Hepatobiliary Pancreat Dis Int

	2020 Vol. 19 No. 4
	Published: 2020-08-15


	Pages 305-406
	EDITORIAL ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver NEW TECHNIQUES CLINICAL IMAGE LETTERS TO THE EDITOR ORIGINAL ARTICLES ON LIVING DONOR LIVER TRANSPLANTATION REVIEW ARTICLES ON LIVING DONOR LIVER TRANSPLANTATION

EDITORIAL

	305	Lerut J
		Living donor liver transplantation: A complex but worthwhile undertaking ^Hot!
		Since its’ first applications in clinical pediatric and adult liver transplantation practice by Strong et al. and Makuuchi in 1989 [1,2 ], living donor liver transplantation (LDLT) has been an ever increasing part of the today’s practice of liver transplantation.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 305-306 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 78 )

ORIGINAL ARTICLES ON LIVING DONOR LIVER TRANSPLANTATION

	307	Feng MX, Zhang JX, Wan P, Qiu BJ, Gu LH, Zhang JJ, Xia Q
		Hepatic artery reconstruction in pediatric liver transplantation: Experience from a single group
		Background: The reconstruction of hepatic artery is a challenging part of the pediatric liver transplantation procedure. Hepatic artery thrombosis (HAT) and stenosis are complications which may result in ischemic biliary injury, causing early graft lost and even death. Methods: Two hundred and fifty-nine patients underwent liver transplantation in 2017 in a single liver transplantation group. Among them, 225 patients were living donor liver transplantation (LDLT) and 34 deceased donor liver transplantation (DDLT). Results: In LDLT all reconstructions of hepatic artery were microsurgical, while in DDLT either microsurgical reconstruction or traditional continuous suture technique was done depending on different conditions. There were five (1.9%) HATs: four (4/34, 11.8%) in DDLT (all whole liver grafts) and one (1/225, 0.4%) in LDLT ( P = 0.001). Four HATs were managed conservatively using anticoagulation, and 1 accepted salvage surgery with re-anastomosis. Until now, 3 HAT patients remain in good condition, whereas two developed biliary complications. One of them needed to be re-transplanted, and the other patient died due to biliary complications. Conclusions: Microsurgical technique significantly improves the reconstruction of hepatic artery in pediatric liver transplantation. The risk for arterial complications is higher in DDLT. Conservative therapy can achieve good outcome in selected HAT cases.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 307-310 . [Abstract] ( 67 ) [HTML 1KB] [PDF 0KB] ( 75 )

	311	Lee JM, Lee KW
		Techniques for overcoming atretic changes of the portal vein in living donor liver transplantation
		Background: Spontaneous diversion of the portal flow through collateral vessels into the systemic circulation is frequently observed in liver transplant recipients with severe portal hypertension. This induces main portal vein atretic change and modifies flow into the collateral even after donor graft implantation. These atretic changes make liver transplantation challenging. In this article we described several methods for overcoming this challenge by appropriate surgical techniques. Methods: Three anastomotic techniques for living donor liver transplantation were performed in patients with atretic changes in the portal vein. Results: The three techniques were (1) venoplasty to widen the diameter by using the recipient’s portal vein, and the diameter of the recipient’s portal vein was enlarged using their own portal vein stump patch; (2) conduit with cryopreserved vessels, and we dissected around the superior mesenteric vein and splenic vein junction and a conduit was built using the cryopreserved vessels; and (3) left gastric varix to portal vein anastomosis, if the recipients had large gastric varix and variceal wall was sufficiently thick for anastomosis. Conclusions: Selection of optimal methods for portal vein anastomosis is essential in patients with atrophic change on the portal vein. If these methods are used aptly, they can be considered as favorable methods for overcoming each situation.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 311-317 . [Abstract] ( 57 ) [HTML 1KB] [PDF 0KB] ( 76 )

