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Background New Zealand health services are responsible for equitable health service delivery, particularly for Māori, the Indigenous peoples of New Zealand. Recent research has indicated the presence of inequities in publicly funded bariatric surgery in New Zealand by ethnicity, but it is unclear whether these inequities persist after adjustment for co-morbidities. Objectives To determine whether receipt of publicly funded bariatric surgery varies by ethnicity, after adjustment for co-morbidities. Setting New Zealand primary care. Methods A cohort study of New Zealanders aged 30–79 years who had cardiovascular risk assessment in primary care between January 1, 2010 and June 30, 2018. Data were collated and analyzed using an encrypted unique identifier with regional and national datasets. Cox proportional hazard modeling was performed to determine the likelihood of receipt of a primary publicly funded bariatric procedure up to December 31, 2018, after adjustment for sex, age, ethnicity, locality, socioeconomic deprivation, body mass index, diabetes status, smoking status, and co-morbidities. Results A total of 328,739 participants (44% female, median age 54 yr [interquartile range, IQR, 46–62], 54% European, 13% Māori, 13% Pacific, 20% Asian) were included in the study and followed up for a median of 5.6 years (IQR 4.1–6.9). The likelihood of receipt of bariatric surgery was lower for Māori and Pacific compared with Europeans (adjusted hazard ratio .82 [95% CI .69–.96] and .24 [.20–.29], respectively). The likelihood of receiving bariatric surgery was also inversely related with increasing socioeconomic deprivation and rurality. Conclusions Consistent with data worldwide, there is evidence of unequal access to publicly funded bariatric surgery by ethnicity, locality as well as socioeconomic deprivation among New Zealanders who were cardiovascular risk assessed in primary care.

Patients waitlisted for elective general surgery in New Zealand used to be prioritised by multiple tools that were inconsistent, did not reflect clinical judgement and were not validated. We describe the development and implementation of a national prioritisation tool for elective general surgery in New Zealand, which could be applicable to other OECD countries. The tool aims to achieve equity of access, transparency, reliability and should be aligned with clinical judgement. The General Surgery Prioritisation Tool Working Group commenced development of a prioritisation tool in 2014 which showed strong correlation with clinical judgement (r = 0.89), excellent test-retest reliability (r = 0.98) and significantly lower variability (p < 0.001). Preliminary findings showed no significant difference in scores attributable to age, gender or ethnicity. General Surgeons were in favour of the tool criteria and agreed on the importance of prioritisation; however a minority opposed its introduction. Health organisations and general practitioner groups were in favour, however, along with many surgeons, expressed apprehensions regarding subjectivity, manipulation, equity of access and degree of benefit. Despite reservations, the majority of stakeholders were supportive and through collaboration between clinicians and the government, the tool was implemented in 2018 in New Zealand. Overall, the prioritisation tool is a reliable method of assessing priority, demonstrating transparency and reflecting clinical judgement, with equity of access to be further assessed by evaluation in clinical practice.

Introduction Bariatric surgery is the most effective intervention for alleviating obesity and its complications. Indigenous people worldwide experience higher rates of obesity and obesity disease burden. However, few studies exploring bariatric surgery among Indigenous peoples are published. In this study we aimed to explore the motivation of Māori women in coming forward for bariatric surgery. Methods Māori women who had bariatric surgery prior to December 31, 2014, were invited to participate in semi-structured interpersonal interviews. Kaupapa Māori research, an Indigenous Māori research methodology, informed this study. Interviews were recorded, transcribed and subject to inductive thematic analysis. Results Twenty-nine Māori women participated in semi-structured interpersonal interviews. The majority of women reported that the presence of obesity-related disease alongside the desire for a better quality of life served as the greatest sources of motivation for having bariatric surgery. Whānau (family) were key for participants achieving the preoperative milestones needed to be accepted for bariatric surgery. Interpersonal experiences of fat-shaming and yo-yo dieting also impacted their choice to have surgery. Conclusion This study is one of the first to describe the motivations of Indigenous Māori women to have bariatric surgery. Our study conveys the importance of health, a desire to have a better quality of life and whānau in motivating Māori women to come forward for bariatric surgery.

Introduction Indigenous peoples suffer high rates of obesity and obesity-related disease worldwide. Currently, bariatric surgery is the most effective intervention for severe obesity and obesity-related disease. The role bariatric surgery plays in alleviating the obesity burden amongst Indigenous peoples is unknown. We aimed to collate studies investigating bariatric surgery in Indigenous peoples and to provide a simple framework to use in future research surrounding this important issue. Materials and methods We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that investigated outcomes for Indigenous peoples at any point along the bariatric surgery journey were included. Results Six articles were included in this review. Three studies investigated access to bariatric surgery and the remaining three studies investigated short to long-term outcomes following bariatric surgery. A narrative review was performed given study heterogeneity and quality of included studies. Indigenous peoples had lower access to bariatric surgery and in one study had greater weight loss in comparison to non-Indigenous peoples. Conclusion Despite a paucity of studies, it appears that there is emerging interest in investigating bariatric surgery among Indigenous peoples. We encourage those who seek to investigate this important issue at any point along the bariatric surgery journey, to do so using an equity-based approach.

