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

Robotic IPOM versus eTEP repair of midline ventral hernias (February 2023)

During robotic ventral hernia repair, mesh can be placed intraabdominally (intraperitoneal onlay mesh [IPOM]) or extended totally extraperitoneally (eTEP). The REVEAL trial, which randomly assigned 100 patients with midline ventral hernia ≤7 cm to either robotic IPOM or robotic eTEP repair, did not detect differences in postoperative pain, opioid consumption, same-day discharge rate, and postoperative quality of life [1]. IPOM repair required less surgeon workload and shorter operative time. Although eTEP utilizes less expensive uncoated meshes, that cost-saving is offset by the longer operative time. As such, surgeons may choose a technique based on the characteristics of the hernia and their experience. (See "Robotic component separation techniques", section on 'Outcomes'.)

ARTERIAL AND VENOUS ACCESS

Partial versus total graft excision for hemodialysis graft infection (November 2022)

Patients with localized hemodialysis arteriovenous (AV) graft infection are frequently managed with partial excision and graft revision to salvage the access. However, a meta-analysis of observational studies including a total of 555 AV graft infections found that partial graft excision was associated with higher rates of recurrent infection (27 versus 5 percent) and need for reoperation (20 versus 3 percent) compared with total graft excision [2]. Although partial excision can successfully manage AV graft infection in approximately 80 percent of patients, it is important to frequently reassess the graft to ensure the infection has been adequately controlled. (See "Arteriovenous graft creation for hemodialysis and its complications", section on 'Graft infection'.)

BARIATRIC SURGERY

Apixaban and rivaroxaban after bariatric surgery (February 2023)

The anticoagulants apixaban and rivaroxaban are typically given at a fixed dose without drug monitoring. Two areas of concern are use in individuals with a very high body mass index (BMI) and use following bariatric surgery, which disrupts the gastrointestinal anatomy and might affect absorption. In a retrospective series of 102 adults who required anticoagulation for venous thromboembolism (VTE) after bariatric surgery, there were no episodes of VTE recurrence in individuals treated with apixaban and one recurrence in an individual treated with rivaroxaban; this individual had multiple other risk factors (foot ulcers, boot immobilization, and a BMI of 54 kg/m²) [3]. When these anticoagulants are used in individuals with a high BMI and/or post-bariatric surgery, measurement of a trough level is used to ensure absorption. (See "Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects", section on 'High BMI and post-bariatric surgery'.)

Sleeve gastrectomy versus gastric bypass for adolescents with severe obesity (January 2023)

For metabolic weight loss surgery in adolescents, sleeve gastrectomy (SG) (figure 1) is increasingly used rather than Roux-en-Y gastric bypass (RYGB) (figure 2) based on short-term observational data that suggests similar weight loss but fewer complications with SG. In an observational study of 855 adolescents undergoing weight loss surgery with five-year follow-up, SG compared with RYGB was associated with reduced frequency of emergency department visits (53.3 versus 59.9 percent) and hospitalization (36.9 versus 52.1 percent) [4]. There was no significant difference in the frequency of complications (1.5 versus 2.1 percent) or reoperations (7.2 versus 7.7 percent), and outcomes for weight loss and obesity comorbidities were not reported. These findings support the trend towards preferential use of SG for weight loss surgery in adolescents pending further data on weight and comorbidity outcomes. (See "Surgical management of severe obesity in adolescents", section on 'Sleeve gastrectomy'.)

COLORECTAL SURGERY

Standard transabdominal versus transanal total mesorectal excision for radical resection of rectal cancer (February 2023)

Total mesorectal excision (TME) is an integral part of any radical resection of rectal cancer. Some centers are experimenting with transanal TME (TaTME). In a randomized trial of 116 patients undergoing laparoscopic rectal surgery for cancer, TaTME resulted in a lower conversion rate to open surgery than the standard transabdominal approach (LaTME; 2 versus 11 percent), with similar overall morbidity rates [5]. Local recurrence rates were not significantly different (TaTME: one patient [1.8 percent], LaTME: three patients [6.1 percent]), although median follow-up was only 39 months. Because TaTME carries a steep learning curve (about 40 cases), it should be reserved for high-volume centers. Most centers should continue to perform standard LaTME. (See "Radical resection of rectal cancer", section on 'Transanal TME'.)