REVIEW ARTICLES ON LIVING DONOR LIVER TRANSPLANTATION

	318	Balci D, Kirimker EO
		Hepatic vein in living donor liver transplantation
		Right lobe living donor liver transplantation (LDLT) is a major development in adult LDLT that has sig- nificantly increased the donor pool by providing larger graft size and by decreasing risk of small-for-size graft syndrome. However, right lobe anatomy is complex, not only from the inflow but also from the outflow perspective. Outflow reconstruction is one of the key requirements of a successful LDLT and ve- nous drainage of the liver graft is just as important as hepatic inflow for the integrity of graft function. Outflow complications may cause acute graft failure which is not always easy to diagnose. The right lobe graft consists of two sections and three hepatic venous routes for drainage that require reconstruction. In order to obtain a congestion free graft, several types of vascular conduits and postoperative interventions are needed to assure an adequate venous allograft drainage. This review described the anatomy, functional basis and the evolution of outflow reconstruction in right lobe LDLT.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 318-323 . [Abstract] ( 68 ) [HTML 1KB] [PDF 0KB] ( 84 )

	324	Lin TS, Co JS, Chen CL, Ong AD
		Optimizing biliary outcomes in living donor liver transplantation: Evolution towards standardization in a high-volume center ^Hot!
		Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation. While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction, our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors, in particular, our surgical protocols. We present herein, the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts. Over this period of transition, our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0% to 10.2%.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 324-327 . [Abstract] ( 55 ) [HTML 1KB] [PDF 0KB] ( 73 )

	328	Kaido T
		Recent evolution of living donor liver transplantation at Kyoto University: How to achieve a one-year overall survival rate of 99%? ^Hot!
		Previously, living donor liver transplantation was considered as a “high-risk, high-return”medical treat- ment due to the relatively high short-term mortality. It is our task to change “high-risk, high-return”into a “low-risk, high-return”situation. In this review article, the recent evolutions in living donor liver transplantation for both donors and recipients at Kyoto University such as portal vein pressure modulation, hybrid donor operation, and perioperative management considering sarcopenia, focusing on improvement of short-term outcomes are described. Under a paradigm of “marketing and innovation”, various innovations and efforts have been made over the last decade aiming at improving the short-term outcomes of both donors and recipients. By doing so, excellent short-term results after living donor liver transplantation have been achieved, along with a potentially epoch-making discoveries.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 328-333 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 77 )

	334	Masuda Y, Yoshizawa K, Ohno Y, Mita A, Shimizu A, Soejima Y
		Small-for-size syndrome in liver transplantation: Definition, pathophysiology and management
		Background: Since the first success in an adult patient, living donor liver transplantation (LDLT) has be- come an universally used procedure. Small-for-size syndrome (SFSS) is a well-known complication after partial LT, especially in cases of adult-to-adult LDLT. The definition of SFSS slightly varies among trans- plant physicians. The use of a partial liver graft has risks of SFSS development. Persistent portal vein (PV) hypertension and PV hyper-perfusion after LT were identified as the main factors. Hence, various approaches were explored to modulate PV flow and decrease PV pressure in order to alleviate this syn- drome. Herein, the definition, clinical symptoms, pathophysiology, basic research, as well as preventive and treatment strategies for SFSS are reviewed based on an extensive review of the literature and on our own experiences. Data sources: The articles were collected through PubMed using search terms “liver transplantation”, “living donor liver transplantation”, “living liver donation”, “partial graft”, “small-for-size graft”, “small-for- size syndrome”, “graft volume”, “remnant liver”, “standard liver volume”, “graft to recipient body weight ratio”, “sarcopenia”, “porcine”, “swine”, and “rat”. English publications published before March 31, 2020 were included in this review. Results: Many transplant surgeons performed PV flow modulation, including portocaval shunt, splenic artery ligation and splenectomy. With these techniques, patient outcome has been improved even when using a "small" graft. Other factors, such as preoperative recipients’ nutritional and skeletal muscle status, graft congestion, and donor factors, were also identified as risk factors which all have been addressed using various strategies. Conclusions: The surgical approach controlling PV flow and pressure could help to prevent SFSS especially in severely ill recipients. In the absence of efficacious medications to resolve SFSS, conservative treatments, including aggressive fluid balance correction for massive ascites, anti-microbiological therapy to prevent or control sepsis and intensive nutritional therapy, are all required if SFSS could not be prevented.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 334-341 . [Abstract] ( 70 ) [HTML 1KB] [PDF 0KB] ( 68 )

