Bariatric Surgery and Malpractice: an Extensive Review of Demographics, Complications, Litigation, and Proactive Mitigation Strategies.

The rising prevalence of severe obesity has led to a parallel increase in bariatric surgeries, raising a complex array of medicolegal issues. This review aims to analyze and synthesize literature on bariatric surgery malpractice, focusing on patient demographics, surgical complications, litigation costs, and the nature of malpractice cases. A systematic search was conducted across multiple databases for relevant studies published up to May 2023. Our review endeavors to provide insights into these medicolegal challenges and their implications and foster an informed dialogue on strategies for their effective management. By doing so, we hope to enhance ethical and legally sound bariatric practices, safeguarding both patient welfare and surgical practitioners from legal repercussions.

A novel cell-based screen identifies chemical entities that reverse the immune-escape phenotype of metastatic tumours.

Genetic and epigenetic events have been implicated in the downregulation of the cellular antigen processing and presentation machinery (APM), which in turn, has been associated with cancer evasion of the immune system. When these essential components are lacking, cancers develop the ability to subvert host immune surveillance allowing cancer cells to become invisible to the immune system and, in turn, promote cancer metastasis. Here we describe and validate the first high-throughput cell-based screening assay to identify chemical extracts and unique chemical entities that reverse the downregulation of APM components in cell lines derived from metastatic tumours. Through the screening of a library of 480 marine invertebrate extracts followed by bioassay-guided fractionation, curcuphenol, a common sesquiterpene phenol derived from turmeric, was identified as the active compound of one of the extracts. We demonstrate that curcuphenol induces the expression of the APM components, TAP-1 and MHC-I molecules, in cell lines derived from both metastatic prostate and lung carcinomas. Turmeric and curcumins that contain curcuphenol have long been utilized not only as a spice in the preparation of food, but also in traditional medicines for treating cancers. The remarkable discovery that a common component of spices can increase the expression of APM components in metastatic tumour cells and, therefore reverse immune-escape mechanisms, provides a rationale for the development of foods and advanced nutraceuticals as therapeutic candidates for harnessing the power of the immune system to recognize and destroy metastatic cancers.

Long-term Outcomes of Sleeve Gastrectomy in Adolescent Patients: The Effect of Weight Loss in Younger Years to Outcomes in Adulthood.

BACKGROUND: Childhood obesity is associated with a variety of complications that see their light throughout adulthood. Due to the serious side effects of these morbidities, early intervention is essential. Laparoscopic sleeve gastrectomy (SG) is a safe and effective procedure for the treatment of obesity, however, the long-term data on its use in adolescents is lacking in the literature. METHODS: A retrospective analysis was conducted on all patients that underwent SG aged between 12 and 21 years old at a public hospital in Kuwait. Data on their weight and comorbidities was collected and analyzed. RESULTS: 164 adolescent patients with a mean age of 19 underwent SG. 71% of the patients were female, while the mean weight at surgery was 128.6 kg, corresponding to a BMI of 47.8 Kg/m2. 32% of patients had a starting BMI more than 50, while 6.7% had a BMI over 60. The highest weight loss was achieved at 18 months post-op, corresponding to an EWL of 82.66%. On long-term follow-up, weight loss was maintained over the 13 years post-op. Obstructive sleep apnea resolved in 75% of the patients while hypertension persisted in the 2 patients who were diagnosed with it pre-op. 21 patients developed gastro-esophageal reflux disease 5.7 years post-op, while 20 patients were treated for gall bladder stones 4.4 years post-op. CONCLUSION: It is of ample importance to tackle obesity during childhood before complications ensue later in life. Bariatric surgery, specifically SG, has been found to be an effective and safe weight loss tool, with sustained long-term weight maintenance and resolution of early comorbidities.

Long-term outcomes of revisional one anastomosis gastric bypass post laparoscopic sleeve gastrectomy.

