BACKGROUND: The last decade has witnessed great progress in living donor liver transplantation worldwide. However, biliary complications are more common in partial liver transplantation than in whole liver transplanta...BACKGROUND: The last decade has witnessed great progress in living donor liver transplantation worldwide. However, biliary complications are more common in partial liver transplantation than in whole liver transplantation. This is due to an impaired blood supply of the hilar bile duct during organ procurement and recipient surgery, commonly encountered anatomical variations, a relatively small graft duct, and complicated surgical techniques used in biliary reconstruction. DATA SOURCES: MEDLINE and PubMed were searched for articles on 'living donor liver transplantation', 'biliary complication', 'anatomical variation', 'biliary reconstruction', 'stenting' and related topics. RESULT: In this review, biliary complications were analyzed with respect to anatomical variation, surgical techniques in biliary reconstruction, and protection of the arterial plexus of the hilar bile duct. CONCLUSION: Transecting the donor bile duct at the right place to secure a larger bile duct stump, anastomosing techniques, and stenting methods as well as preserving the blood supply to the bile duct are all important in reducing biliary complications.展开更多
BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation(OLT)remains a debatable question.Some surgeons chose to use a T-tube because they believed that it reduces the inciden...BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation(OLT)remains a debatable question.Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures.Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications.Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated.AIM To provide an updated systematic review and meta-analysis on using a T-tube during adult OLT.METHODS In the electronic databases MEDLINE,PubMed,Scopus,ClinicalTrials.gov,the Cochrane Library,the Cochrane Hepato-Biliary Group Controlled Trails Register,and the Cochrane Central Register of Controlled Trials,we identified 17 studies(eight randomized controlled trials and nine comparative studies)from January 1995 to October 2020.The data of the studies before and after 2010 were separately extracted.We chose the overall biliary complications,bile leaks or fistulas,biliary strictures(anastomotic or non-anastomotic),and cholangitis as outcomes.Odds ratios(ORs)with 95%confidence intervals(CIs)were calculated to describe the results of the outcomes.Furthermore,the test for overall effect(Z)was used to test the difference between OR and 1,where P≤0.05 indicated a significant difference between OR value and 1.RESULTS A total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis.The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010(P=0.012,OR=0.62,95%CI:0.42-0.90),while the same benefit was not seen in studies after 2010(P=0.60,OR=0.76,95%CI:0.27-2.12).No significant difference in the incidence of overall biliary complications(P=0.37,OR=1.41,95%CI:0.66-2.98),bile leaks(P=0.89,OR=1.04,95%CI:0.63-1.70),and cholangitis(P=0.27,OR=2.00,95%CI:0.59-6.84)was observed between using and not using a T-tube before 2010.However,using a T-tube appeared to increase the incidence of overall biliary complications(P=0.049,OR=1.49,95%CI:1.00-2.22),bile leaks(P=0.048,OR=1.91,95%CI:1.01-3.64),and cholangitis(P=0.02,OR=7.21,95%CI:1.37-38.00)after 2010.A random-effects model was used in biliary strictures(after 2010),overall biliary complications(before 2010),and cholangitis(before 2010)due to their heterogeneity(I2=62.3%,85.4%,and 53.6%,respectively).In the sensitivity analysis(only RCTs included),bile leak(P=0.66)lost the significance after 2010 and a random-effects model was used in overall biliary complications(before 2010),cholangitis(before 2010),bile leaks(after 2010),and biliary strictures(after 2010)because of their heterogeneity(I2=92.2%,65.6%,50.9%,and 80.3%,respectively).CONCLUSION In conclusion,the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.展开更多
Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the di...Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction,our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors,in particular,our surgical protocols.We present herein,the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts.Over this period of transition,our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0%to 10.2%.展开更多
