Objectives: To prevent and early diagnose hepatitis B virus reinfection and recurrent hepatitis B following liver transplantation, and to discuss the further treatment of recurrent hepatitis B.
Methods: Liver transplantation recipients received lamivudine for prophylaxis of HBV reinfection. Virological and biochemical data, serum HBV DNA, and immunohistological staining for HBsAg and HBcAg in liver biopsy specimens were tested in due time.
Results: Five patients with hepatitis B virus reinfection and two patients with hepatitis B recurrence were observed after liver transplantation. One patient with recurrent hepatitis B developed chronic severe hepatitis B despite treatment. One patient improved after a series of treatment.
Conclusions: Hepatitis B virus reinfection or recurrent hepatitis B following liver transplantation occurs mostly 6-12 months after operation. The diagnosis of hepatitis B recurrence should be taken into account when liver biochemical data becomes poor during this period. The treatment for recurrent hepatitis B after liver transplantation includes increased dosage of lamivudine, application of famciclovir, and other liver protection measures.

Objective: To study the etiology, prevention and management of acute respiratory distress syndrome (ARDS) after liver transplantation.
Methods: The clinical data of 104 patients with end-stage liver diseases who had had liver transplantations were retrospectively reviewed.
Results: Seventeen patients (16.3%, 17/104) altogether were diagnosed as having ARDS after liver transplantation. Ten of them developed ARDS within 24 hours, of whom 1 died during the operation, and 7 developed ARDS 3 or 4 days after they were extubated and when methylprednisolone was tapered. Fourteen of the 17 ARDS patients (14/17) were found to have overloaded crystalloid infusion, massive transfusion of blood or blood products such as plasma, platelets, in addition to a prolonged surgical time secondary to serious bleeding during the diseased liver removal without evidence of active infection. One was found to have serious systemic infection and operatively disseminated intravascular coagulation. Four of the recipients developed ARDS suddenly when intravenous cyclosporine was given on the 3rd day after operation. One patient of the 4 had all of the aforementioned conditions. Two patients suffered from gastric aspiration. Five (30%, 5/17) of them survived ARDS with the combined treatment consisting of positive end-expiratory pressure mechanical ventilation suctioning as much edema fluid or sputum as possible, administration of diuretics, bolus of corticosteroids, and culture-based antibiotics. Hemeodialysis was indicated for patients with oliguric renal failure.
Conclusions: ARDS is a serious multifactoral complication after liver transplantation with a high mortality and fatality. The most likely cause is fluid overload from crystalloid liquid infusion or massive transfusion. The other predisposing or contributing factors include sepsis, IV use of cyclosporine, fast tapering of corticosteroids, and gastric aspiration. Other factors such as transfusion-related acute lung injury (TRALI), and reperfusion syndrome of the newly implanted liver may also contribute. Though the treatment should primarily be supportive in nature, it is helpful to understand the predisposing and contributing factors and to aid in prevention, management and treatment.

Objective: To investigate the variation of functions of the heart and lung during orthotopic liver transplantation (OLT).
Methods: Pulmonary artery cannula and right radial artery cannula were indewelled before anaesthesia and the parameters of hemodynamics in different periods were monitored. Analysis of variance was used to reveal the variation among the groups. T hypothesis test in paired data was used to compare the preoperative parameters with those in each period during operation and after operation respectively, and to compare the parameters immediately after operation with those in each period after operation respectively.
Results: During the operation, heart rate increased, but blood pressure decreased significantly at the beginning of no-liver period, increased again in a short period and then increased progressively 12 h after operation. Pulmonary artery pressure (PAP) increased from before the no-liver period to 60 h after operation. Pulmonary wedge pressure changed in accordance with the variation of PAP. Cardiac output was maintained at a high-output level from before operation to 60 h after operation. Systemic vascular resistance (SVR) was within the normal limits before operation, whereas pulmonary vascular resistance (PVR) was lower than normal. In the no-liver period during the operation, SVR decreased significantly. Both SVR and PVR increased progressively and returned to normal postoperatively.
Conclusions: The patients undergoing OLT have a high cardiac output and low resistance obstacle before and during the operation, and will recover gradually after operation. Monitoring hemodynamics during the peri-operative period is of signifi.