Background Whilst the early to mid-term efficacy of laparoscopic sleeve gastrectomy (SG) is well established, there is comparatively less detailing of long-term efficacy. The objectives of this study were to evaluate the long-term outcomes of patients undergoing SG at the authors' institution. Methods All patients undergoing SG during the past 5 or more years were eligible. Outcomes included baseline demographic data, preoperative characteristics, percentage excess weight loss (%EWL), co-morbidity improvement and resolution, serum hemoglobin A 1c (HbA 1c ), serum lipid profile, and the Bariatric Analysis Reporting Outcome System (BAROS) questionnaire. A subset analysis was also performed with patients stratified in to super obese (body mass index≥50 kg/m 2 ). Results There were 96 patients who underwent surgery between March 2007 and July 2008. Of these, 10 declined to participate, 28 were unable to be contacted, and 3 were deceased; therefore, 55 patients were included in the analysis. The mean yearly %EWL to postoperative year 5 was 56% (year 1), 55% (year 2), 46% (year 3), 43% (year 4), and 40% (year 5). Combined improvement and resolution rates at 5 years were 79%, 61%, and 73% for type 2 diabetes, hypertension, and obstructive sleep apnea, respectively. The HbA 1c was significantly reduced at long-term follow-up. The mean BAROS score was 3.13 (95% CI: 2.4, 3.9). Weight loss outcomes were less favorable in super obese patients. Conclusion Weight loss outcomes at 5 year follow-up were modest after SG though improvement in co-morbidity status was maintained.

Introduction: Post-operative ileus (POI) is a major problem following elective abdominal surgery. Several studies have been published investigating the use of chewing gum to reduce POI. These studies however, have produced variable results. Thus, there is currently no consensus on whether chewing gum should be widely instituted as a means to help reduce POI. Methods: We performed a systematic literature review to evaluate whether the use of chewing gum post-operatively improves POI in abdominal surgery. A comprehensive review of the literature was conducted according to the guidelines in the PRISMA statement. The following databases were searched: MEDLINE, PUBMED, EMBASE, SCOPUS, Science Direct, CINAHL and the Cochrane Central Register of Controlled Trials. Clinical outcomes were extracted and meta-analysis was performed. Results: There were 1019 patients from 12 randomised controlled studies included in this review. Only one study was conducted in an Enhanced Recovery after Surgery (ERAS) environment. Seven of the twelve studies concluded that chewing gum reduced post-operative ileus. The remaining five studies found no clinical improvement. Overall, there was a small benefit in reducing time to flatus, and time to bowel motion, but no difference in the length of stay or complications. Conclusion: Chewing gum offers only a small benefit in reducing time to flatus and time to passage of bowel motion following abdominal surgery. This benefit is of limited clinical significance. Further studies should be conducted in a modern peri-operative care environment.

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is increasingly used as a single-stage bariatric procedure. However, its safety and efficacy in super-obese patients (body mass index [BMI] > 50 kg/m(2)) is less well defined. This series reports on 400 consecutive patients who underwent LSG at our institution, to evaluate safety and efficacy in the super-obese. MATERIALS AND METHODS We performed a retrospective review of prospectively collected data on 400 consecutive patients who underwent LSG at our institution. We analyzed baseline demographic data, median length of hospital stay, complications, length of follow-up, weight loss, and comorbidity resolution. We graded complications according to the Clavien-Dindo classification system. We classified patients as super-obese and non-super-obese and compared outcomes between groups. We used the two-tailed t-test and Fisher's exact test as necessary. RESULTS There were 400 patients, 291 of whom were female (73%). The mean age was 44 y (standard deviation [SD] ± 9 y). The mean preoperative weight and BMI were 140 kg (SD ± 31 kg) and 49 kg/m(2) (SD ± 9 kg/m(2)), respectively. There were 67 complications (16%) in total. The major complication rate was 7.2%, with one recorded death. The median length of hospital stay was 3 d, and the mean follow-up period was 1 y. A total of 170 patients (43%) were super-obese, with a mean preoperative BMI of 56 kg/m(2) (SD ± 5 kg/m(2)). The mean absolute weight loss (59 versus 36.7 kg; P < 0.01) and percentage excess weight loss (58.9% versus 45.9%; P < 0.01) was significantly higher in the super-obese. The mean postoperative BMI for super-obese patients was 38.9 kg/m(2). There was no difference between groups in the incidence of major complications (8.2% versus 6.5%; P = 0.56). CONCLUSION Laparoscopic sleeve gastrectomy is safe and effective in the super-obese, with acceptable weight loss and no increase in the major complication rate.

Written emotional disclosure (expressive writing) has been shown to reduce stress and speed the healing of punch-biopsy wounds in laboratory studies. However, no research has investigated whether expressive writing can improve wound healing in surgical patients. We investigated whether a pre-operative expressive writing intervention could improve surgical wound healing. A randomized controlled trial was conducted with 76 patients undergoing elective laparoscopic bariatric surgery. Patients were randomized either to write about their thoughts and feelings about distressing events (expressive writing) or to write objectively about how they spent their time (time management), for 20 minutes on 3 consecutive days, beginning two weeks before surgery. In both groups, 24 hour wound fluid was analysed for pro-inflammatory cytokines, and hydroxyproline was collected in ePTFE tubes at the wound site over 14 days. Contrary to our hypothesis, patients who wrote about time management had significantly more hydroxyproline at their wound sites than did expressive writing patients ( t (34) = −2.433, p = .020; 95% CI −4.611 to −0.413) and higher TNF-alpha ( t (29) = −2.423, p = .022, 95% CI −0.424 to −0.036). Many patients in the expressive writing group wrote about pre-surgical anxiety while those in the time-management group wrote about plans for preparing for surgery. These results may differ to laboratory studies due to patients’ high pre-operative anxiety about their surgery, a situation in which time management may be better than expressive writing for managing stress.