Episode 33

Bariatric Breakthroughs in Rural America with Dr. Kabir Mehta

Episode Transcript

Dr. Randy Lehman [00:00:11]: Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision. Welcome back to another episode of the Rural American Surgeon. I'm joined today by Dr. Kabir Mehta, a bariatric surgeon in Hazard, Kentucky, and he's also a co-resident of mine. We were on chief service together. Go way back to Mayo Clinic, Rochester, Minnesota. The days that we all try to block out from our memory. But sometimes it's like that quote from The Office. The bad part about the good old days is nobody tells you that you're in them until they're already over. Something along those lines. So anyway, Dr. Mehta, thank you so much for joining us. It's a real honor.

Dr. Kabir Mehta [00:01:19]: Thanks so much for having me, Randy. It's a pleasure to be here.

Dr. Randy Lehman [00:01:22]: Yeah. So let's start with an introduction of you. Tell us about. Basically, you did general surgery residency at Mayo Clinic and then tell us about your fellowship and your practice since then.

Dr. Kabir Mehta [00:01:33]: Yeah. So you and I started residency together 2015. And so we did that residency, had fun. And I stayed on at Mayo for a year of minimally invasive surgery fellowship where I focused mostly in bariatrics and foregut and did a little bit more of colorectal during that time. After that, ended up looking for jobs. And there were some life forces at the time that wanted me to be here in Hazard in a relatively rural practice. And so that's what landed me here. And it's my third year in practice now, and this is where I'm at with a practice that's bariatric and general surgery, a mix of both, and building more and more on bariatric practice here. So. Yeah.

Dr. Randy Lehman [00:02:25]: What's your catchment area? I'm seeing that Hazard, Kentucky, population is like 5200 people.

Dr. Kabir Mehta [00:02:30]: Yeah, yeah, exactly. So it's a 300-bedded hospital and it's the flagship hospital of a chain of 13 or chain of 14 total. And so we catch pretty much from all of southeast Kentucky. And a lot of the referrals come from either the sister hospitals or nearby smaller critical care access hospitals. So we end up staying fairly busy for a hospital that seems to be sitting in a 5,000 population town.

Dr. Randy Lehman [00:03:01]: Yeah. Now do you get referrals from as far as Pikeville?

Dr. Kabir Mehta [00:03:06]: Yeah, Pikeville has its own medical center there and they're.

Dr. Randy Lehman [00:03:11]: I have a first, second cousin that's currently a fourth year at Pikeville, so that's why I'm asking.

Dr. Kabir Mehta [00:03:17]: Yeah, yeah. So the population between Pikeville and here gets divided. Yeah.

Dr. Randy Lehman [00:03:20]: Okay.

Dr. Kabir Mehta [00:03:21]: We've definitely had patients come from Pikeville to us. Yeah.

Dr. Randy Lehman [00:03:23]: Gotcha. So do they do some bariatrics in Pikeville too?

Dr. Kabir Mehta [00:03:27]: Yes, yes, they have bariatrics there and we have bariatrics here. So patients.

Dr. Randy Lehman [00:03:31]: And then you've got Lexington and what else do you have in southeast Kentucky?

Dr. Kabir Mehta [00:03:37]: Lexington is the closest university hospital to us. Straight west would be Cumberland. That's another bariatric practice there. So those are some of the bariatric centers around.

Dr. Randy Lehman [00:03:50]: Yeah, that's. It's interesting to have a rural bariatric surgeon in my network. So I'm super honored that you've come on. I think this is going to be really enlightening for some of our rural general surgeons. Let's. You didn't come from rural America. Right. So last several guests that I have on, and myself included, you know, I'm practicing in my hometown and it kind of goes without saying why rural surgery is special to me. But the next question I like to ask is, why is rural surgery special to you? So, so what were the draws? Even if there were financial draws, I want to know about that. And then, and then what else have you fallen in love with? I guess.

Dr. Kabir Mehta [00:04:38]: Yeah. So it was never part of my vision initially to be in a rural practice. And the draws weren't financial. It was more forces of life that kind of left me with some options that I had to pick from. And a lot of that had to do with visa arrangements with the government to provide service to a rural community. Now, it might have started that way, but it changed very quickly. And what I've come to love about this practice is patients are super grateful, they get good care, you build close bonds with them and you see them over and over again. You see their families, you see their relatives, their friends. It's a close-knit network, and I love that. The other aspect is it became a little bit of a challenge that I like to overcome, which was I trained, obviously, to do some advanced things and to find a safe way to bring that to the rural population here was a little bit of a challenge. I had to figure out, well, can I do certain operations that I learned to do? Would it be right for them here? Do I have the support if there were other specialties needed, that sort of a thing? So we figured all of that out. I've enjoyed that journey. Now we're at a place where we're expanding our practice here. We're bringing in more services and things like that. So I've loved learning how life is in a rural place, how being a surgeon is in a rural place. So now a lot of what you said back in residency that we used to talk about makes sense. I've lived it now, so.

Dr. Randy Lehman [00:06:16]: Yeah. Beautiful. So the J1 visa was the primary thing that brought you there?

Dr. Kabir Mehta [00:06:20]: Yeah, yeah.

Dr. Randy Lehman [00:06:22]: And then how long have you been there?

Dr. Kabir Mehta [00:06:24]: This, I'm going on my third year.

Dr. Randy Lehman [00:06:26]: And are you going to move?

Dr. Kabir Mehta [00:06:28]: Well, I've, I can probably tell you I just got my extension notice, so we've extended my contract. So.

Dr. Randy Lehman [00:06:34]: All right.

Dr. Kabir Mehta [00:06:35]: Not moving, so.

Dr. Randy Lehman [00:06:36]: And, but you, you're not obligated to stay anymore.

Dr. Kabir Mehta [00:06:39]: That's correct. So I'm staying now? Yes.

Dr. Randy Lehman [00:06:42]: Yeah. There you go. Well, that's cool. What a great story. You joined a practice where they were already doing some bariatrics.

Dr. Kabir Mehta [00:06:50]: Correct. So a couple of my partners are general surgeons that do limited scope bariatric surgery. They'll do sleeve gastrectomies mostly. And so I was able to come in, bring, you know, gastric bypass, duodenal switch, SADI operations, revisions, primarily revisions form 25% of all bariatric operations in today's time. And that's expected to rise. So I was able to bring all of that here. Yeah.

Dr. Randy Lehman [00:07:13]: Yeah. Wonderful. What else do you do outside of that? Anything.

Dr. Kabir Mehta [00:07:17]: So. Yep. So foregut surgery and then general surgery. So, you know, your, your round of the male gallbladders, appendix, hernias. So definitely I'm seeing those skin lesions, soft tissue masses, things like that. And because we're doing more of this advanced, minimally invasive stuff, if we find stomach tumors and other stuff that previously wasn't able to be served here, we're able to add that now.

Dr. Randy Lehman [00:07:48]: Okay. Now we're going to talk today for how I do it. Why don't we just roll into it? So the next segment of the show is a how I do it. We're going to talk about bariatric emergencies because I believe that's relevant for the general surgeon. Speaker A: You're going to get a call from the emergency department, a patient that had a previous bariatric surgery, and they have some bariatric emergencies. You're deciding how you're going to manage it. I have a few other questions about your practice as well, like where you think it's going, maybe how you do a few things, but why don't we start with that? Could you just wax eloquently on bariatric emergencies for a while until I come up with a good question?

Dr. Kabir Mehta [00:08:25]: Yeah, that sounds fine. So bariatric emergencies, that's, I think, a relevant topic for a general surgeon, especially a rural general surgeon, because we're going to have these patients that have had surgeries, either recent or past, and that's different because anatomies in the past used to be different and these have evolved. But I think the first thing the general surgeon on call in rural America needs to delineate is whether it is emergent or non-emergent.

