EPISODE 49

The Truth About Surgical Responsibility with Dr. Adrian Sava

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 The Rural American Surgeon podcast. I'm your host, Dr. Randy Lehman. I have with me today a very special guest coming live from Sweden, Dr. Adrian Sava. Welcome.

Dr. Adrian Sava [00:00:58]: Thank you, Randy.

Dr. Randy Lehman [00:00:59]: Now, you guys are in Sweden today, right?

Dr. Adrian Sava [00:01:03]: Of course, I am.

Dr. Randy Lehman [00:01:03]: And it was a surgery workday for you?

Dr. Adrian Sava [00:01:06]: Yep, it was a normal surgery day. When you called me last time, the first and the last time I was in Norway.

Dr. Randy Lehman [00:01:15]: And you practice both in Norway and Sweden?

Dr. Adrian Sava [00:01:18]: Yeah. You need authorization to practice in both countries, but yeah.

Dr. Randy Lehman [00:01:25]: So let's start with an introduction of you and your training. I think our listener will find it interesting to hear maybe even the differences in training. And then we'll talk about what your practice looks like now and go from there. So tell me first about your background.

Dr. Adrian Sava [00:01:38]: Well, if I think a little better, next year I'm going to fill 30 years in surgery. So, in 1996, I started my residency in general surgery at a university clinic here. In five years, I became a specialist at the same clinic. It was general surgery, mostly oncologic general surgery, I mean, mixed upper GI and colorectal surgery.

Dr. Adrian Sava [00:02:09]: And then in maybe, I think it was 2005, I was thinking about expanding my horizons. In 2006, I went twice to a fellowship in Brussels, Belgium, where I had the pleasure to meet two great professors in bariatric surgery, Kibe Nakadie and Jacques Impens, at St. Pierre Hospital in Brussels. It was a kind of revelation for me, so I decided then that I would like to continue with bariatrics.

Dr. Adrian Sava [00:02:40]: I started after, maybe it was 2010, right after I did my PhD. So I did a lot of bariatric procedures. It was tough in the beginning here in Sweden. We used to do only gastric bypasses and Roux-en-Y gastric bypasses. But before that time, we had a lot of non-conventional bariatric procedures. In the late '80s, early '90s, here in the south of Sweden, there were some surgeons that used to do vertical banded gastroplasty (VBGs).

Dr. Adrian Sava [00:03:12]: In the early 2000s, we started with bariatrics here, so not so much experience from our side. We started with these Roux-en-Y gastric bypasses. Maybe it's worth mentioning that before us, there were some surgeons that used to do these retrocolic, retrogastric gastric bypasses. So, 2006 or '07, we started with anti-gastric bypasses.

Dr. Adrian Sava [00:03:42]: And then, in 2012, 2011, we started with gastric sleeves. Not so many surgeons were willing to do gastric sleeves. The concept was that gastric sleeve is not as good as gastric bypass. So we did a lot of gastric bypasses here. In 2015, I took over as head surgeon for the entire bariatric clinic for the southern part of Sweden.

Dr. Adrian Sava [00:04:13]: In 2015, I started doing most revision surgery here. Maybe for gross estimation, it was more than 30% revision surgeries, revision surgery procedures here, mostly gastric bypasses and gastric sleeves, and then revision. A lot of revision surgery, mostly complications after gastric bypass, revision of surgery after VBG, and then a lot of procedures that were done in the Middle East. Our patients used to travel there

Dr. Adrian Sava [00:04:44]: and come back with complications. All those gastric plications, failed sleeves—I remember it was a tough time. In 2020, I quit the public sector and, in 2021, started my private clinic here in the southern part of Sweden, Malmö. I'm dealing mostly with endoscopies here in my private clinic because it pays well. Then I'm traveling to Norway to operate as a general surgeon.

Dr. Adrian Sava [00:05:17]: And there in Norway, I've been to two places so far. One of them is a bigger clinic, a bigger hospital, regional hospital. We did a lot of laparoscopic procedures and bariatrics, of course. The other one is a smaller hospital that we— We can call it rural surgery.

Dr. Randy Lehman [00:05:48]: Right. Yeah, so laparoscopic hernia surgery, hemorrhoids, varices, what else?

Dr. Adrian Sava [00:06:18]: Gallstones, you know.

Dr. Randy Lehman [00:06:49]: Yeah, of course, gallstones as an afterthought. Great, a lot of stuff to dive into and unpack. First question, in the United States, training-wise, if you want to become a general surgeon, or let's say a bariatric surgeon, you would do four years of college, four years of medical school, five years of general surgery residency, and then you would do a one-year bariatric fellowship. And so, after 14 years, then you would be done. Then you would be a bariatric surgeon. How does that differ from, like, even the undergrad and medical school portions for you?

Dr. Adrian Sava [00:07:12]: We have medical school here in Sweden, four and a half years, and then it's just called— When you are, you have to do your surgery rotation, internal medicine rotation, and GP rotation. Then, after six years, you have a medical degree.

Dr. Randy Lehman [00:08:19]: Okay. You would go straight into that from the equivalent of high school. Like, would you be 18 when you go into that?

Dr. Adrian Sava [00:08:25]: Right after high school, you have to be admitted to the medical school.

Dr. Randy Lehman [00:08:30]: Okay.

Dr. Adrian Sava [00:08:31]: You have to be very, very good here, like everywhere. So when you have a medical degree, then you have to look for a place to do your residency. When you are admitted to a certain hospital, then you do five years of residency regarding general surgery. So, five years of general surgery residency here, and then you become a specialist here. After five years, you can be so-called consultant or attending, as you call it in the United States. Attending surgeon after 10 years of when you started your, when you start your residency. After five years of residency and five years of specialist training, then you can choose your sub-specialization. I was lucky enough to be able to choose bariatric surgery. Back in time, there were not so many places to benefit from that kind of training. After one year, I became a so-called bariatric surgeon here. But here, really, if you are not in the hospital at the university hospital, then the small hospitals— you are not allowed here because of this political decision to centralize big surgery procedures like upper GI surgery centralized at the university centers. I mean esophagus and stomach surgery, cancer surgery, and of course, hepatobiliary pancreatic surgery. Of course, this has to be at the university center. We have one, two, three, four, five, six university centers here. The others are not allowed to do these kinds of procedures in small hospitals. So, if you have esophagus cancer, you have to send it to the university hospital, university clinic here. Colorectal surgery is possible to proceed to do here in smaller hospitals, but not in so-called rural clinics.

Dr. Randy Lehman [00:11:16]: Yeah, how about rectal cancer, APRs, and stuff?

Dr. Adrian Sava [00:11:20]: No, no rectal cancer here at small hospitals, small clinics. Maybe hemicolectomies, but no rectal cancer.

