Besieged in the Bronx: Lessons from an in-hospital mass casualty.

BACKGROUND: An active shooter in a hospital is an emergency extraordinaire. We report a single institution's response to the largest active shooter mass casualty event in American History. METHODS: Review of notification, flow of prioritized patients, and key elements of the day's dynamic after a hospital attack by a lone gunman were commenced. The review includes outcomes on seven victims and assailants. RESULTS: "Code Silver" announced: open display of a weapon. Concise, known, and published chain of command implemented. All house staff to the Emergency Department (ED) via text blast. Operating room (OR) notified. Injured to ED, then triaged to OR. Armed NYPD stationed throughout OR. Senior surgeons controlled key triage during attack with flow controlled from the ED and OR control desk. One fatality plus shooter. CONCLUSION: Success favors the prepared. The response to attack, readiness of medical personnel, mitigation, and recovery have brought the following recommendations: (1) single entrance access; (2) armed, professional guards at all entrances; (3) camouflage metal detectors; (4) mandatory, recurrent hospital-wide active shooter training, mock, and table top; (5) published physician chain of command; (6) intercom code system known to all hospital personnel indicating a weapon is openly displayed; (7) a "no fly" list of former employees who are prohibited on premises; (8) stop the bleed training with kits on every floor; (9) one voice, one face to disseminate information. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level I.

Weight loss outcomes and complications from bariatric surgery in the super super obese.

BACKGROUND: Bariatric surgery has been established as the most effective long-term treatment for morbid obesity. METHODS: We performed a retrospective review of SSO patients treated at our institute between 2008 and 2013 who underwent a laparoscopic gastric bypass (LGBP) or sleeve gastrectomy (LSG). The primary end point for this study was excess weight loss (EWL) at 1, 3, 6, and 12 months. Secondary end points included procedure length (PL), length of stay (LOS), diabetes management and postoperative complications. RESULTS: We identified 135 SSO patients who underwent bariatric surgery (93 LGBP, 42 LSG) at our institute from 2008 to 2013 with a median follow-up of 49 months. The incidence of EWL > 30 % for patients in the LGBP group was 3.9, 29.0, 72.2 and 94.6 % at 1, 3, 6 and 12 months, respectively, while the incidence of EWL > 30 % in patients in the LSG group was 4.2, 25.0, 59.1 and 100 % at 1, 3, 6 and 12 months, respectively. PL was 124 ± 49 min for the LGBP group and 98 + 51 min for the LSG group (p < 0.005). LOS was on average 3.0 days (range 1-21) for the LGBP group and 3.4 days (range 1-13) for the LSG group (p = 0.41). Patients experienced a decrease in their hemoglobin A1C level by 10 % for the LGBP group and 9 % for the LSG group at 1 year (p = 0.89). Postoperative complications were seen in 15.1 % of LGBP patients and 4.8 % of LSG patients. CONCLUSIONS: Bariatric surgery is feasible in the SSO patients with comparable EWL outcomes and postoperative complications to historical non-SSO patients.

Outcomes of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Patients Older than 60.

