A rare case of retroperitoneal teratoma with evidence of papillary thyroid carcinoma: a case report.

BACKGROUND: Teratomas are germ cell tumors composed of somatic tissues from up to three germ layers. Primary retroperitoneal teratomas usually develop during childhood and are uncommon in adults and in the retroperitoneal space. While there are only a few cases of retroperitoneal thyroid tissue, we report a unique case of a retroperitoneal papillary thyroid carcinoma. CASE PRESENTATION: A 41-year-old woman presented in our institution due to intermitted unspecific abdominal pain. Magnetic resonance imaging detected a multi-cystic solid retroperitoneal mass ventral to the psoas muscle and the left iliac artery. After surgical removal of the retroperitoneal mass, histology sections of the specimen indicated evidence of papillary thyroid carcinoma cells. A staging computed tomography scan of the body showed no further manifestations. To reduce the risk of recurrence, total thyroidectomy was performed followed by radioiodine therapy with lifelong hormone substitution. CONCLUSIONS: Primary retroperitoneal teratoma with evidence of papillary thyroid carcinoma is a rare condition. Preoperative diagnosis is difficult due to its non-specific clinical manifestation and lack of specific radiologic findings. Histopathology analysis is necessary for diagnosis. Although surgery is considered the first line treatment, there is still discussion about the extent of resection and the need for total thyroidectomy with adjuvant radioiodine therapy.

Educational challenges and opportunities for the future generation of surgeons: a scoping review.

PURPOSE: Surgery offers exciting opportunities but comes with demanding challenges that require attention from both surgical program administrators and aspiring surgeons. The hashtag #NoTrainingTodayNoSurgeonsTomorrow on 𝕏 (previously Twitter) underscores the importance of ongoing training. Our scoping review identifies educational challenges and opportunities for the next generation of surgeons, analyzing existing studies and filling gaps in the literature. METHODS: Following the PRISMA guidelines, MEDLINE/PubMed was searched in February 2022, using the MeSH terms "surgeons/education," for articles in English or German on general, abdominal, thoracic, vascular, and hand surgery and traumatology targeting medical students, surgical residents, future surgeons, and fellows. RESULTS: The initial search yielded 1448 results. After a step-by-step evaluation process, 32 publications remained for complete review. Three main topics emerged: surgical innovations and training (n = 7), surgical culture and environment (n = 19), and mentoring (n = 6). The articles focusing on surgical innovations and training mainly described the incorporation of structured surgical training methods and program initiatives. Articles on surgical culture examined residents' burnout, well-being, and gender issues. Challenges faced by women, including implicit bias and sexual harassment, were highlighted. Regarding mentoring, mentees' needs, training challenges, and the qualities expected of both mentors and mentees were addressed. CONCLUSION: At a time of COVID-19-driven surgical innovations, the educational and working environment of the new generation of surgeons is changing. Robotic technology and other innovations require future surgeons to acquire additional technological and digital expertise. With regard to the cultural aspects of training, surgery needs to adapt curricula to meet the demands of the new generation of surgeons, but even more it has to transform its culture.

The PLET (Portable Laparoscopic Endo-Trainer) study: a randomized controlled trial of home- versus hospital-based surgical training.

PURPOSE: The purpose of this study was to assess the effect of training with a personal, portable laparoscopic endo-trainer (PLET) on residents' laparoscopic skills. METHODS: The study took place at a tertiary-care academic university hospital in Switzerland. All participants were randomized to either a home- or hospital-based PLET training group, and surgical skill performance was assessed using five laparoscopic exercises. 24 surgical residents, 13 females and 11 males, were enrolled at any training stage. Nine residents completed the assessments. Endpoints consisted of subjective and objective assessment ratings as well as exercise time and qualitative data up to 12 weeks. The primary outcome was the difference in exercise time and secondary outcomes included performance scores as well as qualitative data. RESULTS: The hospital-based training group performed exercises number 1, 3 and 4 faster at 12 weeks than at baseline (p = .003, < 0.001 and 0.024). Surgical skill performance was not statistically significantly different in any of the endpoints between the hospital- and home-based training groups at 12 weeks. Both the subjective and objective assessment ratings significantly improved in the hospital-based training group between baseline and 12 weeks (p = .006 and 0.003, respectively). There was no statistically significant improvement in exercise time as well as subjective and objective assessment ratings over time in the home-based training group. The qualitative data suggested that participants who were randomized to the hospital-based training group wished to have the PLET at home and vice versa. Several participants across groups lacked motivation because of their workload or time constraints, though most believed the COVID-19 pandemic had no influence on their motivation or the time they had for training. CONCLUSION: The PLET enhances laparoscopic surgical skills over time in a hospital-based training setting. In order to understand and optimize motivational factors, further research is needed. TRIAL REGISTRATION: This trial was retrospectively registered on clinicaltrials.gov (NCT06301230).

