[Roles of multidisciplinary team in diagnosis and treatment of suspected cases of COVID-19].

OBJECTIVE: To analyze the roles of multidisciplinary team (MDT) in the diagnosis and treatment of suspected cases of coronavirus disease 2019 (COVID-19). METHODS: The clinical data of 48 patients with suspected COVID-19 admitted in Jinhua Municipal Central Hospital from January 21, 2020 to March 20, 2020 were retrospectively analyzed. RESULTS: In the 48 suspected cases, 18 were diagnosed with COVID-19, and 30 were excluded. Each of the confirmed cases were discussed among MDT for 2 to 12 times with an average of (4.7±3.2) times; while for non-COVID-19 patients were discussed for 2 to 4 times with an average of (2.3±0.6) times. With the guidance of MDT, one COVID-19 patient was transferred to designated provincial hospital after effective treatment; one patient complicated with acute cholecystitis underwent gallbladder puncture and drainage; and COVID-19 was excluded in a highly suspected patient after alveolar lavage fluid examination. Except one transferred patient, all 17 confirmed COVID-19 patients were cured and discharged. There was no cross-infection occurred in suspected patients during the hospitalization. There were no deaths and no medical staff infections. CONCLUSIONS: The efficiency of diagnosis and treatment for suspected COVID-19 patients can be improved with MDT, particularly for complicated cases.

Duodenum-preserving pancreatic head resection vs. pancreatoduodenectomy for benign lesions and low-grade malignancies of the pancreatic head.

BACKGROUND/AIMS: To compare the postoperative results of duodenum-preserving pancreatic head resection (DPPHR) techniques with those of conventional pancreatoduodenectomy (PD). METHODOLOGY: We retrospectively reviewed the records of 58 patients who underwent DPPHR or PD at Jinhua central hospital between May 1998 and May 2011. RESULTS: Eighteen patients underwent DPPHR (Group 1) and 40 conventional PD (Group 2). They were followed up for more than 6 months. Operation time in Group 1 was longer (290±18 min vs 269±14 min, p=0.001). Estimated blood loss in Group 1 was more (633±88 mL vs. 495±131 mL, p=0.003). Intraoperative transfusion in Group 1 was more (533±88 mL vs. 335±218 mL, p=0,001). However, postoperative transfusion was Iess (141±162 mL vs. 440±193 mL, p=0.000). Group 1 had a lower short-term complication rate (16.67% vs. 50.0%, p=0.0 16) and long-term complication rate (11.11% vs. 45.0%, p=0.012). Hospital mortality of both groups were 0. CONCLUSIONS: DPPHR for benign or premalignant lesions is a difficult procedure, but with a lower complication rate than conventional PD. Preserving the entire duodenum and a normal biliary tree allows better short-term and long-term results. DPPHR will be suitable for only a small group of patients and should be performed by experienced surgeons.

Laparoscopic hepatopancreatoduodenectomy for synchronous intrahepatic and extrahepatic cholangiocarcinoma: A case report.

Laparoscopic hepatopancreatoduodenectomy (LHPD) is a complex surgical procedure with high rates of complications and mortality and is performed in a limited number of medical centers. The present study reports a case of a synchronous primary malignant tumor of the left hepatic common bile ducts. A 63-year-old male was admitted to Affiliated Jinhua Hospital, Zhejiang University School of Medicine (Jinhua, China) with a 1 week history of right upper abdominal distension and pain associated with yellow sclera. Preoperative CT and MRI imaging demonstrated a synchronous primary malignant tumor of the left hepatic and common bile ducts; therefore, laparoscopic left hemihepatectomy and pancreaticoduodenectomy were performed. There was no biliary or pancreatic leakage following the operation and the patient was discharged 16 days later. Postoperative pathology verified that the synchronous primary cholangiocarcinoma originated in the left hepatic and common bile ducts. Therefore, LHPD for synchronous primary cholangiocarcinoma may be a safe and feasible treatment for this condition.

Endoscopic pancreatic duct stenting combined with 3D laparoscopic pancreatic tumor resection: Three case reports.

