Hepatobiliary Pancreat Dis Int

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Hepatobiliary Pancreat Dis Int

	2018 Vol. 17 No. 6
	Published: 2018-12-15


	Pages 483-580
	EDITORIAL META-ANALYSIS ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas LETTERS TO THE EDITOR

EDITORIAL

	483	Jin B,Wang YY, Du SD
		Prediction of neoantigens and their application in cancer treatment
		Tumor antigens can be divided into tumor-associated antigens and tumor-specific antigens according to their specificity. Tumorassociated antigens are not unique to tumor cells, and can also be synthesized in small amounts by normal cells. Tumor-specific antigens, also called neoantigens, are formed by peptides that are entirely absent from the normal human genome [1]. Neoantigens are antigenic epitope peptides of the major histocompatibility complex (MHC) located on the surface of malignant cells. They are derived from unique mutations in tumor cells, such as non-synonymous point mutations, indels, gene fusions, or frame shift mutations. The body mounts an immune response against tumors based on the presence of tumor antigens. Neoantigens are produced by mutations in tumor cells and are tumor-specific; therefore, immunotherapy targeting neoantigens does not undergo central and peripheral immune tolerance and has fewer side effects. Thus, neoantigens have many potential applications in immunotherapy of tumors, especially in hepatobiliary and pancreatic cancer.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 483-484 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 89 )

	485	Chen JJ, Li LJ
		Comments on: Perioperative von Willebrand factor dynamics are associated with liver regeneration and predict outcome after liver resection
		Recently the article “Perioperative von Willebrand factor dynamics are associated with liver regeneration and predict outcome after liver resection” was published in Hepatology [1]. Prof. Starlinger et al. aimed to assess the association of von Willebrand factor (vWF) levels and clinical outcome in patients with liver cancers post-liver resection (LR). Based on the mechanism that platelets accumulation in the liver may promote liver regeneration after partial LR in mice, they found the vWF-dependent pattern of platelets accumulation during liver regeneration in patients after surgery. The vWF-antigen (vWF-Ag) level is increased after surgery in similar patterns in patients with or without basic liver disease. Baseline vWF-Ag is higher in patients with cirrhosis than those without fibrosis. Compared to patients with low vWF-Ag, those with high preoperative vWF-Ag have worse postoperative liver function, need prolonged intensive care unit stay and hospital stay, and have high mortality rate. Another finding is that high preoperative levels of vWF-Ag is a marker of underlying chronic liver disease and/or subclinical portal hypertension because of its high correlation with increasing levels of soluble CD163, another noninvasive marker for portal hypertension.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 485-486 . [Abstract] ( 62 ) [HTML 1KB] [PDF 0KB] ( 75 )

META-ANALYSIS

	487	Xing H, Zheng YJ, Han J, Zhang H, Li ZL, Lau WY, Shen F, Yang T
		Protein induced by vitamin K absence or antagonist-II versus alpha-fetoprotein in the diagnosis of hepatocellular carcinoma: A systematic review with meta-analysis
		Background: As a promising biomarker of hepatocellular carcinoma (HCC), protein induced by vitamin K absence or antagonist-II (PIVKA-II) has been studied extensively. However, its diagnostic capability varies across HCC studies. This study aimed to compare the performance of PIVKA-II with alpha-fetoprotein (AFP) in the diagnosis of HCC. Data sources: A systematic literature search was conducted to identify the studies from MEDLINE, Embase and Cochrane Library Databases, which were published up to December 20, 2017 to compare the diagnostic capability of PIVKA-II and AFP for HCC. The data were pooled using random effects model. Pooled sensitivity and specificity were calculated. Summary receiver operating characteristic curve (ROC) was employed to evaluate the diagnostic accuracy of each marker. Results: Thirty-one studies were included. The pooled sensitivity (95% CI) of PIVKA-II and AFP was 0.66 (0.65-0.68) and 0.66 (0.65-0.67), respectively in diagnosis of HCC; and the corresponding pooled specificity (95% CI) was 0.89 (0.88-0.90) and 0.84 (0.83-0.85), respectively. The area under the ROC curve (AUC) of PIVKA-II and AFP was 0.856 (0.817-0.895) and 0.770 (0.728-0.811), respectively. Subgroup analysis showed that PIVKA-II was superior to AFP in terms of the AUC for both small HCC (< 3 cm) [0.863 (0.825-0.901) vs 0.717 (0.658-0.776)] and large HCC (≥ 3 cm) [0.854 (0.811-0.897) vs 0.729 (0.682-0.776)]; for American [0.926 (0.897-0.955) vs 0.698 (0.594-0.662)], European [0.772 (0.743-0.801) vs 0.628 (0.594-0.662)], Asian [0.838 (0.812-0.864) vs 0.785 (0.764-0.806)] and African [0.812 (0.794-0.840) vs 0.721 (0.675-0.767)] HCC patients; and for HBV-related [0.909 (0.866-0.951) vs 0.714 (0.673-0.755)] and mixed-etiology [0.847 (0.821-0.873) vs 0.794 (0.772-0.816)] HCC. Conclusion: This meta-analysis indicates that PIVKA-II is better than AFP in terms of the accuracy for diagnosing HCC, regardless of tumor size, patient ethnic group, or HCC etiology.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 487-495 . [Abstract] ( 60 ) [HTML 1KB] [PDF 0KB] ( 102 )

