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What's new in general surgery
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What's new in general surgery
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2017. | This topic last updated: Jul 25, 2017.

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

Prophylactic negative pressure wound therapy for abdominal wounds (May 2017)

Negative pressure wound therapy (NPWT) is commonly used in the management of wound infection but may also have a prophylactic role. In a trial that randomly assigned 50 patients undergoing open abdominal surgery (clean, clean contaminated, or contaminated) to NPWT or a standard dressing, NPWT reduced the incidence of surgical site infection (SSI) at 30 days (8 versus 32 percent) and the length of hospital stay [1]. Before recommending prophylactic NPWT, large randomized trials are needed to confirm these findings, assess benefits in specific wound types and patient populations, and evaluate other outcomes (eg, cost effectiveness). (See "Negative pressure wound therapy", section on 'Prophylactic use'.)

Negative pressure dressing for closed abdominal wounds (May 2017)

Negative pressure dressings have been widely used to manage open wounds but are less commonly used for closed wounds. In a randomized trial of 50 patients with closed laparotomy incisions, the use of a negative pressure dressing, as opposed to a standard dressing, resulted in fewer wound infections and a shorter mean hospital stay [1]. If these findings are validated by other studies, negative pressure dressings could be used for closed abdominal wounds, particularly when the risk of wound complications is high, such as in obese patients or with a contaminated field. (See "Principles of abdominal wall closure", section on 'Negative pressure dressings'.)

ANESTHESIA AND PERIOPERATIVE CARE

Neuraxial anesthesia in parturients with thrombocytopenia (June 2017)

The risk of spinal epidural hematoma (SEH) associated with neuraxial anesthesia (NA) techniques in patients with thrombocytopenia is poorly defined because SEH is rare. In a systematic review of over 1500 NA procedures in parturients with platelet counts less than 100,000 /microL, no cases of epidural hematoma requiring decompressive laminectomy were identified [2]. A statistical analysis based on data from this cohort suggests that the incidence of epidural hematoma may range from 0.2 percent (for platelet counts 70 to 100,000/microL) to 11 percent (for platelet counts <49,000/microL). These estimates may inform clinical decision-making regarding performance of NA in parturients with thrombocytopenia. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Neuraxial analgesia and low platelets'.)

CDC guidelines for prevention of surgical site infection (June 2017)

The Centers for Disease Control published new guidelines for prevention of surgical site infection in May 2017; these update the prior guidelines published in 1999 [3]. The guidelines state that administration of antibiotic prophylaxis should be timed such that a bactericidal concentration is present in tissue at the time of incision, additional antibiotic prophylaxis is not necessary after the surgical incision is closed, and intraoperative skin preparation should be performed with an alcohol-based antiseptic (unless contraindicated). Our recommendations are generally consistent with these guidelines. (See "Overview of control measures for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Minimum perioperative urine output in abdominal surgery (April 2017)

Maintaining a minimum urine output of 0.5  mL/kg/hour following major abdominal surgery is a common practice, with few supporting data. In a randomized trial of patients at low risk for kidney injury undergoing elective colectomy, levels of markers of kidney health and function were similar whether intravenous fluids were maintained to achieve a minimal urine output of 0.2 or 0.5 mL/kg/hour from induction of anesthesia to two days after surgery [4]. If validated, this approach may allow fluid-sparing in abdominal surgery patients at low risk of kidney injury and, in turn, reduce postoperative morbidity. (See "Enhanced recovery after colorectal surgery", section on 'Postoperative fluid management'.)

Alveolar recruitment maneuvers in postoperative mechanically ventilated patients (April 2017)

Unlike patients with acute respiratory distress syndrome (ARDS) in whom the value of alveolar recruitment maneuvers is known to be beneficial, their role in postoperative patients without ARDS is unknown. One single center study of 320 patients who had undergone elective cardiac surgery and were mechanically ventilated for hypoxemia compared an intensive recruitment strategy with a moderate strategy [5]. An intensive strategy resulted in fewer pulmonary complications as well as decreased intensive care unit length of stay and mortality, without increasing the incidence of barotrauma. This study suggests that the benefit from recruitment maneuvers in postoperative patients without ARDS may be similar to the benefit in patients with ARDS, and further investigation is warranted. (See "Positive end-expiratory pressure (PEEP)", section on 'Postoperative patients'.)

