Cost-Effectiveness Analysis: Selective Use of Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer.

BACKGROUND: Locally advanced rectal cancer has high cure rates with trimodal therapy. Studies sparing neoadjuvant chemoradiation in selected patients show comparable outcomes. OBJECTIVE: This study aimed to determine the cost-effectiveness of selective use of neoadjuvant chemoradiation in this population. DESIGN: A cost-effectiveness analysis model compared selective and blanket use chemoradiation for locally advanced rectal cancer. SETTINGS: Literature review, expert consensus, and a prospective database populated the model. Health care utilization costs were based on information from the Centers for Medicare and Medicaid Services. PATIENTS: Adult patients with stage II and III rectal cancer were selected. MAIN OUTCOMES MEASURES: Primary outcomes were cost, effectiveness in quality-adjusted disease-free life years, net monetary benefit, and incremental cost-effectiveness ratios in dollars per quality-adjusted disease-free life years. Base-case 5-year disease-free survival for both strategies was 65%. One-way sensitivity analysis found the probability of 5-year disease-free survival for selective ranged between 40% and 65%. Probabilistic sensitivity analysis assessed second-order variability. RESULTS: Base-case 5-year disease-free survival demonstrated selective use is dominant with lower cost and higher quality-adjusted disease-free life years. For selective use, cost is $153,176, effectiveness is 2.71 quality-adjusted life years, and net monetary benefit is -$17,564 and for blanket use cost is $176,362, effectiveness is 2.64 quality-adjusted life years, and net monetary benefit is -$44,217. One-way sensitivity analysis shows selective use is dominant for disease-free survival above 61.25% and is preferred for disease-free survival above 53.7%. Probabilistic sensitivity analysis shows selective use is optimal in 88% of the iterations for a population of 10,000 patients. LIMITATIONS: Model was based on data from the literature, prospective database, and expert consensus. CONCLUSION: In a population of patients with locally advanced rectal cancer with base-case disease-free survival of 65%, selective use of neoadjuvant chemoradiation is the superior strategy as long as disease-free survival in this group remains above 53%. See Video Abstract at http://links.lww.com/DCR/C199. ANLISIS DE COSTOEFECTIVIDAD USO SELECTIVO DE QUIMIORRADIACIN NEOADYUVANTE EN CNCER DE RECTO LOCALMENTE AVANZADO: ANTECEDENTES:El cáncer de recto localmente avanzado tiene altas tasas de curación con la terapia trimodal. Los estudios que evitan la quimiorradiación neoadyuvante en pacientes seleccionados muestran resultados comparables.OBJETIVO:Determinar la relación costo-efectividad del uso selectivo de quimiorradiación neoadyuvante en esta población.DISEÑO:Un modelo de análisis de costo-efectividad comparó la quimiorradiación selectiva y de uso general para el cáncer de recto localmente avanzado.AJUSTES:Revisión de literatura, consenso de expertos y una base de datos prospectiva poblaron el modelo. Los costos de utilización de la atención médica se basaron en los Centros de Servicios de Medicare y Medicaid.PACIENTES:Se seleccionaron pacientes adultos con cáncer de recto en estadio II y III.PRINCIPALES MEDIDAS DE RESULTADOS:Los resultados primarios fueron el costo, efectividad en años de vida sin enfermedad ajustados por calidad, el beneficio monetario neto y la relación costo-efectividad incremental en $/años de vida sin enfermedad ajustados por calidad. La supervivencia libre de enfermedad a 5 años del caso base para ambas estrategias fue del 65%. El análisis de sensibilidad unidireccional varió la probabilidad de supervivencia libre de enfermedad a 5 años para uso selectivo entre 40%-65%. El análisis de sensibilidad probabilístico evaluó la variabilidad de segundo orden.RESULTADOS:El caso base de 5 años de supervivencia libre de enfermedad demostró que el uso selectivo es dominante con menor costo y años de vida libre de enfermedad ajustados de mayor calidad. El costo, la efectividad y el beneficio monetario neto para el uso selectivo y general fueron ($153 176; 2,71 QALY; -$17 564) y ($176 362; 2,64 QALY; -$44 217). El análisis de sensibilidad unidireccional demostró que el uso selectivo es dominante para la supervivencia sin enfermedad por encima del 61,25% y se prefiere para la supervivencia sin enfermedad por encima del 53,7%. El análisis de sensibilidad probabilístico demostró que el uso selectivo es óptimo en el 88% de las iteraciones para una población de 10 000 pacientes.LIMITACIONES:Modelo basado en datos de literatura, base de datos prospectiva y consenso de expertos.CONCLUSIÓN:En una población de pacientes con cáncer de recto localmente avanzado con caso base de supervivencia libre de enfermedad del 65%, el uso selectivo de quimiorradiación neoadyuvante para el cáncer de recto localmente avanzado es la estrategia superior, siempre y cuando la supervivencia libre de enfermedad en este grupo se mantenga por encima del 53%. Consulte Video Resumen en http://links.lww.com/DCR/C199. (Traducción-Dr. Fidel Ruiz Healy).

