Hepatobiliary Pancreat Dis Int

	2022 Vol. 21 No. 3
	Published: 2022-06-15


	Pages 205-306
	EDITORIAL META-ANALYSIS REVIEW ARTICLES ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas NEW TECHNIQUES LETTERS TO THE EDITOR

EDITORIAL

	205	Soreide K
		Surgical exploration with non-resection in the setting of resectable, borderline and locally advanced pancreatic cancer
		Pancreatic cancer has an overall dismal prognosis compared to most other malignancies. In general, only about 15%-20% of patients are deemed upfront resectable at time of diagnosis, with a similar proportion presenting with either borderline or locally advanced disease [1]. Novel and more effective treatment regimens including FOLFIRINOX have made yet more patients become resectable, with up to 60% reported in some centers [2]. Technical advances in surgery continue to literally explore new anatomical territory [3]. More aggressive attitude towards resection of involved vessels has provided opportunity for curative attempt resections, even for a subpopulation of biological responders staged with pre-treatment unresectable disease [4,5]. However, while surgery is the dominant modality for a potential curative approach to pancreatic cancer, there is a subgroup of patients scheduled for surgery who ends up with an aborted resection during explorative laparotomy, also referred to as an “openclose laparotomy”. The reasons for such non-resection events are manyfold and have likely changed over time. Indeed, in one Italian study the non-resection rate remained constant at about 25% over two decades [6] . While many institutional series report nonresection rates in the same range, these figures may be influenced by patient selection, referral patterns and institutional policies towards resection and surgical aggressiveness [2,4,6].
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 205-206 . [Abstract] ( 99 ) [HTML 1KB] [PDF 0KB] ( 154 )

META-ANALYSIS

	207	Deprato A, Verhoeff K, Purich K, Kung JY, Bigam DL, Dajani KZ
		Surgical outcomes and quality of life following exercise-based prehabilitation for hepato-pancreatico-biliary surgery: A systematic review and meta-analysis ^Hot!
		Background: Hepato-pancreatico-biliary (HPB) patients experience significant risk of preoperative frailty. Studies assessing preventative prehabilitation in HPB populations are limited. This systematic review and meta-analysis evaluates outcomes for HPB patients treated with exercise prehabilitation. Data sources: A comprehensive search of MEDLINE (via Ovid), Embase (Ovid), Scopus, Web of Science Core Collection, Cochrane Library (Wiley), ProQuest Dissertations, Theses Global, and Google Scholar was conducted with review and extraction following PRISMA guidelines. Included studies evaluated more than 5 adult HPB patients undergoing ≥7-day exercise prehabilitation. The primary outcome was postopera- tive length of stay (LOS); secondary outcomes included complications, mortality, physical performance, and quality of life. Results: We evaluated 1778 titles and abstracts and selected 6 (randomized controlled trial, n = 3; prospective cohort, n = 1; retrospective cohort, n = 2) that included 957 patients. Of those, 536 pa- tients (56.0%) underwent exercise prehabilitation and 421 (44.0%) received standard care. Patients in both groups were similar with regards to important demographic factors. Prehabilitation was associated with a 5.20-day LOS reduction ( P = 0.03); when outliers were removed, LOS reduction decreased to 1.85 days and was non-statistically significant ( P = 0.34). Postoperative complications (OR = 0.70; 95% CI: 0.39 to 1.26; P = 0.23), major complications (OR = 0.83; 95% CI: 0.60 to 1.14; P = 0.24), and mortality (OR = 0.67; 95% CI: 0.17 to 2.70; P = 0.57) were similar. Prehabilitation was associated with improved strength, car- diopulmonary function, quality of life, and alleviated sarcopenia. Conclusions: Exercise prehabilitation may reduce LOS and morbidity following HPB surgery. Studies with well-defined exercise regimens are needed to optimize exercise prehabilitation outcomes.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 207-217 . [Abstract] ( 105 ) [HTML 1KB] [PDF 0KB] ( 83 )

