A Circular RNA, Cholangiocarcinoma-Associated Circular RNA 1, Contributes to Cholangiocarcinoma Progression, Induces Angiogenesis, and Disrupts Vascular Endothelial Barriers.

BACKGROUND AND AIMS: Circular RNAs (circRNAs) and extracellular vesicles (EVs) are involved in various malignancies. We aimed to clarify the functions and mechanisms of dysregulated circRNAs in the cells and EVs of cholangiocarcinoma (CCA). APPROACH AND RESULTS: CircRNA microarray was used to identify circRNA expression profiles in CCA tissues and bile-derived EVs (BEVs). CCA-associated circRNA 1 (circ-CCAC1) expression was measured by quantitative real-time PCR. The clinical importance of circ-CCAC1 was analyzed by receiver operating characteristic curves, Fisher's exact test, Kaplan-Meier plots, and Cox regression model. The functions of circ-CCAC1 and exosomal circ-CCAC1 were explored in CCA cells and human umbilical vein endothelial cells (HUVECs), respectively. Different animal models were used to verify the in vitro results. RNA sequencing, bioinformatics, RNA immunoprecipitation, RNA pulldown, chromatin immunoprecipitation followed by sequencing, and luciferase reporter assays were used to determine the regulatory networks of circ-CCAC1 in CCA cells and HUVECs. Circ-CCAC1 levels were increased in cancerous bile-resident EVs and tissues. The diagnostic and prognostic values of circ-CCAC1 were identified in patients with CCA. For CCA cells, circ-CCAC1 increased cell progression by sponging miR-514a-5p to up-regulate Yin Yang 1 (YY1). Meanwhile, YY1 directly bound to the promoter of calcium modulating ligand to activate its transcription. Moreover, circ-CCAC1 from CCA-derived EVs was transferred to endothelial monolayer cells, disrupting endothelial barrier integrity and inducing angiogenesis. Mechanistically, circ-CCAC1 increased cell leakiness by sequestering enhancer of zeste homolog 2 in the cytoplasm, thus elevating SH3 domain-containing GRB2-like protein 2 expression to reduce the levels of intercellular junction proteins. In vivo studies further showed that increased circ-CCAC1 levels in circulating EVs and cells accelerated both CCA tumorigenesis and metastasis. CONCLUSIONS: Circ-CCAC1 plays a vital role in CCA tumorigenesis and metastasis and may be an important biomarker/therapeutic target for CCA.

Pancreaticoduodenal and choledochal hemangiomatosis with vascular variation in a child: a rare disease with challenge starts from diagnosis-a case report.

BACKGROUND: Visceral hemangiomatosis is a benign tumor (rarer than hemangioma) that has not been reported to occur in the pancreas, duodenum, or choledoch. It can be easily confused with other pancreatic tumors or choledocholithiasis. Herein, we describe a case of a child with pancreaticoduodenal and choledochal hemangiomatosis and the key characteristics for the accurate diagnosis of pancreatic tumors based on previous reports and our findings. CASE PRESENTATION: We report a case of a 2-year and 9-month-old child who presented with repeated and fluctuating jaundice for 3 months with a history of endoscopic stone removal in a local hospital, following the diagnosis of choledocholithiasis. An abdominal computed tomography revealed a previously undiagnosed pancreatic head tumor and celio-mesenteric trunk (a rare vascular variation). This was misdiagnosed as a pancreatic neuroendocrine tumor. Since the patient's parents refused FNA biopsy and insisted on surgery, pancreaticoduodenectomy was performed; however, postoperatively, the child was correctly diagnosed with pancreaticoduodenal and choledochal hemangiomatosis. Although the patient was in good condition and had gained 4 kg in weight 3 months postoperatively, pancreaticoduodenectomy could have been avoided if an accurate diagnosis had been established before or during the operation. CONCLUSION: Our report highlights the difficulty in diagnosing visceral hemangiomatosis. Radiologists, endoscopists, and surgeons should consider this possibility in cases of repeated and fluctuating jaundice that cannot be explained by choledocholithiasis alone.

Advances in Risk Factors for Recurrence of Common Bile Duct Stones.

