Aspetti deontologici e giuridici della Responsabilità professionale del chirurgo in Italia. Evoluzione storica a partire dal '900.

È pleonastico ricordare che ogni individuo raziocinante delle essere responsabile delle sue azioni: deve agire con la coscienza degli scopi che si propone evitando possibili conseguenze negative dei suoi atti. In ambito medico questo tipo di responsabilità è codificata con le norme della "deontologia". Per secoli l'arte terapeutica è stata praticata da individui dotati di una particolare vocazione ed una particolare cultura acquisita da Maestri dell'arte ancor prima che dalla propria esperienza, con nozioni di erboristeria e di elementari conoscenze anatomiche e di fisiologia, circondati da un'aura sacerdotale e da un rispetto derivante dal timore e dall'ammirazione per il coraggio e auspicabilmente dai successi, e facendo riferimento nell'occidente mediterraneo alle regole operative fissate nel Giuramento di Ippocrate, di significato tra il sacro ed il deontologico. Lo sviluppo delle tecniche anestesiologiche a partire dalla seconda metà dell'800 ha determinato l'ampliamento delle iniziative chirurgiche di tipo elettivo, a fianco con gli storici interventi in emergenza per la cura di lesioni traumatiche, ancor prima delle acquisizioni riguardanti le infezioni. Con l'espansione del campo di azione della chirurgia, le possibili complicanze ed i possibili insuccessi hanno fatto da contrappeso ai sentimenti di rispetto e di fiducia nei confronti dei chirurghi, giungendo a far assimilare in tali casi la loro opera quale causa all'origine di danni, provocati rientrando quindi nella categoria dei reati sottoposti alla Legge penale. Così, al termine deontologico di "responsabilità" valido per ogni iniziativa ed ogni professione, per i medici è venuto ad associarsi la qualifica di "professionale", con un significato di presunta colpevolezza. Da una parte le regole deontologiche si sono ampliate, ed hanno coinvolto direttamente il paziente nella fase decisionale delle terapie chirurgiche, formalizzate programmaticamente in moderni codici deontologici ed operativamente nel documento del "consenso informato". Per altro verso le leggi innovative del Codice Civile definito nel 1942, che al posto delle pene del codice penale introduceva il criterio della risarcibilità economica del danno in caso di riconosciuta "responsabilità professionale", ha determinato il coinvolgimento di altre figura professionali, e cioè di avvocati e di medici legali, oltre che delle organizzazioni assicurative, con detrimento alla serenità nell'espletamento delle professioni sanitarie e con l'insorgenza per reazione della cosidetta "medicina difensiva". La concretezza di queste problematiche hanno richiesto l'interessamento attivo della Giurisprudenza con una serie di sentenze, ed una formulazione di decreti e nuove leggi parlamentari, ancora in pieno assestamento nel corso del 2017, lasciano in qualche modo ancora irrisolti alcuni nodi.

LETTERA DEL DIRETTORE.

In nearly three decades to the direction of the journal Annali Italiani di Chirurgia I could add to my personal experiences as surgeon and University Professor of Surgery, those very special in the rather different field of scientific literature from the specific point of view of Chief Editor - English term that identifies the "Director" of a scientific journal. The original wish to enhance and promote the qualities of researches and professional activity of Italian surgery within the journal, after an initial phase of normal management has expanded ambitiously, and over the last decade has been taken new editorial strategic decisions to promote more and more the cultural value and the diffusion of the magazine, for the benefit of its subscribers and its readers. Therefore, since 2007 the preferential adoption of English was introduced, then it became the exclusive language from 2010. Later in 2008 there was the authoritative introduction of the magazine in the "informatics network" with the activation of a "web site" to constitute the parallel Digital Edition of Annali Italiani di Chirurgia, ISSN credited with the CNR, to constitute a large interactive library where there are nowadays collected in free reading all articles published in press from 2000 up to those published in the first half of 2015 - with subsequent to follow. In parallel it was inaugurated the section reserved to the individual "Clinical cases", published exclusively online in the same Digital Edition, with preservation of iconography colors. The own search motor of the "site" (www.annitalchir.com) enables the identification of all articles published in the Digital Edition, whether published in print or exclusively online, proceeding by title, by author, by keyword, and of course by date of publication. The functionality of the purchase mechanism of each article with the procedure of "e-commerce" right from the site and the possibility for all readers to interactively express the own evaluation of published articles, has transformed the site into a "portal" constantly updated, and this has led to the growing number of foreign authors asking access with their papers to the magazine, especially from the Mediterranean area and Eastern Europe. Considering the variety and quality of the studies performed not only in Italy but also in such a vast geographical and cultural area, evident in the articles already published, it seems appropriate not only the substantial analysis by the Scientific Committee of the articles received to be published, but also to underline the care of the formal aspects of those proposed to the press, and to express a series of suggestions, to urge the Authors to improve the formal aspects in the preparation and exposure for their articles, to benefit of their image of Authors and for prestige of the magazine in an international perspective. This is the meaning of the Leading Article of this first issue 2016. I conclude by listing the qualitative preferences adopted for accepting articles to be published, provided that the individual clinical cases - the surgical "chronicle" - have a privileged place in the Digital Edition of Annali Italiani di Chirurgia, preserving the colors of the iconography, but that only exceptionally will be published in the printed issues. IDEAL TYPES OF PAPER to be submitted for publication in Annali Italiani di Chirurgia 1. Results of original research on a topical issue; 2. Update on a theme with contributions of personal experiences; 3. Analysis of personal case histories of prospective studies; 4. Evaluation of case studies personal accompanied by extensive and comprehensive bibliographic revisions; 5. setups on the individual, with the formulation of opinions by the Authors; 6. Proposals for new surgical techniques; 7. Technological innovations; ACCEPTABLE TYPES OF PAPER to be submitted for publication in the Annals of Surgery Italian a) Editorial updating or development to the work of a single author; b) Description of unusual clinical cases (exclusively for online e-publish in www.annitalchir.com); c) Reviews of multicenter studies.

