Hepatobiliary Pancreat Dis Int

	2024 Vol. 23 No. 4
	Published: 2024-08-15


	Pages 331-440
	REVIEW ARTICLES ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas NEW TECHNIQUES CLINICAL IMAGE LETTERS TO THE EDITOR

REVIEW ARTICLES

	331	Mazzarella G, Muttillo EM, Coletta D, Picardi B, Rossi S, Rossi Del Monte S, Gomes V, Muttillo IA
		Solid pseudopapillary tumor of the pancreas: A systematic review of clinical, surgical and oncological characteristics of 1384 patients underwent pancreatic surgery ^Hot!
		Background: Pancreatic solid pseudopapillary tumors (SPTs) are rare clinical entity, with low malignancy and still unclear pathogenesis. They account for less than 2% of exocrine pancreatic neoplasms. This study aimed to perform a systematic review of the main clinical, surgical and oncological characteristics of pancreatic SPTs. Data sources: MEDLINE/PubMed, Web of Science and Scopus databases were systematically searched for the main clinical, surgical and oncological characteristics of pancreatic SPTs up to April 2021, in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Primary endpoints were to analyze treatments and oncological outcomes. Results: A total of 823 studies were recorded, 86 studies underwent full-text reviews and 28 met inclusion criteria. Overall, 1384 patients underwent pancreatic surgery. Mean age was 30 years and 1181 patients (85.3%) were female. The most common clinical presentation was non-specific abdominal pain (52.6% of cases). Mean overall survival was 98.1%. Mean recurrence rate was 2.8%. Mean follow-up was 4.2 years. Conclusions: Pancreatic SPTs are rare, and predominantly affect young women with unclear pathogenesis. Radical resection is the gold standard of treatment achieving good oncological impact and a favorable prognosis in a yearly life-long follow-up.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 331-338 . [Abstract] ( 96 ) [HTML 1KB] [PDF 0KB] ( 72 )

	339	Liu FC, Xie M, Rao W
		Clinical application of COVID-19 vaccine in liver transplant recipients ^Hot!
		Background: Solid organ transplant (SOT) activities, such as liver transplant, have been greatly influenced by the pandemic of coronavirus disease 2019 (COVID-19), a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Immunosuppressed individuals of liver transplant recipients (LTRs) tend to have a high risk of COVID-19 infection and related complications. Therefore, COVID-19 vaccination has been recommended to be administered as early as possible in LTRs. Data sources: The keywords “liver transplant”, "SARS-CoV-2”, and “vaccine”were used to retrieve articles published in PubMed. Results: The antibody response following the 1st and 2nd doses of vaccination was disappointingly low, and the immune responses among LTRs remarkably improved after the 3rd or 4th dose of vaccination. Although the 3rd or 4th dose of COVID-19 vaccine increased the antibody titer, a proportion of patients remained unresponsive. Furthermore, recent studies showed that SARS-CoV-2 vaccine could trigger ad- verse events in LTRs, including allograft rejection and liver injury. Conclusions: This review provides the recently reported data on the antibody response of LTRs following various doses of vaccine, risk factors for poor serological response and adverse events after vaccination.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 339-343 . [Abstract] ( 97 ) [HTML 1KB] [PDF 0KB] ( 97 )

ORIGINAL ARTICLES/Transplantation

	344	Hu QZ, Cao ZR, Zheng WX, Zhao MJ, Gong JH, Chen C,Wu ZJ, Tao R
		HSP110 aggravates ischemia-reperfusion injury after liver transplantation by promoting NF-κB pathway ^Hot!
		Background: Ischemia-reperfusion injury (IRI) poses a significant challenge to liver transplantation (LT). The underlying mechanism primarily involves overactivation of the immune system. Heat shock protein 110 (HSP110) functions as a molecular chaperone that helps stabilize protein structures. Methods: An IRI model was established by performing LT on Sprague-Dawley rats, and HSP110 was silenced using siRNA. Hematoxylin-eosin staining, TUNEL, immunohistochemistry, ELISA and liver enzyme analysis were performed to assess IRI following LT. Western blotting and quantitative reverse transcription-polymerase chain reaction were conducted to investigate the pertinent molecular changes. Results: Our findings revealed a significant increase in the expression of HSP110 at both the mRNA and protein levels in the rat liver following LT (P < 0.05). However, when rats were injected with siRNA-HSP110, IRI subsequent to LT was notably reduced (P < 0.05). Additionally, the levels of liver enzymes and inflammatory chemokines in rat serum were significantly reduced (P < 0.05). Silencing HSP110 with siRNA resulted in a marked decrease in M1-type polarization of Kupffer cells in the liver and downregu- lated the NF- κB pathway in the liver (P < 0.05). Conclusions: HSP110 in the liver promotes IRI after LT in rats by activating the NF-κB pathway and inducing M1-type polarization of Kupffer cells. Targeting HSP110 to prevent IRI after LT may represent a promising new approach for the treatment of LT-associated IRI.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 344-352 . [Abstract] ( 103 ) [HTML 1KB] [PDF 0KB] ( 77 )