	218	El Jamaly H, Eslick GD, Weltman M
		Primary biliary cholangitis in pregnancy: A systematic review with meta-analysis
		Background: The outcomes and disease associations in pregnant women with primary biliary cholangitis (PBC) have not been largely explored. This study aimed to determine the level of evidence associated with maternal and fetal outcomes and other disease associations in female patients with PBC. Data sources: A comprehensive literature search was conducted. Maternal and fetal outcomes were obtained from patients with a previous, current or subsequent diagnosis of PBC. A random-effects model was employed, using odds ratios (ORs) with 95% confidence intervals (CIs). Results: Eleven studies, with 2179 female PBC patients were included. Pregnant women with PBC were significantly more likely to have a miscarriage (OR = 1.27, 95% CI: 1.02-1.58; P = 0.03), and a history of abortion (OR = 1.50, 95% CI: 1.09-2.07; P = 0.01), with absent heterogeneity (I 2 = 0%). PBC pregnant women were significantly more likely to deliver via vaginal birth (OR = 1.69, 95% CI: 1.33-2.14; P < 0.001) with low level heterogeneity (I 2 < 0.001%). Patients had a statistically significant increased likelihood of lifetime smoking (OR = 1.95, 95% CI: 1.17-3.23; P = 0.01). Egger’s regression revealed no evidence of publication bias. Conclusions: This meta-analysis provides pooled evidence that a PBC pregnancy is associated with fetal morbidity and maternal lifestyle associations that may influence pregnancy outcomes. More studies are needed to establish disease associations that may directly affect pregnancy outcomes. These data are essential for clinicians managing these patients before, during or after pregnancy.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 218-225 . [Abstract] ( 88 ) [HTML 1KB] [PDF 0KB] ( 64 )

REVIEW ARTICLES

	226	Gavriilidis P, Edwin B, Pelanis E, Hidalgo E, de’Angelis N, Memeo R, Aldrighetti L, Sutcliffe RP
		Navigated liver surgery: State of the art and future perspectives ^Hot!
		Background: In recent years, the development of digital imaging technology has had a significant influence in liver surgery. The ability to obtain a 3-dimensional (3D) visualization of the liver anatomy has provided surgery with virtual reality of simulation 3D computer models, 3D printing models and more recently holograms and augmented reality (when virtual reality knowledge is superimposed onto reality). In addition, the utilization of real-time fluorescent imaging techniques based on indocyanine green (ICG) uptake allows clinicians to precisely delineate the liver anatomy and/or tumors within the parenchyma, applying the knowledge obtained preoperatively through digital imaging. The combination of both has transformed the abstract thinking until now based on 2D imaging into a 3D preoperative conception (virtual reality), enhanced with real-time visualization of the fluorescent liver structures, effectively facilitating intraoperative navigated liver surgery (augmented reality). Data sources: A literature search was performed from inception until January 2021 in MEDLINE (PubMed), Embase, Cochrane library and database for systematic reviews (CDSR), Google Scholar, and National Insti- tute for Health and Clinical Excellence (NICE) databases. Results: Fifty-one pertinent articles were retrieved and included. The different types of digital imaging technologies and the real-time navigated liver surgery were estimated and compared. Conclusions: ICG fluorescent imaging techniques can contribute essentially to the real-time definition of liver segments; as a result, precise hepatic resection can be guided by the presence of fluorescence. Furthermore, 3D models can help essentially to further advancing of precision in hepatic surgery by permitting estimation of liver volume and functional liver remnant, delineation of resection lines along the liver segments and evaluation of tumor margins. In liver transplantation and especially in living donor liver transplantation (LDLT), 3D printed models of the donor’s liver and models of the recipient’s hilar anatomy can contribute further to improving the results. In particular, pediatric LDLT abdominal cavity models can help to manage the largest challenge of this procedure, namely large-for-size syndrome.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 226-233 . [Abstract] ( 122 ) [HTML 1KB] [PDF 0KB] ( 71 )

