Hepatobiliary Pancreat Dis Int

	2024 Vol. 23 No. 6
	Published: 2024-12-15


	Pages 441-550
	META-ANALYSIS ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas NEW TECHNIQUES CLINICAL IMAGE LETTERS TO THE EDITOR GUIDELINES

GUIDELINES

	551	Zhou L, Zhu JQ, Kou JT, Xu WL, Lyu SC, Du GS, Yang HW, Wang JF, Hu XP, Yu CZ, Yuan CH, Han DD, Sang CQ, Li B, Gao J, Qi HZ, Wang LM, Lyu L, Liu H, Wu JY, Lang R, He Q, Li XL
		Chinese expert consensus on quantitatively monitoring and assessing immune cell function status and its clinical application (2024 edition) ^Hot!
		The immune system is the cornerstone of human health, with most diseases and health conditions closely related to immune status. Therefore, immune status management is a core health issue. In recent years, significant research breakthroughs in immunosuppressants, immune cell therapy, and immune checkpoint inhibitors have enabled clinical experts and researchers to effectively modulate immune status and regulate immunity more efficient. Key questions in the field of immunology include: How can immune function be visually assessed? What constitutes normal immune cell function status? How can immune cell function status be quantitatively evaluated? How can a standardized system for assessing immune cell function status be established? Currently, there is no consensus on these issues worldwide. On August 28, 2023, the National Natural Science Foundation of China announced the National Major Research Plan: Immune Power Digital Decoding Research. Traditional research models have failed to systematically reveal the generation and evolution of immune power. Therefore, China has begun to focus on clarifying the scientific connotation of immune power from multiple perspectives, comprehensively understanding the operating mechanism of the human immune system under health and disease states, deciphering the immune code with a new research paradigm, and promoting the visualization of immunity, which is not only of great significance in clinical disease treatment, but also served in healthy China development strategy.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 551-558 . [Abstract] ( 47 ) [HTML 1KB] [PDF 0KB] ( 44 )

META-ANALYSIS

	559	Kim MK, Choi JH, Cho IR, Lee SH, Ryu JK, Kim YT, Paik WH
		Survival benefit of adjuvant treatment for ampullary cancer with lymph nodal involvement: A systematic review and meta-analysis
		Background: The efficacy of adjuvant treatment (AT) in ampullary cancer (AmC) remains controversial. This systematic review and meta-analysis aimed to evaluate the role of AT for AmC. Data sources: A comprehensive systematic search was performed in PubMed, EMBASE, Cochrane Library, and Web of Science databases. Studies comparing overall survival (OS) and recurrence-free survival (RFS) of patients who underwent AT or not following AmC resection were included. Results: A total of 3971 patients in 21 studies were analyzed. Overall pooled data showed no significant difference in effect on the OS by AT [hazard ratio (HR) = 0.998, 95% confidence interval (CI): 0.768–1.297]. No significant difference in recurrence between the AT and non-AT (nAT) groups was noted (HR = 1.158, 95% CI: 0.764–1.755). In subgroup analysis, patients who received AT showed favorable outcomes in the OS compared with those who received nAT in nodal-positive AmC (HR = 0.627, 95% CI: 0.451–0.870). Neither AT consisted of adjuvant chemotherapy with radiotherapy (HR = 0.804, 95% CI: 0.563–1.149) nor AT with adjuvant chemotherapy (HR = 0.883, 95% CI: 0.642–1.214) showed any significant effect on the OS. Conclusions: The effect of AT in AmC on survival and recurrence did not show a significant benefit. Furthermore, effectiveness according to AT strategies did not show enhancement in survival. AT had an advantage in survival compared with nAT strategy in nodal-positive AmC. In cases of AmC with positive lymph nodal involvement, AT may be warranted regardless of detailed strategies.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 559-565 . [Abstract] ( 42 ) [HTML 1KB] [PDF 0KB] ( 65 )