ORIGINAL ARTICLES/Liver

	353	Jeong S, Park SJ, Na SK, Park SM, Song BC, Oh YH
		Validity of fatty liver prediction scores for diagnosis of fatty liver by Fibroscan
		Background: The Korea National Health and Nutrition Examination Survey nonalcoholic fatty liver disease (K-NAFLD) score was recently developed with the intent to operationally define nonalcoholic fatty liver disease (NAFLD). However, there remained an external validation that confirmed its diagnostic performance, especially in patients with alcohol consumption or hepatitis virus infection. Methods: Diagnostic accuracy of the K-NAFLD score was evaluated in a hospital-based cohort consisting of 1388 participants who received Fibroscan®. Multivariate-adjusted logistic regression models and the contrast estimation of receiver operating characteristic curves were used for validation of the K-NAFLD score, fatty liver index (FLI), and hepatic steatosis index (HSI). Results: K-NAFLD-moderate [adjusted odds ratio (aOR) = 2.53, 95% confidence interval (CI): 1.13-5.65] and K-NAFLD-high (aOR = 4.14, 95% CI: 1.69-10.13) groups showed higher risks of fatty liver compared to the K-NAFLD-low group after adjustments for demographic and clinical characteristics, and FLI-moderate and FLI-high groups revealed aORs of 2.05 (95% CI: 1.22-3.43) and 1.51 (95% CI: 0.78-2.90), respectively. In addition, the HSI was less predictive for Fibroscan®-defined fatty liver. Both K-NAFLD and FLI also demonstrated high accuracy in the prediction of fatty liver in patients with alcohol consumption and chronic hepatitis virus infection, and the adjusted area under curve values were comparable between K-NAFLD and FLI. Conclusions: Externally validation of the K-NAFLD and FLI showed that these scores may be a useful, noninvasive, and non-imaging modality for the identification of fatty liver. In addition, these scores also predicted fatty liver in patients with alcohol consumption and chronic hepatitis virus infection.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 353-360 . [Abstract] ( 84 ) [HTML 1KB] [PDF 0KB] ( 117 )

