Hepatobiliary Pancreat Dis Int

	2022 Vol. 21 No. 4
	Published: 2022-08-15


	Pages 307-408
	EDITORIAL REVIEW ARTICLES ORIGINAL ARTICLES/Liver NEW TECHNIQUES LETTERS TO THE EDITOR Special issue on modern technology in liver surgery and transplantation

Special issue on modern technology in liver surgery and transplantation

	307	Lerut J
		Modern technology, liver surgery and transplantation ^Hot!
		Since the first right hepatectomy performed by Jean-Louis Lortat-Jacob on October 16, 1951 and the first liver transplantation by Thomas Earl Starzl on March 1, 1963, hepatobiliary surgery and liver transplantation had a spectacular development [1,2 ]. After the hesitating beginning in the 1950’s and 1960’s, their evolution really took off in the 1980’, reaching high-speed velocity in the 21st century. Improved knowledge of the (surgical) anatomy, refinement of techniques together with better insights into the (regenerative) physiopathology of the liver led to the development not only of precise surgical techniques but also to carefully-thought surgical strategies combining locoregional and systemic therapies [3–9]. Indeed, a multidisciplinary approach allowed to broaden the access of many patients to a curative treatment. Partial or total hepatectomy after downstaging and/or volume enhancing procedures using advanced locoregional and/or systemic therapies allowed to develop the concepts of two-stage hepatectomy, Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), Intra-Operative UltraSonography-guided (IOUS) parenchymal sparing hepatectomy and liver resection using in-situ cooling as well as reduced-size, split, Resection And Partial liver transplantation with Delayed hepatectomy (RAPID) and living donor liver transplantation (LDLT) [2,9-16 ].
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 307-309 . [Abstract] ( 113 ) [HTML 1KB] [PDF 0KB] ( 105 )

	310	Takemura N, Ito K, Inagaki F, Mihara F, Kokudo N
		Added value of indocyanine green fluorescence imaging in liver surgery
		Recently, indocyanine green (ICG) fluorescence imaging has been widely used as a substitute for cholangiography in hepatobiliary surgery, to detect hepatic tumors, for accurate anatomical hepatectomy, and to increase the safety and accuracy of minimally invasive (laparoscopic and robotic) hepatectomy. The clinical relevance of this method has been increasing gradually, as new procedures develop in this field. Various important roles and the latest added value of ICG fluorescence imaging in liver surgery are discussed in this report.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 310-317 . [Abstract] ( 86 ) [HTML 1KB] [PDF 0KB] ( 93 )

	318	Liu JP, Lerut J, Yang Z, Li ZK, Zheng SS
		Three-dimensional modeling in complex liver surgery and liver transplantation ^Hot!
		Liver resection and transplantation are the most effective therapies for many hepatobiliary tumors and diseases. However, these surgical procedures are challenging due to the anatomic complexity and many anatomical variations of the vascular and biliary structures. Three-dimensional (3D) printing models can clearly locate and describe blood vessels, bile ducts and tumors, calculate both liver and residual liver volumes, and finally predict the functional status of the liver after resection surgery. The 3D printing models may be particularly helpful in the preoperative evaluation and surgical planning of especially complex liver resection and transplantation, allowing to possibly increase resectability rates and reduce postoperative complications. With the continuous developments of imaging techniques, such models are expected to become widely applied in clinical practice.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 318-324 . [Abstract] ( 84 ) [HTML 1KB] [PDF 0KB] ( 100 )

