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DOI: 10.4328/JCAM.5768 Received: 15.02.2018 Accepted: 23.02.2018 Publihed Online: 26.02.2018 Printed: 01.07.2018 Corresponding Author: Sabri Selcuk Atamanalp, Department of General Surgery, Faculty of Medicine, Ataturk University, 25040, Erzurum, Turkey. T.: +904423447560 F.: +904423446528 E-Mail: ssa@atauni.edu.tr ORCID ID: 0000-0003-2561-6461 To the editor: I read the article titled ‘Early-term elective laparoscopic resection after endoscopic detorsion in cases with sigmoid colonic volvulus’ by Gok et al. [1], who reported electively treated 8 cases with sigmoid volvulus (SV). I congratulate the authors for their interesting study, and I want to discuss the criteria for patient determination, waiting period and surgical method in elective surgery in SV. Eastern Anatolia, where I practice, is an endemic SV area [2]. As a result, we have 51.5 years of history and total 1,005 cases of experience with SV, including electively treated 111 patients. Ours is the largest single-center SV series in the world according to the literature listed in Web of Science [3]. In our elective surgery series, open sigmoid resection with anastomosis was applied in 95 cases, while the laparoscopic procedure was performed in 16. Mortality, morbidity, and recurrence rates were 0.0%, 11.7%, and 0.0%, respectively. First, as known, recurrence risk after successful endoscopic detorsion can be as high as 20-90%, with a high mortality rate of up to 35% in SV. For this reason, elective sigmoid colectomy is strongly recommended in most cases [4]. Nevertheless, the patient selection criteria for elective surgery are not well-identified [3]. In my experiences, the physical status classification system of the American Society of Anesthesiologists (ASA), which is commonly used in the preoperative evaluation of the patients, is an important criterion in this field. As we know, while the mortality rates of the patients in ASA Classes I-III are less than 4.3%, it is 7.8-23% in ASA Class IV and 9.4-51% in ASA Class V patients. Due to the high mortality rates of the patients with ASA Classes IV and V, I recommend elective surgery only for ASA Classes I-III patients [2]. On the other hand, in my opinion, advanced age, which worsens the ASA score, is another important criterion to decide elective surgery in SV. Due to the worsened ASA score and based on the limitedness of the life expectancy, I don’t suggest elective surgery in late septuagenarian or older patients with SV [2]. Secondly, the timing of the elective operation is still a subject of debate, and unfortunately, the literature doesn’t give sufficient information about the optimal waiting period between the endoscopic detorsion and the elective surgery [3]. Although a 2-3 day interval is adequate for bowel preparation and optimization of the patient in most cases, in my experiments, a 4-5 day interval is also suitable. Due to most patients seem unwilling to consent to elective surgery after discharging, I prefer to perform the elective surgery in the same hospitalization period [4]. Finally, although as an elective surgical method, open sigmoid resection and anastomosis is an alternative, due to the wellknown advantages of the laparoscopic surgery, I prefer laparoscopic technique in recent years [4], as was used by the authors. I congratulate the authors again and look forward to their reply to my comments.

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