General Surgery

The diagnosis of most inguinal hernias can be made with a focused patient history and physical examination. Routine ultrasounds add little value to the diagnosis and management of clinically evident inguinal hernias and can result in treatment delay. These investigations should therefore not be performed where there is a clearly palpable abdominal wall defect and should instead be limited to use in the evaluation of occult inguinal hernias.

Sources:

Bradley M, Morgan J, Pentlow B et al. The positive predictive value of diagnostic ultrasound for occult herniae. Ann R Coll Surg England 2006; 88:165-167. PMID: 16551410.

Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27:11–18. PMID: 22733195.

For minimally symptomatic hernias, surgical repair can prevent potential complications of hernia incarceration and strangulation, but the risk of post-operative complications from infection, hernia recurrence, and chronic inguinal pain approaches the overall risks of incarceration. Watchful waiting for asymptomatic or minimally symptomatic inguinal hernias is a safe option for carefully selected patients and does not preclude patients from undergoing elective repair should discomfort worsen.

Sources:

De Goede B, Wijsmuller AR, van Ramshorst GH, van Kempen BJ, Hop WCJ, Klitsie PJ, Scheltinga MR, et al. Watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older: a randomized controlled trial. PMID: 28350567.

Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M, Jr, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295(3):285–292. PMID: 16418463.

Herniasurge Working Group International guidelines for groin hernia management. Hernia. (2018) 22:1–165. PMID: 29330835.

Ultrasound is an accurate and cost-effective imaging modality for initial evaluation of suspected appendicitis in the pediatric population. Evidence shows that the sensitivity and specificity of ultrasound is high with reports of up to 95%, though this may vary based on center experience and capabilities. Where findings on ultrasound exam are equivocal, CT can be considered as part of a step-up investigative approach after discussion with the patient and caregivers about risks of childhood radiation exposure.

Sources:

Doria AS, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006 Oct;241(1):83-94. PMID: 16928974.

Khan U, Kitar M, Krichen I Maazoun K, Ali Althobaiti R, Khalif M, Adwani M. To determine validity of ultrasound in predicting acute appendicitis among children keeping histopathology as gold standard. Ann Med Surg. 2018 Dec 18;38:22-27. PMID: 30591836.

Krishnamoorthi R, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: Reducing radiation exposure in the age of ALARA. Radiology. 2011 Apr;259(1):231-9. PMID: 21324843.

Rosen MP, et al. ACR appropriateness criteria® right lower quadrant pain–suspected appendicitis. J Am Coll Radiol. 2011 Nov;8(11):749-55. PMID: 22051456.

Saito JM, et al. Use and accuracy of diagnostic imaging by hospital type in pediatric appendicitis. Pediatrics. 2013 Jan;131(1):e37-44. PMID: 23266930.

Wan MJ, et al. Acute appendicitis in young children: Cost-effectiveness of US versus CT in diagnosis–a markov decision analytic model. Radiology. 2009 Feb;250(2):378-86. PMID: 19098225.

Obtaining routine preoperative radiological and laboratory testing offers little value to the perioperative care of asymptomatic patients undergoing low-risk surgery. Evidence suggests that abnormal results within this setting rarely affect management or change clinical outcomes. Instead, a focused history and physical examination should be performed to identify which preoperative investigations are required. Where preoperative testing may add value is in the setting of symptomatic patients or higher risk surgery where significant blood loss and fluid shifts may be expected. A discussion with the patient, anesthesiologists, and surgical team would help guide decision-making in these circumstances.

Sources:

Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, Arens JF, Caplan RA, Connis RT, Fleisher LA, Flowerdew R, Gold BS, Mayhew JF, Nickinovich DG, Rice LJ, Roizen MF, Twersky RS. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012 Mar;116(3):522–38. PMID: 22273990.

Czoski-Murray C, Lloyd JM, McCabe C, Claxton K, Oluboyede Y, Roberts J, Nicholls JP, Rees A, Reilly CS, Young D, Fleming T. What is the value of routinely testing full blood count, electrolytes and urea, and pulmonary function test before elective surgery in patients with no apparent clinical indication and in subgroups of patients with common comorbidities: a systematic review of the clinical and cost-effective literature. Health Technol Assess. 2012;16(50):1–159. PMID: 23302507.

Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol. 2011;27(2):174–9. PMID: 21772675.

