BACKGROUND: Regulatory T cells (Tregs) play crucial roles in both induction and maintenance of tolerance. This active immune regulation may contribute not only to the control of immune responses to self-antigens and thereby prevent autoimmune diseases, but also the control of responses to non-self molecules in adaptive immunity. Numerous experimental and clinical studies indicate that manipulating the balance between regulatory and responder T cells is an effective strategy to control immune responsiveness after transplantation.
DATA SOURCES: Literature search was conducted using PubMed on the related subjects. Part of the material was based on the most recent work in the authors' laboratory.
RESULTS: We propose some new strategies to achieve transplant tolerance in rodent animals via manipulating Treg function, including using histone deacetylase (HDAC) inhibitor to regulate Foxp3 transcription and enhance Treg suppression, induction of Treg-sparing apoptosis via Nur77, and identification of the co-inhibitory molecule herpes virus entry mediator (HVEM) as an effector molecule for Treg function.
CONCLUSION: Regulation of Treg function will definitely provide us very promising tools to achieve clinical tolerance in the future.

BACKGROUND: Left liver graft from a small donor will not meet the metabolic demands of a larger adult recipient. To overcome the problem of graft size insufficiency, living donor liver transplantation (LDLT) using the right lobe has become a standard method for adult patients. As the drainage of the median sector (segments Ⅴ, Ⅷ and Ⅳ) is mainly by the middle hepatic vein (MHV), the issue of whether the MHV should or should not be taken with the graft or whether the MHV tributaries (Ⅴ5, Ⅴ8) should be reconstructed in the recipient remains to be settled.
DATA SOURCES: An English-language literature search was conducted using MEDLINE (1985-2006) on right lobe living donor liver transplantation, middle hepatic vein, vein graft, hepatic venoplasty and other related subjects.
RESULTS: Some institutions had proposed their policy for the management of the MHV and its tributaries. Dominancy of the hepatic vein, graft-to-recipient weight ratio, and remnant liver volume as well as the donor-to-recipient body weight ratio, the volume of the donor's right lobe to the recipient's standard liver volume and the size of MHV tributaries are the major elements for the criteria of inclusion of the MHV, while for the policy of MHV tributaries reconstruction, the proportion of congestive area and the diameter of the tributaries are the critical elements. Optimal vein grafts such as recipient's portal vein and hepatic venoplasty technique have been used to obviate hepatic congestion and venous drainage disturbance.
CONCLUSIONS: Taking right liver grafts with the MHV trunk (extended right lobe grafts) or performing the MHV tributaries reconstruction in modified right lobe grafts, according to the criteria proposed by the institutions with rich experience, can solve the congestion problem of the right paramedian sector and help to improve the outcomes of the patients. The additional use of optimal vein grafts and hepatic venoplasty also can guarantee excellent venous drainage.

BACKGROUND: During the past years, the number of liver transplantation has increased greatly, but the number of available organs has not increased. In view of the critical shortage of organs, the indications for living-related liver transplantation (LRLT) have broadened since experience with the procedure has been achieved. This study was undertaken to assess the value of multi-slice spiral CT (MSCT) angiography in evaluating the hepatic arterial and veinous anatomy of potential donors for LRLT.
METHODS: MSCT was performed after intravenous injection of contrast material at 3 ml/s. The total dose was calculated as 2 ml/kg. Twenty LRLT donors (2 men and 18 women) were subjected to MSCT angiography of hepatic blood vessels. These were generated by volume rendering and maximum intensity projection, while curved planar reformation was added in 5 patients.
RESULTS: We identified 10 important hepatic vascular variants in 9 of the 20 donors (4 arterial, 4 venous, and 2 portal venous variants). In hepatic arterial variants, two had a replaced right hepatic artery arising from the superior mesenteric artery, an accessory right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery arising from the left gastric artery. In hepatic venous variants, three had an accessory inferior right hepatic vein and one had two accessory inferior right hepatic veins. In hepatic portal venous variants, two had trifurcation of the main portal vein.
CONCLUSIONS: As a non-invasive and reliable method, MSCT angiography is of value in the clinical evaluation of LRLT donors. MSCT angiography should be recommended as a routine preoperative examination for potential LRLT donors.