Long-term quality of life after hybrid robot-assisted and open Ivor Lewis esophagectomy for esophageal cancer in a single center: a comparative analysis.

PURPOSE: Due to improved survival of esophageal cancer patients, long-term quality of life (QoL) is increasingly gaining importance. The aim of this study is to compare QoL outcomes between open Ivor Lewis esophagectomy (Open-E) and a hybrid approach including laparotomy and a robot-assisted thoracic phase (hRob-E). Additionally, a standard group of healthy individuals serves as reference. METHODS: With a median follow-up of 36 months after hRob-E (n = 28) and 40 months after Open-E (n = 43), patients' QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire Core 30 (QLQ-C30) and the EORTC Esophagus specific QoL questionnaire 18 (QLQ-OES18). RESULTS: Patients showed similar clinical-pathological characteristics, but hRob-E patients had significantly higher ASA scores at surgery (p < 0.001). Patients and healthy controls reported similar global health status and emotional and cognitive functions. However, physical functioning of Open-E patients was significantly reduced compared to healthy controls (p = 0.019). Operated patients reported reduced role and social functioning, fatigue, nausea and vomiting, dyspnea, and diarrhea. A trend towards a better pain score after hRob-E compared to Open-E emerged (p = 0.063). Regarding QLQ-OES18, hRob-E- and Open-E-treated patients similarly reported eating problems, reflux, and troubles swallowing saliva. CONCLUSIONS: The global health status is not impaired after esophagectomy. Despite higher ASA scores, QoL of hRob-E patients is similar to that of patients operated with Open-E. Moreover, patients after hRob-E appear to have a better score regarding physical functioning and a better pain profile than patients after Open-E, indicating a benefit of minimally invasive surgery.

Trainees' perceptions of being allowed to fail in clinical training: A sense-making model.

INTRODUCTION: Clinical supervisors allow trainees to fail during clinical situations when trainee learning outweighs concerns for patient safety. Trainees perceive failure as both educationally valuable and emotionally draining; however, the nuance of supervised failures has not been researched from the trainee perspective. This study explored trainees' awareness and their experience of failure and allowed failure to understand those events in-depth. METHODS: We interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. Participants were a purposive sample, representing 1-10 years of clinical training in various specialties. Consistent with constructivist grounded theory, data collection and analysis were iterative, supporting theoretical sampling to explore themes. RESULTS: Trainees reported that failure was a common, valuable, and emotional experience. They perceived that supervisors allowed failure, but they reported never having it explicitly confirmed or discussed. Therefore, trainees tried to make sense of these events on their own. If they interpreted a failure as allowed by the supervisor, trainees sought to ascertain supervisory intentions. They described situations where they judged supervisor's intentions to be constructive or destructive. DISCUSSION: Our results confirm that trainees perceive their failures as valuable learning opportunities. In the absence of explicit conversations with supervisors, trainees tried to make sense of failures themselves. When trainees judge that they have been allowed to fail, their interpretation of the event is coloured by their attribution of supervisor intentions. Perceived intentions might impact the educational benefit of the experience. In order to support trainees' sense-making, we suggest that supervisory conversations during and after failure events should use more explicit language to discuss failures and explain supervisory intentions.

Career goals of surgeons in Switzerland.

