Perihilar cholangiocarcinoma is the common type of malignant tumor in the biliary tract.The diagnosis and treatment of perihilar cholangiocarcinoma involve multiple aspects such as epidemiology，clinical diagnosis， imaging examination， clinical classification and staging， pathology， resectability evaluation，perioperative management， surgical planning， systematic treatment， and follow-up monitoring， which make it as one of the difficult and technically demanding fields in hepatobiliary surgery. In order to guide the more standardized， safe， and effective treatment of hilar cholangiocarcinoma in China， the Society for Hepatopancreato-biliary Surgery of Chinese Research Hospital Association and Editorial Board of Chinese Journal of Digestive Surgery have organized experts in the field of hilar cholangiocarcinoma nationwide to develop the Guideline for diagnosis and treatment of perihilar cholangiocarcinoma （2025 edition）. The aim is to provide standardized diagnosis and treatment plans for perihilar cholangiocarcinoma based on the latest clinical practice and evidence-based medicine principles， to improve diagnosis and treatment levels and patient prognosis， and to provide scientific guidance and reference for surgeons in China.
Neuroendocrine neoplasms （NENs） are extremely rare， mostly occurr in gastrointestinal tract and lung， and the liver is the most common metastatic site. When NENs metastasize to the liver， it will be complicated with a series of complications， which will affect clinical prognosis of patients. With deepening understanding of pathological mechanism， diagnosis and treatment by medical researchers， treatment regimens for patients with NENs liver metastasis have been constantly updated. In this article， the latest diagnosis and treatment of NENs liver metastasis were systematically reviewed by retrieving and analyzing relevant literature at home and abroad， aiming to provide guidance for clinical practitioners， deliver prompt diagnosis and treatment， minimize the impact of the disease and improve survival rate of patients.
Iatrogenic bile duct injury （IBDI） refers to bile duct injury caused by iatrogenic factors during surgery or alternative invasive diagnosis and treatment procedures. With persistent development of laparoscopic technique， laparoscopic cholecystectomy （LC） has become the “gold standard” for the treatment of benign gallbladder diseases. However， accidental bile duct injuries caused by LC occasionally occur in hospitals at all levels and become the most common cause of IBDI. If IBDI were not timely diagnosed or properly treated， it will lead to serious complications such as biliary peritonitis， biliary tract infection， bile duct stenosis， biliary cirrhosis and end-stage liver disease， and even death. Therefore， accurate understanding of the etiology， diagnosis， classification， opportunity for repair， treatment and preventive measures of IBDI plays a significant role. In this article， research progress and current status of IBDI were reviewed， aiming to provide guidance for clinicians to fully unravel the etiology of IBDI， make accurate and timely diagnosis，strictly assess the classification of injury， reasonably determine the opportunity for repair， adopt precise treatment and effectively strengthen preventive measures， thereby further enhancing prevention and treatment effects for IBDI.
Radical surgical resection remains the main treatment for liver tumors. For the liver with two blood supply systems， portal vein and hepatic artery， internal structure of the liver is complex and the risk of intraoperative bleeding is high. Laparoscopic hepatectomy has been widely applied in clinical practice due to multiple advantages of small incision， slight pain and rapid recovery. Multiple methods can be employed to control intraoperative bleeding， such as the selection of different methods of hepatic portal occlusion and use of different surgical instruments， etc. In this article， the application of current main hepatic blood flow occlusion technologies in laparoscopic hepatectomy was reviewed， aiming to provide guidance for clinical practice.
Since Reich completed the first case of laparoscopic resection of benign liver tumor in 1991， laparoscopic hepatectomy （LH） has been gradually applied and promoted. The scope of application of LH ranges from benign lesions to malignant tumors， from local and segmental hepatectomy to hemihepatectomy， and even donor hepatectomy in living donor liver transplantation. The challenges of LH are also increased correspondingly. During complicated laparoscopic hepatectomy， limited visual field， lack of tactile sensation and difficulty in intraoperative hemostasis and other issues lead to an increase in the risk of intraoperative bleeding. Therefore， active prevention and control of bleeding during LH is not only one of the keys to reduce perioperative complications and enhance clinical prognosis， but also the key to the promotion and application of LH. In this article， prevention and treatment strategies of bleeding during LH were reviewed based on literature review combined with clinical experience， aiming to provide reference for clinicians.
In recent years， with gradual development of imaging technology and widespread application of chest CT during pandemic and post-pandemic era， the diagnostic rate of hepatic cystic lesions has been gradually elevated. Hepatic cystic lesions can be divided into benign and malignant types. Benign hepatic cystic lesions mainly include simple hepatic cyst， polycystic liver disease， hepatic echinococcosis，Caroli disease， bile duct hamartoma and intrahepatic biliary cystadenoma， etc. Malignant hepatic cystic lesions comprise intrahepatic biliary cystadenocarcinoma. Hemorrhage and infection are common complications of hepatic cysts. Although benign hepatic cystic lesions are dominant， the occurrence of malignant hepatic cystic lesions should be monitored in clinical settings. It is necessary to comprehensively consider the number，location， size and nature of the cystic lesions and physical condition of the patients and choose different treatment methods in clinical practice. Surgery is the main treatment for patients with hepatic echinococcosis.When patients are clinically diagnosed with cystadenoma， surgical resection should be considered in a timely manner. Extensive attention should be diverted to follow-up and examination for patients with Caroli disease and bile duct hamartoma in case of the incidence of cholangiocarcinoma. In this article， the types， differential diagnosis and treatment options of hepatic cystic lesions were reviewed based on clinical experience.
