Category: Surgeries & Procedures

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New Guidance Advises Stopping Antibiotics after Incision Closure

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Antibiotics administered before and during surgery should be discontinued immediately after a patient’s incision is closed, according to updated recommendations for preventing surgical site infections.

Experts found no evidence that continuing antibiotics after a patient’s incision has been closed, even if it has drains, prevents surgical site infections. Continuing antibiotics does increase the patient’s risk of C. difficile infection, which causes severe diarrhoea, and antimicrobial resistance.

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2022 Update, published in the journal Infection Control and Healthcare Epidemiology, provides evidence-based strategies for preventing infections for all types of surgeries from top experts from five medical organisations led by the Society for Healthcare Epidemiology of America.

“Many surgical site infections are preventable,” said Michael S. Calderwood, MD, MPH, lead author on the updated guidelines. “Ensuring that healthcare personnel know, utilise, and educate others on evidence-based prevention practices is essential to keeping patients safe during and after their surgeries.”

Surgical site infections are among the most common and costly healthcare-associated infections, occurring in approximately 1% to 3% of patients undergoing inpatient surgery. Patients with surgical site infections are up to 11 times more likely to die compared to patients without such infections.

Other recommendations:

  • Obtain a full allergy history from patients who self-report penicillin allergy. Many patients with a self-reported penicillin allergy can safely receive cefazolin, a cousin to penicillin, rather than alternate antibiotics that are less effective against surgical infections.
  • For high-risk procedures, especially orthopaedic and cardiothoracic surgeries, decolonise patients with an anti-staphylococcal agent in the pre-operative setting. Decolonization, which was elevated to an essential practice in this guidance, can reduce post-operative S. aureus infections.
  • For patients with an elevated blood glucose level, monitor and maintain post-operative blood glucose levels between 110 and 150mg/dL regardless of diabetes status. Higher glucose levels in the post-operative setting are associated with higher infection rates. However, more intensive post-operative blood glucose control targeting levels below 110mg/dL has been associated with a risk of significantly lowering the blood glucose level and increasing the risk of stroke or death.
  • Use antimicrobial prophylaxis before elective colorectal surgery. Mechanical bowel preparation without use of oral antimicrobial agents has been associated with significantly higher rates of surgical site infection and anastomotic leakage. The use of parenteral and oral antibiotics prior to elective colorectal surgery is now considered an essential practice.
  • Consider negative-pressure dressings, especially for abdominal surgery or joint arthroplasty patients. Placing negative-pressure dressings over closed incisions was identified as a new option because evidence has shown these dressings reduce surgical site infections in certain patients. Negative pressure dressings are thought to work by reducing fluid accumulation around the wound.

Additional topics covered in the update include specific risk factors for surgical site infections, surveillance methods, infrastructure requirements, use of antiseptic wound lavage, and sterile reprocessing in the operating room, among other guidance.    

Hospitals may consider these additional approaches when seeking to further improve outcomes after they have fully implemented the list of essential practices. The document classifies tissue oxygenation, antimicrobial powder, and gentamicin-collagen sponges as unresolved issues according to current evidence.  

Source: Society for Healthcare Epidemiology of America

Categories : Cardiovascular Disease Surgeries & ProceduresTags :

Smaller Bioprosthetic Aortic Valves Safer than Previously Believed

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Researchers in Sweden have performed a nation-wide study of patients who underwent bioprosthetic aortic valve replacement between 2003 and 2018. The study, published in the Journal of the American College of Cardiology, shows that it is less dangerous than previously believed to receive a small bioprosthetic aortic valve in relation to the patients size.

During surgical aortic valve replacement, the patient receives a valve prosthesis that matches the size of the aortic root. Sometimes, that size is too small in relation to the patient’s body size. This puts strain on the heart to pump enough blood that the body needs through a narrow valve. The level of “narrowness” is measured as Prosthesis Patient Mismatch, PPM.

“Prior studies have shown that both moderate and severe PPM decreases survival and increases the risk for heart failure. In our study, we can confirm that severe PPM decreases survival and increases the risk for heart failure, while moderate PPM has a very limited effect on survival and no effect on the risk for heart failure”, says Michael Dismorr, postdoctoral researcher at the Department of Molecular Medicine and Surgery and first author of the study.

The study

The study included all patients who underwent bioprosthetic aortic valve replacement in Sweden between 2003 and 2018. Patients were identified from the Swedish cardiac surgery register, part of the SWEDEHEART register. The database was enriched with data from other national health data registers. By using the statistical method regression standardization we were able to estimate the risk for the outcomes death, heart failure and reintervention in absolute terms between the groups no, moderate and severe PPM.

