Prophylactic anticoagulation after minimally invasive hysterectomy for endometrial cancer: a cost-effectiveness analysis.

OBJECTIVE: To determine our institutional rate of venous thromboembolism (VTE) following minimally invasive surgery for endometrial cancer and to perform a cost-effectiveness analysis of extended prophylactic anticoagulation after minimally invasive staging surgery for endometrial cancer. METHODS: All patients with newly diagnosed endometrial cancer who underwent minimally invasive staging surgery from January 1, 2017 to December 31, 2020 were identified retrospectively, and clinicopathologic and outcome data were obtained through chart review. Event probabilities and utility decrements were obtained through published clinical data and literature review. A decision model was created to compare 28 days of no post-operative pharmacologic prophylaxis, prophylactic enoxaparin, and prophylactic apixaban. Outcomes included no complications, deep vein thrombosis (DVT), pulmonary embolism, clinically relevant non-major bleeding, and major bleeding. We assumed a willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained. RESULTS: Three of 844 patients (0.36%) had a VTE following minimally invasive staging surgery for endometrial cancer. In this model, no pharmacologic prophylaxis was less costly and more effective than prophylactic apixaban and prophylactic enoxaparin over all parameters examined. When all patients were assigned prophylaxis, prophylactic apixaban was both less costly and more effective than prophylactic enoxaparin. If the risk of DVT was ≥4.8%, prophylactic apixaban was favored over no pharmacologic prophylaxis. On Monte Carlo probabilistic sensitivity analysis for the base case scenario, no pharmacologic prophylaxis was favored in 41.1% of iterations at a willingness-to-pay threshold of $100 000 per QALY. CONCLUSIONS: In this cost-effectiveness model, no extended pharmacologic anticoagulation was superior to extended prophylactic enoxaparin and apixaban in clinically early-stage endometrial cancer patients undergoing minimally invasive surgery. This model supports use of prophylactic apixaban for 7 days post-operatively in select patients when the risk of DVT is 4.8% or higher.

Splenectomy at the time of primary or interval cytoreductive surgery for epithelial ovarian carcinoma: A review of outcomes.

OBJECTIVES: We describe post-operative complications after cytoreductive surgery with and without splenectomy for Stage III or IV epithelial ovarian cancer, and identify areas for quality improvement in post-splenectomy care. METHODS: All patients with ovarian cancer cytoreductive surgery from 2008 to 2018 were identified using an institutional database Gynecologic Oncology Longitudinal Data Collection and Utilization Program (GOLD CUP). We compared patients who had and did not have splenectomy as part of cytoreductive surgery by demographics, comorbidities, stage, operative and post-operative data, readmission rates, progression free survival, overall survival and death from disease. Quality metrics reported include receipt of post-splenectomy education handouts and encapsulated-organism vaccines. Statistical analysis was completed in STATA SE 16.0. RESULTS: We identified 47 patients who underwent splenectomy and 454 who did not during primary or interval cytoreductive surgery. Final stage was IIIB in 1 (2.1%), IIIC in 26 (55.3%), IVA in 7 (14.9%), and IVB in 13 (27.7%) patients. Those with splenectomy had significantly higher stage. Surgery duration and hospital length of stay were longer and blood transfusion more common after splenectomy, but there were no differences in post-operative infection, readmission, or overall survival. Pancreatic leaks were seen in 4/47 (8.5%) patients. Post-splenectomy vaccinations were documented in 42/47 (89.4%) patients. Only 2/47 (4.3%) received post-splenectomy discharge instructions and 3/7 (42.9%) received aspirin for platelets 1 million or more. CONCLUSIONS: While splenectomy adds morbidity, it continues to offer benefit in those patients who can achieve optimal cytoreduction. Areas for quality improvement in post-splenectomy care include receipt of vaccinations, patient discharge information, and timely pancreatic fistula management.

A Revised Markov Model Evaluating Oophorectomy at the Time of Hysterectomy for Benign Indication: Age 65 Years Revisited.

