ABSTRACT: Clinical staging systems for hepatocellular carcinoma (HCC) provide guides to patient assessment and therapeutic decision making. The most commonly used staging systems for HCC internationally are the Okuda classification and the pathologic tumor node metastasis (TNM) classification. But each has its own limitations. New staging systems for HCC have recently been reported from Italy, France, Spain and China. In this review, we evaluated the staging systems of HCC and discussed the natural history and prognosis of tumors of different stages. We believe that a reliable new staging system of HCC patients will be established in the near future.

OBJECTIVE: To assess the role of early peritoneal lavage and drainage in the management of severe acute pancreatitis.
DATA SOURCES: Early peritoneal lavage and drainage was defined as that lavage and drainage should be done in the peritoneal cavity without interference of the pancreas within 72 hours after onset of acute pancreatitis. Biomedical literature database (Medline) from 1981 through 2003 was retrieved and papers about this treatment were analyzed.
RESULTS: Nine papers retrieved included 179 patients with severe acute pancreatitis. In 108 patients undergoing closed peritoneal lavage and drainage, 7 died, in 15 patients having laparoscopic procedure, 1 died, and in 56 patients having open procedure 2 died. The total survival rate was 94.4%.
CONCLUSIONS: Even if extensive pancreatic necrosis occurs, early peritoneal lavage and drainage is feasible to keep the inflammatory pancreas intact and drain peri-pancreatic region in an attempt to improve the survival rate.

OBJECTIVE: To study the efficacy of liver transplantation on end-stage hepatitis B related liver diseases, and the prevention and treatment strategies of hepatitis B recurrence after the transplantation.
METHODS: The efficacy of combined treatment of lamivudine and hepatitis B immune globulin (HBIG) therapy on 24 patients who had received liver transplantation was retrospectively studied.
RESULTS: All the 24 patients with end-stage hepatitis B-related liver diseases treated with lamivudine alone or combined therapy of lamivudine and HBIG showed normal liver function and 21 of them lost hepatitis B virus (HBV) markers. However, the remaining 3 patients became HBsAg positive again soon after liver transplantation.
CONCLUSIONS: Liver transplantation is effective for patients with end-stage hepatitis B-related liver diseases. Combined treatment of lamivudine and HBIG may prevent the recurrence of hepatitis B after the operation.

OBJECTIVES: To investigate the changing patterns of functional and histological status, observe the posttransplantation survival of liver graft under different warm ischemia time (WIT) in rats, and determine the maximum limitation of liver graft to warm ischemia.
METHODS: According to WIT, the rats were randomized into 7 groups, with WIT of 0, 10, 15, 20, 30, 45, 60 minutes respectively. Serum concentrations of alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase were measured at 1, 2, 3 and 5 days after orthotopic liver transplantation respectively. Liver graft specimens were observed histopathologically at the same interval. The rats’ survival in each subgroup was observed.
RESULTS: In terms of graft survival, there was no significant difference between subgroups within 30-minute WIT. In the group with 30-minute WIT, the recipient rats’ survival rate was 83.3% (10/12) at one week, 58.3% (7/12) at one month, and 50.0% (6/12) at 3 months. In the group with 45-minute WIT, the recipient rats’ survival rate was 66.7% (8/12) at one week, 33.3% (4/12) at one month, and 8.3% (1/12) at 3 months, whereas only 8.3% (1/12) of the rats had one-week survival in the group with 60-minute WIT.
CONCLUSIONS: These results indicate that rat liver graft could be safely subject to warm ischemia within 30 minutes. When WIT is prolonged to 45 minutes, the recipients long-term survival is severely insulted, and both function and histological structure of liver graft may develop irreversible damage when WIT is prolonged to 60 minutes.