The study shows that the estimated risk difference between no and moderate PPM for death after 10 years of follow-up was -1.7% (-3.3% to -0.1%) compared to -4.6% (-8.5% to -0.7%) for severe PPM.

The risk difference for heart failure after 10 years of follow-up was -1.1% (-2.5% to 0.2%) between patients with no and moderate PPM.

“A risk difference of a single percent after 10 years of follow-up cannot be said to be of clinical significance, even if it is statistically so. However, it is important to note that these are hard clinical outcomes. We did not have access to “soft” outcomes such as quality of life, which might be decreased in patients with moderate PPM, and in that case of course of great importance to those patients”, says Michael Dismorr.

Next steps

“Now we want to study the effect of PPM in patients who underwent transcatheter aortic valve replacement, a so called TAVR procedure. This is important knowledge when deciding which patients will benefit the most from a surgical replacement, and which patients will benefit the most from a transcatheter replacement”, says Michael Dismorr.

Source: Karolinska Institutet

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Joint Loading may Predict Knee Osteoarthritis after ACL Surgery

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Knee pain
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Arthritis in the knee’s patellofemoral joint (PFJ) is common following anterior cruciate ligament reconstruction (ACLR) and may be linked with altered loading at the joint. In a study published in the Journal of Orthopaedic Research, young adults post‐ACLR who exhibited lower PFJ loading during hopping were more likely to have PFJ osteoarthritis at one year and worsening PFJ osteoarthritis between one and five years post-procedure.

In the study, data for net PFJ contact force were normalised to each participant’s body weight. For every one body weight decrease in the peak PFJ contact force during hopping, the proportion of people at one year post-ACLR with early PFJ osteoarthritis increased by 37%, and the risk of worsening PFJ osteoarthritis between one and five years post-ACLR increased by 55%.

“Clinical interventions aimed at mitigating osteoarthritis progression may be beneficial for those with signs of lower PFJ loading post-ACLR,” the authors wrote.

Source: Wiley

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Inaccurate Anaesthesia Start Times Leading to Lost Revenue

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Inaccurately recording the start of anaesthesia care during a procedure is common and results in significant lost billing time for anaesthesia practices and medical centres, suggests a study being presented at the American Society of Anesthesiologists’ ADVANCE 2023, the Anesthesiology Business Event.

The anaesthesia start time (AST) must be documented from a computer logged into the electronic health record (EHR), and typically occurs once the patient is in the operating room (OR). However, the anaesthesiologist meets with the patient prior to their arrival in the OR and begins tasks that are vital to the procedure, such as administering pre-medication and attaching monitors, time which is is not typically recorded. Depending on the patient and procedure, adding two to five minutes to the AST when logging it would account for the preparation and transit time, researchers say.

“These seemingly minor inaccuracies of recorded AST can cost medical centres and anaesthesia practices hundreds of thousands of dollars in lost revenue,” said Nicholas Volpe Jr, MD, MBA, lead author of the study and an anaesthesiology resident physician at Northwestern University McGaw Medical Center, Chicago. “We suspect most anaesthesiologists are unaware that they aren’t recording AST accurately. It’s not a result of negligence, but rather reflects that workflow hasn’t been optimised for accuracy.”

For the study, the researchers analysed 40 312 procedures with anaesthesia over 12 months at a single academic centre. In 68.74% of cases , AST was recorded as starting once the patient was in the OR, without factoring in the preparation time. Using the national average charge for anesthaesia time, the missing time translated to over $600 000 in lost revenue for the year, the researchers determined.*

“Logging AST is one of the many new tasks that anaesthesiologists learn when starting a new role,” said Dr Volpe. “Transitioning from an internship to clinical anaesthesia practice involves learning a significant amount of new information, and understanding the importance of an accurately recorded AST may seem like a relatively minor issue compared to important patient-care information.”

Several approaches could help address inaccurate AST documentation, including educating anaesthesiologists on how to improve their AST recording practices and providing visual reminders such as signs in the OR, Dr Volpe said. Also, an AST capture function could be built into the EHR mobile application so that AST can be noted by anaesthesiologists on the way to the OR, or the EHR could automatically add two minutes to the AST log time, he said. The researchers plan to roll out some of those initiatives in the spring and determine if they are effective.

*The projected savings are theoretical and not linked to billing at the institution where the study was conducted. 