	234	Fugazza A, Colombo M, Spadaccini M, Vespa E, Gabbiadini R, Capogreco A, Repici A, Anderloni A
		Relief of jaundice in malignant biliary obstruction: When should we consider endoscopic ultrasonography-guided hepaticogastrostomy as an option?
		Background: Since it was first described in 2001, endoscopic ultrasonography-guided biliary drainage (EUS-BD) has emerged as an alternative procedure for achieving an endoscopic internal drainage in case of endoscopic retrograde cholangiopancreatography (ERCP) failure. Biliary drainage can be achieved by ei- ther a transduodenal extrahepatic approach through EUS-guided choledochoduodenostomy (EUS-CDS), or a transgastric intrahepatic approach, namely EUS-guided hepaticogastrostomy (EUS-HGS) which already holds a remarkable place in the treatment of patients with malignant biliary obstruction. Data sources: For this review we did a comprehensive search of PubMed/MEDLINE from inception to May 31, 2021 for papers with a significant sample size (at least 20 patients enrolled) dealing with EUS-HGS. Data on technical success, clinical success and rate of adverse events were collected. Results: A total of 22 studies with different design, com prising 874 patients, were included. Technical success was achieved in about 96% of cases (ranging from 65% to 100%). Clinical success was obtained in almost 91% of cases (ranging from 76% to 100%). Overall rate of adverse events was 19% (ranging from 0% to 35%). Abdominal pain, self-limiting pneumoperitoneum, bile leak, cholangitis, bleeding, perforation and intraperitoneal migration of the stent were the most common. Conclusions: Despite both safety and efficacy profile, at the moment HGS still remains a challenging procedure at every single step and must therefore be conducted by a very experienced endoscopist in interventional EUS and ERCP procedures, who is able to deal with the possible severe adverse events of this procedure. A rapid introduction in clinical practice of dedicated devices is desiderable.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 234-240 . [Abstract] ( 98 ) [HTML 1KB] [PDF 0KB] ( 64 )

ORIGINAL ARTICLES/Liver

	241	Huh JH, Kim KJ, Kim SU, Cha BS, Lee BW
		Obesity is an important determinant of severity in newly defined metabolic dysfunction-associated fatty liver disease ^Hot!
		Background: The recently proposed definition of metabolic dysfunction-associated fatty liver disease (MAFLD) is based on the co-existence of hepatic steatosis with other metabolic disorders, including obesity and metabolic risk abnormalities such as hyperglycemia, high blood pressure and dyslipidemia. This study aimed to assess MAFLD severity according to the presence of metabolic abnormalities and obesity. Methods: Using transient elastography, hepatic steatosis and fibrosis severity were assessed by measuring the controlled attenuation parameter and liver stiffness measurement. A total of 1163 patients with MAFLD were categorized into the following four groups according to metabolic risk abnormalities and obesity presence: non-obese without metabolic risk abnormality group (Group 1; reference group); non-obese with metabolic risk abnormality group (Group 2); obese without metabolic risk abnormality group (Group 3); and obese with metabolic risk abnormality group (Group 4). A multiple logistic regression analysis was performed to determine severe hepatic steatosis and fibrosis risk in each group in both unadjusted and adjusted models. Results: In the adjusted model, the odds ratios (ORs) [95% confidence interval (CI)] for severe hepatic steatosis in Groups 2, 3, and 4 were 1.07 (0.61-1.88), 2.43 (1.44-4.08), and 4.07 (2.56-6.48), respectively (P trend < 0.001). For liver fibrosis, compared with Group 1, Group 2 showed no significant increases in OR, whereas Groups 3 and 4 (obese groups) showed significant increases (OR = 4.70, 95% CI: 1.24-17.82 and OR = 6.43, 95% CI: 1.88-22.02, respectively). Conclusions: Obesity, rather than metabolic abnormality, is the principal determinant of severe hepatic steatosis and fibrosis in patients with MAFLD.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 241-247 . [Abstract] ( 136 ) [HTML 1KB] [PDF 0KB] ( 66 )

	248	Liu HH, Wang J, Zhang Y, Fan YC, Wang K
		Prognostic potential of the small GTPase Ran and its methylation in hepatocellular carcinoma
		Background: Hepatocellular carcinoma (HCC) is a common malignant tumor with high mortality. The prognostic significance of Ran, a member of Ras superfamily, remains unclear in HCC patients. Methods: Based on The Cancer Genome Atlas (TCGA) database and Tumor Immune Estimation Resource (TIMER), we analyzed the correlations among Ran expression, promoter methylation and immune cell infiltration. We also investigated the Ran expression levels in HCC tissues and normal tissues by using quantitative real-time PCR. Results: Ran mRNA expression was significantly increased in HCC tissues compared with the normal tissues (P < 0.001). Time-dependent receiver operating characteristic (ROC) curves showed that Ran ex- pression had predictive value of the 1-, 3- and 5-year overall survival for HCC patients, and the areas under the curves (AUC) were 0.747, 0.634 and 0.704, respectively. Cox regression analysis showed that Ran expression was an independent prognostic factor for HCC patients (HR = 1.492, 95% CI: 1.129- 1.971, P = 0.005). We also found a negative relationship between Ran mRNA expression and its promoter methylation (r = -0.36, P < 0.001). High Ran expression and promoter hypomethylation predicted worse overall survival and progression-free survival (P < 0.05) and were involved in the progression of HCC. Ran expression exhibited significant correlations with immune infiltrates and prognostic immune-related genes. Conclusions: The present study provides further insight into the prognosis of HCC, and Ran could serve as a biomarker for predicting the survival of HCC patients
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 248-256 . [Abstract] ( 69 ) [HTML 1KB] [PDF 0KB] ( 61 )

