Scientific program

August 27, 2021    London, UK

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Surgery and Anesthesia

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Dr. Hana Damirji

Dr. Hana Damirji

University College London United Kingdom

Title: An Evaluation of Morphine Use in Obstetrics During a National Shortage of Diamorphine: A Re-Audit Highlighting Changes in Practice Over Time

Abstract:

An Evaluation of Morphine Use in Obstetrics During a National Shortage of Diamorphine: A Re-Audit Highlighting Changes in Practice Over Time

Introduction: Since the national shortage of diamorphine began in late 2018, preservative-free morphine has been used as an alternative adjunct to local anaesthetics in intrathecal blockade in obstetrics. An initial departmental audit following this enforced change to morphine established a statistically significant increased risk of PONV and reduced patient satisfaction compared with previous diamorphine use. A statistically significant link between intrathecal morphine and reduced post-operative oramorph use was also found. These finding correlate with the different pharmacodynamic profiles of the two drugs. The aim of our re-audit was to evaluate the way in which morphine use changed over time, following our initial audit feedback and with increased familiarity, within our department.

Methods: All obstetric anaesthetic interventions at the Lister Hospital are routinely recorded electronically on the Xentec Epidural Audit System. Data is collected on completion of the procedure and during a post-procedure follow-up 1-3 days later. Data points collected immediately post-procedure include choice of intrathecal opiod and adequacy of block intra-operatively. On follow-up data collected includes overall patient satisfaction, side-effects experienced (including severe PONV and pruritis) and post-operative oramorph requirement. Parturients undergoing intrathecal blockade with morphine (n=104) between 13/07/18 and 20/09/18 had been previously audited. This data set represented the initial use of intrathecal morphine as an alternative to diamorphine: Morphine 1. Upon completion, these audit findings were presented at a local departmental meeting where results were displayed with no protocolised changes suggested or enforced. Post-presentation and following a period of time, a second data set was taken analysing parturients undergoing intrathecal blockade with morphine between 05/09/19 and 01/03/20 (n=374): Morphine 2. Data from these two audit sets were then analysed for comparison.

Results: Statistical analysis was carried out using Chi-Squared tests and results deemed significant if p < 0.05. There was a statistically significant increase in overall patient satisfaction and regional adequacy in the Morphine 2 group versus Morphine 1, with p values of 0.0006 and 0.0051 respectively.  However, no statistically significant change was seen in incidence of severe PONV and pruritis or in post-operative oramorph requirements between  the two groups.

Conclusions: The results above show an overall improvement in patient satisfaction and intra-operative adequacy of intrathecal blockade with morphine use over time. This most likely represents an increased familiarity with intrathecal morphine use as well as changes in practice following presentation of the initial audit results. Practitioners have reported modifications in terms of morphine dosing and/or addition of a second intrathecal adjust, fentanyl. The later agent has the benefit of augmenting the regional blockade more rapidly than morphine whilst not significantly contributing to side-effects experienced. Furthermore, this may account for the lack of change in post-operative oramorph requirement despite a statistically significant improvement in intrathecal block adequacy. Future audits should focus on comparing specific doses of intrathecal morphine and use of a second opiod adjunct.

Biography:

Dr. Hana Damirji is an anaesthetics and intensive care trainee currently working at the Lister Hospital in Stevenage, UK. She completed her medical training in London, graduating from University College London in 2015 with distinction and also obtaining first class honors in Neuroscience iBSc. Previous publications include the initiation of a debriefing session for intensive care trainees, which NHS Improvement listed as one of the top 10 quality improvement measures of 2017. ​

Dr. Avneet Kaur

Dr. Avneet Kaur

Vardhman Mahavir Medical College And Safdarjang Hospital India

Title: Constellation of Rare Complications Following Acute Pancreatitis: A Case Report

Abstract:

