Protein, carbohydrates, fats. These are the essential components of our diet. At the protein information event, nutritionist Deborah Beyli, BSc BHF, explains the role of protein in our nutrition system and the effect of both an undersupply and an oversupply of protein on the body. Free admission. The information event is only open to a limited number of participants. Therefore, registration is requested.
Date/Location: Thursday, Sept. 19, 2019, 7:15 p.m. to 8:15 p.m., Bariatric Surgery Center. Seilerstrasse 8, 3rd floor, Bern
Registration with surname, first name, mobile phone number by e-mail to bc@hin.ch
The opening of the new Swiss1Chirurgie clinic in Brig was a real highlight for the guests, professional visitors and of course also for the team around Dr Jörg Zehetner. In a short speech, the medical specialist for abdominal surgery and reflux treatments praised the great achievements of the builders and was pleased with the successful implementation of the design ideas in the treatment rooms. Great praise for this also came from the visitors to the opening event, who were very enthusiastic not only during the tours of the rooms.
Those present were particularly interested in the medical services offered in the Swiss1Chirurgie clinic in Brig. It was above all Dr. Jörg Zehetner who went from one conversation to the next and did not simply inform about the range of services, for example, in the surgical treatment of obesity. This is how the first individual questions came, combined with the first diagnoses and the scheduling of the upcoming consultations and interventions.
For all those who were able to attend the opening of the Swiss1Chirurgie clinic in Brig on 26.08.2019, it was both an interesting and informative event. This is not least because a new medical service has been created in Brig, which has already met with great acceptance at the other Swiss1Chirurgie locations in line with a growing need.
Have you completed your training as an MPA with further training as a medical practice coordinator in a practice management direction, do you have professional experience and are you looking for a job where you can use your knowledge on a daily basis? Then you should definitely read on:
In our centre, located directly at Bern railway station, we care for and advise our patients in a team with doctors, nutritionists and a psychologist before, during and especially after bariatric surgery procedures. We are actively supported in this work by five medical practice assistants.
As our clinic coordinator is unfortunately leaving us, we are looking for a new team leader for our well-established team for personnel management and planning, practice organisation and administration with, among other things, financial control, marketing, quality management and support for the electronic systems.
You can look forward to an appreciative and collegial working environment with well-structured work processes. We rely on the fact that you like to work independently and are responsible with the organisation of the practice.
If the positive development of the centre and a courteous and professional approach to patients, the team and external partners is as close to your heart as it is to ours, then we look forward to receiving your electronic application directly as an email to ramona.oberholzer@zfbc.ch and meeting you soon.
Mrs Gasser, senior physician, or Mrs Oberholzer, our current practice coordinator, will be happy to answer your questions.
Dr Zehetner from Swiss1Chirurgie is one of the five best surgeons in Europe when it comes to operations on the oesophagus for reflux disease using the LINX system. In Switzerland, he is the undisputed number one in this particular field. As a consultant and preceptor for Johnson & Johnson, he is also available to assist with LINX reflux surgeries in Saudi Arabia.
It was only in July 2019 that the Swiss was called from his summer holiday in Spain to Saudi Arabia to provide the surgeons there with the specialist advice and surgical skills they were looking for in two reflux centres for the LINX Reflux Management System. The missions took place on 28 and 29 July 2019 at Prince Sultan Military Hospital in Riyadh and King Fahd Hospital of the University of Khobar, where a total of five patients were offered the required procedures.
Even though these two reflux centres in Saudi Arabia are already specialised in the surgical treatment of reflux disease, it makes a difference when international luminaries in this field support the procedures with the latest techniques and plenty of experience.
Reflux diseases must be thoroughly diagnosed
The most common symptoms of reflux disease include acid regurgitation and heartburn with chronic value. But these two symptoms alone are not enough to make an accurate diagnosis. A comprehensive clarification of the individual appearance requires a gastroscopy, testing of the oesophageal function and an acid measurement. Only the interaction of several factors makes the diagnosis of gastro-oesophageal reflux disease (GERD) accurate and certain. Then it also depends on the right treatment up to surgical intervention.
Incidentally, this form of reflux disease is not only very common in the western world. This clinical picture is also very widespread in the Middle East, so that more work is being done there on training suitable surgeons and creating appropriate treatment centres. Internationally successful specialists like Dr. Zehetner are in particular demand, especially if they can prove that they have spent at least two years abroad on a fellowship as additional training.
