BACKGROUND:The American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) have published diagnostic guidelines for the evaluation of choledocholithiasis. The applicability and feasibility of these guidelines in a publicly funded health care system, such as ours in Aotearoa New Zealand, are not known. This retrospective study compared the diagnostic performance and utility of these guidelines against our current approach to biliary investigations to explore the feasibility of their local implementation. METHODS:We identified patients with biliary diagnosis during 2017 from admission records. We retrospectively applied the diagnostic criteria of the ASGE 2010, ASGE 2019 and ESGE 2019 guidelines to classify patients as low, intermediate or high risk for choledocholithiasis, and to determine their management if the guidelines were followed. We estimated the diagnostic performance of the guidelines using ERCP or IOC as gold standard. The simulated volume and diagnostic yield of biliary investigations according to guidelines were compared to those observed with our current approach. RESULTS:We included 621 patients, of whom 18% had choledocholithiasis. For diagnosing choledocholithiasis, ASGE 2010, ASGE 2019 and ESGE 2019 guidelines had sensitivities of 79%, 68% and 57% and specificities of 93%, 96% and 97% respectively, if only patients classified as high risk were considered. If patients classified as high or intermediate risk were both considered, their sensitivities increased to > 99% at the expense of lower specificities of 20%-30%. The AUCs for the guidelines were 0.88, 0.85 and 0.83, respectively. When compared to our current approach to biliary investigations, guideline adoption would double MRCP utilisation with correspondingly decreased diagnostic yield. CONCLUSION:Both ASGE and ESGE guidelines for choledocholithiasis may increase the volume of biliary investigations without delivering better diagnostic performance than an ad hoc approach to biliary investigations. Guideline adoption in their current forms cannot be justified in our publicly funded system in Aotearoa New Zealand. Possible contributors to poor guideline performance have been proposed and these will require further research to guide adaptation of the guidelines for our local use.

PURPOSE:Locally advanced gastroesophageal adenocarcinomas commonly relapse early with peritoneal disease, suggesting that a subset of patients harbor occult peritoneal micrometastases at diagnosis. These patients may benefit from peritoneal-directed therapy in the perioperative setting. To facilitate patient selection and evaluation of such therapies, we derived, validated, and compared prediction models for peritoneal recurrence after fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT)-based multimodality treatment using pre- and post-treatment clinicopathologic predictors. METHODS:A total of 2,240 patients from the international Survival and Patterns of Care in the Era-FLOT registry were analyzed. Using Fine-Gray competing-risk regression, patients who developed peritoneal recurrence were compared with those with nonperitoneal recurrence, those who died without recurrence, and those who remained disease-free at follow-up. Pre- and post-treatment variables, obtained at staging and post-FLOT/surgery, respectively, were used to construct pre- and post-treatment predictive models of peritoneal recurrence, with internal validation using bootstrap optimism correction. RESULTS:Peritoneal recurrence was the most frequent (41% of all recurrences) and earliest site of disease relapse (median 9.8 v 11.4 months, P = .024) and was associated with poorer postrecurrence (median 4.4 v 9.8 months, P < .001) and overall (median 17.0 v 24.3 months, P < .001) survival compared with nonperitoneal recurrence. Six pretreatment and eight post-treatment variables independently predicted peritoneal recurrence and were incorporated into pre- and post-treatment models, respectively. At 12, 24, and 36 months postsurgery, both models demonstrated good discriminatory performance in predicting peritoneal relapse with comparable accuracy and risk calibration profiles. Decision curve analysis found that both models were superior to treat-none and treat-all approaches, highlighting their potential clinical utility. CONCLUSION:Peritoneal recurrence remains a common and important problem. We derived pre- and post-treatment prediction models for peritoneal recurrence, also available as web-based calculators. These tools can clinically prognosticate and may advance peritoneal-directed therapies for high-risk patients.

