Hepatobiliary Pancreat Dis Int

	2021 Vol. 20 No. 4
	Published: 2021-08-15


	Pages 307-408
	META-ANALYSIS REVIEW ARTICLES ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas CLINICAL IMAGE LETTERS TO THE EDITOR VIEWPOINTS

META-ANALYSIS

	307	Gavriilidis P, Roberts KJ, de’Angelis N, Aldrighetti L, Sutcliffe RP
		Recurrence and survival following microwave, radiofrequency ablation, and hepatic resection of colorectal liver metastases: A systematic review and network meta-analysis ^Hot!
		Background: Gold standard for colorectal liver metastases (CRLM) remains hepatic resection (HR). However, patients with severe comorbidities, unresectable or deep-situated resectable CRLM are candidates for ablation. The aim of the study was to compare recurrence rate and survival benefit of the microwave ablation (MWA), radiofrequency ablation (RFA) and HR by conducting the first network meta-analysis. Data sources: Systematic search of the literature was conducted in the electronic databases. Both updated traditional and network meta-analyses were conducted and the results were compared between them. Results: HR cohort demonstrated significantly less local recurrence rate and better 3- and 5-year disease-free (DFS) and overall survival (OS) compared to MWA and RFA cohorts. HR cohort included significantly younger patients and with significantly lower preoperative carcinoembryonic antigen (CEA) by 10.28 ng/mL compared to RFA cohort. Subgroup analysis of local recurrence and OS of solitary and ≤ 3 cm CRLMs did not demonstrate any discrepancies when compared with the whole sample. Conclusions: For resectable CRLM the treatment of choice still remains HR. MWA and RFA can be used as a single or adjunct treatment in patients with unresectable CRLM and/or prohibitive comorbidities.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 307-314 . [Abstract] ( 129 ) [HTML 1KB] [PDF 0KB] ( 157 )

REVIEW ARTICLES

	315	Ezhilarasan D
		Mitochondria: A critical hub for hepatic stellate cells activation during chronic liver diseases ^Hot!
		Background: Upon liver injury, quiescent hepatic stellate cells (qHSCs), reside in the perisinusoidal space, phenotypically transdifferentiate into myofibroblast-like cells (MFBs). The qHSCs in the normal liver are less fibrogenic, migratory, and also have less proliferative potential. However, activated HSCs (aHSCs) are more fibrogenic and have a high migratory and proliferative MFBs phenotype. HSCs activation is a highly energetic process that needs abundant intracellular energy in the form of adenosine triphosphate (ATP) for the synthesis of extracellular matrix (ECM) in the injured liver to substantiate the injury. Data sources: The articles were collected through PubMed and EMBASE using search terms “mitochondria and hepatic stellate cells”, “mitochondria and HSCs”, “mitochondria and hepatic fibrosis”, “mitochondria and liver diseases”, and “mitochondria and chronic liver disease”, and relevant publications published before September 31, 2020 were included in this review. Results: Mitochondria homeostasis is affected during HSCs activation. Mitochondria in aHSCs are highly energetic and are in a high metabolically active state exhibiting increased activity such as glycolysis and respiration. aHSCs have high glycolytic enzymes expression and glycolytic activity induced by Hedgehog (Hh) signaling from injured hepatocytes. Increased glycolysis and aerobic glycolysis (Warburg effect) endproducts in aHSCs consequently activate the ECM-related gene expressions. Increased Hh signaling from injured hepatocytes downregulates peroxisome proliferator-activated receptor-γ expression and decreases lipogenesis in aHSCs. Glutaminolysis and tricarboxylic acid cycle liberate ATPs that fuel HSCs to proliferate and produce ECM during their activation. Conclusions: Available studies suggest that mitochondria functions can increase in parallel with HSCs activation. Therefore, mitochondrial modulators should be tested in an elaborate manner to control or prevent the HSCs activation during liver injury to subsequently regress hepatic fibrosis.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 315-322 . [Abstract] ( 146 ) [HTML 1KB] [PDF 0KB] ( 145 )

