BACKGROUND: Pancreatic cancer is an aggressive malignancy with a dismal prognosis. Radical surgery provides the only chance for a cure with a 5-year survival rate of 7%-25%. An effective adjuvant therapy is urgently needed to improve the surgical outcome. This review describes the current status of adjuvant therapy for pancreatic cancer, and highlights its controversies.
DATA SOURCES: A Medline database search was performed to identify relevant articles using the keywords "pancreatic neoplasm", and "adjuvant therapy". Additional papers were identified by a manual search of the references from the key articles.
RESULTS: Eight prospective randomized controlled trials (RCTs) on the use of adjuvant chemotherapy and chemoradiation for pancreatic cancer could be identified. The results for adjuvant regimens based on systemic 5-fluorouracil with or without external radiotherapy were conflicting. The recent two RCTs on gemcitabine based regimen gave promising results.
CONCLUSIONS: Based on the available data, no standard adjuvant therapy for pancreatic cancer can be established yet. The best adjuvant regimen remains to be determined in large-scale RCTs. Future trials should use a gemcitabine based regimen.

BACKGROUND: Living donor liver transplantation (LDLT) has been increasingly used to treat hepatic tumors worldwide in recent years, and is currently the most effective alternative to deceased donor liver transplantation to overcome the problem of organ shortage. LDLT has played an enormous role in treating early malignant hepatic tumors. But the indication of LDLT for malignant hepatic tumors is based on indefinite criteria. This review summarizes the recent studies in LDLT for treating malignant hepatic tumors.
DATA SOURCES: A literature research of the PubMed database was conducted and research articles were reviewed.
RESULTS: The current data on LDLT for malignant hepatic tumors, combined with our hospital experience, indicated that if a patient with hepatocellular carcinoma (HCC) who meets with the conventional Milan criteria cannot undergo tumor resection because of poorly preserved liver function, and a cadaveric graft is difficult to obtain within six months, LDLT may be selected. In a patient with recurrence of HCC after conventional therapies, feasibility, optimal timing, and efficacy of LDLT as a second-line treatment should be determined.
CONCLUSIONS: Tumor recurrence is related to the biological behavior and staging of the tumor. New immunosuppressors which have anti-tumor effects and inhibit the immune system need to be developed. The indications of LDLT for hepatic malignant tumors should be selected meticulously.

BACKGROUND: The objective of this article is to review the literature and discuss the various tools used in hepatobiliary surgery for the measurement of health related quality of life (HR-QOL) and highlight various outcome variables that affect the HR-QOL among patients with common hepatobiliary disorders.
DATA SOURCES: We reviewed HR-QOL articles published in the last 20 years on different hepatobiliary curative or palliative procedures in all languages.
RESULTS: HR-QOL is a questionnaire tool which is utilized to assess the changes in the health status of patients after a hepatobiliary intervention. These surveys are of increasingly importance, as health care providers are challenged to justify treatment approaches and rationale for any surgical intervention. These HR-QOL tools are very helpful for the evaluation of subjective outcome of common hepatobiliary procedures like gastrointestinal quality of life index (GIQLI) for cholecystectomy, functional assessment in cancer therapy (FACT) for liver resection, short form 36 (SF-36) for liver transplantation, and quality of life questionnaire for patients with pancreatic cancer (QLQ-PAN).
CONCLUSIONS: Use of validated and reliable health instruments in hepatobiliary surgery is directed at measuring the impact in a reproducible and valid fashion. Curative or palliative procedures should be offered to the patients of hepatobiliary disorders after the assessment by HR-QOL tools. Because the impairments of function that may occur after different operations vary considerably, an operation-specific assessment of HR-QOL for each type of surgical procedure is becoming an essential principle to follow in a successful healthcare system.

