Hepatobiliary Pancreat Dis Int

	2020 Vol. 19 No. 5
	Published: 2020-10-15


	Pages 407-506
	EDITORIAL META-ANALYSIS REVIEW ARTICLES ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas LETTERS TO THE EDITOR VIEWPOINTS

EDITORIAL

	407	Yang HY, Jin B, Mao YL
		Liver injury in COVID-19: What do we know now?
		Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become a global pandemic. Several large cohort studies have reported liver injury in COVID-19 patients. Here, we reviewed the manifestations and causes of liver injury in COVID-19 patients and the effects of liver injury on the clinical outcomes based on the published literature.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 407-408 . [Abstract] ( 114 ) [HTML 1KB] [PDF 0KB] ( 123 )

	409	Baimas-George MR, Tschuor C, Martinie JB, Iannitti DA, Baker EH, Vrochides D
		The Janus of mIS in hepatobiliary surgery: Importance of maximally invasive surgery in an era of minimally invasive surgery
		As surgeons formidably continue to forge into the twentytwenties, after a considerably coronavirus-induced rocky start, one can predict that the era of minimally invasive surgery (mIS), an era of robotics, telehealth, and enhanced recovery after surgery (ERAS®), is not only here to stay but will continue to thrive, develop, and transform our practices. Critics of robotics platforms would be hard pressed not to indulge in this prediction. Will the satisfyingly large midline “stem to stern”, the impressing exposuregenerating Makuuchi or transverse abdominal, the Kocher, paramedian, McBurney, Chevron, and Pfannenstiel incisions begin to disappear and fade away into a scar minimizing future precluding trauma laparotomies? Most likely not. Understanding and developing the skill and technique for a minimally invasive “mIS” approach does not negate or abrogate the maximally invasive “MIS” ones. It is not one or the other; not a “to be or not to be” Shakespearean scenario. Hepatobiliary surgery is a qualified landscape upon which to illuminate and exemplify this declaration: the necessity and companionship of “mIS” and “MIS” – minimally and maximally invasive surgery.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 409-410 . [Abstract] ( 122 ) [HTML 1KB] [PDF 0KB] ( 136 )

META-ANALYSIS

	411	Gavriilidis P, Sutcliffe RP, Roberts KJ, Pai M, Spalding D, Habib N, Jiao LR, Sodergren MH
		No difference in mortality among ALPPS, two-staged hepatectomy, and portal vein embolization/ligation: A systematic review by updated traditional and network meta-analyses ^Hot!
		Background: There is an ongoing debate on the feasibility, safety, and oncological efficacy of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. The aim of this study was to compare ALPPS, two-staged hepatectomy (TSH), and portal vein embolization (PVE)/ligation (PVL) using updated traditional meta-analysis and network meta-analysis (NMA). Data sources: Electronic databases were used in a systematic literature search. Updated traditional meta-analysis and NMA were performed and compared. Mortality and major morbidity were selected as primary outcomes. Results: Nineteen studies including 1200 patients were selected from the pool of 436 studies. Of these patients, 315 (31%) and 702 (69%) underwent ALPPS and portal vein occlusion (PVO), respectively. Ninety-day mortality based on updated traditional meta-analysis, subgroup analysis of the randomized controlled trials (RCTs), and both Bayesian and frequentist NMA did not demonstrate significant differences between the ALPPS cohort and the PVE, PVL, and TSH cohorts. Moreover, analysis of RCTs did not demonstrate significant differences of major morbidity between the ALPPS and PVO cohorts. The ALPPS cohort demonstrated significantly more favorable outcomes in hypertrophy parameters, time to operation, definitive hepatectomy, and R0 margins rates compared with the PVO cohort. In contrast, 1-year disease-free survival was significantly higher in the PVO cohort compared to the ALPPS cohort. Conclusions: This study is the first to use updated traditional meta-analysis and both Bayesian and frequentist NMA and demonstrated no significant differences in 90-day mortality between the ALPPS and other hepatic hypertrophy approaches. Furthermore, two high quality RCTs including 147 patients demonstrated no significant differences in major morbidity between the ALPPS and PVO cohorts.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 411-419 . [Abstract] ( 133 ) [HTML 1KB] [PDF 0KB] ( 141 )