	361	Shi ZX, Li CF, Zhao LF, Sun ZQ, Cui LM, Xin YJ, Wang DQ, Kang TR, Jiang HJ
		Computed tomography radiomic features and clinical factors predicting the response to first transarterial chemoembolization in intermediate-stage hepatocellular carcinoma
		Background: According to clinical practice guidelines, transarterial chemoembolization (TACE) is the standard treatment modality for patients with intermediate-stage hepatocellular carcinoma (HCC). Early prediction of treatment response can help patients choose a reasonable treatment plan. This study aimed to investigate the value of the radiomic-clinical model in predicting the efficacy of the first TACE treatment for HCC to prolong patient survival. Methods: A total of 164 patients with HCC who underwent the first TACE from January 2017 to September 2021 were analyzed. The tumor response was assessed by modified response evaluation criteria in solid tumors (mRECIST), and the response of the first TACE to each session and its correlation with overall survival were evaluated. The radiomic signatures associated with the treatment response were identified by the least absolute shrinkage and selection operator (LASSO), and four machine learning models were built with different types of regions of interest (ROIs) (tumor and corresponding tissues) and the model with the best performance was selected. The predictive performance was assessed with receiver operating characteristic (ROC) curves and calibration curves. Results: Of all the models, the random forest (RF) model with peritumor ( + 10 mm) radiomic signatures had the best performance [area under ROC curve (AUC) = 0.964 in the training cohort, AUC = 0.949 in the validation cohort]. The RF model was used to calculate the radiomic score (Rad-score), and the optimal cutoffvalue (0.34)was calculatedaccordingto theYouden’sindex. Patientswere thendivided intoa high-risk group (Rad-score > 0.34) and a low-risk group (Rad-score ≤0.34), and a nomogram model was successfully established to predict treatment response. The predicted treatment response also allowed for significant discrimination of Kaplan-Meier curves. Multivariate Cox regression identified six independent prognostic factors for overall survival, including male [hazard ratio (HR) = 0.500, 95% confidence interval (CI): 0.260–0.962, P = 0.038], alpha-fetoprotein (HR = 1.003, 95% CI: 1.002–1.004, P < 0.001), alanine aminotransferase (HR = 1.003, 95% CI: 1.0 01–1.0 05, P = 0.025), performance status (HR = 2.400, 95% CI: 1.20 0–4.80 0, P = 0.013), the number of TACE sessions (HR = 0.870, 95% CI: 0.780–0.970, P = 0.012) and Rad-score (HR = 3.480, 95% CI: 1.416–8.552, P = 0.007). Conclusions: The radiomic signatures and clinical factors can be well-used to predict the response of HCC patients to the first TACE and may help identify the patients most likely to benefit from TACE.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 361-369 . [Abstract] ( 89 ) [HTML 1KB] [PDF 0KB] ( 67 )

	370	Liu SY, Li LH, Liu ZC, Li SX, Dang XW
		Development of a prognostic scoring system for hepatic vena cava Budd-Chiari syndrome with hepatocellular carcinoma
		Background: Hepatocellular carcinoma (HCC) is a serious complication of hepatic vena cava Budd-Chiari syndrome (HVC-BCS) that significantly reduces the survival time of patients. Our study aimed to analyze the prognostic factors influencing the survival of HVC-BCS patients with HCC and to develop a prognostic scoring system. Methods: The clinical and follow-up data of 64 HVC-BCS patients with HCC who received invasive treat- ment at the First Affiliated Hospital of Zhengzhou University between January 2015 and December 2019 were retrospectively analyzed. Kaplan-Meier curves and log-rank tests were used to analyze the survival curve of patients and the difference in prognoses between the groups. Univariate and multivariate Cox regression analyses were performed to analyze the influence of biochemical, tumor, and etiological characteristics on the total survival time of patients, and a new prognostic scoring system was developed according to the regression coefficients of the independent predictors in the statistical model. The prediction efficiency was evaluated using the time-dependent receiver operating characteristics curve and concordance index. Results: Multivariate analysis showed that serum albumin level < 34 g/L [hazard ratio (HR) = 4.207, 95% confidence interval (CI): 1.816-8.932, P = 0.001], maximum tumor diameter > 7 cm (HR = 8.623, 95% CI: 3.771-19.715, P < 0.001), and inferior vena cava stenosis (HR = 3.612, 95% CI: 1.646-7.928, P = 0.001) were independent predictors of survival. A prognostic scoring system was developed according to the above-mentioned independent predictors, and patients were classified into grades A, B, C and D. Significant differences in survival were found among the four groups. Conclusions: This study successfully developed a prognostic scoring system for HVC-BCS patients with HCC, which is helpful for clinical evaluation of patient prognosis.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 370-375 . [Abstract] ( 83 ) [HTML 1KB] [PDF 0KB] ( 77 )

