Hepatobiliary Pancreat Dis Int

	2021 Vol. 20 No. 1
	Published: 2021-02-15


	Pages 1-102
	EDITORIAL ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas CLINICAL IMAGE LETTERS TO THE EDITOR VIEWPOINTS

EDITORIAL

	1	Jegatheeswaran S, Geraghty J, Siriwardena AK
		Multidisciplinary management of patients with post-inflammatory pancreatic necrosis
		Current knowledge of the pathophysiology of acute pancreatitis indicates that pancreatic injury originates at the acinar cell level and then extends through a spectrum of damage ranging from mild peri-acinar inflammatory infiltration and edema to extensive pancreatic parenchymal and peri-pancreatic necrosis [1,2]. Clinical acute pancreatitis correlates closely with this range of injury with the majority of patients experiencing mild disease, some having transient organ dysfunction which typically recovers after adequate resuscitation (moderate acute pancreatitis) and a variable minority exhibiting sustained organ failure together with radiological evidence of pancreatic necrosis (severe acute pancreatitis) [2,3]. Worldwide, the management of this latter category of patients with severe acute pancreatitis remains a challenge. There is no effective direct medical treatment and there is no role for early pancreatic debridement [3,4]. This article provides a concise summary of current multidisciplinary management of patients with post-inflammatory pancreatic necrosis.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 1-3 . [Abstract] ( 116 ) [HTML 1KB] [PDF 0KB] ( 151 )

	4	Lai Q, Vitale A
		BCLC staging system and liver transplantation: From a stage to a therapeutic hierarchy
		The Barcelona Clinic Liver Cancer (BCLC) system was proposed in 1999 with the intent to improve a therapeutic algorithm for the management of patients with hepatocellular carcinoma (HCC) [1]. Both the European and the American Guidelines on the Treatment of HCC have endorsed the BCLC as the standard staging algorithm with prognostic and therapeutic implications [2,3].
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 4-5 . [Abstract] ( 113 ) [HTML 1KB] [PDF 0KB] ( 148 )

ORIGINAL ARTICLES/Transplantation

	6	Otto G, Pitton MB, Hoppe-Lotichius M, Weinmann A
		Liver transplantation and BCLC classification: Limitations impede optimum treatment ^Hot!
		Background: The Barcelona Clinic Liver Cancer (BCLC) system has been endorsed by international guidelines as a staging algorithm of hepatocellular carcinoma. This analysis was performed to assess the outcome of liver transplantation in patients treated against the BCLC recommendations. Methods: The data of 198 patients who underwent liver transplantation for hepatocellular carcinoma were extracted from a prospectively maintained database to classify the patients according to the BCLC system. Results: BCLC staging was as follows: 0, n = 5; A, n = 77; B, n = 41; C, n = 53; and D, n = 22. Accordingly, liver transplantation was performed in the majority of patients against BCLC recommendations. Surgery (n = 16), radiofrequency ablation (n = 15) and transarterial chemoembolization (n = 151) preceded liver transplantation in 182 patients. Sixteen patients were transplanted without pretreatment. The 1-, 5- and 10-year survival rates were 83.8%, 62.4% and 45.9%, and 1-, 5-, and 10-year recurrence rates were 7.7%, 22.7% and 26.7%. The BCLC classification did neither impact survival (P = 0.796) nor recurrence (P = 0.693). In the Cox analysis, RECIST tumor progression and initial alpha fetoprotein were independent predictors of outcome. Conclusions: Neither the oncological nor the functional stratification imposed by the BCLC system was of importance for outcome. Lack of flexibility and disregard of biological parameters hamper its clinical applicability in liver transplantation.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 6-12 . [Abstract] ( 113 ) [HTML 1KB] [PDF 0KB] ( 167 )