ORIGINAL ARTICLES/Transplantation

	323	Schettini AV, Llado L, Heimbach JK, Costello JG, Tranang M, Van Caenegem O, Daly RC, Van den Bergh P, Casasnovas C, Fabregat J, Poterucha JJ, Foguenne M, Ericzon BG, Lerut J
		Symptomatic Val122del mutated hereditary transthyretin amyloidosis: Need for early diagnosis and prioritization for heart and liver transplantation ^Hot!
		Background: Hereditary transthyretin (ATTRv) amyloidosis is an autosomal dominant disease linked to transthyretin gene mutations which cause instability of the transthyretin tetramer. After dissociation and misfolding they reassemble as insoluble fibrils (i.e. amyloid). Apart from the common Val30Met mutation there is a very heterogeneous group of non-Val30Met mutations. In some cases, the clinical picture is dominated by a rapidly evolving restrictive and hypertrophic cardiomyopathy. Methods: A case series of four liver recipients with the highly clinically relevant, rare and particularly aggressive Val122del mutation is presented. Medical and surgical therapeutic options, waiting list policy for ATTRv-amyloidosis, including the need for heart transplantation, and status of heart-liver transplantation are discussed. Results: Three patients needed a staged (1 patient) or simultaneous (2 patients) heart-liver transplant due to rapidly progressing cardiac failure and/or neurologic disability. Domino liver transplantation was impossible in two due to fibrotic hepatic transformation caused by cardiomyopathy. After a follow-up ranging from 3.5 to 9.5 years, cardiac (allograft) function was maintained in all patients, but neuropathy progressed in three patients, one of whom died after 80 months. Conclusions: This is the first report in (liver) transplant literature about the rare Val122del ATTRv mutation. Due to its aggressiveness, symptomatic patients should be prioritized on the liver and, in cases with cardiomyopathy, heart waiting lists in order to avoid the irreversible neurological and cardiac damage that leads to a rapid lethal outcome.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 323-329 . [Abstract] ( 130 ) [HTML 1KB] [PDF 0KB] ( 169 )

ORIGINAL ARTICLES/Liver

	330	Gao TM, Bai DS, Qian JJ, Zhang C, Jin SJ, Jiang GQ
		The growth rate of hepatocellular carcinoma is different with different TNM stages at diagnosis
		Background: Hepatocellular carcinoma (HCC) progresses fast and has a poor prognosis, but the growth rate in different TNM stages is not clear. The present study was to estimate the growth rate of HCC with different TNM stages at diagnosis. Methods: Baseline demographics and tumor characteristics were analyzed for 10145 patients in Surveillance, Epidemiology, and End Results (SEER) Program-registered HCC. Multiple linear regression models were used for age adjustment with patient race, sex, marital status, and HCC grade. Results: The age at diagnosis was younger in Caucasians and males. The adjusted average age of patients with stage I HCC was 65.26 years. The adjusted age of patients with stage II, IIIA, IIIB, and IIIC was -0.17, -0.25, -0.29, and -0.55 adjusted-year younger compared with patients with stage I HCC (all P < 0.001). The adjusted average age of patients with T1 was 65.26 years. The age adjustment was -0.17, -0.26, and -0.55 respectively (all P < 0.001) for T2, T3 or T4 tumors without distant metastases. Conclusions: These findings demonstrated that the more advanced the HCC stage at diagnosis, the younger the age at diagnosis and the faster the HCC growth from tumor occurrence.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 330-336 . [Abstract] ( 123 ) [HTML 1KB] [PDF 0KB] ( 151 )