Constellation of Rare Complications Following Acute Pancreatitis : A Case Report

Acute pancreatitis is characterised by inflammation of pancreas which can be of varying severity depending on the local and systemic complications. An enterovesical fistula is an extremely rare complication of necrotising pancreatitis. Pseudoaneurysms are another rare set of complications associated with pancreatitis that can occur due to the pancratic enzymes eroding the surrounding planes. This case involves the simultaneous presence of these uncommon conditions in a single patient. A chronic alcoholic patient presented to the ED with pain in left lumbar region associated with obstipation, bilious vomiting and fever. A CT scan of abdomen was done which reported necrotic area within body and tail of pancreas involving less than 30% area with multiple hypodense peripherally enhancing collections in anterior pararenal space along with left paracolic gutter and left supramesocolic space. Another collection was seen in superior to dome of bladder with adjacent clumped distal jejunal loops which showed extravasation of oral contrast in the collection. The collection communicated with the bladder with a tract that measured 15.5 mm, suggestive of an enterovesical fistula. The patient was managed conservatively with TPN and an ultrasound guided pigtail catheterization of suprapubic collection to control the intra- abdominal collection. The output through the pigtail catheterization gradually decreased and the urine output became clearer. The patient developed two episodes of hematemesis. It was decided to proceed with a CT angiography that revealed a wide necked splenic artery pseudoaneurysm with no extravasation. Urgent coil embolization of the artery was done. Patient is now doing well.

Biography:

Dr. Avneet Kaur is a general surgery postgraduate resident at VMMC and Safdarjang Hospital, New Delhi. She has an avid interest in the research and enthusiastic about surgical oncology. She is curious about the unusual presentations of the diseases and has been an active member of the conferences organized by the institution.

Dr. Lira Sangtam

Dr. Lira Sangtam

VMMC and Safdarjung Hospital India

Title: Assessing the Burden of Abdominal Tuberculosis in Current Scenario: A Retrospective Single-Centre Study in India

Abstract:

Assessing the Burden of Abdominal Tuberculosis in Current Scenario: A Retrospective Single-Centre Study in India

The diagnosis of abdominal tuberculosis poses quite a unique challenge due to its non-specific clinical presentation and can be a significant cause of mortality and morbidity to patients of any age group.  Diagnosis of abdominal tuberculosis can be made by high index  of clinical suspicion and  correlation with radiologic, microbiologic, histopathologic and molecular studies.  While most abdominal TB cases can be treated conservatively with anti-tubercular therapy, still significant number of cases require surgical intervention due to delayed diagnosis and presentation, multi-drug resistant strains and increasing prevalence of HIV infections . The post-operative care is a daunting task for the surgeons in terms of nutritional aspect, as few of these patient may inevitably develop high output fistula, short bowel syndrome and necessity for prolonged TPN with its associated complications. The whole pathophysiology of abdominal tuberculosis is exhaustively discussed in many literatures published so far; however, in this retrospective five-year study of 380 patients ; we attempted to evaluate the burden of this disease from surgical perspective ; the role of surgery in delayed cases with complications and the spectrum of peri-operative challenges to surgeons in an endemic country like India.  Being an otherwise, potentially treatable infectious disease, initiation of anti- tubercular therapy early in the course of the disease process can help to prevent catastrophic consequences and reduce mortality and morbidity.

Biography:

Dr. Lira Sangtam is a General and laparoscopic surgeon, at VMMC and Safdarjung Hospital, New Delhi, where she also completed her three-years senior residency programme. She also worked as one of the only two surgeons in a remote Island of Lakshadweep, Union territory of India for a year. She has keen interest in minimal access colorectal surgery and pursuing to upgrade her skills in the field.

 

Tugba Han ner

Tugba Han ner

Baskent University School of Medicine Turkey

Title: Neutrophil / Lymphocyte Ratio (NLR) – Trombocyte / Lymphocyte Ratio (TLR): A Predictor of Axillary Lymph Node Metastasis in Breast Cancer Patients?

Abstract:

Neutrophil / Lymphocyte Ratio (NLR) – Trombocyte / Lymphocyte Ratio (TLR): A Predictor of Axillary Lymph Node Metastasis in Breast Cancer Patients?

Background: This study evaluated the relationship between preoperative neutrophil / lymphocyte ratio - platelet / lymphocyte ratio, clinicopathological, radiological factors, and axillary lymph node metastasis in stage I-III breast cancer to determine if axillary surgery can be safely omitted in selected patients.

Methods: The study included 158 Stage I-III breast cancer patients operated on at Baskent University Zubeyde Hanim Research Center between 2011 and 2018. The incidence of axillary lymph node metastasis was correlated with clinical, radiological, pathological, and laboratory (neutrophil count to lymphocyte count, platelet count to lymphocyte count) findings by univariate and multivariate analyses. Sensitivity and specificity calculations, positive predictive value, negative predictive value, positive and negative Likelihood Ratio (accuracy ratio), and exact accuracy were calculated for neutrophil/lymphocyte ratio cut-off values of 3.5 and 1.

