Comparison of the clinical effects of dual-modality endoscopy and traditional laparotomy for the treatment of intra-and extrahepatic bile duct stones

BACKGROUND Bile duct stones(BDSs)may cause patients to develop liver cirrhosis or even liver cancer.Currently,the success rate of surgical treatment for intrahepatic and extrahepatic BDSs is not satisfactory,and there is a risk of postoperative complic-ations.AIM To compare the clinical effects of dual-modality endoscopy(duodenoscopy and laparoscopy)with those of traditional laparotomy in the treatment of intra-and extrahepatic BDSs.METHODS Ninety-five patients with intra-and extrahepatic BDSs who sought medical services at Wuhan No.1 Hospital between August 2019 and May 2023 were selected;45 patients in the control group were treated by traditional laparotomy,and 50 patients in the research group were treated by dual-modality endoscopy.The following factors were collected for analysis:curative effects,safety(incision infection,biliary fistula,lung infection,hemobilia),surgical factors[surgery time,intraoperative blood loss(IBL)volume,gastrointestinal function recovery time,and length of hospital stay],serum inflammatory markers[tumor necrosis factor(TNF)-α,interleukin(IL)-6,and IL-8],and oxidative stress[glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),malondialdehyde(MDA),and advanced protein oxidation products(AOPPs)].RESULTS The analysis revealed markedly better efficacy(an obviously higher total effective rate)in the research group than in the control group.In addition,an evidently lower postoperative complication rate,shorter surgical duration,gastrointestinal function recovery time and hospital stay,and lower IBL volume were observed in the research group.Furthermore,the posttreatment serum inflammatory marker(TNF-α,IL-6,and IL-8)levels were significantly lower in the research group than in the control group.Compared with those in the control group,the posttreatment GSH-Px,SOD,MDA and AOPPs in the research group were equivalent to the pretreatment levels;for example,the GSH-Px and SOD levels were significantly higher,while the MDA and AOPP levels were lower.CONCLUSION Dual-modality endoscopy therapy(duodenoscopy and laparoscopy)is more effective than traditional laparotomy in the treatment of intra-and extrahepatic BDSs and has a lower risk of postoperative complications;significantly shortened surgical time;shorter gastrointestinal function recovery time;shorter hospital stay;and lower intraop-erative bleeding volume,while having a significant inhibitory effect on excessive serum inflammation and causing little postoperative oxidative stress.

Laparoscopic cholecystectomy plus common bile duct exploration for extrahepatic bile duct stones and postoperative recurrenceassociated risk factors

BACKGROUND There remain controversies regarding the surgical treatment of extrahepatic bile duct stones(EHBDSs)in clinical practice.AIM To explore the curative effect of laparoscopic cholecystectomy(LC)plus common bile duct exploration(CBDE)for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.METHODS Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected.Among them,patients treated with open choledocholithotomy plus LC or open cholecystectomy(OC)were set as the control group(n=40),and those treated with LC plus CBDE served as the observation group(n=42).The surgical outcomes of the two groups were compared,the surgical complications and Gas-trointestinal Quality of Life Index(GIQLI)scores were counted,and the one-year prognostic recurrence was recorded.Independent factors for postoperative re-currence were determined using univariate and multivariate analyses.RESULTS The two groups were comparable in the stone residual rate(P>0.05).The ope-ration time(P<0.05),intraoperative bleeding(P<0.05),and total complication rate(P=0.005)were lower in the observation group than in the control group.The observation group exhibited a marked increase in the GIQLI score,which was higher than the control group(P<0.05).A lower one-year recurrence rate was determined in the observation group vs the control group(P=0.027).Sphincter of Oddi dysfunction[odds ratio(OR)=5.712,P=0.007]and the treatment scheme of open choledocholithotomy plus LC or OC(OR=6.771,P=0.008)were the independent risk factors for one-year recurrence in patients after surgery.CONCLUSION LC plus CBDE for patients with EHBDSs can reduce stone residuals,intraoperative bleeding,complications,and postoperative recurrence.

