Abstract:Background and Aims Hepatectomy is one of the main treatment methods for hepatolithiasis. However, the advantages of laparoscopic left-sided hepatectomy (LLH) over open left-sided hepatectomy (OLH) are still controversial. Therefore, this study was performed to compare the clinical efficacy of LLH and OLH in the treatment of hepatolithiasis using propensity score matching method.Methods The clinical data of 331 patients with hepatolithiasis who underwent left hepatectomy (including left lateral hepatectomy and left hemihepatectomy) in the First Affiliated Hospital of Nanchang University from January 2016 to July 2021 were retrospectively analyzed. The patients undergoing laparoscopic surgery (LLH group) and open surgery (OLH group) were matched by PSM at a 1:1 ratio. Main clinical variables were compared between the two groups after match.Results A total of 124 pairs of patients in the two groups were successfully matched after PSM. In LLH group compared with OLH group, the intraoperative blood loss (230.6 mL vs. 326.5 mL) and the overall incidence of complications (9.7% vs. 23.4%) were significantly decreased, and the time to restore food intake (1.9 d vs. 2.6 d), the time to regain ambulation (1.7 d vs. 2.3 d), the length of postoperative hospitalization (8.8 d vs. 10.2 d) and the total hospitalization cost (43 200 yuan vs. 57 000 yuan) were significantly reduced (all P<0.05). There were no significant differences in operative time, number of cases requiring intraoperative blood transfusion, method for common bile duct stone extraction, stone clearance rate, and stone recurrence rate between the two groups (all P>0.05). There was no reoperation and perioperative death in both groups. The open conversion rate in LLH group was 4.0%.Conclusion LLH is a safe and effective treatment for patients with left-sided hepatolithiasis, and it is superior to OLH in terms of intraoperative blood loss, overall complication, and hospitalization cost.

Abstract:Background and Aims Fluorescence cholangiography by intrabiliary indocyanine green (ICG) injection during laparoscopic cholecystectomy (LC) has the advantage of immediate display with zero background liver fluorescence. It is more suitable for complex LC. This study was conducted to investigate the efficacy of fluorescent LC after percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic nasobiliary drainage (ENBD).Methods The clinical data of 120 patients with gallbladder stones undergoing LC from January 2019 to April 2021 were selected. Of the patients, 60 cases underwent fluorescence-navigated LC by injection of ICG through the PTGBD tube or ENBD tube (observation group), and 60 cases underwent conventional LC (control group). The display rates of the extrahepatic bile duct structures and the main clinical variables were compared between the two groups.Results The preoperative general data showed no significant difference between the two groups of patients (all P>0.05). Before dissection of the Calot's triangle, the display rates of the common hepatic duct, the common bile duct, the cystic duct, the junction of cystic duct and common bile duct and the neck of the gallbladder were significantly higher in observation group than those in control group (all P<0.05), but there was no significant difference in display rate of the right hepatic duct between the two groups (P>0.05); After dissection of the Calot's triangle, the display rates of the common hepatic duct, the common bile duct and the junction of cystic duct and common bile duct were significantly higher in observation group than those in control group (all P<0.05). In observation group compared with control group, the operative time, the intraoperative blood loss, the rate of subhepatic drainage tube placement, and length of postoperative hospital stay were all significantly reduced (all P<0.05). There was no significant difference in hospitalization cost and incidence rate of postoperative complications between the two groups (all P>0.05).Conclusions The application of fluorescence-navigated LC is beneficial to improve the display rate of the extrahepatic bile duct structures, decrease the degree of difficulty of complex LC after PTGBD and ENBD, shorten the operative time and postoperative hospital stay, and reduce the intraoperative blood loss and subhepatic drainage tube placement.