ORIGINAL ARTICLES/Biliary

	376	Xiang F, Meng QT, Deng JJ, Wang J, Liang XY, Liu XY, Yan S
		A deep learning model based on contrast-enhanced computed tomography for differential diagnosis of gallbladder carcinoma ^Hot!
		Background: Gallbladder carcinoma (GBC) is highly malignant, and its early diagnosis remains difficult. This study aimed to develop a deep learning model based on contrast-enhanced computed tomography (CT) images to assist radiologists in identifying GBC. Methods: We retrospectively enrolled 278 patients with gallbladder lesions ( > 10 mm) who underwent contrast-enhanced CT and cholecystectomy and divided them into the training (n = 194) and validation (n = 84) datasets. The deep learning model was developed based on ResNet50 network. Radiomics and clinical models were built based on support vector machine (SVM) method. We comprehensively compared the performance of deep learning, radiomics, clinical models, and three radiologists. Results: Three radiomics features including LoG_3.0 gray-level size zone matrix zone variance, HHL first- order kurtosis, and LHL gray-level co-occurrence matrix dependence variance were significantly different between benign gallbladder lesions and GBC, and were selected for developing radiomics model. Multi- variate regression analysis revealed that age ≥65 years [odds ratios (OR) = 4.4, 95% confidence inter- val (CI): 2.1-9.1, P < 0.001], lesion size (OR = 2.6, 95% CI: 1.6-4.1, P < 0.001), and CA-19-9 > 37 U/mL (OR = 4.0, 95% CI: 1.6-10.0, P = 0.003) were significant clinical risk factors of GBC. The deep learning model achieved the area under the receiver operating characteristic curve (AUC) values of 0.864 (95% CI: 0.814-0.915) and 0.857 (95% CI: 0.773-0.942) in the training and validation datasets, which were compa- rable with radiomics, clinical models and three radiologists. The sensitivity of deep learning model was the highest both in the training [90% (95% CI: 82%-96%)] and validation [85% (95% CI: 68%-95%)] datasets. Conclusions: The deep learning model may be a useful tool for radiologists to distinguish between GBC and benign gallbladder lesions.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 376-384 . [Abstract] ( 111 ) [HTML 1KB] [PDF 0KB] ( 70 )

	385	Chen MZ, Xie P, Wu XC, Tan ZH, Qian H, Ma ZH, Yao X
		Comparison of biliary protein spectrum in gallstone patients with obesity and those with normal body weight
		Background: Obesity is a common public health issue and is currently deemed a disease. Research has shown that the risk of gallstones in individuals with obesity is elevated. This study aimed to explore the bile proteomics differences between cholelithiasis patients with obesity and normal body weight. Methods: Bile samples from 20 patients (10 with obesity and 10 with normal body weight) who underwent laparoscopic cholecystectomy at our center were subjected to tandem mass tag labeling (TMT) and liquid chromatography-tandem mass spectrometry (LC-MS/MS), followed by further bioinformatic analysis. Results: Among the differentially expressed proteins, 23 were upregulated and 67 were downregulated. Bioinformatic analysis indicated that these differentially expressed proteins were mainly involved in cell development, inflammatory responses, glycerolipid metabolic processes, and protein activation cascades. In addition, the activity of the peroxisome proliferator-activated receptor (PPAR, a subfamily of nuclear receptors) signaling pathway was decreased in the Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis. Two downregulated proteins in the PPAR signaling pathway, APO A-I and APO A-II, were confirmed using enzyme-linked immunosorbent assay. Conclusions: The PPAR signaling pathway may play a crucial role in the development of cholelithiasis among patients with obesity. Furthermore, biliary proteomics profiling of gallstones patients with obesity is revealed, providing a reference for future research.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 385-392 . [Abstract] ( 92 ) [HTML 1KB] [PDF 0KB] ( 110 )

