A domestically produced self-expanding transcatheter aortic valve controllable bending delivery system(VitaFlow? Ⅲcontrollable bending retrievable delivery system)was first used to perform transcatheter aortic valve replacement(TAVR)in a symptomatic severe aortic valve stenosis patient with severe heart failure and high risk of surgery in China on September 22,2023.The patient successfully completed TAVR under general anesthesia,with good valve position and function after the operation.Before discharge and at one month of follow-up,the patient's symptoms and degree of heart failure were significantly improved.The follow-up results of this case showed that the VitaFlow? Ⅲ controllable bending retrievable delivery system for TAVR is safe and feasible,and future prospective,multicenter clinical trials are expected to evaluate its efficacy.

Background::Although overnight fasting is recommended prior to endoscopic retrograde cholangiopancreatography (ERCP), the benefits and safety of high-carbohydrate fluid diet (CFD) intake 2 h before ERCP remain unclear. This study aimed to analyze whether high-CFD intake 2 h before ERCP can be safe and accelerate patients’ recovery.Methods::This prospective, multicenter, randomized controlled trial involved 15 tertiary ERCP centers. A total of 1330 patients were randomized into CFD group ( n = 665) and fasting group ( n = 665). The CFD group received 400 mL of maltodextrin orally 2 h before ERCP, while the control group abstained from food/water overnight (>6 h) before ERCP. All ERCP procedures were performed using deep sedation with intravenous propofol. The investigators were blinded but not the patients. The primary outcomes included postoperative fatigue and abdominal pain score, and the secondary outcomes included complications and changes in metabolic indicators. The outcomes were analyzed according to a modified intention-to-treat principle. Results::The post-ERCP fatigue scores were significantly lower at 4 h (4.1 ± 2.6 vs. 4.8 ± 2.8, t = 4.23, P <0.001) and 20 h (2.4 ± 2.1 vs. 3.4 ± 2.4, t= 7.94, P <0.001) in the CFD group, with least-squares mean differences of 0.48 (95% confidence interval [CI]: 0.26–0.71, P <0.001) and 0.76 (95% CI: 0.57–0.95, P <0.001), respectively. The 4-h pain scores (2.1 ± 1.7 vs. 2.2 ± 1.7, t = 2.60, P = 0.009, with a least-squares mean difference of 0.21 [95% CI: 0.05–0.37]) and positive urine ketone levels (7.7% [39/509] vs. 15.4% [82/533], χ2 = 15.13, P <0.001) were lower in the CFD group. The CFD group had significantly less cholangitis (2.1% [13/634] vs. 4.0% [26/658], χ2 = 3.99, P = 0.046) but not pancreatitis (5.5% [35/634] vs. 6.5% [43/658], χ2 = 0.59, P = 0.444). Subgroup analysis revealed that CFD reduced the incidence of complications in patients with native papilla (odds ratio [OR]: 0.61, 95% CI: 0.39–0.95, P = 0.028) in the multivariable models. Conclusion::Ingesting 400 mL of CFD 2 h before ERCP is safe, with a reduction in post-ERCP fatigue, abdominal pain, and cholangitis during recovery.Trail Registration::ClinicalTrials.gov, No. NCT03075280.

Objective:To explore the diagnosis and treatment of lymphoepithelioma-like intrahepatic cholangiocarcinoma(LEL-ICC).Methods:The retrospective and descriptive study was conducted. The data of 7 patients with pathological diagnosis of LEL-ICC after hepatectomy who were treated in Lishui Central Hospital in Zhejiang Province from December 1, 2009 to January 30, 2024 were collected. There were 2 males and 5 females. The age range was from 40 to 64 years old, with a median age of 52 years old. All 7 patients showed no obvious clinical symptoms.We analysed the imaging manifestations, pathological features, treatmentsand prognoses of patients.Postoperative follow-upswere conducted via telephone, with a focus on whether the patient had relapsed. The deadline was February 20, 2024.Results:Five cases underwent ultrasound examination, of which 4 cases showed hypoechogenicity and 1 case showed hyperechogenicity. 7 cases underwent MRI examination, showing low signal on T1WI, high signal on T2WI, and high signal on diffusion-weighted imaging. 2 cases had type A enhancement, 2 cases had type B enhancement, and 3 cases had type C enhancement. All 7 cases received surgical treatment, 2 cases were received prophylactic transarterial chemoembolization (TACE) after surgery, and 3 cases were received systemic chemotherapy after surgery; All 7 cases underwent postoperative follow-up, with a follow-up time of 1-166 months and a median follow-up time of 56 months. One case developed hilar and retroperitoneal lymph node metastasis after surgery for 6 months, and underwent surgical treatment. After surgery, chemotherapy was performed. 25 months later, right adrenal gland metastasis reappeared, and after combined treatment, the metastatic lesion was reduced and the patient received surgical treatment and chemotherapy, and there is currently no recurrence. The remaining 6 cases showed no recurrence.Conclusions:LEL-ICC lacks specific clinical symptoms and imaging manifestations, diagnosis relies on histopathological and immunohistochemical examinations. Comprehensive treatment with surgical intervention as the main approach can lead to better prognosis for patients.

