Prof. Tingbo Liang Radical Resection Combined with Intel. Autotransplantation (RRCIA)

Hello. Hello. Hello. Can you hear me? I'm Dr. Liang. Hi, Professor Liang. Good morning. My name is Umberto

Grandi. I'm from Ravenna, a northern city on the Adriatic Sea, but now I am in Rome.

As every year, Professor Palazzini asks me to come here and have a speech with

surgeons all over the world. So I've just read your CV, your curriculum vitae, and it looks like

as I have to introduce you to all the people here, it's a curriculum vitae that's simply

overwhelming. And you are chairman of the first affiliated hospital in the Yang University School

of Enhanced Recovery After Surgery.

Vice Chair of the Professional Committee

of Pancreatic Disease, Chinese Medical Doctor Association.

of Bile Duct Cancer, China Anti-Cancer Association.

So many papers, so many prizes.

I'm really astonished and really honored

Professor Liang to be here with you today.

Okay, thank you very much.

Dear Professor Barzini and Grandi, thank you for your invitation to give me the opportunity to present our recent work.

Even though we cannot talk face-to-face, we can exchange online because of the pandemic disease.

this. Thank you again for your introduction to me. Today I will give

colleagues the title of my presentation, Radical Restriction Combined with Small

Intestine Autotransplantation. We named this technique the RCIA for local

advanced pancreatic cancer. The topic contains the why and how we do it.

Next please. Next. So everyone knows that pancreatic cancer is a highly fatal

disease. The five-year survival ratio is very low. It represents the reporting

only 10% of 5-year survival ratio, only much increment in progress and enhancement, a little

bit progress in patient outcome in the past 30 years compared with other solid organ from

from 5% to 10%, so it is becoming an increasingly common cancer-induced mortality of the patient,

Projecting to become the second leading cause, maybe in 2030, in America, about 80,000 or

90,000 new cases every year, and in China, maybe more than 50,000 every year.

For the staging system, we usually use the clinical staging system.

Most patients, I mean half the patients, when first interview the doctor, the half patient is M1.

I mean already the cancer cell metastasis in liver, lung, and etc. are the audience.

and about 30% is borderline or local vascular, which means the tumor in my

vein, artery around the tumor, depends on degrees of the invited so the

classified borderline or local vascular. Only 30% patient is

a red residual which means the tumor is free from the two vessels so

we can reveal that this paper is the paper published in 1930 last year by John Hopkins

team by professor He Jin he just finished the survey of the international

international pancreas surgery which including the 153 response from the four

countries. Most of the doctors recommended neoadjuvant

chemo and sometimes the modified fiprolox is preferred. 41%

recommended neoadjuvant and half more than preferred chemo plus the

radiosurgery, nearly all were considered well-being resection after the

neoadjuvant for the slight patients. Only half of doctors were considered artery resection,

because why the surgeon worried about the artery resection? Because the worry about the R0 resection

ratio is low, especially for the longitudinal, which means the

CAS-MGA enhancement for lung and lens is severe. Only 14% of surgeons

may be chosen for operation. So next. This is the case we need here.

The patient is 58 years old, female, PS score is 0, low-advanced with longitudinal

enhancement of SMA. She gained weight loss, felt less pain on the C19, decreased to normal range

after new enrollment for four months. However, response evaluation is FD. So how about we will

well choice, next step, who operation which may be select, one step, one option is to

continue the chemotherapy, but as we know, the tumor well have a drug resistance, so

the tumor well progress.

In our global experience, even though modified fuconoxy or AEG, the tumor occurs, the resistance

is about 10 months after onset of tumor. A second operation is surgical

separation, but we worry about the R0, cannot achieve the R0 if we give the

patient a standard resection because the tumor invited the SMA, C-electron

or SMMA so long, we cannot give the reconstruction with the standard

other methods. So usually some doctors may be choice the artificial graft

interpolation, but usually the symbiosis will happen within the three months,

which will induce a complication, and this kind of operation is only applicable for the

short abluminal enhancement because if you're long you can we cannot read a construction

by execution or attribution for the personal smv or sma this paper is the published in

2018. so next one why didn't the surgeon offer the operation even after the first new

new adjoint. As I just mentioned, R0 research ratio is an important factor.