Portal hypertension （PH） is the most severe and common complication of chronic liver diseases， which seriously threatens human health and life. Transjugular intrahepatic portosystemic shunt （TIPS），as a minimally invasive procedure， yields high efficacy in the treatment of PH. Reasonable selection of eligible population and treatment opportunity of TIPS and deep understanding of complications are vital to improve clinical efficacy. In this article， recent research progress in TIPS standard procedures and management of surgical complications was reviewed， aiming to provide theoretical basis for clinical application of TIPS.
To evaluate the safety and efficacy of postoperative targeted immunotherapy of tyrosine kinase inhibitors （TKIs） combined with immune checkpoint inhibitors （ICIs） in patients with high-risk hepatocellular carcinoma （HCC） recurrence.
Methods
Clinical data of 287 HCC patients with high-risk recurrence after undergoing hepatectomy in Sun Yat-sen Memorial Hospital of Sun Yat-sen University were retrospectively analyzed. The local ethical committee approval was received. Among them，233 patients were male and 54 female， aged from 23 to 85 years， with a median age of 56 years. 53 patients received postoperative targeted immunotherapy of TKIs combined with ICIs （adjuvant therapy group）， and 234 patients did not receive any adjuvant therapy （control group）. The influence of confounding factors and selection bias was minimized using 1:2 propensity score matching （PSM）. The primary end point of this study was recurrence-free survival （RFS）， and the secondary end point was overall survival （OS）， and the incidence and severity of treatment-related adverse events. Survival analysis was conducted by Kaplan-Meier method and Log-rank test. The influencing factors of RFS were analyzed by Cox proportional hazard model.
Results
After 1:2 PSM analysis， 41 patients were assigned into the adjuvant therapy group and 72 cases in the control group. After PSM analysis， the median RFS in the adjuvant therapy and control groups was 23.7 and 15.7 months， and the RFS in the adjuvant therapy group was significantly longer than that in the control group （HR=0.601； 95%CI: 0.367-0.986； P=0.041）. There was no significant difference in OS between two groups （HR=0.661； 95%CI: 0.240-1.823； P=0.421）. Subgroup Cox analysis showed that patients aged ≤50 years old， male， HBsAg positive， non-cirrhosis， Child-Pugh class A， AFP＞400 μg/L， MVI，Edmondson grade Ⅲ-Ⅳ， complicated with macrovascular tumor thrombus and two or more risk factors of high-risk recurrence could obtain more benefits from targeted immunotherapy （HR=0.454， 0.554， 0.586，0.449， 0.582， 0.423， 0.399， 0.474， 0.213 and 0.376， all P＜0.05）. 81%（43/53） of patients developed treatmentrelated adverse reactions， and no grade 4 or above treatment-related adverse reactions occurred. Common treatment-related adverse reactions included thrombocytopenia （42%）， hypertension （40%）， neutropenia （25%），gamma glutamyl transpeptidase （GGT） elevation （21%） and anemia （13%）， etc. Common gradeⅢ treatmentrelated adverse reactions consisted of hypertension （4%）， neutropenia （4%） and thrombocytopenia （2%）， etc.
Conclusions
For HCC patients with high-risk recurrence， postoperative targeted immunotherapy of TKIs combined with ICIs can prolong postoperative RFS and yield safe and controllable adverse reactions.
To investigate the influencing factors for surgery in patients with unresectable hepatocellular carcinoma （uHCC） after interventional therapy combined with targeted immunotherapy， and to construct a nomogram prediction model.
Methods
Clinical data of 190 patients with newly-diagnosed uHCC admitted to the Second Affiliated Hospital of Air Force Medical University from January 2022 to June 2024 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them， 163 patients were male and 27 female，aged from 31 to 75 years， with a median age of 55 years. The patients were received interventional therapy combined with targeted immunotherapy. The predictive factors for surgical conversion uHCC were screened by Lasso regression. According to the ratio of 7:3， all patients were divided into the training set （n=133） and test set （n=57）. A nomogram prediction model was constructed in the training set based on the predictive factors by using Logistic regression analysis. ROC curve， calibration curve and clinical decision curve were drawn to assess the degree of discrimination， calibration and clinical applicability of this model.
