DAPRI from sleeve gastrectomy to roux-y gastric bypass

Yes.

Okay.

Good morning.

They have been looking at you from the beginning, but there was no verbal connection, I imagine.

Sorry, which is the problem?

No, I'm saying that you were on from the beginning, but probably nobody spoke with you since now.

Is that right?

Okay.

I don't know.

Okay, anyway, we are looking at you and I'm going to ask you to explain what is the disease

and what is the operation that you are going to perform.

Yeah, okay, so first of all, so do you hear me?

Yes, we hear you and we see the external field.

Great. So, first of all, let me thank Giorgio for the very kind invitation.

And so, thank you so much. And it's okay, it's okay. Thank you.

So, today we are going to convert a patient presenting a sleeve gastrectomy

me to ruin why gastric bypass, because we can send the clinical case, please, because

the patient presented a problem of gastroesophageal reflux, and can you send the slide, Benjamin?

We can see the slide with the clinical history.

Ah, yeah, great. So, you see that, you see there is a, sorry.

A young lady, yeah.

Just a moment because I have a problem with your audio.

Okay, I'll try to.

Okay, so, this is a 32-year-old lady with a BMI of 41.

And the problem is not only the problem of weight.

The problem here is an invalidant gastroesophageal reflux.

And in fact, what we studied with a gastroscopy, we found esophagitis B.

And we have also at the impedanceometry 256 episodes.

You see?

So this is classic. This is really a classic history of patients submitted to obesity surgery and presenting after one, two, three years, not only a problem of regain weight, but also associated comorbidities like reflux.

So, external view.

What we are going now is to convert the sleeve to bypass, and the patient is in French position.

The surgeon is between the two legs of the patient.

Can you send the external image, please?

We can see the external images.

Okay, because I don't have a Benjamin.

Okay, so one of the rules of laparoscopy, as you know very well,

To have the optical system, which is this, in the middle of the triangulation and the walking intra-abdominally.

So I have placed a 10-millimeter trocker for a 30-degree regular length scope into the umbilicus.

And then I place a 12 disposable trocker for grasper, stapler, et cetera, in the mid-clavicular line on the left side of the patient.

And a 5-millimeter trocker here on the mid-clavicular line on the right side.

So, if you want, I'm doing a reduced pore surgery, so one, two, three trochers, and here what we used to do, you will see immediately, to expose the yatal region, what we use is to insert a percutaneous suture, okay?

Okay, can we see the internal images now?

now yeah absolutely if you prefer to speak in french uh it's no problem for us um but i will

keep i know speaking what's your name my name is michele gulia i work in como and um okay i can

understand we we can understand you uh there are the translators so if you prefer to speak in

in French, you can speak in French.

I will answer in English because it's easier for me.

Yeah, but you know, Michele, my name is Giovanni,

and I come from Bergamo.

Ah, OK.

So you can speak in any language.

I, OK.

You can also speak Pugliese if you want.

No, not Bergamasco.

Yes, but here, here, OK, external view, please.

we have a we have a live demonstration and we have here in our different people and so you see

okay yeah yeah we can see and so if you permit me I can speak maybe in French it's it's the best

think I think so it's easier for you okay okay as you want the first step

In the first step, we put a needle, okay, straight, to divaricate the left liver.

So we're going to put a thread on the left lung cartilage, okay?

So the trick is that we have to look for the right pillar of the diaphragm.

So, Michele, what I usually do...

Can you hear me?

Yes, I can hear you well.

Go, go.

Okay, very good.

Il primo step è di andare a cercare l'apice del pilastro destro e allora praticamente ho introdotto un etilon 2.0 con agrodritto.

Abbiamo bisogno di vedere le immagini interne perché adesso vediamo soltanto la sala operatoria.

Ok, buono.

Come back, please.

Come back, come back.

So, this is a straight needle that is inserted here, under the xyphoid, ok?

So, the first step is an ethylene 2.0.

The first step I curve it a little bit like this, ok?

Second step, we are going to look for the tip of the right pillar.

So we are going to look for the right pillar.

The pillar is there, if you can see it.

This is the right pillar.

There is a message inside.

External view, Benjamin.

And on the outside we put two cokers.

External view, do you see it well?

Yes, we have the external images.

Here are the two kellys that hold well.

Look, these are the two kellys that hold the two apexes.

