May 3, 2022
Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Arnold SC, Rafaqat W, Abiad, M, et al. Patience Is Key: Association of Surgical Timing with Clinical Outcomes in Elderly Patients with Sigmoid Volvulus. Am J Surg 2024, in press.
Clinical practice guidelines currently recommend endoscopic decompression followed by sigmoid colectomy during the same hospital admission for patients with sigmoid volvulus. The intent of the guidelines is to minimize the morbidity associated with recurrence of sigmoid volvulus, which has reported rates up to 75%, in patients who are frequently elderly with multiple comorbid conditions.
Available data cited by the authors have confirmed that emergency sigmoid colectomy is associated with increased mortality and morbidity risks. The intent of this study was to compare outcomes in stable patients who underwent endoscopic decompression and had early (≤2 days) sigmoid resection with patients who had later resection. The authors used patient data from a national database (n = 842); included patients were 65 years of age or older and were matched using propensity scoring.
The data analysis showed that patients undergoing delayed sigmoidectomy had equivalent overall mortality risk compared with patients who had early resection. The delayed surgery groups experienced lower rates of cardiovascular complications and addition of diverting colostomy but had increased length of hospital stay and overall costs of care.
The authors encouraged surgeons to carefully balance the risk of cardiovascular complications and ostomy formation when choosing an operative strategy for patients with sigmoid volvulus.
Jacques J, Schaefer M, Wallenhorst T, et al. Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas: A Randomized Comparative Trial. Ann Intern Med. 2024;177(1):29-38.
Piecemeal endoscopic mucosal resection (EMR) of large colonic adenomas is associated with a low risk of adverse periprocedural events but a variable rate of recurrence that necessitates careful follow-up and routine repeat colonoscopy to detect recurrence. Endoscopic en bloc submucosal resection (ESD) can reduce recurrence rates but is associated with an increased risk of adverse events including intraprocedural perforation, delayed bleeding, and postpolypectomy syndrome.
This randomized controlled trial compared outcomes in patients undergoing EMR (n = 182) with matched patients treated with ESD (n = 182). ESD patients had a significantly reduced recurrence rate, but a higher rate of adverse events compared with EMR (35.6% vs 24.5%).
The authors concluded that EMR prevented recurrence and reduced the need for close follow-up and routine repeat colonoscopy but at the cost of increased rates of adverse events.
Wasylyshyn A, Stoneman EK. Management of Candida auris. JAMA. 2024.
This article examines management of candida auris infection. C auris occurs in a significant proportion of surgical patients, especially patients treated in hospitals outside the US, because of transmission from infected surfaces, other patients, and healthcare professionals. More than 5,000 confirmed cases were recorded as of December 31, 2022, along with more than 13,000 cases of colonization. Robust infection prevention practices have led to reduced risk of colonization or infection in patients hospitalized in the US.
The most common clinical presentation of C auris infection is fungemia associated with an intravascular catheter or device. Mortality risk for critically ill patients who become infected ranges from 30% to 72%. Treatment of these infections is challenging because of a high rate of resistance of the organism to antifungal agents such as fluconazole and polyene.
Currently, resistance to echinocandin agents is low, ranging from 2% to 5%, making these agents the best available treatment. There are no current effective decolonization regimens for patients known to be colonized or who are recovering from an active infection.
The authors concluded that continued efforts to improve prevention, achieve early diagnosis, and develop new treatment approaches are necessary.