ORIGINAL ARTICLES/Liver

	13	Zhou Q, Cai H, Xu MH, Ye Y, Li XL, Shi GM, Huang C, Zhu XD, Cai JB, Zhou J, Fan J, Ji Y, Sun HC, Shen YH
		Do the existing staging systems for primary liver cancer apply to combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma? ^Hot!
		Background: The incidence of combined hepatocellular carcinoma-intrahepatic cholangiocarcinoma (cHCC-ICC) is relatively low, and the knowledge about the prognosis of cHCC-ICC remains obscure. In the study, we aimed to screen existing primary liver cancer staging systems and shed light on the prognosis and risk factors for cHCC-ICC. Methods: We retrospectively reviewed 206 cHCC-ICC patients who received curative surgical resection from April 1999 to March 2017. The correlation of survival measures with the histological types or with tumor staging systems was determined and predictive values of tumor staging systems with cHCC-ICC prognosis were compared. Results: The histological type was not associated with overall survival (OS) ( P = 0.338) or disease-free survival (DFS) ( P = 0.843) of patients after curative surgical resection. BCLC, TNM for HCC, and TNM for ICC stages correlated with both OS and DFS in cHCC-ICC (all P < 0.05). The predictive values of TNM for HCC and TNM for ICC stages were similar in terms of predicting postoperative OS ( P = 0.798) and DFS ( P = 0.191) in cHCC-ICC. TNM for HCC was superior to BCLC for predicting postoperative OS ( P = 0.022) in cHCC-ICC. Conclusion: The TNM for HCC staging system should be prioritized for clinical applications in predicting cHCC-ICC prognosis.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 13-20 . [Abstract] ( 106 ) [HTML 1KB] [PDF 0KB] ( 152 )

	21	Muhling T, Rohrbach H, Schepp W, Gundling F
		Overlap of concurrent extrahepatic autoimmune diseases is associated with milder disease severity of newly diagnosed autoimmune hepatitis
		Background: Concurrent extrahepatic autoimmune disorders (CEHAID) are frequently observed in autoimmune hepatitis (AIH). It is not clear whether there is any prognostic significance of CEHAID on AIH. The aim of this study was to examine the prognostic impact of CEHAID and the correlation with the disease severity of AIH. Methods: This study included 65 hospitalized subjects who fulfilled the accepted criteria for AIH during an 8-year period (2009–2016). All records were manually screened for presence of associated autoimmune diseases. Disease severity of AIH was assessed by liver laboratory tests including the ratio of aspartate aminotransferase to alanine aminotransferase (AST/ALT) and liver histology. Results: Among the enrolled patients, 52 (80%) were female (median age 61 years, IQR 45–75). Fifty-six (86.2%) were classified as type-1 AIH. In 26 (40%) patients at least one additional extrahepatic autoimmune disease was diagnosed. Thirty-four subjects were referred to our hospital because of acute presentation of AIH (supposed by an acute elevation of hepatic enzymes) for subsequent liver biopsy resulting in initial diagnosis of AIH. This group was stratified into 3 subgroups: (A) AIH alone (n = 14); (B) overlap with primary biliary cirrhosis (PBC) / primary sclerosing cholangitis (PSC) (n = 11); and (C) with CEHAID (n = 9). AST/ALT ratio was the lowest in subgroup C (median 0.64, IQR 0.51–0.94; P = 0.023), compared to subgroup A (median 0.91, IQR 0.66–1.10) and subgroup B (median 1.10, IQR 0.89–1.36). Patients with AIH alone showed a trend to the highest grade of fibrosis (mean 2.3; 95% CI: 1.5–3.0) with no statistical significance compared to subjects with CEHAID (lowest grade of fibrosis; mean 1.5; 95% CI: 0.2–2.8; P = 0.380) whereas the ongoing inflammation was comparable. Conclusions: AST/ALT ratio and extent of fibrosis were lower in subjects with AIH and CEHAID, compared to subjects with only AIH. Therefore, the occurrence of CEHAID might be a predictor for lower disease severity of newly diagnosed acute onset AIH, possibly caused by an earlier diagnosis or different modes of damage.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 21-27 . [Abstract] ( 116 ) [HTML 1KB] [PDF 0KB] ( 160 )

