[Isoperistaltic endoluminal drainage (IED) in the surgical treatment of upper digestive tract dehiscence]. / Il drenaggio endoluminale isoperistaltico nel trattamento chirurgico delle deiscenze nel tratto alimentare superiore.

Dehiscence of upper gastrointestinal sutures still remains a severe clinical problem and often requires complex surgical repair. Despite its multifactorial aetiopathogenesis, endoluminal pressure seems to play an important role in the onset and maintenance of this complication. The efficacy of isoperistaltic endoluminal drainage (IED) in the operative treatment or prevention of upper gastrointestinal surgical dehiscence was assessed in a retrospective study. The IED procedure is obtained by means of a two-way nasogastric tube inserted in the proximal jejunum through the abdominal and advanced to the site of the leak in order to achieve low endovisceral pressure, normal intestinal free flow downstream of the lesion and monitoring of the healing process. Over the past decade 31 patients (mean age 62 years; 52.9% male) with postoperative dehiscences of the thoraco-abdominal oesophagus, stomach or duodenum underwent reintervention. During the surgical repair an IED was inserted in 17, while no IED was inserted in 14 (NOIED): the two groups were well matched for age, gender, primary pathology, site and type of leak. The overall operative mortality (30 days) was 16% (12.5% IED vs. 20% NOIED), and morbidity was 45% (37.5% IED vs. 53.3% NOIED). The rate of leak relapse was significantly different: 6% IED vs. 20% NOIED. In the last 5 years the IED procedure has also been used preventively with promising outcomes in another 16 other high-risk upper gastrointestinal suture patients. The results of this retrospective study appear to support the use of the IED procedure to minimize the risk of failure of the suture/anastomosis in upper gastrointestinal surgery. Other studies are needed to validate the efficacy of this supplementation of surgical treatment.

[Evolution of surgery for cancer of the anorectal junction]. / Evoluzione chirurgica per i tumori del giunto ano-rettale.

Certain aspects of the epidemiology, classification and therapy of adenocarcinoma of the anorectal junction (< 5 cm from the anal verge) are not well standardised to date. To evaluate the recent advances in the surgical management we reviewed our database, focusing on the oncological and functional results of intersphincteric resection. From 1989 to 2005 we treated 183 adenocarcinomas of the anorectal junction with a curative intent by 106 total proctetomies (84 of which by intersphinteric resection), 54 abdominoperineal resections, 22 transanal local excision and 1 Hartmann procedure. Intersphincteric resections were performed in 51 males and 33 females, mean age 62, with the following clinical stages: 28 stage 1, 55 stages II and III, 1 stage IV; radiotherapy was administered preoperatively to 27 patients and postoperatively to 18. Fifty-five intersphinteric resections were performed by open surgery and 29 by laparoscopy (since 2001). All the procedures were R0 except for 2 R1 (readily converted to abdominoperineal resections). Perioperative mortality (30 days) was 1.1% and the overall morbidity was 27.7% (including a 6% leakage rate). Assessment of anal sphincter function recovery one year after restoration of bowel continuity showed good continence in 76% of the patients; 2 patients have a permanent ostomy. After an average 60-month follow-up (min. 30 months) the local recurrence rate was 2.4% and the actuarial 5-year survival rate 81.7%. Our experience shows a drop in abdominoperineal resections in the last 5 years from 56.5% to 17.8%, while the intersphincteric resection rate has increased from 32.6% to 66%. The oncological results of intersphincteric resection compare favourably with those of abdominoperineal resection and functional recovery appears satisfactory.

Laparoscopic primary repair and isoperistaltic endoluminal drain for Boerhaave's Syndrome.

Spontaneous oesophageal rupture, also known as Boerhaave syndrome (BS), is a rare and potentially lethal pathological condition. BS recognition is difficult, while rapidity of diagnosis, along with extension of the lesion, affects type and outcome of treatment. BS was classically treated by thoracotomy, but laparoscopic (LS), thoracoscopic (TS) surgery, and nonsurgical procedures as endoscopic stent positioning or use of glues have been described. Still, there is no model treatment, and selection of the most appropriate therapeutic procedure is complex in the absence of standardised criteria. We successfully managed a patient affected with BS by LS approach and present our experience along with a review of treatment options so far described. Our treatment integrated positioning of an oesophageal isoperistaltic endoluminal drain (IED), that we routinely use in oesophageal sutures at risk of leakage, and of which there is no previous report in the setting of BS. A 68 year old man presented to our attention with true BS, suspected on chest-abdominal CT scan and confirmed by upper GI contrast swallow test, showing leakage of hydro-soluble contrast from the lower third of the oesophagus. Of note, pleural cavities appeared intact. We performed an urgent laparoscopy 12 hours after the onset of symptoms. Laparoscopic toilet of the inferior mediastinum and dual layer oesophageal repair with pedicled omental flap were complemented by positioning of IED, feeding jejunostomy and two tubular drains. The patient had a slow but consistent recovery where IED played as a means of oesophageal suture protection, until he could be discharged home. We think that, when integrity of the pleura is documented, LS should be priority choice to avoid contamination of the pleural cavities. We have to consider every type of oesophageal repair in BS at risk of failure, and every means of protection of the suture is opportune. In our patient the oesophageal suture, covered with a flap of omentum isolated on a pedicle, has also been protected from excessive oesophageal endoluminal pressures by means of a multi-fenestrated two way endooesophageal drain (IED, two way tube type Salem). Oesophageal drain has the finality of relieving tension and monitoring the healing of the oesophageal repair.