Hepatobiliary Pancreat Dis Int

	2023 Vol. 22 No. 6
	Published: 2023-12-15


	Pages 551-660
	EDITORIAL REVIEW ARTICLES ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas LETTERS TO THE EDITOR THANKS VIEWPOINTS

EDITORIAL

	551	Chen YF, Li LJ
		A new prognostic model for drug-induced liver injury especially suitable for Chinese population
		Drug-induced liver injury (DILI) is a rare side effect of drugs caused by all kinds of prescription or over-the-counter chemicals, biological agents, traditional Chinese medicine (TCM), natural medicine (NM), health products, dietary supplements and their metabolites, and even excipients, which can lead to jaundice, liver failure, or even death. Although it is rare in term of single drug, the occurrence of DILI in all liver injuries is not low due to the wide range of drugs and foods involved. Moreover, there was an increasing trend of incidence of DILI since 2010 worldwide, with Asian regions showing the highest incidence [1].
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 551-553 . [Abstract] ( 20 ) [HTML 1KB] [PDF 0KB] ( 94 )

REVIEW ARTICLES

	554	Bekheit M, Grundy L, Salih AKA, Bucur P, Vibert E, Ghazanfar M
		Post-hepatectomy liver failure: A timeline centered review ^Hot!
		Background: Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. Data sources: This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black’s checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. Results: This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. Conclusions: Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 554-569 . [Abstract] ( 24 ) [HTML 1KB] [PDF 0KB] ( 24 )

	570	Zhou JM, Wang L, Mao AR
		Value and prognostic factors of repeat hepatectomy for recurrent colorectal liver metastasis
		Background: More than 50% of patients with colorectal cancer develop liver metastases. Hepatectomy is the preferred treatment for resectable liver metastases. This review provides a perspective on the utility and relevant prognostic factors of repeat hepatectomy in recurrent colorectal liver metastasis (CRLM). Data sources: The keywords “recurrent colorectal liver metastases”, “recurrent hepatic metastases from colorectal cancer”, “liver metastases of colorectal cancer”, “repeat hepatectomy”, “repeat hepatic resection”, “second hepatic resection”, and “prognostic factors”were used to retrieve articles published in the PubMed database up to August 2020. Additional articles were identified by a manual search of references from key articles. Results: Despite improvements in surgical methods and perioperative chemotherapy, recurrence remains common in 37%–68% of patients. Standards or guidelines for the treatment of recurrent liver metastases are lacking. Repeat hepatectomy appears to be the best option for patients with resectable metastases. The commonly reported prognostic factors after repeat hepatectomy were R0 resection, carcinoembryonic antigen level, the presence of extrahepatic disease, a short disease-free interval between initial and repeat hepatectomy, the number ( > 1) and size ( ≥5 cm) of hepatic lesions, requiring blood transfusion, and no adjuvant chemotherapy after initial hepatectomy. The median overall survival after repeat hepatectomy ranged from 19.3 to 62 months, and the 5-year overall survival ranged from 21% to 73%. Chemotherapy can act as a test for the biological behavior of tumors with the goal of avoiding unnecessary surgery, and a multimodal approach involving aggressive chemotherapy and repeat hepatectomy might be the treatment of choice for patients with early recurrent CRLM. Conclusions: Repeat hepatectomy is a relatively safe and effective treatment for resectable recurrent CRLM. The presence or absence of prognostic factors might facilitate patient selection to improve short- and long-term outcomes.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 570-576 . [Abstract] ( 15 ) [HTML 1KB] [PDF 0KB] ( 31 )

