Objectives: To investigate the effect of gemcitabine plus cisplatin (GC) chemotherapy combined with immunotherapy in patients with unresectable intrahepatic cholangiocarcinoma (ICC) and its prognostic factors. Methods: This is a retrospective case series study. Data of 387 consecutive treatment-naive patients with unresectable ICC admitted to the Third Affiliated Hospital of Naval Medical University (Eastern Hepatobiliary Surgery Hospital from May 2022 to May 2025 were retrospectively collected. All patients received GC regimen chemotherapy combined with immune checkpoint inhibitors. There were 260 males (67.2%) and 127 females (32.8%); the age was (54.4±10.3) years (range: 23 to 82 years). The primary study endpoints were overall survival (OS) time and progression-free survival (PFS) time, and the secondary endpoints were antitumor effects and adverse reactions. Intergroup comparisons were performed using independent sample t-test, Mann-Whitney U test, χ² test, or Fisher's exact probability method. The propensity score matching method was used to match the surgical patients and the non-surgical patients in a 1∶2 ratio, with a caliper value of 0.02. OS and PFS curves were plotted by Kaplan-Meier method, and prognostic factors for OS and PFS were analyzed using univariate and multivariate Cox regression models. Results: Among all patients,the final surgical conversion rate was 8.8% (34/387) and objective response rate was 36.2% (140/387), the median overall survival (mOS) time was 16.67 months (95%CI: 14.80 to 17.79),and the median progression-free survival (mPFS) time was 8.22 months (95%CI: 7.53 to 8.95). The survival time of the surgery group was better than that of the non-surgery group (mOS time: 22.86 months vs. 15.65 months, P=0.038; mPFS time: 13.68 months vs. 7.96 months, P=0.001). The overall incidence of adverse reactions was 98.4%, and the grade Ⅲ to Ⅳ adverse reaction rate was 72.4%. Univariate and multivariate analyses revealed that surgical intervention (HR=0.447, 95%CI: 0.219 to 0.909, P=0.026; HR=0.460, 95%CI: 0.265 to 0.796, P=0.006) was an independent protective factor for OS and PFS. After propensity score matching, multivariate analysis results further demonstrated that surgical intervention(HR=0.211, 95%CI: 0.095 to 0.467, P<0.01; HR=0.254, 95%CI: 0.132 to 0.487, P<0.01) remained an independent protective factor for OS and PFS. Conclusions: Chemotherapy combined with immunotherapy, as a first-line treatment regimen for patients with advanced ICC, has good antitumor effects and can improve patient prognosis without causing serious new adverse reactions. For patients who can undergo surgical resection after conversion and downstaging, radical surgical resection can improve prognosis compared to continuing systemic therapy.

Objective: To investigate risk factors for postoperative lymph node metastasis in patients with intrahepatic cholangiocarcinoma (ICC) after curative resection. Methods: This retrospective case-series study consecutively enrolled 230 patients who underwent initial curative hepatectomy and were pathologically confirmed as ICC at Peking University People's Hospital between January 2015 and September 2025. The cohort comprised 120 men (52.2%) and 110 women (47.8%), with an age(M(IQR)) of 59 (14) years (range:31 to 83 years). Multivariable logistic regression was performed to identify independent risk factors for lymph node metastasis. Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method and Cox proportional hazards models. Subgroup analyses based on lymph node status (N0, N1, and Nx) were conducted to explore the impact of lymphadenectomy extent and postoperative adjuvant therapy on prognosis across subgroups. Restricted cubic spline (RCS) analysis was used to assess the association between lymph node ratio (LNR) and survival outcomes. Results: Among the 230 ICC patients, 144 underwent lymphadenectomy, with a lymph node metastasis rate of 38.9% (56/144). Multivariable logistic regression identified carcinoembryonic antigen>4.7 μg/L (OR=5.895, P=0.030), preoperative radiological lymphadenopathy (OR=11.822, P=0.006), and large duct type histological subtype (OR=18.224, P=0.001) as independent risk factors for lymph node metastasis. Survival analyses showed that lymph node metastasis was associated with shortened OS and DFS (both P<0.01). In subgroup analyses of lymphadenectomy, retrieval of≥6 lymph nodes prolonged DFS in the N1 group (P=0.004) but did not improve OS; in the N0 group, retrieval of<6 lymph nodes was associated with better OS and DFS compared with ≥6 nodes (both P<0.05). RCS analysis demonstrated a significant linear association between LNR and DFS (P=0.006), whereas no association was observed between LNR and OS (P=0.451). Regarding adjuvant therapy, adjuvant treatment improved OS in the overall cohort (P=0.039) but did not prolong DFS (P>0.05). In the N1 group, adjuvant therapy improved OS (P=0.031); in the N0 group, it improved DFS (P=0.031); however, no survival benefit was observed in the Nx group (both P>0.05). Conclusions: Elevated carcinoembryonic antigen, preoperative lymphadenopathy, and large duct type histological subtype are independent risk factors for postoperative lymph node metastasis in ICC. Lymph node status significantly affects prognosis. Patients with lymph node-positive disease may benefit from retrieval of≥6 lymph nodes and postoperative adjuvant therapy, whereas excessive lymphadenectomy should be avoided in lymph node-negative patients, in whom adjuvant therapy mainly contributes to delaying recurrence.

