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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.

To investigate whether a text message intervention improves adherence to preoperative exercise advice prior to laparoscopic sleeve gastrectomy (LSG).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 (METminEighty-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.A daily text message intervention improved adherence to preoperative exercise advice, but this did not correlate with improved surgical recovery.

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.

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

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.

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. The electronic databases, MEDLINE® and EMBASE™, were searched from inception to April 2014. 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. 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.

Aim Enhanced recovery after surgery (ERAS) programmes have been shown to reduce length of stay and peri-operative morbidity. However, there are comparatively few data on their cost effectiveness. The object of this systematic review was to appraise the current literature to determine the cost effectiveness of ERAS and to characterize how cost is reported and evaluated. Method An electronic database search identified studies comparing ERAS with standard peri-operative care in colorectal surgery where an evaluation of cost effectiveness was a primary or secondary outcome. Cost data were converted to euros to enable a more standardized comparison of the studies. There were no limits on study design. Results Seven articles were included in the analysis. The reporting and evaluation of cost data were inconsistent. Reported cost for ERAS ranged from €1989 to €12 805 per patient. Although not all statistically significant, all studies demonstrated cost reductions with ERAS compared with non-ERAS although they were highly variable, ranging from €153 to €6537 per patient. Conclusion Although the review has shown ERAS to be cost effective, there are some important inconsistencies and deficiencies regarding the reporting of data. Authors should therefore be encouraged to report cost data to supplement the literature detailing clinical efficacy.

Background Several recent studies have investigated the role of C-reactive protein (CRP) as an early marker of anastomotic leakage following colorectal surgery. The aim of this systematic review and meta-analysis was to evaluate the predictive value of CRP in this setting. Methods A systematic literature search was performed using MEDLINE, Embase and PubMed to identify studies evaluating the diagnostic accuracy of postoperative CRP for anastomotic leakage following colorectal surgery. A meta-analysis was carried out using a random-effects model and pooled predictive parameters were determined along with a CRP cut-off value at each postoperative day (POD). Results Seven studies, with a total of 2483 patients, were included. The pooled prevalence of leakage was 9·6 per cent and the median day on which leakage was diagnosed ranged from POD 6 to 9. The serum CRP level on POD 3, 4 and 5 had comparable diagnostic accuracy for the development of an anastomotic leak with a pooled area under the curve of 0·81 (95 per cent confidence interval 0·75 to 0·86), 0·80 (0·74 to 0·86) and 0·80 (0·73 to 0·87) respectively. The derived CRP cut-off values were 172 mg/l on POD 3, 124 mg/l on POD 4 and 144 mg/l on POD 5; these corresponded to a negative predictive value of 97 per cent and a negative likelihood ratio of 0·26–0·33. All three time points had a low positive predictive value for leakage, ranging between 21 and 23 per cent. Conclusion CRP is a useful negative predictive test for the development of anastomotic leakage following colorectal surgery.

Junior doctors are increasingly promoted as clinical teachers but there is limited understanding of how they contribute to medical student clerkship learning.To describe contributions made by general surgical interns to the student clerkship learning environment.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.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.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.

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.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).Eight low- to medium-quality RCTs were included in the final analysis. The patients were elderly (mean age60 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.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.

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.

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.

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.

Background The effect of anaesthetic drugs on long-term oncological outcomes after cancer surgery is an area of current interest. Dexamethasone is widely used in anaesthetic practice; however, its effect on long-term survival and cancer outcomes is not known. This study presents the results of a 5-yr follow-up of patients receiving dexamethasone before elective colectomy as part of a previous randomized clinical trial. Methods Sixty patients who underwent elective open colonic resection for any indication between June 2006 and March 2008 were randomized to receive either 8 mg i.v. dexamethasone or placebo before surgery. A 5-yr follow-up analysis was conducted to evaluate overall survival, disease-free survival and recurrence specifically for patients undergoing resection for Stage I–III colon cancer. Kaplan–Meier analysis was performed and log-rank test was used to evaluate difference in survival between groups. Results Forty-three of the 60 subjects had Stage I–III colon cancer and were included in the follow-up analysis. Twenty received preoperative dexamethasone and 23 received placebo. There were no significant differences between groups in baseline or disease characteristics. No differences were found between groups for overall or disease-free survival. In the dexamethasone group, there was a significantly higher rate of distant recurrence (6 compared with 1, P=0.04). Conclusions Preoperative dexamethasone was associated with a higher rate of distant recurrence in patients undergoing colectomy for colon cancer. Given the small sample size, this finding should be interpreted with caution, but warrants further investigation in a prospective study.

