| Background:Since LC was introduced as a technique for treating symptomatic gallstones and cholecystitis in 1987, it has gradually replaced open cholecystectomy. However. LC is not exempt from potentially life-threatening failure In terms of incidence of BDI, the majority of comparative studies of open cholecystectomy and LC have shown a higher rate for LC. The reported incidence ranged between 0% and 3% for LC, which is 10-fold higher than the published incidence of 0% to 0.2% for open cholecystectomy. Laparoscopic bile duct injury tends to be more severe than those with open chelecystectomy. Injuries to the bile duct during LC are often a cause of malpractice litigations. The management of patients following major BDI is a surgical challenge often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers. The strategy of these patients has evolved over the last years by the individual surgeon and institutional philosophy. Major BDI detected during LC can be repaired with a duct-to-duct anastomasis or Roux-en-Y choledochojejunostomy and other repair procedures. The reconstruction of biliary tract is a subject that has been exhaustively studied, and no consensus has been reached as to the ideal model of biliary tract restoration, Controversy exists whether the skills of experienced hepatobiliary surgeons and the strategy of bile duct reconstruction are important factors for obtaining excellent outcome to major BDI following LC. The goal of this clinical study, from the multiple institutions experience from 1997 to 2007, is to compare the restoration outcomes by initial LC surgeon procedure to that by the experienced hepatobiliary surgeon, and the outcomes of different bile duct reconstructive procedures to major BDI following LC. According to the concept of transformation surgery, we will transform the clinical problem to animal experiments, and investigate the effect of Sinomenine on bile duct scarring of rabbit animal model, which has anti-proliferative effect, for providing evidence on prevention the formation of bile duct scar. In the course of the development of scar, macrophages and fibroblasts play an important role. Macrophages in long-term deposit in the bile duct which is a major factor of formation of bile duct stenosis. TGF-β1 as a cytokine secrete from fibroblasts, it play a special role in scar formation, and compared to normal human dermal fibroblasts, expression of TGF-β1 and TGF-β2 isoforms increased in human keloid cells. Hypertrophic scar fibroblasts produce more TGF-β1. The studies of TGF-βantibody showed that blocking of TGF-βcould make the fiber forming level decline. In the study of trauma healing process, we found that macrophages and fibroblasts plays a role of bridge and link in scar formation mechanism, and its cell peak appeared in the 5-9 days of overlapping of inflammatory phase and proliferation period. Therefore, we selected 6-7 days after surgery as a study site to explore the molecular mechanisms and intervention mechanism of biliary scar formation, and detected expression of CD68, TGF-β1 and changes of expression of CD68 mRNA and TGF-β1 mRNA gene in biliary tissue of rabbits' biliary injury model via immunohistochemistry and quantitative RT-PCR. Chinese herb Ovientvine has ability of analgesic, anti-inflammatory, sedative, swelling, diuretic, antihypertensive, antiarrhythmic, histamine release and immune regulation, etc. Experiments confirmed that Sinomenine inhibited carrageenin-induced rat paw edema, and significantly reduced the PGE content intestinal inflammatory exudation of rats. It also inhibited synthesis or release of PG in local inflammation. There are experimental reports that Sinomenine prevent leukocyte aggregation induced by complement activation. Sinomenine has shown better effects of anti-rheumatic, anti-inflammatory, immunosuppressive and anti-proliferation, we further explore the anti-proliferative effect and biliary scar treatment of Sinomenine not only to provide a theoretical basis for clinical applications, and provide a wealth of experimental evidence for the pathogenesis of biliary scar. In this research, we studied expression of CD68 and TGFβ1 of macrophages and fibroblasts in rabbits'biliary scar tissue treated with Sinomenine using immunohistochemistry and quantitative RT-PCR, and understood the difference of expression of CD68, TGFβ1 between experimental group, positive control group and control group. In addition, we explored the effect of Sinoacutine on biliary scar formation for the prevention and treatment of biliary scar formation. Therefore, this study will provide brand new ideas for the treatment of benign biliary strictures in traditional Chinese medicine.Objectives:The goal of this study is to present the multiple institutions experience comparing the outcome of management between initial LC surgeon and specialist,as