Surgical Treatment Pathways Research Articles

Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review.

Uterine leiomyomas are the most common benign uterine tumors in women and are often asymptomatic, with clinical manifestation occurring in 20-25% of cases. The diagnostic pathway begins with clinical suspicion and includes an ultrasound examination, diagnostic hysteroscopy, and, when deemed necessary, magnetic resonance imaging. The decision-making process should consider the impairment of quality of life due to symptoms, reproductive desire, suspicion of malignancy, and, of course, the woman's preferences. Despite the absence of a definitive cure, the management of fibroid-related symptoms can benefit from various medical therapies, ranging from symptomatic treatments to the latest hormonal drugs aimed at reducing the clinical impact of fibroids on women's well-being. When medical therapy is not a definitive solution for a patient, it can be used as a bridge to prepare the patient for surgery. Surgical approaches continue to play a crucial role in the treatment of fibroids, as the gynecologist has the opportunity to choose from various surgical options and tailor the intervention to the patient's needs. This review aims to summarize the clinical pathway necessary for the diagnostic assessment of a patient with uterine fibromatosis, presenting all available treatment options to address the needs of different types of women.

Parental concerns about genital differences in children with congenital adrenal hyperplasia persist regardless of the selected intervention.

Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency (21HD) can affect the in utero development of the genital anatomy of people with the 46XX karyotype. Health professionals engage parents in decision-making regarding managing genitals with this difference, including genital surgery options and patient communication. We sought to investigate parental communication with their daughters regarding clitoral size variation related to neonatal CAH. Semistructured in-person interviews of 24 parents of chromosomal XX children with clitoral size variation attributable to a neonatal CAH diagnosis comprised 3 management categories: (1) clitoral reduction surgery (RS) (7 parents, 9 children), (2) clitoral concealment surgery (CS) (8 parents, 8 children), and no surgery on or around the clitoris (NS) (9 parents, 7 children). Four representative themes, Obvious Choice, Still Different, Parental Burden, and Ignorance Is Bliss, were common across all 3 treatment groups. For most parents, none of the 3 options of genital appearance alteration via clitoral reduction, clitoral concealment surgery, or avoidance of clitoral surgery ameliorated concerns, with most parents expressing an aversion to educating their child on the topic of genital differences, past treatment, or future function. Reliance on surgical treatment pathways to manage this psychosocial concern is ineffective in alleviating parental uncertainty without the application of psychosocial interventions. This was a qualitative study but was limited to parents of children with a specific genital difference, without direct exploration of parental values regarding the clitoris or the application of adequate psychosocial care. Healthcare services must have an impact on parental ability to engage in essential communication with their children in cases such as clitoral size variation related to neonatal CAH. Improved communication skills allow parents to engage in more genuine decision-making and adapt to enduring genital reality, including possible future sexual challenges for their adult child, without resorting to burdensome strategies focused on attempts to perpetuate a benevolent ignorance.

Selection of Surgical Treatment Pathways for Carcinoma of the Root of the Tongue and Discussion of Their Advantages and Disadvantages

Selection of Surgical Treatment Pathways for Carcinoma of the Root of the Tongue and Discussion of Their Advantages and Disadvantages

Assessing variability in breast cancer management across the world: results of a questionnaire survey amongst global international experts in breast cancer management.

Breast cancer is the most common cancer in women worldwide with an estimated 2.3 million breast cancer cases diagnosed annually. The outcome of breast cancer management varies widely across the globe which could be due to a multitude of factors. Hence, a blanket approach in standardisation of care across the world is neither practical nor feasible. To assess the extent and type of variability in breast cancer management across the globe and to do a gap analysis of patient care pathway. An online questionnaire survey and virtual consensus meeting was carried out amongst 31 experts from 25 countries in the field of breast cancer surgical management. The questionnaire was designed to understand the variability in diagnosis and treatment of breast cancer, and potential factors contributing to this heterogeneity. The questionnaire survey shows a wide variation in breast surgical training, diagnosis and treatment pathways for breast cancer patients. There are several factors such as socioeconomic status, patient culture and preferences, lack of national screening programmes and training, and paucity of resources, which are barriers to the consistent delivery of high-quality care in different parts of the world. On-line survey platforms distributed to global experts in breast cancer care can assess gaps in the diagnosis and treatment of breast cancer patients. This survey confirms the need for an in-depth gap analysis of patient care pathways and treatments to enable the development of personalised plans and policies to standardise high quality care.