Results
A total of 51 patients were successfully converted to resection， and the overall conversion rate was 26.8%.Finally， 4 factors were identified by Lasso and Logistic regression analyses， including the Eastern Cooperative Oncology Group-Performance Status （ECOG-PS） score， liver cirrhosis， C-reactive protein-to-albumin （CAR）ratio and neutrophil-to-lymphocyte ratio （NLR）. Based on these 4 factors， a prediction model was constructed and a nomogram was drawn in the training set. The area under the ROC curve （AUC） of this nomogram in the training and testing sets was 0.784 （95%CI: 0.699-0.869） and 0.806 （95%CI: 0.693-0.920）， respectively indicating that a high degree of discrimination. Both the calibration curve and Hosmer-Lemeshow goodnessof-fit test showed that the model had a high degree of calibration （χ2=7.410， P=0.493）. The clinical decision curves were delineated in the training and test sets， revealing that the prediction model yielded high net clinical benefit.
Conclusions
ECOG-PS score， liver cirrhosis， CAR and NLR are the influencing factors of newly-diagnosed uHCC patients receiving interventional therapy combined with targeted immunotherapy before conversion to surgery. The nomogram based on these influencing factors has high predictive capability.
To assess the predictive value of indocyanine green retention rate at 15 min （ICGR15） and albumin-bilirubin （ALBI） score for post-hepatectomy liver failure（PHLF） and prognosis of hepatocellular carcinoma （HCC） patients after hepatic arterial infusion chemotherapy （HAIC）.
Methods
Clinical data of 160 HCC patients who underwent hepatectomy after HAIC in Sun Yat-sen University Cancer Center were retrospectively analyzed. Among them，104 patients were male and 56 female， aged from 23 to 76 years， with a median age of 53 years. PHLP was diagnosed and graded according to the diagnostic criteria of the International Study Group of Liver Surgery （ISGLS）. Receiver operating characteristic （ROC） curve was delineated to evaluate the predictive efficiency of ICGR15 and ALBI score for PHLF. The independent risk factors of PHLF were analyzed by Logistic regression model. Overall survival （OS） and recurrence-free survival （RFS）were analyzed by Kaplan-Meier method and Log-rank test.
Results
Among 160 patients， 39（24.4%）cases developed PHLF， including 9（6.9%） cases of ＞grade B. The area under the ROC curve （AUC） of predictive value of preoperative ICGR15 and ALBI score for PHLF was 0.715 （95%CI: 0.626-0.805）and 0.704 （95%CI: 0.606-0.802）， the optimal thresholds were 0.060 and -2.73， the sensitivity was 0.795 and 0.615， and the specificity was 0.620 and 0.706， respectively. The AUC of predictive value of preoperative ICGR15 and ALBI score for ＞grade B PHLF was 0.798 （95%CI: 0.652-0.953） and 0.768 （95%CI: 0.617-0.920）， and the optimal thresholds were 0.128 and -2.50， the sensitivity was 0.727 and 0.636， and the specificity was 0.872 and 0.891， respectively. Multivariate Logistic regression analysis showed that preoperative international normalized ratio （INR） of ＞1 and ICGR15 of ＞0.060 were the independent risk factors for PHLF （OR=4.82， 6.15， both P＜0.05）. Preoperative ICGR15＞0.128 and age≤60 years old were independent influencing factors for ＞grade B PHLF （OR=6.65， 0.13， both P＜0.05）. All patients were divided into two groups when the threshold of ICGR15 was set as 0.060， and all patients in two groups did not obtain the median OS， with no statistical significance （χ2=0.705， P=0.40）. The median RFS was 22.0 and 20.8 months in two groups， and the difference was not statistically significant （χ2=0.725， P=0.39）.
Conclusions
Preoperative ICGR15 is an independent risk factor for PHLF in HCC patients after HAIC.ICGR15 and ALBI score yield equivalent predictive value for PHLF. HCC patients with preoperative ICGR15 of ＞0.128 or age ＞60 years old are more prone to ＞grade B PHLF.
To investigate the differences of perioperative efficacy and safety of hepatectomy between patients with nonalcoholic fatty liver disease （NAFLD）- and viral hepatitis （VH）-associated hepatocellular carcinoma （HCC）.
Methods
Clinical data of 219 patients with HCC who underwent hepatectomy in Beijing Chaoyang Hospital of Capital Medical University from January 2019 to January 2024 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them， 161 patients were male and 58 female， aged from 32 to 83 years， with a median age of 58 years. 47 cases were diagnosed with NAFLD-associated HCC （NAFLDHCC group） and 172 cases with VH-associated HCC （VH-HCC group）. Preoperative clinical factors， surgeryrelated factors， postoperative pathology， incidence of postoperative complications， total length of hospital stay， length of ICU stay and length of postoperative hospital stay were statistically analyzed between NAFLDHCC and VH-HCC groups. Clinical data between two groups were compared by independent samples t test，rank-sum test and Chi-square test.