REVIEW ARTICLES

	420	Sansone V, Le Grazie M, Roselli J, Polvani S, Galli A, Tovoli F, Tarocchi M
		Telomerase reactivation is associated with hepatobiliary and pancreatic cancers ^Hot!
		Background: Human telomerase reverse transcriptase (hTERT) and its components play a significant role in cancer progression, but recent data demonstrated that telomeres and telomerase alterations could be found in other diseases; increasing evidence suggests a key role of this enzyme in the fields of hepatobiliary and pancreatic diseases. Data sources: We performed a PubMed search with the following keywords: telomerase, hepatocellular carcinoma, cholangiocarcinoma, pancreatic adenocarcinoma by December 2019. We reviewed the relevant publications that analyzed the correlation between telomerase activity and hepatobiliary and pancreatic diseases. Results: Telomerase reactivation plays a significant role in the development and progression of hepatobiliary and pancreatic tumors and could be used as a diagnostic biomarker for hepatobiliary and pancreatic cancers, as a predictor for prognosis and a promising therapeutic target. Conclusions: Our review summarized the evidence about the critical role of hTERT in cancerous and precancerous lesions of the alteration and its activity in hepatobiliary and pancreatic diseases.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 420-428 . [Abstract] ( 126 ) [HTML 1KB] [PDF 0KB] ( 116 )

	429	Ezhilarasan D
		Critical role of estrogen in the progression of chronic liver diseases
		Background: Estrogens regulate sexual function and also have a significant role in various pathophys- iological processes. Estrogens have a non-reproductive role as the modulators of the immune system, growth, neuronal function, and metabolism. Estrogen receptors are expressed in the liver and their impaired expression and function are implicated with obesity and liver associated metabolic dysfunctions. The purpose of the current review is to discuss the disparity role of estrogens on several forms of liver diseases. Data sources: A comprehensive search in PubMed and EMBASE was conducted using the keywords “estrogens and liver diseases”, “estradiol and liver diseases”, “hormones and liver diseases”, “endocrine function in liver diseases”, and “female hormones in liver diseases”. Relevant papers published before September 30, 2019 were included. Results: The present review confirms the imperative role of estrogen in various forms of chronic liver diseases. Estrogens play a key role in maintaining homeostasis and make the liver less susceptible to several forms of chronic liver diseases in healthy premenopausal individuals. In contrast, clinical studies also showed increased estrogen levels with chronic liver diseases. Conclusions: Several studies reported the protective role of estrogens in chronic liver diseases and this has been widely accepted and confirmed in experimental studies using ovariectomized rat models. However, in a few clinical studies, increased estrogen levels are also implicated in chronic liver diseases. Therefore, further studies are warranted at molecular level to explore the role of estrogen in various forms of chronic liver diseases.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 429-434 . [Abstract] ( 141 ) [HTML 1KB] [PDF 0KB] ( 145 )

ORIGINAL ARTICLES/Liver

	435	Zhao ZM, Yin ZZ, Pan LC, Hu MG, Tan XL, Liu R
		Robotic isolated partial and complete hepatic caudate lobectomy: A single institution experience
		Background: Current reports on robotic hepatic caudate lobectomy are limited to Spiegel lobectomy. This study aimed to compare the safety and feasibility of robotic isolated partial and complete hepatic caudate lobectomy. Methods: Clinical data of 32 patients who underwent robotic resection of the hepatic caudate lobe in our department from May 2016 to January 2020 were retrospectively analyzed. The patients were divided into three groups according to the lobectomy location: left dorsal segment lobectomy (Spiegel lobectomy), right dorsal segment lobectomy (caudate process or paracaval portion lobectomy), and complete caudate lobectomy. General information and perioperative results of the three groups were compared and analyzed. Results: Among the 32 patients, none had conversion to laparotomy, three received intraoperative blood transfusion (9.38%), and none had complications of Clavien-Dindo grade III or higher or died in the perioperative period. Among them, 17 patients (53.13%) underwent Spiegel lobectomy, 7 (21.88%) underwent caudate process or paracaval portion lobectomy, and 8 (25.00%) underwent complete caudate lobectomy. The operative time and blood loss in the left dorsal segment lobectomy group were significantly better than those in the right dorsal segment lobectomy and complete caudate lobectomy groups (operative time: P = 0.010 and P = 0.005; blood loss: P = 0.005 and P = 0.017, respectively). The postoperative hospital stay in the left dorsal segment lobectomy group was significantly shorter than that in the complete caudate lobectomy group ( P = 0.003); however, there was no difference in the postoperative hospital stay between the left dorsal segment lobectomy group and right dorsal segment lobectomy group ( P = 0.240). Conclusions: Robotic isolated partial and complete caudate lobectomy is safe and feasible. Spiegel lobectomy is relatively straightforward and suitable for beginners.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 435-439 . [Abstract] ( 112 ) [HTML 1KB] [PDF 0KB] ( 130 )