Choledocholithiasis is a chronic common disease. The incidence of cholelithiasis is 5%-15%, of which 5%-30% are combined with Choledocholithiasis. Although endoscopic cholangiopancreatography (ERCP) + endoscopic sphincterotomy (EST) is the most common treatment procedure, which clearance rate is up to 95%, the incidence of recurrent choledocholithiasis was 4%-25%. The risk factors of recurrence after choledocholithiasis clearance are the focuses of current researches, which are caused by multiple factors. We first systematically summarize the risk factors of common bile duct stones (CBDS) recurrence into five aspects: first-episode stone related factors, congenital factors, biological factors, behavioral intervention factors, and the numbers of stone recurrence.

Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the criterion standard for treating patients with symptomatic gallstone disease; however, the optimal technique for extracting common bile duct stones remains unclear. Recent studies have noted improved outcomes with single-stage techniques, such as intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and laparoscopic common bile duct exploration (LCBDE); however only few studies have directly compared those two single-stage techniques. OBJECTIVES: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we retrospectively analyzed the postoperative outcomes of all patients who underwent single-stage LC for choledocholithiasis from 2005 to 2017. Using Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) codes, we stratified patients into two cohorts: those who underwent iERCP and LCBDE. Applying univariate techniques, we evaluated baseline characteristics and postoperative outcomes for both cohorts. Our primary outcomes of interest were 30-day morbidity and 30-day mortality; our secondary outcomes included rates of reoperation, readmission, operative time, and hospital length of stay. RESULTS: Of the 1814 single-stage LC patients during our 13-year study period, 1185 (65.3%) underwent LCBDE; 629 (34.6%) underwent iERCP. Our univariate analysis showed that the two cohorts were homogeneous in terms of baseline characteristics, including demographics, preoperative comorbidities, laboratory values, and American Society of Anesthesiologists (ASA) scores. 30-day postoperative morbidity (including infectious and noninfectious complications) and overall mortality between groups were low and comparable. The mean operative time was slightly longer with LCBDE (125.1 ± 62.0 min) than iERCP (113.5 ± 65.2 min; P < 0.001), however the mean hospital length of stay, readmission rate, and reoperation rate were similar. CONCLUSION: We found that both iERCP and LCBDE resulted in low, comparable rates of morbidity and mortality. Centers with readily available endoscopic expertise might favor iERCP for its ease of access and shorter operative time. However, LCBDE remains an appropriate technique for patients with choledocholithiasis, especially when immediate endoscopic intervention is unavailable.

The efficacy of limited endoscopic sphincterotomy plus endoscopic papillary large balloon dilation for removal of large bile duct stones.

BACKGROUND: The removal of large bile duct stones (> 15 mm) by conventional endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD) can be challenging, requiring mechanical lithotripsy (ML) in addition to EST or EPBD. The primary complication of ML is basket and stone impaction, which can lead to complications such as pancreatitis and cholangitis. The present study aims to investigate the efficacy of limited EST plus endoscopic papillary large balloon dilation (EST-EPLBD) for large bile duct stone extraction with an extent of cutting < 1/2 the length of the papillary mound. METHODS: We enrolled 185 patients with ≥15 mm bile duct stones who received EST, EPLBD and limited EST-EPLBD treatment from January 1, 2010 to February 28, 2018, at Kaohsiung Chang Gung Memorial Hospital (Kaohsiung, Taiwan). All patients were categorized into three groups: EST group (n = 31), EPLBD group (n = 96), and limited EST-EPLBD group (n = 58). The primary outcome variables were the success rate of complete stone removal and complications. RESULTS: The limited EST-EPLBD group exhibited a higher success rate of the first-session treatment compared with the EST and EPLBD groups (98.3% vs. 83.9% vs. 86.5%; P = 0.032) but required a longer procedure time (32 (12-61) min vs. 23.5 (17-68) min vs. 25.0 (14-60) min; P = 0.001). The need for ML during the procedure was 4 (12.9%) in the EST group, 10 (10.4%) in the EPLBD group and 2 (3.4%) in the limited EST-EPLBD group. Post-procedure bleeding in the EST group was more common than that in the limited EST-EPLBD group (9.7% vs. 0%; P = 0.038). Furthermore, dilated bile duct was the only risk factor for bile duct stone recurrence in the limited EST-EPLBD group. CONCLUSIONS: Limited EST-EPLBD exhibits a higher success rate but requires marginally longer procedure time for the first-session treatment. Furthermore, dilated bile duct is the only risk factor for bile duct stone recurrence in patients undergoing limited EST-EPLBD.

