Aims To explore General Practitioner (GP) and patient perspectives on contemporary post-bariatric surgery care in Australia across metropolitan and regional settings and public and private surgical pathways. Methods This qualitative study used semi-structured interviews with 16 GPs and 19 adults who had undergone sleeve gastrectomy or gastric bypass ≥ 12 months previously. Participants were purposively sampled across metropolitan and regional locations, and public and private surgery settings. Interviews were conducted virtually, transcribed verbatim, and analysed inductively using reflexive thematic analysis. Coding density and participant characteristics were descriptively examined to explore variation by geography and funding sector. Results Six themes were identified: medical care and continuity, healthcare setting constraints, patient-level determinants, navigating surgery outcomes, support, and weight stigma and sensitive communications. GPs emphasised system-level challenges, including inadequate information from surgeons, workload pressures, and the need for stigma-sensitive communication. Patients highlighted inconsistent medical care and access to multidisciplinary services, variable confidence in GP-led follow-up and unmet support needs. GP perspectives were consistent across geographical settings, whereas patient experiences differed by location and surgery funding sector, with greater barriers reported by regional and public patients. Clear handover documentation and structured follow-up were consistently described by GPs and patients as facilitating more coordinated and satisfactory care. Conclusions Post-bariatric surgery care in Australia remains fragmented, with persistent gaps in continuity, multidisciplinary access, and support. Strengthening shared-care frameworks through consistent surgical handover, structured lifelong follow-up, and targeted education for both GPs and patients, would improve care coordination and long-term outcomes.

BACKGROUND:Australian public-private bariatric surgery comparisons have largely focused on access, safety and clinical outcomes, with less evidence describing provider-specific engagement across the perioperative pathway. OBJECTIVES:To compare pre-operative engagement, provider-specific follow-up, attrition and weight outcomes between public and private bariatric surgery pathways in Australia. METHODS:This prospective multi-site observational study included adults undergoing bariatric surgery across two public and two private services in New South Wales (2021-2024). Appointment attendance across the perioperative period (12 months pre- to 24 months post-surgery) was analysed. Engagement, attrition and weight outcomes were compared using non-parametric tests, regression analyses and Kaplan-Meier and Cox proportional hazards models. RESULTS:Of 240 participants, 176 (73.3%) underwent private and 64 (26.7%) public surgery. Public patients had higher baseline weight, BMI, multimorbidity and greater socioeconomic disadvantage (all p < 0.001). They engaged longer pre-operatively (21.6 vs 2.7 months) and attended more MDT appointments (14 vs 2; both p < 0.001), with greater exposure to non-surgical doctors, dietitians, nurses, psychologists, and exercise professionals. Post-operatively, public patients attended a median of 12 (IQR 9-18) appointments compared to 7 (IQR 5-10) in the private services (p < 0.001) and remained engaged longer (18.2 vs 14.5 months). Attrition occurred later in public patients but was similar by 24 months. No statistically significant differences in relative weight loss were detected beyond 6 months. Surgical setting (B =4.344, p < 0.001) and anticipated support need (B =2.194, p = 0.035) were independently associated with post-operative attendance. CONCLUSION:Follow-up engagement appeared to be associated with surgical setting and anticipated support need, while observed weight loss outcomes were broadly similar between sectors. However, baseline differences and observational design preclude conclusions about the comparative effectiveness of the care pathways.

BACKGROUND AND AIMS:With modern healthcare now shifting towards a more patient-centred approach, informed consent and expectation management relies on both easily accessible and accurate information. YouTube is a popular source of medical information for patients, but its lack of regulation, especially on procedures like Ivor-Lewis oesophagectomies, warrants analysis of the quality of content available. This study aims to assess the quality of information on YouTube related to the Ivor-Lewis oesophagectomy for patient education. METHODS:A search of YouTube (www.youtube.com) videos was conducted in May 2025 with the term 'Ivor-Lewis oesophagectomy'. The inclusion criteria required the videos to discuss Ivor-Lewis oesophagectomies, be narrated/subtitled in English, intended for patients and educational in nature. The exclusion criteria removed videos that were non-English, technical surgical videos aimed at healthcare providers, and promotional videos. The videos were evaluated using the DISCERN tool and the Global Quality Score (GQS) and other descriptive statistics. RESULTS:A total of 226 videos were assessed against the inclusion and exclusion criteria. Twelve videos were deemed eligible as per the criteria and were included for analysis. The median view count was 10 961 views and the median length of the videos were 162 s. The median DISCERN score was 52.5/80 with medical institutions garnering the highest median out of all the source categories (58/80). The median GQS score was 4 points. CONCLUSION:YouTube videos on Ivor-Lewis oesophagectomies were largely of poor quality, indicating greater need for regulation and standards for medical information on video-hosting platforms.