	28	Alexandrescu ST, Croitoru AE, Grigorie RT, Tomescu DR, Droc G, Grasu MC, Popescu I
		Aggressive surgical approach in patients with adrenal-only metastases from hepatocellular carcinoma enables higher survival rates than standard systemic therapy
		Background: Although guidelines recommend systemic therapy even in patients with limited extrahepatic metastases from hepatocellular carcinoma (HCC), a few recent studies suggested a potential benefit for resection of extrahepatic metastases. However, the benefit of adrenal resection (AR) for adrenal-only metastases (AOM) from HCC was not proved yet. This is the first study to compare long-term outcomes of AR to those of sorafenib in patients with AOM from HCC. Methods: The patients with adrenal metastases (AM) from HCC were identified from the electronic records of the institution between January 2002 and December 2018. Those who presented AM and other sites of extrahepatic disease were excluded. Furthermore, the patients with AOM who received other therapies than AR or sorafenib were excluded. Results: A total of 34 patients with AM from HCC were treated. Out of these, 22 patients had AOM, 6 receiving other treatment than AR or sorafenib. Eventually, 8 patients with AOM underwent AR (AR group), while 8 patients were treated with sorafenib (SOR group). The baseline characteristics of the two groups were not significantly different in terms of age, sex, number and size of the primary tumor, timing of AM diagnosis, Child-Pugh and ECOG status. After a median follow-up of 15.5 months, in the AR group, the 1-, 3-, and 5-year overall survival rates (85.7%, 42.9%, and 0%, respectively) were significantly higher than those achieved in the SOR group (62.5%, 0% and 0% at 1-, 3- and 5-year, respectively) (P = 0.009). The median progression-free survival after AR (14 months) was significantly longer than that after sorafenib therapy (6 months, P = 0.002). Conclusions: In patients with AOM from HCC, AR was associated with significantly higher overall and progression-free survival rates than systemic therapy with sorafenib. These results could represent a starting-point for future phase II/III clinical trials.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 28-33 . [Abstract] ( 114 ) [HTML 1KB] [PDF 0KB] ( 172 )

	34	Yan Y, Luo YH, Zheng DF, Mu T, Wu ZJ
		Integrating transcriptomes and somatic mutations to identify RNA methylation regulators as a prognostic marker in hepatocellular carcinoma
		Background: RNA methylation modifying plays an important role in the occurrence and progression of a range of human cancers including hepatocellular carcinoma (HCC), which is characterized by a mass of genetic and epigenetic alterations. However, the treatment targeting these alterations is limited. Methods: We used comprehensive bioinformatics analysis to analyze the correlation between cancer-associated RNA methylation regulators and HCC malignant features in network datasets. Results: We identified two HCC subgroups (cluster 1 and 2), which had clearly distinct clinicopathological, biofunctional and prognostic characteristics, by consensus clustering. The cluster 2 subgroup correlated with malignancy of the primary tumor, higher tumor stage, higher histopathological grade and higher frequency of TP53 mutation, as well as with shorter survival when compared with cluster 1. Gene enrichment indicated that the cluster 2 correlated to the tumor malignancy signaling and biological processes. Based on these findings, an 11-gene risk signature was built, which not only was an independent prognostic marker but also had an excellent power to predict the tumor features. Conclusions: Our study indicated that RNA methylation regulators are vital for HCC malignant progression and provide an important evidence for RNA methylation, methylation regulators are actionable targets for anticancer drug discovery.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 34-45 . [Abstract] ( 100 ) [HTML 1KB] [PDF 0KB] ( 161 )

