Professor Joaquim José Gama-Rodrigues was born in Cruzeiro, state of São Paulo, Brazil, on December 2, 1935. Following his family's example and vocation, he pursued education in public schools, initially in Guaratinguetá, near his hometown, and later attended Colégio Estadual Presidente Roosevelt in São Paulo city.

He successfully passed the entrance exam and immediately gained admission to the Faculty of Medicine of Universidade de São Paulo (FMUSP) in 1954, ranking 38^th among his peers. He never left until compulsory retirement, at age 70, in 2005.

His vocation has always been the incessant pursuit for knowledge, following the example set by his mentors, to increasingly expand his expertise. This drive led him to undertake scientific initiation at the Surgical Technique Department, where his efforts culminated in a study published in an indexed journal while he was still a student.

He consistently prioritized sharing knowledge with his peers, leading him to assume roles such as the speaker of his class and student representative at the National Union of Students (UNE) and State Union of Students (UEE) on numerous occasions. This associative activity persisted throughout his academic journey, initially as a representative of physicians and later as a representative of full professors and associates of FMUSP.

In 1960, he graduated and achieved 1^st place in the Residency in General Surgery exam, at the Hospital das Clínicas of FMUSP. His excellence was further recognized when he was elected chief resident by his peers. At that time, he held a seat on the Administrative Committee, and actively contributed to the laying of the "foundation stone" for the building that accommodates hospital residents.

In this nurturing environment, he found himself drawn to morphological subjects, an area in which the character and intellectual discipline of Renato Locchi's inspiring personality stood out. His interest in surgery was quickly piqued, at which point he received invaluable encouragement and support from extraordinary mentors at the onset of his journey. The esteemed names of Alípio Corrêa Netto and Arrigo Raia deserve mention. As a recent graduate, he also benefited from the valuable guidance of Antonio Barros de Ulhôa Cintra and Carlos da Silva Lacaz, among many other luminaries in the field. Such an exceptional experience prompted him to contemplate the need to always be prepared to fulfill the institutional requirements that evolve within work communities over time. He realized that continuous personal improvement was an inevitable obligation in this pursuit.

He obtained doctorate in medicine with the thesis entitled "Motor changes of the esophagus in patients with esophageal varices caused by schistosomiasic portal hypertension" in 1972¹; the title of Associate Professor with the thesis entitled "Sliding Hiatal Hernia. Esophageal Fundogastropexy Associated with Hiatoplasty, Clinical, Morphological and Functional Assessment" in 1974²; and the title of Full Professor of Surgery in the Department of Gastroenterology of FMUSP, in 2002, through a public tender.

He held the position of Head of the Department of Gastroenterology and Surgery at FMUSP and Head of the Stomach and Small Intestine Surgery Service at the Hospital das Clínicas of the Universidade de São Paulo. Additionally, he was a full member of the Board of Directors of USP from 1990 until 2005.

In his associative endeavors, he served as a founding member and president of the Brazilian College of Digestive Surgery, 2001–2002. He was also the creator and founding member, along with several colleagues, of the Brazilian Gastric Cancer Association, for which he was elected as the association's first president, from 1999 to 2001, and again for the 2004–2006 biennium. His contributions led to the presidency of the International Gastric Cancer Association (IGCA) from 2007 to 2009. Furthermore, he served as the director of the Angelita and Joaquim Gama Institute for Research and Teaching in the Digestive System and is a founding member of the Brazilian Association for the Prevention of Bowel Cancer (ABRAPRECI) since 2004.

He is an honorary member of the American College of Surgeons, a title bestowed upon him in 2006, as well as an honorary member of the Brazilian College of Surgeons, awarded in 2018.

He participated in the organization of numerous medical congresses, notably serving as the president of the 7^th World Gastric Cancer Congress held in São Paulo, in May 2007. In addition, he is president of the Organizing Committee of the International Rectal Cancer Forum (Fórum Internacional de Câncer do Reto – FICARE), a biennial event held in São Paulo since 2007. He has made significant contributions through important publications on this topic³,⁴.

He has authored 251 scientific articles indexed in PubMed and boasts an impressive H-index of 54. He has held various positions in esteemed scientific journals, including member of the Editorial Committee of the World Journal of Surgery, Hepatogastroenterology, Acta Cirúrgica Brasileira, Arquivos Brasileiros de Cirurgia Digestiva, Arquivos de Gastroenterologia, and of Gastric Cancer; the first being based in the USA, the last at IGCA in Tokyo, and the others in São Paulo.

It is noteworthy to mention that Professor José Joaquim Gama-Rodrigues was a mentor and motivator for doctors, disciples, and researchers alike. He actively fostered opportunities and supported the career development of his peers, colleagues, and residents, participating in the creation of the Endoscopy Service at the Hospital das Clínicas of FMUSP. As director of the Stomach and Small Intestine Service, he headed the "GENOMA" project, a groundbreaking initiative aimed at advancing the study of Gastric Cancer. This project not only modernized and standardized gastric cancer surgery in Brazil and Latin America but also facilitated international collaborations, particularly with Japan and other international centers⁵–⁷. As a result of his efforts, this activity allowed him to bring the 7^th World Gastric Cancer Congress to our country in 2007, laying the foundation for its return in 2015.

