Health economics in Enhanced Recovery After Surgery programs.

PURPOSE: The Enhanced Recovery After Surgery (ERAS) program aims to combine and coordinate evidence-based perioperative care interventions that support standardizing and optimizing surgical care. In conjunction with its clinical benefits, it has been suggested that ERAS reduces costs through shorter convalescence and reduced morbidity. Nevertheless, few studies have evaluated the cost-effectiveness of ERAS programs. The aim of this systematic review, therefore, is to evaluate the claims that ERAS is cost-effective and to characterize how these costs were reported and evaluated. SOURCE: The electronic databases, MEDLINE(®) and EMBASE™, were searched from inception to April 2014. PRINCIPAL FINDINGS: Seventeen studies met the inclusion criteria and were included for review. Enhanced Recovery After Surgery protocols in various abdominal surgeries have been investigated, including colorectal, bariatric, gynecological, gastric, pancreatic, esophageal, and vascular surgery. All studies reported cost savings associated with hastening recovery and reducing morbidity and complications. All studies included in this review focused primarily on in-hospital costs, with some attempting to account for readmission costs and follow-up services. In all but two studies, the breakdown of cost data for the individual studies was poorly detailed. CONCLUSIONS: In conclusion, ERAS protocols appear to be both clinically efficacious and cost effective across a variety of surgical specialties in the short term. Nevertheless, studies reporting out-of-hospital cost data are lacking. Further research is required to determine how best to evaluate both medium- and long-term costs relating to ERAS pathways while taking quality of life data into account.

The Surgical Recovery Score correlates with the development of complications following elective colectomy.

BACKGROUND: The Surgical Recovery Score (SRS) is a validated, comprehensive recovery assessment tool used to measure functional recovery after major surgery. To further evaluate its clinical applicability, this study investigated whether the SRS correlates with clinical outcomes and the occurrence of complications after elective colectomy. MATERIALS AND METHODS: We conducted a retrospective review of prospectively collected data for consecutive patients undergoing elective colonic resection within an enhanced recovery program at our institution from September 2008 to September 2011. We administered the 31-item SRS questionnaire preoperatively (baseline) and on postoperative days 1, 3, 7, 14, and 30. We scored individual questionnaires as a percentage of the maximum possible score, with a higher SRS indicating improved functional recovery (range, 17-100). We prospectively recorded clinical outcomes and graded 30-d complications as per the Clavien-Dindo classification. We conducted univariate and logistic regression analysis to determine the correlation of the SRS to the development of complications. RESULTS: We evaluated 134 patients, 62 of whom developed minor complications (grades 1-2) (46%) and 21 of whom developed major complications (grades 3-5) (16%). The SRS was similar at baseline in the complicated and uncomplicated groups but significantly lower on postoperative days 3, 7, 14, and 30 in patients who developed major complications, and on days 7 and 14 in patients who developed minor complications. In a logistic regression analysis, the SRS on postoperative day 3 was independently associated with the development of any complication, as well as major complications specifically. CONCLUSIONS: In addition to measuring functional recovery, the SRS closely correlates with the development of complications after elective colectomy and offers a reliable outcome measure to assess overall postoperative recovery.

Effect of preoperative exercise on cardiorespiratory function and recovery after surgery: a systematic review.

BACKGROUND: This systematic review aims to investigate the extent to which preoperative conditioning (PREHAB) improves physiologic function and whether it correlates with improved recovery after major surgery. METHODS: An electronic database search identified randomized controlled trials (RCTs) investigating the safety and efficacy of PREHAB. The outcomes studied were changes in cardiorespiratory physiologic function, clinical outcomes (including length of hospital stay and rates of postoperative complications), and measures of changes in functional capacity (physical and psychological). RESULTS: Eight low- to medium-quality RCTs were included in the final analysis. The patients were elderly (mean age >60 years), and the exercise programs were significantly varied. Adherence to PREHAB was low. Only one study found that PREHAB led to significant improvement in physiologic function correlating with improved clinical outcomes. CONCLUSION: There are only limited data to suggest that PREHAB confers any measured physiologic improvement with subsequent clinical benefit. Further data are required to investigate the efficacy and safety of PREHAB in younger patients and to identify interventions that may help improve adherence to PREHAB.