LINX system is currently the best
For the surgical treatment of reflux disease after appropriate diagnosis, the LINX system has proven to be the best treatment method. The LINX system is a ring-shaped chain of titanium-coated magnets that is placed around the end of the oesophagus during laparoscopic surgery. This significantly limits suffering, minimises secondary damage and restores patients’ well-being.
This was also the case during the missions in the summer of 2019 in Saudi Arabia, where, with the help of Dr Zehetner from Swiss1Chirurgie, the surgical procedures were successfully performed by the Arab surgeons.
Prof. Dr. Zehetner greatly appreciates the cooperation with his colleagues from Saudi Arabia.
The expert was particularly impressed by the professionalism, the surgical skills and the outstanding hospitality of the Arab surgeons.
“Hospitality is very important here, you are generously served Arabic food, and the gratitude and appreciation is extremely high.
“The beauty of such teaching assignments is the common language that doctors and health workers all over the world speak with each other: Tolerance towards other cultures, putting the patient first, helping and healing.”
The LINX Reflux System is only offered after extensive clarification. Dr. Zehetner will inform you about the exact operation, the advantages, risks and side effects in one of his consultation hours at Swiss1Chirurgie in Bern, Brig or Solothurn.
After London 2017 and Dubai 2018, the World Congress of the International Federation of Societies of Obesity Surgery (IFSO) was held this year in the Spanish capital Madrid.
One of the topics was the stigmatisation of overweight patients. There was agreement on this topic that morbid obesity is indeed a chronic disease and requires appropriate treatment. The times when overweight patients are ridiculed, laughed at or even insulted in public must finally be over. With obesity surgery, this group of patients also has access to a variety of different treatments and interventions that can successfully address and permanently treat this condition.
This was an important topic in the meeting of bariatric surgery specialists from the cantons of Switzerland, who had the opportunity to exchange views on this topic at a joint dinner during the congress.
What is the state of facts?
In Switzerland, there are primary centres and centres of reference for obesity surgery. Whereas in a primary centre only the first operation for patients with BMI 35-49 may be performed, in a reference centre re-operations (new corrective operations) and very heavy patients (BMI greater than 50) may be operated on. This is an arrangement that makes it difficult for many patients to undergo continuous treatment that is ultimately accompanied by visible, tangible and countable success in the long run.
Swiss1Chirurgie has responded to this together with the Beau-Site clinic in Bern and the Espace Chirurgie clinic in Biel. The obesity surgeons in Biel perform the initial operations at the Hirslanden Klinik Linde and the re-operations with Dr Zehetner at the Klinik Beau-Site. At the Beau-Site Clinic in Bern alone, 500 of the 4,500 surgical procedures performed annually throughout Switzerland are carried out. At the Centre for Bariatric Surgery in Bern (ZFBC), these patients are pre-cared for, operated on by Swiss1Chirurgie surgeons and then followed up again at the ZFBC. This means that within the Hirslanden network, Swiss1chirurgie has the greatest expertise in bariatric surgery in Switzerland and guarantees the highest level of patient safety.
What patients with problems after obesity surgery can do
Have you already had obesity surgery and are not receiving follow-up care? Or have you put on a massive amount of weight again after the operation and don’t know what to do next?
Ask your general practitioner to refer you to one of our Swiss1Chirurgie locations in Bern, Solothurn or Brig (www.swiss1chirurgie.ch). We can then admit you to our aftercare programme at the Centre for Bariatric Surgery (www.zfbc.ch) or arrange for clarifying examinations for a possible corrective operation to lose weight again.
Of course, the World Congress also focused on the big issues in obesity surgery. Here are a few key points on the results:
The most common obesity surgery worldwide is the tube stomach (sleeve).
The gastric band is hardly ever done anymore, under 1% of all overweight operations.
In patients with reflux, the gastric bypass has advantages over the sleeve.
In severely overweight patients, OAGB (one loop anastomosis gastric bypass) is also a possible option.
Endoscopic revisions such as anastomotic stenosis with Apollo Overstitch are used more frequently, especially in cases of dumping and recent weight gain.
Learn more? Then simply contact me and let me advise you on the most promising options for the surgical treatment of obesity and reflux disease.