In collaboration with Prof. Arrigo Raia, Prof. Angelita Habr-Gama, and Prof. Henrique Walter Pinotti, he played a role in the inception of the renowned GASTRÃO, the foremost Brazilian event in the realm of Digestive System Surgery and Gastroenterology, which has recently celebrated 50 years of continuous operation.

Building upon this foundation, in 1988, along with Prof. Henrique Walter Pinotti and other collaborators, he created the Brazilian College of Digestive Surgery. Six years later, in 1994, their efforts culminated in the formation of the medical specialty Digestive System Surgery. His performance was fundamental at the Conselho Federal de Medicina plenary session, for the acceptance and implementation of that specialty which has since become a cornerstone of medical practice in Brazil.

The Professor was the recipient of numerous accolades and distinctions, renowned for his excellence as a surgical educator and researcher. He was bestowed the title of Honored Professor by three graduating classes at FMUSP. He received honors from the Lusíada Academy of Sciences, Letters and Arts of São Paulo, where he was later appointed as an honorary member. In 2010, he was honored with the Order of Merit of Infante Dom Henrique and became an esteemed honorary member of Casa de Portugal in São Paulo.

Professor Joaquim José Gama-Rodrigues epitomizes the essence of a true PROFESSOR, embodying the qualities of a compassionate "human being," "doctor," "surgeon," and "teacher," leaving behind a rich cultural and humanistic legacy that serves as a beacon of guidance for generations to come

EDITORIAL

^IUniversidade Estadual de Campinas - UNICAMP

^IIUniversidade de São Paulo - USP

^IIIUniversidade Federal do Paraná - UFPR/Faculdade Evangélica do Paraná- FEPAR, Brazil

In the last ten years several authors have reported progressive increase in the prevalence of adenocarcinoma of the esophagus and the esophagogastric junction in occidental countries^1,2,3,4 and also in some oriental ones⁵. The main factors involved are chronic gastroesophageal reflux, untreated Barrett's esophagus, smoking and obesity⁶. The low intake of fresh fruits, vegetables and cereal fibers may raise this risk^7,8,9,10.

Obesity is associated with the prevalence of various types of tumors and may be an association between patterns of fat distribution and risk of malignant transformation of Barrett's esophagus, for example. Furthermore, altered metabolic profiles in metabolic syndrome may be a key factor in the genetic/cellular changes cycle that mark the progression of Barrett's esophagus to cancer.

Surgery is the primary mode in the treatment of adenocarcinoma of the esophagus. However, the results of surgical treatment alone are limited.

Another aspect to be considered is the fact that in Western countries - where there is no endoscopic surveillance programs - generally adenocarcinomas of the esophagogastric junction are diagnosed in advanced stages, with disease extension to the serosa or to regional lymph nodes at the moment of diagnosis. Thus, adjuvant and neoadjuvant therapies have attracted the interest of several research groups in order to improve survival rates and relatively low cure.

Therefore, the increasing prevalence of this disease in the world, its association with risk factors significant for the population, their surgical treatment - esophagectomy - with important risks and its poor prognosis despite the best surgical techniques, fully justify the need to study new therapeutic strategies.

Adjuvant therapy is generally defined as a treatment that is given after transaction considered "curative" (R0 resection) in order to improve the chances of long term survival. Depending on the type of disease, may be adjuvant chemotherapy, radiotherapy or both.

Adjuvant therapy after surgery has theoretical advantages and disadvantages.

The potential advantages are: a) may or not be based on pathological staging, and in potentially inaccurate clinical staging; b) patients who might benefit from adjuvant therapy can be identified, avoiding toxicity in those who do not need or will not be benefited with this treatment; c) delay, resulting from the neoadjuvant therapy, is prevented and the resection is carried; d) dysphagia is released early in the treatment; e) nutrition can be maintained by jejunostomy performed during the operation; and f) toxicity of neoadjuvant therapy does not affect the operation.

The potential disadvantages are: a) blood flow in the area of resection can be reduced and reducing the amount of chemotherapeutic agents in locoregional tumor bed; b) the therapy target for radiotherapy has been removed in the operation, complicating the definition of the fields to do it; c) postoperative surgical complications may delay adjuvant therapy; d) deaths in the immediate preoperative do not permit completion of adjuvant therapy, causing bias in survival data; and f) the effects of neoadjuvant therapy on tumor resectability are eliminated.

The publication that guides adjuvant treatment is the one of Macdonald et al.⁴ in 2001. Was a prospective randomized study involving 556 patients with high risk of recurrence of adenocarcinoma of the stomach and the esophagogastric junction (2/3 with T3 or T4 tumors and 85% with lymph node metastases). The research evaluated the possible benefit of adjuvant chemoradiation. The median overall survival in the surgery group unique was 27 months, whereas in associated with adjuvant chemoradiation was 36 months. The authors concluded that postoperative chemoradiotherapy should be considered for all patients with high risk of recurrence of gastric adenocarcinoma or esophagogastric junction who underwent to curative resection.