Naldemedine for opioid-induced constipation (March 2017)

The benefit of naldemedine, an oral peripherally acting opioid receptor antagonist, for opioid-induced constipation (OIC) was shown in two identically designed 12-week phase III randomized trials conducted in patients with noncancer chronic pain and OIC [6]. In a preliminary report, naldemedine, compared with placebo, decreased constipation and was well tolerated with no signs or symptoms of opioid withdrawal or decrease in opioid analgesic efficacy. Naldemedine has been approved in the United States for OIC in adult patients with chronic noncancer pain [7]. However, efficacy has also been shown for treatment of OIC in cancer patients [8], and naldemedine can be used off label in this population. The European Medicines Agency has approved naldemedine for treatment of OIC without restriction to noncancer pain [9]. (See "Cancer pain management with opioids: Prevention and management of side effects", section on 'Other oral agents'.)

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) [10]. 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'.)

ARTERIAL AND VENOUS ACCESS

Fish oil does not reduce thrombosis of hemodialysis arteriovenous fistulas (March 2017)

Fish oil may reduce intimal hyperplasia, which is an important cause of hemodialysis arteriovenous (AV) access failure. The majority of trials evaluating the effectiveness of fish oil for reducing AV access failure have been performed in the setting of AV grafts. Now, a multicenter trial has specifically evaluated AV fistulas. In this trial, over 500 patients with newly created AV fistulas were randomly assigned to receive fish oil (4 g/day) or placebo for 12 weeks [11]. At 12 months follow-up, no significant differences between the groups were observed for the primary composite outcome of fistula failure, or for any of the individual outcomes (fistula thrombosis, fistula abandonment, cannulation failure). We do not administer fish oil to individuals with AV fistulas for the sole purpose of preventing AV fistula failure; however, the administration of fish oil may be indicated for other clinically relevant cardiovascular benefits, particularly among individuals with coronary heart disease and its risk equivalents. (See "Overview of hemodialysis arteriovenous graft maintenance and thrombosis prevention".)

BARIATRIC SURGERY

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 [12]. 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'.)

COLORECTAL SURGERY

Laparoscopic versus open surgery for rectal cancer (May 2017)

Transabdominal rectal cancer surgery can be performed via open, laparoscopic, or robotic approaches. In a systematic review and meta-analysis of 14 randomized trials, laparoscopic surgery resulted in a higher rate of noncomplete total mesorectal excision than open surgery (13 versus 10 percent) [13]. Other technical outcomes were not different. Long-term data are needed to determine whether the higher rate of noncomplete total mesorectal excision will result in worse survival. In the absence of these data, the best surgical approach needs to be determined individually by tumor and patient characteristics, as well as surgeon experience. (See "Rectal cancer: Surgical principles", section on 'Laparoscopic versus open approach'.)

Risk of colon cancer in patients with diverticulitis (April 2017)

The utility of routine colonoscopy after acute diverticulitis is debated. An analysis of data from a Danish registry showed that patients hospitalized for diverticulitis were twice as likely to develop colon cancer over the 18-year study period as those without diverticulitis, and over 50 percent of colon cancers were diagnosed within one year of diagnosis of diverticulitis [14]. This study underscores the importance of endoscopic surveillance in patients with diverticular disease and supports our recommendation for performing a colonoscopy after the complete resolution of an episode of acute diverticulitis in patients who have not had a colonoscopy within a year. (See "Acute colonic diverticulitis: Medical management", section on 'Colonoscopy for all patients'.)