Abstract:Background and Aims Laparoscopic cholecystectomy combined with laparoscopic transcystic common bile duct exploration (LC+LTCBDE) and endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy combined with laparoscopic cholecystectomy (ERCP/EST+LC) both are minimally invasive procedures for the treatment of cholecystolithiasis with choledocholithiasis. However, the merits of the two procedures are still under debate. Therefore, this study was performed to compare the efficacy of the two minimally invasive procedures in the treatment of concomitant cholecystolithiasis and choledocholithiasis through a retrospective analysis.Methods The clinical data of 161 patients with concomitant cholecystolithiasis and choledocholithiasis whom been treated in the Second People's Hospital of Neijiang City from July 2017 to August 2020 were retrospectively analyzed. Of the patients, 78 cases underwent LC+LTCDBE, and 83 cases were subjected to ERCP/EST+LC. The operation success rate, residual stone rate, operative time, length of hospitalization, and incidence rates of postoperative short- and long-term complications were compared between the two groups.Results There was no significant difference in the operation success rate and residual stone rate between the two groups (both P>0.05). In LC+LTCDBE group versus ERCP/EST+LC group, the operative time was longer (156.13 min vs. 129.39 min), the length of hospitalization was shorter (8.17 d vs. 13.06 d), and the hospitalization cost was lower (17 582.68 yuan vs. 29 403.10 yuan), all the differences had a statistical significance (all P<0.001). The incidence rate short-term of bile leakage was higher (7.7% vs. 0, P=0.010), but the incidence rate of pancreatitis was lower in LC+LTCDBE group than those in ERCP/EST+LC group (1.3% vs. 8.4%, P=0.037); the incidence rate of long-term cholangitis was lower in LC+LTCDBE group than that in ERCP/EST+LC group (1.3% vs. 8.4%, P=0.037). No statistical difference was noted in stone recurrence rate between the two groups (P>0.05).Conclusion Both LC+LTCBDE and ERCP/EST+LC are safe and effective surgical approaches for concomitant cholecystolithiasis and choledocholithiasis. Moreover, LC+LTCBDE offers a shortened length of hospitalization, reduced hospitalization cost, and decreased long-term complications compared with ERCP/EST+LC. Thus, it can be regarded as the preferred choice under the same indications.

Abstract:Background and Aims Hepatectomy is an important method for the treatment of hepatolithiasis. In recent years, a great progress has been made in the application of laparoscopic hepatectomy. Compared with open surgery, laparoscopic surgery has the advantages of less trauma, rapid recovery and short hospital stay. But there are few clinical studies on application of laparoscopic left hemihepatectomy in hepatolithiasis patients with a previous history of abdominal surgery. Therefore, this study was conducted to investigate the clinical application value of laparoscopic left hemihepatectomy in hepatolithiasis patients with a previous history of abdominal surgery through a retrospective analysis.Methods The clinical data of 172 patients with hepatolithiasis who underwent laparoscopic left hemihepatectomy from January 2017 to December 2020 in Deyang People's Hospital were retrospectively analyzed. The patients with previous history of abdominal surgery (observation group) and those without previous history of abdominal surgery (control group) were matched using propensity score matching (PSM) at a 1∶1 ratio. The main clinical variables and follow-up results were compared between the two groups of patients.Results There were 43 patients in each group after match, with balanced and comparable baseline data. In observation group compared with control group, the operative time was significantly prolonged (225 min vs. 252 min, P<0.05), but no significant differences were seen in intraoperative blood loss, conversion rate, time to postoperative ambulation, time to postoperative tube removal, length of postoperative hospital stay and incidence of overall postoperative complications (all P>0.05). There were no significant differences in terms of liver function parameters and C-reactive protein levels between the two groups on the first day after operation (all P>0.05). The median follow up time was 21( range 3-48) months, no significant differences were noted in stone clearance and stone recurrence between the two groups during follow-up period (both P>0.05).Conclusion Using laparoscopic left hemihepatectomy for the treatment of hepatolithiasis in patients with a previous history of abdominal surgery is safe, feasible and effective. Although the operative time will be prolonged due to the additional surgical procedures for detachment of the adhesions during operation, it will not increase the adverse impacts on other aspects.

