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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: Sep 2017. | This topic last updated: Oct 09, 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.


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'.)


Oral fluid intake before anesthesia (August 2017)

Oral intake is generally restricted for two hours before anesthesia, but the volume of clear liquids that should be allowed before this deadline is unclear. In a study of patients who drank ≥2 liters of bowel preparation solution before colonoscopy, no difference in gastric residual volume or gastric pH was observed between those who finished the solution as late as three hours prior to the procedure versus those who finished it the night before [2]. These data provide support for allowing patients free access to clear liquids until two hours prior to anesthesia and are particularly relevant to enhanced recovery after surgery protocols, which may include ingestion of 300 to 400 mL of carbohydrate drinks up to two hours prior to surgery. (See "Preoperative fasting guidelines", section on 'Clear liquids'.)

Vasopressor blood pressure targets in critically ill patients with shock (July 2017)

Hemodynamic support with continuous infusion of a vasopressor agent may be necessary in patients with shock if administration of intravenous fluids fails to restore adequate blood pressure and/or tissue perfusion. In a systematic review of two randomized trials that included 894 critically ill adults with hypotension requiring vasopressor therapy, higher mean arterial pressure (MAP) target values (80 to 85 mmHg in one trial and 75 to 80 mmHg in the other) did not result in a mortality benefit and increased the risk of cardiac arrhythmias, compared with lower targets (65 to 70 mmHg and 60 to 65 mmHg) [3]. We suggest a target MAP of 65 to 70 mmHg, rather than a higher target, in critically ill adults with hypotension who require vasopressor support. Similar MAP target values were recommended in a recent guideline of the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCS-SSAI) [4]. (See "Intraoperative management of shock in adults", section on 'Initial interventions'.)

Confirmatory data on idarucizumab for dabigatran reversal (July 2017)

Idarucizumab (pronounced "I-dare-you-cizumab") is a monoclonal antibody fragment against dabigatran that can reverse the anticoagulant effect within minutes. A preliminary report suggested good efficacy in patients with dabigatran-associated bleeding or those undergoing emergency surgery. In a new report of over 500 patients treated with idarucizumab, most had cessation of bleeding or underwent surgery without abnormal bleeding [5]. We continue to suggest idarucizumab for clinically significant bleeding or emergency surgery in patients on dabigatran with a history or laboratory testing that suggest they are actively anticoagulated. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Dabigatran reversal'.)

New oral direct factor Xa inhibitor betrixaban approved (June 2017)

The US Food and Drug administration has approved a new oral direct factor Xa inhibitor, betrixaban, for venous thromboembolism prophylaxis in acutely ill medical patients [6]. Betrixaban (brand name Bevyxxa) is taken at a dose of 160 mg on day 1 followed by 80 mg once daily for the duration of thromboprophylaxis. In a trial in which over 7500 patients hospitalized for an acute medical illness were randomly assigned to receive betrixaban or the low molecular weight heparin enoxaparin for 35 to 42 days, betrixaban was associated with a trend towards greater efficacy and a similar risk of bleeding compared with enoxaparin. (See "Direct oral anticoagulants and parenteral direct thrombin inhibitors: Dosing and adverse effects" and "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults".)

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 [7]. 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".)

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 [8]. 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 [9]. 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'.)


Long-term effect of Roux-en-Y gastric bypass: 12-year follow-up (October 2017)

The long-term effectiveness of Roux-en-Y gastric bypass (RYGB) is illustrated by a single-center prospective observational study from the United States [10]. At the 12-year follow-up, patients who underwent RYGB lost 45 kg, compared with 2.9 kg for those who sought but did not receive surgery, and 0 kg for controls who did not seek surgery. At 12 years, surgery also reduced the incidence of new-onset diabetes by 91 percent and led to remission of diabetes in 51 percent of patients with type 2 diabetes. The mean percentage weight loss was unchanged between 6 and 12 years after surgery, attesting to the durability of the procedure. (See "Laparoscopic Roux-en-Y gastric bypass", section on 'Weight loss'.)