A 68-year-old man underwent cholecystectomy and choledochoduodenostomy for biliary obstruction and nephrectomy for a renal tumor. Based on clinical and histopathologic findings, autoimmune pancreatitis (AIP) was diagn...A 68-year-old man underwent cholecystectomy and choledochoduodenostomy for biliary obstruction and nephrectomy for a renal tumor. Based on clinical and histopathologic findings, autoimmune pancreatitis (AIP) was diagnosed. The renal tumor was diagnosed as a renal cell cancer. Steroid therapy was started and thereafter pancreatic inflammation improved. Five years after surgery, the patient was readmitted because of pyrexia in a preshock state. A Klebsiella pneumoniae liver abscess complicated by sepsis was diagnosed. The patient recovered with percutaneous abscess drainage and administration of intravenous antibiotics. Liver abscess recurred 1 mo later but was successfully treated with antibiotics. There has been little information on long-term outcomes of patients with AIP treated with surgery. To our knowledge, this is the second case of liver abscess after surgical treatment of AIP.展开更多
BACKGROUND: Optimal surgical technique plays a key role in preventing the postoperative recurrence of hepatolithiasis. Tian et al developed the subcutaneous tunnel and hepatocholangioplasty using the gallbladder (STHG...BACKGROUND: Optimal surgical technique plays a key role in preventing the postoperative recurrence of hepatolithiasis. Tian et al developed the subcutaneous tunnel and hepatocholangioplasty using the gallbladder (STHG) technique and applied it in hepatolithiasis patients who had an approximately normal gallbladder and sphincter of Oddi. However, the technique is controversial. In the present study, a canine model was established for hepatocholangioplasty (HC) and hepaticojejunostomy (HJ) to simulate STHG and Roux-en-Y cholangiojejunostomy in the clinic, respectively. Then, the alterations of bile components in the vicinity of the anastomosis were compared. This may provide an experimental guide for choosing an optimal technique for the treatment of hepatolithiasis in the clinic. METHODS: The animals were randomly separated into a control group (5 dogs) and a model group (stenosis of the common bile duct; 24 dogs). The 24 dogs in the model group were randomly divided into an HC group and an HJ group (12/group). Bile was collected from the bile duct at I and 5 months after the operation, and the bile components were determined. RESULTS: The levels of total bile acid, cholesterol, total bilirubin, and phospholipid in the HC group were higher than those in the HJ group (P<0.05). However, no statistical difference was seen in unconjugated bilirubin and calcium ions. The mucin level in bile in the HC group was lower than that in the HJ group at 5 months after the operation (P<0.05). The postoperative lipid peroxidation level was remarkably lower than that in the HJ group (P<0.05). However, the superoxide dismutase level was remarkably higher than that in the HJ group (P<0.05). Finally, a significant difference was found in the positive bacterial culture rate in bile between the groups. CONCLUSION: Changes of bile components near the anastomosis after HC might be more preferable for preventing hepatolithiasis formation than HJ.展开更多
BACKGROUND The surgical management of bile duct injuries(BDIs)after laparoscopic cholecystectomy(LC)is challenging and the optimal timing of surgery remains unclear.The primary aim of this study was to systematically ...BACKGROUND The surgical management of bile duct injuries(BDIs)after laparoscopic cholecystectomy(LC)is challenging and the optimal timing of surgery remains unclear.The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.AIM To assess timing of surgical repair of BDI and postoperative complications.METHODS The MEDLINE,EMBASE,and The Cochrane Library databases were systematically screened up to August 2021.Risk of bias was assessed via the Newcastle Ottawa scale.The primary outcomes of this review included the timing of BDI repair and postoperative complications.RESULTS A total of 439 abstracts were screened,and 24 studies were included with 15609 patients included in this review.Of the 5229 BDIs reported,4934(94%)were classified as major injury.Timing of bile duct repair was immediate(14%,n=705),early(28%,n=1367),delayed(28%,n=1367),or late(26%,n=1286).Standardization of definition for timing of repair was remarkably poor among studies.Definitions for immediate repair ranged from<24 h to 6 wk after LC while early repair ranged from<24 h to 12 wk.Likewise,delayed(>24 h to>12 wk after LC)and late repair(>6 wk after LC)showed a broad overlap.CONCLUSION The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC.This finding indicates an urgent need for a standardized reporting system of BDI repair.展开更多