Abstract:Background and Aims Percutaneous transhepatic gallbladder drainage (PTGD) followed by elective laparoscopic cholecystectomy (LC) is a commonly used modality for the treatment of acute cholecystitis (AC). It is found in clinical practice that the time interval between PTGD and LC (PTGD-LC interval) would affect the degree of difficulty in performing LC, but the optimal time interval between the two procedures is still an unresolved question. Therefore, this study was performed to investigate the optimal timing of LC after emergency PTGD for AC patients, so as to provide guidance for clinical practice.Methods The clinical data of AC patients undergoing PTGD followed by elective LC in Shengjing Hospital of China Medical University from 2013 to 2019 were collected. According to the degree of difficulty of LC, the patients were classified into non-difficult group and difficult group, and the differences in PTGD-LC interval and other clinical variables between the two groups were compared. The ROC curve for PTGD-LC interval predicting difficult LC was drawn to obtain the cut-off value, and the fitted curve analysis with the PTGD-LC interval as independent variable and the proportion of cases of difficult LC as dependent variable was created to analyze the relationship between PTGD-LC interval and the difficulty of LC.Results A total of 98 patients were enrolled, with 56 cases in non-difficult group and 42 cases in difficult group. The PTGD-LC interval in non-difficult group was significantly longer than that in difficult group (69.0 d vs. 39.5 d, P=0.043), and in addition, the operative time for LC was significantly shorter and the aminotransferase levels were significantly lower in non-difficult group than those in difficult group (all P<0.05). The AUC of the ROC curve for PTGD-LC interval predicting difficult LC was 0.6, and the cut-off value was 40.5 d. The proportion of cases of difficult LC was significantly decreased when the interval was more than 40.5 d (30.8% vs. 66.7%, P=0.001), and meanwhile, the proportion of cases with severe pericholecystic adhesions and length of postoperative hospital stay were significantly reduced (both P<0.05). The fitted curve analysis showed that the proportion of cases of difficult LC reached the highest level at 15.1 d of PTGD-LC interval, followed by a continuous decrease, and then reached the lowest level at 61.7 d of PTGD-LC interval, followed by an increasing trend in later period.Conclusion The PTGD-LC interval is closely associated with the degree of difficulty of the elective LC. Taking both surgical difficulty and patients' quality of life into account, the optimal time interval of the elective LC after PTGD ranges from 40.5 to 61.7 d.

Abstract:Background and Aims Laparoscopic common bile duct exploration (LCBDE) is the main method for the treatment of common bile duct stones. However, due to the lack of sinus tract support, the traditional laparoscopic choledocholithotomy using basket forceps under choledochoscopic guidance is relatively difficult with high technical requirement. Repeated stone extraction may easily cause the damage of the choledochoscopy or injury of the bile duct wall. For the purpose of achieving a high stone extraction rate and low technical requirement, the authors modified the choledochoscopic stone removal procedure by using a self-designed laparoscopic bile duct irrigator to assist choledochoscopic lithotripsy during LCBDE. This study was conducted to summarize the clinical effect of using this method in two centers.Methods The clinical data of 313 eligible patients with common bile duct stones treated with self-designed laparoscopic bile duct irrigator during LCBDE in Fujian Provincial Hospital and Fujian Pucheng County Hospital from January 2017 to January 2021 were reviewed. The perioperative data and short-term outcomes of the patients were analyzed.Results Of the 313 patients, 132 cases were males and 181 cases were females with a mean age of (56.3±13.2) years, 173 cases had solitary stone and 140 patients had multiple stones (the maximum number of stone amount was 10); The median diameter of the stones was 0.5 (0.2-3.1) cm and the median common bile duct diameter was 1.2 (0.6-3.3) cm. All the 313 cases were successfully performed without conversion to open surgery. The stones were completely removed by laparoscopic bile duct irrigator in 281 cases (89.8%), and in 32 cases were extracted in combination with a stone basket. The stones were completely removed in one session in 307 patients (98.1%) while residual stones were found in 6 patients; 157 patients received primary closure and 156 patients underwent T-tube drainage of the common bile duct after operation. The mean operative time was (109.3±29.4) min, the mean intraoperative blood loss amount was (42.5±8.4) mL, and the average length of postoperative hospital stay was (7.6±3.2) d. There were 12 cases of bile leakage, 12 cases of abdominal infection, 9 cases of pulmonary infection, 7 cases of incision infection, and 1 case of postoperative bleeding after operation. All of them were cured after non-surgical approach. The residual stones in all the 6 patients with failure of complete stone removal in the first session were completely cleared by choledochoscopic lithotripsy through the T-tube tract 1.5 months after the operation. Postoperative follow-up was conducted for 6 to 12 months, and no recurrent bile duct stones and biliary stenosis or other complications were noted.Conclusion Using self-designed laparoscopic bile duct irrigator in LCBDE is safe and reliable with high efficiency. It is recommended to be used.