ORIGINAL ARTICLES/Transplantation

	496	Sun Y, Jia LL, Yu WL, Yu HL, Sheng MW, Du HY
		The changes of intraoperative body temperature in adult liver transplantation: A retrospective study
		Background: Body temperature is poorly regulated in patients with end-stage liver disease. Due to the prolonged surgery time and anhepatic time as well as the complex surgical procedures performed in liver transplantation, the body temperature fluctuates greatly. This study investigated the effect of intraoperative body temperature fluctuations on the prognosis of liver recipients. Methods: The body temperatures of liver recipients recorded from the induction of anesthesia (T₀) until the end of surgery (T₁₄) were retrieved. The patients were divided into two groups: the hypothermia group (< 35 °C and ≥ 5 min) and the normothermia group (≥ 35 °C or < 35 °C but < 5 min). Intraoperative and postoperative variables were compared between the two groups, and the correlations between the duration of hypothermia and the medical variables were analyzed. Results: Of the 107 patients, 67 patients were in the normothermia group, and 40 in the hypothermia group. The lowest body temperature was at 5 min after reperfusion for the whole cohort. Compared with the normothermia group, patients in the hypothermia group were more prone to bleeding, had a longer intubation time and increased rates of bacterial infection and acute pulmonary edema after liver transplantation (P < 0.05). Hypothermia time was positively correlated with bleeding volume, intubation time, units of blood transfusions and intensive care stay, but negatively correlated with urine output. Conclusions: The intraoperative body temperature exhibited a graphical "V" trend, and the lowest temperature was at 5 min after reperfusion. The longer the duration of hypothermia, the more unfavourable the prognosis.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 496-501 . [Abstract] ( 54 ) [HTML 1KB] [PDF 0KB] ( 83 )

ORIGINAL ARTICLES/Liver

	502	Amisaki M, Uchinaka E, Morimoto M, Tokuyasu N, Sakamoto T, Honjo S, Saito H, Fujiwara Y
		Post-operative albumin-bilirubin grade predicts long-term outcomes among Child-Pugh grade A patients with hepatocellular carcinoma after curative resection ^Hot!
		Background: Although Child-Pugh grade A patients with hepatocellular carcinoma (HCC) are candidates for curative resection, some may have a poor prognosis. The albumin-bilirubin (ALBI) grade, a measure of liver function based on albumin and bilirubin, has the potential to detect Child-Pugh grade A HCC patients with poor prognosis. Because components of the ALBI grade can be measured easily even after surgery, we explored the predictive values of ALBI in patient prognosis after HCC resection. Methods: In this retrospective case-control study, we included 136 HCC patients who underwent curative resection between January 2004 and December 2013 at our hospital. ALBI grade was calculated from laboratory data recorded the day before surgery and at post-operative day 5. Results: Pre- and post-operative ALBI grade predicted patients' long-term outcomes (P = 0.020 and P < 0.001, respectively, for overall survival, and P = 0.012 and P = 0.015, respectively, for recurrence-free survival). Post-operative ALBI grade was associated with patients' surgical factors of repeated hepatic resection (P = 0.012), intra-operative bleeding (P = 0.006), and surgery duration (P = 0.033). Furthermore, post-operative ALBI grade, rather than pre-operative ALBI grade, was an independent predictive factor of long-term outcome of Child-Pugh grade A patients with HCC. Conclusions: Post-operative ALBI grade is useful to predict the prognosis in patients after HCC resection.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 502-509 . [Abstract] ( 67 ) [HTML 1KB] [PDF 0KB] ( 84 )

