Hepatobiliary Pancreat Dis Int

	2018 Vol. 17 No. 1
	Published: 2018-02-15


	pages 9-92
	META-ANALYSIS REVIEW ARTICLES ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas LETTERS TO THE EDITOR

META-ANALYSIS

	9	Cao Q, Yu CB, Yang SG, Cao HC, Chen P, Deng M, Li LJ
		Effect of probiotic treatment on cirrhotic patients with minimal hepatic encephalopathy: A meta-analysis
		Background: Minimal hepatic encephalopathy (MHE) is an early and reversible form of hepatic encephalopathy. The documentations on the treatment with probiotics are inconsistent. The present meta-analysis was to verify the role of probiotics in the treatment of cirrhotic patients with MHE. Data sources: Seven electronic databases were searched for relevant randomized controlled trials (RCTs) published until July 2015. The effects of probiotics on serum ammonia, endotoxin, and MHE were evaluated. Results: A total of 14 RCTs (combined n=1132) were included in the meta-analysis. When probiotics were compared to placebo or no treatment, probiotics were more likely to reduce values in the number connection test (NCT; week 4: MD=−30.25, 95% CI: −49.85 to −10.66), improve MHE (week 4: OR=0.18, 95% CI: 0.07 to 0.47; week 12: OR=0.15, 95% CI: 0.07 to 0.32), and prevent overt HE progression (week 4: OR=0.22, 95% CI: 0.07 to 0.67) in patients with liver cirrhosis. When probiotics was compared to lactulose, probiotics tended to reduce serum ammonia levels (week 4: MD=−0.33 μmol/L, 95% CI: −5.39 to 4.74; week 8: MD=6.22 μmol/L, 95% CI: −24.04 to 36.48), decrease NCT (week 8: MD=3.93, 95% CI: −0.72 to 8.58), improve MHE (week 4: OR=0.93, 95% CI: 0.45 to 1.91; week 12: OR=0.73, 95% CI: 0.35 to 1.51) and prevent the development of overt HE (week 4: OR=0.96, 95% CI: 0.17 to 5.44; week 12: OR=2.7, 95% CI: 0.50 to 14.64) in patients with liver cirrhosis. However, lactulose appears to be more effective in reducing NCT values as compared to probiotics (week 4: MD=6.7, 95% CI: 0.58 to 12.82). Conclusion: Probiotics can decrease serum ammonia and endotoxin levels, improve MHE, and prevent overt HE development in patients with liver cirrhosis.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 9-16 . [Abstract] ( 172 ) [HTML 1KB] [PDF 0KB] ( 190 )

REVIEW ARTICLES

	17	Pavlidis ET, Pavlidis TE
		Pathophysiological consequences of obstructive jaundice and perioperative management ^Hot!
		Background: Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management. Data sources: A PubMed was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated. Results: The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier, the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production (TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders, nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases. Conclusion: The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 17-21 . [Abstract] ( 174 ) [HTML 1KB] [PDF 0KB] ( 187 )

	22	Xu J, Ji SR, Zhang B, Ni QX, Yu XJ
		Strategies for pancreatic anastomosis after pancreaticoduodenectomy: What really matters? ^Hot!
		Background: The postoperative pancreatic fistula rate remains approximately 10–20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate. Data sources: Studies were identified by searching PubMed for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: “duct-to-mucosa”, "invagination”, "pancreaticojejunostomy”, "pancreaticogastrostomy”, and “pancreaticoduodenectomy”. The search was limited to English publications. Results: Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy. Conclusion: Pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 22-26 . [Abstract] ( 167 ) [HTML 1KB] [PDF 0KB] ( 163 )

