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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 in incisional hernia repair (October 2016)
Mesh is widely used in incisional hernia repair, but the balance of risks versus benefits remains controversial. A registry-based cohort study including over 3000 elective incisional hernia repairs compared the outcomes of open and laparoscopic mesh repair with open nonmesh repair . At five years, mesh repair was associated with fewer reoperations for recurrences, but more reoperations for mesh-related complications. Based on this and other studies, we use mesh for repairing moderate- to large-sized hernias to reduce recurrences. For smaller hernias (<4 cm) where the risk of recurrence is low, mesh can be omitted to avoid potential complications. (See "Incisional hernia", section on 'Suture repair versus mesh repair'.)
ANESTHESIA AND PERIOPERATIVE CARE
Airway device for small infants during anesthesia (March 2017)
Many pediatric anesthesiologists routinely use an endotracheal tube (ETT) in small infants, but whether the choice of airway device in these patients affects the risk of perioperative respiratory adverse events (PRAEs) is unclear. In a trial that assigned 180 infants <1 year of age to a laryngeal mask airway (LMA) or an endotracheal tube (ETT) for airway management for general anesthesia, use of LMAs resulted in lower risks of all perioperative PRAEs (18 versus 53 percent) and laryngospasm/bronchospasm (4 versus 19 percent) . Further study is required before basing the choice of airway device for infants on the risk of PRAEs as the incidence of PRAEs with ETT in this population was unusually high, criteria for extubation were not specified, the anesthetic techniques were not standardized, and all patients were cared for by attending pediatric anesthesia specialists. (See "Anesthesia for the child with a recent upper respiratory infection", section on 'Choice of airway device'.)
FDA issues warning about anesthesia for pregnant patients and children under three years of age (December 2016)
The US Food and Drug Administration has warned about potential negative effects on the developing brain from administration of anesthetics and sedatives to pregnant women and children under age three, especially for repeated exposures or procedures lasting more than three hours . However, the degree of risk remains unclear. A single, brief exposure to anesthesia probably does not cause neurotoxicity in healthy young children. Further study is required to determine the effects of prolonged or repeated anesthetics, variability among anesthetic agents and combinations of drugs, and patient factors that may confer vulnerability to anesthetic neurotoxicity. At present, there is no compelling evidence that any specific anesthetic agent should be avoided during pregnancy or in young children, or that necessary surgery should be delayed because of concerns about neurotoxicity. (See "Management of the pregnant patient undergoing nonobstetric surgery", section on 'Fetal brain development'.)
Ketofol versus propofol for procedural sedation (December 2016)
Ketofol, a combination of ketamine and propofol, is purported to provide good conditions while reducing harmful side effects during procedural sedation and analgesia (PSA) performed outside the operating room, but studies to date have failed to identify clinically significant differences between ketofol and propofol alone. These findings were confirmed in a randomized, multicenter trial involving over 500 patients receiving PSA that reported no significant differences in the rate of adverse respiratory events (oxygen desaturation, apnea, or hypoventilation) between those managed with ketofol or propofol . While multiple studies confirm that ketofol is safe and effective, there is no convincing evidence that it improves clinically significant outcomes or reduces important (albeit rare) complications during PSA compared with propofol. (See "Procedural sedation in adults outside the operating room", section on 'Ketamine and propofol (ketofol)'.)
Transfusion outcomes with "fresh" versus "old" blood (November 2016)
The INFORM trial (Informing Fresh versus Old Red Cell Management) is the largest trial to compare clinical outcomes with "fresh" versus "old" blood . In INFORM, over 20,000 hospitalized adults who required transfusion were randomly assigned to receive "old" red blood cells (RBCs; stored for a mean of 24 days) or "fresh" RBCs (stored for a mean of 13 days). There were no differences in mortality or hospital length of stay. Smaller trials in adults, children, and neonates have also concluded that outcomes are unaffected by RBC storage duration. (See "Red blood cell transfusion in adults: Storage, specialized modifications, and infusion parameters", section on 'Clinical relevance of storage time'.)