Dr. Randy Lehman [00:11:31]: Yeah, makes sense.

Dr. Adrian Sava [00:11:33]: I think it's almost the same as in the United States.

Dr. Randy Lehman [00:11:38]: You know, it is. The thing is, the United States is so huge.

Dr. Adrian Sava [00:11:41]: Yeah.

Dr. Randy Lehman [00:11:42]: So you've got like, I'm looking up here, the demographics. Sweden's ten and a half million people, and Indiana, my state, which is a smaller state, is 7 million people. So actually, probably similar demographics. We've got a couple of major, like a main city, Indianapolis, in the center, and then we've got a few other larger cities, like three, maybe four, that you would, that would probably be doing kind of what you're describing. And then, like, a lot of the other stuff goes. There's two big hospitals down in Indianapolis that, like, most of the HPB surgery, for example, in our state is done at. But it's not like that's a hard and fast rule. It kind of depends on the doctor. So, like in Lafayette, for example, there's about nine surgeons down there, and that's kind of a city with 250,000 people. One of them will do, like, rectal cancer. All the rest of them don't, but they don't, like, not let him, you know, and he still probably picks and chooses, would be my guess. And then me, you know, being in rural surgery, I mean, I do more things in the rural place than I would say a lot of people that are practicing in the same. Well, we have what's called a critical access hospital. There has to be a hospital with 25 beds or less. A lot of times, they have two ORs, maybe one endoscopy room. That's like a common size. Those are the hospitals that I'm choosing to operate in. One of them is the hospital I was born in. I'm trying to, like, keep these small hospitals alive. They're a big landmark and a big figure in a small town that may only have, like, 5 to 10,000 people in it, and it's actually a big employer for the town. We have a lot of impoverished people, a lot of old people that live in these environments, and so the burden of travel for them is quite inconvenient, and they want their care local. So my whole mission is to go get the best training I can bring it back, close to home for.

Dr. Adrian Sava [00:13:45]: For.

Dr. Randy Lehman [00:13:45]: For these folks. And so I would say how I do my practice, there's a lot of surgeons like me in the United States, but there's also a lot of surgeons that are doing rural practice in the United States. And they're kind of just doing the scopes, you know, and just a few minor lumps and bumps, and then taking their cases back to a city of 100 or 200,000. So both models exist in the US, but probably just the latter one is what's mostly happening in Sweden.

Dr. Adrian Sava [00:14:14]: Well, it's difficult to compare Sweden with the United, with Indiana. I mean, there are, I can, I can say they are two different worlds. While there are many similarities, it's the same surgery, right?

Dr. Randy Lehman [00:14:33]: Same surgery. At the end of the day, it's just how do you kind of deliver it? We have, you know, and then our system is very fragmented too. So do you guys have one payer? I mean, you're saying that you have your own private clinic. So I'd like to know how that works too.

Dr. Adrian Sava [00:14:51]: Well, it depends if you. Small procedures can be done at the private clinics, but not the big procedures. There are private clinics used to operate prostate cancer and. But not so. So far that I know of, no clinic that used to operate colorectal surgery. Cancer surgery, I mean, or Whipple's.

Dr. Randy Lehman [00:15:26]: No, but what you're describing as a clinic, some places they'll have like a laparoscopic setup, and they could do a gallbladder, you think?

Dr. Adrian Sava [00:15:35]: Here in Sweden, we used to do only laparoscopic gallbladders. Only if it's complicated, you have to surely convert. But yeah, it's only laparoscopic setups.

Dr. Randy Lehman [00:15:47]: Right, but like, that would be done in a clinic. Like what you're calling a clinic setting, right?

Dr. Adrian Sava [00:15:52]: Gallbladders can be operated in both private and public hospitals.

Dr. Randy Lehman [00:15:59]: Like for us, we would probably call it like an ambulatory surgery center. A private ambulatory surgery center. We like, clinic specifically to us usually means just the office, you know, where we're seeing patients and maybe doing very minor things like biopsies and stuff. Not like an actual procedure room or operating room. But I've talked to, just because I've talked to my cousin who lives in Germany, he told, you know, I told him I started a business called Liberty Clinic, and he's like, oh, you have your own clinic? Like it was a big deal. I'm like, no, it's just, just an office, you know, it's not like an OR. But now, so our audience is clear, when you're saying in the clinic, private clinic, that means probably something up to including what we'd imagine as a surgery center. Yeah. And then who's the payer? Do they have insurance that pays, or.

Dr. Adrian Sava [00:16:47]: Is this paid cash here in Sweden? Nobody's paying cash here. We have public insurance. No private insurance. We have private insurance, of course, but the public insurance is covering everything here in Sweden. So you as a patient have to pay only maybe $20 a day as long those days you are staying in. So all the rest is paid by your public, is paid by your public insurance, health insurance.

Dr. Randy Lehman [00:17:25]: So if you bring a person in for endoscopy in your private clinic, then the government's paying you.

Dr. Adrian Sava [00:17:33]: As a private clinic, you have two choices: to make a contract with the region. We are called, as you call in the United States, your states, Indiana and everything else, California or Florida. Here we are calling those states regions. And I live and work here in the southern part of Sweden, which is called Skåne or Skane, as you can see used to pronounce outside Sweden. So you have two choices to make a contract with your region, and the region is paying for your patients. So your patients don't need to pay anything. The same as at a public hospital. So they come in, they're paying $20, and then everything else is already paid. I can give you an example. For colonoscopy, they used to pay about how much? $600 the region is paying now.

Dr. Randy Lehman [00:18:40]: Those are US dollars or US. Okay.

Dr. Adrian Sava [00:18:45]: Yeah. Or 6,000 Swedish crowns.

Dr. Randy Lehman [00:18:50]: Okay.

Dr. Adrian Sava [00:18:51]: This is what you get for one colonoscopy, plus, minus $100 if you, if you're doing polypectomy or maybe $80. No, so these are the tariffs.

Dr. Randy Lehman [00:19:07]: Okay.

Dr. Adrian Sava [00:19:09]: So the patient doesn't feel a difference if they are coming to you or to the public hospitals. The politics here is to help the public hospitals, public clinics too, because they have to wait here. A lot to come to.

Dr. Randy Lehman [00:19:34]: Can you accept that payment and cover your overhead well and make a good income off of that rate?

Dr. Adrian Sava [00:19:42]: Yeah.

Dr. Randy Lehman [00:19:43]: Okay.

Dr. Adrian Sava [00:19:45]: It's all right. I don't complain.

Dr. Randy Lehman [00:19:48]: How many scopes can you do a day?

Dr. Adrian Sava [00:19:51]: Well, it depends. I used to do around 7, 8 colonoscopies or up to 12 until 1 o'clock, from 7 to 1. So 12 procedures, 12 endoscopies, up to 8 colonoscopies.