Results: Neutrophil and platelet values were significantly higher in patients with lymph node metastasis. Neutrophil / lymphocyte ratio - platelet / lymphocyte ratio values were higher in patients with axillary lymph node metastasis, but this was not statistically significant. Axillary lymph node metastasis was not associated with age, lymphocyte, monocyte count, estrogen receptor, progesterone receptor, or c-erb B2 status. The incidence of axillary lymph node metastasis was statistically significantly higher in the presence of lymphovascular invasion. Sensitivity, specificity, positive predictive value, and negative predictive value were 93.85%, 16.67%, 44.9%, and 78.9% respectively for axillary lymph node metastasis while the neutrophil / lymphocyte ratio was ≥ 3.5. Specificity, sensitivity, positive predictive value, and negative predictive value were 97.78%, 9.23%, 75.0%, and 59.9% respectively for axillary lymph node metastasis while the neutrophil / lymphocyte ratio < 1.

Conclusions: For axillary lymph node metastasis, neutrophil, platelet counts, lymphovascular invasion status, radiological and pathological mass size, and presence of radiological axillary lymphadenopathy are the statistically significant independent variables. They provide information that can help surgeons decide on the treatment of breast cancer patients with certain neutrophil / lymphocyte ratio values (neutrophil / lymphocyte ratio < 1 and neutrophil / lymphocyte ratio ≥ 3.5).

Biography:

Tuğba Han Öner works as a General Surgery specialist in İzmir Başkent University Zübeyde Hanım Application and Research Center in İzmir Karşıyaka district.

Dr. Dalamagka Maria

Dr. Dalamagka Maria

Medical University of Sofia-Medical School -Sofia- Greece

Title: Pain Management

Abstract:

Pain Management

When acute pain turns into chronic, then it is not a symptom of a disease, but it is a disease in itself. It lasts longer than the expected course of the disease or injury. Usual period of 3-6 months. In the past the answer to chronic pain was: "everything is in your mind". A useful definition by Margo McCaffrey is: "pain is what describes the person who experiences it and exists when he says he exists." The International Union for the Study of Pain says it is "an unpleasant aesthetic and emotional experience, combined with actual or potential tissue damage, or described in terms of such damage". Pain is transmitted through the body through the nervous system when nerve endings detect damage to a part of the body.

Today, pain specialists can understand how pain is created: the way the nervous system, including the spinal cord, interacts with the brain to create the sensation of pain. Knowledge of the neurotransmitter system, the chemical messengers that transmit nerve signals, has paved the way for important new methods of treating pain. In recent years, scientists have learned how to manage these chemical messengers to change the way they interact with brain signals. This has led to the use of antidepressants and other drugs, which work with certain chemicals in the brain, such as which affect emotions and help in perceiving pain. There are now drugs that are very effective. And with advances in MRI, researchers can prove that the changes are very real in the brain. We can see exactly where the sensation of pain in the brain is created, when it is activated by a stimulus. We can see the effects of pain on a person's emotional state. There is also a new concept, a process called central awareness. If the initial pain from an injury is not treated properly, then these pain signals are sent repeatedly, resulting in changes in the central nervous system, which make it increasingly vulnerable. So over time, even normal stimuli can be perceived as painful. With this knowledge, pain specialists are now prescribing medications that attack moderate to severe chronic pain from different perspectives: innovative drugs, nerve-targeting techniques, and drug delivery pumps that offer strong nerve analgesia. Doctors also approve of the use of psychotherapy, relaxation techniques, hypnosis and alternative therapies, such as acupuncture, which rely on the growing evidence of a brain-body connection to relieve chronic pain. There is still much to learn, but research has shown evidence of the development of even newer treatment options. Pain specialists now prescribe medications that attack moderate to severe chronic pain from different angles: innovative drugs, nerve-targeting techniques, and drug pumps, which offer strong nerve root analgesia. Doctors also approve of the use of psychotherapy, relaxation techniques, hypnosis and alternative therapies, such as acupuncture, which rely on the growing evidence of a brain-body connection to relieve chronic pain. There is still much to learn, but research has shown evidence of the development of even newer treatment options. Pain specialists now prescribe medications that attack moderate to severe chronic pain from different angles: innovative drugs, nerve-targeting techniques, and drug pumps that offer strong analgesia to nerve roots. Doctors also approve of the use of psychotherapy, relaxation techniques, hypnosis and alternative therapies, such as acupuncture, which rely on the growing evidence of a brain-body connection to relieve chronic pain. There is still much to learn, but research has shown evidence of the development of even newer treatment options. and drug delivery pumps, which offer a strong analgesia to the nerve roots. Doctors also approve of the use of psychotherapy, relaxation techniques, hypnosis and alternative therapies, such as acupuncture, which rely on the growing evidence of a brain-body connection to relieve chronic pain. There is still much to learn, but research has shown evidence of the development of even newer treatment options. and drug delivery pumps, which offer a strong analgesia to the nerve roots. Doctors also approve of the use of psychotherapy, relaxation techniques, hypnosis and alternative therapies, such as acupuncture, which rely on the growing evidence of a brain-body connection to relieve chronic pain. There is still much to learn, but research has shown evidence of the development of even newer treatment options.