BACKGROUND: The proportion of population older than 60 years is rapidly increasing. The majority of this older population suffers from multiple comorbid conditions including obesity. Non-surgical means of weight loss do not offer a predictable solution. Surgical interventions seem to be the most promising solution for the obesity problem, but there is a relative lack of data in literature regarding bariatric procedures in older populations. OBJECTIVES: Our study aims to evaluate the safety and efficacy of bariatric surgery in patients older than 60 years of age, to determine the weight loss, rate of operation-related complications, and impacts of surgery on comorbid conditions, and to compare the effectiveness of bariatric surgery in older patients to the effectiveness of bariatric surgery for the general population at Montefiore Medical Center. METHODS: A retrospective review of patients' medical records were used to collect data to create databases to identify patients older than 60 years age who underwent bariatric surgery procedures spanning a 4-year period between January 2009 and October 2013. Data reviewed included age, sex, height, pre-operative weight, and body mass index (BMI), presence of obesity-related comorbid conditions, procedures performed, mortality, immediate or delayed complications, length of follow-up, excess weight lost, BMI points lost, percent of excess weight loss (%EWL), hemoglobin Alc (HgbA1c), and effects on obesity-related comorbid conditions. The percent of excess weight loss and number of complications within the older patient group were compared to the general population, which consists of patients between the ages of 22 and 59. RESULTS: Ninety-eight patients were identified. Seven patients did not follow up at any time period, and the eight patients who had laparoscopic adjustable gastric band (LAGB) were also excluded due to insufficient data. Overall, 83 patients who were above the age of 60 were examined; 30 patients had laparoscopic sleeve gastrectomy (LSG), and 53 patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). The average patient age was 63.4 years, the average pre-operative weight was 122.3 kg, and the average excess body weight was 54.8 kg. The pre-existing comorbid conditions included 90.4 % hypertension (HTN), 63.9 % diabetes mellitus (DM), 50.6 % hyperlipidemia (HL), 34.9 % obstructive sleep apnea (OSA), and 30.1 % asthma. The average %EWL at 3 months, 6 months, and 12 months was 37.0, 51.3, and 65.2 %, respectively. A significant proportion of patients reported resolution or improvement in comorbid conditions. When results were compared to the general, population there was no significant difference in the number of complications that occurred within each of the two groups. The difference in %EWL at the 12-month follow-up was not statistically significant between the general population and the older patients, which suggests that both groups lost a similar amount of weight and that bariatric surgery on patients who are above the age of 60 is effective. CONCLUSIONS: Bariatric surgery can be safe and effective for patients older than 60 years of age with a low morbidity and mortality; the weight loss and improvement in comorbidities in older patients were clinically significant. When compared to the general population, there was no statistically significant difference in the average %EWL at 12 months or the number of complications due to surgery. Long-term effects of such interventions will need further studies and investigations.

Comparison of stricture rates using three different gastrojejunostomy anastomotic techniques in laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: No single gastrojejunostomy anastomosis technique (GJA) in Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently preferred over another. Bendewald et al. confirmed that there was no difference in anastomotic stricture rates when comparing hand-sewn (HS), linear-stapled (LS), and circular-stapled (CS) GJA techniques. We present and analyze our own institutional data to readdress stricture rates. METHODS: From January 2010 to January 2013, 860 consecutive patients underwent LRYGB using HS, LS, and CS anastomotic techniques at a single institution. All patients in this study were followed to see if they had a complication of a stricture within this time period. Hospital records were retrospectively reviewed and those who had stricture complications shown on endoscopy requiring intervention were compiled and compared using univariate analysis. RESULTS: Patient demographics did not differ substantially between the three groups. The most common technique employed was LS (n = 429, 49.8%), followed by CS (n = 254, 29.5%) and HS (n = 177, 20.6%), respectively. Using multivariate analysis, there was a significant difference in the rate of strictures between the anastomotic techniques (LS 4.42%, HS 2.82%, CS 1.18%, p = 0.0163). CONCLUSIONS: Our data show that the discussion of which anastomotic technique is superior should be reopened given the statistically significant low rate of strictures in patients who underwent LRYGB with a CS anastomosis in comparison with LS and HS anastomoses.

Adipocyte-specific IKKß signaling suppresses adipose tissue inflammation through an IL-13-dependent paracrine feedback pathway.

Adipose tissue inflammation is one pathway shown to mediate insulin resistance in obese humans and rodents. Obesity induces dynamic cellular changes in adipose tissue to increase proinflammatory cytokines and diminish anti-inflammatory cytokines. However, we have found that anti-inflammatory interleukin-13 (IL-13) is unexpectedly induced in adipose tissue of obese humans and high-fat diet (HFD)-fed mice, and the source of IL-13 is primarily the adipocyte. Moreover, HFD-induced proinflammatory cytokines such as tumor necrosis factor alpha (TNF-α) and IL-1ß mediate IL-13 production in adipocytes in an IKKß-dependent manner. In contrast, adipocyte-specific IKKß-deficient mice show diminished IL-13 expression and enhanced inflammation after HFD feeding, resulting in a worsening of the insulin-resistant state. Together these data demonstrate that although IKKß activates the expression of proinflammatory mediators, in adipocytes, IKKß signaling also induces the expression of the anti-inflammatory cytokine IL-13, which plays a unique protective role by limiting adipose tissue inflammation and insulin resistance.

Single-incision laparoscopic cholecystectomy learning curve experience seen in a single institution.