Source: American Society of Anesthesiologists

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Cannabis Worsens Peripheral Artery Bypass Outcomes

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Cannabis use may negatively impact outcomes in peripheral artery bypass (PAB) surgery, suggests a study published in Annals of Vascular Surgery.

Researchers analysed more than 11 000 available cases to review patient cannabis use and postoperative outcomes for lower extremity bypass after 30 days and one year. The minimally invasive PAB procedure uses a vein or synthetic to tube to divert blood around a narrowed or blocked artery in a leg.

Results reveal that patients who used cannabis prior to lower extremity bypass had decreased patency, meaning the graft had a higher chance of becoming blocked or occluded, and were 1.25 times more likely to require amputation one year after surgery. Cannabis users were also 1.56 times more likely to use opioids after discharge.

“The findings show a need for screening for cannabis use and open conversations between patients and clinicians to help inform preoperative risk assessment and decision-making for lower extremity bypass,” said senior author Peter Henke, MD, FACS, FAHA

“While its exact mechanisms are unclear, cannabis and its active compounds play a role in platelet function and microcirculation that may lead to decreased rates of limb salvage after lower extremity bypass,” Henke said.

Around 43% of individuals in the United States and Canada have used cannabis. Previous studies suggest cannabis use has effects on the cardiovascular system, including increased risk of heart attack and stroke. The study did not find any association with stroke or heart attack after lower extremity bypass.

While future study is needed to further understand cannabis’ full effect on outcomes, researchers note, the findings will help clinicians counsel patients who are undergoing vascular surgery.

“While past studies on the effects of cannabis use on pain response suggested an increase in pain tolerance after smoking cannabis, our studies and other contemporary findings show the opposite,” said Drew Braet, M.D., first author and integrated vascular surgery resident at U-M Health. “Given the increase in cannabis use and abuse in conjunction with the opioid epidemic, the results suggest a need for a better understanding of pain management for cannabis users who are having vascular surgery.”

Source: Michigan Medicine – University of Michigan

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Better Outcomes with Bypass Surgery in Chronic Limb-threatening Ischaemia

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Performing open bypass surgery to restore circulation for people with a severe form of peripheral artery disease (PAD) resulted in better outcomes for specific patients compared to a less-invasive procedure, according to findings published in the New England Journal of Medicine.

PAD is a condition in which blood flow to one or both legs is reduced by a buildup of fatty plaque in the arteries. One in 10 of patients with this condition develop a severe form of PAD called chronic limb-threatening ischaemia (CLTI), a painful and debilitating condition that can lead to amputation if untreated. Up to about 22 million people worldwide have CLTI, which is also associated with an increased risk of heart attack, stroke, and death.

“Given the projected rise in the number of patients with chronic limb-threatening ischaemia, it is critically important that we understand the full impact of our interventions for this disease,” said Matthew Menard, MD, a study author and associate professor of surgery and co-director of the endovascular surgery program at Brigham and Women’s Hospital, Boston. “These findings help do that and also can assist clinicians and caregivers in providing the best possible care to patients.”

The Best Endovascular versus Best Surgical Therapy for Patients with CLTI (BEST-CLI) trial is a landmark study supported by the National Heart, Lung, and Blood Institute (NHLBI).

To compare effectiveness of two common treatments for CLTI, researchers enrolled 1830 adults who were planning to have revascularisation, a procedure used to restore blood flow in their blocked arteries, and who were eligible for both treatment strategies.

One treatment strategy was an open bypass surgery, in which blood is redirected around the blocked leg artery by using a segment of a healthy vein. The other strategy was an endovascular procedure, where a balloon is dilated and/or a stent is placed in the blocked segment of the artery to improve blood flow. To compare the surgical strategy to the less-invasive endovascular approach, researchers randomised participants into one of two parallel trials between 2014–2021.

The first trial, defined as cohort 1, included 1434 adults who were judged to be the best candidates for the bypass surgery because they had an adequate amount of an optimal vein (the single-segment great saphenous vein) preferred for the procedure. Participants were then randomly assigned to have either a surgical bypass or endovascular procedure. Researchers followed the trial participants for up to seven years.

The second trial, defined as cohort 2, included 396 adults who were not the best candidates for the open bypass because they did not have an adequate amount of the preferred saphenous vein. They were randomised to have either an endovascular procedure or a bypass that used alternate graft material instead of the saphenous vein. Participants were followed-up for up to three years.