BACKGROUND: Recurrence of hepatitis B virus (HBV) after orthotopic liver transplantation is very common in the absence of adequate prophylaxis and is often associated with poor prognosis because of the development of cirrhosis, fibrosing cholestatic hepatitis, or fulminant hepatitis. Therefore it is important to study the prevention of HBV reinfection after liver transplantation.
METHODS: Recombinant Fab (rFab) was constructed to evaluate gene therapy for post-transplantation HBV re-infection. Hepatocytes were divided into three groups: HBV-infection, rFab-blocked HBV-infection, and control. The inhibition of HBsAg adsorption test, the micro-cytotoxicity assay, and the blockade test of HBV infection were carried out. The HBsAg adsorption rate, the hepatocyte death rate and the HBV infection rate were statistically analyzed.
RESULTS: The HBsAg adsorption rate blocked by rFab in the HBsAg adsorption test was 0.3%. The hepatocyte death rate was 98.8% induced by rFab in the micro-cytotoxicity assay, 1.3% in the rFab-blocked HBV-infected group and 77% in the HBV-infected group in the blockade test of HBV.
CONCLUSIONS: We found that rFab effectively blocked HBV infection in human hepatocytes. This provides an attractive alternative for hepatitis B prophylaxis.

BACKGROUND: Calcineurin inhibitor-related renal toxicity affects patient and graft survival in transplant recipients. This study aimed to determine whether sirolimus is effective and safe in treating renal insufficiency related to tacrolimus after liver transplantation.
METHODS: Tacrolimus for primary immunosuppression was used in 16 patients after liver transplantation. Patients with a creatinine level higher than 132.6 µmol/L were eligible for conversion to sirolimus. Simultaneously, the dose of tacrolimus was decreased to half. Blood urea nitrogen, creatinine, tacrolimus level, liver function and rejection episodes were monitored dynamically.
RESULTS: All patients showed improvement of renal function after conversion to sirolimus. Blood creatinine level was reduced from 146.8±92.4 to 105.3±71.3 µmol/L (P<0.05). One patient had an acute rejection episode that was successfully treated with pulsed corticosteroids and low-dose tacrolimus. The side-effects of sirolimus included hyperlipidemia (4 patients) and leukocytopenia (2).
CONCLUSION: Sirolimus can be safely used in liver transplant recipients suffering from tacrolimus-related renal insufficiency.

BACKGROUND: The non-function and dysfunction of primary liver graft likely involves dependence on Kupffer cells and hepatic innervation. The present experiment was designed to study the expression of P-selectin and intercellular adhesion molecule-1 (ICAM-1) mRNA in liver graft and to elucidate the role of Kupffer cells and the sympathetic nerve of the liver in down-regulating this expression.
METHODS: Donor rats were given hexamethonium, a sympathetic ganglionic blocking agent, and/or gadolinium chloride, an inhibitor of Kupffer cells. Then the changes of graft P-selectin and ICAM-1 mRNA expression were measured after liver transplantation.
RESULTS: The expressions of P-selectin and ICAM-1 mRNA were increased after liver transplantation, and down-regulated by liver denervation and elimination of Kupffer cells.
CONCLUSIONS: Live donor denervation and elimination of Kupffer cells down-regulated the expressions of P-selectin and ICAM-1 mRNA in grafts. This may decrease graft ischemia/reperfusion injury.

BACKGROUND: The frequency and pattern of hyperbilirubinemia after open-heart surgery and its severe perioperative complications are not well clarified. The purpose of this study was to investigate the incidence and nature of postoperative jaundice in patients undergoing cardiac operation, to analyze the determinants, and to identify the clinical significance of this complication with regard to the associated morbidity and mortality.
METHODS: A prospective observational study was made during the period of 2003-2004 in a Surgical Intensive Care Unit of a Cardiac Surgery Center, Athens. One hundred twenty-eight adult patients for open heart surgery were divided into three groups. Group A included 50 patients who underwent coronary artery bypass crafting (CABG), group B 31 patients who were subjected to aortic valve replacement (AVR)+CABG and group C 47 patients who underwent mitral valve replacement (MVR)+CABG. Aminotransferases, alkaline phosphatase, gamma-glutamyl-
transpeptidase and both types of bilirubin were determined at admission, 24 hours after the operation and thereafter according to clinical evolution. The presence of jaundice was associated with elevated serum bilirubin above 3 mg/dl.
RESULTS: Hyperbilirubinemia developed in 34 patients (26.5%). The incidence of postoperative jaundice was higher in patients who were subjected to MVR+CABG than to CABG and AVR+CABG. Hyperbilirubinemia was correlated with prolonged cardiopulmonary by-pass time (P<0.001), aortic cross-clamping time (P<0.001), the use of intra aortic balloon pumping (P<0.001), the administration of inotrops and the number of blood and plasma transfusions. Postoperative jaundice resulted mainly from an increase in conjugated bilirubin.
CONCLUSIONS: Although hyperbilirubinemia seems to be multifactorial, the type of operation, the preoperative hepatic dysfunction due to advanced heart failure (NYHA Ⅱ-Ⅲ) and the decreased hepatic flow during the operation seem to determine the incidence of jaundice.