Rules to be adopted for publishing a scientific paper.

The main question to ask himself when preparing to write an article is "why publish a scientific paper?" First of all to publish an own article qualifies his author - or authors - as "scientist". Because the surgery is a mixture of art and knowledge, which coexist and interreact mutually increasing each other, scientific publications are the world where ideas are shared. Secondly, to an academic career is essential to be Author of scientific publications; but also for those who follow an hospital career or simply exercise the surgical profession in other contexts it represents the opportunity to communicate their experience and give a personal contribution to the knowledge of the art. The commitment of the academic world in particular must also stimulate new generations to pursue not only technical skills but at the same time updating their knowledge, and its members must also take on the role of researchers. The dissemination of ideas in the scientific community is a milestone for progress, because if they are not shared their concrete value is fleeting, and professional surgical activity value is itself transient and ephemeral, while the written documentation very often goes beyond the time, but certainly beyond space, stably transmitting ideas: "scripta manent". To write a "paper" - as a scientific publication is conventionally and internationally named - requires compliance with specific rules, which make it suitable to diffusion and well used by the readers. These appropriate rules are stated in the similar although variable "Guidelines for the Authors" set by the editors of most scientific journals - as also of Annali Italiani di Chirurgia - on the common purpose of making clear, comprehensive and concise the exposure of the study that is the motivation of the publication. The printed papers - as well the more recent on-line publications in digital format - use a very different language from that spoken in conferences and in verbal communications. Exemplary is the form of presentation used in the best "papers" of British tradition, where every effort is aimed at the clarity and brevity, for definite, consequential and well understood conclusions. Beyond any residual national pride, in the scientific world that has been globalized well earlier than other sectors of civil life, it is not a surrendering to a foreign tradition to conform oneself to the British model when writing a paper - and not simply adopting the English language - with the certainty to better achieve the brevity, clarity and concreteness of an exhaustive communication. "Be brief and you'll be good" - this is a suggestion always of great value to overcome the congestion and convulsions of our times. Furthermore in following the rules suggested by the "Guidelines for Authors" in writing a paper gives the Author the adjunctive advantage of a preventive and autonomous checking the validity and interest of the article as for premises, objectivity and reality of conclusions, and therefore vehicle of at least of one clear element of knowledge and progress, although possibly and despite of a "niche" argument. A paper is much more effective as more focused on a well-defined theme and as such more easily understood and its conclusions more easily assimilated. Therefore in the formal preparation of a paper, the critical sense must develop itself and grow, added to the vocation of following and attain the curiosity of knowledge typical of surgery, but following the typical procedure of the medical profession in the approaching march to the diagnosis, and then to the identification of the correct therapeutic indications which must take into account individual patient characteristics. As the very technical skill in performing the therapy chosen and agreed with the patient, completion of the professional duties, must not leave aside a constant exercise of criticism and self-criticism at every stage of the profession, similarly this same critical sense is also necessary in the preparation of a scientific paper to transmit a concrete, valid and original scientific contribution. It is useful to keep in mind that, as any student knows and does perhaps unconsciously, those who read an article do not follow the order in which it is printed, but having considered the catchy title go directly to review the conclusions. If still interested, they go on to the Abstract or to Summary, and only at this point if intrigued they read the Introduction, and then the material and method of study with their results, and finally the discussion, and to the end they read anew the Conclusions. However, in the formal drafting of a paper one has to remember this very likely sequence in reading an article and adapt accordingly: first put into focus the conclusions, which in fact are the reason of the publication. Therefore this must lead us to give up writing an article such as a report or a conference, and to conform attentively to the Anglo-Saxon model of presentation of a paper. A last point concerns the