Minimally invasive oesphagectomy has been found to reduce complications, length of stay and have improved post-operative quality of life compared to open oesophagectomy. Multiple techniques of the oesophagogastric anastomosis have been described in Australia including a three-stage approach with a neck anastomosis and a two-stage approach utilising the trans-orally placed anvil. We describe a two-stage approach with an intra-thoracic hand-sewn anastomosis for a junctional oesophageal cancer.

Metabolic and bariatric surgery (MBS) is used to achieve significant and sustained weight loss. Considerable MBS are performed on women of reproductive age, with limited data regarding risks and management pre-conception and peripartum. Our retrospective audit assessed adult women in pregnancy with prior MBS, attending a specialised, multidisciplinary obesity service between January 2018 and July 2022. Baseline clinical and demographic characteristics, including surgical data, anthropometry, nutritional status, and pregnancy outcomes were collected for each pregnancy and evaluated. Across 189 women and 210 pregnancies, pre-pregnancy obesity (BMI ≥ 30) prevalence was 55.9

AIMS:To explore information-seeking behaviours, influences, expectations, and healthcare professional and psychosocial support needs among individuals preparing for bariatric surgery in New South Wales (NSW), Australia, and to examine differences across public/private and metropolitan/regional healthcare settings. METHODS:Baseline data were collected from a longitudinal, prospective cohort study (HREC 2020/ETH02984) using a purpose-designed questionnaire, from April 2021-September 2024. Adults were recruited from four bariatric services (two public, two private) across metropolitan and regional NSW. Outcomes included self-reported demographics, information sources, beliefs, and support needs prior to surgery. RESULTS:Participants (n = 238) were predominantly female (79.0 %), aged 43 ± 11.3 years, with a median BMI of 44.5 kg/m² (IQR 39.4-49.7). Of the cohort, 74.0 % attended private and 66.8 % metropolitan services. Public participants had significantly higher BMI than private (48.3 vs 42.2 kg/m², p < 0.05). Key barriers to weight loss included stress, illness, medications, and limited support, particularly in regional and public groups. Most accessed information from the internet (72.0 %) and GPs (67.0 %), with GP involvement higher in regional (81.7 %) and public (82.5 %) settings. Peer experiences strongly influenced decision-making. Participants expected 33-35 % total weight loss, above typical Australian outcomes (29.0 %), and were motivated by health (94.7 %), quality of life (90.0 %), and activity (81.4 %). Common concerns included weight regain (90.0 %), excess skin (89.0 %), and dietary restrictions (75.0 %). Most (71.8 %) anticipated support for 12 months or less or were unsure. CONCLUSION:Individuals preparing for bariatric surgery reported high expectations and varied healthcare professional and psychosocial support needs. Differences across settings highlight inequities in access, supporting the need for tailored, multidisciplinary care and realistic goal-setting.

BACKGROUND:Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP. METHODS:Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications. RESULTS:We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks. CONCLUSION:Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.

Abstract Purpose In the wake of the global obesity epidemic, bariatric surgery has become critical to prevent the complications of obesity and reduce the impact across health care systems. Laparoscopic Gastric Band insertion was at one point the most performed bariatric operation for obesity. In Australia, due to the limited publicly funded bariatric units, LAGB insertion is often performed in the private health sector. However, the post operative course for many of these patients who underwent LAGB has been fraught with complications often resulting in presentation to emergency, explantation of the LAGB and further surgical intervention. and is considered unfavourable in management of obesity. Methodology We performed a search of medical subject headings within PubMed, Medline and Embase for the terms ‘Gastric Band*’, ‘remov*’, ‘explant*. Following removal of duplicates, a total of 46 articles detailing the incidence of gastric band removals. Studies were included if they included discrete cohorts of patients who have undergone LAGB insertion, reported data on incidence of removal and median follow up >3 years. Results Results of the literature review will be discussed. Conclusion While it is considered unfavourable as a surgical option for management of obesity, public hospitals continue to absorb many patients who have undergone this procedure placing stress on an already stretched system. The incidence of LAGB varies in the literature. The authors would like to provide an updated review of the literature to determine the incidence of LAGB to better inform patients and health care providers.