PURPOSE: Recent studies from the United States and Germany have shown a general decline in the number of surgical residents, as trainees increasingly prioritize a positive work-life balance. The current study sought to evaluate the career goals of surgeons in Switzerland. METHODS: Members of the Swiss College of Surgeons, being surgical consultant or attending regardless of specialty, were surveyed online as to their purported career goals, future employment ideals, aspired leadership positions, and managerial training. RESULTS: A total of 269 questionnaires were analysed. Most participants (93%) were board- certified and 30% of participants were female. With regard to desired specialty, 50% of participants intended to pursue a career in visceral surgery followed by general surgery, traumatology, hand and plastic surgery, vascular surgery and thoracic surgery. Regardless of specialty, 53% of respondents strived for the position of senior physician, while 28% indicated a desire to become chief physician. In terms of work environment, most participants preferred to seek employment at a cantonal hospital, followed by a rural hospital, a university hospital, private practice or a non-clinical setting. About half of respondents favoured the option of part time employment of 80% or less and about a quartile intended to retire before 62 years of age. CONCLUSION: The current study found that surgeons in Switzerland remain highly motivated to pursue leadership positions in their respective fields. Going forward, the challenge will lie in reconciling the needs of the respective departments with the personal ambition, career opportunities, and desired work-life balance of young trainees.

Commentary on "supervisory knowing in practice across medical specialties" : Scalpel, please! Why is it more challenging to hand over the scalpel than a ward round for future surgeons' learning?

In the dynamic, non-linear world of medical education, balancing patient care and trainee learning is a complex task. This commentary responds to the original article by Noble et al. (2023), which challenges the perceived tension between patient care and trainee learning in the surgical environment and advocates for their co-occurrence across various medical specialties. The article explores supervisory practices across disciplines and proposes a holistic reconceptualization of clinical supervision in surgery. From various perspectives, the importance of hands-on opportunities in the operation theatre and the challenges trainees encounter in gaining practical experience are emphasized. Strategies aimed at improving clinical supervision and enhancing surgical education are suggested. By addressing these challenges and providing more opportunities for hands-on training across specialties, surgical education programs can better prepare trainees for the demands of their future careers while ensuring high-quality patient care.

A phenomenological exploration of the impact of COVID-19 on the medical education community.

INTRODUCTION: The COVID-19 pandemic has caused unprecedented stress to the medical education community, potentially worsening problems like burnout and work-life imbalance that its members have long been grappling with. However, the collective struggle sparked by the pandemic could generate the critical reflection necessary for transforming professional values and practices for the better. In this hermeneutic phenomenological study, we explore how the community is adapting-and even reconceptualising-their personal and professional roles amidst the COVID-19 crisis. METHOD: Between April and October 2020, we conducted 27 (17F, 10M) semi-structured interviews with medical trainees (8), physicians (8), graduate students (3) and PhD scientists (8) working in medical education in Canada, the United States and Switzerland. Data analysis involved a variety of strategies, including coding for van Manen's four lifeworld existentials, reflexive writing and multiple team meetings. RESULTS: Participants experienced grief related to the loss of long-established personal and professional structures and boundaries, relationships and plans for the future. However, experiences of grief were often conflicting. Some participants also experienced moments of relief, perceiving some losses as metaphorical permissions slips to slow down and focus on their well-being. In turn, many reflected on the opportunity they were being offered to re-imagine the nature of their work. DISCUSSION: Participants' experiences with grief, relief and opportunity resonate with Ratcliffe's account of grief as a process of relearning the world after a significant loss. The dismantling of prior life structures and possibilities incited in participants critical reflection on the nature of the medical education community's professional practices. Participants demonstrated their desire for more flexibility and autonomy in the workplace and a re-adjustment of the values and expectations inherent to their profession. On both individual and systems levels, the community must ensure that long-standing calls for wellness and work-life integration are realised-and persist-after the pandemic is over.

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

PURPOSE: Clinical supervisors acknowledge that they sometimes allow trainees to fail for educational purposes. What remains unknown is how supervisors decide whether to allow failure in a specific instance. Given the high stakes nature of these decisions, such knowledge is necessary to inform conversations about this educationally powerful and clinically delicate phenomenon. MATERIALS AND METHODS: 19 supervisors participated in semi-structured interviews to explore how they view their decision to allow failure in clinical training. Following constructivist grounded theory methodology, the iteratively collected data and analysis were informed by theoretical sampling. RESULTS: Recalling instances when they considered allowing residents to fail for educational purposes, supervisors characterized these as intuitive, in-the-moment decisions. In their post hoc reflections, they could articulate four factors that they believed influenced these decisions: patient, supervisor, trainee, and environmental factors. While patient factors were reported as primary, the factors appear to interact in dynamic and nonlinear ways, such that supervisory decisions about allowing failure may not be predictable from one situation to the next. CONCLUSIONS: Clinical supervisors make many decisions in the moment, and allowing resident failure appears to be one of them. Upon reflection, supervisors understand their decisions to be shaped by recurring factors in the clinical training environment. The complex interplay among these factors renders predicting such decisions difficult, if not impossible. However, having a language for these dynamic factors can support clinical educators to have meaningful discussions about this high-stakes educational strategy.

Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass?

PURPOSE: Internal hernias (IH) are frequent complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Closure of the jejunal mesenteric and the Petersen defect reduces IH incidence in prospective and retrospective trials. This study investigates whether closing the jejunal mesenteric space alone by non-absorbable suture and splitting the omentum can be beneficial to prevent IH after LRYGB. METHODS: Observational cohort study of 785 patients undergoing linear LRYGB including omental split at a single institution, with 493 patients without jejunal mesenteric defect closure and 292 patients with closure by non-absorbable suture, and a minimal follow-up of 2 years. Patients were assessed for appearance and severity of IH. Additionally, open mesenteric gaps without herniated bowel as well as early obstructions due to kinking of the entero-enterostomy (EE) were explored. RESULTS: Through primary mesenteric defect closure, the rate of manifest jejunal mesenteric and Petersen IH could be reduced from 6.5 to 3.8%, but without reaching statistical significance. The most common location for an IH was the jejunal mesenteric space, where defect closure during primary surgery reduced the rate of IH from 5.3 to 2.4%. Higher weight loss seemed to increase the risk of developing an IH. CONCLUSION: The closure of the jejunal mesenteric defect by non-absorbable suture may reduce the rate of IH at the jejunal mesenteric space after LRYGB. However, the beneficial effect in our collective is smaller than expected, particularly in patients with good weight loss. The Petersen IH rate remained low by consequent T-shape split of the omentum without suturing of the defect.

Learner-centered education: ICU residents' expectations of teaching style and supervision level.

BACKGROUND: If the education of intensive care unit (ICU) residents focuses on individual learning behavior, the faculty's style of teaching and level of supervision need to be adapted accordingly. The aim of this study was to delineate the associations between residents' perceived learning behavior, experience, and demographics and their expectations with regard to teaching style and supervision levels. METHODS: This multicenter survey obtained data on ICU residents' base specialty, duration of ICU training, individual postgraduate year, gender, and number of repetitions of ICU skills. Using 4-point Likert scales, residents assessed perceived learning behavior, expected teaching style, and supervision level for respective skills. Multivariate regression analysis was used to evaluate associations between assessed variables. RESULTS: Among 109 residents of four interdisciplinary ICUs, 63 (58%) participated in the survey and 95% (60/63) questionnaires were completed. The residents' perceived learning behavior was associated with number of skill repetitions (p < 0.0001), internal medicine as base specialty (p = 0.02), and skill type (p < 0.0001). Their expected teaching style was associated with learning behavior (p < 0.0001) and skill type (p < 0.0001). Their expected supervision level was associated with skill repetitions (p < 0.0001) and skill type (p < 0.0001). CONCLUSION: For effective learner-centered education, it appears useful to recognize how the residents' learning behavior is affected by the number of skill repetitions and the skill type. Hence, faculty may wish to take into account the residents' learning behavior, driven mainly by skill complexity and the number of skill repetitions, to deliver the appropriate teaching style and supervision level.

Allowing failure for educational purposes in postgraduate clinical training: A narrative review.

Background: Educational domains such as pedagogy or psychology have embraced the philosophy that "allowing failure" in training and practice is essential to learn. In clinical training, however, allowing learners to fail is not explicitly discussed as a strategy, possibly due to the negative implications for patients. Therefore, we do not know whether clinical supervisors allow trainees to fail for educational purposes and, if so, how this supervisory strategy is used. Methods: To inform research on this topic, we conducted a narrative review to understand what was known about this educational strategy in postgraduate medicine. Results: Analyzing the selected literature, we found no studies directly exploring the question of clinical supervisors allowing failure as an educational strategy. However, related literature on resident errors suggested that trainees perceived their own errors to be highly instructive and that factors such as a sense of responsibility and emotional response influenced the educational impact of these errors. Conclusions: The lack of discussion in the medical education literature regarding allowing failure for learning suggests that we need research into the nature and extent of this supervisory strategy which may hold educational benefits but must be employed in a manner that upholds patient safety and safeguards trainee resilience.

