Significance of controlling chronic proliferative cholangitis in the treatment of hepatolithiasis

Development of a simplified model and nomogram in preoperative diagnosis of pediatric chronic cholangitis with pancreaticobiliary maljunction using clinical variables and MRI radiomics

OBJECTIVE

The aim of this study was to develop a model that combines clinically relevant features with radiomics signature based on magnetic-resonance imaging (MRI) for diagnosis of chronic cholangitis in pancreaticobiliary maljunction (PBM) children.

METHODS

A total of 144 subjects from two institutions confirmed PBM were included in this study. Clinical characteristics and MRI features were evaluated to build a clinical model. Radiomics features were extracted from the region of interest manually delineated on T2-weighted imaging. A radiomics signature was developed by the selected radiomics features using the least absolute shrinkage and selection operator and then a radiomics score (Rad-score) was calculated. We constructed a combined model incorporating clinical factors and Rad-score by multivariate logistic regression analysis. The combined model was visualized as a radiomics nomogram to achieve model visualization and provide clinical utility. Receiver operating curve analysis and decision curve analysis (DCA) were used to evaluate the diagnostic performance.

RESULTS

Jaundice, protein plug, and ascites were selected as key clinical variables. Eight radiomics features were combined to construct the radiomics signature. The combined model showed superior predictive performance compared with the clinical model alone (AUC in the training cohort: 0.891 vs. 0.767, the validation cohort: 0.858 vs. 0.731), and the difference was significant (p = 0.002, 0.028) in the both cohorts. DCA confirmed the clinical utility of the radiomics nomogram.

CONCLUSION

The proposed model that combines key clinical variables and radiomics signature is helpful in the diagnosis of chronic cholangitis in PBM children.

New clinical pathological classification and treatment system for hepatolithiasis

Hepatolithiasis is a complex disease with extensive lesions. There are currently many clinical classifications available. However, these classifications cannot accurately reflect the pathological changes and degree of hepatolithiasis, and are not conducive to communication. Various methods are used for treatment of hepatolithiasis, but they are often misused. We tried to establish a new HLDO classification based on the clinicopathological characteristics of hepatolithiasis and a treatment system based on this classification, so as to comprehensively and accurately describe the pathological changes and degree, scientifically and reasonably treat it, and reduce its residual stone rate and recurrence rate.

Biliary antibiotics irrigation for E. coli-induced chronic proliferative cholangitis and hepatolithiasis: A pathophysiological study in rabbits

BACKGROUND

The gram-negative bacteria secreted endotoxin, Lipopolysaccharide (LPS), plays important roles in the formation and recurrence of hepatolithiasis and chronic biliary inflammation in patients of Southeast Asia. We aimed to elucidate the anti-inflammatory effect and mechanism of local antibiotics irrigation on chronic proliferative cholangitis (CPC) and hepatolithiasis.

METHODS

Escherichia coli was injected into rabbit bile ducts to induce CPC. Rabbits were divided into sham operation (SO), povidone-iodine, Metronidazole plus chlorhexidine, ofloxacin, furacillin, Neosporin® G.U., and CPC groups. Local irrigation was performed for 28 days after CPC was established. Residual E. coli and LPS, and the expression of MCP-1, CD14, COX-2, VEGF, IL-6, NF-κB, TNF-α, Fas, TGF-β1, α-SMA, Collagen-I, β-glucuronidase, PKC, C-myc, and Mucin 5AC were assessed in bile duct tissues.

RESULTS

The residual E. coli and LPS, and expression of MCP-1, CD14, COX-2, IL-6, NF-κB, TNF-α, Fas, TGF-β1, α-SMA, β-glucuronidase, PKC, C-myc, and Mucin 5AC in the SO, povidone-iodine, Metronidazole plus chlorhexidine, ofloxacin, and Neosporin® G.U. groups were significantly lower than those in the furacillin and CPC groups (P<0.05). VEGF and Collagen-I levels in the SO, povidone-iodine, metronidazole plus chlorhexidine, and ofloxacin groups were significantly lower than those in the furacillin, Neosporin® G.U., and CPC groups (P<0.05).

CONCLUSIONS

LPS affects the pathophysiology of E. coli caused chronic proliferative cholangitis and hepatolithiasis recurrence. Local antibiotics irrigation could prevent chronic proliferative cholangitis and stones formation by decreasing LPS-induced proinflammatory and profibrotic cytokines release. Povidone iodine, metronidazole plus chlorhexidine, and ofloxacin were more effective than Neosporin® G.U. and furacillin.

