What's new in surgery

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ABDOMINAL WALL AND HERNIA SURGERY

Mesh fixation for open retromuscular ventral hernia repair (August 2023)

In open retromuscular ventral hernia repair, transfascial sutures are typically used to secure the mesh, which can add operative time and cause pain. In a recent randomized trial of 325 patients who underwent open retromuscular repair of a ventral hernia, the one-year recurrence rate was similar with or without transfascial suture fixation of the mesh (7 versus 9 percent) [1]. Based on these results, we no longer suggest mesh fixation for ventral hernias <20 cm wide that are repaired with retromuscular techniques and the anterior fascia can be closed. (See "Open posterior component separation techniques", section on 'Mesh placement and closure'.)

COLORECTAL SURGERY

Timing of appendectomy for uncomplicated appendicitis (November 2023)

Appendectomy is traditionally performed urgently to reduce the risk of perforation. However, a large randomized trial showed that patients with uncomplicated appendicitis (including those with appendicolith on computed tomography) who had an in-hospital delay of up to 24 hours before surgery had no increased risk of perforation or other complications compared with those who underwent surgery within 8 hours [2]. Given these data and general acceptance of antibiotic management of these patients, we suggest performing appendectomy within 24 hours of presentation in patients with uncomplicated appendicitis who elect to undergo surgery. (See "Management of acute appendicitis in adults", section on 'Timing of appendectomy'.)

BREAST SURGERY

Regional nodal radiation in early breast cancer (November 2023)

Studies are evaluating the impact of adjuvant regional nodal radiotherapy (RT) in patients with early breast cancer. In a meta-analysis including over 12,000 patients, absolute improvements in breast cancer recurrence and mortality from regional nodal RT in trials from the 1990s through 2000s were greatest for patients at highest risk for recurrence; absolute reductions in 15-year breast cancer mortality were 1 to 2 percent among those with no positive axillary lymph nodes, 2 to 3 percent among those with one to three positive nodes, and 4 to 5 percent for those with four or more positive nodes [3]. However, no benefits were observed in earlier trials of nodal RT. The discrepancy is likely due to refinements in radiation techniques. For patients with node-positive or high-risk node-negative breast cancer, we offer adjuvant regional nodal RT. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer", section on 'Approach'.)

Peritumoral lidocaine injection before incision for breast cancer surgery (September 2023)

In a multicenter, randomized trial of over 1000 patients with early breast cancer undergoing mastectomy or breast-conserving surgery, peritumoral injection of 0.5% lidocaine prior to incision improved five-year disease-free survival (87 versus 83 percent) and five-year overall survival (90 versus 86 percent) [4]. The mechanism is unknown but thought to involve blocking voltage-gated sodium channels and thereby preventing activation of prometastatic pathways. The trial protocol for surgical management of breast cancer deviated from what may be considered standard treatment in many clinical practices, so further validation is necessary; however, peritumoral injection of lidocaine may be a reasonable intervention given its simplicity and minimal cost. (See "Breast-conserving therapy", section on 'Incision'.)

ENDOCRINE SURGERY

Cardiometabolic features of adrenal incidentaloma with mild autonomous cortisol secretion (December 2023)

In some individuals with adrenal incidentaloma, mild autonomous cortisol secretion (MACS) is evident in the absence of clinical features of Cushing syndrome. The long-term risks of MACS and optimal management strategies are not well defined. In a meta-analysis of 47 observational studies in 17,156 patients with adrenal incidentaloma, individuals with MACS (defined as serum cortisol 1.8 mcg/dL after a 1 mg overnight dexamethasone suppression test) exhibited a higher prevalence of diabetes, hypertension, and dyslipidemia compared with individuals with nonfunctioning adrenal adenomas [5]. Further, patients with MACS who underwent adrenalectomy showed greater improvement in cardiometabolic parameters than those who did not undergo surgery. These findings demonstrate the potential cardiometabolic risks of MACS and support our preference for adrenalectomy in patients with MACS and younger age or evidence of cardiometabolic dysregulation. (See "Evaluation and management of the adrenal incidentaloma", section on 'Clinical manifestations'.)

Health consequences of thymectomy (September 2023)

The thymus naturally involutes with age, which makes its function in adults unclear. In a study that compared long-term outcomes of adults who required thymectomy with a matched control population, thymectomy was associated with increases in all-cause mortality and cancer at five years (mortality: 8.1 versus 2.8 percent; cancer: 7.4 versus 3.7 percent) [6]. When patients with preoperative infection, cancer, or autoimmune disease were excluded, thymectomy was also associated with an increase in autoimmune disease (12.3 versus 7.9 percent). These findings suggest that avoiding incidental removal of the thymus may minimize potential long-term health consequences. (See "Thymectomy", section on 'Potential complications related to altered immune function'.)

