Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a new surgical management which brings hopes of cure to patients with primary or metastatic liver tumor who do not have sufficient future liver remnant (FLR).This review summarizes the current research on the development,indication,surgical procedures and safety of ALPPS.It also discusses the major concerns and unanswered doubts of ALPPS,such as the comparison with selective portal vein embolization (PVE) and the long-term oncological progression.

Parathyroid carcinoma is a rare sporadic disease.Clinical manifestations include hypercalcemia,increased urinary calcium and urinary calculus,osteoporosis,and pathologic fracture.While this patient complained of pollakiuria,urgency,and painful urination,thus might lead to misdiagnosis or missing of diagnosis of parathyroid carcinoma.This article is herewith presented to call attention to discovery,diagnosis,and treatment of parathyroid carcinoma.

Objective To investigate CT findings of hepatic necrosis and regeneration after liver failure.Methods Five patients with liver failure underwent CT scan before orthotopic liver transplantation.These findings were retrospectively reviewed and correlated with gross specimen and pathologic findings obtained after transplantation.Results Among 5 cases,the CT appearances of liver failure can be divided into 3 types.(1)Massive confluent aggregate foci in 2 patients demonstrated low attenuation and high attenuation as geographical patlerns on CT scans before contrast enhancement.respectively.The histopathological liver changes showed massive necrosis and regencratinn. Regions of necrosis enhanced to attenuation greater than that of normal liver parenchyma in portal-venous phase,the regions of regeneration enhanced to attenuation greater than that of normal liver parenchyma in arterial phase on postcontrast CT images.(2)In 2 patients,diffuse nodules of liver demonstrated high attenuation on plain CT scans,which was nodular necrosis and nodular regeneration pathologically.All enhanced to attenuation greater than that of normal liver parenchyma in arterial phase.The former showed hypointensity in portal-venous phase and equilibrium phase.The latter enhanced to attenuation equal to that of normal liver parenchyma in portalvenous phase and equilibrium phase on postcontrast CT images.(3)Multiple small foci in 1 case demonstrated low attenuatiun on precontrast CT images and enhanced to hyperintensity in portal-venous phase and isointensity in arterial phase and equilibrium phase on postcontrast CT images.The histopathological liver changes showed multiple necrosis.Conclusion Liver failure may reveal characteristic imaging patterns at CT.

Objective Nanoknife,also called irreversible electroporation,is a new technique of tissue ablation.Short,microsecond electrical pulses with high voltage are applied to the cell membrane,causing pores to form within the membrane and finally leading to cell death.The current study was to investigate the efficacy and safety of the nanoknife in the ablation of the healthy pig pancreas.Methods Three healthy pigs underwent open pancreatic tissue ablation with nanoknife,and blood leukocytes and amylase were detected before and after treatment.Three pigs were sacrificed and gross specimens were collected on day 5,day 10 and day 15 after the procedure,respectively.HE staining and TUNEL staining were conducted and tissue,cellular and subcellular structures were observed under the ordinary microscope and transmission electron microscopy.Results Three experimental pigs recovered well after the procedure.No significant adhesions were found surrounding the pancreatic tissue,and the ablation zone was slightly harder.Transiently increased leukocyte count and amylase level were observed after the ablation,which decreased to the normal level on day 3 after treatment.Under light microscope,the pancreatic tissues in ablation zone appeared to be significantly different from the normal surrounding regions,with more cell death and more apoptotic cells detected by TUNEL staining.The subcellular structure changes also changed under electron microscope.But the main pancreatic duct and its large branches,together with arteriovenous distributions did not change much.Conclusions Nanoknife pancreatic tissue ablation can induce irreversible damage.In the ablation area,pancreatic duct and vascular structures are kept intact.Within a reasonable voltage range and appropriate electrical pulses setting,nanoknife ablation is safe in vivo experiment.