At the end of the trial, the researchers found that participants in cohort 1 who received the bypass were 32% less likely to have major medical events related to CLTI than those who had an endovascular procedure. This result was driven by a 65% reduction in major repeat surgeries or procedures to retain blood flow in the lower leg and a 27% reduction in major amputations. No differences were found in death rates between the participants who received the bypass surgery and those who received an endovascular procedure.

Adults in cohort 2 – those who did not have the optimal vein for the bypass – had no major differences in outcomes based on having had an open bypass or an endovascular procedure.

“Our findings support complementary roles for these two treatment strategies and emphasise the need for preprocedural planning to assess patients and inform what treatment is selected,” said co-principal investigator Alik Farber, MD, at Boston Medical Center.

Common symptoms of CLTI include leg and foot pain, foot infections, and open sores on the leg and foot that don’t fully heal. Without having a procedure to redirect or open blocked blood flow to the lower body, about 4 in 10 adults with CLTI have a lower leg or foot amputation.

BEST-CLI is the largest CLTI clinical trial to date and builds on prior research that aims to answer questions about the risks and benefits of revascularisation strategies for CLTI.

Source: NIH/National Heart, Lung and Blood Institute

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Pair of Studies Reveal Ways to Improve Surgical Care in Countries like South Africa

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Surgical care experts published two important studies in The Lancet that will help to provide safer surgery for thousands of patients around the world – particularly in Low- and Middle-income Countries (LMIC) such as South Africa.

Researchers found that routinely changing gloves and instruments just before closing wounds could significantly reduce Surgical Site Infection (SSI), the most common post-operative complication. This switch could prevent as many as 1 in 8 cases of SSI.

Secondly, they tested a new toolkit that can make hospitals better prepared for pandemics, heatwaves, winter pressures and natural disasters that could reduce cancellations of planned procedures around the world.

Surgical infections

Patients in LMICs are disproportionately affected by wound infections. The ChEETAh trial was run in Benin, Ghana, India, Mexico, Nigeria, Rwanda and South Africa. With the publication of their findings in The Lancet, researchers are calling for the practice to be widely implemented – particularly in LMICs.

Co-author Mr Aneel Bhangu, from the University of Birmingham, commented: “Surgical site infection is the world’s most common postoperative complication – a major burden for both patients and health systems. Our work demonstrates that routine change of gloves and instruments is not only deliverable around the world, but also reduced infections in a range of surgical settings. Taking this simple step could reduce SSIs by 13% – simply and cost-effectively.”

Patients who develop SSI experience pain, disability, poor healing with risk of wound breakdown, prolonged recovery times and psychological challenges. In health systems where patients have to pay for treatment this can be a disaster and increases the risk of patients being plunged into poverty after their treatment. The simple and low-cost practice of changing your gloves and instruments just before closing the wound is something which can be done by surgeons in any hospital around, meaning a huge potential impact.

Surgical Preparedness Index

Experts from the NIHR Global Research Health Unit on Global Surgery also unveiled their ‘Surgical Preparedness Index’ (SPI) in The Lancet. This is a key study assessing the extent to which hospitals around the world were able to continue elective surgery during COVID.

Researchers identified different features of hospitals that made them more or less ‘prepared’ for times of increased pressure. Using COVID as an important example, they highlighted that health systems are put under stress for all sorts of reasons each year – from seasonal pressures to natural disasters, and warfare. A team of clinicians from 32 countries designed the SPI which scores hospitals based on their infrastructure, equipment, staff, and processes used to provide elective surgery. The higher the resulting SPI score, the more prepared a hospital is for disruptions.

After creating the SPI tool, the experts asked 4714 clinicians in 1632 hospitals across 119 countries to assess the preparedness of their local surgical department. Overall most hospitals around the world were poorly prepared, and suffered a big drop in the number of procedures they were able to provide during COVID. A 10-point increase in the SPI score corresponded to four more patients that had surgery per 100 patients on the waitlist.

Lead author Mr. James Glasbey, from the University of Birmingham, commented: “Our new tool will help hospitals internationally improve their preparation for external stresses ranging from pandemics to heatwaves, winter pressures and natural disasters. We believe it help hospitals to get through their waiting lists more quickly, and prevent further delays for patients. The tool can be completed easily by healthcare workers and managers working in any hospital worldwide – if used regularly, it could protect hospitals and patients against future disruptions.”

Professor Dion Morton, Barling Chair of Surgery at the University of Birmingham and Director of Clinical Research at the Royal College of Surgeons of England commented: “Although not all postoperative deaths are avoidable, many can be prevented by increasing investment in research, staff training, equipment, and better hospital facilities. We must invest in improving the quality of surgery around the world.”

