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What's new in surgery

What's new in surgery
Authors:
Kathryn A Collins, MD, PhD, FACS
Wenliang Chen, MD, PhD
Literature review current through: Feb 2022. | This topic last updated: Feb 28, 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.

ABDOMINAL WALL AND HERNIA SURGERY

Chronic pain after groin hernia surgery in females (January 2022)

Males are 10 times more likely to have groin hernia surgery than females, thus females are underrepresented in most studies. In a Swedish hernia registry including >4000 female patients, compared with male patients, females were 30 percent more likely to have chronic groin pain and 18 percent reported chronic pain affecting daily activity at one year after groin hernia repair [1]. Risk factors for chronic pain in females were high body mass index, high American Society of Anesthesiologists classification, and femoral hernia, but not surgical methods or emergency versus elective surgery. (See "Post-herniorrhaphy groin pain", section on 'Epidemiology and risk factors'.)

Prophylactic negative pressure wound therapy after cesarean birth (December 2021)

The value of prophylactic negative pressure wound therapy (pNPWT) after cesarean birth is under investigation. In a meta-analysis of trials comparing pNPWT with standard wound care in patients with obesity undergoing cesarean birth, the intervention reduced the risk of surgical site infection (SSI) (1.7 versus 8.3 percent; RR 0.79, 95% CI 0.65-0.95) but not other wound complications (eg, dehiscence, seroma), readmission, or reoperation, and it increased skin blistering [2]. Limitations of the analysis included practice variations in surgical care, inconsistent definitions, lack of blinding, and industry sponsorship of some trials. Additional rigorous research is needed before pNPWT can be recommended for patients with obesity undergoing cesarean birth. (See "Cesarean birth: Patients with obesity", section on 'Negative pressure wound therapy'.)

BARIATRIC SURGERY

Bariatric surgery versus nonsurgical management of NASH in patients with obesity (January 2022)

Nonalcoholic steatohepatitis (NASH) is a common cause of chronic liver disease, and obesity is a major risk factor for developing NASH. In the SPLENDOR study of over 1000 patients with histologically confirmed NASH and obesity, gastric bypass or sleeve gastrectomy was associated with a significantly lower 10-year cumulative incidence of major adverse liver outcomes (2.3 versus 9.6 percent) and major cardiovascular events (8.5 versus 15.7 percent) compared with nonsurgical management [3]. The general approach to NASH in patients with obesity is lifestyle modification and weight loss; if that fails, bariatric surgery is the best alternative. (See "Outcomes of bariatric surgery", section on 'Nonalcoholic fatty liver disease'.)

Adjustable intragastric balloon for weight loss (December 2021)

Intragastric balloon therapy is a minimally invasive, temporary method of inducing weight loss. In a randomized trial of 288 adults with obesity at seven United States centers, treatment with an adjustable balloon (Spatz) plus lifestyle modification for eight months resulted in greater total body weight loss than lifestyle modification alone (15 versus 3.3 percent) [4]. After balloon removal, 74 percent of patients maintained at least 40 percent of the weight lost for another six months. Adjustment of balloon volume permitted greater weight loss or improved tolerance of the balloon. The Spatz balloon is not yet approved by the US Food and Drug Administration. (See "Intragastric balloon therapy for weight loss", section on 'Lifestyle intervention'.)

COLORECTAL SURGERY

Long-term appendectomy rates following initial antibiotics for appendicitis in adults (January 2022)

Antibiotic therapy has been proposed as an alternative to surgery for uncomplicated appendicitis. In 2020, the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial reported that the 30-day general health status of patients treated with antibiotics was comparable to the appendectomy group; however, 29 percent of medically-treated patients required appendectomy by 90 days. Longer-term data from this trial now confirm high rates of subsequent appendectomy after initial medical therapy: 40 percent at one year, 46 percent at two years, and 49 percent at three and four years [5]. Given these high appendectomy rates, we continue to suggest surgery for uncomplicated appendicitis and reserve antibiotic therapy for those who are medically unfit for or decline surgery. (See "Management of acute appendicitis in adults", section on 'Evidence for nonoperative management'.)