So if the patient can attain R0, the overall survival is better, but if there

is R1 or R2, the prognosis is worse compared with non-surgical, even the

similar okay so this is a two paper published already why the internal

analysis of the CoQ007 trial, the result show OS is 16.9 months for

the surgery for the non-surgery but if the patient have chance

surgery, the OS is more than 26 months, and the DFS is different, if we can attend the

R06. We published our results in the Journal of Oncologists two years ago. We compare local

patients which receive neoadjuvant, if the patient be transferred to the

standard resection, the OS and PFS is better than the local lines which have no

opportunity to receive the surgery, I mean the fail to transfer to successful.

So in our group, only the transfer ratio for localize of the new adjoining is a 34%.

This full chart shows how well we resolved for the CA and SMA invasion patient.

This is published in British General Surgery last year, and just as our consideration,

variation, we worry about the tumor inviting the SMGA or silicones around, I mean the shells.

So during refraction, the ulcer advocate gave the shells for resection.

If the resection is okay, I mean the negative, maybe the shells dissection or sometimes the

the short signal artery part and the cancer is better.

But for the patients,

the tumor inside the SMA or cell trunk very long

on the cells or around the cell trunk or the SMA cells

is positive.

Why?

I mean, what method will be preferred?

confirmed, and this kind of patients is very common.

So the aim to achieve the R0, REPS and DPK is for some kind of patient with tumor located

in the neck or body and tail fungus, which means the aim of the REPS and DPK is also

to attend, in order to attend the R0 restriction, but the tumor invited the same drug, or SMA

disperse part, or proximal and distal part both, how could we do?

So we try the RICIA, I mean the radical restriction, combined with the intestinal auto transplantation

which technically means the aim to remove the tumor invited the important vessel and in order

to R0 restriction. In order to our new technique, we revealed before the paper published already

from the 1996 to the 2002, only six reports which include Australia, USA, Italy, Japan, China and

only 16 local advanced patients involved, but the OS is only

more than one year, only six patients received neurodegenerative

because at that time we have no effective arrangements, only one patient

only underwent in viral resection. I mean most patients

is in block outside the body including the small intestine and the tumor

outside the body and resection tumor outside

your body and the re-implantation of the small intestine again which

which today I didn't well discuss this technique's disadvantage, I just report our primary experience.

So neurodivergent chemo is necessary to benefit the RIC-A because some little patients received

neurodivergent just published the regimen in early single drug, I mean the dystopian

early.

Okay, so the shortcoming Professor Tim's report. So relatively high per

operative mortality, this group, which includes 8 patients, 5

patients die within 6 months, most patients die within 3 months

because of the complication, and the relative low ratio of the

neoadjuvant came out, only performed in local vans located in the head of the progress. I mean

this kind of sex patient is PD plus the small intestine. So which gave us some thinking,

can we improve the safety of the RICIA, that the neoadjuvant, the new neoadjuvant,

I mean the new neoadjuvant regimen can improve the survival, I mean such as the AG regimens or

a new fiprofenoxy, etc. And is there any type of the RRCA for the different locations of the tumor

which is including the tumor located in the prior body or tumor invited cell drug in both

the SMA or SMV. Next question. So the advantage of the neurodivergent is very familiar to

to every surgeon of the physician with family advantage, which will remove the latent metastasis

on the CDC.

We will give our chance, select some of the appropriate patients which can be received

the RICI or standard restrictions.

So our improvement tool establishes the whole purpose of the measurement for patients, which

which includes neurodegenerative chemo, surgery, adjuvant chemo again, and follow-up.