OBJECTIVE: To perform an updated Markov modeling to assess the optimal age for bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy for benign indication. METHODS: We performed a literature review that assessed hazard ratios (HRs) for mortality by disease, age, hysterectomy with or without BSO, and estrogen therapy use. Base mortality rates were derived from national vital statistics data. A Markov model from reported HRs predicted the proportion of the population staying alive to age 80 years by 1-year and 5-year age groups at time of surgery, from age 45 to 55 years. Those younger than age 50 years were modeled as either taking postoperative estrogen or not; those 50 and older were modeled as not receiving estrogen. Computations were performed with R 3.5.1, using Bayesian integration for HR uncertainty. RESULTS: Performing salpingo-oophorectomy before age 50 years for those not taking estrogen yields a lower survival proportion to age 80 years than hysterectomy alone before age 50 years (52.8% [Bayesian CI 40.7-59.7] vs 63.5% [Bayesian CI 62.2-64.9]). At or after age 50 years, there were similar proportions of those living to age 80 years with hysterectomy alone (66.4%, Bayesian CI 65.0-67.6) compared with concurrent salpingo-oophorectomy (66.9%, Bayesian CI 64.4-69.0). Importantly, those taking estrogen when salpingo-oophorectomy was performed before age 50 years had similar proportions of cardiovascular disease, stroke, and people living to age 80 years as those undergoing hysterectomy alone or those undergoing hysterectomy and salpingo-oophorectomy at age 50 years and older. CONCLUSION: This updated Markov model argues for the consideration of concurrent salpingo-oophorectomy for patients who are undergoing hysterectomy at age 50 and older and suggests that initiating estrogen in those who need salpingo-oophorectomy before age 50 years mitigates increased mortality risk.

Total Talus Replacement: Case Series and Literature Review.

Custom 3D printed total talus implants have been used successfully as a functional alternative to arthrodesis or amputation in cases of severe talar destruction or loss. However, the ideal material and construct still remains to be elucidated. Current models have been made from aluminum ceramic, cobalt chrome, stainless steel, titanium, or metal combinations. The implants may be constrained (subtalar arthrodesis) or unconstrained (press fit within mortise). They may also be combined with a tibial prosthesis or used in isolation. The majority of currently published case studies examine unconstrained and isolated implants. This case study presents satisfactory 1-y outcomes in 3 cobalt chrome constrained total talar implants used in combination with a tibial prosthesis, and a literature review of total talus replacements.

Pathologic findings and clinical outcomes in women undergoing risk-reducing surgery to prevent ovarian and fallopian tube carcinoma: A large prospective single institution experience.

OBJECTIVES: Risk-reducing salpingo-oophorectomy (RRSO) is recommended for women at increased risk of ovarian, fallopian tube (FT), and peritoneal carcinoma (collectively OC). We describe rates of occult neoplasia in the largest single-institution prospective cohort of women undergoing RRSO, including those with mutations in non-BRCA homologous repair (HRR) genes. METHODS: Participants undergoing RRSO enrolled in a prospective tissue bank between 1999 and 2017. Ovaries and FTs were serially sectioned in all cases. Participants had OC susceptibility gene mutations or a family history suggesting OC risk. Analyses were completed in Stata IC 15.1. RESULTS: Of 644 women, 194 (30.1%) had mutations in BRCA1, 177 (27.5%) BRCA2, 27 (4.2%) other HRR genes, and 15 (2.3%) Lynch Syndrome-associated genes. Seventeen (2.6%) had occult neoplasms at RRSO, 15/17 (88.2%) in the FT. Of BRCA1 carriers, 14/194 (7.2%) had occult neoplasia, 8/194 (4.1%) invasive. One PALB2 and two BRCA2 carriers had intraepithelial FT neoplasms. Occult neoplasm occurred more frequently in BRCA1/2 carriers ≥45 years of age (6.5% vs 2.2%, chi square, p = .04), and 211/371 (56.9%) BRCA1/2 carriers had surgery after guideline-recommended ages. Four in 8 (50%) invasive and 2/9 (22%) intraepithelial neoplasms had positive pelvic washings. None with intraepithelial neoplasms developed recurrence or peritoneal carcinoma. CONCLUSIONS: BRCA1 carriers have the highest risk of occult neoplasia at RRSO, and the frequency increased with age. Women with BRCA1/2 mutations often have RRSO beyond recommended ages. One PALB2 carrier had FT intraepithelial neoplasia, a novel finding. Serial sectioning is critical to identifying occult neoplasia and should be performed for all risk-reducing surgeries.

First Metatarsophalangeal Joint Space Area Decreases Within 1 Month After Implantation of a Polyvinyl Alcohol Hydrogel Implant: A Retrospective Radiographic Case Series.