	440	Zhuo JY, Lu D, Lin ZY, Cen BN, Wei XY, Xie HY, Zheng SS, Xu X
		C-C motif chemokine ligand 16 inhibits the progression of liver cirrhosis via inactivating hepatic stellate cells ^Hot!
		Background: Liver cirrhosis results from many forms of chronic damage, characterized by accumulation of extracellular matrix. The present study aimed to explore a potential non-invasive biomarker and its mechanism in the progression of liver cirrhosis. Methods: Gene Expression Omnibus (GEO) dataset (GSE15654, n = 216) was analyzed to screen genes associated with progression of liver cirrhosis. A total of 181 plasma samples, including healthy control (HC, n = 20), chronic hepatitis B (CHB, n = 77) and HBV-related liver cirrhosis (LC, n = 84), were enrolled for validation. In vitro and in vivo experiments were employed for the mechanistic investigation. Results: GEO dataset analysis showed that relatively low mRNA-expression of C-C motif chemokine ligand 16 (CCL16) was associated with elevated Child-Pugh score ( P = 0.034) and worse prognosis ( P = 0.025). Plasma CCL16 level decreased in a stepwise pattern, with a median concentration of 10.29, 6.57 and 4.47 ng/mL in the HC, CHB and LC groups, respectively ( P < 0.001). Low plasma CCL16 was significantly related to hepatic dysfunction both in the CHB and LC groups ( P < 0.05). Combination of CCL16 and ALT showed improved distinguishing capability for LC compared to either alone. In vitro , CCL16 expression was downregulated by lipopolysaccharide and hypoxia. Overexpression of CCL16 from human normal liver cell line (LO2) reduced the extracellular matrix associated proteins (Col1 and Col4) in human hepatic stellate cell line (LX-2). In vivo , the pathological feature of cirrhosis was alleviated by the hepatocyte-specific expression of CCL16. Conclusions: CCL16 could be a feasible plasma marker to predict the occurrence and progression of liver cirrhosis. CCL16 might impact liver cirrhosis through inactivating hepatic stellate cells.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 440-448 . [Abstract] ( 120 ) [HTML 1KB] [PDF 0KB] ( 124 )

	449	Sai WL, Yao M, Shen SJ, Zheng WJ, Sun JY, Wu MN, Wang L, Yao DF
		Dynamic expression of hepatic GP73 mRNA and protein and circulating GP73 during hepatocytes malignant transformation ^Hot!
		Background: Hepatic Golgi protein-73 (GP73) expression is related to hepatocellular carcinoma (HCC) progression. The aim of this study was to investigate the dynamic expression of GP73 mRNA and protein during hepatocytes malignant transformation. Methods: Human GP73 expressions in 88 HCC tissues and their self-control surrounding tissues were examined by immunohistochemistry, and survival time of HCC patients was evaluated by the Kaplan-Meier method. HCC model of Sprague-Dawley rats was made by diet containing 2-fluorenylacetamide. The rats were divided into the control, hepatocyte degeneration, precanceration, and HCC groups to observe GP73 protein and mRNA alterations during hepatocytes malignant transformation. Results: The GP73 expression was significantly higher in the cancerous tissues than that in the surrounding tissues, with shorter survival time, and the positive rates of GP73 protein in human HCC tissues were 53.3% at stage I, 84.0% at stage II, 84.6% at stage III, and 60.0% at stage IV, respectively. The positive rates of hepatic GP73 protein and mRNA in the rat models were none in the control group, 66.7% and 44.4% in the hepatocytes degeneration group, 88.9% and 77.8% in the hepatocytes precanceration group, and 100% in the HCC group, respectively. There was a positive correlation ( r = 0.91, P < 0.01) between hepatic GP73 and serum GP73 during rat hepatocytes malignant transformation. Conclusions: Abnormal GP73 expression may be a sensitive and valuable biomarker in hepatocarcinogensis.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 449-454 . [Abstract] ( 137 ) [HTML 1KB] [PDF 0KB] ( 129 )