We will manage long-term complications.

I mean, I will introduce it later.

So the neurodegenerative, we usually give the patient with a good response to chemo

survey, PS score is 0 to 1, SMA invited by tumor or SMA, we invited two

intensive, two reconstruct with standard measures, and the patient no

distanced metastasis. We usually give the patient MRI or PET-CT scan before

we give the patient, before we give the surgery. And step two, we will prepare, I mean

the planned HGA or PHA reconstruction if possible and remove the small intestine, tumor restriction,

implantation of small intestine, digestive tract reconstruction. This is the full chart and

follow up the contents including the recurrence of survival, complication of

such as infection, diarrhea, and diabetes, etc. So look at the

longitudinal cell-tronc and SME encasement, how we do. So for example, your tumor

invites the cell-tronc, and the GDH is okay, maybe we give the

modified PBE, this is a very common

the method, the tumor invited the cell trunk and the GDLase invited both, so we

usually gave the total pancreatectomy and the cell trunk removed and have the artery

graft reconstruction in order to prevent the liver is chemic. If the tumor invited

the lower, I mean the SMM or SMV very long, we give the PD and small

intensity autotransplantation. This is the type 1, we named the type 1

RR-CIA. Again if the tumor located only the body and neck of the pancreas, the

the head of the pancreas is okay, so we give the type 2, we mean the distal pancreatectomy

plus small intestine auto transplantation.

After some time, the tumor invites the surgical crown on the board, the SMA or SMZ, because

the tumor is large and surgical crown and SMA is really near, so the tumor invites the

both important muscles, we will usually give the type III RICIA, which means total pancreatectomy,

total gastric tectomy, and small intestine transplantation also. I will give the short

video later. So this is the chart, this is our cartoon, first type of abdominal cavity

separation, dissection SMV free of the tumor, we mean for smell, not for

the distal part, and the pancreas duodenal tectomy, it has lymph node

dissection, I mean the stage 6 lymph node dissection, because we

usually, we usually, it's necessary to cause ALTA and IVC in order to

to endothelmosis later, so small intestine resection and control

corporeal larvae and starch with eyes and vascular endothelmosis by

just stereo tract reconstruction, which is the common, is similar is PD, this

this is the graph, so the PD related on the R-ICI type 1, it shows

portvin clamp, tumor removed, and the stem of the pancreas, and the

hepatitis R is okay, so the right side is shows we do the portvin and SMA

cancer already, and BW small intestine, anastomosis already. Next,

this is type 2 RICI video, okay go on, this is the sex, 54, female,

female, and before, back please, I will talk to this patient, this is a female, this lady

fell off the ibuprofen for two weeks, C19 is more than 16,000, 6,000, CTMI showed the

local device, we gave the biopsy, and gave the patient MDD discharge, gave the neurodegenerative,

We get the modified prognosis for 16 cycles and SBRT for 5 days.

So the evolution again is a stable disease, the tumor shrink, tumor marker decrease to

the normal range.

So we start to plan the reticle restriction combined with small intestine auto-transplantation.

So next, we can reveal the CT and MRI, imagine show the SMA invited by the tumor, even though

the tumor survey is effective, so we cannot give the patient tumor removed with the PD

only.

So next please. So we usually give this CT venous imaging, we will show the tumor invited,

the important muscle and some of the branch, some of the

the length of the vasotumor be invited. okay next so I will give the

video operation. this video is about 10 minutes so first we give the

operation in order to find the only micrometastasis in the abdominal wall

so first step is dissection SMA, SMV, which we didn't touch the tumor

only in the distal part, the tumor invited the muscle in the proximal, so

this is dissection of the aorta and IVC, we usually give the lymph node

the signaling and the forensics, which including the setting A or setting B

station, which is the dissection of the SMA, the roots are just near the left

ring, we use the vessel of the left ring, so you very easy to pause the SMA

roots. This patient tumor invited only distal part, so this is the

cells and the soft tissue around the SMA, we give the first section, the result is