BACKGROUND: Cardiac output monitoring is important for critical patients. This study aimed to determine the delayed response of continuous cardiac output (CCO) thermodilution measurement, whether CCO and bolus cardiac output (BCO) thermodilution agree sufficiently to be used interchangeably, and whether CCO monitoring is reliable for patients undergoing liver transplantation.
METHODS: Thirteen patients undergoing liver transplan-tation without veno-venous bypass were studied (37-66 years old, weight 46-75 kg). Continuous and bolus thermodilution measurements were performed at predefined time points using an "Opti-Q" SvO2/CCO monitor (Abbott Laboratories, North Chicago, IL, USA). Bias and 95% limits of agreement were calculated according to Bland and Altman analysis. The limits of agreement by which two methods are judged to be interchangeable were defined in advance as ±(13%×BCOmean) L/min. The repeatability and relative error of CCO, and the differences between CCO and the mean of the two measurements were calculated.
RESULTS: Cardiac output measurements yielded 196 data pairs with ranges of 1.9 to 17.9 L/min for CCO and 2.1 to 18.3 L/min for BCO. The response time of CCO was delayed in the early phases after caval clamping and after reperfusion. At most of the measurement points, bias and 95% limits of agreement were -0.18±1.91 L/min. 95% limits of agreement did not fall within the predetermined limits of agreement of ±1.14 L/min. The repeatability coefficient of CCO was 0.36 L/min and the relative error was 4.6±4.7%. The mean difference between CCO and the average of the two methods was -0.09 L/min (0.49 L/min).
CONCLUSIONS: In patients undergoing liver transplantation, the delayed response of CCO limits its application during the early phases after caval clamping and after reperfusion of the graft. The two methods are not interchangeable even in hemodynamic stability. Continuous thermodilution monitoring, however, is reliable or acceptable for clinical purposes.

BACKGROUND: With the maturation and popularization of skills in liver transplantation (LT), patients with hepatocellular carcinoma (HCC) have an alternative choice. LT as a curative treatment for HCC provides good liver function and systemic condition to recipients. Preoperative tumor characteristics are critical in selecting optimal candidates for LT to optimize the use of donor livers and to achieve a long-term survival. The present study aimed to elucidate the risk factors of HCC involved in fatal recurrence in the first year after LT and to investigate their utility in selecting suitable candidates for LT.
METHODS: From April 2002 to October 2005, 303 patients who had received orthotopic LT for HCC were reviewed. Of these patients, those with diffuse intrahepatic or multiple systemic recurrent lesions who died within 1 year after surgery were investigated as fatal recurrence group (48 patients) and the remaining patients including those who were disease-free without recurrence, those who were alive with recurrence in the first year, or those who died in the first year of other causes, served as control group (255). The two groups were compared by demographics, tumor, and histopathological characteristics for their prognostic significance by logistic regression analysis.
RESULTS: Multivariate analysis between the fatal recurrence group and the control group showed that the presence of vascular invasion, a tumor size greater than 6.5 cm, and a preoperative serum alpha-fetoprotein (AFP) level greater than 1000 µg/L were risk factors for fatal recurrence. Increased risk factors reduced the suitability of candidates for LT and diminished survival in the first year. 85.71% of the patients with all three risk factors, 37.84% of those with two factors, 13.64% of those with one factor, and 6.71% of those without risk factors died from tumor recurrence within 1 year after transplantation.
CONCLUSIONS: Vascular invasion, tumor size ≥6.5 cm, and preoperative serum AFP level ≥1000 µg/L were significant predictors of fatal recurrence after LT for HCC. Patients with two or more risk factors should not be candidates for LT.

BACKGROUND: The incidence of hepaticojejunostomy stricture is 4%-10% in experienced centres. Many access loops have been designed and used to facilitate endoscopic intervention for this complication of hepaticojejunostomy. In this study, we investigated the effectiveness and safety of gastric access loop.
METHODS: A retrospective analysis was conducted on 13 patients who had undergone hepaticojejunostomy with gastric access loop between June 1999 and September 2003. Eleven patients were followed up for a mean period of 51 months (range 20-81 months). Two patients were lost to follow up.
RESULTS: On follow-up, 8 patients had patent jejuno-gastrostomy (end to side anastomosis between Roux loop of jejunum and stomach) and hepaticojejunostomy. Three patients developed stricture of jejunogastrostomy at 41 months, 63 months and 81 months of follow-up. Among these 3 patients, one also had hepaticojejunostomy stricture. In the patient with hepaticojejunostomy stricture, dilatation of jejunogastrostomy stricture was attempted but failed. None of the patients had any evidence of bile gastritis/cholangitis. There was no procedure related morbidity/mortality.
CONCLUSIONS: Further studies involving large numbers of patients are required before wide application of gastric access loop in hepaticojejunostomy though it is a safer option than percutaneous transhepatic manipulations or revision surgery.