In 2016, the U.S. Food and Drug Administration approved the first and only polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus. The implant functions as a bumper to maintain first metatarsophalangeal joint space to prevent contact of the phalangeal base with the first metatarsal head. Short-term and intermediate outcomes with this implant have reported positive outcomes with no radiographic outcomes of implant wear or subsidence. We performed a retrospective radiographic review of 27 consecutive patients who received the implant and measured preoperative and postoperative joint space area (JSA). We found a significant improvement in JSA (p < .001) between the preoperative JSA and JSA at the first postoperative visit at 1 to 2 weeks. We also found a significant decrease in JSA (p < .001) between the first postoperative visit and the second postoperative visit at 5 to 12 weeks. This information could have further implications for implant design as well as how we can better achieve functional improvements in the first metatarsophalangeal joint in patients with hallux rigidus.

Educating Obstetrics and Gynecology Residents on Transgender Patients: A Survey of Program Directors.

OBJECTIVE: To describe education on transgender health provided by obstetrics and gynecology residency programs and to identify the facilitators and barriers to providing this training. METHODS: We conducted a cross-sectional survey to evaluate transgender health education in residency among a representative sample of 100 of the 236 obstetrics and gynecology residency programs listed in the 2015 Electronic Residency Application Service catalogue. We compared programs that did and did not offer transgender education on demographics, presence and type of transgender education offered, and reasons for and barriers to offering transgender health education using χ or Fisher's exact testing. RESULTS: We found that 31 out of 61 (51%, 95% CI 38-64%) programs completing the survey offered transgender health education in residency. Compared with programs that offered no education, residency programs offering education were more likely to report that transgender health education was very important (19/31, 61% [95% CI 42-78%] vs 7/30, 23% [95% CI 9-42%]), resident interest (20/31, 64% [95% CI 45-81%] vs 11/30, 37% [95% CI 20-56%]), and the presence of a transgender population requesting services (28/31 or 90% [95% CI 74-98%] vs 16/30 or 53% [95% CI 34-72%]). Among the 31 programs that offered transgender health education, 30 (97%; 95% CI 83-99%) provided formal didactic sessions and 20 (64%; 95% CI 45-81%) offered health screening for both male-to-female and female-to-male transgender patients, but 17 (55%; 95% CI 36-73%) did not offer gender-affirming hormone therapy. Among the 30 programs that did not currently offer transgender health education, 24 (80%; 95% CI 61-92%) planned to establish a transgender education program in the next year. CONCLUSION: Our survey of obstetrics and gynecology residency programs highlights the interest in transgender health education for a systemically underserved population of patients.

Treatment of recurrent granulosa cell tumor with metformin and letrozole, a case report.

•Cytotoxic chemotherapy has questionable efficacy against granulosa cell tumor.•Aromatase inhibitors may provide alternative treatment for granulosa cell tumors.•Metformin may be a beneficial adjunct in treating recurrent granulosa cell tumors.

Surgical Treatment of Lisfranc Injury With Plantar Plate Approach.

Midfoot injuries are the second most common athletic foot injury documented in the published data. High-energy Lisfranc dislocations are commonly seen secondary to traumatic etiologies and disrupt the strong midfoot ligaments supporting the arch. These injuries require immediate surgical intervention to prevent serious complications such as compartment syndrome and amputation. The present case series reports a new Lapidus plate system used in 3 patients who underwent arthrodesis procedures for Lisfranc joint dislocation. Three patients in their fourth to fifth decade of life presented with a traumatic injury at the Lisfranc joint and subsequently underwent open reduction and internal fixation using the plantar Lapidus Plate System (LPS; Arthrex, Naples, FL). The LPS was placed in a predetermined safe zone, with measures taken to avoid the insertional points of the tibialis anterior and peroneus longus tendons. Radiographs were obtained for ≤6 months postoperatively and revealed consolidation across the fusion site, intact hardware, and satisfactory alignment. On examination, the corrections were well maintained and free of signs of infection. Clinical evaluation showed no indication of motion within the tarsometatarsal joint and no tenderness to palpation surrounding the fusion sites. All 3 patients successfully returned to their activities of daily living without discomfort or pain. Modern surgical treatment of Lisfranc injuries most commonly includes open reduction and internal fixation, accompanied by arthrodesis. The present case series has demonstrated that the LPS provides relief, stability, and compression of the joint in our small cohort of patients who experienced a traumatic injury to the Lisfranc joint.

Titanium Scaffolding: An Innovative Modality for Salvage of Failed First Ray Procedures.