language of the presentation of a paper. Using own native language, in our case Italian, it is easy to the precise in language and is facilitated the communication of concepts, but that restricts the communication to own linguistics environment, whereas all scientific knowledge and the surgical one in particular, in accordance as stated by the motto of the International Society of Surgery "La Science n'a pas de Patrie", needs no linguistic boundaries. We should not feel therefore humiliated and colonized in adopting the English language in publishing our papers, because it has become the language of science globally adopted, indeed we must consider positively this choice for formal and substantial reasons. Formally the use of English forces ourselves to conform to a language traditionally pragmatic, schematic and synthetic typical of the Anglo-Saxon world, so renouncing to the usual subordinate phrases of Italian language, that may result contrary to its ingenuous purpose, making instead less clear and more foggy the concepts. This achieves in the meantime the advantage of a better and more schematic final clarity. We must take in mind from the very beginning the final concept you want to express with every sentence, and take it in the highest account. From a substantial point of view the adoption of English opens at the best the entire scientific world to all cultural contributions, no longer limited to the national linguistic areas, that now, in the globalized world of knowledge remains provincial even though vector of undisputed professional value and experience of Italian surgery. Any possible inadequacies of the used English language - that should be carefully avoided in terms of syntactic and orthographic rules, with the eventual help of a native language fellow - can anyways be accepted within certain limits as the price of a globalization of the diffusing knowledge, become even more evident by the introduction of digital editions. A special case is given by the publication of experiences derived from individual case reports. Clearly it is evident the impulse to disclose one's own individual experience, or because of its rare occurrence, or on the enthusiastic wave of a diagnosis successfully completed or because of the own satisfaction in choosing and performing an effective treatment successfully achieved thank to a surgical technique exceptional or of particularly difficulty. One can, however, make the mistake of aiming to publish "a case report" simply to show off one's skills and personal professional value. It is a short-sighted goal that gives the author an ephemeral satisfaction, but it will almost inevitably penalizated in the judgment of colleagues who read it. For psychological reasons it is difficult for someone to cheer the professional success of a not related fellow, and therefore it is advisable to refrain from this type of publication, which is a waste of time not very profitable, both to the one's reputation and for the likely rejection by the most accredited scientific journals. The publication of a case report must follow the same rules set for a "genuine article", with the difference that in the introduction has to be immediately highlighted the particularity of the experience, possibly framing it in common knowledge. The presentation of the clinical and strategic aspects is the result of a careful reflection on the surgical experience lived, because its exposure has to be very different from an extemporaneous oral presentation, which is by nature open to a free immediate confrontation in oral discussions that follow.

[Professional responsibility in surgery and informed consent. Reflections of a clinical surgeon.] / Responsabilità professionale in chirurgia e consenso informato Riflessioni di un clinico chirurgo.

The medico-legal conflict especially against the surgical profession is reaching ever higher levels, such as to make consider threatened the choice for surgery of the future generations. Surgery is an Art characterized by enthusiasm and entrepreneurship chosen on the basis of a genuine vocation, but nowadays becomes increasingly prey to indirect interests, with profound negative influence on the serenity of its operators. The current legislation, for civil controversies exposes the surgeons to a presumptive judgment of guilt unless the demonstration with proofs of wrong claims, and even from television screens come daily suggestions and incitements to carry out claims also if related to the last ten years of treatments received, if someone suspects or considers to have been object of "malpractice", and particularly without payment for promoters of the shares for lawyers and medico-legal specialists. We try to analyze the situation as objectively as possible, highlighting the inconsistencies and illusions for the rules alleged to protect both the patient and the surgeon, emphasizing instead the responsibilities of different professional groups, while not denying the need for full commitment of surgeons to operate with prudence, diligence and competence.