General surgical interns contributing to the clerkship learning environment of medical students.

BACKGROUND: Junior doctors are increasingly promoted as clinical teachers but there is limited understanding of how they contribute to medical student clerkship learning. AIM: To describe contributions made by general surgical interns to the student clerkship learning environment. METHODS: The mixed-methods study involved two focus groups attended by volunteer interns and Year 4 students, and a student questionnaire collecting quantitative data. Focus group transcripts were evaluated using a qualitative analysis system. RESULTS: Six interns and five students attended focus groups in June and August 2011. Qualitative analysis found that intern contributions to student learning can be grouped under four distinct roles: physician, supervisor, teacher and person. Data from 85 questionnaires (response rate 57%) revealed that intern-student encounters occurred daily in the surgical wards and emergency department. Interns demonstrated bedside procedures, clerical/administrative tasks and interpretation of laboratory and radiological investigations. Appreciated for approachability, friendliness and ability to relate to students, interns also played a crucial role in integrating students into the surgical team. This significantly correlated to clerkship enjoyment. CONCLUSIONS: Surgical interns improve clerkship learning environments by demonstrating "personal" skills such as friendliness, approachability and relatedness. This has important implications for preparing interns as clinical preceptors.

Short- and Long-Term Outcomes in Patients With Lower Extremity Amputations Undergoing Total Hip and Knee Arthroplasty.

Background: Joint replacement following amputation is scarcely reported. The primary aim of this study was to evaluate patient-reported outcomes (PROMS) and revision rates among lower extremity amputees undergoing total hip (THA) or knee arthroplasty (TKA). Methods: This was a retrospective cohort analysis of lower extremity amputees undergoing THA/TKA between August 2002 and August 2022 in a single tertiary center. Demographic and clinical data were collected from prospectively populated surgical databases and patient electronic records. PROMS included Oxford Knee Score, Oxford Hip Score, and 5-level EuroQol 5-dimension questionnaires. Twenty-three TKAs and 21 THAs were performed in 38 patients. The mean age at arthroplasty procedures was 59.8 (24-87) years. The mean clinical follow-up duration for THA and TKA was 9.1 and 4.5 years, respectively. Seven TKAs and 6 THAs were ipsilateral to the amputated side. Results: The 10-year revision rates were 9.5% (2/21) and 5.9% (1/17) in the TKA and THA cohorts, respectively. TKA revisions occurred due to aseptic loosening. Six (26%) TKA cases experienced stump complications. Overall PROMS completion was 61.9% (13/21) and 64.7% (11/17) in TKA and THA patients, respectively. The average Oxford Hip Score/Oxford Knee Score of THA and TKA cohorts were 40.8 and 34.2, respectively. EuroQol 5-dimension questionnaire visual analog scores were higher in the THA cohort than those in the TKA cohort without statistical significance (59.1 vs 50.5, P = .214). The overall survival rate for the study was 94.7% at 5 years (36/38). Conclusions: TKA/THA in lower extremity amputees can be successful, with low revision rates and good prosthesis function. Potential pitfalls highlighted include prosthesis malalignment, postprocedural rehabilitation, and stump complications.

Perioperative use of statins in elective colectomy.

