[Surgical approach in the management of oesophageal tumours: considerations based on therapeutic results]. / Approccio chirurgico al tumore dell'esofago: considerazioni in base ai risultati terapeutici.

Over the last two decades, oesophageal cancers, although considered among the most malignant visceral tumours, have witnessed a gradual increase in survival rates at a distance after surgery. The aims of the study were to present the results of our surgical approach and, on this basis, to discuss a number of considerations regarding the type of intervention to be adopted. In a retrospective study we recruited 105 patients with oesophageal cancer treated with various types of oesophageal resection, with or without thoracotomy, in the Division of General Surgery of the Civic Hospital of Sondrio. The postoperative mortality rate was 12%, with 40.2% of non-lethal complications. The average overall survival, whether in patients R0 or not, was 31.2 months (range: 1-167), with actuarial survival rates of 63.2% at one year, 30.3% at three years and 22.1% at five years. This was not significantly influenced by the type of surgery or by the location or histology of the cancer, while TNM stage, degree of parietal infiltration and the presence or absence of lymph-node metastases were significant factors. Although we limited the lymphadenectomy to "standard or extended two-field" operations, our overall survival at five years was similar to that of surgeons advocating much more extensive lymphadenectomy. In our case most of the relapses occurred at the systemic level and in the short term, on average after 12.7 months, meaning that micrometastases were probably already present at the time of intervention (82.4% of these patients, in fact, had stage N1 cancers). We prefer cervical anastomosis owing to the possibility it affords of greater oesophageal resection and to its relative safety in case of dehiscence. We always perform a right cervicotomy, which allows us to avoid having to move the patient on the operating table and to have fewer injuries to the recurrent nerve.

[Combination of endovenous laser treatment and a surgical approach for venous disease]. / EVLT (EndoVenous Laser Treatment) combinato con approccio chirurgico per la malattia venosa.

The aim of our study was to report our experience with endovenous laser treatment (EVLT), initiated with an exclusively US-guided approach, but then combined with a surgical approach. Over the period from September 2003 to December 2005 in the Sondrio Hospital General Surgery Unit 61 patients were submitted to EVLT. In the first 13 cases the procedure was performed under ultrasonographic guidance, whereas later we opted for a combined technique in which the use of the laser was preceded by high ligation of the saphenous vein ("crossectomy") together with complete sectioning of the venous collaterals (48 cases). We observed no complications related to the saphenous vein ligation, whilst EVLT proved safe and easy to perform. Considering successful EVLT as ultrasonographically documented absence of flow in the saphenous vein, a statistically significant difference (p < 0.01) was found between the patients treated using the combined strategy (absence of flow in 92.0% of cases) and those treated with EVLT alone (absence of flow in 54.6% of cases). If EVLT is combined with high ligation of the saphenous vein, it is easier to obtain complete sclerosis of the saphenous trunk, avoiding possible recurrences, amongst other things thanks to the ligation of all the collateral veins that flow into the cross. Moreover, particular selection of patients to be submitted to EVLT proves less necessary, thus substantially increasing the indications for the procedure.

[Laparoscopic Nissen-Rossetti fundoplication: intermediate and long-term outcomes]. / Fundoplicatio laparoscopica tipo Nissen-Rossetti. Risultati a medio-lungo termine.

The aim of this study was to report our personal experience with laparoscopic antireflux surgery using the Nissen-Rossetti fundoplication technique and to analyse the clinical and functional outcomes. From 1994 to 2002, 52 patients with gastro-oesophageal reflux disease underwent laparoscopic surgery after previously being submitted to endoscopy, gastro-oesophageal pH-metry and oesophageal manometry. A Nissen-Rossetti total fundoplication (short and floppy) was performed in all patients, even in those with defective peristalsis. The mortality rate was O and the mean operative time 72 minutes. Among the complications observed in the follow-up (3-100 months), dysphagia was the most frequent (11 patients, 21.1%); this was transient and invariably mild in 8 cases (15.4%), and persistent in 3 (5.7%), though again mild. The reflux symptoms were completely cured in 98.1% of the patients. This experience suggests that laparoscopic surgery is a safe and effective procedure for the treatment of gastro-oesophageal reflux disease. Precise selection of patients and adequate surgical technique are essential.