Reflux disease refers to various symptoms that can be explained by an increased reflux of acidic stomach contents into the oesophagus. This reflux is caused by a disturbed closure mechanism of the lower sphincter of the oesophagus.
Jörg Zehetner MD Professor (USC) MMM, FACS, FEBS (hon.)
Reflux disease, also known as gastroesophageal reflux disease – or GERD for short – is one of the most common diseases of the digestive tract. Thus, about ten percent of the population suffer from the symptoms of reflux disease.
What are the causes and risk factors for reflux disease?
Obesity, pregnancy, excessive consumption of nicotine and alcohol and various medications are among the risk factors that can promote the occurrence of reflux disease.
There are two main causes of reflux disease:
The function of the lower sphincter of the oesophagus is insufficient.
The mobility of the oesophagus is reduced.
Both triggers can be either primary – i.e. without specific reasons – or secondary – related to other diseases or disorders.
What are the symptoms of reflux disease?
The leading symptom of reflux disease is usually a burning pain that is felt behind the breastbone – so-called heartburn. This pain can occur in combination with a sour taste in the mouth and frequent belching.
Other symptoms that may be associated with reflux disease are:
– Nausea and vomiting
– frequent coughing attacks
– Infections in the larynx and throat area
– Swallowing discomfort
– Pain in the upper abdomen
– frequent hoarseness
– Pain and burning in the throat
It is characteristic of reflux disease that the above-mentioned complaints often occur after eating, after drinking alcohol or after eating sweet or fatty foods.
How is reflux disease diagnosed?
First of all, the doctor will ask about the patient’s symptoms, general lifestyle habits and possible concomitant diseases. This is followed by a thorough physical examination. If the suspicion of reflux disease is confirmed, the doctor has various examination options at his disposal.
Endoscopy
This is an endoscopy of the oesophagus. This examination allows the doctor to assess the condition of the oesophageal mucosa and evaluate its texture.
During an endoscopy, the doctor can determine whether and to what extent there is an infection of the mucous membrane. It is also possible to take a mucosal sample during this examination. It is then analysed in the laboratory with the aim of identifying changes in the tissue.
pH-metry
pH-metry is another test option to diagnose reflux disease. A thin tube is inserted through the patient’s nose into the oesophagus and remains there for up to 24 hours.
The aim is to continuously measure the acidity level, i.e. the pH value, within the oesophagus over a longer period of time. This examination can help determine whether stomach contents are flowing back into the oesophagus and in what quantities.
Further diagnostic procedures
In order for the doctor to be able to assess the swallowing process of the patient more precisely, he sometimes orders an X-ray examination. With this method, the patient has to swallow a contrast medium mush, which can then be seen in the X-ray image.
If symptoms suggest damage to the airways, an additional examination by an ear, nose and throat specialist may be useful.
Self-help for reflux disease
Nutrition factor
In the context of reflux disease, those affected often suffer from digestive disorders. These can be curbed with a diet as rich in protein as possible, as proteins stimulate the stomach to produce the hormone gastrin. This in turn improves the muscle tension of the oesophageal sphincter so that it can subsequently close better again.
Basically, the course of reflux disease can be positively influenced by choosing the right amount of food and nutrition. Small, low-fat and low-carbohydrate portions are recommended.
It is also advisable to eat meals a few hours before going to bed.
Factor stimulants
If you suffer from reflux disease, you should completely avoid consuming alcohol if possible, as this leads on the one hand to the slackening of the lower oesophageal sphincter and on the other hand to direct damage to the stomach lining.
However, the influence of coffee on reflux disease is controversial. On the one hand, caffeine can stimulate stomach acid production, which can further irritate the mucous membrane. On the other hand, caffeine increases the production of gastrin, which promotes the functionality of the oesophageal sphincter.
People who suffer from reflux disease should generally avoid nicotine. Nicotine leads to an increase in gastric acid production and is also known to have other negative effects on the body.
What are the treatment options for reflux disease?
Usually, the doctor first prescribes conventional therapy for the patient with reflux disease. This consists of the self-help measures already mentioned and, under certain circumstances, an additional accompanying drug therapy.
Surgery, on the other hand, is rarely used and is mainly indicated in cases of additional diseases affecting the gastrointestinal tract.