negative, this is the CBD transection, in order to the contamination, we ligate the CBD

the two ends. So this is a right represented capital artery, just from the SMA. So we will

reconstruct. In order to reconstruct RI's capital artery, we suppose the capital artery and GDA,

because DIGMA didn't invite the GDA so we wanted to use the GDA step

and other slow-mo is with RI replacement right have the RT so we

suppose the dis-support of the GDA so the VASA is normal, we decision gain

remove the station 12, the pod vein, there, we pause the normal tissue of the pod vein,

the tumor just beyond, just in the lower part of the pod vein, we didn't do any

sheath for the tumor, only around the tumor we dissect it, so we transection

slow mark, you just use a stabilizer and the coaxial maneuver is the

renal, the sacral, we prepare to transaction of the small

intestine and the right colon, we want to remove the small intestine, so we try

this K-mean line here, so this is the first male of the small

intensity, to the trisection and up the fold, trisection the roots again, the J2 is second

branch of the J genome arch, and again we preserve the circuit in order to elevate

of the diarrhea, of the wound, of the resection, of the surgery, so the roots of the

SMV is just free, so this is the bifurcation of the SMV, small

intestines removed outside the body, and lavage to the venous plastic,

use the autograft elective vein and elective, so trans-saccharine pancreas, we want to

remove the tumor because the port vein and spleen vein is okay, so you can see the

fibrosis after the chemo and reading, so this is the GDA stack, on the right side

the hepatoartritis and the sclerosis, this is necessary to reconstruction because the

patient received so many times the chemotherapy, and the liver cell injury,

sometimes the yellow liver or blue liver, depends on the regimen you select,

so the sufficiency of the blood supply to liver is very important, so we use the

stem SMA because the first section is negative, it is the root of the SMA, we just do, we now do the

graft with endothelmosis with SMA. So in the big tumble, we use the

Ehrlich artery and vein to reconstruct the prostate of the small intestine

in vessel, so it's good. The length and the diameter is okay. We do the vein and

the thrombosis, the patients, the swimming and the port vein conjunction site is

on the most location, but the port vein has a large hole, not port vein but

but spleen vein had large hole, we will give the suture again, so the small intestine is

repurposed, so here we repair the spleen vein, maybe it's IMV

location, so the small intestine is okay, recovery the blood supplication, we do the

the duct of the mucosa changing on the nose lobe with pancreas. If you worry about the pancreas leakage,

maybe you can external drainage of the pancreas. At the first phase,

I mean the first 10 cases, we worry about the leakage, because the leakage may be

induced a very severe complication, I mean that may be induced the

anemoses, the vascular anemoses, leakage in the blood, blood bleeding, so we usually give

internal, internal, outside, I mean the genital pancreas, the

outside body, but now we didn't, we only give the stand, the internal stand, so

So in this patient, we do the anterior wall anastomosis of the pancreas.

So okay, next procedure is very common, which includes pyrotractor anastomosis with small

intestine and gastrointestinal nostrils.

Okay I will finish this type 1, RICIA.

Okay go on.

the type 2 is very simple compared to type 1, because of the time limit, I

didn't know what I didn't want to show the video, again this is the card to show

the distribution of the pangolin technique and the SMA ligation, transaction, and

the representation of the similarity in terms of speed. if you can't do type 1, type 2

is very simple, very easy and accomplished, so we will skip here. Type 3 is very complicated

because the tumor invited both of the cellulose and SMA, so you must consider

liver artery sublocation and small intestine sublocation, so the vessel shape,

muscle length, another muscle is the side, you must pause quietly, this

cartoon shows total pancreatitis, total gastrointestinal, okay I will show

the video again, we can see this patient is very young, only 64

64 male, abdominal pain for four months, C19 is okay, but the CGA is high, so the

CDMI biopsy and MD discussion, the patient belongs to local

vans and we gave the motilofibrosis for health cycle and SBRT. The tumor

mark, decrease the normal range, and evolution is the SD, the tumor shrink, SD.

