SAN DIEGO—Now in its 10th year, “10 Hot Topics in General Surgery” was yet again a popular session at the 2022 Clinical Congress of the American College of Surgeons. Last month (February 2023), General Surgery News highlighted the key messages and takeaways from the symposium’s first five presentations. Here we focus on the remainder of the talks, which continued the session’s legacy of providing surgeons with an array of timely and useful information and strategies to carry forward into their clinical practice.
Controversies in Managing Clostridioides difficile
The symposium’s sixth topic was presented by Emily S. Huang, MD, MAEd, an assistant professor of surgery at The Ohio State University, in Columbus, who discussed current controversies in Clostridioides difficile colitis.
Pathogenesis is a hot topic in C. difficile colitis, with antibiotic-related bowel preparation a common suspect. Yet as Dr. Huang explained, research has found that oral antibiotic bowel prep is safe and may even provide a protective effect against postoperative C. difficile infections in colorectal surgery (J Gastrointest Surg 2018;22[11]:1968-1975).
C. difficile colitis was once thought to owe its pathogenesis to major disruptions in the gut microbiome, although as Dr. Huang reported, that belief is changing. “There’s actually new evidence now to suggest that the C. difficile itself potentiates this disruption,” she said. Indeed, research has found that C. difficile toxins promote inflammatory mucosal damage and microbiome changes.
The role of using fecal microbiota transplant (FMT) to reintroduce a normal microbiome is another important consideration in C. difficile colitis. As Dr. Huang discussed, several studies support the use of FMT in recurrent C. difficile infection, and these studies have shown that FMT can be 60% to 90% effective on the first attempt, particularly when used in conjunction with antibiotics. In terms of administration route, nasogastric tubes and capsules are more effective than enemas.
Surgical approaches can also be used, of which loop ileostomy with colonic lavage is an alternative to total colectomy for fulminant C. difficile colitis. In a recent meta-analysis of five observational studies comprising 3,683 patients, researchers found similar mortality rates for loop ileostomy and total colectomy (26.2% and 31.3%, respectively; P=0.22) (Dis Colon Rectum 2020;63[9]:1317-1326). However, the ostomy reversal rate was both statistically and clinically significantly higher after the loop ileostomy (80% vs. 25%; P=0.002).
Finally, Dr. Huang touched on infection control measures.
“Everyone knows that old adage that C. difficile is afraid of the color yellow. But seriously, when can we stop wearing the yellow gowns?”
Despite such frustrations, patients can continue to shed C. difficile spores for weeks after infection. So, it is recommended that contact precautions be combined with soap-and-water handwashing. Infection control specialists also recommend the continuation of contact isolation precautions for at least 48 hours after the cessation of a patient’s diarrhea symptoms, although most institutions will extend this to the duration of the patient’s hospital stay. Although recommendations differ regarding patients who are readmitted with relevant symptoms, Dr. Huang recommended a conservative approach in these instances, particularly in institutions with relatively high C. difficile infection rates.
Clinical practice guidelines issued by the American Society of Colon and Rectal Surgeons offer more insights into managing C. difficile infections (Dis Colon Rectum 2021;64[6]:650-668).
“In summary, use a bowel prep for colorectal surgery and don’t worry about it,” Dr. Huang said. “Understand that C. difficile likely profits from its own mischief in altering the gut microbiome. Know that FMT can be used for recurrent cases. Loop ileostomy lavage is absolutely safe to try for the right patient and may give your patient a better chance of stoma reversal. And keep the contact precautions going for at least 48 hours after the diarrhea stops, particularly if your hospital is dealing with a higher than expected C. difficile infection rate.”
Gallbladder Polyps: Watch or Operate?
In the seventh presentation of the session, Nathaniel J. Soper, MD, a professor and the chair of surgery at the University of Arizona College of Medicine, in Phoenix, discussed gallbladder polyps and the decision to operate or observe them. As he explained, the majority of gallbladder polyps are detected incidentally, and most are considered pseudopolyps (cholesterol polyps, focal adenomyosis, hyperplastic polyps, inflammatory polyps). Those that are true polyps are either adenomas or adenocarcinomas.