Internal view, please.

that hold the two ends of the on the right pillar ok and therefore in automatic

I now have an exposition of the correct natal region without change

then so we are going to do here we are going to do here we are going to look on board we are going to sit

So, this is the previous sleeve. This was an adhesion between the stomach and the liver.

Can you show it here, please?

Here, you see? It was the adhesion between here and here.

Here, there is an injury. I think it's an angioma, but we will do an IRM post-op.

Allora, il primo step quando hai questo tipo di intervento è di mobilizzare lo stomaco

completamente, in modo da avere l'esposizione lungo la grande curva, in modo poi da transecare

a circa 5 centimetri dalla zeta line, quindi più o meno qui, con una stapler, e fare

gastro-diagnostic anastomosis.

Okay?

Va bene.

Donc, on va faire la libération de la grand corpure.

Okay?

Donc, met un peu le patient sur les roulis droits, s'il te plaît.

Allora, Michele, il mio cameraman è una lady,

è una signora che viene...

Tu vieni da dove?

De Cordova, no?

España.

Yes, and my assistant is called Ani.

Beautiful, Cordoba is really beautiful.

Beautiful, wow.

Cordoba is very nice.

And the other assistant is Adria, who also comes from Madrid.

That's right.

No, Tenerife, not Madrid.

So here I am behind, you see, so here I have opened, this is the one that in general is the

back cavity, but here it is not the back cavity because it is the adhesions between the

large pips and the stomach, ok? So, in general, the intervention is performed,

Please show it to us.

It is performed with the crochet,

simply for the surgeon's habit.

We're going to use the crochet hook here because it's just a habit of the house.

But of course you can use other instruments to make this kind of section.

One question, is it all in Italian at the congress?

There is a translation.

Simultaneous translation.

So you can speak in any language you want.

This is the left diaphragm.

What I don't usually do, because there is no herniated hernia here,

is to leave it intact, otherwise you have to open and reduce it.

In this case I leave it there.

Please come back a little to the back, if you please.

Simone, can you take a little, Adriano, if you please,

take a little tissue lacquer and we'll go over here.

Now, the step here, show us a little, if you please.

You see there's a cross with the word 5?

Yes.

And more or less, we're going to transfer the stomach here

because the goal is to reduce the gastric volume

per ridurre l'acidità ok oltre che a incrementare il peso quindi questo è più

o meno quindi siamo qui quindi a questo livello

probabilmente questo è le targe

And so this is the left gastric vein, here.

Yes.

So we're going to put ourselves right here, a little higher,

so that we can still maintain a...

So I put myself a little higher and I'm more or less at five centimeters, see?

Yes.

Yes, if you please.

So there's a technique, which is to pass behind and to transact.

But in general, what I do is simply to stay perigastric, so that in perigastric I do not have the difficulty of having a devascularization at the level of the tranche de section, of the suture line.

Okay, so here I'm just going to open it slowly, slowly, slowly, slowly, slowly, slowly, slowly, slowly, slowly, slowly, slowly.

So, let's talk about 40 years old, I think.

I was born and raised in the majority of the world.

I have too many reactions.

I'm a young boy, very young, 18 years old,

who had made a journey, let's say, adventurous, in Asia.

At this point, I put a...

How do you say it?

A fettuccia.

A fettuccia.

Ecco, non mi ricordavo più.

Deve ricordare le fettuccine.

Esatto, questa.

Ok?

Quindi, questo qui è, diciamo, il trucco.

Allora, in genere faccio un piccolo nodo, giusto per non avere...

Allora, l'anestesista...

Can you remove the gastric probe?

So I ask the anesthesiologist to remove the gastric probe.

Here is a good passage.

You see?

Yes.

You see that it is clear.

So it goes well.

There we are going to put the graft.

Ok?

Now at this point, Michele,

I put a line, sorry, a graph, a linear, articulated, and external view, please.

Can you see the external view?

Dimash, can you see it well?

Yes, now we have an external view.

The discussion we can have is...

Invert, eh?

Invert, please.

So the discussion we can have is what type of graph do we use, and I use a green one because the stomach, when it has a riddle, is always a bit adherential and thick.

So this is the grapher. We're going to put a grapher with a thickness of 4.2 to close the stomach well.

And we're going to put it through the trocar, which is here, in the right flank.

Internal view, please.