Dr. Randy Lehman [00:20:12]: Okay.

Dr. Adrian Sava [00:20:13]: Five for gastroscopies.

Dr. Randy Lehman [00:20:16]: And then would you say your overheads, what is it? About 50% of the total collections? Sorry, when I say overhead, I mean your expenses. Well.

Dr. Adrian Sava [00:20:29]: Maybe. Maybe more.

Dr. Randy Lehman [00:20:31]: More than 50% of it goes to expenses.

Dr. Adrian Sava [00:20:35]: Having said 50%, no, no, less. Less than 50.

Dr. Randy Lehman [00:20:40]: Okay. So more than 15 and less than.

Dr. Adrian Sava [00:20:43]: 50. More than 30.

Dr. Randy Lehman [00:20:45]: And that's a big range. Yeah. Okay. I would say private practices in the United States, if they can keep their overhead below 50%, they're doing okay.

Dr. Adrian Sava [00:20:56]: There's a lot of things you have to deal with here. If you have your own private clinic, you have to fix everything. You have to choose your own staff, your personnel, and you have to choose them well. Very well. Otherwise, it's going to be very difficult for you.

Dr. Randy Lehman [00:21:15]: Yeah. How many people work for you?

Dr. Adrian Sava [00:21:19]: Four.

Dr. Randy Lehman [00:21:19]: Any of them family members?

Dr. Adrian Sava [00:21:23]: Nope.

Dr. Randy Lehman [00:21:24]: Okay. And no other doctors in the practice?

Dr. Adrian Sava [00:21:29]: I'm the only one.

Dr. Randy Lehman [00:21:30]: Okay, gotcha. So, what do you need? Like a surgery tech and a nurse maybe, or who all? What's your staff look like?

Dr. Adrian Sava [00:21:39]: Two nurses and one, three, and one like office person. Office secretary.

Dr. Randy Lehman [00:21:47]: Yeah. Okay, very good. Well, that's a great intro and I just think it's so, like you said, different and foreign to what we basically do. Although, you know, here you have that opportunity to take Medicare, make your own practice if you want to, but most people choose to work for hospitals the way that it's going right now. And then there's actually a surgery center. I think the other second option you were going to say is, don't contract with the government. Would it just be cash pay or it would be commercial insurance that would be paying, in that second option, if you choose.

Dr. Adrian Sava [00:22:26]: To not make a contract with the region or the government here in Sweden, you are already handicapped as a private doctor because most of the patients are going to choose the option not to pay. Because here in our country everyone is already paying their health insurance. So, why pay more when I can pay less, right?

Dr. Randy Lehman [00:22:54]: Of course, yeah. But in the United States, we actually have a couple places that are starting up. It's a newer concept, which is cutting out insurance altogether, cutting out the government altogether, and they have basically a cash price. People love the transparency, right? And they love the service, and you know, no wait lines, and usually the service is better. There was a place in Oklahoma that started it, and now in Indiana, we have Wellbridge Surgical. I think it's just on the north side of Indianapolis, and it's a cash-only surgery center. We have people in the United States that have very high deductible plans, and those people will use those services. There are health, Christian health sharing ministries where it's like having insurance, but they're still cost-sensitive because they're actually turning into the group. Those places will seek out, those people will usually seek out the lowest cost. Some people still don't have insurance, although they should be able to get government insurance if they want to. And now we're having people from Canada, where there's a long wait line up there, and they're like, "I'll just pay so you can get my gallbladder out for $6,500. All right, I'll just come down and do it," you know? So I'm very curious to see how that goes because generally, I'm definitely a capitalist, and I believe in a free market. And I'm also living it and breathing it every day, the waste in healthcare that predominantly in the United States occurs because we have to have an army of people on our billing end to fight with the army of people that are working on the insurance side. And the people that have been hired by insurance exist to deny claims, and they've been told, they're instructed to deny. We have to have people basically to fight that. They just blanket deny like 10% right off the top, and they'll just choose not to respond for no reason and not pay you, and you have to go chase it down. It's only because they're trying to make it hard enough that you eventually say forget it, I'm going to consider that bad debt and not have to get paid. That's the problem with the for-profit insurance companies.

Dr. Adrian Sava [00:25:15]: Well, if you live in a country where you can choose how you're going to pay your taxes, I think it's all right. But if you live here, it's impossible to choose how you're going to pay your taxes because the state is already taking your taxes between 40 and 60%. So if you are already paying the taxes, how can you choose to pay extra?

Dr. Randy Lehman [00:25:45]: Right.

Dr. Adrian Sava [00:25:46]: For a private care provider. So this is the biggest difference here. We are all paying here. So why should I pay more?

Dr. Randy Lehman [00:25:58]: Yeah.

Dr. Adrian Sava [00:26:00]: But if you, I don't like politics and economics, but sometimes you have to say it bluntly. It covers a lot. You don't have to pay for your studies; you have no loans here. My kids, they are grown-ups, didn't have to pay anything for their medical degrees. So there are pros and cons.

Dr. Randy Lehman [00:26:28]: Yep. I think it's just different, and you're absolutely right. That's not like right or wrong, it's just very different. Of course, obviously, I greatly prefer like what I grew up with.

Dr. Adrian Sava [00:26:39]: I totally agree and understand your point.

Dr. Randy Lehman [00:26:41]: You know, that's why freedom is one of my greatest values. You know, it's probably because it's been preached to me because I grew up in America, you know. But let's move on though to some other sections of the show. First one is just why is surgery special to you? So what is it about your job that, you know, you said you're fortunate to get into. You use words like that, you know, and you just, you seem like you are proud of what you've been able to do. And why is that? What's so special about this job?

Dr. Adrian Sava [00:27:10]: In my case, surgery was a call. In the early '80s, as a teenager, I already knew in my heart, deep in my heart at the time, I was going to pursue a medical career. So, in 1990, I got admitted to medical school. And then two years before I, in the fourth year of medical school, I went to my university professor and told him, "I want to be a surgeon. What should I do in order to become a surgeon?" And he told me, "You know what? Go to Dr. and learn some things." And then he came and controlled, checked me up if I was there. So in my final year, I went to him, I went back to him and I told him, "You know what? I heard what you said to me. I went to the urgent, and I was there for two years in my free time, and I would like to continue to be a surgeon, to fulfill my dream." And then he said, "Okay, you can be my resident." And I started to help one of the best professors in general surgery I have ever seen in my life. I was blessed in my life, I can admit it. So for me, it was a very simple, straightforward call. But it came with a lot of sacrifices. You have to sacrifice something in your life. Your free time, your time with your kids, your children. And then when they are 18, they're going to tell you, as my son told me, "You know, Dad, you were never home when I was a kid. So that's why I'm not going to be a doctor." So he became a dentist.

