Metaverse and Telementoring: From Surgery to Workshop.

BACKGROUND: The Coronavirus 2019 (COVID-19) pandemic has favored the growth of telemedicine systems and in this context the idea of Metaverse was born and developed. A 3D reality in which people can interact with each other through digital reproductions of themselves. Metaverse has already been tested in numerous medical fields due to its ability to combine visual and auditory information with tactile sensations. The purpose of this study is to highlight its potential also in its ability to be used as a telementoring place where the skills and knowledge of surgeons from all over the world can be combined. MATERIAL AND METHODS: The first HPB Surgery Workshop was held at the "Metaverse Surgical Hospital, USA". During the workshop, surgeons located in various parts of the world reported on hepatic, pancreatic and biliary tract surgery and remotely supported the execution of a robotic liver resection. RESULTS: The Metaverse gave the opportunity for surgeons to meet and discuss HPB pathologies and its surgical strategies and for surgeons in training to interface with experts by participating in a moment of advanced training. CONCLUSION: In the Metaverse, telementoring can be used at very low cost to improve clinical and surgical practice.

Efficacy and safety of Propionibacterium extract gel versus glyceryl trinitrate ointment in the treatment of chronic anal fissure: a randomized controlled trial.

AIM: Chronic anal fissure (CAF) is an extremely frequent finding in clinical practice. Several topical agents have been proposed for its treatment with the common goal of increasing anodermal blood flow to promote healing. The aim of this study was to compare the efficacy and safety of a Propionibacterium extract gel (PeG) and 0.4% glyceryl trinitrate ointment (GTN) in patients with CAF. METHOD: Patients were randomly allocated to a PeG or GTN group and medication was administered every 12 h for 40 days. The primary outcome was the success rate, as measured by a decrease in the REALISE scoring system for anal fissure at 10, 20 and 40 days after initiating either treatment. The secondary outcomes recorded at the same time points were healing rate, visual analogue scales for itching and burning, rate of complications and adverse events, patient quality of life and satisfaction, and cost analysis. RESULTS: A total of 120 patients were enrolled, and 96 patients (PeG, n = 53; GTN, n = 43) completed the primary outcomes. A significant decrease over time in the REALISE score was observed in both groups. Adverse events occurred more frequently in the GTN group than in the PeG group, peaking at visit 1 [37 (63.8%) vs. 2 (3.4%), respectively], with headache being the most prevalent. The between-treatment cumulative average costs per patient were significantly higher for GTN than that for PeG at each follow-up visit. There were no other significant differences between the two groups for any of the other outcomes. CONCLUSION: While there was no difference in healing rates between the two treatments, PeG was more cost-effective and associated with fewer adverse events.

Anastomotic Leak Rate and Prolonged Postoperative Paralytic Ileus in Patients Undergoing Laparoscopic Surgery for Colo-Rectal Cancer After Placement of No-Coil Endoanal Tube.

BACKGROUND: Colorectal cancer (CRC) is the second most common gastrointestinal tumor in men and the third in women. Left-hemicolectomy (LC) and low anterior resection (LAR) are considered the gold standard curative treatment. In this retrospective study, we evaluated the presence or absence of post-operative complications, in all patients who underwent Video-laparoscopic (VLS) LAR/LC with No Coil trans-anal tube positioning, and compared the data with the current literature on the topic. METHODS: Thirty-nine patients diagnosed with CRC of the descending colon, splenic flexure, sigma, and rectum were recruited. LC was performed for sigmoid and descending colon cancers, while LAR was applied for tumors of the upper two-thirds of the rectum. The No Coil trans-anal tube (SapiMed Spa, Alessandria, Italy) was placed in all patients of the study at the end of surgical treatment. RESULTS: Eighteen patients received a LAR-VLS (46%) and 21 patients received a LC-VLS (54%). The average length of hospital stay after surgery was 7 days. PPOI occurred in only one in 39 patients (2.6%) who had undergone LAR-VLS. As for complications, in no patient of the study did AL (0%) occur. CONCLUSION: In patients undergoing LAR-VLS and LC-VLS, we performed colorectal anastomosis and in the same surgical operation we introduced the No-Coil device. Although this is a preliminary study and subject to further investigation, we believe that the No Coil tube positioning may reduce the time of presence of first flatus and feces and the risk of AL.