Pancreatic cancer remains as one of the most lethal malignancies. Resistance to conventional therapies has led to little improvement in the survival of pancreatic cancer patients over the past few decades. Immune-based treatment strategies for pancreatic cancer, such as immune-checkpoint inhibitors, therapeutic vaccines, and combination immunotherapies show promise. Many immunotherapies have been explored in clinical trials, but they have yet to show significant therapeutic effects. Nevertheless, immunotherapy is inevitably the future of pancreatic cancer cure. This article introduces the current research progress and bottlenecks of immunotherapy for pancreatic cancer and puts forward further optimization directions and solutions. We hope to provide a reference for the future use of immunotherapy for pancreatic cancer.

Objective:To investigate the clinical characteristics of choledocholithiasis com-bined with periampullary diverticulum and influencing factor for difficult cannulation of endoscopic retrograde cholangiopancreatography (ERCP).Methods:The retrospective case-control study was conducted. The clinical data of 1 920 patients who underwent ERCP for choledocholithiasis in 15 medical centers, including the First Hospital of Lanzhou University, et al, from July 2015 to December 2017 were collected. There were 915 males and 1 005 females, aged (63±16)years. Of 1 920 patients, there were 228 cases with periampullary diverticulum and 1 692 cases without periampullary diverticulum. Observation indicators: (1) clinical characteristics of patients with choledocholithiasis; (2) intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis; (3) influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range) or M( Q1, Q3), and com-parison between groups was conducted using the Wilcoxon rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Logistic regression model was used for univariate and multivariate analyses. Results:(1) Clinical characteristics of patients with choledocholithiasis. Age, body mass index, cases with complications as chronic obstructive pulmonary disease, diameter of common bile duct, cases with diameter of common bile duct as <8 mm, 8?12 mm, >12 mm, diameter of stone, cases with number of stones as single and multiple were (69±12)years, (23.3±3.0)kg/m 2, 16, (14±4)mm, 11, 95, 122, (12±4)mm, 89, 139 in patients with choledocholithiasis combined with periampullary diverticulum, versus (62±16)years, (23.8±2.8)kg/m 2, 67, (12±4)mm, 159, 892, 641, (10±4)mm, 817, 875 in patients with choledocholithiasis not combined with periampullary diver-ticulum, showing significant differences in the above indicators between the two groups ( t=?7.55, 2.45, χ2=4.54, t=?4.92, Z=4.66, t=?7.31, χ2=6.90, P<0.05). (2) Intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis. The balloon expansion diameter, cases with intraoperative bleeding, cases with hemorrhage management of submucosal injection, hemostatic clip, spray hemostasis, electrocoagulation hemostasis and other treatment, cases with endoscopic plastic stent placement, cases with endoscopic nasal bile duct drainage, cases with mechanical lithotripsy, cases with stone complete clearing, cases with difficult cannulation, cases with delayed intubation, cases undergoing >5 times of cannulation attempts, cannulation time, X-ray exposure time, operation time were 10.0(range, 8.5?12.0)mm, 56, 6, 5, 43, 1, 1, 52, 177, 67, 201, 74, 38, 74, (7.4±3.1)minutes, (6±3)minutes, (46±19)minutes in patients with choledocholithiasis combined with periampullary diverticulum, versus 9.0(range, 8.0?11.0)mm, 243, 35, 14, 109, 73, 12, 230, 1 457, 167, 1 565, 395, 171, 395, (6.6±2.9)minutes, (6±5)minutes, (41±17)minutes in patients with choledocholithiasis not combined with periampullary diverticulum, showing significant differences in the above indicators between the two groups ( Z=6.31, χ2=15.90, 26.02, 13.61, 11.40, 71.51, 5.12, 9.04, 8.92, 9.04, t=?3.89, 2.67, ?3.61, P<0.05). (3) Influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Results of multivariate analysis showed total bilirubin >30 umol/L, number of stones >1, combined with periampullary diverticulum were indepen-dent risk factors for difficult cannulation in patients with periampullary diverticulum who underwent ERCP for choledocholithiasis ( odds ratio=1.31, 1.48, 1.44, 95% confidence interval as 1.06?1.61, 1.20?1.84, 1.06?1.95, P<0.05). Results of further analysis showed that, of 1 920 patients undergoing ERCP for choledocholithiasis, the incidence of postoperative pancreatitis was 17.271%(81/469) and 8.132%(118/1 451) in the 469 cases with difficult cannulation and 1 451 cases without difficult cannula-tion, respectively, showing a significant difference between them ( χ2=31.86, P<0.05). In the 1 692 patients with choledocholithiasis not combined with periampullary diverticulum, the incidence of postopera-tive pancreatitis was 17.722%(70/395) and 8.250%(107/1 297) in 395 cases with difficult cannula-tion and 1 297 cases without difficult cannulation, respectively, showing a significant difference between them ( χ2=29.00, P<0.05). In the 228 patients with choledocholithiasis combined with peri-ampullary diverticulum, the incidence of postoperative pancreatitis was 14.865%(11/74) and 7.143%(11/154) in 74 cases with difficult cannulation and 154 cases without difficult cannulation, respectively, showing no significant difference between them ( χ2=3.42, P>0.05). Conclusions:Compared with patients with choledocholithiasis not combined with periampullary divertioulum, periampullary divertioulum often occurs in choledocholithiasis patients of elderly and low body mass index. The proportion of chronic obstructive pulmonary disease is high in choledocholithiasis patients with periampullary diverticulum, and the diameter of stone is large, the number of stone is more in these patients. Combined with periampullary diverticulum will increase the difficult of cannulation and the ratio of patient with mechanical lithotripsy, and reduce the ratio of patient with stone complete clearing without increasing postoperative complications of choledocholithiasis patients undergoing ERCP. Total bilirubin >30 μmol/L, number of stones >1, combined with periampullary diverticulum are independent risk factors for difficult cannulation in patients of periampullary diverticulum who underwent ERCP for choledocholithiasis.