BACKGROUND:In Australian and Aotearoa New Zealand (ANZ), it is unclear whether minimally invasive transthoracic Ivor Lewis esophagectomy (MIO) is superior to open techniques with regards to perioperative and oncological outcomes. Most evidence on this topic have been derived from high-volume centers prior to the advent of perioperative FLOT chemotherapy. How these findings are applicable to the ANZ context, where oesophagectomies are typically performed in low-moderate volume centers, is unknown. This study compares perioperative outcomes and long-term survival between patients undergoing transthoracic open versus hybrid and total MIO following neoadjuvant FLOT chemotherapy across multiple ANZ centers. METHODS:Retrospective analysis of transthoracic oesophagectomies undertaken between 2017 and 2022 following neoadjuvant FLOT chemotherapy from 22 ANZ centers. The primary endpoint was the rate of major (Clavien-Dindo grade ≥ 3) postoperative complication. Secondary endpoints included nodal yield, surgery time, length-of-stay, and rates of perioperative complications, positive resection margins, ICU readmissions, in-hospital mortality, 30-day hospital readmissions, textbook outcome, adjuvant chemotherapy delivered, as well as disease free (DFS) and overall survival (OS). RESULTS:Open esophagectomy, hybrid MIO and total MIO was performed in 155 (62.5%), 61 (24.6%), and 32 (12.9%) patients, respectively. From open to total MIO, there was a stepwise decrease in the rate of major postoperative complications (Open: 38.7%, hybrid MIO: 29.5%, total MIO: 15.6%, p = 0.032). This was associated with reduced length-of-stay [Median(IQR), Open: 14 (11-23), hybrid MIO: 13 (11-23), total MIO: 10 (8-12), p = 0.031], and lower rates of pulmonary (Open: 49.0%, hybrid MIO: 42.6%, total MIO: 28.1%, p = 0.031), cardiac (Open: 20.0%, hybrid MIO: 6.6%, total MIO: 3.1%, p = 0.006), sepsis (Open: 18.7%, hybrid MIO: 8.2%, total MIO: 3.1%, p = 0.022), and wound (Open: 12.3%, hybrid MIO: 3.3%, total MIO: 0.0%, p = 0.019) complications. No significant differences were observed in other perioperative endpoints. Moreover, institutional factors including enhanced recovery after surgery programs and hospital case volume interacted with surgical technique to influence postoperative complication rates. Importantly, adjusted DFS and OS were comparable between the three groups. CONCLUSIONS:In ANZ, MIO was associated with fewer complications and comparable survival compared to open transthoracic esophagectomy. These findings support the safety of MIO in lower-volume settings in the era of perioperative FLOT chemotherapy.

To compare perioperative, oncological, and survival outcomes of total gastrectomy (TG) versus subtotal gastrectomy (SG) in patients with locally advanced distal diffuse gastric adenocarcinoma treated with perioperative 5-fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) chemotherapy. Diffuse distal gastric cancer is characterized by infiltrative growth patterns and early nodal metastasis. Whilst radical resection remains the cornerstone of curative treatment, the optimal extent of surgery with TG or SG, remains debated. This international multicenter cohort study analyzed data from patients with histologically confirmed diffuse gastric adenocarcinoma, located > 5 cm from the gastroesophageal junction. Endpoints included surgical margin status, nodal yield, perioperative morbidity, recurrence patterns, time-to-recurrence (TTR), and overall survival (OS). Outcomes were compared using multivariate analyses. In total, 188 (39.0