Nursing Effect of Rapid Rehabilitation Surgery Concept in Laparoscopic Surgery for Extrahepatic Bile Duct Stones

Objective: To explore the application value of rapid rehabilitation concept in patients with extrahepatic bile duct stones under laparoscopy during perioperative period. Methods: 90 patients with extrahepatic bile duct stones treated in our hospital from January 2022 to February 2023 were selected as the research object and randomly divided into the study group and the control group. The control group was given routine care, and the observation group was given rapid surgical rehabilitation care. The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time, hospitalization time and complication rate were compared between the two groups. The independent sample T test was used for the measurement data, and the x2 test was used for the counting data, and the difference was statistically significant (P Results: The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time and hospitalization time in the study group were shorter than those in the control group (all P Conclusion: The concept of rapid rehabilitation can significantly improve the perioperative nursing effect of patients with extrahepatic bile duct stones and accelerate their rehabilitation, which is worth improving and popularizing.

Correlation of glycosyltransferases mRNA expression in extrahepatic bile duct carcinoma with clinical pathological characteristics

BACKGROUND: The incidence of extrahepatic bile duct carcinoma (EBDC) has been increasing, especially in aged people, but the glycobiology of the tumor is not elucida- ted. In this study we investigated the expressions of three glycosyltransferases in 35 patients with EBDC and 35 pa- tients with benign biliary duct disease (BBDD) as well as their clinicopathological significance. METHOD: The patients were divided into several sub- groups by tumor differentiation, TNM stage, and invasion by the standards recommended by UICC. Tumor samples were immediately frozen in liquid nitrogen after resection, followed by mRNA determination of enzymes in the tissue using a mRNA selective reverse trancriptase-polymerase chain reaction kit. The mRNA levels of different groups were semi-quantitatively compared. RESULTS: The mRNA levels of N-acetylglucosaminyltrans- ferase V (GnT-V) and a subtype of α2,3 sialyltransferases for N-glycans, ST3Gal- were elevated 7.75 and 5.39 times in EBDC as compared with BBDD, respectively, and they were correlated to several clinicopathological factors including tumor advancement, differentiation, metastasis, and invasiveness. The mRNA expression of another sialyl- transferase, ST6Gal- , was also 0.63-fold higher in EBDC than in BBDD, but not involved in the clinicopathological characteristics. CONCLUSION: The elevated expression of these three gly- cosyltransferases can be considered as an important molecu- lar event in the occurrence and progression of EBDC.

Classifying extrahepatic bile duct metachronous carcinoma by de novo neoplasia site

Extrahepatic bile duct(EHBD)cancer may occur metachronously,and these cancers are resectable with a favorable prognosis.We aimed to identify the pattern of metachronous EHBD cancer.We classified the cases of metachronous EHBD cancer reported in the literature thus far and investigated two new cases of metachronous EHBD cancer.A 70-year-old female underwent R0 bile duct resection for a type 1 Klatskin tumor(pT-1N0M0).A 70-year-old male patient underwent R0 bile duct resection for a middle bile duct cancer(pT2N1M0).Imaging studies of both patients taken at 14 and 24mo after first surgery respectively revealed a metachronous cholangiocarcinoma that required pancreaticoduodenectomy(PD).Histopathology of the both tumors after PD revealed cholangiocarcinoma invading the pancreas(pT3N0M0).Both patients have been free from recurrence for 6 years and 16 mo respectively after the second surgery.Through a review of the literature on these cases,we classified the pattern of metachronous EHBD cancer according to the site of de novo neoplasia.The proximal remnant bile duct was most commonly involved.Metachronous EHBD cancer should be distinguished from an unresectable recurrent tumor.Classifying metachronous EHBD cancer may be helpful in identifying rare metachronous tumors.

Hepatitis C and B Virus Infection in Chinese Patients with Extrahepatic Bile Duct Carcinoma