ORIGINAL ARTICLES/Transplantation

	566	Guo CX, Li JH, Wang ZX, Li WZ, Zhang J, Xing H, Liu S, Wei T, Li L, Li RD
		Short-term postoperative bacteriobilia or fungibilia in liver transplantation patients with donation after circulatory death allografts associated with a longer hospital stay: A single-center retrospective observational study in China
		Background: Normal bile is sterile. Studies have shown that cholangitis after liver transplantation (LT) was associated with a relatively poor prognosis. It remains unclear whether the bacteriobilia or fungibilia impact the patient outcomes in LT recipients, especially with donation after circulatory death (DCD) allografts, which was correlated with a higher risk of allograft failure. Methods: This retrospective study included 139 LT recipients of DCD grafts from 2019 to 2021. All patients were divided into two groups according to the presence or absence of bacteriobilia or fungibilia. The prevalence and microbial spectrum of postoperative bacteriobilia or fungibilia and its possible association with outcomes, especially hospital stay were analyzed. Results: Totally 135 and 171 organisms were isolated at weeks 1 and 2, respectively. Among all patients included in this analysis, 83 (59.7%) developed bacteriobilia or fungibilia within 2 weeks post-transplantation. The occurrence of bacteriobilia or fungibilia [ β= 7.43, 95% CI (confidence interval): 0.02 to 14.82, P = 0.049], particularly the detection of Pseudomonas ( β= 18.84, 95% CI: 6.51 to 31.07, P = 0.003) within 2 weeks post-transplantation was associated with a longer hospital stay. However, it did not affect the graft and patient survival. Conclusions: The occurrence of bacteriobilia or fungibilia, particularly Pseudomonas within 2 weeks post-transplantation, could influence the recovery of liver function and was associated with prolonged hospital stay but not the graft and patient survival.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 566-572 . [Abstract] ( 36 ) [HTML 1KB] [PDF 0KB] ( 106 )

ORIGINAL ARTICLES/Liver

	573	Kim NH, Kang JH, Kim HJ
		Impact of nonalcoholic fatty liver disease on the risk of gallbladder polyps in lean and non-obese individuals: A cohort study
		Background: The association between non-obese or lean nonalcoholic fatty liver disease (NAFLD) and gallbladder polyps (GBPs) has not yet been evaluated. We aimed to determine whether NAFLD is an independent risk factor for the development of GBPs, even in non-obese and lean individuals. Methods: We analyzed a cohort of 331 208 asymptomatic adults who underwent abdominal ultrasonography (US). The risk of GBP development was evaluated according to the obesity and NAFLD status. Results: The overall prevalence of NAFLD and GBPs ≥5 mm was 28.5% and 2.9%, respectively. The preva- lence of NAFLD among 160 276 lean, 77 676 overweight and 93 256 obese participants was 8.2%, 31.2%, and 61.1%, respectively. Individuals with NAFLD had a significantly higher incidence of GBPs with a size of ≥ 5 mm [adjusted odds ratio (OR) = 1.18; 95% confidence interval (CI): 1.11–1.25]. A higher body mass index and its categories were also significantly associated with an increased risk of GBPs ≥5 mm. More- over, risk of GBPs ≥ 5 mm was significantly increased even in NAFLD individuals who are not obese (lean: adjusted OR = 1.36, 95% CI: 1.19-1.54; overweight: adjusted OR = 1.14, 95% CI: 1.03–1.26, respectively). Conclusions: Non-obese/lean NAFLD is an independent risk factor for GBP development, suggesting that NAFLD may play an important role in the pathogenesis of GBPs regardless of the obesity status. Therefore, a more thorough evaluation for GBPs may be necessary when hepatic steatosis is detected on abdominal US, even in non-obese or lean individuals.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 573-578 . [Abstract] ( 34 ) [HTML 1KB] [PDF 0KB] ( 45 )