And then, at this point, there are two possibilities.

o introdurre la steppe da laterale a mediale, così, oppure da mediale a laterale. Secondo

me però, siccome così è un po' più, je pense, penso che la cosa migliore sia così.

I have a question for you, if you had a trokar from 10-12 instead of the one from 5, wouldn't

it have been easier to make this transition?

If you had had a trocar from 10-12 instead of 5, wouldn't this passage have been easier?

Yes, why not? It's a possibility.

Yes, it's possible, of course.

Yes, with the roticulator it's also good.

Ok, so, we don't have a probe inside.

Prepare the probe. Ok? Ok.

Okay, so now we're going to cut the stomach, so that we're, in general, there's always a little bit of bleeding on the line of the graph, but not immediately.

You'll see that here, soon, it's going to appear.

So, at this point.

You don't use the same guard or the other?

No.

No.

In general, no. We have done a study that was published in 2009, in memory, of the use of Simgard in the sleeve.

It is a randomization between Simgard versus non-Simgard versus running suture.

And the difference, there is a difference especially in bleeding, but not in terms of fistula.

But the problem is that it costs 625 euros per one.

C'è stato un recente lavoro sugli annals of surgery di una importantissima

multicentrica americana con tantissimi casi dove si è visto che l'utilizzo

delle striscette protettive riduce i sanguinamenti ma ci sono più fistole.

It's a very recent work on many thousands of patients, so less bleeding but more fistula, on the sleeves.

Ok, I don't have any current.

Yes, yes, but it's very recent.

Allora, qui facciamo una sutura manuale tra l'intestino, che ho cercato a livello dell'angolo

del treize, e la tasca gastrica, ok?

So we're going to do a suture, so an anastomosis.

I'm going to do a suture like this, yes, yes, when I'm done.

Show me a little bit. Gastro-jejunal.

Yes, yes.

Terminal-lateral, because the stomach is terminal.

On the other hand, here, it's lateral, sorry.

Yes, show me a little bit.

I first do the compliments, a very beautiful and beautiful statement.

Thank you, because I don't know until when...

The thread I use, Michele, is a PDS1.

I didn't see well which intestinal tract you took.

I went to the duodenal-giginal angle,

the famous Traiz.

And basically I have chosen an ANSA that rises without tension, regardless of the length of the ANSA, which is the biliary ANSA.

What is the ANSA? Can you repeat it?

It is the biliary ANSA, that is the digestive biliary, which is this one.

Okay.

Yeah, l'ansia alimentare.

Sì.

Allora, mostra un po'.

Allora, ici, on va a faire la suture.

Donc, vous voyez que on prend...

Pratiquement, on fait la...

A toute épaisseur, l'intestin grêle et l'estomac.

Allora, quello che sto dicendo, mi chiede è che, semplicemente,

realizzo una sutura a tutto...

Yes, all thickness and lateral term. There are more possibilities and you can also make a term-to-term, but it depends from case to case.

In this moment I don't have any calibration probe in the stomach because it is not important for now but in a few minutes I will ask the anesthesiologist to lower it.

The reason why I use a PDS1 is because, as you can see, it's a thread that slides well

and secondly it's a very resistant thread because when you do this type of traction, what happened

success with the thread we used before, which was PDS 2.0, we often broke it. And the other trick is to stay close to the whole month for the small intestine, so that then we open here and we have enough space without falling on the half of the intestine to pass the probe and do the

the anterior supragittum of the anastomosis, ok?

Yes.

So, it's an anastomosis that, in general,

I do in a single layer.

In general, in a single layer.

The only times we do it in a double layer,

so a multi-mucous inner layer,

is when the mucosa is very strained and so it's a bit like if there was edema.

You often have it in the reduce, but let's see, in theory, if everything goes well,

Don't worry, let's just do an external layer, an external layer, sorry.

A posterior and a anterior one.

So, here we are at the end.

Thank you very much.

The probe is 36 French, can you see it?

Yes.

The probe is here.

You can see it, right?

Yes.

It helps you with the incision.

Exactly.

So, you clamp the probe.

I'm asking to clamp the sound, so I'm going to put the sound, as you can see, to calibrate.

It's done by a tutor.

Show me a little.

So, here.

Yes, we can also see very well.

In general, I do first one here, then one here.

Show me a little.

Michele, is the quality of the image good?

It's pretty good, yes.

We send it to Benjamin, because the image is not in 6.

That PDS thread has clips at the end?