Updated guideline and meta-analysis on hemoglobin thresholds for blood transfusion (November 2016)
An updated systematic review and meta-analysis of randomized trials involving over 12,000 patients has provided more support for the use of a restrictive transfusion strategy (giving less blood, transfusing at a lower hemoglobin level, typically 7 to 8 g/dL) for most hemodynamically stable medical and surgical patients who are not actively bleeding or symptomatic from anemia . An updated 2016 guideline from the AABB (an international organization) also supports the use of restrictive thresholds . The major exception is patients with acute coronary syndromes (ACS), for whom data from large randomized trials are not available and for whom pilot trials suggest a more liberal threshold may be associated with better outcomes. We continue to use an individualized approach to transfusion in patients with ACS. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Society guidelines'.)
Safety of magnetic resonance imaging and gadolinium in pregnancy (September 2016)
Magnetic resonance imaging (MRI) may be used for diagnostic imaging in pregnancy when ultrasound examination is inadequate; however, fetal safety has not been conclusively established. Recently, the largest study of MRI in pregnancy (over 1700 exposed and 1.4 million unexposed births) reported that first-trimester MRI was not associated with significantly increased risks for stillbirth, neonatal death, congenital anomaly, neoplasm, or vision or hearing loss in children followed up to age four years, when adjustments were made for differences between exposure groups . The study also found that gadolinium exposure at any time during pregnancy was associated with an increased risk for stillbirth and neonatal death. Children exposed in utero were at increased risk for rheumatological, inflammatory, or infiltrative skin conditions, but not congenital anomalies or nephrogenic systemic fibrosis (NSF). This study is a major addition to the body of evidence supporting the safety of MRI in pregnancy when medically indicated. It also provides the first data supporting existing recommendations to avoid use of gadolinium-based contrast agents in pregnant women, when possible. (See "Diagnostic imaging procedures during pregnancy", section on 'Magnetic resonance imaging'.)
ARTERIAL AND VENOUS ACCESS
Regional anesthesia for hemodialysis arteriovenous fistula creation (November 2016)
Regional anesthesia during the creation of hemodialysis arteriovenous fistulas causes arterial and venous dilation, which may improve early fistula patency. In a trial that randomly assigned 126 adults receiving primarily radiocephalic or brachiocephalic fistulas to brachial plexus block or local anesthesia, brachial plexus block resulted in a higher rate of primary fistula patency and a trend toward a higher rate of functional patency at three months . Based upon these findings, we suggest brachial plexus block for the creation of arteriovenous fistulas, rather than using local anesthesia alone. (See "Creating an arteriovenous fistula for hemodialysis", section on 'Type of anesthesia'.)
Glycemic outcomes following bariatric surgery in obese patients with type 2 diabetes (February 2017)
Additional follow-up from a bariatric surgery trial in obese patients with type 2 diabetes (134 patients in follow-up study, 150 patients in initial trial) continues to show reduced glycated hemoglobin (A1C) in the two surgical arms at five years, although there has been some regression in all groups from the one-year results . The proportion of patients with A1C ≤6 percent was 29 percent for gastric bypass and 23 percent for sleeve gastrectomy, compared with 5 percent for controls (intensive medical therapy). While these results are encouraging, we require longer-term follow-up with documentation of improved clinically important outcomes, such as reduced vascular complications or reduced mortality, before routinely recommending bariatric surgery for obesity-related type 2 diabetes that is resistant to multiple medications. (See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Surgical treatment of obesity'.)
Surgical margin in breast conserving surgery for ductal carcinoma in situ (October 2016)
For women undergoing breast conserving therapy for ductal carcinoma in situ (DCIS), surgical resection margins have a significant impact on local recurrence, but the optimal margin has been controversial. A meta-analysis found a 2 mm margin was associated with a twofold reduction in local recurrence rates compared with a positive margin, and equivalent recurrence rates compared with wider margins . A multidisciplinary consensus guideline advises that 2 mm be the standard for an adequate margin in DCIS treated with breast conserving surgery followed by whole breast irradiation . Clinical judgment is advised when determining whether patients with a negative but <2 mm margin require re-excision. (See "Breast conserving therapy", section on 'Margins for DCIS'.)