Results
The body mass index （BMI） of patients in the NAFLD-HCC group was （24.8±2.3） kg/m2， significantly higher than （23.9±2.8） kg/m2 in the VH-HCC group （t=2.098，P=0.037）. Preoperative AFP in the NAFLD-HCC group was 2.2（0.8，13.0） μg/L， significantly lower than 20.1（3.3，271.4） μg/L in the VH-HCC group （Z=-4.967， P＜0.001）. In NAFLD-HCC group， 42%（20/47） of HCC patients were diagnosed accidentally， whereas 70%（121/172） were detected during physical examination in the VH-HCC group， and the difference was statistically significant （χ2=46.620， P＜0.001）. In the NAFLDHCC group， preoperative liver CT value was 31（25，35） HU， significantly lower than 59（52，67） HU in the VHHCC group （Z=-9.992， P＜0.001）. No significant difference was noted in operation time， blood loss， incidence of postoperative complications and postoperative length of hospital stay between two groups （all P＞0.05）.Subgroup analysis showed that blood loss of NAFLD-HCC patients with moderate to severe steatosis was 1 100 （238，1 800） ml， significantly higher than 400（200，800） ml in the VH-HCC group （Z=2.651， P=0.008）.The average tumor diameter in the NAFLD-HCC group was （5.2±2.5） cm， significantly larger than （4.0±2.1）cm in the VH-HCC group （t=3.352， P＜0.001）.
Conclusions
Compared with patients with VH-HCC，NAFLD-HCC patients have higher BMI and lower preoperative AFP. HCC is mainly diagnosed accidentally in the NAFLD-HCC group， while it is mostly detected during physical examination in the VH-HCC group.Although the safety of hepatectomy is equivalent between two groups， NAFLD-HCC patients with moderate to severe steatosis have a higher amount of intraoperative blood loss and higher surgical risk.
To assess the safety and efficacy of laparoscopy-choledochoscopyduodenoscopy treatment and laparoscopy-choledochoscopy treatment for cholelithiasis complicated with choledocholithiasis.
Methods
Clinical data of 103 patients with cholelithiasis complicated with choledocholithiasis in Hunan Province Directly Affiliated TCM Hospital from March 2022 to December 2023 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them， 53 patients were male and 50 female， aged from 20 to 82 years， with a median age of 57 years. According to different treatment， they were divided into the laparoscopy-choledochoscopy-gastroscopy triple-scopy group （n=54） and laparoscopy-choledochoscopy double-scopy group （n=49）. In the triple-scopy group， patients were treated with laparoscopic cholecystectomy+laparoscopic common bile duct exploration+choledochoscopic lithotomy+nasobiliary drainage+primary closure of common bile duct. In the double-scopy group， patients underwent laparoscopic cholecystectomy+laparoscopic common bile duct exploration+choledochoscopic lithotomy+T tube drainage.Perioperative conditions and efficacy were observed between two groups. The operation time and time to first flatus were compared by t test. Intraoperative blood loss and C-reactive protein （CRP） were compared by rank-sum test. The incidence of complications and efficacy were compared by Chi-square test.
Results
The operation time in the triple-scopy and double-scopy groups was （131±20） min and （129±23） min respectively，with no statistical significance （t=0.611， P＞0.05）. Intraoperative blood loss in the two groups was 20（10，21）ml and 20（10，30） ml， and the difference was not statistically significant （Z=0.842， P＞0.05）. In the triplescopy group， postoperative CRP level was 19（15，30） mg/L， significantly lower than 30（15，35） mg/L in the other group （Z=-2.176， P＜0.05）. In the triple-scopy group， the time to first flatus and extubation time was （2.1±0.5） d and （7.7±0.7） d， significantly shorter than （2.7±0.7） d and （47.4±5.7） d in the other group（t=-5.169，-50.495； both P＜0.05）. The incidence of postoperative complications in the triple-scopy group was 4%（2/54）， significantly lower than 16% （8/49） in the double-scopy group （χ2=4.669， P＜0.05）. The proportion of remarkable efficacy in the triple-scopy group was 96%（52/54）， significantly higher than 84%（41/49） in double-scopy group （χ2=4.669， P＜0.05）.
Conclusions
Compared with the combination of laparoscopy and choledochoscopy， the laparoscopy-choledochoscopy-duodenoscopy combination can mitigate postoperative inflammatory reaction， accelerate postoperative recovery， reduce the risk of surgical complications and enhance surgical efficacy in patients with cholelithiasis complicated with choledocholithiasis.
To evaluate the application of enhanced recovery after surgery （ERAS）in elderly patients undergoing laparoscopic combined with choledochoscopic lithotomy of common bile duct and primary closure.
Methods
Clinical data of 96 elderly patients with common bile duct stones who underwent laparoscopic combined with choledochoscopic lithotomy of common bile duct primary closure in the First Affiliated Hospital of Anhui University of Science and Technology were analyzed retrospectively.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them， 47 patients were male and 49 female， aged from 60 to 93 years， with a median age of 68 years.According to different perioperative interventions， all patients were divided into the ERAS and conventional groups. Perioperative indexes such as operation time and length of hospital stay were compared by ranksum test， and the incidence of complications was compared by Chi-square test.