“It’s important to differentiate this because although gallbladder cancer is not very prevalent in the United States, the five-year survival rate for stage IV disease is only 2%,” Dr. Soper said.
One of the most important factors in treating gallbladder polyps is imaging, which plays a primary role in diagnosis and decision making. As Dr. Soper discussed, the primary imaging modality is transabdominal ultrasonography. High-resolution, contrast-enhanced 3D ultrasound is said to boast superior sensitivity and specificity, although data are lacking in this regard. Other imaging modalities include endoscopic ultrasound, CT, MRI and PET. All of these alternative imaging modalities may be useful to aid decision making in difficult cases.
Several characteristics influence the management of gallbladder polyps, including polyp size, number of polyps, sessile morphology, patient age, presence of stones, gallbladder symptoms, ethnicity and the presence of primary sclerosing cholangitis. Of these variables, Dr. Soper said the most important one is polyp size.
A 2020 article showed that 85% of polyps smaller than 10 mm were nonneoplastic (PLoS One 2020;15[9]:e0237979). In contrast, 90% of polyps 10 mm or larger were neoplastic in nature—either adenoma or adenocarcinoma. Similarly, a 2021 study by Fujiwara et al showed that polyps smaller than 15 mm were rarely cancer (Surg Endosc 2021;35[9]:5179-5185).
“But when you get above 15 mm, the incidence of cancer increases markedly,” Dr. Soper noted.
The management of gallbladder polyps was made easier recently by the release of updated joint guidelines from a group of several European societies (Eur Radiol 2022;32[5]:3358-3368). In short, the guidelines generally recommend cholecystectomy for polyps 10 mm or larger if the patient is fit for surgery and no alternative cause of the patient’s symptoms is demonstrated.
For polyps smaller than 10 mm, cholecystectomy is still recommended if patients present with symptoms that may be attributable to the gallbladder. Patients without such symptoms who, nonetheless, present with risk factors for malignancy are also candidates for cholecystectomy, depending on the size of the polyp. Finally, patients without symptoms may or may not be followed, depending on the polyp size.
“In conclusion,” Dr. Soper said, “gallbladder polyps are frequently seen on transabdominal ultrasonography. The aim is for us to distinguish true polyps from pseudopolyps, and polyp size is the most important indicator for true polyps. You have to consider the symptoms, risk factors and polyp growth if you’re surveilling these patients over time.”
Managing Inguinal Hernias in Women
The question of how to surgically repair inguinal hernias in women was addressed by William H. Hope, MD, who offered two possibilities: laparoscopic or open repair. He is an associate professor of surgery at the Novant/New Hanover Regional Medical Center, in Wilmington, N.C. As Dr. Hope said, although inguinal hernias are nine to 12 times more common in male individuals, the general prevalence of the disorder means that women still commonly present with it. Furthermore, femoral hernias are about four times more common in the female than in the male population.
Management of groin hernias was discussed at length in a comprehensive set of guidelines issued by the HerniaSurge Group (Hernia 2018;22[1]:1-165).
“The guidelines cover everything you need to know with inguinal hernias,” Dr. Hope said. “Thankfully, they also look specifically at hernias in females.”
In that respect, the guidelines note that provided the requisite expertise is available, women with groin hernias should undergo laparoscopic repair with mesh implantation.
Guidelines notwithstanding, the question of whether to perform laparoscopic or open inguinal hernia repairs in women is a viable one.
“While laparoscopic inguinal hernia repair is on the rise in the United States, there are still many open inguinal hernia repairs being performed in females,” Dr. Hope noted. Nevertheless, performing open inguinal hernia repairs in female patients opens the door to the possibility of missed femoral hernias, which is a key factor in reoperation.
Indeed, a 2018 nationwide registry study from Sweden demonstrated that women undergoing such procedures had higher reoperation rates than their male counterparts (Am J Surg 2018;216[2]:274-279).