BACKGROUND: Statins have many beneficial effects and may attenuate the proinflammatory and metabolic stress response to surgery and consequently reduce postoperative morbidity. OBJECTIVE: This study investigated whether perioperative use of statins improved short-term outcomes after elective colectomy. DESIGN: This study is a retrospective review of prospectively collected data. SETTINGS AND PATIENTS: This study was conducted in consecutive patients undergoing elective colonic resection within an enhanced recovery program at a tertiary hospital (Manukau Surgery Centre, Middlemore Hospital, Auckland, New Zealand) from January 2005 to December 2010. MAIN OUTCOME MEASURES: Complications, hospital stay, and readmissions were recorded for 30 days postoperatively. Postoperative functional recovery was measured by the use of the validated Surgical Recovery Score. Serum proinflammatory cytokines were measured on postoperative day 1. RESULTS: There were 269 patients; 86 patients were on a statin perioperatively, whereas 183 patients had no statin. Members of the statin group were older (median age, 72 vs 69 years; p = 0.021), included more men (53% vs 40%; p = 0.049), and included a higher number of patients with an ASA score of 3 (55% vs 22%; p < 0.001). Patients on statin therapy had a significantly lower number of anastomotic leaks (1% vs 7%; p = 0.031). However, there was no significant difference in total complications or median hospital stay. The 2 groups had comparable functional recovery, and there was no significant difference in serum cytokine levels. LIMITATIONS: This retrospective study did not analyze type, duration, or dose of statins given perioperatively. CONCLUSION: Patients on perioperative statins had greater baseline perioperative risks compared with nonusers, but they achieved equivalent outcomes overall. Statin use was associated with reduced anastomotic leaks. Thus, perioperative statin use may reduce morbidity after elective colectomy, and this finding warrants further investigation.

Single-stage laparoscopic sleeve gastrectomy: safety and efficacy in the super-obese.

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.

Ischial screw fixation can prevent cup migration in 3D-printed custom acetabular components for complex hip reconstruction.

INTRODUCTION: Custom acetabular components have become an established method of treating massive acetabular bone defects in hip arthroplasty. Complication rates, however, remain high and migration of the cup is still reported. Ischial screw fixation (IF) has been demonstrated to improve mechanical stability for non-custom, revision arthroplasty cup fixation. We hypothesize that ischial fixation through the flange of a custom acetabular component aids in anti-rotational stability and prevention of cup migration. METHODS: Electronic patient records were used to identify a consecutive series of 49 custom implants in 46 patients from 2016 to 2022 in a unit specializing in complex joint reconstruction. IF was defined as a minimum of one screw inserted into the ischium passing through a hole in a flange on the custom cup. The mean follow-up time was 30 months. IF was used in 36 cups. There was no IF in 13 cups. No difference was found between groups in age (68.9 vs. 66.3, P = 0.48), BMI (32.3 vs. 28.2, P = 0.11) or number of consecutively implanted cups (3.2 vs. 3.6, P = 0.43). Aseptic loosening with massive bone loss was the primary indication for revision. There existed no difference in Paprosky grade between the groups (P = 0.1). 14.2% of hips underwent revision and 22.4% had at least one dislocation event. RESULTS: No ischial fixation was associated with a higher risk of cup migration (6/13 vs. 2/36, X2 = 11.5, P = 0.0007). Cup migration was associated with an increased risk for all cause revision (4/8 vs. 3/38, X2 = 9.96, P = 0.0016, but not with dislocation (3/8 vs. 8/41, X2 = 1.2, P = 0.26). CONCLUSION: The results suggest that failure to achieve adequate ischial fixation, with screws passing through the flange of the custom component into the ischium, increases the risk of cup migration, which, in turn, is a risk factor for revision.

Text messaging improves preoperative exercise in patients undergoing bariatric surgery.

BACKGROUND: To investigate whether a text message intervention improves adherence to preoperative exercise advice prior to laparoscopic sleeve gastrectomy (LSG). METHODS: A single-blinded parallel design 1:1 ratio randomized controlled trial was performed in patients undergoing LSG as a single-stage bariatric procedure for morbid obesity. The intervention group received preoperative daily text messages. The primary outcome was adherence to preoperative exercise advice as assessed by the number of participants partaking in ≥450 metabolic equivalent minutes (METmin-1 ) exercise activity per week preoperatively. RESULTS: Eighty-eight patients were included in the analysis with 44 allocated to each arm. Adherence and exercise activity increased significantly from baseline in the exposure group (EG) but not in the control group (CG). Adherence was significantly higher in the EG at the end of the intervention period compared to the CG. Despite increased exercise activity, there was no improvement in 6-min walk test or surgical recovery. CONCLUSION: A daily text message intervention improved adherence to preoperative exercise advice, but this did not correlate with improved surgical recovery.

