Comparison of Effective Cost and Complications after Abdominoperineal Resection: Primary Closure versus Flap Reconstruction

Bilateral Superior Gluteal Artery Perforator (SGAP) Flap: Modified Concept in Perineal Reconstruction

Background/Objectives: Perineal reconstruction after abdominoperineal excision often requires complex closures and is fraught with wound healing complications. Flap-based approaches introduce non-irradiated vascularized tissue to the area of resection to fill a large soft-tissue defect and dead space, reduce the risk of infection, and facilitate wound healing. Employing perforator flaps with their beneficial donor site properties, the authors have developed a concept of bilateral superior gluteal artery perforator (SGAP) flaps to restore extensive perineal defects. Methods: This retrospective case series was conducted between September 2015 and December 2019. We included three patients who received bilateral SGAP flap reconstruction after oncological resection. One deepithelialized SGAP flap was used for obliteration of dead space, combined with the contralateral SGAP flap for superficial defect reconstruction and wound closure. Results: Within this patient population, two male and one female patient, with a median age of 62 years (range, 52-76 years), were included. Six pedicled SGAP flaps were performed with average flap dimensions of 9 × 20 cm (range 7-9 × 19 × 21). No flap loss or no local recurrence were documented. In one case, partial tip necrosis with prolonged serous drainage was observed, which was managed by surgical debridement. No further complications were detected. Conclusions: The combination of two SGAP flaps provides maximal soft tissue for defect reconstruction and obliteration of dead space, while maintaining a very inconspicuous donor site, even with bilateral harvesting. Given these advantages, the authors recommend this promising approach for successful reconstruction of perineal defects.

A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis

BACKGROUND

To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis.

METHODS

An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed.

RESULTS

Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap.

CONCLUSIONS

Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.

Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis

A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis

BACKGROUND

Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm.

METHODS

A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature.

RESULTS

Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates.

CONCLUSION

Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

Perineal Reconstruction With the Profunda Artery Perforator Flap

BACKGROUND

Abdominoperineal resection is used to treat a variety of colorectal pathologies. Traditionally, the vertical rectus abdominis myocutaneous flap has been most commonly used for reconstruction. Here, we explore the role of the profunda artery perforator (PAP) flap for perineal reconstruction.

METHODS

A prospectively maintained database was retrospectively analyzed to identify patients who had undergone perineal reconstruction with a pedicled PAP flap. Parameters of interest included age, sex, body mass index, primary diagnosis, comorbidities, and history of radiation, and postoperative complications.

RESULTS

Fifteen patients (5 men and 10 women) with a median age of 52 years (interquartile range, 48.5-61.5 years) were included in the study. Median body mass index was 26.3 kg/m2 (interquartile range, 24.0-29.3 kg/m2). Patients underwent abdominoperineal resection for treatment of rectal cancer (n = 9, 60.0%), recurrent anal squamous cell carcinoma (n = 3, 20.0%), and Crohn's disease (n = 3, 20.0%). Twelve patients (80.0%) underwent neoadjuvant radiotherapy. Eight patients (53.3%) experienced a total of 10 complications (2 major and 8 minor). The most common complication was donor (n = 3, 20.0%)/recipient (n = 3, 20.0%) site wound dehiscence. Stable soft tissue coverage was achieved in all patients.

CONCLUSIONS

The PAP flap provides stable soft tissue coverage of perineal defects with a low donor-site morbidity. This flap should be strongly considered in the reconstructive algorithm when approaching perineal defects.

Outcomes of the Composite Anterolateral Thigh Flap for Perineal Reconstruction After Postoncological Abdominoperineal Resection

BACKGROUND

The vertical rectus abdominis flap is considered the gold standard in perineal reconstruction after oncological abdominoperineal resection; however, it has a nonnegligible donor site morbidity. The anterolateral thigh flap offers reliable soft tissue coverage.

OBJECTIVE

The aim was to analyze long-term outcomes of composite anterolateral thigh-vastus lateralis flaps in oncological abdominoperineal resections.

DESIGN

We conducted a retrospective cohort analysis of a prospectively maintained database.

SETTINGS

This study was conducted in the Lausanne University Hospital. Annually, approximately 10 oncological abdomioperineal resections are performed. Literature reports 7% to 20% of patients undergoing abdominoperineal resection require flap reconstruction; in our institution, approximately 2 patients with large defects after abdominoperineal resections required reconstruction.

