Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione

Background and Objectives: Pulmonary and mediastinal masses are diagnostic challenges for digestive endosonographers, and patients with these conditions are usually managed in thoracic or pulmonology units. EUS with tissue acquisition can result in adequate samples for histological examination and molecular analysis. Its spread among digestive endosonographers is limited; thus, we aimed to investigate the current management practices among the EUS Italian centers for those patients with mediastinal or pulmonary lesions to identify the principal areas of disagreement and help guide future research towards useful standardization. Methods: A 44‑question survey was sent during a temporal trend of 3 months to the endosonographers in Italian centers performing EUS. The survey includes questions with either a single answer choice or with multiple options exploring different aspects of the EUS done for the evaluation of thoracic lesions. The questions were grouped into specific sections: expertise of the center, periprocedural management, procedural aspects, and future perspectives. Results: Thirty-nine centers completed the survey, 27 (69.2%) from the north of Italy. Only 2 centers among the responders did not perform any mediastinal EUS (5.13%). The majority of centers (22, 59.5%) performed between 0 and 30 mediastinal EUS yearly, and only 3 centers did more than 100 mediastinal EUS per year. Responders were mainly gastroenterologists (34, 87.2%) versus surgeons (5, 12.8%). Only 5 centers performed mediastinal EUS in a shared room with bronchoscopy and endobronchial ultrasound (13.5%). The procedure was considered simple for 20 (54.1%) responders, complex for 5 (13.5%), and needed to be performed in a tertiary thoracic center for 12 (32.4%). Franseen and Fork tips were the most used tips (67.6% and 27%, respectively), and the most common needle diameter was 22 gauge (86.5%). Fifteen centers (40.5%) preferred deep sedation with an anesthesiologist without endotracheal intubation. The main growing indications appear to be local EUS-guided treatments (tumors or collections). Conclusions: This is the first survey assessing an evaluation on mediastinal/pulmonary EUS, which is well represented in Italy. Nonetheless, centers largely have low volumes of these procedures. Our results show heterogeneity in the management of patients affected with mediastinal/pulmonary lesions needing tissue acquisition. More studies also involving pulmonologists, thoracic surgeons, and oncologists are needed to increase data and understanding regarding this procedure.

Pancreatic and periampullary cancers are among the most challenging malignancies. Centralization of care and multidisciplinary management have been associated with improved outcomes. In 2024,the Italian Ministry of Health established a national Steering Committee with the objective of defining a centralized model for the management of pancreatic and periampullary diseases and identifying the minimum requirements for referral centers across Italy. The Steering Committee met every four weeks through plenary and focused working groups. Using data from the National Agency for Regional Health Services and the National Outcome Program, all ICD-9 codes related to pancreatic, periampullary, and distal biliary diseases were analyzed. Criteria were developed according to international recommendations and structured into a Hub-and-Spoke network model. Pancreas Units(Hub centers) were defined as hospitals providing 24/7 multidisciplinary expertise, advanced diagnostic and interventional capabilities, and a minimum surgical volume of ≥ 30 pancreatic resections per year with 90-day mortality < 10% (target < 5% within 3 years). Spoke centers were required to adhere to standardized diagnostic–therapeutic pathways and participate in multidisciplinary team meetings, without performing pancreatic surgery. Based on catchment area analyses, one Hub center per 700,000–1,200,000 inhabitants was recommended. Additional requirements included structured multidisciplinary processes, standardized diagnostic pathways, and integration with national research and training networks. This national model provides a comprehensive framework for centralizing pancreatic and periampullary diseases care. By defining minimum standards, enhancing multidisciplinary coordination, and concentrating complex procedures in high-performance centers, this initiative aims to improve outcomes, reduce regional disparities, and create a sustainable national Pancreas Unit network.

Haemorrhage and blood product usage are common in venoarterial extracorporeal membrane oxygenation (VA ECMO) and associated with increased mortality. A prospective, investigator-initiated, longitudinal observational cohort study on major haemorrhagic events in 12 ECMO centres from 3 continents for three predefined subgroups (VA ECMO initiated during cardio-pulmonary resuscitation (ECPR), after cardiothoracic surgery (CTS), for cardiogenic shock (CS)). The aim was to describe haemorrhagic complications as well as transfusion practice and anticoagulation for the whole population as well as the subgroups. In addition, independent baseline predictors for red blood cell (RBC) transfusions were evaluated. 545 prospective patients were included between 2019 and 2022 (ECPR 149, CTS 169, CS 227). Hospital mortality was 46%. Over 2796 days 406 major haemorrhage events in 286 (52%) patients were recorded. CTS and ECPR patients had more frequent events occurring earlier in their course. 88% received RBC transfusions (1.27 (95%CI 1.22 – 1.31) units/day) with significantly more transfusions for CTS and ECPR patients. Platelet transfusion rates were highest in the CTS group (0.58 (95%CI 0.53–0.64) units/day). Haemoglobin and platelet count prior to transfusion were independent of subgroups and averaged (78 g/L (IQR 73, 84), 58 × 10^9/L (IQR 37, 85), respectively). However, platelet count prior transfusion was only marginally higher on days with major haemorrhage (74 × 10^9/L (IQR 50, 104). Systemic anticoagulation was started within the first 24 h in 83% (95% CI 80–87%) of patients, most frequently in CS patients (90%, CI 85–95%). Independent baseline predictors for RBC transfusion were ECPR (IRR 1.50, 95%CI 1.19–1.89) and prior use of antiplatelets (IRR: 1.43, 95%CI 1.13–1.80). Myocarditis and pulmonary embolism were associated with a lower rate of transfusion when compared to myocardial infarct (IRR: 0.57 (0.37–0.89), IRR: 0.67 (0.45–1.00, respectively). Haemorrhagic complications differ in clinical subgroups and RBC transfusion exposure is by far higher than in other critically unwell populations. We identified ECPR and antiplatelet therapy as additional predictors. Transfusion practice for RBC and platelets is variable and does not always follow international guidelines.