Objective: To investigate whether apoptotic cell death is involved in liver xenograft rejection and the molecular mechanism of apoptosis.
Methods: After hamster-to-rat orthotopic liver transplantation, apoptosis in the xenograft was observed histologically and by in situ end-labelling of fragmented DNA. CD8 antigen, perforin, Fas-L and TGF-β1 were observed immunohistochemically in the graft.
Results: In xenogenic rejection, OX8 (CD8) positive T lymphocyte was observed on day 2 post-transplantation, evidently on day 5. The expression of perforin and Fas-L in grafts occurred on day 4 post-transplantation, and it was more evident in the rejection. In control group,the lymphocyte was rarely seen, and the expression of Fas-L and perforin was not found. Both xenogeneic and syngeneic grafts showed the expression of TGF-β1 on the first day after transplantation. The expression of TGF-β1, however, increased subsequently in the xenogeneic graft in contrast to its normalization in the syngeneic graft. In the xenogeneic graft, apoptosis occurred on day 1 after transplantation, decreased on day 2, increased on day 3, and peaked on day 5. Apoptosis was similar in the syngeneic and xenogeneic grafts on day 1 after transplantation, but decreased to normal one day later. The more severe apoptosis, the more severe acute rejection, and the more evident expression of perforin, Fas-L and TGF-β1.
Conclusion: Apoptosis as a mechanism of cell death exists in the acute rejection of liver xenograft, and it is related closely to the expression of perforin, TGF-β1 and Fas-L.

Aim: To investigate the feasibility and rationality of liver transplantation as an indication for patients with intrahepatic stones.
Methods: Liver transplantation was successfully performed for a 28-year-old man and a 42-year-old woman, both with intrahepatic stones.
Results: Patient 1 had digestive tract bleeding on the postoperative day 6 and he was discharged from the hospital on the postoperative day 25. He is in good health 14 months after operation. Patient 2 also had hemorrhage from the digestive tract on the postoperative day 44 and a leakage of end-to-side intestinal anastomosis on the postoperative day 47. She has resumed her work and is in good health from the postoperative month 12.
Conclusion: Liver transplantation is safe and effective for patients with intrahepatic stones.

Background: More than two decades have gone by since the early report of resection for small hepatocellular carcinoma (HCC), which resulted in improved prognosis of HCC.
Objective: To review the past and recent data, and prospect the future in this field.
Data sources: Literature and recent data from the Liver Cancer Institute of Fudan University, Shanghai, China.
Data synthesis: 1232 patients with small HCC from the institute were analyzed between 1960-1984 (n=107) and 1985-1999 (n=1125). The increase of limited resection rate from 69.5% to 82.5% contributed in part to the increase of resectability from 76.6% to 95.5%, decrease of operative mortality from 2.4% to 1.2%, and improvement of 5-year survival after resection (from 53.1% to 64.0%). The 5-year survival was higher after limited resection than after lobectomy, being 64.4% versus 55.9%. The 5-year survival after resection was superior to that after cryosurgery and other regional cancer therapies (32.8%). However, molecular studies found that biological characteristics were only slightly better in small HCC than in large HCC.
Conclusions: Resection remains the treatment choice for small HCC with compensated liver function, while regional cancer therapies and liver transplantation are alternatives for patients with incompensated liver function. Biological characteristics remain the leading factor influencing prognosis of small HCC.

Background: Appropriate preclinical evaluation of a bioartificial liver assist device (BAL) demands a large animal model, as presented here, that demonstrates many of the clinical features of acute liver failure and that is suitable for clinical qualitative and quantitative evaluation of the BAL. A lethal canine liver failure model of acute hepatic failure that removes many of the artifacts evidenced in prior canine models is presented.
Methods: Six male hounds, 24-30 kg, under isoflurane anesthesia, were administered 1.5 g/kg D-galactosamine intravenously. Canine supportive care followed a well-defined management protocol that was guided by electrolyte and invasive monitoring consisting of arterial pressure, central venous pressure, extradural intracranial pressure (ICP), pulmonary artery pressure, and end-tidal CO2. The animals were treated until death-equivalent, defined as inability to sustain systolic blood pressure >80 mmHg for 20 minutes despite maximal fluids and 20 μg•kg-1•min-1 dopamine infusion.
Results: The mean survival time was 43.7±4.6 hours (mean±SE). All animals showed evidence of progressive liver failure characterized by increasing liver enzymes (aspartate transaminase from 26 to 5977 IU/L; alanine transaminase from 32 to 9740 IU/L), bilirubin (0.25 to 1.30 mg/dl), ammonia (19.8 to 85.3 μmol/L), and coagulopathy (prothrombin time from 8.7 to 46 s). Increased lability and elevations in intracranial pressures were observed. All animals were refractory to maintenance of cerebral perfusion pressure even with only mode-rately elevated intracranial pressure. Severe neurologic obtundation, seen in 2 of 6 animals, was associated with elevations of ICP above 50 mmHg. Post-mortem liver histology showed evidence of massive hepatic necrosis. Postmortem blood and ascites microbial growth was consistent with possible translocation of intestinal microbes.
Conclusions: The improved lethal canine liver failure model presented here reproduces many of the clinical features of acute liver failure. The model may prove useful for qualitative and quantitative evaluation of BALs.