	579	Zhou YD, Zhang WY, Xie GH, Ye H, Chu LH, Guo YQ, Lou Y, Fang XM
		Inadvertent perioperative hypothermia and surgical site infections after liver resection ^Hot!
		Background: In the overall surgical population, inadvertent perioperative hypothermia has been associated with an increased incidence of surgical site infection (SSI). However, recent clinical trials did not validate this notion. This study aimed to investigate the potential correlation between inadvertent perioperative hypothermia and SSIs following liver resection. Methods: This retrospective cohort study included all consecutive patients who underwent liver resection between January 2019 and December 2021 at the First Affiliated Hospital, Zhejiang University School of Medicine. Perioperative temperature managements were implemented for all patients included in the analysis. Estimated propensity score matching (PSM) was performed to reduce the baseline imbalances between the normothermia and hypothermia groups. Before and after PSM, univariate analyses were performed to evaluate the correlation between hypothermia and SSI. Multivariate regression analysis was performed to determine whether hypothermia was an independent risk factor for postoperative transfusion and major complications. Subgroup analyses were performed for diabetes mellitus, age > 65 years, and major liver resection. Results: Among 4000 patients, 2206 had hypothermia (55.2%), of which 150 developed SSI (6.8%). PSM yielded 1434 individuals in each group. After PSM, the hypothermia and normothermia groups demonstrated similar incidence rates of SSI (7.0% vs. 6.3%, P = 0.453), postoperative transfusion (13.7% vs. 13.3%, P = 0.743), and major complications (10.1% vs. 9.0%, P = 0.309). Univariate regression analysis revealed no significant effects of hypothermia on the incidence of SSI in the group with the highest hypother- mia exposure [odds ratio (OR) = 1.25, 95% confidence interval (CI): 0.84-1.87, P = 0.266], the group with moderate exposure (OR = 1.00, 95% CI: 0.65-1.53, P = 0.999), or the group with the lowest exposure (OR = 1.11, 95% CI: 0.73-1.65, P = 0.628). The subgroup analysis revealed similar results. Regarding liver function, patients in the hypothermia group demonstrated lower γ-glutamyl transpeptidase (37 vs. 43 U/L, P < 0.001) and alkaline phosphatase (69 vs. 72 U/L, P = 0.016). However, patients in the hypothermia group exhibited prolonged activated partial thromboplastin time (29.2 vs. 28.6 s, P < 0.001). Conclusions: In our study of patients undergoing liver resection, we found no significant association between mild perioperative hypothermia and SSI. It might be due to the perioperative temperature managements, especially active warming measures, which limited the impact of perioperative hypothermia on the occurrence of SSI.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 579-585 . [Abstract] ( 47 ) [HTML 1KB] [PDF 0KB] ( 65 )

ORIGINAL ARTICLES/Biliary

	586	Chan KS, Baey S, Shelat VG, Junnarkar SP
		Are outcomes for emergency index-admission laparoscopic cholecystectomy performed by hepatopancreatobiliary surgeons better compared to non-hepatopancreatobiliary surgeons? A 10-year audit using 1:1 propensity score matching
		Background: Emergency index-admission cholecystectomy (EIC) is recommended for acute cholecystitis in most cases. General surgeons have less exposure in managing “difficult”cholecystectomies. This study aimed to compare the outcomes of EIC between hepatopancreatobiliary (HPB) versus non-HPB surgeons. Methods: This is a 10-year retrospective audit on patients who underwent EIC from December 2011 to March 2022. Patients who underwent open cholecystectomy, had previous cholecystitis, previous endoscopic retrograde cholangiopancreatography or cholecystostomy were excluded. A 1:1 propensity score matching (PSM) was performed to adjust for confounding variables (e.g. age ≥75 years, history of abdominal surgery, presence of dense adhesions). Results: There were 1409 patients (684 HPB cases, 725 non-HPB cases) in the unmatched cohort. Majority (52.3%) of them were males with a mean age of 59.2 ±14.9 years. Among 472 (33.5%) patients with EIC performed ≥72 hours after presentation, 40.1% had dense adhesion. The incidence of any morbidity, open conversion, subtotal cholecystectomy and bile duct injury were 12.4%, 5.0%, 14.6% and 0.1%, respectively. There was one mortality within 30 days from EIC. PSM resulted in 1166 patients (583 per group). Operative time was shorter when EIC was performed by HPB surgeons (115.5 vs. 133.4 min, P < 0.001). The mean length of hospital stay was comparable. EIC performed by HPB surgeons was independently associated with lower open conversion [odds ratio (OR) = 0.24, 95% confidence interval (CI): 0.12–0.49, P < 0.001], lower fundus-first cholecystectomy (OR = 0.58, 95% CI: 0.35–0.95, P = 0.032), but higher subtotal cholecystectomy (OR = 4.19, 95% CI: 2.24–7.84, P < 0.001). Any morbidity, bile duct injury and mortality were comparable between the two groups. Conclusions: EIC performed by HPB surgeons were associated with shorter operative time and reduced risk of open conversion. However, the incidence of subtotal cholecystectomy was higher.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 586-594 . [Abstract] ( 31 ) [HTML 1KB] [PDF 0KB] ( 58 )