BACKGROUND: In the isolated liver perfusion (ILP) technique, the liver is temporarily isolated from the systemic circulation in order to infuse large doses of chemotherapeutic agents through the hepatic inflow. The hepatic tissue can show a drug concentration higher than that after systemic chemotherapy, and a general toxic reaction from chemotherapeutic agent is avoided. In a modified ILP model in rats, we explored the distribution of the chemotherapeutic agent, fluorouracil (5-FU) in the systemic circulation and in the hepatic tissue, and assessed the pathological changes in the liver.
METHODS: 306 Sprague-Dawley rats were randomly divided into 4 groups: control, ILP without 5-FU, ILP with 5-FU at different doses, and infusion of 5-FU through the portal vein. All animals were subjected to modified ILP, and 5-FU concentrations in the hepatic tissue and the systemic blood were determined at different time points. Levels of thromboxane B2 (TXB2) and 6-keto-prostaglandin F1α (6-keto-PGF1α), and changes in hepatic function, pathology and liver enzymes were assessed.
RESULTS: ILP through the portal vein at three dosages (25, 50 and 100 mg/kg) resulted in significantly higher 5-FU concentrations in the liver tissue for 50 and 100 mg/kg and there was only a small leakage of 5-FU from the perfusion system into the systemic circulation. The pathological findings revealed that the liver tissue tolerated ILP below the maximum tolerance dose (MTD) of 5-FU. If the 5-FU dose exceeded the MTD the ultrastructure and the enzymatic activity of hepatocytes were clearly affected. The change of TXB2 and PGF1α balance were closely related to the injury of hepatic tissue caused by ILP with 5-FU doses greater than the MTD.
CONCLUSIONS: Hepatic tissue sustains a higher drug concentration using ILP than that from systemic chemotherapy, and avoids a general toxic reaction to the drug entering into the systemic circulation. Evident injury may not occur in hepatocytes, and the changes of liver function are slight and transient by using ILP with no more than the MTD of 5-FU.

BACKGROUND: Present studies on the reversal of multi-drug resistance (MDR) are almost entirely limited to in vitro systems, and are seldom carried out in vivo. In order to study MDR under the in vivo situation, a MDR cell strain was used to establish a model in nude mice via orthotopic implantation directed by B-ultrasonography. This model is expected to provide a good platform for evaluating strategies to reverse the phenomenon of primary hepatocellular carcinoma (HCC) MDR.
METHODS: An orthotopic MDR1 hepatoma was obtained by injecting the cell lines HepG2 and HepG2/ADM subserosally into the liver of nude mice (10 control and 20 MDR mice). The injections were made under B-ultrasonographic direction. Ultrasonography and laparotomy were used to assess tumor growth, and the long chain PCR technique was applied to sequence the MDR1 gene from multi-drug resistant human HCC cells, HepG2/ADM, and corresponding implanted tumor tissues. Furthermore, MDR1 mRNA and P-gp protein expression were evaluated by reverse transcriptase-polymerase chain reaction (RT-PCR), Western blotting, and immunohistochemical methods.
RESULTS: The success rates of tumor implantation and induction of MDR were 100% (30/30) and 95% (19/20), respectively. The 3.8kbp MDR1 gene band was detected from the HepG2/ADM cell line and the corresponding implanted tumor tissues, and the MDR1 gene sequence coincided with that reported in GenBank. The expressions of MDR1 mRNA and P-gp protein in MDR mice were significantly higher than those in the control group. There was a significant difference in P-gp protein expression between MDR and control mice.
CONCLUSION: A MDR model has been successfully established in nude mice via orthotopic implantation of multi-drug resistant human HCC cells directed by ultrasonography.