Duration of antibiotics after appendectomy for complicated appendicitis (February 2023)

Appendectomy for complicated appendicitis (ie, necrosis, perforation, or abscess formation) is usually followed by a course of antibiotics, but the optimal duration is unclear. In a randomized trial comparing two versus five days of postoperative intravenous antibiotics in over 1000 patients with complicated appendicitis (most undergoing laparoscopic appendectomy), the composite rate of infectious complications and mortality was similar for both groups (10 percent with two days versus 8 percent with five days) [6]. However, the two-day group had a higher rate of emergency room visits (15 versus 8 percent). These data suggest that two days of treatment after laparoscopic appendectomy may be sufficient for complicated appendicitis. We typically treat for two to four days. (See "Management of acute appendicitis in adults", section on 'Antibiotics for perforated appendicitis'.)

Timing for reversing loop ileostomy created during ileal pouch anal anastomosis (January 2023)

The ileal pouch anal anastomosis (IPAA) procedure used to treat ulcerative colitis is often protected with a loop ileostomy. A trial of early (7 to 12 days) versus late (after 8 weeks) ileostomy reversal was terminated early due to higher complication rates (70 versus 17 percent) and more severe complications (30 versus 0 percent) in the early reversal group [7]. As such, IPAA-associated loop ileostomies should not be reversed sooner than within two weeks of their creation. The surgical convention is to reverse them between two and three months. (See "Surgical management of ulcerative colitis", section on 'Staged approach to IPAA'.)

Role of wound packing after drainage of perianal and perirectal abscess (September 2022)

After incision and drainage of a perianal or perirectal abscess, it is common practice to pack the wound, under the assumption that this will facilitate further drainage by wicking and prevent premature skin closure. In the PPAC2 trial of 443 patients with a primary perianal abscess, nonpacking, compared with packing, resulted in similar rates of fistula formation (11 versus 15 percent) and abscess recurrence (6 versus 3 percent), differences that were not statistically significant [8]. However, the nonpacking group had lower average pain scores (28 versus 38 on a 100-point visual analog scale). Given these and similar findings from two earlier small trials, we now suggest not packing the wound after drainage of perianal or perirectal abscess. (See "Perianal and perirectal abscess", section on 'Role of wound packing'.)

BREAST SURGERY

Breast implant-associated cancer (October 2022)

Breast implant-associated malignancies are rare, with most concern related to breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The US Food and Drug Administration and the American Society of Plastic Surgery have recently focused on breast implant-associated squamous cell cancer (BIA-SCC), which can also occur in the capsule surrounding the implant [9]. Clinical features of BIA-SCC that differ from BIA-ALCL include its longer average time to onset after implantation, more aggressive behavior, and higher mortality. BIA-SCC is also associated with either smooth or textured implants, whereas BIA-ALCL is predominantly associated with textured implants. When treating patients who have late-onset peri-implant changes, seroma, or mass, it is essential to consider the possibility of BIA-SCC in addition to BIA-ALCL. (See "Implant-based breast reconstruction and augmentation", section on 'Squamous cell carcinoma'.)

