As a receptor mediating the transmembrane signal transduction in the innate immunity, Toll-like receptor 4 (TLR4) is a bridge between innate immunity and required immunity, and plays an important role when signal-transducing of some cells are activated. Recent reports show that TLR4 expresses in the different glial cells and strongly links to the innate immune activation and inflammatory response in the central nervous system (CNS). TLR4 plays a key role in the processes of brain damage by infection of the CNS, stroke, cerebral hemorrhage and trauma. In this review, we concentrate on recent findings regarding the progress of function and mechanism of TLR4 in the processes of the CNS damage in various diseases.

Severe acute pancreatitis is sometimes complicated by a syndrome of cerebral dysfunction, referred to as pancreatic encephalopathy. Demyelination is found in autopsy and considered as basic pathologic evidence in patients with pancreatic encephalopathy. Myelin basic protein detection in cerebrospinal fluid and blood, combined with magnetic resonance imaging scan might indicate the demyelinatic change. Further large-scale study on both pathogenesis and diagnosis of this disease is needed.

Objective To analyze the characteristics and prognostic factors of gallbladder carcinoma and investigate the measures of various modus operandi. Methods The clinicopathological data of 181 patients with advanced gallbladder carcinoma treated in our hospital from June 2002 to June 2008 were retrospectively analyzed. SPSS16. 0 software package was used for statistical analysis.Results The overall median survival rate of the 181 patients with gallbladder carcinoma was 6 months. The median survival rate after radical resection for gallbladder carcinoma was 19.5 months,which was remarkably higher than other R1 resection, R2 resection and palliative operation groups (P ＜0. 01) The RO resection rates were 95.5%, 62. 2%, 14.1% and 4.7%, respectively based on different pathological stages of Nevin( Ⅱ , Ⅲ, Ⅳ, and Ⅴ ). There were significant differences among all groups (P＜0.01). The Cox multivariate analysis revealed that pathological stages of Nevin, total bilirubin, CA-199 and therapeutic method had significantly higher risk ratios for gallbladder carcinoma.Conclusion Radical resection may help to improve the survival rate and prognosis of advanced gallbladder carcinoma.

Gallbladder carcinoma (GC) is the most common malignant tumor in bile duct system.Xanthogranulomatous cholecystitis (XGC) is a benign inflammatory gallbladder disease.It is often misdiagnosed between them.This paper,through reviewing the literature and summarizing our own clinical experience,will give a better understanding on the two diseases,which was summarized as follows:inflammation is important both in the pathogenesis of GC and XGC,and we can make the correct diagnosis and choose an appropriate treatment by analy zing the feature of disease history,image data and rapid intraoperative pathological diagnosis.Radical resection remains the first choice in the treatment of GC,but the extent of resection is controversial.Normally,cholecystectomy is sufficient for curing XGC,but different surgeries are needed according to the specific disease conditions.

Objective To discuss the clinical feasibility and safety of modified invaginated pencreaticojejunostomy approach (Jiang's anastomosis) which was developed by the team of biliary surgery department from Shanghai Eastern Hepatobiliary Surgery Hospital.Methods Clinical data of 289 patients receiving modified invaginated pencreaticojejunostomy approach in pancreaticoduodenectomy were retrospectively studied.Wilcoxon signed-rank test,Chi-square and logistic regression tests were comprehensively used to evaluate the postoperative complications and the association with POPF.Results One hundred and sixtythree of 289 patients (54.6％) experienced postoperative complications after pancreaticoduodenectomy procedure.There were 45 onsets of severe complications,accounted for 17.6％ (45/255).Perioperative mortality was 3.1％ (9/289).The most common complications included celiac effusion and infection (26.6％),delayed gastric emptying (17.6％),gastroenterological tract fistula (12.4％),gastroenterological tract hemorrhage (9.7％).Additionally,the incidence of POPF was 9.3％,which all conformed as biochemical fistula (6.9％) and grade-B fistula (2.4％).Conclusions As a risk factor,POPF may play crucial role in celiac hemorrhage and infection associated with pancreaticoduodenectomy.Modified invaginated pencreaticojejunostomy approach (Jiang's anastomosis) with easy manipulation,wide indication,safe and effective performance,could be recommended to reduce POPF incidence.