PATIENTS

Twenty-nine pedicled anterolateral thigh-vastus lateralis flaps in 27 consecutive patients (mean age 63 years +/-11.2, 23 with radiochemotherapy) after abdominoperineal resection to cover large defects (median 190 cm2, 48-600 cm2) were analyzed.

INTERVENTION

Pedicled composite anterolateral thigh-vastus lateralis flaps were performed after oncological abdominoperineal resection.

MAIN OUTCOME MEASURES

Descriptive statistical analysis was conducted. Short- and long-term outcomes were analyzed, univariate and multivariate analyses were performed. Median follow-up was 16 months (12-48 months).

RESULTS

Flap-related postoperative complications occurred in 16 flaps; flap-survival was 100%. Multivariate logistic analysis identified initial defect size as predictive for complications. Patients with larger defects (≥ 190 cm2) had higher complication rates (p = 0.006). Long-term analysis revealed 3 chronic fistulae, 2 tumor recurrences, 1 flap dysesthesia, and one perineal acne inversa.

LIMITATIONS

Limitations include retrospective analysis, selection bias, and lacking a control group. Sample size limits statistical power.

CONCLUSIONS

The pedicled anterolateral thigh-vastus lateralis flap offers reliable, stable tissue with low morbidity and good long-term outcomes. Complications compared favorably with current literature describing perineal reconstructions with rectus abdominis flaps. The composite anterolateral thigh flap is a valid alternative without the setback of abdominal donor site morbidity. See Video Abstract at http://links.lww.com/DCR/B757.RESULTADOS DEL COLGAJO COMPUESTO ANTEROLATERAL DE MUSLO PARA LA RECONSTRUCCIÓN PERINEAL DESPUÉS DE LA RESECCIÓN ABDOMINOPERINEAL POST ONCOLÓGICAANTECEDENTES:El colgajo vertical de recto abdominal se considera el estándar de oro en la reconstrucción perineal después de la resección abdominoperineal oncológica, sin embargo, tiene una morbilidad no despreciable en el sitio donante. El colgajo anterolateral del muslo ofrece una cobertura confiable de los tejidos blandos.OBJETIVO:El objetivo fue analizar los resultados a largo plazo de los colgajos compuestos anterolaterales del muslo - vasto lateral - en resecciones abdominoperineales oncológicas.DISEÑO:Realizamos un análisis, retrospectivo, de tipo cohorte, de una base de datos mantenida prospectivamente.AJUSTES:Este estudio fue realizado en el hospital universitario de Lausanne. Anualmente se realizan aproximadamente 10 resecciones abdominoperineales oncológicas. La literatura reporta que entre el 7 y el 20% de los pacientes que se someten a una resección abdominoperineal requieren de reconstrucción con colgajo; en nuestra institución, aproximadamente 2 pacientes con grandes defectos tras la resección abdominoperineal requirieron reconstrucción.PACIENTES:Fueron analizados veintinueve colgajos pediculados anterolaterales de muslo - vasto lateral - en 27 pacientes consecutivos (edad media 63 años +/- 11,2, 23 con radio quimioterapia) después de la resección abdominoperineal para cubrir defectos grandes (mediana 190 cm2, 48-600 cm2).INTERVENCIÓN:Tras la resección abdominoperineal oncológica se realizaron colgajos pediculados compuestos anterolaterales de muslo - vasto lateral.PRINCIPALES MEDIDAS DE RESULTADO:Fue realizado un análisis estadístico descriptivo. Fueron analizados los resultados a corto y largo plazo - fueron realizados así mismo análisis uni y multivariados. La mediana de seguimiento fue de 16 meses (12-48 meses).RESULTADOS:Complicaciones postoperatorias relacionadas con el colgajo ocurrieron en 16 colgajos, la supervivencia del colgajo fue del 100%. El análisis logístico multivariado identificó al tamaño del defecto inicial como predictor de complicaciones. Aquellos pacientes con defectos más grandes (≥190 cm2) tuvieron mayores tasas de complicaciones (p = 0,006). El análisis a largo plazo reveló tres fístulas crónicas, dos recidivas tumorales, una disestesia de colgajo y un acné perineal inverso.LIMITACIONES:Las limitaciones incluyen análisis retrospectivo, sesgo de selección y falta de grupo de control. El tamaño de la muestra limita el poder estadístico.CONCLUSIONES:El colgajo pediculado anterolateral de muslo - vasto lateral - ofrece tejido confiable y estable con baja morbilidad y buenos resultados a largo plazo. Los resultados de las complicaciones se mostraron favorables con respecto a la literatura actual que describe reconstrucciones perineales con colgajos de recto abdominal. El colgajo compuesto anterolateral de muslo es una alternativa válida sin el revés de la morbilidad del sitio donante abdominal. Consulte Video Resumen en http://links.lww.com/DCR/B757. (Traducción-Dr. Osvaldo Gauto).

