Gallstones are the primary benign disease diagnosed and treated in biliary surgery.With the development of medical technology and the increasing awareness of health among the population,the detection rate of gallstones has been increasing annually,with the majority being asymptomatic or mild cases.Currently,the clinical treatment of gallstones mainly includes observation,conservative,or surgical treatment(laparoscopic cholecystectomy).However,there remains some controversy regarding the clinical management of these patients.For asymptomatic or mild gallstones,the main point of contention in both academic and clinical settings is how to determine the indications for cholecystectomy.This article reviews relevant literature from both domestic and international sources,addressing the controversies surrounding the clinical management of gallstones and the determination of indications for cholecystectomy,and elaborates on these issues from multiple perspectives.

The difficult radical cure of intrahepatic bile duct stones is attributed to their tendency to leave residues and recur.Therefore,it is crucial to raise awareness of the importance of standardized treatment.The inability to perform true anatomical liver resection and effectively correct bile duct stenosis are the root causes of stone retention and recurrence.Precise and comprehensive preoperative assessment is the prerequisite for standardized treatment.Attention should be focused on evaluating the distribution of stones,biliary strictures,the function of the Oddi sphincter,as well as the anatomical variations of the hepatic artery,bile duct,and portal vein.Therefore,the author proposed the LHO classification and CRL classification to guide decision-making.High-quality and meticulous surgery is the core of standardized treatment.Timely and correct management of complications and standardized postoperative follow-up throughout the process are the guarantee and continuation of standardized treatment.By integrating various techniques such as perihilar surgical techniques,and strictly adhering to the"removing lesions,removing all stones,correcting strictures,and ensuring unobstructed drainage"principle,standardized treatment can improve the safety and effectiveness of the treatment of intrahepatic bile duct stones,reducing the stone retention and recurrence rates.

Polycystic ovary syndrome(PCOS)is a common endocrine disorder in women of reproductive age and is closely associated with obesity.In recent years,the role of bariatric and metabolic surgery in improving obesity complicated with PCOS has gradually attracted attention.The Chinese Society of Thyroid and Metabolism Surgery,Chinese Society of Surgery,Chinese Medical Association,Chinese Society for Metabolic&Bariatric Surgery,Chinese College of Surgeons,Chinese Medical Doctor Association,Metabolic Disease Professional Committee of the Chinese Medical Education Association,and the National Key Laboratory of Reproductive Medicine and Offspring Health jointly developed this consensus based on the latest domestic and foreign guidelines,clinical research evidence,and expert opinions.In the consensus,the diagnostic criteria,preoperative evaluation,surgical indications,selection of surgical methods,perioperative management,and postoperative PCOS follow-up are recommended to provide standardized guidance for bariatric metabolic surgery for obese patients with PCOS.

Intestinal obstruction is one of the most common and challenging acute abdominal conditions in general surgery,and its prevention and treatment have always been a key focus in clinical practice.The advent of ileus tubes has provided a new approach to the treatment,prevention,and auxiliary diagnosis of intestinal obstruction.It has significantly improved the success rate of non-surgical treatment and played an essential role in preventing recurrence and assisting in diagnosis.In recent years,with the widespread application of the ileus tubes,an increasing number of hospitals have begun using this treatment method.However,there are still considerable controversies regarding to the indications of ileus fubes,management of complications,efficacy evaluation,and the timing of surgical intervention.Given the lack of authoritative reference standards for the standardized use of ileus tubes and the absence of relevant guidelines or consensus to guide their clinical practice at home and abroad,experts in this field in our country have formed an editorial panel at the initiative of the Anorectal Physicians Branch of the Chinese Medical Doctor Association,and the Bowel Obstruction Branch of the Hunan Province Geriatric Society.Based on the latest evidence from clinical practice and relevant research findings,the expert panel developed the"Expert consensus on clinical application of ileus tubes in prevention and treatment of bowel obstruction."This consensus aims to provide guidance for physicians in general surgery,gastroenterology,interventional medicine,and related specialties,hoping to promote the standardized clinical application of ileus tubes in China.