	46	Gu LH, Gu GX, Wan P, Li FH, Xia Q
		The utility of two-dimensional shear wave elastography and texture analysis for monitoring liver fibrosis in rat model
		Background: Liver fibrosis is a common pathological change caused by a variety of etiologies. Early diagnosis and timely treatment can reverse or delay disease progression and improve the prognosis. This study aimed to assess the potential utility of two-dimensional shear wave elastography and texture analysis in dynamic monitoring of the progression of liver fibrosis in rat model. Methods: Twenty rats were divided into control group (n = 4) and experimental groups (n = 4 per group) with carbon tetrachloride administration for 2, 3, 4, and 6 weeks. The liver stiffness measurement was performed by two-dimensional shear wave elastography, while the optimal texture analysis subsets to distinguish fibrosis stage were generated by MaZda. The results of elastography and texture analysis were validated through comparing with histopathology. Results: Liver stiffness measurement was 6.09 ± 0.31 kPa in the control group and 7.10 ± 0.41 kPa, 7.80 ± 0.93 kPa, 8.64 ± 0.93 kPa, 9.91 ± 1.13 kPa in the carbon tetrachloride induced groups for 2, 3, 4, 6 weeks, respectively (P < 0.05). By texture analysis, histogram and co-occurrence matrix had the most frequency texture parameters in staging liver fibrosis. Receiver operating characteristic curve of liver elasticity showed that the sensitivity and specificity were 95.0% and 92.5% to discriminate liver fibrosis and non-fibrosis, respectively. In texture analysis, five optimal parameters were selected to classify liver fibrosis and non-fibrosis. Conclusions: Two-dimensional shear wave elastography showed potential applications for noninvasive monitoring of the progression of hepatic fibrosis, even in mild fibrosis. Texture analysis can further extract and quantify the texture features in ultrasonic image, which was a supplementary to further visual information and acquired high diagnostic accuracy for severe fibrosis.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 46-52 . [Abstract] ( 123 ) [HTML 1KB] [PDF 0KB] ( 160 )

ORIGINAL ARTICLES/Biliary

	53	El Nakeeb A, Sultan A, Ezzat H, Attia M, Abd ElWahab M, Kayed T, Hassanen A, AlMalki A, Alqarni A, Mohammed MM
		Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study ^Hot!
		Background: Bile duct injury (BDI) after cholecystectomy remains a significant surgical challenge. No guideline exists to guide the timing of repair, while few studies compare early versus late repair BDI. This study aimed to analyze the outcomes in patients undergoing immediate, intermediate, and delayed repair of BDI. Methods: We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020. The patients were divided into three groups based on the time of BDI reconstruction. Group 1 underwent an immediate reconstruction (within the first 72 hours post-cholecystectomy, n = 156); group 2 underwent an intermediate reconstruction (from 4 days to 6 weeks post-cholecystectomy, n = 75), and group 3 underwent delayed reconstruction (after 6 weeks post-cholecystectomy, n = 181). Results: Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3. Favorable outcome was observed in 111 (71.2%) patients in group 1, 31 (41.3%) patients in group 2, and 157 (86.7%) patients in group 3 (P = 0.0001). Multivariate analysis identified that complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1, the use of external stent was an independent factor of favorable outcome in group 2, and level E4 BDI was an independent factor of unfavorable outcome in group 3. Transected BDI and level E4 BDI were independent factors of unfavorable outcome. Conclusions: Favorable outcomes were more frequently observed in the immediate and delayed recon- struction of post-cholecystectomy BDI. Complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of a favorable outcome.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 53-60 . [Abstract] ( 128 ) [HTML 1KB] [PDF 0KB] ( 169 )

	61	Hu FL, Chen HT, Guo FF, Yang M, Jiang X, Yu JH, Zhang FM, Xu GQ
		Biliary microbiota and mucin 4 impact the calcification of cholesterol gallstones
		Background: Cholesterol gallstones account for over 80% of gallstones, and the pathogenesis of gallstone formation involves genetic and environmental factors. However, data on the evolution of cholesterol gall- stones with various densities are limited. This study aimed to determine the roles of microbiota and mucins on the formation of calcified cholesterol gallstones in patients with cholelithiasis. Methods: Paired gallbladder tissues and bile specimens were obtained from cholelithiasis patients who were categorized into the isodense group and calcified group according to the density of gallstones. The relative abundance of microbiota in gallbladder tissues was detected. Immunohistochemistry and enzyme-linked immunosorbent assay were performed to detect the expression levels of MUC1, MUC2, MUC3a, MUC3b, MUC4, MUC5ac and MUC5b in gallbladder tissues and bile. The correlation of microbiota abundance with MUC4 expression was evaluated by linear regression. Results: A total of 23 patients with gallbladder stones were included. The density of gallstones in the isodense group was significantly lower than that of the calcified group (34.20 ± 1.50 vs. 109.40 ± 3.84 HU, P < 0.0001). Compared to the isodense group, the calcified group showed a higher abundance of gram-positive bacteria at the fundus, in the body and neck of gallbladder tissues. The concentrations of MUC1, MUC2, MUC3a, MUC3b, MUC5ac and MUC5b in the epithelial cells of gallbladder tissues showed no difference between the two groups, while the concentrations of MUC4 were significantly higher in the calcified group than that in the isodense group at the fundus (15.49 ±0.69 vs. 10.23 ±0.54 ng/mL, P < 0.05), in the body (14.54 ± 0.94 vs. 11.87 ± 0.85 ng/mL, P < 0.05) as well as in the neck (14.77 ± 1.04 vs. 10.85 ± 0.72 ng/mL, P < 0.05) of gallbladder tissues. Moreover, the abundance of bacteria was positively correlated with the expression of MUC4 (r = 0.569, P < 0.05) in the calcified group. Conclusions: This study showed the potential clinical relevance among biliary microbiota, mucins and calcified gallstones in patients with gallstones. Gram-positive microbiota and MUC4 may be positively associated with the calcification of cholesterol gallstones.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 61-66 . [Abstract] ( 125 ) [HTML 1KB] [PDF 0KB] ( 182 )