Targeting Stem Cells with Hyperthermia: Translational Relevance in Cancer Patients.

BACKGROUND: Tumor recurrences or metastases remain a major hurdle in improving overall cancer survival. In anticancer therapy, some patients inevitably develop chemo-/radiotherapy resistance at some point. Cancer stem cells are the driving force of tumorigenesis, recurrences, and metastases, contributing also to the failure of some cancer treatments. SUMMARY: Emergent evidence suggests that stem cell diseases are at the base of human cancers, and tumor progression and chemo-/radiotherapy resistance may be dependent on just a small subpopulation of cancer stem cells. Hyperthermia can be a strong cancer treatment, especially when combined with radio- or chemotherapy. It is a relatively safe therapy, may kill or weaken tumor cells, and significantly increases the effectiveness of other treatments. However, these mechanisms remain largely unknown. A literature search was performed using PubMed including cited English publications. The search was last conducted in December 2019. Search phrases included "stem cells," "hyperthermia," "cancer," and "therapy." Abstracts, letters, editorials, and expert opinions were not considered for the drafting of the study. Key Message: Our goal was to focus on and to summarize different biological features of cancer stem cells and new therapeutic approaches using hyperthermia and its potential translation to human clinical trials.

No Coil® placement in patients undergoing left hemicolectomy and low anterior resection for colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) is the most common tumor of the gastrointestinal tract. Anastomotic leak (AL) and prolonged postoperative ileus (PPOI) are two important complications of colorectal surgery. In this observational retrospective study, we evaluated the positive effects of transanal tube No Coil® in patients with CRC undergoing low anterior resection (LAR) and left hemicolectomy (LC). METHODS: Thirty-eight cases and forty controls resulted eligible for the final sample. No Coil® placement (SapiMed Spa, Alessandria, Italy) was considered an inclusion criteria for the case group. No Coil® was placed immediately after the end of surgical treatment. RESULTS: PPOI was significantly more frequent in the control group. AL was evident in 1 patient (2.6%) of cases and 3 patients (7.5%) of controls. No statistical difference was found in AL occurrence between groups. POI days and AL resulted associated with hospital stay. POI days were negatively associated with No Coil placement and positively with AL. CONCLUSION: With our preliminary data, we suggest that No Coil® placement can be considered as a valuable procedure assisting colorectal surgery, but further studies are required to confirm and enlarge actual evidence.

Mast Cells, Angiogenesis and Lymphangiogenesis in Human Gastric Cancer.

Gastric cancer is diagnosed in nearly one million new patients each year and it remains the second leading cause of cancer-related deaths worldwide. Although gastric cancer represents a heterogeneous group of diseases, chronic inflammation has been shown to play a role in tumorigenesis. Cancer development is a multistep process characterized by genetic and epigenetic alterations during tumour initiation and progression. The stromal microenvironment is important in maintaining normal tissue homeostasis or promoting tumour development. A plethora of immune cells (i.e., lymphocytes, macrophages, mast cells, monocytes, myeloid-derived suppressor cells, Treg cells, dendritic cells, neutrophils, eosinophils, natural killer (NK) and natural killer T (NKT) cells) are components of gastric cancer microenvironment. Mast cell density is increased in gastric cancer and there is a correlation with angiogenesis, the number of metastatic lymph nodes and the survival of these patients. Mast cells exert a protumorigenic role in gastric cancer through the release of angiogenic (VEGF-A, CXCL8, MMP-9) and lymphangiogenic factors (VEGF-C and VEGF-F). Gastric mast cells express the programmed death ligands (PD-L1 and PD-L2) which are relevant as immune checkpoints in cancer. Several clinical undergoing trials targeting immune checkpoints could be an innovative therapeutic strategy in gastric cancer. Elucidation of the role of subsets of mast cells in different human gastric cancers will demand studies of increasing complexity beyond those assessing merely mast cell density and microlocalization.