Objectives: To obtain very end full-length cDNA of hepatitis C virus (HCV) 5’untranslated region (5’UTR) and analyze its primary and secondary structure.
Methods: A patient infected genotype 2a HCV was identified by reverse transcription-nested polymerase chain reaction (RT-PCR) and restriction fragment length polymorphism (RFLP). Total RNA isolated from the serum was used as template, and the cDNA of the 5’untranslated region was amplified using rapid amplification of cDNA ends (RACE). The fragments were recombinated by A-T clone strategy, and the recombinants were confirmed by RFLP and PCR, and sequenced subsequently. Secondary structures were analysed by RNAdraw.
Results: Very end full-length cDNA of genotype 2a HCV 5’UTR was obtained by RACE. In five clones obtained, three contained full-length 5’UTR cDNA; A21G, G170A, T222C, T247C, C339T substitutions were found as compared to HC-J6. Homological results of HCV-1, HC-J6, HC-C2, HC-J8 were 93.6%-94.4%, 92.1%-93%, 98.8%-99.7%, 96.2%-96.5%, respectively; however, the substitutions did not alter secondary structure. Two of 5 clones were deletions of 53bp and 135bp at the 5’terminal of HCV 5’UTR, respectively.
Conclusions: RACE can be used to obtain the full-length cDNA of 2a genotype HCV 5’UTR. Genes deleted at the 5’terminal of HCV circulate in hepatitis C patients.

Objective: To study the induction of sensitivity to ganciclovir (GCV) or acyclovir (ACV) in human hepatocellular carcinoma (HCC) cell line transferred by an Epstein-Barr virus (EBV)-based replicon expression vector carrying the herpes simplex virus thymidine kinase (HSV-tk) gene, including killing and “bystander” effect, and also the gene delivery procedure and route of gene therapy in vivo for HCC.
Methods: Liposome-entrapped plasmid pDR2/tk was transferred into HCC cells, and then different concentrations of GCV or ACV were added. The transferred cells were mixed with untransferred HCC cells in different proportion and 200 μmol/L GCV was then added into each well. After 72 hours, all samples were measured by MTT colorimetric assay. An EBV-based plasmid eukarotic expression vector carrying IL-2 cDNA was used. Three models of gene direct injection in the local liver, injection through the portal vein, and injection through the embolized hepatic artery were established in closed Wister rats. For each model, two subgroups, injected either naked plasmid DNA or lipofectin-plasmid complex were included. The expression of the IL-2 gene was regularly examined immunohistochemically.
Results: GCV or ACV could apparently kill the transferred HCC cells at a concentration of 0.2 μmol/L. The inhibition rate was changed with different drug concentrations. The “bystander” effect was obviously induced at a transferred to untransferred HCC cells ratio of 1∶5. IL-2 gene expression was observed in liver cells of all animals on day 3, which reached peak within 3-7 days, and declined after day 7. Injection of naked plasmid DNA through the hepatic artery plus embolization obtained a best expression.
Conclusions: EBV-based vector is suitable for carrying suicide gene therapy for hepatocellular carcinoma. Gene direct delivery in vivo combined with interventional surgery can be used to treat hepatocellular carcinoma.

Objective: To identify the roles of serum IL-18, IL-10, TNF-α and sIL-2R in the pathogenisis of chronic hepatitis C and the effects of interferon on the mentioned serum cytokines.
Methods: The levels of IL-18, IL-10, TNF-α and sIL-2R were detected in 10 healthy controls, 24 asymptomatic HCV carriers, and 27 patients with chronic hepatitis C (before and after IFN treatment) by enzyme linked immunosorbent assay (ELISA).
Results: The levels of IL-18, IL-10, TNF-α and sIL-2R in the patients of chronic hepatitis C were higher than those in the healthy controls (P＜0.05＝ and in asymptomatic HCV carriers (P＜0.05＝. The values of the mentioned cytokines showed a significant positive correlation to GPT. The levels of the mentioned cytokines decreased obviously after IFN treatment (P＜0.05＝, while the serum levels of IL-10 and sIL-2R reduced in sequence in no-response group, partial-response group and complete-response group.
Conclusions: IL-18, IL-10, TNF-α and sIL-2R co-participate in the pathogenisis of chronic hepatitis C, and are used to evaluate the effect of IFN on the immune state of organisms, and IL-10 and sIL-2R are important for predicting the anti-viral efficacy of IFN.