	337	Zhang LH, Wang D, Li Z, Wang G, Chen DB, Cheng Q, Hu SH, Zhu JY
		Overexpression of anillin is related to poor prognosis in patients with hepatocellular carcinoma
		Background: Anillin (ANLN) is required for tumor growth. It has been proven that knockdown of ANLN effectively reduces the occurrence of hepatocellular carcinoma (HCC) in transgenic mice. However, the functional role of ANLN in HCC patients remains to be elucidated. Methods: Both microarray and TCGA project were used for the analyses of ANLN expression and regu- lation in HCC. The effect of ANLN on proliferation and cell cycle was detected by CCK-8, colony formation assay and flow cytometry. ANLN expression was measured by immunohistochemistry. Correlation between ANLN expression and clinicopathological features was assessed by Pearson Chi-square test and 5-year overall survival after liver resection was evaluated by Kaplan-Meier method. Results: Increased copy number, decreased methylation levels in the CpG island and upregulated histone hypermethylation of ANLN were found in HCC. Knockdown of ANLN inhibited proliferation and induced G2/M phase arrest in SMMC-7721 cells. ANLN was mainly expressed in the nucleus and showed significantly higher expression levels in cancerous tissues than those in paired adjacent tissues. Moreover, nuclear ANLN expression levels in HCC metastases were significantly higher than those in primary HCC. The results of Cox proportional hazards regression model suggested that ANLN nuclear expression in HCC was an independent risk factor for poor 5-year overall survival of patients after liver resection. Conclusions: ANLN is a potential therapeutic target for HCC. Patients with nuclear ANLN overexpression in HCC tissue may need adjuvant therapy after liver resection.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 337-344 . [Abstract] ( 116 ) [HTML 1KB] [PDF 0KB] ( 151 )

	345	Zhang MY, Jiang HJ, Jiang H, Zhang RJ, Wang ZC
		Micro-positron emission tomography imaging of angiogenesis based on (18)F-RGD for assessing liver metastasis of colorectal cancer
		Background: Positron emission tomography (PET) imaging is a non-invasive method to visualize and quantify the tumor microenvironment. This study aimed to explore the feasibility of 18 F-AIF-NOTA- E[PEG 4 -c(RGDfk)] 2 (denoted as 18 F-RGD) PET quantitative parameters to distinguish the angiogenesis in colorectal cancer (CRC) mice which has different metastatic potential. Methods: Twenty LoVo and twenty LS174T of CRC liver metastases animal models were established by implantation of human CRC cell lines via intrasplenic injection. Radiotracer-based micro-PET imaging of animal model was performed and the uptake of 18 F-RGD tracer in the tumor tissues was quantified as tumor-to-liver maximum or mean standardized uptake value (SUVmax or SUVmean) ratio. Pearson correlation was used to analyze the relationship between radioactive parameters and tumor markers. Results: The SUVmax and SUVmean ratios of LoVo model were significantly higher than those of LS174T in both liver metastasis and primary tumor lesions (P < 0.05). A significant difference was observed in both vascular endothelial growth factor (VEGF) and Ki67 expressions between LoVo and LS174T primary tumors (P < 0.05). The tumor-to-liver SUVmax or SUVmean ratio of 18 F-RGD showed a moderate correlation with VEGF expression (r = 0.5700, P = 0.001 and r = 0.6657, P < 0.001, respectively), but the SUVmean ration showed a weak correlation with Ki67 expression (r = 0.3706, P < 0.05). The areas under the receiver operating characteristic (ROC) curves of 18 F-RGD SUVmean ratio, SUVmax ratio for differentiating LoVo from LS174T tumor were 0.801 and 0.759, respectively. Conclusions: The tumor-to-liver SUVmean ratio of 18 F-RGD was a promising image parameter for the process of monitoring tumor angiogenesis in CRC xenograft mice model.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 345-351 . [Abstract] ( 140 ) [HTML 1KB] [PDF 0KB] ( 135 )

