International study of the Complex Stress Reaction Syndrome:Implications for transdiagnostic clinical practice

BACKGROUND The debate regarding diagnostic classification systems in psychiatry(categorial vs dimensional systems)has essential implications for the diagnosis,prevention and treatment of stress reactions.We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries,and termed it the Complex Stress Reaction Syndrome(CSRS).AIM To investigate CSRS,Type A(psychiatric symptoms,spanning anxiety,depression,stress symptoms,and posttraumatic stress disorder(PTSD)),with or without long-coronavirus disease(COVID)residuals(CSRS,Type B,neuropsychiatric symptoms spanning cognitive deficits and fatigue,excluding systemic symptoms).Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population(Type A)or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals(Type B).METHODS 977 individuals in four continents(North America,Europe,Australia and the Middle East)completed the online study questionnaire in six languages using the Qualtrics platform.The study was managed by six teams in six countries that promoted the study on social media.The questionnaire assessed anxiety,depression,stress symptoms and PTSD(CSRS,Type A),cognitive deficits and fatigue(CSRS,Type B).The data were analyzed using Proportion Analyses,Multivariate Analysis of Co-Variance(MANCOVA),linear regression analyses and validated clinical cutoff points.RESULTS The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety,depression,stress symptoms,and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents,age groups,and gender.This supports the transdiagnostic argument embedded in the CSRS(Type A).The same pattern of results was found in infected/recovered individuals.The prevalence of the 4 psychiatric symptoms combination was significantly greater than that of 5 and 6 symptoms,when adding cognitive deficits and fatigue,respectively.MANCOVA showed a significant three-way interaction(age×gender×continent).Further analyses showed that the sources of this three-way interaction were threefold relating to two sub-populations at-risk:(1)Individuals that self-identified as non-binary gender scored significantly higher on all 4 psychiatric symptoms of the CSRS,Type A at young age groups(<50 years old)in North America compared to(self-identified)women and men located in the 4 continents studied,and to other ages across the adult life span;and(2)This pattern of results(CSRS,Type A)was found also in women at young ages(<40 years old)in North America who scored higher compared to men and women in other continents and other ages.Linear regression analyses confirmed the MANCOVA results.CONCLUSION These results show a combined mental health risk factor related to stress reactivity,suggesting that the CSRS is sensitive to populations at risk and may be applied to future identification of other vulnerable sub-populations.It also supports the transdiagnostic approach for more accurate prevention and treatment.Time will tell if such transdiagnostic syndromes will be part of the discussions on the next revisions of the traditional classification systems or whether the crisis in psychiatry further evolves.

Tree Role in Environmental Quality Amelioration of the Sapienza University of Rome Campus

The capability of trees growing in the Campus of Sapienza University of Rome to improve environmental quality was analyzed. Measurements of CO2 concentration, air temperature and humidity, traffic density and noise level were carried out along a transect from streets outside the Campus to sites inside. Moreover, measurements were also carried out at the Experimental Garden placed inside the Campus. In each of the considered sites, diameter at breast height, plant height and carbon stored in the tree aboveground biomass were calculated. Air temperature in summer was 5% lower inside the Campus than in the surrounding streets, while relative humidity increased by 4%. CO2 concentration in winter was 11% lower inside than in the surrounding streets. Carbon stored by trees was 374 Mg to which Pinus pinea, Cedrus deodara, Quercus ilex and Tilia × europaea contributed by 30%, 20%, 18% and 13%, respectively. Moreover, noise level was 36% lower inside than in the surrounding streets.

Closed-loop hydrometallurgical treatment of end-of-life lithium ion batteries: Towards zero-waste process and metal recycling in advanced batteries

This work presents an enhanced hydrometallurgical process for recycling lithium ion batteries. First, endof-life batteries were processed in a physical pre-treatment plant to obtain a representative electrode material. The resulting leachate was purified forth by iron-precipitation, liquid–liquid extractions, and an innovative Li–Na separation, in order to obtain valuable products. These products include high-grade graphite, cobalt oxide(Co3O4, purity 83%), cobalt oxalate(CoC2O4, purity 96%), nickel oxide(Ni O, purity89%), and lithium carbonate(Li2CO3, purity 99.8%). The recovery rate was quantitative for graphite, between 80% and 85% for cobalt depending on the nature of the recovery method, 90% for nickel, and 72%for lithium. Secondary streams were also valorized to obtain sodium sulfate(Na2SO4, purity 96%), and MnCoFe2O4 magnetic nano-sorbents according to the zero-waste concept. In order to close the loop, recycled Co3O4 and NiO were used as conversion-type anode materials for advanced lithium ion batteries showing promising performances.