No, I understand.

No, they are threads that we made.

You made some nodes.

I saw, I saw.

You made some nodes.

Yes, ok.

7 knots.

It's a...

It's a good trick.

Sonda.

Sonda.

Sonda.

Sonda.

Now let's go on, the stomach in general, I'll open it a little more here.

Adesso il secondo step è senza sonda, con il sopraggitto anteriore, andiamo all'angolo.

Allora, dall'esterno all'interno all'angolo, ok?

Si.

E poi dall'interno all'esterno.

This is the first one, now I'll do one or two more and then I'll reinforce the other angle with the back stroke.

Okay?

Show me.

Yes.

So, the thing I'm doing is to make a suture in the anterior part between the stomach

and the skull.

And we're going to do this first, and then we're going to continue with the subjects

that we put later.

I think it's the echo, I'm not so sure.

So this is, we have done three of the passages.

Don Convara pront le fil posteriore.

Convara ferle qua.

Allora per adesso Michele non ho la sonda.

Dentro ce l'ho giusto nello stomaco.

Si.

Now I'm going to do two passes at the medial angle of the anastomosis,

with the back overhang, so that if you want to safeguard this here,

because if you have a fistula you have it at the corners.

Sure, so you're taking a lot of care when you're making the corners.

vedo che adesso stai sudurando con la mano sinistra si questo passaggio in

genere lo faccio così perché viene meglio cioè è una questione di di

ergonomia nel senso che vedi metto il portaghi da 10 nello stomaco poi si può

usare anche un portaghi al posto del grasper però è una questione di

habit. Yes, it seems easy when you do it.

All right, let's keep going.

I want to put this well inside, you see?

So, Lorenz, can you push the probe?

Now I ask the anesthesiologist, because this angle has been safeguarded, ok?

Yes.

And this is our anterior ultrasound.

Now I ask, go there, the probe is here, go there, go there, go there.

Go there, go there, go there, again, go there, go there, go there, go there, perfect, thank you.

So the trick now, Michele, is that the anesthesiologist turns the probe.

So, Lorenzo, do it as usual, because I'll rotate it, because if he rotates the probe, do you see it?

Yes.

Do you see that it rotates?

Yes.

It prevents me from taking it with the needle.

Okay.

Okay?

Show me a little.

I'm telling you because it's already happened to me.

Yes, in being very overwhelmed. But for this there is still a basic therapy.

The basic therapy is there anyway.

The PCI is only used when the patient is explained how to bend in all the pain,

As it is explained there, it is not that you can crush it in 20 seconds, there is a limit to it.

You need to prepare the patient.

Can you show me the T-PLAIN?

You need to prepare the T-PLAIN.

And this?

Let's see.

Let's not put the therapy on the bottom.

So, now?

With the catheterine, etc., and then we talk with the patient.

We also explained it to him before, before the electropent, so that it is also a little shiny.

Now I'll probably give one more pass. This is our suture. I think it's quite correct.

Yes. A question. Why do you prefer the manual anastomosis to the mechanical one?

Well, there are two reasons. The first is because when you have this type of intervention,

This is the very short pocket, if you make a linear suture, for example, the diagraph line from the introduction comes more or less here, so in the middle of the gastric pocket.

And the second is that it is reported in literature that with linear anastomosis, for example lateral-lateral, you have more or less 15-18% of ulcerous post.

This disease here already has a reflux problem.

Se invece scegli un'anastomosi circolare, si può, però io non la faccio più, lo faccio,

credo che risale nel nostro istituto al 2004-2003, perché avevamo troppo tasso di stenosi,

nonostante una circolare da 25, non da 21.

Ok.

So you said that using a linear suture to do the anastomosis there is a greater incidence of anastomotic ulcers?

No, ulcera con la lineare, esatto.

Ulcera sull'anastomosis?

Più o meno, sì.

Sì, è un'ulcera anastomotica, sì, sì.

Ho un caso ancora settimana prossima da revisione, da smontare l'anastomosi e rifarla.

Il problema è che se tu hai un'ulcera qui che non guarisce perché è un'ulcera non ischemica,

but because you have a diagraphic line, which is this, plus the diagraphic line of the anastomosis,

so you have tissue between two diagraphic lines that is not good.

So the problem is that when you reoperate it, you end up with a gastric bag that is almost esophageal.