OBJECTIVE: To investigate the protective mechanism of different ischemic preconditioning (IPC) to ischemia/reperfusion (I/R) injury of rat liver graft.
METHODS: 192 Wistar rats were randomly divided into 4 groups (48 rats in each group): control group (group C), experimental group 1 (group E1), experimental group 2 (group E2), and experimental group 3 (group E3). IPC was not carried out in group C. In the experimental groups, IPC was carried out by blocking blood flow of the portal vein and hepatic artery and then reperfusion by removal of the clamp before donor liver was resected. Group E1: 5-minute ischemia and 10-minute reperfusion; Group E2: 5-minute ischemia and 5-minute reperfusion and one more the same procedure; Group E3: 10-minute ischemia and 15-minute reperfusion. Four hours after IPC, liver transplantations were performed. Recipient blood and graft samples were obtained to determine the levels of ALT, AST, TNF-α and apoptosis index at 0.5, 2, 6, 24 hours after portal vein reperfusion.
RESULTS: At 0.5, 2 hours after portal vein reperfusion, the levels of TNF-α in the experimental groups E1, E2, and E3 were significantly lower than in the control group (P<0.05), and the levels in group E2 were significantly lower than in groups E1 and E3 (P<0.05). At 24 hours, the levels of TNF-α in group E2 were significantly lower than in groups C, E1 and E3 (P<0.05). At 2 and 6 hours, apoptosis index in the experimental groups E1, E2, and E3 was significantly less than in the control group (P<0.05). Apoptosis index in group E2 was significantly less than groups E1 and E3 (P<0.05). At 24 hours apoptosis index in the experimental groups E1, E2, and E3 was significantly less than in the control group (P<0.05).
CONCLUSIONS: Ischemic preconditioning could attenuate liver graft injury by decreasing apoptosis of hepatocytes and production of TNF-α. The method of IPC with 5-minute ischemia, 5-minute reperfusion and one more the same procedure is a better way to protect liver graft from ischemia-reperfusion injury.

OBJECTIVES: To compare the effects of different treatments for hepatocellular carcinoma (HCC) with tumor thrombosis in the portal vein (TTPV) and evaluate the factors influencing the prognosis.
METHODS: One hundred and thirty-eight patients with HCC associated with TTPV, whose liver function was compensative and the tumor with TTPV can probably be resected together, were divided into four groups: conservative treatment group (n=14); chemotherapy group (n=19); surgical resection group (n=19); and surgical resection with postoperative chemotherapy group (n=64).
RESULTS: The median survivals of the four groups were 3.5, 7.1, 10.1 and 13.4 months, respectively. The 0.5-, 1-, 2-, and 3-year cumulative survival rates of the surgical resection with postoperative chemotherapy group were 53.7%, 37.6%, 30.7% and 14.0% respectively, which were significantly higher than those of the other three groups (P<0.05). Both univariate and multivariate analysis revealed that postoperative chemotherapeutic course was the most important factor affecting the surgical results.
CONCLUSIONS: If patients’ liver function is compensative and tumors with TTPV can be removed together, exploration should be done. Surgical resection combined with postoperative chemotherapy can achieve the best results. More chemotherapeutic courses after surgical resection can be prescribed if the patients have good hepatic functional reserve.

OBJECTIVE: To assess the indications, efficacy and clinical significance of percutaneous cryoablation for liver carcinoma after transcatheter liver artery chemoembolization (TACE).
METHODS: Thirty-four patients with histologically or clinically confirmed primary or metastatic carcinomas were treated with TACE. One week to 1 month later, they were treated percutaneously under ultrasound guidance using cryosurgical system in the period of July 2001-June 2002. All patients were followed up to determine serum tumor marker, CT scans, MRI images or ultrasound images.
RESULTS: This therapy was performed in 34 patients including 32 patients with Child A liver reserve, 2 patients with Child B and no patient with Child C. There were 28 patients with primary liver cancer and 6 patients with metastatic liver cancer. During the follow-up period (3 to 15 months), 41.1% patients were recognized clinically cured because the serum tumor markers became normal, or CT scans and MRI images revealed that the lesion became completely necrotic. 44.1% patients were recognized effectively treated.
CONCLUSIONS: Percutaneous cryoablation combined with TACE is a choice of treatment for liver carcinoma. It is minimally invasive, safe and effective for those patients with liver cancer unsuitable for surgery.

OBJECTIVE: To assess the diagnostic standards and treatment of severe Budd-Chiari syndrome (BCS).
METHODS: The clinical data of 126 patients with severe BCS treated from November 1994 to June 2001 at our hospital were retrospectively analyzed. Percutaneous transhepatic recanalization and dilation and/or stent placement of the main hepatic vein was performed in 10 patients. Mesocaval C type shunt with artificial graft was performed in 68 patients, splenojugular shunt in 33, mesojuglar shunt in 1, and mesocaval shunt or improved splenopneumopexy after percutaneous intraluminal angioplasty and stent placement of the inferior vena cava in 14.
RESULT: Six patients died during perioperation. In 120 patients followed up for 6 months to 7 years, 89 had excellent results and 31 good results.
CONCLUSIONS: Diagnostic standards of severe BCS are suggested. Proper treatment should be used according to the pathological changes of the inferior vena cava and main hepatic veins.