ENDOCRINE SURGERY

Contrast medium washout in lipid-poor adrenal masses (November 2022)

Computed tomography (CT) with contrast medium washout is often used to distinguish benign adrenal adenomas from nonbenign lesions. However, few studies have examined the utility of contrast washout for evaluating indeterminate, lipid-poor adrenal masses. In a retrospective study of 336 masses with attenuation value >10 Hounsfield units, contrast washout ≥60 percent had a sensitivity of 77 percent and specificity of only 70 percent for benign adenoma in adrenal masses <4 cm in size [10]. Among adrenal masses at least 4 cm in size, the prevalence of malignancy was similar between those with (17 percent) and without (23 percent) contrast washout ≥60 percent. Further, three of nine pheochromocytomas exhibited contrast washout of 60 percent or greater. These findings suggest that contrast medium washout may have limited utility in lipid-poor adrenal masses for excluding malignancy and pheochromocytoma. (See "Evaluation and management of the adrenal incidentaloma", section on 'Delayed contrast-enhanced CT'.)

PERIOPERATIVE CARE

Guidelines for reducing the environmental impact of perioperative care (March 2023)

Avoiding unnecessary resource use and controlling emissions are important approaches to reduce the environmental impact of perioperative care. Updated Canadian Anesthesiologists' Society guidelines re-emphasize specific strategies that include choosing reusable, reprocessable equipment rather than single-use disposable items, recycling materials when feasible, and responsibly using inhalation anesthetic agents (eg, low fresh gas flow during delivery; minimizing use of desflurane and nitrous oxide; selecting alternative techniques such as total intravenous anesthesia [TIVA] or neuraxial or regional anesthetic approaches when appropriate) [11]. (See "Environmental impact of perioperative care", section on 'Managing supplies, equipment, and medications'.)

Updated guidance for preoperative COVID-19 testing (February 2023)

In December 2022 the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation published a joint statement updating recommendations about preoperative COVID-19 testing [12]. Instead of routine preoperative universal COVID-19 testing in asymptomatic patients, they now recommend preoperative screening for symptoms of COVID-19 and contact with patients with COVID-19, robust infection control measures, and targeted testing taking into account community incidence of COVID-19 and facility ability to distance patients. Asymptomatic screening may be associated with unnecessary procedure delays and additional cost and is unlikely to provide benefit if infection prevention strategies are used. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Preoperative screening and testing'.)

New guideline for managing perioperative patients on cannabis and cannabinoids (January 2023)

The American Society of Regional Anesthesia and Pain Medicine (ASRA) has developed a new guideline for managing the perioperative patient on cannabis and cannabinoids, given the increasing number of such patients [13]. Among the recommendations, all patients reporting chronic use of cannabinoids should be counseled on the potential risks of continued perioperative use. Elective surgery should be postponed in patients with altered mental status or impairment of decision-making capacity due to acute cannabis intoxication; even in the absence of overt intoxication, a delay of at least two hours after smoking cannabis is recommended to avoid a possible increased risk of myocardial infarction. (See "Anesthesia for patients with substance use disorder or acute intoxication", section on 'Cannabis (marijuana)'.)

Timing of surgery after ischemic stroke (December 2022)

The risk of perioperative stroke is increased in patients with a prior ischemic stroke, though optimal timing of surgery after stroke is unclear. In a database study including nearly six million patients, the risk of postoperative ischemic stroke was increased eightfold in patients who had a stroke within 30 days before surgery, compared with those who never had a stroke [14]. The risk of recurrent stroke decreased and leveled off for surgery between 60 and 90 days after stroke, but remained elevated. The timing of surgery in patients with prior ischemic stroke should consider the risk of recurrent stroke and the risk of delaying surgery. We suggest delaying elective surgery for at least three months, and if possible up to nine months, after a stroke to reduce the risk of recurrence. (See "Perioperative stroke following noncardiac, noncarotid, and nonneurologic surgery", section on 'Timing of surgery after ischemic stroke'.)

Routine glove and instrument change prior to closure of abdominal incisions (December 2022)

Whether changing gloves and using new instruments prior to wound closure affects surgical site infection (SSI) rates is uncertain. In an unblinded cluster randomized trial of over 13,000 patients undergoing intra-abdominal surgery in low- to middle-income (LMIC) countries, the risk of SSI was lower when routine glove and sterile instrument change was performed prior to closure compared with no glove or instrument change (16 versus 19 percent) [15]. The results from this study support a theoretical advantage of changing gloves before closure as a method to reduce the risk of SSI. The LMIC setting may limit generalizability to other settings. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Surgical attire and barrier devices'.)