Dr. Randy Lehman [00:29:23]: And your daughter as well, right?

Dr. Adrian Sava [00:29:24]: My daughter as well. So both myself and my wife, we are both doctors. My wife is an ophthalmologist. So, okay. It's not easy to have two parents who are doctors. So there is sacrifice in everything you do.

Dr. Randy Lehman [00:29:45]: Anything that you would do differently.

Dr. Adrian Sava [00:29:47]: If I had to choose, if I could choose now back in 1996, maybe not general surgery, maybe plastic surgery. Because I like plastic surgery, and I have always been attracted to it. So when I became a specialist in general surgery, I applied to plastic surgery too.

Dr. Randy Lehman [00:30:18]: Okay.

Dr. Adrian Sava [00:30:18]: And then, for some reason, I said no, I should continue with general surgery.

Dr. Randy Lehman [00:30:27]: Sure.

Dr. Adrian Sava [00:30:27]: Plastic surgery was my second choice.

Dr. Randy Lehman [00:30:29]: Is plastic surgery, like, mostly cosmetic surgery, or is it reconstructive functional surgery that interests you the most?

Dr. Adrian Sava [00:30:38]: Mostly reconstructive surgery.

Dr. Randy Lehman [00:30:40]: Very interesting. So now that you did go the path that you went, you've landed on basically being a bariatric surgeon. We usually do a "how I do it" section of the show. Today we're going to talk about Roux-en-Y gastric bypass. We'll discuss the operation itself and also some differences from the US. We usually start with indications. Obviously, obesity is a clear indicator for Roux-en-Y gastric bypass. Obviously, there are certain things like a sleeve, you know, you're not going to do. If you have a patient with reflux disease, you're not going to do a sleeve. You choose a Roux-en-Y gastric bypass. Is there anything besides that reflux component that would make you choose a Roux-en-Y gastric bypass over some other bariatric operations?

Dr. Adrian Sava [00:31:22]: Before 2015, Roux-en-Y gastric bypass was number one here in Sweden. Then we started to do more sleeves than gastric bypasses here for some reason.

Dr. Randy Lehman [00:31:35]: Just because it's easier, probably, right?

Dr. Adrian Sava [00:31:38]: No, not because it's easier. It depends on if you have a patient that is highly obese, that has a BMI, let's say, 55. It's not easy to choose a sleeve. I will always, I'm going always to recommend a gastric bypass. But if you have diabetes, a patient with a BMI of 40, 41, no reflux, a young patient never been pregnant before, why not a sleeve? So it depends. If you have a diabetic patient who is difficult to control, then a gastric bypass could be the best option. But you always have to think about possible complications after a gastric bypass. So gastric bypass is not complication-free. You have to do it properly. But even if you do it perfectly, there are complications that can occur. So it's a difficult choice. Sometimes you start an operation thinking, okay, we are going to do a sleeve. Then when you start to free around the GE junction, and you can see that this patient has a hiatal hernia, well, maybe it's better to do a bypass.

Dr. Randy Lehman [00:33:27]: And there's room to switch, like you kind of go to the operating room consented for both.

Dr. Adrian Sava [00:33:32]: Yeah, you have to have consent. The patient has to give you consent. So I used to ask the patient before, do I have free hands to choose myself which is better for you? And if a patient says, no, I will only have a sleeve, okay, then we're doing a sleeve. Except if there's a big hiatal hernia, then you have to tell the patient, okay, if you have a big hiatal hernia. We don't usually do preoperative CT scans on every patient, so sometimes we don't know. On a regular basis, if the patient has no symptoms, then we don't usually do a gastroscopy before a sleeve or gastric bypass.

Dr. Randy Lehman [00:34:25]: Okay?

Dr. Adrian Sava [00:34:26]: Neither. So sometimes there's an intraoperative surprise that you have over a 3 cm hiatal hernia. Then you have to suture the hiatus and do the sleeve. But, you know, hiatus sutures sometimes can fail. Then you have a sleeve herniation, and then it's much worse than before. Then you have to convert the sleeve to gastric bypass because of the reflux. Regarding gastric bypass, there are a lot of things to consider when you choose a gastric bypass. Five years ago, we started to do Single Anastomosis Sleeve Ileal Loop (SASI). It's a combination between sleeve and gastric bypass. You do a sleeve, and then you go to the ileocecal valve, measure 120 cm, and then do gastroenterostomy. So SASI, as far as I know, we don't do here in Sweden. We stopped doing duodenal switches. Not anymore.

Dr. Randy Lehman [00:35:57]: And then when you do your sleeve, your SASI, you divide. Is it pre or post-pyloric to make your anastomosis? Because you do your sleeve, and then you divide somewhere between the stomach and the duo, right?

Dr. Adrian Sava [00:36:15]: You don't divide anything. You do a sleeve, and then 120 cm distal from the ileocecal valve, you're lifting up a small bowel and do a gastroenterostomy.

Dr. Randy Lehman [00:36:32]: Gastroentero. So you're. You leave the last part of the stomach and the pylorus all attached to the...

Dr. Adrian Sava [00:36:41]: Yeah, sure, sure. Okay. You try to do it as close as possible to the pylorus.

Dr. Randy Lehman [00:36:49]: Okay.

Dr. Adrian Sava [00:36:50]: The antrum part.

Dr. Randy Lehman [00:36:52]: Got it.

Dr. Adrian Sava [00:36:53]: The anastomosis.

Dr. Randy Lehman [00:36:54]: And you're. Are you still actively doing that? Which patient would that operation be best for?

Dr. Adrian Sava [00:37:03]: For what?

Dr. Randy Lehman [00:37:04]: For a SASI. SASI.

Dr. Adrian Sava [00:37:08]: SASI. The ones who want to have a sleeve.

Dr. Randy Lehman [00:37:14]: Okay.

Dr. Adrian Sava [00:37:15]: But it's bigger than usual.

Dr. Randy Lehman [00:37:18]: Okay. So a high BMI.

Dr. Adrian Sava [00:37:20]: A high BMI, but refuses to have a gastric bypass and they can't have reflux.

Dr. Randy Lehman [00:37:23]: Bypass, but refuses to have a gastric bypass.

Dr. Adrian Sava [00:37:28]: Yeah, sure. Every sleeve has to come without reflux. So, no sleeve with reflux with GERD.

Dr. Randy Lehman [00:37:38]: Got it. Well, let's talk about your technique for the Roux-en-Y gastric bypass. First question, are you doing everything with straight stick laparoscopic or are you using the robot?