Liver transplantation represents the only definitive treatment for patients with end-stage liver disease.However,the shortage of liver donors provokes a dramatic gap between available grafts and patients on the waitin...Liver transplantation represents the only definitive treatment for patients with end-stage liver disease.However,the shortage of liver donors provokes a dramatic gap between available grafts and patients on the waiting list.Whole liver bioengineering,an emerging field of tissue engineering,holds great potential to overcome this gap.This approach involves two main steps;the first is liver decellularization and the second is recellularization.Liver decellularization aims to remove cellular and nuclear materials from the organ,leaving behind extracellular matrices containing different structural proteins and growth factors while retaining both the vascular and biliary networks.Recellularization involves repopulating the decellularized liver with appropriate cells,theoretically from the recipient patient,to reconstruct the parenchyma,vascular tree,and biliary network.The aim of this review is to identify the major advances in decellularization and recellularization strategies and investigate obstacles for the clinical application of bioengineered liver,including immunogenicity of the designed liver extracellular matrices,the need for standardization of scaffold fabrication techniques,selection of suitable cell sources for parenchymal repopulation,vascular,and biliary tree reconstruction.In vivo transplantation models are also summarized for evaluating the functionality of bioengineered livers.Finally,the regulatory measures and future directions for confirming the safety and efficacy of bioengineered liver are also discussed.Addressing these challenges in whole liver bioengineering may offer new solutions to meet the demand for liver transplantation and improve patient outcomes.展开更多
Background:The application of robotic-assisted radical resection in perihilar cholangiocarcinoma(pCCA)remains poorly defined.This study aimed to evaluate the safety and efficacy of robotic-assisted radical resection f...Background:The application of robotic-assisted radical resection in perihilar cholangiocarcinoma(pCCA)remains poorly defined.This study aimed to evaluate the safety and efficacy of robotic-assisted radical resection for pCCA in our institute.Methods:Between July 2017 and July 2022,pCCA patients undergoing robotic-assisted and open radical resection at First Affiliated Hospital of Sun Yat-sen University(Guangzhou,China)were included.The short-term outcomes were compared by using propensity-scored matching(PSM)analysis.Results:Eighty-six pCCA patients were enrolled.After PSM at a ratio of 1:2,10 and 20 patients were assigned to the roboticassisted and open groups,respectively.There were no significant disparities in the clinicopathological features between the two groups.The robotic-assisted group had significantly longer operation time(median:548 vs 353 min,P=0.004)and larger total number of lymph nodes examined(median:11 vs 5,P=0.010)than the open group.The robotic-assisted group tended to have a lower intraoperative blood loss(median:125 vs 350 mL,P=0.067),blood transfusion rates(30.0%vs 70.0%,P=0.056),and post-operative overall morbidities(30.0%vs 70.0%,P=0.056)than the open group,even though the differences were not statistically significant.There were no significant differences in the negative resection margin,post-operative major morbidities,or post-operative length-of-stay between the robotic-assisted and open groups(all P>0.05).Conclusions:Robotic-assisted radical resection of pCCA may get a larger total number of lymph nodes examined than open surgery.Provided robotic-assisted surgery may be a feasible and safe technique for selected pCCA patients.展开更多
基金supported by grants from the National Key Technology R&D Program in the Eleventh Five-Year Plan of China(2008BAI60B01 and 2008BAI60B02)
文摘BACKGROUND: The last decade has witnessed great progress in living donor liver transplantation worldwide. However, biliary complications are more common in partial liver transplantation than in whole liver transplantation. This is due to an impaired blood supply of the hilar bile duct during organ procurement and recipient surgery, commonly encountered anatomical variations, a relatively small graft duct, and complicated surgical techniques used in biliary reconstruction. DATA SOURCES: MEDLINE and PubMed were searched for articles on 'living donor liver transplantation', 'biliary complication', 'anatomical variation', 'biliary reconstruction', 'stenting' and related topics. RESULT: In this review, biliary complications were analyzed with respect to anatomical variation, surgical techniques in biliary reconstruction, and protection of the arterial plexus of the hilar bile duct. CONCLUSION: Transecting the donor bile duct at the right place to secure a larger bile duct stump, anastomosing techniques, and stenting methods as well as preserving the blood supply to the bile duct are all important in reducing biliary complications.
基金National Natural Science Foundation of China,No.81770491The Innovation Capacity Support Plan of Shaanxi Province,No.2020TD-040.