well as the outcome of different operative procedures to major BDI following LC. We studied the effect of Sinoacutine on biliary scar tissue formation, expression of CD68. TGFβ1 and expression of CD68 mRNA, TGF-β1 mRNA gene by animal experiments. In addition.we explored the molecular mechanisms and intervention mechanism of biliary scar formation, and investigate anti-proliferative effect and biliary scar treatment of Sinomenine.Methods:We have retrospectively collected data of 77 cases of peroperatively detected major BDI in LC at 15 general surgical institutions from 1997 to 2007. We classified 42 cases treated by an experienced biliary surgeon as group A, and 35 cases treated by initial LC surgeon as group B.48 cases were treated with duct-to-duct anastomosis as group C. and 29 cases were treated with Roux-en-Y choledochojejunostomy as group D. The median duration of follow-up was 62 months. The outcome of groups was compared. We selected 60 New Zealand rabbits as experimental animals, weighing 1500-2500g. The rabbits were randomly divided into three groups,20 each group. The control group only received an injection of 2 ml saline. The positive control group was intraperitoneally injected 2 ml hydrocortisone. The experimental group was received an intraperitoneally injection of 2 ml Sinomenine intraoperative and postoperative 1-7 day. After 6-7 days postoperatively, the rabbits were put to death, and we obtained the bile duct tissue from upper and lower parts (0.5cm) of injury site. Cell structural changes in injury bile duct tissue were studied with HE by light microscope; expression and location of CD68, TGF-β1 detemined by immunohistochemistry; expression of CD68 mRNA, TGF-β1 mRNA assayed by Quantitative RT-PCR.Results:In group A,7/42 (16.7%) patients developed a failure.2/7(28.6%) patients were treated by secondary operation. In group B,24/35 (68.6%) patients developed a failure.17/24(70.8%) patient were treated by secondary operation.1/35 (2.85%) patient died. The significant differences were observed in failure and secondary operation (16.7% versus 68.6%, p<0.01 and 28.6% versus 70.8%, p<0.01). There is no significant difference between the group C and group D in the failure rate (28.5% versus 11.7%,p>0.05). In control group, we find proliferation of fibroblasts on the surface of bile duct by HE staining, which under the new capillaries and a small amount of macrophages, lymphocytes, plasma cells infiltration scattered. Lower layer of bile duct are the proliferation of fibroblasts, a small amount of collagen fibers and more fibroblasts. For the positive control group, there are a small amount of bile duct fibroblasts on the surface of bile duct, the proliferation of fibroblasts, collagen fibers, new capillaries, lymphocytes, plasma cells scattered on the lower layer. Collagen fibers bundles in some area are broad, and fibroblasts are less, the same situation appears in the experimental group. The experimental group shows a small amount of surface disordered bile duct fibroblasts, the lower layer of bile duct has the proliferation of fibroblasts, collagen fibers, new capillaries, which showing multifocal infiltrates of neutrophils, lymphocytes, without collagen. Immunohistochemical specimens were randomly took from each of four high power field (100 times) to observe and counted the positive cells. Data averaged for statistical analysis (x±s). The immunohistochemical staining showed that the number of CD68, TGF-(31 protein positive cells in control group increased, but that in positive control group and experimental group decreased. By pairwise comparison, the experimental group and positive control group were no significant difference, but two groups compared with the control group were statistically significant.Conclusions:(1) A multiple institutional cooperative methodology between local surgical institution and tertiary care centers provided a good way to limit further operations, failure. The reconstructive strategy is important and should be selected according to the type of injury and the diagnosed status of major BDI. (2) The effect of sinoacutine on formation of inflammation and proliferation phase of macrophage and fibroblast cell was remarkable. (3) Sinoacutine significantly reduces the expression of CD68. TGF-β1 protein in bile duct scar tissue. (4) Sinoacutine significantly reduces the expression of CD68 mRNA. TGF-β1 mRNA in bile duct scar tissue. (5) Sinoacutine inhibited proliferation of bile duct scar tissue through down-regulation the expression of TGF-β1 protein, CD68 mRNA and TGF-β1 mRNA. (6) The inhibitory effect of Sinoacutine on proliferation of bile duct scar tissue was similar to that of hydrocortisone. (7) Sinoacutine has a bright future in the clinical treatment of benign biliary stricture.
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