	325	Wei JW, Fu SR, Zhang J, Gu DS, Li XQ, Chen XD, Zhang ST, He XF, Yan JF, Lu LG, Tian J
		CT-based radiomics to predict development of macrovascular invasion in hepatocellular carcinoma: A multicenter study ^Hot!
		Background: Macrovascular invasion (MaVI) occurs in nearly half of hepatocellular carcinoma (HCC) pa- tients at diagnosis or during follow-up, which causes severe disease deterioration, and limits the possibility of surgical approaches. This study aimed to investigate whether computed tomography (CT)-based radiomics analysis could help predict development of MaVI in HCC. Methods: A cohort of 226 patients diagnosed with HCC was enrolled from 5 hospitals with complete MaVI and prognosis follow-ups. CT-based radiomics signature was built via multi-strategy machine learning methods. Afterwards, MaVI-related clinical factors and radiomics signature were integrated to construct the final prediction model (CRIM, clinical-radiomics integrated model) via random forest modeling. Cox-regression analysis was used to select independent risk factors to predict the time of MaVI development. Kaplan-Meier analysis was conducted to stratify patients according to the time of MaVI development, progression-free survival (PFS), and overall survival (OS) based on the selected risk factors. Results: The radiomics signature showed significant improvement for MaVI prediction compared with conventional clinical/radiological predictors (P < 0.001). CRIM could predict MaVI with satisfactory areas under the curve (AUC) of 0.986 and 0.979 in the training (n = 154) and external validation (n = 72) datasets, respectively. CRIM presented with excellent generalization with AUC of 0.956, 1.000, and 1.000 in each external cohort that accepted disparate CT scanning protocol/manufactory. Peel9_fos_InterquartileRange [hazard ratio (HR) = 1.98; P < 0.001] was selected as the independent risk factor. The cox-regression model successfully stratified patients into the high-risk and low-risk groups regarding the time of MaVI development ( P < 0.001), PFS (P < 0.001) and OS (P = 0.002). Conclusions: The CT-based quantitative radiomics analysis could enable high accuracy prediction of subsequent MaVI development in HCC with prognostic implications.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 325-333 . [Abstract] ( 91 ) [HTML 1KB] [PDF 0KB] ( 62 )

	334	Schulze M, Elsheikh Y, Boehnert MU, Alnemary Y, Alabbad S, Broering DC
		Robotic surgery and liver transplantation: A single-center experience of 501 robotic donor hepatectomies
		Background: Over the past two decades robotic surgery has been introduced to many areas including liver surgery. Laparoscopic liver surgery is an alternative minimally invasive approach. However, moving on to the complexity of living donor hepatectomies, the advantages of robotic versus laparoscopic approach have convinced us to establish the robotic platform as a standard for living donor hepatectomy. Methods: From November 2018 to January 2022, 501 fully robotic donor hepatectomies, including 177 left lateral donor lobes, 112 full left lobes and 212 full right lobes were performed. Grafts were donated to 296 adult recipients and 205 pediatric recipients. Donor age, sex, body weight, body mass index (BMI), graft weight, graft to body weight ratio (GBWR), operative time, blood loss, first warm ischemic time, pain score, length of intensive care unit (ICU) stay and hospital stay, and complications were retrospectively analyzed based on a prospectively kept database. Recipients were evaluated for graft and patient survival, age, sex, BMI, body weight, model of end-stage liver disease score, blood loss, transfusions, operative time, cold ischemic time, length of hospital stay and complications. Results: There was no donor mortality. Two cases needed to be converted to open surgery. The median blood loss was 60 mL (range 20-800), median donor operative time was 6.77 h (range 2.93-11.53), median length of hospital stay was 4 days (range 2-22). Complication rate in donors classified following Clavien- Dindo was 6.4% (n = 32) with one grade III complication. Three-year actual recipient overall survival was 91.4%; 87.5% for adult recipients and 97.1% for pediatric recipients. Three-year actual graft overall survival was 90.6%; 87.5% for adult recipients and 95.1% for pediatric recipients. In-hospital mortality was 6%, 9.1% (27/296) for adult recipients and 1.4% (3/205) for pediatric recipients. The recipients’ morbidity was 19.8% (n = 99). Twenty-eight recipients (5.6%) had biliary and 22 (4.4%) vascular complications. Six (12.0%) recipients needed to be re-transplanted. Conclusions: With growing experience it is nowadays possible to perform any donor hepatectomy by robotic approach regardless of anatomical variations and graft size. Donor morbidity and quality for life results are encouraging and should motivate other transplant centers with interest in minimally invasive donor surgery to adopt this robotic technique.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 334-339 . [Abstract] ( 91 ) [HTML 1KB] [PDF 0KB] ( 65 )