Merchant R, Chartrand D, Dain S, Dobson G, Kurrek MM, Lagace A, et al. Guidelines to the practice of anesthesia–revised edition 2015. Can J Anesth. 2015;62(1):54-67. PMID: 25323121.

Soares Dde S, Brandao RR, Mourao MR, Azevedo VL, Figueiredo AV, Trindade ES. Relevance of routine testing in low risk patients undergoing minor and medium surgical procedures. Rev Bras Anestesiol. 2013;63(2):197–201. PMID: 23601261.

The aim of screening investigations for colorectal cancer, such as fecal immunochemical test (FIT) and colonoscopy, is to reduce deaths through early detection and removal of polyps (a precursor to colon cancer) and early stage colorectal cancers. While colonoscopy is a safe screening modality, increased risks have been associated with advanced age and comorbidities. Life expectancy, presence of symptoms, personal and family history, previous investigations, and patient preference must all be considered in order to determine the safety and appropriateness of screening investigations and surveillance colonoscopy. If colonoscopy is determined to be unsafe or inappropriate, FIT should not be offered as an alternative.

Sources:

Brenner H, Stock C, Hoffmeister M. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. BMJ. 2014;348:g2467. PMID: 24922745.

Lieberman DA, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: A consensus update by the US multi-society task force on colorectal cancer. Gastroenterology. 2012 Sep;143(3):844-57. PMID: 22763141.

Lin J, Piper M, Perdue L. Screening for colorectal cancer: a systematic review for the US preventive services task force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016.

Qaseem A, et al. Screening for colorectal cancer: A guidance statement from the American College of Physicians. Ann Intern Med. 2012 Mar 6;156(5):378-86. PMID: 22393133.

U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. preventive services task force recommendation statement. Ann Intern Med. 2008 Nov 4;149(9):627-37. PMID: 18838716.

CPM for early stage breast cancer lacks evidence for survival benefit in average risk women with unilateral breast cancer. CPM can be associated with chronic pain, poor cosmetic outcome, and doubles the risk of post-operative infection and bleeding. Recommended surgical options for treatment for a unilateral early breast cancer in average risk women include lumpectomy and nodal staging or unilateral mastectomy and nodal staging. CPM is recommended for women with unilateral breast cancer and previous Mantle field radiation or a BRCA 1/2 gene mutation. CPM can also be considered by the surgeon on an individual basis for women with unilateral breast cancer and a genetic mutation in the CHEK2/PTEN/p53/PALB2/CDH1 genes, and in women who may have difficulty achieving symmetry after unilateral mastectomy. In all cases, the rationale, risks, and benefits of CPM should be discussed with patients and carefully considered based on each individual patient’s particular situation.

Sources:

Fayanju OM, Stoll, CR, Fowler, S, Colditz GA, Margenthaler JA. Contralateral prophylactic mastectomy after unilateral breast cancer: a systematic review and meta-analysis. Ann Surg. 2014 Dec; 260(6): 1000–1010. PMID: 24950272.

Metcalfe K, Gershman S, Ghadirian P, Lynch HT, Snyder C, Tung N, Kim-Sing C, Eisen A, Foulkes WD, Rosen B, Sun P, Narod SA. Contralateral mastectomy and survival after breast cancer in carriers of BRCA1 and BRCA2 mutations: retrospective analysis. BMJ. 2014;348: p226. PMID: 24519767.

Wright, FC, Look Hong NJ, Quan ML, Beyfuss K, Temple S, Covelli A, Baxter N, Gagliardi AR. Indications for contralateral prophylactic mastectomy: a consensus statement using modified Delphi methodology. Ann Surg. 2018 Feb;267(2):271-279. PMID: 28594745.

Opioid use poses considerable health risks to patients including opioid use disorder, overdose, and side-effects such as psychomotor impairment. While opioid analgesia may be appropriate in select circumstances, prolonged use of opioids beyond the immediate postoperative period and for chronic non-cancer pain is not recommended. Instead, clinicians and patients should consider alternative therapies, such as non-opioid pharmacologic therapy or non-pharmacologic therapies. If opioid analgesia is required, the lowest effective dose, potency, and number of doses required to address the acute pain episode should be prescribed.

Sources:

Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain [Internet]. 2018 Aug 31.

Scully RE, et al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA Surg. 2018 Jan 1. PMID: 28973092.

Shah A, et al. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 17;66(10):265-269. PMID: 28301454.