{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T02:57:29Z","timestamp":1789181849522,"version":"build-2803163510"},"reference-count":18,"publisher":"Oxford University Press (OUP)","issue":"3","license":[{"start":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T00:00:00Z","timestamp":1781654400000},"content-version":"vor","delay-in-days":36,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004622","name":"Dutch Cancer Society","doi-asserted-by":"publisher","award":["157715771"],"award-info":[{"award-number":["157715771"]}],"id":[{"id":"10.13039\/501100004622","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In rectal cancer patients undergoing abdominoperineal resection (APR), a gluteal turnover flap has been proposed to reduce perineal morbidity; however, its cost-effectiveness remains unclear. This multicentre randomized clinical trial evaluated the cost-effectiveness of perineal closure with a gluteal turnover flap compared with primary closure after APR for rectal cancer.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This secondary analysis of the BIOPEX-2 trial enrolled patients undergoing APR for rectal cancer at 19 hospitals (18 in the Netherlands, 1 in the UK) who were randomized in 1:1 to primary closure or gluteal turnover flap closure. Outcome assessors for wound healing and interviewers collecting cost and quality-of-life data were blinded to allocation. The outcome of interest was 12-month cost-effectiveness, including procedural costs, post-hospitalization care, wound care, rehospitalization, workforce participation, and health-related quality of life (QoL), as measured by EQ-5D\u2122 and EQ-VAS scores collected via blinded telephone interview at \u2265 24 months. Missing data were handled by multiple imputation. Mean costs were calculated, and bootstrapping was used to estimate cost differences. QoL was compared between groups according to the presence of perineal complications.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The BIOPEX-2 trial randomized 175 patients; of these, 165 patients were analysed for the cost-effectiveness study (86 in the primary closure group, 79 in the gluteal turnover flap closure group). The mean total cost was \u20ac53 397 (95% confidence interval (c.i.) \u20ac46 645 to \u20ac60 149) for primary closure and \u20ac45 079 (95% c.i. \u20ac42 201 to \u20ac47 957) for gluteal turnover flap closure, yielding a mean cost reduction of \u20ac8318 (95% c.i. \u20ac928 to \u20ac15 709) favouring the gluteal turnover flap. The primary closure group had higher outpatient (total \u20ac71 316 versus \u20ac53 387), specialized wound (mean \u20ac1200 versus \u20ac720), and home care (mean \u20ac3842 versus \u20ac2504) costs. Patients with perineal complications reported significantly lower EQ-VAS and EQ-5D\u2122 scores. Although these complications occurred more frequently in the primary closure group, no significant differences in QoL were observed between the randomization groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Gluteal turnover flap closure is a cost-saving strategy for perineal wound closure following APR in patients with rectal cancer. These findings support broader implementation and offer potential benefits for both patients and healthcare providers. Registration number: NCT04004650 (http:\/\/www.clinicaltrials.gov).<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/bjsopen\/zrag059","type":"journal-article","created":{"date-parts":[[2026,4,16]],"date-time":"2026-04-16T11:42:45Z","timestamp":1776339765000},"source":"Crossref","is-referenced-by-count":1,"title":["Cost-effectiveness of the gluteal turnover flap for perineal wound closure after abdominoperineal resection: randomized clinical trial"],"prefix":"10.1093","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-8850-6166","authenticated-orcid":false,"given":"R","family":"van den Berg","sequence":"first","affiliation":[{"name":"Department of Surgery, Erasmus University Medical Center , Rotterdam ,","place":["the Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G D","family":"Musters","sequence":"additional","affiliation":[{"name":"Department of Surgery, Zaans Medical Center , Zaandam ,","place":["the Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9980-8613","authenticated-orcid":false,"given":"C","family":"Verhoef","sequence":"additional","affiliation":[{"name":"Department of Surgery, Erasmus University Medical Center , Rotterdam ,","place":["the Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H M","family":"Blommestein","sequence":"additional","affiliation":[{"name":"Erasmus School of Health Policy & Management, Erasmus University Rotterdam , Rotterdam ,","place":["the Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3146-3310","authenticated-orcid":false,"given":"P J","family":"Tanis","sequence":"additional","affiliation":[{"name":"Department of Surgery, Erasmus University Medical Center , Rotterdam ,","place":["the Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"BIOPEX-2 Study Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S","family":"Sharabiany","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S","family":"Kreisel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R","family":"Hompes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J B","family":"Tuynman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"O","family":"Lapid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"E H J","family":"Belgers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B","family":"Singh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A A W","family":"van Geloven","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R J C L M","family":"Vuylsteke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J H W","family":"de Wilt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J","family":"Melenhorst","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J W A","family":"Leijtens","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M","family":"Vermaas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J","family":"Rothbarth","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J W A","family":"Burger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"F","family":"Polat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H F J","family":"Fabry","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A G J","family":"Aalbers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J H","family":"Wijsman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B","family":"Lamme","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A","family":"van