Due to the unique location and aggressive tumor biology,hilar cholangiocarcinoma,intrahepatic cholangiocarcinoma,and gallbladder cancer often present with obstructive jaundice and require extensive liver resection,also exhibit high rates of recurrence and metastasis after radical excision. Therefore,surgeons should make treatment decisions based on the biliary anatomy of patients and the biological characteristics of tumors as it significantly affects patient′s prognosis. Treatment strategy should be made to ensure the successful implementation of radical resection for biliary tract malignant tumors while maximizing the survival benefits of patients. Firstly,conversion of liver function by relieving jaundice technology and conversion of tumor biological characteristics through systematic therapy,followed by the conversion of future liver remnant. Currently,there are still controversies surrounding indications,methods,standards of relieving jaundice,and treatment plans,cycles,evaluation of therapeutic effects for systematic conversion therapy,and the standards and techniques of conversion therapy for future liver remnant.This article discusses these issues through literature analysis and the author′s experience in the hope of resonating with colleagues.

Objectives:To evaluate the efficacy and safety of the self-fixing and self-detachable drainage stent in pancreaticojejunostomy and to provide supportive data for the follow clinical trials.Methods:This is an experimental research in animals which completed from February 2022 to September 2022. A self-fixing and self-detachable pancreaticojejunostomy drainage stent was designed for Hong′s pancreaticojejunostomy technique based on the theory of “fistula healing” in pancreaticojejunostomy. Ten biocompatibility tests were completed invitro before this study. Twenty-five Bama minipigs were selected and double-ligated in the neck of the pancreas to dilate the distal main pancreatic duct. Twenty-three of them were successfully modelled and divided into three groups by a stratified random method: pancreaticojejunostomy drainage stent group (referred to as stent group) with 11 pigs, pancreatic duct to jejunal mucosa anastomosis group (referred to as manual suture group) with 8 pigs, sham operation group with 4 pigs. The anastomic time,amylase content in postoperative abdominal drainage fluid and the tolerable pressure value of pancreaticojejunostomy were compared between the stent group and the manual suture group. An abdominal X-ray fluoroscopy examination was adopted to detect the detach time of the stent. A postoperative pathological examination was performed to verify the healing time,the type of treatment and the stricture rate of pancreaticojejunostomy. Quantitative data was analyzed by independent sample t-test. The classified data were analyzed by Fisher′s exact test. Results:There were no significant differences in the diameter of the pancreatic duct and pancreatic texture,the time of pancreaticojejunostomy,the amylase content in postoperative peritoneal drainage fluid,and the tolerable pressure value of the pancreaticojejunostomy between the stent group and the manual suture group(all P>0.05). Abdominal X-ray fluoroscopy showed that the stents gradually detached and were removed from the body 21 days after operation,and all stents were detached in the follow 3 months after operation. Pancreaticojejunostomy healed 7 days after operation based on fistula formation in the stent group,and 14 days in the manual suture group. The incidence of anastomotic stricture within 35 days after operation was 2/8 in the stent group and 6/8 in the manual suture group (Fisher′s exact test: P=0.132). Conclusion:The stent method is safer and simpler than the manual suture method in pancreaticojejunostomy of Bama minipigs, with shorter anastomotic healing time and lower stricture rate.

Due to the unique location and aggressive tumor biology,hilar cholangiocarcinoma,intrahepatic cholangiocarcinoma,and gallbladder cancer often present with obstructive jaundice and require extensive liver resection,also exhibit high rates of recurrence and metastasis after radical excision. Therefore,surgeons should make treatment decisions based on the biliary anatomy of patients and the biological characteristics of tumors as it significantly affects patient′s prognosis. Treatment strategy should be made to ensure the successful implementation of radical resection for biliary tract malignant tumors while maximizing the survival benefits of patients. Firstly,conversion of liver function by relieving jaundice technology and conversion of tumor biological characteristics through systematic therapy,followed by the conversion of future liver remnant. Currently,there are still controversies surrounding indications,methods,standards of relieving jaundice,and treatment plans,cycles,evaluation of therapeutic effects for systematic conversion therapy,and the standards and techniques of conversion therapy for future liver remnant.This article discusses these issues through literature analysis and the author′s experience in the hope of resonating with colleagues.