Dr. Adrian Sava [00:37:49]: Not here in our center. We don't use robotic bariatric surgery because the costs are too high for a simple procedure. For us, it takes 40 minutes to do a gastric bypass, 20 minutes to do a sleeve. So it doesn't justify the costs. If you do robotic surgery, it's much, much easier, of course. But you have to train. The learning curve for laparoscopic surgery is much longer than for robotic surgery. So no, I'm just using laparoscopic surgery. The procedure is simple.

Dr. Randy Lehman [00:38:36]: Yeah, talk me through the. We'll just choose Roux-en-Y because you have to pick one now. We can't talk about every case, but talk me through how you do the operation from positioning, port placement, how you do you know, every step of it.

Dr. Adrian Sava [00:38:50]: The patient is in a beach chair position. You're standing between the legs, you as the operator, and your assistant is on the patient's left side. So only one assistant and the assistant nurse is on the patient's right side. So, normal port positioning. You start by coming in at the lesser sac, right below the GE junction. Then you are stapling horizontally with a 45 linear stapler. We use to use the Covidien yellow cartridge, and then one or maybe two vertical stapler cartridges too. The goal is to have a very small pouch only to be able to make a gastroenterostomy, not more. Maximum 3 to 4 cm, 3 x 3 or 4 x 3 cm. So, a very small pouch. This is the goal. Then you're switching to the infracolic region. You're lifting up your transverse colon. Identify the Treitz ligament. And then measuring around 60 centimeters. This is the BP limb. You lift, make a small incision, and with a linear stapler, 45 millimeters, the same yellow cartridge, you're stapling with a small pouch. Then 120 in row limb. You're doing enteroenterostomy with the same 45-character yellow cartridge. Convenience. You're closing the horse, of course, with G or NE anastomosis or JJ anastomosis. When you're done with it, you have to close the defect. The mesentery defect we are still using. We have these metallic clips that help us to close the defects very fast.

Dr. Randy Lehman [00:41:23]: Let me pause you for one second and just ask a specific question about how you did your JJ laparoscopically. So you're bringing your obviously 60 cm distal to ligament rights, 120 cm Roux limb. You line them up side by side. Do you place a stitch or anything to hold it before you make your enterotomies and slide your stapler in?

Dr. Adrian Sava [00:41:48]: No. When the assistant is holding the BP limb and me, as an operator, I'm holding the Roux limb with sonication. I make one hole in the BP limb, one hole in the Roux limb, then in with a stapler stapling, and then the remnant hole. I'm suturing with absorbable sutures.

Dr. Randy Lehman [00:42:20]: Two layers or one layer?

Dr. Adrian Sava [00:42:24]: Two layers in the GGE and one layer in JJ anastomosis.

Dr. Randy Lehman [00:42:29]: Just one layer. And then are you, when you put that, when you stitch that down, anything special, like, is that a canal stitch or anything like that?

Dr. Adrian Sava [00:42:41]: I'm holding with a needle holder like this. Then I'm sewing just regular suture in G anastomosis.

Dr. Randy Lehman [00:42:52]: Not in-and-out, in-out, on the other side. You're just doing over and over.

Dr. Adrian Sava [00:42:58]: Yeah. And then JJ anastomosis is only one layer.

Dr. Randy Lehman [00:43:02]: Yeah.

Dr. Adrian Sava [00:43:04]: We are still using Vicryl, but 3.0-micro.

Dr. Randy Lehman [00:43:09]: Yeah. Your knots, they're outside of the bowel. You're not burying the knot, right?

Dr. Adrian Sava [00:43:15]: Always outside the bowel. And then leakage test. It's a 32 French tube through the G anastomosis. It's mandatory.

Dr. Randy Lehman [00:43:30]: Okay. Obviously, don't do that for the JJ.

Dr. Adrian Sava [00:43:34]: No. Yeah, not for the JJ, but there is some finesse when you're doing the JJ. You have to be very careful when you suture the JJ anastomosis hole after stapling in order to not be very hard when you do the suture because you don't need this JJ kinking. This is very important in order to avoid this chronic abdominal pain because the chronic abdominal pain is almost always related to the dysfunctional gig anastomosis. When you close the mesentery defect to the GJ anastomosis, you have to be very careful not to do very hard or take too much tissue.

Dr. Randy Lehman [00:44:26]: Yeah.

Dr. Adrian Sava [00:44:28]: You have to avoid kinking.

Dr. Randy Lehman [00:44:32]: The reason I dive so deep into this is because I'll have a lot of general, well, first off, myself and my audience is basically somebody like myself, like a general surgeon, non-bariatric. If you want to do a laparoscopic small bowel to small bowel anastomosis, that's very much a general surgery operation. Say you're operating for bowel obstruction and you're trying to keep your incisions small and whatnot. So that's why I'm digging in really deep to exactly the technique of this and looking for your tips.

Dr. Adrian Sava [00:45:00]: So another tip is to divide the mesentery before your stapling in order to have a free JJ anastomosis. Otherwise, you're going to have a very high JJ anastomosis, which is prone to this kinking later, and then it can cause this chronic abdominal pain post-gastric bypass. Nobody can explain what is going on. Nothing on the, you cannot see anything on CT scans. This is very difficult.

Dr. Randy Lehman [00:45:40]: Okay.

Dr. Adrian Sava [00:45:41]: To solve.

Dr. Randy Lehman [00:45:42]: So when you're, I understand you're bringing the, it's basically isoperistaltic, the two limbs.

Dr. Adrian Sava [00:45:51]: No, it's antiperistaltic. Because when you've done the JJ anastomosis, you have to divide the BP limb from, it has to fall down.

Dr. Randy Lehman [00:46:03]: Right? But the stuff is coming down this way and also the stuff is coming down your Roux limb this way too, right?

Dr. Adrian Sava [00:46:09]: Because when you're done with the G anastomosis, you're going down 120 cm. Then you have to do a JJ anastomosis. You're sewing the hole, and then you have to divide between these two anastomoses with a stapler. Then this JJ anastomosis has to fall down properly. Otherwise, it's going to be very, very difficult to fix it.

Dr. Randy Lehman [00:46:36]: Okay.

Dr. Adrian Sava [00:46:38]: If you follow with me.

Dr. Randy Lehman [00:46:40]: I'm not, but that's okay. And I might take this out because I'm not so sure. Let me try to ask, just practically. So you have your BP limb coming down, and it's cut, right? And then you take, you do the JJ first, right?

Dr. Adrian Sava [00:46:59]: No, I'm doing the GJ first.

Dr. Randy Lehman [00:47:02]: Okay. So you drag that up and you do your GJ. Now this limb is hanging down 120 cm. They don't run this side by side like this. You actually come down, loop, and it comes back up alongside, like something like this.

Dr. Adrian Sava [00:47:20]: When you're doing your first anastomosis, gastrojejunostomy, and then you are doing your JJ anastomosis, then you have an omega loop.