Persistent dysexecutive syndrome after pneumococcal meningitis complicated by recurrent ischemic strokes:A case report

Meningitis is a possible complication of pneumococcal infection concerning acute otitis media and sinusitis.It might compromise cognitive function,both for the infection itself and the vascular events that sometimes follow the acute phase.CASE SUMMARY Here we describe the case of a 32-year-old female patient admitted to the emergency room due to extensive pneumococcal meningitis as a consequence of sinus outbreak.She presented with extensive laminar ischemic damage in the acute phase,resulting in severe cognitive and behavioural impairment.Four years of follow-up,through neuropsychological assessments and neuroradiological investigations,demonstrated the presence of subsequent vascular events,3 months and 2 years after onset.CONCLUSION The case is discussed in light of scientific knowledge of the long-term outcomes of this pathology in order to potentially improve diagnosis and promote better outcomes.

A systematic review of salivary biomarkers in Parkinson's disease

The search fo r reliable and easily accessible biomarkers in Parkinson's disease is receiving a growing emphasis,to detect neurodegeneration from the prodromal phase and to enforce disease-modifying therapies.Despite the need for non-invasively accessible biomarke rs,the majo rity of the studies have pointed to cerebrospinal fluid or peripheral biopsies biomarkers,which require invasive collection procedures.Saliva represents an easily accessible biofluid and an incredibly wide source of molecular biomarkers.In the present study,after presenting the morphological and biological bases for looking at saliva in the search of biomarkers for Parkinson's disease,we systematically reviewed the results achieved so far in the saliva of different cohorts of Parkinson's disease patients.A comprehensive literature search on PubMed and SCOPUS led to the discovery of 289articles.After screening and exclusion,34 relevant articles were derived fo r systematic review.Alpha-synuclein,the histopathological hallmark of Parkinson's disease,has been the most investigated Parkinson's disease biomarker in saliva,with oligomeric alphasynuclein consistently found increased in Parkinson's disease patients in comparison to healthy controls,while conflicting results have been reported regarding the levels of total alpha-synuclein and phosphorylated alpha-synuclein,and few studies described an increased oligomeric alpha-synuclein/total alpha-synuclein ratio in Parkinson's disease.Beyond alpha-synuclein,other biomarkers to rgeting diffe rent molecular pathways have been explored in the saliva of Parkinson's disease patients:total tau,phosphorylated tau,amyloid-β1-42(pathological protein aggregation biomarkers);DJ-1,heme-oxygenase-l,metabolites(alte red energy homeostasis biomarkers);MAPLC-3beta(aberrant proteostasis biomarker);cortisol,tumor necrosis factor-alpha(inflammation biomarkers);DNA methylation,miRNA(DNA/RNA defects biomarkers);acetylcholinesterase activity(synaptic and neuronal network dysfunction biomarkers);Raman spectra,proteome,and caffeine.Despite a few studies investigating biomarkers to rgeting molecular pathways different from alpha-synuclein in Parkinson's disease,these results should be replicated and observed in studies on larger cohorts,considering the potential role of these biomarkers in determining the molecular variance among Parkinson's disease subtypes.Although the need fo r standardization in sample collection and processing,salivary-based biomarkers studies have reported encouraging results,calling for large-scale longitudinal studies and multicentric assessments,given the great molecular potentials and the non-invasive accessibility of saliva.