	595	Huang YX, Xu C, Zhang CC, Liu GY, Liu XC, Fan HN, Pan B, Li YC
		Vascular reconstruction provides short-term and long-term survival benefits for patients with hilar cholangiocarcinoma: A retrospective, multicenter study ^Hot!
		Background: In patients with hilar cholangiocarcinoma (HCCA), radical resection can be achieved by resection and reconstruction of the vasculature. However, whether vascular reconstruction (VR) improves long-term and short-term prognosis has not been demonstrated comprehensively. Methods: This was a retrospective multicenter study of patients who received surgery for HCCA with or without VR. Variables associated with overall survival (OS) and recurrence-free survival (RFS) were identified based on Cox regression. Kaplan-Meier curves were used to explore the impact of VR. Restricted mean survival time (RMST) was used for comparisons of short-term survival between the groups. Patients’ intraoperative and postoperative characteristics were compared. Results: Totally 447 patients were enrolled. We divided these patients into 3 groups: VR with radi- cal resections ( n = 84); non-VR radical resections ( n = 309) and non-radical resection (we pooled VR- nonradical and non-VR nonradical together, n = 54). Cox regression revealed that carbohydrate antigen 242 (CA242), vascular invasion, lymph node metastasis and poor differentiation were independent risk factors for OS and RFS. There was no significant difference of RMST between the VR and non-VR radical groups within 12 months after surgery (10.18 vs. 10.76 mon, P = 0.179), although the 5-year OS ( P < 0.001) and RFS ( P < 0.001) were worse in the VR radical group. The incidences of most complica- tions were not significantly different, but those of bile leakage ( P < 0.001) and postoperative infection ( P = 0.009) were higher in the VR radical group than in the non-VR radical group. Additionally, the levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) up to 7 days after surgery tended to decrease in all groups. There was no significant difference in the incidence of postoperative liver failure between the VR and non-VR radical groups. Conclusions: Radical resection can be achieved with VR to improve the survival rate without worsening short-term survival compared with resection with non-VR. After adequate assessment of the patient’s general condition, VR can be considered in the resection.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 595-603 . [Abstract] ( 59 ) [HTML 1KB] [PDF 0KB] ( 61 )

	604	Chen J, Liu ZT, Lyu JT, Jiang GP
		Impact of metabolic disorders on gallstone disease and perioperative recovery after laparoscopic cholecystectomy
		Background: Gallstone disease (GSD), nonalcoholic fatty liver disease (NAFLD), metabolic dysfunction-associated fatty liver disease (MAFLD), and metabolic syndrome (MetS) are common medical disorders worldwide. This study aimed to ascertain how NAFLD, MAFLD, MetS, and other factors affect the development of GSD, and how the GSD-associated factors influence patient recovery after laparoscopic cholecystectomy (LC). Methods: We included 200 patients who were diagnosed with GSD and underwent LC between January 2017 and February 2022. A total of 200 subjects without GSD and “non-calculous causes”during the same period were also included as controls. We compared the metabolic disorder differences between GSD patients and controls. Furthermore, we subgrouped patients based on the comorbidities of preoperative NAFLD, MAFLD, and MetS, and compared the impacts of these comorbidities on short-term post-LC functional recovery of the patients. Results: The prevalence of NAFLD and MetS were higher in GSD patients (P < 0.05). Based on multivariate logistic regression analysis, hyperglycemia [odds ratio (OR) = 2.2, 95% confidence interval (CI): 1.4–3.4, P = 0.001] and low high-density lipoprotein cholesterol (HDL-C) level (OR = 1.8, 95% CI: 1.1–3.1, P = 0.048) were linked to GSD. NAFLD and MetS linked to liver enzymes after LC (P < 0.05). MetS also linked to the levels of inflammatory indicators after LC (P < 0.05). The obesity, hyperlipidemia, low HDL-C level, and hyperglycemia linked to liver enzymes after LC (P < 0.05). Hyperlipidemia, low HDL-C level, and hypertension linked to inflammation after LC (P < 0.05). Conclusions: The prevalence of GSD may be linked to NAFLD and MetS. Hyperglycemia and low HDL-C level were independent risk factors of GSD.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 604-612 . [Abstract] ( 35 ) [HTML 1KB] [PDF 0KB] ( 58 )