Dr. Kabir Mehta [00:08:55]: Since we have limited time, I want to focus on emergent stuff that they're going to be stuck with handling. Emergencies, just like other general surgery emergencies, include some kind of gastrointestinal perforation. Most pertinent here would be a marginal ulcer perforation for a gastric bypass patient. Typical risk factors are smoking, NSAIDs, steroids, things like that. A lot of rural America, I found out, at least in my neck of the woods, they like to smoke, quit for some time, but then they've been back into it, which can lead to this.

Dr. Kabir Mehta [00:09:26]: If you get a gastric bypass with a perforating marginal ulcer, really the first thing before you even get into that case is to be sure you're familiar with the gastric bypass anatomy. Whether it's looking up a Google image or looking back at a case that you've done in the past or talking to a colleague, that's a worthwhile effort to be familiar with the anatomy, similar to how you would handle a perforated peptic ulcer in a native stomach or native duodenum. Some of the principles go along the same way.

Dr. Kabir Mehta [00:09:57]: If you're going to handle those things laparoscopically, you're probably okay to handle this laparoscopically. If you're more comfortable doing this open, understandable. Whatever you're most comfortable with, the goal is to contain the perforation, wide drainage, and resuscitation, right? If you happen to see a small marginal ulcer perforation, these typically are at the gastrojejunostomy or just distal to it, on the jejunum side of it. If it's a small hole, you can patch it just fine, lay drains, try to do a distal feeding tube of some kind.

Dr. Kabir Mehta [00:10:27]: A remnant stomach gastrostomy tube or a jejunostomy tube would be fine. Preferred would obviously be a remnant stomach G-tube. Some patients have had their remnant stomachs removed, and then you're left with a J-tube option. You can choose the BP limb, which most people don't think to be the preferred limb. You can choose the BP limb to place a jejunostomy tube in it. And so that patient, if you've patched the hole, laid the drains, and placed a feeding axis, let them recover.

Dr. Kabir Mehta [00:10:58]: Standard management for pulling the drains and letting them recover, and then they can have follow-up with the bariatric surgeon for any further definitive management, in terms of gastrojejunostomy revision and things like that.

Dr. Randy Lehman [00:11:28]: That's perfect. Let me re-summarize what you said. Patient comes in, marginal ulcer perforation. Look up the anatomy, decide your best approach. Close and patch the hole, drain, feeding tube in the remnant stomach, unless it's not there. Then put it in the BP limb as a Witzel J-tube, correct?

Dr. Kabir Mehta [00:11:55]: Yeah, that's perfect.

Dr. Randy Lehman [00:11:56]: And then afterwards, we're going to keep them NPO until they see the bariatric surgeon.

Dr. Kabir Mehta [00:12:01]: Well, you can keep them NPO, let them recover. You can do an upper GI study, make sure there's not an active leak. If you think there's not an active leak, you can pull one of the drains or both drains, make sure they continue to have their tube feeds, and have them follow up. Remember BID Protonix, open capsule or Protonix powder, and sucralfate. Those go a long way in healing these ulcers and perforations, so that's important.

Dr. Randy Lehman [00:12:30]: So otherwise, though, if the drainage is looking good, I mean, we can start them on clears in a couple, like a couple of days or how long until you would start them on that?

Dr. Kabir Mehta [00:12:41]: Yeah, that's mostly dependent on clinical progress, but I would wait at least four days or so. Four or five days. We traditionally used to wait all five days. Do an upper GI study, make sure it's clean, start them on clears, leave the drain in, watch for signs like grape soda coming out of the drain. Not ready yet. So that sort of thing, waiting, being on the conservative side, wait a little bit longer.

Dr. Randy Lehman [00:13:05]: Okay, I'm going to dig into one more piece of this. How would you prefer for me to patch that hole? What type of suture? And do I use omentum or what?

Dr. Kabir Mehta [00:13:19]: Yeah, absorbable suture. And omentum would be great. You can frequently close the smaller ones with a sort of modified Graham patch equivalent. Close it and then patch it. If you can't close it because it's too indurated, don't try to rip it or make the hole bigger. Patch it. Ensure the patch is airtight. You can even do an intraoperative EGD, do a leak test. If your patch is solid, you're going to be happy with it. So omentum would be great.

Dr. Randy Lehman [00:13:49]: So omental patch. I saw a picture. I don't like it, of closing the hole and then tying a knot and then using the tails of that knot to just put omentum over the top and tie it. But then it doesn't really patch on it. That's a dumb way to do it, right?

Dr. Kabir Mehta [00:14:06]: Yeah, I don't like that myself either. It's not an air seal method at all.

Dr. Randy Lehman [00:14:10]: Yeah. So do a stitch over here and then a stitch on the other side.

Dr. Kabir Mehta [00:14:16]: You know, tongue of omentum.

Dr. Randy Lehman [00:14:17]: Tongue of omentum all the way around. Make sure that it's tight.

Dr. Kabir Mehta [00:14:21]: And tight but not strangulate it. Don't kill that tongue of omentum.

Dr. Randy Lehman [00:14:25]: Yeah, it's going to swell in the next 24 to 48 hours. So approximate, don't strangulate. Kind of strategy. Makes sense. And nice. And we're back. All right, so next bariatric emergency, let's move on.

Dr. Kabir Mehta [00:14:42]: Yeah. So the next one to consider is an internal hernia. So again, you've got an acute abdomen situation. Patient's unstable, don't need to be alarmed, don't need to be afraid. Oh, this is a bariatric anatomy. Same principles. Anytime you have a hernia, it's similar to, let's say, you have a strangulated inguinal hernia or a strangulated ventral hernia. Your goals are to reduce the hernia, resect dead bowel, put it back together.