Objectives:To evaluate the efficacy and safety of the self-fixing and self-detachable drainage stent in pancreaticojejunostomy and to provide supportive data for the follow clinical trials.Methods:This is an experimental research in animals which completed from February 2022 to September 2022. A self-fixing and self-detachable pancreaticojejunostomy drainage stent was designed for Hong′s pancreaticojejunostomy technique based on the theory of “fistula healing” in pancreaticojejunostomy. Ten biocompatibility tests were completed invitro before this study. Twenty-five Bama minipigs were selected and double-ligated in the neck of the pancreas to dilate the distal main pancreatic duct. Twenty-three of them were successfully modelled and divided into three groups by a stratified random method: pancreaticojejunostomy drainage stent group (referred to as stent group) with 11 pigs, pancreatic duct to jejunal mucosa anastomosis group (referred to as manual suture group) with 8 pigs, sham operation group with 4 pigs. The anastomic time,amylase content in postoperative abdominal drainage fluid and the tolerable pressure value of pancreaticojejunostomy were compared between the stent group and the manual suture group. An abdominal X-ray fluoroscopy examination was adopted to detect the detach time of the stent. A postoperative pathological examination was performed to verify the healing time,the type of treatment and the stricture rate of pancreaticojejunostomy. Quantitative data was analyzed by independent sample t-test. The classified data were analyzed by Fisher′s exact test. Results:There were no significant differences in the diameter of the pancreatic duct and pancreatic texture,the time of pancreaticojejunostomy,the amylase content in postoperative peritoneal drainage fluid,and the tolerable pressure value of the pancreaticojejunostomy between the stent group and the manual suture group(all P>0.05). Abdominal X-ray fluoroscopy showed that the stents gradually detached and were removed from the body 21 days after operation,and all stents were detached in the follow 3 months after operation. Pancreaticojejunostomy healed 7 days after operation based on fistula formation in the stent group,and 14 days in the manual suture group. The incidence of anastomotic stricture within 35 days after operation was 2/8 in the stent group and 6/8 in the manual suture group (Fisher′s exact test: P=0.132). Conclusion:The stent method is safer and simpler than the manual suture method in pancreaticojejunostomy of Bama minipigs, with shorter anastomotic healing time and lower stricture rate.

Hepatocellular carcinoma(HCC) is one of the most common malignancies of the digestive system,which is prone to be associated with microvascular or macrovascular invasion. Among them,HCC with inferior vena cava tumor thrombus(IVCTT) or right atrium tumor thrombus(RATT) is rare and has a poor prognosis. However,surgical treatment of HCC with IVCTT and (or) RATT is rarely reported and summarized. The review described the classification of HCC tumor thrombus with IVCTT and (or) RATT, summarized the progress of surgical approaches and surgical operations,and introduced a case of thrombectomy after pushing from the outer surface of the atrium,rendering the RATT to the inferior vena cava under non-cardiopulmonary bypass. The review also proposed the prospective treatments for HCC with IVCTT or RATT,providing clinical guidance to hepatobiliary surgeons.

Objective:To investigate the clinical value of the novel approach,radical resection of the retroperitoneal lipo-lymphatic layer (RRRLLL),in the surgical treatment of resectable pancreatic head cancer.Methods:Between June 2020 and June 2022,a total of 221 patients with pancreatic head cancer underwent surgical treatment using the RRRLLL approach(RRRLLL group),while 107 patients received traditional surgical treatment(traditional group) in five high-volume pancreatic centers in China. Data from surgical technique and clinical perioperative outcomes,including lymph node harvested,surgical time,and complications,were analyzed. The RRRLLL group consisted of 144 males and 77 females with an age of (67.5±9.0) years(range:41.3 to 81.1 years). The traditional group included 71 males and 36 females,with an age of (66.3±8.1) years(range:45.1 to 79.2 years). Statistical analysis was performed using the K-S test, Z test,or χ 2 test, respectively. Results:Pancreaticoduodenectomy was performed successfully in all patients,achieving R0 resection. RRRLLL group surgery required mobilization of retroperitoneal adipose and lymphatic tissues starting from the right edge of the inferior vena cava and extending to the left side,up to the superior mesenteric artery,down to the inferior mesenteric artery,and left to the left side of the aorta,including the perineural and lymphatic tissues around the superior mesenteric artery and the sheath of the mesenteric artery. However,the traditional group did not include the areas mentioned above in the scope of clearance. There were no statistically significant differences between the RRRLLL group and the traditional group in terms of age,sex,tumor size,T stage,and vascular invasion (all P>0.05). However,the number of lymph nodes harvested in the RRRLLL group was significantly higher at 28.7±9.0 (range: 18 to 39) compared to 18.2±8.0 (range: 12 to 21) in the traditional group ( Z=-10.691, P<0.05). There were no statistically significant differences in the number of positive lymph nodes,N staging,and postoperative complications between the two groups. Conclusion:The RRRLLL approach improved lymph node dissection compared to the traditional approach,potentially leading to reduced recurrence rates.

Hepatocellular carcinoma(HCC) is one of the most common malignancies of the digestive system,which is prone to be associated with microvascular or macrovascular invasion. Among them,HCC with inferior vena cava tumor thrombus(IVCTT) or right atrium tumor thrombus(RATT) is rare and has a poor prognosis. However,surgical treatment of HCC with IVCTT and (or) RATT is rarely reported and summarized. The review described the classification of HCC tumor thrombus with IVCTT and (or) RATT, summarized the progress of surgical approaches and surgical operations,and introduced a case of thrombectomy after pushing from the outer surface of the atrium,rendering the RATT to the inferior vena cava under non-cardiopulmonary bypass. The review also proposed the prospective treatments for HCC with IVCTT or RATT,providing clinical guidance to hepatobiliary surgeons.

