Finding what works-Patients' long-term experiences of weight maintenance post bariatric surgery: A systematic review and thematic synthesis of qualitative studies.

Individuals with obesity can attain significant weight loss in a relatively short timeframe following bariatric surgery; however, new healthy behaviors must be sustained in perpetuity to maintain weight loss. This study investigates patients' views on the facilitators and barriers to long-term weight loss maintenance following bariatric surgery. Systematic searches of Medline, PsycINFO, and CINAHL databases identified 403 studies with 15 fitting the study inclusion criteria. Included studies were independently appraised using Critical Appraisal Skills Program (CASP). Data extraction and thematic synthesis generated three themes: changing food relationships, navigating inter- and intrapersonal influences, and caring health professionals. These appeared across six organizing sub-themes: building new food relationships, creating healthy habits, relationships with others, internalized stressors, finding and defining success, and ongoing patient education. Patients experienced a variety of barriers and facilitators to weight loss maintenance, with some facilitators diminishing over time. The findings demonstrate the importance of considering patients' perspectives and individual contexts to assist them to negotiate and overcome challenges to long-term weight loss maintenance post-bariatric surgery.

Outcomes of liver resection for hepatocellular carcinoma in octogenarians.

BACKGROUND: There is a dearth of information about operative outcomes in patients ≥80 years for hepatocellular carcinoma (HCC) from Western institutions. We compare the result of HCC resections in patients <80 years vs. patients ≥80 years from our institution in the UK. METHODS: We conducted a retrospective review of all patients undergoing liver resections for HCC between 2005 and 2015. Demographics, comorbidities, morbidity, mortality and survival were compared between the two age groups. RESULTS: 200 patients underwent resection for HCC in this time period. Nineteen patients were ≥80 years and 181 were <80 years. Comorbidities measured by the Charlson Comorbidity Index were significantly higher in the ≥80 group (p < 0.0001). There was no significant difference in the extent of resection in the two groups. Morbidity and mortality between the <80 years and the ≥80 years group were not significantly different (morbidity 27% vs.16%; p = 0.29) (mortality 7% vs. 0%; p = 0.11). The one-year (83.4% vs. 88.2%; p = 0.83), five-year (56.3% vs. 55.8%; p = 0.83) and the overall survival rate rates (887 days vs. 1035 days; p = 0.66) were not significantly different between the groups. DISCUSSION: Liver resection should not be precluded based on age alone; with good outcomes in patients ≥80 years justifying surgery.

From scratch: developing a hepatic resection service for metastatic colorectal cancer.

BACKGROUND: Waitemata District Health Board has New Zealand's largest catchment and busiest colorectal unit. The upper gastrointestinal unit was established in 2005, in part to provide a hepatic resection service for patients with colorectal carcinoma metastatic to the liver. The aim of this investigation was to report on quality indicators for the hepatic resection of colorectal carcinoma in the development of a regional resection service. METHODS: Prospectively collected data on patients undergoing hepatic resection for colorectal carcinoma between 2005 and 2014 was reviewed and correlated with costing data and national hepatic resection rates. RESULTS: A total of 123 patients underwent 138 hepatic resections for metastatic colorectal cancer with a median hospital stay of 8 days (range 4-37 days), a zero 30-day mortality and a median cost of NZ$21 374 for minor hepatectomy and NZ$43 133 for major hepatectomy. Actuarial 5-year disease-free survival was 44%, with 28 patients alive and disease free at 5 years post-resection. Median overall survival was not reached. Review of national hepatic resection rates indicate that Waitemata District Health Board performs one sixth of all hepatic resections in New Zealand and that this treatment modality may be underutilized in the management of patients with metastatic colorectal cancer. CONCLUSION: A regional hepatic resection centre for colorectal metastases can be established in areas of population need and can provide a high-quality, cost-effective service.

The volume, cost and outcomes of pancreatic resection in a regional centre in New Zealand.