Dr. Kabir Mehta [00:15:12]: Keep it simple in your mind. And again, if you're familiar with Roux-en-Y anatomy, you're going to know a Peterson's defect, you're going to know a JJ mesenteric defect. Those are the typical offenders. The jejunostomy is supposed to be in the left upper quadrant. If it's not in the left upper quadrant on the CT scan, then, you know, there's an internal hernia. That's one of the telltale signs. And again, you're going to get in, go open or laparoscopic, whatever's in your comfort zone, and you're going to run the bowel. You can run it many different ways, but bottom line accomplishes the same goal. Start the Roux limb, run it distal all the way to the ileocolic junction, or start at the ileocolic junction and work your way back. Either way, that's going to be your alimentary limb. The other limb you're going to look for is the biliopancreatic limb. So, when you find the JJ, run the second limb proximal, and you're going to run it all the way back to the ligament of Treitz. Again, you're going to make sure both of those limbs are laying free of any kind of internal hernias. If you happen to reduce an internal hernia and you do identify it, obviously you make sure to close it. Closing that is done with permanent suture material. So use Ethibond, use a non-absorbable V-Loc, whatever you prefer. Some people like silk. We found that silk is not necessarily non-absorbable over the course of decades. Or maybe it's not so great for bariatric patients if they lose more weight, hard to say. But use a non-absorbable suture for that hernia defect. Aside from that, again, you're going to resect any dead bowel. If you think it's just hemorrhagic, not ischemic, you can watch that. You can do your ICG injection, you could do some kind of assessment of intraoperative perfusion, or you can wrap it in a moist towel, come back in 10 to 15 minutes and see if it's declared itself. So that's how you handle that. An important thing is not to get pulled into thinking a few things: your standard "oh, this is adhesive small bowel obstruction and I'm going to NG tube, decompress this patient, and going to do gastrographin." For these patients, you may have a biliopancreatic limb that's herniated through the Peterson's defect and it's ischemic or not. Even if it's not ischemic, it's at least not a part of your alimentary tract, so the contrast goes from the esophagus pouch, Roux limb, common channel, and never sees the BP limb. And that's not a pass for your gastrographin challenge. So you have to have a high index of suspicion for abdominal pain for gastric bypass patients, so don't ignore them. Speaker A: Yeah, what a great point. So I'm coming up on five years out of residency. I have not managed a situation like this a single time in five years, but yet I'm expected to be able to manage it, right? So some of those things that you're telling me, it's like, yeah, that makes sense, but like, literally, when you don't think about it for five years, you forget. Yeah, you can forget. So let me summarize what you said again. And then I got a couple of questions. So step one, get access. Well, step one, NG tube. Speaker B: You can always do NG tube again if it's not an alimentary tract obstruction. If you have a BP limb obstruction, you're going to have the BP limb distension, the remnant stomach distension, but you're not going to have Roux limb distension at all. Speaker A: Yeah, that makes sense. Speaker B: Right? Speaker A: All right, so step one, get access. Speaker B: Yeah. Speaker A: Follow your Roux limb from the anastomosis to the JJ. Follow your BP limb back up from the JJ to the ligament of Treitz looking for your obstruction. If it's all dilated, then you got a distal obstruction and follow it distally to the ligament of Treitz, basically, and then identify your obstruction. That's just a regular routine, possibly adhesive bowel obstruction, probably most commonly in that situation. Right. Reduce your hernia, resect any dead bowel, do your bowel assessment and repair the defect with non-absorbable suture. And that's basically it. I have a question. Do you use non-absorbable suture to close your defects at the initial time of surgery now? Speaker B: Absolutely. Yeah. Speaker A: It hasn't always been done, right? Speaker B: No. At least at Mayo, at least at our training programs, absolutely. Everybody closed defects. Everybody closed them with permanent suture. There is some debate and people that don't close them; there are still surgeons that don't close them. I don't favor that. I'm definitely well into the camp of close every defect. Please don't let an avoidable problem happen. Speaker A: Okay. A second question is: go ahead and describe the two defects to us if you don't mind. Speaker B: Yeah, yeah. So again, we're going to talk about, let's simplify this to an antecolic, antegastric. We're talking about some terms here, but basically, you've got a pouch made out of the proximal cardia of the stomach, and you've got a segment of jejunum that is going to come up to that pouch. That segment can be brought up anterior to the transverse colon, anterior to the remnant stomach, and the anastomosis could be made that way. And that's an antecolic, antegastric Roux limb. Now, the mesentery of this Roux limb will arch over the transverse colon. And so where the cut edge of the mesentery of the Roux limb approximates the cut edge of the mesocolon, the transverse mesocolon, that space becomes a potential internal hernia space. That's actually a pseudo-Peterson's defect. The Peterson's defect was defined initially when they used to do more retrocolic Roux limbs. And so they would make a hole in the transverse mesocolon, push the Roux limb through that into the retrogastric space or the lesser sac. And so the defect between the Roux limb mesentery and the transverse mesocolon and the posterior mesentery or the posterior wall of the abdomen was the true Peterson's defect. So antecolic, antegastric has a pseudo-Peterson's. That's the defect that you want to close. Speaker A: Okay. And you close that when? For first off, how do you do your Roux-en-Y? Speaker B: Antecolic, antegastric? I do them robotic or laparoscopic. Speaker A: Okay. Speaker B: Yeah. Speaker A: And you do it both ways? Or you mean mostly robotic now? Speaker B: Now it's transitioned mostly robotic. Yeah. Speaker A: Okay. But you close that defect. So you stitch the transverse colon mesentery to that cut edge of the mesentery with a permanent stitch, correct? Speaker B: Yes. It's either a V-Loc, non-absorbable, or it's an Ethibond. If I'm doing it lap, just the way the technique has developed for me, it's Ethibond. If it's robotic, it's non-absorbable all the same. Speaker A: You use a three or two? Speaker B: Yeah, yeah. Speaker A: Okay. Speaker B: Yeah. Either way, two or three won't make a huge difference as long as you've got adequate approximation. One thing to remember in that bite, when you're taking bites on the Roux limb mesentery, don't take massive bites because you're going to snag the vasculature. But I think that's general sense that most surgeons have anyway. Speaker A: Yeah, don't hit the middle colic either. Speaker B: Right, right, right. Speaker A: All right. And then your other defect, the other... Speaker B: Defect is the jejunojejunostomy defect. So you have an end-to-side jejunojejunostomy created as a part of this anatomy. And so the cut edge mesentery of the end jejunum going onto the side of the other jejunum, that's going to become your common channel. There's space between those two mesenteries, and that's your jejunojejunostomy mesenteric defect. Those have almost never been found to be a problem for internal hernias; it's typically the Peterson's pseudo-Peterson's situation. Speaker A: Gotcha. Thank you. Any other bariatric emergencies?

Dr. Kabir Mehta [00:23:57]: You could run into a jejuno-jejunostomy intussusception. So when these are made larger, they're implicated. The triple staple technique of a jejuno-jejunostomy involves making a common enterotomy, a proximal staple fire, a distal staple fire, close to the common enterotomy. That makes for a pretty large jejuno-jejunostomy. You can have an intussusception through that, and that's typically not known to cause your Roux limb obstruction. It can frequently cause just the BP limb obstruction. And so, CT scan imaging will show you remnant stomach dilatation, duodenum dilatation, proximal jejunum in the left upper quadrant dilatation may not necessarily mean Roux limb and alimentary limb dilatation. And so again, an NG tube won't be helpful there. Not saying that gastric bypass patients would never benefit from an NG tube. You can easily have a common channel obstruction or a Roux limb obstruction that you need an NG tube in and decompress them that way. But in intussusception, again, you manage it as an obstruction. You're going to go in, find the area, reduce the intussusception, assess for viability. Majority of the times, even if it is viable, you're almost obligated to resect and reconstruct that anastomosis. There are some surgeons that would say, "Hey, if you've reduced it and it's viable, you can pexy that segment that's intussuscepting and create some kind of adhesion that will prevent it from doing that again." But again, the other faction of surgeons, to which I belong, we believe in just resect, redo it, don't make it a super wide anastomosis, and you should be sorted from that problem.

Dr. Randy Lehman [00:25:50]: Okay, so can you describe like to the level of an intern how to do the reconstruction, like really in gory detail?

Dr. Kabir Mehta [00:26:03]: So Roux or JJ reconstruction.

Dr. Randy Lehman [00:26:06]: JJ reconstruction. Okay, because you're saying if there's an intussusception there, it's because it's too big, and the right answer is to resect and reconstruct it.

Dr. Kabir Mehta [00:26:15]: Yeah. Correct. Correct. So I'm going to do the simpler explanation. There are some nuances to this. You could have a situation where you could salvage having to transect all three limbs and making two anastomoses, but that's a little bit hard to explain without diagrams or being in that situation. So presume you have a JJ intussusception that you've decided needs reconstruction at this point. You're going to transect. You're going to try to waste as minimal bowel as possible. You're going to transect the BP limb just proximal to the JJ. You're going to transect the Roux limb just proximal to the JJ and the common channel just distal to the JJ. Now that is out of the system. Divide the mesentery as you need to. Now you're going to connect the Roux to the common channel, whatever is the Roux, and connect to the common channel end of it. And again, you're going to do— I don't know how much detail you want to get into, but it's a small bowel anastomosis. Line it up, common enterotomy, staple, close the common enterotomy. You're done with that anastomosis, and then you've got the BP.

Dr. Randy Lehman [00:27:21]: Okay, hold on. This is your your Roux limb back to, and you're doing this like anti-peristaltic side to side. Or do you line the two up side by side, and it probably won't make any difference?