New management of hepatolithiasis: Can surgery be avoided? (with video)

BACKGROUND

The presence of hepatolithiasis (HL) is prevalent in eastern countries. It is a clinical entity which is rarely reported in non-surgical series because the standard treatment is the surgical option. Currently, treatment has evolved, with the use of endoscopic techniques being increased and the number of hepatectomies being decreased. SpyGlass™ is a small-calibre endoscopic direct cholangiopancreatoscopy developed to explore and perform procedures in the bile and pancreatic ducts. Single-operator peroral cholangioscopy (POC) is an endoscopic technique useful for treating difficult bile duct stones.

AIMS

To assess the usefulness, efficacy, and safety of POC with the SpyGlass™ system in patients with HL.

PRIMARY OBJECTIVES

to achieve technical success of the procedure and clinical success of patients with HL.

STUDY DESIGN AND PATIENTS

Retrospective, single-centre cohort study of patients with HL from April 2012 to August 2018. SpyGlass™ was chosen in symptomatic patients referred from the surgery unit as the first-line procedure. To perform electrohydraulic lithotripsy (EHL), we used a Northgate Autolith IEHL generator with a 0.66-mm biliary probe.

RESULTS

We performed a total of 13 procedures in 7 patients with HL. The mean age was 46 years (range 35-65) and 3/7 of patients were female. We achieved technical success in 5/7 cases (71.4%) and clinical success in 4/7 cases (57%).

DISCUSSION

SpyGlass™ is safe and effective in the treatment of HL. With these results, we confirm the need for management of patients with HL in a multidisciplinary team. When the endoscopic approach is the option, this procedure must be performed by experts in advanced endoscopy.

EGFR monoclonal antibody panitumumab inhibits chronic proliferative cholangitis by downregulating EGFR

In hepatolithiasis, chronic proliferative cholangitis (CPC), an active and longstanding inflammation of stone-containing bile ducts with enhanced mucin-producing activity, not only affects the progression of the disease, it can also induce biliary carcinogenesis. The present study aimed to examine the effect of the epidermal growth factor receptor (EGFR) monoclonal antibody panitumumab (Pani) on CPC. Following the establishment of CPC rat models, periodic acid Schiff staining was used to observe the positive rate of EGFR expression. The expression levels of EGFR, mucin 5AC (MUC5AC), Ki-67, type I collagen and mammalian target of rapamycin (mTOR), and the activity of β-glucuronidase (β-G), were measured. The rats treated with Pani demonstrated a significantly lower degree of hyperproliferation of the epithelium and submucosal glands of the bile duct and collagen fibers of the bile duct wall, a significantly decreased positive rate of EGFR, reduced phosphorylation of mTOR, decreased expression of EGFR, MUC5AC, Ki-67 and type I collagen, and reduced β-G activity. The therapeutic effects in rats treated with 4 and 6 mg/kg of Pani were more marked than those in rats treated with 2 mg/kg of Pani. Collectively, the data obtained in the present study suggest that the EGFR monoclonal antibody Pani can effectively inhibit the excessive proliferation and stone-forming potential of bile duct mucosa in CPC with a receptor saturation effect. Therefore, Pani offers promise as a treatment for the prevention and control of intra-hepatic choledocholithiasis caused by CPC.

Incidence and Prognosis of Subsequent Cholangiocarcinoma in Patients with Hepatic Resection for Bile Duct Stones

BACKGROUND AND AIM

Cholangiocarcinoma (CCA) often develops after the hepatic resection for hepatolithiasis as well as indwelling it. We studied the incidence and prognosis of subsequent CCA in patients with hepatolithiasis in South Korea.

METHODS

We identified individuals with diagnosed CCA at the time of or after surgery, during 2002-2016, from the Korean National Health Insurance. The incidences and survival rates of subsequent CCA were analyzed and compared with concomitant CCA. The standardized incidence ratios (SIRs) of CCA in this cohort were evaluated in the standard Korean population. All data were stratified by the presence of intrahepatic or extrahepatic CCA, age and sex.

