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

Contemporary role of the plastic and reconstructive surgeon in the outcome of female peripelvic defects after oncologic extirpation

BACKGROUND

Reconstruction of female oncologic peripelvic defects is challenging due to complex anatomy, neoadjuvant chemoradiation, operative resection margins, and wound healing risks. Functional restoration requires thoughtful management focused on defect reconstruction and patient-reported outcomes.

METHODS

A retrospective chart review of peripelvic reconstruction in female patients at MD Anderson Cancer Center from 2016 to 2023. Data collected included the patient's comorbidities, tumor characteristics, and reconstructive details. Complications were classified as nonoperative or operative within 30 days. Patient outcomes included hernia rates, sexual activity, and revision needs.

RESULTS

In the study period, 164 patients underwent peripelvic defect reconstruction. Most had colorectal (57%), anal (17%), or gynecologic malignancies (10%). 83% had prior radiation. 33.3% had Class II or III obesity. The most common resection was open colorectal resection with partial vaginectomy (66%). Pedicled flaps (93%) were frequently used, mainly vertical rectus abdominis muscle (65%) and gracilis (11%). For multi-visceral resections, abdominal-based flaps were used in 95% of open cases and thigh-based flaps in 88.9% of robotic cases. 51% had formal abdominal wall repair. Complications occurred in 47%, with 9.1% needing surgery. Postoperative hernias were reported in 4.9%, with 3% requiring repair. Approximately 11% reported being sexually active at the last follow-up. Of those instructed on vaginal dilator therapy (42%), 24.6% were sexually active.

CONCLUSION

Peri-pelvic soft tissue reconstruction in the oncologic population is safe. Operative complications and hernia rates are low. In robotic surgery, thigh-based flaps are increasingly used to reconstruct the peripelvic region. Return to sexual activity is higher in patients when given dilator therapy instruction.

Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis

Across the nation, patients with locally advanced gastric cancer (LAGC) are managed with modalities including upfront surgery (US) and perioperative chemotherapy (PCT). Preoperative therapies have demonstrated survival benefits over US and thus long-term outcomes are expected to vary between the options. However, as these 2 modalities continue to be regularly employed, we sought to perform a decision analysis comparing the costs and quality-of-life associated with the treatment of patients with LAGC to identify the most cost-effective option. We designed a decision tree model to investigate the survival and costs associated with the most commonly utilized management modalities for LAGC in the United States: US and PCT. The tree described costs and treatment strategies over a 6-month time horizon. Costs were derived from 2022 Medicare reimbursement rates using the third-party payer perspective for physicians and hospitals. Effectiveness was represented using quality-adjusted life-years (QALYs). One-way, two-way, and probabilistic sensitivity analyses were utilized to test the robustness of our findings. PCT was the most cost-effective treatment modality for patients with LAGC over US with a cost of $40,792.16 yielding 3.11 QALYs. US has a cost of $55,575.57 while yielding 3.15 QALYs; the incremental cost-effectiveness ratio (ICER) was $369,585.25. One-way and two-way sensitivity analyses favored PCT in all variations of variables across their standard deviations. Across 100,000 Monte Carlo simulations, 100% of trials favored PCT. In our model simulating patients with LAGC, the most cost-effective treatment strategy was PCT. While US demonstrated improved QALYs over PCT, the associated cost was too great to justify its use.