Conventional (non-surgical) procedures
In the context of reflux therapy, proton pump inhibitors are the drug of first choice. These drugs are generally well tolerated and eliminate symptoms in 90 percent of sufferers. However, once the tablets are stopped, half of the patients experience a recurrence of symptoms.
In order to curb the excessive production of gastric acid, the use of medicines that reduce gastric acid – so-called antacids – has also proven to be useful.
Operative procedures
Fundoplicatio
This surgical intervention makes sense, for example, if the reflux disease repeatedly leads to infections of the oesophagus. As a result, scarring occurs and the oesophagus narrows.
The aim of fundoplicatio surgery is to improve the closing function of the lower end of the oesophagus and at the same time support the mobility of the oesophagus.
Magnetic ring surgery
Magnetic ring surgery is a comparatively new, gentle surgical procedure. In this procedure, the doctor places a chain of magnetic beads around the outlet of the oesophagus. The magnetic beads attract each other and seal the anti-reflux valve by pulling the chain together.
During the swallowing process, the beads can separate again and food and drinks can enter the stomach. The ring then closes again.
This surgical procedure can usually be done in a minimally invasive way. The operation takes about 20 minutes.
Fig. 1 The LINX® system helps the oesophagus resist opening, preventing or reducing reflux.
Fig. 2 The LINX® system stretches to allow normal swallowing.
Conclusion
Reflux disease is comparatively widespread. It can be treated quite well with the help of various self-help measures and possibly an accompanying drug therapy. Surgery is only necessary or advisable in individual cases.
Swiss1Chirurgie and bariatric surgery specialist Prof. Dr. Jörg Zehetner invited the public to attend the lecture “The truth about morbid obesity”. Not only people affected by obesity but also relatives and interested people who want to know what morbid obesity is really about and what treatment options are available are invited to attend.
Dr. Jörg Zehetner was able to make an essential statement right at the beginning of his interesting lecture: Obesity is a widespread disease that can have many causes. In addition to changes in diet and exercise habits, there are also pathological processes in the body that favour significant overweight and cannot always be combated with diets and changes in lifestyle habits alone.
Obesity as a widespread disease
The fact that obesity is no longer an isolated phenomenon became clear when concrete figures and predicted developments regarding obesity were used as arguments. Less exercise in everyday working life, stress and above all an overabundance of food are the obvious causes of obesity. And the development in the USA shows where the path could also lead in Europe if no clear and timely countermeasures are taken. However, these facts and insights are of little use, especially to those currently and acutely affected. For these people it is important to get real help beyond good advice and helpless stigmatisation. And such help is found in many cases in surgical interventions that clearly break the spiral of overweight suffering.
The image of the fat, lazy overweight person must be corrected
Especially when it comes to morbid obesity, those with a BMI over 30 feel exposed to widespread prejudice and downright mantras. Eat less, move more, do without a lot and strengthen your self-confidence. These are all suggestions that overweight sufferers get plenty of. The actual development and especially the psyche of those affected are neither changed nor strengthened by this. What remains is endless suffering full of diets, setbacks and ultimately giving up.
This can be changed if a real impact on nutrition, weight development and self-esteem is offered with appropriate medical services. Appropriate obesity surgery is in many cases of morbid obesity the best and only means to actually stop the downward spiral. It is clear that it is not only the surgical intervention itself that provides help. Changes in lifestyle habits and strengthening the psyche of those affected are also part of the process.
Swiss1Chirurgie can help with morbid obesity
With several locations in Switzerland, Swiss1Chirurgie is one of the largest private practices in Switzerland, which has also addressed the issue of obesity surgery, among other things. The internationally highly recognised specialist in obesity surgery, Dr Jörg Zehetner, has placed the problem of morbid obesity at the centre of his work and offers actual help for morbid obesity in the Swiss1Chirurgie clinics and the Centre for Bariatric Surgery (ZFBC). The start of a successful treatment is always the patient’s understanding that something has to be done. This is followed by detailed information and advice about the medical options. If the conditions are right, surgery is often the best option. However, this process will only be successful and individually satisfying if the important follow-up care and help in changing lifestyle habits is also offered afterwards. And in this area, too, Swiss1Chirurgie shows itself to be a professional partner at the side of patients.