Roux-en-Y gastric bypass versus sleeve gastrectomy in patients with type 2 diabetes (September 2017)

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) comprise over 95 percent of bariatric procedures performed in patients with type 2 diabetes in North America, but the optimal procedure to maximize glycemic control is unclear. In one study, diabetes remission (glycated hemoglobin [A1C] <6.5 percent off medications) was achieved in 49 percent of patients after RYGB and 28 percent after SG at a median of seven years [11]. By classifying diabetes preoperatively as mild, moderate, or severe by a nomogram based on four variables, the authors found that RYGB resulted in a higher rate of diabetes remission than SG for patients with moderate diabetes and a similar rate as SG for those with mild diabetes. For patients with severe diabetes, both procedures had low rates of diabetes remission. We believe the choice between RYGB and SG should be based on clinical factors in addition to glucose control, such as the patient's overall surgical risk and whether the patient has severe acid reflux, Crohn disease, or requires organ transplantation. (See "Laparoscopic sleeve gastrectomy", section on 'Diabetes mellitus'.)


Long-term outcomes of women with breast cancer and sentinel node metastasis (October 2017)

The American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial established the safety of omitting routine axillary lymph node dissection (ALND) in women with early-stage breast cancer, no palpable axillary adenopathy, and one or two metastatic sentinel lymph nodes. Now, extended follow-up to about 10 years continues to show that both overall survival and disease-free survival after sentinel lymph node dissection (SLND) alone are noninferior to ALND [12]. These results support Z0011's early conclusion that women undergoing breast conserving surgery and SLND do not require routine ALND. (See "Overview of sentinel lymph node biopsy in breast cancer", section on 'One or two sentinel node metastases'.)


Routine lateral lymph node dissection for low rectal cancer (July 2017)

In patients with rectal cancer, total mesorectal excision (TME) is standard procedure, but lateral lymph node dissection is not routinely performed, especially when nodes are clinically negative. In a large Japanese trial of patients with stage II/III rectal cancer below the peritoneal reflection and clinically negative lateral nodes randomly assigned to TME with or without lateral node dissection, the five-year relapse-free survival rate was similar for both groups, but the local recurrence rate was higher without lateral lymph node dissection, and most recurrences occurred in the lateral compartment [13]. This trial affirmed that routine lateral node dissection is warranted in Japan due to the high prevalence of lateral node involvement. In the United States, TME alone may be sufficient given the widespread use of neoadjuvant therapy (not offered in this trial). Therapeutic lateral node dissection can be offered to select patients with clinically positive lateral nodes. (See "Rectal cancer: Surgical principles", section on 'Routine lateral or extended lymphadenectomy'.)

Updated ESMO guidelines for rectal cancer (July 2017)

The European Society for Medical Oncology (ESMO) has updated their guidelines for treatment of rectal cancer [14]. Among the many changes from the 2013 guidelines, they suggest a selective approach to postoperative chemoradiotherapy in patients with resected stage II and III disease (table 1), recommending it only for patients with certain high-risk features identified at the time of surgery (table 2). The guidelines also suggest that neoadjuvant chemoradiotherapy be reserved for transmural (T3) tumors with >5 mm of extramural invasion; for other cases, initial surgery is preferred. (See "Adjuvant therapy for resected rectal adenocarcinoma", section on 'Indications'.)

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) [15]. 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 [16]. 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 [9]. 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'.)


Partial pancreaticoduodenectomy versus duodenum-preserving pancreatic head resection for chronic pancreatitis (September 2017)

Head-dominant chronic pancreatitis can be treated surgically with either partial pancreaticoduodenectomy or duodenum-preserving pancreatic head resection (DPPHR). In a multicenter randomized trial (ChroPac), the two procedures resulted in similar quality of life at 24 months with no significant differences in major morbidity and mortality rates [17]. DPPHR resulted in shorter operative time (4.7 versus 5.3 hours), but more readmissions due to chronic pancreatitis (27 versus 11 percent). Given that both procedures are equally effective and morbid, surgeons should choose based on their experience and the patient's anatomical and clinical conditions. (See "Surgery for chronic pancreatitis", section on 'Head-dominant disease'.)

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 [18]. 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'.)


Antibiotic therapy for skin abscess (July 2017)

Management of skin abscess consists of incision and drainage; the role of antibiotic therapy depends on individual clinical circumstances, including abscess size. In a randomized trial including more than 780 patients with skin abscess ≤5 cm (most were larger than 2 cm) who underwent incision and drainage, higher cure rates were observed among those who received antibiotic therapy with methicillin-resistant Staphylococcus aureus (MRSA) coverage (trimethoprim-sulfamethoxazole or clindamycin) than those who received placebo (82 or 83 percent versus 69 percent); MRSA was isolated in 49 percent of cases [19]. These findings support our approach to management of patients with skin abscess, in which we suggest antibiotic therapy in addition to incision and drainage for patients with skin abscess ≥2 cm. (See "Cellulitis and skin abscess in adults: Treatment", section on 'Role of antibiotic therapy'.)