Abstract We present the case of a 66-year-old male with spontaneous oesophageal perforation treated with oesophageal stenting. This patient reports sudden onset severe anterior chest pain after coughing and haematemesis with a background medical history of Type II DM, ESRF on Haemodialysis, Hypertension, OSA and takes prophylactic Aspirin. Endoscopy reveals multiple areas of oesophageal perforation in the proximal, middle, and distal oesophagus as well as a haematoma extending the entire length of the oesophagus to the COJ. This was treated with insertion of a WallFlex™ Fully Covered Oesophageal Stent as the patient was unsuitable for surgery. The result was re-epithelialisation of the entire oesophagus and complete resolution of the perforation at the mid-oesophagus. Dutch physician Boerhaave first described spontaneous oesophageal perforation in 1724. Commonly, these were treated surgically with associated high morbidity and mortality. Advances in endoscopic and stent technology has given clinicians a greater armamentarium to treat patients especially in the frail end elderly population. These advances include choices such as stent covers, biodegradable and removable stents, and anti-reflux valves. Complications with oesophageal stents such as fistula formation, stent migration and retrosternal pain are often associated with the length of placement. The choice of a fully covered retrievable oesophageal stent in our case provided reconstitution of oesophageal lumen and minimisation of mediastinal sepsis. With the progress in stent technology, we believe there will be greater use of endoscopic oesophageal stenting for oesophageal perforations bridges the gap between operative and non-operative management.