Percutaneous transhepatic cholangioscopic lithotripsy using soft fiber-optic choledochoscope.

Many patients with intrahepatic cholelithiasis need surgical treatment during their life. For patients with hepatolithiasis, conventional therapy methods suggest partial hepatectomy or hepatic transplantation, while both kinds of surgery carry a considerable risk and trauma. Under such conditions, percutaneous transhepatic cholangioscopic lithotripsy provides an alternative method for hepatolithiasis treatment. Conventional rigid choledochoscope applied in percutaneous transhepatic cholangioscopic lithotripsy often lack sufficient flexibility for complete intrahepatic bile duct inspection. In this article, we report a case of one patient with complex hepatolithiasis and choledocholithiasis who received percutaneous transhepatic cholangioscopic lithotripsy using the newly-developed soft fiber-optic choledochoscope. This treatment represents a safe and effective outcome. We came to the conclusion that soft fiber-optic choledochoscope guided percutaneous transhepatic cholangioscopic lithotripsy seems a promising treatment option for selected patients with hepatolithiasis, especially for those who cannot accept conventional methods.

Loss of cellular FLICE-inhibitory protein promotes acute cholestatic liver injury and inflammation from bile duct ligation.

Cholestatic liver injury results from impaired bile flow or metabolism and promotes hepatic inflammation and fibrogenesis. Toxic bile acids that accumulate in cholestasis induce apoptosis and contribute to early cholestatic liver injury, which is amplified by accompanying inflammation. The aim of the current study was to evaluate the role of the antiapoptotic caspase 8-homolog cellular FLICE-inhibitory (cFLIP) protein during acute cholestatic liver injury. Transgenic mice exhibiting hepatocyte-specific deletion of cFLIP (cFLIP-/-) were used for in vivo and in vitro analysis of cholestatic liver injury using bile duct ligation (BDL) and the addition of bile acids ex vivo. Loss of cFLIP in hepatocytes promoted acute cholestatic liver injury early after BDL, which was characterized by a rapid release of proinflammatory and chemotactic cytokines (TNF, IL-6, IL-1ß, CCL2, CXCL1, and CXCL2), an increased presence of CD68+ macrophages and an influx of neutrophils in the liver, and resulting apoptotic and necrotic hepatocyte cell death. Mechanistically, liver injury in cFLIP-/- mice was aggravated by reactive oxygen species, and sustained activation of the JNK signaling pathway. In parallel, cytoprotective NF-κB p65, A20, and the MAPK p38 were inhibited. Increased injury in cFLIP-/- mice was accompanied by activation of hepatic stellate cells and profibrogenic regulators. The antagonistic caspase 8-homolog cFLIP is a critical regulator of acute, cholestatic liver injury. NEW & NOTEWORTHY The current paper explores the role of a classical modulator of hepatocellular apoptosis in early, cholestatic liver injury. These include activation of NF-κB and MAPK signaling, production of inflammatory cytokines, and recruitment of neutrophils in response to cholestasis. Because these signaling pathways are currently exploited in clinical trials for the treatment of nonalcoholic steatohepatitis and cirrhosis, the current data will help in the development of novel pharmacological options in these indications.

Pathological features of primary sclerosing cholangitis identified by bile proteomic analysis.