Objective: To develop an early diagnostic model for intrahepatic cholangiocarcinoma (ICC) based on serum peptidomic profiling. Methods: This is a retrospective cohort study. Serum samples and clinical data of 421 participants treated at four hospitals in China between April 2018 and November 2023 were retrospectively collected. The cohort included 260 males (61.8%) and 161 females (38.2%), with a age(M(IQR)) of 65(15) years (range: 24 to 93 years). According to the diagnostic results, participants were divided into three groups: 166 patients in the intrahepatic cholangiocarcinoma (ICC) group (39.4%), 118 healthy controls (28.0%), and 137 patients with benign liver diseases (32.6%). The 421 samples were allocated to a training set and a testing set at a ratio of 2︰1 using stratified random sampling for model construction and internal validation. To evaluate the application value of the constructed serum peptide ICC diagnostic model in real-world clinical settings, the latter part of this study was conducted as a prospective, two-center real-world study. Subjects who visited the Sir Run Run Shaw Hospital affiliated with Zhejiang University School of Medicine and the First Affiliated Hospital of Wenzhou Medical University from January 2024 to December 2025 were enrolled as an external validation set according to inclusion and exclusion criteria. Serum peptides were detected using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, and peptide spectra of serum samples were analyzed by label-free quantitative methods. Differential peptides were screened using the Kruskal-Wallis H nonparametric test, followed by feature screening combined with a genetic algorithm to construct a logistic regression-based diagnostic model in the training set. The model stability was assessed through ten-fold cross-validation, and validation was performed in an external real-world cohort. Diagnostic performance was evaluated using the receiver operating characteristic curve and its area under the curve (AUC), with sensitivity, specificity, and positive predictive value calculated. The clinical application value of the model was assessed using decision curve analysis. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed on the proteins corresponding to the differential peptides. Results: A total of 107 serum peptides showing significant differences between the ICC group and the healthy control and benign liver disease groups were identified. Eight core peptides with the strongest discriminatory ability for ICC were selected using a genetic algorithm, and a logistic regression-based diagnostic model was constructed accordingly. The model demonstrated good discriminative ability and stability in the training set, testing set, and ten-fold cross-validation. In the external real-world validation cohort, the diagnostic performance was favorable, with a positive predictive value of 90.6%, sensitivity of 89.2%, specificity of 91.4%, and an AUC of 0.971. Decision curve analysis showed that the model provided significant net clinical benefit across a wide range of threshold probabilities. GO and KEGG enrichment analyses indicated that proteins corresponding to the differential peptides were mainly involved in the complement-coagulation cascade and platelet activation pathways, suggesting that abnormalities in these networks may be associated with the occurrence and progression of ICC..Conclusion The serum peptidomics-based diagnostic model provides high accuracy for early ICC detection and offers molecular insights that may inform future mechanistic studies and therapeutic investigations.

Cholangiocarcinoma is a highly aggressive malignancy with a poor prognosis, and surgical resection remains the only potentially curative treatment. Hepatopancreatoduodenectomy (HPD) represents a radical surgical option for selected patients with locally advanced cholangiocarcinoma involving both the perihilar region and the peripancreatic bile duct. Although HPD can increase the resection rate and the likelihood of achieving R0 margins, it is associated with substantial perioperative mortality and morbidity, and its survival benefit remains controversial. In recent years, advances in surgical techniques and perioperative management have improved the safety of HPD, allowing a subset of carefully selected patients to achieve long-term survival. However, HPD has not yet been established as a standard treatment for locally advanced cholangiocarcinoma and should be performed with caution under strict indications in high-volume centers. This review summarizes current evidence regarding the indications, surgical strategies, perioperative safety, and survival outcomes of HPD in the management of cholangiocarcinoma.