BACKGROUND:Functional compromise contributes significantly to adverse outcomes after emergency laparotomy. Sarcopenia, defined as reduced muscle strength and muscle quantity, has been seldom assessed in patients undergoing emergency laparotomy. The aim of this study was to examine functional compromise in emergency laparotomy using sarcopenia, myosteatosis, and frailty parameters and evaluate impacts on functional and patient-centred outcomes. METHODS:Patients aged greater than or equal to 55 years who underwent emergency laparotomy and preoperative computed tomography (CT) at two hospitals in New Zealand between February 2022 and October 2023 were included in a prospective database. Sarcopenia was measured using the SARC-F questionnaire, isokinetic dynamometry to measure hand grip strength, and skeletal muscle quantity according to CT. Myosteatosis was determined using CT and frailty was assessed using the Clinical Frailty Scale. Predictors for rehabilitation, days alive and out of hospital at 90 days, and risk of not returning home were analysed using relative risk and proportional means regression. Secondary outcomes were 3- and 6-month mortality and inpatient morbidity defined using the Clavien-Dindo classification. RESULTS:A total of 101 patients undergoing emergency laparotomy during the study interval were analysed; 21.6% of participants had sarcopenia, 34.7% had myosteatosis, and 24.8% were living with frailty. Muscle strength parameters (low grip strength and a positive SARC-F questionnaire) had significant relationships with primary outcomes. Low grip strength (less than 27 kg for male patients and less than 16 kg for female patients) was most significant for risk of admission for rehabilitation (adjusted risk ratio 5.48 (95% c.i. 2.03 to 14.82)). A positive SARC-F questionnaire (an overall score of greater than or equal to 4 out of 10) was most significant for not returning home (adjusted risk ratio 8.26 (95% c.i. 1.81 to 37.76)). Isolated low muscle quantity (less than 52.4 cm2/m2 for male patients and less than 38.5 cm2/m2 for female patients) demonstrated no relationship. Being frail was most significant for a reduced number of days alive and out of hospital at 90 days (-13.4% compared with non-frail participants (95% c.i. -24.3% to -0.8%)). Sarcopenia and low grip strength were the only parameters to demonstrate a relationship with 3- and 6-month mortality. CONCLUSION:Sarcopenia and frailty parameters are major determinants of functional compromise and predict adverse outcomes after emergency laparotomy. Muscle strength is more important than mass, and measurable without imaging, streamlining its clinical application.

Background: Diagnosing acute appendicitis often requires biochemical and imaging support which may not be feasible in low- and middle-income countries (LMICs). The APPEND score, developed in New Zealand, includes C-reactive protein (CRP) which in resource-limited settings, may be hindered by slow processing times. This study aims to evaluate a modified APPEND score (mAPPEND), excluding CRP for diagnosing appendicitis in a New Zealand Pasifika cohort. Methods: This secondary analysis utilized data from two cohorts (2011 and 2017) from Middlemore Hospital, Auckland. Patients aged >= 15 years with right iliac fossa pain for < 7 days were included, excluding those with prior appendicectomy or generalized peritonitis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated, and diagnostic performance was assessed using receiver operating characteristic curve analysis, comparing the area under the curve (AUC) for both scores. Results: Among 143 Pasifika patients, the AUC for the APPEND and mAPPEND scores were comparable (0.84 vs. 0.85 respectively, p = 0.41). The mAPPEND score demonstrated high diagnostic accuracy with scores between 1 and 2 showing high sensitivity (100% and 97%) and NPV (90% and 92%), scores 4-5 showing high specificity (94% and 100%, respectively) and PPV (90% and 100%, respectively), and a score of 3 being the most efficient with a sensitivity of 82% and specificity of 71%. Conclusion: The mAPPEND score maintains high diagnostic accuracy for appendicitis in a New Zealand Pasifika population. This modified score is a simple and viable tool in settings where CRP testing is unfeasible, supporting its use in Pacific Island countries.

BACKGROUND:To determine if the positive outcomes from clinical trials regarding the safety and efficacy of metabolic bariatric surgery are reproducible at a national level. METHODS:A longitudinal registry-based observation study with data collected from all persons undergoing metabolic bariatric surgery in Australia from 28 February 2012-31 December 2021 including data from 122,567 index patients who underwent 134,625 completed bariatric procedures. MAIN OUTCOMES AND MEASURES:Defined adverse outcomes at 90-days (unplanned readmission, intensive care admission and re-operation; death), annual change in weight (percent total body weight loss (TBWL)), diabetes treatment and need for re-operation. RESULTS:79.0% of participants were female. Mean age on the day of surgery was 44.0 years (SD 11.8; range 12.9-87.9 years) and mean BMI 41.7 kg/m2 (SD 7.6). At 5-years participants who underwent one anastomosis gastric bypass had TBWL 34.88% (SD 8.67%), roux-en-Y gastric bypass 30.73 % (SD 9.47%); sleeve gastrectomy 26.5% (SD 10.5%) and adjustable gastric bands 17.6% (SD 12.1%). At 90-days 3.6% of procedures recorded a defined adverse event. 13,904 (13.6%) primary participants reported being treated for diabetes at baseline. No medication for diabetes was required by 71.6% (follow-up 58%) at 1-year and 61% (follow-up 22%) at 5-years. 13 904 (13.6%) primary participants reported being treated for diabetes at baseline. No medication for diabetes was required by 71.6% (follow-up 58%) at 1-year and 61% (follow-up 22%) at 5-years. CONCLUSIONS:Metabolic bariatric surgery is safe and induces substantial weight loss with reduced need for diabetes medications in the real-world. CLINICALTRIALS: GOV ID:NCT03441451.