Why laparoscopists may opt for three-dimensional view: a summary of the full HTA report on 3D versus 2D laparoscopy by S.I.C.E. (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie).

BACKGROUND: Three-dimensional view in laparoscopic general, gynaecologic and urologic surgery is an efficient, safe and sustainable innovation. The present paper is an extract taken from a full health technology assessment report on three-dimensional vision technology compared with standard two-dimensional laparoscopic systems. METHODS: A health technology assessment approach was implemented in order to investigate all the economic, social, ethical and organisational implications related to the adoption of the innovative three-dimensional view. With the support of a multi-disciplinary team, composed of eight experts working in Italian hospitals and Universities, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaire and self-reported interviews, applying a final MCDA quantitative approach, and considering the dimensions resulting from the EUnetHTA Core Model. RESULTS: From systematic search of literature, we retrieved the following studies: 9 on general surgery, 35 on gynaecology and urology, both concerning clinical setting. Considering simulated setting we included: 8 studies regarding pitfalls and drawbacks, 44 on teaching, 12 on surgeons' confidence and comfort and 34 on surgeons' performances. Three-dimensional laparoscopy was shown to have advantages for both the patients and the surgeons, and is confirmed to be a safe, efficacious and sustainable vision technology. CONCLUSIONS: The objective of the present paper, under the patronage of Italian Society of Endoscopic Surgery, was achieved in that there has now been produced a scientific report, based on a HTA approach, that may be placed in the hands of surgeons and used to support the decision-making process of the health providers.

Favorable Management of Low Colorectal Anastomotic Leakage with Transanal Conventional and Endoscopic Drainage (GelPOINT® Path Transanal Access Platform).

OBJECTIVE: We describe our experience with transanal-laparoscopic treatment of anastomotic leakage. SUMMARY OF BACKGROUND DATA: Anastomotic leakage leads to high mortality rates, morbidity, a complicated post-operative course and increased cost. The management of low anastomotic leakage after anterior resection of rectal cancer is not standardized. METHODS: This was a retrospective cohort study based on prospectively collected data. Among patients who underwent anterior resection for rectal cancer in our division between January 2014 and October 2017, 14 developed colorectal or colo-anal anastomotic leakage and underwent reoperation with a transanal approach. Data regarding patient demographics, reoperative outcomes, morbidity, length of hospital stay, mortality, leak closure and long-term outcomes are presented. RESULTS: In all patients, anastomotic healing was confirmed by radiology. No perioperative complications were detected. One patient presented anastomotic stricture after 20 months, which was successfully treated with dilatation. CONCLUSIONS: There is little information available on the management of anastomotic leakage after anterior resection for rectal cancer. Although more studies are needed to standardize patient selection criteria and evaluate the long-term outcome of these procedures, minimally invasive transanal conventional and laparoscopic anastomotic leak repair is a feasible and safe surgical option that can often avoid the need for anastomotic takedown and stoma formation.

Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity.

PURPOSES: Management of staple-line leaks following laparoscopic sleeve gastrectomy (LSG) is challenging and controversial. Guidelines for leak treatment are not standardized and often involve multidisciplinary management by surgical, medical and radiological methods. Herein we present our experience and proposed strategy for handling leaks after LSG. PATIENTS AND METHODS: Retrospective data regarding LSG performed from April 2012 to October 2017 at the Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital "G. Martino", University of Messina, Italy, were reviewed. The management approaches and the surgical, endoscopic, and percutaneous procedures used were examined. Outcomes measured included the prevalence of gastric leaks, radiological features, related morbidities and mortalities, hospital stay and management. RESULTS: LSG was performed in 310 patients. Eight patients were managed for gastric leak within the 5-year period: 5 (1.6% overall prevalence) from our division, 3 referred from another hospital. All cases were successfully treated conservatively with combined CT/US-guided drainage using a locking pigtail catheter and endoscopic gastric stent positioning. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (Hanarostent® 24 cm; M.I. Tech, Seoul, Korea) in addition to pigtail drains (Drainage Catheter Locking Pigtail 8F/21cm; Tru-Set® Ure-Sil, Skokie, IL, USA). Complete closure of the leak was achieved in all patients. The mean time from presentation to healing was 74 days ± 37.76 (SD). None of the patients underwent remedial surgery. CONCLUSION: This study presents our management strategy for leak resolution in LSG patients. Based on our results, we strongly recommend the conservative and combined management of gastric leaks following LSG by endoscopic stenting and percutaneous drainage.