Okay, we plan to give the type Shui, RICIA, go on please. So we can see the CD tumor

invited sector stronger, and SMA very long, from the root to the distal part.

Portovene main trunk is okay. Tubercussion, SMV, sputum vein, and the portovene

conjunctio is invited back to. So this video is similar with our inspiration.

Gave the G2-protonol dissection and small internal root dissection in order to

you post normal normal vessels, which including the artery and the vein, in order to prevent the

the lymph leakage, I mean the Kelly leakage, Kelly leakage post operation, so you usually

give the suture around the SMASB, the soft tissue, so in order to preserve the

as long as possible small intensity, we preserve some of the branch of the SMA

but we must you must confirm the tumor didn't divide the branch of some of the

branch of the SMA, so dissection around the capital duodenal ligament, the tumor

invited the hepatotribe right and left, so this here we

show the course L and IVC, and lymph node assembling, and the

free section, transaction, the shake, and so the tissue around the SME, ligate and

transition between the SMMA and the SMMA, the soft tissue like this. So for this kind of

procedure, we must do the capillary artery anastomosis first,

and we again later we only can transition of the portal vein. So this is soft gas

the transduction, we remove the total gastric, stomach, in order to prevent the

contamination, just give the suture, this is a sliver of into the esophagus,

dissection the retropartinal continues around the around the renal,

This is the adrenal gland, the vein, just like this, so this is the branch of this

aorta. We adjust the opening and enlargement with the hole, we have the

wide-shape graph, one end to side onosomosis with the L first, and this time

the tumor look in the body, the podium is painted, but the haploid artery is already

stopped, I mean the transition beyond the tumor and near the hydra, I mean. So first

we do the nose hair, and to check any leakage, bleeding I mean, so it's okay,

the Y-shaped graft, one branch gave to the right side of the hepatotorchic artery, this branch

have two orifices, I mean two have the bifurcation in the end, one end to the

the end of the right side of the right hepatic artery, another end to the left

of the left hepatic artery, an ophthalmosis, so the patient is very complicated, the operation is very

complicated, we do the two anophthalmosis for hepatic artery, we cover the right

hepatic artery already and the left side anophthalmosis, we usually use

the 7-0 protein or sometimes with 8 or 9 because we usually do the

living donor liver transplant for infants. Every year we perform them 400

cases. I just finished two cases of living donor liver

transplantation yesterday and today we do the two cases the sublip liver

liver transplantation for infants, so the anastomosis of the

hepatitis A is very easy, so the hepatitis A recovery, the bladder

supplication, I mean the liver is okay, so at this time we can

transect and put away. This is the trunk of the cell trunk, and this is the SMA, we

just the transduction near the IELTS, this is free from tumor, this case is different,

another I just show the video because the rules of the SMA is okay in another patient,

but the tumor invited both the rules of CETACON and SMA in this patient, so we do the small

intensity representation, first do the reconstruction with artery, with y-sheet, y-arm of the graft,

so it's very easy, we use the C0 protein continuous, it only takes 5 minutes usually,

with this camera of the small intensity, usually within 2 hours, sometimes it's only

30 minutes. So the artery reconstruction is okay, the protein, not protein, SMV

reconstruction. SMV with protein. So if we give enough length of the graft during

the back table, it's very easy to recover the small enough in the back spot. So we

We unclamp the blood muscle, you can see every endothelial muscle is okay.

The small endothelium becomes red, we do the esophagus with the geogeno nozzle with the

filler.