	455	Li ZT, Liu H, Zhang WQ
		NLRC3 alleviates hypoxia/reoxygenation induced inflammation in RAW264.7 cells by inhibiting K63-linked ubiquitination of TRAF6
		Background: NOD-like receptor family CARD domain containing 3 (NLRC3) plays an important role in both innate and adaptive immunity. This study was to explore the function and related mechanisms of NLRC3 in a hypoxia/reoxygenation (H/R)-induced inflammatory response in RAW264.7 cells. Methods: Liver ischemia-reperfusion (I/R) model in mice and H/R model in RAW264.7 cells were con- structed. Western blotting was used to determine the protein expression level of NLRC3 in liver tissue and NLRC3, TRAF6, p-p65, p65, I κB-α, and the K63-linked ubiquitination level of TRAF6 in cells. The immunofluorescence assay was performed to evaluate the nuclear level of the NF-κB (p65). ELISA was conducted to measure the content of IL-1 βin serum and cell supernatant. The interaction between NLRC3 and TRAF6 in cells was analyzed by the Co-IP assay. Results: The NLRC3 protein level in liver tissue was decreased with the prolongation of reperfusion time ( P < 0.05). The expression of NLRC3 and I κB-αprotein in RAW264.7 was decreased gradually, while the expression of p-p65 and TRAF6 proteins and K63-linked ubiquitination of TRAF6 were increased gradually with the prolongation of reoxgenation time ( P < 0.05). The Co-IP assay revealed that NLRC3 and TRAF6 can bind to each other directly. However, NLRC3 had no effect on the expression of TRAF6 protein. The ubiquitination test results showed that the K63-linked ubiquitination level of TRAF6 in H/R + Lv-NLRC3 group was significantly lower than that in the H/R + negative control (NC) group ( P < 0.05). Moreover, the activation of NF-κB in H/R + Lv–NLRC3 group was inhibited compared with that in the H/R + NC group, and the level of the inflammatory factor IL-1 βin the cell culture supernatant was also decreased accordingly ( P < 0.05). Conclusions: NLRC3 might alleviate H/R-induced inflammation in RAW264.7 cells by inhibiting K63-linked ubiquitination of TRAF6.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 455-460 . [Abstract] ( 125 ) [HTML 1KB] [PDF 0KB] ( 141 )

ORIGINAL ARTICLES/Biliary

	461	Jo IH, Kim YJ, Chung WC, Kim J, Kim S, Lim ES, Ahn H, Ryu SY
		Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections ^Hot!
		Background: The rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms. Methods: We performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia. Results: Gram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19–25.23; P = 0.029). Conclusions: Previous gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 461-466 . [Abstract] ( 126 ) [HTML 1KB] [PDF 0KB] ( 179 )