PURPOSE: Revisional bariatric surgeries following laparoscopic sleeve gastrectomy (LSG) have demonstrated a dramatic increase worldwide. Recently, one-anastomosis gastric bypass (OAGB) has become a contender as an appropriate revisional procedure; however, no long-term data currently exist on the effectiveness of it as a revisional surgery post-LSG. METHODS: A retrospective analysis was performed on all patients who underwent LSG at a public hospital in Kuwait from 2008 to 2017. A list was obtained of those who underwent revisional OAGB surgery after initial LSG, after which a phone survey was performed and demographics were analyzed. RESULTS: A total of 29 patients underwent revisional OAGB post-initial LSG, of which 89.7% were female. Prior to LSG, the mean weight of the patients was 127.5 kg, and the mean BMI was 49.0 kg/m2. The mean weight loss after initial LSG was 43.8 kg, while the average duration until patients underwent revisional OAGB was 5.3 years. The cause for revision was weight regain (86.2%) or inadequate weight loss (13.8%). Prior to undergoing revisional OAGB, the weight and BMI of the patients was 110.9 kg and 42.4 kg/m2, respectively. Revisional OAGB demonstrated a %excess weight loss of 14.5%, 31.9%, 48.0%, 56.3%, 57.2%, and 54.7% at 2 weeks, 3 months, 6 months, 1 year, 4 years, and 5 years, respectively. Twelve morbidities were reported during the follow-up period. CONCLUSION: Revisional bariatric surgery is technically demanding and may be associated with a high complication rate. However, OAGB as a revisional procedure has proven to be safe and effective in the long-term outcomes of revisional OAGB patients post-LSG.

Outcomes and risk analysis after tricuspid valve surgery for non-Ebstein 2-ventricle congenital tricuspid valve diseases.

Objectives: Tricuspid valve (TV) surgery remains understudied and little data exist describing the surgical indications, outcomes, and prognostic factors for pediatric patients with non-Ebstein 2-ventricle congenital TV lesions. This study aims to describe early and late outcomes of pediatric patients with non-Ebstein congenital TV lesions undergoing isolated TV procedures at a single institution. Methods: All patients who underwent TV surgery for non-Ebstein congenital TV disease between 2006 and 2018 were included. Patients who had missing preoperative data, patients with single-ventricle physiology, congenitally corrected transposition of the great arteries, and patients undergoing TV intervention as part of repair of an atrioventricular canal defect were excluded. The primary end point was the occurrence of TV reintervention or TV regurgitation (TR) ≥ moderate. Results: A total of 85 patients were included. The tricuspid lesion was isolated TR in 80 (94.1%), isolated tricuspid stenosis in 3 (3.5%) and mixed disease in 2 (2.4%) patients. Median age at surgery was 33 years (interquartile range, 12-53 years). TV repair and TV replacement were performed in 66 (77.6%) and 19 (22.4%) patients, respectively. One (1.2%) patient underwent TV reoperation during the same admission. There was no in-hospital mortality. Median follow-up was 3.3 years (interquartile range, 0.1-4.7 years). The overall cumulative incidence of TV reintervention or TR deemed moderate or greater at 1, 3, and 5 years was 3% ± 2%, 11% ± 4%, and 20% ± 8%. In multivariable analysis, age younger than 12 years (P = .04) and mitral valve regurgitation deemed moderate or greater (P = .01) were independent risk factors for TV reintervention or recurrent TR deemed to be moderate or greater at last follow-up. Conclusions: TV surgery in patients with non-Ebstein congenital TV disease can be performed with good outcomes. TV reintervention or TR deemed moderate or greater occurred in 20% of patients on midterm follow-up. Patients younger than age 12 years are at higher risk for recurrent TR or TV reintervention, whereas preoperative MR deemed moderate or greater increases this risk, especially in patients older than age 12 years. There was no difference in outcomes between TV replacement and repair.

Specific cannabinoids revive adaptive immunity by reversing immune evasion mechanisms in metastatic tumours.

Emerging cancers are sculpted by neo-Darwinian selection for superior growth and survival but minimal immunogenicity; consequently, metastatic cancers often evolve common genetic and epigenetic signatures to elude immune surveillance. Immune subversion by metastatic tumours can be achieved through several mechanisms; one of the most frequently observed involves the loss of expression or mutation of genes composing the MHC-I antigen presentation machinery (APM) that yields tumours invisible to Cytotoxic T lymphocytes, the key component of the adaptive cellular immune response. Fascinating ethnographic and experimental findings indicate that cannabinoids inhibit the growth and progression of several categories of cancer; however, the mechanisms underlying these observations remain clouded in uncertainty. Here, we screened a library of cannabinoid compounds and found molecular selectivity amongst specific cannabinoids, where related molecules such as Δ9-tetrahydrocannabinol, cannabidiol, and cannabigerol can reverse the metastatic immune escape phenotype in vitro by inducing MHC-I cell surface expression in a wide variety of metastatic tumours that subsequently sensitizing tumours to T lymphocyte recognition. Remarkably, H3K27Ac ChIPseq analysis established that cannabigerol and gamma interferon induce overlapping epigenetic signatures and key gene pathways in metastatic tumours related to cellular senescence, as well as APM genes involved in revealing metastatic tumours to the adaptive immune response. Overall, the data suggest that specific cannabinoids may have utility in cancer immunotherapy regimens by overcoming immune escape and augmenting cancer immune surveillance in metastatic disease. Finally, the fundamental discovery of the ability of cannabinoids to alter epigenetic programs may help elucidate many of the pleiotropic medicinal effects of cannabinoids on human physiology.

