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Phlebology is not a specialty for its own in Italy. Phlebological patients are treated by vascular and general surgeons, dermatologists, phlebologists, angiologists, internists and even general practitioners. Even tough guidelines present a series of recommendations based on evidence-based medicine, guidelines may also be a tool to unify the diagnostic and therapeutic approach in a vast medical field like phlebology. Since vascular surgeons and phlebologists are particularly involved in phlebology-related pathologies the scientific societies of the Italian Society of Phlebology (SIF) and the Italian Society for Vascular and Endovascular Surgery (SICVE) decided to cooperate for the preparation of phlebo-lymphological guidelines. These guidelines comprehend also an important chapter dealing with the lymphology of the lower extremities; phlebological active physicians are often faced with lymphatic pathologies and a good differential diagnosis can be sometimes very helpful. Sclerotherapy and Surgery as the major therapeutical alternatives are extensively analyzed, but also the compression therapy, the medical and physical therapy are presented under the critical view of evidence based analyses. Separate chapters deal with the treatment alternatives for superficial and deep venous thromboses and the recommendations for the treatment of venous ulcers. The current scientific evidences were confronted with the experiences of Italian specialists and the particular practice and reality in Italy. They represent therefore the actual valid positions and recommendations in Italy which shall be updated regularly.

Carotid surgery variably modifies carotid afferent innervation, thus affecting arterial baroreceptor sensitivity. Low arterial baroreflex sensitivity is a well-known independent risk factor for cardiovascular diseases. The aim of this study was to assess the 4-mo effects of carotid endarterectomy (CEA) on arterial baroreceptor sensitivity and cardiovascular autonomic profile in patients with unilateral carotid stenosis. We enrolled 20 patients (72 ± 8 yr) with unilateral >70% carotid stenosis. ECG, beat-by-beat blood pressure, and respiration were continuously recorded before and 126 ± 9 days after CEA, at rest and during a 75° head-up tilt. Both pharmacological (modified Oxford technique, BRS) and spontaneous (index α, spectral analysis) arterial baroreflex sensitivity were assessed. Cardiovascular autonomic profile was evaluated by plasma catecholamines and spectral indexes of cardiac sympathovagal modulation [low-frequency R-R interval (LFRR), low frequency-to high frequency ratio (LF/HF), high-frequency R-R interval (HFRR)] and sympathetic vasomotor control [low-frequency systolic arterial pressure (LFSAP)] obtained from heart rate and SAP variability. After CEA, both the index α and BRS were higher (P < 0.02) at rest. SAP variance decreased both at rest and during tilt (P < 0.02). Before surgery, tilt did not modify the autonomic profile compared with baseline. After CEA, tilt increased LF/HF and LFSAP and reduced HFRR compared with rest (P < 0.02). Four months after CEA was performed, arterial baroreflex sensitivity was enhanced. Accordingly, the patients' autonomic profile had shifted toward reduced cardiac and vascular sympathetic activation and enhanced cardiac vagal activity. The capability to increase cardiovascular sympathetic activation in response to orthostasis was restored. Baroreceptor sensitivity improvement might play an additional role in the more favorable outcome observed in patients after carotid surgery.

Background/aims: The authors are interested in determining the diagnostic and surgical approach followed in different Italian institutions in the treatment of adenocarcinoma of the head of the pancreas, whenever the spleno-mesenteric-portal confluence is invaded., Methodology: A 10-item questionnaire was sent to 21 Italian Centers of Surgical Oncology and a total of 1185 patients treated with pancreaticoduodenectomy were collected from 15 centers. Among them, 164 spleno-mesenteric-portal vein (SMPV) resections were performed., Results: In all collaborative centers, the diagnostic work-up is comparable with what is reported in the literature. An accurate pre- and intra-operative staging and a differential diagnosis between inflammatory and neoplastic involvement of the vessel walls is universally considered essential for its surgical and oncological implications. If vessel involvement is ruled out, 7 centers proceed to pancreasectomy anyway. Direct end-to-end vein reconstruction is used as the primary procedure, but interposition of PTFE and autologous vein grafting may be used. An overall 4.8% post-operative complications only have been reported. Mean perioperative mortality reported is 3.8% (0-11.5%) and morbidity is 22.8% (4.7-57%). Survival rate is 10 months overall. The mean actuarial 5-year survival is 12%., Conclusions: The attitude of the collaborative centers in cases of SMPV involvement varies, with a slight majority favoring a conservative behavior. Surgical resection extended to the vessels is still uncommon, even in centers mostly experienced in surgery of the pancreas. We believe that vascular resections can be safely performed in both of the different conditions: localized tumors locally invading the vessels and neoplasms with massive invasion of the peripancreatic structures. We share with others the opinion that, in experienced centers, extensive resections should have a role for palliation of carcinoma of the pancreas whenever they offer a better quality of life, although life expectancy may not be positively influenced.

In spite of the decreasing incidence of gastric carcinoma, as it is reported in recent reports from the U.S.A., total gastrectomy and its surgical indications results and complications, focus the interest of surgeons. We analize 61 cases of total gastrectomy for carcinoma, treated in the years 1982-1992. Perioperative mortality and long term survival appear highly satisfactory, mainly if one considers that the site and extension of the neoplasms treated would have severely impaired the possibilities of cure or long term survival with surgery of lesser momentum. We believe that nowaday indications for total gastrectomy can be widened in the hope of improving results of gastric cancer surgery with no or little additional risk.

Over 15 years, 172 femoropopliteal saphenous vein bypasses were performed on 151 patients with chronic obstructive arterial disease. Follow-up varied from a minimum of six months to a maximum of 12 years. The operative mortality was 1.32%, the survival rates at five and ten years were 66.54% and 33.91% respectively, and the patency at five and ten years was 52.02% and 37.55%. The good results obtained, even in the majority of patients with trophic lesions and/or rest pain, indicate that direct arterial reconstruction should be considered the only effective treatment for saving a limb which would otherwise have to be amputated.

The writers have reviewed thirteen cases of contusive trauma of the popliteal artery which came under their observation. The incidence of such lesions in arterial trauma is 22 per cent. The limb was saved in 76 per cent; but the result was only functionally good in only 46 per cent. The fundamental factors for successful revascularization are early diagnosis and precise technique. The operation of choice is a by-pass using the saphenous vein from the contralateral limb; this "jumps" right over the focus of arterial contusion.

The paper describes problems related to axillo-femoral (AF) revascularization of the lower limbs on the basis of personal experience of axillo-femoral by-passes performed from 1971 to 1987. The indications to this technique are limited to high-risk patients. The long-term results are analyzed. The paper stresses the difficulties connected with the choice of the level of the proximal and distal anastomoses, as well as the type of prosthesis to be used.

The importance of adequate preventive treatment of ischemic stroke in patients who have previously suffered one or more transitory ischaemic attacks is undisputed. How to implement it is, however, still open to discussion. The choice is essentially between medical therapy with anti-clotting drugs, that using platelet inhibition drugs and endarterectomy. Here the data from the most important trials in various Countries are collected and analysed for better definition of the indications and results of the various treatments.