The concept of endotoxin-mediated rather than direct liver injury in biliary obsruction wasinvestigated using the experimental rat model of bile duct ligation (BDL) and small bowelbacterial overgrowth (SBBO). Small identical doses of intravenous endotoxin (bacterial LPS)caused a significantly more severe liver injury in rats with BDL, compared with sham-operatedrats, suggesting the possible contribution of LPS in this type of liver damage. BDL was thencombined with surgically created jejunal self-filling blind loops, which resulted in SBBO. PlasmaLPS level increased significantly, and once again a more severe liver injury, determined by liverhistology and serum gamma-glutamyl transpeptidase levels, was observed compared with thecontrol group of rats with BDL&#43;self-emptying blind loops. The data presented suggest thatsmall amounts of exogenous LPS and/or the ordinarily innocous amounts of LPS constantlyabsorbed from the intestinal tract may be critical in the hepatic damage caused by obstructionof the biliary tract.

B. B&#252;lent Mente&#351;

Ertan  Tatlicio&#287;lu

G&#252;len  Akyol

&#214;mer  Uluo&#287;lu

Nedim  Sultan

Erdal  Yilmaz

Murat  &#199;elebi

Ferit  Taneri

Zafer  Ferahk&#246;&#351;e

Intestinal Endotoxins as Co-Factors of Liver Injury in Obstructive Jaundice

After partial ligation of the common bile duct (CBD) of guinea pigs, 14 of 16 animals developed pigment gallstones within one week (S group). Intraperitoneal injection of Vit. E and C, each 10 mg/kg daily from 3 days before CBD ligation to one week after the operation (S+V group), decreased the gallstone incidence to 5/14 (exact probability&lt;0.01). The gallstone incidence in the control group, that only received laparotomy without ligation of the CBD, was 0/15. Biochemical analysis of the gallbladder bile showed that stricture of the CBD was associated with a significant increase in levels of unconjugated bilirubin (UCB) and Ca2+ (p&lt;0.05 and &lt;0.01). Simultaneously the scavenging rate (SR) of superoxide radical in bile significantly decreased (p&lt;0.05). Comparing S+V group with S group, the effect of Vit. E and C on the concentrations of UCB and Ca2+ in bile was not significant (both p&gt;0.05), but Vit. E and C normalized the SR, and the difference between S group and S+V group was significant (p&lt;0.05). These results suggested that Vit. E and C, known as antioxidants, enhanced the ability to scavenge oxygen radical in S+V group; and that in addition to the increases of UCB and Ca2+ concentrations, the participation of oxygen radicals might be of importance for pigment gallstone formation induced by bile duct obstruction.

Cong Lin

Tao Shen

Xianbo Fu

Xiaosi Zhou

The Ability of Bile to Scavenge Superoxide Radicals and Pigment Gallstone Formation in Guinea Pigs

Gian Luca Grazi

Professor Guiseppe Gozzetti

Norcantharidin is the demethylated form of Cantharidin, which is the active ingredient of the blister beetle, Mylabris, a long used Chinese traditional medicine. Though not well publicised outside China, Norcantharidin is known to possess significant anti-hepatoma activity, and is relatively free from side effects. In the present study, glucose oxidation in tumour and liver tissue slices harvested from hepatomabearing animals was quantified by measuring the radioactivity of 14C-labelled CO released from 14C-glucose in oxygen-enriched incubation medium. Results were expressed asa tumour/liver ratio. For comparison, treatments with Norcantharidin, Adriamycin and with hepatic artery ligation were studied. The mean tumour/liver ratio was 4.2+2.2 in untreated controls, but dropped significantly to 2.3+0.5 (p&lt;0.05) with intra-arterial Norcantharidin (0.5 mg/kg) and to 2.3+0.7 (p&lt;0.05) with intra-arterial Adriamycin (2.4 mg/kg), and to 2.2+0.7 (p&lt;0.05) with hepatic artery ligation. However, with intravenous Adriamycin at 2.4 mg/kg, the mean tumour/liver ratio was reduced to only 3.5+2.0 and was not significantly different from untreated controls. It is concluded that intra-arterial Norcantharidin is as effective as intraarterial Adriamycin and hepatic artery ligation in suppressing tumour glucose oxidative metabolism. These results imply that Norcantharidin may have a role to play in the chemotherapy ofprimary livercancer.