Source: University of Birmingham

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NASA Technology Enables Nearly Painless Kidney Stone Removal

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Anatomic model of a kidney
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A new ultrasonic technique developed for emergency kidney stone treatments on Mars may offer an option to move kidney stones out of the ureter with minimal pain and no anaesthesia, according to a new feasibility study published in The Journal of Urology.

In the procedure, the physician uses a handheld transducer placed on the skin to direct ultrasound waves towards the stone. Using ultrasound propulsion, the stones can then moved and repositioned to promote their passage, while burst wave lithotripsy (BWL) can break up the stone.

Unlike with the standard technique of shock wave lithotripsy, there is minimal pain according to lead author Dr M. Kennedy Hall, a UW Medicine emergency medicine doctor. “It’s nearly painless, and you can do it while the patient is awake, and without sedation, which is critical.”

The researchers hope that one day the procedure of moving or breaking up the stones could eventually be performed in a clinic or emergency room setting with this technology, Dr Hall added.

Ureteral stones can cause severe pain and are a common reason for emergency department visits. Most patients with ureteral stones are advised to wait to see if the stone will pass on its own. However, this observation period can last for weeks, with nearly one-fourth of patients eventually requiring surgery, Dr Hall noted.

Dr Hall and colleagues evaluated the new technique to meet the need for a way to treat stones without surgery.

The study was designed to test the feasibility of using the ultrasonic propulsion or using BWL to break up stones in awake, unanaesthetised patients, Dr Hall said.

The study recruited 29 patients; 16 received propulsion and 13 received propulsion and BWL. In 19 patients, the stones moved. In two cases, the stones moved out of the ureter and into the bladder.

Burst wave lithotripsy fragmented the stones in seven of the cases. At a two-week follow up, 18 of 21 patients (86%) whose stones were located lower in the ureter, closer to the bladder, had passed their stones. In this group, the average time to stone passage was about four days, the study noted.

One of these patients felt “immediate relief” when the stone was dislodged from the ureter, the study stated.

The next step would a clinical trial with a control group, which would not receive either BWL bursts or ultrasound propulsion, to evaluate the degree to which this new technology potentially aids stone passage, Dr Hall said.

Development of this technology first started five years ago, when NASA funded a study to see if kidney stones could be moved or broken up, without anaesthesia, on long space flights, such as the Mars missions. The technology has worked so well that NASA has downgraded kidney stones as a key concern.

“We now have a potential solution for that problem,” Dr Hall said.

Source: University of Washington School of Medicine/UW Medicine

Categories : Cardiovascular Disease Surgeries & ProceduresTags :

Troponin Levels Help Inform When to Perform Surgery after Heart Attack

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New research from a large study published in the International Journal of Cardiology shows that timing of surgery for some heart attack patients can be improved by analysing troponin levels.

Troponin is a protein involved in muscle contraction that is released into the bloodstream after heart attack, with higher levels indicating more heart damage. Troponin levels help clinicians to determine whether a patient is having a heart attack, or myocardial infarction (MI), and to decide on treatment options such as coronary artery bypass graft (CABG) surgery.

The optimal time to perform surgery following an MI remains unclear. Previous reports have suggested that carrying out surgery in the first few days following an MI is associated with a higher risk of surgical complications and death by not leaving time for the heart to recover. As a result, following an MI, many patients who need bypass surgery wait for more than 10 days before surgery is performed.

Researchers in this study found that some patients who have lower levels of troponin would benefit from having earlier surgery. However, the researchers show that patients with very high troponin levels should have surgery postponed, as their risk of dying was higher if surgery was performed within 10 days of their MI.

There was no benefit in delaying surgery for those with low levels of troponin, according to the study.

Early surgery for MI patients

The researchers suggest that early surgery for MI patients with lower troponin levels would reduce overall length of stay and ease pressure on resources such as staff.

This is the first multicentre study to investigate the interaction between the extent of heart damage, as indicated by troponin levels, and the optimal time to wait for surgery in a large series of MI patients. 

Dr Amit Kaura, lead author of the research, said: “The approach on the safest time to operate on patients following a heart attack varies in hospitals across the UK. Our study could help clinicians make more informed decisions on the best treatment plans for heart attack patients requiring surgery, based on their levels of troponin. It could also lead to a more standardised approach in the NHS on how we treat this patient group, leading to resources being used effectively, shorter stays and improved outcomes for patients.”