Does Laparoscopic Sleeve Gastrectomy lead to Barrett's esophagus, 5-year esophagogastroduodenoscopy findings: A retrospective cohort study.

INTRODUCTION: Laparoscopic Sleeve Gastrectomy (LSG) is one of the most prevalent approaches to tackle obesity and its co-morbidities. The main complication following the LSG is Gastro-esophageal reflux disease (GERD), with most patients developing worsening symptoms of GERD, and a small number progressing to Barrett's esophagus. This retrospective analysis aims to assess the rate of GERD pre- and post- LSG as well as the rate of progression to Barrett's. METHODS: Data was collected from 1639 patients. 92 patients fit our inclusion criteria. Data was then analyzed and summarized against similar literature. RESULTS: Of 64 (69.6%) patients who had normal EGD findings pre-LSG, only 28 patients (30.4%) had the same results 5 years post-LSG (p= < 0.05). The number of patients who had Grade A GERD almost quadrupled post-LSG, increasing from 3 patients (3.3%) to 14 (15.2%). Patients with esophagitis/gastritis/duodenitis increased from 20 (21.7%) to 32 patients (34.8%). Patients with hiatal hernias increased from 4 (4.4%) to 10 patients (10.9%). The most significant result is that 2 out of 92 patients developed Barrett's Esophagus (2.2%), while 7 other patients developed further serious complications. CONCLUSION: LSG is a very effective and safe bariatric procedure. However, the major downslide is that it can lead to the aggravation of GERD symptoms. This paper and the included literature demonstrate that LSG does lead to a substantial increase in the rate of GERD, however, the percentages of Barrett's Esophagus are markedly low. Performing an EGD pre- and post- LSG is an important protocol that aids in the diagnosis and management of LSG related GERD.

Results from the first Kuwait National Bariatric Surgery Report.

BACKGROUND: Currently, more than 30% of the population in the gulf demonstrate a body mass index (BMI) exceeding 30. This burden of obesity has proven to take a toll on the population; therefore, we created the first Kuwait National Bariatric Surgery Database to report on bariatric surgeries performed in Kuwait. METHODS: Data was collected from the six public hospitals in Kuwait. This data was then submitted to a merged National Registry. Data web portal were used to upload, merge, and analyze the data. RESULTS: The average age for participants was 32.6 years. The average preoperative BMI was 45.9 kg/m2 for males and 43.3 kg/m2 for females. 16.4% of males and 12.3% of females presented with type 2 diabetes, while the most prevalent obesity related disease was a poor functional status in both males and females (90.8% and 90.5%, respectively). Most procedures performed in Kuwait are sleeve gastrectomy. The most encountered in-hospital complication after primary bariatric surgery was bleeding (1.5%), with Roux-en-Y gastric bypass (RYGB) having the highest recorded rate of post-operative complications (3.6% bleeding). The overall rate of operative complications was 2.6%, which was most prevalent post-RYGB (10.3%) and lowest post-sleeve gastrectomy (2.5%). CONCLUSION: The importance of tracking and documenting the journey and change in the rates of obesity and effectiveness of bariatric procedures in individual countries with significantly high obesity rates is imperative to be able to create a plan of action to tackle this worldwide epidemic. This report will be able to provide the population with an accurate accounting that demonstrates further the safety of bariatric/metabolic surgery.

Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass.