BREAST SURGERY

IV placement, venipuncture, and blood pressure measurements after breast cancer surgery (October 2021)

Avoiding lymph node dissection is the only preventive measure proven to reduce the risk of developing lymphedema after breast cancer surgery; however, many patients are told to avoid intravenous catheters, venipunctures, and blood pressure measurements in the arm ipsilateral to the previous surgery for the rest of their lives. In agreement with the American Society of Breast Surgeons, the Society for Ambulatory Anesthesia issued a statement that these measures are not contraindicated in patients who have no lymphedema, even if they have had an axillary lymph node dissection [6]. Our approach is generally consistent with this statement. We support shared decision-making that accounts for the individual's risk factors for developing lymphedema, the clinical situation and monitoring needs, and patient preferences. (See "Breast cancer-associated lymphedema", section on 'Unsupported risk reduction strategies'.)

PERIOPERATIVE CARE

Timing of elective surgery after COVID-19 (January 2022)

The appropriate time to schedule elective surgery after COVID-19 is unclear. In a multicenter database study of >5000 patients in the United States with COVID-19 who underwent major elective surgery, surgery in the first four weeks after COVID-19 diagnosis was associated with higher risks of postoperative pneumonia, respiratory failure, sepsis, and pulmonary embolism [7]. These findings are consistent with a prior international study that found increased 30-day mortality after surgery performed within seven weeks of COVID-19 diagnosis. Risks were higher in patients with symptomatic COVID-19 and highest in those symptomatic at the time of surgery. The decision to schedule elective surgery should consider the severity of COVID-19, the risks of complications, and the risks of delaying surgery. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Risk related to timing after infection'.)

Comparison of protocols for the diagnosis of pulmonary embolism (January 2022)

The ideal strategy for diagnosing pulmonary embolism (PE) is unknown. One meta-analysis reported that protocols that used pretest probability (PTP) models, adjusted D-Dimer levels, and/or YEARs criteria excluded more cases of PE without imaging (high efficiency) [8]. However, they also had the highest failure rate (ie, more missed cases of VTE). In addition, such protocols did not perform uniformly across all subgroups, with the lowest efficiency observed in those who were 80 years of age or older and in patients with cancer. In patients with suspected PE, we prefer to use a conventional protocol that combines clinical PTP and unadjusted D-Dimer to direct imaging. Although this approach is associated with a higher rate of imaging, fewer cases of PE are missed and we value the role of imaging when looking for alternate causes of patients' symptoms. (See "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism", section on 'Adjusted D-dimer'.)

Effect of neuraxial versus general anesthesia on postoperative delirium (January 2022)

Compared with general anesthesia, neuraxial or regional anesthesia with light, deep, or no sedation does not consistently decrease the incidence of delirium or other perioperative neurocognitive disorders (PND). A randomized trial in older patients undergoing hip fracture surgery noted a similar incidence of delirium in those who received neuraxial anesthesia (spinal and/or epidural) without any sedation compared with those who received general anesthesia [9]. Similar results have been noted in other randomized trials. We select an appropriate anesthetic technique based on considerations other than risk for PND. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Choice of anesthetic technique'.)

Benefits of patient blood management (December 2021)

Patient blood management (PBM) programs provide guidelines for appropriate use of blood transfusion. In a new series involving >400,000 hospital admissions over an eight-year period, institution of a PBM program was associated with a 22 percent reduction in transfusions [10]. Hospital length of stay and adverse events were also reduced, and there was an estimated cost savings of USD $7 million. PBM programs should not supersede clinical judgment in transfusion decisions, but when well designed and thoughtfully implemented, they can improve quality of care and reduce risks, costs, and burdens associated with transfusion. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Hospital-wide oversight programs/patient blood management'.)