Abstract:Background and Aims Phosphoserine phosphorylase (PSPH) has been reported to be upregulated in multiple types of cancer and have a promoting effect on tumor growth and metastasis. However, its exact role in hepatocellular carcinoma (HCC) is largely unknown. Therefore, this study was conducted to investigate the expression and action of PSPH in HCC, and to explore the potential mechanism.Methods The expressions of PSPH in HCC and adjacent tissue as well as in different HCC cell lines (HepG2, Huh-7, HCCLM3) and normal hepatic cell line (HL-7702) were detected by Western blot and qRT-PCR, respectively. In HepG2 after overexpression or knock down of PSPH, the changes in proliferation and invasion abilities, and the expressions of proliferation markers CCND1 and Ki-67 were determined by CCK-8, EdU and Transwell invasion assays and Western blot, respectively. Meanwhile, the expressions of autophagy-related proteins LC3-II/LC3-I and p62 as well as invasion-associated protein MMP-9, and nuclear translocation of the p65 submit were detected by Western blot and immunofluorescence staining, respectively.Results The PSPH protein expression was significantly up-regulated in HCC tissue compared with adjacent tissue, and the PSPH gene expressions were significantly increased in each HCC cell line compared with normal hepatic cells (all P<0.05). In HepG2 cells after PSPH overexpression, the proliferation and invasion abilities were significantly enhanced, and the expressions of CCND1 and Ki-67 proteins were significantly up-regulated, with increased LC3-II/LC3-I expression and decreased p62 expression as well as enhanced p65 nuclear translocation and up-regulated MMP-9 expression (all P<0.05); in HepG2 cells after PSPH knockdown, the totally opposite changes in these parameters were observed (all P<0.05). The effects of p65 nuclear translocation promotion and MMP-9 up-regulation by PSPH overexpression were inhibited by NF-κB pathway inhibitor shikonin, and the effects of p65 nuclear translocation inhibition and MMP-9 down-regulation by PSPH knockdown were reversed by NF-κB pathway agonist TNF-α (all P<0.05).Conclusion PSPH expression is increased in HCC and high PSPH expression can strengthen the proliferation and metastasis abilities of HCC cells. The action mechanism may be probably associated with its suppressing autophagy and activating NF-κB/MMP-9 signaling pathway.

Abstract:Background and Aims After hepatocellular carcinoma, intrahepatic cholangiocarcinoma (ICC) is the second most common malignant tumor of the liver, with an insidious onset, high malignant level, and a unfavorable prognosis. Although aberrant circRNA expression is linked to the onset and progression of several malignant tumors, the association between circRNA and ICC is rarely investigated. As a result, this study was conducted as a preliminary test to examine circRNA's differential expression in ICC and its biological function.Methods By using high-throughput circRNA chip technology, five specimens of ICC patients confirmed by pathology in Fujian Provincial Hospital were used to screen out differentially expressed circRNA in ICC and corresponding adjacent tissues, and the circRNA with the most obvious change was selected from 500-1500 bp in length and verified by qRT-PCR. The circRNA was then overexpressed in HCCC-9810 and RBE cell lines using lentivirus, and the impact of the circRNA on the biological function of ICC cells was investigated using CCK-8, scratch, Transwell, and flow cytometry.Results Compared with normal tissues adjacent to cancer, there are 76 differentially expressed circRNAs in ICC, including 63 upregulated and 13 downregulated circRNAs. The downregulated hsa_circ_0089153 had a highest fold-change (FC=103.214). The results of qRT-PCR were consistent with those of gene chip. After hsa_circ_0089153 overexpression, the proliferation activity of ICC cells significantly increased [HCCC-9810: over-expression group (114.816±5.138) vs. no-load group (100.000±4.897), RBE: over-expression group (117.235±7.079) vs. no-load group (100.000±14.896) (all P<0.05)]. The apoptosis rate significantly decreased [HCCC-9810: over-expression group (11.277±0.243) vs. no-load group (16.673±0.660) (all P<0.05)]. The migrated and invasive ability significantly increased [HCCC-9810: over-expression group (9.070±1.090) vs. no-load group (6.206±1.197), RBE: over-expression group (6.197±0.687) vs. no-load group (4.198±1.170) (all P<0.05) and HCCC-9810: over-expression group (0.370±0.026) vs. no-load group (0.274±0.014), RBE: over-expression group(0.297±0.016) vs. no-load group (0.250±0.019) (all P<0.05)].Conclusion There are a number of aberrantly expressed circRNAs in ICC, among which hsa_circ_0089153 has a noteworthy low expression. However, unlike most circumstances, overexpression of hsa_circ_0089153 can promote the malignant biological behavior of ICC cells. So, the biological role of hsa_circ_0089153 in ICC and the associated regulatory network still need to be further clarified.