BACKGROUND: Bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (SG) being the most performed procedure as of 2014. However, inadequate weight loss may present the need for a revisional procedure. OBJECTIVES: The aim of this study is to compare the efficacy of laparoscopic resleeve gastrectomy (LRSG) and laparoscopic Roux-en-Y gastric bypass in attaining successful weight loss. SETTING: Public hospital following SG. METHODS: A retrospective analysis was performed on all patients who underwent SG from 2008-2019. A list was obtained of those who underwent revisional bariatric surgery after initial SG, and their demographic characteristics were analyzed. RESULTS: A total of 2858 patients underwent SG, of whom 84 patients (3%) underwent either a revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB) or LRSG. A total of 82% of the patients were female. The mean weight and body mass index (BMI) before SG for the LRSG and rLRYGB patients were 136.7 kg and 49.9 kg/m2 and 133.9 kg and 50.5 kg/m2, respectively. The mean BMI showed a drop from 42.0 to 31.7 (P < .001) 1 year post revisional surgery for the LRSG group and 42.7 to 34.5 (P < .001) for the rLRYGB group, correlating to an excess weight loss (EWL) of 61.7% and 48.1%, respectively. At 5 years post revisional surgery, LRSG patients showed an increase in BMI to 33.8 (EWL = 45.3%), while those who underwent rLRYGB showed a decrease to 34.3 (EWL = 49.2%). Completeness of follow-up at 1, 3, and 5 years for rLRYGB and LRSG were 67%, 35%, and 24% and 45%, 21%, and 18%, respectively. CONCLUSIONS: Revisional bariatric surgery is a safe and effective method for the management of failed primary SG. LRSG patients tended to do better earlier on; however, it leveled off with those who underwent rLRYGB by 5 years.

Long-term outcomes after laparoscopic sleeve gastrectomy in Kuwait.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been established as an effective means of weight loss. Multiple studies report LSG as a cost-effective procedure with few perioperative complications. OBJECTIVES: Report long-term weight changes after LSG in a single center in Kuwait. DESIGN: Retrospective analysis of data collected 5-8 years after surgery. SETTING: A single medical center. PATIENTS AND METHODS: All patients that had undergone LSG between December 2008 and December 2011. MAIN OUTCOME MEASURES: Weight changes, short-term complications following surgery (within one month). SAMPLE SIZE: 187. RESULTS: The mean age at the time of the surgery was 36.5 (10.3) years. Females composed 71.6% of this study population.Two patients (1.1%) presented with a leak within 30 days of the surgery. Twenty-one (11.2%) patients underwent revisional bariatric surgery after LSG. Mean (SD) BMI decreased from 47.1 (8.3) kg/m2 before surgery to 34.3 (7) kg/m2 5-8 years after surgery. Mean (SD) body weight decreased from 126.3 (25.3) kg to 91.6 (19.9) kg 5-8 years following LSG. The mean excess body weight loss was 58.8% (29.2%). CONCLUSION: LSG is a bariatric procedure with low complications and mortality in relation to other forms of bariatric surgery. It is associated with a significant improvement in weight loss in the long term. LIMITATIONS: Recall bias due to the nature of collecting the data, small sample size. CONFLICT OF INTEREST: None.

Female Physicians Leading Health Care in the Arab World.

BACKGROUND AND OBJECTIVES: A global trend in female leadership roles in the medical profession is on the rise, and females have been taking up leadership roles in varying and increasing levels. This study aims to identify changes in trends in the medical field in terms of gender in the last decade in Kuwait. METHODS: A case study was conducted, in which data on leadership positions in Kuwait's government hospitals were obtained from hospital registries. Demographic data about female to male physicians were collected from statistics published by the Department of Manpower, Statistics and Planning of Kuwait's Ministry of Health. In addition, statistics on medical graduates were obtained from the Faculty of Medicine (FOM), Kuwait University (KU). RESULTS: In general, every government hospital in Kuwait has experienced an increase in leadership roles among females; in 2008, among all leadership positions in Kuwait's general hospitals, males occupied a majority of positions (60%); whereas in 2016, the male to female ratio was 1:1. The most change in gender trends was witnessed at Mubarak Al-Kabeer Hospital, where female leaders went from 38% in 2008 to 73% in 2016. The specialties that have the highest number of females in leadership positions across all hospitals from 2008 to 2016 were nuclear medicine, radiology, and laboratory medicine. In KU's FOM, female graduates outweighed male graduates, except in 2005-2006, where females reached a minimum of 48%. The number of female physicians has also increased from its lowest of 31% of the total number of physicians in 2004-2006, to 37% in 2015. CONCLUSION: While women make up more than half of medical graduates in Kuwait at present, significant barriers had restricted their entry into formal medical leadership roles in the past. However, it is now seen that females currently occupy more leadership positions in government hospitals in Kuwait.