	257	Lin LY, Tong YL, Lu YQ
		The characteristics of liver injury induced by Amanita and clinical value of alpha-amanitin detection
		Background: Amanita poisoning as a foodborne disease has raised concerning mortality issues. Reducing the interval between mushroom ingestion and medical intervention could greatly influence the outcomes of Amanita poisoning patients, while treatment is highly dependent on a confirmed diagnosis. To this end, we developed an early detection-guided intervention strategy by optimizing diagnostic process with performing α-amanitin detection, and further explored whether this strategy influenced the progression of Amanita poisoning. Methods: This study was a retrospective analysis of 25 Amanita poisoning patients. Thirteen patients in the detection group were diagnosed mainly based on α-amanitin detection, and 12 patients were di- agnosed essentially on the basis of mushroom consumption history, typical clinical patterns and mush- room identification (conventional group). Amanita poisoning patients received uniform therapy, in which plasmapheresis was executed once confirming the diagnosis of Amanita poisoning. We compared the de- mographic baseline, clinical and laboratory data, treatment and outcomes between the two groups, and further explored the predictive value of α-amanitin concentration in serum. Results: Liver injury induced by Amanita appeared worst at the fourth day and alanine aminotransferase (ALT) rose higher than aspartate aminotransferase (AST). The mortality rate was 7.7% (1/13) in the detection group and 50.0% (6/12) in the conventional group ( P = 0.030), since patients in the detection group arrived hospital much earlier and received plasmapheresis at the early stage of disease. The early detection-guided intervention helped alleviate liver impairment caused by Amanita and decreased the peak AST as well as ALT. However, the predictive value of α-amanitin concentration in serum was still considered limited. Conclusions: In the management of mushroom poisoning, consideration should be given to the rapid detection of α-amanitin in suspected Amanita poisoning patients and the immediate initiation of medical treatment upon a positive toxin screening result.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 257-266 . [Abstract] ( 74 ) [HTML 1KB] [PDF 0KB] ( 60 )

ORIGINAL ARTICLES/Biliary

	267	Yao WY, Wu XS, Liu SL, Wu ZY, Dong P, Gong W
		Preoperative lymphocyte to C-reactive protein ratio as a new prognostic indicator in patients with resectable gallbladder cancer
		Background: Inflammation is often related to cancer, and several inflammatory scores have been established to predict the prognosis of various types of cancer. Our study aimed to determine the prognostic value of the preoperative lymphocyte to C-reactive protein ratio (LCR) for predicting postoperative outcomes in patients with resectable gallbladder cancer (GBC). Methods: A retrospective analysis of 104 GBC patients who received curative surgery at Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine from January 20 0 0 to December 2016 was performed. A time-dependent receiver operating characteristic curve was constructed to evaluate the accuracy of different markers. Univariate and multivariate Cox proportional hazard models were used to define factors associated with overall survival. Results: Among the assessed variables, the preoperative LCR showed the highest accuracy in predicting the overall survival of GBC patients (AUC: 0.736). Decreased preoperative LCR was significantly associated with advanced tumor stage, including tumor invasion ( P = 0.018), lymph node metastasis ( P = 0.011) and TNM stage ( P = 0.022). A low preoperative LCR (cutoffthreshold = 145.5) was an independent risk factor for overall survival in patients with resectable GBC ( P < 0.001). Conclusions: The preoperative LCR is a novel and valuable prognostic indicator of postoperative survival in patients with resectable GBC.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 267-272 . [Abstract] ( 78 ) [HTML 1KB] [PDF 0KB] ( 62 )

