BackgroundBacterial infections in cirrhotic patients remain a challenge. Presepsin has been proposed as a valuable sepsis biomarker. We aimed to assess plasma presepsin levels in uncomplicated cirrhotic patients and to correlate them with liver disease severity and complicating events, defined as documented bacterial infection with or without concomitant portal hypertension-related bleeding, or bleeding without documented bacterial infection, with or without acute kidney injury.MethodsWe prospectively evaluated the presepsin levels of 108 consecutive uncomplicated cirrhotic patients with compensated (55, 50.9%) or decompensated (53, 49.1%) cirrhosis. During the follow up, 20 patients were reevaluated for a complicating event.ResultsMean baseline presepsin levels of the entire population were 440.4 pg/mL. Patients with decompensated cirrhosis exhibited significantly higher baseline levels than patients with compensated cirrhosis (599.1±492.2 vs. 287.5±130.5 pg/mL, P<0.001). In complicated cirrhotic patients, admission levels were remarkably higher than baseline (1438.0±1247.2 vs. 725.3±602.8 pg/mL, P<0.001), especially in those who developed acute kidney injury compared to those who did not (1827.3±1118.8 vs. 1048.7±1302.1 pg/mL, P<0.05). Baseline presepsin levels, using a cutoff of 607.5 pg/mL, could predict liver disease-related 3-month mortality with 77.8% sensitivity and 86.9% specificity: area under the receiver operating characteristic curve 0.825; 95% confidence interval 0.684-0.967; P<0.01.ConclusionsPlasma presepsin levels are elevated in uncomplicated cirrhotic patients, especially in those with advanced liver disease, and rise further in those complicated by an event. Baseline presepsin levels in cirrhotic patients could be used as an additional marker, along with the model for end-stage liver disease score, to predict short-term outcomes.

Hemorrhoids are a common anal disorder which affects both men and women of all ages. One out of ten patients with hemorrhoidal disease, requires surgical treatment. Unfortunately though, hemorrhoidectomy is closely related to complications that can be present early or late postoperatively. In the present manuscript, the safe surgical technique which emphasizes to the identification of the key anatomical structure of the ligament of Parks (Trietz's muscle) is adequately described. A total of 200 patients with grades III and IV hemorrhoids, underwent Milligan-Morgan or Ferguson's hemorrhoidectomy. The mucosal ligament of Parks was identified to all patients and was used as a key anatomical structure through the excision of the hemorrhoids. Its identification guides surgeons during the operation and reduces the major problem of postoperative complications. Finally, since the mucosal ligament of Parks represents a constantly identifiable landmark, it allows simple and reliable identification of the internal sphincter muscle and minimizes the probability of postoperative complications.

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557 Background: HCC recurs in 70-80% of cases following potentially curative liver resection (LR) or radiofrequency ablation (RFA) and the immune component of the liver microenvironment plays a key role in early recurrence. The aim of our study was to retrospectively evaluate, under real life conditions, the overall survival (OS) of patients with advanced HCC (BCLC-C stage), either initially presented in the advanced stage or migrating from BCLC-A to BCLC-C stage within 2 years after curative LR or RFA, treated either with atezolizumab-bevacizumab (ATZ/BEV) combination or with TKIs sequentially (sorafenib as first line and cabozantinib as second line treatment). Methods: Sixty cirrhotic patients with advanced HCC (53 males, mean age 67y, 35% with diabetes, CPT-A=68.3%/CPT-B=28.3%, mean MELD/Na=11, ALBI grade I=28.3%/ALBI grade II=61.7%, 45% with varices) who either initially presented on the BCLC-C stage and were treated with ATZ/BEV (group A, N=19) or TKIs (group B, N=15) or who migrated from BCLC-A to BCLC-C stage within 2 years after LR or RFA and were treated with ATZ/BEV (group C, N=12) or TKIs (group D, N=14) were evaluated. Results: The four groups were comparable for all the baseline parameters evaluated (age p=0.9, gender p=0.1, platelets p=0.4, chronic liver disease etiology p=0.6, coexistence of diabetes p=0.3, presence of varices p=0.1, CPT stage p=0.1, ALBI grade p=0.3). Median OS was significantly higher for group C patients (mean survival 33.7m, median OS was not reached at the time of evaluation) compared to group D (mOS=27m), group A (mOS=13m) and group B (mOS=8m) patients, as presented in figure 1. It is important to note that the survival after HCC recurrence for group C patients (mean survival=18.2m, median OS was not reached at the time of evaluation) was significantly higher compared to those of group D patients (mOS=9m). Conclusions: Median survival of TKI-treated patients after HCC recurrence is less than 12m and is comparable to survivals observed in patients who initially classified in BCLC-C stage, irrespective of treatment schedule. ATZ/BEV combination therapy significantly prolongs survival in patients after early HCC recurrence, a finding that strongly supports the rationale for adjuvant ATZ/BEV therapy in high risk of recurrence patients.