ORIGINAL ARTICLES/Pancreas

	67	Song CY, Shen Y, Lu YQ
		Role of routine check-up in the prognosis of patients with pancreatic cancer: A puzzling phenomenon
		Background: The high coverage of annual routine health check-up in China is a unique phenomenon throughout the world. However, its clinical value is controversial. In this cohort study, we chose pancreatic cancer as a disease model to explore the role of routine check-up in the prognosis of patients with pancreatic cancer. Methods: Data from 157 patients who were diagnosed with pancreatic cancer between January 2010 and April 2014 were collected. Patients were divided into two groups depending on how their disease was detected. Group A (n = 85): Patients were diagnosed with pancreatic cancer in clinic visits. Group B ( n = 72): Patients were diagnosed with pancreatic cancer in routine check-ups. We compared their prognosis. Results: The tumor stage in group B was earlier than that in group A. The 1-year survival rate in group B was significantly higher than that in group A (74.6% vs. 42.4%, P < 0.001), while the 3- and 5-year survival rates of the two groups showed no significant difference (P > 0.05). The difference of overall survival time between the two groups was not significant (22.0 vs. 9.0 months, P = 0.078). Conclusions: The stage of pancreatic cancer diagnosed in routine check-ups was earlier and therefore, the intervention was earlier which improved short-term survival rate. However, early intervention did not improve overall survival in the long-term.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 67-73 . [Abstract] ( 112 ) [HTML 1KB] [PDF 0KB] ( 182 )

	74	Peng JS, Morris-Stiff G, Ali NS, Wey J, Chalikonda S, El-Hayek KM, Walsh RM
		Neoadjuvant chemoradiation is associated with decreased lymph node ratio in borderline resectable pancreatic cancer: A propensity score matched analysis ^Hot!
		Background: Lymph node ratio (LNR) and margin status have prognostic significance in pancreatic cancer. Herein we examined the pathologic and clinical outcomes in patients with borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT) and pancreaticoduodenectomy. Methods: Patients who underwent treatment between January 1, 2012 and June 30, 2017 were included. Sequential patients in the BRPC group were compared to a propensity score matched cohort of patients with radiographically resectable pancreatic cancer who underwent upfront surgical resection. The BRPC group was also compared to sequential patients with radiographically resectable pancreatic cancer who required vein resection (VR) during upfront surgery. Results: There were 50 patients in the BRPC group, 50 patients in the matched control group, and 38 patients in the VR group. Negative margins (R0) were seen in 72%, 64%, and 34% of the BRPC, control, and VR groups, respectively (P = 0.521 for BRPC vs. control; P = 0.002 for BRPC vs. VR), with 24% of the BRPC group requiring a vascular resection. Nodal stage was N0 in 64%, 20%, and 18% of the BRPC, control, and VR groups, respectively (P < 0.001 for BRPC vs. control or VR). When nodal status was stratified into four groups (N0, or LNR ≤0.2, 0.2–0.4, ≥0.4), the BRPC group had a more favorable distribution (P < 0.001). The median overall survival were 28.8, 38.6, and 19.0 months for the BRPC, control, and VR groups, respectively (log-rank P = 0.096). Conclusions: NAT in BRPC was associated with more R0 and N0 resections and lower LNR compared to patients undergoing upfront resection for resectable disease.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 74-79 . [Abstract] ( 119 ) [HTML 1KB] [PDF 0KB] ( 147 )