Dr. Kabir Mehta [00:27:37]: Yeah, you've got the reach. You've got—the reach is good. Just use your common sense. Make sure it's sitting nicely. It's not going to be twisted, you know, and obstructed in any way. Just.

Dr. Randy Lehman [00:27:49]: And you would recommend doing that with a stapled anastomosis? A staple?

Dr. Kabir Mehta [00:27:52]: Be fine. As long as you're confident the bowel will hold the staples. Things like that shouldn't be a problem. Yeah.

Dr. Randy Lehman [00:27:58]: And if you were doing it as a stapled anastomosis and there was tons and tons of reach, exactly how would you choose? Which of those options would you choose? Like, would you fold them in like this so the two ends are together?

Dr. Kabir Mehta [00:28:12]: Yeah.

Dr. Randy Lehman [00:28:14]: Or what?

Dr. Kabir Mehta [00:28:14]: I would do that. Yeah. If I were in that situation, I would do that. It's side to side, functional end to end, but it's anti-peristaltic side to side.

Dr. Randy Lehman [00:28:23]: Yeah. Yeah. So then you would—would you place a stay stitch before you make the enterotomies? You're talking about being laparoscopic or robotic while you're doing this?

Dr. Kabir Mehta [00:28:34]: Yeah.

Dr. Randy Lehman [00:28:34]: You think?

Dr. Kabir Mehta [00:28:35]: Yeah, I mean, I always start exploring, laparoscopic or robotic, depending on robot availability, training of this crew after hours. But let's say I'm doing this lap, explore this lap, run the bowel, find the intussusception. Let's say I reduce it. I want to redo this. So I'll create windows, mesenteric windows at the meso borders of the bowel. Staple across, staple across, staple across all three limbs. Then I would do a stay stitch exactly what you said.

Dr. Randy Lehman [00:29:00]: Yeah.

Dr. Kabir Mehta [00:29:00]: Stay stitch on two ends. I typically like to make those two cut ends face the camera. And so, your, if the camera is coming in from here, you're looking straight down the double barrel. And so, then you make a common enterotomy, staple.

Dr. Randy Lehman [00:29:17]: How far apart are your stay stitches typically?

Dr. Kabir Mehta [00:29:20]: 5, 6 cm. So, and to that effect, since we're talking about stay stitches and going into depth of this, the stay stitch on the end where you're going to close the common enterotomy, make that close to the mesenteric border. Make your enterotomy close to the anti-mesenteric border. Staple it. Because you'll realize the common enterotomy reaches deep in towards the mesenteric border. If your stay stitch is up towards the anti-mesenteric border, you're going to have a hole between the stay stitch and where you're trying to reach to close the common enterotomy.

Dr. Randy Lehman [00:29:55]: Okay, let me, let me just make sure I got this.

Dr. Kabir Mehta [00:29:58]: You're.

Dr. Randy Lehman [00:29:59]: You're going down toward the mesentery on the, on the inside to place your stay stitch.

Dr. Kabir Mehta [00:30:08]: Yeah. So if you've got two ends, cut ends like that. Right.

Dr. Randy Lehman [00:30:11]: Yeah. Right.

Dr. Kabir Mehta [00:30:12]: So your stay stitch should be closer to the mesenteric border.

Dr. Randy Lehman [00:30:18]: Yeah. On the inside. So it sort of folds it out a little bit.

Dr. Kabir Mehta [00:30:21]: Correct. Let it fold up. The distal one you could place on the mesenteric border. Anti-mesenteric border. It doesn't matter.

Dr. Randy Lehman [00:30:27]: The reason for doing that is why.

Dr. Kabir Mehta [00:30:30]: Is to close the common enterotomy. When you, when you've made both enterotomies and you've fired the stapler, the common enterotomy, the, the deeper end of it will get close to the mesenteric border. If your initial stay stitch was close to the anti-mesenteric border, you're going to be in a situation where you either have to cut that stay stitch to completely close the common enterotomy, or you're gonna be struggling trying to find.

Dr. Randy Lehman [00:30:55]: But when you actually make the holes, you make it perfectly.

Dr. Kabir Mehta [00:30:57]: Anti-mesenteric. I do it anti-mesenteric.

Dr. Randy Lehman [00:31:00]: Yeah, yeah. And you make that. So then we've placed these stay stitches, which are what?

Dr. Kabir Mehta [00:31:04]: Stitch a silk for me. It's silk. 2-0 silk.

Dr. Randy Lehman [00:31:07]: Yeah, 2-0 silk. And they're 5 cm apart. And now you make an enterotomy on each side with cautery.

Dr. Kabir Mehta [00:31:13]: Yeah. I usually have a harmonic with me just because I have to take the mesentery. I'll use that harmonic to pinch a little bit of bowel, cut it open.

Dr. Randy Lehman [00:31:21]: Okay. And then you're bringing your stapler in. And it's a what kind of stapler?

Dr. Kabir Mehta [00:31:27]: I have Ethicon here. But if you've got Medtronic, whatever, you've got tri-staple, pretty much. And so white load for battle for me on both of these.

Dr. Randy Lehman [00:31:38]: And so white load, not tan.

Dr. Kabir Mehta [00:31:41]: Yeah. White load for Ethicon is one of the thinnest, and that works well on bell.

Dr. Randy Lehman [00:31:48]: Okay. So do you know the staple head on that?

Dr. Kabir Mehta [00:31:53]: I believe the closed staple height for that is 1.2 millimeters. I forget. Okay. But it's essentially their equivalent of a vascular load. I don't believe they go any thinner than the white load on the Ethicon.

Dr. Randy Lehman [00:32:07]: Okay. And then you haven't had any issues with a delayed leak because it's too tight or anything like that?

Dr. Kabir Mehta [00:32:13]: No, no, it works great. Yeah. The white load on the...

Dr. Randy Lehman [00:32:16]: And you have less issues with bleeding probably with it then.

Dr. Kabir Mehta [00:32:19]: Correct. Never had. Knock on wood. Never had bleeding. Never had leaks on those. So. Yeah. Yeah.

Dr. Randy Lehman [00:32:25]: I don't want to jinx you or anything, but it's small bowel anastomosis usually goes well. We all know that.

Dr. Kabir Mehta [00:32:29]: Yeah.

Dr. Randy Lehman [00:32:30]: All right, so then. Then you fire that stapler. And what's the length?

Dr. Kabir Mehta [00:32:34]: So you use a 60. And I don't necessarily use all of that 60 millimeter length. I use maybe five out of that six centimeters, and that's plenty. Yeah.

Dr. Randy Lehman [00:32:43]: Okay. And then you have a common interrugate. And how do you deal with it?

Dr. Kabir Mehta [00:32:47]: Just close it with Vicryl. And that's running stitch for me. Dunk muco sa. You could do a canal. You could do anything you want. Just make sure it's nicely approximated. You don't need to do an outer layer on it if you're happy with how this is approximated. Well vascularized, those sorts of things.

Dr. Randy Lehman [00:33:02]: Okay. How do you. Okay, if you're gonna do a single layer running Vicryl, that's a 2.0 Vicryl, a laparoscopic single layer with the 2-0 Vicryl and you're not canaling it, you're just running it.

Dr. Kabir Mehta [00:33:15]: Baseball.

Dr. Randy Lehman [00:33:16]: How did you start it? Is your knot on the inside?

Dr. Kabir Mehta [00:33:20]: No, start it. Start the knot on the outside. So you're starting on the, the most anti-mesenteric border. You're going to go down to your stay stitch. Your stay stitch again has to be well exposed. The, the entire otomy has to be well exposed. Your stay stitches.

Dr. Randy Lehman [00:33:34]: You're starting your stitch maybe 5 millimeters past where the inner otomy starts, would you say?

Dr. Kabir Mehta [00:33:39]: Yeah, yeah, 5 millimeters past. Tie a nice knot and then you take your first bite and just take one bite on each side. Yeah.

