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Background: Concurrent acute cholecystitis and acute cholangitis is a unique clinical situation. We tried to investigate the optimal timing of cholecystectomy after adequate biliary drainage under this condition. Methods: From January 2012 to November 2017, we retrospectively screened all in-hospitalized patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and then identified patients with concurrent acute cholecystitis and acute cholangitis from the cohort. The selected patients were stratified into two groups: one-stage intervention (OSI) group (intended laparoscopic cholecystectomy at the same hospitalization) vs. two-stage intervention (TSI) group (interval intended laparoscopic cholecystectomy). Interrogated outcomes included recurrent biliary events, length of hospitalization, and surgical outcomes. Results: There were 147 patients ultimately enrolled for analysis (OSI vs. TSI, 96 vs. 51). Regarding surgical outcomes, there was no significant difference between the OSI group and TSI group, including intraoperative blood transfusion (1.0% vs. 2.0%, p = 1.000), conversion to open procedure (3.1% vs. 7.8%, p = 0.236), postoperative complication (6.3% vs. 11.8%, p = 0.342), operation time (118.0 min vs. 125.8 min, p = 0.869), and postoperative days until discharge (3.37 days vs. 4.02 days, p = 0.643). In the RBE analysis, the OSI group presented a significantly lower incidence of overall RBE (5.2% vs. 41.2%, p < 0.001) than the TSI group. Conclusions: Patients with an initial diagnosis of concurrent acute cholecystitis and cholangitis undergoing cholecystectomy after ERCP drainage during the same hospitalization period may receive some benefit in terms of clinical outcomes.

BackgroundAcute graft-versus-host disease (aGVHD) is a severe and fatal complication after orthotopic liver transplantation (OLT). Clinical manifestations of severe aGVHD can resemble drug-induced Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), and there are also various medications, such as antibiotics and immunosuppressants, used after transplantation, causing a diagnostic dilemma. Furthermore, there have been no standardized diagnostic and therapeutic strategies for OLT-aGVHD due to its rarity.Case summaryA 52-year-old man presented with generalized maculopapular eruptions, fever, and pancytopenia 1 month after OLT and 4 days after taking sulfamethoxazole/trimethoprim. After assessment of the scoring criteria for drug causality of drug allergy, histopathological findings of skin biopsy, lymphocyte activation test of the potential offending drug, and microchimerism study, the diagnosis was in favor of aGVHD mimicking SJS/TEN. Considering severe sepsis, the anti-tumor necrosis factor alpha (TNF-α) agent, etanercept, was used to replace tacrolimus and corticosteroid. Skin lesions resolved gradually after anti-TNF-α biologics rescue; tacrolimus and corticosteroid therapy were re-administrated after controlling sepsis. Pancytopenia recovered and the patient was discharged in a stable condition.ConclusionWe demonstrated a diagnostic strategy for OLT-aGVHD. Targeting therapy with anti-TNF-α blockade and a temporary withdrawal of traditional immunosuppressants may be among effective and safe therapeutic options of OLT-aGVHD for those with severe sepsis.

Chun-Nan Yeh,1 Ren-Chin Wu,2 Chi-Tung Cheng,1 Chun-Yi Tsai,1 Yau-Ren Chang,1 Ta-Sen Yeh,1 Tsung-Han Wu,1 Wei-Chen Lee,1 Kun-Chun Chiang3 1Department of Surgery, Liver Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; 2Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; 3General Surgery Department, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan Background: More than 500,000 people suffered from hepatocelluar carcinoma (HCC) annually and the relative incidence to mortality rate indicates its unfavorable prognosis. Several studies have proved that heme-oxygenase-1 (HO-1) is indirectly engaged in the invasion and the metastasis of some types of malignancies, including breast cancer, prostate cancer, and lung cancer. The role of HO-1 in hepatitis B virus (HBV)-related HCC is still not clarified.Materials and methods: The Western blot, doubling time, cell cycle analysis, migration assay, invasion assay, gene transfection, xenograft animal model, immunohistochemistry staining, and clinical validation study were applied in this study.Results: HO-1 overexpression not only decreased the growth but also inhibited the migration and invasion in human HBV-HCC cells (Hep-3B vs PLC/PRF/5 ). The inhibitory effect on growth, migration, and invasion is further demonstrated by the overexpression of HO-1 in Hep-3B cell by transfection study. Furthermore, HO-1 decreasing the growth of HBV-HCC was confirmed in animal study. The clinical validation illustrated that higher HO1 expression was also associated with favorable disease-free survival of HBV-HCC patients who underwent hepatectomy.Conclusions: We identified HO-1 as a favorable prognostic factor for HBV-HCC patients who underwent hepatectomy. Keywords: HO-1, HBV, HCC, hepatectomy