BACKGROUND: Pancreas transplantation is currently considered to be the most reliable and effective treatment for insulin-dependent diabetes mellitus (also called type 1 diabetes). With the improvement of microsurgical techniques, pancreas transplantation in rats has been the major model for physiological and immunological experimental studies in the past 20 years. We investigated the surgical techniques of pancreas transplantation in rats by analysing the difference between cervical segmental pancreas transplantation and abdominal pancreaticoduodenal transplantation.
METHODS: Two hundred and forty male adult Wistar rats weighing 200-300 g were used, 120 as donors and 120 as recipients. Sixty cervical segmental pancreas transplants and 60 abdominal pancreaticoduodenal transplants were carried out and vessel anastomoses were made with microsurgical techniques.
RESULTS: The time of donor pancreas harvesting in the cervical and abdominal groups was 31±6 and 37.6±3.8 min, respectively, and the lengths of recipient operations were 49.2±5.6 and 60.6±7.8 min. The time for donor operation was not significantly different (P>0.05), but the recipient operation time in the abdominal group was longer than that in the cervical group (P<0.05). In isograft transplantation without any preconditioning, 1-week survival rates were 93.6% and 86.2% in the cervical and abdominal groups, respectively, and were not significantly different (P>0.05).
CONCLUSIONS: Both pancreas transplantation methods are stable models for immunological and physiological studies in pancreas transplantation. Since each has its own advantages and disadvantages, the designer can choose the appropriate method according to the requirements of the study.

BACKGROUND: Fulminant hepatic failure (FHF) is not uncommon in our clinical practice in Bangladesh. There was a rise in acute hepatitis E virus (HEV) in Bangladesh after the 2004 floods. At that time, most of the country was under water for more than a month, leading to sewage contamination of the water supply. The aim of this study was to investigate the etiology of FHF in Bangladesh.
METHODS: In this retrospective study, 23 patients with FHF who presented with severe impairment of hepatocellular function (i.e. encephalopathy, coagulopathy and jaundice) within 6 months of onset of symptoms were included. There were 17 men and 6 women, aged from 18 to 32 years. Four of the women were pregnant.  Patients were tested for markers for common hepatotrophic viruses. A relevant history was taken and the Patient Record Book of the Unit was reviewed.
RESULTS: 56.52% patients (13/23) had HEV infection, and all were anti-HEV IgM-positive tested by ELISA. HBV infection was detected in 34.78% patients (8/23), all of whom were tested positive for either HBsAg or anti-HBs IgM by ELISA. 8.7% patients (2/23) had a positive history for intake of alcohol and/or drugs.
CONCLUSIONS: Acute HEV infection is the leading cause of FHF in Bangladesh. Sewage contamination of the water supply following floods contributes to a higher incidence of HEV infection. HBV infection is also important.

BACKGROUND: Impairment of liver function is the most serious complication that occurs after liver resection or in cirrhotic liver. Postoperative hepatic failure, which is mainly preceded by insufficient remnant liver function and/or postoperative septic complications, is the major cause of hospital mortality. This study was undertaken to evaluate hepatic segmentectomy combined with major hepatic vein (MHV) resection for preserving the remnant liver lobe in the treatment of resectable primary liver cancer.
METHODS: From 1997 to 2007, six patients with primary liver cancer underwent hepatic segmentectomy with MHV resection, and three patients with hepatic vein injury had ligation of the MHV. The remnant liver lobe was preserved after hepatic segmentectomy combined with MHV resection or ligation.
RESULTS: The preserved liver lobe with normal structure could maintain hepatic function and showed no evidence of atrophy or swelling after hepatic segmentectomy combined with MHV resection or ligation.
CONCLUSIONS: After the right inferior hepatic vein is confirmed, and the MHV is occluded experimentally before hepatic segmentectomy combined with MHV resection, progressively deteriorating congestion does not occur in the preserved segment. Ligation or resection of the two MHVs must be avoided in patients with hepatic cirrhosis who have to undergo hepatic segmentectomy combined with MHV resection. Ligation of the MHV in patients with juxtahepatic vein injury is a simple and effective therapeutic modality.