ORIGINAL ARTICLES/Pancreas

	613	Choi JH, Kim WC, Park JK, Lee JK, Lee KT, Lee KH
		Bleeding after endoscopic papillectomy and its risk factors: A single center experience of 196 cases
		Background: Endoscopic papillectomy (EP) is an effective method to remove an ampulla of Vater (AoV) adenoma with minimal invasiveness. We reviewed the clinical outcomes and prognosis of patients un- dergoing EP, including tumor recurrence and adverse events. Methods: A total of 196 patients who underwent EP from January 2004 to December 2017 were included. Clinical information was collected through electronic medical records, and risk factors to predict post- procedural bleeding were analyzed using a multivariate logistic regression model. Results: A total of 93.9% patients (184/196) underwent complete resection. During the follow-up period, 14.7% patients (27/184) experienced tumor recurrence, and two of seven surgically resected tumors were malignant. A total of 45.4% patients (89/196) experienced adverse events related to EP. Delayed bleeding occurred in 16.3% of the patients (32/196), and they were all successfully treated with endoscopic hemostasis and conservative management. The most frequent site of delayed bleeding was the distal end of the papillary orifice, and 56.3% (18/32) patients of delayed bleeding were classified as having mild severity, the others had moderate severity. Familial adenomatous polyposis (FAP) [odds ratio (OR) = 3.80, 95% confidence interval (CI): 1.01-14.29; P < 0.05] and male sex (OR = 2.82, 95% CI: 1.04-7.63; P = 0.04) showed statistical significance in predicting delayed post-EP bleeding. Conclusions: EP for AoV adenoma was a highly effective and safe procedure. The risk of post-EP delayed bleeding was increased in patients with FAP syndrome and male patients, and post-EP bleeding occurred most commonly in the distal part of the AoV.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 613-619 . [Abstract] ( 48 ) [HTML 1KB] [PDF 0KB] ( 62 )

	620	Chen RH, Cao JY, Feng S, Huang HT, Lin YM, Jiang JY, Yi XW, Ling Q
		Integrated chromosomal instability and tumor microbiome re define d prognosis-related subtypes of pancreatic cancer ^Hot!
		Background: Pancreatic cancer is a common malignancy with poor prognosis and limited treatment. Here we aimed to investigate the role of host chromosomal instability (CIN) and tumor microbiome in the prognosis of pancreatic cancer patients. Methods: One hundred formalin-fixed paraffin-embedded (FFPE) pancreatic cancer samples were collected. DNA extracted from FFPE samples were analyzed by low-coverage whole-genome sequencing (WGS) via a customized bioinformatics workflow named ultrasensitive chromosomal aneuploidy detector. Results: Samples were tested according to the procedure of ultrasensitive chromosomal aneuploidy detector (UCAD). We excluded 2 samples with failed quality control, 1 patient lost to follow-up and 6 dead in the perioperative period. The final 91 patients were admitted for the following analyses. Thirteen (14.3%) patients with higher CIN score had worse overall survival (OS) than those with lower CIN score. The top 20 microbes in pancreatic cancer samples included 15 species of bacteria and 5 species of viruses. Pa- tients with high human herpesvirus (HHV)-7 and HHV-5 DNA reads exhibited worse OS. Furthermore, we classified 91 patients into 3 subtypes. Patients with higher CIN score ( n = 13) had the worst prog- nosis (median OS 6.9 mon); patients with lower CIN score but with HHV-7/5 DNA load ( n = 24) had worse prognosis (median OS 10.6 mon); while patients with lower CIN score and HHV-7/5 DNA negative ( n = 54) had the best prognosis (median OS 21.1 mon). Conclusions: High CIN and HHV-7/5 DNA load were associated with worse survival of pancreatic cancer. The novel molecular subtypes of pancreatic cancer based on CIN and microbiome had prognostic value.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 620-627 . [Abstract] ( 58 ) [HTML 1KB] [PDF 0KB] ( 48 )

