Gaetano Burgio

Early extubation after pediatric liver transplantation (PLTx) is increasingly incorporated into enhanced-recovery pathways, yet definitions, selection criteria, and outcome reporting remain inconsistent. This narrative review synthesizes evidence identified through PubMed/MEDLINE (January 2000 through August 2026), citation screening, and supplementary screening of recent reports. Immediate extubation denotes tracheal extubation in the operating room, whereas early extubation has been defined through 24 postoperative hours; delayed extubation and prolonged mechanical ventilation are similarly heterogeneous. The available evidence informs a dynamic framework in which preoperative characteristics define baseline vulnerability, the intraoperative course reflects whether that vulnerability has been overcome or amplified, and the early postoperative course validates the decision. Young age, low body weight, growth failure, or higher disease-severity scores may increase risk but should not function as absolute exclusions; conversely, low scores may underestimate disease-specific risk in metabolic disorders. Direct readiness indicators include effective ventilation, neurological and quantitative neuromuscular recovery, normothermia, stable hemodynamics without escalating vasoactive support, controlled bleeding, satisfactory abdominal closure, and improving acid–base status and lactate clearance. Early extubation is associated with shorter intensive-care and hospital stays in selected cohorts, but causality remains uncertain because evidence is predominantly retrospective and single-center. Standardized definitions and prospective multicenter validation are required.

Background and Aim: Pediatric ERCP remains significantly less studied compared to its application in adults, particularly in infants, due to the limited procedural volume. This study aims to evaluate the indications, procedural specifics, technical success rates, and adverse events associated with pediatric ERCP at a tertiary care center over an 18-year period, with specific attention to patients weighing less than 10 kg. Methods: A retrospective analysis of all ERCPs performed on patients under 18 years of age at ISMETT between 2005 and 2023. Demographic data, indications, procedural specifics, outcomes, and adverse events were collected and reported. Subgroup analyses focusing on initial ERCP procedures were performed and stratified by weight and indication type. Results: 194 ERCPs were performed on 84 patients. Acute or chronic pancreatitis was the most common indication. Technical success was high across weight groups. Adverse events occurred only in patients ≥ 10 kg (7%), predominantly post-ERCP pancreatitis. No adverse events were reported in the <10 kg group. In the “first-ERCP” subgroup, pancreatic indications were associated with a higher adverse event rate than biliary indications, although the estimate was imprecise owing to the small number of events. Conclusions: In our experience as a specialized center, pediatric ERCPs have proven to be safe and effective, even in infants < 10 kg. Pancreatic indications appeared to carry a higher risk for adverse events than biliary indications, although this estimate was imprecise.

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Pain management in patients undergoing kidney transplantation requires careful consideration due to their altered physiology, and potential risks associated with certain analgesic options. In recent years, personalized and multimodal approaches have proven to be pivotal in perioperative pain management, as well as in children. Implementing regional analgesia methods offers a valuable solution in many pediatric surgical settings and the erector spinae plane block (ESPB) could represent a possible analgesic strategy in pediatric patients undergoing renal transplantation. Here, we report the case of a 13-year-old child who underwent living-donor kidney transplantation (LDKx) and received continuous erector spinae plane block (ESPB) for perioperative pain management. This multimodal approach with continuous ESPB resulted in optimal pain control without the need for opioids, allowing for early mobilization and for an optimal postoperative course.

For patients with chronic liver disease (CLD), telemedicine is emerging as a useful tool to prevent liver decompensation or hospitalization, allowing access to and the decentralization of care, even for patients with limited resources. However, research and attendant evidence are still lacking; thus, this review aims to systematically explore the topic of telemonitoring for CLD to describe the currently used tools and clinical outcomes. The review was conducted by using key terms on PubMed/EMBASE and searching for observational studies or clinical trials (according to PRISMA recommendations) that were published between 6 April 2013 and 6 April 2023 to keep the technological framework limited to the last 10 years. The studies were described and grouped according to the aim of telemonitoring, the underlying disease, and the tools adopted to achieve remote monitoring. A total of 32 articles met the inclusion criteria. Of these, 11 articles report the successful use of a telehealth program to support and improve access to care in the management of HCV-related cirrhosis, eight articles examine the efficacy of telemedicine for remote monitoring interventions to prevent or decrease the risk of decompensation in high-risk patients, and five articles examine improvements in the physical performance and quality of life of cirrhotic patients through telehealth rehabilitation programs. Four studies were completed during the recent COVID-19 pandemic. Telehealth has the potential to provide and expand treatment access and reduce barriers to care for the most disadvantaged patients and might be able to reduce the need for hospital readmission for CLD, though most practice to test feasibility is still in the pilot stage.