	273	Chan KS, Hwang E, Low JK, Junnarkar SP, Huey CWT, Shelat VG
		On-table hepatopancreatobiliary surgical consults for difficult cholecystectomies: A 7-year audit
		Background: Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy. Methods: This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as “proactive”and “reactive”, where consults were made be- fore or after surgical incision, respectively. Patient demographics and perioperative details were collected. Results: The median age of the patients was 62.5 years [interquartile range (IQR) 50.8–71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4–7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4–6 mm). Median length of operation and length of stay were 165 min (IQR 124–209 min) and five days (IQR 3–7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann’s pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality. Conclusions: Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 273-278 . [Abstract] ( 71 ) [HTML 1KB] [PDF 0KB] ( 73 )

ORIGINAL ARTICLES/Pancreas

	279	Sahlstrom E, Bereza-Carlson P, Nilsson J, Tingstedt B, Andersson B
		Risk factors and outcomes for patients with pancreatic cancer undergoing surgical exploration without resection due to metastatic disease: A national cohort study ^Hot!
		Background: Unresectable disease is sometimes diagnosed during surgery in patients with pancreatic ductal adenocarcinoma (PDAC). This study aimed to identify preoperative risk factors for metastatic disease diagnosed at surgical exploration and to investigate and compare survival in resected and non-resected patients. Methods: Patients were identified from the Swedish National Pancreatic and Periampullary Cancer Registry 2010-2018. Predictors of metastatic disease were evaluated with a multivariable logistic regression model, and survival was evaluated with Kaplan-Meier estimates and log-rank tests. Results: In total, 1938 patients with PDAC were scheduled for surgery. An unresectable situation was diagnosed intraoperatively in 399 patients (20.6%), including 234 (12.1%) with metastasized disease. In-dependent risk factors for metastasis were involuntary weight loss (OR = 1.72; 95% CI: 1.27-2.33) and elevated carbohydrate antigen 19-9 (CA19-9) (35-599 U/mL, OR = 1.79, 95% CI: 1.11-2.89; ≥600 U/mL, OR = 3.24, 95% CI: 2.04-5.17). Overall survival was lower among patients with metastasized disease than that among patients with a resectable tumor ( P < 0.001). Conclusions: Involuntary weight loss and an elevation of CA19-9 are preoperative risk factors for diagnosing metastasized disease during surgical exploration.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 279-284 . [Abstract] ( 118 ) [HTML 1KB] [PDF 0KB] ( 70 )

	285	Chen MJ, Zheng RH, Cao J, Yao YL, Wang L, Zou XP
		Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) abdominal pain in patients without post-ERCP pancreatitis
		Background: Abdominal pain is often observed after endoscopic retrograde cholangiopancreatography (ERCP). Few studies have focused on the risk factors of post-ERCP abdominal pain without post-ERCP pancreatitis (PEP). This study aimed to identify risk factors of post-ERCP abdominal pain without PEP and investigate characteristics of the abdominal pain in non-PEP patients. Methods: Data from patients who underwent ERCP from August 2019 to January 2020 were retrospectively collected. Characteristics of the abdominal pain after ERCP were recorded and compared between PEP and non-PEP patients. Multivariate analysis was conducted to identify risk factors of non-PEP abdom- inal pain. Results: A total of 1295 ERCP procedures were investigated in this study, among which 100 (7.72%) patients presented post-ERCP abdominal pain without PEP and 63 (4.86%) patients with PEP. Multivariate analysis found 9 risk factors of non-PEP abdominal pain: age ≤65 years [odds ratio (OR): 1.971], primary ERCP (OR: 2.442), dilated extrahepatic bile duct (OR: 1.803), no papilla opening (OR: 2.095), pancreatic guidewire passages (OR: 2.258), white blood cells (WBC) ≤6.0 ×10 9 /L (OR: 1.689), platelet (PLT) ≤250 ×10 9 /L (OR: 2.505), serum γ-glutamyl transferase ( γ−GT ) ≤35 U/L (OR: 2.190), and albumin ≥40 g/L (OR: 1.762). The PEP group had later pain onset, higher pain frequency and longer hospital stay than those of the non-PEP pain group ( P < 0.05). There were no significant differences in the pain duration, visual analogue scale score and mortality between the PEP group and non-PEP pain group ( P > 0.05). Conclusions: This study indicated that age ≤65 years, primary ERCP, dilated extrahepatic bile duct, no papilla opening, pancreatic guidewire passages, lower WBC, lower PLT, normal γ−GT and elevated albu- min were independent risk factors for post-ERCP abdominal pain without PEP. The pain occurred earlier in non-PEP patients than in PEP patients.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 285-292 . [Abstract] ( 77 ) [HTML 1KB] [PDF 0KB] ( 68 )