Objective:To compare preoperative portal vein embolization (PVE) using tris-acryl gelatin microspheres (TAGM) versus coils.Methods:From March 2016 to June 2018, 21 consecutive patients with a future liver remnant (FLR) ratio of less than 45% before planned major hepatectomy for malignant or benign liver diseases were enrolled from the First Department of Biliary Surgery, Eastern Hepatobiliary Surgery Hospital into this study. The patients were divided to receive portal vein embolization (PVE) using TAGM distally and coils proximally (the TC group) and PVE using multiple coils (the CC group). Post-PVE complications, liver function, routine blood tests; FLR hyperplasia, types of liver resection, operation time, intraoperative blood loss, and postoperative complications were compared between the two groups.Results:Eight patients were included in the TC group. There were 4 males and 4 females, with a mean age of (55.3±7.7) years. Of 13 patients included into the CC group, there were 11 males and 2 females, with a mean age of (52.6±11.3) years. There were no significant differences in sex, age, types of hepatic diseases, volume of FLR, ratio of FLR, ratio of standard FLR, types of surgery, operation duration, blood loss, major complications, and liver failure rates between the two groups. All patients in the two groups had successful PVE. The TC group developed effective growth of volume of FLR with one patient who failed to undergo surgery because of tumor progression. In the CC group, four patients failed to undergo liver resection: one patient developed thrombosis of the left branch and main trunk of portal vein; tumor progression occurred in one patient and two patients had insufficient FLR growth. Compared with the CC group, the TC group had a significantly higher volume of FLR hyperplasia [(9.0±2.8) % vs. (5.2±3.8) %, P<0.05], and a faster but insignificant increase in proliferation rate [(11.4±7.1) ml/d vs. (6.9±5.2) ml/d, P>0.05], a greater but insignificant increase in percentage of proliferation [(33.6±20.1) % vs. (20.9±15.1) %, P>0.05]. Conclusions:This study showed that PVE with TAGM plus coils is safe and effective. It induced a better degree of hypertrophy of FLR compared to PVE using multiple coils.

Benign gallbladder diseases are common in general surgery practice, and laparoscopic cholecystectomy (LC) has become the standard treatment for these conditions. With the widespread adoption of LC and the improved understanding of gallbladder disease, it is necessary to re-evaluate the diagnosis and treatment of benign gallbladder disease. Based on the latest expert consensus on the diagnosis and treatment of benign gallbladder disease, this review aims to provide an overview of the diagnostic and treatment strategies for benign gallbladder diseases. Specifically, it focuses on enhancing our understanding of the role of benign gallbladder diseases in the development of gallbladder cancer, the impact of congenital biliary anomalies on the diagnostic and treatment processes of benign gallbladder diseases, and the significance of the preoperative examinations.

Objective To retrospectively study the clinical value and the advantages in " planned hepatectomy" for the "central type" intrahepatic and extrahepatic choledochal cysts.Methods The clinical data of 7 patients with the "central type" of intrahepatic and extrahepatic choledochal cysts which were treated with "planned hepatectomy" from January 2014 through April 2017 at the Department of Biliary Tract Surgery of the Eastern Hepatobiliary Surgery Hospital,Second Military Medical University were retrospectively analyzed.Results All the patients completed radical resection of the intrahepatic and extrahepatic choledochal cysts in accordance with the " planned hepatectomy".The operations included 6 patients who were treated with percutaneous transhepatic cholangial drainage (PTCD) and 5 patients with portal vein embolization (PVE) prior to the surgical excision.Combined right liver resection was performed in 6 patients,and combined left liver resection in one patient.All the 7 patients had a history of chronic cholangitis.Liver volume tests demonstrated that the hemiliver volume to be removed (the embolized hemiliver) significantly decreased after PVE,whereas the hemilivers to be persevered were remarkably enlarged.No complication associated with PTCD and PVE occurred.The mean postoperative hospitalization was 12 days.Liver function tests suggested all the patients recovered well.No postoperative complication of bleeding,infection or liver function failure was observed,except in one patient who experienced pleural and abdominal effusion.Conclusions Combined subtotal hepatectomy may increase the risk of complications associated with the "central type" intrahepatic and extrahepatic choledochal cysts.The surgical strategy in planned hepatectomy can be used effectively to treat the "central type" of intrahepatic and extrahepatic choledochal cysts,with improved surgical safety,decrease in incidences of postoperative liver function failure and residual choledochal cysts.