Dr. Randy Lehman [00:47:31]: Okay.

Dr. Adrian Sava [00:47:32]: Isn't it? Then you have to convert this omega loop into a Roux-en-Y loop. That's why you have to divide these two anastomoses.

Dr. Randy Lehman [00:47:43]: Okay.

Dr. Adrian Sava [00:47:45]: I'm not sure.

Dr. Randy Lehman [00:47:46]: I don't do, you know, not doing bariatric sense training, like did a few cases.

Dr. Adrian Sava [00:47:51]: But if you start, Randy, if you start from the beginning, you are starting from, so you have your small, small pouchy pouch prepared, isn't it? Then you identify your Treitz ligament in 60 cm. You're lifting up antecolic.

Dr. Randy Lehman [00:48:17]: Yes.

Dr. Adrian Sava [00:48:18]: Antigastric. This, this small bowel to the small, small pouch.

Dr. Randy Lehman [00:48:25]: Yes.

Dr. Adrian Sava [00:48:25]: And then you have an omega loop.

Dr. Randy Lehman [00:48:28]: Yep.

Dr. Adrian Sava [00:48:28]: Isn't it? Then you are doing your gastrojejunostomy. And then you are doing your JJ anastomosis. But then you have to divide between these two anastomoses in order to have a separation to convert your omega loop into a Roux-en-Y loop. This is the Swedish technique we used to call it. But everyone

else is doing this right now, so I have to write it out. Here we have the small pouch here. This is the small pouch. And this is the Treitz ligament. This is the BP limb 120. This is the BP limb here. This is a Roux limb 120, 60. And between this one and this one, you have to divide, otherwise you have an omega loop. So this, this is a limb.

Dr. Randy Lehman [00:49:26]: That makes sense. I'm gonna draw what I was imagining and you'll see what I was talking about. I was imagining more like this. See that?

Dr. Adrian Sava [00:49:37]: Yeah, I can see that.

Dr. Randy Lehman [00:49:38]: But it's not that. It's this. This guy here is looped back up. So they're anti.

Dr. Adrian Sava [00:49:44]: No, in reality, it's going to be like this. This antiperistaltic. J, J. This one, this one is the same intestine from this one, but this one is falling down.

Dr. Randy Lehman [00:50:01]: Yeah. And you just let it slide down, and then it goes up antiperistaltic. And is there a reason for that? And what if you didn't do that? What if you flipped that upside down and it was isoperistaltic?

Dr. Adrian Sava [00:50:12]: It's much easier to do it technically.

Dr. Randy Lehman [00:50:15]: Okay.

Dr. Adrian Sava [00:50:15]: Like this.

Dr. Randy Lehman [00:50:16]: Because you're holding on the cut end. Right. So she can hold your cut end of your BP limb up.

Dr. Adrian Sava [00:50:22]: You have a hole here. You have a suture here. You're coming in here with your staple, and then you're stapling here and then suturing here and then dividing between this one and this one.

Dr. Randy Lehman [00:50:35]: Yep. Okay. Thank you for bearing with me. For me being the podcast host, sometimes I have to make myself vulnerable and expose my ignorance so that I can help other people. Because I'm sure if I'm struggling with it, somebody else probably was helpful for them too. So that makes sense. I think we're good on talking about your... Do you hand sew that G.J.

Dr. Adrian Sava [00:50:58]: Or do you staple that gastroenterostomy?

Dr. Randy Lehman [00:51:02]: Well, I'm sorry, I say DJ because gastrojejunal anastomosis. Okay.

Dr. Adrian Sava [00:51:07]: Of course. I am always stapling when I learn myself bariatric surgery. I remember that Professor Kadier had three patients that day. So he asked us which one would you like to see first? So we said circular state. Okay, let's do a circular staple in GJ anastomosis and then the next one linear step. Okay, let's do it linear. And the third one was a hand suture. So he did a hand suture, GJ anastomosis. So how do you work? Basically, we are not doing it anymore. It was a long time ago we stopped using a circular staple.

Dr. Randy Lehman [00:51:57]: Yeah, because you have to make another hole, right?

Dr. Adrian Sava [00:52:00]: Yeah, of course. So this is not practical anymore for us. But if you are very good, you can do a totally hand-sutured GJ anastomosis. But this is not better. Otherwise, a linear staple GJ anastomosis is much faster. And all you have to do is to close the hole. But you have to be very careful when you staple the GJ anastomosis with your 45 magazine. You have to rotate a little bit before you close the magazine in order to avoid, on the backside there is a small part of the gastric pouch that used to become ischemic. So this is the most frequent cause of ulcer in GJ anastomosis: ischemia. So very, very careful. If you are doing the stapling, if you close the staple, you have to rotate a little bit in order to have a bigger area on the backside that is not going to be ischemic. That can cause a marginal ulcer. So we all know that those who are smoking, those who are drinking, or using NSAIDs, they have a complication as a marginal...

Dr. Randy Lehman [00:53:38]: Marginal ulcer.

Dr. Adrian Sava [00:53:39]: Right, marginal ulcer. But the anatomical pathological cause is ischemia: so less ischemia, less marginal ulcers.

Dr. Randy Lehman [00:53:51]: Yeah, I guess that makes sense. I mean, maybe not on the inside bit, but yeah, you can always heal those problems if you have better blood flow. Yeah, makes sense. Hey, I got one more question before we switch to the next segment of the show. What do you think about the smart tissue autonomous robot and supposedly robot suturing a bowel anastomosis? Better than a human. Have you heard that? Better than a human autonomous robot. I'm not talking about human-guided.

Dr. Adrian Sava [00:54:27]: I have no experience with it. For me, robotic surgery is something special. It's much easier to perform, especially when you're operating ventral hernias. It's much easier to work in the roof, so you have more freedom to do the sutures the way you want. But I have no experience with autonomous robots. It's difficult to say if they can totally replace humans. I don't know. Maybe.

Dr. Randy Lehman [00:55:09]: Yeah, I agree it's crazy, but that's what they've had. Robot completely. It's like the human sets up the robot to do the most critical part of the operation. Sounds a bit crazy, but maybe.

Dr. Adrian Sava [00:55:23]: I think my personal belief is that robots are going to replace many professionals, but surgeons are going to be the last ones.

Dr. Randy Lehman [00:55:35]: Yeah. Tend to agree. Very good. Let's keep moving. So we have to get on to the other parts of the show. Which next would be the financial corner. I was wondering if you had a money tip for our listener.

Dr. Adrian Sava [00:55:45]: Surgery is difficult. It's not easy. It's taking its toll on your family. Don't get divorced for sure, but you need a partner to understand you, to support you because you as a surgeon have ups and downs and there are days that can be very difficult.