Peter Mack

Xiao-Fang Ha

Li-Yao Cheng

Efficacy of Intra-arterial Norcantharidin in Suppressing Tumour 14C-labelled Glucose Oxidative Metabolism in rat Morris Hepatoma

Background: This study concerns patients who have choledochal cyst with intrahepatic and extrahepatic involvement (type IVA cyst). The extent of excision and the necessity of hepatectomy, including the intrahepatic cyst in these patients have not been clarified.Study design: We have performed excision of the extrahepatic cyst with hepaticojejunostomy upon 13 patients with type IVA cyst during a 16 year period. The present study was done to examine the size of the anastomotic opening by direct cholangiography two weeks postoperatively. The long-term results were assessed to find the appropriate operative management for patients with type IVA cysts.Results: Intrahepatic cysts were present in both hepatic lobes in 11 patients (85 percent). None of the patients had carcinoma after excision of extrahepatic cyst during the follow-up period, which ranged from two months to 16 years. Postoperative late complications occurred in three patients (23 percent), hepatolithiasis in two and cholangitis in one. The anastomotic opening of hepaticojejunostomy was 13.3±4.5 mm in diameter two weeks postoperatively, which was not significantly different when compared with that in ten patients without late complications (13.4±4.9 mm). The late complications were successfully treated with either antibiotics or percutaneous transhepatic cholangioscopy, and none required a reoperation.Conclusions: The results suggest that additional hepatectomy is not required because carcinoma has rarely occurred from the intrahepatic cyst. Excision of an extrahepatic cyst with a wide hepaticojejunostomy is an acceptable operative management for patients with type IVA cysts.

Russell Strong

Type IVA Choledochal Cyst: Is Hepatic Resection Necessary?

Objective: To investigate clinical experience with the apparent malignant transformation of benign liver cell adenomas.Design: Retrospective review of personal experience and literature.Setting: University hospital and affiliated community hospitals.Patients: All patients diagnosed with liver cell adenomas over a 30-year period.Interventions: Liver resection and/or tumor biopsy.Main Outcome Measures: Gender, age, drug associations, alpha-fetoprotein levels, response to treatment, and survival.Results: Thirteen patients from personal experience and 26 patients from the reports of others had liver cell adenomas that were not resected. Five of these patients subsequently developed hepatocellular carcinoma.Conclusions: Malignant transformation of a liver cell adenoma is a rare phenomenon, but it does occur. Alphafetoprotein levels may be more helpful in diagnosis than expected from previous reports. Solitary benign adenomas should be resected whenever possible. Patients with diffuse multiple tumors should be observed closely over a long period.

David M. Nagorney

Are Hepatic Adenomas Premalignant?

A case of metastatic granulosa cell tumour of the ovary is reported. Investigations revealed a secondary tumour in segment VI and VII of the liver. Right hepatic resection was performed. Microscopic findings revealed a tumour with histological features identical to that removed eleven years before.

Jos&#233; I. Rodr&#237;guez Garc&#237;a

Juan. J. Gonz&#225;lez Gonz&#225;lez

Luis J. Garc&#237;a Fl&#243;rez

Paloma Floriano Rodr&#237;guez

Enrique Mart&#237;nez Rodr&#237;guez

Hepatic Metastases of Granulosa Cell Tumour of the Ovary

Bleeding from oesophageal varices, oesophageal ulcers or oesophagitis is occasionally massive and difficult to control. Octreotide, a synthetic analogue of somatostin lowers portal pressure and collateral blood flow including that through varices, increases lower oesophageal sphincter pressure, and inhibits the gastric secretion of acid as well as pepsin. Our current experience suggests it is effective in controlling acute variceal haemorrhage. Therefore we have examined the efficacy of octreotide in the control of postsclerotherapy bleeding from oesophageal varices, oesophageal ulcers and oesophagitis. During the study period 77 patients experienced a significant gastrointestinal bleed (blood pressure &lt; 100 mm Hg, pulse &gt;
100 beats per min or the need to transfuse 2 or more units of blood to restore the haemoglobin level) following injection sclerotherapy of oesophageal varices. The source of bleeding was varices in 42 patients, oesophageal ulcers in 31 and oesophagitis in 4. All patients received a continuous intravenous infusion of octreotide (50 μg/h) for between 40–140h. If bleeding was not controlled in the first 12h after commencing octreotide hourly bolus doses (50 μg) for 24h were superimposed on the continuous infusion. Haemorrhage was successfully controlled by an infusion of octreotide in 38 of the 42 patients with bleeding from varices, in 30 of 31 patients with oesophageal ulceration, and all patients with oesophagitis. In the 1 patient with persistent bleeding from oesophageal ulceration and in 2 of the 4 with continued haemorrhage from varices, haemostasis was achieved by hourly boluses of 50 μg octreotide for 24h in addition to the continuous infusion. No major complications were associated with octreotide administration. The results of this study clearly indicate that octreotide is a safe and effective treatment for the  control of severe haemorrhage after technically successful injection sclerotherapy.

Spencer A. Jenkins

Andrew N. Kingsnorth

Simon Ellenbogen

Graham Copeland

Nicholas Davies

Robert Sutton

Robert Shields

Octreotide in the Control of Post-Sclerotherapy Bleeding from Oesophageal Varices, Ulcers and Oesophagitis

About this journal

Journal profile

Meet the editorial board

Editor spotlight

Submit your proposal

Do you think there is an emerging area of research that really needs to be highlighted? Or an existing research area that has been overlooked or would benefit from deeper investigation? Raise the profile of a research area by leading a Special Issue.

HPB Surgery