	342	Egawa H
		Challenge to ABO blood type barrier in living donor liver transplantation
		ABO incompatible living donor liver transplantation has the potential to expand the donor pool for patients with end stage liver diseases on the expense of challenges to overcome immunological barriers across blood type. There is a profound impact of age on incidence and severity of antibody mediated rejection (AMR). Even children older than 1 year have chances of AMR; children aged 8 years or older have risks of hepatic necrosis similar to adult liver recipients. The mechanism of AMR is based on circulatory disturbances secondary to inflammation and injury of the vascular endothelium caused by an antibody-antigen-complement reaction. The strategy to overcome ABO blood type barrier is based on both pre-transplant desensitization and adequate treatment of this phenomenon. Nowadays, rituximab is the standard means of desensitization but unfortunately an insufficient aid to treat AMR. Because of low incidence (less than 5% in the rituximab era), in practice of AMR only some case reports about the treatment of clinical AMR are available in the literature. Initial experiences revealed that the proteasome inhibitor, bortezomib might be a promising treatment based on its capacity to deplete plasma cell agents. Although ABO blood type barrier has been counteracted in 95% of patients by applying “rituximab-desensitization”, many issues, such as prediction of high-risk patients of infection and AMR and secure treatment strategies for evoked AMR, remain to be resolved.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 342-348 . [Abstract] ( 63 ) [HTML 1KB] [PDF 0KB] ( 74 )

ORIGINAL ARTICLES/Transplantation

	349	Zhan QF, Ling SB, Deng YN, Shan QN, Ye QW, Xu SJ, Jiang GJ, Lu D, Wei XY, Zhuang L, Zhang W, Shen T, Cen BN, Xie HY, Liu JM, Wu J, Zheng SS, Yang Y, Xu X
		Hangzhou criteria as downstaging criteria in hepatocellular carcinoma before liver transplantation: A multicenter study from China ^Hot!
		Background: The downstaging of hepatocellular carcinoma (HCC) has been confirmed to benefit liver transplantation (LT) patients whose tumors are beyond the transplantation criteria. Milan criteria (MC), a tumor size and number-based assessment, is currently used as the endpoint in these patients. However, many studies believe that tumor biological behavior should be added to the evaluation criteria for downstaging efficacy. Hence, this study aimed to explore the feasibility of Hangzhou criteria (HC), which introduced tumor grading and alpha-fetoprotein in addition to tumor size and number, as an endpoint of downstaging. Methods: We performed a multicenter and retrospective study of 206 patients accepted locoregional therapy (LRT) as downstaging/bridge treatment prior to LT in three centers of China. Results: Recipients were divided into four groups: failed downstaging to the HC (group A, n = 46), successful downstaging to the HC (group B, n = 30), remained within the HC all the time (group C, n = 113), and tumor progressed (group D, n = 17). The 3-year HCC recurrence probabilities of groups B and C were not significantly different (10.3% vs. 11.6%, P = 0.87). The HCC recurrent rate was significantly higher in group A (52.3%) compared with that in group B/C ( P < 0.05). Seven patients (7/76, 9.2%) whose tumor exceeded the the HC were successfully downstaged to the MC, and 39.5% (30/76) to the the HC. In group B, 23 patients remained beyond the MC and their survivals were as well as those of patients within the MC. Conclusions: Compared to the MC, HC downstaging criteria can give more HCC patients access to LT and furthermore, the outcome of these patients is the same as those matching MC downstaging criteria. Hangzhou downstaging criteria therefore is applicable in clinical practice.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 349-357 . [Abstract] ( 73 ) [HTML 1KB] [PDF 0KB] ( 69 )

