Current and Expected Trends for the Marine Chitin/Chitosan and Collagen Value Chains.

Chitin/chitosan and collagen are two of the most important bioactive compounds, with applications in the pharmaceutical, veterinary, nutraceutical, cosmetic, biomaterials, and other industries. When extracted from non-edible parts of fish and shellfish, by-catches, and invasive species, their use contributes to a more sustainable and circular economy. The present article reviews the scientific knowledge and publication trends along the marine chitin/chitosan and collagen value chains and assesses how researchers, industry players, and end-users can bridge the gap between scientific understanding and industrial applications. Overall, research on chitin/chitosan remains focused on the compound itself rather than its market applications. Still, chitin/chitosan use is expected to increase in food and biomedical applications, while that of collagen is expected to increase in biomedical, cosmetic, pharmaceutical, and nutritional applications. Sustainable practices, such as the reuse of waste materials, contribute to strengthen both value chains; the identified weaknesses include the lack of studies considering market trends, social sustainability, and profitability, as well as insufficient examination of intellectual property rights. Government regulations, market demand, consumer preferences, technological advancements, environmental challenges, and legal frameworks play significant roles in shaping both value chains. Addressing these factors is crucial for seizing opportunities, fostering sustainability, complying with regulations, and maintaining competitiveness in these constantly evolving value chains.

A Multicenter Randomized Controlled Trial Comparing Safety, Efficacy, and Cost-effectiveness of the Surgisis Anal Fistula Plug Versus Surgeon's Preference for Transsphincteric Fistula-in-Ano: The FIAT Trial.

OBJECTIVE: To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano. SUMMARY BACKGROUND DATA: The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain. METHODS: Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates. RESULTS: Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY. CONCLUSIONS: The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.

Health economics for treatment of diabetic foot ulcers: a cost-effectiveness analysis of eight skin substitutes.

AIM: Skin substitutes are frequently used to treat chronic diabetic foot ulcers (DFU), and many different options are available. While the clinical efficacy of many products has been evaluated, a comprehensive cost-effectiveness analysis comparing the most popular skin substitutes and using the most recent cost data has been lacking. METHODS: This study compared eight skin substitutes using published efficacy rates combined with the Centers for Medicare and Medicaid Services (CMS) 2018 cost data. The study criteria resulted in the inclusion of seven studies that described efficacy rates for treatment of DFUs using the skin substitutes. RESULTS: The results revealed wide discrepancies between these skin substitutes for the costs of treatments and healing rates in hospital outpatient departments and physician office settings. Healing rates for 12 and 16 weeks ranged from 28% to 68%, while the average cost for treating one DFU varied from $2001 to $14,507 and $1207 to $8791 in the hospital outpatient department and physician's office setting, respectively. The estimated patient share of costs for treating a single DFU ranged from $400 to $2901 and $241 to $1758 in the hospital outpatient department and physician's office setting, respectively. Most importantly, the estimated number of wounds healed out of 100 DFUs per $1000 expenditure with each patient ranged from 3.9-26.5 DFUs in the hospital outpatient department, and 4.3-36.4 DFUs in the physicians' office setting. CONCLUSIONS: This study revealed that the costs of a skin substitute itself did not necessarily correlate with its healing efficacy. These results provide a comprehensive cost-effectiveness analysis to enable integrated health-care systems, health professionals and reimbursement payers to make informed value decisions when treating DFUs.

Perioperative outcomes and hospital costs associated with flowable gelatin hemostatic matrix for lumbar surgeries in real world hospital setting.