RATIONALE: This study explored the safety and feasibility of 3D laparoscopy and intraoperative ultrasound techniques, which made minimally invasive pancreatic surgery more precise and detailed. PATIENT CONCERN: Case 1 was a 51-year-old man with a primary complaint of pancreatic tumor. Case 2 was a 60-year-old woman with complaints of tinnitus for 1 week. Case 3 was a 21-year-old woman with complaints of epigastric pain and abdominal distension for 1 day. DIAGNOSIS: Case 1 and Case 2 were diagnosed with pancreatic neuroendocrine tumors, and Case 3 was diagnosed with an infected solid pseudopapillary tumor of the pancreas. INTERVENTIONS: All 3 patients underwent laparoscopic pancreatic surgery in our hospital. OUTCOMES: All cases received the same perioperative management and no localized stenosis or dilatation of the pancreatic duct was found during follow-up. LESSONS: With the development of minimally invasive surgery and the application of 3D laparoscopy and intraoperative ultrasound technology, pancreatic tumors that are tightly adhered to the main pancreatic duct can successfully be removed using 3D laparoscopic operation.

BarH-Like Homeobox 2 Suppresses Cell Proliferation, Invasion, and Angiogenesis in Hepatocellular Carcinoma by Activating N-Acetylgalactosaminyltransferase 4.

BarH-like homeobox 2 (BARX2) has been identified to play a key role in the development of multiple cancers. Meanwhile, BARX2 may be an independent prognostic biomarker for patients suffering from hepatocellular carcinoma (HCC). Nevertheless, the regulatory role of BARX2 in HCC is still unclear and needs to be unveiled. In this study, the expressions of BARX2 and N-acetylgalactosaminyltransferase 4 (GALNT4) were evaluated by quantitative real-time PCR (qRT-PCR) as well as western blot. Besides, the abilities of cells to proliferate, migrate, invade, and angiogenesis were assessed with CCK-8, colony formation, wound-healing, Transwell, and tube formation assays, separately. Cell apoptosis was determined by flow cytometry analysis. The binding relationship between BARX2 and GALNT4 was predicted by JASPAR website and verified using Chromatin immunoprecipitation (ChIP) and luciferase report assay. It was discovered that BARX2 was reduced in HCC cell lines, while its overexpression greatly repressed cell proliferation, migration, invasion, and angiogenesis and promoted cell apoptosis in HuH7 and MHCC97-H cells. BARX2 could bind to GALNT4 promoter and positively regulate GALNT4 expression. In addition, GALNT4 deficiency partly abolished the inhibitory effects of BARX2 on the progression of HCC. In summary, this study highlights that BARX2 may hold promise for serving as a potential therapeutic target, facilitating the development of a novel therapeutic strategy against HCC.

Distinctive Metabolism-Associated Gene Clusters That Are Also Prognostic in Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma.

Objective: To offer new prognostic evaluations by exploring potentially distinctive genetic features of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Methods: There were 12 samples for gene expression profiling processes in this study. These included three HCC lesion samples and their matched adjacent nontumor liver tissues obtained from patients with HCC, as well as three ICC samples and their controls collected similarly. In addition to the expression matrix generated on our own, profiles of other cohorts from The Cancer Genome Atlas (TCGA) program and the Gene Expression Omnibus (GEO) were also employed in later bioinformatical analyses. Differential analyses, functional analyses, protein interaction network analyses, and gene set variation analyses were used to identify key genes. To establish the prognostic models, univariate/multivariate Cox analyses and subsequent stepwise regression were applied, with the Akaike information criterion evaluating the goodness of fitness. Results: The top three pathways enriched in HCC were all metabolism-related; they were fatty acid degradation, retinol metabolism, and arachidonic acid metabolism. In ICC, on the other hand, additional pathways related to fat digestion and absorption and cholesterol metabolism were identified. Consistent characteristics of such a metabolic landscape were observed across different cohorts. A prognostic risk score model for calculating HCC risk was constructed, consisting of ADH4, ADH6, CYP2C9, CYP4F2, and RDH16. This signature predicts the 3-year survival with an AUC area of 0.708 (95%CI = 0.644 to 0.772). For calculating the risk of ICC, a prognostic risk score model was built upon the expression levels of CYP26A1, NAT2, and UGT2B10. This signature predicts the 3-year survival with an AUC area of 0.806 (95% CI = 0.664 to 0.947). Conclusion: HCC and ICC share commonly abrupted pathways associated with the metabolism of fatty acids, retinol, arachidonic acids, and drugs, indicating similarities in their pathogenesis as primary liver cancers. On the flip side, these two types of cancer possess distinctive promising biomarkers for predicting overall survival or potential targeted therapies.