	352	Pu JL, Huang ZT, Luo YH, Mou T, Li TT, Li ZT, Wei XF, Wu ZJ
		Fisetin mitigates hepatic ischemia-reperfusion injury by regulating GSK3β/AMPK/NLRP3 inflammasome pathway ^Hot!
		Background: Hepatic ischemia-reperfusion (I/R) injury (IRI) represents a crucial challenge in liver transplantation. Fisetin has anti-inflammatory, anti-aging and anti-oxidative properties. This study aimed to examine whether fisetin mitigates hepatic IRI and examine its underlying mechanisms. Methods: Sham or warm hepatic I/R operated mice were pretreated with fisetin (5, 10 or 20 mg/kg). Hepatic histological assessments, TUNEL assays and serum aminotransferase measurements were performed. An in vitro hypoxia/reoxygenation (H/R) model using RAW264.7 macrophages pretreated with fisetin (2.5, 5 or 10 μmol/L) was also used. Serum and cell supernatant concentrations of interleukin-1β (IL-1β), IL-18 and tumor necrosis factor-α (TNF-α) were determined by enzyme-linked immunosorbent assay (ELISA). Protein levels of p-GSK3β, p-AMPK and NLR family pyrin domain-containing 3 (NLRP3)-associated proteins were detected by Western blotting. Results: Compared with the I/R group, fisetin pretreatment reduced pathological liver damage, serum aminotransferase levels, serum concentrations of IL-1β, IL-18 and TNF-α in the murine IRI model. Fisetin also reduced the expression of NLRP3 inflammasome-associated proteins (NLRP3, cleaved caspase-1, IL-1β and IL-18) in I/R-operated liver. The experiments in vitro showed that fisetin decreased the release of IL-1β, IL-18 and TNF-α, and reduced the expression of NLRP3 inflammasome-associated proteins in H/R-treated RAW264.7 cells. Moreover, fisetin increased the expressions of p-GSK3 βand p-AMPK in both models, indicating that its anti-inflammatory effects were dependent on GSK3β/AMPK signaling. The anti-inflammatory effects of fisetin were partially inhibited by the AMPK specific inhibitor compound C. Conclusions: Fisetin showed protective effects against hepatic IRI, countering inflammatory responses through mediating the GSK3β/AMPK/NLRP3 inflammasome pathway.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 352-360 . [Abstract] ( 203 ) [HTML 1KB] [PDF 0KB] ( 147 )

ORIGINAL ARTICLES/Biliary

	361	Oh DJ, Nam JH, Jang DK, Lee JK
		Complications of common bile duct stones: A risk factors analysis
		Background: The latest guidelines recommended that common bile duct stones (CBDSs) should be removed, preferably endoscopically, regardless of the presence of symptoms or complications. However, the removal of CBDSs may not be feasible in very old patients or those with co-morbidities. In these cases, it is important to understand the risk factors for the development of CBDSs-related complications to decide whether or not to treat high-risk patients. Herein, we aimed to identify the risk factors for the development of complications after the diagnosis of CBDSs. Methods: The medical records of patients with CBDSs between October 2005 and September 2019 were retrospectively analyzed. All patients with radiologically-diagnosed CBDSs, including those who received treatment and those who did not, were analyzed. Results: A total of 634 patients were included and 95 (15.0%) patients had CBDS-related complications during the mean follow-up period of 32.6 months. Forty-four (6.9%) high-risk patients remained asymptomatic and did not receive treatment during the follow-up period. In multivariate analyses, size of CBDSs ≥ 5 mm and no treatment within 30 days were independent risk factors for the development of complications. The spontaneous passage of CBDSs was proved radiologically in 9 out of 81 (11.1%) patients within 30 days. Conclusions: It is recommended treating CBDSs within 30 days from the diagnosis, even in high-risk patients, especially if the size is larger than 5 mm.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 361-365 . [Abstract] ( 143 ) [HTML 1KB] [PDF 0KB] ( 154 )

ORIGINAL ARTICLES/Pancreas

	366	Chang RJ, Wang HL, Qin MB, Liang ZH, He JP, Wei YL, Fu HZ, Tang GD
		Ghrelin inhibits IKKβ/NF-κB activation and reduces pro-inflammatory cytokine production in pancreatic acinar AR42J cells treated with cerulein
		Background: Previous studies have provided conflicting results regarding whether the serum ghrelin concentration can reflect the severity of acute pancreatitis (AP). The present study examined the correlation between the serum ghrelin concentration and AP severity in animal models and investigated whether altered ghrelin expression in pancreatic acinar cells influences IKKβ/NF-κB signaling and pro-inflammatory cytokine production. Methods: Mild or severe AP was induced in rats by intraperitoneal injection of cerulein or retrograde cholangiopancreatic duct injection of sodium taurocholate, respectively. After successful model induction, serum ghrelin, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) concentrations were determined by enzyme-linked immunosorbent assay, and IKKβ/NF-κB activation was assessed by immunohistochemistry. Subsequently, stable overexpression or knockdown of ghrelin in AR42J cells was achieved by lentiviral transfection. After transfected cells and control cells were treated with cerulein for 24 h, the TNF-α and IL-1β levels in the supernatants were determined by enzyme-linked immunosorbent assay, and the expression levels of p-p65, IKKβ, and p-IKKβ were detected by Western blotting. Results: In rat AP models, AP severity was correlated with increased IKKβ/NF-κB activation, pro-inflammatory cytokine production, and ghrelin secretion. The levels of pro-inflammatory cytokines TNF-α and IL-1β as well as IKKβ/NFκB signaling activity were increased upon knockdown of ghrelin in the AP acinar cell model and decreased with ghrelin overexpression. Conclusions: Serum ghrelin is related to the severity of AP. Ghrelin may play a protective role in the pathogenesis of AP by inhibiting the pro-inflammatory cytokines and the activation of the IKKβ/NF-κB signaling pathway.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 366-375 . [Abstract] ( 116 ) [HTML 1KB] [PDF 0KB] ( 161 )