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown origin. Previous bile proteomic analyses in patients with PSC have revealed changes in disease activity specific to malignant transformation. In this study, we established a reference bile duct-derived bile proteome for PSC that can be used to evaluate biliary pathophysiology. Samples were collected from patients with PSC or with choledocholithiasis (control) (n=6 each). Furthermore, patients with PSC-associated cholangiocarcinoma (CC) and with CC without concomitant PSC were analyzed. None of the patients showed signs of inflammation or infection based on clinical and laboratory examinations. Proteins overexpressed in patients with PSC relative to control patients were detected by two-dimensional difference gel electrophoresis and identified by liquid chromatography-tandem mass spectrometry. Functional proteomic analysis was performed using STRING software. A total of 101 proteins were overexpressed in the bile fluid of patients with PSC but not in those of controls; the majority of these were predicted to be intracellular and related to the ribosomal and proteasomal pathways. On the other hand, 91 proteins were found only in the bile fluid of controls; most were derived from the extracellular space and were linked to cell adhesion, the complement system, and the coagulation cascade. In addition, proteins associated with inflammation and the innate immune response-e.g., cluster of differentiation 14, annexin-2, and components of the complement system-were upregulated in PSC. The most prominent pathways in PSC/CC-patients were inflammation associated cytokine and chemokine pathways, whereas in CC-patients the Wnt signaling pathway was upregulated. In PSC/CC-patients DIGE-analysis revealed biliary CD14 and Annexin-4 expression, among others, as the most prominent protein that discriminates between both cohorts. Thus, the bile-duct bile proteome of patients with PSC shows disease-specific changes associated with inflammation and the innate immune response even in the absence of obvious clinical signs of cholangitis, malignancy, or inflammation. This article is part of a Special Issue entitled: Cholangiocytes in Health and Diseaseedited by Jesus Banales, Marco Marzioni and Peter Jansen.

Effects of cholecystectomy on recurrent biliary complications after endoscopic treatment of common bile duct stone: a population-based cohort study.

BACKGROUND: The aim of this study was to evaluate the benefits of cholecystectomy on mitigating recurrent biliary complications following endoscopic treatment of common bile duct stone. METHODS: We used the data from the Taiwan National Health Insurance Research Database to conduct a population-based cohort study. Among 925 patients who received endoscopic treatment for choledocholithiasis at the first admission from 2005 to 2012, 422 received subsequent cholecystectomy and 503 had gallbladder (GB) left in situ. After propensity score matching with 1:1 ratio, the cumulative incidence of recurrent biliary complication and overall survival was analyzed with Cox's proportional hazards model. The primary endpoint of this study is recurrent biliary complications, which require intervention. RESULTS: After matching, 378 pairs of patients were identified with a median follow-up time of 53 (1-108) months. The recurrent rate of biliary complications was 8.20% in the cholecystectomy group and 24.87% in the GB in situ group (p < 0.001). In the multivariate Cox regression analysis, the only independent risk factor for recurrent biliary complications was GB left in situ (hazard ratio [HR] 3.55, 95% CI 2.36-5.33). CONCLUSIONS: Cholecystectomy after endoscopic treatment of common bile duct stone reduced the prevalence of recurrent biliary complications.

The Relationship between Age, Common Bile Duct Diameter and Diagnostic Probability in Suspected Choledocholithiasis.

BACKGROUND: Aging has been associated with increasing common bile duct (CBD) diameter and reported as independently predictive of the likelihood of choledocolithiasis. These associations are controversial with uncertain diagnostic utility in patients presenting with symptomatic disease. The current study examined the relationship between age, CBD size, and the diagnostic probability of choledocolithiasis. METHODS: Symptomatic patients undergoing evaluation for suspected choledocolithiasis from January 2008 to February 2011 were reviewed. In the cohort without choledocolithiasis, the relationship between aging and CBD size was examined as a continuous variable and by comparing mean CBD size across stratified age groups. Multivariate analysis examined the relationship between increasing age and diagnostic probability of choledocolithiasis in all patients. RESULTS: Choledocolithasis was diagnosed by MR cholangiopancreatography (MRCP) or endoscopic retrograde (ERCP) in 496 of 1,000 patients reviewed. Mean CBD was 6.0 mm (±2.8 mm) in the 504 of 1,000 patients without choledocolithiasis on ERCP/MRCP. Increasing age had no correlation with CBD size as a continuous variable (r2 = 0.011, p = 0.811). No difference occurred across age groups (Kruskal-Wallis, p = 0.157). Age had no association with diagnostic likelihood of choledocolithiasis (AOR [95% CI] 0.99 [0.98-1.01], adjusted-p = 0.335). CONCLUSION: In a large population undergoing investigation for biliary disease, increasing age was neither associated with increasing CBD diameter nor predictive of the likelihood of choledocolithiasis.