	510	Guo JG, Zhao LP, Rao YF, Gao YP, Guo XJ, Zhou TY, Feng ZY, Sun JH, Lu XY
		Novel multimodal analgesia regimen improves post-TACE pain in patients with hepatocellular carcinoma
		Backgroud: Transarterial chemoembolization (TACE) is the primary palliative treatment for patients with unresectable hepatocellular carcinoma (HCC). However, it is often accompanied by postoperative pain which hinder patient recovery. This study was to examine whether preemptive parecoxib and sufentanil-based patient controlled analgesia (PCA) could improve the pain management in patients receiving TACE for inoperable HCC. Methods: From June to December 2016, 84 HCC patients undergoing TACE procedure were enrolled. Because of the willingness of the individuals, it is difficult to randomize the patients to different groups. We matched the patients' age, gender and pain scores, and divided the patients into the multimodal group (n = 42) and control group (n = 42). Patients in the multimodal group received 40 mg of parecoxib, 30 min before TACE, followed by 48 h of sufentanil-based PCA. Patients in the control group received a routine analgesic regimen, i.e., 5 mg of dezocine during operation, and 100 mg of tramadol or equivalent intravenous opioid according to patient's complaints and pain intensity. Postoperative pain intensity, percentage of patients as per the pain category, adverse reaction, duration of hospital stay, cost-effectiveness, and patient's satisfaction were all taken into consideration when evaluated. Results: Compared to the control group, the visual analogue scale scores for pain intensity was significantly lower at 2, 4, 6, and 12 h (all P < 0.05) in the multimodal group and a noticeably lower prevalence of post-operative nausea and vomiting in the multimodal group (31.0% vs. 59.5%). Patient's satisfaction in the multimodal group was also significantly higher than that in the control group (95.2% vs. 69.0%). No significant difference was observed in the duration of hospital stay between the two groups. Conclusion: Preemptive parecoxib and sufentanil-based multimodal analgesia regime is a safe, efficient and cost-effective regimen for postoperative pain control in HCC patients undergoing TACE.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 510-516 . [Abstract] ( 72 ) [HTML 1KB] [PDF 0KB] ( 110 )

	517	Li ZP,Wang SS,Wang GC, Huang GJ, Cao JQ, Zhang CQ
		Transjugular intrahepatic portosystemic shunt for the prevention of recurrent esophageal variceal bleeding in patients with cavernous transformation of portal vein
		Background: Treatment options for patients with cavernous transformation of portal vein (CTPV) are limited. This study aimed to evaluate the feasibility, efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) to prevent recurrent esophageal variceal bleeding in patients with CTPV. Methods: We retrospectively analyzed 67 consecutive patients undergone TIPS from January 2011 to December 2016. All patients were diagnosed with CTPV. The indication for TIPS was a previous episode of variceal bleeding. The data on recurrent bleeding, stent patency, hepatic encephalopathy and survival were retrieved and analyzed. Results: TIPS procedure was successfully performed in 56 out of 67 (83.6%) patients with CTPV. TIPS was performed via a transjugular approach alone (n = 15), a combined transjugular/transhepatic approach (n = 33) and a combined transjugular/transsplenic approach (n = 8). Mean portosystemic pressure gradient (PSG) decreased from 28.09 ± 7.28 mmHg to 17.53 ± 6.12 mmHg after TIPS (P < 0.01). The probability of the remaining free recurrent variceal bleeding was 87.0%. The probability of TIPS patency reached 81.5%. Hepatic encephalopathy occurrence was 27.8%, and survival rate was 88.9% until the end of follow-up. Four out of 11 patients who failed TIPS died, and 4 had recurrent bleeding. Conclusions: TIPS should be considered a safe and feasible alternative therapy to prevent recurrent esophageal variceal bleeding in patients with CTPV, and to achieve clinical improvement.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 517-523 . [Abstract] ( 55 ) [HTML 1KB] [PDF 0KB] ( 102 )