Obesity is a complex lifelong disease of excessive adiposity, impairing health and well-being.1 Intentional weight loss in those with obesity is associated with reduced risk of many chronic diseases and favourable health outcomes.2 Bariatric surgery, in association with lifestyle change, is currently the most effective and durable strategy for weight management for people living with obesity.3 The literature supporting the weight and health benefits of bariatric surgery is extensive. However, there are equally as many papers presenting a more circumspect outlook, especially regarding psychosocial outcomes.4, 5 These include difficulties adjusting to a new body after surgery, body–mind disconnect, food-related battles, changes in personal relationships, the need for ongoing life-long lifestyle changes and expectations that surgery will fix more than weight.4, 5 Unrealistic, high expectations of surgery are not uncommon6 and those undertaking surgery may underestimate or ignore the prospect of challenges after surgery. Many people struggle to attain and maintain weight loss 2 years and beyond, with reversal of health benefits seen. Weight regains of greater than 15% of initial weight loss in 25%–35% of patients, 2–5 years after surgery are reported in the literature.7, 8 The reasons for modest outcomes include (i) hormonal and metabolic adaptations affecting appetite and satiety, (ii) poor nutritional behaviours and intake (iii) physical inactivity (iv) mental health difficulties and (v) surgical failures.9 Bariatric surgery is underutilized globally for many reasons, including patient and physician attitudes to surgery as a treatment option, low prioritization of obesity treatment overall by policymakers and socio-economic barriers, as most countries provide bariatric surgery only, or majority, within the private health sector or via health insurance.10 When bariatric surgery is offered in the public health system, strict eligibility criteria usually apply. Despite accessibility for relatively few people living with obesity, who would otherwise benefit, support and care following surgery is crucial to beneficial health outcomes. The aim of this review is to provide a synoptic overview of the support and care needs of people undertaking bariatric surgery. This includes research from the perspective of those living with obesity on the role health care professionals provide, and related to the efficacy of various technologies, including virtual health care, apps and social media. A review of the literature was undertaken and included relevant articles sourced from PubMed, MEDLINE and Scopus electronic databases. English language articles exploring support needs for those undertaking bariatric surgery and clinical practice guidelines and recommendations were included. Keywords used in the searches included 'bariatric', the combined term 'metabolic and obesity surgery' and specific surgical terms such as 'sleeve gastrectomy', 'gastric bypass' and 'roux en y'. These terms were linked with themes of 'patient support', 'social support', 'support groups', 'social media', 'health care', 'interventions' and 'technology'. The search aim was to present a balanced and informed review of relevant articles to benefit those working clinically within the bariatric setting. Bariatric surgery, in combination with lifestyle support, is currently the most effective and durable strategy for weight management in the setting of obesity and its associated health conditions.11 The American Society of Metabolic and Bariatric Surgeons and the International Federation for the Surgery of Obesity and Metabolic Disorders recommend bariatric surgery for adults with a BMI ≥35 kg/m2 regardless of high-risk co-morbidities and for those with metabolic disease and a BMI of 30–34.9 kg/m2.3 Reflecting the complexity of obesity, even after bariatric surgery, international guidelines recommend multidisciplinary involvement pre- and post-surgery to ensure informed consent and care of the person living with obesity.3 People with obesity are at higher risk of poor physical and mental health and are more likely to be targets of discrimination and stigma. Bariatric surgery can cause psychosocial changes in people, with some people coping better than others.12, 13 There may be initial improvements in psychosocial functioning, mobility, ability to undertake activities of normal living, self-esteem and feeling included in society.4 However, ongoing 'battles' with food intake and behaviour and feeling uncomfortable in social gatherings are also described in the literature,4 with control over weight and eating diminishing over time.5 Weight stigma and body image dissatisfaction can continue post-surgery and are associated with less weight loss, reduced quality of life and poor mental health compared to pre-surgery.14 A significant number of people with obesity over-estimate potential weight loss following surgery. Possible reasons for this include poor pre-operative education and communication around usual weight loss and regain by the treating team, unrealistic patient expectations and an emphasis on weight as the most important health marker.15, 16 Insufficient weight reduction or weight gain can lead to disappointment personally and within the clinical team.15 Furthermore, people who have lost smaller amounts of weight, may be considered 'non-responders' or 'failures', even though their health and well-being may have improved. The type of support required, when and by whom, and if this support impacts outcomes after bariatric surgery, is largely inconclusive. Qualitative studies using interviews or questionnaires provide a rich source of information, however, study numbers are small, and participants are often recruited from support groups and/or health care organizations.12, 17-19 Therefore, insights may be biased, as cohorts include those already considered proactive in their health.16 Perspectives of those not engaged in support networks or ongoing health care support may provide differing opinions. Despite these methodological limitations, studies of this nature are important as they offer insight from those with lived experience of bariatric surgery. As such, to assess the most appropriate support and care for people who have had bariatric surgery, these perspectives should be prioritized. Health and medical support are essential pre and post-surgery, as is the need for social support. Social support is defined as the psychological and tangible resources provided to an individual enabling more effective coping skills following biological, psychological and social stressors.20 Support networks have been shown to have an immense influence upon a person's physical, psychological and emotional well-being and longevity.21 They can include family, friends and colleagues; caregivers and health professionals; social media and support groups. Support may be considered emotional; informational; tangible; affirmational, or appraisal and from belonging or connectedness, for example, to a community or group.22 Those with lived experience of bariatric surgery express the need for support from a wide network of people and services, and many report the inadequacies of health services to provide this support.5, 18 Achieving patient-defined surgical success, including weight loss and enhanced quality of life,23 is challenging and reports of triumph and trials17 and a lonely struggle16 populates the literature. People undergoing bariatric surgery indicate they want emotional and affirmational support and encouragement from friends, family, peers and the surgical team.19 The support of family and friends influences whether bariatric surgery is undertaken.24 Furthermore, involvement of intimate partners in education pre and post-surgery, has shown to positively impact dietary behaviour, physical activity, intimacy and relationships.24, 25 Lower perceived social support both pre and post-surgery is correlated with higher scores in depression, disordered eating, poorer weight outcomes and greater weight variations.26 Family encouragement is postulated to promote better adherence to a beneficial lifestyle after surgery. Health care professionals are expected to provide specialized advice and encouragement, and address concerns pre and post-surgery.19 Preferred health care professionals are those considered non-judgemental and proactive in care.16, 27 Furthermore, patients desire an understanding of the role of each health care professional in a multidisciplinary team; the structure of upcoming appointments; and topics to be discussed.28 Clinician-produced educational seminars and/or e-bulletins supporting lifestyle change are considered useful.29 Support from health care professionals, especially in addressing weight regain, is reported widely to be required after surgery.16, 18, 19, 27 Table 1 outlines the health care supports and interventions reportedly desired by people following bariatric surgery. Optimal timeframes for follow-up appointments preferred after surgery varies, as does the type of delivery, either in-person or online/via telehealth.30, 35, 36 Many want structured appointment schedules 16, 27, 28, 30 and others prefer ad hoc accessibility.16, 27 In a recent study, attendance significantly increased, when health care facilitated post-operative support groups converted from in-person (mean attendance 14.2 participants) to online (mean attendance 20.8 participants) during the COVID-19 pandemic.31 Support groups can offer inclusion in a safe and accepting environment, where people with lived experience can share their stories without prejudice.32 Post-operatively, online or in-person support groups are reported to be crucial for successful outcomes. The reported benefits of peer support include participants providing role-modelling, information and care, concern, empathy and companionship.17, 29, 33, 38 Participants report a preference for health care professional facilitated support forums.29 Systematic reviews, albeit somewhat dated now,34, 39 have shown associations between attending support groups and weight reduction. Those experiencing weight regain and poor body image are particularly more likely to seek inclusion in support groups, including private social media groups.29, 40 Weight loss and improvements in health following bariatric surgery, requires significant patient-driven