Close relationship between mediators of inflammation and pancreatic cancer: Our experience.

In this editorial, we focus specifically on the mechanisms by which pancreatic inflammation affects pancreatic cancer. Cancer of the pancreas remains one of the deadliest cancer types. The highest incidence and mortality rates of pancreatic cancer are found in developed countries. Trends of pancreatic cancer incidence and mortality vary considerably worldwide. A better understanding of the etiology and identification of the risk factors is essential for the primary prevention of this disease. Pancreatic tumors are characterized by a complex microenvironment that orchestrates metabolic alterations and supports a milieu of interactions among various cell types within this niche. In this editorial, we highlight the foundational studies that have driven our understanding of these processes. In our experimental center, we have carefully studied the mechanisms of that link pancreatic inflammation and pancreatic cancer. We focused on the role of mast cells (MCs). MCs contain pro-angiogenic factors, including tryptase, that are associated with increased angiogenesis in various tumors. In this editorial, we address the role of MCs in angiogenesis in both pancreatic ductal adenocarcinoma tissue and adjacent normal tissue. The assessment includes the density of c-Kit receptor-positive MCs, the density of tryptase-positive MCs, the area of tryptase-positive MCs, and angiogenesis in terms of microvascularization density.

Strategies to decrease morbidity in surgical management of esophageal cancer: a single center experience.

BACKGROUND: In this study we described our experience in decreasing morbidity by performing a few changes during and after the Ivor Lewis esophagectomy. METHODS: This is a retrospective single center experience comparing a control period (group A) and a study period (group B) in patients who underwent esophagectomy for esophageal cancer (control group: 23; study group: 17). Control group had postero-lateral thoracotomy and a gastric tube without aspiration during postoperative period. Study group had limited lateral muscle sparing thoracotomy and postoperatively the gastric tube was routinely left for 1 week with intermittent aspiration (10 times every two hours for 1 week). RESULTS: Average operation time was 312±56 minutes in control period, in study period 189±36 min. Average ICU stay was 10 (7-32) days in the control group, in study group 4 (1-8) days. Anastomotic leak rate was significantly higher in control vs. study group (53.3% vs. 16.6%; P<0.05). Respiratory complications were significantly lower in the study group (47.8% vs. 17.6%). CONCLUSIONS: The combination of a limited lateral thoracotomy and postoperative intermittent aspiration seem to reduce the rate of respiratory and anastomotic complication after Ivor-Lewis' procedure.

Left hemicolectomy and low anterior resection in colorectal cancer patients: Knight-griffen vs. transanal purse-string suture anastomosis with no-coil placement.