Preoperative exercise training before lung cancer resection surgery (December 2022)

Some prehabilitation programs include physical exercise training before elective major surgery. In a meta-analysis of 10 randomized trials with over 600 total patients undergoing open or video-assisted resection of non-small cell lung cancer, preoperative aerobic, resistance, and/or respiratory muscle training reduced the risk of postoperative pulmonary complications by over 50 percent and reduced postoperative hospital stay by more than two days [16]. Similar results were noted in previous systematic reviews. Preoperative exercise training likely has benefits in selected patients undergoing lung resection, particularly those with poor functional capacity. (See "Overview of prehabilitation for surgical patients", section on 'Physical exercise programs'.)

Topical antiseptics to reduce infection of contaminated or dirty wounds (December 2022)

The efficacy of various antiseptic agents applied preoperatively to contaminated or dirty wounds to reduce infection is not well studied. In a multiple-period, cluster-randomized, crossover trial comparing aqueous chlorhexidine gluconate with aqueous povidone-iodine for wound preparation in over 1600 open-fracture repairs, the surgical site infection (SSI) rate was 7 percent in both groups [17]. Other aspects of SSI prevention were at the provider's discretion; thus, 63 percent of patients also received an alcohol-based prewash ostensibly of the intact skin of the operative extremity and all patients received intravenous antibiotics (mean duration three days). Further study is needed to determine the optimal preparation of contaminated or dirty wounds and whether any topical agent influences SSI independent of other factors (eg, prophylactic systemic antibiotics, surgery duration, presence of ischemia). (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Topical antiseptics'.)

CDC updates opioid prescribing guidelines (November 2022)

The United States Centers for Disease Control and Prevention (CDC) has published a new guideline for prescribing opioids for acute, subacute, and chronic pain, updating their 2016 guideline (table 1). The guideline is intended for clinicians who prescribe opioids to outpatients ≥18 years of age and does not apply to pain related to sickle cell disease, cancer, palliative care, or end of life care [18]. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Opioid therapy in the context of the opioid epidemic'.)

Risk factors for mortality after major surgery in older adults (October 2022)

Multiple factors contribute to the increased perioperative risk associated with older age. In a prospective study of nearly 1200 major surgeries among community-living adults ≥65 years old (mean age 79 years), one-year mortality rates were higher in those with frailty (28 versus 6 percent) or probable dementia (33 versus 12 percent), and in those requiring urgent surgery (22 versus 7 percent) [19]. These findings add to other evidence suggesting that absolute age alone has only a modest impact on postoperative outcomes and should not be used as a sole criterion to guide decisions regarding patient selection for a major procedure. (See "Anesthesia for the older adult", section on 'Preanesthesia consultation'.)

SKIN AND SOFT TISSUE SURGERY

Prophylactic negative pressure wound therapy following emergency abdominal surgery (September 2022)

The optimal role of prophylactic negative pressure wound therapy (NPWT) after surgery is unclear and cost is a major limitation of its use. In a meta-analysis of observational studies and randomized trials, prophylactic NPWT following emergency abdominal surgery was associated with significantly lower rates of surgical site infection (SSI) and overall wound infection compared with standard dressings, consistent with other reviews [20]. A cost-effectiveness analysis was not performed. Whether NPWT would be cost-effective in this population or other populations at higher risk for SSI requires further study. (See "Negative pressure wound therapy", section on 'Prophylactic use'.)