Definition determines weight regain outcomes after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is one of the most commonly undertaken bariatric procedures. Weight regain after bariatric surgery, when significant, may be associated with recurrence of diabetes and deterioration in quality of life. Furthermore, it may be more common after SG than bypass procedures. Yet the understanding of the significance of weight regain is hampered by poor reporting and no consensus statements or guidelines. OBJECTIVES: To illustrate how the lack of a standard definition significantly alters reported SG outcomes and to contribute to the discussion of how weight regain should be defined. SETTING: Counties Manukau Health, a public teaching hospital that performs over 150 bariatric procedures per year. METHODS: A retrospective cohort of SG patients followed up at 5 years was used to illustrate how the presence of multiple definitions in the literature significantly affects outcome reporting for weight regain. Post hoc analyses were used to explore the relationship between weight change and clinical outcomes. RESULTS: Applying 6 definitions of weight regain to a retrospective cohort of SG patients resulted in 6 different rates ranging from 9%-91%. Post hoc analyses revealed significant associations between weight change and the Bariatric Analysis Reporting Outcome System (BAROS) score as well as patient opinion. CONCLUSION: The nonuniform reporting of weight regain appears to significantly affect SG outcome reporting. Development of consensus statements and guidelines would ameliorate this problem. Ideally, research groups with access to large robust databases would aid in the development of any proposed weight regain definitions. In the interim, bariatric literature would benefit by all published series clearly reporting how weight regain is defined in the study population.

Perioperative Simvastatin Therapy in Major Colorectal Surgery: A Prospective, Double-Blind Randomized Controlled Trial.

BACKGROUND: Statins have numerous potential benefits relevant to abdominal surgery, and their use has been associated with a reduction in the systemic inflammatory response syndrome, wound infection, and anastomotic leak after colorectal surgery. However, this clinical evidence is limited to retrospective studies. The aim of this study was to prospectively investigate whether perioperative statin therapy can decrease the incidence of complications after major colorectal surgery. STUDY DESIGN: A prospective, double-blind, parallel-group, randomized controlled trial was conducted at 3 tertiary hospitals in New Zealand, between October 2011 and August 2013. Adult patients undergoing elective colorectal resection for any indication or reversal of Hartmann's procedure were randomized with a 1:1 patient allocation ratio to receive either 40 mg oral simvastatin or placebo once daily for 3 to 7 days preoperatively until 14 days postoperatively. The primary outcome was the overall incidence of complications for 30 days postoperatively. Secondary outcomes included the systemic and peritoneal cytokine response (interleukin [IL]-1α, IL-1ß, IL-6, IL-8, IL-10, tumor necrosis factor [TNF]α) on postoperative day 1. RESULTS: There were 132 patients included in the study (65 simvastatin, 67 placebo). There were no significant differences between the 2 groups at baseline with regard to patient, operation, and disease characteristics. There were no significant differences between the 2 groups in the incidence, grade, and type of postoperative complications (simvastatin: 44 [68%] vs placebo: 50 [75%], odds ratio 0.71 [95% CI 0.33 to 1.52], p = 0.444). Plasma concentrations of IL-6, IL-8, and TNFα, and peritoneal concentrations of IL-6 and IL-8, were significantly lower in the simvastatin group postoperatively. CONCLUSIONS: Perioperative simvastatin therapy in major colorectal surgery attenuates the early proinflammatory response to surgery, but there were no differences in postoperative complications.

Five-year results after laparoscopic sleeve gastrectomy: a prospective study.

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.

