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What's new in surgery

What's new in surgery
Wenliang Chen, MD, PhD
Kathryn A Collins, MD, PhD, FACS
Literature review current through: Nov 2022. | This topic last updated: Dec 30, 2022.

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.


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

Patients with localized hemodialysis arteriovenous (AV) graft infection are frequently managed with partial excision and graft revision to salvage the access. However, a meta-analysis of observational studies including a total of 555 AV graft infections found that partial graft excision was associated with higher rates of recurrent infection (27 versus 5 percent) and need for reoperation (20 versus 3 percent) compared with total graft excision [1]. Although partial excision can successfully manage AV graft infection in approximately 80 percent of patients, it is important to frequently reassess the graft to ensure the infection has been adequately controlled. (See "Arteriovenous graft creation for hemodialysis and its complications", section on 'Graft infection'.)

Ultrasound guidance for peripheral intravenous line placement in children (June 2022)

In children, ultrasound guidance is well established for central venous access, but its role for placement of peripheral intravenous (PIV) lines is less clear. A new meta-analysis including five randomized trials performed in children with difficult intravenous access (DIVA) found improved rates of first attempt success (odds ratio 4.6) and overall success (odds ratio 3.3) for ultrasound-guided compared with standard (landmark) techniques during PIV line placement [2]. Based on these data, we suggest using ultrasound-guidance as the initial approach for placing PIV lines in children (but not neonates) with high DIVA scores. (See "Principles of ultrasound-guided venous access", section on 'Children with difficult access'.)


Endoscopic sleeve gastroplasty versus lifestyle modification for weight loss (August 2022)

An endoscopic suturing device designed to perform endoscopic sleeve gastroplasty (ESG) for weight loss has recently been approved by the US Food and Drug Administration. In a multicenter trial (MERIT) comparing ESG plus lifestyle modifications versus lifestyle modifications alone in 209 individuals with class 1 or 2 obesity (BMI 30 to 50 kg/m2), the ESG group lost more weight at 52 weeks (mean excess weight loss [EWL]: 49 versus 3 percent) and had a higher proportion of patients with improvement in ≥1 metabolic comorbidities (80 versus 45 percent) [3]. At 104 weeks, 68 percent of the ESG group maintained ≥25 percent EWL. Although ESG is a promising technique, long-term durability remains unclear. (See "Bariatric procedures for the management of severe obesity: Descriptions", section on 'Expected excess weight loss from ESG'.)

Bariatric surgery and incidence and mortality from some types of cancer (August 2022)

Obesity has been associated with an increased incidence of 13 types of cancer and increased cancer-related mortality, and intentional weight loss appears to decrease these risks. In a retrospective study comparing over 5000 patients who underwent bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) with over 25,000 matched patients receiving nonsurgical care, bariatric surgery was associated with a lower risk of obesity-associated cancer (10-year cumulative incidence: 2.9 versus 4.9 percent) and cancer-related mortality (10-year cumulative incidence: 0.8 versus 1.4 percent) [4]. Substantial weight loss was required to observe a meaningful reduction in cancer risk, and greater weight loss was associated with greater risk reduction. These findings support previous data of the benefits of bariatric surgery. (See "Outcomes of bariatric surgery", section on 'Cancer risk and mortality'.)


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

After incision and drainage of a perianal or perirectal abscess, it is common practice to pack the wound, under the assumption that this will facilitate further drainage by wicking and prevent premature skin closure. In the PPAC2 trial of 443 patients with a primary perianal abscess, nonpacking, compared with packing, resulted in similar rates of fistula formation (11 versus 15 percent) and abscess recurrence (6 versus 3 percent), differences that were not statistically significant [5]. However, the nonpacking group had lower average pain scores (28 versus 38 on a 100-point visual analog scale). Given these and similar findings from two earlier small trials, we now suggest not packing the wound after drainage of perianal or perirectal abscess. (See "Perianal and perirectal abscess", section on 'Role of wound packing'.)