Many patients come for treatment in the final stages of chronic pain, when it is more difficult to treat. The sooner treatment is started, the better the chances of successfully treating the pain. When the pain is severe then doctors turn to stronger drugs to treat it:

Antiepileptics: Medications used to treat seizures are effective in treating chronic pain. It is unclear how they control pain, but it is thought to lead to milder effects of neuropathic pain, such as post-herpes zoster neuralgia. These include Pregabalin (Lyrica), gabapentin (Neurontin) and Carbamazepine (Tegretol). A new generation of antiepileptic drugs seems to be promising, with fewer side effects.

Antidepressants: Low doses of common antidepressants are prescribed for many chronic pain problems. These drugs regulate the levels of chemicals in the brain, and this is thought to be their mechanism in controlling pain. Antidepressants often help when other treatments do not lead to complete pain control. They lead to pain relief, whether the person suffers from depression or not. The doses used to treat pain are usually lower than those used to treat depression. Amitriptyline (Elavil), Nortriptyline (Pamelor) and Norpramin are tricyclic antidepressants prescribed for chronic pain, especially cancer pain. neuropathic pain from diabetic neuropathy and post-herpetic neuralgia from shingles. They affect the levels of chemicals in the brain, such as norepinephrine and serotonin. Duloxetine (Cymbalta) is a serotonin and norepinephrine reuptake inhibitor, which increases the availability of brain chemicals serotonin and norepinephrine. Duloxetine has been approved for the treatment of diabetic neuropathy, fibromyalgia and musculoskeletal pain, such as osteoporosis and chronic back pain.

 Pain relief creams: Topical analgesics, such as capsaicin-containing Zostrix, are often helpful. Capsaicin works by reducing the transmission of a pain chemical called substance P to the brain. Products with these ingredients also have a similar effect: salicylate (found in products such as Aspercreme and Bengay), a substance that reduces inflammation and provides pain relief, and anti-irritants such as camphor, eucalyptus oil and the menthol, which lead to pain relief by causing cold or heat at the site of the pain.

Skin patches: A transdermal patch containing lidocaine can provide relief from chronic pain. Patches have been approved for neuropathic shingles pain, a condition known as post-herpes neuralgia. Lidoderm and Lidopain are two skin patches of lidocaine. Capsaicin is also available in a patch and is placed by the doctor himself and is called Qutenza. It can be used every three months.

Opioids: When the pain is severe then the next stage is opioids. Opioids such as codeine, fentanyl, morphine, oxycodone act on pain receptors at the level of nerve cells and are very effective in controlling severe chronic pain. But opioid use has always been controversial. There is a perception among doctors that they will run into legal problems if they undergo treatment or show excessive zeal in treating opioid pain. It is a factor associated with inadequate training on these drugs. They are very effective for the right patients. They should be used carefully, but they can be used in the long run. There is a small risk of addiction. But studies show that the risk is small when used properly. When prescribed because, pain specialists often use combinations of medications, such as new prolonged-release antidepressants. The combination of drugs allows us to reduce the amount of opioids and leads to better control of pain, because the mechanism of action of opioids is different from other drugs, such as antidepressants and antiepileptics. This approach is critical to treating neuropathic pain, such as diabetic neuropathy. Tramadol (Ultram ER) is a non-opioid drug that acts on opioid receptors. It is indicated in moderate to moderate pain, when continuous pain management is required. Synthetic opioids do not appear to be addictive. They are effective in treating many different pain syndromes. Many doctors prefer them before moving on to opioids.