Background: Efficient hemostasis during lumbar surgery (LS) is associated with better perioperative outcomes. Flowable gelatin hemostatic matrix (FGHM) is a new type of absorbable hemostatic agent, which is effective to control bleeding during spinal surgery. This study aimed to assess the impact of FGHM on perioperative outcomes and hospital costs associated with LS. Methods: This study retrospectively analyzed medical and billing records of patients who underwent LS for spinal degenerative disease in a Chinese tertiary care hospital from 2014 to 2016. The identified patients were further stratified into a FGHM group (n = 108) (using the combination of FGHM and gelatin sponge) and a historical control group (using oxidized cellulose and/or collagen, n = 82) for the adjusted comparisons of the perioperative outcomes using a propensity score matching method. Multiple generalized linear regression was conducted to assess the impact of using FGHM on total hospitalization costs. Results: Comparisons of 64 propensity score matched pairs showed a significantly lower blood transfusion rate (34.4% vs 64.1%, p = 0.005), lower blood transfusion volume (182.7 ± 312.4 vs 301.3 ± 281.0 mL, p = 0.045), reduced post-surgery drainage tube placement rate (82.8% vs 93.8%, p = 0.046), and shorter post-operative days on antibiotics (6.0 ± 2.6 vs 7.1 ± 2.4 days, p = 0.010) in the FGHM group. Although with a relatively high acquisition price, the use of FGHM for hemostasis in LS did not increase the total hospitalization costs (coefficient = -0.001, p = 0.972). Conclusions: The use of FGHM in LS improved perioperative outcomes related to hemostatic effects without increasing overall hospital costs in a real-world hospital setting.

Potential cost-effectiveness of using a collagen-containing dressing in managing diabetic foot ulcers in the UK.

OBJECTIVE: To estimate whether a collagen-containing dressing could potentially afford the UK's National Health Service (NHS) a cost-effective intervention for the management of diabetic foot ulcers (DFUs). METHOD: A decision model depicting the management of a DFU was constructed and populated with a combination of published clinical outcomes, resource use estimates and utilities for DFUs. The model estimated the incremental cost-effectiveness of a collagen-containing dressing plus standard care compared with standard care alone over a period of four months in terms of the incremental cost per quality-adjusted life year (QALY) gained. RESULTS: Treatment of DFUs of >6 months duration with a collagen-containing dressing plus standard care instead of standard care alone is expected to increase the probability of healing from 0.08 to 0.53 by four months and increase health-related quality of life at four months from 0.156 to 0.163 QALYs per patient. Additionally, treatment with a collagen-containing dressing has the potential to reduce management costs by 22% over four months when compared with standard care alone (from £2897 to £2255 per patient). Treatment of new DFUs with a collagen-containing dressing plus standard care instead of standard care alone was also found to improve outcomes for less cost. CONCLUSION: Within the study's limitations, use of a collagen-containing dressing plus standard care instead of standard care alone potentially affords the NHS a cost-effective (dominant) treatment for both non-healing and new DFUs, since it improves outcomes for less cost. Hence, protocols should be established which enable clinicians to effectively introduce collagen-containing dressings into care pathways and monitor response to treatment.

[Topical haemostatic agents in neurosurgery].

Haemostasis is of fundamental significance in neurosurgery, and insufficient control of bleeding is associated with morbidity and mortality. Topical haemostatic agents play an important role, as the characteristics of neuronal tissue limit the use of classical surgical haemostasis techniques. Appropriate choice of agent depends on the location and type of bleeding, but also on knowledge of the products' mechanisms of action, indications, price and accessibility. Biological products are superior to the mechanical in efficacy but require more preparation and are significantly more cost-intensive.

Comparison of two cadaveric acellular dermal matrices for immediate breast reconstruction: A prospective randomized trial.

AlloDerm RTU® and AlloMaxTM are two acellular dermal matrices (ADMs) used in implant-based breast reconstruction. In this study, we examined whether different processing methods for the ADMs lead to a disparity in histologic, clinical, and financial outcomes after breast reconstruction. Thirty patients undergoing implant-based breast reconstruction were randomized into AlloMax or AlloDerm arms (n = 15, each). ADM was placed at the time of immediate reconstruction. Patients were evaluated for complications on postoperative days 7, 14, and 30. During implant exchange, ADM biopsies were taken and compared histologically for vascular and cellular infiltration. Patient satisfaction was evaluated using the BRECON-31 questionnaire 1 year after implant exchange. A cost analysis was performed comparing the two ADMs. Patient demographics and complication rates were similar between the two groups (p > 0.05). Histologically, vessel density and fibroblast/inflammatory cell infiltrate were greater on the dermal side than on the implant side (p < 0.01) in both ADMs, suggesting greater vascular and cellular in-growth from the dermal side. Vessel density in the middle portion of the Allomax biopsies was significantly higher than the same site in the Alloderm biopsies (p < 0.05). The extent of fibroblast/inflammatory cell infiltration was similar in both arms (p > 0.05). The BRECON-31 satisfaction questionnaire yielded similar responses across all metrics between the two study arms. The negotiated price was slightly different when comparing the two ADMs, with no significant difference in ADM reimbursement. In this study, AlloDerm RTU and AlloMax were successfully used for implant-based breast reconstruction with comparable outcomes.