BACKGROUND: Hepatic fungal infection is difficult to diagnose early because of the lack of related clinical knowledge. In this study, we analyzed the ultrasonic manifestations of hepatic fungal infection, in order to determine the diagnostic value of ultrasonography.
METHODS: In 8 patients with hepatic fungal infection, the results of color Doppler flow images (CDFI) and contrast-enhanced ultrasonography (CEUS) were compared with those of ultrasound-guided biopsy.
RESULTS: In the 8 patients with pathologically proven hepatic fungal infection, 5 showed multiple hypoechoic lesions with unequal sizes in the liver, commonly less than 2 cm in diameter. Some of the hypoechoic lesions showed a hyperechoic strip in the periphery, while a minority showed a "bull's eye" pattern, which is considered a typical manifestation of metastatic hepatic carcinoma. Solitary lesions in the right lobe of the liver were found in the other 3 patients. No blood flow signals were found in any lesions with CDFI. In the lesions a "filling defect" pattern was shown by CEUS, indicating no enhancement in the arterial phase, the portal vein phase and the delayed phase, except for 3 patients, in whom the lesions were slightly enhanced in the periphery during the early arterial phase.
CONCLUSIONS: Hepatic fungal infection is characterized by an ultrasonic manifestation of multiple hypoechoic lesions with inequal size. A small number of lesions may show a characteristic "bull's eye" appearance. Moreover, a "filling defect" pattern on CEUS is helpful to make a correct diagnosis. In addition, ultrasound-guided biopsy is an important method for accurate diagnosis of hepatic fungal infection.

BACKGROUND: Transforming growth factors (TGF)-β1, TGF-βR2 and Smad4 belong to the TGF family, and play important roles in carcinogenesis and the development of carcinoma, especially hepatocellular carcinoma (HCC). TGF-β1 is a multipotent polypeptide, which inhibits the growth of epithelial cells including hepatoma cell lines and hepatocytes by inducing apoptosis. TGF-βR2 forms a heterodimeric complex upon binding to TGF-β, and then generates the first step in the signal transduction pathway leading to growth inhibition in coordination with the type 1 receptor. Smad4 protein is an important mediator in the TGF-β signaling pathway, and negatively regulates the growth of epithelial cells. This study aimed to detect the expression of TGF-β1, TGF-βR2 and Smad4 in HCCs and their adjacent normal tissues, while assessing its relations with the clinicopathological parameters of HCC.
METHODS: Forty-seven HCC specimens and their adjacent normal tissues were obtained surgically at the Affiliated Hospital of Medical College, Qingdao University. The expression of TGF-β1, TGF-βR2 and Smad4 was separately detected by immunohistochemistry in all HCC specimens and their adjacent normal tissues, and its relations with the clinicopathological parameters of HCC were assessed.
RESULTS: The positive expression of TGF-β1 was 72.34% in the HCC specimens, which was higher than that in the adjacent normal tissues (P<0.001). The positive expression of Smad4 and TGF-βR2 was 34.04% and 59.57% respectively in the carcinoma specimens. The expression of TGF-β1, TGF-βR2 and Smad4 was significantly higher in groups with a tumor embolus of the portal vein, integrity of the amicula, and Edmondson's Ⅲ-Ⅳ than that in other groups, but it was not related to tumor size (P<0.05).
CONCLUSIONS: TGF-β1 may play an important role in the occurrence and development of HCC. Combined detection of TGF-β1, TGF-βR2 and Smad4 may be useful for the determination of the degree of malignancy and the prognosis of HCC.