System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection

BACKGROUND

Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.

METHODS

Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.

RESULTS

The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI, 1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).

CONCLUSIONS

Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons

BACKGROUND

 Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs).

METHODS

 Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management.

RESULTS

 Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%).

CONCLUSION

 A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.

The Role of Autologous Flap Reconstruction in Patients with Crohn's Disease Undergoing Abdominoperineal Resection

BACKGROUND

Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established.

OBJECTIVE

This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing.

DESIGN

This study is a retrospective chart review.

SETTINGS

Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes.

PATIENTS

Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction.

INTERVENTIONS

Immediate autologous flap reconstruction was performed after abdominoperineal resection.

MAIN OUTCOME MEASURES

The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden.

RESULTS

Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group.

LIMITATIONS

This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study.

CONCLUSIONS

In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416.

EL ROL DE LA RECONSTRUCCIN CON COLGAJO AUTLOGO EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIN ABDOMINOPERINEAL

ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomática que se someten a una resección abdominoperineal pueden experimentar una curación posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de apósito molestos y un aumento del dolor posoperatorio. Cuando se realiza una resección abdominoperineal por razones oncológicas, ocasionalmente se realiza una reconstrucción con colgajo autólogo para optimizar los resultados de la curación y reconstrucción de la herida. Sin embargo, no se ha establecido la función de la reconstrucción con colgajo después de la resección abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstrucción con colgajo en pacientes con enfermedad de Crohn sintomática sometidos a resección abdominoperineal. Presumimos que los pacientes con reconstrucción inmediata con colgajo después de la resección abdominoperineal demostrarán una mejor curación de la herida.DISEÑO:Revisión retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institución se identificaron entre 2010 y 2018 mediante una combinación de los códigos de Terminología actual de procedimientos, Clasificación internacional de enfermedades 9 y Clasificación internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a resección abdominoperineal solamente (APR-solo = 20) y resección abdominoperineal con reconstrucción con colgajo (APR-colgajo = 20).INTERVENCIÓN (ES):Reconstrucción inmediata con colgajo autólogo después de la resección abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fístula, en comparación con los pacientes del grupo APR-solo. Un número menor de pacientes tendió a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 días (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. También hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparación con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clínicas electrónicas. Tamaño de muestra pequeño y estudio de una sola institución.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstrucción inmediata del colgajo después de la resección abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Además, la reconstrucción con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.

Randomised clinical trial for the cost-utility evaluation of two strategies of perineal reconstruction after abdominoperineal resection in the context of anorectal carcinoma: biological mesh repair versus primary perineal wound closure, study protocol for the GRECCAR 9 Study

INTRODUCTION

Abdominoperineal resections performed for anorectal tumours leave a large pelvic and perineal defect causing a high rate of morbidity of the perineal wound (40%-60%). Biological meshes offer possibilities for new standards of perineal wound reconstruction. Perineal fillings with biological mesh are expected to increase quality of life by reducing perineal morbidity.

METHODS AND ANALYSIS

This is a multicentre, randomised and single-blinded study with a blinded endpoint evaluation, the experimental arm of which uses a biological mesh and the control arm of which is defined by the primary closure after abdominoperineal resection for cancer. Patients eligible for inclusion are patients with a proven history of rectal adenocarcinoma and anal canal epidermoid carcinoma for whom abdominoperineal resection was indicated after a multidisciplinary team discussion. All patients must have social security insurance or equivalent social protection. The main objective is to assess the incremental cost-utility ratio (ICUR) of two strategies of perineal closure after an abdominoperineal resection performed for anorectal cancer treatment: perineal filling with biological mesh versus primary perineal closure (70 patient in each arm). The secondary objectives focus on quality of life and morbidity data during a 1-year follow-up. Deterministic and probabilistic sensitivity analyses will be performed in order to estimate the uncertainty surrounding the ICUR. CIs will be constructed using the non-parametric bootstrap approach. A cost-effectiveness acceptability curve will be built so as to estimate the probability of efficiency of the biological meshes given a collective willingness-to-pay threshold.

