Laparoscopic Cholecystectomy Is Best when Access to Imaging Resources Are Available
Nordness MF, Smith MC, Fogel J, et al. Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy. J Am Coll Surg. 2024; in press.
Fenestrated and reconstituting subtotal cholecystectomy (SC) are useful alternatives to laparoscopic cholecystectomy (LC) when LC dissection is difficult and risk for common bile duct injury is high. Each procedure has disadvantages; fenestrated SC can be complicated by biliary fistula whereas reconstituted SC carries a significant risk for recurrent gallstones. This article described a retrospective, single institution study (n = 87) to compare rates of postoperative endoscopic retrograde cholangiography (ERC) as a surrogate for resource use associated with each procedure to determine which type of SC was associated with more postoperative resource use. SC was more likely to be used in older, male patients with higher ASA class. ERC was needed more often in patients who underwent fenestrated SC (usually to manage persistent bile drainage). There were no complications related to recurrent gallstones, but the follow-up interval was short (<30 days). The authors concluded that reconstituted SC may be preferable in settings where postoperative endoscopic and interventional radiology resources are not readily available but long-term outcomes need to be documented.
Two Alternatives to Colonoscopy Are Acceptable for Colorectal Cancer Screening
Colorectal cancer is the third most commonly diagnosed cancer in the US. Early detection can potentially prevent more than 90% of deaths associated with this disease. Screening colonoscopy is the most effective method for early detection of colorectal cancers and advanced adenomas but non-adherence to screening is a major impediment to effectiveness. In the US, only 59% of eligible patients participate in any form of colorectal cancer screening.
Two articles and editorials in the March 2024 issue of The New England Journal of Medicine reviewed the findings of separate studies testing the effectiveness of a blood-based DNA test and a next-generation stool test, respectively.
Blood-Based DNA Test
Chung DC, Gray DM, Singh H, et al. A Cell-Free DNA Blood-Based Test for Colorectal Cancer Screening. N Engl J Med. 2024;390:973-983.
Carethers JM. Improving Noninvasive Colorectal Cancer Screening. N Engl J Med. 2024;390:1045-1046.
This article assessed performance of a blood sample-based cell free DNA assay for detection of colorectal cancer and advanced adenomas.
A cohort of 7,861 patients had the DNA assay and a colonoscopy. The sensitivity of the test for detection of cancer was 83.1%. False positive tests occurred in 10.4% of patients indicating that specificity of the blood test for detection of cancer or high-risk lesions was 89.9%. The authors concluded that the blood-based test was an acceptable method of screening for colorectal cancer.
In the editorial that accompanied this article, Carethers noted that the ease of cell-free DNA blood sample testing combined with its accuracy could lead to improved colorectal cancer screening adherence and decreased cancer-related mortality.
Next-Generation Stool Test
Imperiale TF, Porter K, Zella J, et al. Next-Generation Multitarget Stool DNA Test for Colorectal Cancer Screening. N Engl J Med. 2024;390:984-993.
Lo YMD. Cell-Free DNA for Colorectal Cancer Screening. N Engl J Med. 2024;390:1047-1050.
Imperiale and coauthors reported results of a prospective trial that compared the performance of a stool-based DNA test that measures DNA tumor markers and hemoglobin levels with the currently available fecal immunochemical (FIT) test. A group of patients (n = 20,176) had the stool-based test performed and then underwent screening colonoscopy
Colorectal cancer was diagnosed in 98 patients and 9,117 patients had advanced or non-advanced adenomas. Sensitivity of the test exceeded 90% and was superior to the sensitivity reported for the FIT test. Although sensitivity of the test was acceptable, specificity was lower than that reported for the FIT test.
The authors and the editorialist noted that the accuracy of the test is acceptable and the ease if gathering the stool sample could potentially increase adherence to screening. The accompanying editorial by Lo provided a clear and valuable explanation of the science supporting the use of DNA analysis for cancer screening. Surgeons are encouraged to review the full content of the editorial.