Objective: To study the effect of sequence variability between different genotypes of HCV on the antigenic properties of the NS5a protein of strong antigenic region at position 2212-2313 by using recombinant proteins.
Methods: Thirteen representative sequences from HCV genotypes 1 to 6 were selected to design synthetic genes encoding for this antigenic region. These genes were assembled by PCR from synthetic olionucleotides and expressed in E.coli as hybrid proteins with glutathione S-transferase. All 13 fusion proteins were purified from bacterial lysates and used to test a panel of anti-HCV positive sera (n=61) obtained from patients infected with HCV genotypes 1 through 6.
Results: A comparison of sequences derived from different HCV genotypes showed that the primary structure of this strong antigenic region is highly variable. Percent homology between different genotype sequences varied from 40.4% to 72.5%. All but one protein immunoreacted with 62% to 93% of serum samples. Although a variable degree of genotype specific antigenic reactivity was detected, only one protein demonstrated a noticeable preference to immunoreact with antibodies against the homologous HCV genotype. On the other hand, closely related proteins derived from the same subtype or genotype immunoreacted with significantly different efficiency with HCV antibodies.
Conclusions: Different genotype HCV genes were successfully cloned, expressed and purified. Sequence variability has a profound effect on the antigenic properties of the HCV NS5a immunodominant region. This finding should be considered in the development of diagnostic tests for the efficient detection of anti-HCV activity in serum specimens.

Objective: To investigate the significance of vascular endothelial growth factor (VEGF) in the pathogenesis of liver cirrhosis and the correlation between VEGF and proto-oncogene c-fos and c-myc in cirrhotic liver.
Methods: The proteins of VEGF, c-fos, and c-myc were identified immunohistochemically in each tissue section of 53 cases of liver cirrhosis. The correlations between VEGF, c-fos and c-myc were analyzed. The levels of VEGF protein in different Child gradings were also compared.
Results: The proteins of VEGF were more highly expressed in Child A and B patients than in Child C patients and controls. The expressions of both c-fos and c-myc were not statistically significant between VEGF positive and negative patients.
Conclusions: The protein level of VEGF can reflect the compensation status of cirrhosis patients and may act as an anti-cirrhotic factor. The proto-oncogene c-fos, c-myc and VEGF may have different mechanisms in the course of cirrhosis or hepatic tumorigenesis.

Objectives: To investigate the mutation of the basic core promoter (BCP) of hepatitis B virus (HBV) and clarify the significance of HBV quasispecies groups in patients with chronic HBV infection.
Methods: A set of specific primers was synthesized according to the HBV DNA sequence of a Chinese strain. The BCP was amplified by PCR method from the serum of 40 patients with chronic HBV infection, and the PCR products of 2 patients were subcloned into pGEM Teasy vectors. Polyacrylamide gel electrophoresis (PAGE) was employed to display the deletion mutations, and clones with differential length were selected to be sequenced. Sequence comparison was made to find the difference.
Results: Two or three bands were displayed by PAGE in 60% patients. The results of sequence analysis showed that there are some kinds of mutations in the BCP region. The substitution always occurs in TATA-like boxes, especially from T to C on 140 site. The deletion mutations were detected in TA1, TA2 and TA3. The 8bp, 20bp deletion mutations frequently happened.
Conclusions: There is a hot deletion region in the BCP. The deletion and the substitution in the TATA-like box may influence the expression of preC/C protein. The sequencing results indicate that there are HBV quasispecies groups in patients with chronic HBV infection.

Objective: To investigate the clinical effectiveness of electro-acupuncture therapy (EAT) in combination with liver artery intubation chemotherapy for massive liver cancer.
Methods: A total of 106 patients were divided into 3 groups. In group A, patients underwent EAT in combination with invasive therapy. In group B, patients received EAT alone. In group C, patients underwent liver artery intubation chemotherapy. In group A and B, subcostal oblique incision was performed to expose liver cancer, and electrodes were inserted into the tumor under direct vision. In group A, liver artery intubation was performed during operation, followed by chemotherapy through the tube. Liver artery intubation chemotherapy was performed only in group C.
Results: The effective rate was 73.7% (28/38), 55.6% (20/36) and 28.1% (9/32) in group A, B and C, respectively.
Conclusions: Electro-acupuncture therapy in combination with liver artery intubation chemotherapy achieves best results. It is an effective therapy for massive liver cancer.