Dr. Randy Lehman [00:33:48]: Okay. And then you run it all the way. I've been doing the second layer for all this time and it's totally pointless. You're telling me.

Dr. Kabir Mehta [00:33:54]: Well, again, do what helps you sleep better. Again, there are people out there that do single layer gastrojejunostomies also. I couldn't give up the second layer of the gastroje. I still do two layers. Everything other than that one common anterotomy closure. It's just what we learn, right? Do you just develop comfort with it and you know it works?

Dr. Randy Lehman [00:34:14]: Yeah, that's where experience comes in. I mean, training and then experience. My listener is essentially myself. So first off, but it's also, it's one person that's listening at a time in their headphones as they're exercising, as they're driving in their car. And by the way, I appreciate you for being here and, you know, I want to ask the questions and dumb it down as much as possible because the things that are intuitive, they just get sometimes glossed over. So thank you for going to that level of detail. Now you're going to make another anastomosis. Where do you put it relative to that one you just made?

Dr. Kabir Mehta [00:34:51]: Yeah, so great question. I would want to do two things. One, make sure you've measured the length of the Roux limb. Now, just because you had to resect some, and some of these older anatomies were shorter Roux limbs, make sure the Roux limb is at least 70 cm in length. Majority of the times, you're not trying to get this patient more weight loss. So remember that. And then you're going to make the second anastomosis. Make it, we're going to say distal to your common, distal to your Roux limb to common channel anastomosis. You could make it distal and make it. I say that because you're going to divert bile distal to it. If your proximal anastomosis leaks or something like that, at least bile's not flowing through.

Dr. Randy Lehman [00:35:30]: There's less flow from the other across the other anastomosis. Makes sense.

Dr. Kabir Mehta [00:35:34]: Right. Right. Make sure the Roux limb length is 70 centimeters. And again, there are multiple ways you could do that, Randy. So, for example, if you gave me a patient, I've had to do this for, let's say, common channel reconstructions or lengthenings, the Roux limb lengthening, the BP limb lengthening for more weight loss for these patients, gastric bypass patients. And there are two things. Think about it this way. If you did Roux to common channel anastomosis and then you plugged the BP limb somewhere, you've not changed the alimentary limb length for that patient. Let's say you had a patient that had a short, short common channel. You measure their common channel after resecting for an internal hernia bowel ischemia situation, they're left with, let's say, 100 centimeters of common channel.

Dr. Randy Lehman [00:36:25]: Okay.

Dr. Kabir Mehta [00:36:25]: You've got 50 centimeters of Roux limb. That's a bad situation. Right. So in that case, what I would say is borrow Roux, borrow the BP limb, use the BP to common channel anastomosis. Do that first. And then hook your Roux limb up way proximal onto the BP limb. Therefore, you have prolonged your common channel. Exactly. So you can use those things. So you can make these in any order. Just make, let it make sense to you.

Dr. Randy Lehman [00:36:53]: Yeah. If that doesn't make sense, like, hit the rewind button and listen to a couple of times because it's a little mind-bending, but that makes sense. Yeah. All right, great. So say that you've got plenty of length and you've got 70 centimeters of, you're talking about from the ligament of Treitz.

Dr. Kabir Mehta [00:37:09]: No, Roux limb 70 centimeters from the gastrojejunostomy to where the BP joins in.

Dr. Randy Lehman [00:37:16]: Okay, got it.

Dr. Kabir Mehta [00:37:18]: The issue is bile reflux. If you, so way back in the day, I want to say, don't quote me on this, but I want to say early 2000 maybe, or maybe somewhere in the 2000s. And before, the Roux limb length used to be 40 centimeters at some point, 40 to 50 centimeters at some point. And that's too short, we found out, because the bile goes retrograde into the, the pouch and can cause bile reflux into the esophagus. And that's a pretty bad problem for patients to deal with.

Dr. Randy Lehman [00:37:51]: That makes sense. Yeah. You don't want to redo this again.

Dr. Kabir Mehta [00:37:53]: Yeah.

Dr. Randy Lehman [00:37:55]: Okay, so then you say you have plenty of space. So would you say it's most common that you, I guess most commonly you're putting it distal to you, that anastomosis you just did. So then you bring it down, you lay your, your cut edge. This will be isoperistaltic to the common channel.

Dr. Kabir Mehta [00:38:24]: Yeah.

Dr. Randy Lehman [00:38:25]: And then you do essentially the exact same anatomy. You're... You're looking at the end of the cut edge of your BP limb, and you put two stay stitches, and you use the same staple load, and you close the common enterotomy with a running 3-0 Vicryl single-layer baseball stitch. And then what do you do with the mesenteric defects?

Dr. Kabir Mehta [00:38:47]: Close them again using some kind of permanent suture, like Ethibond, or for the small bowel mesentery. I don't worry too much. On occasion, I've used silk, but, you know, some kind of permanent suture for mesentery defects.

Dr. Randy Lehman [00:39:00]: Would you leave a drain in that situation?

Dr. Kabir Mehta [00:39:02]: For small bowel anastomosis, if there isn't much edema, I wouldn't.

Dr. Randy Lehman [00:39:09]: Would you do anything with the omentum?

Dr. Kabir Mehta [00:39:12]: Wrapping the omentum and things like that? Really not for small bowel. I just make sure it's covered up, so if you ever have to go back, the bowel is not stuck to the anterior abdominal wall. And that's the most I would do with that. Yeah. One quick point on any time you do an anticide BP to common channel anastomosis and you're going to close the common enterotomy. Your common enterotomy can create, if you take big bites, you can cause a Roux limb obstruction because the Roux limb is entering into this anastomosis. And if you oversew that too much, you can have a narrow entry into that wide BP downstream, if that makes sense.

Dr. Randy Lehman [00:39:53]: Yeah, that could be. I could see that being hard to treat without a redo.

Dr. Kabir Mehta [00:39:59]: Correct.

Dr. Randy Lehman [00:40:00]: Okay. Anything else we're missing here on bariatric emergencies or this particular one? I know what I'm going to do when I find myself in this situation now. I'm going to go to TheRuralAmericanSurgeon.com and check the show notes where this is all going to be transcribed, and I'm going to read and say, "Oh, yeah, that's what Kabir said to do." And I may call you too, so very good.

Dr. Kabir Mehta [00:40:22]: Yeah, call me anytime. Well, bariatric emergencies is obviously a very wide topic, but we just picked a couple of common scenarios. You know, you've got a perf GJ or you've got an internal hernia. So we tried to touch on that. Yeah, there are resources out there. You know, one thing you could do is have your listeners join some of these private surgeon groups. They're Facebook groups. They're private, as in they're not open to the public or inpatients, but they're open to surgeons. And so, SAGES has a number of groups. Join these groups. There are so many great videos that come out. Acute care surgery has a group. You know, is that what you're going?

Dr. Randy Lehman [00:41:01]: To propose for the resources for the busy rural surgeon segment?

Dr. Kabir Mehta [00:41:05]: I am, I am. There are so many of these groups. There's...

Dr. Randy Lehman [00:41:09]: Why don't we jump ahead and you tell me your favorite for bariatric? I guess that's probably number one for a rural surgeon. And if you have others.

Dr. Kabir Mehta [00:41:19]: Yeah, well, don't say this at the cost of being judged, but I upload.

Dr. Randy Lehman [00:41:27]: That's everything I say, man.