Objective In China, the incidence of extrahepatic bile duct carcinoma (EBDC) tends to increase over the past decades. The etiology of the noted increase in EBDC is not identified. Approximately, in a half of the overall Chinese patients with EBDC, the causative factors in the development of EBDC have not been demonstrated.There is a high prevalence of hepatitis C virus (HCV) or hepatitis B virus (HBV) in China, both of which can induce malignant transformation of infected cells and strongly associated with hepatocellular carcinoma (HCC). In this study, EBDC tissues from Chinese patients were examined for the presence of HCV and HBV infection to investigate further the potential causes of EBDC.Methods HCV NS5 protein and HBsAg were detected by labeled streptavidin biotin (LSAB) method; HCV RNA and HBV DNA were detected by in situ polymerase chain reaction (IS-PCR) in formalin fixed, paraffin embedded specimens from 51 Chinese patients with EBDC. HCV RNA and HBV DNA were detected by IS-PCR in 34 Chinese patients with specimens of benign lesions of hepatobiliary tract (control group) .Results In 51 case tissue sections of EBDC, NS5 protein was detected in 14 (27.5%), and HBsAg in 5 (9.8%), HCV RNA in 18 (35.4%) and HBV DNA in 8 (15.9%) .respectively, of which HCV and HBV co-infection was detected in 2 (3.9%). In 34 case tissue sections of the control group, HCV RNA was detected in 2 (5.9 % ), and HBV DNA in 3 (8.8%).Conclusion In this study using standard histochemical and PCR techniques, HCV and HBV genomes and their encoding proteins were detected in the tissues of EBDC. The data show that there is a higher than expected incidence of HCV and HBV presence in EBDC tissues than would be expected on serologic grounds. The detectable rate of HCV RNA in EBDC tissues was significantly higher than in control group (x2 = 9.808, P = 0.002). As a result, this study indicates that there is a correlation between the presence of HCV infection and EBDC, and HCV infection has possible etiologic significance in the development of EBDC in China. While HBV DNA was detected in EBDC tissues with the difference in the detectable rate of HBV, DNA being not significance between EBDC tissues and the control group (x2 = 0.853, P = 0.356) . Further research is necessary to determine the presence of a causal relationship between HCV/HBV infection and the development of EBDC.

Intraductal ultrasonography and endoscopic retrograde cholangiography in diagnosis of extrahepatic bile duct stones: a comparative study

BACKGROUND: Intraductal ultrasonography (IDUS) is highly accurate in detection of extrahepatic bile duct stones. This study was to compare the accuracy of IDUS and endo- scopic retrograde cholangiography (ERC) in the diagnosis of extrahepatic bile duct stones. METHODS: Thirty patients suspected of extrahepatic bile duct stones on B ultrasonography, CT, or MRI were en- rolled for study. ERC was performed using a Fujinon duo- denoscope (ED-410XT, ED-410Xu), then IDUS was done by inserting a Fujinon microprobe (PL2220-15) through the endoscopic biopsy channel to detect the extrahepatic bile duct. Finally stones in the extrahepatic bile duct were detected and extracted by endoscopic sphincterotomy (EST). RESULTS: Among the 30 patients, 26 were diagnosed as having cholelithiasis accurately through ERC. In one pa- tient the stone detected by ERC was really floccule. Mis- diagnosis happened in 2 patients with extrahepatic bile duct stones. So the overall accuracy and sensitivity of ERC in the diagnosis of extrahepatic bile duct stones were 86.7% (26/30) and 92.9% (26/28) respectively. In contrast, IDUS showed the results of diagnosis were in consistent with those of EST stone extraction. Its accuracy and sensi- tivity in the diagnosis of extrahepatic bile duct stones were 100% (30/30) and 100% (28/28) respectively. CONCLUSION: IDUS which is superior to ERC in diagno- sing extrahepatic bile duct stones can avoid the visual error of ERC.

Primary signet-ring cell carcinoma of the extrahepatic bile duct:A case report

BACKGROUND Signet ring cell carcinoma(SRCC)is a specific type of mucinous secretory adenocarcinoma,which contains abundant mucus in the cytoplasm and pushes the nucleus to one side of the cell membrane,forming a round or oval,and the nuclear deviations give the cells a signet ring-like appearance.SRCC often originates in the gastrointestinal tract,especially in the stomach.However,primary SRCC of the extrahepatic bile duct is extremely rare.Therefore,little is known about its epidemiology,treatment,and prognosis.CASE SUMMARY An 82-year-old female was admitted with abdominal pain,jaundice,and skin pruritus for 2 mo.She had no specific family history.Physical examination presented normal vital signs,icteric sclera,visible jaundice,and mild tenderness in the right upper abdominal quadrant.Tumor-related cell markers were within normal values.Contrast-enhanced computed tomography revealed a thickened wall of the common bile duct,strengthened with intrahepatic bile duct dilation and multiple round-like lesions in the liver.In addition,the lymph nodes in the hepatic hilum area,the pancreatic head area,and around the abdominal aorta were enlarged.Thus,a preoperative diagnosis of cholangiocarcinoma was established.To alleviate jaundice and prolong the overall survival,percutaneous transhepatic cholangiopancreatic drainage(PTCD)was performed.During the operation,segmental stenosis of the extrahepatic bile duct and a vine-like expansion of the intrahepatic bile duct was observed.Furthermore,a biliary biopsy was performed under fluoroscopy to determine the nature and origin of the lesion.The pathological diagnosis of the biopsy was SRCC.Finally,a diagnosis of primary SRCC of extrahepatic bile duct with distant lymph node metastasis and multiple liver metastases was made based on the radiographic,PTCD,and pathological characteristics.The tumor was diagnosed as T3N1M1 stage IV.Despite our aggressive approach,the patient died of liver failure after 1 mo.CONCLUSION This is the only case report on primary SRCC of the extrahepatic bile duct with distant organ metastasis to date.