Chewing gum and postoperative ileus in adults: a systematic literature review and meta-analysis.

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.

Review article: Perioperative care in enhanced recovery for total hip and knee arthroplasty.

Enhanced recovery pathways for total hip and knee arthroplasty can reduce length of hospital stay and perioperative morbidity. 22 studies were reviewed for identification of perioperative care interventions, including preoperative (n=4), intra-operative (n=8), and postoperative (n=4) care interventions. Factors that improve outcomes included use of pre-emptive and multimodal analgesia regimens to reduce opioid consumption, identification of patients with poor nutritional status and provision of supplements preoperatively to improve wound healing and reduce length of hospital stay, use of warming systems and tranexamic acid, avoidance of drains to reduce operative blood loss and subsequent transfusion, and early ambulation with pharmacological and mechanical prophylaxis to reduce venous thromboembolism and to speed recovery.

Goal-directed fluid therapy in major elective rectal surgery.

INTRODUCTION: Goal-Directed Fluid Therapy (GDFT) has been previously shown to decrease complications and hospital length of stay in major colorectal surgery but the data are not specific to rectal surgery and may be potentially outdated. This study investigated whether GDFT provides clinical benefits in patients undergoing major elective rectal surgery. METHODS: There were 81 consecutive patients in this cohort study. Twenty-seven patients were allotted to GDFT using the Oesophageal Doppler Monitor (ODM) and received boluses of colloid fluid based on corrected flow time and stroke volume. These patients were compared with a historical cohort of the previous 54 patients managed without the ODM. The primary endpoint of the study was 30-day total complications which were defined and graded. Secondary endpoints included hospital length of stay (LOS) and fluid volumes administered. RESULTS: There were no differences at baseline between the two groups. Patients in the treatment group received a higher volume of colloid fluids (1000 mL vs. 500 mL; p < 0.01) but there were no differences in overall fluid volumes administered intraoperatively (3000 mL vs. 3000 mL; p = 0.41). A non-significant trend (p = 0.06) suggested that patients allotted to GDFT had decreased fluid requirement in the first 24 h after surgery. There were no differences in median total fluid volumes (12700 mL vs. 10407 mL; p = 0.95), total complications (22 [81%] vs. 44 [81%]; p = 1.00) or median hospital LOS (9 days vs. 10 days; p = 0.92) between the two groups. CONCLUSION: Intraoperative GDFT did not improve clinical outcomes following major elective rectal surgery.

The relationship between academic assessment and psychological distress among medical students: a systematic review.

A systematic review was conducted to determine the relationship between academic assessment and medical student psychological distress with the aim of informing assessment practices. A systematic literature search of six electronic databases (Medline, Medline IN PROCESS, PubMed, EMBASE, Psychinfo, ERIC) from 1991 to May 2014 was completed. Articles focusing on academic assessment and its relation to stress or anxiety of medical students were included. From 3,986 potential titles, 82 full-text articles were assessed for eligibility, and 23 studies met review inclusion criteria. Studies focused on assessment stress or anxiety, and assessment performance. Consistent among the studies was the finding that assessment invokes stress or anxiety, perhaps more so for female medical students. A relationship may exist between assessment stress or anxiety and impaired performance. Significant risks of bias were common in study methodologies. There is evidence to suggest academic assessment is associated with psychological distress among medical students. However, differences in the types of measures used by researchers limited our ability to draw conclusions about which methods of assessment invoke greater distress. More rigorous study designs and the use of standardized measures are required. Future research should consider differences in students' perceived significance of assessments, the psychological effects of constant exposure to assessment, and the role of assessment in preparing students for clinical practice.

Laparoscopic sleeve gastrectomy: its place in bariatric surgery for the severely obese patient.