Dr. Kabir Mehta [00:41:30]: I upload a lot of operative videos. So I have a YouTube channel that just goes over robotic or laparoscopic cases. So I'm one of those people. I don't always want to watch TV if it's not sports. I'm watching somebody's operative videos, and I want to see how they do it. So does that. That's something. But I pitch into the Facebook groups that I was mentioning. So, SAGES has a lot of these groups: SAGES Acute Care, SAGES Bariatric, SAGES Colorectal. Same thing, you've got robotic bariatric, robotic surgery collaboration. You've got these Facebook groups. You don't think to learn on Facebook that much, but people are posting their operative videos. It's fantastic.

Dr. Randy Lehman [00:42:12]: Dude, my Facebook algorithm has me so dialed in that I saw a post the other day about somebody purchasing a Highland cow and flying it home in their PC12 Pilatus aircraft. And I'm like, okay. The only thing that was missing is, like, they should have been doing surgery on the cow.

Dr. Kabir Mehta [00:42:35]: Yeah.

Dr. Randy Lehman [00:42:36]: Or something, like, while they were flying. But that's like, there you go. I mean, it got me figured out. But I have a lot of surgery stuff that comes up. It's basically like surgery stuff, inspirational stuff, a little bit of sports stuff, you know, like some spirituality, and... Yeah. And then there's cows, like, everywhere.

Dr. Kabir Mehta [00:42:55]: Yeah, that's good stuff, man. That's... That's a good lineup. And what is your YouTube handle? It's Kabir MetaMD.

Dr. Randy Lehman [00:43:03]: We'll put that in the show notes, so you can just go check it out. And if you have any questions about how to do that anastomosis or, you know, want to try some of those techniques out, feel free to check it out and incorporate it into your practice. I think we need to keep moving. I had one more question that I really wanted to ask you, and this is a personal question. So, you know, there's a lot of obesity in America in general, but especially in rural America. And I, I just don't have it in me. I'm sorry to... Well, you know, there's the center of excellence, and there's all the pre-op work that has to go into bariatric surgery. And so we've kind of been taught that. I'm not sure how much of that is actually relevant, but my question is, is it appropriate for a rural general surgeon to be offering a sleeve gastrectomy without also offering a Roux-en-Y gastric bypass? And maybe part B to that question is, what do you really have to do to, to really be doing your due diligence and doing the patient right for your pre-op, post-op things? Should a rural surgeon offer that?

Dr. Kabir Mehta [00:44:19]: Yeah, I would say, realistically, you know, in that situation, you won't be able to do justice. Rural general surgeon.

Dr. Randy Lehman [00:44:30]: So, yeah, somebody that didn't do a bariatric fellowship.

Dr. Kabir Mehta [00:44:32]: Right, right. So it depends on how many sleeves you did in your general surgery residency. You know, there are ways to complicate a sleeve gastrectomy. There are so many ways, and hardly any of them end up without a second operation or multiple operations down the road. And so the first thing is to be sure that you can at least technically be confident and say, I can technically perform this operation without causing complications. And now the question is, should I do it? Do I have the resources? So then we come to the next aspect of it. Is there adequate pre-op counseling? Can you educate the patient? Can you make sure you'll follow the patient, making sure they're not going to be vitamin and mineral deficient, those sorts of things afterwards as well? And then you're going to worry about, okay, if I run into a situation where there's a complication, what are my backups? There's a leak, you know, is my only option to go to the OR and then operatively drain them? Do something with the sleeve, or, hey, I'm not, you know, equipped to handle a complication here without IR, without, let's say, GI help, those sorts of things. Then that's to be taken into account. And the one other aspect that shouldn't be forgotten is, again, if you're not doing Roux-en-Y gastric bypass, you're not doing SADI-S, you're not doing the duodenal switches. Are you truly able to provide the patient a comprehensive list of alternatives? That's part of informed consent, giving them, hey, not everybody has to have a sleeve. I've heard of plenty of surgeons that they have a sleeve in their armamentarium. It's a hammer that they have, and they treat everything as a nail. And that's not fair to the patient. I've also heard the rhetoric being given to the patient, saying, always start with the sleeve. It's the least disruptive. True. It's the least reorganization of your anatomy. That's fair. But is that the best operation?

Dr. Randy Lehman [00:46:37]: Could you have reflux?

Dr. Kabir Mehta [00:46:39]: Certainly not. If you have bad reflux, then gastric bypass is the answer. But also, take diabetes, for example. If you're trying to address diabetes and someone has a BMI of, let's say 55, they have diabetes, recently diagnosed, they don't have reflux, SADI is a great operation for them. It's going to give them the most bang for their buck. With one operation, they can get rid of diabetes and have the best chance they can have. They'll lose more weight and keep it off, as weight regain is less of a problem with it. So my point is, can you have that fair conversation and have the patient make the right decision? There are so many barriers. I feel the answer is going to be no to your question, but in a very select situation, a capable surgeon who has done surgeries can provide the education and a good consent and can take care of them post-op. Yes, in very select, small situations, you could probably do that.

Dr. Randy Lehman [00:47:35]: Yeah. I mean, it sounds like you would have to do it essentially under somebody at a center where you know the complications could also be transferred to, because there's that, you know. But maybe an outreach surgeon too, who's already doing the full complement somewhere else. There are a lot of nuances, so you never say "truly never." But the answer is basically no. So I like that discussion. Thank you very much.

Dr. Kabir Mehta [00:48:04]: Yeah.

Dr. Randy Lehman [00:48:06]: All right. The next segment of the show is called the Financial Corner, and I was wondering if you had a money tip for our listeners.

Dr. Kabir Mehta [00:48:13]: Well, if they've been listening to your show, I'm sure they're all tuned up. I doubt that I'm going to bring anything new to the table here. Randy, you're one of the most judicious and smart planners. I have simple money tips. Don't be afraid of finances. A lot of doctors don't want to manage finances; they'll outsource it. They'll pay hefty amounts to financial advisors who might be abusing their naivety or lack of experience. It won't take you a lot of time to read a book or even just a resource like White Coat Investor, which many doctors use. You've probably given them great advice. Spend a little bit of time on it, and you'll be so grateful to yourself down the road. That's the biggest point I want to make: don't be afraid of managing your finances; it's not that complicated.

Dr. Randy Lehman [00:49:14]: Yeah. So I love that. We don't talk about stock tips here, all right? I mean, I can tell them what I've done, but I don't say, "you should do this specific tax strategy" or whatever, because I'm not an accountant. I believe that you should educate yourself.

Dr. Kabir Mehta [00:49:37]: Yeah.

Dr. Randy Lehman [00:49:39]: Podcasts, like ours, are not financial advisors. We're not fiduciaries. This is for entertainment only, but at the end of the day, save some of your money, don't spend it all, maximize your earning opportunities, try not to lose money. Educate yourself. Those are the principles we mostly talk about. I've seen so many new surgeons buying $700,000 houses, and it's unnecessary. Make sure you're saving money so that if something happens... I have a story for you. I don't know how much I've talked about this on the show, but I developed an allergy. I can't get more disability insurance because of this. I have an allergy to the accelerant in non-latex rubber gloves. It started with a beefy red rash on my fingers, and after attempts to treat it myself, I went to Mayo Clinic. They diagnosed me with an allergy to the accelerant in surgical gloves, which was common enough that Mayo had a pre-printed flyer about it. Now I use Gammax gloves, and I'm much better, but it was stressful.

Dr. Kabir Mehta [00:50:42]: And you've got an allergy still?

Dr. Randy Lehman [00:50:43]: Yes, the accelerant in non-latex gloves. It's an accelerant that's somewhat commonly allergenic. Last year was insane. My fingers developed a red, beefy rash throughout. It started in Honduras with a tiny spot on my hand. I thought it was a fungal issue and kept treating it, but I ended up needing a nurse practitioner to shave off the affected areas for testing. It turned out to be atopic dermatitis. I mistakenly put myself on oral steroids, which temporarily cleared it but caused a flare-up after I stopped. Don't do that. When I was tying knots, the rash was prominent on my fingers from operating.