Age-dependent impairment of number and angiogenic potential of adipose tissue-derived progenitor cells.

BACKGROUND: Adipose tissue-derived stromal cells (ADSCs) are being recognized as a source of stem cells potentially useful for cardiovascular repair. We analysed the abundance and angiogenic activity of adipose tissue-derived progenitor cells (PCs) in elderly patients most likely to benefit from this novel source of stem cells. MATERIALS AND METHODS: Fifty-two subjects (aged 68 ± 13 years) with variable degrees of cardiovascular risk underwent abdominal surgery for intercurrent diseases. Visceral adipose tissue (3 ± 1 g visceral fat per patient) was processed with type-1 collagenase to obtain ADSCs from the stromal-vascular fraction. Adipose tissue-derived PCs were quantified by flow cytometry as %CD45(-)/CD34(+)/CD133(+) cells of total ADSCs. Matrigel angiogenesis assay was used to analyse the ability of ADSCs to form tubes or networks. RESULTS: We found no correlations between number of CD45(-)/CD34(+)/CD133(+) or total ADSCs and quantitative risk parameters including total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, waist circumference, body mass index, and systolic and diastolic arterial pressure. However, increasing age (r = -0·31, P < 0·05) significantly and inversely correlated with levels of adipose tissue-derived CD45(-)/CD34(+)/CD133(+) cells in Matrigel angiogenesis assays; increasing age (r = -0·29, P < 0·05) was related to a reduction of ADSC-derived tubulization. CONCLUSIONS: Ageing may alter the availability of adipose tissue-derived CD45(-)/CD34(+)/CD133(+) cells and their angiogenic functional capacity. Such changes may impair the use of adipose tissue as source of autologous PCs in elderly patients.

[Experimental model to verify the teaching efficiency of General Surgery II]. / Modello sperimentale di verifica dell'efficacia didattica della Chirurgia Generale II.

The modern university teaching, of the Faculty of Medicine and Surgery typical of the Italian university organization, at least for clinical matters must pursue the aim to develop in the students a clinical and responsible sense of the seriousness of the profession they intend to embrace, both for medical that for surgical pathologies. Therefore it is very important the teaching method, above all in a diagnostic key, hopefully making above all the study of the patient the true "book" to read and meditate. Beyond the necessary attendance of the Students to the wards to learn the diagnostic and therapeutic procedure methods to pursue, it is of the utmost importance to verify on the field the development in them of the clinical sense of the correct professional method. Therefore a method of direct teaching by clinical examples and a model for written verification of the student's preparations has been personally introduced and experimented along more than twelve years of general surgery's teaching by the Author. It consist of a Form, very different from the quiz methods of other cultures, that introduces the student, to the correct way to study of each patient since the phase of learning and then in that of the examination. The typical adopted Form is proposed in advance to the students at the beginning of the course of lessons, so they can conform critically their preparation of the entire subject to study preparing to individuate the correct diagnosis on a proposed card simulating a clinical situation, and then to discuss it with the examinator. This method informs the student to the correct procedure in studying a patient, and give the examiner a way of a possible uniformity in his evaluation of the preparations of the student himself.

[Main points of vertical banded gastroplasty technique in open surgery]. / Punti chiave di tecnica della gastroplastica verticale con bendaggio per via laparotomica.

VGP represents the single more diffuse bariatric operation among the others restrictive ones, proposed and used from Mason since 1970. Other restrictive operations followed, introduced in the surgical armamentarium, but the Mason-like procedure remained the reference one, although with variations introduced by the single surgeon. On a basis of a personal experience of 163 patients operated with VGP, the Authors report the personal modifications of the procedure, in search of safety and better results.

[A possible late complication of Mason's vertical gastroplasty: the erosion of the vertical band]. / Possibile complicanza tardiva della gastroplastica verticale secondo Mason: il decubito della benderella.

AIM: To evaluate possible adverse consequences and complications following the procedure of Mason-McLeans Vertical Banded Gastroplasty (VBG), and in those cases the possibility to be related to a surgical mistake. PERSONAL EXPERIENCE: It is based on a casuistic of more than 180 patients, submitted to this restrictive bariatric surgery in the same institution since 2001. Controls of the prescribed postop follow up revealed a very low rate of complications, as only in three cases, all of them with spontaneous presentation, there was a complication related to the banding. RESULTS: All the observed complications were related to a late postoperative inadequate alimentation for excess of meals, after the immediate orthodox behaviour of the first months. DISCUSSION: From the comparative evaluation of all the patients submitted to the Mason-McLean procedure it seems of the utmost evidence the importance of a correct alimentation, mainly to the low bulk of the single meal, to avoid complications and obtain the best EWL%. CONCLUSIONS: Adherence to the guidelines for the post op alimentation in such patients is the key to obtain the best results from the operation avoiding the side effects and complications here described.