Breast implant-associated cancer (October 2022)

Breast implant-associated malignancies are rare, with most concern related to breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The US Food and Drug Administration and the American Society of Plastic Surgery have recently focused on breast implant-associated squamous cell cancer (BIA-SCC), which can also occur in the capsule surrounding the implant [6]. Clinical features of BIA-SCC that differ from BIA-ALCL include its longer average time to onset after implantation, more aggressive behavior, and higher mortality. BIA-SCC is also associated with either smooth or textured implants, whereas BIA-ALCL is predominantly associated with textured implants. When treating patients who have late-onset peri-implant changes, seroma, or mass, it is essential to consider the possibility of BIA-SCC in addition to BIA-ALCL. (See "Implant-based breast reconstruction and augmentation", section on 'Squamous cell carcinoma'.)


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

Computed tomography (CT) with contrast medium washout is often used to distinguish benign adrenal adenomas from nonbenign lesions. However, few studies have examined the utility of contrast washout for evaluating indeterminate, lipid-poor adrenal masses. In a retrospective study of 336 masses with attenuation value >10 Hounsfield units, contrast washout ≥60 percent had a sensitivity of 77 percent and specificity of only 70 percent for benign adenoma in adrenal masses <4 cm in size [7]. Among adrenal masses at least 4 cm in size, the prevalence of malignancy was similar between those with (17 percent) and without (23 percent) contrast washout ≥60 percent. Further, three of nine pheochromocytomas exhibited contrast washout of 60 percent or greater. These findings suggest that contrast medium washout may have limited utility in lipid-poor adrenal masses for excluding malignancy and pheochromocytoma. (See "Evaluation and management of the adrenal incidentaloma", section on 'Delayed contrast-enhanced CT'.)


Timing of surgery after ischemic stroke (December 2022)

The risk of perioperative stroke is increased in patients with a prior ischemic stroke, though optimal timing of surgery after stroke is unclear. In a database study including nearly six million patients, the risk of postoperative ischemic stroke was increased eightfold in patients who had a stroke within 30 days before surgery, compared with those who never had a stroke [8]. The risk of recurrent stroke decreased and leveled off for surgery between 60 and 90 days after stroke, but remained elevated. The timing of surgery in patients with prior ischemic stroke should consider the risk of recurrent stroke and the risk of delaying surgery. We suggest delaying elective surgery for at least three months, and if possible up to nine months, after a stroke to reduce the risk of recurrence. (See "Perioperative stroke following noncardiac, noncarotid, and nonneurologic surgery", section on 'Timing of surgery after ischemic stroke'.)

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

Whether changing gloves and using new instruments prior to wound closure affects surgical site infection (SSI) rates is uncertain. In an unblinded cluster randomized trial of over 13,000 patients undergoing intra-abdominal surgery in low- to middle-income (LMIC) countries, the risk of SSI was lower when routine glove and sterile instrument change was performed prior to closure compared with no glove or instrument change (16 versus 19 percent) [9]. The results from this study support a theoretical advantage of changing gloves before closure as a method to reduce the risk of SSI. The LMIC setting may limit generalizability to other settings. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Surgical attire and barrier devices'.)

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

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

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

The efficacy of various antiseptic agents applied preoperatively to contaminated or dirty wounds to reduce infection is not well studied. In a multiple-period, cluster-randomized, crossover trial comparing aqueous chlorhexidine gluconate with aqueous povidone-iodine for wound preparation in over 1600 open-fracture repairs, the surgical site infection (SSI) rate was 7 percent in both groups [11]. Other aspects of SSI prevention were at the provider's discretion; thus, 63 percent of patients also received an alcohol-based prewash ostensibly of the intact skin of the operative extremity and all patients received intravenous antibiotics (mean duration three days). Further study is needed to determine the optimal preparation of contaminated or dirty wounds and whether any topical agent influences SSI independent of other factors (eg, prophylactic systemic antibiotics, surgery duration, presence of ischemia). (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Topical antiseptics'.)