BACKGROUND: Cholelithiasis is a common entity in China, but its etiology and pathogenesis have not been fully elucidated. Pigment stones of the intrahepatic and extrahepatic bile duct still form a high proportion in China, while they are rare in Europeans. To date, reports on fatty acids in stones remain few. We analyzed the quantity of fatty acids in different stones from Chinese and Japanese cases and discussed the role and mechanism of fatty acids in the formation of pigment stones.
METHODS: Clinical data from 18 Chinese and 37 Japanese patients with different types of stones were analyzed using the procedure for extracting fatty acids from gallstones and high performance liquid chromatography.
RESULTS: The total fatty acid and free fatty acid contents of pigment stones were markedly higher than those in black or cholesterol stones. The ratio of free saturated to free unsaturated fatty acids was highest in intrahepatic and less in extrahepatic pigment stones, which were significantly different from the other two kinds of stones.
CONCLUSIONS: This indicates that phospholipase participates in the course of pigment stone formation. The action of phospholipase A1 is more important than phospholipase A2.

BACKGROUND: Proteomic analysis of bile fluid holds promise as a method to identify biomarkers of bile tract diseases, especially for tumors. Two-dimensional electrophoresis (2-DE) is a popular and proven separation technique for proteome analysis, but using this strategy for bile fluid analysis is still not fully developed. This study was undertaken to (a) establish a reliable method for general clean-up to make bile fluid samples suitable for 2-DE; (b) obtain 2-D biliary maps with high reproducibility and resolution; and (c) identify protein patterns present in 2-D biliary maps for potential tumor biomarker discovery, with the intention of distinguishing malignant from benign causes of bile duct obstruction.
METHODS: Bile fluid samples were obtained from two patients suffering from malignant and benign bile tract obstruction (one patient with cholangiocarcinoma as the experimental case, the other with cholelithiasis as control). A variety of sample preparation options, including delipidation, desalination and nucleic acid removal, were adopted to remove contaminants that affect 2-DE results. After that, each 350 µg purified sample was loaded onto nonlinear IPG strips (18 cm, pH 3-10 and pH 4-7) for first-dimension isoelectric focusing, and 12.5% SDS-PAGE electrophoresis for second dimension separation. Then 2-D maps were visualized after silver staining and analyzed with the Image Master 2-D software.
RESULTS: A large number of protein spots were separated in 2-D maps from the experimental and control groups, with means of 250 and 216 spots on pH 3-10 IPG strips, and 182 and 176 spots on pH 4-7 strips, respectively. Approximately 16 and 23 spots were differentially expressed in matched pairs from the experimental and control cases using pH 3-10 and pH 4-7 strips.
CONCLUSIONS: This study established a reliable sample preparation process suitable for 2-DE of bile fluid. By this method, 2-D biliary maps with high reproducibility and resolution were obtained. The differentially displayed proteomes in the 2-D biliary maps from the experimental and control groups indicated the potential application for bile fluid analysis to identify disease-associated biomarkers, especially for biliary tract tumors.

BACKGROUND: Death-associated protein kinase (DAPK) is a Ca2+/calmodulin-regulated Ser/Thr kinase which is involved in apoptosis. The aberrant methylation of its promoter region CpG islands may be one of the important mechanisms of carcinogenesis. We studied the relationship of methylation status and expression of the DAPK gene with the clinical findings in cholangiocarcinoma.
METHODS: Target DNA was modified by sodium bisulfite, coverting all unmethylated, but not methylated, cytosines to uracil, and subsequently detected by methylation-specific PCR. Moreover, mRNA expression of the DAPK gene was assessed by RT-PCR.
RESULTS: Aberrant methylation of the DAPK gene was detected in 11 (30.6%) of 36 tissue specimens of cholangiocarcinoma, and in 2 (5.6%) of 36 specimens of adjacent normal tissues. DAPK mRNA was not expressed in tumor and adjacent tissues with hypermethylation of the DAPK promoter. There were no statistical differences in the extent of differentiation and invasion, lymph node metastasis or pathologic type between the methylated and unmethylated tissues.
CONCLUSIONS: The frequency of DAPK gene methylation in cholangiocarcinoma is high and it may offer an effective means for earlier auxiliary diagnosis of the malignancy. The DAPK gene is probably suppressed by methylation, and it could become resistant to apoptosis and immunological surveillance. The DAPK gene epigenetically affected by methylation may be associated with the carcinogenesis of cholangiocarcinoma.