Expected Costs of Primary Dental Treatments and Endoscopic Sinus Surgery for Odontogenic Sinusitis.

Treatment of odontogenic sinusitis (ODS) due to apical periodontitis (AP) is highly successful when both dental treatment and endoscopic sinus surgery (ESS) are performed. Variation exists in the literature with regard to types and timing of dental treatments and ESS when managing ODS. This study modeled expected costs of different primary dental and sinus surgical treatment pathways for ODS due to AP. Decision-tree economic model. Decision-tree models were created based on cost and treatment success probabilities. Using Medicare and consumer online databases, cost data were obtained for the following dental and sinus surgical treatments across the United States: root canal therapy (RCTx), revision RCTx, apicoectomy, extraction, dental implant, bone graft, and ESS (maxillary, ± anterior ethmoid, ± frontal). A literature review was performed to determine probabilities of dental and sinus disease resolution after different dental treatments. Expected costs were determined for primary dental extraction, RCTx, and ESS pathways, and sensitivity analyses were performed. Expected costs for the three different primary treatment pathways when dental care was in-network and all diseased sinuses opened during ESS were as follows: dental extraction ($4,753.83), RCTx ($4,677.34), and ESS ($7,319.85). ODS due to AP can be successfully treated with primary dental treatments, but ESS is still frequently required. Expected costs of primary dental extraction and RCTx were roughly equal. Primary ESS had a higher expected cost, but may still be preferred in patients with prominent sinonasal symptoms. Patients' insurance coverage may also impact decision-making. NA Laryngoscope, 132:1346-1355, 2022.

Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis.

Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model. We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006-12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations. Surgical treatment was indicated in 58% (95% CI 57-59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17-27) for prostate cancer to 99% (96-99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (-14%). The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences. University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.

Cost-utility analysis of four common surgical treatment pathways for breast cancer

BackgroundThe aim was to evaluate the cost-utility of four common surgical treatment pathways for breast cancer: mastectomy, breast-conserving therapy (BCT), implant breast reconstruction (BR) and autologous-BR. MethodsPatient-level healthcare consumption data and results of a large quality of life (QoL) study from five Dutch hospitals were combined. The cost-effectiveness was assessed in terms of incremental costs and quality adjusted life years (QALYs) over a 10-year follow-up period. Costs were assessed from a healthcare provider perspective. ResultsBCT resulted in comparable QoL with lower costs compared to implant-BR and autologous-BR and showed better QoL with higher costs than mastectomy (€17,246/QALY). QoL outcomes and costs of especially autologous-BR were affected by the relatively high occurrence of complications. If reconstruction following mastectomy was performed, implant-BR was more cost-effective than autologous-BR. ConclusionThe occurrence of complications had a substantial effect on costs and QoL outcomes of different surgical pathways for breast cancer. When this was taken into account, BCT was most the cost-effective treatment. Even with higher costs and a higher risk of complications, implant-BR and autologous-BR remained cost-effective over mastectomy. This pleas for adapting surgical pathways to individual patient preferences in the trade-off between the risks of complications and expected outcomes.

Management of Hallux Valgus in General Practice in Australia.