Transaxillary decompression for neurogenic thoracic outlet syndrome (September 2022)

Surgical decompression can improve symptoms of neurogenic thoracic outlet syndrome (nTOS) refractory to conservative management, but may not be durable. In the STOPNTOS trial, decompression in patients refractory to conservative management resulted in significantly improved DASH (Disability of the Arm, Shoulder, and Hand) scores at three months compared with continued conservative treatment, and all conservatively treated patients subsequently elected to undergo surgery [21]. Postoperatively, transient neurologic complications occurred in 7 of 46 patients, and 9 patients had persistent or recurrent nTOS after one year. These outcomes are consistent with prior observational studies and support our generally conservative approach. Additional larger trials with longer follow-up are needed to better compare surgery for refractory symptoms with ongoing conservative treatment. (See "Overview of thoracic outlet syndromes", section on 'nTOS'.)

TRAUMA AND BURN SURGERY

Aspirin for venous thromboembolism prophylaxis in multiple-trauma patients (January 2023)

Aspirin is an effective alternative for venous thromboembolism (VTE) prophylaxis in patients undergoing elective orthopedic surgery, but it’s role in trauma-related orthopedic surgery is not well-defined. The PREVENT CLOT trial has now evaluated aspirin in trauma patients with fractures and undergoing surgical fracture fixation [22]. In this trial, which randomized over 12,000 patients, aspirin was noninferior to low molecular weight heparin. Differences in rates of death, pulmonary embolism, deep venous thrombosis, bleeding, and other complications were not clinically significant. This trial supports a role for aspirin for VTE prophylaxis in multiple-trauma patients with orthopedic injuries, but more evidence is needed to determine the optimal timing (initiation) and duration of aspirin therapy before its use can become routine. (See "Venous thromboembolism risk and prevention in the severely injured trauma patient", section on 'Aspirin'.)

Low molecular weight heparin dose adjustment in trauma patients (October 2022)

Low molecular weight heparin (LMWH) is administered to adult trauma patients to reduce the risk of venous thromboembolism (VTE), but questions remain about dosing and monitoring. In a meta-analysis of observational studies including heterogeneous multisystem trauma patients, those who attained prophylactic anti-Xa levels had a lower rate of VTE than those who did not [23]. However, dose adjustment to achieve prophylactic anti-Xa levels paradoxically did not reduce VTE compared with standard fixed enoxaparin dosing. While there is likely a role for LMWH dose adjustment based on anti-Xa levels in trauma patients, the optimal protocol and trauma population that would benefit have not been determined. (See "Venous thromboembolism risk and prevention in the severely injured trauma patient", section on 'Monitoring and adjustment'.)

Tranexamic acid prior to burn wound excision (September 2022)

Intravenous tranexamic acid (TXA) reduces blood loss in severe trauma and other surgeries. In a small trial that included patients with total body surface area (TBSA) burns <30 percent, TXA administered prior to burn wound excision reduced average blood loss compared with placebo, by about 30 mL per cm² burn area excised [24]. Although TXA reduced blood loss, transfusion was not needed in either group, and graft take was near 100 percent in both. Larger trials are needed, particularly among patients with larger TBSA burns, to determine whether intravenous TXA improves clinically meaningful outcomes. (See "Skin autografting", section on 'Other methods'.)

Fascial traction to facilitate primary closure of the open abdomen (September 2022)

For management of patients with an open abdomen, fascial traction techniques are frequently advocated to improve primary abdominal closure. The Eastern Association for the Surgery of Trauma (EAST) performed a systematic review of fascial techniques to inform guidance [25]. In a meta-analysis of four trials, fascial traction (with or without negative pressure techniques) reduced failure of primary fascial closure during the index admission compared with negative pressure techniques alone (20 versus 40 percent) and without any increase in bowel fistula formation or death. These outcomes are consistent with prior reviews and support EAST guidelines to include fascial traction when clinically appropriate. (See "Management of the open abdomen in adults", section on 'Techniques'.)