On the other hand, another North American study - also known as Intergroup 0116 - was the first to demonstrate survival benefit with the use of adjuvant therapy in gastric adenocarcinoma and esophagogastric junction, setting a new standard of care in the United States of America to stage II and III UICC. The information relevant to this editorial is the fact that only 20% of the patients included in this study presented adenocarcinomas of the esophagogastric junction, with 80% of distal adenocarcinomas of the stomach. However, the layout of the Intergroup 0116 has recorded high rates of toxicity.

Nevertheless, the same grupo published a summary presented at the American Society of Clinical Oncology in 2009 which reported the results in patients after ten years of follow-up.

Studies in other countries, such as Australia, England, France and Japan, have assessed and published improved survival with neoadjuvant treatment.

Meta-analysis published by the group GASTRIC - Global Advanced / Adjuvant Stomach Tumor Research International Collaboration Group - in 2010 evaluated the impact of adjuvant chemotherapy (mono and politherapies predominantly based on 5-fluorouracil or its derivatives) in overall survival and disease-free survival in operated patients with advanced gastric adenocaracinoma. Included 17 studies with mean follow-up longer than seven years and involving 3838 patients in total. There were 1000 deaths among 1924 patients in the group undergoing adjuvant therapy between 1857, and 1067 deaths in the group submitted to surgical treatment alone. Adjuvant chemotherapy was associated with a statistically significant benefit in overall survival (HR: 0.82, confidence interval 95% from 0.76 to 0.90, p <0.001) and disease-free survival (HR: 0, 82 confidence interval of 95% from 0.75 to 0.90, p <0.001). The overall five-year survival increased from 49.6% to 55.3% with adjuvant chemotherapy. The authors of this meta-analysis concluded that adjuvant chemotherapy based on the use of 5-fluorouracil is associated with decreased risk of death in advanced gastric cancer compared with operation alone.

A good alternative to the treatment protocol of the Intergroup 0116 was suggested in one study led by Cunningham et al.¹ in 2006 that established the utility of the use of epirubicin, cisplatin and infusional 5-fluorouracil in perioperative patients with gastric or esophagogastric adenocarcinoma potentially curable. Two hundred and fifty patients were randomized to perioperative chemotherapy and 253 patients to surgical treatment alone. The authors of this study that became known worldwide as "MAGIC trial" observed chemotherapy in perioperative leads to decrease in tumor size, reduction in tumor staging, improvement in disease-free survival and overall survival, with no increase in postoperative complications. This study resulted in a new standard of care for patients with gastric adenocarcinoma or esophagogastric junction in the UK

Van Hagen et al.⁹ in 2012 published the results of "CROSS trial." They assessed the neoadjuvant therapy in esophageal cancer and esophagogastric junction. A total of 368 patients were studied, and 366 actually included in the analysis, of which 275 (75%) with adenocarcinoma. Were administered carboplatin, paclitaxel and radiation therapy preoperatively in 178 patients, with the remaining 188 exclusively treated operatively. The median overall survival in the group undergoing neoadjuvant therapy was 49.4 months and 24.0 months in the group treated with surgery, with statistically significant difference. The authors concluded that neoadjuvant chemoradiotherapy in patients with potentially curable tumors surgically presents improved survival.

Analyzing the recent studies of the benefits of adjuvant treatment, Solomon et al.⁶ in a population-based study evaluated chemoradiotherapy in patients operated for adenocarcinoma of the stomach and the esophagogastric junction. Were included 3378 patients who underwent surgery with curative intent, and 636 (18.8%) patients with adenocarcinomas of the esophagogastric junction. These authors found a benefit of adjuvant treatment on survival of those with more advanced stage disease with lymph node invasion or adjacent organs. The authors emphasized the need for careful selection of patients eligible for adjuvant treatment.

Kofoed et al.² in 2012 in Denmark evaluated in a retrospective non-randomized study, in the same way as the present study, the possible benefits of adjuvant protocol recommended by Macdonald et al.⁴ exclusively in patients with adenocarcinoma of the esophagogastric junction. Were evaluated 211 patients who underwent radical surgery, while 116 patients received adjuvant treatment. The authors concluded that adjuvant protocol could be beneficial in patients with lymph node invasion, finding no significant benefit in the other groups.

The study conducted at Unicamp (State University of Campinas, Campinas, SP, Brazil) including 103 patients with adenocarcinoma of the esophagogastric junction, comparing 78 who underwent to operation exclusively and 25 followed by chemoradiation Macdonald et al.4 protocol, showed no increase in survival at five years follow-up.

After over one hundred years of surgery for esophageal cancer, controversies persist about the best treatment and should keep for several years due to the difficulties in conducting prospective studies, randomized, multicentre, with rigorous standardization of surgical technique, and same clinicopathological staging in a large number of patients. In addition, there is the continuous development of new drugs and the establishment of new combinations of drugs already used. But the difficulties, if any, should be taken only as a stimulus for constant and relentless search for the best treatment for our patients

REFERENCES

EDITORIAL

Why and how to evaluate the egress of the medical course?