Dr. Kabir Mehta [00:51:34]: Yeah.

Dr. Randy Lehman [00:51:35]: That's why I mention it in the Financial Corner: get yourself disability insurance as soon as possible, especially as a surgeon! Make sure it's "own specialty." True-own occupation insurance is crucial early in your career because financial catastrophe insurance is what you want. You need car liability insurance because a collision involving fatalities could be financially catastrophic. It's often legally required. But you don't need car insurance, as replacing a car isn't catastrophic unless you're over-stretched financially. Don't insure little things like gadgets or vacations. Insure your life to a point until your net worth allows you not to need it. You definitely need to insure your hands as a surgeon.

Dr. Kabir Mehta [00:54:01]: Yeah, I completely agree. I was going to say, it's going to be expensive—it is expensive—but you can insure yourself for $10,000 or $15,000 post-tax dollars. Whatever you're going to insure yourself for, you could have two policies. You could split that amount into two policies, keep both for the first seven, eight, ten years of your life. After that, you've got a nest egg. You've got some kind of fallback pot. And so you can drop one of those policies and you can still have the lower one, and so definitely have disability insurance. I agree with that wholeheartedly.

Dr. Randy Lehman [00:54:36]: Yeah, that's a great tip. And it puts a little like, what's the word? More like it makes you feel mortal when you buy your disability insurance because you're thinking, okay, I'm buying this until I'm whatever, 60, 65, you know, the payment, which means, oh man, like you don't think about this in your. I didn't think about this when I was a resident, but each case that I do, that is a part of my body of work that I'm going to do as a surgeon, which is finite. There will be a number at the end. And this is a, this is a small percentage. And so like along the way, you know, you think, hey, where, when am I going to be at 10%, 20%, 30% of my practice is over or I'm at the end. And I found that little thing insightful when I was buying my disability insurance.

Dr. Kabir Mehta [00:55:28]: Yeah, definitely insightful on the topic of insurance and talking about catastrophes and things like that. Umbrella insurance, again, I'm not an insurance agent. I don't like to over-insure myself. That's a cheap insurance that adds maybe 10, 20, 30 bucks to your insurance bill per month. But that one covers if your auto is maxed out, house is maxed out, or some other weird thing happens, somebody comes to your house and gets hurt somehow or whatever that covers you for a big amount for a very small fee.

Dr. Randy Lehman [00:56:03]: So do you have an insurance agent?

Dr. Kabir Mehta [00:56:07]: I do have an insurance agent that gets me disability insurance, yes.

Dr. Randy Lehman [00:56:11]: But do you get your umbrella through an agent or did you get it from the company?

Dr. Kabir Mehta [00:56:14]: That's through my home insurance. I also added the umbrella policy to that. And so you bring that up because it's. There's an extra fee for the agent or.

Dr. Randy Lehman [00:56:24]: No, I moved actually to preferring working with an agent.

Dr. Kabir Mehta [00:56:28]: Yeah.

Dr. Randy Lehman [00:56:28]: Because they kind of know my, my overall picture.

Dr. Kabir Mehta [00:56:31]: Yeah.

Dr. Randy Lehman [00:56:32]: And then I feel like they can negotiate me better rates. I feel like if I ever have to do a claim, I just call them, you know, and be like, they help me out through it. And my time is now worth so much that like, while I agree that managing your money, you need to educate yourself. I don't really think that you shouldn't have a financial advisor either. You know, you need to decide on your own. But for something like that, like, you know, it's like having an accountant, having an attorney that you're working, you're paying for some advice and they condense your learning down. Like, I don't want to read about the insurance, you know, it's not worth my time to do that. And especially for insurance there, they're like kind of commission salespeople. So they're actually pretty cheap for you, you know, so be careful. But, but yeah, the last thing I wanted to talk to you about is embracing failure. And we learn lessons more from failure than we do from success. And I was wondering if you could share with us your thoughts on embracing failure and what that might mean long term.

Dr. Kabir Mehta [00:57:38]: Yeah, yeah, I think similar to many people, I took failure hard early on in life. And then as time went on, I realized some of those failures weren't really bad for me. They turned out good. And then I was watching this movie, this one time, and a great little excerpt come up. It's the Zen Master "We'll See" story. And so the story goes, there's a 16-year-old boy in the village, gets a horse for his birthday. Everybody says, oh, how wonderful. And the Zen master says, we'll see. You know, a few months down the road, he falls off the horse, breaks his leg. Everybody says, oh, how terrible, Zen master says, we'll see. A little bit time later, war breaks out, they want all able-bodied men to go to war and this kid can't go because he had a broken leg. And so then the villagers say, oh how great, you don't have to go. And the Zen master says, we'll see. The point being we don't know how something is going to play out for us in the long run. What might seem like a failure today may just be on a grand scale, some way to redirect us from one path onto another. One closed door doesn't mean it's a closed door, but it just means you might have to look for a different open door and another door opens for you and you just keep going down that path. And so don't take it too hard, just give it your best effort, have some intentions, have some plans, but don't be married to the outcome.

Dr. Randy Lehman [00:59:23]: Uh, so yeah, what's the most dramatic example of that in your life?

Dr. Kabir Mehta [00:59:30]: Personal example, one time that particularly stood out. So I'm, I'm doing my rotation. This is at, this is in Boston, at Harvard. Um, so I'm, this is the time, you know, sub-I rotations. You, you kill yourself, right? You, you go to lengths. Um, so I'm, I'm waking up every morning at 3:30, getting to work at 5. Just however I'm doing this, I'm biking in, you know, 20 degrees weather or 30 degrees weather outside.

Dr. Kabir Mehta [01:00:02]: The night before I try to go to bed early, try to keep a, you know, be rested, things like that. Night before, the guy I'm splitting the room, the apartment with is going through something. I try to help him out and we end up staying up pretty late. So I fall asleep pretty late and I don't hear the alarm the next morning. These are surgery rounds. You can't be late. You're completely irresponsible if you're late. So I'm late. The team tells me, well, you know, why don't you just go to clinic today? Don't worry about rounds, don't worry about this.

Dr. Kabir Mehta [01:00:32]: I say, okay, fine, I'm already not feeling great, right? I'm not doing good. So then I find out the shuttle goes to the clinic building at 9:30. Like, all right, I'm in time for that shuttle, by all means. So I'm standing at the shuttle area, it's 9:25. I'm like, okay, I've got a minute, I'm going to go pee because I got to go pee. So I go pee, I come back, it's 9:28, and I'm waiting. The shuttle doesn't arrive. It's 9:45. Find out the shuttle came

Dr. Kabir Mehta [01:01:03]: and left in those two minutes. I can't make it to clinic that day. I'm like, damn. I just. I'm trying, you know, I'm trying. I'm here at 9:28. What's happening? And because I missed that shuttle, now I was forced to take the day. What I did with the day was I was going to reach out to people for feedback, reach out to, you know, do something with the day. And that leads me to send an email to Travis McKenzie. He's a fellow at Brigham at the time. He says, yeah, we'd

Dr. Kabir Mehta [01:01:33]: love to meet you. Why don't we meet for lunch? And so I meet him for lunch. He says, yeah, glad you emailed me because I'm leaving for Rochester today and I wasn't going to be back, and I would have flown back that day to India. So I have that one meeting with him. He becomes my mentor, and he gives me every kind of, you know, training, every kind of advice. He's a philosopher friend. He's such a great guy. Forever grateful to him, Travis McKenzie. And lo and behold, he becomes one of

Dr. Kabir Mehta [01:02:03]: my biggest supporters. I get to Mayo Clinic and I get so such great mentorship from him. And that wouldn't have happened if I didn't sleep late that night, didn't get late to. Didn't miss my alarm, didn't miss the bus. The bus left too soon for its time. Hey, but, you know, the mindset was, hey, you know, I'm just going to do the best I can with whatever I've got. And it just led to a tremendous outcome for me.

