The practical value of applying chemical biliary duct embolization to chemical hepatectomy for treatment of hepatolithiasis

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.

Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma for hepatolithiasis

AIM: To evaluate the long-term outcomes of Oddi sphincter preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS) and risk factors for recurrence in hepatolithiasis.

METHODS: From March 1993 to December 2012, 202 consecutive patients with hepatolithiasis underwent OSPCHS at our department. The Oddi sphincter preserved procedure consisted of common hepatic duct exploration, stone extraction, hilar bile duct plasty, establishment of subcutaneous stoma to the bile duct. Patients with recurrent stones can undergo stone extraction and/or biliary drainage via the subcutaneous stoma which can be incised under local anesthesia. The long-term results were reviewed. Cox regression model was employed to analyze the risk factors for stone recurrence.

RESULTS: Ninety-seven (48.0%) OSPCHS patients underwent hepatic resection concomitantly. The rate of surgical complications was 10.4%. There was no perioperative death. The immediate stone clearance rate was 72.8%. Postoperative cholangioscopic lithotomy raised the clearance rate to 97.0%. With a median follow-up period of 78.5 mo (range: 2-233 mo), 24.8% of patients had recurrent stones, 2.5% had late development of cholangiocarcinoma, and the mortality rate was 5.4%. Removal of recurrent stones and/or drainage of inflammatory bile via subcutaneous stoma were conducted in 44 (21.8%) patients. The clearance rate of recurrent stones was 84.0% after subsequent choledochoscopic lithotripsy via subcutaneous stoma. Cox regression analysis showed that residual stone was an independent prognostic factor for stone recurrence.

CONCLUSION: In selected patients with hepatolithiasis, OSPCHS achieves excellent long-term outcomes, and residual stone is an independent prognostic factor for stone recurrence.

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.

Recurrent pyogenic cholangitis: disease characteristics and patterns of recurrence

Recurrent pyogenic cholangitis (RPC) is characterized by repeated infections of the biliary system with the formation of stones and strictures. The management aims are to treat acute cholangitis, clear the biliary ductal debris and calculi, and eliminate predisposing factors of bile stasis. Operative options include hepatectomy and biliary drainage procedures or a combination of both; nonoperative options include endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) guided procedures. This current study compares the operative and the nonoperative management outcomes in patients with RPC in 80 consecutive patients. In addition, we aim to evaluate our approach to the management of RPC over the past decade, according to the various degrees of severity and extent of the disease, and identify the patterns of recurrence in this complex clinical condition. Initial failure rate in terms of residual stone of operative compared with nonoperative treatment was 10.2% versus 32.3% (P = 0.020). Long-term failure rate for operative compared with non-operative treatment was 20.4% versus 61.3% (P = 0.010). Based on multivariate logistic regression, the only significant factors associated with failure were bilaterality of disease (OR: 8.101, P = 0.007) and nonoperative treatment (OR: 26.843, P = 0.001). The median time to failure of the operative group was 48 months as compared to 20 months in the nonoperative group (P < 0.010). Thus operative treatment is a durable option in long-term resolution of disease. Hepatectomy is the preferred option to prevent recurrent disease. However, biliary drainage procedures are also an effective treatment option. The utility of nonoperative treatment can achieve a reasonable duration of disease free interval with minimal complications, albeit inferior to operative management.

Surgical treatment of complicated hepatolithiasis using the ultrasound-guided fiberoptic choledochoscope

BACKGROUND

The residual stones of postsurgical intrahepatic calculi have been among the most difficult problems in hepatobiliary surgery. Intraoperative ultrasound can clearly display the morphology of intrahepatic bile ducts and the distribution of calculi as well as the position of the choledochoscope and the calculus extraction instruments. Therefore, intraoperative ultrasound can guide the choledochoscope and its auxiliary equipment for calculus extraction. It is necessary to evaluate the effectiveness and safety of surgeries using an ultrasound-guided fiberoptic choledochoscope for the treatment of complicated hepatolithiasis.

METHODS

The 56 cases in group A were selected from patients who had complicated hepatolithiasis treated with calculus extraction therapy using an ultrasound-guided fiberoptic choledochoscope in the authors' hospital between January 2006 and June 2009. The 63 cases of complicated hepatolithiasis in group B were chosen from patients treated with calculus extraction surgeries using a fiberoptic choledochoscope without the guidance of ultrasound from September 2001 through December 2005. Transabdominal ultrasound, T-tube cholangiography, and computed tomography (CT) examination were performed on day 15 after the surgery to compare the complete stone clearance rate, the residual stone rate, and the incidence rate of postoperative complications between groups A and B.