PERIOPERATIVE CARE

Postoperative noninvasive ventilation or high-flow nasal oxygen for patients with obesity (November 2023)

The optimal postoperative ventilatory strategy for patients with severe obesity has been unclear. In a 2023 network meta-analysis of randomized trials that compared various postoperative noninvasive ventilatory strategies in these patients, high-flow nasal oxygen (HFNO) or bilevel positive airway pressure (BiPAP) reduced atelectasis; HFNO, BiPAP, or continuous positive airway pressure (CPAP) reduced postoperative pneumonia; and HFNO reduced length of stay compared with conventional oxygen therapy [7]. For patients with obesity who are hypoxic in the post-anesthesia care unit despite oxygen supplementation and incentive spirometry, we suggest a trial of HFNO, BiPAP, or CPAP prior to considering intubation. (See "Anesthesia for the patient with obesity", section on 'Post-anesthesia care unit management'.)

Negative pressure wound therapy for contaminated surgical wounds (November 2023)

Prophylactic negative pressure wound therapy (NPWT) is used on clean surgical wounds, but it may also be useful for contaminated surgical wounds. In a randomized trial that compared NPWT with standard wound care in 69 patients who underwent surgery for gastrointestinal perforation and had fascial closure, NPWT reduced rates of surgical site infection (18 versus 61 percent) and fascial dehiscence (9 versus 48 percent), increased the rate of delayed primary skin closure (91 versus 48 percent), and decreased median time to wound healing (19 versus 26 days) [8]. The results of this small trial are encouraging, and, in the absence of contraindications, we use NPWT over intact fascia to expedite closure of contaminated surgical wounds. (See "Negative pressure wound therapy", section on 'Prophylactic use'.)

Glucagon-like peptide 1 (GLP-1) receptor agonists may increase risk of aspiration during anesthesia (July 2023)

Patients who take glucagon-like peptide 1 (GLP-1) receptor agonists (eg, semaglutide, liraglutide) for weight loss or diabetes may be at increased risk of aspiration during anesthesia due to delayed gastric emptying. In 2023, the American Society of Anesthesiologists suggested holding the day-of-surgery or weekly dose of GLP-1 agonists prior to elective surgery because of case reports of aspiration [9]. For patients who have not held their GLP-1 (ie, no drug on day of procedure/surgery for daily dosing, no drug in the week prior to procedure/surgery for weekly dosing), gastric ultrasound can be used to assess for gastric contents or a rapid sequence induction and intubation should be considered. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Patients taking GLP-1 receptor agonists'.)

TRANSPLANTATION

Lung transplant outcomes for COVID-19 end-stage lung disease (September 2023)

COVID-19 end-stage lung disease is a new indication for lung transplantation with limited outcome data. Two groups have recently analyzed overlapping cohorts of approximately 400 patients who underwent lung transplantation in the United States for COVID-19-associated end-stage lung disease between March 2020 and August 2022 and who comprised almost 9 percent of all lung transplants performed during this time period [10,11]. Compared with other lung transplant recipients, these patients were generally younger and more likely to need mechanical ventilation or extracorporeal membrane oxygenation support before transplantation. Despite longer hospital stays, overall survival over the first 12 months was similar to that seen in patients who received lung transplantation for other causes (86 to 87 percent). Lung transplantation provides effective treatment for carefully selected patients with irreversible end-stage lung disease caused by COVID-19. (See "Lung transplantation: General guidelines for recipient selection", section on 'Lung disease due to COVID-19'.)

TRAUMA AND BURN SURGERY

Whole blood transfusion for severe traumatic hemorrhage (January 2024)

For severe traumatic hemorrhage, whole blood transfusion is an alternative to balanced component transfusion (1:1:1 ratio of packed red blood cells/plasma/platelets). In an observational study comparing these two approaches, low titer group O whole blood transfusion was associated with lower 24-hour mortality (8 versus 19 percent) and lower volume of blood products received at 72 hours (48 versus 82 mL/kg) [12]. The survival benefit was greatest in patients with shock or coagulopathy. While this study suggests improved outcomes for whole blood transfusion, randomized trials are needed to determine which transfusion strategy might be superior and which patients would benefit the most. (See "Ongoing assessment, monitoring, and resuscitation of the severely injured patient", section on 'Whole blood transfusion'.)

