What's New | Decker

Herbert Chen, MD, FACS, Irene Lou, MD

A recent meta-analysis comparing the safety and efficacy of new oral anticoagulants with those of warfarin revealed comparable safety with a reduction in stroke and systemic embolic events in patients on the new agents… The risk of deep vein thrombosis (DVT) or pulmonary embolism (PE) complications in thyroidectomy and parathyroidectomy patients is very low at 0.16%, with a risk of bleeding requiring a return to the operating room that is 10-fold higher. Venous thromboembolism (VTE) prophylaxis should be reserved for only the highest risk patients undergoing these procedures
Recent results from the EINSTEIN-DVT and -PE studies that compared the efficacy and safety of single-drug oral rivaroxaban versus standard therapy of low-molecular-weight heparin and a vitamin K antagonist for the treatment of DVT/PE revealed similar efficacy of rivaroxaban with lower rates of major bleeding.

J. Jason Hoth, MD, PhD, FACS, Andrea M. Long, MD, Preston R Miller, MD, FACS

Although controversial, multiple institutions have increasingly used angiography routinely in higher-grade spleen injuries undergoing nonoperative management (NOM).
A meta-analysis published in 2011 and a subsequent prospective study in 2014 highlighted the higher splenic salvage rate during NOM when angioembolization is employed in all grade IV and V injuries. This is echoed in a Level 2 recommendation in the Eastern Association for the Surgery of Trauma practice management guidelines from 2016
Subcapsular hematomas also may be at higher risk for delayed rupture, and special consideration should be given to patients with this injury pattern. Also currently controversial is the superiority of proximal embolization versus distal embolization.

Julio Garcia-Aguilar, MD, PhD

Minimally invasive platforms facilitate removal of rectal tumors that are beyond the reach of conventional transanal excision techniques.
The use of neoadjuvant chemoradiotherapy may make local excision a viable option for T2 rectal tumors.
Outcomes for immediate salvage surgery are generally better than for delayed salvage surgery.

The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, MN) is an innovative approach to obtain permanent AV access in patients with subclavian and internal jugular venous occlusions not amenable to open or endovascular means of recanalization.
In 2016, data from the United States Renal Data System (USRDS) showed that 124,675 new patients began therapy for ESRD, whereas the prevalent dialysis population reached 726,331. Of note, after a continuous rise in ESRD patients between 1980 and 2010, for the first time a plateau or even slight decline was seen between 2010 and 2016.
A common tradeoff for the higher long-term patency rates associated with autogenous AV access is failure of maturation of the outflow vein, leading to inadequate venous dilation and either inability to successfully use the AV access for dialysis or early AV access failure. Initial success rates leading to a functional AV access range from 55 to 97%.

Huma Farid, MD

The advent of the HPV vaccination has the potential to impact the incidence of cervical cancer. The vaccine was found to have 100% efficacy against CIN 3+ associated with HPV 16 or 18, and 93% efficacy against CIN 3+ due to other HPV types. The vaccination represents an important step forward in the prevention of HPV infection and cervical cancer.
The ability to genotype HPV and test for high risk HPV types has changed the management of abnormal cervical cytology. HPV cotesting has enhanced the sensitivity of pap smears and has enabled providers to triage which patients should be managed with colposcopy.
The success of HPV genotyping has led to the proposal of primary HPV testing instead of primary pap smear screening, as primary HPV testing has been found to be more sensitive than cytology.

Kimberly A Davis, MD, MBA, FACS, FCCM

CT Scan work-up of cholecystitis is not considered first line imaging for cholecystitis, although the use is prevalent because multiple sources of abdominal pain can be evaluated at the same time.
Percutaneous cholecystostomy may be definitive treatment for acalculous cholecystitis.
Antibiotics should be initiated within 1 hour for patients with hemodynamic instability or organ failure due to acute cholangitis or cholecystitis.
Early laparoscopic cholecystectomy is advocated for all but very frail or hemodynamically unstable patients with calculous cholecystitis.

The Endocrine Society Clinical Practice Guidelines recommend umbilical cord blood sampling only when fetal thyroid disease cannot be diagnosed based on clinical or sonographic data.
In 2009, the US FDA issued a warning on PTU-associated hepatotoxicity, prompting the American Thyroid Associated and the American Association of Clinical Endocrinologist to recommend initiation of PTU in the first trimester, followed by transition to methimazole in the second trimester.
Neonatal hyperthyroidism develops in approximately 1% of babies born to women with Graves disease.

High Risk Surgery Patients