Hospital wide porcine mesh conversion results in cost savings with equivalent clinical outcomes.

BACKGROUND: A variety of biologic mesh is available for ventral hernia repair. Despite widely variable costs, there is no data comparing cost of material to clinical outcome. METHODS: Biologic mesh product change was examined. A prospective survey was done to determine appropriate biologic mesh utilization, followed by a retrospective chart review of those treated from Sept. 2012 to Aug. 2013 with Strattice™ and from Sept. 2013 to Aug. 2014 with Permacol™. Outcome variables included complications associated with each material, repair success, and cost difference over the two periods. RESULTS: 28 patients received Strattice™ and 41 Permacol™. There was no statistical difference in patient factors, hernia characteristics, length of stay, readmission rates or surgical site infections at 30 days. The charges were significantly higher for Strattice™ with the median cost $8940 compared to $1600 for Permacol™ (p < 0.001). Permacol™ use resulted in a savings if $181,320. CONCLUSIONS: Permacol™ use resulted in similar clinical outcomes with significant cost savings when compared to Strattice™. Biologic mesh choice should be driven by a combination of clinical outcomes and product cost.

The Use of Integra Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-Benefit Analysis.

BACKGROUND: INTEGRA® Dermal Regeneration Template is a well-known and widely used acellular dermal matrix. Although it helps to solve many challenging problems in reconstructive surgery, the product cost may make it an expensive alternative compared to other reconstruction procedures. This retrospective study aims at comparing INTEGRA-based treatment to flap surgery in terms of cost and benefit. PATIENTS AND METHODS: We considered only patients treated for scalp defects with bone exposure in order to obtain two groups as homogeneous as possible. We identified two groups of patients: 17 patients treated with INTEGRA and 18 patients treated with flaps. All patients were admitted in our institution between 2004 and 2010, and presented a defect of the scalp following trauma or surgery for cancer, causing a loss of the soft tissues of the scalp with bone exposure without pericranium. To calculate the cost in constant euros of each treatment, three parameters were evaluated for each patient: cost of the surgical procedure (number of doctors and nurses involved, surgery duration, anesthesia, material used for surgery), hospitalization cost (hospitalization duration, dressings, drugs, topical agents), and outpatient cost (number of dressing changes, personnel cost, dressings type, anti-infective agents). The statistical test used in this study was the Wilcoxon Mann-Whitney (α = 0.05). RESULTS: No significant difference was characterized between the two groups for gender, age, presence of diabetes, mean defect size, and number of surgical procedures. All patients healed with good quality and durable closure. The median total cost per patient was €11,121 (interquartile range (IQR) 8327-15,571) for the INTEGRA group and €7259 (IQR 1852-24,443) for the flap group (p = 0.34). A subgroup of patients (six patients in the INTEGRA group and five patients in the flap group) showing defects larger than 100 cm2 were considered in a second analysis. Median total cost was €11,825 (IQR 10,695-15,751) for the INTEGRA group and €23,244 (IQR 17,348-26,942) for the flap group. CONCLUSION: Both treatments led to a good healing of the lesions with formation of soft and resistant tissue. No significant difference was characterized between the two groups for days of hospitalization and costs. In cases of patients with defects larger than 100 cm2 for whom major surgery is needed, the treatment with INTEGRA seemed to be less expensive than the treatment with free flaps or pedicle flaps. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A5 online Instructions to Authors. www.springer.com/00266 .

Biologic mesh in ventral hernia repair: Outcomes, recurrence, and charge analysis.