CLINICAL IMAGE

	80	Zhang XX, Zhu JQ, Zhang H, Kou JT, Ma J, He Q
		Resection of a retrohepatic leiomyosarcoma of the inferior vena cava combined with caudate lobectomy and reconstruction with an allogenic vein
		Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare disease, accounting for 0.5% of soft tissue sarcomas in adults [1] . A diversity of therapeutic methods have been applied to treat this type of tumor. The average survival time of patients who are not treated is merely 3-4 months [2] . The effect of radiotherapy and chemotherapy remains unclear and controversial [3] . On the other hand, the en-bloc resection with negative margins may be the only potentially curative treatment and therefore, can contribute to the long-term survival of the patients [4] . During the operation, a reconstruction graft for the defected IVC needs to be chosen [5] as the graft-related complications are the surgeons’ major concern, which include graft thrombosis and infection [6] . Growing evidence has suggested that an allogeneic vein from donation after brain death or cardiac death is a better choice to avoid these complications [7] . An allogeneic vein has been reported to be safely used in patients with pancreatic cancer in case of the portal vein and/or superior mesenteric vein invasion [8] . A cryopreserved allograft can even be applied in the management of native and prosthetic aortic infections [7] . Herein, we present a case of resection of a retrohepatic leiomyosarcoma of the IVC combined with partial caudate lobectomy and reconstruction with an allogeneic vein.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 80-82 . [Abstract] ( 121 ) [HTML 1KB] [PDF 0KB] ( 157 )

	83	Zhang JY, Luo Y, Liu F, Li B
		Hepatic isolated ectopic adrenocortical adenoma mimicking metastatic liver tumor
		A 55-year-old male had surgery for colon cancer in December 2017. A mass was found in the right posterior lobe of his liver in January 2019. There was no previous history of hepatitis, and all tumor markers were within normal ranges. Ultrasound examination found a 2.0 × 1.7 cm hypoechoic nodule with unclear boundaries and regular shape in hepatic segment VII. Contrast-enhanced ultrasound (CEUS) displayed hyperenhancement in the arterial phase and wash-out in the early portal phase, and the delayed phase was hypoenhanced (Fig. 1 ). Contrast-enhanced computed tomography (CECT) presented a 1.5 cm slightly enhanced hepatic mass in the arterial phase and rim-enhancement in the portal phase (Fig. 2 A-C). Magnetic resonance imaging (MRI) showed high intensity on T2W fat-suppressed scan and peripheral hyperintensity on contrast-enhanced T1W portal phase with no uptake of the contrast agent during the delayed phase (Fig. 2 D-F), and diffusion weight was restricted in the right posterior upper hepatic segment. Preoperative diagnosis was metastatic carcinoma of the liver.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 83-86 . [Abstract] ( 106 ) [HTML 1KB] [PDF 0KB] ( 163 )

	87	Jovanovic MM, Saponjski D, Stefanovic AD, Jankovic A, Milosevic S, Stosic K, Knezevic D, Kovac J
		Giant pseudoaneurysm of the splenic artery within walled of pancreatic necrosis on the grounds of chronic pancreatitis
		Chronic pancreatitis is a long-standing inflammation of the pancreas, characterized by progressive inflammatory and fibrotic changes, resulting in permanent structural damage of pancreatic parenchyma [1] . Pancreatitis (chronic or acute) is the primary risk factor for pseudo-splenic artery aneurysms, along with pancreatic pseudocysts and trauma. As the disease progresses, patients with chronic pancreatitis may develop complications due to exocrine and endocrine pancreatic functional loss, such as fat malabsorption with steatorrhea, glucose intolerance, and ultimately diabetes mellitus [1,2] . Furthermore, severe pancreatic inflammation can cause weakening of vessel walls, with subsequent formation of arterial pseudoaneurysms. Splenic artery is the most commonly affected visceral artery [2,3] . Liver cirrhosis, portal hypertension, liver transplantation, atherosclerosis, hypertension, pregnancy and multiparity are main risk factors for true splenic artery aneurysms [2]. Rupture and intraperitoneal bleeding is the cause of death in 30%−50% of patients. Thus, prompt diagnosis and appropriate treatment are of great clinical importance [4,5] . Herein, we present a case of a giant splenic artery pseudoaneurysm within a walled of necrosis involving pancreatic parenchyma, as a complication of long standing chronic pancreatitis.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 87-89 . [Abstract] ( 115 ) [HTML 1KB] [PDF 0KB] ( 147 )