Surveillance Intensity Comparison by Risk for T1NX Locally Excised Rectal Adenocarcinoma: a Cost-Effective Analysis.

BACKGROUND: Controversy exists regarding the optimal surveillance strategy following local excision of T1NX rectal adenocarcinoma. This study aims to determine the cost-effectiveness of surveillance strategies for locally excised T1NX rectal adenocarcinoma based on histopathologic and local staging risk factors. METHODS: A Markov model with 10-year follow-up was developed for cost-effectiveness analysis of high-, medium-, and low-intensity surveillance strategies after local excision of T1NX rectal adenocarcinoma. Literature review and expert consensus were utilized to populate state/transition probabilities and rewards. Based on this data, 87% of T1NX patients undergoing local excision were low risk. Healthcare utilization costs were based on Centers for Medicare and Medicaid Services data. The primary outcomes were costs in 2018 US dollars and effectiveness in life-years presented as net monetary benefit and incremental cost-effectiveness ratios. One-way sensitivity and probabilistic sensitivity analyses were performed. RESULTS: Net monetary benefit for low-, medium-, and high-intensity surveillance strategies ($393,117.00, $397,978.80, and $397,290.00) shows medium-intensity surveillance to be optimal. One-way sensitivity analysis shows medium-intensity surveillance to be optimal when the cohort is 73-94% low risk. High-intensity surveillance is preferred when less than 73% of the cohort is low risk. Low-intensity surveillance is preferred when greater than 94% is low risk. Probabilistic sensitivity analysis of the base-case shows medium-intensity surveillance is the optimal strategy for 51.5% of the iterations performed. CONCLUSIONS: Medium-intensity surveillance is the most cost-effective surveillance strategy for locally excised T1NX rectal adenocarcinoma in a clinically representative population model.

Perioperative nutrition.

Perioperative nutrition is a vitally important yet often overlooked aspect of surgical care. Significant disparity exists between evidenced-based recommendations and practices encouraged by traditional surgical teaching. The metabolic response to surgical stress is complex. Poor nutrition has been demonstrated to correlate with adverse surgical outcomes. Perioperative nutrition encompasses preoperative, intraoperative, and postoperative care. Preoperative nutritional assessment identifies at-risk patients who benefit from supplementation before surgery. Prehabilitation seeks to prepare patients for the impending surgical stress. Immunonutrition seems to provide a benefit, although its precise mechanisms are unknown. This article provides a review of the current state of perioperative nutrition.

Sleeve gastrectomy and Roux En Y gastric bypass: current state of metabolic surgery.

PURPOSE OF REVIEW: Roux En Y gastric bypass (RYGB) is considered the bariatric gold standard. Recently, sleeve gastrectomy has gained significant popularity. Early evidence suggests sleeve gastrectomy as a well tolerated and efficacious alternative to RYGB. This article compares RYGB and sleeve gastrectomy by reviewing and summarizing recently published clinical trials. RECENT FINDINGS: Surgery remains the most effective therapy for obese patients meeting criteria. Excess weight loss in short-term follow-up appears similar between RYGB and sleeve gastrectomy. Long-term data on sleeve gastrectomy are limited. RYGB is more effective in producing resolution and remission of type II diabetes mellitus, particularly in patients at high risk for relapse. RYGB and sleeve gastrectomy are similar in their reduction of other obesity-related comorbid conditions with the exception of gastroesophageal reflux disease. RYGB has slightly higher overall morbidity but mortality is similar. SUMMARY: RYGB and sleeve gastrectomy are well tolerated and effective bariatric operations and represent metabolic surgery. More prospective, long-term data are needed. Both procedures benefit specific groups of patients better than the other. Research defining the obese patient's metabolic state and the metabolic response to both operations will ultimately allow physicians to optimally match patient and procedure.

Ectopic bone in the abdominal cavity: a surgical nightmare.

