Biliary diseases are common and with many challenges in clinical practice.Even though some big progress appeared in recent years,there are still many hot topics and noanswer questions.Herein,this article summarized some novel achievements and put opening questions on biliary surgical diseases including biliary tract cancer (intrahepatic cholangiocarcinoma,gallbladder carcinoma and hilar cholangiocarcinoma) and cholelithiasis in order to discuss these issues with national colleagues.

Objective To introduce the mechanisms of graft injuries after small-for-size liver transplantation and protective measures.Methods Recently relevant literatures were reviewed and summarized.Results Portal hypertension after small-for-size liver transplantation induces mechanical injuries as well as hepatic sinusoidal microcirculation disturbance and cytokines release,which worsened the injuries.Decrease portal pressure by surgery or drug could improve grafts function.Conclusion Comprehending the mechanisms of graft injuries will contribute a lot for the living donor liver transplantation.

Objective To assess the role of combined use of laparoscopy with diagnostic peritoneal lavage (DPL) in the diagnosis of abdominal stab injury (ASI). Methods From March 2005 to June 2010,21 cases of abdominal and thoracoabdominal stab injuries were analyzed retrospectively.All the cases were diagnosed laparoscopically first.If no significant injury was detected,1 000 ml of normal saline was infused through the abdominal trocar into the peritoneal cavity and routine/regular study on RBCs,WBC,amylase and bile of the effluent fluid was made. ResultsLaparoscopic diagnosis was positive in five cases,including two cases of diaphragmatic injuries,one traumatic bleeding of liver capsule,one small intestinal perforation and one stomach wall perforation.Laparoscopic diagnosis was negative in 16 cases,of which two were detected as intestinal perforation and repaired by laparotomy.The operation time was (120 ± 35.6) min and the hospital stay was (5.3 ± 3.4) d.There were no major complications after operation. Conclusion Combining the visual advantage of laparoscopy with the sensitivity and specificity of DPL can effectively improve the diagnosis of ASI.

The prognosis of hepatocellular carcinoma (HCC)is poor,and tumor thrombus in the portal vein or in the bile duct is an important influencing factor.Approximately 30%of HCC patients are found to have portal vein tumor thrombus (PVTT)when diagnosed,and their median survival time is about 2.7-4.0 months if they do not receive any treatment.The incidence of HCC complicated with bile duct tumor thrombus (BDTT)is less than 10%,while the prognosis is dismal.Once tumor thrombus extends to the major bile ducts,obstructive jaundice and subsequent hepatic dysfunction are inevitable.The survival time of patients with HCC complicated with BDTT is less than 4 months if they only receive palliative biliary stenting.The management of HCC complicated with PVTT or BDTT is challenging with controversy at present.Different treatment approaches and their benefits for patients with HCC complicated with PVTT or BDTT are introduced in this paper.

As the change of concept of health,the aim of medicine is not only to prolong life and improve the function of organs,but also to help patients to integrate to social life.Previous studies always pay much attention to clinical outcomes ineluding mortality,morbidity,long-term or short-term survival,but patients with liver cancer usually have long disease history and with background diseases such as liver cirrhosis.Traditional liver transplantation and liver resection ale both effective modalities for liver cancer,but liver resection has disadvantages of hish recurrence rate and repeated hepatic artery interventional therapy,and liver transplantation is high-cost.So the health economics and life quality of patients should not be ignored when comparing liver transplantation and liver resection.

The management of hilar cholangiocarcinoma was challenging to the surgeons due to difficult operations and low resection rate.Recently,a new mode of multidisciplinary team (MDT) is applied to the diagnosis and treatment of hilar cholangiocarcinoma,which leads to significant changes and development of the diagnosis and treatment for hilar cholangiocarcinoma.In this article,the authors first introduced the recent application of MDT treatment for hilar cholangiocarcinoma on diagnostic methods,staging systems,evaluation for resectability,radical resection,application of liver transplantation and other systematic therapies.Considering the complexity of hilar cholangiocarcinoma,a surgery-centered MDT for hilar cholangiocarcinoma is important and should be promoted.

Hepatolithiasis is still a common biliary disease in China with unknown pathogenesis and poor long-term outcomes.Surgery is probably the only curative treatment to hepatolithiasis.However,surgeons and patients cannot keep trouble from high recurrence and reoperation rates after surgery.Hepatolithiasis is a serious disease,which can cause cholangitis,liver abscess,liver cirrhosis,and even cholangiocarcinoma.Sphincter of Oddi,which controls the unidirectional outflow of bile and separates the bile duct from the bacteria-filled intestinal tract,is thought to be a gatekeeper of the almost-sterile biliary tract.Dysfunction of sphincter of Oddi,including stenosis,spasm and laxity,is closely associated with biliary disease,A lax sphincter of Oddi will aggravate bilioenteric reflux,leading to biliary infection and calculi development eventually.This issue has gradually gained enough attention.How to evaluate sphincter of Oddi function reliably and restore or replace its function,which is key to treat hepatolithiasis and prevent its recurrence,remain unclear.

Pancreatic adenocarcinoma is a highly lethal disease with a high morbidity and dismal prognosis.A multidisciplinary consultation based on evidence-based medicine has become the main modality for treatment of pancreatic adenocarcinoma.National Comprehensive Cancer Network (NCCN) clinical practice guidelines in oncology has been widely recognized and implemented.Recently,the guidelines (version 1.2017) in oncology have been published by NCCN.This article will summarize and interpret the updates of the new version of the NCCN guideline for pancreatic adenocarcinoma.

Objective Misdiagnosis of benign hepatic mass as malignancy is not infrequent. This study was to improve the clinical diagnosis by reviewing our clinical data for space occupying hepatic lesions. Methods In this study 545 patients undergoing hepatic resection for suspected malignant hepatic lesions were retrospectively studied from Jan 1998 to Jun 2004. All patients were pre-operatively assessed with plasma tumor makers, ultrasonography, computed tomography or magnetic resornance imaging. Percutaneous liver biopsy was employed in selected patients. Final pathological data was reviewed to evaluate preoperative diagnosis. Results Twenty-four out of 545 patients were pathologically diagnosed as with benign lesion. Preoperative misdiagnosis involved atypical radiological characteristics, incomprehensive clinical data and inexperienced recognition for liver lesions. Two of 24 cases suffered from minor post-operative complications, and there was no mortality. No recurrence was found by a mean follow-up of 3 years and 1 month. Conclusions Some benign hepatic lesions are easily misdiagnosed as malignant tumor. Appropriate use of multimodality examination in combination with correct algorithm of diagnostic protocol could improve diagnostic accuracy in cases of benign solid space occupying lesions of the liver.

Objective To evaluate liver transplantation for patients with hepatocellular carcinoma (HCC).Methods From Feb,1999 to Mar,2002 a total of 95 cases underwent liver transplantation(LTX) in our centre, among them there were 23 cases of HCC.SPSS 10 0 software was used to evaluate the risk factors on the tumor recurrence after LTX.Results The tumor recurrence rate was 65% during the period of follow up. The patients' tumor free survival rate at 6 and 12 months was 75 0% and 58 3%, respectively. Multi variants analysis revealed that there was a statistical relationship between pretransplant tumor size and tumor recurrence( P =0 024).Statistical relations between preoperative demograplaic, clinical features and post LTX recurrence were not found.Conclusion Large hepatocellular carcinoma is a relative contraindication for LTX.