Application of ultrasonography-elastography score to suspect porto-sinusoidal vascular disease in patients with portal vein thrombosis

Background:Porto-sinusoidal vascular disease(PSVD)and portal vein thrombosis(PVT)are causes of portal hypertension characterized respectively by an intrahepatic and a pre-hepatic obstacle to the flow in the portal system.As PVT may be a consequence of PSVD,in PVT patients at presentation,a pre-existing PSVD should be suspected.In these patients the identification of an underlying PSVD would have relevant implication regarding follow-up and therapeutic management,but it could be challenging.In this setting ultrasonography may be valuable in differential diagnosis.The aim of the study was to use ultrasonography to identify parameters to discriminate between PSVD and“pure”PVT and then to suspect PVT secondary to a pre-existing PSVD.Methods:Fifty-three patients with histologically proven PSVD and forty-eight patients affected by chronic PVT were enrolled and submitted to abdominal ultrasonography with elastography by acoustic radiation force impulse(ARFI).Results:ARFI was higher and superior mesenteric vein(SMV)diameter was wider in PSVD patients than in PVT patients.Thus,a prognostic score was obtained as linear combinations of the two parameters with a good discrimination capacity between PSVD and PVT(the area under the curve=0.780;95%confidence interval:0.690-0.869).Conclusions:A score based on ARFI and SMV diameter may be useful to suspect an underlying PSVD in patients with PVT and to identify a subgroup of patients to be submitted to liver biopsy.

Dynamic contrast enhanced ultrasound in differential diagnosis of hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND Non-invasive differential diagnosis between hepatocellular carcinoma(HCC)and other liver cancer(i.e.cholangiocarcinoma or metastasis)is highly challenging and definitive diagnosis still relies on histological exam.The patterns of enhancement and wash-out of liver nodules can be used to stratify the risk of malignancy only in cirrhotic patients and HCC frequently shows atypical features.Dynamic contrast-enhanced ultrasound(DCEUS)with standardized software could help to overcome these obstacles,providing functional and quantitative parameters and potentially improving accuracy in the evaluation of tumor perfusion.AIM To explore clinical evidence regarding the application of DCEUS in the differential diagnosis of liver nodules.METHODS A comprehensive literature search of clinical studies was performed to identify the parameters of DCEUS that could relate to histological diagnosis.In accordance with the study protocol,a qualitative and quantitative analysis of the evidence was planned.RESULTS Rise time was significantly higher in HCC patients with a standardized mean difference(SMD)of 0.83(95%CI:0.48-1.18).Similarly,other statistically significant parameters were mean transit time local with a SMD of 0.73(95%CI:0.20-1.27),peak enhancement with a SMD of 0.37(95%CI:0.03-0.70),area wash-in area under the curve with a SMD of 0.47(95%CI:0.13-0.81),wash-out area under the curve with a SMD of 0.55(95%CI:0.21-0.89)and wash-in and wash-out area under the curve with SMD of 0.51(95%CI:0.17-0.85).SMD resulted not significant in fall time and wash-in rate,but the latter presented a trend towards greater values in HCC compared to intrahepatic cholangiocarcinoma.CONCLUSION DCEUS could improve non-invasive diagnosis of HCC,leading to less liver biopsy and early treatment.This quantitative analysis needs to be applied on larger cohorts to confirm these preliminary results.

Editorial article to:Animal experimental study on magnetic anchor technique-assisted endoscopic submucosal dissection of early gastric cancer

In this editorial we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2023;15(11):634-680.Gastric cancer(GC)remains the fifth most common malignancy and the fourth leading cause of cancer-related death worldwide.The overall prevalence of GC has declined,although that of proximal GC has increased over time.Thus,a significant proportion of GC cases and deaths can be avoided if preventive interventions are taken.Early GC(EGC)is defined as GC confined to the mucosa or submucosa.Endoscopic resection is considered the most appropriate treatment for precancerous gastrointestinal lesions improving patient quality of life,with reduced rates of complications,shorter hospitalization period,and lower costs when compared to surgical resection.Endoscopic mucosal resection(EMR)and endoscopic sub-mucosal dissection(ESD)are representative endoscopic treatments for EGC and precancerous gastric lesions.Standard EMR implies injection of a saline solution into the sub-mucosal space,followed by excision of the lesion using a snare.Complete resection rates vary depending on the size and severity of the lesion.When using conventional EMR methods for lesions less than 1 cm in size,the complete resection rate is approximately 60%,whereas for lesions larger than 2 cm,the complete resection rate is low(20%-30%).ESD can be used to remove tumors exceeding 2 cm in diameter and lesions associated with ulcers or submucosal fibrosis.Compared with EMR,ESD has higher en bloc resection rates(90.2%vs 51.7%),higher complete resection rates(82.1 vs 42.2%),and lower recurrence rates(0.65%vs 6.05%).Thus,innovative techniques have been introduced.