Incidental gallbladder cancer(IGC)is a type of gallbladder cancer identified during or after cholecystectomy for benign gallbladder diseases through intraoperative or postoperative pathological examination.Since gallbladder cancer often coexists with benign conditions such as gallstones and polyps,and routine abdominal ultrasound has limited sensitivity in early diagnosis,IGC accounts for more than two-thirds of all gallbladder cancer cases.To improve early diagnosis rates,high-risk patients should undergo high-resolution ultrasound after surgery,combined with the use of radiomics and molecular biomarkers to reduce misdiagnosis and missed diagnoses.Most IGC patients are diagnosed at early stages,with a high incidence of residual disease.Delayed radical surgery can effectively improve prognosis.However,for patients with locally advanced disease,radical surgery should not be performed indiscriminately,and conversion surgery may be a better option.The optimal timing for delayed radical surgery is within 2 to 8 weeks after the initial surgery,with specific timing based on the resolution of acute inflammation and the evaluation of tumor staging and metastasis.For patients with T1b and T2 stage cancer,liver segment IVb/V resection and lymph node dissection are recommended to ensure curative outcomes.The application of laparoscopic techniques in gallbladder cancer treatment is becoming increasingly widespread,with confirmed surgical safety and tumor control effects,leading to growing support for minimally invasive treatment among hepatobiliary surgeons.Additionally,indocyanine green-guided fluorescence laparoscopic technology allows for precise lymph node dissection and liver resection,reducing the risk of postoperative complications.In light of the complex anatomy in the hepatic hilum and hepatoduodenal ligament region in IGC patients,performing delayed radical surgery using the 3D laparoscopic PH approach(based on the portal vein and hepatic artery as the anatomical axis)helps prevent organ damage and tumor dissemination.This review summarizes the current surgical treatment of IGC and discusses the application of the PH approach in laparoscopic gallbladder cancer radical surgery.

Gallbladder cancer is the most common malignant tumor of the biliary system,characterized by insidious growth,rapid progression,and skip metastasis.The 5-year overall survival rate is only 5%.Although targeted immunotherapies have emerged in recent years,they are still in the exploratory phase for the treatment of gallbladder cancer,and radical surgical resection remains the only potentially curative treatment.The main goal of surgery is to completely remove the tumor and perform systematic lymph node dissection to reduce the risk of recurrence.Thanks to advances in surgical techniques and continuous optimization of perioperative management,postoperative complications,and hospital mortality in patients undergoing extended radical surgery for gallbladder cancer have decreased.However,the complex mechanisms of gallbladder cancer spread and metastasis make it challenging to determine the optimal scope of surgical resection.Clinical guidelines from different countries and hepatobiliary surgery centers often vary on surgical options,especially regarding the reasonable extent of liver resection,the scope of lymph node dissection and its impact on prognosis,and whether routine extrahepatic bile duct resection should be performed.There remains significant controversy in these areas.Future extensive prospective cohort studies are still needed to provide more evidence-based medical data for the surgical treatment of gallbladder cancer.When designing a surgical plan,surgeons must consider preoperative examination results,intraoperative findings,and pathological evaluation of frozen sections.A balance must be struck between radical treatment and safety and effectiveness.The most appropriate surgical method for each patient should be chosen while also emphasizing establishing a multidisciplinary collaborative system.Based on accurate tumor staging,postoperative adjuvant therapies should be integrated to continue making progress in improving patient prognosis.

Intrahepatic cholangiocarcinoma(ICC)typically has an insidious onset,and most patients have already progressed to advanced stages by the time of initial diagnosis,missing the opportunity for radical surgery.Surgical treatment is the main approach for ICC,but the high early recurrence rate after surgery and poor prognosis remain significant challenges.In recent years,there have been continuous breakthroughs in chemotherapy,immunotherapy,targeted therapy,and combination therapies for ICC,ushering in a new era for systemic treatment.With the improvement of treatment effects,conversion therapy,and neoadjuvant therapy have emerged as prominent topics of interest.However,with the deepening of clinical diagnosis and treatment practices,complex and unresolved issues have gradually emerged,triggering extensive discussions among scholars at home and abroad.Currently,there is no clear,standardized diagnostic and therapeutic process for conversion therapy and neoadjuvant therapy in the guidelines of the National Comprehensive Cancer Network or the Chinese Society of Clinical Oncology.This article aims to comprehensively review the latest progress in neoadjuvant and conversion therapy for ICC and deeply explore the controversial focuses therein,with the expectation of providing useful references for clinical practice and promoting the further development of this field.