ORIGINAL ARTICLES/Transplantation

	27	Zhong CP, Xi ZF, Xia Q
		Clinical analysis of liver transplantation in autoimmune liver diseases ^Hot!
		Background: Autoimmune liver diseases (ALDs) consist of autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), IgG4-associated cholangitis and overlap syndromes. Patients with these diseases may gradually progress to end-stage liver diseases and need liver transplantation. The present study aimed to explore the prognosis of patients with ALDs after liver transplantation. Methods: The clinical data of 80 patients with ALD (24 cases of AIH, 35 of PBC, 15 of PSC and 6 of AIHPBC overlap syndromes) who underwent liver transplantation in Renji Hospital, Shanghai Jiao Tong University School of Medicine from June 2004 to September 2016 were collected retrospectively. The causes of death were analyzed and the postoperative cumulative survival rate was estimated by the Kaplan–Meier method. Recurrence and other complications were also analyzed. Results: Of the 80 patients, 18 were males and 62 were females. The average age was 50.5 years and the average Model for End-stage Liver Disease (MELD) score was 14.1. After a median follow-up of 19.8 months, 8 patients died. The 1-, 3- and 5-year cumulative survival rates were all 89.0%. Three cases of recurrent ALDs were diagnosed (3.8%) but they were not totally consistent with primary diseases. Biliary tract complication occurred in 10 patients (12.5%). The new onset of tumor was observed in 1 patient (1.3%). De novo HBV/CMV/EBV infection was found in 3, 8 and 3 patients, respectively. Conclusion: Liver transplantation is an effective and safe treatment for end-stage ALD.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 27-31 . [Abstract] ( 171 ) [HTML 1KB] [PDF 0KB] ( 190 )

	32	Li JH, Jia JJ, Shen W, Chen SS, Jiang L, Xie HY, Zhou L, Zheng SS
		Optimized postconditioning algorithm protects liver graft after liver transplantation in rats
		Background: Ischemia reperfusion injury (IRI) causes postoperative complications and influences the outcome of the patients undergoing liver surgery and transplantation. Postconditioning (PostC) is a known manual conditioning to decrease the hepatic IRI. Here we aimed to optimize the applicable PostC protocols and investigate the potential protective mechanism. Methods: Thirty Sprague–Dawley rats were randomly divided into 3 groups: the sham group (n=5), standard orthotopic liver transplantation group (OLT, n=5), PostC group (OLT followed by clamping and re-opening the portal vein for different time intervals, n=20). PostC group was then subdivided into 4 groups according to the different time intervals: (10 s×3, 10 s×6, 30 s×3, 60 s×3, n=5 in each subgroup). Liver function, histopathology, malondialdehyde (MDA), myeloperoxidase (MPO), expressions of p-Akt and endoplasmic reticulum stress (ERS) related genes were evaluated. Results: Compared to the OLT group, the grafts subjected to PostC algorithm (without significant prolonging the total ischemic time) especially with short stimulus and more cycles (10 s×6) showed significant alleviation of morphological damage and graft function. Besides, the production of reactive oxidative agents (MDA) and neutrophil infiltration (MPO) were significantly depressed by PostC algorithm. Most of ERS related genes were down-regulated by PostC (10 s×6), especially ATF4, Casp12, hspa4, ATF6 and ELF2, while p-Akt was up-regulated. Conclusions: PostC algorithm, especially 10 s×6 algorithm, showed to be effective against rat liver graft IRI. These protective effects may be associated with its antioxidant, inhibition of ERS and activation of p-Akt expression of reperfusion injury salvage kinase pathway.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 32-38 . [Abstract] ( 156 ) [HTML 1KB] [PDF 0KB] ( 173 )

ORIGINAL ARTICLES/Liver

	39	Tarchouli M, Elabsi M, Njoumi N, Essarghini M, Echarrab M, Chkoff MR
		Liver trauma: What current management?
		Background: The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years. Methods: The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed. Results: The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group. Conclusions: Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 39-44 . [Abstract] ( 147 ) [HTML 1KB] [PDF 0KB] ( 172 )