RESULTS

Of the 7852 patients with hepatectomy for BDS, 433 (5.84%) had concomitant CCA. Over the 12-year follow-up, 107 of 7419 (1.98%) patients were diagnosed with subsequent CCA. Patients with hepatic resection for BDS revealed higher SIRs for subsequent CCA (12.89, 95% CI 10.96-15.15) in cases of both intrahepatic CCA (13.40, 10.55-17.02) and extrahepatic CCA (12.42, 9.98-15.46). The median survival time for subsequent CCA was 0.87 years, while that for concomitant CCA was 2.79 years. Having subsequent CCA (HR 2.71, 95% CI 2.17-3.40) and being male (HR 1.28, 1.05-1.57) were related to a shorter survival time. The CCA site and age at CCA diagnosis were not related to prognoses.

CONCLUSIONS

Subsequent CCA developed in 2% of the patients with hepatic resection for benign BDS until 10 years and was associated with poorer prognoses than concomitant CCA. Future studies focused on the long-term surveillance for CCA in such patients are needed.

A Novel Rabbit Model for Benign Biliary Stricture Formation and the Effects of Medication Infusions on Stricture Formation

BACKGROUND

Benign biliary stricture (BBS) is highly refractory. Currently, there is no effective strategy for prevention of BBS recurrence. The aim of this study is to establish a novel BBS rabbit model and to investigate the efficacy of biliary infusion with anti-proliferative medications for treating BBS.

METHOD

A BBS model was established via surgical injury and biliary infection. The biliary infusion tube was inserted into the common bile duct via the stump of cystic duct after cholecystectomy. Biliary infusions with Rapamycin, Pirfenidone and Fasudil were performed daily during the 4 weeks following the surgery. The wall thickness and luminal area of the bile duct were assessed.

RESULTS

All rabbits formed BBS after surgery. The mortality rate was 13% (8/60) and tube withdrawal rate was 4% (2/48). The thickness of the bile duct wall was significantly reduced; whereas the luminal area of the bile duct was dramatically enlarged in the Rapamycin or the Pirfenidone treated group, compared to the saline treated group. Furthermore, the local treatment significantly decreased the levels of proliferation makers, including PCNA, Collagen I and fibrogenic mediators, including ACTA2 and TGF-beta.

CONCLUSION

We have established a novel animal model for BBS formation. We have further demonstrated that biliary infusion with Rapamycin or Pirfenidone limits the biliary strictures through inhibiting the proliferation of the bile duct wall in this model. This may represent a new avenue for preventing biliary restenosis.

Effective Treatment of Chronic Proliferative Cholangitis by Local Gentamicin Infusion in Rabbits

Background

Hepatolithiasis is highly prevalent in East Asia characterized by the presence of gallstones in the biliary ducts of the liver. Surgical resection is the potentially curative treatment but bears a high risk of stone recurrence and biliary restenosis. This is closely related to the universal presence of chronic proliferative cholangitis (CPC) in the majority of patients. Recent evidence has indicated the association of bacterial infection with the development of CPC in hepatolithiasis. Thus, this study aims to investigate the feasibility and efficacy of local infusion of gentamicin (an antibiotic) for the treatment of CPC in a rabbit model.

Methods

The rabbit CPC model was established based on previously published protocols. Bile duct samples were collected from gentamicin-treated or control animals for pathological and molecular characterization.

Results

Histologically, the hyperplasia of biliary epithelium and submucosal glands were inhibited and the thickness of the bile duct wall was significantly decreased after gentamicin therapy. Consistently, the percentage of proliferating cells marked by ki67 was significantly reduced by the treatment. More importantly, this treatment inhibited interleukin 2 production, an essential inflammatory cytokine, and the enzyme activity of endogenous β-Glucuronidase, a key factor in the formation of bile pigment.

Conclusions

Local gentamicin infusion effectively inhibits the inflammation, cell proliferation, and lithogenesis in a rabbit model of CPC. This approach represents a potential treatment for CPC and thus prevents recurrent hepatolithiasis.

Risk Factors for Cholangiocarcinoma After Initial Hepatectomy for Intrahepatic Stones

BACKGROUND

Aggressive hepatectomy is effective in treating intrahepatic stones and may minimize the deleterious consequences of subsequent cholangiocarcinoma (S-CCA). The risk factors of S-CCA after different methods of hepatectomy may vary with the resection scope of stone-affected segments.