App facilitates information and accompaniment
For overweight people, going to the doctor is not easy. After all, many have already gone through a real odyssey and the fear of repeated failures is growing. It is precisely at this point that comprehensive and thorough information is the first way to learn about new options for treating morbid obesity and then take the right further steps. The actual situation is such that many of those affected no longer want to go straight to the doctor and like to inform themselves in advance on the internet. Not all offers are serious, let alone medically useful. Dr Jörg Zehetner knows this too and has set up a special offer for interested parties and patients with a special Swiss1Chirurgie app.
The app makes it possible to obtain comprehensive information on the various topics and, if interested and required, also to contact the attending physician directly. The convenient app accompanies patients before, during and after surgical treatment and not only provides important information and advice on general processes. Individual counselling is always possible, which is precisely geared to the conditions of the individual patient. The Swiss1Chirurgie app thus becomes part of the professional treatment of morbid obesity and makes it easier for patients to take the right steps.
You can simply download the app via https://m.swiss1chirurgie.ch . Then, among other things, you will also have the opportunity to watch the lecture “The truth about morbid obesity” in a summary or in full length.
At the latest since her furious performance in the qualification round of DSDS, Sina Gossweiler is a well-known young woman in Switzerland but also in Germany. In the process, the charming Swiss fought her way into the final round. And it was not the only struggle Sina Gossweiler had to face in her still quite young life.
Her biggest battle of recent times was probably against the chronic overweight that had caught up with her at the latest after a serious accident. After a long period of immobility due to an accident, her weight had risen to 130 kilograms and she had to repeatedly face stares and open hostility in everyday life. Yet she had wanted everything else, except to be morbidly overweight.
A first appointment at the Centre for Bariatric Surgery in Bern with Dr Jörg Zehetner opened the way to a better, truly easier future. After extensive preliminary discussions and examinations, it was clear to both Sina Gossweiler and Dr Zehetner that a gastric bypass operation with minimally invasive surgical techniques and adequate follow-up care would be the best solution for the young woman with a strong voice and an interest in sports.
Sina was operated on by Dr Zehetner at the Hirslanden Clinics in an operation lasting just under 1 1/2 hours. In harmony with the successful intervention and the subsequent change in lifestyle and dietary habits, the pounds fell off, so that today a weight loss of around 50 kilograms can be recorded.
In the course of her new joy in life, Sina Gossweiler has found a way, besides music, that makes her life more beautiful, healthier and ultimately more satisfying. She discovered her love for running and was even able to successfully participate in a 16km race. Without the will to succeed, without the professional help and the surgical intervention by Dr. Zehetner, none of this would have been possible. And in addition, of course, there is the consistent orientation towards a new way of life, which ensures the success of the medical intervention.
In the audience talk “My way to running”, Sina Gossweiler tells about the difficult path from stigmatised overweight patient to enthusiastic running athlete. And of course about what DSDS and the Centre for Bariatric Surgery in Bern have to do with it.
After the lecture, the audience will have the opportunity to ask Sina Gossweiler and Dr Jörg Zehetner questions about the operation, the prerequisites, life afterwards and sport and nutrition.
We are looking forward to a lively interest in a lecture that should be a good occasion for information not only for chronically overweight people.
Date: 17 October 2019
Location: Centre for Bariatric Surgery ZFBC
Centre for Bariatric Surgery Seilerstrasse 8 3011 Bern
Time: 19:00 until 20:00
Door opening: 6:45 p.m., admission free of charge, prior registration is requested for capacity planning purposes
The new BMI calculator from the Centre for Bariatric Surgery (ZfbC) and swiss1chirurgie combines a high level of convenience with the best tips for any treatment needs.
If you want to know your weight, you stand on the scales. But if you want to know a little more about your physical condition, you can now use the new BMI calculator from the ZfbC/swiss1chirurgie. Without long calculations, the digital BMI calculator determines the body mass index quickly, reliably and with only a few entries, which provides important information about whether the body weight is a health risk.
Just by stating the current weight, height and age, conclusions can be drawn as to whether the values are within the norm or above it. These personal details can be supplemented by the desired weight, details of physical activity and any efforts to achieve weight loss.
The more information is provided, the more concrete the calculations and also the statements on whether there is an urgent need for action and how and under what time frame the weight can be positively influenced under the given conditions.