ORIGINAL ARTICLES/Transplantation

	577	Shen T, Zheng SH, Chen J, Zhou ZS, Yang MF, Liu XY, Chen JL, Zheng SS, Xu X
		Older liver grafts from donation after circulatory death are associated with impaired survival and higher incidence of biliary non-anastomotic stricture ^Hot!
		Background: Grafts from older donors after circulatory death were associated with inferior outcome in liver transplants in the past. But it has seemed to remain controversial in the last decade, as a result of modified clinical protocols, selected recipients, and advanced technology of organ perfusion and preservation. The present study aimed to examine the impact of older donor age on complications and survival of liver transplant using grafts from donation after circulatory death (DCD). Methods: A total of 944 patients who received DCD liver transplantation from 2015 to 2020 were included and divided into two groups: using graft from older donor (aged ≥65 years, n = 87) and younger donor (age < 65 years, n = 857). Propensity score matching (PSM) was applied to eliminate selection bias. Results: A progressively increased proportion of liver transplants with grafts from older donors was observed from 1.68% to 15.44% during the study period. The well-balanced older donor ( n = 79) and younger donor ( n = 79) were 1:1 matched. There were significantly more episodes of biliary non-anastomotic stricture (NAS) in the older donor group than the younger donor group [15/79 (19.0%) vs. 6/79 (7.6%); P = 0.017]. The difference did not reach statistical significance regarding early allograft dysfunction (EAD) and primary non-function (PNF). Older livers had a trend toward inferior 1-, 2-, 3-year graft and overall survival compared with younger livers, but these differences were not statistically sig- nificant (63.1%, 57.6%, 57.6% vs. 76.9%, 70.2%, 67.7%, P = 0.112; 64.4%, 58.6%, 58.6% vs. 76.9%, 72.2%, 72.2%, P = 0.064). The only risk factor for poor survival was ABO incompatible transplant ( P = 0.008) in the older donor group. In the subgroup of ABO incompatible cases, it demonstrated a significant difference in the rate of NAS between the older donor group and the younger donor group [6/8 (75.0%) vs. 3/14 (21.4%); P = 0.014]. Conclusions: Transplants with grafts from older donors (aged ≥65 years) after circulatory death are more frequently associated with inferior outcome compared to those from younger donors. Older grafts from DCD are more likely to develop NAS, especially in ABO incompatible cases.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 577-583 . [Abstract] ( 21 ) [HTML 1KB] [PDF 0KB] ( 24 )

ORIGINAL ARTICLES/Liver

	584	Wang Y, Zou CL, Zhang J, Qiu LX, Huang YF, Zhao XY, Zou ZS, Jia JD
		Development and validation of a novel model to predict liver-related mortality in patients with idiosyncratic drug-induced liver injury ^Hot!
		Background: Early identification of patients with high mortality risk is critical for optimizing the clinical management of drug-induced liver injury (DILI). We aimed to develop and validate a new prognostic model to predict death within 6 months in DILI patients. Methods: This multicenter study retrospectively reviewed the medical records of DILI patients admitted to three hospitals. A DILI mortality predictive score was developed using multivariate logistic regression and was validated with area under the receiver operating characteristic curve (AUC). A high-mortality-risk subgroup was identified according to the score. Results: Three independent DILI cohorts, including one derivation cohort ( n = 741) and two validation co- horts ( n = 650, n = 617) were recruited. The DILI mortality predictive (DMP) score was calculated using parameters at disease onset as follows: 1.913 ×international normalized ratio + 0.060 ×total bilirubin (mg/dL) + 0.439 ×aspartate aminotransferase/alanine aminotransferase –1.579 ×albumin (g/dL) –0.006 ×platelet count (10 9 /L) + 9.662. The predictive performance for 6-month mortality of DMP score was desirable, with an AUC of 0.941 (95% CI: 0.922-0.957), 0.931 (0.908-0.949) and 0.960 (0.942-0.974) in the derivation, validation cohorts 1 and 2, respectively. DILI patients with a DMP score ≥8.5 were stratified into high-risk group, whose mortality rates were 23-, 36-, and 45-fold higher than those of other patients in the three cohorts. Conclusions: The novel model based on common laboratory findings can accurately predict mortality within 6 months in DILI patients, which should serve as an effective guidance for management of DILI in clinical practice.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 584-593 . [Abstract] ( 25 ) [HTML 1KB] [PDF 0KB] ( 35 )