Investigation on Hepatitis C and B Virus Infection in Carcinoma of the extrahepatic bile duct in CHINA

Objective: The incidence of carcinoma of extrahepatic bile duct tends to increase during recent decade in China, but its cause is unclear. This study is to investigate the hepatitis C virus (HCV) and Hepatitis B virus (HBV) infection in the tissues of carcinoma of extrahepatic bile duct and study their correlation. Methods: HCV RNA and HBV DNA was detected by in situ polymerase chain reaction (IS-PCR) in sections of 51 cases of carcinoma of extrahepatic bile duct and 34 cases of control group. Results: Of 51 carcinoma of extrahepatic bile duct, HCV RNA was detected in 18 (35.4%), HBV DNA in 8 (15.9%). In 34 cases of control group, HCV RNA was detected in 2 (5.9%), and HBV DNA in 3 (8.8%). Conclusion:The prevalence of hepatitis C and B viralinfection in the tissues of carcinoma of extrahepatic bile duct was significantly higher than in control group. The findings suggest a correlation between HCV, HBV infection and carcinoma of extrahepatic bile duct, inferring HCV and HBV might be involved in the development of carcinoma of extrahepatic bile duct.

Undifferentiated high-grade pleomorphic sarcoma of the common bile duct:A case report and review of literature

BACKGROUND Undifferentiated pleomorphic sarcoma(UPS)is a rare malignant mesenchymal tumor with a poor prognosis.It mainly occurs in the extremities,trunk,head and neck,and retroperitoneum regions.Owing to the lack of specific clinical manifestations and imaging features,UPS diagnosis mainly depends on pathological and immunohistochemical examinations for exclusive diagnosis.Here we report an extremely rare case of high-grade UPS in the common bile duct(CBD).There are limited available data on such cases.CASE SUMMARY A 70-year-old woman was admitted to our department with yellow eyes and urine accompanied by upper abdominal distending pain for 2 wk.Her laboratory data suggested significantly elevated hepatorenal function levels.The imaging data revealed calculous cholecystitis,intrahepatic and extrahepatic bile duct dilation with extrahepatic bile duct calculi,and a space-occupying lesion at the distal CBD.After endoscopic biliary stenting and symptomatic support therapy,CBD exploration and biopsy were performed.The frozen section indicated malignant spindle cell tumor of the CBD mass,and further radical pancreaticoduodenectomy was performed.Finally,the neoplasm was diagnosed as a high-grade UPS combined with the light-microscopic morphology and immunohistochemical results.CONCLUSION This extremely rare case highlighted the need for increasing physicians'vigilance,reducing the odds of misdiagnosis,and providing appropriate treatment strategies.

Study of Relationship Between the Blood Supply of the Extrahepatic Bile Duct and Duct Supply Branches from Gastroduodenal Artery on Imaging and Anatomy