	628	Revskij D, Woitas A, Kolle B, Umstatter C, Zechner D, Khan FM, Fuellen G, Jaster R
		Effects of triggers of senescence and senolysis in murine pancreatic cancer cells ^Hot!
		Background: The combination of senescence triggers with senolytic drugs is considered a promising new approach to cancer therapy. Here, we studied the efficacy of the genotoxic agent etoposide (Eto) and irradiation in inducing senescence of Panc02 pancreatic cancer cells, and the capability of the Bcl-2 inhibitor navitoclax (ABT-263; Nav) to trigger senolysis. Methods: Panc02 cells were treated with Eto or irradiated with 5–20 Gy before exposure to Nav. Cell survival, proliferation, and senescence were assessed by trypan blue staining, quantification of DNA syn- thesis, and staining of senescence-associated β-galactosidase (SA- β-Gal)-positive cells, respectively. Levels of mRNA were determined by real-time polymerase chain reaction, and protein expression was analyzed by immunoblotting. Panc02 cells were also grown as pancreatic tumors in mice, which were subsequently treated with Eto and Nav. Results: Eto and irradiation had an antiproliferative effect on Panc02 cells that was significantly or tendentially enhanced by Nav. In vivo , Eto and Nav together, but not Eto alone, significantly reduced the proportion of proliferating cells. The expression of the senescence marker γH2AX and tumor infiltration with T-cells were not affected by the treatment. In vitro, almost all Eto-exposed cells and a significant proportion of cells irradiated with 20 Gy were SA- β-Gal-positive. Application of Nav reduced the percentage of SA- β-Gal-positive cells after irradiation but not after pretreatment with Eto. In response to triggers of senescence, cultured Panc02 cells showed increased protein levels of γH2AX and the autophagy marker LC3B-II, and higher mRNA levels of Cdkn1a, Mdm2, and PAI-1 , while the effects of Nav were variable. Conclusions: In vitro and in vivo , the combination of senescence triggers with Nav inhibited tumor cell growth more effectively than the triggers alone. Our data also provide some evidence for senolytic effects of Nav in vitro .
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 628-637 . [Abstract] ( 72 ) [HTML 1KB] [PDF 0KB] ( 66 )

NEW TECHNIQUES

	638	Wu WR, Xu LB, Zhang FP, Feng MB, Peng J, Lin HM, Li J, Liu C
		Pure laparoscopic full-size liver transplantation in adult
		Laparoscopic hepatectomy is now a widely accepted surgical technique in hepatobiliary surgery and is comparably safe and efficient to open hepatectomy [ 1 , 2 ]. In liver transplantation, studies have underscored the safety of laparoscopic or robot-assisted procedures in donor hepatectomy [ 3-5 ]. Donors undergoing laparoscopic or robot-assisted hepatectomy experience reduced postoperative complications and shorter recovery periods [ 6-8 ]. Recently, surgeons in Seoul National University Hospital reported several consecutive living donor liver transplantation (LDLT) with pure laparoscope, hybrid laparoscopic with robotic-assistance, and total robot-assistance [ 9-11 ]. Following closely, surgeons in King Faisal Specialist Hospital at Saudi Arabia reported 3 fully robotic donor hepatectomy and robotic recipient liver graft implantation [ 12 ]. However, to the best of our knowledge, the laparoscopic implantation for a full-size liver graft has not been reported.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 638-643 . [Abstract] ( 30 ) [HTML 1KB] [PDF 0KB] ( 51 )

	644	Tang CJ,Li GG, Jiang CL, Peng SY, Liu SL
		A new surgical approach for pseudocyst of dorsal pancreas
		Pancreatic pseudocyst is a common complication of pancreatitis [ 1 ], and most (around 70%) pancreatic cysts are pseudocysts [ 2 ]. In terms of clinical manifestations, pseudocysts are most often asymptomatic. Treatment is not required for asymptomatic pancreatic pseudocysts, because they tend to be absorbed spontanously [ 3 ]. The probability of spontaneous regression of asymptomatic pseudocysts may be improved by a conservative approach involving bowel rest and parenteral nutrition. No drugs are available for the treatment of pancreatic cysts [ 1 ]. For symptomatic or growing pancreatic pseudocysts, surgery is often required [ 4 ]. A common and effective surgical approach is pancreatic pseudocystgastric/ jejunal anastomosis. However, it is very difficult for the treatment of dorsal pancreatic pseudocysts. The deep dorsal location, complex anatomical relationships and large blood vessels prevent the dorsal wall from anastomosing with the gastrointestinal tract. Our center applied T-tube bridging drainage to solve the problem of anastomosis between dorsal pancreatic pseudocyst and jejunum. From October 2021 to October 2023, 15 patients underwent this surgical approach at our center, and achieved favorable therapeutic outcome. Herein we reported one of the cases below.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 644-647 . [Abstract] ( 30 ) [HTML 1KB] [PDF 0KB] ( 61 )