For this kind of patient, even the complicated procedure, but we didn't worry about the

pancreas leakage. So this kind of patient usually also just in a similar type 1

it recovers most. This picture shows some graft, depends on the subtype of the

removed muscle and your selection of the graft, okay. So up to now we

performed 42 cases in our medical center, I mean by me, this is the largest number,

this is the largest group in the world up to now, type 1 including

that 28, type 3, I mean the body and tail pancreatectomy with a small

small intestine transplantation, only one, type 3, including 14 patients, so I will

mention the two cases is the unplanned RICIG because some young daughter

injury of the SMA, SMV and the reconstruction with the routine method

but the file shows the small intestine very easy mark and the ischemic time is very long

we were vulnerable so we quickly removed the small intestine and take it outside the body

I gave the rubbish and store ice storage and after we prepare we transplanted it again

so the patient has recovered smoothly. If you ever know this technique,

this kind of patient usually, you know, first will fail.

Afterwards, the small amount of veneer crushes and the patient will die. So the most

patient can start to dissolve the chemotherapy within the three months

post operation. Nutrition management is very important because the diarrhea usually

is a very common combination, but with drugs we can

control the number of that diarrhea every day. Risk of recurrence still exists

just with some surgery. No, the pulmonary cancer, sometimes we can give the

patient benefit, use our hands, I mean use our operation, but some tumor we cannot,

not even to give the kind of restriction because of the biological behavior of the pancreas.

So a closer monitor is needed.

The patient selection is very very strict or very important.

Can we have a restriction ratio as high as 67% in local vans for this kind of patient

the plus of the I just mentioned the 44% of the with the

standard method operation of the neurodevelopment of local advanced, next please.

so this table shows the every patient the saturation, the type operation,

construction, artery reconstruction, vein construction, which means SMAS and V

and the pancreatic anosomal type, okay. The combination is very

common, but the severe combination is also usual, but it must be refinement of

technique. Some common complications include diarrhea, DGE, abdominal

infection, hepatitis, and chronic relapsing of the pancreas and

fistula, transplantation of bone necrosis because of thrombosis sometimes.

Okay, up to now we follow up the longest survival patient up to date is OS

OS beyond 35 months, and the DFS dissipation is about 20.5 months.

The general, the total OS after diagnosis is more than 20 months, and after surgery

is beyond 16.7 months.

So the R0 margin, R0 ratio attained 95%, because we removed totally, we

follow up the rule of the non-touch tumor, we give an important section. This is very

different with the standard routine methods, so I'm sure even R0

rule is we can attend this level and we give the patient a neurodegenerative

patient PS is okay we can control the complications severe complications

I'm sure this kind of patient may be outcome very promising okay next so

such a consideration for me and I also give some question surgical procedure

that's the artery endothelmosis, and the vein outflow, we usually select the

port vein, sometimes we select the IVC, once it is small intestine endothelmosis,

it is the internosuloma, pancreatic jejunal nosuloma or pancreatic gastric jejunal nosuloma.

okay next one, so the advantages and challenges including this kind of

the matter. Okay, next one. I will introduce our hospital because I'm chairman of the hospital,

even though I'm a surgeon. We have 10,000 staff and more than 5,000 beds. Every day, every

Every year we service the outpatient about 7 million people, and every year the outpatient

is 220,000, every year we perform 600 large-scale operations, so especially we do every kind

kind of organ transplantation. I just mentioned, liver transplantation, we already do almost

4,000 kinds of transplantation, more than 7,000. And every year we do 400 cases of liver

transplantation, which includes living donor, combined organ transplantation, domino liver

for transplantation and small intestine transplantation is the top one

channel. We just revealed the number we do the last year is the top one in the world

including living donor, small intestine transplantation. And we have this technique so

we application this technique to the puncture treatment. I just gave the

presentation for the local mass. Thank you very much. Thank you Dr. Grandi and

Professor Pazzini. We welcome every colleagues and the physician to visit our post later.

We hope the COVID-19 disappear as quickly as possible. Thank you very much.

So, Professor Yang, I simply have no words to congratulate you for such an outstanding experience, skills, and also genius. Let me say genius.