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 [20,21]. 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'.)


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 [22]. 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 [23]. 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'.)


Recurrence of acid reflux after laparoscopic anti-reflux surgery (October 2017)

Although over 90 percent of patients are satisfied with the results of their anti-reflux surgery, criteria defining treatment success or failure vary among studies. In a population-based study from Sweden including over 2600 patients who underwent laparoscopic anti-reflux surgery, 18 percent developed recurrent reflux necessitating either long-term use of anti-reflux medications (393 patients) or repeat anti-reflux surgery (77 patients) at median follow-up of 5.6 years [24]. Risk factors for recurrence included female sex, older age, and comorbidity. (See "Surgical management of gastroesophageal reflux in adults", section on 'Long-term efficacy'.)


Canadian Task Force on Preventive Health Care's new abdominal aortic aneurysm screening guidelines (September 2017)

Risk factors for abdominal aortic aneurysm (AAA) include older age, male sex, and smoking. In new guidelines, the Canadian Task Force on Preventive Health Care (CTFPHC) recommends one-time screening for AAA with ultrasonography in men aged 65 to 80 years [25]. The CTFPHC recommendation extends the upper age limit (75 years) recommended by others, including the US Preventive Services Task Force (USPSTF), and does not differentiate by smoking status. UpToDate and the USPSTF recommend screening men age 65 to 75 who smoke and only selectively screening never-smokers. (See "Screening for abdominal aortic aneurysm", section on 'Canadian guidelines'.)

Enhanced MRI does not improve prediction of AAA outcomes (September 2017)

Progression of abdominal aortic aneurysm (AAA) is associated with infiltration of inflammatory cells into the wall of the aorta. Such inflammation can be identified by ultrasmall superparamagnetic particles of iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI). In a multicenter study of 342 individuals with AAA ≥4 cm, USPIO uptake was present in 42.7 percent and was associated with increased rates of aneurysm expansion (3.1 versus 2.5 mm per year) and aneurysm rupture/repair (47.3 versus 35.6 percent) [26]. However, baseline AAA diameter and current smoking also predicted aneurysm rupture/repair, and the addition of USPIO uptake did not improve prediction of adverse AAA-related events over clinical features alone. (See "Epidemiology, risk factors, pathogenesis, and natural history of abdominal aortic aneurysm", section on 'Inflammation and the Th2 response'.)

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 [27]. 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 [28]. 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 [29]. 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 [30]. 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'.)


Perioperative medication management in rheumatic disease patients undergoing total hip or knee replacement (July 2017)

An expert panel of rheumatologists and orthopedic surgeons has developed guidelines for the perioperative management of various immunosuppressive medications in patients undergoing total hip or knee arthroplasty [31]. In patients with rheumatic diseases, decisions must balance the potential risks of infection related to immunosuppressive medications with the risk of worsened disease control when medications are withheld. Important recommendations include that nonbiologic disease-modifying antirheumatic drugs (DMARDs) may be continued through the perioperative period, whereas biologic DMARDs should be withheld as close to one dosing cycle as scheduling permits prior to elective hip or knee replacement surgery. (See "Preoperative evaluation and perioperative management of patients with rheumatic diseases", section on 'Medication management'.)

Delay of appendectomy up to 24 hours not related to appendiceal perforation in children with appendicitis (June 2017)

In the past, appendicitis has been considered a surgical emergency that requires prompt appendectomy to avoid perforation and other complications. In a multicenter, prospective observational study of 955 children 3 to 18 years of age, all of whom were treated with appendectomy for appendicitis within 24 hours of arrival to the emergency department, duration of time between initial evaluation and operation was not associated with an increase in appendiceal perforation [32]. This study adds to a growing body of evidence that suggests that adverse outcomes are not increased for children who receive timely administration of antibiotics and undergo appendectomy less than 24 hours after diagnosis. (See "Acute appendicitis in children: Management", section on 'Timing of operation'.)

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