Open versus laparoscopic resection for stage II or III colon cancer (March 2017)
In a trial involving over 1000 patients with stage II or III colon cancer, colon resection performed with complete mesocolic excision and central vascular ligation resulted in equally excellent five-year survivals (over 90 percent) whether surgery was performed open or laparoscopically . Thus, surgeons treating colon cancer have a choice of techniques, but must follow strict oncologic principles, including complete mesocolic excision, to ensure optimal outcomes. (See "Surgical resection of primary colon cancer", section on 'Regional lymphadenectomy'.)
Treatment of acute diverticulitis without antibiotics (February 2017)
Acute diverticulitis is typically treated with antibiotics. However, in a Dutch trial (DIABOLO) that randomly assigned over 500 low-risk patients with first-episode, acute, uncomplicated diverticulitis confirmed with computed tomography to either observation or antibiotic therapy, outcomes were similar for both groups . Because almost all of the patients were admitted to the hospital for one or more days, this trial did not establish the safety of avoiding antibiotic therapy in low-risk outpatients. Thus, until further data become available, UpToDate continues to recommend antibiotic treatment of acute diverticulitis in patients meeting criteria for outpatient management. (See "Acute colonic diverticulitis: Medical management", section on 'Outpatient treatment' and "Acute colonic diverticulitis: Medical management".)
Conventional hemorrhoidectomy versus stapled hemorrhoidopexy for internal hemorrhoids (November 2016)
Conventional hemorrhoidectomy and stapled hemorrhoidopexy are the surgical procedures most commonly used to treat symptomatic or prolapsing internal hemorrhoids. In a large randomized trial comparing the two procedures, stapled hemorrhoidopexy resulted in less postoperative pain in the initial six weeks, but more recurrences and worse symptoms and quality of life at 12 and 24 months . Thus, we suggest conventional hemorrhoidectomy for most patients seeking surgical treatment for symptomatic or prolapsing internal hemorrhoids. Patients who prefer to minimize pain and “downtime” after surgery may benefit from stapled hemorrhoidopexy. (See "Surgical treatment of hemorrhoidal disease", section on 'Conventional versus stapled'.)
HEPATOBILIARY AND PANCREATIC SURGERY
Optimal timing of surgery for acute cholecystitis (March 2017)
Although early surgery is advocated for acute cholecystitis, the recommendation for cholecystectomy within seven days of admission is imprecise. An administrative database study of over 15,000 cholecystectomies for acute cholecystitis reported that the lowest overall morbidity and mortality rates were achieved with surgery on the first or second day after admission . Surgery on the day of admission was associated with a lower rate of biliary injury but a higher rate of nonbiliary complications compared with surgery on subsequent days. Thus, patients with acute cholecystitis should undergo surgery within two days of admission, but only after they have been fully resuscitated and when the most qualified surgeon is available. (See "Treatment of acute calculous cholecystitis", section on 'Timing of cholecystectomy'.)
Prevention of graft reinfection in HCV-infected patients undergoing liver transplantation (December 2016)
In the absence of viral suppression or clearance of chronic hepatitis C virus (HCV) in patients who undergo liver transplantation, the new liver is almost always reinfected. In an open-label study, 16 HCV genotype 1-infected patients undergoing their first liver transplantation from an uninfected donor received a single dose of ledipasvir-sofosbuvir the day they arrived at the hospital for transplantation and once daily for four weeks postoperatively . The sustained virologic response rate 12 weeks after completion of treatment was 88 percent, suggesting that an abbreviated perioperative course of direct-acting antiviral (DAA) treatment can prevent reinfection of the graft. Additional studies are warranted to confirm the efficacy and safety of this approach in other HCV-infected populations and with other DAA regimens. (See "Recurrence of hepatitis C virus infection following liver transplantation", section on 'Perioperative therapy'.)