Objective:To investigate the clinical value of the novel approach,radical resection of the retroperitoneal lipo-lymphatic layer (RRRLLL),in the surgical treatment of resectable pancreatic head cancer.Methods:Between June 2020 and June 2022,a total of 221 patients with pancreatic head cancer underwent surgical treatment using the RRRLLL approach(RRRLLL group),while 107 patients received traditional surgical treatment(traditional group) in five high-volume pancreatic centers in China. Data from surgical technique and clinical perioperative outcomes,including lymph node harvested,surgical time,and complications,were analyzed. The RRRLLL group consisted of 144 males and 77 females with an age of (67.5±9.0) years(range:41.3 to 81.1 years). The traditional group included 71 males and 36 females,with an age of (66.3±8.1) years(range:45.1 to 79.2 years). Statistical analysis was performed using the K-S test, Z test,or χ 2 test, respectively. Results:Pancreaticoduodenectomy was performed successfully in all patients,achieving R0 resection. RRRLLL group surgery required mobilization of retroperitoneal adipose and lymphatic tissues starting from the right edge of the inferior vena cava and extending to the left side,up to the superior mesenteric artery,down to the inferior mesenteric artery,and left to the left side of the aorta,including the perineural and lymphatic tissues around the superior mesenteric artery and the sheath of the mesenteric artery. However,the traditional group did not include the areas mentioned above in the scope of clearance. There were no statistically significant differences between the RRRLLL group and the traditional group in terms of age,sex,tumor size,T stage,and vascular invasion (all P>0.05). However,the number of lymph nodes harvested in the RRRLLL group was significantly higher at 28.7±9.0 (range: 18 to 39) compared to 18.2±8.0 (range: 12 to 21) in the traditional group ( Z=-10.691, P<0.05). There were no statistically significant differences in the number of positive lymph nodes,N staging,and postoperative complications between the two groups. Conclusion:The RRRLLL approach improved lymph node dissection compared to the traditional approach,potentially leading to reduced recurrence rates.

Objective:To evaluate trans-artery pressure perfusion autologous transfusion for laparoscopic splenectomy and pericardial devascularization (LSPD).Methods:The clinical data of patients with laparoscopic splenectomy in Zhejiang Provincial People′s Hospital in recent 3 years were reviewed. The therapeutic effects of 30 LSPD cases with trans-artery pressure perfusion (observation group) and 30 radical LSPD cases (control group) were compared and analyzed.Results:There was no significant difference in age, sex, preoperative liver function grade and spleen volume between the two groups ( P>0.05). All 60 patients completed laparoscopic splenectomy without conversion to laparotomy or death. There was no significant difference in liver function, operation time and intraoperative bleeding between the observation group and the control group ( P>0.05), and there was also no significant difference in blood transfusion, postoperative complications and hospital stay ( P>0.05). The hemoglobin level in the observation group was significantly higher than that in the control group ( P<0.05). Conclusions:Laparoscopic splenectomy and pericardial devascularization with trans-artery pressure perfusion autologous transfusion can increase post-operative hemoglobin value effectively.

Objectives:To examine the efficacy of terminal branches portal vein embolization(TBPVE) for the increment of FLR in hepatocellular carcinoma (HCC) patients and to introduce its clinical value with transcatheter chemoembolization(TACE) in the treatment of HCC patients without surgery.Methods:One hundred and fifty HCC patients from three clinical centers of china underwent TBPVE technique from December 2016 to May 2021,including 89 males and 61 females. The average age was 51.9 years(range:18 to 79 years).One hundred and one patients were diagnosed with a background of HBV infection,including 27 patients with portal venous hypertension.TACE was performed simultaneously with TBPVE in 102 patients.Fifty-three patients underwent hepatectomy,who were subdivided into HBV positive and HBV negative groups,with TACE and without TACE groups to analyze the increment of future liver remnant (FLR), complications and survival data.These data were also analyzed in other 97 patients without hepatectomy.Results:All the patients reached adequate FLR successfully in 14 days after TBPVE including patients with portal venous hypertension.The average increment rates of FLR was 56.2% in 7 days and 57.8% in 14 days after TBPVE. There was no significant difference neither between HBV positive and HBV negative groups(7 days:(55.0±27.3)% vs.(57.8±20.9)%, t=0.885, P=0.373; 14 days:(57.3±24.6)% vs.(58.3±23.7)%; t=0.801, P=0.447),or between with TACE and without TACE groups(7 days:(62.3±26.3)% vs. (48.8±20.6)%; t=1.788, P=0.077;14 days:(64.4±25.0)% vs.(55.2±23.1)%; t=1.097, P=0.257).The morbidity and mortality rates were 20.8% and 1.9% in patients with hepatectomy.The 1-,3-year overall survival(OS) and disease-free(DFS) rates were 87.5%,64.5% and 64.7%,40.6% for patients underwent surgery.There was no significant difference of 1-,3-year OS and DFS between HBV positive and negative groups,but there were different between TACE and without TACE groups.The 1-,3-year OS for patients underwent TBPVE and TACE but without surgery were 80.1%, 53.7%. Conclusion:TBPVE is a good alternative technique for modulation of FLR for staged hepatectomy even in HBV positive HCC patients and can be applied with TACE procedure simultaneously as an option treatment for patients with no intend to surgery.