	340	Feng Z, Wang SP, Wang HH, Lu Q, Qiao W, Wang KL, Ding HF, Wang Y, Wang RF, Shi AH, Ren BY, Jiang YN, He B, Yu JW, Wu RQ, Lv Y
		Magnetic-assisted laparoscopic liver transplantation in swine
		Background: Although laparoscopic technology has achieved rapid development in the surgical field, it has not been applied to liver transplantation, primarily because of difficulties associated with laparoscopic vascular anastomosis. In this study, we introduced a new magnetic-assisted vascular anastomosis technique and explored its application in laparoscopic liver transplantation in pigs. Methods: Two sets of magnetic vascular anastomosis rings (MVARs) with different diameters were developed. One set was used for anastomosis of the suprahepatic vena cava (SHVC) and the other set was used for anastomosis of the infrahepatic vena cava (IHVC) and portal vein (PV). Six laparoscopic orthotopic liver transplantations were performed in pigs. Donor liver was obtained via open surgery. Hepatectomy was performed in the recipients through laparoscopic surgery. Anastomosis of the SHVC was performed using hand-assisted magnetic anastomosis, and the anastomosis of the IHVC and PV was performed by magnetic anastomosis with or without hand assistance. Results: Liver transplants were successfully performed in five of the six cases. Postoperative ultrasonographic examination showed that the portal inflow was smooth. However, PV bending and blood flow obstruction occurred in one case because the MVARs were attached to each other. The durations of load- ing of MVAR in the laparoscope group and manual assistance group for IHVC and PV were 13 ±5 vs. 5 ±1 min ( P < 0.01) and 10 ±2 vs. 4 ±1 min ( P < 0.05), respectively. The durations of MVAR anastomosis in the laparoscope group and manual assistance group for IHVC and PV were 5 ±1 vs. 1 ±1 min ( P < 0.01), and 5 ±1 vs. 1 ±1 min ( P < 0.01), respectively. The anhepatic phase was 43 ±4 min in the laparoscope group and 23 ±2 min in the manual assistance group ( P < 0.01). Conclusions: Our study showed that magnetic-assisted laparoscopic liver transplantation can be successfully carried out in pigs.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 340-346 . [Abstract] ( 66 ) [HTML 1KB] [PDF 0KB] ( 68 )

	347	Briceno J, Calleja R, Hervas C
		Artificial intelligence and liver transplantation: Looking for the best donor-recipient pairing ^Hot!
		Decision-making based on artificial intelligence (AI) methodology is increasingly present in all areas of modern medicine. In recent years, models based on deep-learning have begun to be used in organ transplantation. Taking into account the huge number of factors and variables involved in donor-recipient (D- R) matching, AI models may be well suited to improve organ allocation. AI-based models should provide two solutions: complement decision-making with current metrics based on logistic regression and improve their predictability. Hundreds of classifiers could be used to address this problem. However, not all of them are really useful for D-R pairing. Basically, in the decision to assign a given donor to a candidate in waiting list, a multitude of variables are handled, including donor, recipient, logistic and perioperative variables. Of these last two, some of them can be inferred indirectly from the team’s previous experience. Two groups of AI models have been used in the D-R matching: artificial neural networks (ANN) and random forest (RF). The former mimics the functional architecture of neurons, with input layers and output layers. The algorithms can be uni- or multi-objective. In general, ANNs can be used with large databases, where their generalizability is improved. However, they are models that are very sensitive to the quality of the databases and, in essence, they are black-box models in which all variables are important. Unfortunately, these models do not allow to know safely the weight of each variable. On the other hand, RF builds decision trees and works well with small cohorts. In addition, they can select top variables as with logistic regression. However, they are not useful with large databases, due to the extreme number of decision trees that they would generate, making them impractical. Both ANN and RF allow a successful donor allocation in over 80% of D-R pairing, a number much higher than that obtained with the best statistical metrics such as model for end-stage liver disease, balance of risk score, and survival outcomes following liver transplantation scores. Many barriers need to be overcome before these deep-learning-based models can be included for D-R matching. The main one of them is the resistance of the clinicians to leave their own decision to autonomous computational models.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 347-353 . [Abstract] ( 86 ) [HTML 1KB] [PDF 0KB] ( 75 )

EDITORIAL

	354	Shan S, Jia JD
		Adenovirus and severe acute hepatitis of unknown etiology in children: Offender or bystander? ^Hot!
		On April 6, 2022, the United Kingdom Health Security Agency (UKHSA) released an alert on cases of hepatitis of unknown etiology in children [1]. On April 15, 2022, World Health Organization (WHO) published the first notice of this condition [2]. Later on, similar cases were reported from the UK, other European countries, and other parts of the world. Consequently, the European Center for Disease Prevention and Control (ECDC), the United States (US) Center for Disease Control and Prevention (CDC) and WHO have issued and updated alerts and provided working case definitions of severe acute hepatitis of unknown etiology in children [3–6].
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 354-355 . [Abstract] ( 102 ) [HTML 1KB] [PDF 0KB] ( 74 )