	594	Wang DD, Zhang JF, Zhang LH, Niu M, Jiang HJ, Jia FC, Feng ST
		Clinical-radiomics predictors to identify the suitability of transarterial chemoembolization treatment in intermediate-stage hepatocellular carcinoma: A multicenter study ^Hot!
		Background: Although transarterial chemoembolization (TACE) is the first-line therapy for intermediate-stage hepatocellular carcinoma (HCC), it is not suitable for all patients. This study aimed to determine how to select patients who are not suitable for TACE as the first treatment choice. Methods: A total of 243 intermediate-stage HCC patients treated with TACE at three centers were retrospectively enrolled, of which 171 were used for model training and 72 for testing. Radiomics features were screened using the Spearman correlation analysis and the least absolute shrinkage and selection operator (LASSO) algorithm. Subsequently, a radiomics model was established using extreme gradient boosting (XGBoost) with 5-fold cross-validation. The Shapley additive explanations (SHAP) method was used to visualize the radiomics model. A clinical model was constructed using univariate and multivariate logistic regression. The combined model comprising the radiomics signature and clinical factors was then established. This model’s performance was evaluated by discrimination, calibration, and clinical application. Generalization ability was evaluated by the testing cohort. Finally, the model was used to analyze overall and progression-free survival of different groups. Results: A third of the patients (81/243) were unsuitable for TACE treatment. The combined model had a high degree of accuracy as it identified TACE-unsuitable cases, at a sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of 0.759, 0.885, 0.906 [95% confidence interval (CI): 0.859-0.953] in the training cohort and 0.826, 0.776, and 0.894 (95% CI: 0.815-0.972) in the testing cohort, respectively. Conclusions: The high degree of accuracy of our clinical-radiomics model makes it clinically useful in identifying intermediate-stage HCC patients who are unsuitable for TACE treatment.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 594-604 . [Abstract] ( 32 ) [HTML 1KB] [PDF 0KB] ( 136 )

	605	Dong SC, Bai DS, Wang FA, Jin SJ, Zhang C, Zhou BH, Jiang GQ
		Radiofrequency ablation is an inferior option to liver resection for solitary hepatocellular carcinoma ≤ 5 cm without cirrhosis: A population-based study with stratification by tumor size
		Background: About 10%-20% of all individuals who develop hepatocellular carcinoma (HCC) do not have cirrhosis. Comparisons are rarely reported regarding the effectiveness of radiofrequency ablation (RFA) and liver resection (LR) in survival of HCC without cirrhosis and stratification by tumor size ≤ 5 cm. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database and identified 1505 patients with a solitary HCC tumor ≤ 5 cm who underwent RFA or LR during 2004-2015. Patients were classified into non-cirrhosis and cirrhosis groups and each group was categorized into three subgroups, according to tumor size ( ≤30 mm, 31-40 mm, 41-50 mm). Results: In patients without cirrhosis, LR showed better 5-year HCC cancer-specific survival than RFA in all tumor size subgroups ( ≤30 mm: 82.51% vs. 56.42%; 31-40 mm: 71.31% vs. 46.83%; 41-50 mm: 74.7% vs. 37.5%; all P < 0.05). Compared with RFA, LR was an independent protective factor for HCC cancer-specific survival in multivariate Cox analysis [ ≤30 mm: hazard ratio (HR) = 0.533, 95% confidence interval (CI): 0.313-0.908; 31-40 mm: HR = 0.439, 95% CI: 0.201-0.957; 41-50 mm: HR = 0.382; 95% CI: 0.159-0.916; all P < 0.05]. In patients with cirrhosis, for both tumor size ≤30 mm and 31-40 mm groups, there were no significant survival differences between RFA and LR in multivariate analysis (all P > 0.05). However, in those with tumor size 41-50 mm, LR showed significantly better 5-year HCC cancer-specific survival than RFA in both univariate (54.72% vs. 23.06%; P < 0.001) and multivariate analyses (HR = 0.297; 95% CI: 0.136-0.648; P = 0.002). Conclusions: RFA is an inferior treatment option to LR for patients without cirrhosis who have a solitary HCC tumor ≤5 cm.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 605-614 . [Abstract] ( 14 ) [HTML 1KB] [PDF 0KB] ( 30 )