Consensus on guiding principles for perioperative pain management (October 2021)

Evidence-based multidisciplinary guidelines for the management of acute perioperative pain have been lacking. Recently, a consortium of various specialty organizations published consensus recommendations for seven guiding principles for perioperative pain management (table 1) [11]. We agree with these principles, which seek to improve perioperative pain management by implementing multimodal, opioid-sparing, patient-centered approaches. (See "Management of acute perioperative pain", section on 'General approach'.)

LMW heparin dosing in individuals with high BMI (September 2021)

Optimal dosing of low molecular weight (LMW) heparins for individuals with high body mass index (BMI) is unknown, and guideline recommendations are variable regarding whether to prefer fixed dosing or weight-based dosing for venous thromboembolism (VTE) prophylaxis. A new meta-analysis has evaluated data from 11 studies (nearly 20,000 medical and surgical patients with high BMI) treated with fixed-dose or weight-based dose LMW heparin and found little or no difference in the rates of recurrent VTE or bleeding [12]. Although more data are needed, these results are reassuring and suggest that both approaches are reasonable. (See "Heparin and LMW heparin: Dosing and adverse effects", section on 'Dosing at extremes of body weight'.)

VASCULAR AND ENDOVASCULAR SURGERY

Updated guidelines on venous thromboembolism management (January 2022)

Updated guidelines on the treatment of venous thromboembolism (VTE) were published by the American College of Chest Physicians (CHEST) [13]. Many recommendations are similar to those in the 2016 guideline but either expanded in scope or changed in strength of the recommendation. As new recommendations, for most patients with cancer-related VTE, CHEST suggests a direct oral anticoagulant (DOAC) rather than low molecular weight heparin. For select patients without cancer who require extended anticoagulation beyond the conventional period of three to six months, CHEST suggests low-intensity anticoagulation with a DOAC. While CHEST did not promote aspirin for VTE prevention, they suggest that it may reduce the risk of recurrence when compared with no therapy. (See "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Anticoagulation therapy for venous thromboembolism (lower extremity venous thrombosis and pulmonary embolism) in adult patients with malignancy" and "Selecting adult patients with lower extremity deep venous thrombosis and pulmonary embolism for indefinite anticoagulation".)

Choosing apixaban or rivaroxaban for venous thromboembolism (December 2021)

Although several direct oral anticoagulants (DOACs) are available for treating patients with venous thromboembolism (VTE), no randomized trials support choosing one over another. A recent retrospective study reported that among 37,000 new users of apixaban or rivaroxaban, apixaban was associated with lower rates of recurrent VTE (hazard ratio [HR] 0.77, 95% CI 0.69-0.87) and bleeding (HR 0.60, 95% CI 0.53-0.69) [14]. While these data favor apixaban, we continue to favor an individualized choice among DOACs that also take into consideration cost, availability, and preference for once- versus twice-daily dosing. (See "Venous thromboembolism: Anticoagulation after initial management", section on 'Efficacy' and "Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects".)

Carotid stenting versus endarterectomy for asymptomatic carotid stenosis (September 2021)

Earlier trials comparing transfemoral carotid artery stenting (TF-CAS) with carotid endarterectomy (CEA) for asymptomatic carotid stenosis reported that the periprocedural (30-day) stroke or death rate is higher for TF-CAS, while long-term outcomes are similar. In the recent ACST-2 trial, the periprocedural rate of death or any stroke was slightly higher with TF-CAS compared with CEA, but the difference was not statistically significant [15]. This result largely reflected a higher incidence of nondisabling stroke in the TF-CAS group. The five-year rate of periprocedural death or any fatal or disabling stroke was similar for TF-CAS and CEA (3.3 versus 3.5 percent). For medically stable individuals with asymptomatic carotid stenosis of 70 to 99 percent, we advise a shared decision-making approach; either intensive medical therapy alone or intensive medical therapy plus revascularization with CEA are reasonable treatment options. For those with an unacceptably high surgical risk with suitable anatomy, carotid artery stenting is an alternative. (See "Management of asymptomatic extracranial carotid atherosclerotic disease", section on 'Stenting versus endarterectomy trials'.)