de Ven","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,6,17]]},"reference":[{"key":"2026061710583615400_zrag059-B1","doi-asserted-by":"crossref","first-page":"101839","DOI":"10.1016\/j.bpg.2023.101839","article-title":"Colorectal cancer: a health and economic problem","volume":"66","author":"Klimeck","year":"2023","journal-title":"Best Pract Res Clin Gastroenterol"},{"key":"2026061710583615400_zrag059-B2","volume-title":"Netherlands Comprehensive Cancer Organization (IKNL)","author":"Netherlands Cancer Registry","year":"2025"},{"key":"2026061710583615400_zrag059-B3","doi-asserted-by":"crossref","first-page":"1477","DOI":"10.1007\/s11605-018-3750-9","article-title":"Abdominoperineal resection for rectal cancer in the twenty-first century: indications, techniques, and outcomes","volume":"22","author":"Hawkins","year":"2018","journal-title":"J Gastrointest Surg"},{"key":"2026061710583615400_zrag059-B4","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1097\/SLA.0b013e31816076c3","article-title":"A national perspective on the decline of abdominoperineal resection for rectal cancer","volume":"247","author":"Tilney","year":"2008","journal-title":"Ann Surg"},{"key":"2026061710583615400_zrag059-B5","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1007\/s10350-005-0227-1","article-title":"Outcomes for abdominoperineal resections are not worse than those of anterior resections","volume":"49","author":"Chuwa","year":"2006","journal-title":"Dis Colon Rectum"},{"key":"2026061710583615400_zrag059-B6","doi-asserted-by":"crossref","first-page":"1074","DOI":"10.1097\/SLA.0000000000002020","article-title":"Biological mesh closure of the pelvic floor after extralevator abdominoperineal resection for rectal cancer: a multicenter randomized controlled trial (the BIOPEX-study)","volume":"265","author":"Musters","year":"2017","journal-title":"Ann Surg"},{"key":"2026061710583615400_zrag059-B7","doi-asserted-by":"crossref","first-page":"952","DOI":"10.1097\/DCR.0000000000001349","article-title":"Propensity score adjusted comparison of pelviperineal morbidity with and without omentoplasty following abdominoperineal resection for primary rectal cancer","volume":"62","author":"Blok","year":"2019","journal-title":"Dis Colon Rectum"},{"key":"2026061710583615400_zrag059-B8","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1007\/s10350-004-0827-1","article-title":"Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure","volume":"48","author":"Bullard","year":"2005","journal-title":"Dis Colon Rectum"},{"key":"2026061710583615400_zrag059-B9","doi-asserted-by":"crossref","first-page":"e37","DOI":"10.1097\/SLA.0000000000004763","article-title":"Cumulative 5-year results of a randomized controlled trial comparing biological mesh with primary perineal wound closure after extralevator abdominoperineal resection (BIOPEX-study)","volume":"275","author":"Blok","year":"2022","journal-title":"Ann Surg"},{"key":"2026061710583615400_zrag059-B10","doi-asserted-by":"crossref","first-page":"1602","DOI":"10.1097\/PRS.0000000000002107","article-title":"Primary versus flap closure of perineal defects following oncologic resection: a systematic review and meta-analysis","volume":"137","author":"Devulapalli","year":"2016","journal-title":"Plast Reconstr Surg"},{"key":"2026061710583615400_zrag059-B11","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1186\/s12893-020-00823-7","article-title":"Perineal wound closure using gluteal turnover flap or primary closure after abdominoperineal resection for rectal cancer: study protocol of a randomized controlled multicentre trial (BIOPEX-2 study)","volume":"20","author":"Sharabiany","year":"2020","journal-title":"BMC Surg"},{"key":"2026061710583615400_zrag059-B12","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1007\/s10151-019-02055-1","article-title":"Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer","volume":"23","author":"Blok","year":"2019","journal-title":"Tech Coloproctol"},{"key":"2026061710583615400_zrag059-B13","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1001\/jamasurg.2024.6818","article-title":"Perineal wound closure using gluteal turnover flap after abdominoperineal resection for rectal cancer: the BIOPEX-2 randomized clinical trial","volume":"160","author":"Kreisel","year":"2025","journal-title":"JAMA Surg"},{"key":"2026061710583615400_zrag059-B14","volume-title":"Kostenhandleiding: Voor Economische Evaluaties in de Gezondheidszorg","author":"Zorginstituut Nederland","year":"2016"},{"key":"2026061710583615400_zrag059-B15","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1016\/j.jval.2015.05.009","article-title":"The iMTA productivity cost questionnaire: a standardized instrument for measuring and valuing health-related productivity losses","volume":"18","author":"Bouwmans","year":"2015","journal-title":"Value Health"},{"key":"2026061710583615400_zrag059-B16","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1016\/j.jval.2016.01.003","article-title":"Dutch tariff for the five-level version of EQ-5D","volume":"19","author":"Versteegh","year":"2016","journal-title":"Value Health"},{"key":"2026061710583615400_zrag059-B17","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1016\/j.surg.2022.09.015","article-title":"Perineal reconstruction after radical pelvic surgery: a cost-effectiveness analysis","volume":"173","author":"Prasath","year":"2023","journal-title":"Surgery"},{"key":"2026061710583615400_zrag059-B18","doi-asserted-by":"crossref","first-page":"866e","DOI":"10.1097\/PRS.0000000000006158","article-title":"Comparison of effective cost and complications after abdominoperineal resection: primary closure versus flap reconstruction","volume":"144","author":"Billig","year":"2019","journal-title":"Plast Reconstr Surg"}],"container-title":["BJS Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/bjsopen\/article-pdf\/10\/3\/zrag059\/68540024\/zrag059.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/bjsopen\/article-pdf\/10\/3\/zrag059\/68540024\/zrag059.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T14:58:51Z","timestamp":1781708331000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/bjsopen\/article\/doi\/10.1093\/bjsopen\/zrag059\/8709583"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,12]]},"references-count":18,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,5,12]]}},"URL":"https:\/\/doi.org\/10.1093\/bjsopen\/zrag059","relation":{},"ISSN":["2474-9842"],"issn-type":[{"value":"2474-9842","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,6]]},"published":{"date-parts":[[2026,5,12]]},"article-number":"zrag059"}}