Dr. Randy Lehman [00:56:12]: Are things harder for you and your practice after training or during training? And I guess I'll say harder on your relationship with your spouse.

Dr. Adrian Sava [00:56:24]: The hardest was in the beginning when I was a resident. Yeah. As my son used to say, I was never home.

Dr. Randy Lehman [00:56:33]: Yeah.

Dr. Adrian Sava [00:56:34]: So it's difficult. It's not easy.

Dr. Randy Lehman [00:56:38]: So I had a mentor that told me, we got married the first year of residency, five years, and we got married in the first year. And he said, if you can make it through residency, you can make it through anything. And I do feel that way. Like after I got out of residency, I felt like I had a lot more control over my time and my practice, and I could ramp things up and down. And I’m definitely there a lot more for my family; I'm with my family a ton. And the flexibility, you know, I'm very intentional about it too. You know, I don't have that many other hobbies outside of work and family, but now's the time because I have a six-year-old and an eight-year-old and I don't want them... I know people on both sides of the spectrum, people that their kids are doing exactly what they did, which tells you that their kid believes that it's a good life. You know, and then others, a lot of people I know that their kids say kind of what your kids are saying, which is, I'm choosing not to do that because of what I saw, the toll it took on you. So I'm not trying to, for sure, not trying to get my kids to just do what I did, but I don't want them to be able to say, I'm not doing it because of this, you know, the impact on the family. Yeah.

Dr. Adrian Sava [00:57:49]: In order to survive as a surgeon, you have to... You need to have a discipline. This is what I told my kids. You have to sleep when you have time, because you never know when what is coming next, next hour or next hours. So you have to eat when you can. You cannot afford to do this intermittent fasting. It's difficult as a surgery resident. But then when you're done with your residency, you have more time for your family, you have more time for your spouse. It's true. And your financial situation is much better, of course.

Dr. Randy Lehman [00:58:31]: Yeah.

Dr. Adrian Sava [00:58:33]: But what remains is your discipline. I have to say, I have to admit one thing. You live almost as a soldier.

Dr. Randy Lehman [00:58:46]: Yeah. There's an element of that and definitely that eat when you can, sleep when you can. "Don't mess with the pancreas" is of course, sounds like it's an international, it's...

Dr. Adrian Sava [00:58:56]: Not actual anymore mantra.

Dr. Randy Lehman [00:58:58]: Yeah. Now, not anymore. That's correct. Very good. Well let's. We usually do classic rural surgery stories, but now we'll just do a classic surgery story. Do you have anything that is just classic surgery that, you know, you've told a couple times in the surgery lounge because you just hardly can't believe it yourself? I'm sure you have plenty.

Dr. Adrian Sava [00:59:25]: There's. There are some. Some stories. But. Well, my personal experience. I used to train residents before, maybe this is not usual anymore, but my mentors insisted that you have to do this clinical exam before and then ask for lab and CT scans and everything. Because I remember when I was in my first years as a resident, I called my attending colleague to take a look at a patient, and then he told me from the door, "I can tell you the diagnosis." I said, "Why don't you just do the palpation and everything else?" This patient has abdominal asymmetry. What can it be? Well, as a resident in the first year, I said, I know a lot of things. No, he said, only one thing. Only one thing. Sigmoid volvulus. And it was that.

Dr. Randy Lehman [01:00:39]: Whoa.

Dr. Adrian Sava [01:00:41]: Abdominal asymmetry. And then. Well, in the OR, sometimes it feels like you're desperate. And I remember one of my first esophageal resections. I had a very bad time. I shouldn't allow to say it, but my assistant was not that good.

Dr. Randy Lehman [01:01:10]: Yeah, sure.

Dr. Adrian Sava [01:01:11]: And then I felt like this. I'm desperate. I have no help. What should I do? I got some supradiaphragmatic bleeding and I started to panic. The anesthesiologist was my friend; he's older than I am. And he told me, "Then, you know, Adrian, calm down. You can fix it. If you're lost, then we are all lost." So, at the end of the day, you as a surgeon, as an operative surgeon, not an assistant surgeon, you have to think like this. You have to fix it, and it's you, not someone else. And then this is what helped me when I became an attendant and I had a resident that helped me with an obese patient that had a fish bone into the pancreas. I started to dissect. I started laparoscopically. I came into the lesser sac. Nothing there. And of course, I had to convert to open a big guy over 15 BMI. And then nothing there. Nothing in the lesser sac. I couldn't find anything. Then I said, "Could you all please be quiet in the operating room?" and I told you, took a long peon dissector. I just relied on my feelings. And then I heard it, like, on the bone. It was a perpendicular fish bone that had perforated the backside of the duodenum into the pancreas. No, see, we are calling it, say Boge. No, no rigorous imaging. No, nothing. Only relying on your feeling. And close your clamp and then take it out. Such a big bone.

Dr. Randy Lehman [01:03:41]: Big fish bone. Wow, that's a good one.

Dr. Adrian Sava [01:03:46]: We have a lot of stories, but the worst thing is to discover that you did it wrong. You injured something. It happened to me once. I injured a CBD not knowing. And then you have to reconstruct by yourself. You have to learn to reconstruct, to fix your own errors. This is the most tricky part of:

Dr. Randy Lehman [01:04:18]: Our.

Dr. Adrian Sava [01:04:21]: Surgery, to fix your own mistakes.

Dr. Randy Lehman [01:04:26]: Yeah. So here, actually, in the US in rural surgery, this kind of is a hot topic. The CBD injury identified intraoperatively, I would say, increasingly more and more, we're encouraged not to fix it ourselves and to ship to an HPB surgeon. And the HPB people are specifically asking us to do that. Is that, I would say, true? Say, in those small community settings with no HPB training in Sweden.

Dr. Adrian Sava [01:05:09]: It wasn't that difficult for me because I could do it by myself. But here in Sweden, after 2010, it's mandatory for every cholecystectomy to do an intraoperative cholangiography on the table.

Dr. Randy Lehman [01:05:31]: Okay.

Dr. Adrian Sava [01:05:32]: So when you dissect and before you divide the cystic duct, you have to make a small hole inside with a catheter.

Dr. Randy Lehman [01:05:43]: I do that routinely, but I would say, I mean, a minority, I would say there's probably 10-15% of people in the US that do that routinely. I do it mostly because I'm in a small hospital and we don't do that many. And I want, when I need to, to be able to do it easily. So I just do it for everyone that way. It's easy now even then sometimes my catheter catches on a valve or something and I have a hard time. In that situation, like, are the surgeons, they have to get that full cholangiogram before they get off the table, no matter what?