METHODS

We reviewed the records of 981 patients of primary intrahepatic stones with elective hepatectomy from January 2000 to December 2010. The clinical characteristics of patients in the S-CCA group (n = 55) and the control group (n = 926) were compared. The uniformity between extent of liver resection (ELR) with stone-affected segments (SAS) was segmented into 2 varieties: ELR = SAS with ELR < SAS according to the different hepatic resection scopes. Cox regression model with forward selection was used to identify the risk factors of S-CCA.

RESULTS

In the univariate analysis, significant differences were observed between the S-CCA and control groups concerning stone location (unilateral 43.6 and 65.2 %, bilateral 56.4 and 34.8 %), residual stones (32.7 and 11.6 %), hepaticojejunostomy (43.6 and 30.9 %), and uniformity between ELR with SAS (ELR = SAS 20.0 and 42.6 %, ELR < SAS 80.0 and 57.4 %). Residual stones [hazard ratio (HR) 2.101, P = 0.016], hepaticojejunostomy (HR 1.837, P = 0.026) and uniformity between ELR and SAS (HR 2.442, P = 0.013) were independent prognostic factors for S-CCA by a Cox regression analysis with forward selection. In the subsection of ELR = SAS group, the 5- and 10-year postoperative tumor occurrence rates of unilateral and bilateral stones group were 0.9 versus 1.9 % and 3.0 versus 4.1 %, respectively (P = 0.663, log-rank). In the other subsection of ELR < SAS group, the 5- and 10-year postoperative tumor occurrence rates of unilateral and bilateral stones group were 3.4 versus 3.9 % and 6.8 versus 13.2 %, respectively (P = 0.047, log-rank), and the 5- and 10-year postoperative tumor occurrence rates of residual stones and non-residual stones group were 5.8 versus 3.0 % and 16.0 versus 7.9 %, respectively (P = 0.015, log-rank).

CONCLUSIONS

Patients who underwent aggressive hepatectomy and had ELR = SAS had better outcomes than those with ELR < SAS. In the patients with ELR = SAS, the S-CCA rates of unilateral and bilateral stones were low and comparable. However, patients with ELR < SAS and bilateral intrahepatic or residual stones should be monitored more carefully for high-risk factors of S-CCA.

Four Major Factors Contributing to Intrahepatic Stones

Intrahepatic stone is prevalent in Asian countries; though the incidence declines in recent years, the number of patients is still in a large quantity. Because of multiple complications, high recurrence rates, serious systemic damage, and a lack of extremely effective procedure for the management, it is more important to find out the etiology and pathogenesis of intrahepatic stones to prevent the disease from happening and developing rather than curing. A number of factors contribute to the development of the disease, such as cholestasis, infection, and anatomic abnormity of bile duct and bile metabolic defect. The four factors and possible pathogenesis will be discussed in detail in the review.

Choledochoscopic high-frequency needle-knife electrotomy for treatment of anastomotic strictures after Roux-en-Y hepaticojejunostomy

BACKGROUND

Anastomotic stricture is a complex and substantial complication following Roux-en-Y hepaticojejunostomy. Initially, endoscopic and percutaneous approaches are often attempted, but the gold standard remains surgical biliary reconstruction, especially for refractory stricture. However, this solution leaves much room for improvement, due to the challenging nature of the biliary reconstruction procedure, in which anastomotic stricture may still occur.

AIMS

To investigate the feasibility and effectiveness of choledochoscopic high-frequency needle-knife electrotomy as an intervention in the treatment of anastomotic strictures following Roux-en-Y hepaticojejunostomy.

METHODS

From February 2010 to October 2014, clinical data was collected and retrospectively compared for patients who underwent balloon dilation or/and choledochoscopic high-frequency needle-knife electrotomy for the treatment of anastomotic strictures after Roux-en-Y hepaticojejunostomy.

RESULTS

A total of 38 patients underwent successful choledochoscopic treatment and all the anastomotic strictures were removed successfully, 19 of which were treated with electrotomy, 7 with balloon dilation, and 12 with both electrotomy and balloon dilation. Among these groups,the average operating times were 6.9 ± 2.4 min,10.1 ± 6.8 min, and 20.2 ± 13.5 min, respectively. The average stent supporting times were 6.3 ± 0.7 months, 6.5 ± 0.6 months, and 6.1 ± 0.4 respectively. The mean follow-up after stent removal was 42.1 ± 27.4 months, and in 26.3 % (5/19), 28.5 % (2/7) and 16.7 % (2/12) of cases, recurrent anastomotic stricture occurred. Of these 9 total patients with recurrent anastomotic, two patients were successfully rescued by full-covered self-expanding removable metal stents and 7 patients by electrotomy combined with balloon dilation.