	615	Peng HY, Duan SJ, Pan L, Wang MY, Chen JL, Wang YC, Yao SK
		Development and validation of machine learning models for nonalcoholic fatty liver disease
		Background: Nonalcoholic fatty liver disease (NAFLD) had become the most prevalent liver disease worldwide. Early diagnosis could effectively reduce NAFLD-related morbidity and mortality. This study aimed to combine the risk factors to develop and validate a novel model for predicting NAFLD. Methods: We enrolled 578 participants completing abdominal ultrasound into the training set. The least absolute shrinkage and selection operator (LASSO) regression combined with random forest (RF) was conducted to screen significant predictors for NAFLD risk. Five machine learning models including logistic regression (LR), RF, extreme gradient boosting (XGBoost), gradient boosting machine (GBM), and support vector machine (SVM) were developed. To further improve model performance, we conducted hyperparameter tuning with train function in Python package ‘sklearn’. We included 131 participants completing magnetic resonance imaging into the testing set for external validation. Results: There were 329 participants with NAFLD and 249 without in the training set, while 96 with NAFLD and 35 without were in the testing set. Visceral adiposity index, abdominal circumference, body mass index, alanine aminotransferase (ALT), ALT/AST (aspartate aminotransferase), age, high-density lipoprotein cholesterol (HDL-C) and elevated triglyceride (TG) were important predictors for NAFLD risk. The area under curve (AUC) of LR, RF, XGBoost, GBM, SVM were 0.915 [95% confidence interval (CI): 0.886–0.937], 0.907 (95% CI: 0.856–0.938), 0.928 (95% CI: 0.873–0.944), 0.924 (95% CI: 0.875–0.939), and 0.900 (95% CI: 0.883–0.913), respectively. XGBoost model presented the best predictive performance, and its AUC was enhanced to 0.938 (95% CI: 0.870–0.950) with further parameter tuning. Conclusions: This study developed and validated five novel machine learning models for NAFLD predic- tion, among which XGBoost presented the best performance and was considered a reliable reference for early identification of high-risk patients with NAFLD in clinical practice.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 615-621 . [Abstract] ( 17 ) [HTML 1KB] [PDF 0KB] ( 107 )

	622	Zhang JS, Wang ZB, Lai ZZ, Yang JW, Song WJ, Wei YB, Mei J, Wang JG
		Polyethylene glycol crosslinked decellularized single liver lobe scaffolds with vascular endothelial growth factor promotes angiogenesis in vivo
		Background: Improving the mechanical properties and angiogenesis of acellular scaffolds before transplantation is an important challenge facing the development of acellular liver grafts. The present study aimed to evaluate the cytotoxicity and angiogenesis of polyethylene glycol (PEG) crosslinked decellularized single liver lobe scaffolds (DLSs), and establish its suitability as a graft for long-term liver tissue engineering. Methods: Using mercaptoacrylate produced by the Michael addition reaction, DLSs were first modified using N-succinimidyl S-acetylthioacetate (SATA), followed by cross-linking with PEG as well as vascu- lar endothelial growth factor (VEGF). The optimal concentration of agents and time of the individual steps were identified in this procedure through biomechanical testing and morphological analysis. Subsequently, human umbilical vein endothelial cells (HUVECs) were seeded on the PEG crosslinked scaffolds to detect the proliferation and viability of cells. The scaffolds were then transplanted into the subcuta- neous tissue of Sprague-Dawley rats to evaluate angiogenesis. In addition, the average number of blood vessels was evaluated in the grafts with or without PEG at days 7, 14, and 21 after implantation. Results: The PEG crosslinked DLS maintained their three-dimensional structure and were more translu- cent after decellularization than native DLS, which presented a denser and more porous network structure. The results for Young’s modulus proved that the mechanical properties of 0.5 PEG crosslinked DLS were the best and close to that of native livers. The PEG-VEGF-DLS could better promote cell proliferation and differentiation of HUVECs compared with the groups without PEG cross-linking. Importantly, the average density of blood vessels was higher in the PEG-VEGF-DLS than that in other groups at days 7, 14, and 21 after implantation in vivo. Conclusions: The PEG crosslinked DLS with VEGF could improve the biomechanical properties of native DLS, and most importantly, their lack of cytotoxicity provides a new route to promote the proliferation of cells in vitro and angiogenesis in vivo in liver tissue engineering.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 622-631 . [Abstract] ( 19 ) [HTML 1KB] [PDF 0KB] ( 109 )