	358	Ying Y, Li RD, Ai JW, Zhu YM, Zhou X, Qian YY, Chen XC, Wang XY, Zhang HC, Li Y, Weng SS, Yu YQ, Tao YF, Huang YX, Wang ZX, Zhang WH
		Infection within 2 weeks before liver transplantation closely related to prognosis of posttransplant infection: A single-center retrospective observational study in China
		Background: Infections still represent the main factors influencing morbidity and mortality following liver transplantation. This study aimed to evaluate the incidence and risk factors for infection and survival after liver transplantation. Methods: We retrospectively examined medical records in 210 liver recipients who underwent liver transplantation between April 2015 and October 2017 in our hospital. Clinical manifestations and results of pathogen detection test were used to define infection. We analyzed the prevalence, risk factors and prognosis of patients with infection. Results: The median follow-up was 214 days; the incidence of infection after liver transplantation was 46.7% ( n = 98) which included pneumonia (43.4%), biliary tract infection (21.9%), peritonitis (21.4%) and bloodstream infection (7.6%). Among the pathogens in pneumonia, the most frequently isolated was Acinetobacter baumanii (23.5%) and Klebsiella pneumoniae (21.2%). Model for end-stage liver disease (MELD) score (OR = 1.083, 95% CI: 1.045–1.123; P < 0.001), biliary complication (OR = 4.725, 95% CI: 1.119–19.947; P = 0.035) and duration of drainage tube (OR = 1.040, 95% CI: 1.007–1.074; P = 0.017) were independent risk factors for posttransplant infection. All-cause mortality was 11.0% ( n = 23). The prognostic factors for postoperative infection in liver recipients were prior-transplant infection, especially pneumonia within 2 weeks before transplantation. Kaplan-Meier curves of survival showed that recipients within 2 weeks prior infection had a significantly lower cumulative survival rate compared with those without infection (65.2% vs. 90.0%; hazard ratio: 4.480; P < 0.001). Conclusions: Infection, especially pneumonia within 2 weeks before transplantation, complication with impaired renal function and MELD score after 7 days of transplantation was an independent prognostic factor for postoperative infection in liver transplant recipients.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 358-364 . [Abstract] ( 64 ) [HTML 1KB] [PDF 0KB] ( 70 )

	365	Yang Z, Wang S, Tian XY, Xie QF, Zhuang L, Li QY, Chen CZ, Zheng SS
		Impact of treatment modalities on patients with recurrent hepatocellular carcinoma after liver transplantation: Preliminary experience
		Background: Post-liver transplantation (LT) hepatocellular carcinoma (HCC) recurrence still occurs in approximately 20% of patients and drastically affects their survival. This study aimed to evaluate the efficacy of various treatments for recurrent HCC after LT in a Chinese population. Methods: A total of 64 HCC patients with tumor recurrence after LT were enrolled in this study. Univariate and multivariate analyses were performed to identify factors affecting post-recurrence survival. Results: Of the 64 patients with recurrent HCC after LT, those who received radical resection followed by nonsurgical therapy had a median overall survival (OS) of 20.9 months after HCC recurrence, significantly superior to patients who received only nonsurgical therapy (9.4 months) or best supportive care (2.4 months). The one- and two-year OS following recurrence was favorable for patients receiving radical resection followed by nonsurgical therapy (93.8%, 52.6%), poor for patients receiving only nonsurgical therapy (30.8%, 10.8%), and dismal for patients receiving best supportive care (0%, 0%; overall P < 0.001). Median OS in sorafenib-tolerant patients treated with lenvatinib was 19.5 months, far surpassing the patients that discontinued sorafenib or were treated with regorafenib after sorafenib failure (12 months, P < 0.001). Compared with tacrolimus-based immunosuppressive therapy, OS was significantly increased with sirolimus-based therapy at one and two years after HCC recurrence ( P = 0.035). Multivariate analysis showed radical resection combined with nonsurgical therapy for recurrent HCC and sorafenib-lenvatinib sequential therapy were independent favorable factors for post-recurrence survival. Conclusions: Aggressive surgical intervention in well-selected patients significantly improves OS after recurrence. A multidisciplinary treatment approach is required to slow down disease progression for patients with unresectable recurrent HCC.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 365-370 . [Abstract] ( 90 ) [HTML 1KB] [PDF 0KB] ( 79 )