Gallbladder cancer is a highly malignant tumor of the biliary system. Radical resection remains the only treatment that can significantly improve patient prognosis. However,surgical management of gallbladder cancer in clinical practice still faces numerous challenges: intraoperative frozen section pathology and postoperative pathological examination are critical diagnostic tools,yet their accuracy is limited by medical technology and the inherent complexity of pathological diagnosis. Surgical strategies involving the extent of hepatectomy,lymph node dissection,and management of extrahepatic bile ducts remain controversial. This article systematically analyzes relevant guidelines and literature from domestic and international sources,combined with the clinical experience of the author's team,to address these challenges. The aim is to provide clinicians with more practical reference recommendations,thereby promoting the standardization and individualization of surgical treatment for gallbladder cancer.

Objective: To compare the efficacy and safety of hepatectomy based on portal vein territory versus hepatectomy based on diseased biliary tree territory in treating hepatolithiasis. Methods: This is a retrospective cohort study,and clinical data from consecutive 365 hepatolithiasis patients from two hospitals between January 2014 and January 2020 were collected. The cohort included 123 males and 242 females,with an age of (54.0±11.9) years (range: 13 to 83 years). Participants were grouped according to surgical approach. The regional hepatectomy group based on the territories of affected bile ducts comprised 262 cases (88 males,174 females),with an age of (53.9±12.0) years. The hepatectomy group based on the portal vein territories comprised 103 cases (35 males,68 females), with an age of (54.4±11.7) years. Observation indicators: (1) Recurrence-free interval;(2) Complication rates (intraoperative,postoperative,and long-term). Inverse probability of treatment weighting (IPTW) was employed to simulate a randomized trial by weighting observations with the inverse of the treatment probability,thereby eliminating confounding bias and balancing baseline characteristics between patients undergoing lesion bile duct tree basin resection and those undergoing portal vein basin resection. The safety and efficacy outcomes between the two groups were compared using the χ2 test, the Mann-Whitney U test, as well as Kaplan-Meier curves with the Log-rank test. Results: After IPTW,318 patients were included in the diseased biliary tree territory group and 361 patients were included in the portal vein territory group. The overall morbidity rate and ascites rate in the diseased biliary tree territory group were both significantly lower than those in the portal vein territory group (after IPTW: 49.7% (158/318) vs. 63.7% (230/361), χ2=13.016, P<0.01; 9.4% (30/318) vs. 18.6% (67/361), χ2=10.765, P=0.001,respectively). The 5-year recurrence-free interval rates in the resection group of the diseased bile duct tree basin and the resection group of the portal vein basin were 79.9% and 73.9%, respectively, with no statistically significant difference (P=0.126). Conclusion: The total complication rate and ascites incidence following hepatectomy targeting the diseased biliary drainage territory are somewhat lower than those after portal vein territory hepatectomy,while both approaches demonstrated comparable efficacy. Objective.

Malperfusion syndrome (MPS) is a life-threatening complication of acute aortic dissection (AAD). Current management of AAD with MPS faces challenges in early detection and revascularization strategies. To address these issues, the Thoracic Aortic Group,Vascular Surgeon Branch of Chinese Medical Doctor Association has developed this expert consensus based on the latest evidence. The consensus elaborates on the pathophysiology, epidemiology, diagnostic criteria and classifications of AAD with MPS, and proposes a stratified treatment strategy based on the ischemic organs and underlying mechanisms, aiming to standardize clinical practice and improve patient outcomes.

With advancements in surgical techniques and the improvement of diagnosis and treatment levels for early gastric cancer (EGC), minimally invasive approaches and function preservation have become shared goals for both patients and clinicians. Laparoscopic-endoscopic cooperative surgery combined with sentinel lymph node navigation surgery (LECS-SNNS) has gained significant attention due to its dual advantages in minimal invasiveness and physiological function preservation. However, robust evidence to guide its clinical implementation remains limited. Therefore, this consensus systematically reviews the research evidence regarding the clinical application of LECS-SNNS in EGC and formulates 20 expert-based recommendations, which including preoperative assessment, surgical procedures, intraoperative endoscopic maneuvers, pathological diagnosis, postoperative management, and follow-up. This consensus aims to provide comprehensive guidance for the standardized application and promotion of LECS-SNNS, with the goal of advancing precision, minimally invasive, and function-preserving treatment for EGC.