Biliary surgery has a long history,with biliary strictures being a common clinical issue in this field.These strictures primarily include benign strictures,malignant strictures,and biliary strictures of unknown etiology.The nature of the biliary stricture directly determines the treatment approach.For strictures that are difficult to characterize with CT and MRCP/MRI,endoscopic ultrasound,and related technologies are important tools for the diagnosis and treatment.The rise of technologies such as confocal laser endomicroscopy,optical coherence tomography,and next-generation sequencing has expanded the diagnostic and therapeutic options for biliary strictures.Furthermore,endoscopic surgeons or treatment teams who are proficient in both endoscopic techniques and surgical procedures have unique strengths when dealing with complex anatomical structures or resectable biliary tumors.Although significant advancements have been made in biliary surgery in recent years,particularly in endoscopic technology,surgical techniques,and diagnostic methods,several challenges still remain to be addressed.Here,the authors provide a review of the current status,advancements,and challenges in the endoscopic surgical treatment of biliary strictures,with the aim of offering insights for clinical practice.

Intrahepatic cholangiocarcinoma(ICC)is a malignancy with an insidious onset and extremely high mortality,often resulting in the inability to perform radical surgery due to vascular invasion and metastasis.The middle hepatic vein(MHV),located adjacent to the left and right hepatic veins and the second hepatic hilum,is an essential component of the hepatic vascular system.Patients with ICC involving the MHV face significant treatment challenges,and there is considerable debate regarding the optimal treatment decisions.Conversion therapy has provided new hope for patients with initially unresectable ICC,particularly for those with MHV invasion,who have an urgent need for such treatment.This article combines relevant research findings and clinical experience of the authors'team to discuss several challenges in conversion therapy for ICC with MHV invasion,aiming to provide reference for the clinical management of these patients.

Intrahepatic cholangiocarcinoma(ICC)is a highly aggressive liver malignancy characterized by a subtle onset and rapid progression.Most patients are diagnosed at advanced stages,making radical surgical resection impossible,and the overall prognosis is poor.The ability to convert initially unresectable ICC to resectable tumors through multimodal comprehensive treatment is significant for prolonging patient survival.In recent years,with the application of immunotherapy and targeted therapy in advanced ICC,as well as improvements in surgical techniques,radiation therapy,hepatic arterial infusion chemotherapy,and selective internal radiation therapy,along with updates in treatment strategies and concepts,some initially unresectable ICC tumors have become resectable following downstaging with various treatment modalities,which has brought new hope for improving conversion resection success rates and patient prognosis.However,conversion therapy for ICC still faces numerous challenges and controversies,including the lack of a recognized standard treatment regimen,limited overall conversion success rates,a lack of long-term follow-up data to demonstrate survival benefits after conversion resection,and unresolved issues such as whether patients who achieve clinical complete remission should undergo resection or be monitored.Given that most current studies on ICC conversion therapy are small-sample,retrospective studies or case reports,lacking high-level evidence from randomized controlled trials,and the majority of studies include various types of biliary tract cancers without considering the heterogeneity across different anatomical locations,the relevance of these findings for guiding ICC conversion treatment strategies is limited.There is an urgent need for high-quality,multi-center,large-sample,prospective clinical studies and basic research to explore optimal ICC translational therapy regimens with rapid efficacy,high objective response rates,and good safety profiles,identify patient populations with potential benefits from different treatments,and develop individualized treatment strategies to improve conversion success rates and ultimately enhance patient prognosis.This article reviews the progress in the conversion treatment of unresectable ICC,intending to provide a reference for clinical practice.