. Histology confirmed periampullary adenocarcinoma.
CONCLUSIONS: Adult intussusceptions are mostly caused by tumors. Contrast CT is the investigation of choice, although ultrasound can be used. One should have a low threshold for suspecting malignancy, obtain frozen section histology, and seek appropriate help at an early stage.