PURPOSE:The Australian and New Zealand Bariatric Surgery Registry is developing a bariatric-specific patient-reported outcome measure (PROM) to capture patient outcomes. This study aimed to establish an item bank and questionnaire to assess which outcomes are considered the most important by pre- & post-surgical patients and healthcare practitioners. METHODS:Initial qualitative studies were undertaken to provide an in-depth understanding of patients' lived experiences, and a targeted literature search was conducted to identify appropriate PROMs. Items from identified PROMs were pooled and categorised to form the basis of a questionnaire developed to interrogate bariatric patients' and healthcare practitioners' opinions on the importance of the various outcomes. RESULTS:1,867 items from 76 instruments were extracted and pooled to form the item bank. Items were categorised and refined to generate an Outcome Importance Questionnaire containing 68 items across 10 domains. 313 participants completed the survey, including 48 pre-surgical patients, 180 post-surgical patients, and 85 Healthcare Practitioners. 52 outcomes (of 68; 76.5%) were prioritised by at least 1 group with 'Overall mental health', 'Co-morbidities', 'Satisfaction with surgery' and 'Satisfaction with quality of life' rated as the most important outcomes. CONCLUSION:The item bank and outcome importance questionnaire demonstrated good coverage of patient-reported outcomes considered important to all stakeholders. Initial results identified distinct differences in preference votes by patient and healthcare practitioner groups, with sufficient variation to identify those outcomes considered the most important. Additional rounds of testing, including participant-suggested outcomes and forced-choice questions, will facilitate consensus on the most important outcomes for future inclusion in a Registry-based bariatric-specific PROM.

BACKGROUND:Optimal management of acute biliary disease should include an assessment for possible choledocholithiasis (CBDS). Various diagnostic guidelines have been developed by expert bodies for this purpose, but uncertainties remain about their performance in wider practice. METHODS:For this systematic review and meta-analysis, we searched MEDLINE, Embase, and Scopus for studies on adult populations published in English language between 2000 and August 2024. All studies pertaining to the performance of diagnostic guidelines developed or adopted by regional, national, or international professional bodies are considered, but we excluded diagnostic tools or scoring systems developed locally with limited scopes, such as those employed by a single institution or a group of related institutions. We extracted or derived performance measures in the forms of true positive, true negative, false positive, and false negative and performed meta-analysis using a multilevel random effects model to calculate pooled sensitivity and specificity for the reviewed guidelines and summarized their performance using summary ROC curves and AUCs. The quality of the evidence was assessed with the PROBAST risk of bias and applicability tool. This study is registered on PROSPERO (CRD42024581409). FINDINGS:Of 1892 records identified, 31 studies were eligible with data available, all of which had a low to moderate risk of overall bias. All studies focused on one or more of three international guidelines, namely the ASGE guidelines in 2010, the revised ASGE guidelines in 2019, and the ESGE guidelines in 2019. For distinguishing patients at high risk for CBDS from those not at high risk, ASGE 2010, ASGE 2019, and ESGE guidelines have pooled sensitivities of 65% (CI: [57,73]), 63% (CI: [53,73]), and 62% (CI: [50,74]) and pooled specificities of 57% (CI: [48,66]), 75% (CI: [65,83]), and 82% (CI: [71,90]), respectively. For distinguishing patients at low risk for CBDS from those at greater than low risk, ASGE 2010, ASGE 2019, and ESGE guidelines have pooled sensitivities of 97% (CI: [92,99]), 95% (CI: [90,98]), and 84% (CI: [70,93]) and pooled specificities of 7% (CI: [3,18]), 11% (CI: [7,18]), and 15% (CI: [8,28]), respectively. Overall, the AUCs for ASGE 2010, ASGE 2019, and ESGE guidelines are 0.65, 0.74, and 0.73, respectively. CONCLUSION:ASGE 2019 and ESGE guidelines have comparable performance, with their key strength being the ability to rule out CBDS in low-risk patients, allowing these patients to proceed with cholecystectomy without additional workup. All guidelines have limited specificity in identifying patients at high risk for CBDS and cannot reliably select patients for upfront ERCP. PROSPERO REGISTRATION:CRD42024581409.