Jurandir Marcondes Ribas Filho^I; Eleuses Vieira de Paiva ^II

^IProfessor of the Post-Graduate Program in Principles of Surgery of the Evangelic Faculty of Paraná. Fellow of the Brazilian College of Digestive Surgery

^IIFormer Chairman of the Brazilian Medical Association. Federal Deputy (SP)

For adequate medical care the World Health Organization recommends that there should be one doctor for every 1000 inhabitants. Today, Brazil has approximately 350 000 physicians of whom 300 000 are active. The current average is therefore about 1.5 doctors per 1000 inhabitants. With this ratio, we occupy the first place in the world ranking, and even higher in India and China. This numerical exaggeration leads to distortions in medical training and finding space in the labor market, making it sometimes demeaning.

For sure, the heart of this issue is the indiscriminate proliferation of medical schools. In the 60's there were 29. In the late 90's amazingly 92. Brazil now has more than 190 medical schools. Geometrically increased the number of new schools, besides the authorization to increase the number of students enrolled in courses previously existing.

This concern is not corporate, but it looks to be in defense of the quality of medical care to the population. This is also the desire of the people themselves who expect to have greater professionalism in service and see the best of medical technology be applied to his illness.

We understand and agree that in order to have well-trained people, is necessary to review not only the graduate students, but the faculties and the infrastructure of the institution. Meanwhile, it is understood also that the evaluation of the person while medical student is of great importance for the formation of the good doctor, as they will be the graduates of tomorrow.

The Regional Council of Medicine of São Paulo (CREMESP) has applied annual evaluations of medical graduates. In the last year disapproval average was 46%; to be approved, the examinee should hit at least 60% of questions prepared. This alone demonstrates the poor education of our students to pursue the noble profession. We understand that CREMESP Resolution 239 of July 2012 which requires final evaluation of the newly formed medical student is valid to permit registry in Regional Council of Medicine - CRM. However, it seems not socially just.

The authors feel that it is necessary to create mechanisms that oblige schools not only be worried about the quality of education they teach, but also with the students learning while in school and success as professionals.

In order to evaluate more fairly the student, one of the authors (EVP), as a Brazilian Congressman, proposed 4638/2012 Bill of 2012 which provide rules for "establishment of criteria for judging schools and medical students."

Among the important points on it, is the creation of bank of items developed by the Ministry of Education, under the supervision of the Federal Medical Council, Scientific Council of the Brazilian Medical Association and the Brazilian Association of Medical Education, to be applied of each medical school. Evaluations would be held on 2nd, 4th and 6th years of the medical course, and the content will be gradually and cumulatively differentiate according to the curriculum of the course.

Another important point in this project is foreseen that, for students who have two negative evaluations, the school should ensure an appropriate recovery plan, which must be submitted, assessed and monitored by the Ministry of Education, at no additional cost.

It is also foreseen in the project to penalize medical schools who have more than 50% of students with negative evaluations, with 75% off vacancies in next years. And yet, those schools that maintain the negative results for more than two consecutive evaluations, they will have their access exams suspended until the results come back to positive.

Becomes clear that the project in question aims to establish a socially fairer evaluation of the future doctor, allowing students recovery along its course, capacitating him better to medical practice; so, Brazil will have medical doctors better prepared to exercise the noble profession and the Brazilian population will have better health assistance.

I accepted the honorable invitation to write this editorial about Professor Julio Cezar Uili Coelho with a dubious feeling: if, on the one hand, our fraternal friendship of more than 40 years together facilitates this task, on the other hand, I am faced with the Herculean challenge of summarizing the academic trajectory of one of the greatest professionals in Digestive Surgery in our country and in the world. Very few professors can be compared to Prof. Julio Coelho in terms of scientific publications, both quantitatively and qualitatively, in the impeccable university career and enviable academic training pursued in Brazil and, later, on both sides of the Atlantic.

The third son of Mr. Fabio and Mrs. Nefege, Julio was born in the north of the state of Paraná, in the small town of Ibiporã, on March 22, 1953. His father came from the city of Muriaé (state of Minas Gerais) and his mother, from the district of Batista Botelho (state of São Paulo). Its family roots originate in Italy, Portugal, Spain and Syria, a reflection of the exuberant miscegenation of our country, this true melting pot that enriches us so much.

As a child, Julio moved to Maringá (PR), where he started elementary school and, later, the family permanently settled in Curitiba (capital of PR). He studied Medicine at Universidade Federal do Paraná (UFPR), where he graduated in 1976.

During college, Julio stood out as an excellent student, being approved in tutoring services and internships within and outside UFPR. From 1977 to 1979, he was a resident physician in the discipline of Gastrointestinal Surgery at UFPR, under the coordination of Prof. Giocondo Villanova Artigas, who played an important role in his education.

After completing his medical residency, seeking to improve his university education, he entered the University of Illinois, in Chicago (USA), under the supervision of Professors Lloyd M. Nyhus and Bernard Sigel, from 1979 to 1982, where he worked as a resident in general surgery and later as a clinical fellow. He also had the opportunity to attend the master's and PhD programs at this prestigious university, where he completed his master's thesis in 1980 and his PhD in medicine in 1982. During this period of intense scientific activity, he participated in several pioneering and world-renowned studies on the use of perioperative ultrasound.