	524	Chong CCN, Cheung ST, Cheung YS, Chan AWH, Chan SL, Yu SCH, Lai PBS
		Novel biomarkers GEP/ABCB5 regulate response to adjuvant transarterial chemoembolization after curative hepatectomy for hepatocellular carcinoma ^Hot!
		Background: Transarterial chemoembolization (TACE) is the most commonly used adjuvant therapy for hepatocellular carcinoma (HCC) after curative resection. Responses to TACE are variable due to tumor and patient heterogeneity. We had previously demonstrated that expression of Granulin-epithelin precursor (GEP) and ATP-dependent binding cassette (ABC)B5 in liver cancer stem cells was associated with chemoresistance. The present study aimed to evaluate the association between GEP/ABCB5 expression and response to adjuvant TACE after curative resection for HCC. Methods: Patients received adjuvant TACE after curative resection for HCC and patients received curative resection alone were identified from a prospectively collected database. Clinical samples were retrieved for biomarker analysis. Patients were categorized into 3 risk groups according to their GEP/ABCB5 status for survival analysis: low (GEP-/ABCB5-), intermediate (either GEP+/ABCB5- or GEP-/ABCB5+) and high (GEP+/ABCB5+). Early recurrence (recurrence within 2 years after resection) and disease-free survival were analyzed. Results: Clinical samples from 44 patients who had followed-up for more than 2 years were retrieved for further biomarker analysis. Among them, 18 received adjuvant TACE and 26 received surgery alone. Patients with adjuvant TACE in the intermediate risk group was associated with significantly better overall survival and 2-year disease-free survival than those who had surgery alone (P = 0.036 and P = 0.011, respectively). Adjuvant TACE did not offer any significant differences in the early recurrence rate, 2-year disease-free survival and overall survival for patients in low and high risk groups. Conclusions: Adjuvant TACE can only provide survival benefits for patients in the intermediate risk group (either GEP+/ABCB5- or GEP-/ABCB5+). A larger clinical study is warranted to confirm its role in patient selection for adjuvant TACE.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 524-530 . [Abstract] ( 77 ) [HTML 1KB] [PDF 0KB] ( 92 )

	531	Wu LL, Chen JX, Li K, Su ZZ, Long YL, Luo LP, Xu EJ, Zheng RQ
		Potential application of ultrasound-guided thermal ablation in rare liver tumors
		Background: With the advances of imaging techniques, the detection rate of rare liver tumor is increased. However, the therapeutic strategies of the rare liver tumors remain limited. Methods: We analyzed twelve pathologically confirmed rare liver tumors in 8 patients. All of the patients underwent ultrasound (US) guided biopsy and subsequent thermal ablation. The tumors were ablated according to the preoperative plans and monitored by real-time US. CT/MRI fused with contrast enhanced US (CEUS) or three-dimensional (3D) US-CEUS images were used to guide and assess the ablation zone more accurately during thermal ablation. The rate of technical efficacy was assessed based on the contrast-enhance CT/MRI (CECT/MRI) results one month after ablation. Local tumor progression (LTP), recurrence and complications were followed up and recorded. Results: Among these twelve nodules, nine were subject to US-guided thermal ablation, whereas the other three inconspicuous nodules were subject to CEUS-guided thermal ablation. Intra-procedure CT/MRI-CEUS or 3D US-CEUS fusion imaging assessments demonstrated that the ablation zone sufficiently covered the original tumor, and no immediate supplementary ablation was required. Additionally, no major complications were observed during the follow-up period. The postoperative CECT/MRI confirmed that the technique success rate was 100%. Within the surveillance period of 13 months, no LTP or recurrence was noted. Conclusions: US-guided thermal ablation was feasible and safe for rare liver tumors. The use of fusion imaging technique might make US-guided thermal ablation as effective as surgical resection, and this technique might serve as a potential therapeutic modality for rare liver tumors in the future.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 531-537 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 103 )