“That’s a curious finding,” Dr. Hope noted. “Why would that be? We think it’s a function of missed femoral hernias. At the time of the initial open operation, the surgeon likely did not evaluate that.”
In another study, Ehlers et al concluded that after adjusting for differences, female individuals were less likely to receive guideline-concordant groin hernia repair and were more likely to regret surgery than were males (Hernia 2022;26[3]:823-829).
“So, there is definitely a difference in females and males for inguinal hernia,” Dr. Hope pointed out. “Therefore, I would submit that you should do these laparoscopically. If you are going to do them open in females, you should have a high index of suspicion of femoral hernias. Finally, remember that outcomes are different in females than in males.”
Ventral Hernia Repair in Contaminated Fields
Ajita S. Prabhu, MD, an associate professor of surgery at the Cleveland Clinic Lerner College of Medicine, in Ohio, discussed the nuances of ventral hernia repair in a contaminated field, particularly the type of mesh that should be used in these situations. As she explained, there is currently no synthetic, biologic or bioabsorbable mesh that carries an FDA indication in contaminated settings.
“That being the case, I think we’re probably better off in the company of some data, as flawed as it may be,” Dr. Prabhu said.
Dr. Prabhu highlighted the results of a handful of prospective trials, all of which examined biologic and bioabsorbable meshes. In the RICH study, researchers concluded that the use of Strattice (AbbVie)—an intact, porcine, acellular dermal matrix—allowed for successful, single-stage reconstruction in more than 70% of patients who underwent repair of contaminated ventral incisional hernia (Surgery 2012;152[3]:498-505). The COBRA study, on the other hand, evaluated the biosynthetic absorbable mesh in patients with highly contaminated wounds (Ann Surg 2017265[1]:205-211). This trial found that the novel mesh demonstrated efficacy with respect to long-term recurrence and quality of life for contaminated ventral hernia repairs.
The PHASIX study followed comorbid patients with CDC class 1 wounds following ventral and incisional hernia repair (J Am Coll Surg 2022;235[6]:894-904). It was found that use of P4HB mesh was associated with infrequent complications and durable hernia repair outcomes over a five-year follow-up period. Finally, the BRAVO study examined OviTex (TELA Bio)—an ovine reinforced tissue matrix mesh—in 92 patients, of whom 65 completed 24-month follow-up (Ann Med Surg [Lond] 2022;83:104745). The investigation concluded that the novel mesh formulation was a viable option in ventral hernia repair.
“What we can take away from these studies is two things,” Dr. Prabhu said. “No. 1, there’s not very much out there, and No. 2, if we’re looking at safety, I think we have to acknowledge that synthetic mesh may not be as bad as we thought previously.”
The recent publication of a randomized controlled trial may help shed more light on the subject. The multicenter investigation compared biologic and synthetic meshes in 253 patients undergoing open retromuscular ventral hernia repair, and found that synthetic mesh demonstrated a superior two-year hernia recurrence risk with a comparable safety profile, yet at a price about 200 times less than the biologic mesh (JAMA Surg 2022;157[4]:293-301). Nevertheless, Dr. Prabhu urged surgeons to consider the potential benefits and drawbacks of each approach when deciding which material to use, instead of taking a single study’s findings as a definitive answer.
“The elephant in the room, however, is that if you look at the sources of contamination in our study,” Dr. Prabhu added, “almost every single patient in the trial could have been staged, but wasn’t.”
In these situations, she said the more relevant question to likely ask is whether surgeons should attempt to definitively repair a hernia or stage the repair in a contaminated field.
“Not all contamination is equal,” Dr. Prabhu added. “When we’re not in an emergency but we have a contaminated defect and the patient needs an operation, we have to consider if there’s an opportunity to stage the operation, eradicate the contamination and then come back. If an operation can be staged, definitive repair likely should be avoided in favor of converting it to a clean future case, where possible.”