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

Objective: To investigate the role of hepatic and gastric alcohol dehydrogenase (ADH) in different pathologic stages of alcoholic liver disease (ALD).
Methods: Thirty-nine Wistar rats were divided randomly into two groups: model group (24) and control group (15). The ALD model was established by infusing alcohol into the stomach. After hepatic and gastric tissues had been stained by enzyme histo-cytochemistry assay, the activity varieties of hepatic and gastric ADH were observed by an optical microscope, and the activity alterations were also determined by LUZEX-F image analysis as a semi-quantitative method.
Results: The activity of hepatic ADH gradually increased, but that of gastric ADH gradually decreased in the different pathologic stages of alcoholic liver disease. There was a significant difference between the model group and control group (P<0.05).
Conclusions: Along with occurrence of ALD, the activity of hepatic ADH gradually increased, but that of gastric ADH gradually decreased, showing that the activity alterations of hepatic and gastric ADH may play an important role in the onset and development of ALD.

Objective: To discuss the methods and effects of serial therapies oriented by surgery in the treatment of primary large liver cancers.
Methods: From January 1993 to June 1999, 191 patients with large liver carcinoma were treated surgically. The size of tumors varied from 5.2 to 19.7 cm (mean 9.4 cm). Several types of liver resections were made in 121 patients and as a supplement, cryosurgery was carried out for the remaining 70 patients. Importable drug delivery system was instituted intraoperatively. Transcatheter arterial chemo-embolization (THP 30-60 mg, E-ADM 20-40 mg, CDDP 40-80 mg, MMC 10-20 mg, iodin oil 5-30 ml), percutaneous ethanol injection, bioimmunotherapy and traditional Chinese medicine were used pre- and post-operatively. CT angiography and CT during arterial portography were used to find satellite nodules. Early stage recurrences were predicted by AFPmRNA in peripheral blood. Child-Pugh’s classification plus branch chain amino acid/aromatic amino acid ratio (BCAA/AAA) was adopted in evaluating pre-operative liver functions.
Results: Marked results were observed after serial treatments oriented by surgery. The 1-, 3- and 5-year survival rates in resection group were 75.8%, 45.6% and 30.4%, respectively. The 1- and 3-year survival rates in cryosurgery group were 63.2% and 37.0%. The operative mortality was 1.57%. Recurrence rates were 69.2% in AFPmRNA positive group and 33.3% in AFPmRNA negative group (P<0.05). The BCAA/AAA ratio was lower than 1.5 in two patients who died of hepatic failure after resection.
Conclusions: Serial treatments with surgery as the chief modality gives satisfactory results in patients with large primary liver carcinoma. This regimen should be regarded as a main strategy to deal with large liver carcinoma. AFPmRNA in the peripheral blood, signifying a recurrence, may become a new clinical parameter. The BCAA/AAA ratio plus Child-Pugh’s classification is able to evaluate more accurately liver function reserve before surgery.

Objective: To study the effect of bacterial infection, use of antibiotics, active bleeding at endoscopy, and the severity of liver disease as prognostic factors in hepatic cirrhotic patients during the first 5 days after the episode of esophageal or gastric variceal hemorrhage.
Methods: Seventy-six hepatic cirrhosis patients with esophageal or gastric variceal bleeding were enrolled. Bleeding was managed in a standardized protocol using octreotide and vasopressin in sclerotherapy or band ligation for active bleeding at endoscopy. The screening protocol for bacterial infection consisted of chest radiograph; blood, urine and ascitic fluid cultures; the severity of liver disease shown by Child-Pugh score.
Results: Active bleeding was observed at endoscopy in 40 patients (53%). Failure to control bleeding within 5 days occurred in 36 patients (45%). Empirical antibiotic treatment was used in 53 patients (67%), whereas bacterial infections were documented in 43 patients (57%). Multivariate analysis showed that proven bacterial infection (P<0.01) or antibiotic use (P<0.05) as well as active bleeding at endoscopy (P<0.01) and Child-Pugh score (P<0.01) were independent prognostic factors of failure to control bleeding.
Conclusion: Bacterial infection is associated with fai-lure to control esophageal or gastric variceal bleeding in hepatic cirrhotic patients.