Tranexamic acid for burn wound excision (November 2023)

Randomized trials have established that tranexamic acid (TXA) reduces blood loss and transfusion requirements in various surgical settings, but data in burn surgery are limited. In a meta-analysis of observational studies evaluating intravenous and topical TXA in burn surgery, use of TXA was associated with reductions in blood loss, use of intraoperative transfusion, and number of units transfused but no change in venous thromboembolism or mortality rates [13]. Based on this review and data from other surgical settings, we routinely administer intravenous TXA for burn wound excisions over 20 percent of total body surface area. (See "Overview of the management of the severely burned patient", section on 'Coagulopathy'.)

No benefit of Cryoprecipitate in massive transfusion protocol for trauma (October 2023)

Cryoprecipitate is a source of fibrinogen; some institutions may include it in their massive transfusion protocols for trauma patients. In a new trial, 1604 trauma patients were randomly assigned to receive or not receive Cryoprecipitate in addition to a standard massive transfusion protocol [14]. Mortality at 28 days was comparable between the no Cryoprecipitate controls and the Cryoprecipitate group (26 versus 25 percent). This finding supports the practice of reserving Cryoprecipitate for patients with low fibrinogen levels. Transfusion medicine personnel and/or individuals with hemostasis expertise can help to determine the value for specific patients. (See "Cryoprecipitate and fibrinogen concentrate", section on 'Trauma'.)

VASCULAR AND ENDOVASCULAR SURGERY

Phosphodiesterase type 5 inhibition for Raynaud phenomenon (January 2024)

Phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil and tadalafil are widely used to treat digital ischemia from Raynaud phenomenon. In an updated meta-analysis of nine randomized trials comprising 411 patients with Raynaud phenomenon (most of whom had scleroderma), treatment with PDE5 inhibition resulted in three fewer attacks weekly and a reduction in the average duration of the attacks by five minutes [15]. However, PDE5 inhibition led to minimal to no reduction in the pain associated with Raynaud phenomenon. This study implies that while PDE5 inhibition has a modest impact on the duration and frequency of Raynaud attacks, it might not be adequate to address all symptoms experienced by patients with severe disease. (See "Treatment of Raynaud phenomenon: Initial management", section on 'Phosphodiesterase type 5 inhibitor'.)

Genes associated with an increased risk for Raynaud phenomenon (October 2023)

A genetic basis for Raynaud phenomenon (RP) is supported by family and twin studies, but robust evidence for specific causal genes has been lacking. A genome-wide association study has identified two candidate genes associated with an increased risk for RP: ADRA2A and IRX1 [16]. The potential role of these genes in the pathogenesis of RP requires further study. (See "Pathogenesis and pathophysiology of Raynaud phenomenon", section on 'Genetic factors'.)

OTHER SURGICAL SPECIALTIES

Pregnancy and childbirth after urinary incontinence surgery (January 2024)

Patients with stress urinary incontinence (SUI) have historically been advised to delay midurethral sling (MUS) surgery until after childbearing because of concerns for worsening SUI symptoms following delivery. In a meta-analysis of patients with MUS surgery who were followed for a mean of nearly 10 years, similar low SUI recurrence and reoperation rates were reported for the 381 patients with and the 860 patients without subsequent childbirth [17]. Birth route did not affect the findings. Although the total number of recurrences and reoperations was small, this study adds to the body of evidence suggesting that subsequent childbirth does not worsen SUI outcomes for patients who have undergone MUS. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Subsequent pregnancy'.)

Tranexamic acid to reduce bleeding after percutaneous nephrolithotomy (December 2023)

Postoperative bleeding can occur after percutaneous nephrolithotomy (PNL) for kidney stone removal; most bleeding is venous in origin and can be managed with conservative measures. A recent meta-analysis of 10 randomized trials found that use of tranexamic acid (TXA), an antifibrinolytic agent used to reduce bleeding in other clinical settings, may reduce the risk of blood transfusion after PNL [18]. Most trials were conducted in low- to middle-income settings in populations that were younger than those in higher-income settings; whether these findings are generalizable to practice in higher-income settings is uncertain. Pending additional data, we do not routinely use TXA after PNL. (See "Kidney stones in adults: Surgical management of kidney and ureteral stones", section on 'Bleeding'.)

Choice of intervention for aortic stenosis with low surgical risk (November 2023)

The choice of intervention for severe aortic stenosis (AS) is based upon an individualized assessment by a multidisciplinary heart valve team. Two randomized trials reported outcomes for transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in selected low surgical risk patients with severe AS [19,20]:

●In one trial in which nearly 1500 patients were randomly assigned to TAVI with a self-expanding valve or SAVR, rates of mortality, disabling stroke, and aortic valve rehospitalization at four years were similar in the two groups.