RESULTS

The intrahepatic calculi were completely removed in 53 group A cases. The complete stone clearance rate was 94.6%, and the residual stone clearance rate was 5.4%. In group B, 51 cases had complete stone removal, for a stone clearance rate of 81% and a residual stone rate of 19%. The difference in the residual stone rates between the two groups is statistically significant (p=0.025). No hemobilia, biliary perforation, or other complications were observed in either group.

CONCLUSION

Use of the intraoperative ultrasound-guided fiberoptic choledochoscope in the treatment of complicated hepatolithiasis can significantly reduce the residual stone rate of intrahepatic biliary calculi and significantly improve the treatment effect 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.

Significance of controlling chronic proliferative cholangitis in the treatment of hepatolithiasis

BACKGROUND

Recently, high stone recurrence and biliary restenosis rates in hepatolithiasis patients have been confirmed to be closely related to chronic proliferative cholangitis (CPC). However, the effective management of CPC has not yet been established.

METHODS AND RESULTS

A vicious cycle exists between the presence of intrahepatic calculi and CPC: both the stone itself and secondary biliary infection can stimulate persistent hyperplasia in the biliary duct wall, leading to the occurrence of CPC and biliary stricture. The recurrent attacks of CPC will, in turn, facilitate new stone formation via mucoglycoprotein production, or induced biliary stricture and cholestasis. Thus, even when the stone is completely removed and the biliary tract stenosis is corrected, residual CPC will persist and progress, with an underlying risk for postoperative stone recurrence and biliary tract restenosis. Therefore, the perfect hepatolithiasis treatment would target stone removal and correction of the biliary tract stricture, as well as control of postoperative residual CPC. In fact, CPC, the management of which has been traditionally ignored, is the key to breaking this vicious cycle.

CONCLUSIONS

Overall, the subsequent treatment of residual CPC after operation or choledochoscopic lithotomy would be helpful to decrease postoperative stone recurrence and the rate of biliary restenosis. Adding such treatment would reduce the incidence of surgical reintervention and choledochoscopic lithotomy, and it would also improve the postoperative hepatolithiasis outlook.

Epidermal growth factor receptor as a target for anti-proliferative treatment of proliferative cholangitis in hepatolithiasis

BACKGROUND

In recent years, with a deeper understanding of pathologic changes in hepatolithiasis, more and more attention has been paid to the relationship of postoperative remnant proliferative cholangitis (PC) with stone recurrence and biliary restenosis, but effective management strategies have not yet been developed. Thus, the aim of this study was to determine whether epidermal growth factor receptor inhibitor (AG-1478) could inhibit hyperplasia and lithogenic potentiality of PC.

METHODS

The PC animal model was established via retrograde insertion of a 5-0 nylon thread into the common bile duct through Vater's papilla. The common bile duct in the therapeutic group received a single intraluminal administration of AG-1478, followed by weekly intraperitoneal injections of AG-1478. Subsequently, influence of EGFR inhibitor on hyperplasia, apoptosis, and lithogenic potential of PC were evaluated via histology, expression changes of EGFR, BrdU, Ki-67, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL), Fas, mucin 5 AC, and collagen I.

RESULTS

EGFR inhibitor AG-1478 was effective not only in inhibiting the mRNA and protein expression of EGFR, BrdU, and Ki-67, but also in increasing Fas mRNA expression and TUNEL-positive cells, as a result leading to the inhibition of hyperplasia of the biliary epithelium, submucosal gland, and collagen fibers in the diseased bile duct. Additionally, collagen I expression and fibrous thickness of the bile duct wall was significantly reduced, thereby reducing the incidence of biliary tract stricture secondary to PC. Also of note, treatment with AG-1478 could efficiently decrease the lithogenic potential of PC via inhibition of mucin 5AC expression and mucoglycoprotein secretion, hereby facilitating prevention of stone recurrence.

CONCLUSION

EGFR antagonist AG-1478 had a potent anti-proliferative and anti-fibrotic effectiveness on PC and, therefore, holds promise as a candidate of PC treatment.

Treatment of chronic proliferative cholangitis with c-myc shRNA

AIM: To investigate the feasibility and effectiveness of c-myc shRNA in inhibiting the hyperplastic behavior and lithogenic potentiality of chronic proliferative cholangitis (CPC), in order to prevent stone recurrence and biliary restenosis.

METHODS: An animal model of CPC was established by giving intralumenally 0.5 mL of c-myc shRNA. Then, the effects of c-myc shRNA on hyperplastic behavior and lithogenic potentiality of CPC were evaluated by histological observation, immunohistochemistry, real-time PCR and Western blotting for c-myc, proliferating cell nuclear antigen (PCNA), procollagen III, mucin 5AC, enzymatic histochemistry for β-glucuronidase, and biochemistry for hydroxyproline in the diseased bile duct.