Objective:To investigate the risk factors for acute cholangitis after endoscopic retrograde cholangiopancreatography (ERCP) and to construct its nomogram.Methods:Clinical data of patients who underwent ERCP for common bile duct stones in the First Hospital of Lanzhou University from January 2014 to December 2019 were retrospectively analyzed. A total of 95 patients with acute cholangitis after the operation (the acute cholangitis group) were included and 285 patients without acute cholangitis after the operation (the non-acute cholangitis group) were selected by random sampling at 1∶3 via the software. Logistic regression analysis was used to evaluate the risk factors for acute cholangitis after ERCP. A nomogram model was established to predict the incidence of acute cholangitis after ERCP based on the results of multivariate analysis.Results:Univariate analysis showed that there were significant differences in age, combination with diabetes, levels of alanine aminotransferase, alkaline phosphatase and glucose, roughness in gallbladder wall, bile duct diameter, stenosis in lower bile duct, proportion of patients who underwent endoscopic retrograde biliary drainage and endoscopic nasobiliary drainage between the two groups ( P<0.05). Logistic multivariate regression analysis showed that advanced age ( OR=1.108, 95% CI:1.079-1.138, P<0.001), combination with diabetes ( OR=4.524, 95% CI:1.299-15.758, P=0.018), roughness in gallbladder wall ( OR=2.495, 95% CI:1.106-5.630, P=0.028), increased bile duct diameter ( OR=1.303, 95% CI:1.181-1.437, P<0.001), and stenosis in lower bile duct ( OR=4.192, 95% CI:2.508-7.005, P<0.001) were independent risk factors for acute cholangitis after ERCP. Based on the results of multivariate analysis, the nomogram of acute cholangitis after ERCP was established. The area under the receiver operator characteristic curve was 0.887. Conclusion:Advanced age, combination with diabetes, rough gallbladder wall, increased diameter of bile duct and stenosis in lower bile duct are independent risk factors for acute cholangitis after ERCP. Clinicians can make clinical intervention based on the nomogram of risk factors above to improve the prognosis of patients.

Pancreatic cancer is one of the deadliest gastrointestinal malignancies in the world. Although the standard of treatment has been improved, it is not enough to effectively improve the prognosis of patients. As a major component of tumor microenvironment, tumor-associated macrophage (TAM) plays an important role in the field of tumor development, invasion and metastasis, angiogenesis, chemotherapy resistance and immune escape, and are closely related to poor prognosis of patients. Therefore, in-depth exploration of the complex mechanism of TAM in pancreatic cancer immunotherapy may provide new insights into the regulation of pancreatic cancer microenvironment. This article comprehensively introduces the role and mechanism of TAM in the progression of pancreatic cancer, summarizes the pancreatic cancer treatment strategies for TAM and proposes further optimization schemes, hoping to provide a new direction and reference for TAM-based pancreatic cancer immunotherapy.