Dr. Adrian Sava [01:06:18]: No, no, it's not 100% you have to do it. But if you can, it's good. It's good to do it. Put your catheter through the cysticus into the CBD. But if there's very high inflammation there, sometimes it's very difficult. So just divide it. You have to be sure that you're not dividing too close to the CBD. So it's better to leave some extra remnant than to injure the CBD. This is difficult. There are many anatomic variants. So gallbladder surgery can be very tricky. It can be very tricky.

Dr. Randy Lehman [01:07:07]: I had a mentor tell me, there's no glory in a lap coli because if it goes well, it's just expected to go well. But then when it goes bad, it's all your fault. All right. Very good. Any resources that you use on a regular basis? The last segment of our show is resources for the busy rural surgeon. Like maybe web-based or book resources that you just think are you just wouldn't live without.

Dr. Adrian Sava [01:07:32]: As a rural surgeon, well, as a surgeon, you have to do TEPs, TAPP procedures, hernias, small things, cholecystectomies. Keep yourself updated, talk to colleagues. If you're doing bariatric surgery, you have to be updated, you have to go to the IFSO Congress. It's every year. IFSO in order to hear the others, how they are doing, what kind of results they have.

Dr. Randy Lehman [01:08:08]: Are you a member of the American College of Surgeons?

Dr. Adrian Sava [01:08:10]: No.

Dr. Randy Lehman [01:08:11]: Okay, so you have your own organizations and things. What's funny about what you said, not funny, but just like, you know, almost expected, is that's the most common thing that most of my guests say. They say your cell phone, your contacts and your groups and your professional organizations, those are the best resources to just stay in contact with other surgeons. I thought when I started the show and I had this segment, I was thinking, well, someone's going to give me like website stuff, textbooks that they love, things like that. But it's not. It's really that, you know, connecting with other surgeons that I think is going to be able to power you through what you now have is like a 30-year career.

Dr. Adrian Sava [01:08:52]: Something I don't have to be. I don't have to be a member of the American College of Surgeons.

Dr. Randy Lehman [01:08:57]: Right.

Dr. Adrian Sava [01:08:57]: I am a member of the Swedish College.

Dr. Randy Lehman [01:08:59]: Right, exactly.

Dr. Adrian Sava [01:09:00]: Yeah.

Dr. Randy Lehman [01:09:01]: But for us, I would say American College of Surgeons is a good place to be for a rural surgeon. We actually have the North American Rural Surgical Society, which I'm a member of and a big proponent of. So, yeah, there's, you know, whether you're in bariatrics, colorectal, whatever your specialty groups are, you know, stay connected. Yeah.

Dr. Adrian Sava [01:09:20]: At the end of the day, I still remember a colleague from Norway, he's my age. After I had to redo his colostomy, he fought very hard to do a robotic rectal resection. No, it was amputation. And then he did a colostomy. It was one of the best colostomies. So I was on call a few days after this operation and

then I had to redo this. And he was so sad. But at the end of the day, he said, "You know what, Adrian? At the end of the day, this is only a profession. To be a surgeon is only a job at the end of the day. We have sacrificed a lot, but you don't have to sacrifice your whole life. It's only a job. It affects you a lot." Your fails, you have to, you wish to do it perfectly. But I have another friend. He is one of the best esophageal cancer surgeons, but he's not operating anymore. He's just giving advice and everything. He used to say in the last five years, I'm the only surgeon that has no complications. I raised my eyebrows since I said how, how it comes. He said, I'm not afraid anymore.

Dr. Randy Lehman [01:11:07]: I stopped operating five years ago. Exactly.

Dr. Adrian Sava [01:11:09]: Of course. So this is only a job at the end of the day.

Dr. Randy Lehman [01:11:16]: Yeah. It can be hard to separate your identity, I mean, when you pour so much into it. So. But you have to. And you carry around the surgeon's graveyard, you know, they call it. Basically, you're talking about your failures, your complications. But you know, what is the best, maybe as we close, what is the best way to maintain that sort of separation? The healthy separation from surgery as your job, if you will, and you as a person.

Dr. Adrian Sava [01:11:47]: You need to find your own balance. It's difficult to give advice to someone, to a colleague, because your own balance can be different. Regarding is not the same as my own balance. So you have to find your, your hobbies, you have to respect your family. Yeah, it's difficult sometimes. The burnout syndrome is. I have many, many colleagues. I was almost there. This burnout syndrome can eat you up. It's difficult sometimes. You're losing your way. You're just working, working. Patience, patience. Then who is suffering? Your family? Yourself? You have to look after your health, your spirit, spine problems as a surgeon.

Dr. Randy Lehman [01:12:50]: Yeah. Tell me. Lastly, I think you're a member and a leader in the Nazarene Church in Sweden. And so how does that affect you on a daily life? As you talk about this balance, maybe you think about your purpose and your why you exist. How does that, how does your faith come into play?

Dr. Adrian Sava [01:13:16]: As a minister, you have to respect God's word. It's not interfering in a negative way. It's interfering with your faith in a more positive way. But you have to be very careful to be humble. To be humble to. To know your place as a surgeon. Sometimes. You used to write high.

Dr. Randy Lehman [01:13:49]: Yeah. That's the reputation.

Dr. Adrian Sava [01:13:51]: You have to remember yourself in the mirror, be humble, thank God for everything, and follow Christ.

Dr. Randy Lehman [01:14:00]: Yeah.

Dr. Adrian Sava [01:14:00]: It's that simple.

Dr. Randy Lehman [01:14:02]: That's beautiful. Yeah. Surgery is a very humbling profession. Easy to get cocky in surgery. Hard to stay that way, though.

Dr. Adrian Sava [01:14:08]: Of course.

Dr. Randy Lehman [01:14:09]: Yeah.

Dr. Adrian Sava [01:14:10]: And I have to thank my family for that. They are putting me down every time. We, as surgeons, we used to be cocky. That's often.

Dr. Randy Lehman [01:14:26]: That's great. Well, this has been absolutely my pleasure and I'm so glad the Internet has worked so well across the pond. I mean, this is like, it's like you're, you know, in the next town over. I can't believe it.

Dr. Adrian Sava [01:14:39]: Well, one of the miracles that has to be used properly.

Dr. Randy Lehman [01:14:43]: Yep. Yes. So thank you so much. And if you're ever out my direction, I hope you look me up and you keep doing all this great work that you're doing. And I really appreciate you being a guest on the show.

Dr. Adrian Sava [01:14:57]: Thank you for having me. I wish you all the blessings and keep doing what you do. This is a blessing to be there where you in your hometown to do surgery there. Everyone knows you. Yep.

Dr. Randy Lehman [01:15:14]: Yep. It's beautiful.

Dr. Adrian Sava [01:15:15]: This is a big blessing.

Dr. Randy Lehman [01:15:18]: Yep. It was everything I pretty much hoped for. And thank you also to the listener for being with us for this episode of the Rural American Surgeon. And we will see you on the next episode of the show.