Results
In the ERAS group，the operation time， intraoperative blood loss， time to first flatus， length of hospital stay and hospitalization expense were 137（110，180） min， 28（20，31） ml， 2.1（2.0，2.3） d， 14.3（12.0，17.0） d and 2.4（2.1，2.8）×104 Yuan，significantly less than 172（138，218） min， 50（20，60） ml， 2.7（2.0，3.0） d， 19.7（15.8，22.3） d and 3.2（2.7，3.4） ×104 Yuan in the conventional group （Z=-3.140， -3.810， -3.210， -4.940， -5.710； all P＜0.05）. The WBC at postoperative 5 d in the ERAS group was （5.7±2.0）×109/L， significantly lower than （7.5±2.4）×109/L in the conventional group （t=-7.390， P＜0.05）. At postoperative 5 d， the levels of ALT， AST and C-reactive protein in the ERAS group were 24（20，34） U/L， 24（19，31） U/L and 31（9，28） mg/L， significantly lower than 76（55，86） U/L， 37（24，55） U/L and 58（30，77） mg/L in the conventional group （Z=-6.574， -3.985， -4.566； all P＜0.05）. The incidence of postoperative complications in the ERAS group was 20%（10/50）， significantly lower than 59%（27/46） in the conventional group （χ2=15.145， P＜0.05）.
Conclusions
The application of ERAS is feasible， safe and effective in elderly patients with common bile duct stones receiving primary closure of laparoscopic combined with choledochoscopic lithotomy of common bile duct， which can accelerate postoperative recovery and lower hospitalization expense.
To compare clinical efficacy between one-stage laparoscopic common bile duct exploration combined with laparoscopic cholecystectomy （LCBDE+LC） and two-stage endoscopic retrograde cholangiopancreatography combined with LC （ERCP+LC） for choledocholithiasis complicated with cholecystolithiasis without common bile duct dilatation （6-10 mm in diameter）.
Methods
Clinical data of 104 patients with choledocholithiasis and cholecystolithiasis admitted to Jiangyin People’s Hospital from January 2017 to December 2022 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them， 44 patients were male and 60 female， aged from 21 to 78 years， with a median age of 48 years. All patients were divided into the LCBDE+LC （n=56） and ERCP+LC groups （n=48） according to surgical methods. The operative and postoperative condition between two groups were compared by Chi-square test or t test.
Results
The success rate of stone removal in the LCBDE+LC group was 98%（55/56）， significantly higher than 85%（41/48） in the ERCP+LC group （P＜0.05）. The incidence of postoperative complications was 12.5%（7/56）and 12.5%（6/58） in two groups， and the difference was not statistically significant （χ2=2.270， P=0.132）. In the LCBDE+LC group， 4 patients developed grade A bile leakage， 2 cases of incisional infection and 1 case of surgical site hematoma， who were cured after conservative treatment. In the ERCP+LC group， 1 case had bleeding after ERCP， 1 case of acute pancreatitis and 1 case of incisional infection， who were healed after conservative treatment. 2 cases of duodenal perforation were treated with open repair of duodenal perforation and peritoneal lavage and drainage. 1 of them was recovered after treatment and the other case died of multiple organ failure at postoperative 2 weeks. In the LCBDE+LC group， the length of postoperative hospital stay was （5.6±2.4） d， significantly shorter than （10.3±2.5） d in the ERCP+LC group （t=13.560， P＜0.05）. In the LCBDE+LC group， hospitalization expense was （2.3±1.1）×104 Yuan， significantly less than （3.5±0.9）×104 Yuan in the ERCP+LC group （t=8.443， P＜0.05）. In the LCBDE+LC group， the score of satisfaction at postoperative 6 weeks was （2.3±0.3）， significantly higher than （1.9±0.7） in the ERCP+LC group （t=5.252，P＜0.05）. During 1-year follow-up， no bile duct stenosis was found， 2 cases of bile reflux， 1 case of cholangitis and 1 case of stone recurrence were found in the LCBDE+LC group. In the ERCP+LC group，3 cases developed bile reflux， 2 cases of cholangitis and 2 cases of stone recurrence.
Conclusions
Compared with ERCP+LC， LCBDE+LC yields higher success rate of stone removal， shorter length of hospital stay， less hospitalization expense and higher degree of satisfaction in the treatment of choledocholithiasis complicated with cholecystolithiasis without common bile duct dilatation. However， the incidence of complications and long-term efficacy is similar between two groups.
To investigate the application of dorsal approach in laparoscopic resection of paracaval portion of the caudate lobe.
Methods
Clinical data of 6 patients undergoing laparoscopic resection of paracaval portion of the caudate lobe in the First Affiliated Hospital of Hunan Normal University from January 2020 to July 2023 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them， 2 patients were male and 4 female， aged （47±12） years. All patients underwent laparoscopic resection of paracaval portion of the caudate lobe via dorsal approach. Perioperative conditions and complications were observed.
Results
The operation time of 6 patients was （158±28） min. The occlusion time of porta hepatis was （40±16） min.Intraoperative blood loss was 147 （50±280） ml. No intraoperative blood transfusion was given. The length of postoperative hospital stay of 6 patients was 3.0-7.0 d， with a median of 5.3 d. No severe complications such as bleeding and bile leakage occurred after operation. Postoperative pathological examination showed that 2 cases were diagnosed with hepatic cavernous hemangioma with a diameter of 7.2 and 9.0 cm， 2 cases of focal nodular hyperplasia with a diameter of 5.2 and 5.9 cm， 1 case of hepatocellular carcinoma with a diameter of 2.7 cm and 1 case of intrahepatic cholangiocarcinoma with a diameter of 2.5 cm， respectively.