	376	Daryabor G, Shiri EH, Amirghofran Z, Kamali-Sarvestani E
		In vitro-derived insulin-producing cells modulate Th1 immune responses and induce IL-10 in streptozotocin-induced mouse model of pancreatic insulitis
		Background: Insulitis is defined by the presence of immune cells infiltrating in the pancreatic islets that might progress into the complete β-cell loss. The immunomodulatory properties of bone marrow-derived mesenchymal stem cells (BM-MSCs) have attracted much attention. This study aimed to evaluate the possible immunomodulatory effects of rat BM-MSCs and MSCs-derived insulin-producing cells (IPCs) in a mouse model of pancreatic insulitis. Methods: Insulitis was induced in BALB/c mice using five consecuti ve doses of streptozotocin. MSCs or IPCs were directly injected into the pancreas of mice and their effects on the expression of Th subsets-related genes were evaluated. Results: Both BM-MSCs and IPCs significantly reduced the expression of pancreatic Th1-related IFN-γ (P < 0.001 and P < 0.05, respectively) and T-bet genes (both P < 0.001). Moreover, the expression of IL-10 gene was significantly increased in IPC-treated compared to BM-MSC- or PBS-treated mice (P < 0.001 both comparisons). Conclusions: BM-MSCs and IPCs could successfully suppress pathologic Th1 immune responses in the mouse model of insulitis. However, the marked increase in IL-10 gene expression by IPCs compared to BM-MSCs suggests that their simultaneous use at the initial phase of autoimmune diabetes might be a better option to reduce inflammation but these results need to be verified by further experiments.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 376-382 . [Abstract] ( 115 ) [HTML 1KB] [PDF 0KB] ( 163 )

CLINICAL IMAGE

	383	Zhang WL, Fang ZP, Shi BY, Chen T, Lv SD, Wang C, Hu P, Zhang FB
		Low-pressure pulse flushing choledochoscopy combined with neodymium laser lithotripsy for the treatment of intrahepatic bile duct stones
		Cholelithiasis is a common and frequently occurring disease in East Asia. Intrahepatic bile duct stone is a benign disease, but the recurrence rate is high. The incidence of postoperative residual stones after traditional manual stone removal can be 30%–96% [1]. The emergence of endoscopes is therefore a milestone in the treatment of hepatolithiasis. Among the various approaches, choledochoscopy combined with laser lithotripsy has become the main procedure for intrahepatic bile duct stone removal [2]. Lithotripsy alone has the disadvantages of low stoneremoving efficiency and blurred choledochoscope vision while performing the procedure. Currently, our team has achieved satisfactory results in the removal of intrahepatic bile duct stones with low-pressure pulse flushing and neodymium laser lithotripsy.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 383-386 . [Abstract] ( 110 ) [HTML 1KB] [PDF 0KB] ( 136 )