This is the main reason why in general there is a learning curve, but I think the manual anastomosis is like the intracorporeal sutures,

un aspetto che penso

in laparoscopia

è fondamentale

certo

penso

sento un'altra voce

ci sono altri interventi

sotto?

allora qua siamo in regia

per cui siamo collegati con

una decina di sali operatorie

So there are nine of my colleagues who are commenting and so you probably also hear them talking.

The management room is very large.

Okay. Are there many participants?

You are on screen number 15. So for the moment 15 connections.

Okay. So this is over. Now...

Thank you.

I'll do it for you.

Look, Michele, this is...

Show it a little better.

He'll show it correctly.

So, this is the feeding lance.

This is the lance

that comes from the trident.

Show it a little here.

This is the part

of the posterior suture.

Show it a little higher.

Can you lift the probe a little bit?

Yes.

S'il te plait.

Vas-y, encore.

Vas-y, vas-y, encore, encore, encore, encore,

retire, retire, retire.

Retire, retire, retire, retire.

Parfait.

Allora, qui.

E questa è la nostra sutura.

Bene.

Ok?

Sì.

Ok, adesso.

Primo step.

Allora, il nodo è qui.

Sì.

Quindi, più o meno qui.

Graspa.

Echelon de Blanc, s'il te plait.

Allora, mettiamo una graffe bianca.

Donc, on va a couper maintenant les grèles qui arrivent du 13

pour faire une construction d'Omega,

parce que maintenant c'est une construction d'Omega,

une construction qu'on appelle un Y.

Ok?

Ok?

Now we have to be sure that the node is outside.

Do you see that they are outside?

Yes.

Every now and then it has happened to me to take the knot in the line of the graph, but nothing happens.

If you want a further fixation.

So here, these are our two knots.

Yes.

This is our anastomosis.

Prima di andare a misurare, apro già l'ansa biliare, così sono già pronto, ok?

Quindi, di nuovo, utilizzo un semplice strumento per abitudine e scuola qui.

Allora, adesso, Michele, la misura dell'ansa alimentare, ok?

Quanto lunga?

Okay, so this is the lance that goes to the iliosecal valve, so it's a common lance, we put it there like that, and that's the end of the alimentary lance with the food that comes from there.

At this moment, we are going to make a small sign here, this is the end here, we are going to open it.

This is the food chain and this is the common chain, because it will be together the billiard chain.

Allora, dicevo che la misura è 50 perché qui c'è un grosso dibattito su quanto deve

essere la lunghezza, però di base devi sapere che i malati operati di bypass hanno un problema

If you have a long hangover and they continue to eat incorrectly, especially hyperglycemic,

so sugars, you have a problem of continuous glycemic insult, therefore hyperinsulinemia

with consequent hypoglycemia, for which a continuous vicious circle is fed and therefore

So, again, there is the entroit line, if you say so, of sugars, and so if you make an ansa that is as short as possible,

however not long, this vicious circle is inferior.

So, at the beginning we made an ansa of 150, and for about 4 years we have changed to 50,

because we have more or less 15 patients out of about 1,500

who have developed post-bypass diabetes after 6 years of follow-up.

So, this is the anastomosis between the biliary and the alimentary anastomosis.

Okay?

Yes.

Wait, it's not...

There, it's better.

Annie, thank you very much.

Annie wasn't in agreement.

You're not in agreement, are you?

Okay.

Yes, I don't know...

The two...

The two...

The two...

The long...

Ah, yes, I'll give you the two.

The long.

Can you give me the long?

Yes.

So, again, do you see how it's knotted?

Yes, yes.

This is a PDF.

2.0

2.0 here

here

now I'll show you better

what we do is

a passage

at full thickness

but then you pull it back

a little bit

so that

that remains only the serose then it is all thick yes ok then a little piece

back to exit only here

So the preparation of the vase is not the trust of the instrument, the application is in the cases in which it can be done.

I see it in this way, if I prepare a vase like this, I also put a thread in it, because if I had the trust of the instrument, then I would have bought the instrument.

At this point, again a trick, you put the crash inside so as not to close the last passage, but all together, ok?

You can finish the suture with just one overhang, or it's a little more elegant to use two.

Those knots are made by the instrumentalist?

No, it was made by Adria, who is our Spanish assistant, and who specializes in it.

We don't have an instrumentalist.

Ah, ok.

Torino, can you hear me?

There is a cut in costs here in Belgio, you know.