	538	Bekheit M, Audebert C, Bucur P, Adriaensen H, Bled E,Wartenberg M, Vignon-Clementel I, Vibert E
		Transit time ultrasound perivascular flow probe technology is superior to MR imaging on hepatic blood flow measurement in a porcine model
		Background: The hepatic hemodynamics is an essential parameter in surgical planning as well as in various disease processes. The transit time ultrasound (TTUS) perivascular flow probe technology is widely used in clinical practice to evaluate the hepatic inflow, yet invasive. The phase-contrast-MRI (PC-MRI) is not invasive and potentially applicable in assessing the hepatic blood flow. In the present study, we compared the hepatic inflow rates using the PC-MRI and the TTUS probe, and evaluated their predictive value of post-hepatectomy adverse events. Methods: Eighteen large white pigs were anaesthetized for PC-MRI and approximately 75% hepatic resection was performed under a unified protocol. The blood flow was measured in the hepatic artery (Qha), the portal vein (Qpv), and the aorta above the celiac trunk (Qca) using PC-MRI, and was compared to the TTUS probe. The Bland-Altman method was conducted and a partial least squares regression (PLS) model was implemented. Results: The mean Qpv measured in PC-MRI was 0.55 ± 0.12 L/min, and in the TTUS probe was 0.74 ± 0.17 L/min. Qca was 1.40 ± 0.47 L/min in the PC-MRI and 2.00 ± 0.60 L/min in the TTUS probe. Qha was 0.17 ± 0.10 L/min in the PC-MRI, and 0.13 ± 0.06 L/min in the TTUS probe. The Bland-Altman method revealed that the estimated bias of Qca in the PC-MRI was 32% (95% CI: -49% to 15%); Qha 17% (95% CI: -15% to 51%); and Qpv 40% (95% CI: -62% to 18%). The TTUS probe had a higher weight in predicting adverse outcomes after 75% resection compared to the PC-MRI (β= 0.35 and 0.43 vs β = 0.22 and 0.07, for tissue changes and premature death, respectively). Conclusions: There is a tendency of the PC-MRI to underestimate the flow measured by the TTUS probes. The TTUS probe measures are more predictive of relevant post-hepatectomy outcomes.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 538-545 . [Abstract] ( 74 ) [HTML 1KB] [PDF 0KB] ( 89 )

ORIGINAL ARTICLES/Biliary

	546	Han MG, Cho E, Park CH, Jun CH, Park SY
		Self-expandable metal stents for choledocholithiasis in Billroth II gastrectomy patients
		Background: Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents (FCSEMSs) for the management of common bile duct (CBD) stones in a subset of patients with a history of Billroth II gastrectomy. Methods: This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed. Results: A group of 15 patients (10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation (6), small or flat papilla with unclear margin (5), current use of double antiplatelet agents or an anticoagulant (2), unwanted instrumentation of the cystic duct (1), and insecure position of the scope (1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications. Conclusion: Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 546-552 . [Abstract] ( 67 ) [HTML 1KB] [PDF 0KB] ( 90 )

ORIGINAL ARTICLES/Pancreas

	553	Lee JC, Kim H, Kim HW, Lee J, Paik KH, Kang J, Hwang JH, Kim J
		It is necessary to exam bottom and top slide smears of EUS-FNA for pancreatic cancer
		Background: Despite many reports on the diagnostic yield of cytology from endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), inter-slide differences are unknown. This prospective study aimed to compare diagnostic yield and cellular characteristics of bottom slides (BS) and top slides (TS) from EUS-FNA cytology performed without an on-site cytopathologist. Methods: In patients with suspected pancreatic cancer on previous imaging explorations, a single endoscopist performed EUS-FNA and obtained 2 sets of cytology slide (8 BS and 8 TS), 1 cellblock slide, and 1 biopsy slide. Both slide sets were randomly assigned. A cytopathologist with more than 10 years of expertise in pancreatic cytopathology blindly inspected and compared two slide sets. Results: In total, 73 specimens [42 head (57.5%), 16 body (21.9%), and 15 tail (20.5%)] were acquired for final analysis. Seventy-one cases were finally diagnosed with pancreatic cancer. The sensitivity and specificity of BS were 80.3% and 100.0%; and of TS 78.9% and 100.0%, respectively. In analyzing inter-slide difference, 66 cases (90.4%) showed consistent results between BS and TS. However, seven (9.6%) were positive only in one slide sets (4 BS and 3 TS). The proportions of specimens more than moderate and high cellularity were 75.3% and 60.3% in both slide sets (P> 0.99), and the proportion of artifact-free sets were 50.7%, and 52.1% for the BS and TS, respectively (P= 0.869). Conclusions: Although BS and TS exhibited highly consistent diagnostic yields in cytologic smears from EUS-FNA, the proportion of inter-slide discordance is clinically considerable. Both slide sets need to be examined if there is no on-site cytopathologist.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 553-558 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 99 )