Conclusions
For experienced laparoscopic team， it is safe and feasible to perform laparoscopic resection of paracaval portion of the caudate lobe via dorsal approach for patients with benign paracaval tumors and eligible patients with malignant tumors after screening.
To investigate the clinicopathological features， treatment and prognosis of hepatic sarcomatoid carcinoma （HSC）.
Methods
Clinical data of 14 patients with HSC admitted to the First Affiliated Hospital of Guangxi Medical University from March 2002 to March 2022 were retrospectively analyzed. Among them， 12 patients were male and 2 female， aged from 46 to 77 years， with a median age of 56 years. Clinical features， imaging manifestations， pathological findings， treatment and prognosis were summarized and analyzed between two groups. According to different treatment， 14 patients were divided into the surgery（n=9） and non-surgery groups （n=5）. Survival status was compared between two groups. Survival analysis was performed by Kaplan-Meier method and Log-rank test.
Results
The male-to-female ratio was 6∶1.11 patients developed initial symptoms of epigastric discomfort， 1 case of weight loss， and 3 patients were detected during physical examination. 11 cases were with positive HBsAg， 11 cases had a serum ALB level ＜34 g/L and 1 case of TB level ＞17.1 μmol/L， 1 case of AFP level ＞400 μg/L， and 3 cases of CA19-9 level ＞40 kU/L.11 cases were graded as Child-Pugh grade A and 3 cases of grade B. One patient was classified as stageⅠB，5 cases of stage Ⅲ and 8 cases of stage Ⅳ based on the TNM staging system. Among 14 patients， 8 cases had lymph node metastases. Imaging examination detected intratumoral necrosis in 7 cases. Vimentin， CK， P53 and Ki-67 were positive. The follow-up time was 1.0-58.0 months， with a median of 8.5 months. The median overall survival （OS） of 14 patients was 5 months. The median OS of surgery group was 5 months， and 25 months for non-surgery group. There was no statistical difference in OS between two groups （χ2=0.356， P=0.551）.
Conclusions
Clinical manifestations， laboratory and imaging examination of HSC are non-specific， and the diagnosis depends on pathological examination. No significant difference is found between surgical and nonsurgical treatment. Nevertheless， extended radical resection combined with multi-organ resection contributes to improving the quality of life and prolonging the survival time in certain patients.
To investigate the classification for arterial invasion of pancreatic cancer and the corresponding surgical strategies.
Methods
Clinical data of 17 patients with locally advanced pancreatic cancer admitted to PLA Rocket Force Characteristic Medical Center from July 2021 to May 2024 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them， 9 patients were male and 8 female， aged from 47 to 71 years，with a median age of 61 years. 13 cases were diagnosed with moderately and poorly differentiated pancreatic adenocarcinoma， 2 cases of pancreatic adenosquamous carcinoma， 1 case of pancreatic ductal adenocarcinoma and 1 case of ampullary adenocarcinoma （pancreaticobiliary type）. 10 patients were diagnosed with portal veinsuperior mesenteric vein and superior mesenteric artery invasion， 3 cases of portal vein-superior mesenteric vein and common hepatic artery invasion， 2 cases of portal vein-superior mesenteric vein and proper hepatic artery invasion， and 2 cases of portal vein-superior mesenteric vein and celiac trunk invasion， respectively.According to the arterial invasion sites， all patients were divided into typeⅠ， Ⅱand Ⅲ， and each type was further divided into different subtypes. Perioperative situations such as intraoperative situations， complications and postoperative recovery were observed.
Results
The surgerics of 17 patients were completed successfully.According to different types of arterial invasion of pancreatic cancer， different surgical methods were adopted. Among them， 7 cases were classified as type Ⅰ （3 cases of typeⅠa， 3 cases of type Ⅰb and 1 case of typeⅠd） and 10 cases of typeⅡ. Intraoperative blood loss was 500-3 600 ml， with a median of 1 153 ml.All 17 patients received blood transfusion. The operation time was 6.5-13.0 h， with a median of 9.5 h. The length of ICU stay was 2-10 d， with a median of 5 d. The length of hospital stay was 15-48 d， with a median of 30 d. Perioperatively， 1 patient died of postoperative anastomotic leakage and abdominal infection， and the remaining 16 patients were discharged. 6 cases developed complications， including 3 cases of gastrointestinal bleeding， 1 case of abdominal bleeding， 1 case of bile leakage and 1 case of lymphatic leakage. 1 patient with gastrointestinal bleeding was successfully treated with gastroscopic hemostasis， and 2 patients were treated with conservative treatment such as acid-suppressive therapy， hemostasis， fasting and nasogastric tube decompression， etc. Patients with abdominal bleeding were treated by terminating use of anticoagulants. Those with bile and lymphatic leakage were successfully treated with drainage and conservative treatment. 16 patients were followed up. As of the submission date， 6 patients survived and 10 patients died.