BACKGROUND: Peroxisome proliferator-activated receptor gamma (PPAR-γ) and nuclear factor kappa B (NF-κB) play important roles in liver fibrosis. This study aimed to investigate the effects of Dan-shao-hua-xian, a preparation of traditional Chinese medicine, on the expression of PPAR-γ and NF-κB in the fibrotic livers of rats.
METHODS: Seventy Wistar rats were randomly divided into 4 groups: treatment (model, 8 weeks+treatment, 8 weeks; group A), natural recovery (model, 8 weeks+ saline, 8 weeks; group B), model (model only, 8 weeks; group C), and control (normal, untreated, 16 weeks; group D). Each group consisted of 20 rats (except for group D, which had 10). Fibrotic liver models were induced in rats by subcutaneous injection of CCl4, oral administration of alcohol and a high-lipid/low-protein diet for 8 weeks. After the models were established, the rats in group A were orally given Dan-shao-hua-xian capsules daily for another 8 weeks. Then, the liver indices serum hyaluronic acid (HA), tumor necrosis factor-alpha (TNF-α) and alanine aminotransferase (ALT) were measured. The degree of hepatic fibrosis was evaluated by optical microscopy. Hydroxyproline (Hyp) in the liver tissue was determined. The expression of PPAR-γ was detected by immunohistochemical techniques. The protein levels of PPAR-γ and NF-κB were determined by Western blotting.
RESULTS: The concentrations of serum HA, TNF-α and Hyp in group C increased compared with group D (P<0.05), and they decreased in group A compared with group C (P<0.05). The expression of PPAR-γ in group C decreased compared with group D (P<0.05), and it increased in group A compared with groups B and C (P<0.05). Similarly, Western blotting showed that the expression of PPAR-γ in group C decreased compared with group D, and it increased in group A compared with group C. The expression of NF-κB increased in group C compared with group D (P<0.05), and it decreased in group A compared with group C (P<0.05).
CONCLUSION: Dan-shao-hua-xian capsules enhance the expression of PPAR-γ but decrease that of TNF-α and NF-κB in the liver tissues of CCl4-induced hepatic fibrotic rats. These effects may play a role in its activity in treating hepatic fibrosis.

BACKGROUND: Toll-like receptors (TLRs) are a family of type 1 transmembrane receptors, which can recognize different pathogen-associated molecular patterns. Among them, TLR-4 is specific to lipopolysaccharide. It transfers the infection signal into the cell and promotes the translocation of nuclear factor kappa B (NF-κB) to the nucleus and the subsequent transcriptional activation of genes encoding pro- and anti-inflammatory cytokines and chemokines. Acute cholangitis (AC) is a common biliary tract infection in oriental countries, and often leads to liver injury. The activation of TLR-4 and its significance in liver injury in rats with AC remain unclear.
METHODS: Rat models of AC (biliary tract obstruction+E. coli injection, n=36) and control models (biliary tract obstruction+saline, n=18) were made. Liver tissue injury was investigated by pathological examination. The levels of serum TNF-α and IL-10 were measured by enzyme-linked immunosorbent assay, and the expressions of TLR-4, NF-κB mRNAs and proteins in the liver were detected by RT-PCR, immunohistochemical staining and Western blotting, respectively.
RESULTS: Severe liver tissue injury in rats with AC was evident as shown by pathological examination. TLR-4 and NF-κB were strongly expressed in the cytoplasm of hepatocytes in the AC group. They were negative or slightly positive in the control group. TLR-4 mRNA and protein in the liver of rats with AC increased 1 hour after biliary tract ligation and E. coli injection, and peaked at 6 hours after surgery. Twenty-four hours later, they began to decrease. The expression of TLR-4 was paralleled by that of NF-κB in the liver and TNF-α in serum.
CONCLUSION: The higher expression of TLR-4 in the liver of rats with AC may be involved in liver injury through the activation of NF-κB and release of cytokines such as TNF-α.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is useful to assess exocrine pancreatic function by combining rapid imaging acquisition with the administration of secretin, a gastrointestinal hormone that stimulates the secretion of bile and pancreatic juice. However, extensive data on this method are lacking. This study aimed to determine whether MRCP with secretin administration is able to simultaneously detect alterations of both the pancreatic ducts and exocrine pancreatic function.
METHODS: All subjects older than 18 years who underwent magnetic resonance imaging (MRI) and cholangio-Wirsung magnetic resonance imaging (CWMRI) for suspicion of benign or malignant pancreatic diseases from January 2006 to December 2006 were enrolled in the study. MRI and CWMRI were carried out using a dedicated apparatus.
RESULTS: Eighty-seven patients (46 males, 41 females, mean age 59.7±14.6, range 27-87 years) were enrolled. Of the 87 patients, 39 had a normal pancreas on imaging, 20 had an intrapapillary mucinous tumor (IPMT), and the rest had chronic pancreatitis (7), serous cystadenoma (6), a previous attack of acute biliary pancreatitis (5), congenital ductal abnormalities (5), mucinous cystadenoma (3), previous pancreatic head resection for autoimmune pancreatitis (1), or cholangiocarcinoma (1). Morphologically, we found two pseudocysts (one of the 7 patients with chronic pancreatitis, and one of the 5 patients after an attack of acute pancreatitis; the latter pseudocyst communicated with the main pancreatic duct). Calcifications were found in 3 of the 7 patients with chronic pancreatitis. All patients with IPMT and mucinous cystadenoma and 3 patients with serous cystadenoma were histologically confirmed. The remaining patients were followed up adequately to confirm the diagnosis by imaging. According to the Matos criteria, 73 patients (83.9%) were of grade 3, 8 grade 2, 4 grade 1, and 2 grade 0. The only pancreatic diseases which impaired the exocrine pancreatic secretion stimulated by secretin were chronic pancreatitis (57.1% of the patients, grade 0-1) and the IPMT mixed type in 2 of the 4 patients was grade 1.
CONCLUSION: Secretin MRCP is a useful technique to simultaneously detect the presence of alterations of the pancreatic ducts and exocrine pancreatic function.