文摘BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation(OLT)remains a debatable question.Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures.Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications.Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated.AIM To provide an updated systematic review and meta-analysis on using a T-tube during adult OLT.METHODS In the electronic databases MEDLINE,PubMed,Scopus,ClinicalTrials.gov,the Cochrane Library,the Cochrane Hepato-Biliary Group Controlled Trails Register,and the Cochrane Central Register of Controlled Trials,we identified 17 studies(eight randomized controlled trials and nine comparative studies)from January 1995 to October 2020.The data of the studies before and after 2010 were separately extracted.We chose the overall biliary complications,bile leaks or fistulas,biliary strictures(anastomotic or non-anastomotic),and cholangitis as outcomes.Odds ratios(ORs)with 95%confidence intervals(CIs)were calculated to describe the results of the outcomes.Furthermore,the test for overall effect(Z)was used to test the difference between OR and 1,where P≤0.05 indicated a significant difference between OR value and 1.RESULTS A total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis.The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010(P=0.012,OR=0.62,95%CI:0.42-0.90),while the same benefit was not seen in studies after 2010(P=0.60,OR=0.76,95%CI:0.27-2.12).No significant difference in the incidence of overall biliary complications(P=0.37,OR=1.41,95%CI:0.66-2.98),bile leaks(P=0.89,OR=1.04,95%CI:0.63-1.70),and cholangitis(P=0.27,OR=2.00,95%CI:0.59-6.84)was observed between using and not using a T-tube before 2010.However,using a T-tube appeared to increase the incidence of overall biliary complications(P=0.049,OR=1.49,95%CI:1.00-2.22),bile leaks(P=0.048,OR=1.91,95%CI:1.01-3.64),and cholangitis(P=0.02,OR=7.21,95%CI:1.37-38.00)after 2010.A random-effects model was used in biliary strictures(after 2010),overall biliary complications(before 2010),and cholangitis(before 2010)due to their heterogeneity(I2=62.3%,85.4%,and 53.6%,respectively).In the sensitivity analysis(only RCTs included),bile leak(P=0.66)lost the significance after 2010 and a random-effects model was used in overall biliary complications(before 2010),cholangitis(before 2010),bile leaks(after 2010),and biliary strictures(after 2010)because of their heterogeneity(I2=92.2%,65.6%,50.9%,and 80.3%,respectively).CONCLUSION In conclusion,the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.
文摘Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction,our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors,in particular,our surgical protocols.We present herein,the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts.Over this period of transition,our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0%to 10.2%.
文摘A 68-year-old man underwent cholecystectomy and choledochoduodenostomy for biliary obstruction and nephrectomy for a renal tumor. Based on clinical and histopathologic findings, autoimmune pancreatitis (AIP) was diagnosed. The renal tumor was diagnosed as a renal cell cancer. Steroid therapy was started and thereafter pancreatic inflammation improved. Five years after surgery, the patient was readmitted because of pyrexia in a preshock state. A Klebsiella pneumoniae liver abscess complicated by sepsis was diagnosed. The patient recovered with percutaneous abscess drainage and administration of intravenous antibiotics. Liver abscess recurred 1 mo later but was successfully treated with antibiotics. There has been little information on long-term outcomes of patients with AIP treated with surgery. To our knowledge, this is the second case of liver abscess after surgical treatment of AIP.
文摘BACKGROUND: Optimal surgical technique plays a key role in preventing the postoperative recurrence of hepatolithiasis. Tian et al developed the subcutaneous tunnel and hepatocholangioplasty using the gallbladder (STHG) technique and applied it in hepatolithiasis patients who had an approximately normal gallbladder and sphincter of Oddi. However, the technique is controversial. In the present study, a canine model was established for hepatocholangioplasty (HC) and hepaticojejunostomy (HJ) to simulate STHG and Roux-en-Y cholangiojejunostomy in the clinic, respectively. Then, the alterations of bile components in the vicinity of the anastomosis were compared. This may provide an experimental guide for choosing an optimal technique for the treatment of hepatolithiasis in the clinic. METHODS: The animals were randomly separated into a control group (5 dogs) and a model group (stenosis of the common bile duct; 24 dogs). The 24 dogs in the model group were randomly divided into an HC group and an HJ group (12/group). Bile was collected from the bile duct at I and 5 months after the operation, and the bile components were determined. RESULTS: The levels of total bile acid, cholesterol, total bilirubin, and phospholipid in the HC group were higher than those in the HJ group (P<0.05). However, no statistical difference was seen in unconjugated bilirubin and calcium ions. The mucin level in bile in the HC group was lower than that in the HJ group at 5 months after the operation (P<0.05). The postoperative lipid peroxidation level was remarkably lower than that in the HJ group (P<0.05). However, the superoxide dismutase level was remarkably higher than that in the HJ group (P<0.05). Finally, a significant difference was found in the positive bacterial culture rate in bile between the groups. CONCLUSION: Changes of bile components near the anastomosis after HC might be more preferable for preventing hepatolithiasis formation than HJ.