Integration of Environmental and Social Values in Cultural Spaces:Sustainable and Inclusive Wayfinding Materials for Museums

In the context of use of large museum centers,numerous national and international methodological experiments show that the wayfinding project must consider the needs of both habitual users(user-centered design)and local communities(design for communities)and the importance of environmental protection(eco-design)as a priority interest of the community.This“double target”,“user-centered”and“environment-centered”can be applied during the selection process of materials to be used in the project.With respect to these possibilities,this contribution intends to present the results of research focused on material characterization of the reception and distribution spaces of large museum centers.This characterization is based on use of sensory materials and aims to evaluate their impact on the usability and sustainability of wayfinding systems.The paper directed towards a proposal for organization of integrated information on new generation so-called smart materials;within the design of a wayfinding system,these can balance the aesthetic-perceptual and performance and environmental impact,in order to allow designers to make informed decisions oriented towards inclusion and sustainability.The study was addressed by conducting two phases of systematic literature and library review of materials.The investigations conducted led to achievement of a first research result which consists in the identification of a“standard sheet”for the mapping and cataloging of the materials used for wayfinding.The“standard sheet”allows organizing the information on smart,sensorial,and eco-friendly materials,balancing the aesthetic-perceptive component with the performance on the environmental impact along the entire life cycle in a circular perspective.This tool could guide designers towards an environmental communication project oriented towards sustainability and is effective for usability and wayfinding.

Carbon Dioxide Sequestration Capability of the Botanical Garden of Rome: Environmental and Economic Benefits

Carbon dioxide (CO2) is one of the most abundant anthropogenic greenhouse gases contributing to increase air temperature. Urban areas covered by parks, gardens, tree-lined avenues, sports fields, and hedges are important sinks for CO2. Urban green areas should include the Botanical Gardens, taking into consideration their key role in ex situ plant conservation as well as air quality amelioration and social benefits. In such context, the CO2 sequestration capability of the most representative plant collections developing in the Botanical Garden of Rome and their influence on microclimate was analyzed. Our results highlight that plant collections have a CO2 sequestration capability of 6947 Mg CO2 year-1. The CO2 sequestration capability and air temperature lowering by plant collections growing in the Botanical Garden have positive effects (p ≤ 0.05) on the surrounding area resulting in 4% CO2 concentration and 1°C air temperature decreasing at 150 m from the centre of the Garden.

Understanding the Benefits from Green Areas in Rome: The Role of Evergreen and Deciduous Species in Carbon Dioxide Sequestration Capability

Urban areas are a major source of anthropogenic carbon dioxide (CO2) emissions because of road traffic and local heating with natural gas, oil or coal. Rome is among the largest European cities (129,000 ha) with a large volume of green areas (69.6% of the total Municipality area). The CO2 sequestration (CS) capability for the greenery extending for about 300 km2 inside the area delimited by the Great Ring Road (GRA) in Rome was calculated combining satellite data with CS data measured in the field. Data from Sentinel-2 were collected and the Normalized Difference Vegetation Index (NDVI) was computed on a pixel-base. Three plant classes homogeneous in terms of annual NDVI profile were identified: deciduous trees (DT), evergreen trees (ET) and meadows (M) covering an area of 14,142.027 ha within the GRA, of which M had the highest percentage (48%), followed by DT (27%) and ET (25%). CS ranged from 428,241,492.9 Tons CO2 year-1 (ET) to 263,072,460.6 Tons CO2 year-1 (M). The total CS of the greenery inside the GRA was 1049,490,355.4 Tons CO2 year-1 resulting in an annual economic value of $772,424,901.6/ha. The CO2 sequestration capability of the considered plant classes could be incorporated into the national greenhouse gas emission budget to calculate the contribution of CO2 sequestration to the economy of Rome.