Conclusions
For patients with locally advanced pancreatic cancer， it is safe and feasible to adopted corresponding surgical interventions according to the site， scope and degree of arterial invasion.
To evaluate the significance and clinical application of Heidelberg triangle dissection in surgical treatment of pancreatic cancer by systematic review.
Methods
In April 2024， literature review was conducted from PubMed， Web of Science， Elsevier Journals， CNKI， Chongqing VIP and Wanfang databases using the key words: （“pancreatic cancer” OR “pancreatic neoplasm”） AND（“triangle” OR “Heidelberg technique” OR “Heidelberg triangle”） in English databases， and the key words:“ pancreatic cancer” OR “pancreatic neoplasm” AND “triangle”） in Chinese databases. The search results were limited to human research and articles in Chinese and English. Two authors independently reviewed and screened the literature. The quality of literatures was assessed by the Newcastle-Ottawa Scale （NOS）.
Results
2 152 studies were retrieved， and 4 retrospective cohort studies were finally included in the systematic review. The NOS scores of the included studies were ranged from 6 to 8. 525 patients were included in this study， including 327 cases of pancreaticoduodenectomy （PD） cohorts， 114 cases of total pancreatectomy （TP） cohorts and 84 cases of laparoscopic pancreaticoduodenectomy （LPD）. In the PD cohorts，the operation time in the Heidelberg tringle dissection group was （556±46） min， significantly longer than（501±61） min in the standard group （t=3.62， P＜0.05）. The median survival time after surgery was 21 months，significantly longer than 15 months in the standard group （χ2=4.30， P＜0.05）. The 3-year tumor recurrence rate was 55.56%， significantly lower than 83.33% in the standard group （P=0.040）. In the TP cohorts， the operation time in the Heidelberg tringle dissection group was 434（385，490） min， significantly longer than 367（315，445） min in the standard group （P=0.0002）. Intraoperative blood loss was 1 650（1 150，2 550） ml，significantly more than 800（500，1500） ml in the standard group （P＜0.0001）. The R0 resection rate was 30.8%， significantly higher than 10.5% in the standard group （P=0.0475）. In the LPD cohorts， the number of dissected lymph nodes in the Heidelberg tringle dissection group was 11.31±2.46， significantly more than 9.49±2.28 in the standard group （t=3.51， P＜0.05）. The R0 resection rate was 76.92%， significantly higher than 53.33% in the standard group （χ2=5.06， P=0.024）.
Conclusions
Heidelberg triangle dissection is safe and feasible in the surgical resection of pancreatic cancer， which can effectively reduce postoperative tumor recurrence rate and prolong the survival time of patients.
To evaluate the effect of Kirsten rat sarcoma virus （KRAS） gene mutation on clinical prognosis of resectable pancreatic cancer.
Methods
Clinical data of 96 patients with pancreatic cancer admitted to People’s Hospital of Xinjiang Uygur Autonomous Region from January 2022 to May 2023 were retrospectively analyzed. Among them， 62 patients were male and 34 female， aged from 54 to 76 years，with a median age of 70 years. The informed consents of all patients and families were obtained and the local ethical committee approval was received.Preoperative CA19-9 level was 29-4 500 kU/L. 50 cases were diagnosed with pancreatic head cancer and 46 cases of pancreatic body and tail cancer. All patients received adjuvant chemotherapy after surgery. The KRAS gene mutation in the patients was observed. Prognostic factors of pancreatic cancer patients were identified by Cox proportional hazard model. Survival analysis was performed by Kaplan-Meier method and Log-rank test.
Results
The mutation rate of KRAS gene in pancreatic cancer patients was 71%（68/96）. The detection of KRAS mutation sites showed that the four most frequent mutation sites of KRAS gene were p.G12D（n=33）， p.G12V（n=19）， p.G12R （n=7） and p.Q61H （n=5）， and 4 cases were other sites. Among KRAS mutation sites， p.G12D and p.G12V were the dominant sites. Multivariate Cox regression analysis demonstrated that KRAS gene mutation， tumor differentiation and lymphatic vessel invasion were the independent risk factors for clinical prognosis of pancreatic cancer （HR=2.424， 2.314，1.782； all P＜0.05）. The follow-up time was 6-36 months， with a median of 21 months. The 1-year survival rate of pancreatic cancer patients with KRAS gene mutation after operation was 94.1%， and 96.4% for those without KRAS gene mutation， and the difference was statistically significant （χ2=23.400， P＜0.05）. However，the difference was not statistically significant between the KRAS p.G12D and non-p.G12D mutation subgroups（χ2=0.055， P＞0.05）.
Conclusions
KRAS gene mutation is an independent risk factor for the clinical prognosis of patients with resectable pancreatic cancer. Patients with KRAS gene mutation have poor prognosis. However，no significant difference is noted in clinical prognosis among patients with different KRAS mutation sites.