ORIGINAL ARTICLES/Pancreas

	393	Li MZ, Guo T, Feng YL, Zhang SY, Bai XY, Wu X, Xu K, Yang AM
		Diabetes mellitus in patients with type 1 autoimmune pancreatitis at diagnosis and after corticosteroid therapy ^Hot!
		Background: A high prevalence of diabetes mellitus (DM) coexisting with autoimmune pancreatitis (AIP) is observed. However, evidence on the circumstances under which corticosteroid therapy (CST) for AIP improves or worsens DM is scarce. This study aimed to demonstrate and identify predictors of DM control under the influence of CST. Methods: Patients diagnosed with type 1 AIP were enrolled from a prospectively maintained cohort and were classified into three groups according to the chronology in which AIP and DM were diagnosed: pre-existing DM (pDM), concurrent DM (cDM), and non-DM (nDM). The responses of DM to CST were assessed when corticosteroid was ceased or tapered to a maintenance dose and classified as ‘improvement’ and ‘non-improvement’ (including ‘no change’ and ‘exacerbation’). Results: Among 101 patients with type 1 AIP, 52 (51.5%) patients were complicated with DM at the time of AIP diagnosis, with 36 patients in the cDM group and 16 patients in the pDM group. The incidences of diffuse pancreatic swelling (72.2%) and pancreatic body/tail involvement (91.7%) were significantly higher in the cDM group than in both the pDM and nDM groups. Of the 52 patients with DM, CST was administered in 48 cases. Multivariate logistic analysis identified that elevated serum gamma-glutamyl transferase (GGT) level at AIP diagnosis [odds ratio (OR) = 0.032, 95% confidence interval (CI): 0.003-0.412, P = 0.008] and pancreatic atrophy after CST (OR = 0.027, 95% CI: 0.0 03-0.295, P = 0.0 03) were negatively associated with DM control improvement. Conclusions: Patients with diffuse pancreatic swelling and pancreatic body/tail involvement in pancreatitis tended to be complicated with cDM at AIP diagnosis. CST exerted a beneficial effect on the clinical course of DM in nearly half of the AIP patients complicated with DM at diagnosis, particularly in those without elevated serum GGT levels at diagnosis and who did not experience pancreatic atrophy after CST.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 393-398 . [Abstract] ( 104 ) [HTML 1KB] [PDF 0KB] ( 73 )

	399	Yin ZZ, Gao YX, Zhao ZM, Hu MG, Tang WB, Liu R
		Robotic versus laparoscopic surgery for sporadic benign insulinoma: Short- and long-term outcomes
		Background: Minimally invasive surgery is the optimal treatment for insulinoma. The present study aimed to compare short- and long-term outcomes of laparoscopic and robotic surgery for sporadic benign insulinoma. Methods: A retrospective analysis of patients who underwent laparoscopic or robotic surgery for in- sulinoma at our center between September 2007 and December 2019 was conducted. The demographic, perioperative and postoperative follow-up results were compared between the laparoscopic and robotic groups. Results: A total of 85 patients were enrolled, including 36 with laparoscopic approach and 49 with robotic approach. Enucleation was the preferred surgical procedure. Fifty-nine patients (69.4%) underwent enucleation; among them, 26 and 33 patients underwent laparoscopic and robotic surgery, respectively. Robotic enucleation had a lower conversion rate to laparotomy (0 vs. 19.2%, P = 0.013), shorter operative time (102.0 vs. 145.5 min, P = 0.008) and shorter postoperative hospital stay (6.0 vs. 8.5 d, P = 0.002) than laparoscopic enucleation. There were no differences between the groups in terms of intraoperative blood loss, the rates of postoperative pancreatic fistula and complications. After a median follow-up of 65 months, two patients in the laparoscopic group developed a functional recurrence and none of the patients in the robotic group had a recurrence. Conclusions: Robotic enucleation can reduce the conversion rate to laparotomy and shorten operative time, which might lead to a reduction in postoperative hospital stay.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 399-405 . [Abstract] ( 88 ) [HTML 1KB] [PDF 0KB] ( 120 )

NEW TECHNIQUES

	406	Deng JF, Peng CH, Zhang Y, Xu XF, Tong RL, Zhai ZL, Chen DY, Zhang C, Wu LM, Wu J
		Achieving laparoscopic anatomic resection for hepatocellular carcinoma by fluorescence guided positive staining of hepatic cone unit
		Laparoscopic anatomical liver resection has been increasingly reported worldwide, but how to demarcate the resection planes is technically challenging [1]. Positive staining technique with intraoperative indocyanine green (ICG)-fluorescence imaging has been introduced as an effective tool for real-time intraoperative guidance [2]. Liver anatomy is complex. Generally, liver is composed of 9 segments, each is composed of two to three subsegments, and each subsegment contains several hepatic cone units. A hepatic cone unit is dominated by a tertiary or quaternary hepatic pedicles [3].
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 406-411 . [Abstract] ( 93 ) [HTML 1KB] [PDF 0KB] ( 66 )