Among the newest opioids for pain control are: The Duragesic transdermal patch for moderate to severe pain. Provides continuous supply of opioid fentanyl for 72 hours. More options for pain flares: There are two fast-acting drugs that contain fentanyl. They were developed for cancer patients who have sudden pain and are already taking opioids for cancer pain. Fentanyl citrate (Actiq) comes in the form of a lollipop and Fentora is a soluble tray in the mouth.

The following procedures can also help control pain:

Nerve blockages: When a group of nerves causes pain in a specific organ or area of ​​the body, the pain can be ruled out by injecting a local anesthetic. This is a nervous breakdown. Injections and nerve blocks are more effective in treating acute pain. But also in patients with a depressed nerve, nerve blockages can alleviate the pain so that the patient can function and start physical therapy. And if treatment is started early, the development of chronic pain will be prevented. Radiofrequency ablation: A small area of ​​nerve tissue is heated to reduce pain signals from that area. The procedure is performed under the guidance of CT imaging. A needle is inserted into the affected nerve area and an electric current is used to thermally destroy the target. A new technique, the application of high frequency pulses, offers only neurotransformation, without leading to nerve damage, as the temperature does not exceed 45o C. The control of chronic pain lasts from three to six months. This is a great advantage, because it is a very localized and very specific treatment for pain. It's not a panacea, but it can really make a difference in some cases. TENS .: Percutaneous electrical nerve stimulation. The treatment is useful for short-term pain relief. It includes a small device, which distributes low level electricity and helps to exclude pain. It is very useful in the treatment of various types of muscle pain and is often used with infusions at Ttrigger point (myoperitoneal trigger points, which are alginate in pressure, parts of the body). Trigger point injection: These are sore spots on muscle or connective tissue. They can sensitize the nerves around them and cause pain in other parts of the body. Particular sensitivity can also develop in nearby muscles or areas of the body. A local anesthetic (sometimes a steroid) is injected into the trigger point to relieve the pain. It usually requires only a few treatments to resolve the trigger point and the pain that arises from it. It is a relatively simple and safe process. "Pain pacemakers": The technique is called electrical spinal cord stimulation and involves a pacemaker (neurostimulator) implanted in the body. The neurostimulator provides low-level electrical signals to the spinal cord or to specific nerves and prevents the transmission of pain to the brain (electrodes are placed in the epidural space and connected to the neurostimulator). The patient can adjust the on / off switch and adjust the intensity of the electrical signals. Electrical stimulation of the spinal cord is applied when other techniques have failed, as well as when a cancerous pain has infiltrated a nerve root. Implantable drug delivery pumps. These are also called intrathecal pumps because they send analgesic drugs to the spinal cord. Local anesthetics, Opioids and other analgesics can be given through these implantable pumps. At the touch of a button, it is injected analgesic and nerve block, so as not to transmit pain to the spinal cord. These pumps are often used in cancer patients, but also in patients who have tried drugs but developed side effects. The dosage is much lower than that of the oral one, so the side effects are less. There is also a psychological benefit to pumps, as controlling pain can help in the prevention of post-traumatic stress. Surgery: Surgery can help in some cases. Removing a tumor can offer pain relief, as can shrinking a tumor with radiotherapy. In neurosurgery, nerves are cut to control the pain.

Advice for better

Dealing with chronic pain: It is very difficult to live with a chronic pain, which leads to depression, anxiety, anger and can make the pain worse. Negative emotions reduce the body's endogenous opioids and increase its sensitivity to pain. When chronic pain settles, the person's life shrinks to give way to pain. Activities are limited and this perpetuates the vicious cycle of pain as the perception of pain becomes worse. Health, work and interpersonal relationships "bleed". Sleep and mood disorders perpetuate the sensation of pain. With counseling, patients gain skills in managing chronic pain. They can also find solutions to everyday problems that cause them stress and depression,