INTRODUCTION: Single-incision laparoscopic surgery (SILS) is laparoscopic surgery done by one incision through the umbilicus. Cholecystectomy lends itself well to a SILS approach. As these procedures have become more widely adapted, it is important to determine the approximate learning curve to decrease two surgical endpoints: (1) time to completion of the procedure; and (2) decreased incidence of conversion. METHODS: We prospectively reviewed our series of 50 cholecystectomies done using the SILS approach between May 2008 to September 2008. All cases were performed by two advanced laparoscopic surgeons at a single institution. Data was collected immediately after the case and entered into an Excel database. Cases were performed by insufflating the abdomen with a Veress needle through the umbilicus followed by placement of 5-mm ports at the umbilicus. RESULTS: Patient ages ranged between 21 and 82 years with a median age of 45 years. Body mass index (BMI) range was 21 to 42 kg/m with a mean of 30 kg/m. Average length of time for cases was 1 hour 9 minutes with a range between 55 minutes and 120 minutes. The average length of time for the first 25 cases was 80 minutes. When compared with cases 26 to 50 the average length of time was 60 minutes (P<0.05). The conversion rate to conventional laparoscopic cholecystectomy was 10%. Conversion was accomplished through the addition of a 5-mm port elsewhere on the abdominal cavity. After the tenth case, the incidence of conversion went down to zero. When conversions were further stratified, they occurred within each individual surgeon's first ten cases. CONCLUSIONS: The learning curve for successful consistent completion of SILS cholecystectomy cases appears to be after 25 cases. In addition, conversion rates drop dramatically after the first ten cases.

Single incision laparoscopic cholecystectomy: a single center experience.

INTRODUCTION: Single Incision Laparoscopic Surgery (SILS) is a variation in which trocar scars are hidden in the umbilicus. We sought to determine whether SILS cholecystectomy is a safe alternative to a conventional laparoscopic cholecystectomy. METHODS: We retrospectively reviewed our series of 205 SIL cholecystectomies (SILC) performed between May 2008-June 2010. The first 50 cases were done by initially insufflating the abdomen with a veress needle through the umbilicus and then placing 3, 5 mm ports in the umbilicus. The remaining cases were performed using a cut down approach at the umbilicus, followed by placement of a three-trocar SILS port under direct vision. RESULTS: Two hundred and five patients (M:F = 48:157) underwent SILC during the study period. Median age was 45 (range = 21-62). Mean BMI range was 35 (range = 21-44). Mean operative time was 60 min (range = 40-120 min) and a follow up period that ranges from 1 to 21 months. Patient pathologies included: Chronic cholecystitis (74%), Acute cholecystitis (17%), Choledocholithiasis (6.8%), Gallstone pancreatitis (2%) and gallbladder polyp (0.5%). An additional port was placed in the umbilicus in 3% of cases. No cases were converted to open. Complications occurred in 4% of cases including: 3 patients with retained stones, 2 patients with post-op wound infection, 2 patients with incisional hernias in the umbilical region and 1patient with a veress injury. CONCLUSION: SIL cholecystectomy can be done safely. It offers a better cosmetic result, which may lead to greater patient satisfaction.

Single-incision laparoscopic-assisted right colon resection for cancer.

INTRODUCTION: We present an approach to laparoscopic right colon resection utilizing a single port placed through the umbilicus. The technique described is performed through a single small umbilical incision with a virtually scar-free result. METHODS: A 77-year-old woman with a tubulovillous adenoma in her cecum underwent a laparoscopic right colectomy using a single port placed through the umbilicus. Straight and reticulating laparoscopic instruments were utilized. RESULTS: The total operative time was 112 minutes. No intraoperative or postoperative complications occurred. The patient was discharged home on day 5 postoperatively with normal bowel function and tolerance of a solid diet. CONCLUSIONS: Laparoscopic right colectomy can be safely performed through a single incision through the umbilicus with an excellent cosmetic result.

Intestinal malrotation in a patient undergoing laparoscopic gastric bypass.

Intestinal malrotation is an anomalous disorder resulting from the incomplete rotation and fixation of the midgut during embryonic development. Although most patients present early in life with symptoms of bowel obstruction, others remain asymptomatic throughout their lives. We report the case of a 40-year-old morbidly obese woman with no significant past medical history, found to have intestinal malrotation on initial laparoscopic exploration for gastric bypass.

Appendiceal diverticulitis in a youth.

Appendiceal diverticulitis as the etiology of right lower quadrant pain is an uncommon entity in younger populations. The incidence is <1 per cent among patients under 30 years of age undergoing appendectomy. Herein, we present a case of a 17-year-old male with perforated appendiceal diverticulitis. The history, physical findings, diagnosis, and treatment are outlined. Additionally the literature concerning appendiceal diverticulitis is reviewed.