BACKGROUND:Although open repair has historically been the preferred approach over laparoscopic repair for acutely strangulated and incarcerated groin hernias, the laparoscopic approach is gaining popularity. This systematic review and meta-analysis aims to investigate the safety and clinical outcomes of laparoscopic and open groin hernia repair in the emergency setting. METHODS:PubMed, Embase, Scopus, Cochrane Library, and Web of Science were systematically searched for articles comparing clinical outcomes between laparoscopic and open emergency groin hernia repair in adult patients. The primary outcome was the length of hospital stay. Secondary outcomes included operative time, postoperative complications, recurrence, reoperation, postoperative mortality, and the rate of conversion from laparoscopic to open repair. Risk of bias was assessed. RESULTS:Thirteen articles (4 prospective and 9 retrospective cohort studies) were included, with a total of 38,659 patients enrolled. Laparoscopic repair resulted in shorter length of hospital stay (MD -2.96 days [95% CI -4.91, -1.01] and p = 0.0074) and lower risk of wound infection (RR 0.29 [95% CI 0.20, 0.43] and p < 0.0001]. No statistically significant differences were observed between the two groups regarding operative time (p = 0.1006), risk of seroma formation (p = 0.3142), and risk of respiratory complication (p = 0.9880). Rate of conversion from laparoscopic to open repair as recorded in five studies was 2.78% ([95% CI 0.60, 11.92]). CONCLUSION:Emergency laparoscopic repair of groin hernias results in shorter length of hospital stay and lower risks of postoperative morbidity and mortality, with no difference in operative time when compared to open repair. Although further large-scale prospective cohort studies and randomized controlled trials may be required to draw definitive conclusionsregarding the optimal surgical approach, laparoscopic repair of groin hernias appears to be a safe and feasible alternative to conventional open repair in the acute setting.

Background: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored. Methods: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of >= 5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. Results: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. Conclusion: Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Objective: This study aims to assess whether the rate of readmissions after ureterorenoscopy (URS) is dependent on results of urine microscopy, culture and sensitivity (MC&S) or nitrite dipstick test performed before the procedure. Patients and Methods: All patients attending for ureteroscopy for stone disease over 12 months were included and had urine dipstick performed immediately prior to the surgery with mid-stream urine (MSU) sample sent for culture. Asymptomatic bacteriuria (ABU) was not treated before ureteroscopy. All included patients received standard antibiotic prophylaxis. Readmissions within 30 days of the procedure were evaluated. Results: A total 120 ureteroscopies were included, of which 20% had ABU. Eight patients (6.67%) were readmitted due to all procedure-related complications; among them, five (4.17%) were readmitted with urinary tract infection (UTI). Readmission rates with UTIs were similar for patients with sterile urine and those who had untreated ABU. Of those patients who were readmitted with UTI, all had a negative nitrite result on preoperative urine dipstick specimens. Most patients (54.17%) who had ABU also had a negative urinary nitrite test. Conclusions: Screening and routine treatment of ABU before ureteroscopy for urolithiasis may be unnecessary provided patients have standard antibiotic prophylaxis. Moreover, urine nitrite testing before ureteroscopy may not be a useful screening test for ABU before ureteroscopy. Level of evidence: 2

