Congenital bile duct dilatation may occur in any part of the biliary tree,and the diagnosis and treatment of lesions involving the intrahepatic bile duct is the most challenging issue.Surgical operation plays a dominant role in the management of congenital bile duct dilatation,with the purposes of relieving symptoms and preventing disease progression and malignant transformation.Surgical principles are radical resection of lesions and reconstruction of unobstructed bile drainage.Hepatectomy is the main surgical procedure for congenital bile duct dilatation with involvement of the intrahepatic bile duct,and liver transplantation can be used for diffuse lesions.Therefore,we believe that hepatectomy and early intervention will maximize patients' benefits.

Continuous progress of medicine and related areas are initiating and motivating a paradigm transformation of traditional surgery to precise surgery,which is characterized by precision in decision making and surgical intervention.The strategy of precise surgery is to seek a balance of maximized lesion removal,maximized organ sparing and minimal surgical invasiveness.Due to the special location and biological characteristics,the therapy of hilar cholangiocarcinoma is still challenging.To meet the demand of precise surgery,the knowledge of anatomy,biological characteristics and liver functional reserve is needed and the technical aspects of pre-surgical intervention,liver resection and reconstruction of vessels are also very important.

Objective To assess the clinical efficacy of percutaneous transhepatic portal embolization (PTPE) before the extended right hemihepatectomy for the treatment of hilar cholangiocarcinoma. Methods We successfully carried out a percutaneous transhepatic portal embolization in a patient with hilar cholangiocarcinoma and liver cirrhosis. Hepatic hemodynamics, liver volume,liver functions, and pathological changes were recorded after the procedure. Results After PTPE, the patient developed an inflammatory response manifested by a transient fever (39.2 ℃ at peak on the 5th postoperative day) and a mild abdominal pain. There were no other complications such as nausea, vomitting, hemorrhage, or bile leakage. The volume of the left lobe increased from 417.0 ml to 522.4 ml (enlargement rate, 125.2%); the volume of the right lobe decreased from 1041.3 ml to 1017.4 ml (diminishment rate, 97.7%). The ratio of the left lobe to the whole liver increased from 28.6% to 33.9%. The velocity of blood flow of the left portal vein increased by 100% and 39% on the day of operation and the 6th day after operation, respectively (from 12.8 ml/s preoperatively to 23.2 ml/s and 17.1 ml/s). The values of ICG R15 and ICG-K returned to normal levels. On the 17th day after PTPE, the quantity of bile drainage from the left lobe exceeded that from the right lobe. The extended right hemihepatectomy was performed 34 days after PTPE. During operation, an obvious hypertrophy of the left lobe and a distinct demarcation line between the segment 5, 6, and 7 (S5,6,7) and other segments were observed. Postoperative recovery was uneventful. The pathological examination found stenosis and embolization of the portal vein, as well as the degeneration, necrosis, and apotosis of the liver cells in the embolized lobe. Conclusions Portal vein embolization can effectively induce the hypertrophy of the unembolized lobe, which increases the safety level of following extended hemihepatectomy in patients with impared liver functions.

65 years) with acute cholecystitis treated by PTGBD in this hospital between January 2001 and December 2005. All the patients were not symptomatically relieved after conservative therapy and/or had severe accompanying co-morbidities. Results A successful tube insertion was achieved in 29 patients, whereas insertion failure was encountered in 1 patient because the gallbladder was full of stones, in which a bile aspiration was performed. The dislodgement of drainage tube occurred in 2 patients (one patient underwent a re-insertion and the other was symptomatically relieved without insertion). Exacerbation of the condition developed in 1 patient after the treatment, and an open cholecystostomy with abdominal irrigation and drainage was performed. Twenty-seven patients were discharged from hospital with the drainage tube intact. Of them, the drainage tube was removed 3 weeks after PTGBD in 25 patients, was maintained for 8 weeks until surgery in 1 patient, and was dislodged in 1 patient. Twenty-eight patients with calculous cholecystitis underwent a delayed surgery, including LC in 25 patients, stone removal by choledochofiberscope in 2 patients, and open surgery in 1 patient because of accompanying choledocholithiasis and retroperitoneal mass (adrenal tumor). In another 4 patients with choledocholithiasis, an intraoperative choledochofiberscopy during LC was performed in 2 patients, and endoscopic sphincterotomy after LC was conducted in 2. No surgery related deaths or bile duct injuries occurred. Conclusions Combined use of PTGBD and delayed LC in elderly patients with acute cholecystitis is safe and effective.

Since the 1980s, indications for resection of hilar cholangiocarcinoma have progressively improved. Operation is superior to any other therapeutic modalities with regard to survival rate and quality of life. Currently, hepatic lobectomy, extended hepatic lobectomy, extrahepatic bile duct resection, regional lymphadenectomy and Roux-en-Y hepatoenteric jejunos-tomy are recommended as the treatment of choice for most patients with hilar cholangiocarcinoma. However, controversy still remains regarding the diagnosis and treatment of hilar cholangiocarcinoma, including the assessment of longitudinal tumor extension, the evaluation of hepatic reserve function, the value of biliary drainage, the indication of portal vein emboliza-tion, the range of hepatic resection, the contribution of com-bined vascular resection, and the effectiveness of liver transplan-tation. This article summarizes these main issues requiring further investigation.