Repair of a giant diaphragmatic hernia using the dual approach.

Bochdalek hernias are diaphragmatic defects seen in pediatrics. About 5-25% of the cases are diagnosed in adulthood, and present with symptoms of chest and abdominal problems. This is a case of an 18-year-old male who presented to the emergency department with epigastric pain, vomiting and dyspnea. Most of the left-sided organs had herniated to the left chest cavity. Immediate surgery was performed. The stomach, spleen and colon were reduced into the abdominal cavity. The diaphragm defect was repaired laparoscopically, but there were limitations due to inadequate space, leading to difficult visualization of the posterior diaphragmatic leaflet. A thoracoscopic approach was taken where we saw the left kidney herniated through the repair site posteriorly. It was reduced and the defect was closed. The early diagnosis of Bochdalek hernias is important to prevent stomach/intestinal strangulation. Laparoscopic surgeons need to be prepared for a thoracic approach in giant congenital diaphragmatic hernias.

The prevalence of musculoskeletal injuries in bariatric surgeons.

OBJECTIVE: To investigate the prevalence of musculoskeletal (MSK) injuries in bariatric surgeons around the world. BACKGROUND: As the popularity of bariatric surgery increases, efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. However, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with a recent report showing a 73-88% prevalence of physical complaints in surgeons performing laparoscopic surgeries. METHODS: A web-based survey was designed and sent out to bariatric surgeons around the world. Participants were queried about professional background, primary practice setting, and various issues related to bariatric surgeries and MSK injuries. RESULTS: There were 113 responses returned from surgeons from 34 countries around the world. 68.5% of the surgeons have had more than 10 years of experience in laparoscopic surgery, 65.8% in open, and 0.9% in robotic surgery. 66% of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in 27.2% of the surgeons. It was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic, with 29.4% of the surgeons reporting that this pain has affected their task accuracy/surgical performance. A higher percentage of females than males reported pain in the neck, back, and shoulder area when performing laparoscopic procedures. Supine positioning of patients evoked more discomfort in the wrists, while the French position caused more discomfort in the back region. A higher percentage of surgeons who did not exercise experienced more issues in the neck and back region, while those that exercised more than 3 h a week experienced issues in their shoulders and wrists in both open and laparoscopic approaches. Only 57.7% sought medical treatment for their MSK problem, of which 6.35% had to undergo surgery for their issue, of which 55.6% of those felt that the treatment resolved their problem. CONCLUSION: MSK injuries and pain are a common occurrence among the population of bariatric surgeons (66%), and has the ability to hinder performance at work. Therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life.

Stop the bleed campaign: A qualitative study from our experience from the middle east.

BACKGROUND: Bleeding due to unintentional injuries are a leading cause of death in the younger population. The immediate involvement of lay bystanders has been proven to be imperative in outcomes, however, there still is less than 30% of out-of-hospital resuscitation attempts initiated by them. STUDY DESIGN: The Stop the Bleed campaign was initiated in Kuwait in September-2017, with the aim to raise awareness and train the general public on emergency situations. A survey questionnaire was distributed to a sample of 150 participants to assess their comprehension. RESULTS: A total of 1531 participants were trained by the campaign. More than half of the participants have had no previous training of any sort for emergency situations, with the majority (86%) of those queered expressing desire to learn about how to deal with trauma and bleeding cases. After training, most participants were able to demonstrate knowledge of how to deal with unstoppable bleeding, know where and when to place a tourniquet, knew how to respond to epistaxis, and the ability to recognize signs of internal bleeding, with 89% expressing that the 'Stop the Bleed' campaign was useful for promoting health and raising awareness on safety of individuals. CONCLUSION: With the appropriate first-aid training and skill retention, lay members of the public can potentially contribute to a positive and important post-trauma medical response.

Complete atrioventricular canal repair with a decellularized porcine small intestinal submucosa patch.