	387	Chierici A, Intotero M, Granieri S, Paleino S, Flocchini G, Germini A, Cotsoglou C
		Timely synergic surgical and radiological aggressiveness improves perioperative mortality after hemorrhagic complication in Whipple procedure
		Pancreaticoduodenectomy (PD) is a surgical procedure that exposes the patients to a wide range of postoperative complications that can also be lethal. Postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and postpancreatectomy hemorrhage (PPH) are among the most common. PPH has a lower incidence (3%−16%) [1] compared to POPF (3%−45%) [2] and DGE (19%−57%) [3], but it is burdened by a high mortality rate (16%−36%) [4,5]. The management of this complication is particularly demanding, and it needs the close cooperation of multidisciplinary teams: the pancreatic surgeon, the interventional radiologist, and the endoscopist. Although sometimes the severity of this condition seems overwhelming, the combination of multiple procedures can limit the morbidity and mortality related to PPH. The present study aimed to describe the postoperative course of a patient who underwent PD for periampullary adenocarcinoma at our institution and received three emergency laparotomies and three radiological procedures to successfully manage a grade C PPH.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 387-390 . [Abstract] ( 119 ) [HTML 1KB] [PDF 0KB] ( 158 )

	391	LeeW, Li X, Lee S, Chandan VS
		Primary pancreatic gastrointestinal stromal tumor
		Gastrointestinal stromal tumor (GIST) arises from the interstitial cells of Cajal (ICC) and is the most common mesenchymal tumor of the gastrointestinal tract, accounting for approximately 1%-2% of all malignant gastrointestinal tract tumors [1]. The most common sites of origin are stomach and small bowel. Rarely extra-gastrointestinal GISTs are reported originating from omentum, mesentery and retroperitoneum [2,3]. Primary pancreatic GIST is exceedingly rare with only approximately 50 reported cases [4–7]. The reported age for patients with primary pancreatic GIST ranges from 30 to 84 years, without sex predilection. The common clinical manifestations include dull abdominal pain, abdominal mass, bleeding/anemia and weight loss; however, some cases are diagnosed incidentally [4,8]. Here, we report a very rare case of primary pancreatic GIST presenting as a 6 cm solid mass with cystic component in the pancreatic head region.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 391-393 . [Abstract] ( 109 ) [HTML 1KB] [PDF 0KB] ( 129 )

	394	Kotha S, Berry P
		Hepatic, pancreatic and renal manifestations of a ciliopathy
		Hepatorenal fibrocystic diseases are inherited disorders, characterized by developmental abnormalities and fibrocystic degeneration of the portobiliary system and kidneys [1]. They are part of a larger group of disorders referred to as “ciliopathies” which affect 1 in 1000 people. Polycystic kidney disease is the most common kidney manifestation, while others include nephronophthisis, glomerulocystic disease and cystic dysplasia. Hepatic manifestations include Caroli’s disease, congenital hepatic fibrosis and polycystic liver disease.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 394-395 . [Abstract] ( 96 ) [HTML 1KB] [PDF 0KB] ( 131 )

VIEWPOINTS

	396	Varbobitis IC, Booth JC, Griffiths CL, Chandra N
		Practical guide to improving diagnostic sensitivity of bile duct brushings
		Despite recent advances in hepatopancreatobiliary (HPB) endoscopy, pancreatobiliary (PB) tract brushing remains the first diagnostic approach in cases of indeterminate PB strictures. An accurate cytological diagnosis is critical to establishing an early and definite diagnosis before proceeding to aggressive chemotherapy regimens or major operations like a Whipple’s procedure. Nevertheless, the value of PB brushings is compromised by the fact that they have been historically characterized by low and variable sensitivity [1] and considerable intra- and inter-observer variability [2]. In an attempt to achieve a more objective interpretation of brushing specimens, cytological assessments have employed standardized reporting systems such as the classification proposed by the Papanicolaou Society of Cytopathology [3] which suggests classifying the reports into the following sub-categories: non-diagnostic, negative, atypical, neoplastic (benign or other), suspicious and positive. Nevertheless, a significant proportion of cytological assessments will still be compromised by inherent challenges in several components involved in the processes of sampling, preparation, examination and interpretation of brush smears.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 396-399 . [Abstract] ( 103 ) [HTML 1KB] [PDF 0KB] ( 152 )