	45	Lee SW, Lee TY, Yang SS, Tung CF, Yeh HZ, Chang CS
		Risk factors and metabolic abnormality of patients with non-alcoholic fatty liver disease: Either non-obese or obese Chinese population
		Background: Non-alcoholic fatty liver disease (NAFLD) occurs not only in obese individuals but also in non-obese ones. The aim of this study was to focus on the association between NAFLD and metabolic events in a non-obese or obese Chinese population. Methods: Data collected from subjects registered at Taichung Veterans General Hospital from January to December 2009 were analyzed. The exclusion criteria were alcoholics, chronic hepatitis B or C. Patients included in analyses were assigned to four groups according to sonography of their liver (normal or NAFLD), and body mass index (BMI) levels (non-obese if BMI<25 kg/m2 or obese if BMI≥25 kg/m2). Results: There were 745, 208, 770 and 285 patients enrolled in four groups labeled non-obese normal liver (group A), non-obese NAFLD (group B), obese normal liver (group C) and obese NAFLD (group D), respectively. The highest ratio of metabolic syndrome existed in the group B (26.9%), followed by group A (11.7%), group D (10.9%) and finally the group C (5.2%). The positive association with NAFLD in non-obese individuals was significant in triglyceride (OR=1.01; 95% CI: 1.01–1.02) and glucose (OR=1.02; 95% CI: 1.01–1.03), while the positive association with NAFLD in obese subjects was only significant in triglyceride (OR=1.01; 95% CI: 1.01–1.02). The positive association was most significant in all cases (adjusted OR=2.41; 95% CI: 1.78–3.24), especially in non-obese individuals (OR=2.81; 95% CI: 1.92–4.12). Conclusions: Non-obese NAFLD subjects displayed a higher proportion of metabolic abnormality. Hyperlipidemia and hyperglycemia had the most positive strength association with NAFLD.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 45-48 . [Abstract] ( 128 ) [HTML 1KB] [PDF 0KB] ( 170 )

ORIGINAL ARTICLES/Biliary

	49	Nennstiel S, Tschurtschenthaler I, Neu B, Algul H, Bajbouj M, Schmid RM, von Delius S,Weber A
		Management of occluded self-expanding biliary metal stents in malignant biliary disease
		Background: Occlusion of self-expanding metal stents (SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients. Methods: Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS, management strategies, stent patency, subsequent interventions, survival time and case charges. Results: A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency (88 vs. 143 days, P=0.069), median survival time (95 vs. 192 days, P=0.116), median subsequent intervention rate (53.4% vs. 40.0%, P=0.501) and median case charge (€5145 vs. €3473, P=0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months, significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS (93.3% vs. 57.1%, P=0.037). Conclusions: In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 49-54 . [Abstract] ( 149 ) [HTML 1KB] [PDF 0KB] ( 186 )

	55	Chen M, Wang L, Wang Y, Wei W, Yao YL, Ling TS, Shen YH, Zou XP
		Risk factor analysis of post-ERCP cholangitis: A single-center experience
		Background: Endoscopic retrograde cholangiopancreatography (ERCP) may have complications. Our study aimed to investigate the risk factors and prevention of post-ERCP cholangitis. Methods: We retrospectively analyzed 4234 cases undergone ERCP in the Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2008 to December 2013. Patient-related factors and procedure-related factors were analyzed to find the risk factors of post-ERCP cholangitis. The time point of post-ERCP cholangitis was also analyzed. Univariate and multivariate analyses were performed to define the independent risk factors of post-ERCP cholangitis. Results: The success rate of ERCP was 96.8% (4099/4234). The overall complication rate was 9.4% (399/4234). Post-ERCP cholangitis occurred in 102 cases (2.4%, 102/4234). The most dangerous time of post-ERCP cholangitis was from 24 h–48 h after ERCP (45.1%, 46/102). Univariate analysis revealed that age, hypertension, diabetes, previous ERCP history, biliary stent insertion, pancreatography, endoscopic sphincterotomy, balloon dilation and hilar obstruction were risk factors of post-ERCP cholangitis (P<0.05). Multivariate analysis indicated that age, previous ERCP history and hilar obstruction were independent risk factors (P<0.05). While endoscopic stone extraction was the potential protective factor. Conclusions: Many risk factors are involved in post-ERCP cholangitis. Among them, old age, previous ERCP history and hilar obstruction were independently related to this post-ERCP complication.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 55-58 . [Abstract] ( 142 ) [HTML 1KB] [PDF 0KB] ( 194 )