REVIEW ARTICLES

	356	de la Pinta C
		Radiomics in pancreatic cancer for oncologist: Present and future
		Radiomics is changing the world of medicine and more specifically the world of oncology. Early diagnosis and treatment improve the prognosis of patients with cancer. After treatment, the evaluation of the response will determine future treatments. In oncology, every change in treatment means a loss of therapeutic options and this is key in pancreatic cancer. Radiomics has been developed in oncology in the early diagnosis and differential diagnosis of benign and malignant lesions, in the evaluation of response, in the prediction of possible side effects, marking the risk of recurrence, survival and prognosis of the disease. Some studies have validated its use to differentiate normal tissues from tumor tissues with high sensitivity and specificity, and to differentiate cystic lesions and pancreatic neuroendocrine tumor grades with texture parameters. In addition, these parameters have been related to survival in patients with pancreatic cancer and to response to radiotherapy and chemotherapy. This review aimed to establish the current status of the use of radiomics in pancreatic cancer and future perspectives.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 356-361 . [Abstract] ( 85 ) [HTML 1KB] [PDF 0KB] ( 65 )

ORIGINAL ARTICLES/Liver

	362	Yoon YI, Lee SG, Moon DB, Hwang S, Kim KH, Kim HJ, Choi KH
		Morbidity analysis of left hepatic trisectionectomy for hepatobiliary disease and live donor
		Background: Despite remarkable advances in surgical techniques and perioperative management, left hepatic trisectionectomy (LHT) remains a challenging procedure with a somewhat high postoperative morbidity rate compared with less-extensive resections. This study aimed to analyze the short- and long-term outcomes of LHT and identify factors associated with the postoperative morbidity of this technically demanding surgical procedure. Methods: The medical records of 53 patients who underwent LHT between June 2005 and October 2019 at a single institution were retrospectively reviewed. The independent prognostic factor of postoperative morbidity was analyzed using the logistic regression model. Results: Hepatocellular carcinoma was the most common indication for surgery (n = 21), followed by hilar cholangiocarcinoma (n = 14), intrahepatic cholangiocarcinoma (n = 10), and other pathologies (including colorectal liver metastasis, hepatolithiasis, gallbladder cancer, living donor, hemangioma, and multilocular biliary cyst; n = 8). The rates of postoperative morbidities of Clavien-Dindo grade 3 or higher and 90-day mortality were 39.6% and 1.9%, respectively. The 1-, 3-, and 5-year overall survival rates were 81.1%, 61.4%, and 44.6%, respectively. Multivariate analysis revealed that preoperative jaundice [hazard ratio (HR) = 6.15, 95% confidence interval (CI): 1.57–24.17, P = 0.009] and operative time > 420 min (HR = 4.66, 95% CI: 1.27–17.17, P = 0.021) were independent predictors of postoperative morbidity. Conclusions: The in-hospital mortality of LHT surgery can be minimalized by a reliable preoperative evaluation of liver function and selection of the dominant anatomic features of right posterior sector, active and appropriate preoperative management for obstructive cholangitis and compensatory hypertrophy of the future remnant posterior sector, and the experience of the surgeon.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 362-369 . [Abstract] ( 71 ) [HTML 1KB] [PDF 0KB] ( 69 )