The study reviewed patients who had a non-ST segment elevation myocardial infarction (NSTEMI) due to a blockage to their coronary arteries who required a CABG.

About 20% of NSTEMI patients have a CABG. The optimal timing for CABG surgery in patients with uncomplicated NSTEMI has been unclear. Prior to the new research, some studies had suggested that early surgery was associated with higher mortality post operation. This has led to a tendency for CABG to be delayed if a patient’s condition remains stable. However, other studies had reported similar mortality rates after early versus late surgery, concluding that delaying surgery in all patients after uncomplicated NSTEMI is not warranted and does not improve outcomes. No previous study had investigated in a large group of patients whether there was an association between the extent of heart damage (as measured by troponin levels) and the wait for surgery on survival.

Heart data insights

The team analysed data from the NIHR HIC of 1746 patients with NSTEMI and unstable angina (UA) where insufficient cardiac blood supply leads to an MI. The cohort consisted of 1684 patients with NSTEMI and 62 with UA. The average age of the group was 69 and 21% were female. They underwent CABG within 90 days at one of five cardiac centres before their surgery between 2010 and 2017. 

The researchers compared patients’ troponin levels, wait between surgery and outcomes after surgery within the first 30 days and over a period of five years. Pre-operative troponin level strongly predicted early mortality, and this was significantly influenced by the interval to surgery. The average wait for patients with high troponin levels to surgery was nine days. Sixty patients died within 30 days after surgery and another 211 patients died over a period of five years following surgery. They found that for those who had troponin levels of less than 100 times the normal upper limit, delaying surgery to after 10 days was not associated with lower survival. For patients with higher troponin levels, early survival increased progressively with a longer time to surgery – survival was highest in those who had surgery after day 10. 

Dr Amit Kaura said: “For patients with troponin levels of under 100 times the normal upper limit, extending the waiting time or surgery did not improve early survival. This finding is particularly significant as two-thirds of patients presenting with troponin levels of under 100 are waiting on average 12 days for surgery after being admitted to hospital. There are potential cost saving implications with our research by performing earlier surgery in this group of patients with lower troponin levels”.

The effect of troponin levels pre-operation on survival was limited to the first 30 days after surgery. Late survival was determined by other risk factors, such as age and other co-morbidities such as hypertension.

Further studies are needed in the form of prospective trials to assess the impact of troponin and timing of surgery on survival following a heart attack, the researchers say.

Source: Imperial College London

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Remove All Secondary Kidney Stones, Study Suggests

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A new study showed, during kidney stone removal procedures, leaving small asymptomatic stones behind significantly increases the risk of a patient’s relapse in the following five years. The study findings appear in the New England Journal of Medicine.

Typically, stones < 6mm in diameter that are not a procedure’s primary target are not removed but monitored, since ‘secondary’ stones have high rates of successful passage if they move into the ureter, explained Dr Mathew Sorensen, a urologist at the University of Washington School of Medicine and the study’s lead author.

“Before this study, the clinical views were pretty mixed on whether some of these stones should be treated,” he said. “Most clinicians would decide, based on the size of the stone, whether it hit the bar for treatment, and if it did not, you would often ignore the little stones.”

The researchers studied 75 patients who were treated at multiple institutions over 2015 to 2021. About half of the patients had only their large primary stone treated, while the others had primary and secondary stones removed. Relapse was defined as having to go to the emergency room or undergo an additional procedure due to a recurrence or if a follow-up CT scan showed that the secondary stones grew.

Removal of the secondary stones reduced the relapse rate by 82%, the researchers found, leading the authors to recommend that smaller stones should not be left behind.

“Results of our trial support the removal of small asymptomatic renal stones at the time of surgery with a larger stone,” their paper concluded. The authors noted that while removal of smaller stones could add to the procedure’s duration and cost, those costs would likely be less than those associated with a patient’s repeat procedure or visit to the emergency room. Some patients in the study visited the emergency department multiple times and then required surgery, the report noted.

Dr Sorensen said he would share the study results with colleagues with the hope of changing their sensibility toward smaller stones. Further study is needed to determine whether treatment of small stones alone is justified, as technology improves and the costs and risks of intervention diminish, he said.

“I think we have proven through this rigorous study that removal of the small asymptomatic stones is beneficial when feasible and in patients that are candidates to have all their stones treated in one procedure,” he noted. “Leaving the stones behind risk trouble in the future.”

Source: University of Washington School of Medicine/UW Medicine