	371	Zhou ZJ, Chen GS, Si ZZ, Li Q, Bin YY, Qi HZ, Li JQ
		Prognostic factors influencing outcome in adult liver transplantation using hypernatremic organ donation after brain death
		Background: Hypernatremic donors was regarded as the expanded criteria donors in liver transplantation. The study was to investigate the effects of donor hypernatremia on the outcomes of liver transplantation and identify the prognostic factors possibly contributing to the poor outcomes. Methods: Donor serum sodium levels before procurement were categorized as normal sodium ( < 155 mmol/L), moderate high sodium (155–170 mmol/L), and severe high sodium ( ≥170 mmol/L). Furthermore, we subdivided the 142 hypernatremic donors ( ≥155 mmol/L) into two subgroups: subgroup A, the exposure time of liver grafts from hypernatremia to reperfusion was < 36 h; and subgroup B, the exposure time was ≥36 h. The outcomes included initial graft function, survival rates of grafts and recipients, graft loss and early events within the first year following liver transplantation. Results: There were no significant differences in the 1-year survival rates of grafts and recipients, 1-year graft loss rates and early events among the normal, moderate high and severe high sodium groups. However, the overall survival rates of grafts and recipients in subgroup A were significantly higher than those in subgroup B. Cox model showed that the exposure time (HR = 1.117; 95% CI: 1.053–1.186; P < 0.001), cold ischemia time (HR = 1.015; 95% CI: 1.006–1.024; P = 0.001) and MELD (HR = 1.061; 95% CI: 1.003–1.121; P = 0.037) were the important prognostic factors contributing to the poor outcomes of recipients with hypernatremic donors. Conclusions: The level of donor sodium immediately before organ procurement does not have negative effects on the early outcomes following adult liver transplantation. For hypernatremia liver donors, minimization of the exposure time from hypernatremia to reperfusion is critical to prevent graft loss.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 371-377 . [Abstract] ( 79 ) [HTML 1KB] [PDF 0KB] ( 72 )

	378	Wang MX, Chen D, Zhao YY, Yang B, Jiang JP, Zeng FJ, Wei L, Chen ZS
		Role of selected criteria and preventive chemotherapy in tumor recurrence after liver transplantation
		Background: Long-term survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) patients remains poor because of tumor recurrence. To improve the prognosis of HCC patients after LT, we aimed to identify different transplantation criteria and risk factors related to tumor recurrence and evaluate the effect of preventive chemotherapy in a single center. Methods: In total, data on 20 variables and the survival of 199 patients with primary HCC who underwent LT between 2005 and 2015 were included for analysis. The patients were divided into the following three groups: Group 1, within the Milan and Hangzhou criteria ( n = 51); Group 2, beyond the Milan but within the Hangzhou criteria ( n = 36); and Group 3, beyond the Milan and Hangzhou criteria ( n = 112). Survival probabilities for the three groups were calculated using multivariate Cox regression analysis. The association between preventive therapy and HCC-recurrence after LT was analyzed by multiple logistic regression analysis. Results: Child-Pugh stage C and hepatitis B virus (HBV) infection were independent risk factors for patients with tumor recurrence who did not meet the Milan criteria. The overall survival rates of the 199 patients showed statistically significant differences among the three groups ( P < 0.001). Moreover, no significant difference was noted in the survival rate between Group 1 and Group 2 ( P > 0.05). Multivariate logistic regression analysis showed that postoperative prophylactic chemotherapy reduced the risk of tumor recurrence in patients who did not meet the Hangzhou and Milan criteria (OR = 0.478; 95% CI: 0.308–0.741; P = 0.001). Conclusions: Child-Pugh classification and HBV infection were the independent risk factors of tumor recurrence in HCC patients with LT. The Hangzhou criteria were effective and analogous compared with the Milan criteria. Preventive chemotherapy significantly reduced the risk of recurrence and prolonged the survival time for HCC patients beyond the Milan and Hangzhou criteria after LT.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 378-383 . [Abstract] ( 82 ) [HTML 1KB] [PDF 0KB] ( 77 )