BACKGROUND:The National Emergency Laparotomy Audit (NELA) risk prediction tool has demonstrated superiority in predicting 30-day mortality after emergency laparotomy (EL). The aim of our study was to evaluate the accuracy of NELA in calculating long-term (5 year) mortality and determine factors predicting long-term risk of death after EL. METHODS:This retrospective cohort study included consecutive patients who underwent EL for any indication other than trauma between May 2012 and June 2017 at a large tertiary and academic teaching center. The primary outcome was all-cause postoperative mortality at 1 and 5 years. The c statistic (<1.0, excellent; <0.90, good; 0.80, fair; 0.70, poor) was used to assess accuracy of the NELA. Multivariable regression was used to identify independent risk factors for 5-year mortality after EL. RESULTS:From a total of 758 patients, observed mortality continued to increase from 15.4% at 1 year up to 31.4% at 5 years. The NELA risk score accurately classified deceased patients at both 1 year ( c = 0.82; 95% confidence interval [CI], 0.78-0.85) and 5 years ( c = 0.82, 0.79-0.85) after EL. History of ascites (adjusted odds ratio [aOR], 3.3; 1.0-11.3; p = 0.048), chronic obstructive pulmonary disease (aOR, 1.9; 1.1-3.4; p = 0.030), congestive heart failure (aOR, 3.6; 1.2-11.5; p = 0.025), myocardial infarction (aOR, 2.6; 1.5-4.6; p = 0.001), and a new cancer diagnosis (aOR, 2.8; 1.7-4.8; p < 0.0001) were independent prognostic factors for death 5 years after EL. CONCLUSION:Long-term prognosis after EL remains poor for at least 5 years postoperatively. The NELA score is accurately able to predict risk of death up to 5 years after EL. History of ascites, chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction, and a new diagnosis of cancer were independent prognostic factors for long-term mortality after EL. LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level IV.

Introduction Emergency laparotomy (EL) is a high-risk operation which is increasingly performed on an aging patient population. Objective frailty assessment using a validated index has the potential to improve preoperative risk stratification. This study aimed to assess the correlation between frailty and long-term mortality and morbidity outcomes for older EL patients. Secondary aims were to compare the 11-item and shortened five-item modified frailty indices (mFIs) in terms of value and predictive validity. Methods A prospective multicenter observational study of patients aged ≥55 y undergoing EL was conducted across five hospitals in New Zealand between 2017 and 2022. Frailty was measured using the 11-item and abbreviated five-item mFIs. Multivariable logistic regression was used to determine whether frailty was independently associated with one-year postoperative mortality and other morbidity outcomes. Correlation between the two frailty indices were assessed with the Spearman's correlation coefficient (P). Results Frailty assessments were performed in 861 participants, with the prevalence being 18.7% and 29.8% using the 11-item and five-item mFIs, respectively. Both frailty indices demonstrated similar associations with one-year mortality (two-fold increased risk), major complications, admission to intensive care unit, rehabilitation, and 30-d readmission. The 11-item mFI demonstrated a greater association with early mortality (four-fold increased risk), reoperations, and increased length of stay compared with the five-item frailty index. Spearman P was 0.6 (P < 0.001). Conclusions Frailty, as identified by the 11-item and five-item mFIs, was associated with one-year mortality and other important morbidity outcomes for older EL patients. These forms of frailty assessment provide important information that may aid in risk assessment and patient-centered decision-making.

A potential complication of bariatric surgery is development of nutritional deficiencies. Study aims were to assess prevalence of micronutrient deficiencies in preoperative bariatric patients and to examine for ethnic differences. Retrospective analysis of 573 patients that underwent bariatric surgery at Counties Manukau District Health Board was carried out. Mean preoperative levels of albumin, calcium, phosphate, folate, vitamin B12, vitamin D, magnesium, haemoglobin, haematocrit, mean cell volume, mean cell haemoglobin, ferritin, iron, and transferrin were calculated. Chi square, fisher exact test, and multiple logistic regression was used to assess for differences in prevalence of micronutrient deficiencies across ethnicities. The most common micronutrient deficiency was vitamin D (30.85