Well, my first question, well, you already have answered, but it seems to me a very complex

procedure, and I think it can be only performed by a well-trained team and in a high-volume

hospital, but you already told me something about your hospital, so I just wanted to know

how many people do you treat per year, but I've seen already the slides.

and how many surgeons works with you that's it would be interesting again yeah please

okay i will answer your first question yeah where we do the our hvb team is very large

i mean the way we have the almost the 200 daughter you are hvb girl hvb girl yeah we

We have more than 600 beds in HBP, which include the liver, pancreas, bariatric disease, and

liver transplantation.

So every year we do more than 13,000 cases of the HBP surgery, which includes the liver

cancer, pancreas surgery, about 1,000 cases of pancreas surgery, which includes pancreas

cancer and benign.

so I just mentioned, so for this complicated procedure, in our group

because we have technique of the organ transformation, we usually to tackle

some very tiny of the artery and vascular anosomosis, for young

doctor, almost every young doctor can do this, have this technique, so

So it's very easy to do this procedure, I mean.

I already told you, it's astonishing.

These are Easterner numbers, of course.

We are not so, how to say,

it should not be possible in Italy.

And I really love the way,

what you are transmitting to us in this,

about this field.

And a second question is that when I understand

I understand that RRCIH, radical resection combined with intestinal autotransplantation, when feasible, may facilitate and block resection of the tumor and yield a higher R0 rate.

but being mostly a colorectal surgeon

and after my first years of residency in Bologna

when I was in a liver transplantation unit

I'm somehow worried about the worm ischemia of the bowel

you already told us something

but can you stress again

how do you behave with the bowel

when it's out of the body?

You mean the ischemic time? You mean the small intensity ischemic time, right?

Yep.

Yeah. For the liver, as you just mentioned, you study in the USA, the cold storage within 10 hours is okay, it's safe.

But for the small intensity, usually 6 hours.

six hours, but for the auto transplantation of small intestine, we usually

reprofession within two hours, because it is a planned procedure, we just

prepare and remove the small intestine, and it's okay, we remove the

just the larvae and remove the tumor and the reprofession very quickly, so

within six hours, it's okay, it's saved for the small intestine.

Usually, the mucosa will be injured because of the cell and sometimes after the operation

the patient will have diarrhea, but one week or two weeks is okay recovery.

Thank you so much.

I don't know if there is someone, colleague, who wants to ask something extra.

Jacopo, anything?

Thank you, Professor Leung. It's a great pleasure for us to have the opportunity to see your procedure.

I'm really impressed because it's something that we can't propose in our centers just because it's a really complicated procedure for us and for our volume of patients.

but I think today we can learn a lot from you and I'm no words just I want to say thank you and in

Italy particularly in our Center in case like those you have shown us we we can propose only

to continue chemotherapy or sometimes we can suggest to use radiotherapy to treat

this this lesion obviously you asked for your data you obtained a good overall

survival of these patients so there is a difference maybe we need some studies to

to better understand the differences in our survival between normal practice, so continue

chemotherapy and your procedure.

But it's a really good procedure.

Again, I think it's a little bit complicated to perform in our centers, but maybe it's

just because our volume is not like your volume.

And, yeah, now for these type of patients,

we are studying something other like radiofrequency,

some other local procedure, but our palliative procedure.

Your procedure is a curative procedure, so that's the difference.

So again, thank you very much for your presentation.

Thank you.

Thank you very much for your so high evaluation to our group.

Yeah, we learned so much from Vitaly, the physician and colleagues, such as liver transplant

or biliary tract surgery, etc.

So we hope we celebrate each other bilaterally, we change in future.

In the future, we hope you and your colleagues with the department or group will exchange maybe face-to-face in the future.

Hopefully. Thank you very much, Professor. Thank you.

Thank you.

Thank you. Bye.

Bye-bye.