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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
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 . 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
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 . 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 . 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 . However, efficacy has also been shown for treatment of OIC in cancer patients , 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 . (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) . 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'.)
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'.)
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) . 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 . 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 . 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 '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 . 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 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 . 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 . 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'.)
VASCULAR AND ENDOVASCULAR SURGERY
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 . 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 . 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'.)
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'.)
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'.)
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