OBJECTIVE: To explore the effect of two dominating signaling pathways, VEGF/KDR and angiopoietins/Tie2, on the formation of new blood vessel in hepatocellular carcinoma (HCC) growth and metastasis.
METHODS: RT-PCR and Western blot were employed to evaluate the VEGF/KDR and angiopoietins/Tie2 expression in samples from 23 patients with HCC. Meanwhile, microvessel density (MVD) was determined as a marker of angiogenesis by counting CD34 positive cells with the method of immunohistochemistry.
RESULTS: The two pathways were activated in all HCC samples. The expressions of vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang2) were significantly higher (P<0.05) in hepatocellular carcinoma tissues and the margin of the tumor than those in control groups, and so did CD34 positive cells. Although significant difference in the expression of kinase insert domain containing receptor (KDR) and Ang1/Tie2 was not observed in all groups, their distinct high levels were seen in hepatoma and its margin compared with normal and cirrhotic liver. VEGF and Ang2 expressions were seen up-regulated in HCC with vascular invasion and satellite lesion.
CONCLUSIONS: The two signaling pathways, VEGF/KDR and angiopoietins/Tie2 are activated in the process of angiogenesis in HCC and modulate the formation of new blood vessels. The imparity of the two signaling pathways’ activation is to benefit HCC metastasis. In the two pathways, VEGF and Ang2 may play an important role in the process of angiogenesis, and are necessary indicators for the prognosis and metastasis of HCC. This study provides another clue for the exploration of anti-angiogenic agents.

OBJECTIVE: To study the relationship between oval cells and primary hepatocarcinoma and the expression of c-kit and proliferating cell nuclear antigen (PCNA) in oval cells of rats with hepatocellular carcinoma.
METHODS: A hundred and twenty clean SD rats were divided into three groups: normal group, cancer-induction group and intervention group. The normal group was fed with standard forage while the rest two groups were fed with 3’-methyl-2-methylamino-azobenzene (DAB) to induce carcinoma for 14 weeks and then fed with standard forage and water. Uscharidin was injected abdominally to the intervention group from the first week to the 14th week. All rats were killed and biopsy specimens were taken from the left and right liver lobes for immunohistochemical staining of c-kit and PCNA on the 2nd, 4th, 6th, 8th, 10th, 12th, 14th, 16th, 18th, 20th, 22nd, and 24th week.
RESULTS: From the 2nd to 14th week after liver infection, c-kit positive cells, mainly oval cells were found in the portal area in the carcinoma-induction group and dotted positive pigmentations in liver lobules. In the 22nd week, a large number of cancerous nodes occurred and nuclei heteromorphism was apparent; the number of positive cell decreased but positive cells could be sparsely observed in cancerous nodes. In the 2nd week of the carcinoma-induction process, PCNA positive cells were oval cells in the portal area. In the 4th week, a lot of hepatic cells were positively stained, especially in the central vein area. In the 6th week, PCNA positive cells could be seen in the lobules of the liver. In the 8th week, the number of PCNA cells decreased comparatively. From the 10th to 14th week, oval cells in the portal area were still over-expressed. From the 16th to 24th week, a large number of cancerous nodes occurred and PCNA was over-expressed in some of them. In necrotic cancerous nodes, the para-cancerous PCNA positive cells were sparsely distributed and their number was less than that of PCNA positive cells of cancerous tissues.
CONCLUSIONS: Hepatic stem cells originating from the terminal biliary plexus of the portal area are involved in the development of hepatocarcinoma because c-kit positive cells expressed in cancerous nodes, accompany the whole process of the development. In the middle inflammatory period of carcinoma-induction, the expression of PCNA in hepatic cells peaked, but the index decreased in the late inflammatory period and in the proliferated fibrosis stage. The expression of PCNA is a tortuous process, going up, down, then up again from normal tissues to cancerous tissues. Combined with pathological findings, PCNA can be considered as a warning index for carcinomatous cells.

OBJECTIVES: To study the structure specificity of Echinococcus granulosus 95 (Eg95) gene and the open reading frame (ORF) of the full-length cDNA sequence in Xinjiang, northwestern China and construct Eg95 Xinjiang strain DNA vaccine.
METHODS: Primers of Eg95 were designed on the basis of the sequence of Eg95 antigen cDNA. Genomic DNA was extracted from E.granulosus protoscoleces (sheep) in Xinjiang. The Eg95 gene and full-length Eg95 cDNA were amplified by PCR from the genomic DNA and protoscolex cDNA library of E.granulosus in Xinjiang, respectively. The Eg95 gene was cloned into pUCm-T plasmid and the Eg95 cDNA into eukaryotic expression plasmid pcDNA3 for the construction of full-length ORF DNA vaccine pcDNA3-Eg95/XJ. Both Eg95 gene and Eg95 cDNA were sequenced and analyzed by DNAman and NCBI/Blast program.
RESULTS: DNA sequence analysis of Eg95 Xinjiang strain (Eg95/XJ) cDNA fragment indicated that the coding region of the full-length of Eg95/XJ was 471bp and that encoding a peptide with 156aa and the genomic DNA size was 1191bp. Homological comparison showed that the ORF of Eg95/XJ cDNA was identical to the cDNA sequence of Eg95 reported in the reading frame, but the genomic DNA was a new sequence, named Eg95/XJ and the multiple nucleotide differences, which were represented in Eg95/XJ gene in comparison with those of the New Zealand strain, occurred predominantly in the non-coding regions of the gene. The pcDNA3-Eg95/XJ positive clone was the exact recombinant plasmid and could be used as a DNA vaccine.
CONCLUSION: pcDNA3-Eg95/XJ Xinjiang strain DNA vaccine is successfully constructed.