	370	Xi B, Luo FZ, He B, Wang F, Li ZK, Lai MC, Zheng SS
		High nuclear ABCG1 expression is a poor predictor for hepatocellular carcinoma patient survival
		Background: ATP-binding cassette transporter G1 (ABCG1) regulates cellular cholesterol homeostasis and plays a significant role in tumor immunity. But, for hepatocellular carcinoma (HCC), the role of ABCG1 has not been investigated. Thus, the aim of this study was to evaluate the prognostic value and clinico- pathological significance of ABCG1 in HCC. Methods: One hundred and four adult patients with HCC were enrolled, and ABCG1 expression in paired HCC specimens was determined by immunohistochemistry. All these patients were stratified by ABCG1 expression, Kaplan-Meier analysis was used to compare the overall survival (OS) and recurrence-free survival (RFS), and Cox regression analysis was used to determine independent predictors of tumor recurrence. Results: Upregulation of ABCG1 was observed in HCC samples compared to matched tumor-adjacent tissues. Patients with high nuclear ABCG1 expression had lower OS and RFS ( P = 0.012 and P = 0.020, respectively). High nuclear ABCG1 expression was related to larger tumor size ( P = 0.004) and tumor recurrence ( P = 0.027). Although ABCG1 was expressed in the cytoplasm, cytosolic expression could not predict the outcome in patients with HCC. A new stratification pattern was established based on the heterogenous ABCG1 expression pattern: high risk (High nucleus /Low cytosol ), moderate risk (High nucleus /High cytosol or Low nucleus /Low cytosol ), and low risk (Low nucleus /High cytosol ). This ABCG1-based risk stratification could distinguish the different OS and RFS in patients with HCC. Multivariate Cox regression analysis indicated that ABCG1 high risk was an independent predictor of poor RFS ( P = 0.015). Conclusions: High nuclear ABCG1 expression indicates poor prognosis in patients with HCC. Asymmetric distribution of ABCG1 in the nucleus and cytoplasm may have an important role in tumor recurrence.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 370-377 . [Abstract] ( 63 ) [HTML 1KB] [PDF 0KB] ( 78 )

	378	Pu XY, Zheng DF, Lv T, Zhou YJ, Yang JY, Jiang L
		Overexpression of transcription factor 3 drives hepatocarcinoma development by enhancing cell proliferation via activating Wnt signaling pathway
		Background: Transcription factor 3 (TCF3) plays pivotal roles in embryonic development, stem cell maintenance and carcinogenesis. However, its role in hepatocellular carcinoma (HCC) remains largely unknown. This study aimed to analyze the correlation between TCF3 expression and clinicopathological features of HCC, and further explore the underlying mechanism in HCC progression. Methods: The expression of TCF3 was collected from the Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO) HCC datasets, and further confirmed by immunostaining and Western blotting assays. The correlation between TCF3 expression and the clinicopathological features was evaluated. Bioinformatical analysis and in vitro experiments were conducted to explore the potential role of TCF3 in HCC development. Results: Both the mRNA and protein levels of TCF3 were significantly higher in HCC tumor tissues compared to tumor adjacent tissues ( P < 0.001 and P < 0.01). Analysis based on TCGA datasets showed that TCF3 was positively correlated with tumor clinical stage and grade, and patients with high TCF3 expression had shorter overall survival ( P = 0.012), disease-specific survival ( P = 0.022) and progression-free survival ( P = 0.013). Similarly, the immunostaining results revealed that the high expression of TCF3 was closely correlated with tumor size ( P = 0.001) and TNM stage ( P = 0.002), and TCF3 was an independent risk factor of HCC. In vitro study exhibited that TCF3 knockdown dramatically suppressed cancer cell proliferation, and the underlying mechanism might be that the silencing of TCF3 reduced the expression of critical regulating proteins towards cell cycle and proteins involved in Wnt signaling pathways. Conclusions: TCF3 expression is significantly elevated in HCC and positively associated with the tumor size and TNM stage, as well as poor prognosis of HCC patients. The mechanism might be that TCF3 promotes cancer cell proliferation via activating Wnt signaling pathway.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 378-386 . [Abstract] ( 65 ) [HTML 1KB] [PDF 0KB] ( 71 )

NEW TECHNIQUES

	387	Spaggiari M, Tulla KA, Aguiluz G, Di Cocco P, Castro Gil L, Benedetti E, Tzvetanov IG, Giulianotti PC
		Robotic-assisted placement of hepatic artery infusion pump for the treatment of colorectal liver metastases: Role of indocyanine green (with video)
		Surgical resection remains the only definitive treatment for colorectal liver metastasis (CRLM). However, only a minority of cases are deemed resectable at the time of diagnosis. Systemic chemotherapy along with hepatic artery infusion (HAI) is an effective and safe regional chemotherapy modality for the downstaging of patients with isolated unresectable CRLM [1]. This modality improves patient response rate up to 80% and secondary resection rate up to 47% in isolated unresectable CRLM [2]. The limited usage of this therapy could be due to the morbidity and mortality associated with open surgery in a population with a reduced chance of long-term survival. The application of minimally invasive techniques circumvents the complications related to laparotomy and decreases the recovery time needed to initiate chemotherapy [3]. Although the robotic-assisted HAI pump placement has been pre- viously described [1,4], to our best knowledge, we report the first case using indocyanine green (ICG) for in vivo perfusion test.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 387-391 . [Abstract] ( 86 ) [HTML 1KB] [PDF 0KB] ( 87 )