BACKGROUND: Many investigators have indicated that overexpression and amplification of the human proto-oncogene c-erbB-2 is an independent prognostic factor for primary tumors. We studied expression of c-erbB-2 protein in tissues from extrahepatic cholangiocarcinoma, tissues peripheral to the carcinoma and normal bile ducts, and discussed the occurrence and development of extrahepatic cholangiocarcinoma. Another aim was to explore possible application of the c-erbB-2 gene for clinical diagnosis, pathological differentiation and treatment of extrahepatic cholangiocarcinomas.
METHODS: The c-erbB-2 expression levels from 75 samples of extrahepatic cholangiocarcinoma, 48 samples of tissues peripheral to the carcinoma and 9 samples from normal bile ducts were assayed by immunohistochemical streptavidinbiotin complex (SABC).
RESULTS: The rates of c-erbB-2 expression in extrahepatic cholangiocarcinomas, tissues peripheral to the carcinomas, and normal bile ducts were 80% (60/75), 56% (27/48), and 0% (0/9), respectively. In the extrahepatic cholangiocarcinomas, the expression of c-erbB-2 was directly proportional to the malignant grade and tumor metastasis. The expression rate of c-erbB-2 in tumors with nerve infiltration was significantly higher than in those without nerve infiltration. The expression rates of c-erbB-2 in tumors with histological grade Ⅲ/Ⅳ were significantly higher than in those with histological grade Ⅰ. The expression of c-erbB-2 was not correlated with the size or position of tumors, blood vessel infiltration or patients' sex or age.
CONCLUSIONS: c-erbB-2 was only expressed in extrahepatic cholangiocarcinomas and tissues peripheral to the carcinomas but not in normal bile ducts, indicating that c-erbB-2 may play an important role in the occurrence and development of extrahepatic cholangiocarcinoma. The fact that the expression level of c-erbB-2 was highly correlated with differentiation grade and metastasis of the tumor suggests potential clinical importance of c-erbB-2 as a tumor biomarker in the diagnosis, treatment and prognosis of extrahepatic cholangiocarcinoma.

BACKGROUND: Severe acute pancreatitis (SAP) is a serious disease with many complications, high mortality and poor prognosis. It is characterized by rapid deterioration and poses one of the most difficult challenges in clinical practice. Previous investigations suggest that SAP is one of the main causes of intra-abdominal pressure (IAP) increase. The aim of this study was to evaluate the utility of IAP-monitoring in predicting the severity and prognosis of SAP.
METHODS: Eighty-nine patients with SAP who had been treated from February 2001 to December 2005 were studied. Since bladder pressure accurately reflects IAP, we measured it instead of IAP. Bladder pressure was measured at the time of admission and every 12 hours in the course of the disease, 9 consecutive times in all. The APACHE Ⅱ scores of all patients were obtained within 24 hours after admission. According to a maximum bladder pressure <10 cmH2O, all patients were divided into two groups, mildly-elevated and severely-elevated. Mortality and mean APACHE Ⅱ scores in the two groups were calculated. In addition, the mean bladder pressure and APACHE Ⅱ scores in survivors were compared with those in deaths.
RESULTS: Sixty-eight of the 89 patients were in the severely-elevated group. Mortality and mean APACHE Ⅱscores in this group were much higher than those in the mildly-elevated group (mortality, 39.71% vs. 9.52%; mean APACHE Ⅱ score, 23.15±7.42 vs. 15.95±5.35, P<0.01). The mean bladder pressures and APACHE Ⅱ scores in deaths were significantly greater than those in survivors (mean bladder pressure, 14.1±3.8 vs. 9.2±2.3 cmH2O, P<0.01; mean APACHE Ⅱ score, 27.83±4.87 vs. 18.37±6.74, P<0.01).
CONCLUSION: It is suggested that IAP may be used as a marker of the severity and prognosis of SAP.

