Cost-effectiveness of selective decontamination of the digestive tract to decrease infectious complications in colorectal cancer surgery: An analysis of the SELECT trial

J R D Reuvers; E Gaikhorst; Â Jornada Ben; J Scholten; M van Egmond; J E Bosmans; H B A C Stockmann; G Kazemier; J B Tuynman; G S A Abis; S J Oosterling; SELECT-trial group

doi:10.1016/j.ejso.2023.107116

Cost-effectiveness of selective decontamination of the digestive tract to decrease infectious complications in colorectal cancer surgery: An analysis of the SELECT trial

Eur J Surg Oncol. 2023 Dec;49(12):107116. doi: 10.1016/j.ejso.2023.107116. Epub 2023 Oct 27.

Authors

J R D Reuvers¹, E Gaikhorst², Â Jornada Ben³, J Scholten⁴, M van Egmond⁵, J E Bosmans⁶, H B A C Stockmann⁷, G Kazemier⁸, J B Tuynman⁹, G S A Abis¹⁰, S J Oosterling¹¹; SELECT-trial group

Collaborators

SELECT-trial group:
G S A Abis¹², H J Bonjer¹³, J B Tuynman¹³, M van Egmond¹³, H B A C Stockmann¹⁴, N de Korte¹⁴, Y I Z Acherman¹⁴, S J Oosterling¹⁴, F C den Boer¹⁵, D J A Sonneveld¹⁶, A E Budding¹⁷, L Poort¹⁷

Affiliations

¹ Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134, TM, Hoofddorp, the Netherlands; Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VU University, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands; Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands. Electronic address: j.reuvers@amsterdamumc.nl.
² Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134, TM, Hoofddorp, the Netherlands; Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VU University, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands; Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands. Electronic address: e.gaikhorst@amsterdamumc.nl.
³ Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands. Electronic address: a.jornadaben@vu.nl.
⁴ Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134, TM, Hoofddorp, the Netherlands. Electronic address: jscholten@spaarnegasthuis.nl.
⁵ Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VU University, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands; Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands. Electronic address: m.vanegmond@amsterdamumc.nl.
⁶ Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081, BT, Amsterdam, the Netherlands. Electronic address: j.e.bosmans@vu.nl.
⁷ Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134, TM, Hoofddorp, the Netherlands. Electronic address: stockmann@spaarnegasthuis.nl.
⁸ Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VU University, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands. Electronic address: g.kazemier@amsterdamumc.nl.
⁹ Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VU University, De Boelelaan 1108, 1081, HZ, Amsterdam, the Netherlands. Electronic address: j.tuynman@amsterdamumc.nl.
¹⁰ Department of Surgery, Meander Medical Centre, Maatweg 3, 3813, TZ, Amersfoort, the Netherlands. Electronic address: gaborabis@gmail.com.
¹¹ Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2134, TM, Hoofddorp, the Netherlands. Electronic address: sj.oosterling@spaarnegasthuis.nl.
¹² Meander Medisch Centrum, Amersfoort, the Netherlands.
¹³ Amsterdam University Medical Centers, the Netherlands.
¹⁴ Principal Investigator, Spaarne Gasthuis, Hoofddorp, the Netherlands.
¹⁵ Zaans Medisch Centrum, Zaandam, the Netherlands.
¹⁶ Westfries Gasthuis, Hoorn, the Netherlands.
¹⁷ Inbiome, Amsterdam, the Netherlands.

PMID: 37907018
DOI: 10.1016/j.ejso.2023.107116

Abstract

Introduction: Selective decontamination of the digestive tract (SDD) is effective in reducing infectious complications in elective colorectal cancer (CRC) surgery. However, it is unclear whether SDD is cost-effective compared to standard antibiotic prophylaxis.

Material & methods: Economic evaluation alongside multicenter randomized controlled trial, the SELECT-trial, from a healthcare perspective. Patients included underwent elective surgery for non-metastatic CRC. The intervention group received oral non-absorbable colistin, tobramycin and amphotericin B (SDD) next to standard antibiotic prophylaxis. Both groups received a single shot intravenous cefazolin and metronidazole preoperatively as standard prophylaxis. Occurrence of postoperative infectious complication in the first 30 postoperative days was extracted from medical records, Quality-Adjusted Life-Years (QALYs) based on the ED-5D-3L, and healthcare costs collected from the hospital's financial administration.

Results: Of the 455 patients, 228 were randomly assigned to intervention group and 227 patients to the control group. SDD significantly reduced the number of infectious complications compared to control (difference = -0.13, 95 % CI -0.05 to -0.20). No difference was found for QALYs (difference = 0.002, 95 % CI -0.002 to 0.005). Healthcare costs were statistically significantly lower in the intervention group (difference = -€1258, 95 % CI -2751 to -166). The ICER was -9872 €/infectious complication prevented and -820,380 €/QALY gained. For all willingness-to-pay thresholds, the probability that prophylactic SDD was cost-effective compared to standard prophylactic practice alone was 1.0.

Conclusion: The addition of SDD to the standard preoperative intravenous antibiotic prophylaxis is cost-effective compared to standard prophylactic practice from a healthcare perspective and should be considered as the standard of care.

Keywords: Anastomotic leakage; Colorectal surgery; Cost-effectiveness; Infectious complications; Oral antibiotics; Surgical site infection.

Publication types

Randomized Controlled Trial
Multicenter Study

MeSH terms

Anti-Bacterial Agents* / therapeutic use
Colorectal Neoplasms* / drug therapy
Colorectal Neoplasms* / surgery
Cost-Benefit Analysis
Decontamination
Humans
Postoperative Complications / epidemiology
Postoperative Complications / prevention & control

Substances

Anti-Bacterial Agents