LETTERS TO THE EDITOR

	392	Coubeau L, Iesari S, Henry P, D’Abadie P, Vanbuggenhout A, Reding R
		Insights in living-donor liver transplantation associated with two-stage total hepatectomy: First case in neuroendocrine tumor metastases and functional assessment techniques
		While organ shortage commonly dooms patients on waiting list, alternative options as living-donor liver transplantation (LDLT) are assiduously sought. The principles of liver surgery rule LDLT: there must be sufficient residual volume in the donor and sufficient implanted volume for the recipient. However, the liver left-to-right segmentation confronts us with a respective volume distribution of 1/3–2/3 or even 1/4–3/4. The volume of the left lobe is then too small to ensure the “hepatostat” in the recipient [1], whereas the procurement of a right graft would jeopardize liver residual function in the donor. A Norwegian team combined partial liver transplantation with the procedure associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This technique was labelled as RAPID (resection and partial liver transplantation with delayed total hepatectomy) and involved deceased-donor left lobes collected by splitting [2]. The first step includes left hepatectomy (segments II, III and IV) and left-graft orthotopic implantation (segments II and III). The native right liver is deportalized by ligation of the right portal pedicle. The ALPPS principles are respected: the reorientation of the complete portal flow towards the graft stimulates regeneration and the physical separation between the remnant and the graft embodies the concept of parenchymal transsection. The rapid volumetric increase of the graft allows right hepatectomy, i.e. the second step, within 15 days. The living-donor RAPID (LD-RAPID), based on left lateral lobe from living donation, has been more recently described [3]. A technical limitation to RAPID seemed to be portal hypertension restricting the technique to non-parenchymal liver diseases, but it has been shown that with good modulation of the portal flow the RAPID technique is applicable to the cirrhotic patient compensated with portal hypertension for hepatocellular carcinoma [4].
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 392-395 . [Abstract] ( 60 ) [HTML 1KB] [PDF 0KB] ( 91 )

	396	She WH, Dai WC, Fung JYY, Cheung TT, Chan ACY, Lo CM
		Recurrent pyogenic cholangitis: An indication for liver transplantation
		Recurrent pyogenic cholangitis (RPC), also known as Hong Kong disease [1] , is an unique disease entity with a decreasing incidence. It is characterized by the formation of intrahepatic biliary pigmented stones, which results in stricturing of the biliary tree followed by obstruction and repeated attacks of cholangitis. Inadequate treatment eventually leads to liver abscess, parenchymal atrophy, complications of cirrhosis including end-stage liver disease, and risk of cholangiocarcinoma. Treatment for RPC in the initial phase of presentation include sepsis control with antibiotics and drainage of the biliary system, either endoscopically or radiologically. Definitive management requires surgery such as partial hepatectomy and/or hepaticocutaneous jejunostomy. The formation of the cutaneous limb would allow subsequent clearance of intrahepatic ductal stones by endoscopic means. Whether to perform hepatectomy or not would depend on the severity of cirrhosis and the presence of stones, liver abscess, and liver atrophy. Liver transplantation (LT) has been reported as a potential treatment option for patients with diffuse bilateral RPC [2] or secondary biliary cirrhosis. However, the evidence is scarce. We shall report a series of our patients who received LT as the definitive treatment for RPC.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 396-398 . [Abstract] ( 68 ) [HTML 1KB] [PDF 0KB] ( 72 )