Breaking down barriers to bariatric care: a qualitative study on how telemedicine could transform patient experiences in a Swiss monocentric setting.

OBJECTIVE: Telemedicine is becoming an increasingly feasible option for patients with chronic diseases due to its convenience, cost-effectiveness and ease of access. While there are certain limitations, the benefits can be appreciated by those seeking repetitive care. The perception of telemedicine as an alternative to recurrent, in-person appointments for patients with obesity in structured bariatric programmes is still unclear. This content analysis' primary endpoint was to explore how patients within our bariatric programme perceived telemedicine and virtual consultations as a new way of communication during COVID-19. DESIGN: A qualitative study using semistructured interviews and qualitative content analysis method by Elo and Kyngäs following four steps: data familiarisation, coding and categorising with Quirkos software and final interpretation guided by developed categories. SETTING: University Hospital, Switzerland. PARTICIPANTS: We conducted 33 interviews with 19 patients from a structured bariatric programme. RESULTS: Most patients shared positive experiences, acknowledging the convenience and accessibility of virtual appointments. Others voiced concerns, especially regarding telemedicine's limitations. These reservations centred around the lack of physical examinations, difficulties in fostering connections with healthcare providers, as well as barriers stemming from language and technology. The research identified a spectrum of patient preferences in relation to telemedicine versus in-person visits, shaped by the immediacy of their concerns and their availability. CONCLUSION: While telemedicine is increasingly accepted by the public and provides accessible and cost-effective options for routine follow-up appointments, there are still obstacles to overcome, such as a lack of physical examination and technological limitations. However, integrating virtual alternatives, like phone or video consultations, into routine bariatric follow-ups could improve continuity and revolutionise bariatric care.

Using Trainee Failures to Enhance Learning: A Qualitative Study of Pediatric Hospitalists on Allowing Failure.

INTRODUCTION: Attendings allow trainee failure when perceived educational benefits outweigh potential patient harm. This strategy has not been explored in pediatrics, where it may be shaped by unique factors. Our objectives were to understand if, when, and how pediatric hospitalists allow trainees to fail during clinical encounters. METHODS: Using constructivist grounded theory, we conducted semistructured interviews with 21 pediatric hospitalists from a children's hospital in the United States. Iterative, constant comparative analysis took place concurrent with data collection. During regular team meetings, we refined and grouped codes into larger themes. RESULTS: Nineteen of the 21 participants shared that they intentionally allowed failure as a teaching strategy, acknowledging this strategy's emotional power and weighing the educational benefits against harms to current and future patients, caregivers, and trainees. Participants described a multistep process for allowing failure: 1) initiate an orientation to signal that they prioritize a psychologically safe learning environment; 2) consider factors which influence their decision to allow failure; and 3) debrief with trainees. However, participants did not explicitly alert trainees to this teaching strategy. They also avoided using the word "failure" during debriefs to protect trainees from psychological harm. CONCLUSIONS: Most pediatric hospitalists in this study allowed failure for educational purposes. However, they did so cautiously, weighing the educational value of the failure against the safety of both current and future patients, the relationship with the caregivers, and the trainees' well-being. Future research should involve trainees to more comprehensively understand the experience and effectiveness of this teaching strategy.

Breaking the Silence: A Workshop for Medical Students on Dealing With Failure in Medicine.

