Objective:To explore the safety of laparoscopic modified transcystic biliary drainage(modified C-tube technique)in the treatment of biliary stones and application of diagnosing biliary disease.Methods:A retrospective analysis was conducted on the clinical data of 68 cases of biliary stones successfully treated with laparoscopic modified C-tube technique from August 2021 to December 2023.The safety,effectiveness,and area of applications were analyzed.The reliability of the principle of the modified fixation method was verified by using an ex vivo gallbladder.Results:Three cases of ex vivo gallbladder demonstrated that the strength of the modified fixation method was reliable,and the sinus tract formed by suture after immediate extraction of the C tube could be dislocated and closed,resisting the bile outflow caused by the weight of the gallbladder.Among the 68 patients,42 were difficult biliary stones,6 were suspected common bile duct stones,and 5 were extrahepatic bile duct stones combined with intrahepatic bile duct stones.Among them,48 cases underwent choledochoscopy assisted trans-choledochal approach for stone removal,and 10 cases underwent transcystic approach stone removal,Six patients underwent simply basket exploration and removal of stones through the cystic duct(5 patients had no residual stones on postoperative C-tube angiography,1 patient had suspected residual stones,and the patient refused further examination and treatment for no symptom),and 4 patients only underwent biliary drainage through the cystic duct;two patients with retained stone passed after the use of topical nitrate drip infusion via C-tube,seven cases underwent endoscopic retrograde cholangiopancreatography(ERCP),stone removal with the assistance of a C-tube after laparoscopic surgery,and the results were uneventful.The mean surgical time was(131±44)min(76-279 min),the maximum daily drainage volume of the C-tube was(401±235)mL/d(10-1 150 mL/d),the hospital stay was(8.6±3.6)d(2-19 d),and the mean time of C-tube removal was(11±6.9)d(5-46 d).There were 14 overall complications,including 2 residual stones,and 12 C-tube related complications,comprising of 1 gradeⅢ a,2 grade Ⅱ,and 9 grade Ⅰ.There were 9 cases of C-tube related adverse events that did not cause complications,including 3 of early detachment,2 of displacement,and 4 of deep insertion.The median follow-up time after surgery was 21(2-30)months,and 5 patients had recurrent stones.Among them,4 patients had slow contrast outflow during cholangiogram,and 1 patient had obvious pancreaticobiliary reflux.55 patients underwent C-tube amylase measurement,and 9 cases showed a significant increase in bile amylase(349-44 936 U/L),suggesting the presence of pancreaticobiliary reflux.Conclusion:Laparoscopic modified C-tube technique can be effectively used in the treatment of biliary stones,which is relatively safe and can be attempted in the diagnosis of biliary diseases.

Minimally invasive treatment for gallbladder cancer has gradually become a routine surgery in experienced hepatobiliary pancreatic centers, with its minimally invasive indications gradually expanding and becoming more refined. In terms of the scope of preventive liver resection, it tends to be conservative, and there are still many controversies about preventive lymph node dissection. Minimally invasive treatment for accidental gallbladder cancer has been accepted.

Objective:To evaluate the occurrence of pancreaticobiliary reflux and its clinical and imaging characteristics in patients after common bile duct stone surgery.Methods:A retrospective analysis of 123 patients who underwent bile amylase measurement after common bile duct stone extraction was conducted to analyze the occurrence of pancreaticobiliary reflux and its correlation with clinicoradiological data.Results:Among the 123 patients, 72 patients had pancreaticobiliary reflux (58.5%), of which 10 were in a state of high biliary amylase levels. Among the 32 patients who underwent simultaneous measurement of C-tube cephalic (liver side) and caudal (duodenal papilla side) amylase, the cephalic side amylase was lower than the caudal side amylase with a significant statistical difference ( P<0.001). Compared with patients without pancreaticobiliary reflux, patients in the status of pancreaticobiliary reflux and high biliary amylase levels were no statistically significant difference in age, gender, emergency visit, papillary diverticulum, preoperative biliary pancreatitis, preoperative common bile duct diameter, C-tube cholangiography common bile duct diameter, and imaging common bile duct diameter>10mm. Among the 123 patients in this group, 5 cases showed pancreaticobiliary maljunction on C-tube cholangiography, of which only 1 case had such manifestation by preoperative MRCP. There was no statistically significant difference in amylase levels between patients with pancreaticobiliary maljunction and patients with occult pancreaticobiliary reflux ( P=0.698). Conclusions:Pancreatic bile reflux is common among patients after choledocholithotomy, with a lack of preoperative clinical imaging predictive method. Bile amylase measurement is the key to diagnosis.