	399	Garancini M, Scotti MA, Gianotti L, Rovere A, Uggeri F, Braga M, Romano F
		Branching patterns of the left portal vein and consequent implications in liver surgery: The left anterior sector
		There are still some open issues about the systematization of the knowledge of the branching of the left portal vein (LPV) and the division in anatomo-functional units within the left liver. The first controversial topic concerns the division of S4 in subsegments. The Brisbane 2000 system of Nomenclature of Hepatic Anatomy and Resections (B2000) [1] does not mention such subdivision, but in literature this is still a matter of discussion. Some scholars described S4 s vascularization as a “bouquet of vessels” from the right horn (the right distal branching at the tip of LPV) and found no rational in subdividing S4 [2]. On the contrary, others reported that S4 may have several portal branches originating even from the umbilical portion (UPLPV), the angle, or the transverse portion of the LPV (TPLPV) and concluded that frequently S4a (the superior portion of S4) and S4b (the inferior portion of S4) are independently supplied and represent two separated subsegments [3].
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 399-402 . [Abstract] ( 72 ) [HTML 1KB] [PDF 0KB] ( 69 )

	403	Talakic E, Igrec J, Kaufmann-Buhler AK, Janek E, Stephan S, Schemmer P, Fuchsjager M
		Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas mimicking pancreatic pseudocyst
		Undifferentiated carcinoma with osteoclast-like giant cells (UCOGC) is one of eight histological subtypes of pancreatic ductal adenocarcinoma (PDAC) according to the 2019 WHO classification [1] . It accounts for < 1% of exocrine pancreatic carcinomas. This rare variant occurs in slightly younger patients than conventional PDAC, with a slight female predominance (male:female,7:10). On imaging, UC-OGC appears as a large cystic-solid mass with areas of hemorrhage and necrosis. Thus, they may potentially resemble pancreatic pseudocysts. Given the rarity of this variant, the prognosis is unclear, with reports of a median survival of 11 months for unresectable tumors on the one hand, and long-term survival > 5 years on the other hand. Mucinous cystic neoplasms are predisposing factors for their development in 20% of the cases. Common clinical signs and symptoms include abdominal pain, weight loss, and jaundice, but UC-OGC tends to be asymptomatic in early stages. We reported one rare case of UC-OGC together with a review of previously published cases in English language using the search term “undifferentiated carcinoma osteoclastic giant cell pancreas”.
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 403-405 . [Abstract] ( 53 ) [HTML 1KB] [PDF 0KB] ( 67 )

	406	Takeshita K, Asai S, Fujimoto N, Ichinona T, Akamine E, Takenaka M
		Safety of rectal indomethacin (100 mg) for the prevention of post-ERCP pancreatitis in the Japanese population: A single-center prospective pilot study
		Endoscopic retrograde cholangiopancreatography (ERCP) causes adverse events; post-ERCP pancreatitis (PEP) is one of the frequent adverse events. Recently, the efficacy of rectal administration of non-steroidal anti-inflammatory drugs (NSAIDs) before or after ERCP for PEP prevention has been reported [1]. The European Society of Gastrointestinal Endoscopy and American Society for Gastrointestinal Endoscopy recommend routine rectal administration of 100 mg NSAIDs immediately before or after ERCP for patients without any contraindication [2,3]. However, the use of rectal administration of 100 mg NSAIDs is uncommon in Japan and not covered by health insurance policies. The feasibility and safety of NSAID use at low doses (25–50 mg) for PEP prevention have been certainly obtained only from single-center randomized and retrospective studies [4,5]. The clinical trial in China indicated that the rectal administration of 100 mg indomethacin does not cause drugrelated severe adverse events and its PEP-reducing effect is obvious [6] . It demonstrates the safety and efficacy of rectal administration of 100 mg indomethacin for PEP prophylaxis in an Asian population. Moreover, recently the ineffectiveness of low-dose indomethacin in terms of PEP prevention was reported [7]. As there is no report on the safety of rectal administration of 100 mg indomethacin in Japanese individuals, we conducted this single-arm, prospective, pilot study. The protocol of this trial was approved by the Institutional Review Board of Tane General Hospital and registered in the University Hospital Medical Information Network Clinical Trials Registry (Registration number: UMIN0000289000). This study was performed in compliance with the Ethical Principles for Medical Research Involving Human Subjects outlined in the Declaration of Helsinki in 1975 (revised in 2013).
		Hepatobiliary Pancreat Dis Int. 2022; 21(4): 406-408 . [Abstract] ( 70 ) [HTML 1KB] [PDF 0KB] ( 74 )

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