To investigate the expression level of CCAAT enhancer binding protein ζ antisense strand （CEBPZOS） in hepatocellular carcinoma （HCC） tissues and the mechanism of CEBPZOS in promoting the progression of HCC.
Methods
Based on TCGA and GTEx databases， the correlation between the expression of CEBPZOS and clinical stages and prognosis was analyzed. Hepa1-6 cell lines with CEBPZOS knockdown/overexpression were constructed. The effect of CEBPZOS knockdown/overexpression on the proliferation and migration of Hepa1-6 cells was assessed by CCK-8 assay， colony formation assay，Transwell migration chamber and scratch assay， respectively. Hepa1-6-luc cell lines with CEBPZOS knockdown/overexpression and mouse models with subcutaneous HCC were constructed. The changes of tumor radiation intensity were dynamically monitored by in vivo imaging of small animals. Meantime，the changes in body weight of mice were also recorded. The experimental data between two groups were compared by one-way ANOVA. Survival analysis was performed by Kaplan-Meier method and Log-rank test.
Results
Based on TCGA and GTEx database analyses， the expression level of CEBPZOS mRNA in liver cancer tissues was significantly higher than that in normal tissues adjacent to liver cancer （P＜0.05）. With the progression of tumors （stageⅠ-Ⅲ）， the expression level of CEBPZOS mRNA showed an increasing trend（F=6.41， P＜0.05）. The overall survival and disease-free survival rates in the CEBPZOS overexpression group were significantly lower than those in the CEBPZOS knockdown group （HR=2.00，1.70； both P＜0.05）. CCK-8 and colony formation assays in vitro showed that the proliferation ability of Hepa1-6 cells was significantly decreased after CEBPZOS knockdown， whereas that of Hepa1-6 cells with CEBPZOS overexpression was enhanced （F=148.60， 223.80， both P＜0.05）. Scratch test and Transwell migration chamber revealed that the migration ability of Hepa1-6 cells was decreased after CEBPZOS knockdown， while that of Hepa1-6 cells was increased after CEBPZOS overexpression （F=387.50，80.97； both P＜0.05）. Animal experiments showed that the tumor radiation intensity of mice in the CEBPZOS overexpression group was significantly enhanced over time （F=142.80， P＜0.05）. On the 5th， 9th and 14th d， the tumor radiation intensity was the highest in the CEBPZOS overexpression group， while that in the CEBPZOS knockdown group was the lowest （F=5.24，52.77， 111.00； all P＜0.05）. The body weight of mice in the CEBPZOS overexpression group was significantly increased on the 10th， 12th and 14th d （F=10.27， 28.70， 29.25； all P＜0.05）.
Conclusions
CEBPZOS is highly expressed in HCC， which is closely associated with rapid progression of tumors， high TNM stage and poor prognosis. CEBPZOS can promote the progression of HCC by accelerating the proliferation and migration of tumor cells， which is a potential prognostic biomarker and therapeutic target.
Hepatic alveolar echinococcosis （HAE） is a zoonotic parasitic disease caused by E.multilocularis infection， which is globally distributed. In China， it is mainly prevalent in the western agricultural and pastoral areas such as Xinjiang， Qinghai and Xizang， which seriously endangers the health of people of all ethnic groups and affects economic development. The liver is the main target organ of HAE. The lesions constantly grow in an infiltrative pattern， manifested with biological behavior resembling malignant tumors， also known as “worm cancer”. In the late stage， it can invade the hepatic inflow and outflow tract vessels and adjacent tissues and organs， even leading to liver failure in severe cases. At present， radical surgical resection combined with albendazole drug therapy is the first choice. The development of the disease is relatively hidden. Upon admission， most patients are diagnosed with large lesions and the invasion of the main vessels， which brings challenges to radical surgery. At present， with the development of precise medicine and individualized diagnosis and treatment concepts， surgical treatment methods have been significantly improved. In this article， the latest progress in surgical treatment of HAE was reviewed， aiming to provide theoretical basis for the formulation of diagnosis and treatment strategies for HAE.
Acute pancreatitis （AP） is one of the common acute abdomen in the digestive system. It varies in disease severity， constantly complicated with pancreatic or peripancreatic infection. Especially if AP progresses into acute necrotizing pancreatitis， it will significantly increase the risk of multiple organ failure and even death. In addition， the incidence rate of AP is on the rise. Tremendous progress has been made in the study of the changes and treatment of gut microbes in AP patients. However， complicated relationship exists between the diversity and complexity of gut microbes and its role in target organs. AP patients not only develop impaired intestinal barrier function and altered microbial diversity， but also experience increased intestinal bacterial translocation induced by local or systemic inflammatory stimuli， forming a vicious circle and further elevating the proportion of critically ill patients. Therefore， restoring intestinal mucosal barrier function and diversifying gut microbes may be the key to prevent disease progression. In this article， the changes of intestinal mucosal barrier damage and intestinal microbiota imbalance during AP were reviewed by retrieving relevant literature， aiming to provide theoretical basis for the treatment of AP.