Objective:To evaluate the effect of different options of preoperative biliary drainage (PBD) on perioperative complications of patients undergoing pancreaticoduodenectomy (PD).Methods:The clinical data of patients undergoing PD for periampullary carcinoma from January 2016 to November 2021 at Third Affiliated Hospital of Naval Medical University (Shanghai Eastern Hepatobiliary Surgery Hospital) were retrospectively analyzed. The 303 patients including 199 males and 104 females, aged (64.2±8.8) years. According to PBD, the patients were divided into two groups: percutaneous transhepatic biliary drainage (PTBD) group ( n=228) and endoscopic retrograde cholangiopancreatography (ERCP) group ( n=75). PBD operation-related complications (including bleeding, biliary leakage, etc.), postoperative complications of PD (including pancreatic fistula, biliary leakage, surgical site infection, etc.) and perioperative complications (PBD operation-related complications + postoperative complications of PD) were compared between the two groups. Univariate and multivariate logistic regression analysis were used to analyze factors influencing perioperative complications of PD. Results:The incidence of PBD operation-related complications in PTBD group was 10.1% (23/228), lower than that in ERCP group 25.3%(19/228), and the difference was statistically significant (χ 2=10.99, P=0.001). The incidence of postoperative complications of PD in PTBD group was 38.2%(87/228), lower than that in ERCP group 69.3%(52/75), the difference was statistically significant (χ 2=22.09, P<0.001). The incidence of total perioperative complications in PTBD group was 44.3% (101/228), lower than that in ERCP group 73.3%(55/75), the difference was statistically significant (χ 2=19.05, P<0.001). Multivariate logistic regression analysis showed that patients with periampullary carcinoma undergoing ERCP biliary drainage and PD had increased risk of surgical site infection ( OR=2.86, 95% CI: 1.59-5.16, P<0.001) and pancreatic fistula ( OR=3.06, 95% CI: 1.21-7.74, P=0.018). Conclusion:ERCP biliary drainage is a risk factor for postoperative pancreatic fistula and surgical site infection in patients with periampullary carcinoma undergoing PD. PTBD should be recommended as the first choice for the patients underwent PD.

Objective:To study the risk factors of lymph node metastases in patients with intrahepatic cholangiocarcinoma (ICC) and to establish a risk prediction model of lymph node metastases in ICC.Methods:The clinicopathological data of 587 ICC patients who underwent radical hepatectomy and lymph node dissection at Third Affiliated Hospital of Naval Medical University (Shanghai Eastern Hepatobiliary Surgery Hospital) from January 2007 to December 2011 were retrospectively analyzed. There were 395 males and 192 females with ages which ranged from 20 to 82 (54.7±10.8) years. Independent risk factors of lymph node metastases were studied using univariate and multivariate logistic regression analysis, and a risk prediction model was established. Receiver operating characteristic (ROC) curve was used to evaluate the accuracy of this model.Results:Of 587 patients, 158 (26.9%) had lymph node metastases. Multivariate logistic regression analysis showed that platelet count >300×10 9/L ( OR=1.985, 95% CI: 1.030-3.824, P=0.041), carbohydrate antigen 19-9 >37 U/ml ( OR=2.978, 95% CI: 1.994-4.448, P<0.001), tumor situated in left hemiliver ( OR=1.579, 95% CI: 1.065-2.341, P=0.023), multiple tumors ( OR=1.846, 95% CI: 1.225-2.783, P=0.003), and absence of cirrhosis ( OR=2.125, 95% CI: 1.192-3.783, P=0.011) were independent risk factors for lymph node metastases in ICC. The area under the ROC curve was 0.714, with a cutoff value of 0.215, and the sensitivity and specificity being 75.9% and 58.3%, respectively. Conclusions:The risk prediction model of ICC lymph node metastases was established using readily available clinical data obtained before operation. This model has good predictive values and can provide a reference for treatment decision on patients with ICC.