Current Literature

Article Discusses Cognitive, Capacity, and Consent for Elective Surgery in Older Adults

Kepper PJ, Hardi A, Holden S, Holden T. Cognition, Capacity, and Consent for Elective Surgery in Older Adult Populations. J Am Coll Surg. 2023, in press.

This article provided important perspectives on the role of cognitive assessment as a component of the informed consent process. Another critical item emphasized in the article is determination of a patient’s capacity to communicate, understand information, reason, and deliberate about choices relevant to the anticipated surgical procedure.

An increased appreciation of the presence of mild cognitive impairment, present in up to 34% of patients aged ≥65 and up to 85% of patients older than 80, and the impact of perioperative cognitive decline (POCD) that may lead to delirium with increased mortality risk and greater need for discharge to an assisted living facility has stimulated efforts to include cognitive and capacity assessments in preoperative visits.

The authors recommended easily included features of the preoperative visit that can assess cognitive status and facilitate the consent process, including use of a multidisciplinary team (surgeon, anesthesiologist, and nursing professionals) as well as a brief cognitive function test (Mini-Cog) with low scores triggering consultation with a geriatrician or neurologist. Having a surrogate caregiver present in the preoperative evaluation and consent sessions will facilitate the consent process when significant cognitive impairment is detected.

Integrating cognitive and capacity assessments into the preoperative evaluation may increase the chance of achieving as complete a consent as possible while minimizing the morbidity associated with POCD.

Fecal Immunochemical Tests Are Accurate and Cost Effective for Detecting Early Stage Colorectal Cancer

Allen CJ, Bloom N, Rothka M, et al. Comprehensive Cost Implications of Commercially Available Noninvasive Colorectal Cancer Screening Modalities. J Am Coll Surg. 2023, in press.

Although colonoscopy is the most highly recommended procedure for colorectal cancer screening, the inconvenience and patient discomfort associated with this approach has led to increasing use of non-invasive screening modalities such as the fecal immunochemical test (FIT) and the multitarget stool DNA test (Cologuard® or CG). This study used data from a national insurer database to determine the annual costs of each of these tests.

The patient cohort (n = 119,334) was used to determine the usage and cost of each modality, and patients from the database who were treated in the authors’ institution were assessed for cancer diagnosis and stage of disease. The data analysis showed that FIT was used in 40% of the cohort and CG was used in 38.1%. The combined annual cost was $13.7 million; shifting to only FIT testing would lower the cost to $7.9 million.

After patient matching, the rate of early stage cancer detection was equivalent for both testing methods. The authors concluded that significant cost savings could be realized by conversion to FIT testing.

Contrast-Enhanced CT Imaging Is Significantly More Accurate than Unenhanced for Emergency Diagnosis of Abdominal Pain

Shaish H, Ream J, Huang C, et al. Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department. JAMA Surg 2023:e231112. doi: 10.1001/jamasurg.2023.1112 [published Online First: 20230503]

Computed tomography (CT) imaging is used frequently to confirm the diagnosis and document the need for intervention in patients with abdominal pain. Although contrast-enhanced imaging is known to have the highest diagnostic accuracy, intravenous and oral contrast are frequently omitted because of concern for acute kidney injury and allergic reactions.

This article reported a multicenter diagnostic accuracy study of contrast-enhanced CT imaging in 201 consecutive adult patients who underwent emergency evaluation for abdominal pain. The contrast was then digitally removed from the images, and six radiologists (three faculty and three residents) who were blinded to the findings of the contrast-enhanced CT scans evaluated the digitally altered images.

The analysis showed that unenhanced CT imaging was 30% less accurate when compared with contrast-enhanced imaging. Additional data cited in the article showed that the risk of acute kidney injury in patients without evidence of renal insufficiency (GFR >30 mL/1.73M²) approached 0%, while the risk of an allergic reaction in patients with no history of a reaction or history of a mild reaction was 1%.

The authors recommended that patients without significant risk factors should have contrast-enhanced CT imaging for evaluation of abdominal pain.

Editorial

Yeh DD, Moreno CC, Patel MB. Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain. JAMA Surg 2023:e231119. doi: 10.1001/jamasurg.2023.1119 [published Online First: 20230503]

In the editorial that accompanied the article D. Dante Yeh, MD, MHPE, FACS, and coauthors agreed with the findings of the study and stressed that a 30% reduction in accuracy was an unacceptable sacrifice. They urged increased usage of contrast-enhanced CT imaging in patients with low or no risk of complications.