Background： Liver transplantation has become the treatment of choice for patients with end-stage acute or chronic hepatic disease. Bile duct complications are common events after liver transplantation. The aim of this study was to evaluate the blood supply of the human bile duct and identify the underlying mechanisms of bile duct complications after liver transplantation. Methods： The duct supply branches from gastroduodenal artery and blood supply of extrahepatic bile duct system were re-evaluated through selective hepatic angiography from 600 patients. In addition, 33 cadavers were injected with latex casting material into the common hepatic artery, then the extrahepatic bile duct and the branches from the common hepatic artery were carefully dissected to visualize the gastroduodenal artery and its branching to the extrahepatic bile duct. Results： The bile duct artery arose from the branch of the gastroduodenal artery in 8.1% （49/600）. Of these 49 individuals, the bile duct artery was supplied by the gastroduodenal artery （61.22%, 30/49）, the proper hepatic artery （14.29%, 7/49）, or both the gastroduodenal artery and the proper hepatic artery （24.49%, 12/49）. In our study of 33 cadavers, the percentage that the bile duct artery arose from the gastroduodenal artery was 27.27%. The blood supply to the bile extrahepatic bile ducts was divided into different segments and formed longitudinal and arterial network anastomosed on the walls of the duct. Conclusions： There is a close relationship between the duct supply branches from gastroduodenal artery and the blood supplying patterns of the extrahepatic bile duct system. In liver transplant surgery, the initial part of the gastroduodenal artery is preferred to be preserved in the donor liver. It is of great significance to improve the success rate of operation and reduce complications.

Current surgical treatment for bile duct cancer

Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy （PD）, plus extrahepatic bile duct resection and regional lyrnphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD （hepatopancreatoduodenectomy） has been applied to selected patients with widespread tumors. Preoperative biliary drainage （BD） followed by portal vein embolization （PVE） enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.

Successful endoscopic treatment of an intraductal papillary neoplasm of the bile duct

We present a case of a 76-year-old man with right upper quadrant abdominal pain and weight loss,who was found to have an intraductal papillary neoplasm of the bile duct(IPNB)of the pancreaticobiliary subtype,deemed curatively resectable.The patient declined surgery and opted for endoscopic therapy.He underwent two sessions of endoscopic retrograde cholangiopancreatography(ERCP)-guided radiofrequency ablation(RFA).Ten months later,no evidence of recurrence was identified on repeat ERCP.To our knowledge,this is the first reported case of successful use of RFA as a primary treatment modality for resectable IPNB.

Prognostic factors in patients with middle and distal bile duct cancers

AIM: To identify the influence of the surgery type and prognostic factors in middle and distal bile duct cancers.

Carcinosarcoma of common bile duct:A case report

BACKGROUND Carcinosarcomas of the common bile duct(CBD)are an extremely rare finding in the clinical setting.Based on a review of 12 literatures,3 cases had the imaging features of ossification.Carcinosarcomas are prone to distant metastasis,as they possess clinical features of both carcinoma and sarcoma,and generally have with a poor prognosis.Due to the small number of cases reported,clinical experience in the diagnosis and treatment of the disease is lacking.CASE SUMMARY The patient was a 75-year-old woman who had experienced recurrent chills with nausea and vomiting for 3 mo.Computed tomography,magnetic resonance imaging,endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography led to the diagnosis of malignant tumor of the CBD.The patient ultimately underwent cholecystectomy,CBD resection,and choledochojejunostomy.Postoperative pathological examination revealed carcinosarcoma of the CBD,and the latest follow-up showed that the patient is recovering well.Based on previous case reports,some carcinosarcoma has ossification characteristics in imaging.If it is misdiagnosed as biliary calculi,the use of laser lithotripsy in surgery may lead to tumor diffusion.Choledochoscopy and narrow band staining of mucosa are very important for diagnosis.CONCLUSION We herein present a rare case of carcinosarcomas of the CBD,we found the tumours may have imaging features of polypoid growth and ossification only when the sarcomal components are bone differentiation,while show soft tissue shadow when non bone differentiation.Confirmation of diagnosis depends greatly upon postoperative pathological examination and the adjuvant treatment has not been established,which leads to the poor prognosis.