Objectives: To study prospectively the enhancement features of small hepatocellular carcinoma (SHCC) with multi-phase scanning of dynamic MRI and spiral CT, and discuss the superiority of dynamic MRI to spiral CT.
Methods: Multi-phase dynamic contrast scanning of high field MRI and spiral CT were performed in 53 patients with SHCC. The arterial phase, portal venous phase and delayed phase scanning of spiral CT was done after the pre-contrast scanning of the entire liver. MRI was performed with SE sequence and fast multiplanar spoiled gradient-recalled sequence dynamic multi-phase contrast scanning.
Results: Seventy-six lesions were found in all 53 patients. Sixty-nine and 54 of the 76 lesions enhanced obviously in MRI and spiral CT arterial phase scanning respectively. The typical enhancement patterns of SHCC in the arterial phase, portal venous phase and delayed phase scanning of MRI and spiral CT were hyper-hypo-hypointense (dense) and hyper-iso-hypointense (dense). Atypical enhancement patterns were hyper-hyper-hyperintense (dense), hyper-iso-isointense (dense) and hypo-hypo-hypointense (dense).
Conclusions: Both MRI and spiral CT multi-phase dynamic contrast-enhanced scanning could demonstrate the enhancement features of SHCC, and arterial phase scan of MRI was superior to spiral CT in reflecting the hypervascular characterization of SHCC. In addition, MRI was better than spiral CT in characterization of hepatic lesions combined with SE sequence.

Objective: To assess the value of intraoperative ultrasonography in hepatobiliary surgery.
Methods: Aloka-650 and Aloka-500 with a 3.5 MHz probe were used in preoperative ultrasonography and those with 5 MHz or 7.5 MHz probes in intraoperative ultrasonography. All patients with carcinoma were confirmed pathologically.
Results: In 44 patients with liver cancer (76 tumors), the diagnostic rate of intraoperative ultrasonography was 97% (74/76), which was markedly higher than 84% (64/76) of preoperative ultrasonography (P<0.05). The diagnostic rate (92%; 22/24) of intraoperative ultrasonography for tumors ≤2 cm in diameter was markedly higher than that (54%; 13/24) of preoperative ultrasonography (P<0.01). The diagnostic rate (94%; 16/17) of intra-operative ultrasonography for tumor embulus of the vein was also markedly higher than that (53%; 9/17) of preoperative ultrasonography (P<0.01). The diagnostic rates of intraoperative and preoperative ultrasonography for cholelithiasis were 99% (108/109) and 97% (106/109) respectively (P>0.05). Yet the diagnostic rate (100%; 12/12) of intraoperative ultrasonography for gallbladder carcinoma was markedly higher than that (66.7%; 8/12) of pre-operative ultrasonography (P<0.05). The diagnostic rates of intraoperative ultrasonography for choledocholith and biliary tract cancer were all 100%, markedly higher than those (83%; 20/24 and 75%; 12/16) of preoperative ultrasonography (P<0.05).
Conclusions: Intraoperative ultrasonography can raise the detective rate of the liver occupying lesions comparing with that of preoperative untrasonography. It is of valuable in selecting operative scheme and locating small lesions.

Objective: To investigate the expression of cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) in extra-hepatic cholangiocarcinoma and the relationship between their expression and clinicopathological parameters.
Methods: COX-1 and COX-2 were detected in 56 extra-hepatic cholangiocarcinomas, including 31 matched tissues originating from non-tumorous bile ductal tissue adjacent to tumours and 6 normal bile ductal tissues, by immunohistochemistry strept avidin-biotin complex using isozyme selective antibodies.
Results: There was no difference in expression of COX-1 between carcinomas (96%, 54/56) and noncancerous specimens (94%, 29/31, P>0.05) or normal bile ductal tissues (100%, 6/6, P>0.05). The positive rate of COX-2 expression in extra-hepatic cholangiocarcinomas (86%, 48/56) was significantly higher than their matched tissues (39%, 12/31, P<0.01) and normal bile ductal tissues (0%, 0/6, P<0.01). Overexpression of COX-2 in extra-hepatic cholangiocarcinoma was related to the metastasis of lymph nodes, distant organs or tissues (P<0.05) as well as the degree of tumour differentiation (P<0.05).
Conclusions: The overexpression of COX-2 plays a crucial role in the carcinogenesis and development of extra-hepatic cholangiocarcinoma, indicating that COX-2 may serve as a target for chemoprevention of extra-hepatic cholangiocarcinoma.

Objectives: To evaluate endoscopic duodenal sphincterotomy and improve its success rate.
Methods: Needle-shaped knife was used for endoscopic sphincterotomy (EST) in 476 patients with biliary or pancreatic diseases from March 1995 to October 2000.
Results: Direct incision was made in 243 patients, papillary fenestration in 89, and opposite incision in 144. The papilla located beside and in the diverticulum in 56 and 12 patients, respectively. EST emergency was made in 147 patients. ERCP after EST because of the difficulty in intubation was made successfully in 62 patients. Mild complications occurred in 14 patients (2.94%), all of whom were cured after symptomatic treatment.
Conclusions: EST with needle-shaped knife has such advantages as safety in operation and convenience in incision. It is suitable for the papilla with different shape, with a higher success rate.