ORIGINAL ARTICLES/Pancreas

	59	El Nakeeb A, ElGawalby A, Ali MA, Shehta A, Hamed H, El Refea M, Moneer A, Abd El Rafee A
		Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial
		Background: The efficacy of octreotide to prevent postoperative pancreatic fistula (POPF) of pancreaticoduodenectomy (PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD. Methods: This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct <3 mm were randomized to 2 groups. Group I did not receive postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF. Results: A total of 104 patients were included in the study and were divided into two randomized groups. There were no significant difference in overall complications and its severity. POPF occurred in 11 patients (21.2%) in group I and 10 (19.2%) in group II, without statistical significance (P=0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage (P=0.083), delayed gastric emptying (P=0.472), and early postoperative mortality (P=0.727). Conclusions: Octreotide did not reduce postoperative morbidities, reoperation and mortality rate. Also, it did not affect the incidence of POPF and its clinically relevant variants.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 59-63 . [Abstract] ( 152 ) [HTML 1KB] [PDF 0KB] ( 191 )

	64	Abdel-Rahman O
		Evaluation of the 8th AJCC staging system for pathologically versus clinically staged pancreatic adenocarcinoma: A time to revisit a dogma? ^Hot!
		Background: The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic exocrine adenocarcinoma has been released. The current study seeks to assess the 7th and 8th editions among patients registered within the surveillance, epidemiology and end results (SEER) database. Methods: SEER database (2010–2013) has been accessed through SEER∗Stat program and AJCC 8th edition stages were reconstructed utilizing the collaborative stage descriptions. Kaplan–Meier analysis of overall survival and pancreatic cancer-specific survival analyses (according to both 7th and 8th editions and according to whether pathological or clinical staging were conducted) has been performed. Multivariate analysis of factors affecting pancreatic cancer-specific survival was also conducted through a Cox proportional hazard model. Results: A total of 18 948 patients with pancreatic adenocarcinoma were identified in the period from 2010–2013. Pancreatic cancer-specific survival among pathologically staged patients and according to the 8th edition showed significant differences for all pair wise comparisons among different stages (P<0.0001) except for the comparison between stage IA and stage IB (P=0.307) and the comparison between stage IB and stage IIA (P=0.116). Moreover, P value for stage IA vs IIA was 0.014; while pancreatic cancer-specific survival according to the 7th edition among pathologically staged patients showed significant differences for all pair wise comparisons among different stages (P<0.0001) except for the comparison between IA and IB (P=0.072), the comparison between stage IIA and stage IIB (P=0.065), the comparison between stage IIA and stage III (P=0.059) and the comparison between IIB and III (P=0.595). Among clinically staged patients (i.e. those who did not undergo initial radical surgery), the prognostic performance of both 7th and 8th stages for both overall survival and pancreatic cancer-specific survival was limited. Conclusion: There is clearly a need to have two staging systems for pancreatic adenocarcinoma: pathological and clinical staging systems.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 64-69 . [Abstract] ( 164 ) [HTML 1KB] [PDF 0KB] ( 221 )

	70	Crino SF, Conti Bellocchi MC, Bernardoni L, Manfrin E, Parisi A, Amodio A, De Pretis N, Frulloni L, Gabbrielli A
		Diagnostic yield of EUS-FNA of small (≤15mm) solid pancreatic lesions using a 25-gauge needle
		Background: Early detection of small solid pancreatic lesions is increasingly common. To date, few and contradictory data have been published about the relationship between lesion size and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) diagnostic yield. The aim of this study was to assess the relation between the size of solid pancreatic lesions and the diagnostic yield of EUS-FNA using a 25-gauge needle in a center without available rapid on-site evaluation. Methods: In the retrospective cohort study, we selected patients who underwent EUS-FNA for solid pancreatic lesions with a 25-gauge needle from October 2014 to October 2015. Patients were divided into three groups (≤15mm, 16–25mm and >25 mm), and the outcomes were compared. Results: We analyzed 163 patients. Overall adequacy, sensitivity, specificity and accuracy were 85.2%, 81.8%, 93.7%, and 80.4%, respectively. When stratified by size, the sensitivity and accuracy correlated with size (P=0.016 and P=0.042, respectively). Multivariate analysis showed that lesion size was the only independent factor (P=0.019, OR=4.76) affecting accuracy. The role of size as an independent factor affecting accuracy was confirmed in a separate multivariate analysis, where size was included in the model as a covariate (P=0.018, OR=1.08). Conclusion: Our study demonstrates that, in the absence of rapid on-site evaluation, mass size affects the accuracy of EUS-FNA of solid pancreatic lesions.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 70-74 . [Abstract] ( 126 ) [HTML 1KB] [PDF 0KB] ( 187 )