ORIGINAL ARTICLES/Pancreas

	467	Yan J, Zhou CX, Wang C, Li YY, Yang LY, Chen YX, Hu JJ, Li GH
		Risk factors for delayed hemorrhage after endoscopic sphincterotomy
		Background: Hemorrhage is one of the most serious complications of endoscopic sphincterotomy (EST). The risk factors for delayed hemorrhage are not clear. This study aimed to explore the risk factors for post-EST delayed hemorrhage and suggest some precautionary measures. Methods: This study analyzed 8477 patients who successfully underwent endoscopic retrograde cholangiopancreatography (ERCP) and EST between January 2007 and June 2015 in the First Affiliated Hospital of Nanchang University. Univariate and multivariate analyses were performed to find the risk factors for delayed hemorrhage after EST. Results: Of the 8477 patients screened, 137 (1.62%) experienced delayed hemorrhage. Univariate analysis showed that male, the severity of jaundice, duodenal papillary adenoma and carcinoma, diabetes, intraoperative bleeding, moderate and large incisions, and directional deviation of incision were risk factors for post-EST delayed hemorrhage ( P < 0.05). Multivariate analysis showed that intraoperative bleeding [odds ratio (OR) = 3.326; 95% CI: 1.785–6.196; P < 0.001] and directional deviation of incision (OR = 2.184; 95% CI: 1.266–3.767; P = 0.005) were independent risk factors for post-EST delayed hemorrhage. Conclusions: Delayed hemorrhage is the most common and dangerous complication of EST. Intraoperative bleeding and directional deviation of incision are independent risk factors for post-EST delayed hemorrhage.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 467-472 . [Abstract] ( 133 ) [HTML 1KB] [PDF 0KB] ( 143 )

	473	Yang Y, Liu RB, Liu Y, Jiang HJ
		Incidence and risk factors of pancreatitis in obstructive jaundice patients after percutaneous placement of self-expandable metallic stents
		Background: Percutaneous transhepatic biliary drainage is an alternative treatment for patients with malignant distal biliary obstruction. The aim of this study was to investigate the occurrence of pancreatitis in patients who had undergone percutaneous placement of a biliary stent and to assess the risk factors for pancreatitis and the treatment outcomes. Methods: From January 2010 to October 2016, 980 patients in our hospital who underwent percutaneous placements of self-expandable metallic stents for obstructive jaundice were retrospectively analyzed. The incidence of pancreatitis and risk factors were assessed by univariate and multivariate logistic regression analysis. Therapeutics, such as somatostatin, which were also adminstrated to release the symptom and promote the restoration of normal function of pancreas, were also analyzed. Results: Pancreatitis occurred in 45 (4.6%) patients. One patient died from severe acute pancreatitis. Multivariate logistic regression analysis showed that common bile duct stent placement was the only independent risk factor that related to pancreatitis (odds ratio = 2.096, 95% CI: 1.248–5.379; P = 0.002). By using somatostatin, the concentrations of serum amylase and lipase were decreased in 44 patients with pancreatitis. No major complications were found during the treatment. Conclusions: Pancreatitis is a relatively low complication of percutaneous placement of biliary stents. The common bile duct stent placement is the only independent risk factor that related to pancreatitis. In this case, the percutaneous transhepatic biliary drainage is a preferred method for treatment. Furthermore, somatostatin is a secure and efficacious method to release the symptom and promote the restoration of pancreatic function.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 473-477 . [Abstract] ( 115 ) [HTML 1KB] [PDF 0KB] ( 131 )