To describe the management of hallux valgus by general practitioners (GPs) in Australia. We analyzed data from the Bettering the Evaluation and Care of Health program from April 2000 to March 2016. Patient and GP encounter characteristics were extracted. Hallux valgus encounters were identified using the International Classification of Primary Care, Version 2 Plus terms hallux valgus and bunion. Data were summarized using descriptive statistics and 95% confidence intervals around point estimates. The data set included 1,568,100 patient-encounter records among which hallux valgus was managed 658 times (4.2 management occasions per 10,000 encounters). This management rate extrapolates to an estimated 60,000 GP-patient encounters across Australia in the most recent year data were available (from 2015 to 2016). The management rate was 3 times higher in female compared to male patients and was most frequent among patients ages 45-64 years. Hallux valgus was most frequently managed by referral to orthopedic surgeons (28 per 100 management occasions), counseling or advice (25 per 100), and referral to podiatrists (16 per 100). Pharmacologic management was also frequently used (20 per 100) and primarily involved prescription of nonsteroidal antiinflammatory drugs (7 per 100). Hallux valgus is a commonly encountered problem in Australian general practice and is mostly managed by provision of advice and referral to orthopedic surgeons and podiatrists. Further research is required to examine the factors that influence the selection of surgical and nonsurgical treatment pathways by GPs and their comparative effectiveness.

Cost-effectiveness of Surgical Treatment Pathways for Prolapse.

To evaluate the cost-effectiveness of surgical treatment pathways for apical prolapse. We constructed a stochastic Markov model to assess the cost-effectiveness of vaginal apical suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy. We modeled over 5 and 10 years, with 9 pathways accounting for up to 2 separate surgical repairs, recurrence of symptomatic apical prolapse, reoperation, and complications, including mesh excision. We calculated costs from the health care system's perspective. Over 5 years, compared with expectant management, all surgical treatment pathways cost less than the willingness-to-pay threshold of US $50,000 per quality adjusted life-years. However, among surgical treatments, all but 2 pathways were dominated. Of the remaining 2, laparoscopic sacrocolpopexy followed by vaginal repair for apical recurrence was not cost-effective compared with the vaginal-only approach (incremental cost-effectiveness ratio [ICER], >$500,000). Over 10 years, all but the same 2 pathways were dominated. However, starting with the laparoscopic approach in this case was more cost-effective with an ICER of US $6,176. If the laparoscopic approach was not available, starting with the robotic approach similarly became more cost-effective at 10 years (ICER, US $35,479). All minimally invasive surgical approaches for apical prolapse repair are cost-effective when compared with expectant management. Among surgical treatments, the vaginal-only approach is the only cost-effective option over 5 years. However, over a longer period, starting with a laparoscopic (or robotic) approach becomes cost-effective. These results help inform discussions regarding the surgical approach for prolapse.

Implementation of the G-BA Quality Management Guideline Regarding Surgical Checklist at a University Maximum Care Hospital - Claim and Reality

Surgical treatment pathways can favor the development of Adverse Events (AE) due to the inherent complexity of their service delivery. The World Health Organization (WHO) Surgical Safety Checklist (SSC) is an instrument that effectively reduces perioperative morbidity and mortality. Against this background, in 2016 the Federal Joint Committee (G-BA) issued a Quality Management Directive (QM-RL) making the use of checklists mandatory for surgical procedures. The aim of this study was to compare the checklist compliance of all ten surgical organizational units of the University Medical Center Mainz in the second half of 2017 and 2018. In addition to the annex of the SSC, the processing of the subitems »Sign-In«, »Team-Time-Out« and »Sign-Out« was evaluated. A comparison of 2017 with 2018 showed an increase in all parameters (»Creation of checklist« (94.2 / 96.5%), »Sign-In« (81.4 / 84.4%), »Team-Time-Out« (56.8 / 62.4%) and »Sign-Out« (50.7 / 57.9%), without, however, statistical significance (p>0.05). In contrast, there were significant differences between certified and non-certified surgical operating units. The parameters showing significant differences were found to be »Sign-In« (87.9 / 71.8%; p=0.034), »Team-Time-Out« (68.4 / 39.4%; p=0.029) and »Sign-Out« (62.1 / 33.6%; p=0.029) for 2017 and »Team-Time-Out« (76.2 / 41.7%); p=0.019) and the »Sign-Out« (71.3 / 37.9%; p=0.019) for 2018. From 2017 to 2018, there was increased implementation of the SCC, particularly in certified facilities. Therefore, the external control of prescribed quality features, for instance, as part of a certification procedure, appears to be a suitable tool for increasing checklist compliance.