Silibinin Therapy Improves Cholangiocarcinoma Outcomes by Regulating ERK/Mitochondrial Pathway.

Background: Silibinin is widely utilized drug in various cancer treatments, though its application in cholangiocarcinoma has not yet been explored. For the first time, we evaluated the anticancer potential and underlying molecular mechanism of silibinin in treatment of cholangiocarcinoma treatment. Methods: HuCCT-1 and CCLP-1 cells were chosen to be an in vitro study model and were exposed to various concentrations of silibinin for indicated times. Cell viability was evaluated by the cell counting kit-8 (CCK-8) assay and half maximal inhibitory (IC50) concentrations were calculated. Cell proliferation capacity was determined through the use of colony formation and 5-Ethynyl-2'- deoxyuridine (EdU) assays. Cell apoptosis and cycle arrest were assessed by Live/Dead staining assay and flow cytometry (FCM). The protein levels of extracellular regulated protein kinases (ERK)/mitochondrial apoptotic pathway were evaluated through western blotting (WB). Mitochondrial membrane potential changes were determined via 5,5',6,6'-Tetrachloro-1,1',3,3'-tetraethyl-imidacarbocyanine iodide (JC-1). A cholangiocarcinoma cell line xenograft model was used to assess the anti-tumor activity of silibinin in vivo. Results: Inhibition of the ERK protein by silibinin led to a significant decrease in mitochondrial membrane potential, which, in turn, caused Cytochrome C to be released from the mitochondria. The activation of downstream apoptotic pathways led to apoptosis of cholangiocarcinoma cells. In general, silibinin inhibited the growth of cholangiocarcinoma cell line xenograft tumors. Conclusions: Silibinin is able to inhibit cholangiocarcinoma through the ERK/mitochondrial apoptotic pathway, which makes silibinin a potential anti-tumor drug candidate for cholangiocarcinoma treatment.

Identification of Prognostic Glycolysis-Related lncRNA Signature in Tumor Immune Microenvironment of Hepatocellular Carcinoma.

Purpose: The purpose of this study was to construct a novel risk scoring model with prognostic value that could elucidate tumor immune microenvironment of hepatocellular carcinoma (HCC). Samples and methods: Data were obtained through The Cancer Genome Atlas (TCGA) database. Univariate Cox analysis, least absolute shrinkage and selection operator (LASSO) analysis, and multivariate Cox analysis were carried out to screen for glycolysis-related long noncoding RNAs (lncRNAs) that could provide prognostic value. Finally, we established a risk score model to describe the characteristics of the model and verify its prediction accuracy. The receiver operating characteristic (ROC) curves of 1, 3, and 5 years of overall survival (OS) were depicted with risk score and some clinical features. ESTIMATE algorithm, single-sample gene set enrichment analysis (ssGSEA), and CIBERSORT analysis were employed to reveal the characteristics of tumor immune microenvironment in HCC. The nomogram was drawn by screening indicators with high prognostic accuracy. The correlation of risk signature with immune infiltration and immune checkpoint blockade (ICB) therapy was analyzed. After enrichment of related genes, active behaviors and pathways in high-risk groups were identified and lncRNAs related to poor prognosis were validated in vitro. Finally, the impact of MIR4435-2HG upon ICB treatment was uncovered. Results: After screening through multiple steps, four glycolysis-related lncRNAs were obtained. The risk score constructed with the four lncRNAs was found to significantly correlate with prognosis of samples. From the ROC curve of samples with 1, 3, and 5 years of OS, two indicators were identified with high prognostic accuracy and were used to draw a nomogram. Besides, the risk score significantly correlated with immune score, immune-related signature, infiltrating immune cells (i.e. B cells, etc.), and ICB key molecules (i.e. CTLA4,etc.). Gene enrichment analysis indicated that multiple biological behaviors and pathways were active in the high-risk group. In vitro validation results showed that MIR4435-2HG was highly expressed in the two cell lines, which had a significant impact on the OS of samples. Finally, we corroborated that MIR4435-2HG had intimate relationship with ICB therapy in hepatocellular carcinoma. Conclusion: We elucidated the crucial role of risk signature in immune cell infiltration and immunotherapy, which might contribute to clinical strategies and clinical outcome prediction of HCC.