CDC updates opioid prescribing guidelines (November 2022)

The United States Centers for Disease Control and Prevention (CDC) has published a new guideline for prescribing opioids for acute, subacute, and chronic pain, updating their 2016 guideline (table 1). The guideline is intended for clinicians who prescribe opioids to outpatients ≥18 years of age and does not apply to pain related to sickle cell disease, cancer, palliative care, or end of life care [12]. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Opioid therapy in the context of the opioid epidemic'.)

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

Multiple factors contribute to the increased perioperative risk associated with older age. In a prospective study of nearly 1200 major surgeries among community-living adults ≥65 years old (mean age 79 years), one-year mortality rates were higher in those with frailty (28 versus 6 percent) or probable dementia (33 versus 12 percent), and in those requiring urgent surgery (22 versus 7 percent) [13]. These findings add to other evidence suggesting that absolute age alone has only a modest impact on postoperative outcomes and should not be used as a sole criterion to guide decisions regarding patient selection for a major procedure. (See "Anesthesia for the older adult", section on 'Preanesthesia consultation'.)

New guidance on COVID-19 testing before elective surgery (July 2022)

During the initial COVID-19 pandemic, many guidelines recommended universal SARS-CoV-2 testing prior to surgery, with a possible delay of elective surgery for patients who test positive. Now, an updated joint statement from the American Society of Anesthesiologists and Anesthesia Patient Safety Foundation suggests that in areas of low-to-moderate community SARS-CoV-2 transmission, institutions may choose to not require preoperative testing for asymptomatic, vaccinated patients scheduled for lower-risk procedures [14]. They continue to recommend universal preoperative testing in areas of high COVID-19 transmission and for symptomatic patients. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Preoperative screening and testing'.)


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

The optimal role of prophylactic negative pressure wound therapy (NPWT) after surgery is unclear and cost is a major limitation of its use. In a meta-analysis of observational studies and randomized trials, prophylactic NPWT following emergency abdominal surgery was associated with significantly lower rates of surgical site infection (SSI) and overall wound infection compared with standard dressings, consistent with other reviews [15]. A cost-effectiveness analysis was not performed. Whether NPWT would be cost-effective in this population or other populations at higher risk for SSI requires further study. (See "Negative pressure wound therapy", section on 'Prophylactic use'.)

Transaxillary decompression for neurogenic thoracic outlet syndrome (September 2022)

Surgical decompression can improve symptoms of neurogenic thoracic outlet syndrome (nTOS) refractory to conservative management, but may not be durable. In the STOPNTOS trial, decompression in patients refractory to conservative management resulted in significantly improved DASH (Disability of the Arm, Shoulder, and Hand) scores at three months compared with continued conservative treatment, and all conservatively treated patients subsequently elected to undergo surgery [16]. Postoperatively, transient neurologic complications occurred in 7 of 46 patients, and 9 patients had persistent or recurrent nTOS after one year. These outcomes are consistent with prior observational studies and support our generally conservative approach. Additional larger trials with longer follow-up are needed to better compare surgery for refractory symptoms with ongoing conservative treatment. (See "Overview of thoracic outlet syndromes", section on 'nTOS'.)


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

Low molecular weight heparin (LMWH) is administered to adult trauma patients to reduce the risk of venous thromboembolism (VTE), but questions remain about dosing and monitoring. In a meta-analysis of observational studies including heterogeneous multisystem trauma patients, those who attained prophylactic anti-Xa levels had a lower rate of VTE than those who did not [17]. However, dose adjustment to achieve prophylactic anti-Xa levels paradoxically did not reduce VTE compared with standard fixed enoxaparin dosing. While there is likely a role for LMWH dose adjustment based on anti-Xa levels in trauma patients, the optimal protocol and trauma population that would benefit have not been determined. (See "Venous thromboembolism risk and prevention in the severely injured trauma patient", section on 'Monitoring and dose adjustment'.)

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

For management of patients with an open abdomen, fascial traction techniques are frequently advocated to improve primary abdominal closure. The Eastern Association for the Surgery of Trauma (EAST) performed a systematic review of fascial techniques to inform guidance [18]. In a meta-analysis of four trials, fascial traction (with or without negative pressure techniques) reduced failure of primary fascial closure during the index admission compared with negative pressure techniques alone (20 versus 40 percent) and without any increase in bowel fistula formation or death. These outcomes are consistent with prior reviews and support EAST guidelines to include fascial traction when clinically appropriate. (See "Management of the open abdomen in adults", section on 'Techniques'.)

