Continuous Erector Spinae Plane Block for Pain Management in a Pediatric Kidney Transplant Recipient: A Case Report and Review of the Current Literature.

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.

Combining living and deceased donation for pediatric first isolated liver transplantation: A win-win even in countries with high deceased donor donation rates.

BACKGROUND: Split and living donor liver transplantations are both key surgical strategies for development of pediatric liver transplant programs. Often, however, teams tend to prioritize only one preferentially. METHODS: In the context of a very active national split liver graft allocation program (Italy), retrospective study of 226 consecutive pediatric first isolated liver transplants performed by a single team using organs from both deceased and living donors. Clinical characterisitics and outcome were compared. RESULTS: In the context of a steadily slowly decreasing split graft offer, living donation activity steadily increased. Deceased and living donation accounted for 52.6% and 47.4% of transplantations, respectively. Both strategies were equally used for transplanting patients up to 30 kg of weight, while deceased donors were predominantly used for older recipients. Technical variants represented 86% of all transplants, with 183 conisting of left lateral segment grafts (76 split liver grafts and 107 left grafts from living donors). Outcome of both surgical strategies was similar, with excellent outcomes at early, mid-, and long-term. CONCLUSIONS: Splitting livers of deceased donors and using living donation were complementary and non-competitive strategies for developping pediatric liver transplant activity. Implementing both activities in parallell allowed to maintain stable the number of annual transplant in Italy and allowed to reach superior outcomes. This analysis provides evidence that living donation plays a role in Italy despite an existing very active "mandatory-split" national policy.

Revisiting the forgotten "full-right full-left" liver division: Simplified technique and new strategical considerations for clinical implementation in Italy.

BACKGROUND: Full-right/full-left liver splitting was introduced early in the 90s as part of the great wave of technical innovations that characterized that decade. One approach was to divide the liver on the right of the Cantlie's line and leave the middle hepatic vein with the left graft, with both grafts allocated to adults. Both grafts had some functional disadvantages and exposed the adult recipients to some early hepatic dysfunction, and the results were not great. An alternative approach consisted of an ex situ division of the liver, exactly along Cantlie's line, thus sharing the middle hepatic vein between the two grafts. None of these two techniques were really adopted, and there has been nearly no transplantation of this type in the last decade worldwide. METHOD AND RESULTS: The authors propose a variation of the latter technique that was used recently with success: The division of the liver is made simpler; the two grafts are prepared ex situ and need a simple vascular reconstruction (one venous patch on each graft); and the grafts can be implanted using very standard techniques. CONCLUSION: Because candidates for liver transplantation weighing 25-60 kg (old children, teenagers, and some small adults) are often at some disadvantage in getting size-matched livers (this range of weight is less represented in the donor population), implementing the latter technique would help provide adequate grafts for them. In Italy, where many livers offered for splitting are not used, there would be ample room for implementing this option within the actual donor pool and allocation system.

The role of liver transplantation in the care of primary hepatic vascular tumours in children.

Liver transplantation (LT) is the standard of care for many liver conditions, such as end-stage liver diseases, inherited metabolic disorders, and primary liver malignancies. In the latter group, indications of LT for hepatoblastoma and hepatocellular carcinoma evolved and are currently available for many non-resectable cases. However, selection criteria apply, as the absence of active metastases. Evidence of good long-term outcomes has validated the LT approach for managing these malignancies in the context of specialist and multidisciplinary approach. Nevertheless, LT's role in treating primary vascular tumours of the liver in children, both benign and malignant, remains somewhat controversial. The rarity of the different diseases and the heterogeneity of pathological definitions contribute to the controversy and make evaluating the benefit/risk ratio and outcomes quite difficult. In this narrative review, we give an overview of primary vascular tumours of the liver in children, the possible indications and the outcomes of LT.

Total Esophagogastric and Cologastric Dissociation in Neurologically Normal Children: Systematic Review.