Screening for cardiovascular disease before kidney transplantation (October 2016)
Cardiovascular disease is the leading cause of mortality in kidney transplant recipients. Although pretransplant cardiac evaluation is recommended for potential transplant candidates, the optimal screening strategy has not yet been identified. In a prospective study comparing clinical risk factor assessment with coronary artery calcium (CAC) scores among 138 pretransplant patients, CAC scores were not superior to risk factor assessment in identifying patients who would benefit from noninvasive testing for coronary heart disease (CHD) . Both clinical risk factor assessment and CAC scores had a poor positive predictive value but a high negative predictive value for identifying patients with CHD. (See "Evaluation of the potential renal transplant recipient", section on 'Coronary heart disease'.)
Perioperative complications in minimally invasive live donor nephrectomy (September 2016)
Minimally invasive donor nephrectomies account for more than half of live donor nephrectomies performed for kidney transplantation. A systematic review of over 32,000 minimally invasive live donor nephrectomies demonstrated a low operative mortality rate of 0.01 percent and low rates of intraoperative and postoperative complications (primarily bleeding and infections) . Comparison of the different minimally invasive techniques found similar complication rates between hand-assisted versus non-hand-assisted, laparoscopic versus retroperitoneoscopic, and multiport versus single-port procedures. (See "Benefits and complications of minimally invasive live-donor nephrectomy", section on 'Donor morbidity'.)
VASCULAR AND ENDOVASCULAR SURGERY
Ticagrelor versus clopidogrel for prevention of cardiovascular events in patients with peripheral artery disease (January 2017)
Antiplatelet therapy is recommended for patients with peripheral artery disease (PAD) to prevent future cardiovascular events. The EUCLID trial randomly assigned nearly 14,000 patients with symptomatic PAD to ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily . The clopidogrel group had less ischemic stroke (1.9 versus 2.4 percent), but there were no significant differences between groups for the composite primary outcome (cardiovascular death, myocardial infarction [MI], or ischemic stroke) or for death, MI, acute limb ischemia, need for revascularization, or major bleeding. Patients receiving ticagrelor were more likely to discontinue treatment due to dyspnea or minor bleeding. These data support the use of clopidogrel rather than ticagrelor as an alternative to aspirin for patients with PAD. (See "Overview of lower extremity peripheral artery disease", section on 'Antithrombotic therapy'.)
Long-term follow-up of percutaneous femoropopliteal angioplasty for claudication (January 2017)
Whether minimally invasive vascular intervention improves the clinical status of patients with claudication due to peripheral artery disease (PAD) is debated. The early outcomes of a trial comparing femoropopliteal percutaneous transluminal angioplasty (PTA), a supervised exercise program (SEP), or combined treatment (PTA + SEP) found combined treatment produced a greater improvement in some clinical outcome measures than PTA or SEP alone. However, longer-term follow-up (mean 5.2 years) is now available and showed no significant differences between the groups for observed treadmill walking distances, restenosis rates, or quality-of-life outcomes . These results support our recommendation to treat claudication with a medical therapy regimen that includes risk factor modification and exercise therapy (and possibly pharmacologic therapy), rather than any form of vascular intervention. (See "Management of claudication", section on 'Initial therapy'.)
Angioplasty in renal artery stenosis (November 2016)
In patients with atherosclerotic renal artery stenosis, a meta-analysis of trials comparing percutaneous transluminal renal angioplasty (PTRA) with stent placement plus medical therapy with medical therapy alone found no benefit from PTRA on mortality, end-stage renal disease, major cardiovascular events, or blood pressure control . One or more major periprocedural complications occurred in 7.1 percent of patients who underwent PTRA. Thus, in patients with renal artery stenosis and clinical characteristics similar to those enrolled in these trials, we suggest not revascularizing and instead treating with medical therapy alone. (See "Treatment of unilateral atherosclerotic renal artery stenosis", section on 'Revascularization versus medical therapy alone'.)