ORIGINAL ARTICLES/Liver

	384	Jin X, Fu B, Wu ZJ, Zheng XQ, Hu JH, Jin LF, Tang LL
		Serum chitinase-3-like protein 1 is a biomarker of liver fibrosis in patients with chronic hepatitis B in China
		Background: Serum chitinase-3-like protein 1 (CHI3L1) is a potential biomarker for fibrosis assessment. We aimed to evaluate serum CHI3L1 as a noninvasive diagnostic marker for chronic hepatitis B virus-related fibrosis. Methods: Serum CHI3L1 levels were measured by ELISA in 134 chronic hepatitis B (CHB) patients. Sig- nificant fibrosis was defined as a liver stiffness > 9.7 kPa. The performance of CHI3L1 was assessed and compared to that of other noninvasive tests by receiver operating characteristic (ROC) analysis. Results: Serum CHI3L1 levels were significantly higher in CHB patients with significant hepatic fibrosis ( ≥F2) than in those without significant hepatic fibrosis ( < F2) (56.5 ng/mL vs. 81.9 ng/mL, P < 0.001). In CHB patients, the specificity and sensitivity of CHI3L1 for predicting significant fibrosis were 75.6% and 59.1%, respectively, with a cut-off of 76.0 ng/mL and an area under the ROC curve of 0.728 (95% CI: 0.637–0.820). Conclusions: Serum CHI3L1 levels could be an effective new serological biomarker for the diagnosis of liver fibrosis. Moreover, CHI3L1 is feasible in monitoring disease progression.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 384-389 . [Abstract] ( 70 ) [HTML 1KB] [PDF 0KB] ( 70 )

NEW TECHNIQUES

	390	Kniepeiss D, Talakic E, Schemmer P
		Echinococcus granulosus: A novel parenchymal sparing surgical treatment
		Human echinococcosis is a zoonosis caused by Echinococcus (E.) tapeworms. There are different species, but E. granulosus and E. multilocularis have clinical relevance causing cystic and alveolar echinococcosis, respectively. Cystic echinococcosis (CE) is defined as presence of one or more hydatid cysts, most frequently in the liver and the lungs, less usual in the kidneys, bones, spleen, pancreas, heart or brain. The location, the number and size of the cysts determine the severity of the disease [1] .
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 390-393 . [Abstract] ( 60 ) [HTML 1KB] [PDF 0KB] ( 71 )

CLINICAL IMAGE

	394	Cassar N, Gregory S, Menon K
		New variation of median arcuate ligament compression causing hepatic arterial hypoperfusion during liver transplantation
		Satisfactory blood flow after hepatic arterial anastomosis in liver transplantation is a critical point of the operation. Problems with this anastomosis can result in hepatic artery thrombosis with resultant graft failure and patient morbidity and mortality. Causes of hepatic artery thrombosis include problematic technique, hepatic artery dissection, external compression (e.g. from hematoma), hypercoagulable state, splenic arterial steal and rarer causes such as median arcuate ligament compression (MALC). A careful review of preoperative radiology and imaging will reveal these rare instances and enable a proper intraoperative plan.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 394-395 . [Abstract] ( 76 ) [HTML 1KB] [PDF 0KB] ( 65 )