ANZ Journal of SurgeryEarly View LETTER TO THE EDITOR Invited author's response to Letter to the Editor 'Complexities of bariatric surgery funding and registry capture limits LOS conclusion applicability' Chiara Chadwick MBBS, FRACS, Chiara Chadwick MBBS, FRACS orcid.org/0000-0002-5866-6919 Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Oesophago-Gastric and Bariatric Unit, Alfred Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorPaul R. Burton PhD, FRACS, Paul R. Burton PhD, FRACS Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Oesophago-Gastric and Bariatric Unit, Alfred Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorJennifer Reilly FANZCA, PhD, Jennifer Reilly FANZCA, PhD orcid.org/0000-0002-7109-8493 Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Department of Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorDianne Brown BEc(Hons), Dianne Brown BEc(Hons) Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorJennifer F. Holland BSpPath, MHlthInfoMgmt, Jennifer F. Holland BSpPath, MHlthInfoMgmt Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorAngus Campbell BSc, Angus Campbell BSc Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorJenifer Cottrell ADC Cert., DDS, Jenifer Cottrell ADC Cert., DDS Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorAndrew D. MacCormick PhD, FRACS, Andrew D. MacCormick PhD, FRACS Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, Australia Department of Surgery, University of Auckland, Auckland, New ZealandSearch for more papers by this authorIan Caterson PhD, FRACP, Ian Caterson PhD, FRACP Boden Initiative, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorWendy A. Brown PhD, FRACS, Wendy A. Brown PhD, FRACS orcid.org/0000-0002-0137-2688 Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Oesophago-Gastric and Bariatric Unit, Alfred Health, Melbourne, Victoria, Australia Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this author Chiara Chadwick MBBS, FRACS, Chiara Chadwick MBBS, FRACS orcid.org/0000-0002-5866-6919 Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Oesophago-Gastric and Bariatric Unit, Alfred Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorPaul R. Burton PhD, FRACS, Paul R. Burton PhD, FRACS Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Oesophago-Gastric and Bariatric Unit, Alfred Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorJennifer Reilly FANZCA, PhD, Jennifer Reilly FANZCA, PhD orcid.org/0000-0002-7109-8493 Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Department of Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Victoria, AustraliaSearch for more papers by this authorDianne Brown BEc(Hons), Dianne Brown BEc(Hons) Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorJennifer F. Holland BSpPath, MHlthInfoMgmt, Jennifer F. Holland BSpPath, MHlthInfoMgmt Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorAngus Campbell BSc, Angus Campbell BSc Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorJenifer Cottrell ADC Cert., DDS, Jenifer Cottrell ADC Cert., DDS Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this authorAndrew D. MacCormick PhD, FRACS, Andrew D. MacCormick PhD, FRACS Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, Australia Department of Surgery, University of Auckland, Auckland, New ZealandSearch for more papers by this authorIan Caterson PhD, FRACP, Ian Caterson PhD, FRACP Boden Initiative, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, New South Wales, AustraliaSearch for more papers by this authorWendy A. Brown PhD, FRACS, Wendy A. Brown PhD, FRACS orcid.org/0000-0002-0137-2688 Monash University Department of Surgery, Central Clinical School, Alfred Health, Melbourne, Victoria, Australia Oesophago-Gastric and Bariatric Unit, Alfred Health, Melbourne, Victoria, Australia Monash University, School of Public Health and Preventive Medicine, Bariatric Surgery Registry, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 22 April 2024 https://doi.org/10.1111/ans.19005 Dr. Wendy Brown is an Editorial Board member of ANZ Journal of Surgery and a co-author of this article. To minimize bias, they were excluded from all editorial decision-making related to the acceptance of this article for publication. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Ettorchi-Tardy A, Levif M, Michel P. Benchmarking: a method for continuous quality improvement in health. Healthc Policy. 2012; 7: e101–e119. PubMedGoogle Scholar 2Chadwick C, Burton PR, Brown D et al. Bariatric surgery efficiency, safety and health outcomes in government versus privately funded hospitals. Obes. Surg. 2023; 33: 1160–1169. 10.1007/s11695-023-06489-3 PubMedGoogle Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