Total esophagogastric dissociation (TEGD) was first described by Bianchi as a definitive procedure for gastroesophageal reflux disease (GERD) in neurologically impaired children. In the last 20 years, different centers extended the indication to neurologically normal (NN) patients with GERD associated with congenital or acquired esophageal anomalies. The aim of this paper is to analyze the role of TEGD in this cluster of patients. A PubMed and Google Scholar search was conducted. All cases of NN children who underwent TEGD for GERD were collected. Patient characteristics and outcomes were analyzed. Complications were classified according to Clavien-Dindo classification. Forty-eight children were identified. In 56.25%, TEGD was the first anti-reflux procedure, while in 43.75% it was performed after failed fundoplications. Mean follow-up was 5.5 years. Mortality related to surgery was 2.08%. All of the survivors improved their condition, with resolution of GERD and weight gain. In addition, 50% of children weaned off enteral nutrition, with 14.6% having their gastrostomy removed, while 41.67% maintained partial enteral supplementation. Respiratory symptoms almost disappeared in 54.17% of patients. This review suggests that TEGD can also be considered for NN children where conventional methods seem insufficient to control reflux and preserve pulmonary function. Nevertheless, long-term follow-up is still required.

Difficult Vascular Access in Children with Short Bowel Syndrome: What to Do Next?

Short Bowel Syndrome and intestinal failure are chronic and severe conditions that may require life-long parenteral nutrition in children. Survival of these children rely on the correct functioning of central venous catheters; therefore, careful management, prevention, and treatment of complications is of paramount importance. Despite a growing awareness of preserving the vascular real estate, a certain number of patients still experience a progressive and life-threatening exhaustion of vascular access. We searched the literature to highlight the current management of children with vascular exhaustion, specifically focusing on vascular access salvage strategies and last-resource alternative routes to central veins. Given the paucity of data, results are reported in the form of a narrative review.

Epidemiology and Surgical Management of Foreign Bodies in the Liver in the Pediatric Population: A Systematic Review of the Literature.

Retention of foreign bodies (FB) in the liver parenchyma is a rare event in children but it can bring a heavy burden in terms of immediate and long-term complications. Multiple materials can migrate inside the liver. Clinical manifestations may vary, depending on the nature of the foreign body, its route of penetration and timing after the initial event. Moreover, the location of the FB inside the liver parenchyma may pose specific issues related to the possible complications of a challenging surgical extraction. Different clinical settings and the need for highly specialized surgical skills may influence the overall management of these children. Given the rarity of this event, a systematic review of the literature on this topic was conducted and confirmed the pivotal role of surgery in the pediatric population.

Paediatric Liver Transplantation During COVID-19 Pandemic: Lessons Learned and Unanswered Questions.

COVID-19 pandemic has imposed many challenges on paediatric liver transplantation (PLT) services and has necessitated several adaptations in different stages of the process to ensure transplant centres can still deliver the proposed services in addition to protecting patients and staff against infection. This review article digs through the current literature to clarify the challenges imposed by SARS-CoV2 on PLT centres globally. It provides an overview of current practice as well as suggestions from experts in the field to overcome multiple obstacles. In paediatrics, the reaction to SARS-CoV2 may be less severe than that seen in the adult population, but this can change in view of newly discovered virus strains. Response of transplant centres to the current pandemic was variable depending on the anticipated risk and available resources. Telemedicine has helped PLT programmes to continue their activities while protecting patients, as well as staff against the risk of SARS-CoV2 virus. Further studies are needed to guide immunosuppression management in post-transplant infected candidates; answering this critical question will help PLT centres solve this dilemma.

Customized Cutting Template to Assist Sternotomy in Pectus Arcuatum.

PURPOSE: Pectus arcuatum is an anterior chest wall deformity that requires transverse wedge sternotomy. Determining and delivering the correct cutting angle are crucial for successful correction. This report describes the early clinical experience with a novel cutting template technology able to deliver the optimal cutting angle. DESCRIPTION: From patients' computed tomographic scans, the optimal cutting angle is obtained using computer-aided design. A template comprising slots tilted at the right cutting angle and a safety block to avoid damaging the posterior periosteum is printed through additive manufacturing. EVALUATION: The template allows surgeons to perform a precise wedge sternotomy, safely sparing the posterior periosteum in all patients, without complications. Postoperative chest roentgenograms and clinical photographs demonstrate optimal sternal realignment and cosmetic outcome. In this report, the mean operative time was 110 minutes. All patients were successfully discharged, with a mean length of stay of 4 days. CONCLUSIONS: Transverse wedge sternotomy aided by a computer-aided design-devised cutting template may reduce the technical challenge of this procedure, thereby increasing its safety and reducing operative times and hospital stay. Further research on long-term patient outcomes is necessary.