CONCLUSIONS

Choledochoscopic high-frequency needle-knife electrotomy is both feasible and safe in the treatment of anastomotic stricture after Roux-en-Y hepaticojejunostomy, with a similar long-term outcome to balloon dilation in treating anastomotic stricture after Roux-en-Y hepaticojejunostomy. A combination of choledochoscopic electrotomy concurrent with balloon dilation should be recommended based on the low rate of recurrence.

Epithelial-to-mesenchymal transition and hepatolithiasis

Epithelial-to-mesenchymal transition (EMT) is a complex physiological and pathological process in which epithelial cells acquire mesenchymal characteristics. EMT occurs during embryogenesis and organ development, wound healing and organ regeneration, tumor migration and invasion. In recent years, cholangiocytes have been shown to undergo EMT in different cholangiopathies including hepatolithiasis. Transforming growth factor-β/Smads signaling is considered the master regulator. The purpose of this article is to introduce the concept and type of EMT, summarize recent advances that support or refute the concept that cholangiocytes are capable of phenotype transition of hepaticlithiasis and discuss the probable mechanism.

Effects of epidermal growth factor receptor inhibitor on proliferative cholangitis in hepatolithiasis

BACKGROUND

There is currently no effective medication to prevent stone recurrence after choledochoscopic lithotomy or to treat proliferative cholangitis (PC), which is the pathologic basis of hepatolithiasis. This study aimed to investigate whether gefitinib, an epidermal growth factor receptor (EGFR) inhibitor, inhibited cholangio hyperplasia and lithogenesis in PC.

METHODS

After cholangioscopic lithotomy, indwelling catheters were placed in the diseased bile duct lumens in 94 patients with hepatolithiasis. Subsequently, 49 of the 94 patients were treated with 250 mg gefitinib solution via a catheter twice a week, and they were subjected to choledochoscopic biopsy at 6 and 12 weeks. The rest 45 hepatolithiasis patients without gefitinib treatment served as controls.

RESULTS

The expressions of EGFR, PCNA and procollagen I were significantly reduced in the patients treated with gefitinib in 12 weeks compared with those in the control group. Patients in the gefitinib group had a much lower degree of hyperplasia of the biliary epithelium, submucosal glands and collagen fibers compared with those in the control group. Gefitinib treatment significantly decreased mucin 3 expression and beta-glucuronidase activity.

CONCLUSION

Postoperative gefitinib treatment could significantly inhibit PC-mediated hyperplasia and lithogenesis, which might provide a novel strategy for the prevention of biliary restenosis and stone recurrence in patients with hepatolithiasis.

Choledochoscopic high-frequency needle-knife electrotomy as an effective treatment for intrahepatic biliary strictures

BACKGROUND AND AIM

Hepatolithiasis is associated with the presence of intrahepatic biliary strictures, and balloon dilatation is the main approach. However, this method is difficult to implement if the bile duct distal to the stricture is blocked by stones. Therefore, alternative methods need to be explored to effectively treat hepatolithiasis. The aim of this study is to investigate the feasibility and effectiveness of choledochoscopic high-frequency needle-knife electrotomy for the treatment of intrahepatic biliary strictures.

METHODS

Clinical data of 58 patients suffering from intrahepatic bile duct strictures from January 2011 to January 2013 were retrospectively analyzed. Choledochoscopic electrotomy was used to resolve the strictures.

RESULTS

One hundred thirty-four sites of intrahepatic bile duct strictures were discovered. The average operating time of electrotomy is 5.6 min (range, 1 ∼ 15 min). Structured bile duct tissue bleeding occurred in eight sites (8/134, 6.0%) but were resolved by endoscopic high-frequency electric cautery. After the operations, 14 cases of cholangitis (14/58, 24.1%), three cases of delayed hemobilia, one case of liver abscess (1/58, 1.7%), and seven cases of stenting exodus (7/58, 12.1%) were observed despite conservative treatment and stenting reset. The average supporting time was 7.0 months (6 ∼ 9 months). No abnormal bile duct structure or presence of stone was found according to choledochoscopy. The follow-up period ranged from 12 to 48 months. Hepatolithiasis recurred in five (5/58, 8.6%) patients, and the cumulative recurrent probability of intrahepatic bile duct stricture was 5.2% (7/134).