OBJECTIVE: To investigate the protective effect of L-arginine (L-arg) against liver ischemic-reperfusion (I/R) injury in rat model and its possible mechanism.
METHODS: Male Sprague-Dawley rats were randomized into sham group: hepatoduodenal ligament mobilized, but not clamped; control group: hepatic ischemia only; Arg group: 5 minutes before hepatic ischemia, L-arg (200 mg/kg) injected via the dorsal penis vein; Arg+L group: 10 and 5 minutes before hepatic ischemia, L-NAME (30 mg/kg) and L-arg (200 mg/kg) injected via the dorsal penis vein, respectively; and Fmk group: 5 minutes before hepatic ischemia, ZVAD-fmk (15 mg/kg) injected via the dorsal penis vein. The liver was subjected to ischemia for 40 minutes by Pringle’s maneuver, and reperfusion was initiated by removing clamp. The 7-day survival rate, alanine transaminase (ALT) level, caspase-3 activity and apoptotic hepatocyte count were compared among these groups.
RESULTS: After 40 minutes of ischemia and 6 hours of reperfusion, the 7-day survival rate of the Arg group was significantly higher than that of the control and Arg+L groups (P<0.05). The ALT level, caspase-3 activity and apoptotic hepatocyte count in the Arg group were decreased significantly than those in the control and Arg+L groups (P<0.01). The caspase-3 activity and apoptotic hepatocyte count in the Arg group were slightly higher than those in the sham and Fmk groups, but there was no statistical significance.
CONCLUSIONS: L-arg could ameliorate liver I/R injury and the possible protective mechanism is inhibition of hepatocyte apoptosis via inhibition of caspase-3 activity by nitric oxide synthesis.

OBJECTIVE: To assess a sensitive and specific technique for detecting serum HBV DNA with an HBV DNA probe labelled directly by alkaline phosphatase (AlkPhos Direc probe).
METHODS: AlkPhos Direc probe was prepared with purified HBV DNA labelled directly by alkaline phosphatase. The probe and chemiluminescent substrate CDP-star for AP were used in hybridization assay. HBV DNA was detected by autoradiography on a film. The results of 80 samples were compared between the chemiluminescent dot blot hybridization assay with the AlkPhos Direc probe and another assay with the digoxigenin-labelled HBV DNA probe. The correlation of seventy-sample results of fluorescent quantitative HBV DNA PCR assay and dot blot hybridization assay with the AlkPhos Direc probe was analysed.
RESULTS: The sensitivity of the AlkPhos Direc probe was 10 pg at least. The coincidence of the AlkPhos Direc probe was 100% compared with that of the digoxigenin-labelled HBV DNA probe. A correlation coefficient of HBV DNA quantitative results between fluorescent quantitative HBV DNA PCR assay and dot blot hybridization assay with the AlkPhos Direc probe was 0.98 (P<0.01).
CONCLUSIONS: The method detecting HBV DNA in serum with the HBV DNA AlkPhos Direc probe is sensitive and specific. The results of the two assays with the AlkPhos Direc probe or with the digoxigenin-labelled HBV DNA probe are completely coincident. The correlation of HBV DNA quantitative results between fluorescent QPCR assay and dot blot hybridization assay with the AlkPhos Direc probe is satisfactory.

OBJECTIVE: To study the relationship between the different replication status of hepatitis B virus (HBV) and mutations in the core promoter (CP) in mother and her child infected by mother-to-infant transmission.
METHODS: The core promoter was amplified by PCR and cloned into pGEM-T vector with the T-A cloning technique. The recombinant plasmid pGEM-CP was confirmed by digestion with restriction enzyme Apa Ⅰ and Sac Ⅰ. Two clones were selected to be sequenced in each patient.
RESULTS: Every pair of mother and child had same serotype and genotype and the homology of nucleotides encoding “a” determinant was 98%-100%. The number of mutations in the core promoter of patients with a high replication status was less than that in those with a low replication status. Mutations were mainly distributed in basia core promoter (BCP) and the inhibitor region of Kunitz-type serine protease. This difference was not associated with mother or child.
CONCLUSION: The different replication status of HBV is caused by mutations in the core promoter in mother and child infected by mother-to-infant transmission and appears to be not associated with the status of development of the infection.