LETTERS TO THE EDITOR

	400	Liu JG, Wang J, Sun W, Zhang JJ, Wang YJ, Shu GM, Lou C, Du Z
		ALPPS in the treatment of liver cancer with insufficient future liver remnant
		In 2007, Schlitt firstly reported that the rapid compensatory increase of future liver remnant (FLR) after surgery can be achieved in a very short time which is known as a revolutionary breakthrough of liver surgery for huge or multiple liver cancer therapy [1]. de Santibañes and Clavien later proposed the medical term "ALPPS" [2]. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was mainly used for treating colorectal liver metastases (CRLM) and consequently was considered an emerging surgical technique for hepatocellular carcinoma (HCC). Up to now, surgical resection is still the most common curative treatment for liver cancer [3]. HCC is the major primary liver cancer in China, and 85%–90% patients with HCC present different degrees of cirrhosis [4], while only about 15%–30% of them are eligible for radical resection [5]. The main reason is that patients are not able to tolerate large-scale hepatectomy or one-stage radical hepatectomy due to the insufficient FLR after tumor resection. In recent years, ALPPS has emerged to win the surgical opportunity for patients with liver cancer who were initially considered unresectable. Also ALPPS prevents postoperative liver failure, especially for the patient who is not willing to receive a liver transplant.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 400-402 . [Abstract] ( 102 ) [HTML 1KB] [PDF 0KB] ( 137 )

	403	Shi XP, Lao DH, Xu Q, Zhang M, Lu YH, Gong Y, Wang T
		Vancomycin-induced acute kidney injury after liver transplantation
		Multidrug-resistant Gram-positive bacteria Staphylococcus aureus and Enterococcus species emerge as major pathogens after liver transplantation (LT). Although vancomycin remains the best choice of drug for treating those infections, it is associated with significant nephrotoxicity. Acute kidney injury (AKI) is a common complication in liver recipients due to a combination of factors related to the recipient, donor graft, intraoperative and posttransplant events. At present, no liver recipients have been enrolled in any study evaluating the nephrotoxicity of vancomycin. It remains mostly unexplored whether the special pathophysiological state during the perioperative period along with the concurrent use of nephrotoxic agents, affects vancomycin-induced AKI (VI-AKI). Moreover, the relationship between the initial trough concentration and the incidence of nephrotoxicity in liver recipients is uncertain. Therefore, it is necessary to explore the relationship between the initial vancomycin trough concentration and the incidence of nephrotoxicity in LT patients and analyze the extent to which the use of concurrent nephrotoxic medications contributes to VI-AKI.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 403-406 . [Abstract] ( 93 ) [HTML 1KB] [PDF 0KB] ( 136 )

	407	Yang MJ, Kim AR, Hwang JC, Yoo BM, Kim JH
		Long-type double-balloon enteroscopy-assisted ERCP using hand-made accessories in Roux-en-Y hepaticojejunostomy (with video)
		Short-type balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is becoming the procedure of choice for biliopancreatic disease treatment in patients with postoperative anatomy [1,2]. However, it has not yet been available in many countries. Although a long-type balloon enteroscope with a 200-cm working length has been widely used for small bowel endoscopy, its use for ERCP was limited by the lack of commercially available extra-long accessories [3]. We hereby describe the successful use of hand-made ERCP accessories for long-type doubleballoon enteroscopy (DBE)-assisted therapeutic ERCP in a case with Roux-en-Y hepaticojejunostomy reconstruction and recurrent bilioenteric anastomotic stricture. A 73-year-old woman presented to our emergency department with a 5-day history of progressive worsening of right upper quadrant pain and jaundice. She had undergone a bile duct segmental resection, cholecystectomy, and Roux-en-Y hepaticojejunostomy 10 years prior for high-grade dysplasia of the common hepatic duct, and a percutaneous transhepatic cholangioscopy and balloon dilation 3 years prior for a benign bilioenteric anastomotic stricture and hepatolithiasis. Abdominal computed tomography showed focal wall thickening at the hepaticojejunostomy anastomotic site and diffuse dilation of the intrahepatic bile duct, which suggested a recurrent anastomotic stricture. Balloon dilation, bile duct clearance, and multiple plastic stenting through long-type DBE-assisted ERCP were indicated. Hand-made ERCP accessories with working length ≥ 230 cm were prepared before the ERCP procedures.
		Hepatobiliary Pancreat Dis Int. 2021; 20(4): 407-408 . [Abstract] ( 100 ) [HTML 1KB] [PDF 0KB] ( 132 )

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