What is the Optimum Utilization of Cancer Surgery in High Income Settings? A National Population Based Analysis

Background: Estimating the optimum rate for utilization of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps and to calculate the optimum workforce and other resources including budgets required to meet service needs. A population-based benchmark rate for optimum surgical utilization in high income settings has not been developed to inform policymakers and service provision but was recommended by the Lancet Oncology Commission into Global Cancer Surgery. Here we have developed and validated the first such instrument. Methods: The latest clinical guidelines were examined, and surgical treatment pathways were mapped for each cancer, broadly reflecting contemporary high income models of care. The optimum utilization of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. The population based epidemiological data such as stage of cancer, tumour characteristics, and fitness for surgery were derived from Australia and other comparable high-income settings. The probabilities across the clinical pathways of each cancer was multiplied and added together to estimate the optimum rates of cancer surgical utilization and compared with actual rates of utilization. Findings: Surgical treatment is indicated in 58% (95% CI 57% to 59%) of newly diagnosed cancer patients in Australia, at least once during the course of their treatment but varies between 22% and 99% for site specific cancers. The actual utilization was higher for some cancers including prostate, head &neck and cervix, whereas it was lower for other cancers such as lung, ovary and pancreas. Interpretation: There are discordances in modelled versus actual utilisation rates that require more in depth analysis. This approach provides a new template for other high income and emerging economies to rationally plan and assess their cancer surgery provision. Funding Statement: University of New South Wales Scientia Scholarship. Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: The data on the actual surgical utilization from the South Western Sydney Clinical Cancer Registry was obtained with necessary ethical clearance.

Abstract P5-15-05: Long-term quality of life after four common surgical treatment pathways for breast cancer and the effect of complications