Inflammatory breast cancer.

The very original definition of carcinomatous mastitis suggests the main diagnostic difficulty of this onchologic condition. Actually it is more correctly appointed as inflammatory breast cancer, because notwithstanding the inflammatory appearance, it is a true systemic breast cancer, for which surgery represents an only marginal treatment resource. If is now well known that radical mastectomy is ineffective and only a combination of CT and RT offers survival results of some value. But the actual correct multi modal treatment cannot be undertaken if not after a correct diagnostic confirmation, avoiding an anti-inflammatory therapeutic attempt that is time consuming and possibly deceptive. Surgery and histology can be the only means of a correct diagnosis when FNAB is falsely negative, but the lymph nodes must be the preferential tissue to examinate to avoid long lasting drainage from the breast parenchyma after a biopsy, that delays the beginning of the true treatment.

Diaphragmatic relaxation: pathophysiological alterations and current possibilities of surgical repair.

Diaphragmatic relaxation is a pathology not frequently observed because it is generally oligosymptomatic. The development of modern technology has induced an important contribution to the diagnosis and treatment of the disease which can find a possibility of restoration in surgery. A 63-year-old patient with a light syndrome of respiration deficiency and an altered relaxed profile of the right cupola was subjected to surgical treatment with the technique of diaphragmatic plicature without any adverse implication during and after the operation. After a brief recovery, the patient was discharged and after 9 years he affirmed still absence of dyspnoea from limited labor and absence of respiration problems. The selected surgical technique for the restoration of the altered muscle is the diaphragmatic plicature without incision or excision of the altered part of the muscle. The preferable access way today is that of laparotomy which is devoid of problems of thoracotomy and generally it permits quite easily the restoration of all diaphragmatic defects. Diaphragmatic plicature is a simple, effective and long-lasting intervention but we cannot determine the complete recovery of the normal contractile function of the muscle. There is no morbidity and mortality directly related to this technique, the latter incidentally associated with complications of general anesthesia.

[Lights and shadows in the radio-television broadcasting on medical informations]. / Luci ed ombre dell'editoria radiotelevisiva su temi della salute tra informazione e propaganda.

Some actual difficulties in the medical praxis, arising and growing in the social environment, and well known to the operating physicians and surgeons, should stimulate a careful analysis of the situation in search of the more likely causes and to draw the more suitable remedy. One of them certainly is the constant, and sometimes invading, presence of radio-television broadcasting in the all day life of everybody of more o less deepened programs inherent to themes of health. It is of the utmost importance to think over the topic, especially in order to evaluate the positive and negative aspects of the impact of radio and television media on the sensibility of the patients and in order to reflect on their reactions, and as a reflex on the professional behaviour of the physicians and surgeons, with all the lights and shadows.

An original use in low colo-rectal anastomosis of the new surgical device "grasping tie".

The grasping tie is an original and mechanical tool, conceived and planned to be used in digestive surgery to do the equivalent of a purse string. Its use is conceived to make easier the mechanical anastomosis in the more difficult situations as the oesophago-jejunal or the very low colo-rectal ones, as in the example of the presented paper. A thin ribbon of nylon will be progressively tightened as a one-way running knot upon the tract of the gut, either directly or about the axis of a circular stapler. Once completed the stapler suture it will be completely extracted together with the muscle-mucosal rings, so that nothing of the ribbon remains in the patient. The use of the grasping tie is also advantageous in quickly closing the gut above and below a tumour, to a safer manipulation and to reduce the contamination of the operative field. An original and useful use of the grasping tie is demonstrated in the present paper for the surgical treatment of a low rectal cancer with preservation of the anus. Its use is that to close the distal stump of the rectum below the tumour, to take away from the pelvis the proximal stump with the tumour, and then to proceed to the mechanical anastomosis in a now wide operatory field, introducing in the anus an enteral dilator and preparing on it the definitive purse string, as illustrated.

[Traumas in road accidents]. / La traumatologia della strada.