NEW TECHNIQUES

	293	Zhang FM, Jiang X, Li S, Ning LG, Guo FF, Xu GQ
		Simplified calculation of bile cholesterol saturation index
		Gallstones (cholelithiasis) are masses in the gallbladder or biliary tract that are caused by abnormally high levels of either cholesterol or bilirubin in bile [1]. It is a multifactorial disease and the main pathogenesis is the increased secretion of bile cholesterol, which can increase the cholesterol saturation index (CSI) of bile. Patients with CSI greater than 1 are more likely to develop gallstones. Bile is a kind of dark green to yellowish-brown liquid containing > 90% water. Cholesterol, lecithin and bile salts are the three main lipid species in bile and combined to form the main components of gallstones [1].
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 293-294 . [Abstract] ( 100 ) [HTML 1KB] [PDF 0KB] ( 161 )

LETTERS TO THE EDITOR

	295	Yang Z, Sun JQ, Wang S, Zhuang L, Zheng SS
		Response to pretransplant downstaging therapy predicts patient outcome after liver transplantation for hepatocellular carcinoma with portal vein tumor thrombus
		Downstaging therapy has been confirmed to help patients whose tumors are beyond the liver transplantation (LT) criteria to gain the opportunity for LT with long-term survival. Zhan et al. [1] recently demonstrated that patients with hepatocellular carcinoma (HCC) beyond the Hangzhou criteria on initial diagnosis without extrahepatic metastasis or vascular invasion have comparative outcomes with those matching Milan criteria after LT if these patients are successfully downstaged to the Hangzhou criteria [1]. However, whether the downstaging therapy prolongs the survival time of those with portal vein tumor thrombosis (PVTT) is not clear. Our study was to add some data in this field.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 295-298 . [Abstract] ( 86 ) [HTML 1KB] [PDF 0KB] ( 160 )

	299	Yang WT, Ma JS, Zhu HF, Zhong L, Li QG
		Successful liver transplantation from a donor with immune thrombocytopenia
		Immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disease, which results from a combination of humoral and cell-mediated attacks on platelets and megakaryocytes [1–3]. ITP patients are always presented as heterogeneous clinical bleeding manifestations. Fatal bleeding such as intracranial hemorrhage is the main cause of death, which turns the patients into potential organ donors. Several studies indicated that the donor lymphocytes secreting autoantibody may be transferred to recipients after transplantation [4,5]. Transplantation-mediated alloimmune thrombocytopenia (TMAT) was donor-derived thrombocytopenia after solidorgan transplantation [6]. TMAT is a rare complication after transplantation, and the recipients of TMAT may present more severe bleeding events than the donors. A total of 6 recipients with TMAT after liver transplantation from ITP donors have been reported internationally [6–11], among which 3 recipients died and 3 survived. Thus, liver transplantation from ITP donors is relatively risky, and as a marginal donor organ, the use of ITP donor liver is controversial. There are no relevant guidelines for the safety assessment and treatment of ITP donor liver transplantation up to now. Here we reported a successful case with TMAT in liver transplant recipient from ITP donor in purpose of improving our understanding of TMAT.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 299-302 . [Abstract] ( 72 ) [HTML 1KB] [PDF 0KB] ( 63 )

	303	Saragoni L, Pacilio CA, Cavaliere D, Limarzi F, Isopi C, Ercolani G
		Solid serous cystadenoma of the pancreas: A rare tumor with challenging differential diagnosis
		Cystic tumors of the pancreas are rare, accounting for 1%-5% of exocrine pancreatic tumors. Serous cystadenoma (SCA) was firstly described by Compagno and Oertel in 1978 as a benign glycogenrich neoplasm [1]. In 1996 Perez-Ordonez et al. [2] reported the first case of a solid variant of SCA; since then, 23 cases of this extremely uncommon tumor variant were reported. Due to its rarity and unusual imaging appearance, a correct differential diagnosis is difficult and can lead to mistaken diagnosis and unnecessary treatment. According to Surgical CAse REport (SCARE) Guidelines [3], we present the second case of pancreatic solid SCA (SSCA) reported in Italy, the first surgically treated with a robotic approach worldwide.
		Hepatobiliary Pancreat Dis Int. 2022; 21(3): 303-306 . [Abstract] ( 91 ) [HTML 1KB] [PDF 0KB] ( 67 )

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