Therapeutic prone positioning is widely used to improve oxygenation in patients with acute respiratory distress syndrome but is associated with an increased risk of pressure injuries, particularly affecting facial and anterior body regions. This systematic review was conducted according to PRISMA 2020 and Joanna Briggs Institute guidelines and was prospectively registered in PROSPERO (CRD42023442604). PubMed, CINAHL, Web of Science, Scopus, and the Cochrane Library were searched from inception to June 2025, including grey literature. Primary studies involving adult, mechanically ventilated patients undergoing therapeutic prone positioning and evaluating pressure injury prevention strategies were included. Methodological quality was assessed using JBI critical appraisal tools. Owing to clinical and methodological heterogeneity, findings were synthesized using a Synthesis Without Meta-analysis (SWiM) approach. Eight studies with heterogeneous designs were included. Preventive interventions mainly comprised prophylactic dressings, repositioning and support devices, and comprehensive care bundles. Most strategies were associated with a reduction in pressure injury incidence, particularly in facial and anterior anatomical areas. Greater effectiveness was observed when interventions were implemented within structured protocols supported by staff training and multidisciplinary coordination. Preventive strategies appear effective in reducing pressure injuries associated with prone positioning in critically ill patients. The implementation of standardized, bundled prevention protocols may improve patient safety in intensive care settings.

There is still poor evidence about the safety and feasibility of minimally invasive liver surgery (MILS) for huge (> 10cm) hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long- term outcomes of MILS versus open liver resection (OLR) for patients with huge HCC. Data regarding all consecutive patients undergoing liver resection for huge HCC were retrospectively collected from Asian (South Korean) and European (Italian and French) referral HPB centers. The cases were propensity score matched for age, center, extent of the resection, tumor size, and tumor number. A total of 198 patients were included in the study. Before matching there were statistically significant differences in tumor size (p < 0.01) and rates of major hepatectomies performed (p = 0.03). After PSM two cohorts of 39 patients were obtained, with no statistically significant differences in all the compared preoperative characteristics. No significant differences were found in terms of major complications, in-hospital mortality, and operative time, between the matched cohorts. The median length of hospital stay was significantly lower after MILS (7 vs. 10days, p < 0.01), as well as the median intraoperative estimated blood loss (500ml vs 800ml, respectively; p = 0.02) and the rates of intraoperative transfusions (25.6% vs 48.7%, respectively; p = 0.03). After a median follow-up of 52months, there were no significant differences between OLR and MILS in median OS (44 vs. 93.6months, respectively; p = 0.07). Median DFS was improved after MILS (49.8 vs. 7months, respectively; p < 0.01). MILS for huge HCC can be safe and effective in selected cases in referral centers, being able to reduce intraoperative blood loss, and to shorten median hospital stay.

As regards traumatology in the 21st century, some precedence should be given to the treatment of lesions to the tendons of the hand. This is due to the high functional value of this extremity for the human body, both in terms of work and social life. The aim of this article is to analyse the surgical and rehabilitation treatment of traumatic lesions to the hand; specifically, with regard to the ana- tomical position of the lesions and the site of the interruption of the tendon. It will be evident that only an intervention which combines both surgery and physi- okinetic therapy can allow for the restoration of full functionality.

Extracorporeal membrane oxygenation (ECMO) is a vital intervention for patients with severe respiratory failure, particularly in unresponsive acute respiratory distress syndrome (ARDS) cases. However, patient selection for ECMO remains a significant challenge. This study aims to identify novel immune-based biomarkers to improve eligibility assessment and predict outcomes in critically ill COVID-19 patients undergoing ECMO. This monocentric observational retrospective cohort study included 80 patients with severe COVID-19-related pneumonia who required ECMO support due to unresponsive ARDS. The patients were admitted to the intensive care unit (ICU) of IRCCS-ISMETT Hospital between September 2020 and April 2021, before the availability of COVID-19 vaccines. All patients were infected with the original SARS-CoV-2 Wuhan strain. Using machine learning approaches, the study analyzed clinical and laboratory data, cytokine levels, RNA sequencing (RNA-seq), and immune cell profiles collected within two days of hospitalization. The analysis identified a 5.56-fold increased mortality risk in patients presenting with a combination of immune factors: a T cell exhaustion profile, low interferon-alpha (IFNα) levels, and high calprotectin levels. These immune markers were strongly associated with poorer outcomes in patients undergoing ECMO. Our findings highlight the critical role of immune profiling in ECMO patient selection and outcome prediction. Incorporating immune-based biomarkers into clinical assessments may enhance the evaluation of ECMO eligibility and guide treatment decisions, ultimately improving patient outcomes.