OBJECTIVE: To study the changes of immune function in liver cirrhosis patients after splenectomy combined with resection of hepatocellular carcinoma (HCC).
METHODS: Sixteen patients with HCC associated with liver cirrhosis were divided into two groups: splenectomy combined with hepatectomy (splenectomy group n=7) and hepatectomy (non-splenectomy group, n=9). T lymphocyte subsets such as CD4, CD8, CD4/CD8 and Th lymphocyte cytokines such as interferon γ (IFN-γ), IL-2, IL-10 in 7 ml peripheral venous blood before operation and 2 months after operation were examined and compared between the two groups.
RESULTS: There was no significant difference in pre-operative CD4, CD8, CD4/CD8, IL-2, IFN-γ, IL-10 levels in the two groups. Two months after operation, the levels of CD4 (38.2%±3.7%), CD4/CD8 (1.7±0.3), IFN-γ (104.4±14.9 pg/ml), IL-2 (98.6±18.6 pg/ml) were increased and those of CD8 (23.7±3.7 pg/ml), IL-10 (55.5±11.2 pg/ml) levels were decreased in the splenectomy group. The levels of CD4 (32.5%±4.0%), CD4/CD8 (1.1±0.1), IFN-γ (70.5±12.6 pg/ml), IL-2 (80.9±13.5 pg/ml) in the non-splenectomy group were much lower than those in the splenectomy group, but the levels of CD8 (29.4%±4.0%), IL-10 (89.4±10.0 pg/ml) in the non-splenectomy group were significantly higher than those in the splenectomy group (P<0.05).
CONCLUSIONS: Splenectomy combined with hepatectomy for HCC patients associated with liver cirrhosis does not decrease but promote the recovery of T lymphocyte subsets and Th1/Th2 cytokines from imbalance and improve anti-tumor immune function of the patients.

OBJECTIVE: To clarify the natural history of chronic hepatitis B so as to evaluate its long-term therapeutic outcome of the patients and the efficacy of antiviral drugs.
METHODS: A cohort of 183 biopsy-proven chronic hepatitis B patients (mean age of 31.75±8.03 years, male/female ratio: 152∶31) and 247 controls were followed up retrospectively for 11.81±4.08 years. This study was focused on long-term clinical outcome including the rates of liver cirrhosis, hepatocellular carcinoma and death, apart from the long-term effect of antiviral drugs and prognostic factors.
RESULTS: In the 183 chronic hepatitis B patients, 22 (12.02%) developed liver cirrhosis, 12 (6.56%) developed hepatocellular carcinoma, and 20 (10.93%) died. The 5-, 10- and 15-year survival rates were 97.27%, 91.62%, and 84.47%, respectively. The 5-, 10- and 15-year incidence rates of HCC were 0, 3.19%, and 11.56%, respectively. In the 247 controls, 6 (2.43%) died; none of them developed cirrhosis or HCC. The rates of death, liver cirrhosis, and HCC in the hepatitis B patients were markedly different (P<0.005) compared with the controls. The overall mortality of hepatitis B patients was 4.5-fold higher than the general population. Cox multiple regression analysis showed that old age, severe histological injury, and positive HBeAg were closely related to liver cirrhosis; old age, severe histological injury, and male were major factors leading to death. The independent variable of predicted HCC was not found.
CONCLUSION: The long-term outcome of hepatitis B patients is poor and the efficacy of antiviral drugs needs further study.

OBJECTIVES: To observe expression of CD14 protein and its gene in Kupffer cells induced by lipopolysaccharide (LPS) and explore the role of CD14 in LPS-induced Kupffer cell activation.
METHODS: Kupffer cells were isolated from Wistar rat livers by in situ collagenase digestion, followed by culture and incubation with 100 μg/ml LPS for 0, 30, 60 and 120 min, respectively. CD14 protein expressed on the membrane of Kupffer cells was examined using confocal microscopy and Western blotting analysis. Expression of CD14 mRNA in Kupffer cells was determined by reverse transcription polymerase chain reaction (RT-PCR). Tumor necrosis factor (TNF)-α and interleukin (IL)-6 in the supernatant were measured using enzyme-linked immunosorbent assay (ELISA) kit.
RESULTS: Expression of CD14 mRNA and CD14 protein in isolated Kupffer cells was upregulated quickly after LPS stimulation and increased with time. Likewise, there was a time-dependent increase of TNF-α and IL-6 in the supernatant with upregulation of CD14 expression. There were significant differences between normal and LPS-stimulated Kupffer cells (P<0.05).
CONCLUSIONS: LPS can upregulate expression of CD14 protein and its gene in isolated Kupffer cells. CD14 may play an important role in the activation of LPS-induced Kupffer cells.