Objective: To investigate the incidence of aberrant bile duct and its management during laparoscopic cholecystectomy (LC).
Methods: In 10 000 patients undergoing laparoscopic cholecystectomy from 1992 to July 2001, 3 had the involvement of the right accessory hepatic duct. In patient 1, the aberrant duct drained into the cystic duct was confirmed by open operation. In patient 2, the aberrant duct, which drained to the common bile duct (CBD), was injured and treated with suture and ligature under laparoscopy. In patient 3, the aberrant duct, which also drained to the CBD, was confirmed and preserved.
Results: All patients recovered well except patient 1 who had a transient elevation of ALT. No bile leakage or other complication occurred.
Conclusions: Only variation near the confluence and the entrance of the cystic duct into the bile duct is discovered during laparoscopic cholecystectomy. Right accessory hepatic duct is common and should be preserved during the operation. The accidentally injured small accessory hepatic duct can be treated with ligature without severe disturbance to liver function.

Objective: To evaluate the procedures and timing of operation as well as long-term postoperative effect of congenital choledochal cysts (CCC) in adults.
Methods: The procedures and timing of operation, effective rate, re-operation rate and incidence of carcinoma after operation for 70 adult patients with CCC from January 1980 to June 1999 were analyzed retrospectively.
Results: The re-operation rate of external drainage was 86% (6/7). The effective rate of internal drainage was significantly lower than that of cyst resection (3/10 vs 45/49, χ2=20.94, P<0.001). The re-operation rate and incidence of carcinoma of internal drainage were higher than those of cyst resection (5/10 vs 3/49, χ2=13.64, P<0.001 and 3/10 vs 3/49,  χ2=5.18, P<0.025). The reoperation rate of emergency surgery was higher than that of selective operation (8/10 vs 6/56, χ2=24.37, P<0.001).
Conclusions: External drainage should be the first-aid measure and the therapy of choice on emergency basis. Internal drainage should never be attempted. Cyst resection with Roux-en-Y hepaticojejunostomy is recommended as the treatment of choice in selective operation.

Abstract: Severe acute pancreatitis is a disease of rapid onset and progression with high mortality and morbidity. A new concept suggests that it is multifactorially induced and involves multi-links and that therapy must be directed to several more important links at the same time. The regimen of integrated traditional Chinese and western medicine acts on the same or different sites and links to inhibit or block the inflammatory cascades. Concomitantly, preventive measures were taken at the start of the treatment for preventing the progression of the disease, protecting the function of vital organs, and avoiding the occurrence of complications. No mortality or serious complications occurred in a series of 38 patients with Balthazar’s CT grading of D and E. The treatment regimen and the mechanisms of actions of these drugs were delineated in detail in the tables and figure; the regimen is highly recommended for clinical use.

Objective: To study the effects of angiostatin(AS) gene mediated by liposome on human pancreatic cancer cell line SW1990.
Methods: Angiostatin gene was cloned into the eukaryotic expression vector pRC/CMV. The recombinant of pRC/CMV-AS was introduced into the pancreatic cancer cell line, SW1990. The mechanism of anti-tumor was studied and tested.
Results: The eukaryotic expression vector pRC/CMV-AS was identified by the restriction digest. pRC/CMV-AS was stably integrated into the target cells and expressed by Western blot and drug-sensitivity tests, and inhibited the vascular endothelial cells proliferation in vitro. In addition, the effects of the angiostatin vector on reducing the volume of tumors implanted in nude mouse models were also noted.
Conclusion: This study demonstrated that the recombinant pRC/CMV-AS mediated by liposome may play a potential role in the treatment of pancreatic cancer in the future.