In November 1980, he was approved in a public tender to become assistant professor in the discipline of Gastrointestinal Surgery at UFPR, a position he assumed in April 1982, when he returned from the USA. For holding a PhD in medicine, he was subsequently promoted to associate professor at the institution.

From August 1983 to June 1985, he left UFPR to improve himself, at the postdoctoral level, at the University of Texas, where, under the supervision of Prof. Frank G. Moody, he was a visiting assistant professor in the Department of Surgery, also with intense scientific activity and dozens of cutting-edge publications in the area of gastrointestinal motility.

With the result of his research on gastrointestinal motility, he obtained a Doctor of Medicine degree from the University of Limburg (Maastricht, Netherlands) in 1985. Later, he received a scholarship and the fellow title of the Alexander von Humboldt Foundation and worked as a visiting professor at the Heidelberg University, where he received the title of Doctor of Medicine after passing the Rigorosum examination and his thesis being approved with Magna Cuminatum academic distinction. In summary, Julio Coelho has three PhDs from leading universities in Europe and the USA, all of which were revalidated in Brazil.

In early 1986, he resumed his duties as associate professor of Gastrointestinal Surgery at UFPR. In July of the following year, he was approved in a public tender for Titular Professor at the Department of Surgery at the School of Medicine of Ribeirão Preto, Universidade de São Paulo.

With funding for research from the Funding Agency for Studies and Projects (Financiadora de Estudos e Projetos – FINEP) and scholarships from the National Council for Scientific and Technological Development (CNPq), he formed the Gastrointestinal Motility Laboratory of the Gastrointestinal Surgery discipline, of which he assumed the coordination in 1989, a position he holds to this day.

In 1990, he edited the book entitled Aparelho digestivo. Clínica e cirurgia [“Gastrointestinal system. Clinic and surgery”], with 1,400 pages, 174 chapters and 270 collaborators, with the participation of 89 professors from 21 countries. The second edition was published in 1996, followed by the third in 2005, and the fourth in 2012¹. This book, the best seller in Brazil in this area, is adopted by several universities in the country. In 2009, he published the Manual de clínica cirúrgica. Cirurgia geral e especialidades [“Handbook of surgery clinics. General surgery and specialties”], in two volumes, totaling 2,746 pages, 305 chapters, and 361 collaborators from 26 countries².

In 1990, he was approved in the first place in the public tender for full professor of the Department of Surgery at UFPR, becoming, at the time, the youngest full professor of surgery in Brazil. In September 1991, he successfully performed the first liver transplantation in Paraná, at Hospital de Clínicas of UFPR. This program is still active to date, with hundreds of adult and pediatric transplant recipients³,⁵,⁶.

His scientific production is enviable. Julio Coelho has more than 400 published works, of which 124 abroad, 28 editorials and hundreds of studies presented in national and international congresses, in addition to over one hundred book chapters and abstracts published⁴.

He participated in 367 round tables, symposiums, colloquiums, panels, and videosurgery presentations and delivered 328 lectures in several Brazilian states and 19 abroad. He was a visiting professor at 11 universities in the USA, Europe, and Asia and supervised 31 master's and PhD students. He participated in 84 university committees and medical societies, including: president of the Brazilian College of Digestive Surgery (Colégio Brasileiro de Cirurgia Digestiva – CBCD) in the 2005-2006 biennium, Chairman of the Board of Paraná of the Brazilian College of Surgeons (Colégio Brasileiro de Cirurgiões); president of the Paraná Society of Gastroenterology and Nutrition (Sociedade Paranaense de Gastroenterologia e Nutrição) and of the Paraná Society of Laparoscopy (Sociedade Paranaense de Cirurgia Laparoscópica).

During his tenure as president of the CBCD, he was responsible for preparing the Manuais de orientação para o paciente [“Guidance Handbooks for Patients”]. These handbooks were created to help physicians guide their patients regarding the condition to be treated, symptoms, diagnosis, treatment, complications, care, and prevention. They also include a free and informed consent, in which patients attest that they received all the instructions from their surgeons before any procedure and that all their doubts were clarified. Surgeons acquire the handbooks and make them available to patients in their offices for consultation on the following topics: gallstones, gastroesophageal reflux disease, morbid obesity, stomach cancer, and inguinal hernia. The handbooks are periodically reviewed and continue to be acquired by CBCD members, as they are recognized for the importance of clarifying patients about their conditions.

Julio Coelho received 39 awards and honors in Brazil and abroad, including: honorable mention from the Chicago Society of Surgery (USA), in 1981; Cirurgião Jovem [“Young Surgeon”] Award from the Brazilian College of Surgeons (1988); National Gastroenterology Award (1990); Science and Technology Award of the State of Paraná (1991); Award from the Surgical Assembly of the Brazilian College of Surgeons (1992); Gold Medal from the Oswaldo Cruz Foundation of the Brazilian Ministry of Health (2002); and Paraná Medical Association Award — Distinction in Medicine in Teaching and Research (2007). He is also a member of the Paraná Medicine Academy, of the editorial board of 15 national and international medical journals, and has participated in 236 examination boards for university professors and thesis defenses at several Brazilian universities.