OBJECTIVE: To evaluate the predictive value of magnetic resonance cholangiography (MRC) in selected patients before laparoscopic cholecystectomy (LC).
METHODS: Patients with risk factors for common bile duct (CBD) stones scheduled for elective LC from March 1999 to May 2001, underwent MRC followed by endoscopic retrograde cholangiography (ERC) to detect the stones and the accuracy of MRC. Selection of suspected patients was based on clinical, ultrasonographic, and laboratory criteria.
RESULTS: During a 26-month period, a total of 267 patients were studied. Seventy-eight MRC identified patients were found to have CBD stones by ERC or laparoscopic cholangiography in the study. Seven of 78 patients were misdiagnosed as having CBD stones by MRC. In this study, MRC had a sensitivity of 100%, a specificity of 96.3%, a positive predictive value of 91.8%, and a negative predictive value of 100% for the detection of common bile duct stones.
CONCLUSIONS: With the use of LC, ERC is frequently performed before LC to detect CBD stones; but it is invasive with a well-documented complication rate. MRC is a simple non-invasive method for preoperative screening for CBD stones in at-risk patients. In this study if ERC had been limited to patients with a positive MRC, it would have reduced the need for ERC by 68.2%, and the complications of preoperative examination would be minimized significantly.

OBJECTIVE: To explore the prognostic factors of gallbladder carcinoma and the relationship between operative procedure and prognosis of gallbladder carcinoma.
METHOD: A retrospective clinical analysis was made in 56 patients with gallbladder carcinoma who had undergone surgery at our department from 1995 to 2001.
RESULTS: Of the 56 patients, 20 were men and 36 women with a male to female ratio of 1∶1.56. Their age ranged from 41 to 79 years with a mean of 59.6 years. Thirty-four patients suffered from gallstones. Abdominal pain (83.9%) and jaundice (41.1%) were the main symptoms. Thirty patients (Nevin stage Ⅱ in 5 patients, Ⅲ in 3, Ⅳ in 4, and Ⅴ in 18) received radical or extended radical resection; non-radical resection was performed in 11 patients of Nevin stage Ⅴ; and 15 patients of Nevin stage Ⅴ were subjected to biopsy with or without palliative bypass procedure. Statistical analysis showed that operative procedure, staging of Nevin, and gallstone affected significantly postoperative survival, but age, sex, preoperative serum bilirubin level, numbers of tumor location, histopathological type and grade were not significant prognostic factors. After radical resection was classified with Nevin staging, we found that all the patients of stage II were alive. Meanwhile the postoperative survival periods of radical resection groups of stage III to V, palliative resection group, and biopsy with/without palliative drainage group were statistically different.
CONCLUSIONS: From Nevin stage II to V, the survival period of respective stage group, which treated with curative operation, became shorter gradually. In those patients of stage V, the survival period of curative operation group was longer than that of palliative resection group, and that of the latter was better than that of biopsy with/without palliative drainage group. So radical resection was still the unique way to better prognosis.

OBJECTIVE: To improve the surgical effects of hilar duct stricture.
METHODS: The clinical data of 76 patients with hilar bile duct stricture treated at our hospital from 1990 to 2000 were analyzed. The diagnosis was determined by triad signs of cholangitis, increase of ALP and γ-GGT levels, dilation of intrahepatic and extrahepatic bile ducts confirmed by ultrasonography (US), computed tomography (CT), percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (ERCP). The location of stricture was divided according to the Bismuth classification standard.
RESULTS: Among the 76 patients, 46 (60.5%) suffered from injurious stricture, including 13% of Bismuth type Ⅰ, 39% of type Ⅱ, 19.4% of type Ⅲ, and 28.2% of type Ⅳ. Inflammatory stricture was found in 28 patients, locating in the left hepatic duct (LHD) 46.4% (13/28), the right hepatic duct (RHD) 35.7% (10/28), and the common hepatic duct (CHD) 17.9% (5/28), respectively. The percentages of patients with stricture due to Mirizzi’s syndrome, bile duct cyst, and sclerosing cholangitis were 9.2%, 3.9% and 2.6%, respectively. Bile duct repair procedures included biliary reconstruction with pedicled umbilical vein graft for 9.2% of the patients, and proximal cholangiojejunostomy combined with LHD and RHD plasticity for 92.2%. Seventy of the 76 patients were followed up for 2-10 years, and the excellent outcome rate was 94.7%.
CONCLUSIONS: Injurious stricture is the major type of hilar bile duct stricture. Inflammatory stricture is mainly composed of RHD. Hilar bile duct stricture should be treated surgically according to various etiological features and technical principles of biliary repair.