The clinical value of applying portal vein resection and reconstruction in left trisectionectomy for treating advanced hilar cholangiocarcinoma is approved, while it is still a big challenge for clinicians. One female patient suffering from abdominal pain and jaundice received treatment in the General Hospital of PLA in July, 2009. She was prelimiarily diagnosed with Bismuth type Ⅲ a hilar cholangiocarcinoma. A tube was inserted in the left lateral inferior bile duct to carry out percutaneous transhepatic biliary drainage (PTBD). After the anatomic variation of the left bile duct was found, the diagnosis was revised as Bismuth type Ⅳ. A left trisectionectomy was proposed, and another PTBD tube was inserted in the right posterior bile duct.Combined portal vein resection and reconstruction and left trisectionectomy was successfully performed. The postoperation course was uneventful, except for the transient liver dysfunction and biliary-enteric anastomotic leakage.

At present,it is not uncommon for patients with biliary dilatation who have failed to undergo multiple operations in clinic.Dong's classification has a definite guiding significance for choosing appropriate surgical methods.Active hepatectomy with "tailor-made" treatment can cure refractory biliary dilatation involving intrahepatic bile ducts.At present,there are still some controversies about the range of hepatectomy and the management of type D lesions in children.At the same time,we should pay close attention to the long-term complications after dilated bile duct resection.

The annual congress of Japan Surgical Society is a famous academic event in the field of surgery,and the participants can learn from the latest research results of all the major surgical disciplines.The authors selected topics of the ll8th annual congress in 2018,including the latest research results and progresses of laparoscopic hepatectony,liver transplantation,extrahepatic bile duct carcinoma and pancreatic surgery.The purpose of this study is to provide new information and reference for optimizing the diagnosis and treatment of hepatobiliary and pancreatic diseases.

Intrahepatic cholangiocarcinoma has low resectability rate, high recurrence and short survival. It is very important to formulate and optimize the strategy of surgical treatment. The only potentially effective treatment for intrahepatic cholangiocarcinoma is surgical resection. Liver transplantation also has some application prospects. Intrahepatic cholangiocarcinoma can be divided into four types: mass forming type, intraductal growth type, periductal infiltration type, mass forming + periductal infiltration(mixed)type. Clinically, the treatment strategy is mainly determined according to the general classification. The application of methods such as preoperative portal vein embolism, neoadjuvant therapy and lymph node dissection make it possible for more patients to undergo surgical resection and improve the surgical effect. Adjuvant treatment including chemotherapy and radiotherapy can significantly improve the prognosis of the patients. The rapid development of molecular targeted therapy and immunotherapy is gradually changing the clinical treatment of intrahepatic cholangiocarcinoma.

Objective:To investigate the computed tomography (CT)-based integrated deep learning model for qualitative and quantitative classification of hepatic portal vein.Methods:The retrospective study was conducted. The CT imaging data of 291 patients undergoing upper-abdomen enhanced CT examination in the Beijing Tsinghua Changgung Hospital of Tsinghua University from October 2017 to January 2019 were collected. There were 195 males and 96 females, aged (51±12)years. The hepatic portal vein was reconstructed using the three-dimensional reconstruction system. Three-dimensional point cloud was input to the encoder model to obtain the three-dimen-sional reconstructed vectorized representation, which was used for qualitative classification and quantitative representation classification. Measurement data with normal distribution were repre-sented as Mean± SD, and comparison between groups was conducted using the paired t test. Count data were repre-sented as percentages or absolute numbers, and comparison between groups was analyzed using the paired chi-square test. Results:(1) Three-dimensional reconstruction of portal vein and anatomical classification. Three-dimensional structure was reconstructed in the 291 patients. Classification of main hepatic portal vein showed 211 cases of Akgul type A, 29 cases of Akgul type B, 16 cases of Akgul type C, 10 cases of Akgul type D, and 25 cases of unclassifiable. (2) Prediction of qualitative classification of main hepatic portal vein. Of the 291 patient samples, 25 unclassifiable or poor quality samples were excluded, 266 samples were used for automated qualitative classification of the main portal vein by machine model. There were 211 cases of Akgul type A, 29 cases of Akgul type B, 26 cases of Akgul type C&D. The Macro-F1 of 266 patients was 61.93%±40.50% and the accuracy was 84.99%, versus 32.38%±19.81% and 61.65% of Random classifier, showing significant differ-ences between them ( t=7.85, χ2=62.89, P<0.05). (3) Quantitative representation of portal vein classification. The probabilities of quantitative classification for Akgul qualitative classification of similar samples included P@1 as 73%±45%, P@3 as 70%±37%, P@5 as 69%±35%, P@10 as 67%± 32%, mean reciprocal rank(MRR) as 80%±34%, versus 57%±50%, 58%±35%, 58%±32%, 58%± 30%, 70%±37% of the baseline model, showing significant differences between the two analytical methods ( t=5.22, 5.11, 5.00, 4.99, 3.47, P<0.05). Conclusion:The automated classification model for the hepatic portal vein structure was constructed using CT-based three-dimensional reconstruc-tion and deep learning technology, which can achieve automatic qualitative classification and quanti-tatively describe the hepatic portal vein structure.