ORIGINAL ARTICLES/Biliary

	632	Tong T, Tian L, Deng MZ, Chen XJ, Fu T, Ma KJ, Xu JH, Wang XY
		The efficacy and safety of endoscopic ultrasound-guided fine-needle biopsy in gallbladder masses ^Hot!
		Background: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is a widely used modality for acquiring various target samples, but its efficacy in gallbladder masses is unknown. The aim of this ret- rospective study was to evaluate the efficacy and safety of EUS-FNB in patients with gallbladder masses. Methods: The study samples were composed of patients from March 2015 to July 2019 who needed to identify the nature of gallbladder masses through EUS-FNB. The outcomes of this study were the adequacy of specimens, diagnostic yields, technical feasibility, and adverse events of the EUS-FNB in gallbladder masses. Results: A total of 27 consecutive patients with a median age of 58 years were included in this study. The 22-gauge FNB needle was feasible in all lesions. The median follow-up period of the patients was 294 days. The specimens sufficient for diagnosis account for 89% (24/27) and 93% (25/27) in cytology and histology, respectively. The overall diagnostic yields for malignancy showed the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 95.45% [95% confidence interval (CI): 75.12%-99.76%], 100% (95% CI: 46.29%-10 0%), 10 0% (95% CI: 80.76%-100%), 83.33% (95% CI: 36.48%- 99.12%), and 96.30% (95% CI: 80.20%-99.99%), respectively. The subgroup analysis revealed that FNB could obtain sufficient specimens and high diagnostic yields in both gallbladder mass < 20.5 mm group and ≥20.5 mm group. One patient experienced mild abdominal pain after the procedure and recovered within one day. Conclusions: EUS-FNB is a reasonable diagnostic tool for the pretreatment diagnosis of patients with gallbladder masses, especially for patients who may miss the opportunity of surgery and need sufficient specimens to identify the pathological type so as to determine chemotherapy regimens. Further large-scale studies are needed to confirm our conclusion.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 632-638 . [Abstract] ( 25 ) [HTML 1KB] [PDF 0KB] ( 32 )