Alternative approaches to

Chronic pain: Stress aggravates the pain, so a relaxation technique is great useful in all types of pain. When the patient is upset with something, his pain will rise several points on the pain scale. Biofeedback, for example, helps people train their minds to control bodily functions, such as muscle tension, respiration and heart rate, leading to a reduction in stress and stress responses. Relaxation techniques are an important part of treating pain. Deep breathing, meditation, guided mental imagery, and hypnosis allow the mind to help the body. Regular exercise helps reduce stress and promote relaxation, which helps relieve chronic pain. Acupuncture, a traditional Chinese technique, has earned the respect of Western medicine. The National Institutes of Health recognizes acupuncture as an effective way to treat pain, especially in headaches and back pain, and suggests that the technique may help with other chronic pain conditions, such as arthritis, fibromyalgia and muscle aches. Acupuncture is extremely useful with pain and more and more insurance companies abroad are covering acupuncture treatments.

Biography:

Studies:
DIPLOMA OF MEDICINE of the Medical University of Sofia-Medical School -Sofia- Bulgaria Master's degree (recognition by DIKATSA)

Clinical Experience:

  • Three-month training in regular Pathology, Surgery and Cardiology Outpatient Clinics and Emergency Clinics of the General Hospital of Trikala and in the Anesthesiology Department of the General Hospital of Trikala (20/10/2003 - 10/01/2004).
  • Twelve-month field service at the Farkadonas Police Station, General Hospital of Trikala, Prefecture of Trikala (2004-2005).
  • Specialization in Anesthesiology at the General Hospital of Larissa and part of it and at the University Hospital of Larissa (19/12/2005 -20/9/2010)
  • Curator of B 'Anesthesiology at the General Hospital of Edessa-border A' (8/06/2011 to 8/8/2017. Permanent Decision 11/2016)
  • Curator of 2nd Anesthesiology at the General University Hospital of Larissa (8/8/2017 until today) Upgrade to Curator A '19/07/2018 Scientific work
  • Doctoral dissertation (Doctor of Medicine AUTh - 2016). In the context of the dissertation, attending postgraduate courses, two consecutive years and presentation of three postgraduate theses. Writing the dissertation on "Pain" and publishing the study in BMJ (2015). The topic of the doctoral dissertation entitled "Postoperative analgesia and electroacupuncture in plastic inguinal hernia repair with mesh" was announced in the number 16 / 14-4-2011 meeting of the General Assembly of the Medical School of AUTh. The Test for the doctoral diploma was graded with Excellent on 7/12/2015 and the award for a doctorate in Medicine took place on 7/3/2016.
  • Diploma in Medical Acupuncture (2009). Postgraduate training in medical acupuncture ICMART (2 years). Additional four postgraduate seminars in medical acupuncture.

Rodolfo J. Oviedo, MD, FACS, FASMBS

Title: Robotic Gastrointestinal Surgery

Abstract:

Robotic Gastrointestinal Surgery

The field of gastrointestinal surgery has experienced the progression of minimally invasive techniques including the robotic approach, which enables surgeons to perform the most advanced operations with minimal tissue trauma, decreased risk of complications, and improved ergonomics which mimic the human hand movements with enhanced visualization.  The robotic applications in gastrointestinal surgery for benign and malignant disorders has revolutionized the way in which surgery is performed in the United States and other countries.  The sub-specialties of metabolic and bariatric, colorectal, hepatobiliary and pancreatic, and foregut/anti-reflux surgery have witnessed the production of high-quality randomized controlled trials, meta analyses, prospective and retrospective cohort studies which have established, in many instances, superior results to those of laparoscopy and at least non-inferior outcomes.  The following lecture will present an abbreviated yet thorough overview of the current status of robotic gastrointestinal surgery.  It will also illustrate the advances that have been achieved to date as a product of perseverance, determination, and the pursuit of innovation with patient safety as the priority.

Biography:

Rodolfo J. Oviedo, MD, FACS, FASMBS graduated from medical school at The University of Texas at San Antonio in 2007, and from Houston Methodist General Surgery Residency Program in 2013.  He decided to pursue an Advanced Minimally Invasive Gastrointestinal and Bariatric Surgery Fellowship at Baptist Hospital of Miami from 2017 to 2018.  He is a board-certified and fellowship-trained metabolic and bariatric surgeon, robotic advanced gastrointestinal surgeon, and flexible endoscopic surgeon.  He is a Diplomate of the American Board of Surgery, a Fellow of the American College of Surgeons, and a Fellow of the American Society for Metabolic and Bariatric Surgery.