Preoperative assessment of hilar cholangiocarcinoma: combination of cholangiography and CT angiography.

BACKGROUND: Hilar cholangiocarcinoma is one of the most difficult carcinomas to manage because of the location of the main tumor at the hepatic hilus and the complex anatomy of the biliary, arterial, and portal systems. To plan an operation, it is important to acquire accurate information about the relationship between hilar cholangiocarcinoma and adjacent vessels. This study aimed to evaluate the clinical value of cholangiography combined with spiral CT three-dimensional (3D) angiography for a preoperative assessment of hilar cholangiocarcinoma. METHODS: From March 2007 to August 2009, cholangiography was performed in 13 patients with hilar cholangiocarcinoma. Meanwhile, contrast-enhanced abdominal scanning was performed using 16-slice spiral CT, and the 3D images of the hepatic artery and portal vein were acquired. The level and range of invasion of the hepatic artery, the portal vein, and the bile duct, the preoperative Bismuth classification, and T-staging were recorded and compared with those after surgical exploration. RESULTS: The hepatic artery and portal vein were reconstructed successfully in all these patients. Percutaneous transhepatic cholangiography was performed in 9 patients, endoscopic retrograde cholangiopancreatography in 1, and magnetic resonance cholangiopancreatography in 3. The CT angiography records of invasion of the hepatic artery were consistent with the results of explorations in these patients. The data from 5 of the 13 patients were consistent with those on invasion of the portal vein. The results of the Bismuth classification and the T-staging system were consistent with those of surgical exploration in 12 of the 13 patients. Seven of 8 patients who were estimated to be suitable for operation based on images were curatively treated and 5 who were judged to be unsuitable for curative operation by cholangiography and CT angiography were confirmed intraoperatively and underwent palliative procedures. CONCLUSIONS: Cholangiography combined with multi-slice spiral 3D CT angiography can satisfactorily delineate the local invasion of hilar cholangiocarcinoma and accurately evaluate the resectability. This approach, therefore, contributes to the planning of safe operation.

Laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for pancreatic duct stone: A case report and review of literature.

To study a more micro-invasive procedure for patients having pancreatic duct stones (PDS). Till now, there has been no report of laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for PDS in the English literature. An 82-year-old man suffered from subxiphoid pain associated with a dilated pancreatic duct (7 mm) containing one stone, but without a mass in the head of the pancreas. Laparoscopic pancreatic duct incision, stone removal, and T-type tube drainage were successfully performed without intraoperative or postoperative complications. An uneventful operation was performed with laparoscopically completed procedures in 160 min. The intraoperative loss of blood was around 50 mL. After patient a discharge on day 11, complete relief from the subxiphoid pain was reported at a follow-up visit 15 mo later. Laparoscopic pancreatic duct incision with stone removal and T-type tube drainage is applicable in carefully selected patients and can be effectively and safely used for the treatment of the abdominal pain of chronic pancreatitis.

Pathogenesis and treatment to postoperative bile leakage: report of 38 cases.