ETHICS AND DISSEMINATION

The study was approved by the Regional Ethical Review Board of 'Nord Ouest 1' (protocol reference number: 20.05.14.60714; national number: 2020-A01169-30).The results will be disseminated through conventional scientific channels.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02841293).

Hospital volume is associated with cost and outcomes variation in 2,942 pelvic reconstructions

BACKGROUND

Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed.

METHODS

Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost.

RESULTS

In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p < 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p < 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[β], 0.454; 95% Confidence Interval, 0.346-0.596; p < 0.001) and increased hospital cost (Exp[β], 1.351; 95% Confidence Interval, 1.285-1.421; p < 0.001).

CONCLUSIONS

Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.

Surgery for spinal deformity: non-elective admission status is associated with higher cost of care and longer length of stay

INTRODUCTION

Surgery is commonly indicated for adult spinal deformity. Annual rates and costs of spinal deformity surgery have both increased over the past two decades. However, the impact of non-elective status on total cost of hospitalization and patient outcomes has not been quantified.

OBJECTIVE

To evaluate the impact of admission status on patient outcomes and healthcare costs in spinal deformity surgery.

METHODS

All patients who underwent spinal deformity surgery at a single institution between 2008 and 2016 were grouped by admission status: elective, emergency (ED), or transferred. Demographics were compared by univariate analysis. Cost of care and length of stay (LOS) were compared between admission statuses using multivariable linear regression with elective admissions as reference. Multivariate logistic regression was utilized to assess in-hospital complications, discharge destination, and readmission rates.

RESULTS

There were 427 spinal deformity surgeries included in this study. Compared to elective patients, ED patients had higher Elixhauser Comorbidity Index scores (p < 0.0001), longer LOS (+ 10.9 days, 97.5% CI 6.1-15.6 days, p < 0.0001), and higher costs (+ $20,076, 97.5% CI $9,073-$31,080, p = 0.0008). Transferred patients had significantly higher Elixhauser scores (p = 0.0002), longer LOS (+ 8.8 days, 97.5% CI 3.0-14.7 days, p < 0.0001), and higher rates of non-home discharge (OR = 15.8, 97.5% CI 2.3-110.0, p = 0.001).

CONCLUSION

Patients admitted from the ED undergoing spinal deformity surgery had significantly higher cost of care and longer LOS compared to elective patients. Transferred patients had significantly longer LOS and a higher rate of non-home discharge compared to elective patients.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

Simple Summary

Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C.

Abstract

Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

RECURRENT PERINEAL HERNIA — LAPAROSCOPIC SURGICAL TREATMENT: CLINICAL CASE

Background: Recurrent postoperative perineal hernia is a rare complication of such operation as posterior pelvic evisceration. This condition can reduce the quality of life in the postoperative period and requires surgical restoration of the impaired pelvic anatomy.Clinical case: A 54-year old female patient applied to the MSU University clinic in July 2020 with the protrusion in the perineal area. She was diagnosed with recurrent perineal postoperative hernia. She was diagnosed with rectal cancer T4N1M0 and uterine dysplasia in 2017, 6 courses of neoadjuvant polychemoradiation therapy were performed; she underwent extralevator abdominal-perineal resection with uterine extirpation and the permanent colostomy formation in 2018. A perineal postoperative hernia was diagnosed in March 2020, perineal transabdominal plastic surgery was performed with a mesh implant. A recurrent perineal hernia was diagnosed in April 2020, the patient underwent laparoscopic alloplasty with a composite mesh implant. On the 9th postoperative day, she was discharged in a satisfactory condition without any complaints.Conclusion: Postoperative perineal hernia is a fairly rare complication in surgical practice. The recurrent rate is quite high. The insufficient number of patients, the short follow-up period and the wide range of surgical treatment methods do not allow evaluating the results adequately. It is necessary to conduct large randomized clinical trials to assess the efficacy of surgical interventions and to determine the indications for certain procedures.