Objective To investigate the diagnosis and treatment for severe hemorrhage of portal vein system after pancreaticoduodenectomy (PD).Methods Clinical data of 6 patients with severe portal vein hemorrhage after PD in Chinese PLA General Hospital from January 2000 to December 2017 were retrospectively analyzed.All patients were male,aged 50-70 years with a median age of 56 years.The informed consents of all patients were obtained and the local ethical committee approval was received.The primary diseases were 2 cases of distal bile duct carcinoma,2 cases of pancreatic head ductal adenocarcinoma,1 case of duodenal carcinoma and 1 case of duodenal papilla carcinoma.3 patients underwent pylorus-preserving PD and 3 underwent classic PD.Results Among the 2 149 cases undergoing PD,6 suffered from portal vein system hemorrhage after operation with an incidence of 0.28％.Portal vein hemorrhage occurred from 6 to 38 d after PD with a median of 20 d.All 6 cases were complicated with pancreatic fistula,with symptom of abdominal bleeding or hematochezia.Portal vein or superior mesenteric vein hemorrhage was confirmed by reoperation or angiography.3 patients received portal vein stent implantation and 3 underwent reoperation.After operation,4 cases survived and 2 died of hemorrhagic shock.Conclusions Massive portal vein system hemorrhage after PD is rare.Its diagnosis depends on clinical manifestations,surgical exploration and angiography.The treatments include surgical suture and interventional therapy.Portal vein stent implantation has been proven a safe and effective treatment and can be the preferred alternative treatment for the complication.

Objective:The study aimed to study the efficacy and safety of combined dual therapy using anti-programmed death (PD)-1 and tyrosine kinase inhibitor (TKI) with combined triple therapy using anti-PD-1, TKI and locoregional intervention triple therapy in patients with postoperative refractory recurrent liver cancer.Methods:Patients with postoperative refractory recurrent liver cancer who had undergone either anti-PD-1 and TKI dual therapy or anti-PD-1, TKI and locoregional intervention triple therapy between July 2016 and March 2019 at the First Medical Center, Chinese PLA General Hospital were retrospectively studied. Tumor responses were assessed by the modified response evaluation criteria in solid tumors and overall survival and progression free survival were compared. Adverse events were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events.Results:Of 63 patients who were included in this study, there were 25 patients in the dual therapy group (16 males and 9 females, aged 54.3±8.8 years) and 38 patients in the triple therapy group (31 males and 7 females, aged 55.5±8.4 years). The 1-year survival rate of the triple therapy group was significantly higher than the dual therapy group (94.5%vs 54.9%) ( P<0.01). The disease control rate was 64.0% (16/25) in the dual therapy group and 84.2% (32/38) in the triple therapy group, and the difference was not significant ( P>0.05). The incidence of treatment-related adverse events in the triple therapy group and the dual therapy group were 78.9% (30/38) and 80% (20/25), respectively. There was no treatment-related death in the 2 groups. Conclusions:Anti-PD-1 and TKI dual therapy and anti-PD-1, TKI and locoregional intervention triple therapy were effective and tolerable treatments for postoperative refractory recurrent liver cancer. The latter treatment had a significantly better clinical benefit on survival outcomes.

It is intractable to Complex biliary stricture therapy after liver transplantation and other biliary operations is intractable.The routine therapies are to place stents with ERCP or do choledochojejunostomy.The former,however,is of little effect for patients with complex biliary stricture or completed obstruction.And the latter is more difficult and is with high rate postoperative complications due to the previous operation history.The application of magnetic compression offers a new direction of minimally invasive therapy of complex biliary structure.This article summarizes the current situation of the therapy of complex biliary structure with magnetic compression and the existing obstacles.