behavioural change, with a lifetime of adherence.4, 41 Guidelines recommend the ongoing involvement of a multidiscipline health care team.3 Health care professionals, including the bariatric surgeon, physician/general practitioner, dietitian, clinical psychologist, exercise physiologist/physiotherapist and nurses can all provide informational support to people undertaking bariatric surgery.17 Providing initial education and information about surgery enables people to make an informed choice when giving consent and presents an opportunity to address realistic expectations and follow-up requirements.41 The value of additional pre-operative exercise, diet and behaviour therapy does not appear to lead to beneficial post-operative weight loss.42, 43 However, evaluations of these pre-operative interventions do show a trend towards improvements in post-operative mental health, physical activity and dysfunctional eating and preoperative weight reduction, which may improve operative fitness.43 Pre-operative education allows the selection of the correct procedure, ensures baseline assessments are completed and that informed consent is possible.41 In addition, they may help to reduce being lost to medical follow-up post-surgery.44 Reports that patients may be overwhelmed by information leading up to surgery, is one reason why education before bariatric surgery may not be as effective.45 It is also likely that motivation for change and receptivity to interventions may be improved only when challenges are encountered post-operatively.42 Behavioural interventions are recommended to optimize health, weight, and psychosocial outcomes from bariatric surgery.13 Post-operative interventions, delivered over one year by a MDT, have been found to be favourable for weight management and some health and psychosocial outcomes.13, 42, 45 It is hypothesised that during the 12–24-month period immediately post-surgery, where weight loss is typically rapid, self-confidence is elevated and motivation to change is at its peak.45 Increased weight loss is reported with intensive multidisciplinary team interventions of greater than six months, delivered post-operatively by any health care professional (dietitian, clinical psychologist, or exercise scientist).42 Attrition rates from follow-up appointments after bariatric surgery are known to be high, as much as 60% in the first year and 72% in the second year following surgery.30 Barriers to attendance at follow-ups with health care professionals are reportedly due to (i) the occurrence of weight gain/regain, (ii) a mismatch of weight expectations between the treating clinicians and patients (iii) the expectation of clinical disappointment if targets are not met27 and (iv) the time taken, costs incurred attending appointments, and distance from the service.18, 28 This indicates that there is a need for more effective communication between health care professionals and their patients. Given the high rates of attrition post-bariatric surgery, time, distance and cost constraints, issues related to weight stigma, and the reported desire for peer-support, utilization of technology must be considered.46 Three quarters of surgical candidates report accessing the internet while researching the procedure47 and studies show people are interested in this communication form, especially if incorporated into usual care. Technology has the potential to reach more people than is possible face-to-face; engage with people who are physically, socially, or mentally isolated; and engage for longer periods of time.48 Virtual care may also present a cost-effective alternative to in-person appointments for clinicians and patients. Virtual care including telehealth, text messages, telephone, online programs, videoconferencing, mobile applications and audio-visual media, is emerging as an effective modality for delivering healthcare interventions to patients.35, 48, 49 Due to the need for safe patient care during the COVID-19 pandemic, there has been an exponential rise in the use of telehealth and other virtual healthcare strategies.50 Virtual care offers an alternative to face to face consultations and is available to most health care professionals to be used when clinically appropriate. It can be used for individual or group consultations and within multidisciplinary clinics.50 Many public and private health care services employ a hybrid model of care (virtual and face-to-face communication), benefiting both the clinician and health care recipient.51 There are, however, many barriers to using virtual care50 which are presented in Box 1. Virtual care has been found to be useful in obesity treatment and management and studies show it to be as effective as usual care in weight loss and maintenance following bariatric surgery.52 Furthermore, interventions using virtual care have shown improvements on validated questionnaires for measuring disordered eating, binge eating, food addiction and emotional eating.52 This could be due to increased availability of support from the health care team and patient preference when discussing sensitive issues. There are many apps available to use on smartphones marketed to individuals who have had bariatric surgery. These apps track weight, food intake, exercise, activities and sleep patterns and provide information, recipes, and offer reminders.53 Some apps also link users, providing a community of consumers who can offer advice and support to each other. It has been suggested that people most at risk of missing appointments and who are difficult to reach, may potentially benefit from the use of mobile applications.53 Heuser et al54 developed an app providing surgical and dietary education and the ability to record symptoms. They compared 30-day post-operative outcomes between those using the app, (n = 396) and those not using the app (n = 458). Although length of stay, emergency admissions and readmissions were not different between the two groups, those who used the app for 30 days reported that they needed to call the hospital less, had a better postoperative experience and were more able to manage symptoms at home. However, this contrasts with another study that found some app users felt less involved in post-bariatric surgery programs and more burdened with recording when compared to those engaging in care face-to-face.55 The PromMera Swedish study, a large randomized controlled design study evaluating a smartphone app supporting lifestyle change is ongoing. This study will offer much needed information on whether app-based interventions are effective in this setting.56 Apps may present a user-friendly way to connect, educate and support large cohorts of people on the bariatric surgery pathway with accurate information. However, few studies have shown the effectiveness of this mode of support and beneficial health outcomes. Social media serves as a repository for users to access and exchange information and to provide and receive support from those with similar experiences.22 These sites provide the safety of anonymity, which may be one reason why people living with high levels of stigma, including those with obesity, are avid users when seeking health information.57 A recent (Robinson et al46) narrative review concluded that online forums, including social media, offered people going through bariatric surgery a place to seek quick, relatable and supportive advice from others with lived experience, which assisted in decision making.46 People, especially those long-term post-surgery, look for encouragement and inspiration from social media, less so education.40 Feelings of connectedness and linking with a personal 'buddy' enabled emotional support. Connectivity with health care professionals via these forums was also considered beneficial.46 People seeking bariatric surgery information and support are turning to social media, the internet and online platforms.46, 49 Young adults, in particular, are using a wide range of social media platforms including YouTube, Facebook and Instagram, to gain health information.58 Members of social media sites commonly seek assistance and validation from other users for medical and nutritional concerns, recommendations for tools and products, and to post about appearance changes and weight loss progress. Post responses are based largely on personal experience.59 Social media platforms can promote misinformation, weight bias and may adversely affect mental health.60 Information provided on these sites is usually unregulated, with content uploaded from those with lived experience, marketers, advertisers and sometimes, from health experts.58 A study reviewing post bariatric surgery nutrition advice on YouTube, found information to be of low educational quality.61 Furthermore, dietary advice provided on social media has also been found to be largely inaccurate or ambiguous.59 Guidance should be provided to people following bariatric surgery cautioning against the misinformation available on the internet. Health care practitioner moderated social media, as part of clinical care, may present an opportunity to provide education, motivation, support and a chance for members to learn from others with lived experience.40 Significant adaptations to lifestyle after bariatric surgery, especially related to dietary and social behaviours and a changed appearance, can be challenging for many people. The literature clearly reports that people with lived experience value non-judgemental support and care from their medical and health care team to help them cope. Support from social networks of family, friends and peers is equally important. The value of these social supports can be overlooked and underutilized by health care professionals, which presents a missed opportunity for meaningful connections and interventions. Utilizing technology, as a means of connecting with and supporting people undertaking bariatric surgery, may present an opportunity for health care professionals, however, further investigations with outcomes measures are required. All authors reviewed and approved the manuscript. The authors would like to acknowledge medical librarians at the University of Sydney for their support. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australian University Librarians. The authors declare they have no competing or conflicts of interest. This review did not require ethics approval.