Minimum perioperative urine output in abdominal surgery (April 2017)

Maintaining a minimum urine output of 0.5  mL/kg/hour following major abdominal surgery is a common practice, with few supporting data. In a randomized trial of patients at low risk for kidney injury undergoing elective colectomy, levels of markers of kidney health and function were similar whether intravenous fluids were maintained to achieve a minimal urine output of 0.2 or 0.5 mL/kg/hour from induction of anesthesia to two days after surgery [4]. If validated, this approach may allow fluid-sparing in abdominal surgery patients at low risk of kidney injury and, in turn, reduce postoperative morbidity. (See "Enhanced recovery after colorectal surgery", section on 'Postoperative fluid management'.)

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 [15]. 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 [16]. 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".)

HEPATOBILIARY AND PANCREATIC SURGERY

Optimal timing of reoperation for gallbladder cancer incidentally found at cholecystectomy (May 2017)

When gallbladder cancer is diagnosed incidentally after cholecystectomy, most patients require a second operation to remove residual disease. In a retrospective analysis of the optimal timing of reoperation by the US Extrahepatic Biliary Malignancy Consortium, reoperation four to eight weeks after the initial cholecystectomy was associated with improved overall survival compared with earlier or later reoperation [17]. This finding requires prospective validation before we would routinely recommend scheduling reoperation four to eight weeks after initial surgery. In practice, timing reoperation may also be influenced by nonclinical factors, such as access to a qualified surgeon or center. (See "Surgical management of gallbladder cancer", section on 'Identified by pathology'.)

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 [18]. 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'.)

TRAUMA AND BURN SURGERY

Choice of regional anesthesia for severe rib fractures (July 2017)

Whether there is a preferred form of regional anesthesia for managing refractory pain due to severe rib fractures is unknown. A large retrospective study that compared outcomes of epidural analgesia versus paravertebral block in over 2000 patients with multiple rib fractures observed similar rates of in-hospital mortality, length of stay, pneumonia, intensive care admission, use and duration of mechanical ventilation, and other complications [19]. Thus, either technique appears to be a reasonable analgesic option for rib pain refractory to oral and parenteral therapy. (See "Inpatient management of traumatic rib fractures", section on 'Regional anesthesia'.)

Focused Assessment with Sonography for Trauma (FAST) does not change outcomes in hemodynamically stable children with blunt torso trauma (June 2017)

Focused Assessment with Sonography for Trauma (FAST) is routinely used to rapidly identify pericardial effusion or intraabdominal hemorrhage in hemodynamically unstable pediatric patients with blunt trauma. Its utility in hemodynamically stable children after trauma is less clear. In an unblinded, randomized trial of 925 hemodynamically stable children evaluated for blunt torso trauma, FAST combined with standard emergency assessment, compared with standard care alone, did not lower missed intraabdominal injury (IAI) rates, frequency of abdominal computed tomography (CT), mean emergency department length of stay, or hospital charges [20]. Negative results on ultrasonography did lower the managing physician's clinical suspicion for IAI but did not decrease the use of abdominal CT. Thus, routine use of FAST in stable trauma patients does not appear to alter important clinical outcomes.(See "Trauma management: Approach to the unstable child", section on 'FAST (Focused Assessment with Sonography for Trauma)' and "Approach to the initially stable child with blunt or penetrating injury", section on 'Abdominal trauma'.)

VASCULAR AND ENDOVASCULAR SURGERY

Elective abdominal aortic aneurysm repair in women (June 2017)

Women with an asymptomatic abdominal aortic aneurysm (AAA) have a poorer prognosis than men with AAA of the same diameter. A systematic review and metaanalysis that compared outcomes of women versus men following AAA repair revealed some reasons for this disparity: women were less likely to be offered intervention at the conventional threshold, a smaller proportion of women were eligible for endovascular instead of open repair, and 30-day operative mortality was higher for women regardless of the type of repair [21]. Reducing the AAA diameter at which elective repair of asymptomatic AAA is offered to women may improve prognosis. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'Female gender'.)