ORIGINAL ARTICLES/Pancreas

	639	Li MY, Cui HZ, Hao JN, Xu DB, Zhang EL, Yin ZZ, Zhao ZM
		“Parenchyma transection-first”strategy is superior to “tunnel-first”strategy in robotic spleen-preserving distal pancreatectomy with conservation of splenic vessels
		Background: Creating a tunnel between the pancreas and splenic vessels followed by pancreatic parenchyma transection (“tunnel-first”strategy) has long been used in spleen-preserving distal pancre- atectomy (SPDP) with splenic vessel preservation (Kimura’s procedure). However, the operation space is limited in the tunnel, leading to the risks of bleeding and difficulties in suturing. We adopted the pan- creatic “parenchyma transection-first”strategy to optimize Kimura’s procedure. Methods: The clinical data of consecutive patients who underwent robotic SPDP with Kimura’s procedure between January 2017 and September 2022 at our center were retrieved. The cohort was classified into a “parenchyma transection-first”strategy (P-F) group and a “tunnel-first”strategy (T-F) group and analyzed. Results: A total of 91 patients were enrolled in this cohort, with 49 in the T-F group and 42 in the P-F group. Compared with the T-F group, the P-F group had significantly shorter operative time (146.1 ±39.2 min vs. 174.9 ±46.6 min, P < 0.01) and lower estimated blood loss [40.0 (20.0–55.0) mL vs. 50.0 (20.0–100.0) mL, P = 0.03]. Failure of splenic vessel preservation occurred in 10.2% patients in the T- F group and 2.4% in the P-F group ( P = 0.14). The grade 3/4 complications were similar between the two groups ( P = 0.57). No differences in postoperative pancreatic fistula, abdominal infection or hemorrhage were observed between the two groups. Conclusions: The pancreatic “parenchyma transection-first”strategy is safe and feasible compared with traditional “tunnel-first strategy”in SPDP with Kimura’s procedure.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 639-644 . [Abstract] ( 18 ) [HTML 1KB] [PDF 0KB] ( 21 )

VIEWPOINTS

	645	Frountzas M, Schizas D, Kykalos S, Toutouzas KG
		“Oligometastatic pancreatic cancer” definition: The first step
		Pancreatic ductal adenocarcinoma (PDAC) is nowadays the fourth leading cause of cancer-related death worldwide, but according to recent estimations it will become the second leading cause of cancer-related deaths in the USA up to 2030, following lung cancer. The implementation of neoadjuvant chemotherapy during recent years led to an increase of overall survival at 35 months in PDAC after R0 resection [1] . However, pancreatic cancer has a particularity that makes it a real challenge for clinicians: only 20% of patients are diagnosed early enough to have a resectable pancreatic cancer, whereas 40% of patients present with locally advanced or non-resectable disease, while the rest present with distant metastases [2] . Systemic chemotherapy plays the main role in metastatic PDAC treatment: polychemotherapy regimens such as FOLFIRINOX (folinic acid, 5-fluorouracil, irinotecan and oxaliplatin) or combination of gemcitabine/nab-paclitaxel seemed to improve median overall survival from 6.8 to 11.1 months and 6.7 to 8.5 months, respectively [3] .
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 645-647 . [Abstract] ( 18 ) [HTML 1KB] [PDF 0KB] ( 28 )

	648	Ielpo B, Alborino S, Melloul E, Salvatori F, Lai Q, Rossi M, Demartines N, Di Saverio S
		Interventional treatment options for management of delayed arterial hemorrhage after major hepato-pancreatic-biliary surgery
		Hilar cholangiocarcinoma is a biliary malignancy arising from the perihilar biliary tree, which is associated with poor oncological outcomes due to its aggressive biology, chemo-resistance and insidious onset [1] . As stated by Di Martino et al., the standard of care is radical resection, and during the last decades, there have been great effort s to improve survival of potentially resectable hilar cholangiocarcinoma, with surgery being the treatment associated with longer survival [2] . However, radical resection still represents a challenging operation with high risk of intraoperative and postoperative complications.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 648-649 . [Abstract] ( 15 ) [HTML 1KB] [PDF 0KB] ( 110 )