BACKGROUND: Congenital heart defects affect nearly 1% of all children born per year in the United States, and complete atrioventricular canal (CAVC) accounts for 2%-9%. While several patch materials have been used for septal defect closure during CAVC repair, clear superiority of one material over another has yet to be established. METHODS: A retrospective review of clinical outcomes following CAVC repair at Morgan Stanley Children's Hospital/Columbia University was performed on operations conducted from March 2010 to September 2017. Univariate and Kaplan-Meir survival analyses were utilized to evaluate primary outcomes of interest following CAVC repair in the modern surgical era. RESULTS: A total of 73 patients were analyzed, with an average operative age of 22 weeks. The majority (71%) of the patients underwent a 2-patch repair. A CorMatrix patch was used for ventricular septal defect(VSD) closure in 77% of the patients, and/or in 75% of atrial septal defect closures. There was one in-hospital mortality (1.4%) due to respiratory failure. One patient required a pacemaker. At mid-term follow-up (1.6 years), a total of 7 patients required 8 reoperations due to cardiac-related indications, including 5 for left atrioventricular valve (LAVV) repair, 1 for LAVV replacement, and 2 isolated residual VSDs. CONCLUSION: A standardized repair for CAVC results in excellent outcomes in the current era, with low rates of reoperations. CorMatrix for the closure of CAVC has proven to produce good results with equivalent outcomes to other patch materials. Its ease of use and pliability make it an attractive alternative for consideration.

The pedigree of baraitric surgery: A case series of revisional surgery post laparoscopic sleeve gastrectomy in 3 sisters.

INTRODUCTION: Obesity is a complex disease involving multiple factors that play a role in its development, including genetics. Given the high prevalence of obesity in Kuwait, this is of particular interest. CASE: This is a case of 3 sisters that presented to a single surgeon for morbid obesity with starting body mass indexes (BMI) of 46.9 kg/m2,56 kg/m2,and 51.3 kg/m2. All three elected to undergo a laparoscopic sleeve gastrectomy as an initial procedure. They presented to thier surgeon 5.5 years later with weight regain. The first patient elected to undergo a Laparoscopic Re-Sleeve Gastrectomy, the second Roux-en-Y Gastric Bypass, and the third Single-Anastomosis Gastric Bypass. The patients were followed up for 2-years post-revisional, for which the % EWL was 35.5%, 48.4% and 25.2%, respectively. CONCLUSION: Our study was also able demonstrate how effective revisional surgery is, when genetics are accounted for, with our results showing RYGB as a revisional procedure being superior to the other options.

The aftermath of the Kuwait mosque bombing: A retrospective cohort analysis and lessons learned.

INTRODUCTION: The occurrence of terrorist attacks are still recurrent incidents plaguing the middle east region. However, Kuwait has been mostly spared from these attacks over the years. Therefore, when the bombing of the mosque in 2015 happened, it shocked a country that is not prepared for such disasters. Our aim was to present the incident that occurred on that day and on the lessons learned from it. METHODS: A collaborative effort among the hospitals in Kuwait examined the details and outcomes of the initial response to the bombing. The centers reported their retrospective data, which was analyzed to determine prehospital and intra-hospital management and assess the medical response to the terrorist bombing. RESULTS: A total of 239 victims were involved in the explosion, of which 18 were pronounced dead on site. 147 (67%) were transferred to the hospital for care 22 min after the explosion occurred. The injuries seen were not localized to one region of the body, but afflicted various organ systems. 86 patients were admitted to the hospital, for which five required urgent surgical intervention. Total mortality (on-site and in-hospital) reported after the bombing was 11.2%. CONCLUSION: Rapid response after a mass casualty is of utmost importance for the adequate management of the victims of such tragedies, and could ensure excellent outcomes if performed precisely. However, many lessons can be learned from this shocking event, especially that it exposed the gaps currently present in our disaster plan systems and the importance of looking into addressing them.

Short-Term Results of Revisional Single-Anastomosis Gastric Bypass After Sleeve Gastrectomy for Weight Regain.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become the most performed bariatric procedure as of 2015. However, inadequate weight loss may present the need for revisional procedures. OBJECTIVES: The objective of this study was to analyze the efficacy of single-anastomosis gastric bypass (SAGB) in attaining successful weight loss following an initial LSG. METHODS: A retrospective analysis was performed on all patients who underwent LSG at Amiri Hospital, Kuwait from 2008 to 2017. A list was obtained of those who underwent revisional SAGB surgery after initial LSG, and their demographics were analyzed. RESULTS: A total of 31 patients underwent revisional SAGB bariatric surgery after initial LSG, of which 87.1% were female. Prior to LSG, the mean weight of the patients was 127.5 kg and the mean BMI was 49.0 kg/m2. The mean weight loss after initial LSG was 43.8 kg, while the average duration until patients underwent revisional SAGB was 5.1 years. The cause for revision was weight regain (86.2%), inadequate weight loss (10.3%), or the development of a complication (reflux) (6.5%). Prior to undergoing revisional SAGB, the weight and BMI of the patients were 110.9 kg and 42.6 kg/m2, respectively. This demonstrated a %excess weight loss of 14.5, 31.9, 48.0, and 58.9% 2 weeks, 3 months, 6 months, and 1-year post-SAGB, respectively. Three (10.3%) morbidities were reported and thereafter successfully resolved. CONCLUSION: Revisional SAGB bariatric surgery is a safe and effective method in the short-term basis for the management of inadequate primary LSG.