Objective: This study aimed to compare the postoperative and pathological outcomes between carboplatin, paclitaxel, radiotherapy (CROSS) and 5-FU, leucovorine, oxaliplatin and docetaxel (FLOT) in esophageal adenocarcinoma (EAC) patients from an international, multicenter cohort. Summary of Background Data: Ongoing debate exists around optimum approach to locally advanced EAC, with proponents for perioperative chemotherapy, such as FLOT, or multimodal therapy, in particular the CROSS regimen. Methods: Patients undergoing CROSS (n = 350) and FLOT (n = 368), followed by curative esophagectomy for EAC were identified from the Oesophagogastric Anastomosis Audit. Results: The 90-day mortality was higher after CROSS than FLOT (5% vs 1%, P = 0.005), even on adjusted analyses [odds ratio (OR): 3.97, confidence interval (CI)(95%): 1.34-13.67]. Postoperative mortality in CROSS were related to higher pulmonary (74% vs 60%) and cardiac complications (42% vs 20%) compared to FLOT. CROSS was associated with higher pathologic complete response (pCR) rates (18% vs 10%, P = 0.004) and margin-negative resections (93% vs 76%, P < 0.001) compared with FLOT. On adjusted analyses, CROSS was associated with higher pCR rates (OR: 2.05, CI95%: 1.26-3.34) and margin-negative resections (OR: 4.55, CI95%: 2.70-7.69) compared to FLOT. Conclusions: This study provides real-world data CROSS was associated with higher 90-day mortality than FLOT, related to cardio-pulmonary complications with CROSS. These warrant a further review into causes and mechanisms in selected patients, and at minimum suggest the need for strict radiation therapy quality assurance. Research into impact of higher pCR rates and R0 resections with CROSS compared to FLOT on long-term survival is needed.