Respiratory Disorders in Acromegalic Patients

Purpose: To evaluate the prevalence and clinical performance of obstructive sleep apnoea syndrome (OSAS) in acromegalic patients, focusing on the possible correlation between alterations of pulmonary microcirculation and patient’s clinical and hormonal parameters. Methods: We enrolled 22 acromegalic patients with apnea hypopnea index (AHI) ≥ 5 if symptomatic, or ≥15 in the absence of sleep related symptoms. Patients underwent the following evaluations: GH and IGF-1 serum levels, arterial blood gas test, spirometry, carbon monoxide diffusing capacity (DLCO), home-based cardiorespiratory sleep and pulmonary function test. Results: The prevalence of OSAS was 66.6%. Patients with a severe form of OSAS appeared to be affected from acromegaly for more years than those with a lower severity of disease and those with acromegaly duration > 10 years had significantly higher levels of glycated hemoglobin. We observed a positive correlation between GH level at diagnosis and DLCO value, showing that acromegalic patients have an increase in static and dynamic respiratory volumes and alveolar-capillary exchange surface compared to the general population. We also observed a positive correlation between baseline serum IGF-1 level and DLCO/VA and between years of disease and DLCO/VA, showing the association of increased lung volume and increase of the exchange surface. Conclusions: The results of this study add new information on lung volume and alveolar gas exchange in acromegaly. Our findings highlight the role of SSA as therapy with positive impact on complication and comorbidities of acromegaly.

Relationship between Atmospheric CO₂Concentration and Vegetation in a Hospital Area: The Policlinico Umberto I in Rome

The capability of the plants growing in the Policlinico Umberto I, one of the most important hospitals in Rome, to lower carbon dioxide (CO2) and air temperature was analyzed. The CO2 concentration inside and outside the hospital and traffic density in the streets surrounding the area was monitored monthly. Measurements of structural plant traits were carried out. The highest CO2 concentration was monitored in winter-spring (425 ± 8 ppm, mean value) when traffic density peaks, decreasing by 17% in summer. During the day-time, the highest CO2 concentration (433 ± 61 ppm, mean value) was measured in the first hours of the morning (9:00) decreasing by 12% from 11.00 to 13.00 in relationship with traffic density decreasing (p 0.05). Among the greening present in the hospital area, the “group of trees” plays an important role in lowering CO2 concentration compared to meadows. Moreover, outside the Policlinico air temperature was, on average, 17% higher compared to the inside. The results show the effectiveness of plants in improving air quality and suggest that greening traits may be used to realise an inventory available for tree planting programs to ameliorate the quality of life.

The Effectiveness of Clinical Colloquium Established by the “Drawing Recall” Technique in University Counselling Services for Student Mental Health

An experimental assessment of the effectiveness of university counselling was conducted through the “Stress Drawing Recall” Technique applied before and after a clinical colloquium with 70 university students of both genders, aged 18 - 35 years, who had requested this service. Another 70 students waiting to undergo the colloquium were interviewed as a control group. Two parallel series of drawings depicting personal stress situations were collected and, after evaluation by three expert judges in “double-blind” conditions, led to establishing five forms of development of the graphic language from the first to second drawing, defined as follows: a) distension, with a reduction in stress indicators and increase in comfort indicators;b) explicit representation of conflict resolution;c) appearance of new elements, with persisting conflict;d) increase in stress indicators;e) invariant or equivalent repetition of the stress drawing. Results showed that students who underwent the clinical colloquium (experimental group) changed their stress drawings mainly in the direction of distension and conflict resolution, while the control group had more invariant or equivalent repetition of the stress situation (?= 62.77;p < 0.001). The events depicted in the stress drawings were divided into three categories: a) limited short-term stressful situations due to mainly external agents;b) externally induced stressful situations with intense emotional resonance;c) wide-ranging long-lasting stressful situations with great involvement of the self. The participants were divided into: a) very anxious subjects;b) averagely anxious subjects;c) not very anxious subjects, on the basis of their scores on two questionnaires: the MPI (1959) and the STAI (1970). There is a correspondence between the subjects’ level of conflict and extension of the depicted stress. This confirms the usefulness of the Stress Drawing Recall Technique in psychological counselling.