	478	Shimamoto N, Ito M, Chiba M, Honma S, Imazu H, Sumiyama K
		Antitumor effect of VEGFR2-targeted microbubble destruction with gemcitabine using an endoscopic ultrasound probe: In vivo mouse pancreatic ductal adenocarcinoma model ? ^Hot!
		Background: Ultrasound-targeted microbubble destruction (UTMD) induces cellular inflow of drugs at low intensity, while high intensity eradicates tumor vessels. Since vascular endothelial growth factor receptor 2 (VEGFR2) is highly expressed in pancreatic ductal adenocarcinoma (PDAC), VEGFR2-targeted microbub- ble (MB) might additionally increase the tissue specificity of drugs and thus improve antitumor effects. In addition, fixing the dual pulse intensity could maximize MB properties. This study evaluated the one-off (experiment 1) and cumulative (experiment 2) treatment effect of UTMD by regulating the dual pulse output applied to PDAC using VEGFR2-targeted MB. Methods: C57BL/6 mice inoculated with Pan-02 cells were allocated to five groups: VEGFR2-targeted MB + gemcitabine (GEM), VEGFR2-targeted MB, non-targeted MB + GEM, GEM, and control groups. After injection of GEM or GEM and either VEGFR2-targeted or non-targeted MB, UTMD was applied for several minutes at low intensity followed by high intensity application. In experiment 1, mice were treated by the protocol described above and then euthanized immediately or at the tumor diameter doubling time (TDT). In experiment 2, the same protocol was repeated weekly and mice were euthanized at TDT regardless of protocol completion. Histological analysis by CD31 and VEGFR2 staining provided microvascular density (MVD) and VEGFR2 expression along vessels (VEGFR2v) or intra/peripheral cells (VEGFR2c). Results: In experiment 1, TDT was significantly longer in the VEGFR2-targeted MB + GEM group compared to the non-targeted MB + GEM, GEM, and control groups, while the VEGFR2-targeted MB group showed no statistical significance. MVD and VEGFR2v in the immediate euthanasia was significantly lower in the VEGFR2-targeted MB + GEM and VEGFR2-targeted MB groups than other conditions. In experiment 2, the VEGFR2-targeted MB + GEM group produced significantly longer TDT than the GEM or control groups, whereas the VEGFR2-targeted MB group showed no significant difference. Histology revealed significantly reduced VEGFR2v and VEGFR2c in the VEGFR2-targeted and non-targeted MB + GEM groups, while only VEGFR2v was significantly less in the VEGFR2-targeted MB group. Conclusions: UTMD-mediated GEM therapy with the dual pulse application using VEGFR2-targeted MB substantially suppresses PDCA growth.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 478-485 . [Abstract] ( 126 ) [HTML 1KB] [PDF 0KB] ( 168 )

VIEWPOINTS

	486	Lou JM, Ren ZG, Li A, Rao BC, Yu ZJ
		Fecal microbiota transplantation has therapeutic effects on chronic hepatits B patients via altering composition of gut microbiota
		Chronic hepatits B (CHB) is an increasingly disturbing public health issue worldwide. Currently, interferon and oral antiviral drugs such as entecavir (ETV) or tenofovir disoproxil fumarate (TDF) are two internationally recognized drugs for the treatment of CHB. However, the HBeAg clearance or seroconversion rate is low even in patients with long-term antiviral therapy. Many patients have to increase the dosage of antiviral therapy drugs [1] . Intestinal microorganisms are confirmed to play an important role in the pathogenesis of different chronic liver diseases including CHB, and fecal microbiota transplantation (FMT) may be a novel treatment strategy for CHB.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 486-487 . [Abstract] ( 116 ) [HTML 1KB] [PDF 0KB] ( 107 )

	488	Pande R, Hodson J, Marudanayagam R, Mirza D, Isaac J, Roberts KJ
		Venous resection at pancreaticoduodenectomy can be safely performed in the presence of jaundice
		Venous resection at pancreaticoduodenectomy (PD) has established itself as a viable treatment for borderline resectable cancer, with equivalent survival to those patients undergoing PD for cancer without venous resection [1]. Thus surgery for these patients is clearly desirable, when possible, compared to palliative care. However, there is concern and debate about the safety of venous resection at PD [2]. There is a need to improve patient pathways, outcome and experience [3]. To this end, in patients who present with jaundice, it is clear that surgery without preoperative biliary drainage (PBD) reduces complications [4]. In 2015, our team introduced a ‘fast track’ program to routinely perform PD in the presence of jaundice [5]. This change of practice has become routine, with most patients now undergoing surgery without PBD. It is, however, unclear whether portal vein (PV) resection + PD is safe in the setting of jaundice. The aim of this study, therefore, was to compare outcomes and complications between patients with or without jaundice undergoing PD with associated resection of the superior mesenteric vein (SMV) and/or PV.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 488-491 . [Abstract] ( 123 ) [HTML 1KB] [PDF 0KB] ( 105 )

LETTERS TO THE EDITOR

	492	Gupta V
		Post-cholecystectomy bile leak is not always synonymous with acute bile duct injury: Need for reclassification
		Bile leak after laparoscopic cholecystectomy remains a significant cause of postoperative morbidity. Cystic duct stump is the most common site (~70%) of bile leak after cholecystectomy [1] . Incidence of bile leak from the cystic duct stump is 0.5%−3% which is higher (4%−7%) in cases with complicated gallstone disease (e.g. acute cholecystitis) [2] .
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 492-494 . [Abstract] ( 107 ) [HTML 1KB] [PDF 0KB] ( 143 )