PROBLEM: Failure is a powerful teacher but an emotionally stressful experience. Before residency, when failure in clinical training is inevitable, medical students should learn to talk about and cope with failure. However, medical school curricula rarely include this topic, and physicians seldom share their mistakes and failures with trainees. This report describes and evaluates a workshop on dealing with failure in medicine. APPROACH: Two attending surgical consultants and a life coach facilitated the workshop between February 2021 and February 2022, which consisted of different educational approaches, such as presentations, small group discussions, and journal clubs. The sessions aimed to enable medical learners to identify and analyze actual and potential failure events in everyday clinical practice and learn from them, disclose and communicate medical failures and "speak up," reflect on failure and develop coping strategies, and understand the moderating role of fear of failure. OUTCOMES: Thirty medical students participated in the workshop. Dealing with failure in a productive manner was the medical learners' key learning objective and anticipated takeaway from the workshop. After the workshop, 19 of the 30 participants anonymously completed the standard university evaluation form. The medical students gave the workshop a mean (SD) rating of 8.59 (0.98) on a Likert scale ranging from 1 to 10. They felt better prepared to approach future challenges in a constructive manner after being equipped with strategies to deal with failure. Listening to the failure experiences of faculty and peers in a safe environment helped them accept that failure is inevitable. NEXT STEPS: The findings suggest that medical students appreciated a safe environment to discuss failure. By promoting a safe learning environment early in the medical career, medical schools could make an important contribution to reducing the stigma of failure and eliminating the shame and blame culture, thus contributing to students' well-being.

Medical students on the COVID-19 frontline: a qualitative investigation of experiences of relief, stress, and mental health.

Objective: During the early stages of the COVID-19 pandemic, medical students were abruptly removed from clinical rotations and transitioned to virtual learning. This study investigates the impact of this shift on students' wellbeing and preparedness for advanced training. Methods: Through qualitative research methods, including semi-structured interviews, the experiences of medical students working on the COVID-19 frontline were explored. Results: The comprehensive findings of the study shed light on the profound emotional journey that medical students embarked upon during the relentless public health crisis. Within the chaos and overwhelming demands of the pandemic, medical students discovered a profound sense of purpose and fulfillment in their contributions to the welfare of the community. Despite the personal sacrifices they had to make, such as long hours, limited social interactions, and potentially risking their own health, students reported feelings of relief and gratitude. Conclusion: Tailored support systems for medical students' wellbeing are crucial for improving healthcare delivery during crises. Medical schools should adopt a holistic curriculum approach, integrating interdisciplinary learning and prioritizing student wellbeing. Recognizing the pandemic's impact on students and implementing targeted support measures ensures resilience and contributes to an improved healthcare system.

Mid-Term Outcomes After Conversion Procedures Following Laparoscopic Sleeve Gastrectomy.

PURPOSE: In the long term, laparoscopic sleeve gastrectomy (SG) may be associated with insufficient weight loss (IWL), gastroesophageal reflux disease (GERD), and persistence or relapse of associated medical problems. This study's objective is to present mid-term results regarding weight loss (WL), evolution of associated medical problems, and reoperation rate of patients who underwent a conversion after SG. METHODS: Retrospective single-center analysis of patients with a minimal follow-up of 2 years after conversion. RESULTS: In this series of 549 SGs, 84 patients (15.3%) underwent a conversion, and 71 met inclusion criteria. They were converted to short biliopancreatic limb Roux-en-Y gastric bypass (short BPL RYGB) (n = 28, 39.4%), biliopancreatic diversion with duodenal switch (BPD/DS) (n = 19, 26.8%), long biliopancreatic limb Roux-en-Y gastric bypass (long BPL RYGB) (n = 17, 23.9%), and re-sleeve gastrectomy (RSG) (n = 7, 9.9%). Indications were GERD (n = 24, 33.8%), IWL (n = 23, 32.4%), IWL + GERD (n = 22, 31.0%), or stenosis/kinking of the sleeve (n = 2, 2.8%). The mean pre-revisional body mass index (BMI) was 38.0 ± 7.5 kg/m2. The mean follow-up time after conversion was 5.1 ± 3.1 years. The overall percentage of total weight loss (%TWL) was greatest after BPD/DS (36.6%) and long BPL RYGB (32.9%) compared to RSG (20.0%; p = 0.004; p = 0.049). In case of GERD, conversion to Roux-en-Y gastric bypass (RYGB) led to a resolution of symptoms in 79.5%. 16.9% of patients underwent an additional revisional procedure. CONCLUSION: In the event of IWL after SG, conversion to BPD/DS provides a significant and sustainable additional WL. Conversion to RYGB leads to a reliable symptom control in patients suffering from GERD after SG.