	412	Angsuwatcharakon P, Kongkam P, Ridtitid W, Piyachaturawat P, Vongwattanakit P, Ananchuensook P, Faknak N, Vanduangden K, Rerknimitr R
		Aberrant bile duct communicating with the cystic duct: From early detection to management of late surgical complications
		The aberrant hepatic duct is classified by Huang et al. [1] into type A (right intrahepatic duct variant) and type B (left intrahepatic duct variant). Type A and B are further classified into 5 (A1- 5) and 6 (B1-6) subtypes, respectively. The variation of cystic duct involves only in type A. Type A1 or classic arrangement refers to the formation of the common hepatic duct (CHD) by the left hepatic duct (LHD) and the right hepatic duct (RHD). The RHD has two tributaries composed of the right anterior hepatic duct (RAHD) and the right posterior hepatic duct (RPHD). Then, the common bile duct (CBD) is formed when the cystic duct joins with the CHD ( Fig. 1 ). Type A2 refers to the RAHD and RPHD joining with LHD at hepatic hilum, and the absence of the RHD. Type A3 refers to the RAHD or RPHD directly draining to the LHD. Type A4 refers to the RAHD or RPHD directly draining to the CHD. Type A5 refers to the RAHD, RPHD or RHD directly draining to the cystic duct (or aberrant bile duct communicating with the cystic duct, ACC) ( Fig. 1 ) [1] . A recent systematic review including 17 045 subjects reported the global prevalence of type A1-5 being 62.6%, 11.5%, 11.5%, 6.4%, and 0.58%, respectively [2] . Unrecognized type A5 could lead to complications after cholecystectomy, especially bile leakage or stricture. Preoperative cholangiograms, either by magnetic resonance cholangiography (MRC), endoscopic retrograde cholangiography (ERC) or intraoperative cholangiogram (IOC), could be helpful to detect this variation. However, these cholangiograms are not routinely done. Therefore, this variation is usually suspected after the development of postoperative complications. Herein, we present five cases of ACC which include two preoperative cases and three postoperative cases.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 412-416 . [Abstract] ( 118 ) [HTML 1KB] [PDF 0KB] ( 64 )

	417	Del Fabbro D, Procopio F, Galvanin J, Costa G, Famularo S, Palmisano A, Donadon M, Torzilli G
		Intraoperative cholangio-ultrasonography (IOCUS) during hepatectomy with resection of the biliary confluence: An effective alternative to intraoperative cholangiography
		Intraoperative ultrasonography (IOUS) in hepatobiliary surgery is well known as an essential tool for radical and safe hepatectomies, allowing to perform parenchymal sparing surgery and, as consequence, to expand the surgical indications for patients otherwise considered unresectable. Nevertheless, since many years, despite its effectiveness in the study of vascular anatomy of the liver, the gold standard for the assessment of biliary anatomy during surgery is intraoperative cholangiography (IOC), which is used for the validation of preoperative imaging as well as for guiding reconstruction in case of bile duct injury or resection.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 417-420 . [Abstract] ( 84 ) [HTML 1KB] [PDF 0KB] ( 66 )

	421	Ahuja M, Joshi K, Coldham C, Muiesan P, Dasari B, Abradelo M, Marudanayagam R, Mirza D, Isaac J, Bartlett D, Chatzizacharias NA, Sutcliffe RP, Roberts KJ
		Hepatic vein reconstruction during hepatectomy: A feasible and underused technique
		Complete surgical resection (R0) of liver tumors, primary or metastatic, remains the main objective in management of primary and metastatic liver tumors [1]. Tumors invading to the proximity of the hepatic venous outflow pose a peculiar challenge to achieve R0 resections, because this location may render a tumor unresectable. The median survival of patients with liver tumor without surgery is less than 12 months [2]. Even with surgery, post-hepatectomy liver failure and subsequently increased mortality are the main problems associated with complex resection [3]. Moreover, when the vein is affected, vein resection and subsequent reconstruction are necessary. Vascular resection is a standard practice in liver resection and transplantation [4], for example, hepatic vein reconstruction during a living-donor liver transplant, porto-mesenteric axis reconstruction during resection of advanced pancreatic cancer and caval reconstruction during resection of retroperitoneal tumors. Thus, novel techniques like total hepatic vascular exclusion (HVE) [5], veno-venous bypass [6] and ex vivo hepatic resection [7,8] have facilitated curative resections of tumors close to one or more major hepatic veins.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 421-427 . [Abstract] ( 82 ) [HTML 1KB] [PDF 0KB] ( 137 )