Background: Colorectal cancer (CRC) is considered one of the most frequent neoplasms of the digestive tract with a high mortality rate. Left hemicolectomy (LC) and low anterior resection (LAR) with minimally invasive laparoscopic and robotic approaches or with the open technique are the gold standard curative treatment. Materials and methods: Seventy-seven patients diagnosed with CRC were recruited between September 2017 and September 2021. All patients underwent a preoperative staging with a full-body CT scan. The goal of this study was to compare both types of surgeries, LC-LAR LS with Knight-Griffen colorectal anastomosis and LC-LAR open with Trans-Anal Purse-String Suture Anastomosis (the TAPSSA group), by positioning a No-Coil transanal tube (SapiMed Spa, Alessandria, Italy), in terms of postoperative complications such as prolonged postoperative ileus (PPOI), anastomotic leak (AL), postoperative ileus (POI), and hospital stay. Results: The patients were divided into two groups: the first with 39 patients who underwent LC and LAR in LS with Knight-Griffen anastomosis (Knight-Griffen group) and the second with 38 patients who underwent LC and LAR by the open technique with the TAPSSA group. Only one patient who underwent the open technique suffered AL. POI was 3.76 ± 1.7 days in the TAPSSA group and 3.07 ± 1.3 days in the Knight-Griffen group. There were no statistically significant differences in terms of AL and POI between the two different groups. Conclusion: The important point that preliminarily emerged from this retrospective study was that the two different techniques showed similarities in terms of AL and POI, and therefore, all the advantages reported in the previous studies pertaining to No-Coil also hold good in this study regardless of the surgical technique used. However, randomized controlled trials are needed to confirm these findings.

[Relationship between overweight, obesity and malocclusion in a sample of children]. / Correlazione tra status nutrizionale e malocclusione in un gruppo di bambini tra i 3 e i 12 anni d'età. Correggere lo stile di vita.

Obesity and malocclusion are two very common disease worldwide affecting both adults and children, posing a threat to the physical and mental health. Our observational study assesses the impact of being obese and overweight in the development of malocclusion among childhood subjects (3-12 year old).

The Effects of Low-frequency Vibration on Aligner Treatment Duration: A Clinical Trial.

Objectives: The aim of this study was to investigate the effectiveness of an orthodontic tooth movement acceleration device (AcceleDent, OrthoAccel Technologies, Houston, Texas) when used during an aligner treatment. Materials and Methods: Adult patients who began an aligner treatment (Lineo, Micerium Lab, Avegno, Italy) were allocated to two treatment groups. The first one (Group A), with a 7-day aligner change regimen, used the AcceleDent device for 20 min per day, whereas the second one (Group B) changed the aligners every 14 days and did not use any device. The registered outcomes were the possibility of completing the treatment, the number of aligners needed and treatment duration in the two groups. Moreover, we assessed patients' perception of pain during the first week of treatment. Results: Twenty-four patients were allocated to Group A or B depending on the acceptance of AcceleDent use. Patients which used AcceleDent (Group A) completed the treatment using each aligner for fewer days than those belonging to Group B (9.0 ± 1.0 and 15.4 ± 1.2 days, respectively) (P < 0.001). As a secondary outcome, a significant difference was found in pain perception during the first week of treatment between the two groups (P < 0.05). Conclusions: This controlled clinical trial shows that is possible to apply a 7-day change regimen together with AcceleDent use and successfully complete an aligner treatment with a significant saving of time when compared to a standard 14-days change regimen. Finally, the use of this device allowed reduction in pain perception during the orthodontic treatment.

The Role of Magnetic Resonance Imaging in the Planning of Surgical Treatment of Deep Pelvic Endometriosis.

Background: To prospectively evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for the planning of surgical treatment of deep pelvic endometriosis. Materials and Methods: From January 2020 to December 2021, we evaluated 72 patients with symptoms characteristic of endometriosis to plan appropriate surgical treatment. Sensitivity (Se), specificity (Sp), positive and negative predictive values (VPP/VPN), and the accuracy of MRI for the detection of deep pelvic endometriosis were calculated. Results: Seventy-two patients (mean age, 35.5 years; range, 20-46 years) suspected of having pelvic endometriosis were recruited. Pelvic endometriosis was confirmed at pathologic examination in 56 (77.7%) of 72 patients. A total of 22 (39.3%) of 56 patients were subjected to video laparoscopy (VLS), and 16 (72.2%) of 22 were treated by surgery. Se, Sp, VPP, and VPN in intestinal endometriosis diagnosis were, respectively, 100%, 93.3%, 100%, and 87.5%, and diagnostic accuracy was 95.4%. MRI Se in ureteral endometriosis diagnosis was 50%, Sp 100%, VPP 100%, VPN 78%, and diagnostic accuracy 82%. MRI Se in endometrioma diagnosis was 92.3%, Sp 100%, VPP 100%, VPN 90%, and diagnostic accuracy 95.4%. MRI Se in rectum-vaginal septum (SRV) endometriosis diagnosis was 80%, Sp 100%, VPP 100% VPN 85.7%, and diagnostic accuracy 91%. The MRI Se in the diagnosis of endometriosis involving ULS was 100%, Sp 92.8%, VPP 89%, VPN 100%, and diagnostic accuracy 95.4%. Complete concordance results in a 100% accuracy for all calculated values in diagnosing bladder endometriosis localizations. Conclusion: MR imaging demonstrates high accuracy in detecting deep pelvic endometriosis in specific locations. It allows the localization of deep pelvic lesions with highly fibrotic components that are hardly recognizable with other imaging methods and not visible with VLS.