	559	Rodriguez-Lopez M, Tejero-Pintor FJ, Perez-Saborido B, Barrera-Rebollo A, Bailon-Cuadrado M, Pacheco-Sanchez D
		Severe morbidity after pancreatectomy is accurately pre dicte d by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center ^Hot!
		Background: Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. Methods: A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. Results: Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer-Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586-0.887; P = 0.007) and 0.712 (95% CI: 0.555-0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. Conclusions: PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 559-565 . [Abstract] ( 80 ) [HTML 1KB] [PDF 0KB] ( 82 )

LETTERS TO THE EDITOR

	566	Liu GP, Cheng K, Luo JJ,Wang XJ, Xin YN, Xuan SY
		Diagnosis and management of arterioportal fistula occurring after percutaneous transhepatic portal vein cannula-assisted TIPS
		Transjugular intrahepatic portosystemic shunt (TIPS) is usually considered the choice for managing complications of portal hypertension such as refractory ascites, esophagogastric variceal bleeding and recurrent bleeding uncontrolled with first line treatment. In recent years, TIPS has been successfully used to treat Budd-Chiari syndrome, hepatic hydrothorax, and portal vein thrombosis.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 566-569 . [Abstract] ( 61 ) [HTML 1KB] [PDF 0KB] ( 94 )

	570	Spadaccini M, Lleo A, Ceriani R, Covini G, Rimassa L, Torzilli G, Di Tommaso L, Aghemo A
		Alpha-fetoprotein screening in patients with hepatitis C-induced cirrhosis who achieved a sustained virologic response in the direct-acting antiviral agents era
		Hepatocellular carcinoma (HCC) is the most common primary liver tumor and the third cause of cancer-related deaths worldwide. HCC is the consequence of malignant transformation of hepatocytes and mainly occurs in patients with cirrhosis. Hepatitis C virus (HCV) chronic infection is a leading cause of end-stage liver disease and HCC in the Western countries [1]. The approval of direct-acting antiviral agents (DAAs) for the treatment of HCV has revolutionized the management of the disease, as no absolute contraindication to treatment exists and sustained virological response rates (SVR) exceeding 90% can be achieved independently of disease severity [2].
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 570-574 . [Abstract] ( 58 ) [HTML 1KB] [PDF 0KB] ( 86 )

	575	Machado MCC, Souza HP
		The increased severity of acute pancreatitis in the elderly is mainly related to intestinal barrier dysfunction
		Severe acute pancreatitis in the elderly is characterized by significant morbidity and mortality rates, with a higher financial impact when compared to the same disease in younger patients [1]. There are some obvious differences between these two populations. The most glaring one is the presence of multiple comorbidities in elderly patients. A previous study showed that comorbidities, such as cardiovascular and renal comorbidities, significantly influence the outcomes of older patients with acute pancreatitis [1]. However, this relationship between age-related comorbidities and outcome is not a consensus. In a recent paper, morbidity and mortality in elderly patients with acute pancreatitis were not affected by multiple comorbidities and higher Charlson score present in older individuals [2]. However, it observed a higher incidence of intra-abdominal infected collections in elderly population, suggesting that the worse outcome of older individuals may be due to increased intestinal bacterial translocation.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 575-577 . [Abstract] ( 53 ) [HTML 1KB] [PDF 0KB] ( 92 )

	578	Hu JK, Li XM, Gu BH, Zhang F, Li YM, Chen H
		Helicobacter pylori and portal hypertensive gastropathy
		H. pylori lives in the gastric epithelial cells, sometimes in gastric glands. Whether or not the proliferation and biological behavior of H. pylori can be influenced by the status of the gastric mucosa is still unknown. Portal hypertensive gastropathy (PHG) is a blood drainage obstructive disease. In this pathologic environment, gastric mucosa may be further impaired when patients are infected with H. pylori . The role of H. pylori in the pathogenesis of PHG and the effect of PHG on H. pylori infection is poorly defined and controversial. We wonder whether H. pylori or its products can migrate to distant organ after anatomical changes of gastric mucosa by PHG.
		Hepatobiliary Pancreat Dis Int. 2018; 17(6): 578-580 . [Abstract] ( 78 ) [HTML 1KB] [PDF 0KB] ( 103 )

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