Julio married Célia Zardo Coelho at the end of college education and they had two daughters, who were born in the USA: Caroline, in Chicago, and Christine, in Houston. Both of them are lawyers. Caroline gave him two of his greatest treasures: the grandsons Nicholas and Anthony. Julio married Karla Christina Maron Coelho in 1991, over 30 years ago, and shares a stable and peaceful life with her. She is his refuge after his exhausting surgical journeys. Karla is also his companion on the many exotic trips they often take.

For leisure, in addition to the exotic trips he usually takes and the countless cruises around the world, Julio has an enviable collection of more than 500 statues, mostly African and Asian, as well as countless Greco-Roman ones, all cataloged and kept with great care as a souvenir of his travels. Currently, Julio needs to share the time dedicated to his statues with his grandchildren, who constantly challenge him to overcome his restricted football skills.

Finally, I feel privileged to enjoy his friendship, share his knowledge and the paths taken in the Department of Surgery at UFPR alongside such an illustrious and emblematic professional, whose character is solidly forged in ethics, seriousness, competence, and dedication to the academic life.

Antonio Carlos Ligocki Campos is President of the Brazilian College of Digestive Surgery (2023–2024).

REFERENCES

My first contact with Professor Paulo Roberto Savassi Rocha was in November 1983, therefore exactly 40 years ago, when I went to Belo Horizonte to participate in the Judging Committee for the defense of his doctoral thesis, at Universidade Federal de Minas Gerais (UFMG), at the invitation of the late Professor Alcino Lázaro da Silva¹.

As I didn’t know the candidate, I requested Professor Alcino to ask him to send me a summary of his Curriculum Vitae, so that I could know who the Post graduate student was, author of the work I was going to analyze.

I must confess that I was impressed with his publications and two edited books. He was a surgeon who was already qualified and linked to the University.

The thesis, entitled Determination of the optimal points for resection of ischemic intestinal loops by “Dopplerometry, Thermometry and Fluoresceinoscopy: Experimental study in dogs”, analyzed a topic — intestinal ischemia and extensive resections — in which I was very interested². Once again, I was impressed with the clarity and didactics in the presentation of the work, as well as with the security and propriety in the answers to the formulated questions.

During the flight back to São Paulo, in the company of Doctor Emil Burihan, Full Professor of Vascular Surgery at Escola Paulista de Medicina, now Universidade Federal de São Paulo (UNIFESP), also a member of the Judging Committee, we talked about the candidate and the thesis argument and concluded that we were witnessing the birth of a future great professor at UFMG.

Doctor Paulo Roberto Savassi Rocha is a mineiro in heart and soul and, like any good mineiro, enchanted by his land, its history, and its values. He graduated from UFMG in 1969.

After graduation, he worked for a period as an assistant to Professor Mahrdas Salvador Nankran, a renowned surgeon from Belo Horizonte, who contributed a lot to his training and growth. He then took the exam, being admitted as a resident of General Surgery at the Hospital das Clínicas of UFMG, in Belo Horizonte. After completing the residency program, he took another exam, this time joining as Teaching Instructor of the Surgery Service. He then enrolled in the Postgraduate Course (stricto sensu), defended his thesis and had a rapid and fulminant evolution in his academic career, reaching the position of Full Professor of Surgery in 1991.

Its trajectory is very rich. In a short period of time, he became a well-known surgeon throughout Brazil. He is a constant figure in the most important surgical events, with dozens and dozens of lectures both in the country and abroad, being invited to numerous participations in examining committees of postgraduate theses and competitions in the academic career in several institutions in the country.

For more than four decades he was a professor at the university, with intense administrative and technical-scientific activities, including:

• -advisor professor of the Post Graduate Program in Sciences Applied to Surgery;
• -effective member of the Board of the Post Graduate Program in Surgery;
• -chairman of the Research Committee of the Department of Surgery;
• -member of the Commission for the Project and Implementation of the Outpatient Surgery Sector;
• -director of the division of Digestive Tract and Gastrointestinal Surgery
• -supervisor of over 40 Master’s and Doctoral theses;
• -actively participated in the training of a significant number of surgeons and residents in General Surgery and Digestive System;
• -author of more than 30 scientific books on topics in Gastroenterology, Fundamentals of Clinical Surgery, Surgical Emergencies, Complications in Surgery of the Digestive Tract;
• -Enthusiastic about the use of videosurgery since its inception in the 1990s, he was one of the first surgeons in the country to publish the experience with laparoscopic cholecystectomy³,⁴,⁵.

In 2002, he inaugurated with his great partner, Professor Aloísio de Paula Castro, the Instituto Alfa de Gastroenterologia, one of the most complete and important Services for Diseases of the Digestive System in the Country.

He received numerous honors and decorations. To name just a few of them:

• -State Legislative Merit Medal, awarded by the Legislative Assembly of Minas Gerais in 2010;
• -Medical Personality of the Year, granted by the Medical Association of Minas Gerais in 2011;
• -Medical Excellence Award from the Academia Mineira de Medicina, in 2012;
• -Diploma of Honor of Merit from the Medical Association, the Regional Council and the Union of Doctors of the State of Minas Gerais, in 2019;
• -honored several times by graduating students of the Medicine Course at the Federal University of Minas Gerais.