Open versus endovascular repair for ruptured abdominal aortic aneurysm (June 2017)

Whether endovascular aneurysm repair (EVAR) improves outcomes for ruptured abdominal aortic aneurysm (AAA) is unclear. A meta-analysis of four trials comparing EVAR with conventional open surgical repair found no clear differences in 30-day mortality or morbidity [22]. We prefer EVAR rather than open AAA repair whenever it is anatomically and logistically feasible, but based on these results, it is equally appropriate to undertake open repair. (See "Surgical and endovascular repair of ruptured abdominal aortic aneurysm", section on 'Open surgical versus endovascular repair'.)

Comprehensive geriatric assessment before elective vascular surgery (June 2017)

Older adults undergoing vascular surgery have a high incidence of medical co-morbidities that increase the risk for perioperative morbidity and mortality. In a trial that compared comprehensive geriatric versus standard preoperative assessment in patients at least 65 years old undergoing major elective vascular surgical procedures, comprehensive geriatric assessment reduced postoperative complications and length of stay, with a trend toward fewer discharges to a higher level of dependency [23]. This trial underscores the need to accurately assess medical risk prior to undertaking elective vascular surgery in older adults. (See "Overview of lower extremity peripheral artery disease", section on 'Revascularization'.)

Rivaroxaban for treatment of superficial vein thrombosis (May 2017)

Short-term anticoagulation is recommended for treatment of superficial vein thrombosis (SVT) in patients at high risk for venous thromboembolism (VTE). The phase 3b SURPRISE trial randomly assigned over 400 patients with SVT to oral rivaroxaban (a direct factor Xa inhibitor) or subcutaneous fondaparinux and found that both groups had similar rates of symptomatic VTE, progression or recurrence of SVT, and all-cause mortality at 45 days [24]. There were no major bleeds in either group, but clinically relevant nonmajor bleeding occurred more often in the rivaroxaban group. Thus, rivaroxaban appears to be an effective anticoagulant for patients with SVT and may be a more convenient and less expensive option than subcutaneous therapy. (See "Phlebitis and thrombosis of the superficial lower extremity veins", section on 'Increased risk for thromboembolism'.)

Rivaroxaban versus aspirin for indefinite treatment of venous thromboembolism (April 2017)

The optimal antithrombotic agent for patients with venous thromboembolism (VTE) who have indications for indefinite therapy to reduce the risk of recurrent VTE is unclear. A randomized trial compared rivaroxaban (a direct factor Xa inhibitor) and aspirin for long-term treatment of patients who had completed a 6- to 12-month course of therapeutic anticoagulation [25]. Rivaroxaban, either at a treatment (20 mg daily) or a prophylactic (10 mg daily) dose, was superior to aspirin in preventing VTE recurrence for up to 12 months, without increasing the risk of major bleeding. While rates of recurrence were comparable between both doses of rivaroxaban, further studies are warranted before reduced intensity regimens can be recommended. For most patients with VTE requiring long-term treatment, we suggest full intensity anticoagulation rather than low intensity regimens or aspirin. (See "Rationale and indications for indefinite anticoagulation in patients with venous thromboembolism", section on 'Factor Xa and direct thrombin inhibitors'.)

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 [26]. 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'.)

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 [27]. 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'.)

OTHER GENERAL SURGERY

Delafloxacin for treatment of skin and soft tissue infections (July 2017)

Delafloxacin, a fluoroquinolone, has been approved by the US Food and Drug Administration for treatment of bacterial skin and soft tissue infections. It has activity against staphylococci (including methicillin-resistant strains), gram-negative bacteria (including Pseudomonas aeruginosa and Enterobacteriaceae), and some anaerobes (including Clostridium difficile) but does not have activity against enterococci. In two phase III clinical trials, the drug was statistically noninferior to the combination of vancomycin and aztreonam at the endpoint of early clinical response at 48 to 72 hours [28,29]. Given limited clinical experience with delafloxacin, at this time its use should be reserved for patients who do not respond to or do not tolerate first-line antimicrobial agents. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections", section on 'Delafloxacin'.)

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REFERENCES

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