Direct diverticular peroral endoscopic myotomy for the treatment of thoracic esophageal diverticula: technique and outcomes.

BACKGROUND: Diverticular peroral endoscopic myotomy (POEM) is an alternative to surgery for the management of symptomatic thoracic esophageal diverticula. Conventionally, this requires proximal tunnel formation but a direct approach may simplify the technique. Herein, we report the outcomes of direct diverticular-POEM (DD-POEM). METHODS: We conducted a single-center prospective observational study evaluating DD-POEM. This involved a direct approach to the diverticulum. Success was defined as an Eckardt score of ≤ 3 without the need for reintervention. RESULTS: 10 patients underwent DD-POEM (median age 72 years; interquartile range [IQR] 14.3; male 60 % [n = 6]). Median diverticulum size was 40 mm (IQR 7.5) and median location was 35 cm from the incisors (IQR 8.3). Five patients (50 %) had an underlying dysmotility disorder. The median procedure duration was 60 minutes (IQR 28.8). There were no adverse events. The median hospital stay was 1 day (IQR 0.75). The pre-procedure median Eckardt score of 6 (IQR 4) significantly improved to 0 (IQR 0.75; P < 0.001) at a median follow-up of 14.5 months (IQR 13.8). Success was achieved in all patients. CONCLUSIONS: DD-POEM was a safe technique for the management of thoracic esophageal diverticula. Owing to its simplicity and excellent performance it should be further evaluated for the treatment of this disorder.

The past, present and future of liver cancer control for Maori.

Liver cancer is among the most commonly diagnosed and least-survivable cancers in New Zealand. There are stark disparities between the Indigenous Maori population in incidence of and mortality from liver cancer relative to non-Maori. In this review, we have summarised the key risk factors for liver cancer, and the key activities undertaken in New Zealand, over time, to control this disease, with a focus on how risk factors and interventions aimed at reducing them differentially impact Maori. We have conducted a narrative literature review. The disproportionate burden of liver cancer experienced by Maori is primarily driven by disparities in viral exposure to hepatitis B and C between ethnic groups. Efforts to control hepatitis-associated liver cancer in New Zealand have lacked national coordination, further driving disparities in liver cancer survival between Maori and NZ Europeans. A national primary care-based programme to detect and treat hepatitis B and C and to screen for liver cancer among high-risk patients, along with renewed effort to maximise hepatitis B vaccination rates, has the potential to substantially reduce the burden of hepatitis-associated liver cancer and address a significant health disparity between Maori and non-Maori.

Equity of travel required to access first definitive surgery for liver or stomach cancer in New Zealand.

In New Zealand, there are known disparities between the Indigenous Maori and the majority non-Indigenous European populations in access to cancer treatment, with resulting disparities in cancer survival. There is international evidence of ethnic disparities in the distance travelled to access cancer treatment; and as such, the aim of this paper was to examine the distance and time travelled to access surgical care between Maori and European liver and stomach cancer patients. We used national-level data and Geographic Information Systems (GIS) analysis to describe the distance travelled by patients to receive their first primary surgery for liver or stomach cancer, as well as the estimated time to travel this distance by road, and the surgical volume of hospitals performing these procedures. All cases of liver (ICD-10-AM 3rd edition code: C22) and stomach (C16) cancer that occurred in New Zealand (2007-2019) were drawn from the New Zealand Cancer Registry (liver cancer: 866 Maori, 2,460 European; stomach cancer: 953 Maori, 3,192 European), and linked to national inpatient hospitalisation records to examine access to surgery. We found that Maori on average travel 120km for liver cancer surgery, compared to around 60km for Europeans, while a substantial minority of both Maori and European liver cancer patients must travel more than 200km for their first primary liver surgery, and this situation appears worse for Maori (36% vs 29%; adj. OR 1.48, 95% CI 1.09-2.01). No such disparities were observed for stomach cancer. This contrast between cancers is likely driven by the centralisation of liver cancer surgery relative to stomach cancer. In order to support Maori to access liver cancer care, we recommend that additional support is provided to Maori patients (including prospective financial support), and that efforts are made to remotely provide those clinical services that can be decentralised.

Low but increasing rates of inflammatory bowel disease in Maori: a report from Lakes District Health Board IBD.

Inflammatory bowel diseases (IBD) are chronic, inflammatory diseases that are increasingly prevalent in New Zealand. Previous regional studies describe significantly lower rates of IBD in Maori compared to non-Maori. This article reports the prevalence and incidence of IBD at Lakes District Health Board, and discusses potential contributing factors to the observed increasing incidence rates in Maori. Although the rates are still less than non-Maori, colonisation with increased urbanisation and changes in diet and hygiene suggest that IBD rates may continue to increase in Maori.

Equity of timely access to liver and stomach cancer surgery for Indigenous patients in New Zealand: a national cohort study.

OBJECTIVES: When combined, liver and stomach cancers are second only to lung cancer as the most common causes of cancer death for the indigenous Maori population of New Zealand-with Maori also experiencing substantial disparities in the likelihood of survival once diagnosed with these cancers. Since a key driver of this disparity in survival could be access to surgical treatment, we have used national-level data to examine surgical procedures performed on Maori patients with liver and stomach cancers and compared the likelihood and timing of access with the majority European population. DESIGN, PARTICIPANTS AND SETTING: We examined all cases of liver and stomach cancers diagnosed during 2007-2019 on the New Zealand Cancer Registry (liver cancer: 866 Maori, 2460 European; stomach cancer: 953 Maori, 3192 European) and linked these cases to all inpatient hospitalisations that occurred over this time to identify curative and palliative surgical procedures. As well as descriptive analysis, we compared the likelihood of access to a given procedure between Maori and Europeans, stratified by cancer and adjusted for confounding and mediating factors. Finally, we compared the timing of access to a given procedure between ethnic groups. RESULTS AND CONCLUSIONS: We found that (a) access to liver transplant for Maori is lower than for Europeans; (b) Maori with stomach cancer appear more likely to require the type of palliation consistent with gastric outlet obstruction; and (c) differential timing of first stomach cancer surgery between Maori and European patients. However, we may also be cautiously encouraged by the fact that differences in overall access to curative surgical treatment were either marginal (liver) or absent (stomach).

Letter on an iceberg.

In the public sphere, issues are like icebergs. This somewhat hackneyed metaphor illustrates that, while one facet of an issue is perceived, what is not seen is the hidden substructure of power and culture that form and reinforce it, buoying the issue to prominence above the surface.