	650	Chang KW, Yang Z, Wang S, Zheng SS
		Hepatic arterial anastomosis in adult liver transplantation
		Hepatic arterial reconstruction remains a critically challenging technique in liver transplantation, as efficient graft and patient survival are dependent on strong and continuous arterial blood supply to the donor liver [1,2]. Complex arterial reconstruction has been identified as a crucial risk factor for arterial thrombosis [1–5]. Consequently, selecting the appropriate arterial reconstruction method to decrease hepatic artery thrombosis has garnered the attention of the surgical community. The first case of a standard surgical technique employed in a patient with hepatic malignancy was reported in 1969 [6] . Arterial reconstruction was performed through anastomosis of the donor’s celiac trunk to the recipient’s common hepatic artery. Over the past decade, significant advancements have been made in the field of hepatic arterial reconstruction. Several studies have reported favorable outcomes with aortohepatic anastomosis, with or without conduits [7–9] , celiac trunk [10,11] or splenic artery [1,4,12] in liver recipients with unusable hepatic arteries due to complete thrombosis, intimal dissection, small size, or inadequate blood flow. Regarding the choice of arterial anastomosis sites, the surgeons either decide intraoperatively after evaluating the quality and blood flow of the recipient hepatic artery or make the decision preoperatively in case of known thrombosis. The surgeon also selects an alternative arterial site based on the surgeon’s judgment [10] .
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 650-652 . [Abstract] ( 17 ) [HTML 1KB] [PDF 0KB] ( 26 )

	653	Tao FZ, Jiang RL
		Antibiotics management in severe acute pancreatitis
		Severe acute pancreatitis (SAP) is a common and critical disease. It is life-threatening at any time if multiple organ dysfunction occurs. SAP may develop secondary infection, often iatrogenic [1] . To treat infected SAP, appropriate antibiotic use and nosocomial management is critical, along with adequate drainage of the infected foci and optimizing the immune function. Not only is the use of powerful antibiotics necessary to minimize mortality, but early use is also necessary to reduce the occurrence of drug-resistant bacteria. Therefore, antibiotic management is clinically important and requires careful attention.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 653-654 . [Abstract] ( 14 ) [HTML 1KB] [PDF 0KB] ( 20 )

LETTERS TO THE EDITOR

	655	Rondelli F, Bugiantella W, Chillitupa CIZ, Marcacci C, De Rosa M
		Left-sided gallbladder: A rare biliary tree anomaly
		Hepatobiliary anatomical variations may increase the complexity of surgery with a relevant risk of iatrogenic lesions. Left-sided gallbladder (LSG) is a rare and little known condition whereby the viscus is located on the visceral surface of the left lobe of the liver and is often discovered unexpectedly during surgery. The position of the gallbladder over the liver pedicle and the simultaneous presence of variations in the liver vascularization are potentially associated to a challenging surgical dissection and consequently to an increased risk of morbidity. Despite open approach remains an option in more complex procedures, cholecystectomy is usually performed with a minimally invasive technique, which is generally safe even in the rare case of an LSG, as long as a high level of awereness of anatomical variations and a careful surgical dissection are pursued.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 655-657 . [Abstract] ( 14 ) [HTML 1KB] [PDF 0KB] ( 31 )

	658	Cao LP, Zhong X, Chen KJ, Yu J
		Endoscopic retrograde cholangiopancreatography management for choledochocele in a young female
		Choledochocele, also known as type III choledochal cysts in the classification by Todani et al. [1] , is a congenital abnormality of the biliary system. It is characterized by a cystic dilation of intramural segment of the distal common bile duct (CBD) protruding into the descending duodenum. Choledochocele makes up about 0.5% −4% of choledochal cysts [ 1 , 2 ]. Compared with other subtypes, the incidence of choledochocele is extremely low and it frequently presents in adults at a relatively older age, with an average age of 51 years [3] . The diagnosis and treatment are challenging. Here, we present a case of a young female patient with this rare disease entity, who recovered after effective endoscopic retrograde cholangiopancreatography (ERCP) management.
		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 658-660 . [Abstract] ( 20 ) [HTML 1KB] [PDF 0KB] ( 40 )

THANKS

	661
		Thanks

		Hepatobiliary Pancreat Dis Int. 2023; 22(6): 661-A9 . [Abstract] ( 31 ) [HTML 1KB] [PDF 43KB] ( 95 )

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