Abstract Background: Comparing the quality of life (QoL) for all common breast cancer surgery options could support decision-making. However, current evidence generally consists of non-preference-based outcomes for sub-comparisons of options which are unsuitable for the calculation of Quality Adjusted Life Years (QALYs), the preferred outcome in health economics. The preference-based EQ-5D-5L is specifically designed to provide the Q in QALY and could facilitate a (health-care) wide comparison of breast cancer surgery options. This study gives an overview of both non-preference and preference-based QoL after four common surgical breast cancer treatment pathways. Method: Breast cancer patients from a large multicenter observational cohort in the Netherlands were invited for participation in an online survey. QoL was obtained by the EQ-5D-5L, EORTC-QLQ-C30/-BR23 and Breast-Q questionnaires. Patient cohorts based on surgical procedure (breast-conserving surgery (BCS), mastectomy (MAS), autologous breast reconstruction (A-BR) and implant-based breast reconstruction (I-BR) were compared after propensity-weighted adjustment of pretreatment differences. Results: Of all invited patients, 1871 responded, respectively patients treated with BCS (n=615), MAS (n=507), A-BR (n=330), and I-BR (n=419). Table 1 shows QoL outcomes without overlapping 95% CI. Patients reported complications in 47% of the A-BR, 32% of the I-BR, 18% BCS and 22% of the MAS groups. QoL outcomes differed statistically significantly between patients with and without complications for all groups, except the I-BR group. Table 1:patient-reported quality of life per surgical treatment for propensity-weighted cohorts BCSMASA-BRI-BR Estimated sample sizen=434.0n=386.3n=178.6n=295.5EQ-5D-5L Utility Overall0.844a0.805b0.849a0.850a No complication0.859a0.878b0.847a0.818a,b Complication0.771a0.771a,c0.816b,c0.861bBreast-Q Satisfaction with breasts 65.52a60.65b71.29c59.39b Satisfaction with outcome 75.75a66.37b Psychosocial well-being 73.77a66.50b75.78a71.60a Sexual well-being 62.70a50.00b63.33a56.38c Physical well-being: chest 67.39a73.47b,c75.81c72.64bEORTC-QLQ-C30 Physical function 84.53a82.94a85.62a,b87.97b Role function 84.35a80.70b84.02a,b86.02a Pain 15.41a18.93b17.18a,b15.89a,b Financial problems 5.23a8.22b12.30b7.71a,bEORTC-QLQ-BR23 Body image 87.45a80.49b82.28b82.35b Sexual functioning 27.90a27.51a31.95a,b33.35b Sexual enjoyment 57.03a54.82a64.24b63.80b Breast symptoms 13.45a9.94b8.79b10.82a Arm symptoms 12.68a17.12b18.18b16.82dMean values of the respective outcome scale after propensity score weighting and are derived from an estimator of the average treatment effect on the population. Values in the same row not sharing the same subscript do not show overlapping 95% Confidence Intervals in a pairwise comparison. Discussion: Preference-based QoL outcomes are an essential input for cost-effectiveness analyses, used to justify the use of care in a society progressively confronted with increasing health care expenses. The results from this large multicenter cohort study contribute substantially to the current knowledge in the field of breast cancer reconstructive surgery. Citation Format: Kouwenberg CA, Ligt KM, Rakhorst HA, Leeuw D, Siesling S, Buschbach JJ, Kranenburg LW, Mureau MA. Long-term quality of life after four common surgical treatment pathways for breast cancer and the effect of complications [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-05.

Summary: 2017 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse

The aim of this article is to summarize the relevant findings that inform the 2017 International Consultation on Incontinence pathway for surgical treatment of pelvic organ prolapse (POP). We conducted an evidence-based review of the English-language peer-reviewed literature relating to POP surgery published prior to December 2016. Level 1 evidence (randomized controlled trials [RCTs] or systematic reviews of RCTs) was preferred; however, level 2 (poor-quality RCT, prospective cohort studies) or 3 evidence (case series or retrospective studies) has been included if level 1 data were lacking. The committee evaluated the literature and made recommendations based on the Oxford grading system summarized as follows: grade A recommendation usually depends on consistent level 1 evidence; grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs; grade C recommendation usually depends on level 3 studies or "majority evidence" from level 2/3 studies or Delphi-processed expert opinion; grade D, "no recommendation possible," would be used where the evidence is inadequate or conflicting. The recommendations from each chapter of the review are presented and serve to inform an evidence-based pathway for the surgical treatment of prolapse. A Web-based interactive application of the pathway is presented. The 2017 International Consultation on Incontinence pathway on surgery for POP is designed as an adjunct to transparent consultation and consent relating to POP surgery. The final decision regarding surgical intervention can be made only after a shared decision-making process between the patient and the clinician that will evaluate a variety of individual factors that cannot be assessed in the pathway.

Discussion of “Oncoplastic reduction mammaplasty, an effective and safe method of breast conservation”

