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

Abstract

BACKGROUND: Flap reconstruction is recommended for select patients undergoing abdominoperineal resection to mitigate complications. However, the clinical effectiveness and financial implications of flap reconstruction remain unknown. The authors aim to compare the costs and complications for patients undergoing abdominoperineal resection with and without flap reconstruction. METHODS: The Truven MarketScan Databases (2009 to 2016) were used to perform retrospective population-based analysis of colorectal carcinoma patients who underwent abdominoperineal resection with and without flap reconstruction. Univariate and multivariable logistic regressions were used to study effective cost (cumulative cost/number of healthy days) and complications. RESULTS: Of 2557 total abdominoperineal resection patients, 194 patients underwent flap reconstruction. Patients undergoing flap reconstruction had a higher Elixhauser Comorbidity Index (p = 0.004) and were more likely to have local invasion (p < 0.001). At 6 months postoperatively, there were no differences in complications between the two groups (p = 0.116). Flap reconstruction was protective against intraabdominal infections (OR, 0.4; 95 percent CI, 0.2 to 0.9; p = 0.033) but conferred an increased risk of wound complications (OR, 1.5; 95 percent CI, 1.0 to 2.3; p = 0.039). Total median cost of care was similar (abdominoperineal resection alone, $40,050; abdominoperineal resection with flap, $41,380; p = 0.456). Effective cost was greater for abdominoperineal resection alone ($259/healthy day) than abdominoperineal resection with flap ($186/healthy day) but was not statistically significant (p = 0.17). CONCLUSIONS: Patients with flap reconstruction displayed a higher comorbidity score and more extensive disease, but these unfavorable factors did not result in a higher complication rate, total cost, or effective cost. Therefore, flap reconstruction for complex perineal defects confers a benefit in select patients and is a judicious use of health care resources. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.