BACKGROUND: Biologic mesh choice in ventral hernia repair is challenging due to lack of prospective data. This study examines long-term, single-center biologic mesh outcomes. METHODS: Prospective operative outcomes data was queried for open ventral hernia repair with biologic mesh. Univariate and multivariate analysis were used to compare mesh outcomes. RESULTS: In the study, 223 patients underwent open ventral hernia repair with biologic mesh, including 40 with Alloderm, 23 AlloMax, 70 FlexHD, 68 Strattice, and 22 Xenmatrix. Overall, 9.8% had an American Society of Anesthesiology classification of 4, 54.6% with a classification of 3, and 35.6% with a classification of 1 or 2. Operative time averaged 241 minutes with estimated blood loss of 202 mL. Hernia defects averaged 257 ± 245 cm2 with mesh size 384 cm2. Biologic mesh was used as a fascial bridge in 19.6%, component separation was performed in 47.5%, and 82% had concomitant procedure. Inpatient mortality was 1.4%. Hernia recurrence varied significantly by mesh type: 35% Alloderm, 34.5% AlloMax, 37.1% FlexHD, 14.7% Strattice, and 59.1% Xenmatrix (P = .001). The mean follow-up was 18.2 months. After multivariate analysis comparing to Strattice, AlloMax had a 3.4 higher odds ratio for recurrence, FlexHD a 2.9 odds ratio, and Xenmatrix a 7.8 odds ratio. The rate of mesh infections requiring explantation was <1%. Total hospital charges averaged $131,004 ± $143,320. Mean charges varied significantly between meshes; Xenmatrix was the most expensive and AlloMax was the least expensive (P < .05). CONCLUSION: In 223 ventral hernia repair performed with biologic mesh at a tertiary care institution, Strattice, a porcine acellular dermal mesh, had significantly lower odds of hernia recurrence compared with AlloMax, FlexHD, and Xenmatrix. Choice of biologic mesh affects long-term postoperative outcomes in ventral hernia repair.

Economic outcomes among Medicare patients receiving bioengineered cellular technologies for treatment of diabetic foot ulcers.

OBJECTIVE: To assess the real-world medical services utilization and associated costs of Medicare patients with diabetic foot ulcers (DFUs) treated with Apligraf (bioengineered living cellular construct (BLCC)) or Dermagraft (human fibroblast-derived dermal substitute (HFDS)) compared with those receiving conventional care (CC). METHODS: DFU patients were selected from Medicare de-identified administrative claims using ICD-9-CM codes. The analysis followed an 'intent-to-treat' design, with cohorts assigned based on use of (1) BLCC, (2) HFDS, or (3) CC (i.e., ≥1 claim for a DFU-related treatment procedure or podiatrist visit and no evidence of skin substitute use) for treatment of DFU in 2006-2012. Propensity score models were used to separately match BLCC and HFDS patients to CC patients with similar baseline demographics, wound severity, and physician experience measures. Medical resource use, lower-limb amputation rates, and total healthcare costs (2012 USD; from payer perspective) during the 18 months following treatment initiation were compared among the resulting matched samples. RESULTS: Data for 502 matched BLCC-CC patient pairs and 222 matched HFDS-CC patient pairs were analyzed. Increased costs associated with outpatient service utilization relative to matched CC patients were offset by lower amputation rates (-27.6% BLCC, -22.2% HFDS), fewer days hospitalized (-33.3% BLCC, -42.4% HFDS), and fewer emergency department visits (-32.3% BLCC, -25.7% HFDS) among BLCC/HFDS patients. Consequently, BLCC and HFDS patients had per-patient average healthcare costs during the 18-month follow-up period that were lower than their respective matched CC counterparts (-$5253 BLCC, -$6991 HFDS). LIMITATIONS: Findings relied on accuracy of diagnosis and procedure codes contained in the claims data, and did not account for outcomes and costs beyond 18 months after treatment initiation. CONCLUSION: These findings suggest that use of BLCC and HFDS for treatment of DFU may lower overall medical costs through reduced utilization of costly healthcare services.

Economic analysis and review of the literature on implant-based breast reconstruction with and without the use of the acellular dermal matrix.