OTHER SURGICAL SPECIALTIES

Prophylactic negative pressure wound therapy after cesarean birth (December 2021)

The value of prophylactic negative pressure wound therapy (pNPWT) after cesarean birth is under investigation. In a meta-analysis of trials comparing pNPWT with standard wound care in patients with obesity undergoing cesarean birth, the intervention reduced the risk of surgical site infection (SSI) (1.7 versus 8.3 percent; RR 0.79, 95% CI 0.65-0.95) but not other wound complications (eg, dehiscence, seroma), readmission, or reoperation, and it increased skin blistering [2]. Limitations of the analysis included practice variations in surgical care, inconsistent definitions, lack of blinding, and industry sponsorship of some trials. Additional rigorous research is needed before pNPWT can be recommended for patients with obesity undergoing cesarean birth. (See "Cesarean birth: Patients with obesity", section on 'Negative pressure wound therapy'.)

Spinal versus general anesthesia for hip fracture surgery (December 2021)

Whether the use of spinal versus general anesthesia for hip fracture surgery affects outcomes is uncertain. In a multicenter randomized trial (REGAIN) comparing the two techniques in 1600 patients who underwent hip fracture surgery, both groups had similar mortality, ability to walk at 60 days postoperatively, postoperative delirium, and time to discharge [16]. The spinal anesthesia group had lower rates of in-hospital mortality, acute kidney injury, and critical care admission, but statistical analysis was not performed for these outcomes. For patients in whom either type of anesthesia would be appropriate, we suggest spinal anesthesia to reduce the need for mechanical ventilation and achieve a more rapid return to baseline mental status. (See "Anesthesia for orthopedic trauma", section on 'Choice of anesthetic technique for hip fracture'.)

Extended dosing of tranexamic acid for total knee arthroplasty (November 2021)

For patients undergoing total knee arthroplasty, prophylactic tranexamic acid (TXA) at the time of surgery is recommended to minimize blood loss. The TRAC-24 trial found that extending TXA dosing for 24 hours postoperatively reduced the indirect calculated blood loss at 48 hours compared with intraoperative dosing alone (mean difference 126 mL), but mortality and thromboembolic events were similar for both groups [17]. We administer postoperative TXA to patients with excessive bleeding. Additional study is required before routine postoperative TXA can be recommended. (See "Total knee arthroplasty", section on 'Tranexamic acid'.)

OTHER GENERAL SURGERY

Counseling and consent prior to breast implants (November 2021)

Due to ongoing concerns about the possible risk of systemic illness or anaplastic large cell lymphoma in patients with silicone gel-filled breast implants, the US Food and Drug Administration (FDA) now requires a boxed warning on all breast implants with updated labeling to communicate device materials and long-term study results [18]. The FDA will also restrict the sale and distribution of breast implants to only health care providers and facilities that provide information to patients using the "Patient Decision Checklist." The goal of the checklist is to ensure that the patient understands the risks, benefits, and other information about the breast implant device prior to proceeding with surgery. (See "Implant-based breast reconstruction and augmentation", section on 'Informed consent'.)