OBJECTIVE: To compare the efficacy of metal versus plastic biliary stent implantation in the treatment of malignant biliary obstruction.
METHODS: Percutaneous transhepatic self-expandable metal stent (MS, n=61) and 10F plastic stent (PS, n=34) were placed in 95 patients with malignant biliary obstruction in three hospitals of Guangdong province. All patients were followed up until death or at least one year after the procedure. Kaplan-Meier analysis was used to compare the survival of the patients and the rates of stent patency.
RESULTS: The 30-day mortality rate was lower in the MS group (6/61, 9.8%) than in the PS group (9/34, 26.5%, P<0.05). The 30-day reobstruction rate and the complication rate were 15.0%, 16.4% in the MS group and 32.4%, 29.4% in the PS group, respectively (P<0.01). The median patency period of stents and median survival period of the patients were 230 days, 224 days in the MS group and 90 days, 94 days in the PS group, respectively (P<0.01).
CONCLUSION: Metal stent is clinically superior to plastic stent in the treatment of malignant biliary obstruction.

OBJECTIVE: To improve the successful rate of endoscopic biliary drainage.
METHODS: Three hundred and fifty-two patients with biliary obstruction were given biliary drainage via duodenoscope from January 1998 to December 2002. 258 patients received endoscopic naso-biliary drainage (ENBD), 51 endoscopic retrograde biliary drainage (ERBD), and 43 endoscopic metal biliary endoprothesis (EMBE).
RESULTS: Of the 352 patients with biliary obstruction, 337 succeeded in drainage by endoscopy and 15 failed. Ten ENBD failed patients were handled successfully by readjustment of the site of the naso-biliary tube. In 3 ERBD failed patients, 2 were given plastic stents with appropriate length and got a fluent drainage. Percutaneous transhepatic biliary drainage (PTBD) was performed in one patient after failure of endoscopic management. In 2 patients with failed EMBE, one stent could not exceed the site of tumor stricture and one was obstructed by tumor implantation only one month after EMBE. Placement of another metallic stent and a plastic stent through the previous prothesis for each patient ensured a successful drainage.
CONCLUSIONS: The effect of endoscopic biliary drainage for biliary obstruction is definite. Drainage failure can be avoided or remedied as early as possible by taking some active measures.

OBJECTIVE: To explore platelet activation and the protective effect of aprotinin in patients with hepatolithiasis.
METHODS: The count of platelets and levels of CD62P and CD63 were measured by flow cytometry in 38 patients with hepatolithiasis. Several measurements were carried out after treatment with aprotinin.
RESULTS: The levels of CD62P, CD63 in patients with hepatolithiasis were higher than those in patients with cholecystolithiasis (P<0.05), but the count of platelets was lower (P<0.05). After operation, the levels of CD62P, CD63 were significantly increased in patients with hepatolithiasis, but the count of platelets was lower (P<0.05). Postoperative levels of CD62P, CD63 were significantly lower in patients treated with aprotinin than in normal controls (P<0.05); but there was no significant change in the count of platelets in the two groups.
CONCLUSION: Platelet activation occurs in patients with hepatolithiasis, and may be inhibited by aprotinin.

OBJECTIVE: To analyse the clinical features of uncinate process carcinoma of the pancreas and the diagnosis and treatment of this malignancy.
METHOD: Fifty-nine patients with pancreas uncinate process carcinoma treated from January 1998 to September 2002 at our hospital were analysed retrospectively.
RESULTS: Major symptoms of these patients were upper abdominal pain accompanied with lumbar pain, body weight loss and jaundice. Thirty-seven patients received regional pancreaticoduodenectomy (RP), 16 partial resection of the superior mesenteric vein-portal vein (SMV-PV) or superior mesenteric artery (SMA) and reconstruction, 1 anhydrous alcohol injection in the celiac nerve plexus, regional chemotherapy via a chemotherapy pump, and liver biopsy, and 5 no operation. The survival of the patients after operation was 2-46 months (median 12.1 months). Eleven patients are still alive with a longest survival of 46 months. The 1- and 3-year survival rates were 37.7% and 5.6%.
CONCLUSIONS: Pancreas uncinate process carcinoma invading the adjacent SMV/SMA-PV causes difficulty in early diagnosis and poor prognosis, which are related to its location, not tumor’s aggressive nature. This carcinoma has a high resection rate of 89.8%.

