A Review of the Management of Sporadic Colorectal Adenomas in Young People: Is Surveillance Wasted on the Young?

The national incidence of colorectal cancer is increasing in people younger than 50 years old. Although diagnostic colonoscopy is detecting more sporadic adenomas in young adults, there are no guidelines for post-polypectomy surveillance. The aim of this review was to survey the medical literature on the prevalence of sporadic adenomas in young adults, subsequent risk of metachronous neoplasia, and lastly to provide several concluding recommendations for clinical practice. We found that the prevalence of sporadic adenomas in young adults is greater than initially estimated and dependent upon factors such as colonoscopy indication and age. The incidence of metachronous colorectal neoplasia following polypectomy is unclear but does not appear to be greater than that of older adults. Risk factors for metachronous neoplasia include findings on index colonoscopy, male gender, smoking status, and certain medical comorbidities. Upon finding a colorectal adenoma in a young person, we suggest that a detailed family history be obtained to confirm that it is truly sporadic. Testing adenomas for evidence of Lynch syndrome is low yield. Strategies to inform surveillance intervals may include an assessment of risk factors for metachronous neoplasia, although surveillance intervals shorter than those recommended in current guidelines are not warranted. Future research should focus on obtaining long-term, prospective data on the incidence of metachronous neoplasia in diverse patient populations.

Reducing Cost and Complexity of Fecal Microbiota Transplantation Using Universal Donors for Recurrent Clostridium difficile Infection.

INTRODUCTION: Fecal microbiota transplantation resolves recurrent Clostridium difficile infections in greater than 82% of patients. Highly screened, processed universal donor fecal material is available. We compared cost and scheduling efficiency of fecal microbiota transplantation by universal donors to patient-directed donors. METHODS: Medical records from a prospectively maintained database of recurrent C. difficile patients who underwent fecal microbiota transplantation between 2012 and 2017 were reviewed retrospectively. Patient-directed donor stool was prepared in our microbiology laboratory using protocol-based screening. We transitioned to purchasing and using universal donor fecal material in 2015. Clinical outcomes, adverse events, time between consult to infusion, consultation fees, and material costs were compared. This was a retrospective comparison of two historical cohorts. RESULTS: A total of 111 fecal microbiota transplantations were performed on 105 patients (56 from patient-directed donors and 55 from universal donors). Median recipient age was 66 years (18-96) with male to female ratio of 1:2.7, equivalent in both cohorts. Total consultation fees were significantly lower in the universal donor group owing to fewer infectious disease consultations. Costs for donor screening and stool preparation were lower in the universal donor cohort ($485.0 vs. $1189.90 ± 541.4, p < 0.001, 95% CI 559.9-849.9). Time from consultations to infusion was shorter in the universal donor cohort (18.9 ± 19.1 vs. 36.4 ± 23.3 days, p < 0.001, 95% CI 9.521-25.591). Recurrences within 8 weeks after fecal microbiota transplantation were equivalent (p = 0.354). Adverse events were equivalent. CONCLUSIONS: Fecal microbiota transplantation using universal donors versus patient-directed donors for recurrent C. difficile showed comparable efficacy and short-term complications. The use of universal donors resulted in significant cost savings and scheduling efficiency.