Abstract:Background and Aims Endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stent placement is a minimally invasive interventional therapy with demonstrable efficacy for patients with malignant obstructive jaundice (MOJ) who have no chance of radical surgery. However, the risk factors affecting the early bilirubin lowering effect are still unclear yet. Therefore, this study was conducted to analyze the risk factors affecting the therapeutic effect, so as to provide guidance for clinical intervention.Methods The clinical data of MOJ patients with no chance of radical surgery undergoing ERCP-guided biliary stent placement from January 2014 to January 2021 in Department of Hepatobiliary Surgery, Affiliated Hospital of Zunyi Medical University were retrospectively collected. The bilirubin lowering effects on 4-7 d and 1 month after operation were observed. The risk factors affecting the bilirubin lowering effect were determined by univariate analysis and multivariate Logistic regression analysis.Results A total of 171 patients undergoing successful ERCP-guided biliary stent placement were enrolled. Of the 171 patients, the total bilirubin (TBIL) level decreased more than 30% compared with the preoperative value in 100 cases (significant efficacy), and the degree of TBIL decrease did not reach above standard in 61 patients (unsatisfactory efficacy), and the total effective rate was 64.3% (110/171). Among the 63 patients with complete postoperative 1 month follow-up data, the TBIL level returned to normal in 31 cases and did not return to normal in 32 cases, and the total recovery rate was 49.2%. High-grade obstruction (OR=9.223, P<0.01) and preoperative Child-Pugh class C (OR=2.864, P<0.01) were independent risk factors for bilirubin lowering effect on 4-7 d after operation. High-grade obstruction (OR=13.813, P<0.05) and plastic stent implantation (OR=76.981, P<0.01) were independent risk factors for bilirubin lowering effect on 1 month after surgery.Conclusion ERCP-guided biliary stent implantation is an effective way to reduce jaundice in MOJ patients losing the chance of radical surgery. For patients with risk factors affecting bilirubin lowering, the relevant intervention should be undertaken as much as possible and physician-patient communication should be reinforced. As for the stent selection, comprehensive consideration involving many factors is recommended.

Abstract:Background and Aims Distal cholangiocarcinoma (DCC) is characterized by insidious onset, high degree of malignancy, and difficult early diagnosis. Most patients have progressed to the middle or late stage at the time of diagnosis, with no chance for radical treatment. So, identifying reliable serum markers of DCC is of great importance for early diagnosis and treatment benefit assessment. The systemic immune-inflammatory index (SII) calculated by lymphocyte, neutrophil and platelet and counts is a comprehensive inflammatory index, and has been used for prognostic analysis in variety of malignant conditions. However, its application value in DCC patients has not been demonstrated. Therefore, this study was conducted to investigate the prognostic value of SII in DCC patients after pancreatoduodenectomy (PD).Methods The clinical data of 117 DCC patients undergoing PD in Fuxin Mining General Hospital of Liaoning Health Industry Group from January 2010 to June 2016 were retrospectively analyzed. Using the ROC curve approach, the performances of preoperative SII, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) in predicting the 5-year overall survival (OS) of DCC patients were rated, and the optimal cut-off vale of SII to evaluate the prognosis of DCC patients was determined. The relations of SII with the clinicopathologic characteristics of the patients were analyzed, and the risk factors for postoperative survival of the patients were determined by univariate and multivariate analyses.Results The prediction efficiency of preoperative SII (AUC=0.649) was higher than that either of PLR (AUC=0.595) or NLR (AUC=0.552), and its cut-off value was 975. In high SII group (SII>975), the proportions of patients with preoperative cholangitis, high levels of CEA and CA19-9 and large intraoperative blood loss were higher than those in the low SII group (SII≤975), with statistical significance (all P<0.05), while there were no significant differences in recurrence rate, recurrence site and other clinicopathologic variables between the two groups (all P>0.05). The median survival time for the entire group was 49 (19-104) months. Univariate analysis showed that preoperative CA19-9 level, vascular invasion, lymph node metastasis, T stage, portal vein reconstruction, degree of radical resection, and preoperative SII were significantly associated with the postoperative 5-year OS of DCC patients (all P<0.05). Multivariate analysis revealed that the presence of lymph node metastasis (HR=2.406, 95% CI=1.437-4.026, P=0.001), portal vein reconstruction (HR=1.549, 95% CI=1.075-2.365, P=0.043), and SII>975 (HR=1.793, 95% CI=1.205-2.668, P=0.015) were independent risk factors for postoperative 5-year OS of DCC patients.Conclusion Preoperative SII is an effective indicator for predicting the postoperative prognosis in DCC patients. DCC patients with SII>975 may face a poor postoperative prognosis, and for them the follow-up should be strengthened and other treatment measures should be considered.