Objective:To explore the safety of laparoscopic modified transcystic biliary drainage(modified C-tube technique)in the treatment of biliary stones and application of diagnosing biliary disease.Methods:A retrospective analysis was conducted on the clinical data of 68 cases of biliary stones successfully treated with laparoscopic modified C-tube technique from August 2021 to December 2023.The safety,effectiveness,and area of applications were analyzed.The reliability of the principle of the modified fixation method was verified by using an ex vivo gallbladder.Results:Three cases of ex vivo gallbladder demonstrated that the strength of the modified fixation method was reliable,and the sinus tract formed by suture after immediate extraction of the C tube could be dislocated and closed,resisting the bile outflow caused by the weight of the gallbladder.Among the 68 patients,42 were difficult biliary stones,6 were suspected common bile duct stones,and 5 were extrahepatic bile duct stones combined with intrahepatic bile duct stones.Among them,48 cases underwent choledochoscopy assisted trans-choledochal approach for stone removal,and 10 cases underwent transcystic approach stone removal,Six patients underwent simply basket exploration and removal of stones through the cystic duct(5 patients had no residual stones on postoperative C-tube angiography,1 patient had suspected residual stones,and the patient refused further examination and treatment for no symptom),and 4 patients only underwent biliary drainage through the cystic duct;two patients with retained stone passed after the use of topical nitrate drip infusion via C-tube,seven cases underwent endoscopic retrograde cholangiopancreatography(ERCP),stone removal with the assistance of a C-tube after laparoscopic surgery,and the results were uneventful.The mean surgical time was(131±44)min(76-279 min),the maximum daily drainage volume of the C-tube was(401±235)mL/d(10-1 150 mL/d),the hospital stay was(8.6±3.6)d(2-19 d),and the mean time of C-tube removal was(11±6.9)d(5-46 d).There were 14 overall complications,including 2 residual stones,and 12 C-tube related complications,comprising of 1 gradeⅢ a,2 grade Ⅱ,and 9 grade Ⅰ.There were 9 cases of C-tube related adverse events that did not cause complications,including 3 of early detachment,2 of displacement,and 4 of deep insertion.The median follow-up time after surgery was 21(2-30)months,and 5 patients had recurrent stones.Among them,4 patients had slow contrast outflow during cholangiogram,and 1 patient had obvious pancreaticobiliary reflux.55 patients underwent C-tube amylase measurement,and 9 cases showed a significant increase in bile amylase(349-44 936 U/L),suggesting the presence of pancreaticobiliary reflux.Conclusion:Laparoscopic modified C-tube technique can be effectively used in the treatment of biliary stones,which is relatively safe and can be attempted in the diagnosis of biliary diseases.

Minimally invasive treatment for gallbladder cancer has gradually become a routine surgery in experienced hepatobiliary pancreatic centers, with its minimally invasive indications gradually expanding and becoming more refined. In terms of the scope of preventive liver resection, it tends to be conservative, and there are still many controversies about preventive lymph node dissection. Minimally invasive treatment for accidental gallbladder cancer has been accepted.

Objective:To evaluate the occurrence of pancreaticobiliary reflux and its clinical and imaging characteristics in patients after common bile duct stone surgery.Methods:A retrospective analysis of 123 patients who underwent bile amylase measurement after common bile duct stone extraction was conducted to analyze the occurrence of pancreaticobiliary reflux and its correlation with clinicoradiological data.Results:Among the 123 patients, 72 patients had pancreaticobiliary reflux (58.5%), of which 10 were in a state of high biliary amylase levels. Among the 32 patients who underwent simultaneous measurement of C-tube cephalic (liver side) and caudal (duodenal papilla side) amylase, the cephalic side amylase was lower than the caudal side amylase with a significant statistical difference ( P<0.001). Compared with patients without pancreaticobiliary reflux, patients in the status of pancreaticobiliary reflux and high biliary amylase levels were no statistically significant difference in age, gender, emergency visit, papillary diverticulum, preoperative biliary pancreatitis, preoperative common bile duct diameter, C-tube cholangiography common bile duct diameter, and imaging common bile duct diameter>10mm. Among the 123 patients in this group, 5 cases showed pancreaticobiliary maljunction on C-tube cholangiography, of which only 1 case had such manifestation by preoperative MRCP. There was no statistically significant difference in amylase levels between patients with pancreaticobiliary maljunction and patients with occult pancreaticobiliary reflux ( P=0.698). Conclusions:Pancreatic bile reflux is common among patients after choledocholithotomy, with a lack of preoperative clinical imaging predictive method. Bile amylase measurement is the key to diagnosis.