BACKGROUND: The pancreas has a strong regeneration potential in mammals. Previous studies suggested that pancreas regeneration is correlated with proliferation and differentiation of pancreatic stem cells, but the field of pancreatic stem cells is still in its infancy. This study was undertaken to detect the expression of pancreas/duodenal homeobox-1 (PDX-1) and proliferation of pancreatic duct epithelial cells in remnant pancreas during regeneration after partial pancreatectomy in rats, and characterize the source of pancreatic stem cells. 
METHODS: Partial pancreatectomy (90%) was performed on four- to five-week-old Sprague-Dawley rats, and duct epithelial cells and acinar cells were detected by immunohistochemical staining and scored using the 5-bromo-2-deoxyuridine (BrdU) labelling index at various time points. Western blotting and reverse transcriptase-polymerase chain reaction (RT-PCR) were used to assess the expression of PDX-1 protein and mRNA, respectively.
RESULTS: At 24 hours after partial pancreatectomy, proliferation started in the main, large and small duct cells, and persisted in small duct cells to day 5. The experimental and control groups were significantly different (P<0.001). BrdU-positive acinar cells were greatly increased and reached a peak on day 5. PDX-1 protein was only faintly detectable in pancreatic ductal cells on day 1 after partial pancreatectomy. On days 2 and 3, a 2-3 fold increase in PDX-1 protein was observed, corresponding to the characteristic 42 kD protein in Western blotting. The operated and sham-operated groups also differed significantly (P<0.05). PDX-1 protein expression on days 5 and 7 after operation did not differ from that of the control group. RT-PCR revealed that PDX-1 mRNA expression did not significantly differ between the operated group and the sham-operated group at various time points.
CONCLUSIONS: Pancreatic stem cells in pancreatic ductal epithelial cells are involved in the regeneration of remnant pancreas and the expression of PDX-1 in ductal cells is due to posttranscriptional regulation.

The middle hepatic vein (MHV) lies in the midplane of the liver. The classical teaching of right or left hepatectomy is transection of liver 1 cm to the right or left wall of the MHV in order to avoid bleeding. However, guidance of liver transection is lost if the course of the MHV is not known. By exposing the MHV early in the phase of liver transection and following its course to the inferior vena cava, a precise liver transection plane could be obtained. Such technique has the potential of achieving adequate tumor-free resection margin, avoiding damage to intrahepatic portal pedicles, preserving venous drainage and functional liver tissue, and less postoperative infection.

BACKGROUND: The presence of dual pathology can cause diagnostic dilemmas. We present a case of adenocarcinoma of the ampulla of Vater with concurrent amiodarone hepatotoxicity.
METHODS: Painless jaundice associated with a palpable gallbladder was investigated clinically, radiologically, endoscopically and via liver biopsy.
RESULTS: Liver biopsy showed amiodarone hepatotoxicity. Endoscopic biopsy identified an ampullary adenoma. However, the endoscopic ultrasound and intra-operative findings suggested a malignancy, which was confirmed postoperatively.
CONCLUSIONS: While the classic findings of Courvoisier’s Law are borne out in this case, the etiology of jaundice is twofold. Although dual pathology is uncommon it should always be considered.

BACKGROUND: Mirizzi syndrome is a rare complication of cholelithiasis. Adenomyomatosis is a common tumor-like lesion of the gallbladder.
METHODS: A 52-year-old man was admitted to our hospital complaining of right hypochondriac pain and jaundice. Ultrasonography and computed tomography revealed stones in the gallbladder and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography revealed narrowing of the common bile duct caused by compression of the gallbladder. Laparotomy revealed type Ⅱ Mirizzi syndrome.
RESULTS: Partial cholecystectomy with a Roux-en-Y hepaticojejunostomy reconstruction was performed. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen in the gallbladder. A segmental type of adenomyomatosis of the gallbladder was diagnosed. 
CONCLUSIONS: The pathogenic link between the two peculiar entities is unclear. A possible explanation is considered that the pathogenesis of Mirizzi syndrome is resulted from chronic inflammation due to adenomyomatosis.

BACKGROUND: Lumbar hernia is a rare congenital or acquired defect of the posterior abdominal wall. The acquired type is more common and occurs mainly as an incisional defect after flank surgery. Incarceration or strangulation of hernia contents is uncommon.
METHOD: Segmental liver incarceration through a recurrent incisional lumbar defect was diagnosed in a 58 years old woman by magnetic resonance imaging.
RESULTS: The patient underwent an open repair of the com-plicated hernia. An expanded polytetraflouoroethylene (e-PTFE) mesh was fashioned as a sublay prosthesis. She had an uncomplicated postoperative course. Follow-up examinations revealed no evidence of recurrence.  
CONCLUSIONS: Although lumbar hernia rarely results in incarceration or strangulation, early repair is necessary because of the risks of complications and the increasing difficulty in repairment as it enlarges. Surgical repair is often difficult and challenging.