Objective:To analyze the correlations between the prognosis of patients with pancreatic cancer and macrophage infiltration, and to find the differential gene correlated with macrophage infiltration in patients with pancreatic cancer through bioinformatics.Methods:A total of 32 patients with pancreatic cancer admitted to the First Hospital of Lanzhou University from June 2015 to December 2018 were selected as the research objects, including 19 males and 13 females, with the age of (61.8±2.8) years. Cancer tissues, adjacent tissues, and related clinical data were collected. F4/80 (macrophage marker) immunohistochemical staining was performed on the samples. The survival time was followed up and its correlation with the above indexes was analyzed. The pancreatic cancer data from The Cancer Genome Atlas (TCGA) database was used for bioinformatics analysis.Results:The survival time of pancreatic cancer patients was negatively correlated with degree of macrophage infiltration in cancer tissues ( r=-0.522, P=0.002), but not with adjacent tissues ( r=0.168, P=0.358). The degree of macrophage infiltration in cancer tissue combined with preoperative serum carbohydrate antigen 19-9 (CA19-9), tumor TNM stage and vascular invasion can predict survival up to 47.4% of the survival time ( R2=0.474). TCGA database bioinformatic analysis showed that in pancreatic cancer there were 95 differentially expressed genes significantly correlated with M2 macrophage infiltration, among which JPH3 (positive correlation) and IL17REL (negative correlation) were the main genes. Conclusion:The degree of macrophage infiltration in cancer tissue can be used as a prognostic factor for patients with pancreatic cancer, and the combination with preoperative serum CA19-9, tumor TNM stage and vascular invasion is more accurate in predicting the prognosis. The related mechanism of M2 macrophage infiltration can be studied around the differential genes such as JPH3 and IL17REL.

Objective:To investigate the drainage efficacy of different types of plastic stents in endoscopic ultrasound (EUS)-guided transgastric drainage for pancreatic pseudocysts.Methods:Clinical data of patients with pancreatic pseudocyst who underwent EUS-guided transgastric drainage in the surgical endoscopic center of the First Hospital of Lanzhou University from March 2014 to December 2020 were retrospectively analyzed. Patients were divided into the 10 F double plastic stents group and the 7 F double plastic stents group. The drainage efficacy, complications and long-term outcomes of the two groups were compared.Results:A total of 29 patients were included, 11 in the 10 F double plastic stents group and 18 others in the 7 F double plastic stents group. The operation time of the two groups was 48.2±8.0 min and 34.7±5.8 min, respectively, showing significant difference ( t=5.24, P<0.001). There was no significant difference in the incidence of postoperative complications such as abdominal pain [18.2% (2/11) VS 5.6% (1/18)], fever [9.1% (1/11) VS 11.1% (2/18)] or bleeding (both none) between the two groups (all P>0.05). Two months after the operation, abdominal CT scan showed that the complete disappearance rates of cysts cavity in the 10 F and 7 F groups were 90.9% (10/11) and 88.9% (16/18), respectively, with no significant difference ( P=1.00). Conclusion:There are similar drainage effect and postoperative complications rates between the 7 F and the 10 F plastic stent in EUS-guided transgastric drainage for pancreatic pseudocysts. However, operation with the 7 F stent is more convenient for a shorter time, which is worth of clinical promotion.

Objective To explore the value of preoperative LAR combined with AFP in evaluating the prognosis of patients with HCC. Methods We retrospectively analyzed the clinical data of 106 patients with HCC. Kaplan-Meier method was used to draw the survival curve. Univariate analysis was used to analyze possible variables affecting LAR. Cox risk regression model was used to evaluate the clinical value of preoperative LAR and AFP on the prognosis of HCC patients. Results The DFS and OS of the high LAR group and the high AFP group were shorter than those of the low LAR group and the low AFP group (P < 0.05). LAR≥4.58, AFP≥400μg/L and T3-T4 were independent risk factors affecting DFS and OS of HCC patients (P < 0.05). Postoperative interventional surgery was an independent factor influencing OS prolongation (P < 0.05). The DFS and OS were the shortest in the high LAR and high AFP group, and the DFS and OS were the longest in the low LAR and low AFP group (P < 0.05). Conclusion Preoperative LAR and AFP are independent poor prognostic factors of HCC. Preoperative LAR combined with AFP has a certain value in judging the prognosis of HCC patients.