	495	Tang R, Zhang XJ, Liao MJ, Li A, Zhao WP, Lu Q
		Optimized liver resection range and perioperative safety in patients with high levels of indocyanine green R15
		The indocyanine green (ICG) clearance test is an objective measurement of functional liver reserve (FLR) [1] . The liver can preserve normal functions with a 70%−80% functional liver volume resection [2] and the remnant is capable of regeneration. However, liver regenerative properties are affected by hepatitis, fatty liver, cirrhosis and damage caused by chemotherapy [3] . ICG combined with the Child-Pugh score are main criteria for evaluating FLR. A safe hepatectomy procedure requires the remnant liver to be 25%−30% of the normal volume. For patients with an indocyanine green retention rate at 15 min (ICG-R15) > 20%, segment liver resection, limited hepatectomy or tumor enucleation is recommended, but there has been no clear clarification of the essential remnant liver volume [4] . In China, the experts’ consensus of preoperative evaluation of liver reserve function incorporates ICGR15 tests. R SE [essential functional liver volume (EFLV)/standard liver volume (SLV)] is introduced to evaluate the safety of hepatectomy [5] . For patients with ICG-R15 levels between 20% and 30%, R SE = 80% and those with an ICG-R15 level range of 30%−40% or > 40%, safe surgeries like limited hepatectomy and tumorectomy are recommended [6] . There is a paucity of studies that focus on surgical safety for patients with an ICG-R15 > 20%. Herein we aimed to evaluate safe liver resections in these patients.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 495-498 . [Abstract] ( 118 ) [HTML 1KB] [PDF 0KB] ( 129 )

	499	Mercadal-Hally M, Vaidya S, Vilca-Melendez H, Heaton N, Dhawan A, Grammatikopoulos T
		Pancreatoblastoma: A rare indication for liver transplantation in children
		Pancreatoblastoma (PB) is one of the exocrine pancreatic tumors and the most common malignant pancreatic tumor in young children. Patients can present with abdominal distension, pain, fatigue, vomiting and failure to thrive. Exocrine pancreatic tumors usually affect patients between 1 and 8 years, with a median age of 5 years. There is a slight preponderance in males and those of Asian descent [1] . PB is considered to be embryonic in origin with moderately raised serum alpha-fetoprotein (AFP) levels [2] . Axial imaging is necessary to assess other organ involvement, a common complication in adult patients, but diagnosis is confirmed on tissue histology [3] . Complete surgical resection is the treatment of choice, if achievable. Indications for neoadjuvant systemic chemotherapy include large tumors that involve adjacent major blood vessels or other organs and metastatic disease [1] . Herein we report a pediatric case of PB with liver metastases who underwent liver transplantation for metastatic liver disease.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 499-501 . [Abstract] ( 116 ) [HTML 1KB] [PDF 0KB] ( 110 )

	502	Luo CF, Xu J, Lu YQ
		Hepatic abscess resulted from a toothpick piercing the gastric wall into the liver
		Foreign bodies’ ingestion is a common phenomenon, and most of the ingested foreign bodies pass through the gut uneventfully. In clinical practice, less than 1% of these patients develop complications such as gut wall penetration or perforation [1-3] . We present a rare complication of hepatic abscess secondary to the toothpick piercing the gastric wall into the liver. The abscess was successfully treated by endoscopic retrieval of the foreign body and empirical antibiotic therapy, without drainage or laparotomy.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 502-504 . [Abstract] ( 110 ) [HTML 1KB] [PDF 0KB] ( 108 )

	505	Donati M, Zanatta M, Basile F
		Is the Bismuth-Corlette IIIb stage really an unfavorable situation for resectability of Klatskin tumors? A critical appraisal
		We read with considerable interest the paper from Passeri et al. [1] questioning how the IIIb preoperative determination of a Klatskin tumor could be considered a risk factor for unresectability, and we could not refrain from making some critical recommendations about it.
		Hepatobiliary Pancreat Dis Int. 2020; 19(5): 505-506 . [Abstract] ( 114 ) [HTML 1KB] [PDF 0KB] ( 123 )

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