Tranexamic acid prior to burn wound excision (September 2022)

Intravenous tranexamic acid (TXA) reduces blood loss in severe trauma and other surgeries. In a small trial that included patients with total body surface area (TBSA) burns <30 percent, TXA administered prior to burn wound excision reduced average blood loss compared with placebo, by about 30 mL per cm2 burn area excised [19]. Although TXA reduced blood loss, transfusion was not needed in either group, and graft take was near 100 percent in both. Larger trials are needed, particularly among patients with larger TBSA burns, to determine whether intravenous TXA improves clinically meaningful outcomes. (See "Skin autografting", section on 'Other methods'.)

Protein supplementation for fracture healing (July 2022)

While general guidance for patients recovering from a fracture often includes ensuring that protein intake is adequate, very few controlled trials have assessed the role of protein in fracture healing. In a single-center trial of 400 patients with pelvic or extremity fractures requiring surgical repair, those assigned to receive essential amino acid supplementation had lower overall complication rates (30.5 versus 43.8 percent) and significantly less early skeletal muscle wasting than those assigned to standard care and nutrition [20]. While the trial was not completely blinded and further study is needed, these results support guidance for adequate daily protein intake in patients with healing fractures. (See "General principles of definitive fracture management", section on 'Overview and basic measures including nutrition'.)


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

The BEST-CLI trial randomly assigned two cohorts of patients (over 1800 patients in total) with chronic limb-threatening ischemia (CLTI) to surgical bypass or endovascular revascularization [21]. All patients in the first cohort had a single segment of suitable great saphenous vein (GSV) on ultrasound. At a mean 2.7 years follow-up, surgery reduced the composite outcome of major adverse limb events or all-cause death in this cohort (43 versus 57 percent). No patient in the second cohort had a suitable GSV, and the composite outcome was not significantly different for surgery versus endovascular revascularization in this cohort. For patients with CLTI judged to be suitable candidates for either approach, we suggest a bypass-first strategy when a single segment of suitable GSV is available. Otherwise, a bypass-first or endovascular-first approach is appropriate. (See "Management of chronic limb-threatening ischemia", section on 'Approach to revascularization'.)

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

The Global Limb Anatomic Staging System (GLASS) classifies infrainguinal peripheral artery disease severity. A systematic review evaluated outcomes stratified by GLASS stage for nearly 2500 limb revascularizations for chronic limb-threatening ischemia (CLTI) [22]. For endovascular intervention, higher GLASS stage was associated with more adverse limb outcomes than lower GLASS stage. For surgical bypass, limb outcomes were similar across GLASS stages, and for higher GLASS stages were better than with endovascular intervention. This study suggests that GLASS stage predicts limb outcomes, particularly after endovascular revascularization. Whether patients with CLTI and higher GLASS stage should preferentially be managed with surgical bypass requires further study. (See "Management of chronic limb-threatening ischemia", section on 'Anatomic pattern of disease'.)

Intervention for restenosis after carotid endarterectomy (September 2022)

The optimal approach to reintervention for recurrent stenosis after carotid endarterectomy (CEA) has not been established. Options include redo CEA, transfemoral carotid artery stenting (TF-CAS), and transcarotid artery stenting (TCAR). In a review of over 4000 patients with recurrent stenosis from the Vascular Quality Initiative (VQI) database, the risk of perioperative ischemic events was lower for TCAR compared with TF-CAS or redo CEA [23]. Controlled studies are needed to confirm these outcomes, and longer follow-up is important to determine the rate of restenosis after TCAR. (See "Complications of carotid endarterectomy", section on 'Approach to reintervention'.)