CLINICAL IMAGE

	428	Liu SL, Li GG, Cheng W, Peng C, Song YH
		T-tube bridging fistula jejunal anastomosis for treatment of pancreatic lumbar dorsal fistula after necrotizing pancreatitis
		Infectious pancreatic necrosis causes external pancreatic fistula in some patients. Generally, external pancreatic fistula requires fistula-gastric and/or intestinal anastomosis, and digestive endoscopic interventional treatment [1–3]. It is especially difficult to treat external pancreatic fistulas with small fistulas where the external fistula is located in the lower back. The common treatment is to remove the body and tail of the pancreas and the spleen. This operation is very traumatic. A new pancreatic fistula may still occur at the pancreatic stump. The above operations may lead to unnecessary resection of the spleen, colon injury and other complications. In order to solve this problem, we innovatively used T-tube bridging fistula jejunal anastomosis plus continuous negative pressure suction to treat three cases of external pancreatic fistulas in the lower back, and all of them achieved good results.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 428-430 . [Abstract] ( 89 ) [HTML 1KB] [PDF 0KB] ( 58 )

	431	Liu BJ, Jin CH, Guo YL, Ke ZG, Huang JJ, Cao LP
		Pancreatic giant malignancy simulating a gastrointestinal stromal tumor
		Pancreatic acinar cell carcinoma (PACC) is a rare malignant tumor of pancreatic epithelial cells, which produces pancreatic exocrine enzymes. PACC originates from acinar cells and terminal branches of the pancreatic ducts in the exocrine tissue of the pancreas. PACC accounts for 1%−2% of pancreatic exocrine tumors [1] . Herein, we present an elderly woman with PACC who recovered after effective laparoscopic surgery. The tumor was located on the left side of the abdomen; imaging suggested that it was a gastrointestinal stromal tumor of the gastric wall origin, infiltrating the tail of the pancreas and omentum, while postoperative pathology suggested PACC.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 431-433 . [Abstract] ( 89 ) [HTML 1KB] [PDF 0KB] ( 112 )

LETTERS TO THE EDITOR

	434	Xue L, Wan DL, Hu C, Ke QH, Zhou J, Shen Y
		Concomitant hepatocellular carcinoma recurrence and mantle cell lymphoma
		Mantle cell lymphoma (MCL) is a rare subgroup of B-cell non-Hodgkin’s lymphoma (NHL) that occurs in approximately 6% of NHL patients. Chronic hepatitis and cirrhosis may promote hepatocellular carcinoma (HCC) development. Here, we report an even rarer case with coexisting HCC and MCL.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 434-437 . [Abstract] ( 85 ) [HTML 1KB] [PDF 0KB] ( 113 )

	438	Lin BY, Zhang QJ, Yang Z, Zheng SS
		Middle hepatic vein variation provides a safe path for anterior transection of hepatocellular carcinoma in caudate lobe
		Hepatocellular carcinoma (HCC) is one of the main causes of cancer related death worldwide, and new cases are expected to continue to increase in future [1] . Surgical resection is still the best way to remove the tumor and improve patient’s prognosis. However, resection of caudate lobe often presents a technical challenge, even to accomplished hepatic surgeons. Caudate lobe is located anterior to the inferior vena cava (IVC) and posterior to the bifurcation of the portal vein (PV), generally consists of three regions: the paracaval portion, the left Spiegel lobe and the process portion [2] . The anatomy of the paracaval portion includes the liver parenchyma ventral to the hepatic IVC and the area between the Spiegel lobe and the right lobe adjacent to the middle hepatic vein (MHV) ventrally, which was classified by Couinaud as segment IX [3] . Here, we presented a case of HCC with successful downstaging therapy, as well as variation of MHV, which provides a safe path for anterior transection of segment IX.
		Hepatobiliary Pancreat Dis Int. 2024; 23(4): 438-440 . [Abstract] ( 87 ) [HTML 1KB] [PDF 0KB] ( 66 )

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