Everywhere.

And so, but it's already a bit, and you know that we no longer have the instrumentalist, it will be at least six years, at least.

Okay, now, I'll continue with the above, it's always before, it's clear, but the first, and then it's very important, what we do is to close the defects, because the problem is that these patients here lose weight and the meso becomes even thinner,

And even if it is closed, there is still a risk of internal hernia post-op, not immediately, after a few months.

So here we have almost closed.

The thing I was saying is that we are going to close the two defects, so the mesenteric defects.

and what we call a petersen between the transverse mesocolon and the mesenter of the alimentary lens

so that we avoid the risk of internal hernia, so internal hernia, and especially of occlusion.

So patients who arrive in an emergency with an occlusion problem.

Okay, problem A.

24 hours, I say this because I had a surgery and therefore I know it,

to do a nematoma during this procedure

and if it were to happen, it is something that can be solved in a short time.

So you use non-absorbable thread for this procedure?

Non-absorbable.

It's a problem, so it's not absorbable, it slides well, and now I'm going to do the external node.

Okay, I don't know if you can see it, but maybe you can see it.

So, you first press the roll button, please, and then stop.

So, this here is, let's say, the end of the anastomosis, the day-to-day day-to-day, which is this, okay?

Yes.

This here is, you see, you could see the node, you see the node is here?

Yes, you can see it.

Ok, this is our closure.

This is the defect that we have closed here.

Now, the other defect is this here.

It's between the whole month of the food cycle and the month of the transverse colon, okay?

Okay.

So, why?

Because the problem is, don't mind, when you have even more weight loss, what happens, unfortunately, is this.

Look, you here.

Earlier, Dr. Rizzarelli said that you were not able to move it to the other side because it was too rigid.

I'm not sure if it's a preparation or not a preparation because it seems to me a bit like an argument.

And then maybe...

It's a big discussion, honestly.

Without wanting to...

What happens is this here, you see?

That is, you have an internal salerni, as they say,

and the migration of the small intestine from the aneurysm creates the sclerosis.

You see, when you have this, this here then goes into occlusion and you also have the risk of

perforation on the distal stomach if you have biliary lancers, okay?

Yes, I heard.

Unfortunately, you need to do it in certain conditions.

The person does not do it, but does a little bit.

So you, to have the colon clean, instead you find the colon.

I write 10 financial notes.

It is the format of the guides, you can go wherever you want.

Then it's over.

At least that's my idea.

Ok.

If there is a cord...

I'll prepare the tests.

Facciamo il testo, il controllo dell'anastomosi, in genere lo facciamo con l'aria, c'è la

possibilità di farlo anche con il blu di metilene, ma è buono.

Noi qui facciamo in genere con l'insufflazione di aria nello stomaco.

So, Michele is here now, we are done, let's do the test, we have a bit more of the trend,

Head down and a little roll to the left.

Usually I put my head down, naturally, but above all the bed towards the middle,

the left cubit, so that I have the physiological solution that goes only here.

We're going to blow a second, eh?

Do you also do it when it's this color, you do it with water?

Yes, yes, yes. Water and air.

OK, go ahead. Perfect.

OK.

There are no bubbles, eh?

Sure.

OK?

Voilà.

And that's it. Now we remove the trockers and the intervention is over.

No, in general we don't leave it on, first because the patient will drink water tomorrow,

he has a liquid diet after tomorrow and if everything goes well he comes out on the third

day.

Second, because we leave it on only when we do a biliopacriatic derivation, because here

Here you have a gastric pocket that is more or less 50 cc, not more.

And so you don't have the problem of an important volume to decompress.

In general, no, we don't do...

Drainage?

I don't use it anymore, because if I do, I drain it.

Drainage?

Drainage, in general, we leave it until the third day, in the primary interventions,

for this type of intervention. If the intervention went well and there are no

problems for operators, it is not a choice. In general, we do not put it.

Ok. And post-operator checks of the anastomosis, do you do them?

do we do them only in the case of only in case you mean like for example or gas or

blue of methylene no if there is a drainage as in this case tomorrow morning we do the

blue if the blue is negative we give water to drink instead if there is a doubt

Thank you very much and congratulations for your skill.

It was a nice intervention, a nice operation, very clean, very fast and very educational.

PRESIDENTE DEL CONSIGLIO COMUNALE FABRIZIO FERRANTE