Background Oesophageal Doppler monitor (ODM)-guided fluid therapy has been recommended for routine use in patients undergoing colorectal surgery. However, recent trials have suggested either equivalent or inferior results for patients randomized to ODM-guided fluid management, especially when compared with fluid restriction or within the context of optimized perioperative care. Hence, an updated systematic review and meta-analysis was conducted. Methods A systematic review and meta-analysis was conducted of all randomized trials exploring ODM-guided fluid management in major colorectal surgery with the endpoints total complications and length of hospital stay (LOS). Subset analyses were planned a priori specifically to investigate the role of the ODM in the context of fluid restriction or optimized perioperative care. Results Six high-quality trials comprising a total of 691 patients were included in the final analysis. ODM-guided fluid therapy did not influence the incidence of complications (odds ratio 0·74, 95 per cent confidence interval (c.i.) 0·50 to 1·11; P = 0·15), with moderate heterogeneity in the results (I2 = 33 per cent; P = 0·19). There was no difference in mean LOS between patients receiving ODM-guided fluid therapy and controls: mean difference −0·88 (95 per cent c.i. –2·89 to 1·13) days (P = 0·39). There was no difference in complications or LOS when ODM-guided fluid therapy was compared with fluid restriction or used within an otherwise optimized perioperative environment. Conclusion ODM-guided fluid therapy did not influence LOS or complications in patients undergoing colorectal surgery. Results favouring the ODM were seen only in early studies, whereas newer trials did not show any benefit from such monitoring.

Background Optimized perioperative care within an enhanced recovery after surgery (ERAS) protocol is designed to reduce morbidity after surgery, resulting in a shorter hospital stay. The present study evaluated this approach in the context of sleeve gastrectomy for patients with morbid obesity. Methods Patients were allocated to perioperative care according to a bariatric ERAS protocol or a control group that received standard care. These groups were also compared with a historical group of patients who underwent laparoscopic sleeve gastrectomy at the same institution between 2006 and 2010, selected using matched propensity scores. The primary outcome was median length of hospital stay. Secondary outcomes included readmission rates, postoperative morbidity, postoperative fatigue and mean cost per patient. Results Of 116 patients included in the analysis, 78 were allocated to the ERAS (40) or control (38) group and there were 38 in the historical group. There were no differences in baseline characteristics between groups. Median hospital stay was significantly shorter in the ERAS group (1 day) than in the control (2 days; P < 0·001) and historical (3 days; P < 0·001) groups. It was also shorter in the control group than in the historical group (P = 0·010). There was no difference in readmission rates, postoperative complications or postoperative fatigue. The mean cost per patient was significantly higher in the historical group than in the ERAS (P = 0·010) and control (P = 0·018) groups. Conclusion The ERAS protocol in the setting of bariatric surgery shortened hospital stay and was cost-effective. There was no increase in perioperative morbidity. Registration number: NCT01303809 (http://www.clinicaltrials.gov).

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-1β, 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.

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.A literature review was conducted using specific search terms in multiple medical databases.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.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.

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.

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.

l l Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMGCoA] or HMG-CoA reductase inhibitors) are the most commonly prescribed class of lipid-lowering drugs. In addiion to their established role in the medical management of ardiovascular disease, benefits have also been demontrated in cardiac and vascular surgery, where they have een shown to decrease cardiovascular complications nd reduce perioperative mortality. These cardioprotective effects also extend to the wider surgical population, with similar benefits seen in noncardiovascular surgical settings. Interestingly, some cardiovascular benefits of statins precede any substantial reduction in cholesterol levels or preexisting atheroma. Thishasbeenattributed to theadditional ffects of statins that extend beyond cholesterol-lowering, includng anti-inflammatory, antioxidant, immunomodulatory, and ibrinolytic properties. The mechanism behind these holesterol-independent or pleiotropic effects of statins is ecoming increasingly recognized. Through inhibition of he HMG-CoA reductase enzyme, statins inhibit the conersion of HMG-CoA to mevalonate and important downtream isoprenoids, such as farnesyl pyrophosphate and eranyl-geranyl pyrophosphate. In addition to reducing holesterol synthesis, inhibition of these intermediate molcules decreases isoprenylation of important signaling molcules, such as RhO and Ras, which leads to modulation of arious cellular activities (Fig. 1). These effects on ellular function are considered the basis for the observed holesterol-independent effects of statins (Table 1). Along with their cardioprotective effects, these pleiotroic properties are relevant to the general surgical populaion and there is growing evidence that statins can offer articular benefits in abdominal surgery. Laboratory tudies have demonstrated the relevance of these pleiotroic effects to abdominal surgery, with statins improving

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.