Objective To preliminarily analyze the efficacy of laparoscopic surgery versus open surgery in patients with intrahepatic cholangiocarcinoma(ICC).Methods A retrospective analysis was conducted on 84 patients with ICC who underwent surgical resection from September 2010 to March 2023,including 45 cases in the laparoscopic surgery group and 39 in the open surgery group.By using propensity score matching,34 matched pairs were successfully identified.The study compared intraoperative blood loss,proportion of achieving≥6 lymph nodes dissection,R0 resection rate,complication,postoperative hospital stay,survival,and recurrence between the two groups.Results In the laparoscopic group,intraoperative blood loss was significantly less than that in the open surgery group(median:250 ml vs.750 ml,Z=-3.406,P=0.001).The proportion of achieving≥6 lymph node dissection in the former was lower than that in the latter,but the difference was not statistically significant(5.9%vs.17.6%,χ2=1.275,P=0.259).There was no statistical difference in R0 resection rate between the laparoscopic group and the open surgery group[88.2%(30/34)vs.82.4%(28/34),χ2=0.469,P=0.493].The complication rate in the laparoscopic group was 17.6%(6/34),significantly lower than 47.1%(16/34)in the open surgery group(χ2=6.719,P=0.010);however,the rate of severe complication was the same in both groups at 2.9%(χ2=0.000,P=1.000).Laparoscopic surgery significantly shortened the postoperative hospital stay(median:7 d vs.10 d,Z=-3.021,P=0.003).The median overall survival in the laparoscopic group was 60.6 months,significantly longer than 15.9 months in the open surgery group(log-rank χ2=5.788,P=0.016).The median recurrence-free survival was 26.4 months in the laparoscopic group,significantly longer than 7.6 months in the open surgery group(log-rank χ2=4.532,P=0.033).Conclusions Compared to open surgery,laparoscopic surgery for ICC offers advantages such as less blood loss,lower complication rate,shorter postoperative hospital stay and longer survival.It achieves comparable R0 resection rate and adequate lymph node dissection.

Objective:To explore the expression of PD-L1 and B7-H3 in intrahepatic cholangiocarcinoma (ICC) and their relationship with the prognosis after surgery.Methods:Clinicopathological data of 63 ICC patients undergoing surgery at the Department of General Surgery, Peking University Third Hospital, from Sep 2016 to Mar 2023 were retrospectively analyzed.Results:PD-L1 and B7-H3 are highly expressed in 41.3% and 60.3% of ICC patients, respectively, and their expression levels were positively correlated with each other( P=0.005). High PD-L1 expression is significantly associated with poor tumor differentiation ( P=0.014), while high B7-H3 expression is significantly related to lymph node metastasis ( P=0.035). In patients with high co-expression of PD-L1 and B7-H3, the overall survival ( P=0.031) and recurrence-free survival ( P=0.031) were significantly decreased. High co-expression of PD-L1 and B7-H3 is an independent risk factor for recurrence in ICC ( HR=3.998, 95% CI: 1.211-13.198; P=0.023). Conclusions:ICC patients with high expression of both PD-L1 and B7-H3 have a poor prognosis. Using both as the combined biomarker significantly improves the prediction of long-term survival after surgery, compared to using either one alone.

Intrahepatic cholangiocarcinomas (ICC) arise above the second order bile ducts, has a unique biological characteristics. Liver resection is the most effective treatment. Minimally invasive surgery, associating liver partition and portal vein ligation for staged hepatectomy, regional lymphadenectomy and liver transplantation are the main advancement of surgical treatment in ICC. Traditional CT and laboratory markers are incorporated to predict long-term outcomes after resection for ICC. Adjuvant chemotherapy and neoadjuvant therapies are proved to be the optimal treatment in selected patients. A lot of targetable mutations have been comprehensively characterised and clinical data is emerging on targeting these oncogenic drivers. Also, the role of immunotherapy has been examined and is an area of intense investigation. Herein, a deeper understanding of the molecular and genomic pathogenesis of this entity has led to several advances in the individualized treatment of ICC.

Objective: To explore the feasibility of laparoscopic treatment for incidental gallbladder cancer(IGBCA) and analyze the factors influencing prognosis. Methods: A retrospective study of 71 patients with IGBCA received laparoscopic treatment at Department of General Surgery, Peking University Third Hospital from January 2007 to December 2016 was conducted,the clinicopathological data and prognosis were analyzed. There were 18 males and 53 females,aged 23 to 81 years. They were divided into two groups based on the presence of intraluminal mass in the gallbladder. Sixty-five of the 71 patients received laparoscopic radical resection, the prognosis of them were compared with 14 patients with open radical resection. Results: Among the 71 patients,65 patients received radical resection,3 patients simple gallbaldder resection and 3 patients palliative resection. Postoperative complications occurred in 6 patients. IGBCA were detected by frozen section in 57 patients,with the accuracy of 96.5%,while the accuracy of T stage is 43.8% in the 48 patients received T stage evaluation during frozen section examination. The T stages based on final pathology were Tis(n=6),T1a(n=5),T1b(n=10),T2(n=46),and T3(n=4).The number of harvested lymph node was 4.7±2.9(range:2-12).There are 14 patients with lymph node metastasis. The 50 patients with intraluminal gallbladder mass include 21 patients with ≤T1b stage and 29 patients with ≥T2 stage, while the 21 patients without intraluminal gallbladder mass are all with ≥T2 stage. The median survival time of the 71 patients was 33 months, with the 5-year cumulative survival rate 67.3%. The 5-year cumulative survival rate is 78.5% for the 65 patients who received radical resection,comparable with those who received open radical resection(P=0.485).Univariate analysis demonstrated that T stage, lymph node metastasis, G grade, lymphovascular invasion, neural invasion, acute cholecystectomy, bile spillage, gallbladder mass and preoperative CA19-9/CEA were the most important prognostic factors(P<0.05). Conclusions Laparoscopic treatment for IGBCA is feasible, especially for those with intraluminal gallbladder mass. The accuracy of frozen section examination in evaluating T stage is low.