BACKGROUND:Healthcare systems globally face the issue of resource constraints and need for prioritization of elective surgery. Inclusive, explicit prioritization tools are important in improving consistency and equity of access to surgery across health systems. The General Surgical Prioritization Tool developed by New Zealand's Ministry of Health scores patients for elective non-cancer surgery based on surgeon's clinical judgement and patient derived Impact on Life (IoL) scores. This study aims to measure the changes in patient derived IoL scores after common general surgical procedures to enable direct comparison and inform future prioritization. METHOD:This longitudinal observational study enrolled 322 participants who had undergone elective general surgical procedures. Participants were contacted 3 to 9 months after their procedures and requested to complete the IoL questionnaire. The primary endpoint was the change in IoL scores after surgery among the different procedures. RESULTS:Overall, 229/304 (75%) participants responded to the questionnaire and there were no significant baseline differences between responders and non-responders. Patients in the gallbladder treatment group had the greatest improvement in IoL scores. Patients across all ethnic groups had similar changes in IoL scores. Multivariate analysis showed that gallbladder surgery (relative to hernia surgery) and pre-surgery IoL scores significantly predicted improvement. CONCLUSION:The patient reported IoL score recorded at prioritization for surgery all reduced, albeit to varying amounts, after common general surgical procedures. This, combined with the fact that IoL scores predicted post-operative improvement support their inclusion in prioritization tools in addition to surgeon derived components.

BACKGROUND:The Ninth Perioperative Mortality Review Committee (POMRC) report found the likelihood of death was over three times higher in Māori youth compared to non-Māori (age: 15-18 years) in the 30-days following major trauma. The aim of our study is to investigate variations in care provided to Māori youth presenting to Te Whatu Ora Counties Manukau (TWO-CM) with major trauma, to inform policies and improve care. METHODS:This was a retrospective, observational study of 15-18-year-olds admitted to Middlemore Hospital from January 2018 to December 2021 following major trauma (Injury Severity Score (ISS) >12 or with (ISS) <12 who died). Data were obtained from the New Zealand Trauma Registry (NZTR). Six key performance indicators were studied against hospital guidelines/international consensus: Deaths, Cause-of-death, trauma call, RedBlanket activations, time-to-computed tomography (CT), and time-to-operating theatre (OT). RESULTS:Of 77 patients, five deaths occurred, four non-Māori, and one Māori (P = 0.645). Five trauma calls were not activated (P = 0.642). There was no statistically significant difference for both median time to CT (P = 0.917) and time to CT for patients with GCS >13 (P = 0.778) between Māori and non-Māori. Five patients did not meet guidelines for time-to-OT (three non-Māori and two Māori) (P = 0.377). CONCLUSION:No statistically significant variations in care were present for Māori youth presenting with major trauma, these findings did not match the national trend.

BACKGROUND:Quality performance indicators for the management of oesophagogastric cancer can be used to objectively measure and compare the performance of individual units and capture key elements of patient care to improve patient outcomes. METHODS:Two systematic reviews were completed to identify evidence-based quality performance indicators for the surgical management of oesophagogastric cancer. Based on the indicators identified, a two-round modified Delphi process with invitations was sent to all members of the Australia and Aotearoa New Zealand Gastric and Oesophageal Surgery Association. The expert working group discussed each suggested indicator and either removed, added, or adjusted the list of indicators of oesophagogastric cancer. RESULTS:The final list of both OG cancer indicators included Specialized Multi-disciplinary team discussion, Endoscopy documentation, Staging Contrast CT Chest/Abdomen and Pelvis, Neoadjuvant or Adjuvant chemo/radiotherapy administered in accordance with the Local multi-disciplinary team, Pathological margin clearance (R0 Resection), Lymphadenectomy retrieving 15 or more nodes, Formal review of pathological findings and documentation, Postoperative complications, 30-day and 90-day postoperative mortality, clinical surveillance and Specialized Dietetic guidance. Indicators specific to gastric cancer included Preoperative biopsy for pathological diagnosis and Staging Laparoscopy. Indicators specific to oesophageal cancer include positron emission tomography scan if CT negative for metastasis, Perioperative Oesophagectomy Care Pathway, length of stay of 21 days or more, and Unplanned readmission within 30 days. CONCLUSIONS:The results of this study present a core set of indicators for the surgical management of oesophagogastric cancer that can be used to measure quality and compare performance between different units.