Abstract:Background and Aims Primary neuroendocrine carcinoma of the gallbladder (GB-NEC) is extremely rare and its prognosis is generally poor. There are few studies systematically summarizing its clinical characteristics now due to the scarce cases of GB-NEC. Therefore, this study was performed to summarize and analyze the GB-NEC cases treated in the Xinghua People's Hospital, Yangzhou University and the reported cases of GB-NEC in literature in recent 20 years in order to increase the awareness of this disease.Methods The clinical data of 3 patients with GB-NEC treated in the authors' hospital were reviewed, and the relevant data of 121 reported cases of GB-NEC in literature from January 2000 to December 2020 were extracted. The general clinical feature, prognostic factors and treatment outcomes of patients were analyzed.Results The 3 GB-NEC patients were all hospitalized for non-specific symptoms including abdominal pain and underwent surgical treatment. Their specimens were confirmed as GB-NEC (including one case of accidental gallbladder cancer) by postoperative pathological and immunohistochemical examinations. All the 3 patients received postoperative adjuvant chemotherapy, and 2 cases died and one case was still alive during a short- or medium-term period of follow-up. Of the total 124 patients with GB-NEC, the median age was 58 years, female cases accounted for 62.9% (78/124), 72.1% (44/61) were small cell carcinoma and 32.5% (29/84) were mixed neuroendocrine carcinoma. The median survival time was 11 months in the whole group of patients, and was decreased as the clinical stage advanced in different clinical stage groups. Analysis of the variables of 49 patients with complete data showed that age >80 years (HR=1.364, 95% CI=1.026-1.860, P=0.049), TNM stage (stage II vs. stage I: HR=10.408, 95% CI=2.554-42.404, P=0.001; stage III vs. stage I: HR=13.167, 95% CI=3.288-52.732, P<0.001; stage IV vs. stage I: HR=38.022, 95% CI=9.738-148.459, P<0.001), surgery (non-radical surgery vs. non-surgery: HR=0.122, 95% CI=0.022-0.786, P=0.027; radical surgery vs. non-surgery: HR=0.088, 95% CI=0.019-0.481, P=0.006) and receiving chemotherapy or not (HR=0.517, 95% CI=0.305-0.983, P=0.042) were independent factors affecting survival outcomes. The increase of carbohydrate antigen 125 (CA125) level was associated with higher clinical stage (r=0.727, P<0.05). In subgroup analysis, the surgical procedure (cholecystectomy vs. radical surgery: HR=2.889, 95% CI=0.908-9.168, P=0.072) and receiving chemotherapy or not (HR=3.120, 95% CI=0.768-12.676, P=0.112) exerted no significant influence on the outcomes in stage I and II patients. The surgical procedure (cholecystectomy plus metastasis resection vs. radical surgery: HR=0.675, 95% CI=0.113-4.023, P=0.667) and receiving chemotherapy or not (HR=2.109, 95% CI=0.808-5.994, P=0.127) had no significant effect on the outcome in stage III patients. Chemotherapy offered a survival advantage in stage IV patients (HR=2.785, 95% CI=1.376-5.636, P=0.004), which was mainly reflected in patients with small cell carcinoma (median survival time: 9 months vs. 3 months, P<0.001), while was not significant in patients with large cell carcinoma (median survival time: 5 months vs. 2 months, P=0.247); Surgery did not improve the prognosis of stage IV patients (radical surgery vs. non-surgery: HR=0.533, 95% CI=0.232-1.233, P=0.138; non-radical surgery vs. non-surgery: HR=0.932, 95% CI=0.434-2.000, P=0.856).Conclusion Improving the early diagnosis efficiency is important for the prognosis of patients with GB-NEC. For staged IIII patients, surgical resection can be performed, but radical cholecystectomy is unnecessary; chemotherapy can help improve the survival rate and increase the chance of surgical resection in patients with advanced small cell carcinoma. CA125 may be used as a prognostic indicator for GB-NEC, but it still needs more studies to be proven.