Neuroendocrine carcinoma of the common hepatic duct coexisting with distal cholangiocarcinoma:A case report and review of literature

BACKGROUND Neuroendocrine carcinoma(NEC)of the extrahepatic bile duct is very rare,and the treatment and prognosis are unclear.Herein,we report the case of a middleaged female with primary large cell NEC(LCNEC)of the common hepatic duct combined with distal cholangiocarcinoma(dCCA).Additionally,after a review of the relevant literature,we summarize and compare mixed neuroendocrine-nonneuroendocrine neoplasm(MiNEN)and pure NEC to provide a reference for selecting the appropriate treatment and predicting the prognosis of this rare disease.CASE SUMMARY A 62-year-old female presented to the hospital due to recurrent abdominal pain for 2 months.Physical examination showed mild tenderness in the upper abdomen and a positive Courvoisier sign.Blood tests showed elevated liver transaminase and carbohydrate antigen 199 levels.Imaging examination revealed node dissection was performed,and hepatic duct tumours were unexpectedly found during surgery.Pathology suggested poorly differentiated LCNEC(approximately 0.5 cm×0.5 cm×0.4 cm),Ki-67(50%),synaptophysin+,and chromogranin A+.dCCA pathology suggested moderately differentiated adenocarcinoma.The patient eventually developed lymph node metastasis in the liver,bone,peritoneum,and abdominal cavity and died 24 months after surgery.Gene sequencing methods were used to compare gene mutations in the two primary bile duct tumours.CONCLUSION The prognosis of MiNEN and pure NEC alone is different,and the selection of treatment options needs to be differentiated.

Biliary cystadenoma

The diagnosis of cystadenoma is rare, even more so when located in the extrahepatic bile duct. Unspecific clinical signs may lead this pathology to be misdiagnosed. The need for pathological anatomy in order to distinguish cystadenomas from simple biliary cysts is crucial. The most usual treatment nowadays is resection of the bile duct, together with cholecystectomy and Roux-en-Y reconstruction.

Surgical treatment of gallbladder cancer:An eight-year experience in a single center

BACKGROUND Gallbladder cancer(GBC)is the most common biliary malignancy and has the worst prognosis,but aggressive surgeries[e.g.,resection of the extrahepatic bile duct(EHBD),major hepatectomy and lymph node(LN)dissection]may improve long-term survival.GBC may be suspected preoperatively,identified intraoperatively,or discovered incidentally on histopathology.AIM To present our data together with a discussion of the therapeutic strategies for GBC.METHODS We retrospectively investigated nineteen GBC patients who underwent surgical treatment.RESULTS Nearly all symptomatic patients had poor outcomes,while suspicious or incidental GBCs at early stages showed excellent outcomes without the need for two-stage surgery.Lymph nodes around the cystic duct were reliable sentinel nodes in suspicious/incidental GBCs.Intentional LN dissection and EHBD resection prevented metastases or recurrence in early-stage GBCs but not in advanced GBCs with metastatic LNs or invasion of the nerve plexus.All patients with positive surgical margins(e.g.,the biliary cut surface)showed poor outcomes.Hepatectomies were performed in sixteen patients,nearly all of which were minor hepatectomies.Metastases were observed in the left-sided liver but not in the caudate lobe.We may need to reconsider the indications for major hepatectomy,minimizing its use except when it is required to accomplish negative bile duct margins.Only a few patients received neoadjuvant or adjuvant chemoradiation.There were significant differences in overall and disease-free survival between patients with stages≤IIB and≥IIIA disease.The median overall survival and disease-free survival were 1.66 and 0.79 years,respectively.CONCLUSION Outcomes for GBC patients remain unacceptable,and improved therapeutic strategies,including neoadjuvant chemotherapy,optimal surgery and adjuvant chemotherapy,should be considered for patients with advanced GBCs.

The right hepatic artery syndrome

Various benign and malignant conditions could cause biliary obstruction. Compression of extrahepatic bile duct (EBD) by right hepatic artery was reported as a right hepatic artery syndrome but all cases were compressed EBD from stomach side. Our case compressed from dorsum was not yet reported, so it was thought to be a very rare case. We present here the first case of bile duct obstruction due to the compression of EBD from dorsum by right hepatic artery.

Therapeutic Mechanisms of Single Chinese Medicine Herb or Their Extracts for Extrahepatic Obstructive Jaundice

Obstructive jaundice （O J） is classified as extrahepatic OJ or intrahepatic OJ. Extrahepatic OJ is attributed to a variety of intricate etiological factors. Research has begun with Chinese medicine （CM）, which can be used as an adjunctive therapy for extrahepatic OJ. Particular attention has been paid to the therapeutic effects and their mechanisms of single CM herb and relevant extracts. The roles of single CM or their extracts during adjunctive therapy for extrahepatic OJ have been described briefly, This review focuses on the effects and their mechanisms of relevant herbal medicines.