BACKGROUND: Solid-pseudopapillary tumor of the pancreas (SPTP) is an uncommon and enigmatic pancreatic neoplasm that occurs mainly in young women. Although more and more cases have been reported in recent years, misdiagnosis and incorrect treatment still frequently take place. This study was designed to stimulate consideration of this tumor.
METHODS: We retrospectively reviewed the experience of diagnosis and treatment of 15 patients with SPTP and compared them with 516 patients with pancreatic cancer from January 1997 to March 2007.
RESULTS: Most of the SPTP cases were asymptomatic except for one palpable mass. Almost all SPTPs demonstrated a solid structure with hypo- or iso-attenuation, cystic structure with hypo-attenuation on pre-contrast CT scan, and enhancement of solid portions on post-contrast CT scan. By contrast, most cases of pancreatic carcinoma had multiple symptoms and abnormal blood results. The tumors showed hypo-attenuation on both pre-contrast and post-contrast CT scan, and only a few showed iso-attenuation on post-contrast CT scan. All cases of SPTP in our group were cured by surgical resection, while only 16.86% of patients with pancreatic carcinoma could undergo a radical resection.
CONCLUSIONS: Clinical features and CT scans were helpful to differentiate SPTP from pancreatic carcinoma. Radical surgical resection was the most effective and safe method for the treatment of SPTP.

BACKGROUND: TNF-related apoptosis-inducing ligand (TRAIL) is a death ligand of the TNF-superfamily that has been implicated in inducing apoptosis in some tumor cells. The purpose of this study was to find out if TRAIL could induce the expression of uPA, IL-8, MMP-7 and MMP-9.and to explore the corresponding potential signaling transduction pathway in pancreatic cancer cells.
METHODS: Colo357wt, Panc89 and PancTuⅠ cell lines were stimulated by TRAIL (100 ng/ml). Crystal violet cell vitality assay was used to check the sensitivity to TRAIL-induced apoptosis. Real-time RT-PCR tested the expression of uPA, IL-8, MMP-7 and MMP-9.
RESULTS: TRAIL can stimulate the expression of uPA, IL-8, MMP-7 and MMP-9 in pancreatic cancer cell lines, especially in Colo357wt. The members of caspases, MEK1/2, PKC, and NF-κB are involved in TRAIL-induced expression of uPA, IL-8, MMP-7 and MMP-9. Furthermore, caspases play a different role in Colo357wt, Panc89 and PancTuⅠ.
CONCLUSIONS: TRAIL-treatment may result in the enhancement of invasion involving the signaling pathways of caspases, MEK1/2, PKC and NF-κB, in pancreatic cancer cells. It points to the necessity to carefully evaluate in vivo side effects of TRAIL.