Abstract:Background and Aims Liver transplantation has been proposed as an alternative treatment for patients with unresectable hilar cholangiocarcinoma (hCCA), but it is still controversial in some aspects. Therefore, this study was conducted to summarize the clinical efficacy of liver transplantation for 6 patients with unresectable hCCA, so as to provide information for clinical decision-making.Methods The clinicopathologic data and survival status of 6 hCCA patients who underwent liver transplantation and regular follow-up in Shanghai Jiaotong University School of Medicine affiliated Ruijin Hospital from January 2015 to March 2021 were retrospectively analyzed.Results All the 6 patients underwent the standard orthotopic whole liver transplantation. The postoperative pathology showed mass-forming type lesion in 2 cases, infiltrating type lesion in 2 cases and endophytic type lesion in 2 cases; the diameter >3 cm in 4 cases; peripheral nerve invasion in 2 cases, portal vein invasion in 3 cases and intrahepatic metastasis in 2 cases; adenosquamous carcinoma in 1 case and adenocarcinoma in 5 cases; G2-moderately differentiated histological grade in 3 cases and G3-poor differentiated histological grade in 3 cases; pTMN stage II in 1 case, stage IIIa in 1 cases, stage IIIc in 2 cases and stage IV in 1 case. During follow-up, 3 cases were alive, of whom, long-term tumor-free survival was achieved in 2 cases with endophytic and polypoid type adenocarcinoma and decompensated cirrhosis, and 1 case with mass-forming type adenocarcinoma undergoing preoperative neoadjuvant chemoradiotherapy survived with disease free for 20 months by far; 3 cases were dead, of whom 1 case with mass-forming type adenosquamous cholangiocarcinoma survived for 18 months after operation, and 2 cases with biliary tract infiltration survived for 2 months and 24 months, respectively. Preoperative biliary drainage and combination of immunosuppressor and chemotherapy after surgery exerted no obvious effect on the survival of the patients.Conclusion In hCCA patients, liver transplantation may offer better results to those with endophytic and polypoid type adenocarcinoma and decompensated liver cirrhosis as well as exclusion of lymph node metastasis, even no preoperative neoadjuvant chemoradiotherapy is given, but yield dismal results in those with lymph node metastasis and peripheral infiltration.

Abstract:Background and Aims Hepatoid adenocarcinoma of the stomach (HAS) is a special and rare type of gastric cancer, and there are very few studies on HAS with enough sample size. This study collected the relevant literature reports and analyzed the current status of HAS in China in recent years through a Meta-analysis of clinical data.Methods Chinese and English electronic journal databases were searched, including Wanfang Journal Full-text Database, China Biomedical Literature Database (CBM), Chinese Science and Technology Journal Database (VIP), PubMed Database. The clinical data of HAS in China were screened and extracted, and survival analysis were performed.Results A total of 294 cases of HAS reported in the literature from January 2014 to January 2021 were included in the regional analysis, and it was found that 86.4% of the reported cases were distributed in Beijing and some of the coastal areas. Among the 95 cases with complete data, 77 were males (81.1%) and 18 were females (18.9%), with an age span of 40-79 years. There were 70 patients (73.7%) with elevated serum AFP, of whom 47 cases (49.5%) had serum AFP>500 ng/mL. At the time of diagnosis, the TNM stages in 74 case were classified as stage III or IV, and 30 (31.6%) of them had liver metastases. The median survival time was only 11 months, and the 3-year cumulative survival rate was 12.4%. Women relative to men (HR=2.472, 95% CI=1.247-4.904, P=0.010), AFP>500 ng/mL (HR=1.987, 95% CI=1.073-3.677, P=0.029), palliative surgery or no versus radical surgery (HR=0.223, 95% CI=0.099-0.500, P<0.001) were independent risk factors for the prognosis of HAS.Conclusion HAS cases in China are mainly reported in Beijing and some of the coastal areas, and are rare in inland regieons. HAS is more common in middle aged and elderly men, but the prognosis in women is worse. Serum AFP>500 ng/mL is an independent risk factor for HAS. HAS is often diagnosed at an advanced stage, liver metastases are common and the overall prognosis is poor, but aggressive radical surgery may yield survival benefits.