The development of the field of Oncoplastic breast surgery has expanded the number of patients eligible for breast conserving therapy for breast cancer. Studies have demonstrated equivalent survival and locoregional control to conventional lumpectomy and mastectomy 1 Clough K. van la Parra R. Thygesen H. et al. Long-term results after oncoplastic surgery for breast cancer. A 10 year follow-up. Ann Surg. 2017 Apr 26; ([Epub ahead of print])https://doi.org/10.1097/SLA.0000000000002255 Crossref PubMed Scopus (92) Google Scholar and oncoplastics has developed as the third pathway for surgical treatment of breast cancer. In Canada only 7% of patients have immediate breast reconstruction with mastectomy often a result of challenges coordinating combined procedures and concerns about effects of radiation on reconstruction. Following the publication of the MA20 study 2 Whelan T. Olivotto I. Parulekar W. et al. Regional Nodal irradiation in early stage breast cancer. NEJM. 2015; 373: 307-316 Crossref PubMed Scopus (606) Google Scholar most patients with nodal metastasis are being offered radiation at our center. This makes oncoplastic procedures an attractive option for many patients. Oncoplastic reduction mammaplasty, an effective and safe method of breast conservationThe American Journal of SurgeryVol. 215Issue 5PreviewOncoplastic breast conserving surgery (BCS) can enhance both cosmetic and oncologic breast cancer outcomes. This study evaluates the outcomes and complications associated with oncoplastic reduction mammaplasty performed by surgical breast oncologists. Full-Text PDF

Proximal femoral fractures: Can we improve further surgical treatment pathways?

In hip fracture surgery, the exact choice of implant often remains somewhat unclear for the individual surgeon, but the growing literature consensus has enabled publication of evidence-based surgical treatment pathways. The aim of this article was to review author pathways and national guidelines for hip fracture surgery and discuss a method for future pathway/guideline implementation and evaluation. By a PubMed search in March 2015 six studies of surgical treatment pathways covering all types of proximal femoral fractures with publication after 1995 were identified. Also we searched the homepages of the national heath authorities and national orthopedic societies in West Europe and found 11 national or regional (in case of no national) guidelines including any type of proximal femoral fracture surgery. Pathway consensus is outspread (internal fixation for un-displaced femoral neck fractures and prosthesis for displaced among the elderly; and sliding hip screw for stabile- and intramedullary nails for unstable- and sub-trochanteric fractures) but they are based on a variety of criteria and definitions - and often leave wide space for the individual surgeons' subjective judgement. Appearing neither exhaustive nor exclusive, most of the pathways seem difficult to evaluate scientifically, which might explain why only very few have been evaluated for compliance, reliability and complications after implementation in an actual clinical setting. We therefore introduce a model for step-wise pathway implementation including proper scientific evaluation. Surgical treatment pathways for proximal femoral fractures are available in literature and nationally with somewhat evidence based treatment consensus, but the scientific evaluation of the pathways them selves needs to be optimised.

Clinical pathway for surgical treatment of primary lung cancer (2012 Edition).

Diagnosis is based on the “Diagnosis and Treatment Practices for Primary Lung Cancer (2011)” and the “Diagnosis Practices for Primary Lung Cancer (2011)” released by the Ministry of Health of China

Modelling the carbon footprint of reflux control

Background The NHS is responsible for approximately 30% of all public sector carbon emissions. The Climate Change Act 2008 introduced legally binding targets to cut emissions of greenhouse gases (GHGs) by at least 80% of the 1990 baseline by 2050. This paper seeks to examine two different strategies for the treatment of gastro-oesophageal reflux disease and their modelled costs and carbon emissions. Methods This study uses data from the costs of care of patients in the REFLUX study and NHS England Carbon Emissions Carbon Footprinting Report to model the carbon emissions associated with medical and surgical treatment of gastro-oesophageal reflux disease. The main outcome measures are modelled financial costs and carbon emissions for medical and surgical treatment pathways. Results There is a high initial cost (financially and carbon emissions) for surgery, however subsequent year-on-year financial spend and carbon emissions are lower in patients who have had surgical treatment such that the total modelled financial cost of surgery is lower in the 14th year and carbon emissions are lower in the 9th year. The model is sensitive to changes in the efficiency of pharmaceutical procurement and surgical failure rate. Conclusions The model has demonstrated that in cases of equivalent clinical benefit one pathway may be preferred on the basis of other factors including carbon emissions.