The Use of Whole Blood in Trauma
The final presentation of the session was left to Richard S. Miller, MD, the chair of surgery at JPS Health Network, in Fort Worth, Texas, who discussed the use of whole blood in trauma. As he explained, the use of whole blood in trauma patients owes the majority of its experience to military settings dating back to World War I, when the British transfused whole blood between soldiers using stainless steel needles. By the start of the Vietnam War, the U.S. Army had switched to component therapy, only to see the return to whole blood in the 2000s with military operations in Iraq and Afghanistan.
“And now, we’re starting to see this use of whole blood again in civilian trauma,” Dr. Miller said.
He went on to discuss the state of the literature regarding the use of whole blood in trauma patients, although he acknowledged that most research has been conducted in military personnel. A 2020 meta-analysis examined 27 studies published between 2006 and 2020, comprising more than 10,000 units of fresh whole blood in more than 3,000 patients, mainly military personnel. The analysis found equivalent overall survival between use of fresh whole blood and component therapy, although individuals who received fresh whole blood were more severely injured than those who received components (J Trauma Acute Care Surg 2020;89[4]:792-800).
In a retrospective 2022 study of more than 1,100 combat casualties, researchers found that resuscitation with warm fresh whole blood was associated with a significant reduction in six-hour mortality, with a dose-dependent effect (Surgery 2022;171[2]:518-525). In 2013, Cotton et al conducted a randomized controlled pilot study comparing modified whole blood with component therapy in severely injured patients requiring large-volume transfusions. The trial found that whole blood did not reduce transfusion volumes in severely injured patients who were predicted to receive massive transfusion (Ann Surg 2013;258[4]:527-532). However, when the researchers excluded patients with severe brain injuries, it was found that the use of whole blood significantly reduced transfusion volumes.
“In civilian trauma, cold-stored, low-titer group O whole blood is the whole blood therapy of choice,” Dr. Miller said.
There are several reasons for this preference. Cold-stored platelets retain their hemostatic potential. There is also adequate concentrations of coagulation factors. When preserved in citrate phosphate dextrose solution between 1° C and 6° C, cold-stored whole blood has a shelf life of 21 to 35 days. Finally, multiple studies show that this usage is safe, effective and feasible. “The question is: Is it beneficial in civilian trauma?” Dr. Miller noted.
One study that sought to answer this question was conducted by Hazelton et al (J Trauma Acute Care Surg 2019;87[5]:1035-1041). In examining 92 patients who received cold whole blood and 182 matched blood component therapy patients, the researchers found that those who received cold whole blood had significantly greater mean hemoglobin and hematocrit at 24 hours. Interestingly, trauma bay mortality was also significantly decreased in cold whole blood recipients, although 30-day mortality was comparable between the groups.
“I’ve reviewed the world’s literature on whole blood and looked at every systematic review and meta-analysis out there for whole blood in civilian trauma,” Dr. Miller said. “The bottom line is that whole blood is safe and does have an apparent benefit in terms of blood product utilization, with evidence of improved early survival in the military.
“Cold-stored, low-titer group O blood is the product of choice in the civilian setting,” he added.
A Final Word on the ACS Session
For session co-moderator E. Christopher Ellison, MD, a professor emeritus of surgery at The Ohio State University, in Columbus, deciding on which topics to cover each year is a challenge that he and his fellow co-moderator Kenneth Sharp, MD, relish.
“We understand the landscape of surgery, and there are always lots of potential topics to choose from,” Dr. Ellison told General Surgery News. As he revealed, many of these topics are the product of discussions posted in the American College of Surgeons’ various online communities.
“We go in there and look for the things that people are concerned about,” he said. “We’ve already started generating the list for next year.”
Should history be any indication of future performance, that session will be as popular as its predecessors.
“We want to have interesting topics, but not too detailed,” Dr. Ellison added. “We want people to come in, watch a six-minute presentation and have an ‘aha moment’ after each one. I think that’s what the audience really likes about it. All I can say is that people keep coming back, so we must be doing something right!”
This article is from the March 2023 print issue.
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