BACKGROUND: Use of the acellular dermal matrix (ADM) in two-stage implant-based breast reconstruction has been widely adopted. Despite an increasing focus on health care costs, few reports have addressed the financial implications of ADM use. This study sought to examine the costs of the two-stage technique with and without ADM, concentrating on the direct variable costs of patient care during the expansion process. METHODS: A retrospective review of a prospectively maintained database was conducted. Data were collected on 132 cases resulting in a second-stage exchange for a permanent implant. The findings showed that AlloDerm was used in 61 reconstructions and Strattice in 23 reconstructions. The primary outcome was the number of fills required to achieve the final expander fill volume. The cost of subsequent patient encounters for expansion was estimated using institutional cost data. RESULTS: The number of fills required to achieve the final volume was higher in the non-ADM group (6.5 ± 1.7) than in the ADM group (3.6 ± 1.4) (p < 0.0001). No significant difference was found in the small fill volumes (<350 ml; 5.3 vs. 3.7; p > 0.05). The difference was significant in the larger fill volumes (>500 ml; 8.3 vs. 3.7; p < 0.05). Relative to non-ADM reconstruction, with AlloDerm at current prices, the cost increase ranged from $2,727.75 for large reconstructions to $3,290.25 for small reconstructions ($2,167.75-$2,739.25 with Strattice). CONCLUSION: The use of ADM in two-stage reconstruction reduces the number of visits required for reconstructions with 350 ml or more. However, at current pricings, the direct cost of ADM use does not offset the cost savings from the reduced number of visits. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Isolation and characterization of pepsin-solubilized collagen from the integument of sea cucumber (Stichopus vastus).

BACKGROUND: Sea cucumber (Stichopus vastus) is considered an underutilized resource, since only its stomach and intestines are eaten raw as salad in a few countries and the remaining parts, especially the integument rich in collagen, is discarded. Hence a valuable by-product having potential nutraceutical and pharmaceutical applications is wasted. In the present investigation, pepsin-solubilized collagen (PSC) from the integument of S. vastus was isolated, purified and characterized. RESULTS: Sodium dodecyl sulfate-polyacrylamide gel electrophoretic analysis showed that the purified collagen was of type I, consisting of three α1 chains of approximately 122 kDa each. The peptide map of PSC digested by V8 protease was different from that of calf skin type I collagen. Fourier transform infrared spectroscopy revealed that the triple helical structure was well preserved in isolated collagen. The denaturation temperature of PSC was 21.23 °C and showed good gel-forming capability at pH 6.5 and 300 mmol L⁻¹ NaCl. CONCLUSION: It is inferred that the collagen isolated from S. vastus integument has potential for use as an alternative to land-based mammalian collagen in food, nutraceuticals and pharmaceutical industries.

Cost minimisation analysis of using acellular dermal matrix (Strattice™) for breast reconstruction compared with standard techniques.

BACKGROUND: We performed a cost analysis (using UK 2011/12 NHS tariffs as a proxy for cost) comparing immediate breast reconstruction using the new one-stage technique of acellular dermal matrix (Strattice™) with implant versus the standard alternative techniques of tissue expander (TE)/implant as a two-stage procedure and latissimus dorsi (LD) flap reconstruction. METHODS: Clinical report data were collected for operative time, length of stay, outpatient procedures, and number of elective and emergency admissions in our first consecutive 24 patients undergoing one-stage Strattice reconstruction. Total cost to the NHS based on tariff, assuming top-up payments to cover Strattice acquisition costs, was assessed and compared to the two historical control groups matched on key variables. RESULTS: Eleven patients having unilateral Strattice reconstruction were compared to 10 having TE/implant reconstruction and 10 having LD flap and implant reconstruction. Thirteen patients having bilateral Strattice reconstruction were compared to 12 having bilateral TE/implant reconstruction. Total costs were: unilateral Strattice, £3685; unilateral TE, £4985; unilateral LD and implant, £6321; bilateral TE, £5478; and bilateral Strattice, £6771. CONCLUSIONS: The cost analysis shows a financial advantage of using acellular dermal matrix (Strattice) in unilateral breast reconstruction versus alternative procedures. The reimbursement system in England (Payment by Results) is based on disease-related groups similar to that of many countries across Europe and tariffs are based on reported hospital costs, making this analysis of relevance in other countries.

Acellular dermal matrices: economic considerations in reconstructive and aesthetic breast surgery.

This article is a review of cost considerations and outcomes pertaining to the use of acellular dermal matrices (ADMs) in reconstructive and aesthetic breast surgery. The history of the use of ADMs in breast surgery and all case series describing outcomes and use of ADM in breast reconstructive and aesthetic surgery are reviewed. Weighted averages for clinically relevant outcomes for reconstructive and aesthetic breast surgery are provided. Cost considerations of ADM use in breast surgery are described and as an example, a single institution's experience with implementation of ADM into a preexisting breast surgery program, is used.

Cost-effectiveness analysis of autologous chondrocyte implantation: a comparison of periosteal patch versus type I/III collagen membrane.