The new BMI calculator of the Centre for Bariatric Surgery Bern is available on the website of the ZfbC https://www.zfbc.ch/bmi/ and swiss1chirurgie https://www.swiss1chirurgie.ch/bmi/ as well as in the newly developed app https://m.swiss1chirurgie.ch#/module/5784837 and can be used immediately. In this way, health-conscious people can in fact check their current status at any time and from anywhere, even with their smartphone, and make decisions to optimise their body weight in terms of health. The link between the BMI calculator and the medical tips for the prevention and treatment of morbid overweight (obesity) is extremely interesting. Causes, correlations and effects are presented here just as comprehensibly as the treatment approaches of the ZfbC.
The BMI calculator of the ZfbC/swiss1chirurgie has the potential to cause a sensation not only in Switzerland but also internationally. The new BMI calculator will therefore also be presented by Prof. Dr. Jörg Zehetner at a congress to be held soon in the USA, CHINA, MIDDLE EAST, EUROPE and ASIA. There, the digital BMI calculator will be able to show directly what it can really do. The interest of the experts is just as great as the need of the population. After all, the USA is one of the countries in the world where morbid obesity is one of the main causes of secondary diseases such as high blood pressure, heart disease, musculoskeletal disorders and diseases, heart attacks and strokes due to obesity. This also includes the psychological and social impairments that are often associated with being significantly overweight.
With the convenient BMI calculator of the ZfbC, the way to an easy digital calculation of the Body Mass Index is opened for medical laymen as well as for medical specialists. Although BMI alone is not a definitive measure of treatment options, it is an important indicator of whether treatment is needed and under what circumstances the best treatment outcomes can be achieved.
The American College of Surgeons Clinical Congress (ACS Congress) is held annually in October in the USA. This year, San Francisco, California, was the meeting place for specialised surgeons who stand for innovation and reliable surgical technique with special achievements in their field. However, no surgeon is admitted to the top ranks of international colleagues all by himself. The ACS Congress is mainly attended by members of the American College of Surgeons. However, only those who have previously achieved the title Fellow of the American College of Surgeons (FACS) can become members here.
Already during his stay in the USA from 2008 to 2015, Dr Jörg Zehetner attended the ACS Congress every year. And he received the title FACS on the occasion of a solemn convocation, which as an admission ceremony seals membership in the “American College of Surgeons” society. Prerequisites for this title are a completed specialist training in surgery as well as several years of successful professional practice and the recommendation of at least three academic specialist colleagues. So the hurdles are set high if you want to become a member of this select society. For Dr Jörg Zehetner of Swiss1Chirurgie, this membership in the “American College of Surgeons” society became a reality as early as 2014.
New developments and old friendships
Of particular interest were the new developments in obesity surgery and reflux surgery. In these special fields, Dr. Zehetner has been a sought-after specialist colleague for years due to his high level of expertise, who is always interested in new surgical techniques and, first and foremost, in the sustainable success of the interventions. A central topic during this year’s congress was robotic surgery. There was a lot to learn, even though the first day of the congress in particular was also associated with the difficulties of jet lag after the journey from Bern to San Francisco.
The reunion with the American colleagues from the time when they worked together at the Department of Surgery at the University of Southern California (USC) was a little more relaxed. Old friendships could be revived just as much as the exchange on the specialist topics, which were the focus of attention at the congress anyway.
The cooperation with the specialists from California and with colleagues at the University of San Diego resulted in numerous research findings, which Dr. Zehetner was able to publish in many publications even after 2015. Especially the research projects in the field of reflux diseases, oesophageal cancer as well as obesity surgery have led to results that still have an impact on surgery today and offer real cures for patients.
American contacts in the German-speaking world
Competence in the special subject areas exists in the German-speaking world, but is hardly noticed internationally. It is therefore important that Dr Jörg Zehetner, with his successful professional experience and scientific work on the topics, is an important and currently the only link between the American surgical societies and the experts in the German-speaking countries.
In the International Relation Committee of the SSAT (Society of the Alimentary Tract) he is the only member from the DACH region and thus ensures a successful exchange with the American colleagues.
The SSAT and three other societies hold the world’s largest and most important congress for surgeons and gastroenterologists every year in May. For the coming year, Digestive Disease Week is planned for the period from 2 to 05 May 2020. By then at the latest, Dr Jörg Zehetner will again be able to cultivate his international contacts with specialist colleagues and shine with his characteristic surgical competence. With or without jet lag.