CONCLUSIONS

Choledochoscopic high-frequency needle-knife electrotomy could be considered as a simple, safe, and effective complementary approach for treating intrahepatic biliary strictures.

Segmental Bile Duct-Targeted Liver Resection for Right-Sided Intrahepatic Stones

Hepatectomy is a safe and effective treatment for intrahepatic stones (IHSs). However, the resection plane for right-sided stones distributed within 2 segments is obstacle because of atrophy-hypertrophy complex formation of the liver and difficult dissection of segmental pedicle within the Glissonean plate by conventional approach. Thus, we devised segmental bile duct-targeted liver resection (SBDLR) for IHS, which aimed at completely resection of diseased bile ducts. This study aimed to evaluate the outcomes of SBDLR for right-sided IHSs. From January 2009 to December 2013, 107 patients with IHS treated by SBDLR in our center were reviewed in a prospective database. Patients' intermediate and long-term outcomes after SBDLR were analyzed. A total of 40 (37.4%) patients with localized right-sided stone and 67 (62.7%) patients with bilateral stones underwent SBDLR alone and SBDLR combined with left-sided hepatectomy, respectively. There was no hospital mortality of this cohort of patients. The postoperative morbidity was 35.5%. The mean intraoperative blood loss was 414  mL (range: 100-2500). Twenty-one (19.6%) patients needed red blood cells transfusion. The intermediate stone clearance rate was 94.4%; the final clearance rate reached 100% after subsequent postoperative cholangioscopic lithotomy. Only 2.8% patients developed stone recurrence in a median follow-up period of 38.3 months. SBDLR is a safe and effective treatment for right-sided IHS distributed within 2 segments. It is especially suitable for a subgroup of patients with bilateral stones whose right-sided stones are within 2 segments and bilateral liver resection is needed.

Sequential embolization of the branches of the bile duct and portal vein to the targeted hepatic lobe in rats

BACKGROUND

The high recurrence rate of hepatolithiasis and the high operative risk of right posterior, caudate or multiple lobe hepatectomy are the unsettled problems in hepatobiliary surgery. The present study was to investigate the efficacy of chemical hepatectomy performed via applying sequential embolization of the branches of the bile duct and portal vein to the targeted hepatic lobe.

METHODS

The bile duct and portal vein branches of the median hepatic lobe of rats were treated with: 1) bile duct embolization followed by portal vein ligation (BDE+PVL) and 2) portal vein ligation followed by bile duct embolization (PVL+BDE). The efficacy of chemical hepatectomy in BDE+PVL and PVL+BDE groups was compared with that of sole BDE by histology and Western blotting analysis of collagen I expression.

RESULTS

After six weeks of the chemical hepatectomy, rats in the BDE group showed hepatocyte damages, fibrosis and "self-cut" only in the periphery of the embolized lobe. In contrast, rats in the PVL+BDE and BDE+PVL groups exhibited complete necrosis of hepatocytes and replacement with proliferative ductules and collagen fibers, leading to complete fibrosis and "self-cut" phenomenon in the whole targeted lobe. Collagen I expression in the PVL+BDE group was slightly higher than that in the BDE+PVL group; however, no statistically significant difference was noted.

CONCLUSION

The sequential embolization of the bile duct and portal vein branches to the targeted hepatic lobe may be a feasible and effective approach to acheive the ideal effect of chemical hepatectomy in a short period of time.

Applying chemical bile duct embolization to achieve chemical hepatectomy in hepatolithiasis: a further experimental study

BACKGROUND

Hepatolithiasis is the presence of calculi within the bile ducts of the liver. It represents a significant problem for hepatobiliary surgery because of its high recurrence rate and the associated risk for partial hepatectomy. This study was designed to explore the long-term efficacy of chemical biliary duct embolization (CBDE) to treat recurrent hepatolithiasis.