	75	Asaoka T, Miyamoto A, Maeda S, Hama N, Tsujie M, Ikeda M, Sekimoto M, Nakamori S
		CA19-9 level determines therapeutic modality in pancreatic cancer patients with para-aortic lymph node metastasis
		Background: In general, para-aortic lymph node (LN16) metastasis has been considered as a contraindication for pancreatic resection. However, some pancreatic cancer patients with LN16 metastasis have been reported to survive for longer than expected after pancreatectomy. The purpose of this study was to determine whether pancreatic cancer patients with LN16 metastasis might benefit from surgery. Methods: We retrospectively reviewed 201 consecutive patients with invasive pancreatic ductal adenocarcinoma who underwent surgery at Osaka National Hospital between April 2003 and December 2012. These patients included 22 patients with LN16 metastasis who underwent an extended lymphadenectomy and 25 patients who underwent a palliative surgical biliary and gastric bypass. The clinicopathological data and outcomes were evaluated using univariate and multivariate analyses. Results: The overall survival of the patients with LN16 metastasis was poorer than that of the LN16-negative patients (P=0.0014). An overall survival analysis of the LN16-positive patients stratified according to the preoperative CA19-9 level showed a significant difference between patients with a low preoperative CA19-9 level (≤360 U/mL) and those with a high preoperative CA19-9 level (>360 U/mL) (P=0.0301). No significant difference in overall survival of patients was observed between those with LN16 positivity and those who underwent bypass surgery. However, the overall survival of the LN16-positive patients with a CA19-9 level ≤360 U/mL (n=11) was significantly higher than that of those who underwent bypass surgery (P=0.0452). Conclusion: Surgical resection and extended lymphadenectomy remains an option for pancreatic cancer patients with LN16-positivity whose CA19-9 level is ≤360 U/mL.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 75-80 . [Abstract] ( 131 ) [HTML 1KB] [PDF 0KB] ( 221 )

	81	Lee SH, Hong TH
		Pancreatic parenchymal injection of ethanol and octreotide to induce focal pancreatic fibrosis in rats: Strategies to eliminate postoperative pancreatic fistula
		Background: Postoperative pancreatic fistula (POPF) is more likely to occur in a soft pancreas compared to a hard pancreas in which fibrosis has progressed. There is almost no leakage at the anastomosis site or cut surface of a hard pancreas. The aim of this study was to induce localized fibrosis at the cut surface of the pancreas in a rat model. Methods: Thirty-six rats were divided into three groups (group S: normal saline group; group E: ethanol group; and group O: octreotide group). Each rat was directly injected with a particular compound at the duodenal lobe of the pancreatic parenchyma. Each group was divided into three subgroups according to the time of post-injection sacrifice (1, 2, or 4 weeks). The hardness, suture holding capacity (SHC), and histological fibrosis grade of each pancreas were measured. Results: The hardness, SHC, and fibrosis grade of groups E and O were increased at week 1, with greater increases in group E (all P<0.001). In a subgroup comparison, the hardness, SHC, and fibrosis grade of group E tended to decrease gradually over time, with no regular pattern evident in group O. A comparison between the injected site (duodenal lobe) and non-injected site (splenic lobe) of the pancreas revealed increases in the three parameters of group E only in the duodenal lobe, with increases in group O at both the duodenal and splenic lobes. Conclusions: Parenchymal injection of ethanol and octreotide increased pancreatic fibrosis. Unlike octreotide, ethanol provoked localized fibrosis that was maintained over time. It is expected that ethanol injection could eliminate POPF during pancreatic surgery.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 81-85 . [Abstract] ( 143 ) [HTML 1KB] [PDF 0KB] ( 200 )