Abstract:Gallbladder neuroendocrine carcinoma (GB-NEC) is a rare clinical entity. In recent years, some advances have been made in terms of preoperative imaging diagnosis, survival prediction and treatment of GB-NEC. In clinical practice, the different patients' conditions and the efficacy of different treatment schemes should be taken into account to provide the most appropriate individualized treatment plan. Here, the authors review the clinical and basic research of GB-NEC in recent years, and summarize the pathogenesis, pathological classification, diagnosis, treatment progress and prognosis of GB-NEC based on the literature of case report of GB-NEC and other relevant data.

Abstract:Endoscopic retrograde cholangiopancreatography with stent implantation have gradually become the standard palliative care for patients with distal malignant biliary obstruction. Nevertheless, the function of the sphincter of Oddi is eliminated and the normal anatomical structure of the biliary tract is changed with the placement of stents of various materials. As a result, the duodenal contents will likely flow back into the bile duct, leading to a significantly increased probability of cholangitis in patients and seriously affecting the patients' quality of life. In order to reduce the occurrence of associated adverse events such as bile duct reflux, anti-reflux stents have appeared. Most of them are designed by adding an anti-reflux valve at the end of the stent to function as an anti-reflux barrier. They can be categorized into anti-reflux plastic stents and anti-reflux metal stents according to the material, and also can be named by the shape of the anti-reflux valve such as the windsock anti-reflux stents, funnel anti-reflux stents and duckbill anti-reflux stents. A number of clinical studies demonstrated that most anti-reflux stents can not only reduce the occurrence of cholangitis, but also prolong the average patency time of the stent, with favorable clinical results. However, due to differences in the material and design of different types of stents, problems such as stent clogging and stent displacement still require to be further resolved. Here, the authors address the research progress and clinical application of anti-reflux biliary stents with different materials and structures by review of the relevant literature.

Abstract:Portal vein thrombosis (PVT) refers to thrombosis that occurs in the portal vein system and (or) its branches. Acute PVT after hepatectomy refers to the thrombotic state that occurs within 30 d after operation, or before the formation of collateral circulation of the portal vein. If there is no timely intervention, the thrombus will spread along the portal vein system, resulting in a sharp decrease in hepatic blood flow, high risk of serious complications such as liver failure and high mortality. There are great differences in the incidence and mortality rates for PVT after hepatectomy in domestic and foreign literature. The incidence reported in domestic literature is low, but the mortality is high. Acute PVT after hepatectomy have complex etiologies, and there are many risk factors, including non-operative factors (liver cirrhosis, hepatocellular carcinoma, advanced age) and surgical factors ( frequent and prolonged inflow occlusion, combination with portal vein reconstruction, right trisectionectomy or right hemihepatectomy, major hepatectomy, caudate lobectomy, synchronous splenectomy, long operative time, bile leakage, extrahepatic bile duct resection, etc.). The clinical manifestation of the patients is unspecific, and some patients do not have any symptoms and signs, which leads to the difficulty of early diagnosis. The obvious changes of D-dimer as well as the sudden and sharp deterioration of liver function indexes during their improvements after hepatectomy have diagnostic significance, but PVT after hepatectomy is mainly diagnosed by imaging examination, and abdominal enhanced CT have high sensitivity and specificity. At present, there is no clear prophylaxis and treatment guidelines.For patients with risk factors for thrombosis, the blood determination of thrombin-antithrombin III complex, D-dimer, antithrombin Ⅲ and soluble form of glycoprotein VI has a certain value in predicting postoperative PVT. For patients with risk factors for PVT, it is recommended that enhanced CT should be performed routinely to screen PVT. The treatment methods include anticoagulation, thrombolysis and thrombectomy, and individualized treatment should be selected through accurate evaluation of patients. There are no clear prevention and treatment guidelines for PVT after hepatectomy. Early detection and early treatment are the keys to improve the prognosis of patients. By searching the literature concerning PVT after hepatectomy at home and abroad, the authors summarize the latest research results on risk factors, clinical manifestations, diagnosis, treatment and prophylaxis of PVT after hepatectomy.