His activities in medical associations were also intense:

• -he held several boards and was president, in the 2002–2003 term, of the Brazilian College of Digestive Surgery;
• -full member and founder of the Brazilian Association of Gastric Cancer;
• -sector vice-president of the Brazilian College of Surgeons (1995–1997).

However, the most important moment of his academic life occurred in March 2016, when he received the title of Professor Emeritus of the School of Medicine of Universidade Federal de Minas Gerais, which crowned his path of successes and achievements.

Professor Savassi Rocha, in addition to being an excellent doctor, surgeon, and teacher, is also a writer. He found this other path in his rich existence.

In addition to his more than 30 medical books, he wrote two of poetry, and one of short stories: Catarse in 1993, Desenredo in 2017 (poetry), and Intercadência in 2019 (short stories), books that overflow his emotions and feelings. As it is said in the works, “poetry touches the soul and stories assess the fundamental values of human existence”.

I cannot fail to mention that his main literary reference is João Guimarães Rosa, from Minas Gerais, whom he considers the greatest of all writers, the great genius of literature. Savassi Rocha is an ardent “Rosean”¹!

Professor Paulo Roberto Savassi Rocha is one of the most brilliant minds I have had the pleasure of meeting. I enjoyed the privilege of working together in the National Directory of the Brazilian College of Surgeons. He, always calm, thoughtful, and a peacemaker. I have followed his trajectory for 40 years, his personal life and his academic career. We were together on countless occasions. I have deep respect and admiration for him. Simple man, cultured, educated, elegant and in love with his family.

I would like to thank the Brazilian College of Digestive Surgery for the privilege and honor of being invited to write about Professor Paulo Roberto Savassi Rocha, who belongs to the great field of Medicine in Minas Gerais and who enriches the gallery of national Surgery.

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Laparoscopic surgery has been widely diffused since 1990, having exponential growth since then. Contributed to this fact the obvious benefits of the avoidance of large abdominal incisions, less surgical trauma, less perioperative morbidity, smoother and faster postoperative recovery, wide acceptance by patients, who started demanding technology. In addition, many surgeons quickly joined the laparoscopy and there was a great cooperative effort worldwide. Unprecedented and widespread dissemination of knowledge occurred, especially because the view on a monitor and its easy recording and retransmission, unlike open surgery everyone could see the proceedings, or repeatedly on videos.

Robotic surgery has been introduced from the year 2000 and has had marked increase in its use since them. The operations that are performed laparoscopically can be made through the robot, with more accuracy and safety. The use of robot favors a less invasive operation; with a much better view of the organs being operated; with great approximation of the structures; with the surgeon's vision in three dimensions; procedure even less invasive; and with less tissue trauma.

Who controls the movements of the robot is the surgeon through a special console, dominating every movement of the grippers and the camera. The clamps have more delicate movements, being literally controlled with fingertips.

It´s possible to have great accuracy, due to the interface of the "robot" between the arms of the surgeon and the patient's operated organs. Robotic grippers are specially designed to simulate the movements of the surgeon's hands, allowing dexterity never achieved by laparoscopic surgery. The surgeon do not use any force to control the robotic arms, doing movements with the extremities of the fingers; thus, there is much less fatigue in prolonged procedures. The robot heps the trained surgeon perform operations even more safe and accurate.

Another relevant feature of the robot, of great importance is the possibility of extensive training in simulators. There is an outfit named MIMIC with programs that simulate situations of object manipulation, movement, energy use, sutures, etc. The surgeon is aware of their performance by an assessment that appears immediately after exercise, showing numerous variables that exercise demand, directing the aspect that need to be improved, or if it was correctly done. The surgeon can thus become familiar with the equipment and thorough training, perform initial procedures with more skill and accuracy, reducing the learning curve (as demonstrated in controlled studies) and possibly reducing the risk of occurrence of accidents and complications, which occur in the learning curve of surgery, either open, laparoscopic or robotic approach.

Robotic prostatectomy has been achieving similar oncological outcomes to laparotomy, with the advantage of better preservation of erectile function due to the precise dissection of the pelvic nerves. It is now considered a standard of excellence in the operation of prostate cancer. Robotic gynecologic surgery got significant increase in recent years, also leading to very good results.

In the digestive tract, virtually all operations can be performed through the assistance of the robot. In obesity surgery allows better access to organs, maximized visualization and high precision in the sutures. In esophageal surgery provides precise, anatomic, minor assault procedures. When operating the intestine, the robot must allow release of the structures, preserving vessels and nerves which help to preserve continence and potency functions, important to patients. Assisted by the robot operations greatly help the surgeon to bring greater benefit and safety for their patients, especially when there are anastomoses or dissections requiring high precision and privileged view; reoperations or revisions are thus much better performed with the aid of the robot. The dual console allows second surgeon to assist or interfere, facilitating training during the learning curve.

However, the most important point of this new technology is the introdution of a new paradigm in surgery: the existence of a device (called robot, in lack of a better name) that allows the use of computer programs for performing tasks. No other surgical platform, at present, has this feature. Laparoscopic forceps are directly controlled by the surgeon's hands and, with the exception of the power instruments, little change occurred over the past 20 years.