AIM: Laparoscopic sleeve gastrectomy (LSG) was initially used as a staging procedure for high-risk patients undergoing bariatric surgery. However, it is now being increasingly favoured as a single-stage procedure. This article discusses the use of LSG as a single-stage procedure for the treatment of obesity and related comorbidities. METHODS: A literature review was conducted using specific search terms in multiple medical databases. RESULTS: Early and mid-term weight loss results show that LSG is comparable to more established bariatric procedures. It also produces satisfactory resolution of obesity related comorbidities such as type two diabetes mellitus (T2DM). There are minimal published outcome data to assess its long-term effectiveness and safety. This is particularly true in super-obese patients with current data suggesting less satisfactory acheivement of a normal BMI in this group of patients. CONCLUSION: LSG is safe and produces satisfactory weight loss and comorbidity resolution in the early and mid-term period. However, further data are required to assess its long-term effectiveness as well as its effectiveness in super-obese patients.

Propensity score analysis evaluating preoperative glucocorticoid administration in elective colectomy.

BACKGROUND: Preoperative glucocorticoid (GC) administration attenuates the physiological response to surgery and improves clinical outcomes. However, GC use is not yet universally implemented. A propensity score analysis was performed to evaluate preoperative GC use in elective colectomy. METHODS: A retrospective review of prospectively collected data was conducted for all patients who had undergone elective colectomy within an established Enhanced Recovery After Surgery (ERAS) programme at our institution from January 2006 to 2010. Demographic data, surgery type, glucocorticoid administration and clinical outcomes including complication rates and length of hospital stay (LOS) were investigated. Univariate and propensity score analyses were conducted with statistical significance identified as p ≤ 0.05. RESULTS: There were 253 patients included in the analysis, of which 146 received preoperative GC. There were significant baseline differences between those who received GC and those who did not in male gender (GC: 56 (38%); non-GC: 58 (54%); p = 0.02) and American Society of Anesthesiologists (ASA) III (GC: 40 (27%); non-GC: 43 (40%); p = 0.04). On univariate analysis, there were no significant differences in the incidence of total complications, major complication, anastomotic leak and infectious complication. On propensity score analysis, preoperative GC administration was found to be independently associated with a reduction in LOS (GC: 5; Non-GC: 6; p = 0.04). CONCLUSION: Preoperative GC administration is associated with a reduction in LOS without an increase in postoperative complications.

Optimizing perioperative care in bariatric surgery patients.

Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.

Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school.

INTRODUCTION: International interest in peer-teaching and peer-assisted learning (PAL) during undergraduate medical programs has grown in recent years, reflected both in literature and in practice. There, remains however, a distinct lack of objective clarity and consensus on the true effectiveness of peer-teaching and its short- and long-term impacts on learning outcomes and clinical practice. OBJECTIVE: To summarize and critically appraise evidence presented on peer-teaching effectiveness and its impact on objective learning outcomes of medical students. METHOD: A literature search was conducted in four electronic databases. Titles and abstracts were screened and selection was based on strict eligibility criteria after examining full-texts. Two reviewers used a standard review and analysis framework to independently extract data from each study. Discrepancies in opinions were resolved by discussion in consultation with other reviewers. Adapted models of "Kirkpatrick's Levels of Learning" were used to grade the impact size of study outcomes. RESULTS: From 127 potential titles, 41 were obtained as full-texts, and 19 selected after close examination and group deliberation. Fifteen studies focused on student-learner outcomes and four on student-teacher learning outcomes. Ten studies utilized randomized allocation and the majority of study participants were self-selected volunteers. Written examinations and observed clinical evaluations were common study outcome assessments. Eleven studies provided student-teachers with formal teacher training. Overall, results suggest that peer-teaching, in highly selective contexts, achieves short-term learner outcomes that are comparable with those produced by faculty-based teaching. Furthermore, peer-teaching has beneficial effects on student-teacher learning outcomes. CONCLUSIONS: Peer-teaching in undergraduate medical programs is comparable to conventional teaching when utilized in selected contexts. There is evidence to suggest that participating student-teachers benefit academically and professionally. Long-term effects of peer-teaching during medical school remain poorly understood and future research should aim to address this.