Hyperthermic intraperitoneal chemotherapy and colorectal cancer: From physiology to surgery.

The pursuit of this paper is to collect principal reviews and systematic reviews about hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS) used in colorectal cancer (CRC). We focus on principal biological aspects of CRC, hyperthermia effects, and surgical procedures. We searched PubMed/MEDLINE for the principal reviews and systematic reviews published from 2010 to 2021 regarding the bimodal treatment (CRS + HIPEC) against local and advanced CRC. In the literature, from several studies, it seems that the efficacy of bimodal treatment with an accurate CRS can extend overall survival. Despite these studies, there are not still any straight guidelines more detailed and scheduled about the use of combined treatment in patients with CRC. Even if the concept is still not very clear and shared, after a careful evaluation of the published data, and after some technical and pathophysiological descriptions, we concluded that it is possible to improve the overall survival and quality of life and to reduce the tumor relapse in patients affected by locally advanced (pT4) CRC with peritoneal metastases.

Transverse Asymmetries of the Maxilla Even in Healthy and Apparently Symmetrical Subjects.

In the formulation of an orthodontic treatment plan, the three-dimensional analysis of the dental arches represents a fundamental moment for the evaluation of all the morphological parameters necessary in order to have a correct and complete diagnosis. In this regard, the study of the dental arches on the horizontal plane is sometimes neglected or not thorough enough. When evaluating the transverse dimensions of the dental upper arche, the presence of an asymmetry is frequently found, and it means that an hemiarch is larger than the other. Furthermore, any variation in one of the three planes of space always involves an alteration also on the other two planes in order to have compensation. The morphology of a bone segment depends on various factors, mainly genetical, acquired and environmental. Regarding the environmental factors, the function determines the morphology, but this in turn determines the function. In the case of unilateral mastication, the upper maxilla will be asymmetrical, so growing patients will have compensation on other skull bones. From these considerations arises the need for a careful study of the horizontal plane of the maxilla in the presence of a malocclusion during diagnostic evaluations. These asymmetries, however, must be evaluated and quantified in the diagnostic phase in order to formulate a correct plan of treatment. The aim of this work is to demonstrate that there are almost always transverse asymmetries of the maxilla, albeit of a slight entity, even in healthy and apparently symmetrical subjects.

Safety and Efficacy of Degradable Starch Microspheres Transcatheter Arterial Chemoembolization (DSM-TACE) in the Downstaging of Intermediate-Stage Hepatocellular Carcinoma (HCC) in Patients With a Child-Pugh Score of 8-9.

