A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury

OBJECTIVE

Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed.

METHOD

Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n = 103; delayed, n = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes--probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon.

RESULTS

Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated 2750 pounds, giving an ICER of 487 pounds per QALY. DS produced a gain of 3.73 QALYs for a cost of 2667 pounds, giving an ICER of 719 pounds per QALY. Both procedures fell below the 10,000 pounds per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark.

CONCLUSION

If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.

Pulmonary metastases from cervical cancer in Sri Lanka

Cervical cancer is the second commonest malignancy in Sri Lankan women. The records of 2075 patients treated for cervical cancer from 1989 to 1993 were reviewed. Thirty-eight patients (1.8%) developed pulmonary lesions consistent with metastases. The median age at the time of presentation with metastases was 49.8 (range 24-73) years. Ten patients (26.3%) had pulmonary metastases at presentation. Twenty-eight (73.7%) developed metastases during follow-up. By the end of 2 years 27 (96.4%) of these patients had developed pulmonary metastases. The median time from diagnosis of cervical cancer to the detection of pulmonary metastases was 9 months. The commonest histological cell type was the large cell non-keratinising squamous carcinoma. Nine (23.7%) of these patients were asymptomatic. Two patients had lung metastases on initial staging chest X-ray while the other seven were detected during routine 3-monthly surveillance chest X-rays as follow up of primary treatment. This emphasises the importance of incorporating routine surveillance chest X-ray as part of the regular follow up. All patients with pulmonary metastases had abnormal shadows in chest X-rays. Nodular lesions were the commonest radiological findings. Local disease was controlled in 17 (55.3%) of the patients who developed metastases during follow-up, while 11 (28.9%) had active disease. There were 24 patients with spread to other sites at the time of diagnosis of pulmonary metastases. The discovery of effective chemotherapy agents is anticipated.

Glove failure: an occupational hazard of surgeons in a developing country

Financial constraints necessitate the reuse of gloves after autoclaving in Sri Lanka. The incidence of glove failure following elective surgery for gynaecological malignancies was studied. Punctures were located by filling gloves with water. The perforation rate was 194/654 (29.6%). Coincidentally, well-fitting gloves were unavailable during part of the study. The puncture rate was significantly higher (P < 0.01) during this period. Defects were found in 12.75% of gloves prepared for reuse. The rate of perforations per operation was 72/88 (81.8%). This increased to 32/32 (100%) when ill-fitting gloves were used, compared with 40/56 (71%) when the proper sizes was available. 6% of new gloves had punctures. In 29 (14.9%) instances the surgical team was aware of glove failure. Factors contributing to glove fragility were: purchase of inferior quality gloves; reuse; shortage of appropriate glove sizes; and imprecision of the test for perforations prior to autoclaving. Health administrators in developing countries should purchase good-quality disposable gloves, and replenish stocks in time.