Road accidents are nowadays one of the most important cause of injuries, deaths and definitive invalidity, except the war casualties. All the developed countries are affected by this problems, and all the efforts are in progress to make aware the people, mostly the drivers, of all the possible preventive measures. Not all the accident are per se cause of death or invalidity, and there are a lot of evitable deaths and definite morbidity, but an incongruous help can worsen the outcome or menace the final validity and life itself. The injuries affect in different ways the driver and the passenger, and the same safety devices designed to protect the travellers, as safety belts and air bags, can hit them with peculiar mechanisms. A particular attention must be paid to the children, too often transported without the correct safety measures. Very important are the correct steps of the first aid, the succession of the treatment manoeuvres, and the environment were the patients can and must be treated. The Trauma Center represents an ideal solution for the best treatment, but its organization is far from simple, particularly in our country so different in the various regions as population, road, towns and villages distribution, especially in the mountainous districts. Every effort must be done to organize al the best the first, second and definite aid and treatment, together with the active and passive safety devices, and with a correct road education, to stop the true epidemic impact of the road accidents.

[Experience of many years with the Mason-Mc Lean procedure for the treatment of obesity]. / Esperienza pluriennale con l'intervento di Mason-Mc Lean per il trattamento dell'obesità.

Bariatric surgery is still in search of a general agreement among surgeons for the more advisable technical procedure, and the various solutions actually overall performed are almost only on empirical basis. The main wanted result of such variety, of procedures is represented by the possibility to restore the body weight to physiological values without adverse effects. The Authors' experience is referred to 94 consecutive surgical procedures to treat obese patients and is completely homogenous, with all the patients treated by vertical gastroplasty, and the most of them are almost completely controlled till 24 months for clinical, biological, psychological and weight parameters. The complete absence of complications and the relevant compliance of all patients, without biological derangement from the normal values, correction of those preoperatively altered, and with the restoration of the body weight to the mean normal values of BMI, encourage the Authors to sustain the great advisability of the chosen technique.

[History and pathophysiologic analysis of the various techniques in bariatric surgery]. / Storia e analisi fisiopatologica delle diverse tecniche di chirurgia bariatrica.

Bariatric surgery for the treatment of morbid obesity or overweight refractory to medical therapy was born at the beginning of second half of the twentieth century, and its first steps were uncertain and with a not jet well definite purpose. In fact the main result to be pursued seemed to be simply the reduction of body weight, and any change of anatomy of the digestive tract able to reduce the absorbtion of nutrients was judged adequate. But very early the adverse consequences of malabsorption so obtained became evident, and other operations possibly free from those complications were devised and clinically tested. So aside the by-pass operations many other surgical procedures found their room, all of them aiming to fight the ever more diffuse obesity of the people. This historical review of the various surgical procedures attempted in these last sixty years for morbid obesity is very interesting for a better understanding of the problem and to have a solid basis for future rational choices.

[Study of the antireflux action of the Roux-en-Y jejunal loop in reconstruction after gastrectomy and nutritional status in the follow-up]. / Studio della funzione antireflusso dell'ansa digiunale alla Roux nella ricostruzione dopo gastrectomia e stato nutrizionale nel follow-up.

The Roux-en-Y recostruction after total or subtotal gastrectomy for gastric cancer is frequently performed to prevent esophageal alkaline reflux. Also after total gastrectomy and end-to-side gastrojejunal anastomosis, as usual in former experience, the alkaline reflux can be efficaciously treated by conversion in an esophago-jejunal Roux-en-Y procedure. The main factor preventing reflux is the length of jejunal loop, at least of 35-40 cm. The recostruction with a Roux-en-Y jejunal loop offers the advantage to meet together two primary requirements: the restoration of digestive travel from esophagus to intestine, and the prevention of on alcaline reflux esophagitis, both with relevant simplicity and without a time-consuming surgical technique. Also as a consequence the postoperative morbidity is decreased. The obvious suitable requirement is a sufficient lenght of the jejunal loop for a reservoir of the ingested food and to oppose the antiperistaltic jejunal movements thanks to the effects of the new activated jejunal pace-maker.

[Simulated used of the "grasping tie" as in esophago-jejunostomy after total gastrectomy]. / Uso simulato del "Grasping Tie" come per esofago-digiunostomia dopo gastrectomia totale.

Simulated test of effectiveness of the original tool grasping tie--technically already illustrated in a former paper listed in bibliography--for fixing a spongy rubber tube simulating an oesophagus on a circular stapler head axis, by tightening over it a nylon ribbon slip-knot (the tie). After connecting the head to the stapler anvil through an other spongy rubber tube simulating a jejunal loop, and the firing of the stapler, it is demonstrated the correct circular anastomosis achievable.