Long-term outcomes of endovascular versus open abdominal aneurysm repair (November 2016)
For intact aneurysms, endovascular repair of abdominal aortic aneurysms (EVAR) results in lower perioperative mortality than open repair, but data on long-term risks and benefits are sparse. In the longest follow-up study, the endovascular aneurysm repair trial (EVAR 1) reported that the early benefit of EVAR was lost beginning about eight years after randomization due to late fatal secondary aneurysm ruptures, and that total mortality was the same for EVAR or open repair by the end of the follow-up period (mean 12.7 years) . The EVAR group also had higher cancer mortality, which was not reported in similar studies and may have been related to more frequent surveillance in EVAR 1. This study affirms previous data that EVAR does not result in a long-term survival advantage over open repair. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'EVAR 1 trial'.)
OTHER SURGICAL SPECIALTIES
Tonsillectomy or watchful waiting for children with recurrent throat infections (February 2017)
A systematic review of studies comparing tonsillectomy with watchful waiting for children with mild to moderate recurrent throat infections concluded that tonsillectomy provided a modest reduction in number of throat infections and health care utilization in the first postsurgical year, but little to no long-term difference in these outcomes or quality of life . Hence, we suggest not performing tonsillectomy in children who are only mildly or moderately affected. Tonsillectomy is an option for children who are severely affected (ie, ≥7 episodes in one year, ≥5 episodes in each of two years, or ≥3 episodes in each of three years), although watchful waiting is a reasonable alternative. The decision should be made on a case-by-case basis after weighing the risks and benefits in the individual child, and the values and preferences of the family and child. (See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Mildly or moderately affected children'.)
Vertebroplasty for osteoporotic compression fractures (November 2016)
The indications for and timing of vertebroplasty for the treatment of osteoporotic compression fractures are controversial. In a trial comparing vertebroplasty or simulated vertebroplasty (sham) in 120 patients with acute (less than six weeks) vertebral fracture and back pain, more patients in the vertebroplasty group achieved clinically significant lower pain scores at 14 days . Two previous sham-controlled trials, however, did not show a significant reduction in pain with vertebroplasty, likely due to differences in study design, including different sham procedures for the control arm and varying definitions of acute vertebral fracture. (See "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment", section on 'Vertebroplasty'.)
Alpha-1-blocker therapy for symptoms from benign prostate hyperplasia (November 2016)
Drug treatment can reduce symptoms from benign prostatic hyperplasia (BPH), but the comparative effectiveness of different drug treatments has not been well studied. A meta-analysis commissioned by the Agency for Healthcare Research and Quality (AHRQ) compared drugs or combinations of drugs developed in the past 10 years for treatment of BPH with monotherapy using older drugs . Treatment with a newer alpha-1-blocker (AB) (silodosin), a combination of an anticholinergic drug (fesoterodine, tolterodine, or solifenacin) with an AB, or a phosphodiesterase type 5 (PDE-5) inhibitor (tadalafil) resulted in similar short-term symptom relief but a greater risk of adverse effects compared with treatment with an older AB (primarily tamsulosin). There was insufficient evidence to draw conclusions about other newer drugs. Thus, we suggest initial treatment of BPH symptoms with an AB alone, and choose the AB based upon cost, side effects (particularly hypotension), and potential medication interactions (especially with PDE-5 inhibitors). (See "Medical treatment of benign prostatic hyperplasia", section on 'Efficacy and administration'.)
M. chimaera infections associated with cardiac surgery (October 2016)
Clusters of disseminated infection with Mycobacterium chimaera in the United States, Europe, and elsewhere have been linked to exposure to contaminated Stockert 3T heater-cooler devices during cardiac surgery . In the United States, the Food and Drug Administration recommends retiring 3T heater-cooler devices and accessories that have tested positive for M. chimaera or that have been linked to known infections and refraining from using any 3T heater-cooler device manufactured before September 2014 except in emergency situations. Providers of patients who have undergone cardiac surgery should be aware of the possibility of M. chimaera infection, even months to years following the procedure. (See "Overview of nontuberculous mycobacterial infections in HIV-negative patients", section on 'Disseminated disease'.)
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