Dr. Randy Lehman [01:02:30]: Yeah. It turned something terrible into something great. That's insane. What a story. And yes, what a mentor, Travis McKenzie. And that's just. That's just serendipitous. I can't believe it. Or providential. I believe providential, actually.

Dr. Kabir Mehta [01:02:46]: Yeah. I don't think Travis knows that story, so.

Dr. Randy Lehman [01:02:49]: He doesn't. We're gonna share this with him. He's gotta know. And he needs to come on this show, too. He's from Alaska.

Dr. Kabir Mehta [01:02:57]: Yeah. Yeah. Oh, yeah. Talk about rural. Yeah, that's right. That's right. Yeah. Alaska. You had a guest here that's from Alaska.

Dr. Randy Lehman [01:03:09]: Yes. Practicing in Alaska training. Mayo product.

Dr. Kabir Mehta [01:03:12]: Yeah, There you go. Yeah. You had a whole episode on that.

Dr. Randy Lehman [01:03:15]: Yep. And that she's got quite the practice up there, too, so that's awesome. We can put a link to that in the show notes as well. And then I've got, I've got a little story of my own. Maybe I don't want to steal take away from what you said, but the same thing has happened to me probably multiple times. Probably happened to everybody. But you know, I didn't actually want to go to college when I graduated high school; I didn't really know what I wanted to do. But anyway, long story short, I ended up going to Purdue just because my buddy was going there. And I chose pharmacy because I had to choose something I didn't want to be an engineer. They had a good pharmacy school, and a series of conversations basically led to that and then ended up I had four semesters of declining GPA and didn't get into pharmacy school after two years. Right. There's a thousand pre-pharm and 100 of them get in. So I watched all my classmates switch to easier majors. And then I got very, mainly motivated by spite to not switch to like hospitality, you know. And so I went in. I remember going in and telling my health care advisor, whatever academic advisor, like, I'm going to med school now, you know, because I was so mad. And they're like, don't do that, don't do that, man. You look at your grades, look at your trajectory. This is not going to be a good solution. I'm like, no, no, it'll be fine. Because I knew, you know, I was not trying at all. Like, I was sleeping through my exams and stuff. So then I switched majors and got straight A's and then got, you know, 99% on the MCAT. And then I was confident enough to go to. I applied again the next year to pharmacy school, got in and then I went and like turned them down. You know, this is like my great moment as a, as an immature, almost still teenager, and then moved on. But I mean, that was still a pretty low low not getting them. That was like the first thing that I tried and didn't succeed at, you know, was getting into pharmacy school. But it was, of course, that was the right thing. Like I shouldn't, I would be miserable as a pharmacist, you know, and discovered completely my passion and calling and it just. But you could never have gotten me out of high school and said, okay, you're gonna go. Thirteen more years of training. Like it was enough. Like six seemed like too much already, you know.

Dr. Kabir Mehta [01:05:29]: Yeah, well, I, I can say this world's a better place with you being a surgeon. And to your listeners, I want to say this very loud and clear. Randy was hands down probably the most driven person at Mayo Clinic when we were there and always, always was, you know, looking for cases, looking for work to do. The guy was never free and a hard-working guy. Driven. And when I found out he's doing this podcast, I was like, sure, of course, of course. Randy be found doing this among 10 other things that he's going to excel at every one of them, you know, so tremendous guy. I. Randy, I think we both align on this one thing, which is I think you and I both like setting goals and working towards them and achieving them. And I know everybody does that in some sort of a way, but so far, at least in life, it hasn't ended for me. I'm still thinking, okay, what am I going to do next? And I see you and I see that you've already done the next thing and the next thing, so, so that's awesome and I love that and I think your viewers are benefiting from this and a lot of people will, so.

Dr. Randy Lehman [01:06:40]: Well, thank you, Kabir. That is the nicest thing I think anybody said for, for quite a while to me. So I really appreciate it. And I, I mean, that was a brutal time, but it was a fun time. And you look back on it, the further and further you get away from it, the more you actually enjoy it. Yeah, but cranking out those cases, I mean, it was great training. And it's, it also isn't, you know, you don't realize how much like we're all just surgery residents. Right. So we all seem very the same as the next guy when we're all, there's like what, 50, 60, you know, general surgery residents there at a time and they're all just kind of lumped together and you can see like differences between us, but it's kind of like many things, we're more similar than we are different. And compared to the general population, we had this very unique shared experience. And all of those people, you know, they're doing incredible things in the world and what you're doing is insane. So I love and Hazard Kentucky, what a cool place. Like to say that. You know, I've got this person, we did chief residence, you know, service together, and he's bariatric surgeon serving southeast Kentucky. Like, I just, I love it.

Dr. Kabir Mehta [01:08:06]: So thank you, man.

Dr. Randy Lehman [01:08:07]: Thanks for what you said and thanks for what you're doing.

Dr. Kabir Mehta [01:08:10]: Yes, yes, yes. All true things that I said. And no, it's, it's been a pleasure and honor. And, you know, for a moment I thought I wasn't going to be going to be able to do the extent, the breadth of surgery that I learned, the complexity that I learned at Mayo Clinic, I wouldn't be able to do here because of the limitations of the hospital. But it's worked out great. The hospitals worked with me. And so now we're doing, I mean, we believe this. We're doing modified duodenal switches. We're doing revisions. We're doing everything that I was doing at Mayo Clinic, I'm doing here. And so that's, that's, for me, that's, that's the ultimate thing. Am I doing everything that I can do for patients? So, yeah.

Dr. Randy Lehman [01:08:48]: How many bariatric surgeries are you doing a year?

Dr. Kabir Mehta [01:08:52]: Last year I crossed 50 bariatric surgeries. This year we're on track to cross a lot more. It's looking like a much bigger number this year. So I don't want to count my chickens before they've hatched, but it's looking like a lot, lot bigger number than that.

Dr. Randy Lehman [01:09:06]: So. Yeah. So every week you're doing a bariatric surgery, though, in a town of 5,000? Well, 50, 52 weeks. That's how I came up with that math.

Dr. Kabir Mehta [01:09:15]: But yeah, yeah, yeah, that's fair. On average, obviously, there's, there's weeks that I'm on vacation or CME or on call, that sort of a thing. So, but yeah, I know the numbers gone, gone up for a lot more. I think I'm going to hit that number probably before it's half of this year.

Dr. Randy Lehman [01:09:32]: So that is so cool. Well, I am so thankful for you and your time that you can share this stuff with us. And we will share these show notes on theruralamericansurgeon.com so if you trigger that in your head and you want to come back in it, even in an emergency situation, I don't know if that would be helpful to anyone, but it will be to me. I'll put it that way. So thanks again. I really appreciate it.

Dr. Randy Lehman [01:09:52]: It's great to talk to you, Kabir.

Dr. Kabir Mehta [01:10:05]: Thanks very much, Randy. It's been a pleasure, and I hope to see more of your work and your shows on this podcast.

Dr. Randy Lehman [01:10:05]: And if this is helpful to you, listener, in any way, please don't forget to give us a review, like us on Facebook, and share this with your friends. We're trying to create a rural surgeons' sort of surgeon lounge, in a sense, so that we can talk about some of these things that nobody else knows about. So, thanks again for being here, and we'll see you on the next episode of The Rural American Surgeon. Oh, just so you know, we're gonna plant maple trees when we get home. The maple trees. Okay, we got to do them. Sorry, the send-out. We're going to plant maple trees. Charlotte's excited, and she wants to share it with the whole world, so we got some that grew up in the flower garden, but we're going to try to keep them alive. All right. See you later.