On the other hand, are well known the incredible advances in diagnostic medicine since the introduction of computer programs in imaging and interventional equipment; innovations in these areas occur almost daily. This same feature is now available to the surgeon. Computer programs can, for instance, be inserted to allow different examinations during operation; identification of lymph nodes compromised by tumor; differentiation over vessels, nerves and other tissues. From this premise, the possibilities are almost endless bring new technologies in the future.

The technology using green dye - binds to blood proteins - injected by peripheral vein is commercially available. Through fluoroscopy in a special camera the surgeon may identify differences between healthy and tumor cells; check the vascular supply of the parenchyma or viscera; identify the bile duct during cholecystectomy. The surgeon can quickly change from normal to fluoroscopic camera. Allows more accurate removal of tumors; make safer intestinal anastomosis for making sure the proper irrigation of the extremities; increase the security of difficult cholecystectomy, where the anatomy is often inaccurate or anomalous. It has been said that, as this technology allows for much better accuracy in the identification of the structures of the hepatic hilum and reduces the risk of inadvertent bile duct injury, it could be considered unethical not to offer this technology to patients.

The robotic platform is evolving exponentially. There is, at present, only one company with equipment released by the authorities for human use. There is already a new generation released for use next year, and new prototype is currently being tested. When released some patents, several new equipment, already in testing, will be available on the market. Then, it is possible to have important decrease in costs, which is now the main obstacle to its widespread use.

The robots are here to stay. The possibilities of computer programs interact are almost endless. Costs will decrease considerably in the next years. So, the future has arrived!

The Brazilian health system is mixed: public and private. There is a public system - SUS and the system of supplementary health (health insurance companies). The SUS was very well designed and implemented for about 25 years (1988). ANS - National Agency of Supplemental Health is even younger, created in January 2000. ANS is the regulatory agency under the Ministry of Health. The two systems coexist, but do not interact properly.

A hundred and fifty million people depend exclusively on SUS and health operators have about 52 million users. Several of these users also use SUS on health demands and, in different ways, all Brazilians use SUS (health surveillance, for example).

Public health funding has not been sufficient to meet the demands of the people. The share of spending occurs in three levels, but there is a progressive exemption from federal portion, sacrificing increasingly the federative states and especially the municipal budget. About 12 years the share of federal spending on health was around 60% of the whole. Today only 42%, as around 58% come from states and municipalities. Municipalities must apply at least 12% and states at least 15% of its budget on public health. The supplementary system, which serves about 25% of the population, has more resources than the public system.

While we recognize improvements in the public health system, its management is not qualified, because there is predominant political and electoral bias in the choice of the managers; instead of this, we should expect to have strong technical influence. Also, is not used adequately the largest and most qualified efficiency of the supplemental health care sector. Besides not having enough resources, they are badly applied and associated to the rampant corruption that persists in our country, that has good, orderly and worker people.

We believe that public-private partnerships and effective prioritization of the health sector could bring more gains to the system, directly benefiting the population, especially the poor and needy, already suffering a lot due to poverty, delays in education, infrastructure and safety.

Not only suffers the health care, but also teaching and research. The assistance should prioritize access to quality, ensuring the two main entry points to the system: primary or basic and emergency care. An integrated network should exist, with permanent control and evaluation, with referral and counter-referral of patients using SUS.

The teaching in the sector has been less than optimal. Several medical schools were opened, in the majority as private schools and without conditions for functioning: good physical structure for practical activities, as well as current curriculum for Brazilian medical needs and qualified teachers. The federal government claims that our medical schools train few students each year, and insists to authorize new vacancies, 40-50 every year. We need to better educate our doctors and other healthcare professionals. The same happens in post-graduate level where it is also prioritized the quantity, over quality. Let us form the required amount with proper qualifications; it is possible and is the best way.

The residency, which has been the gold standard for care, has suffered from misplaced interventions with high dictatorial meddling. There is no planning for the number of health professionals (doctors, nurses, dentists, physiotherapists etc.) for today or for the next 10, 20 or 30 years. We continue improvising, wanting to import models from other countries, making use of them with patterns that are not adequate to our reality. Why the government managers say they want in Brazil 2.7 physicians per 1,000 population? To be equal to the UK? Well, today we have several cities that outperform this index: Brasília, Rio de Janeiro, São Paulo and others; even there, the public system keep on being chaotic - analyzed by the offered quality. The waiting list of patients for consultations, complementary exams and surgical procedures is enormous. Several of these patients rely upon themselves in emergencies, overloading them and many die from preventable causes.

Clinical research in Brazil, the world's seventh largest economy, also shames us when compared to many countries. There stubborn bureaucracy and overlapping of powers, among many inefficiencies, greatly delays the analysis of several studies. We are behind in clinical research from the point we are able to be. All of us lose: patients, researchers and our country Brazil. Some patients fail to participate in studies that can mean gains in quality of life and even cure. Our researchers lose several opportunities, especially studies in phase I and II. At the end, Brazil loses because the gain is undeniable; research leads to the development, create wealth and currencies.

However, if much can and must be done, and if we realize that the people in charge cannot do, we should use our democratic power to change this sad scenario. Brazil is much more than any of us, any political party. The health is our greatest duty and the Brazilian population deserves respect!