[THE RISK OF CHOLANGITIS OCCURRENCE AFTER ENDOSCOPIC INTERVENTIONS ON PAPILLA MAGNA OF DUODENUM].

Results of treatment of 72 patients, suffering choledocholithiasis, using transpapillary endoscopic interventions, were analyzed. In patients of the first group a complete endoscopic papillosphincterotomy was performed, and in the second group ­ a partial endoscopic papillosphincterotomy in combination with balloon dilatation of duodenal papilla magna. The rate of occurrence of late and immediate complications in the groups was compared.

[BALLOON DILATATION IN COMBINATION WITH A DOSED PAPILLOTOMY IN THE TREATMENT OF DIFFICULT FORMS OF CHOLEDOCHOLITHIASIS].

Results of treatment was studied in 2008 - 2015 yrs in 57 patients, suffering "difficult stones" (choledocholithiasis), in whom a dosed papillotomy in combination with the balloon dilatation. The advantages of application of combined dosed endoscopic papillosphincterotomy and balloon dilatation, comparing with complete endoscopic papillosphincterotomy, while treating "difficult stones" of common biliary duct, were established. Application of the procedure have guaranteed a good access through the duodenal papilla magna and have permitted to perform the calculi extraction in a less traumatic way, what have promoted its function preservation, and reduction of a postoperative complications rate, the patients' stationary treatment duration, and the remote complications rate. Using questionnaire SF-36, the quality of life was analyzed in patients, in whom in remote period the duodenal papilla magna function was preserved.

[SURGICAL TREATMENT OF ACUTE CHOLANGITIS IN CHOLEDOCHOLITHIASIS].

The results of surgical treatment of 184 patients for obstructive jaundice and an acute cholangitis in choledocholithiasis were analyzed. Acute cholangitis was diagnosed in 62 (33.7%) patients. Sensitivity of a Tokyo Guidelines (2013)--TG 13 criteria for diagnosis and estimation of the course severity of an acute cholangitis was studied. Dynamics of postoperative laboratory parameters was studied. There was established, that occurrence of obturation jaundice and cholangitis coincides with pronounced hepatic function disorders, which are preserved after a bile outflow restoration also, and changes in peripheral blood. Severity of inflammatory reaction reflects hematological indices, the most informative of which is an intoxication index.

[POSSIBILITY OF ENHANCING OF THE TRANSPAPILLARY INTERVENTIONS EFFICACY, APPLYING OPTIMIZATION OF THEIR ANESTHESIOLOGICAL SUPPORT].

In 2015 yr еndoscopic transpapillary interventions (ЕТI), performed for diseases of the hepatopancreatoduodenal zone organs, were done in 697 patients. In 315 (45.2%) of them ЕТI were diagnostic, in 382 (54.8%) ­ performed with treatment objective. Меdicinal support for the ЕТI conduction in 631 (90.5%) patients have included conduction of superficial sedation and local anesthesia of pharynx. Аnesthesiological support was applied in 66 (9.5%) patients, including total intravenous anesthesia ­ in 11 (16.6%), еndotracheal narcosis ­ in 55 (83.4%). Using of general anesthesia in comparison to superficial sedation creates more favorable conditions for the ЕТI performance, what have permitted to reduce their duration and complications rate twice.

[MORPHOLOGICAL CHANGES OF THE LIVER IN OBTURATION JAUNDICE, CAUSED BY CHOLEDOCHOLITHIASIS, DEPENDING ON ITS DURATION].

Abstract The results of surgical treatment of 184 patients for obturation jaundice, caused by choledocholithiasis, were analyzed. Morphological changes of the liver were studied in 20 patients. There were three groups of patients delineated, depending on the obturation jaundice duration: up to 7 days, from 8 to 14 days, more than 15 days, and also a group of patients after the bile outflow restoration. The obturation jaundice occurrence in choledocholithiasis is accompanied by significant morphological changes in the liver, severity of which is enhancing while the obturation jaundice persistence increasing. While persistence of obturation jaundice through 8 days and more the connective tissue volume is enhancing, a relative volume of hepatocytes is reducing and a stromal-parenchymatous index is increasing. The bile outflow restoration secures significant reduction of intensity of alterative and inflammatory changes in hepatic parenchyma, as well as activation of reparative processes in the tissue. In cholangitis, caused by P. aeruginosa and E. coli, according to morphological investigations data, in the liver a diffuse purulent cholangitis on background of chronic changes in accordance to duration of the obturation jaundice persists.