Objective: To summarize retrospectively the experience in diagnosis and surgical treatment of pancreatic insulinoma.
Method: 74 patients who had been operated on and confirmed pathologically from July 1967 to July 2001 were enrolled. They were 37 men and 37 women, aged 41.91 years on average.
Results: In all patients with typical Whipple’s triad, the ratio of insulin to glucose was measured over 0.3 for at least one time. 52.70% of the patients were once misdiagnosed, and only 20.27% of them were correctly diagnosed in a year after onset of symptoms. Their average course of the disease was 3.36 years. B-ultrasonography and endoscopic ultrasonography (EUS) showed a low positive rate for localization of insulinoma. CT and magnetic resonance imaging (MRI) could correctly detected 63.41% and 63.64% of tumors respectively, in sharp contrast to a localization rate of 90% for arterial stimulation and venous sampling (ASVS). Single insulinoma was observed in 66 patients (89.19%), multiple insulinoma in 2 (2.70%), hyperplasia in 4 (5.41%), and malignant insulinoma in 2 (2.70%). Most (85.29%) of the benign insulinomas were less than 2 cm in diameter. Simple enucleation was the major operative procedure for benign tumors. In 88.52% of the patients, glycemia increased to normal in 30 minutes after tumor excision, and in the remaining patients within 2 hours. 97.26% of the patients experienced temporary hyperglycemia but recovered in a week. The major complications of insulinoma included pancreatic fistulae (27.27%) and pancreatitis (5.19%).
Conclusions: Better recognization of insulinoma and its rational examination are essential to early diagnosis. CT can be first used for localization, otherwise ASVS is used. Surgery is the major choice for the treatment of insulinoma, but cautions should be taken to pancreatic fistulae after operation.

Objective: To summarize the experience in the surgical treatment of chronic pancreatitis.
Methods: 189 patients with pancreatitis admitted from May 1983 to August 1999 to our hospital were reviewed.
Results: 136 (72%) patients received surgical treatment including pancreatoduodenectomy (15 patients), distal pancreatectomy (12), internal drainage of pancreatic pseudocyst (28), side-to-side pancreaticojejunostomy (16), relief of biliary stenosis (58), and pancreatic biopsy (7). Pain was relieved in 97.8% of the patients, and the complication rate was 1.5%.
Conclusions: It is crucial to select various surgical strategies at a proper time for chronic pancreatitis patients. Patients with chronic pancreatitis complicated by dilation or obstruction of the pancreatic duct or with biliary pancreatitis should be operated on in early stages, whereas those with other types of chronic pancreatitis should receive the therapy focusing on the alleviation of their symptoms, not on early surgical intervention. The timing and modality of surgery are important in improving the life quality of the patients and changing their natural history of the disease.

Objective: To study retrospectively the manifestations and characteristics of solid cystic tumor of the pancreas(SCTP)on CT.
Methods: Nine patients with solid cystic tumor of the pancreas underwent resection with pathological and immunohistochemical confirmation. All the patients were female, aged 27.7 years on average at onset of the disease. CT scan was performed in patients with or without intravenous injection of contrast medium; it was also performed in the arterial phase in 4 patients.
Results: Solid and cystic structures were observed in tumors of the pancreas. Solid structure demonstrated low or iso-density on unenhanced CT, poor enhancement in the arterial phase and marked enhancement in the portal venous phase on contrast material-enhanced CT. Cystic structure showed low density on both pre- and pro-contrast views. The CT findings of tumors with predominantly cystic or equal proportion of solid and cystic structure: mural nodules for solid structure, “floating cloud” signs, or solid and cystic crossing distributions. Cystic structure of tumors predominately solid presenting as a beading appearance under capsule. In round, oval and completely encapsulated tumors in the pancreas, the greater vessel enhanced with well-defined margins on pro-contrast images. No dilatation was observed of the common bile and pancreatic ducts.
Conclusion: The characteristics of solid cystic tumor of the pancreas revealed by CT could confirm the diagnosis of the disease in combination with onset age and sex of patients.

Background: Neural invasion is a special metastatic route in pancreatic cancer and responsible for the high recurrence in curatively resected cases.
Objective: To summarize the characteristics and mechanisms of neural invasion in pancreatic carcinoma for the better treatment of this disease.
Data sources: The international literatures were reviewed about the definition, incidence and mechanisms of neural invasion and its clinicopathology, diagnosis and treatment.
Data synthesis: Neural invasion is defined when the medial perineurium is involved by cancer cells, accounting for 45%-100% of all cases. It can be divided into different kinds or stages according to its locations and the number of nerve fascicles involved. Invasion along vascularity, lymphatic vessels, perineural space and neurotropism is considered as its primary mechanisms. No clinicopathologic factors are correlated with neural invasion. Intravascular ultrasound, CT scan and immunostaining K-ras gene analysis can be used to diagnose neural invasion pre-, intra- or postoperatively.
Conclusion: Neural invasion is an important prognostic factor for the recurrence of pancreatic carcinoma after pancreatectomy. Because of its high incidence, pancreatectomy with extended radical retroperitoneal dissection should be considered as a basic procedure in the treatment of pancreatic carcinoma.