BACKGROUND: Autologous chondrocyte implantation (ACI) involves the use of a periosteal patch (ACI-P) as a cover for transplanted chondrocytes. Theoretically, this periosteal patch provides mesenchymal stem cells and growth factors that encourage chondrocyte development/differentiation. However, there is a significant rate of graft hypertrophy with the use of periosteum compared with using a type I/III collagen patch (ACI-C). This type I/III collagen patch, although not approved by the United States Food and Drug Administration for ACI, has been used extensively in Europe and in an "off-label" nature in the United States as a cover during ACI. PURPOSE: To examine the cost effectiveness of ACI and determine whether ACI-C is more cost effective than ACI-P. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: Outcome data and complication rates from patients undergoing ACI (ACI-P and ACI-C) were derived from the best evidence in the literature. Costs were determined by examining the typical patient charges undergoing ACI at a local orthopaedic hospital. The costs, results, and complication rates were used to develop a decision analysis model comparing ACI-P to ACI-C. RESULTS: The cost of ACI-P was $66,752 and for ACI-C was $66,939.50 ($187.50 difference). The cost per quality-adjusted life year (QALY) for ACI-P was $9466 compared with $9243 for ACI-C. Sensitivity analysis was performed regarding the additional cost of the type I/III collagen patch ($780) in ACI-C as well as the rate of graft hypertrophy after ACI-P (25%). This analysis revealed that the cost of the type I/III collagen patch would have to reach $1721, or the rate of graft hypertrophy after ACI-P reduced to almost 11%, before ACI-P became more cost effective than ACI-C. CONCLUSION: This cost-effectiveness analysis reveals that, while both ACI-P and ACI-C are cost effective, ACI-C is slightly more cost effective than ACI-P. This is likely secondary to the significant rate of patch-related complications associated with ACI-P, which is significantly reduced with ACI-C. Although the model is very sensitive to differences in outcomes between ACI-P and ACI-C, there is no high-quality evidence to suggest that there is a significant difference between the two. Thus, ACI-P becomes more cost effective if the cost of the type I/III collagen membrane is significantly increased or if the rate of graft hypertrophy after ACI-P were to be markedly reduced.

The partial AlloDerm sling: reducing allograft costs associated with breast reconstruction.

BACKGROUND: Many surgeons now incorporate Acellular Dermal Matrix (ADM) into expander-based breast reconstruction. ADM is safe, provides full expander coverage, eliminates the need for additional muscular dissection and has improved aesthetic outcomes. However, its use increases surgical costs. Whether this cost is offset by decreased operative times or a reduced number of revision procedures is unknown. METHODS: We have developed a new technique that minimises the amount of ADM required in many patients. The 'partial sling' approach has been used for 145 consecutive patients (197 breasts) by a single surgeon from 2007 to 2010. After mastectomy, any portion of the pectoralis major insertion at, or <1 cm from, the planned inframmary fold is left intact and becomes the inferior margin of the expander pocket. The minimal size of ADM required is then determined by measuring from the pectoralis to the lateral breast margin. In this study, we exclusively used AlloDerm. Preoperative breast measurements, intra-operative fill volume, time to exchange procedure, number of expansion procedures and complications were recorded for all patients. RESULTS: Patients were grouped according to the surface area (cm(2)) of ADM required. Good aesthetic outcomes were obtained in all groups. Two groups had a significant difference in intra-operative fill volumes but this did not correlate to an increase in the number of expansion procedures required. Of 197 reconstructed breasts less than 64 cm(2) of ADM was used for 40 breasts (20%). CONCLUSIONS: The partial AlloDerm sling can minimise the costs associated with ADM use in breast reconstruction for many patients without increasing complications or altering aesthetic outcomes.

Outcomes after abdominal wall reconstruction using acellular dermal matrix: a systematic review.