[IMPACT OF RONCOLEUKIN ON BALANCE OF CYTOKINS IN COMPLEX TREATMENT OF OBTURATION JAUNDICE OF NONTUMORAL GENESIS].

The results of surgical treatment of 137 patients, suffering obturation jaundice of non-tumoral etiology, were analyzed. In all the patients the cause of obturation jaundice was choledocholithiasis. Roncoleukin was infused intravenously additionally in a complex of therapy. A degree of hepatic dysfunction was determined, taking into account the cholestasis markers. In 23 patients purulent cholangitis have occurred on background of obturation jaundice. Concentration of cytokins TNF-α, IFN-γ, IL-1, IL-2, IL-4, IL-6, IL-10 in sera were determined, using immunoassay analysis. The cytokins dysbalance severity preoperatively and dynamics of its changes have depended upon the hepatic dysbalance degree and presence of purulent cholangitis; a dysbalance is deeper, when the hepatic dysfunction is higher. Application of pathogenetically substantiated purposeful cytokinotherapy, including roncoleukin, have promoted the cytokins dysbalance elimination and improvement of the patients treatment results.

[COMBINATION OF LAPAROLIFTING WITH DOSATED CARBOXYPNEUMOPERITONEUM WHILE PERFORMANCE OF MINIINVASIVE INTERVENTIONS FOR BILIARY CALCULOUS DISEASE].

Comparative analysis of the treatment results in 97 patients for biliary calculous disease, complicated by choledocholithiasis, using the stressed standard carboxyperitoneum method (12 mm Hg) and the dosed one lift-assisted carboxyperitoneum (4 - 6 mm Hg), was conducted. Perioperative indices of hemodynamics arid postoperative pain syndrome severity were considered the criterions of the stressor-like and the damaging action. The results obtained witness trustworthy a more safe effect of the method of the labor space creation.

[TRANSPAPILLARY INTERVENTIONS FOR AN ACUTE PANCREATITIS].

Experience of the endoscopic retrograde pancreatocholangiography performance in emergency (in 4-6 h after admittance to hospital) in 513 patients with suggestion for biliary acute pancreatitis (AP) presence was adduced. In 451 (87.9%) patients preliminary diagnosis was confirmed: in 402 (89.1%)--calculous cholecystitis, complicated by choledocholithiasis, was revealed, in 49 (10.9%)--residual choledocholithiasis. Establishment of biliary genesis of an AP assumes performance of endoscopic papillosphincterotomy and choledocholithextraction. Biliary causes of an AP were excluded in 62 (12.1%) patients, in 34 (54.8%) of them characteristic changes in duodenum were revealed, in 13 (21.0%)--destructive changes of pancreatic ductal system. While diagnosis of an AP of nonbiliary origin a conservative tactics of treatment was selected.

[MICROBIAL LANDSCAPE OF BILE IN PATIENTS WITH AN ACUTE PURULENT CHOLANGITIS].

Bacteriological analysis was conducted in 136 patients with an acute purulent cholangitis (APCH). The APCH causes were: choledocholithiasis--in 40 (29.9%) patients, coexistence of a common biliary duct stricture and choledocholithiasis--in 39 (28.7%), compression of external biliary ducts by the oedematous pancreatic head in secondary pancreatitis--in 15 (11%), pericholedocheal lymphadenitis--in 3 (2.2%).

[CLINIC-EXPERIMENTAL SUBSTANTIATION OF OZONOTHERAPY APPLICATION IN THE TREATMENT OF PURULENT CHOLANGITIS AND OBTURATION JAUNDICE].

Efficacy of the ozonotherapy application as an important component of complex treatment in purulent cholangitis (PCH) was studied. In choledocholithiasis (without infectioning of bile) ozonotherapy may be prescribed as additional component at complex treatment. In PCH ozonotherapy application have promoted the improvement of laboratory indices in 6.6 times, comparing with such, occurring after basic therapy.