LETTERS TO THE EDITOR

	86	Cheung CY, Chok KSH, Lee OJ, Lo KS, Chan SC, Lo CM
		Asia’s first combined liver transplant and aortic valve replacement
		To the editor: Liver transplantation is the only cure for patients with endstage liver disease. It is however an ultra-major surgery which is physiologically challenging to the cardiopulmonary function of the patients. Hence, in patients who also have valvular heart disease or coronary artery disease, liver transplantation would be considered to be contraindicated unless their cardiac problems could be corrected. On the other hand, coagulopathy and the risk of postoperative liver decompensation associated with end-stage liver disease would render the patients unsuitable for corrective valve repair or coronary artery bypass graft surgery. In the literature, there are only a small number of cases of combined liver transplantation and cardiac surgery.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 86-87 . [Abstract] ( 149 ) [HTML 1KB] [PDF 0KB] ( 195 )

	88	Felli E, Meniconi RL, Colasanti M, Vennarecci G, Ettorre GM
		Complete resection of the hepatic veins: The role of right inferior vein
		To the editor: In the recent years liver surgery has been dramatically improved because of technical and technological innovations, perioperative and intraoperative intensive care, better knowledge of liver physiology and early recognition and treatment of postoperative complications. Last but not least, liver anatomy, though not so recent in its topographic organ description, is still a cornerstone of surgical strategy today [1,2]. It is important to consider the future liver remnant volume, blood inflow and outflow before the major liver resection. Insufficient drainage of vascularized liver parenchyma may lead to postoperative liver congestion, transection surface bleeding and hepatic failure. Hepatic veins drain the majority of liver outflow, with the exception of the spigelian veins and the accessory right veins, which are variables in number and caliber, that drain directly into the inferior vena cava. An accessory right inferior vein can be of great importance in case of large bilobar primary or secondary liver tumors to achieve R0 resection and adequate venous drainage. The incidence of an inferior right hepatic vein is reported in 9%−28% of patients according to anatomical studies [3], with variable dimension and hemodynamic importance. Baer et al. [4] reported in 1991 the first case of subtotal hepatectomy with resection of the three hepatic veins in a patient with an accessory right inferior vein. In the preoperative evaluation of hepatic surgery, adequate future liver remnant has to be considered, together with adequate arterial and portal inflow, venous outflow and biliary drainage. For large bilobar tumors involving the three hepatic veins, resection is possible if a right accessory inferior hepatic vein is present, or if the hepatic vein can be reconstructed.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 88-90 . [Abstract] ( 147 ) [HTML 1KB] [PDF 0KB] ( 187 )

	91	Athanasiou A, Spartalis E, Hennessy M, Spartalis M, Moris D, Damaskos C, Pikoulis E
		Effects of terlipressin versus splenectomy on liver regeneration after partial hepatectomy in rats: What we know so far?
		To the editor: We read with great interest the article entitled "Comparativestudy of the effects of terlipressin versus splenectomy on liver regeneration after partial hepatectomy in rats" by Ulmer et al. [1].The aim of this study was to analyse the impact of terlipressin versus splenectomy on postoperative liver function and liver regeneration in rats undergoing 70% partial hepatectomy. Ulmer and his colleagues concluded that neither the administration of terlipressin nor splenectomy improved liver regeneration after 70% partial hepatectomy in rats. This is a very interesting research in our understanding regarding the study of postoperative liver failure and liver regeneration after modulation of portal vein pressure. However, there are some questions which demand further consideration.
		Hepatobiliary Pancreat Dis Int. 2018; 17(1): 91-92 . [Abstract] ( 133 ) [HTML 1KB] [PDF 0KB] ( 189 )

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