BACKGROUND: Infectious complications are common during the postoperative course of a liver transplant recipient. Malaria, however, is a rare complication in such a setting.
METHOD: We report post-transplantation malaria causing elevation of liver enzymes in two recipients.
RESULTS: Both patients who had undergone living donor liver transplantation showed elevated levels of liver enzymes and fever during the postoperative course. Investigations (including liver biopsy in one patient) were initially inconclusive in determining the cause of liver dysfunction. The diagnosis of malaria was established in both cases by peripheral blood smear. Liver function transiently worsened with antimalarial treatment but subsequently became normal.
CONCLUSION: This report highlights the importance of excluding such uncommon causes of post-transplantation liver dysfunction, especially when either the recipient or the donor comes from a region endemic for malaria.

BACKGROUND: Duodenal gastrointestinal stromal tumors (GISTs) are rare. Because of the complex anatomy of the duodenum, the methods of resection of these tumors are controversial and diverse.
METHODS: We report a case of a duodenal GIST in the anterolateral wall of the second part of the duodenum, which was successfully managed by local excision. The surgery was facilitated by preoperative mapping with Indian ink and navigation by endoscopy to assess the adequacy of resection and to avoid injury to the ampulla.
RESULT: Reconstruction was successful with a duodenojejunostomy and protected by a nasoduodenal drain.
CONCLUSION: The patient had no postoperative complications and the tumor was confirmed to be a GIST of the duodenum successful with an adequate resection margin.

BACKGROUND: Complications from gallstones and laparoscopic cholecystectomy can be serious and fatal if there is a delay in recognition and treatment. We aim to present two unusual, life threatening vascular complications as a result of gallstones and laparoscopic cholecystectomy. Their management is highlighted with a brief review of literature.
METHODS: Data for the article were gathered from clinical case note review. Radiology database was used for images. A brief literature review was undertaken using Pubmed search. The keywords used included hemobilia, pseudoaneurysm, arterio-biliary fistula and laparoscopic cholecystectomy.
RESULTS: The article highlights two individual case reports. The first case constitutes an 81-year woman who had cystic arterial erosion causing hematemesis, while the second patient was a 57-year man who presented with hemobilia from a pseudoaneurysm of right hepatic artery (RHA) following laparoscopic cholecystectomy. Cystic arterial erosion was treated with subtotal cholecystectomy with duodenal defect closure while the pseudoaneurysm underwent radiological intervention.
CONCLUSIONS: Cystic artery erosion and pseudoaneurysm causing arteriobiliary fistula are rare vascular complications related to the biliary tree. A high index of suspicion and timely intervention is important. Trauma to arteries should be avoided during laparoscopic cholecystectomy.

The Author reply:
     We thank Mr Bhanot for his interest in this case report and his thoughtful comments (Bhanot UK. Pancreatic ductal adenocarcinoma associated with pancreatic ductal intraepithelial neoplasia (Letters to the Editor). Hepatobiliary Pancreat Dis Int 2008;7:106-107.). We fully agree with him that the current grading system for PanINs into PanIN-1, PanIN-2 and PanIN-3 lack interobserver reproducibility.^[1] At the Consensus meeting on classification of pancreatic intraepithelial neoplasia and intraductal papillary neoplasia held at The Johns Hopkins Hospital in 2003^[2] also it was felt that though the three-tiered classification systems for PanINs and IPMNs have been invaluable in the genetic analyses of these precursor neoplasms, there is considerable interobserver variability in the assigning of histologic grades and there is morphometric evidence that a two-tier system (low-grade/high-grade) may be more reproducible.^{[1, 3]} But, still they have recommended that till the time further genetic and morphologic studies refine the histologic grading of PanINs, and that  existing three tier grading should be adhered to for the sake of consistency in grading.
    We also fully agree with Mr Bhanot that practically in surgical decision-making, PanIN can be clubbed in two groups--PanIN-1 and -2 in one group, as these are usually incidental findings and they do not require further resection and PanIN-3 in the other group, as further resection is required in these patients to prevent recurrence.^[4]
    Though Hisa et al^[5] have shown that PanIN-3 might extend up to 25 mm, it is sometimes  difficult to differentiate between  PanIN and secondary ductal involvement by invasive carcinoma (i.e. cancerization of ducts).^{[6, 7]} Practically for deciding the extent of pancreatic resection, most surgeons would send the pancreatic resection margin for frozening and proceeding accordingly.