BACKGROUND: Bile leakage remains a serious complication after biliary surgery. The aim of this study was to assess the etiology, diagnosis and treatment of postoperative biliary leakage. METHODS: Thirty-eight patients with biliary leakage we treated in recent 8 years were analyzed retrospectively. Among them, 8 patients had bilioenterostomy leakage, 7 accessory bile duct leakage, 7 cholecyst bed leakage, 6 leakage after removal of T-tube, 5 leakage after laparoscopic cholecystectomy, 3 leakage around T-tube, and 2 leakage caused by choledochal damage. Drainage was performed in 17 patients, reoperation in 13, drainage plus percutaneous transhepatic cholangio drainage (PTCD), endoscopic retrograde cholangiography (ERCP), endoscopic nasobiliary drainage (ENBD) and endostenting in 5, and drainage plus growth hormone in 3. RESULTS: In this series, 37 patients were cured, and 1 died of multiple organ dysfunction syndrome (MODS). These patients were hospitalized for 2 weeks to 8 weeks. The drainage group was hospitalized shorter than the undrainage group. CONCLUSIONS: A piece of white gauze can be used to touch surgical area in detecting biliary leakage intraoperatively. Mucous to mucous suture of the bile duct and appropriate time for removal of T-tube are recommended to prevent biliary leakage. Reoperation is essential to acute peritonitis. Drainage can be used if leakage don't diffuse or it occurs after pulling out T-tube. Drainage plus ERCP, ENBD, PTCD and drainage are effective.

[Surgical treatment for hepatic metastases from colorectal carcinoma].

OBJECTIVE: To explore the indications and effect of surgical resection for hepatic metastases from colorectal adenocarcinoma and to discuss the implications of clinicopathologic features on the prognosis. METHODS: A retrospective study of 61 patients undergoing hepatectomy for metastatic tumors from colorectal adenocarcinoma from January 1991 to December 2000 in our hospital was performed retrospectively. RESULTS: The 1-, 3- and 5-year survival rates after hepatic resection were 72.13%, 58.10% and 26.01% respectively. Complications occurred in 8 cases. Tumor pesudomembrance was found in 20 cases. Dukes stage, pathologic type,the number of hepatic metastases and tumor pesudomembrance were all significant factors for prognosis after surgery (P< 0.05). The 3-year survival rate of the patients with postoperative comprehensive treatment was higher than that with non-postoperative treatment (P< 0.05). The size of hepatic metastases and the resecting time didn't affect the prognosis (P > 0.05). CONCLUSION: The hepatic metastases from colorectal cancer should be treated by a surgical approach. The earlier stage of clinical pathology,higher differentiation extent, metastases less than 3, the formation of pesudomembrance of the metastatic tumor and the postoperative comprehensive treatment predict a better survival.

[Detection of telomerase activity of exfoliated cells in bile and its clinical impact].

BACKGROUND & OBJECTIVE: Some studies revealed that telomerase activity could be detected in exfoliated cancer cells in body fluid such as urine, pancreatic juice, pleural effusion that is a good diagnostic marker for malignancies. However, few reports about telomerase in exfoliated cancer cells in bile are available. The current study was designed to determine the telomerase activity of exfoliated cells in bile and its clinical impact in the patients with malignant obstructive jaundice. METHODS: Telomerase activity was determined by using a modified PCR-based telomeric repeat amplification protocol(TRAP)-sliver stain assay. RESULT: Telomerase activity was detected in 33 of 44(75%) bile specimens from patients with malignant tumor. In contrast, only 1 of 19(5.3%) bile samples from cholelithiasis was telomerase positive. There was no relation ship between the positive rate of telomerase activity and the clinicopathological finds including metastatic status and differentiation, but telomerase positive rate was higher in bile from patients with pancreatic carcinoma and cholangiocarcinoma. Comparison of telomerase assay with cytologic examination showed that, among the 44 patients with malignant obstructive jaundice, 31 cases underwent cytological examination, cancer cells were found only in 3(9.7%) bile specimens, and all cytological examination positive specimens were telomerase positive. CONCLUSION: The TRAP assay can effectively detect telomerase activity of the exfoliated cancer cells in bile. Telomerase could be a molecular marker for diagnosis of malignant bile duct disease. The detection of telomerase activity in bile could become a useful adjunct in the cytologic examination.