Introduction. With the rising rate of obesity world-wide, there are increasing weight loss options including operative and non-operative techniques. Endoscopic intragastric balloons (IGB) have gained popularity since its inception three decades ago and is viewed as a less invasive alternative to bariatric surgery. However, complications, though rare and probably under-reported, can be associated with significant morbidity and mortality. Case Presentation. We present the case of a 44-year-old woman who presented with a two-day history of upper abdominal pain, nausea, and obstipation, on the background of a Spatz3™ Balloon (Spatz FGIA, Great Neck, NY, USA) endoscopically placed seven months prior. Computed tomography scan confirmed small bowel obstruction due to a migrated IGB, requiring laparotomy and enterotomy for retrieval. Conclusion. With the development of new types of IGB and increasing usage, it is important to monitor for issues and complications.

Background: No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer. Method: This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III-V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%). Results: Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC. Conclusion: Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer. (C) 2020 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

AbstractBackgroundThe complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.MethodsData from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.ResultsOf 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).ConclusionTrainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Oesophageal dilatation following laparoscopic-assisted gastric banding (LAGB) is a well-described complication reported in up to 80% of LAGB patients [ 1, 2]. Severe oesophageal dilatation in addition to aperistalsis is known as megaoesophagus. Symptomatic compression cardiac compression from oesophageal dilatation as a complication of LAGB is an extremely rare complication and is presented in this case report.

INTRODUCTION: With the advent of more minimally invasive procedures like endoscopic sleeve gastroplasty (ESG) for weight loss and metabolic disorders, we are seeing more cases of patients presenting with sub-optimal results for consideration of alternative weight loss surgery. The report aims to describe our experience in converting ESG to laparoscopic sleeve gastrectomy and highlight our suggested technique, challenges and pitfalls. PRESENTATION OF CASES: We described two bariatrics cases detailing our findings on initial endoscopy along with methods used to reverse ESG hardware, followed by issues encountered during sleeve gastrectomy 1 month later. Case 1 being of a 33 year old female (BMI - 50.7) with previous laparoscopic band removal and 2 ESG attempts, while case 2 is a 31 year old female (BMI 44.6) with previously failed gastric balloon and ESG. DISCUSSION: ESG reversal was performed without difficulty via endoscopy with visible sutures cut and hardware removed with snares. In both cases, the stomach was easily endoscopically distensible. During sleeve gastrectomy, extra-gastric adhesions along with more gastro-gastric sutures were encountered in case 1. In case 2, ESG hardware was noted on the external surface of stomach with misfiring of 3rd stapler reload during sleeve gastrectomy likely related to unidentified retained hardware. No post-operative complications occurred in either of the cases with adequate weight loss on one month follow up. CONCLUSION: In our experience, ESG conversion to sleeve gastrectomy is feasible and for the most part, uncomplicated. In our case series, we described a two staged approach to conversion although a single staged conversion is theoretically feasible. (C) 2020 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.