CLINICAL IMAGE

	648	Zhou JF, Chen Z
		A rare case of IgG4-related pancreatitis diagnosed preoperatively by endoscopic ultrasound-guided fine needle aspiration
		Immunoglobulin G4-related disease (IgG4-RD) can affect organs and tissues throughout the body. IgG4-related pancreatitis, also called type 1 autoimmune pancreatitis (AIP), occurs in 60% of patients with IgG4-RD [1] . IgG4-related pancreatitis is a general inflammatory disease infiltrated by immunoglobulin IgG4-positive plasma cells. Typical images exhibit diffuse or partial pancreatic swelling with delayed enhancement and no obvious upstream duct dilation [2] . However, type 1 AIP occasionally appears in atypical clinical images and clinically mimics other pancreatic neoplasms (PN), such as pancreatic cancer (PC), intraductal papillary mucinous neoplasms (IPMN) and neuroendocrine neoplasm. It is very important for physicians or surgeons to distinguish between AIP and PN because the diagnosis greatly influences the selection of therapeutic schedule. AIP frequently responds rather readily to corticosteroid therapy while other PNs may need operations. Although the diagnostic criteria of AIP have been proposed [ 3 , 4 ], it still lacks practical strategies to differentiate between AIP and PN, particularly localized AIP. Confirmative pathological diagnosis is still the gold standard, but open biopsy is relatively invasive. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is less invasive and has a relatively high accuracy rate for distinguishing the essence of PN.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 648-652 . [Abstract] ( 31 ) [HTML 1KB] [PDF 0KB] ( 51 )

LETTERS TO THE EDITOR

	653	Kim SM, Moon DB, Yoon YI, Lee SG
		Borderline resectable giant hepatic cavernous hemangioma and coexisting hemangiomatosis should be a new indication for living donor liver transplantation: A report of two cases
		Hemangioma is a benign liver tumor that rarely requires treatment if the patient is asymptomatic [ 1 ]. However, great cavernous hemangioma (GCH) can lead to symptoms due to its mass effect and Kasabach-Merritt syndrome (KMS) [ 2 ]. GCH treatment options vary; therefore, tailoring treatment to individual patients according to their condition, such as symptoms, tumor location, and liver function, is important. Occasionally, GCH is associated with hemangiomatosis, and its boundaries with normal tissue are unclear [ 3 ], leading to a lack of consensus on the initial therapeutic approach, with literature primarily comprising case reports or series [ 4 ]. This study presented two cases of GCH and coexisting hemangiomatosis; the patients underwent liver resection of the main mass to relieve symptoms but ultimately required liver transplantation (LT). We aimed to describe the role of LT in these patients.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 653-657 . [Abstract] ( 34 ) [HTML 1KB] [PDF 0KB] ( 63 )

	658	Shang ZX, Yu QJ, Luo FZ, Zhuang L, Zheng SS, Yang Z
		Split liver transplantation with complicated portal vein variations in graft
		Liver transplantation (LT) is the most effective method for endstage liver disease. Split liver transplantation (SLT) is an effective method to enlarge the number of liver grafts. However, because of the existence of portal vein variations, right hemi-grafts splitting and recipients’ portal vein (PV) reconstruction might be more challenging [ 1 , 2 ]. According to the origins of intrahepatic PV branches, Nakamura and his coworkers [3] classified PV variants into five classes (Fig. S1): type A to E. It is reported that the standard anatomy in PV branching pattern accounts for only 65% of investigated population, and that the most common anatomic variation of main portal vein (MPV) is trifurcation variation followed by right posterior portal vein (RpPV) as a first branch of MPV [4] . Type C and D variations are the two most technique highly demanding types. The variation of PV in donated liver graft still challenges surgeons, especially in the field of SLT. There is still a lack of a common sense about the modality of complicated variations in PV reconstruction. Here, we presented two complicated SLT cases, existence of type C and D PV variations in grafts, respectively.
		Hepatobiliary Pancreat Dis Int. 2024; 23(6): 658-660 . [Abstract] ( 34 ) [HTML 1KB] [PDF 0KB] ( 62 )

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