RESULTS: Treatment with c-myc shRNA efficiently suppressed the hyperplasia of biliary epithelium, submucosal gland, and collagen fiber by inhibiting mRNA and protein expression of c-myc. More importantly, it decreased the lithogenic potentiality of CPC by inhibiting the expression of mucin 5AC and the secretion of endogenous β-glucuronidase. Further investigation indicated that c-myc shRNA-3 had a better inhibitory effect on CPC.

CONCLUSION: Treatment with c-myc shRNA-3 can control CPC and reduce the lithogenic potentiality of CPC.

Treatment of hepatolithiasis by chemical bile duct embolization: report on 2 cases

The high recurrence of hepatolithiasis has not been settled effectively until now, which lead us to present a new therapy of the chemical bile duct embolization to resolve it. In our selected 2 patients, multiple biliary calculi, complicated by biliary stricture, were found in the inferior branch of left lateral bile duct via preoperative cholangiography. After the choledochoscopic cholelithotomy, the combination of absolute ethanol and N-butyl-cyanoacrylate were injected into the diseased biliary duct lumen. Two months later, their T-tube cholangiography demonstrated that the targeted biliary ducts were completely embolized, thus effectively preventing the calculous recurrence. Twelve and 15 months later, their computed tomography scan showed that the inferior segments of left lateral lobes were almost completely atrophied and disappeared, thus successfully achieving the chemical "resection" of the diseased hepatic lobe. Chemical bile duct embolization may be a feasible and safe technique to prevent the calculous recurrence and concurrently achieve the effect of chemical hepatectomy for highly selected hepatolithiasis cases.

Laparoscopic hepatectomy for hepatolithiasis: a feasibility and safety study in 29 patients

BACKGROUND

Hepatolithiasis is a prevalent disease in Southeast Asia. Hepatectomy was considered the best treatment for majority of cases. Laparoscopic hepatectomy is a new procedure for liver lesions that uses a minimal invasive approach. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy for hepatolithiasis by comparing it with open hepatectomy.

METHODS

From November 2002 to March 2006 a total of 30 consecutive patients underwent laparoscopic hepatectomy for hepatolithiasis in Sir Run Run Shaw Hospital. Twenty-nine were included in this study (a converted case was excluded) and called the laparoscopic hepatectomy group (LH). During the same period 22 patients with hepatolithiasis who met the inclusion criteria for laparoscopic hepatectomy were selected for open hepatectomy and called the open group (OH). All operations were performed by the authors. There was no significant difference in preoperative data between the two groups. Data were statistically compared.

RESULTS

Compared with open hepatectomy, those who underwent laparoscopic hepatectomy had a shorter postoperative hospital stay and fasting time, a lower postoperative serum aminotransferase level, and a higher postoperative serum albumin level. Stone clearance rate (intermediate rate, 89.7% vs. 86.4%; final rate, 100% vs. 96.5%), stone recurrence rate (0% vs. 4.5%), operating time, and intraoperative blood loss were similar for the two groups. Six complications occurred, two (6.8%) in LH and four (18.2%) in OH. There was no perioperative mortality in either group.

CONCLUSION

Laparoscopic hepatectomy for hepatolithiasis is feasible and safe in selected patients.

Postoperative bile leakage managed successfully by intrahepatic biliary ablation with ethanol

We report a case of postoperative refractory bile leakage managed successfully by intrahepatic biliary ablation with ethanol. A 75-year-old man diagnosed with hepatocellular carcinoma underwent extended posterior segmentectomy including the caudate lobe and a part of the anterior segment. The hepatic tumor attached to the anterior branch of the bile duct was detached carefully and resected. Fluid drained from the liver surface postoperatively contained high concentrations of total bilirubin, at a constant volume of 150 mL per day. On d 32 after surgery, a fistulogram of the drainage tube demonstrated an enhancement of the anterior bile duct. Endoscopic retrograde cholangiography demonstrated complete obstruction of the proximal anterior bile duct and no enhancement of the peripheral anterior bile duct. On d 46 after surgery, a retrograde transhepatic biliary drainage (RTBD) tube was inserted into the anterior bile duct under open surgery. However, a contrast study of RTBD taken 7 mo post-surgery revealed that the fistula remained patent despite prolonged conservative management, so we decided to perform ethanol ablation of the isolated bile duct. Four mL pure ethanol was injected into the isolated anterior bile duct for ten minutes, the procedure being repeated five times a week. Following 23 attempts, the volume of bile juice reached less than 10 mL per day. The RTBD was clamped and removed two days later. After RTBD removal, the patient had no complaints or symptoms. Follow-up magnetic resonance imaging demonstrated atrophy of the ethanol-injected anterior segment without liver abscess formation.