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

Topical eutectic mixture of local anesthetics (EMLA) reduces pain associated with cutaneous injection. A trial now reports significantly lower pain scores for EMLA compared with no EMLA prior to tumescent anesthetic injection for venous radiofrequency ablation [24]. EMLA was administered two to three hours before the procedure to ensure complete anesthetic absorption. The longer duration of EMLA application likely led to the improved pain scores reported in this trial but not in an earlier trial in which EMLA was applied only 20 minutes before the procedure. (See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Medications'.)


Aspirin versus enoxaparin to prevent venous thromboembolism after hip or knee arthroplasty (September 2022)

The role of aspirin as a sole agent for venous thromboembolism (VTE) prophylaxis in adult patients undergoing total hip or knee arthroplasty (THA, TKA) is debated. In a recent, randomized crossover trial of over 9700 patients following THA or TKA that compared aspirin (100 mg orally per day) to enoxaparin (40 mg subcutaneously per day), symptomatic distal deep vein thrombosis was more common in patients receiving aspirin (2.4 versus 1.2 percent) [25]. There was no difference in the rates of major bleeding (< 0.5 percent) and death. Study limitations include the trial being stopped early for harm and lack of blinding of hospitals to treatment allocation. Nevertheless, these findings indicate that aspirin alone is inferior to enoxaparin and supports our practice of not using aspirin as the sole agent for VTE prophylaxis in patients following THA or TKA. (See "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement", section on 'Aspirin'.)

Removal of small, asymptomatic kidney stones and risk of relapse (August 2022)

In patients undergoing surgical removal of kidney or ureteral stones, the benefits of simultaneously removing small, asymptomatic stones are uncertain. In a trial that randomly assigned 73 adults scheduled for endoscopic stone removal surgery and with small (<6 mm) asymptomatic (secondary) stones on preoperative computed tomography to removal of both primary and secondary stones (treatment group) or primary stones alone (control group), rates of stone relapse were lower in the treatment group after a median of four years [26]. Removing secondary stones added a median of 25 minutes to overall surgery time, and rates of adverse events were similar between the groups. These findings support our approach of routinely removing ipsilateral asymptomatic stones when removing an obstructing or symptomatic stone by endoscopic methods. (See "Kidney stones in adults: Surgical management of kidney and ureteral stones", section on 'Removal of secondary stones'.)

Role of surgery for large left-sided cardiac valve vegetation (July 2022)

Patients with left-sided native valve infective endocarditis with a large (>10 mm) vegetation are at high risk for mortality, but a benefit from early valve surgery in this setting has not been established. An observational study of over 700 patients with left-sided infective endocarditis found that although patients with large vegetations had a high early mortality rate, vegetation size was not an independent predictor of mortality [27]. Among patients with large vegetations without heart failure or uncontrolled infection, the mortality rate was similar with or without valve surgery. For patients with large vegetations, we perform an individualized risk-benefit assessment comparing early surgery with expectant management based upon multiple factors including response to antibiotic therapy, presence of embolic events, and surgical risk. (See "Surgery for left-sided native valve infective endocarditis", section on 'Vegetation characteristics and risk of embolization'.)

Robotic radical cystectomy with intracorporeal urinary diversion versus open surgery (July 2022)

As radical cystectomies are increasingly performed with robot assistance, urinary diversion is being performed intracorporeally rather than via a mini-laparotomy. In a randomized trial of 317 patients, robot-assisted radical cystectomy with intracorporeal urinary diversion resulted in fewer thromboembolic (1.9 versus 8.3 percent) and wound complications (5.6 versus 16.0 percent) than open radical cystectomy [28]. Patients undergoing robotic cystectomy also reported better quality of life and less disability early postoperatively. If the oncologic outcomes are comparable as to be determined by longer-term follow-ups, robot-assisted radical cystectomy with intracorporeal urinary diversion may replace open surgery for patients with bladder cancer. (See "Radical cystectomy", section on 'Perioperative'.)

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  2. Mitchell EO, Jones P, Snelling PJ. Ultrasound for Pediatric Peripheral Intravenous Catheter Insertion: A Systematic Review. Pediatrics 2022; 149.
  3. Abu Dayyeh BK, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet 2022; 400:441.
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