An operator methodology for the global dynamic analysis of stochastic nonlinear systems

In a global dynamic analysis,the coexisting attractors and their basins are the main tools to understand the system behavior and safety.However,both basins and attractors can be drastically influenced by uncertainties.The aim of this work is to illustrate a methodology for the global dynamic analysis of nondeterministic dynamical systems with competing attractors.Accordingly,analytical and numerical tools for calculation of nondeterministic global structures,namely attractors and basins,are proposed.First,based on the definition of the Perron-Frobenius,Koopman and Foias linear operators,a global dynamic description through phase-space operators is presented for both deterministic and nondeterministic cases.In this context,the stochastic basins of attraction and attractors’distributions replace the usual basin and attractor concepts.Then,numerical implementation of these concepts is accomplished via an adaptative phase-space discretization strategy based on the classical Ulam method.Sample results of the methodology are presented for a canonical dynamical system.

Prognostic role of metformin in diabetes mellitus type 2 patients with hepatocellular carcinoma:A systematic review and meta-analysis

BACKGROUND Hepatocellular carcinoma(HCC)is among the commonest malignancies associated with significant cancer-related death.The identification of chemopreventive agents following HCC treatments with the potential to lower the risk of HCC adverse course is intriguing.Metformin,a first-line agent used in the treatment of type 2 diabetes mellitus(T2DM),has been associated with inhibition of HCC growth.AIM To determine whether metformin can prevent adverse events(i.e.,death,tumor progression,and recurrence)after any HCC treatment in T2DM patients.METHODS A systematic review of the published literature was undertaken focused on the role of metformin on outcomes in patients with T2DM and HCC receiving any tumor therapy.A search of the PubMed and Cochrane Central Register of Controlled Trials Databases was conducted.RESULTS A total of 13 studies(n=14886 patients)were included in this review.With regard to the risk of death,a decreased risk was reported in cases receiving metformin,although this decrease was not statistically significant[odds ratio(OR)=0.89,P=0.42].When only patients treated with curative strategies were considered,a more marked correlation between metformin and favorable cases was reported(OR=0.70,P=0.068).When analyzing palliative treatment,there was no statistical significance in terms of the correlation between metformin and favorable cases(OR=0.74,P=0.66).As for the risks of progressive disease and recurrence,no obvious correlation between metformin use and reduced risk was reported.When sub-analyses were performed for patients from different regions,the results for patients from Eastern countries showed a tendency for decreased risk of death in T2DM cases receiving metformin(OR=0.69,P=0.17),but the same was not seen in patients from Western countries(OR=1.19,P=0.31).CONCLUSION Metformin failed to show a marked impact in preventing adverse effects after HCC treatment.A trend was reported in T2DM cases receiving curative therapies in relation to the risk of death,especially in patients from Eastern regions.Great heterogeneity was reported among the different studies.Further large studies are required to definitively clarify the real impact of metformin as a chemopreventive agent for HCC.

Vacuum Correlations, Detector Efficiency Fluctuations and Classical Dynamic Violations of CH-Inequality

We study in this paper the possible influence of vacuum fluctuations on photo detection and its background noise in Bell tests. We analyze its consequences on the standard statistical analysis of data showing that it is not fulfilled anymore the conventional hypothesis of a Poisson like probability density distribution of single photodetection events. We assume that vacuum fluctuations are due to real and measurable fluctuating fields, as recently confirmed experimentally, and that their non null correlations outside the light cone contribute to photon coincidence rates making them time dependent. We introduce a generalized Bell like correlation function which contains a new term due to supposed vacuum induced photon counting events. We deduce then a generalization of CH-inequality which takes in account the effect of these vacuum electric fields on detector efficiency. We predict an apparatus temperature fluctuations during photon detection which we suggest could be observed by looking for colored noise thermal emission of the photodetectors, generalizing the standard white noise prediction of C.S.L. models on wave function collapse postulate. We discuss an experimental test of this prediction, based on the idea of inducing a thermal wave on the whole quantum detectors, aimed to observe time dependent deviations from standard stationary statistical predictions of Quantum Mechanics.

Interventional treatment options for management of delayed arterial hemorrhage after major hepato-pancreatic-biliary surgery

Hilar cholangiocarcinoma is a biliary malignancy arising from the perihilar biliary tree,which is associated with poor oncological outcomes due to its aggressive biology,chemo-resistance and insidious onset[1].As stated by Di Martino et al.,the standard of care is radical resection,and during the last decades,there have been great efforts to improve survival of potentially resectable hilar cholangiocarcinoma,with surgery being the treatment associated with longer survival[2].However,radical resection still represents a challenging operation with high risk of intraoperative and postoperative complications.