INTRODUCTION: Heterotopic mesenteric ossification (HMO) is a rare clinical entity with less than 40 reported cases in the literature. Frequently associated with prior abdominal surgery or trauma, the precise etiology and optimal approach to its management remain undefined. CASE REPORT: The index patient is a 58-year-old male who originally presented with perforated diverticulitis. Following resection, the patient developed an enterocutaneous fistula. After a trial of conservative management, the patient underwent exploration and was found to have widespread intra-abdominal calcification. Sheets of calcific tissue were resected, and a diagnosis of HMO was confirmed via pathology. The patient had a postoperative course complicated by bleeding and redevelopment of enteric fistula. Following a prolonged hospital course requiring multiple operations, the fistula persists, and the patient remains on parenteral nutrition. DISCUSSION: The etiology of HMO is unknown. Diagnosis requires a high degree of clinical suspicion, as radiologic findings are often misleading. A review of 18 cases demonstrates significant morbidity associated with operative intervention. Nonsteroidals, in particular indomethacin, have been shown to decrease heterotopic ossification, but their role in mesenteric disease is not clearly defined. CONCLUSION: HMO is a rare but complicated pathologic process. A trial of conservative management with NSAIDs, bowel rest, and total parenteral nutrition is prudent, given the high rate of morbidity and mortality associated with operative intervention.

Survival and quality of life after minimally invasive esophagectomy: a single-surgeon experience.

BACKGROUND: Reports on quality of life (QOL) after minimally invasive esophagectomy (MIE) have been limited. This report compares perioperative outcomes, survival, and QOL after MIEs with open transthoracic esophagectomy (TTE) and open transhiatal esophagectomy (THE). METHODS: After institutional review board approval, retrospective review of a prospectively maintained database identified patients who underwent esophageal resection for esophageal cancer at Creighton University between August 2003 and August 2010. Patients with preoperative stage 4 disease, emergent procedures, laparoscopic transhiatal esophagectomies, or esophagojeujunostomies were excluded from the study. The study patients were categorized as having undergone open TTE, open THE, or MIE. Overall survival (OS) was the interval between diagnosis and death or follow-up assessment. Disease-free survival (DFS) was the interval between surgery and recurrence, death, or follow-up assessment. For the patients who survived at least 1 year after surgery, QOL was assessed using European Organization for Research and Treatment of Cancer (EORTC-QLQ, version 3.0) and esophageal module (EORTC-QLQ OES 18) questionnaires. RESULTS: The study criteria were satisfied by 104 patients. Lymph node harvest with MIE (median = 20) was similar to that with open TTEs (median = 19) and significantly higher (P < 0.001) than that with open THEs (median = 12). The percentage of patients requiring intraoperative blood transfusion in the MIE group (23.4%) was significantly lower (P < 0.001) than in the open TTE (73.1%) and THE (67.7%) groups. The volume of intraoperative blood product transfusion was significantly lower for the MIE patients (median = 0 ml) than for the open TTE (median = 700 ml) and THE (median = 700 ml) patients. The incidence of respiratory complications with MIEs (10.64%) was significantly lower than with open TTEs (34.61%) and THEs (32.26%). The groups did not differ significantly in terms of R0 resection rates, OS, DFS, or QOL. CONCLUSIONS: MIEs offer a safe and viable alternative to open esophagectomies because they reduce the need and volume of intraoperative blood product transfusion and postoperative respiratory complications without compromising oncological clearance, survival, and QOL.

Prognostic implications of lymphadenectomy in esophageal cancer after neo-adjuvant therapy: a single center experience.

INTRODUCTION: The objective of this study is to explore the prognostic implications of lymphadenectomy in esophageal cancer patients after neo-adjuvant therapy. METHODS: Retrospective review of a prospectively maintained database identified esophageal cancer patients with locoregional disease who received neo-adjuvant therapy and surgery. Patients were grouped based on the number of nodes resected, pathological lymph node status, and percentage of positive nodes. Kaplan-Meier curves were used to analyze overall survival (OS) and disease-free survival (DFS). Log-rank test was used to compare survival between groups. RESULTS: Eighty-four patients formed the study group. Patients with ≥ 18 nodes resected had a significantly longer median OS than those with <18 nodes resected (68.6 vs. 29.6 months; p = 0.014). Lymph node-negative patients had significantly longer median OS (51.4 vs. 27.4 months; p = 0.025) and DFS (45.3 vs. 12.9 months; p = 0.03) when compared to lymph node-positive patients. Patients with a percentage of positive nodes <0.25 had a significantly longer median OS (31.1 vs. 17.8 months; p = 0.015) and DFS (21.7 vs. 8.9 months; p = 0.021) than patients with ≥ 0.25% positive. CONCLUSION: Extent of lymphadenectomy, percentage of positive nodes, and pathological lymph node status are significant prognostic markers in patients who undergo esophagectomy after neo-adjuvant therapy.