REFERENCES

  1. Jakobsson E, Lundström KJ, Holmberg H, et al. Chronic Pain After Groin Hernia Surgery in Women: A Patient-reported Outcome Study Based on Data From the Swedish Hernia Register. Ann Surg 2022; 275:213.
  2. Gillespie BM, Thalib L, Ellwood D, et al. Effect of negative-pressure wound therapy on wound complications in obese women after caesarean birth: a systematic review and meta-analysis. BJOG 2022; 129:196.
  3. Aminian A, Al-Kurd A, Wilson R, et al. Association of Bariatric Surgery With Major Adverse Liver and Cardiovascular Outcomes in Patients With Biopsy-Proven Nonalcoholic Steatohepatitis. JAMA 2021; 326:2031.
  4. Abu Dayyeh BK, Maselli DB, Rapaka B, et al. Adjustable intragastric balloon for treatment of obesity: a multicentre, open-label, randomised clinical trial. Lancet 2021; 398:1965.
  5. CODA Collaborative, Davidson GH, Flum DR, et al. Antibiotics versus Appendectomy for Acute Appendicitis - Longer-Term Outcomes. N Engl J Med 2021; 385:2395.
  6. Society for Ambulatory Anesthesia (SAMBA) Statement on Intravenous Catheter Placement, Venipuncture and Blood Pressure Measurements in the Ipsilateral Upper Extremity after Breast Cancer Surgery with and without Axillary Lymph Node Dissection https://samba.memberclicks.net/assets/docs/SAMBA_Statements/SAMBA_Statement_IV-Breast-Surg.pdf (Accessed on October 19, 2021).
  7. Deng JZ, Chan JS, Potter AL, et al. The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States. Ann Surg 2022; 275:242.
  8. Stals MAM, Takada T, Kraaijpoel N, et al. Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis. Ann Intern Med 2022; 175:244.
  9. Li T, Li J, Yuan L, et al. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial. JAMA 2022; 327:50.
  10. Warner MA, Schulte PJ, Hanson AC, et al. Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center. Mayo Clin Proc 2021; 96:2980.
  11. Mariano ER, Dickerson DM, Szokol JW, et al. A multisociety organizational consensus process to define guiding principles for acute perioperative pain management. Reg Anesth Pain Med 2022; 47:118.
  12. Ceccato D, Di Vincenzo A, Pagano C, et al. Weight-adjusted versus fixed dose heparin thromboprophylaxis in hospitalized obese patients: A systematic review and meta-analysis. Eur J Intern Med 2021; 88:73.
  13. Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545.
  14. Dawwas GK, Leonard CE, Lewis JD, Cuker A. Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data. Ann Intern Med 2022; 175:20.
  15. Halliday A, Bulbulia R, Bonati LH, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398:1065.
  16. Neuman MD, Feng R, Carson JL, et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med 2021; 385:2025.
  17. Magill P, Hill JC, Bryce L, et al. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total knee arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J 2021; 103-B:1595.
  18. FDA strengthens safety requirements and updates study results for breast implants. www.fda.gov/news-events/press-announcements/fda-strengthens-safety-requirements-and-updates-study-results-breast-implants (Accessed on November 08, 2021).
Topic 16577 Version 10977.0

References

1 : Chronic Pain After Groin Hernia Surgery in Women: A Patient-reported Outcome Study Based on Data From the Swedish Hernia Register.

2 : Effect of negative-pressure wound therapy on wound complications in obese women after caesarean birth: a systematic review and meta-analysis.

3 : Association of Bariatric Surgery With Major Adverse Liver and Cardiovascular Outcomes in Patients With Biopsy-Proven Nonalcoholic Steatohepatitis.

4 : Adjustable intragastric balloon for treatment of obesity: a multicentre, open-label, randomised clinical trial.

5 : Antibiotics versus Appendectomy for Acute Appendicitis - Longer-Term Outcomes.

6 : Antibiotics versus Appendectomy for Acute Appendicitis - Longer-Term Outcomes.

7 : The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States.

8 : Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis.

9 : Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial.

10 : Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center.

11 : A multisociety organizational consensus process to define guiding principles for acute perioperative pain management.

12 : Weight-adjusted versus fixed dose heparin thromboprophylaxis in hospitalized obese patients: A systematic review and meta-analysis.

13 : Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report.

14 : Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data.

15 : Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy.

16 : Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.

17 : Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total knee arthroplasty: results of a randomized controlled trial (TRAC-24).