Terapia chirurgica dell'acalasia scompensata: prevalenza e fattori di rischio per lo sviluppo del carcinoma esofageo, risultati clinico-funzionali a lungo termine della chirurgia conservativa e dell'esofagectomia

La chirurgia conservativa o l’esofagectomia, possono essere indicate per il trattamento della disfagia nell’acalasia scompensata. L’esofagectomia è inoltre finalizzata alla prevenzione dello sviluppo del carcinoma esofageo. Gli obiettivi erano: a) definire prevalenza e fattori di rischio per il carcinoma epidermoidale; b) confrontare i risultati clinici e funzionali di Heller-Dor con pull-down della giunzione esofagogastrica (PD-HD) ed esofagectomia. I dati in analisi, ricavati da un database istituito nel 1973 e finalizzato alla ricerca prospettica, sono stati: a) le caratteristiche cliniche, radiologiche ed endoscopiche di 573 pazienti acalasici; b) il risultato oggettivo e la qualità della vita, definita mediante questionario SF-36, dopo intervento di PD-HD (29 pazienti) e dopo esofagectomia per acalasia scompensata o carcinoma (20 pazienti). Risultati: a) sono stati diagnosticati 17 carcinomi epidermoidali ed un carcinosarcoma (3.14%). Fattori di rischio sono risultati essere: il diametro esofageo (p<0.001), il ristagno esofageo (p<0.01) e la durata dei sintomi dell’acalasia (p<0.01). Secondo l’albero di classificazione, soltanto i pazienti con esito insufficiente del trattamento ai controlli clinico-strumentali ed acalasia sigmoidea presentavano un rischio di sviluppare il carcinoma squamocellulare del 52.9%. b) Non sono state riscontrate differenze statisticamente significative tra i pazienti sottoposti ad intervento conservativo e quelli trattati con esofagectomia per quanto concerne l’esito dell’intervento valutato mediante parametri oggettivi (p=0.515). L’analisi della qualità della vita non ha evidenziato differenze statisticamente significative per quanto concerne i domini GH, RP, PF e BP. Punteggi significativamente più elevati nei domini RE (p=0.012), VT (p<0.001), MH (p=0.001) e SF (p=0.014) sono stati calcolati per PD-HD rispetto alle esofagectomie. In conclusione, PD-HD determina una miglior qualità della vita, ed è pertanto la procedura di scelta per i pazienti con basso rischio di cancro. A coloro che abbiano già raggiunto i parametri di rischio, si offrirà l’esofagectomia o l'opzione conservativa seguita da protocolli di follow-up.

Modelling coupled physical-biogeochemical processes in ice-covered oceans

The last decades have seen a large effort of the scientific community to study and understand the physics of sea ice. We currently have a wide - even though still not exhaustive - knowledge of the sea ice dynamics and thermodynamics and of their temporal and spatial variability. Sea ice biogeochemistry is instead largely unknown. Sea ice algae production may account for up to 25% of overall primary production in ice-covered waters of the Southern Ocean. However, the influence of physical factors, such as the location of ice formation, the role of snow cover and light availability on sea ice primary production is poorly understood. There are only sparse localized observations and little knowledge of the functioning of sea ice biogeochemistry at larger scales. Modelling becomes then an auxiliary tool to help qualifying and quantifying the role of sea ice biogeochemistry in the ocean dynamics. In this thesis, a novel approach is used for the modelling and coupling of sea ice biogeochemistry - and in particular its primary production - to sea ice physics. Previous attempts were based on the coupling of rather complex sea ice physical models to empirical or relatively simple biological or biogeochemical models. The focus is moved here to a more biologically-oriented point of view. A simple, however comprehensive, physical model of the sea ice thermodynamics (ESIM) was developed and coupled to a novel sea ice implementation (BFM-SI) of the Biogeochemical Flux Model (BFM). The BFM is a comprehensive model, largely used and validated in the open ocean environment and in regional seas. The physical model has been developed having in mind the biogeochemical properties of sea ice and the physical inputs required to model sea ice biogeochemistry. The central concept of the coupling is the modelling of the Biologically-Active-Layer (BAL), which is the time-varying fraction of sea ice that is continuously connected to the ocean via brines pockets and channels and it acts as rich habitat for many microorganisms. The physical model provides the key physical properties of the BAL (e.g., brines volume, temperature and salinity), and the BFM-SI simulates the physiological and ecological response of the biological community to the physical enviroment. The new biogeochemical model is also coupled to the pelagic BFM through the exchange of organic and inorganic matter at the boundaries between the two systems . This is done by computing the entrapment of matter and gases when sea ice grows and release to the ocean when sea ice melts to ensure mass conservation. The model was tested in different ice-covered regions of the world ocean to test the generality of the parameterizations. The focus was particularly on the regions of landfast ice, where primary production is generally large. The implementation of the BFM in sea ice and the coupling structure in General Circulation Models will add a new component to the latters (and in general to Earth System Models), which will be able to provide adequate estimate of the role and importance of sea ice biogeochemistry in the global carbon cycle.