Objective To summarize the preliminary clinical outcomes of combination therapy with molecular targeted agents/immunological agents and to explore the potential value of multidisciplinary therapy in the treatment of postoperative refractory recurrent hepatobiliary tumor.Methods 52 cases of postoperative refractory recurrent hepatobiliary tumor during June 2016 to January 2019 from outpatient and inpatient departments at the First Medical Center of PLA General Hospital were prospectively collected,including 37 males and 15 females,with a mean age of (56.2 ± 8.5) years.Referring to the results of next-generation sequencing (NGS) and other-omics,we designed individualized therapy options for each patient.Follow-ups were done regularly and tumor responses were assessed by modified response evaluation criteria in solid tumors (mRECIST).Results Of 52 patients,median follow-up was 10 months (range 3-31 months).14 (26.9％) patients achieved a complete response (CR).8 (15.3％) patients achieved a partial response (PR).14 (26.9％) patients had stable disease (SD).16 (30.8％,including 4 deaths) had progressive disease (PD).Objective response rate and disease control rate were 42.3％ (22/52) and 69.2％ (36/52),respectively.The median progression-free survival (PFS) was 7 months.6-and 12-month overall survival rates were 100％ (48/48),87.5％ (21/24),respectively.Conclusions Precision medicine has good guidance on the treatment of refractory recurrence of hepatobiliary tumors.The combination therapy of multi-target tyrosine kinase inhibitors and immune checkpoint inhibitors may achieve better disease control and deserve further promotion in clinical application.

Objective To study the surgical treatment of hepatic hemangiomas and the timing of surgery.Methods A retrospective study was conducted on 908 patients with giant hemangiomas who underwent surgery between December 1997 and December 2017.The clinical data,surgical indications,surgical outcomes,lesion size,and the effect of TAE were compared.Results The diameter (mean + /-S.D.)of the resected hepatic cavernous hemangiomas was (11.1 ± 6.2) cm (the longest diameter was 60 cm).585 patients (64.4％) underwent enucleation of hepatic hemangiomas and 323 patients (35.6％) underwent anatomical hepatectomy.Six patients died perioperatively (mortality rate 0.7％).The incidence of severe complication (Clavien-Dindo grade 3 ～ 5) was 3.8％.The incidence of severe postoperative complication for enucleation (2.7％) was significantly less than anatomic liver resection (5.6％,P ＜0.05).When the lesion was more than 20 cm,the complication and mortality rates were significantly higher than those less than 20 cm (P ＜ 0.05).The complication and mortality rates in patients who underwent TAE before surgery were significantly higher than those without TAE (P ＜ 0.05).Conclusions Surgical enucleation of hemangiomas was superior to anatomical hepatectomy.With increase in tumor size,the risk of surgery increased.Surgical treatment was safe and effective for giant hepatic hemangiomas.For giant hepatic hemangiomas with significant increase in size,prompt surgical treatment is recommended.

Objective To investigate the application value of nephroscopic treatment for the infection after internal drainage in severe acute pancreatitis patients complicated with walled-off necrosis (WON). Methods Clinical data of 5 WON patients who were misdiagnosed with pancreatic pseudocyst and developed infected pancreatic necrosis after undergoing internal drainage in Chinese PLA General Hospital between January 2010 and February 2016 were retrospectively analyzed. Among the 5 patients, 3 were males and 2 were females, with the age ranging from 39 to 67 years old and the median of 47 years old. Two cases underwent open internal drainage and 3 underwent gastroscopic percutaneous catheter internal drainage. Typical clinical and imaging manifestations of infected pancreatic necrosis were all observed postoperatively. The informed consents of all patients were obtained and the local ethical committee approval was receive. Patients initially underwent CT guided percutaneous catheter drainage (PCD), and then underwent percutaneous nephroscopic debridement of peripancreatic necrotic tissues by retroperitoneal approach and postoperative lavage and drainage. Results Four cases recovered and discharged from hospital after once nephroscopic treatment, and 1 after twice nephroscopic treatment. The median postoperative length of stay was 15(7-32) d. No perioperative death or postoperative complications were observed. Conclusions Nephroscopic treatment is a good remedial therapy with advantages of minimal invasion and good efficacy for infection after internal drainage in patients with WON who are misdiagnosed with pancreatic pseudocyst.