VIEWPOINTS

	90	Bianco G, Pascale MM, Frongillo F, Nure E, Agnes S, Spoletini G
		Transjugular portosystemic shunt for early-onset refractory ascites after liver transplantation
		Liver transplantation (LT) is the most effective treatment for end-stage liver disease and complications of portal hypertension (PHT). However, PHT can relapse as a consequence of viral, alcoholic or metabolic chronic liver disease (CLD) recurrence, rejection, vascular abnormalities, small-for-size syndrome and technical complications (e.g., portal or hepatic veins stenosis and/or thrombosis) [1] .
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 90-93 . [Abstract] ( 120 ) [HTML 1KB] [PDF 0KB] ( 169 )

LETTERS TO THE EDITOR

	94	Zhang PP, She XG, Cheng K, Liu H, Niu Y, Ming YZ
		Liver transplantation for liver failure in kidney transplantation recipients with hepatitis B virus infection
		Worldwide, approximately 400 million patients have chronic hepatitis B virus (HBV) infection [1] . Because of the high incidence of HBV in China, the incidence of HBV infection in uremia and kidney transplantation (KTx) patients is 2.5% and 2.7%, respectively [2] . Since the first successful organ transplant conducted between twins in 1954, refined surgical techniques, improved immunosuppressive protocols, and improved perioperative management of transplant patients have resulted in improved patient and graft survivals following K Tx [3] . However, the K Tx community is now challenged with liver failure due to the increased risk of HBV viral activation and replication induced by immunosuppressive therapy. Harnett et al. [4] highlighted that KTx recipients with HBV infection had lower 5-year survival (61%) than patients on dialysis (85%). Although these KTx recipients were treated with regular anti-HBV therapy, the incidence of liver failure was increased in KTx patients with HBV infection. Currently, isolated liver transplantation (LTx), sequential liver and kidney transplantation (SLKT), and combined liver and kidney transplantation (CLKT) are the optimal treatments for patients with liver failure and hepatorenal syndrome [5] . However, the outcomes of KTx recipients following isolated LTx, SLKT or CLKT for HBV-associated liver failure remain to be studied. Herein, we report our experience in ten HBV-positive KTx recipients with liver failure undergoing LTx.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 94-98 . [Abstract] ( 116 ) [HTML 1KB] [PDF 0KB] ( 172 )

	99	Tang R, Yu LH, Han JW, Lin JY, An JJ, Lu Q
		Abdominal drainage systems in modified piggyback orthotopic liver transplantation
		Whether orthotopic liver transplantation requires the placement of an abdominal drainage system is a controversial topic. A number of studies have suggested that prophylactic placement of abdominal drainage systems do not improve the diagnostic rate of complications such as bile leakage and hemorrhage after liver transplantation, even increased the risk of infection [1–3] . However, there is no uniform standard for the selection of drainage tube and how to place the drainage tube in orthotopic liver transplantation. The types and placement modes of the drainage tubes used in each center are different. If adequate drainage is not possible, it may affect the drainage efficiency, which may lead to the misunderstanding that “it is unnecessary to place the drainage tube”. Herein we aimed to explore the most efficient abdominal drainage in modified piggyback orthotopic liver transplantation, based on the types and placement modes of drainage tubes in our clinical practice.
		Hepatobiliary Pancreat Dis Int. 2021; 20(1): 99-102 . [Abstract] ( 111 ) [HTML 1KB] [PDF 0KB] ( 174 )

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