VASCULAR AND ENDOVASCULAR SURGERY

Surgical bypass or endovascular revascularization for chronic limb-threatening ischemia (November 2022)

The BEST-CLI trial randomly assigned two cohorts of patients (over 1800 patients in total) with chronic limb-threatening ischemia (CLTI) to surgical bypass or endovascular revascularization [26]. All patients in the first cohort had a single segment of suitable great saphenous vein (GSV) on ultrasound. At a mean 2.7 years follow-up, surgery reduced the composite outcome of major adverse limb events or all-cause death in this cohort (43 versus 57 percent). No patient in the second cohort had a suitable GSV, and the composite outcome was not significantly different for surgery versus endovascular revascularization in this cohort. For patients with CLTI judged to be suitable candidates for either approach, we suggest a bypass-first strategy when a single segment of suitable GSV is available. Otherwise, a bypass-first or endovascular-first approach is appropriate. (See "Management of chronic limb-threatening ischemia", section on 'Approach to revascularization'.)

Global Limb Anatomic Staging System (GLASS) and limb outcomes after revascularization for chronic limb-threatening ischemia (September 2022)

The Global Limb Anatomic Staging System (GLASS) classifies infrainguinal peripheral artery disease severity. A systematic review evaluated outcomes stratified by GLASS stage for nearly 2500 limb revascularizations for chronic limb-threatening ischemia (CLTI) [27]. For endovascular intervention, higher GLASS stage was associated with more adverse limb outcomes than lower GLASS stage. For surgical bypass, limb outcomes were similar across GLASS stages, and for higher GLASS stages were better than with endovascular intervention. This study suggests that GLASS stage predicts limb outcomes, particularly after endovascular revascularization. Whether patients with CLTI and higher GLASS stage should preferentially be managed with surgical bypass requires further study. (See "Management of chronic limb-threatening ischemia", section on 'Anatomic pattern of disease'.)

Intervention for restenosis after carotid endarterectomy (September 2022)

The optimal approach to reintervention for recurrent stenosis after carotid endarterectomy (CEA) has not been established. Options include redo CEA, transfemoral carotid artery stenting (TF-CAS), and transcarotid artery stenting (TCAR). In a review of over 4000 patients with recurrent stenosis from the Vascular Quality Initiative (VQI) database, the risk of perioperative ischemic events was lower for TCAR compared with TF-CAS or redo CEA [28]. Controlled studies are needed to confirm these outcomes, and longer follow-up is important to determine the rate of restenosis after TCAR. (See "Complications of carotid endarterectomy", section on 'Approach to reintervention'.)

Pretreatment with topical eutectic mixture of local anesthetics before venous radiofrequency ablation (September 2022)

Topical eutectic mixture of local anesthetics (EMLA) reduces pain associated with cutaneous injection. A trial now reports significantly lower pain scores for EMLA compared with no EMLA prior to tumescent anesthetic injection for venous radiofrequency ablation [29]. EMLA was administered two to three hours before the procedure to ensure complete anesthetic absorption. The longer duration of EMLA application likely led to the improved pain scores reported in this trial but not in an earlier trial in which EMLA was applied only 20 minutes before the procedure. (See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Medications'.)

OTHER SURGICAL SPECIALTIES

Sublobar versus lobar resection in small, peripheral NSCLC (February 2023)

Among patients with small, peripheral non-small cell lung cancer (NSCLC), previous data suggested improved survival with sublobar relative to lobar resection. By contrast, in a recent randomized trial in nearly 700 patients with peripheral NSCLC with a tumor of ≤2 cm and pathologically confirmed node-negative disease, sublobar resection resulted in a similar overall survival compared with lobar resection (80 versus 79 percent) [30]. Five-year disease-free survival was also similar (63.6 versus 64.1 percent). Given that the sum of data suggests at least equivalent and possibly improved survival, we continue to suggest sublobar resections in patients with small, peripheral NSCLC, when technically feasible. This approach should be limited to primary tumors ≤2 cm located in the outer one-third of the lung parenchyma, with lobar nodes that are uninvolved on frozen section. (See "Management of stage I and stage II non-small cell lung cancer", section on 'Small peripheral tumors'.)