Objective: To develop and validate a nomogram model based on CT imaging features for predicting the very early recurrence (VER) of patients with intrahepatic mass-forming cholangiocarcinoma (IMCC) after radical resection. Methods: This is a retrospective multicenter case series study. Retrospective analysis of clinic data was conducted in IMCC patients who underwent curative resection and contrast-enhanced CT at three independent institutions from Jiangsu province between January 2009 and December 2019 (institution 1: the First Affiliated Hospital with Nanjing Medical University; institution 2: Yancheng First People's Hospital; institution 3: Changzhou First People's Hospital). A total of 282 patients were included. A preoperative nomogram was developed based on a training cohort of 179 IMCC patients who were collected from institution 1. In the training cohort, univariate and multivariate Logistic regression analysis were used to construct the nomogram. The constructed model was validated in an independent external dataset (103 IMCC patients received surgical treatment at institution 2 and institution 3). The predictive efficacy of the nomogram model was evaluated using the receiver operating characteristic curve and its area under the curve (AUC), calibration curve, and decision curve analysis (DCA), and was compared with the AJCC 8th edition staging system. Results: The preoperative clinical-imaging prediction model was constructed based on the albumin-bilirubin grading and three CT imaging features (tumor size, multi-nodular type, and arterial phase enhancement pattern). In the training cohort, the predictive efficacy of the preoperative clinical-imaging model (AUC=0.819, 95%CI: 0.756 to 0.883) was significantly higher than that of the AJCC 8th edition staging system (AUC=0.707, 95%CI: 0.633 to 0.782)(P=0.006); in the external validation cohort, the predictive efficacy of the preoperative clinical-imaging model (AUC=0.766, 95%CI: 0.672 to 0.861) was slightly better than that of the AJCC 8th edition staging system (AUC=0.709, 95%CI: 0.611 to 0.808), but the difference was not statistically significant (P=0.370). The calibration curve indicates that the predicted probabilities of the clinical-imaging nomogram model are in good agreement with the actual observed values. The DCA showed that this model has better clinical net benefit compared to the AJCC 8th edition staging system. Conclusions: The preoperative albumin-bilirubin grading and three CT imaging features, including tumor size, multi-nodular type, and arterial phase enhancement pattern, are independent risk factors for postoperative VER in IMCC patients. The clinical-imaging nomogram model constructed based on the albumin-bilirubin grading and these three imaging features can accurately predict postoperative VER in IMCC patients before surgery, providing a reference for the selection of individualized treatment strategies.

Objective: To evaluate the feasibility and efficacy of intraoperative neurophysiological monitoring (IONM) in endovascular repair (EVAR) procedures for aortic pathologies at high risk of spinal cord ischemia (SCI). Methods: This is a retrospective case series study. Clinical data of 19 patients with thoracoabdominal aortic aneurysms or other complex aneurysms involving branches in the aortic arch or visceral branch arteries who underwent elective fenestrated or branched endovascular aortic repair between August 2024 and May 2025 at the Department of Vascular Surgery, Zhongshan Hospital, Fudan University, were retrospectively reviewed. There were 15 male and 4 female patients, with an age of (63.9±13.3) years (range: 30 to 80 years). All patients were identified as at high risk for SCI based on a spinal cord ischemia risk stratification model and related clinical indicators. Multimodal IONM was applied intraoperatively in all patients, including transcranial electrical stimulation motor evoked potentials, somatosensory evoked potentials, and compound motor unit action potentials. Based on monitoring results, one or more managements would be employed accordingly, including increasing mean arterial pressure, reducing cerebrospinal fluid pressure, correcting anemia, temporary aneurysm sac perfusion, or staged surgery. The perioperative and prognostic conditions of 19 patients were observed. Results: Technical success was achieved in 19 patients without any monitoring-related complications. In 4 patients, no IONM alerts occurred and no SCI developed postoperatively. In 15 patients, monitoring alerts were detected; among them, 12 alerts were resolved after intraoperative management. In the remaining 3 patients, alerts persisted, including 1 patient who showed progressive deterioration in monitoring signals and developed postoperative paraplegia (bilateral lower limb motor strength was grade 0), which recovered to grade 5 after 3 months. The last 2 patients exhibited unilateral alarms without progressive deterioration, thus allowing the procedures to be completed. Conclusion: IONM could provide early intraoperative warnings of SCI in EVAR, enabling the surgical team to take timely interventions and minimize the incidence and damage of SCI.