●In another trial in which 1000 patients were randomly assigned to TAVI with a balloon-expanding valve or SAVR, rates of mortality, stroke, and rehospitalization at five years were similar in the two groups.

These trials indicate generally favorable results for TAVI up to four and five years for selected low surgical risk patients with severe AS and anatomical suitability for TAVI; additional data, including longer-term outcomes, will further inform the choice of intervention in this clinical setting. (See "Choice of intervention for severe calcific aortic stenosis", section on 'In low-risk symptomatic patients'.)

No benefit to routinely adding vancomycin for prophylaxis before joint replacement (November 2023)

For preoperative antibiotic prophylaxis in patients undergoing joint replacement, vancomycin is sometimes added to cefazolin to empirically cover methicillin-resistant staphylococci. In a randomized trial of over 4000 patients undergoing joint replacement, the rate of surgical site infection was similar following prophylaxis with cefazolin plus vancomycin compared with cefazolin plus placebo (4.5 versus 3.5 percent) [21]. There were no differences in rates of infection due to methicillin-resistant Staphylococcus aureus (MRSA) or Staphylococcus epidermidis. We use cefazolin alone for prophylaxis in patients undergoing joint replacement who are not known to have MRSA colonization or infection. (See "Prevention of prosthetic joint and other types of orthopedic hardware infection", section on 'Antimicrobial prophylaxis'.)

Timing of prophylactic aortic surgery for patients with bicuspid aortic valve (October 2023)

The optimal timing for prophylactic aortic surgery for patients with a bicuspid valve (BAV) and ascending aorta diameters of 5.0 to 5.4 cm is uncertain. In a retrospective multicenter study including nearly 500 patients with BAV and aortic diameters in this range who were followed for a median of seven years, over one-half of the patients underwent elective aortic surgery, with an operative mortality rate of 1.9 percent [22]. Aortic dissection occurred during surveillance in 1.8 percent of the nearly 500 patients. These findings illustrate the risk trade-offs for early surgery versus surveillance for patients with BAV; a randomized trial is underway to compare these approaches in patients with ascending aorta diameters of 5.0 to 5.4 cm, including patients with BAV. (See "Bicuspid aortic valve: Intervention for valve disease or aortopathy in adults", section on 'Without high-risk features'.)

High-dose dual-antibiotic loaded cement does not reduce infection compared with low-dose single-antibiotic loaded cement in hip arthroplasty (September 2023)

The optimal dosing and effectiveness of antibiotic-loaded cement for hip arthroplasty is uncertain. In a randomized trial, high-dose dual-antibiotic-loaded cement did not reduce the incidence of deep surgical site infection after hip arthroplasty compared with low-dose single-antibiotic-loaded cement [23]. Based on this trial, when antibiotic cement fixation is selected for hip arthroplasty, available cement preparations that use a low-dose single antibiotic are adequate for reducing the risk of surgical site infection and also minimize the risk of fixation weakening associated with high-dose dual-antibiotic-loaded cement. (See "Total hip arthroplasty", section on 'Total hip arthroplasty implant design'.)

Thoracic epidural analgesia for cardiac surgical patients (September 2023)

Neuraxial analgesia is not generally employed for cardiac surgery in the United States due to concerns about spinal epidural hematoma (SEH) after systemic anticoagulation for cardiopulmonary bypass. However, a recent meta-analysis including 51 randomized trials in cardiac surgical patients noted thoracic epidural analgesia (TEA) was associated with shorter lengths of stay in the intensive care unit and hospital (by approximately seven hours and one day, respectively), as well as lower pain scores and rates of delirium, transfusion, arrhythmia, and pulmonary complications [24]. No trial reported a case of SEH. These findings support the use of TEA in cardiac surgical patients. (See "Postoperative care after cardiac surgery", section on 'Neuraxial and regional anesthetic techniques'.)

Standard versus extended lymphadenectomy for radical cystectomy (August 2023)

The benefit of an extended lymphadenectomy during radical cystectomy is controversial. In a phase III trial, 618 patients with cT2-4a N0-2 bladder cancer underwent radical cystectomy with standard or extended lymphadenectomy and were followed for six years [25]. Although more lymph nodes were removed with extended lymphadenectomy (median 39 versus 25), this did not result in more favorable outcomes as rates of nodal metastasis, disease-free survival, and overall survival were similar. Furthermore, extended lymphadenectomy resulted in a higher rate of severe complications (16 versus 8 percent) and more deaths within 90 days (19 versus 7 patients). Given these results, radical cystectomy should be performed with bilateral standard lymphadenectomy, which includes removal of at least 12 external and internal iliac and obturator nodes. (See "Radical cystectomy", section on 'Lymphadenectomy'.)