OBJECTIVE: To explore the clinical value of laparoscopy and laparoscopic ultrasonography (LUS) in judging the resectability of pancreatic head cancer.
METHODS: LUS was employed as a prospective diagnosis of tumor staging before exploratory laparotomy in 22 patients diagnosed with pancreatic head cancer to identify whether the liver and peritoneum had small metastases or local invasion to the portal vein, superior mesenteric vessel, aorta, inferior vena cava.
RESULTS: In the 22 patients receiving laparoscopy and LUS, we found peritoneal or surface liver metastases (3 patients), hepatic parenchyma metastases (1), and pancreatitis proved by biopsy under ultrasound guidance (1). Laparotomy was avoided in these 5 patients. Of the remaining 17 patients, 8 patients, including 2 patients with portal vein emboli due to tumor metastases had hypertrophic lymph nodes or tumor invasion of local vessels in the peritoneal cavity, retroperitoneum, and omentum and the other 9 patients had resectable tumors shown by LUS. The 17 patients were subjected to exploratory laparotomy, and pancreaticoduodenectomy was successful in 8 patients.
CONCLUSIONS: Laparoscopy and LUS can be used to precisely estimate the possibility of resection of pancreatic head cancer, and prevent unnecessary exploratory laparotomy and its complications. It can be used as a routine examination before exploratory laparotomy.

OBJECTIVE: To detect the expression and variation of the p53 gene in hepatocarcinogenesis of tree shrews induced by hepatitis B virus (HBV) and aflatoxin B1 (AFB1).
METHODS: Tree shrews were divided into four groups: group A, infected with HBV and fed with AFB1; group B, only infected with HBV; group C, fed with AFB1 alone; and group D normal control. The tree shrews underwent liver biopsy every 15 weeks. Liver and tumor tissues were detected by immunohistochemistry and molecular biotechnologies.
RESULTS: The incidence of hepatocellular carcinoma (HCC) was higher in group A (66.7%) than in groups B (0) and C (30%). HCC occurrence was earlier in group A than in group C (120.0±16.6 wk vs 153.3±5.8 wk, t=3.336, P<0.01). Mutated p53 protein was not found in all groups before 75 weeks of experiment. At the 105th week, the expression rates of mutated p53 protein were 78.6%, 60.0% and 71.4% in groups A, B and C respectively, which were significantly higher than that in group D (10%) (χ2≥5.03, P<0.05). An abnormal band of the p53 gene was detected in groups A and C. The mutational points of the p53 gene in liver cancer of tree shrews were at codon 275, 78 and 13. Nucleotide sequence and amino acids sequence of tree shrew’s wild-type p53 were 91.7% and 93.4% in homology compared with those of human p53, respectively.
CONCLUSIONS: Remarkable synergistic effect on HCC exists between HBV and AFB1. Mutated p53 protein expressed before occurrence of HCC promotes the development of HCC. HBV and AFB1 may synergistically induce p53 gene mutation.

ABSTRACT: Hepatic angiomyolipoma is an uncommon primary benign epithelial liver neoplasm. Most patients with angiomyolipomas are middle-aged women who commonly present with epigastric fullness or pain. Angiomyolipomas are tumors consisting of three tissue types: blood vessels, smooth muscle, and fat. Hepatic angiomyolipomas may be difficult to differentiate from other liver neoplasms by noninvasive imaging. We report a 58-year-old asymptomatic woman with a mass in the right lobe of the liver, found incidentally on routine abdominal sonography. Preoperative radiographic evaluation revealed a 6.5-cm hypervascular lesion abutting the inferior vena cava. Preoperative histologic study demonstrated an epithelial neoplasm suspicious for hepatocellular carcinoma. Metastatic workup was negative. At resection, the tumor was found to be an angiomyolipoma composed of lipoid, vascular and smooth muscle cells. Further staining was positive for HMB-45. Resection margins were negative. The woman had an uneventful recovery and was discharged on postoperative day seven. She currently remains well several months after her right hepatectomy.

OBJECTIVE: To introduce our experience with modified Appleby operation in the treatment of a patient with advanced carcinoma of the body and tail of the pancreas, which invaded the common hepatic, splenic and celiac arteries.
METHODS: The celiac artery was ligated at its start point, and distal pancreas and involved arteries were resected en bloc. Pyloric and right gastroepiploic arteries should be preserved to keep blood supply to the stomach and pulsation of the proper hepatic artery be felt after occlusion of the common hepatic artery.
RESULTS: The patient was free from epigastric and back pain after the operation, although she died of liver metastasis after seven months. CT scan did not show local reccurrence before her death.
CONCLUSION: This procedure can increase the resectability and radical extent of locally advanced cancer of the body and tail of the pancreas and offer patients a better quality of life.