According to the EASL Guidelines for the management of hepatocellular carcinoma, transcatheter arterial chemoembolization is the first-line treatment recommended for intermediate-stage HCC. Furthermore, it is widely accepted that patients beyond the Milan criteria can be considered for a liver transplant after successful downstaging to within the Milan criteria. Response to downstaging treatments significantly influences not just drop-outs, but also the rate of post-transplantation tumor recurrences. TACE with degradable starch microspheres represents an alternative to conventional TACE with lipiodol and TACE with drug-eluting beads, and it leads to transient arterial occlusion allowing lower activation of hypoxia-inducible factors and less release of vascular endothelial growth factor, a promoter of neoangiogenesis, tumor proliferation, and metastatic growth. In patients with intermediate-stage HCC and a Child-Pugh score of 8 or 9, life expectancy may be dominated by cirrhotic liver dysfunction, rather than by the tumor progression itself; hence, locoregional treatments might also be detrimental, precipitating liver dysfunction to an extent that survival is shortened rather than prolonged. Data on tolerability, toxicity, and effectiveness of DSM-TACE are limited but encouraging. Between January 2015 and October 2020, 50 consecutive patients with intermediate-stage hepatocellular carcinoma and a Child-Pugh score of 8/9, who had undergone DSM-TACE as the first-line treatment, were eligible for the study. A total of 142 DSM-TACEs were performed, with a mean number of 2.84 procedures per patient. The mean time-to-downstaging was 19.2 months, with six patients successfully downstaged. OS was about 100% at six months, 81.8% at 12 months, and 50% at 24 months. Twenty-two patients experienced adverse events after chemoembolization. The median OS and safety of DSM-TACE in this study are comparable with other published investigations in this field. Furthermore, 12% of patients were successfully downstaged. Hence, the results of the current investigation demonstrate that DSM-TACE is effective and safe in intermediate-stage HCC, achieving an interesting downstaging rate. Such data were observed in the population subset with a Child-Pugh score of 8 or 9, in which life expectancy may be determined by cirrhotic liver dysfunction, so the achievement of a balance between the safety and efficacy profile of the TACE treatment is crucial.

Safety and Efficacy of Degradable Starch Microspheres Transcatheter Arterial Chemoembolization as a Bridging Therapy in Patients with Early Stage Hepatocellular Carcinoma and Child-Pugh Stage B Eligible for Liver Transplant.

In patients with early-stage hepatocellular carcinoma, awaiting liver transplantation, current guidelines by AASLD and ESMO recommend a bridging therapy with a loco-regional treatment to prevent progression outside transplantation criteria. The standard of care in delaying disease progression has been recognized to be the transarterial chemoembolization. Permanent occlusion of tumor feeding vessels has effects on tumour stromal microenvironment by inducing intra- and intercellular signaling processes counteracting hypoxia, such as the release of vascular endothelial growth factor, a promoter of neoangiogenesis, tumour proliferation and metastatic growth. Among chemoembolization interventions, TACE with degradable starch microspheres represents an alternative to conventional cTACE and DEB-TACE and it minimizes detrimental effects on tumour stromal microenvironment, guaranteeing a transient occlusion of tumour feeding arteries and avoiding VEGF overexpression.Between January 2015 and September 2020, 54 consecutive patients with early-stage hepatocellular carcinoma and Child-Pugh stage B, who had undergone DSM-TACE as a bridging therapy while awaiting liver transplantation, were eligible for the study. A total of 154 DSM-TACE was performed, with a mean number of 2.85 procedures per patient. 18 patients (33.3%) succeeded in achieving liver transplantation, with a mean waiting time-to-transplantation of 11.7 months. The cumulative rates of patients still active on the WL at 6 months were about 91 and 93% when considering overall drop-out and tumour-specific drop-out respectively. Overall survival was about 96% at 6 months and 92% at 12 months. 17 patients experienced adverse events after the chemoembolizations. For patients with HCC in the transplant waiting list and within the Child-Pugh B stage, life expectancy may be dominated by the liver dysfunction, rather than by the tumour progression itself. In this population subset, the choice of LRT is critical because LRT itself could become a dangerous tool that is likely to precipitate liver dysfunction to an extent that survival is shortened rather than prolonged. Hence, the current study demonstrates that DSM-TACE is not far from being an ideal LRT, because it has an excellent safety profile, maintaining an efficacy that guarantees a clear advantage on the dropout rate with respect to the non-operative strategy, thus justifying its use.