Continuous renal replacement therapy (CRRT) following orthotopic liver transplantation (OLT) is usually started for multifactorial reasons, with variable incidence among series. This paper presents a single-center retrospective observational study on the early use (within one week) of CRRT after consecutive cadaveric OLT from January 2008 to December 2016. Preoperative patient characteristics and intraoperative data were collected, and patients were divided into two groups (CRRT and no CRRT) to explore the factors associated with the use of CRRT. Repeated measurements of postoperative creatinine were analyzed with generalized estimating equation (GEE) models. Among 528 OLT patients, 75 (14.2%) were treated with CRRT at least once in the first week. Patients treated with CRRT showed lower survival in a Kaplan–Meier curve (log-rank p value < 0.01). Patients treated with CRRT had a more severe preoperative profile, with a significantly higher age, MELD, BUN, creatinine, and total bilirubin, as well as a longer surgery time and a higher number of transfusions of red blood cells, plasma, and platelets (all p values < 0.05). In a stepwise multiple analysis, the following characteristics remained independently associated with the use of CRRT: the MELD score OR 1.12 (95% CL: 1.07–1.16), p value < 0.001, and the preoperative value for blood urea nitrogen OR 1.016 (95% CL: 1.010–1.023), p value < 0.001. The early use of CRRT after OLT occurred at a low rate in this large cohort; however, it was associated with worse outcomes. Apart from the preoperative severity, repeated intraoperative hypotension episodes, which were likely modifiable or preventable, were associated with the increased use of CRRT and higher postoperative creatinine.

Background: Hepatic resection remains the treatment of choice for patients with early-stage HCC with preserved liver function. Unfortunately, however, the majority of patients develop tumor recurrence. While several clinical factors were found to be associated with tumor recurrence, HCC pathogenesis is a complex process of accumulation of somatic genomic alterations, which leads to a huge molecular heterogeneity that has not been completely understood. The aim of this study is to complement potentially predictive clinical and pathological factors with next-generation sequencing genomic profiling and loss of heterozygosity analysis. Methods: 124 HCC patients, who underwent a primary hepatic resection from January 2016 to December 2019, were recruited for this study. Next-generation sequencing (NGS) analysis and allelic imbalance assessment in a case-control subgroup analysis were performed. A time-to-recurrence analysis was performed as well by means of Kaplan–Meier estimators. Results: Cumulative number of HCC recurrences were 26 (21%) and 32 (26%), respectively, one and two years after surgery. Kaplan–Meier estimates for the probability of recurrence amounted to 37% (95% C.I.: 24–47) and to 51% (95% C.I.: 35–62), after one and two years, respectively. Multivariable analysis identified as independent predictors of HCC recurrence: hepatitis C virus (HCV) infection (HR: 1.96, 95%C.I.: 0.91–4.24, p = 0.085), serum bilirubin levels (HR: 5.32, 95%C.I.: 2.07–13.69, p = 0.001), number of nodules (HR: 1.63, 95%C.I.: 1.12–2.38, p = 0.011) and size of the larger nodule (HR: 1.11, 95%C.I.: 1.03–1.18, p = 0.004). Time-to-recurrence analysis showed that loss of heterozygosity in the PTEN loci (involved in the PI3K/AKT/mTOR signaling pathway) was significantly associated with a lower risk of HCC recurrence (HR: 0.35, 95%C.I.: 0.13–0.93, p = 0.036). Conclusions: multiple alterations of cancer genes are associated with HCC progression. In particular, the evidence of a specific AI mutation presented in 20 patients seemed to have a protective effect on the risk of HCC recurrence.

There are several airway devices available for difficult tracheal intubation (DTI) management, but the failure rate remains high. The use of laryngoscopy to facilitate the fibreoptic-bronchoscope intubation (CLBI) has been increasingly reported in DTI situations, but it has not been formally studied yet. We designed a single-centre simulation study on DTI (neck rigidity and tongue oedema) comparing three techniques: direct laryngoscopy (DL), video-laryngoscopy (VLS) and CLBI. Eighteen anaesthesiologists naïve to VLS/CLBI approaches, participated in the study. The primary outcome was the intubation rate at the first attempt. Secondary outcomes were an overall time-to-intubate (TTI) and time-to-ventilate (TTV), success at the second and third attempt and ease of intubation as evaluated by a subjective 5-point Likert scale. The CLBI technique had a higher success rate at the first attempt than DL (66% vs 22%, p=0.007), while VLS did not (44%, p=0.16). A trend towards higher success at the third attempt was found for both VLS and CLBI vs DL (p=0.07 and p=0.06, respectively). The VLS had a shorter overall TTV than DL (88±60 vs 121±59 sec, respectively, p=0.04) and a trend towards a shorter TTI (81±61 vs 116±64 sec, respectively, p=0.06). The CLBI approach showed a non-significantly lower TTI/TTV as compared to DL (p=0.10 and p=0.16, respectively). Anaesthesiologists judged that the intubation with VLS (3.7±1.0) and CLBI (3.8±1.0) was easier than with DL (1.7±0.8, both p<0.001). In a simulated DTI scenario, CLBI had a higher success rate at the first attempt than DL, while VLS did not. By the third attempt, both rescue techniques had a trend towards a higher success rate than DL. The CLBI technique seems a promising alternative for the management of DTI.