BACKGROUND: The frequency, costs and outcome of pancreatic resection (both pancreaticoduodenectomy and distal pancreatectomy) were reviewed in our own institution and correlated with regional population growth as well as national resection rates and locations. METHODS: Demographic, pathological and outcome data on pancreaticoduodenectomy and distal pancreatectomy were obtained from a prospectively maintained database for the years 2005-2009 and 2010-2014. During this period, the catchment population grew from 460 000 to 567 000. Costing information was obtained from the hospital-independent costing and coding committee, and the locations and rates of pancreatic resection were obtained by interrogating the national minimum dataset. RESULTS: A total of 41 pancreatectomies (29 pancreaticoduodenectomy, 12 distal pancreatectomy) were performed between 2005 and 2009, increasing to 84 pancreatectomies (55 pancreaticoduodenectomies, 27 distal pancreatectomies and two total pancreatectomies) between 2010 and 2014. This constituted one sixth of the national volume of pancreatic resections. There was no difference in patient demographics or indications for resection between the two time periods; however, portal vein resection was used more frequently in the second period. Margin positivity rate decreased (7 of 41 versus 8 of 84) and lymph node harvest increased (median 8 nodes versus median 15 nodes) between the two time periods. Overall 30-day mortality was 1.6%. CONCLUSION: In New Zealand, regional rates of pancreatic resection reflect regional population demands, and institutional growth is driven by local population requirements. Institutional growth can be achieved with the maintenance of internationally accepted outcomes and quality indicators.

Development and initial outcomes of an upper gastrointestinal multidisciplinary clinic.

INTRODUCTION: Patients with upper gastrointestinal cancer are often comorbid and require complex surgical treatments for their cancers, meaning that their preoperative assessment can be based around numerous outpatient assessments with multiple services. A multidisciplinary clinic (MDC) was developed for the assessment of patients with confirmed or suspected upper gastrointestinal cancers. METHODS: Face-to-face meetings were held between stakeholder services at Waitemata District Health Board, and clinic resource allocated. Significant IT modification of existing clinic booking software was required. RESULTS: Between September 2014, and September 2015, there were a total of 165 new patient, and 710 follow-up appointments. All new patients were seen by a surgeon and then other specialties. Of the 165 new patient appointments, 146 (88%) patients had a definitive treatment plan in place and were cleared by anaesthesia and intensive care at the end of the clinic. Staff and patients report high levels of satisfaction for the clinic. CONCLUSION: A dedicated MDC has provided a single forum where complex patients can be reviewed, and a definitive treatment plan formulated in nearly 90% of patients, even when this involves multiple medical and paramedical specialties with high levels of patient and clinician satisfaction.

Surgical management in patients with pancreatic cancer: a Queensland perspective.

BACKGROUND: Little has been published regarding presenting symptoms, investigations and outcomes for patients with pancreatic cancer in Australia. Data from a series of patients undergoing attempted resection in Queensland, Australia, are presented with the aim of assisting development of consistent strategies in disease management. METHODS: We reviewed the medical records of 121 patients who underwent attempted surgical resection and who took part in a case-control study between 2007 and 2009. Information relating to symptoms, investigations, surgical procedures and outcomes was captured. RESULTS: The mean age was 63 years and 60% were men. The most common presenting symptoms were jaundice (64%) and pain (63%). Over 80% of patients had multiple imaging investigations or laparoscopy prior to surgery. Seventy-eight patients (64%) had a completed resection and 23% of these had involved margins. The presence of metastases and/or involvement of vessels or adjacent structures precluded resection in the remaining patients. The 1-year survival for patients whose resections were completed was 77% compared with 51% for those whose tumours were not resectable (P = 0.004). There was no 30-day mortality and 68% of patients were alive 1 year after diagnosis. Resections were performed in 11 different hospitals but over 90% of patients underwent their surgery in one of five high-volume centres. CONCLUSION: The Queensland experience is consistent with that reported internationally. A significant proportion of attempted resections was not completed because preoperative staging underestimated disease extent. Most patients with potentially resectable disease are being treated in high-volume centres.

HIV resistance testing in the USA--a model for the application of pharmacogenomics in the clinical setting.

Although there is debate about how and when the medical community will readily adopt pharmacogenomics into clinical practice, HIV genotyping has become an integral part of AIDS patient management in the USA since 1996. Genotyping for HIV-1 drug resistance serves as a paradigm for the way pharmacogenomics is likely to be introduced into patient care. This review discusses the unique role that HIV-1 genotype testing plays in identifying resistance in patients and how that information is used to modify therapy selection and impact the progression of disease. In addition, the important issues relating to reimbursement and the cost-effectiveness of genotyping are also discussed.