BACKGROUND: Complex abdominal wall defects can present a significant challenge to the reconstructive surgeon. In 2003, acellular dermal matrix (ADM) was introduced as an alternative to synthetic materials with suggestions that it has improved capacity to integrate with surrounding tissues with less inclination towards infection, erosion, extrusion, adhesion formation and rejection compared with synthetic materials. This systematic review was conducted to evaluate the existing literature describing the use of ADM for abdominal wall reconstruction in an attempt to identify factors that may affect outcomes. METHODS: A review of the MEDLINE database using the search terms 'dermal matrix' and 'abdomen' or 'hernia' for prospective and retrospective human studies in English was performed. Exclusion criteria were animal studies, case reports, reviews and articles that dealt only with ADM for repair of congenital abdominal wall defects, hiatal, parastomal or inguinal hernias and enterocutaneous fistulae. Two independent reviewers performed the systematic review with the same a priori criteria, with discrepancies reconciled by the senior author. RESULTS: In October 2010, 3394 articles were identified as potentially inclusive based on the search term 'dermal matrix'. When filtered for 'abdomen' or 'hernia', 83 articles were found. Ultimately, 30 articles met criteria. No other systematic reviews, meta-analyses or randomised controlled trials were identified in the existing literature. CONCLUSIONS: At this current time, there is a paucity of high-level evidence comparing ADM with other methods interfering with the ability of physicians to make data-driven recommendations on clinical indications, surgical techniques and outcomes following ADM-assisted abdominal wall reconstruction.

The use of AlloDerm in postmastectomy alloplastic breast reconstruction: part II. A cost analysis.

BACKGROUND: Increasingly, AlloDerm is being used in alloplastic breast reconstruction, and has been the subject of a recent systematic review. The authors' objective was to perform a cost analysis comparing direct-to-implant with AlloDerm reconstruction to two-stage non-AlloDerm reconstruction. METHODS: Seven clinically important health outcomes and their probabilities for both types of reconstruction were derived from the recent review. A decision analytic model from the Canadian provincial payer's perspective was constructed based on these health states. Direct medical costs were estimated from a university-based hospital, yielding expected costs for direct-to-implant reconstruction with AlloDerm and two-stage non-AlloDerm reconstruction. Sensitivity analyses were conducted. RESULTS: Baseline and expected costs were calculated for direct-to-implant AlloDerm and two-stage non-AlloDerm reconstruction. Direct-to-implant reconstruction with AlloDerm was found to be less expensive in the baseline ($10,240 versus $10,584) and expected cost ($10,734 versus $11,251) using a 6 × 16-cm AlloDerm sheet. With a 6 × 12-cm sheet, expected cost falls to $9673. By increasing direct-to-implant operative time from 2 hours to 2.5 hours, expected cost rises to $11,784. If capsular contracture rate requiring revision is set at 15 percent for both procedures, expected costs are $10,926 and $11,251 for direct-to-implant and two-stage procedures, respectively. If the capsular contracture rate is lowered for either procedure, this has minimal impact on expected cost. CONCLUSIONS: Although AlloDerm is expensive, it appears to be cost-effective if used for direct-to-implant breast reconstruction. The methods used here may be extrapolated to different centers incorporating local costs and complication rates. A formal randomized controlled trial, including costs, is recommended.

An economic evaluation of surgery versus collagen injection for the treatment of female stress urinary incontinence.

OBJECTIVE: To use data from a randomized controlled trial and update an earlier economic evaluation of surgery versus collagen injection for the treatment of female stress urinary incontinence (SUI). MATERIALS AND METHODS: A decision tree model was developed using probabilities of success and complications from a randomized controlled trial. Resource use and cost data were taken from the earlier economic evaluation. The primary outcome was treatment success, which was defined as a negative 24 hour PAD test given 1 year post-treatment. The evaluation was conducted from the 'healthcare system' perspective and separate analyses were undertaken for Ontario and Québec. Sensitivity analyses were used to examine uncertainty in probabilities and costs. RESULTS: Surgery was generally more costly and more successful than collagen injection. Incremental cost effectiveness ratios indicated that the healthcare system would incur an additional cost of $121.08 to $341.35 per additional patient that was successfully treated with surgery. Sensitivity analyses showed that surgery would be less costly and more successful than collagen injection if the postoperative length of hospital stay was reduced to 1 day. Surgery might also be more cost effective than collagen injection if the number of injections used to treat patients were to increase beyond two for treatment successes and four for treatment failures. CONCLUSIONS: Collagen injection is an outpatient procedure without risk of significant morbidity or complications. However, this does not readily translate into a clear cost effective advantage relative to surgery. In some cases, surgery may be more cost effective than collagen injection in the treatment of female SUI.