文摘BACKGROUND The surgical management of bile duct injuries(BDIs)after laparoscopic cholecystectomy(LC)is challenging and the optimal timing of surgery remains unclear.The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.AIM To assess timing of surgical repair of BDI and postoperative complications.METHODS The MEDLINE,EMBASE,and The Cochrane Library databases were systematically screened up to August 2021.Risk of bias was assessed via the Newcastle Ottawa scale.The primary outcomes of this review included the timing of BDI repair and postoperative complications.RESULTS A total of 439 abstracts were screened,and 24 studies were included with 15609 patients included in this review.Of the 5229 BDIs reported,4934(94%)were classified as major injury.Timing of bile duct repair was immediate(14%,n=705),early(28%,n=1367),delayed(28%,n=1367),or late(26%,n=1286).Standardization of definition for timing of repair was remarkably poor among studies.Definitions for immediate repair ranged from<24 h to 6 wk after LC while early repair ranged from<24 h to 12 wk.Likewise,delayed(>24 h to>12 wk after LC)and late repair(>6 wk after LC)showed a broad overlap.CONCLUSION The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC.This finding indicates an urgent need for a standardized reporting system of BDI repair.
基金support from the Fulbright Visiting Scholar Program(2023-2024).
文摘Liver transplantation represents the only definitive treatment for patients with end-stage liver disease.However,the shortage of liver donors provokes a dramatic gap between available grafts and patients on the waiting list.Whole liver bioengineering,an emerging field of tissue engineering,holds great potential to overcome this gap.This approach involves two main steps;the first is liver decellularization and the second is recellularization.Liver decellularization aims to remove cellular and nuclear materials from the organ,leaving behind extracellular matrices containing different structural proteins and growth factors while retaining both the vascular and biliary networks.Recellularization involves repopulating the decellularized liver with appropriate cells,theoretically from the recipient patient,to reconstruct the parenchyma,vascular tree,and biliary network.The aim of this review is to identify the major advances in decellularization and recellularization strategies and investigate obstacles for the clinical application of bioengineered liver,including immunogenicity of the designed liver extracellular matrices,the need for standardization of scaffold fabrication techniques,selection of suitable cell sources for parenchymal repopulation,vascular,and biliary tree reconstruction.In vivo transplantation models are also summarized for evaluating the functionality of bioengineered livers.Finally,the regulatory measures and future directions for confirming the safety and efficacy of bioengineered liver are also discussed.Addressing these challenges in whole liver bioengineering may offer new solutions to meet the demand for liver transplantation and improve patient outcomes.
文摘Background:The application of robotic-assisted radical resection in perihilar cholangiocarcinoma(pCCA)remains poorly defined.This study aimed to evaluate the safety and efficacy of robotic-assisted radical resection for pCCA in our institute.Methods:Between July 2017 and July 2022,pCCA patients undergoing robotic-assisted and open radical resection at First Affiliated Hospital of Sun Yat-sen University(Guangzhou,China)were included.The short-term outcomes were compared by using propensity-scored matching(PSM)analysis.Results:Eighty-six pCCA patients were enrolled.After PSM at a ratio of 1:2,10 and 20 patients were assigned to the roboticassisted and open groups,respectively.There were no significant disparities in the clinicopathological features between the two groups.The robotic-assisted group had significantly longer operation time(median:548 vs 353 min,P=0.004)and larger total number of lymph nodes examined(median:11 vs 5,P=0.010)than the open group.The robotic-assisted group tended to have a lower intraoperative blood loss(median:125 vs 350 mL,P=0.067),blood transfusion rates(30.0%vs 70.0%,P=0.056),and post-operative overall morbidities(30.0%vs 70.0%,P=0.056)than the open group,even though the differences were not statistically significant.There were no significant differences in the negative resection margin,post-operative major morbidities,or post-operative length-of-stay between the robotic-assisted and open groups(all P>0.05).Conclusions:Robotic-assisted radical resection of pCCA may get a larger total number of lymph nodes examined than open surgery.Provided robotic-assisted surgery may be a feasible and safe technique for selected pCCA patients.