The safety and efficacy of the procedureless intragastric balloon.

BACKGROUND: Obesity is on a continuous rise worldwide, and with it, novel bariatric procedures have emerged. The introduction of gastric balloons has opened up a nonsurgical option for patients opting for it. However, they still require some form of sedation and endoscopy for insertion and/or removal. OBJECTIVES: The Elipse balloon is a novel creation that has managed to bypass both these procedures; therefore, the investigation into its effectiveness is of importance. SETTING: Royale Hayat, Sabah, and Amiri Hospitals, Kuwait. METHODS: This is a multicenter, prospective analysis of all patients who underwent the Elipse balloon insertion. For the duration of 4 months, weight, body mass index, and the occurrence of adverse events was documented. RESULTS: A total of 135 patients were included, with a mean age of 33.5 years. At the 4-month mark, the mean weight of the patients showed a drop of 13.0 kg (P = .000), and the mean body mass index showed a drop of 4.9 units (P = .000). The mean percent total weight loss was 15.1%. All patients reported nausea in the first day of insertion; however, 69.6% reported complete resolution by the third day. Two patients (1.5%) vomited the balloon early, 3 patients (2.2%) had to have the balloon removed early due to intolerance, 3 patients (2.2%) experienced early deflation, 18 (13.3%) patients reported episodes of diarrhea around the time of deflation, and 29 (21.5%) patients experienced colicky abdominal pain in the week of balloon deflation. One patient experienced small bowel obstruction after which the balloon was removed via laparoscopic enterotomy. CONCLUSION: This study aimed to evaluate the safety and effectiveness of the Elipse balloon in the largest population studied as of date. It was also able to demonstrate that it can be safely and successfully swallowed, filled, imaged, and passed. In addition, it effectively aided in weight loss, showing promising results.

Mothers' and fathers' involvement in intervention programs for deaf and hard of hearing children.

PURPOSE: Parental involvement in the rehabilitation process of deaf and hard of hearing (DHH) children is considered vital to children's progress. Today, fathers are more likely to be involved in their children's care. Nevertheless, father involvement has been understudied and relatively little is known about their involvement in families with children who are deaf or hard of hearing. In addition, there are scant data on the correlates of parents' involvement. This study explored similarities and differences in parental involvement between mothers and fathers in intervention programs for their D/HH children and tested a set of personal and social contextual variables that posited to affect parental involvement in a unique socio-cultural group. METHODS: Thirty Israeli-Arab couples (mothers and fathers) of young D/HH children took part. Each parent completed four self-report measures of parental involvement, parenting stress, parental self-efficacy, and social support. RESULTS: Mothers were significantly more involved than fathers in their child's intervention. Specifically, they report on higher interest and attendance and overall being more actively engaged with professionals in the child's intervention. Both mothers and fathers had a rather passive style of involvement in their child's intervention. Parental self-efficacy and informal and formal social support were associated with father involvement. For mothers, only formal social support was associated with involvement. CONCLUSION: For the Israeli-Arab population, the findings underscore the differences between mothers' and fathers' multiple dimensions of involvement in the intervention program of their D/HH children and their predictors. The results suggest important avenues for prevention and intervention activities when working with families of children who are D/HH. Implications for rehabilitation Parental involvement in intervention programs for children who are deaf or hard of hearing (D/HH) is vital to children's progress and an essential component of implementing family-centered service provision. Understanding of both mothers and fathers multiple dimensions of involvement and the factors that facilitate or hinder their parental involvement in their children's intervention programs, will equip professionals to better support parents of D/HH children aligned with the principles of family centered care service delivery. Mothers and fathers style of involvement reflects on gaps between the goals of family centered care and their implementation in the realities of everyday practice. The experiences and behaviors of mothers and fathers should not be seen as interchangeable.