MATERIALS AND METHODS

A rabbit model of hepatolithiasis was established, and CBDE was achieved using oxybenzene and N-butyl-cyanoacrylate. The short-term (6 wk) and long-term (12 wk) efficacy of CBDE treatment was compared by observing the degree of atrophy, fibrosis, proliferation of collagen fibers, and apoptosis of hepatocytes and hepatic stellate cells in the embolized hepatic lobe. Biochemical measurement of β-glucuronidase was also evaluated to determine the effect of CBDE on stone formation.

RESULTS

Six weeks after CBDE, there was liver cell destruction, collagen accumulation, and bile duct proliferation only in the peripheral part of the target lobe. Twelve weeks after CBDE, "self-cut" chemical hepatectomy was achieved, as manifested by the destruction of almost all the hepatocytes in the target lobe, bile duct proliferation, and collagen fiber accumulation. The β-glucuronidase activity was markedly lower in the embolized lobe than in the nonembolized lobe. In contrast, bax, caspase-3, caspase-9, and α-smooth muscle actin expression was substantially higher in the embolized lobe than in the sham-operation group at 6 wk, but was lower at 12 wk.

CONCLUSIONS

CBDE is a potentially effective therapeutic approach for treating and preventing the recurrence of hepatolithiasis.

Anti-proliferation activity of celecoxib in cholangitis

AIM: To investigate the application value of celecoxib in treating chronic proliferative cholangitis (CPC).

METHODS: Thirty healthy male Sprague-Dawley rats were randomly divided into three groups: sham-operation group (n = 10), CPC model group (n = 10), and celecoxib therapy group (n = 10). CPC was induced in rats by inserting a 5-0 nylon suture into the common bile duct up to the porta hepatis retrogradely through the vater papilla. Rats in the sham-operation group only underwent abdominal wall incision and suturing. Celecoxib [50 mg/(kg·d)] was injected into the abdominal cavity of each rat in the therapy group from day 1 after operation. All rats were executed 1 wk after operation. The anti-proliferation activity of celecoxib was evaluated by hematoxylin and eosin (HE) staining, periodic acid-Schiff (PAS) staining, Masson staining and immunohistochemistry staining of the biliary epithelial mucosa, submucosal gland and collagen fiber in the bile duct wall of CPC rats.

RESULTS: The proliferative degree of the biliary epithelial mucosa and submucosal gland as well as the fibrotic degree of the biliary wall in the celecoxib therapy group were obviously lower than those in the CPC group, but still higher than those in the sham-operation group. Immunohistochemistry analysis showed that the expression intensity of cyclooxygenase 2 (COX-2) in the celecoxib therapy group was obviously inferior to that in the CPC model group (IA: 8.62 ± 0.19 vs 35.27 ± 0.43, P < 0.05), but close to that in the sham-operation group (IA: 8.62 ± 0.19 vs 8.41 ± 0.13, P > 0.05).

CONCLUSION: By down-regulating COX-2 expression, celecoxib can effectively inhibit the hyperplasia of the biliary epithelial mucosa, submucosal gland, and collagen fiber and reduce the amount of mucous glycoprotein secreted by the submucosal gland, thus holding the promise for controlling CPC and reducing the recurrence of intrahepatic bile duct stones.

Efficacy of antisense gene therapy for proliferative cholangitis

AIM: To compare the effects of short hairpin RNAs (shRNAs) targeting the proliferating cell nuclear antigen (PCNA), c-Myc and cdc2 k genes on the hyperplastic behavior and lithogenic potential of proliferative cholangitis (PC), and to select the best target for antiproliferative treatment of PC.

METHODS: A rat model of PC was developed by retrogradely inserting a nylon thread into the common bile duct. Using the nylon thread as the guide wire, an intralumenal injection of PCNA, c-Myc and cdc2 k shRNAs into the common bile duct was performed in three different groups of model rats, respectively.

RESULTS: Compared to the c-Myc and cdc2 k shRNA treatment groups, the degree of hyperplasia of biliary epithelium and collagen fibers in the bile duct wall in the PCNA shRNA treatment group were significantly decreased. In addition, the protein expression and secretion of mucin from the hyperplastic biliary epithelium and peribiliary gland were remarkably reduced in the PCNA shRNA treatment group.

CONCLUSION: PCNA shRNA possesses more strong inhibitory effects on collagen fiber hyperplasia in and mucin secretion from the bile duct wall of rats with experimental PC than c-Myc and cdc2 k shRNAs. Therefore, PCNA shRNA holds more promise for prevention of postoperative biliary restenosis and stone recurrence in PC patients.