LETTERS TO THE EDITOR

	396	Baimas-George MR, Pickens RC, Sulzer JK, Vrochides D, Martinie JB, Levi DM, Iannitti DA
		A ten-year experience of inferior vena cava reconstruction for malignancy: The importance of a multidisciplinary approach with hepatobiliary surgery
		Tumor invasion of the inferior vena cava (IVC) through direct erosion is a rare and poor prognostic feature of aggressive hepatic or perihepatic malignancies [1,2] . Literature shows poor response to chemotherapy, such that resection often is the only option for improved survival [3] . Multidisciplinary collaborations can expand technical options; incorporation of transplant techniques has led to successful R0 resection involving difficult vascular reconstruction and extended resection [4,5] . This study describes and analyzes the ten-year collaborative experience of hepatobiliary (HPB) surgeons in management of malignancies involving the perihepatic IVC.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 396-398 . [Abstract] ( 72 ) [HTML 1KB] [PDF 0KB] ( 69 )

	399	Mao JX, Teng F, Sun KY, Liu C, Ding GS, Guo WY
		Two-in-one: A pooled analysis of primary hepatic neuroendocrine carcinoma combined/collided with hepatocellular carcinoma
		Primary hepatic neuroendocrine carcinoma (PHNEC) combined/ collided with hepatocellular carcinoma (HCC) is a rare and intriguing disease with characteristics of two histologically different cancers. Usually, a combined type refers to the cases in which hepatic neuroendocrine carcinoma (HNEC) and HCC components intermingle with each other and cannot be clearly separated in the transitional areas, while a collision type refers to those in which the two distinct cancers occurred simultaneously and independently. Sometimes it is difficult to readily distinguish these two types. We searched PubMed, Medline, China Science Periodical Database, and VIP Database with the publication from January 1980 to January 2019, using the keywords (“hepatic neuroendocrine carcinoma” or “HNEC”) and (“hepatocellular carcinoma” or “HCC”). After manually excluding records on secondary HNEC and other types of liver cancer, a total of 28 cases in 24 reports [1–24] were identified and summarized in Table 1 . The current summary thus aimed to provide more information about the clinical manifestations, managements and prognosis of this rare disease.
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 399-403 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 74 )

	404	Yu T, Yue YQ, Chen J, Ren HB, Ji R, Cheng BQ
		Endoscopic papillary large balloon dilation with or without sphincterotomy for large bile duct stones removal: Short-term and long-tem outcomes
		Simplifying the endoscopic procedures and reducing the procedure time are necessary, while guaranteeing that the stone retrieval efficacy is an important prerequisite for minimizing the risk of complications after endoscopic retrograde cholangiopancreatography (ERCP). Compared with endoscopic sphincterotomy (EST), which can effectively extract common bile duct stones, endoscopic papillary balloon dilatation (EPBD) causes less bleeding and perforation and preserves the function of sphincter of Oddi [1,2]. However, in comparison with EST, EPBD is related to a higher risk of pancreatitis [2,3]. Retrieving large bile duct stones ( ≥10 mm) using the conventional techniques EST and EPBD is difficult. The use of EST combined with endoscopic papillary large balloon dilation (EPLBD) for bile duct stone removal was first introduced by Ersoz et al. [4], and this innovation has become useful in patients with large or difficult stones. In addition, removing the bile duct stones should be considered urgent. Especially, EPLBD procedure is appropriate for patients with unfavorable anatomy for EST, such as those who underwent Roux-en-Y or Billroth II gastrectomy [5].
		Hepatobiliary Pancreat Dis Int. 2020; 19(4): 404-406 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 57 )

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