Daniel P. Lemanu

Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery.

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.

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.

Systematic review and meta‐analysis of oesophageal Doppler‐guided fluid management in colorectal surgery

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.

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.

Health economics in Enhanced Recovery After Surgery programs

PurposeThe 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.SourceThe electronic databases, MEDLINE® and EMBASE™, were searched from inception to April 2014.Principal findingsSeventeen 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.ConclusionsIn 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.RésuméObjectifLe programme de Récupération rapide après la chirurgie (RRAC) vise à combiner et coordonner des interventions de soins périopératoires basées sur des données probantes qui soutiennent la standardisation et l’optimisation des soins chirurgicaux. En association avec ses avantages cliniques, il a été suggéré que la RRAC réduisait les coûts grâce à une convalescence raccourcie et une moindre morbidité. Néanmoins, peu d’études ont évalué le rapport efficacité-coût des programmes de RRAC. Le but de cette synthèse systématique est donc d’évaluer l’argument de rentabilité de la RRAC et de préciser dans quelle mesure ces coûts ont été rapportés et évalués.SourcesUne recherche a été menée dans les bases de données électroniques MEDLINE® et EMBASE™ depuis les origines du concept jusqu’en avril 2014.Constatations principalesDix-sept études répondaient aux critères d’inclusion et ont été analysées. Les protocoles de Récupération rapide après la chirurgie concernant différentes interventions chirurgicales abdominales (colorectales, bariatriques, gynécologiques, gastriques, pancréatiques, œsophagiennes et vasculaires) ont été étudiés. Toutes les études rapportaient des économies associées à l’accélération de la récupération et à la réduction de la morbidité et des complications. Toutes les études incluses dans cette synthèse étaient principalement centrées sur les coûts hospitaliers, certaines d’entre elles tentant de prendre en compte les coûts de réadmission et des services de suivi. Hormis dans deux études, la ventilation des coûts était médiocrement détaillée dans chacune de ces études.ConclusionsEn résumé, les protocoles de RRAC semblent efficaces à court terme à la fois sur le plan clinique et sur celui de la rentabilité dans une gamme de spécialités chirurgicales. Néanmoins, il manque dans ces études les données concernant les coûts hors de l’hôpital. D’autres recherches seront nécessaires pour déterminer comment mieux évaluer à la fois les coûts à court et à long terme en rapport avec les programmes de RRAC, tout en prenant en compte les données de qualité de vie.

A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery

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.

Association between preoperative glucocorticoids and long-term survival and cancer recurrence after colectomy: follow-up analysis of a previous randomized controlled trial

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.

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.

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.