Anastomotic strictures in colorectal surgery: treatment with endoscopic balloon dilation

The incidence of anastomotic stricture following colorectal surgery has increased in recent years. This complication is observed in 2-5% of all operated patients and is probably due to the greater number of low anastomoses performed with surgical staplers. We observed 31 patients with postoperative stricture, arising from one to nine months post-surgery. All patients had been treated for colorectal cancer and underwent endoscopy either during routine follow-up or for symptoms of stenosis. In 16 patients (group A) the stricture diameter was less than 4 mm and the patients had symptoms attributable to partial bowel obstruction. In the remaining 15 patients (group B), who had difficult bowel movements, the stricture diameter ranged from 4 to 8 mm. All patients were treated with endoscopic dilation using achalasia balloons. The results were considered good when the post-dilation anastomosis diameter achieved was at least 13 mm, fair when it was 9-12 mm and poor when it was less than 9 mm. The short term results (3 weeks) were good in 27 patients (87.2%), fair in 3 patients (9.6%), and poor in 1 patient (3.2%). After several unsuccessful dilations, the latter was treated by surgery. Follow-up at 3-4 months of the remaining 30 patients revealed good results in 20 (66.6%), fair in 6 (20%), and poor in 4 (13.3%). In 1 of these 4 patients, cancer recurrence was observed and a new surgical resection was performed. In 2 patients a self–expandable metal stent was inserted for 4-6 weeks, with satisfactory results. In 1 patient a biodegradable polydioxanone stent was inserted with good results after 6 months. Follow-up at 3-4 months showed good results in 25 patients. After 38 months, cancer recurrence in the area of the anastomosis was observed in 1 patient, who was treated surgically. Endoscopic dilatation should be considered the first therapeutic approach in case of anastomotic strictures, as it is immediately effective, repeatable, and does not preclude surgery if this should become necessary. .

Città Metropolitane e Smart Governance Iniziative di successo e nodi critici verso la Smart City

The volume contains the results of the research project "Governance Analysis Project (GAP) for the Smart Energy City. The actualization of Smart Cities in the Metropolitan Areas of Europe and Italy” conducted within the PON “Smart Energy Master for the energy management of the territory” at the University Federico II of Naples (TeMA Lab of the Department of Civil, Architectural and Environmental Engineering). Smart Cities have gained increasing relevance in the scientific debate and in the national and international operational practice, emerging as one of the opportunities to rethink cities and, more generally, the life of urban communities. First reflections, researches and projects on the issue seem to converge towards the idea that a “smart” urban development should not only be a result of the yet necessary and unavoidable infrastructural endowment (physical capital) and of its continuing innovation, but also of the quality of human, social and environmental capital, conceived as strategic factors for development. A “smart” city is, primarily, a city able to effectively satisfy the needs of its citizens respecting the rules imposed by the environmental context. It is in such a debate that the project GAP fits with the aim to address Smart Cities in light of the administrative reorganization of Italian large cities as a consequence of the Law 56/2014. With a scientific approach, the volume provides a comprehensive and updated framework of how Italian and European Metropolitan cities are declining the Smart City issue and this thanks to the collection of a wide-ranging screening represented by more than 1.000 initiatives including researches, projects, interventions, technologies, etc. Furthermore, one original element of this research is that after an analysis conducted through indirect sources, a phase of dialogue with “stakeholders” was carried out (and of this there is a wide picture in the volume in which, by the way, are reported long excerpts of the interviews). This has enabled to give a clearer framework of what is now experimenting in Italian and European cities, avoiding being totally naïve for interventions and projects labelled as “smart”, but often lacking of innovative methods and contents.