Shortening of the first ray is a potential complication associated with first metatarsal procedures. Correction of this deformity conventionally has required the use of a tricortical bone graft to lengthen the bone. Graft complications, including donor site morbidity, poor graft stability, and graft resorption, have revealed a need for an alternative procedure. The present report shows that titanium cage scaffolding has lower extremity applications beyond its previous uses in the ankle and spine. Two patients underwent surgical correction for failed first ray procedures using a titanium cage apparatus with a calcaneal autograft and other biologic agents. The scaffolds were appropriately sized to fill the defect. Patients remained non-weightbearing until radiographic evidence of healing appeared. Success was determined by diminished pain, a return to activity, ambulation, and patient satisfaction. Patients exhibited faster-than-anticipated healing, including a return to protected weightbearing activities and increased stability within 6 weeks. Titanium cage implants provide long-term stability and resistance to stress and strain in the forefoot. The implant we have described, newly applied to the first ray, is analogous to a system used in salvage of failed ankle replacements. In addition to reducing reliance on the iliac crest bone graft, the titanium cage apparatus is advantageous because it is customized to fill a defect using computed tomography scanning, thereby reducing graft failure secondary to an improper shape. These cases demonstrate the potential beneficial applications for titanium cages in failed first ray reconstruction.

Metastases from lung adenocarcinoma within a leiomyoma: A case report.

BACKGROUND: Pulmonary adenocarcinoma rarely spreads to the gynecologic tract, and has not been fully reported to metastasize within a leiomyoma. CASE: A 47 year-old woman with recurrent pulmonary adenocarcinoma was incidentally found to have a positron emission tomography (PET) avid pelvic mass at the time of restaging. She was also noted to be anemic, and reported significant vaginal bleeding. She was taken for an uncomplicated hysterectomy. She was unexpectedly found to have adenocarcinoma within a leiomyoma, consistent with metastasis from her primary pulmonary adenocarcinoma. CONCLUSION: We report one of the first cases of pulmonary adenocarcinoma metastatic to a uterine leiomyoma. A personal history of cancer should always be considered in patients presenting with symptomatic leiomyoma.

Minimally Invasive Approach to Achilles Tendon Pathology.

Many surgical procedures have been described for Achilles tendon pathology; however, no overwhelming consensus has been reached for surgical treatment. Open repair using a central or paramedian incision allows excellent visualization for end-to-end anastomosis in the case of a complete rupture and detachment and reattachment for insertional pathologies. Postoperative wound dehiscence and infection in the Achilles tendon have considerable deleterious effects on overall functional recovery and outcome and sometimes require plastic surgery techniques to achieve coverage. With the aim of avoiding such complications, foot and ankle surgeons have studied less invasive techniques for repair. We describe a percutaneous approach to Achilles tendinopathy using a modification of the Bunnell suture weave technique combined with the use of interference screws. No direct end-to-end repair of the tendon is performed, rather, the proximal stump is brought in direct proximity of the distal stump, preventing overlengthening and proximal stump retraction. This technique also reduces the suture creep often seen with end-to-end tendon repair by providing a direct, rigid suture to bone interface. We have used the new technique to minimize dissection and exposure while restoring function and accelerating recovery postoperatively.

Pulmonary pleomorphic carcinoma metastasis to the midfoot.

Metastases to the bones in the foot are extremely uncommon, occurring in approximately 0.01% of all metastatic bone disease. We describe a case of an 82-year-old female with a metastatic pulmonary sarcomatoid carcinoma lesion to the midfoot. This rare and aggressive pulmonary malignancy has a poor prognosis. The purpose of the present case report was to highlight the key roles that medical history and biopsy, combined with a multispecialty approach, play in accurately diagnosing and appropriately treating a patient with metastatic bone disease.

Metastatic calcaneal lesion associated with uterine carcinosarcoma.

Metastatic lesions of uterine carcinosarcoma most commonly occur in the abdomen and lungs and less frequently in highly vascularized bone. We report a rare case of an 86-year-old female with uterine carcinosarcoma with metastasis to the left calcaneus. The patient had a history of uterine carcinosarcoma with hysterectomy and bilateral salpingo-oophorectomy, along with bilateral pelvic and aortic lymphadenectomy, with no adjuvant therapy. The initial pedal complaint was that of left foot pain. The initial radiographic findings were negative; however, magnetic resonance imaging scans revealed a substantial area of marrow edema in the calcaneus. An excisional biopsy was performed, and histopathologic analysis revealed adenocarcinoma with features consistent with the patient's previous uterine tumor specimen. The patient was given one treatment of chemotherapy and was discharged to a hospice, where she died of her disease 2 weeks later.

Modified Blair tibiotalar arthrodesis for post-traumatic avascular necrosis of the talus: a case report.

Surgical treatment of post-traumatic avascular necrosis of the talus coupled with collapse often results in limited treatment options. Of those options, the Blair tibiotalar arthrodesis has been beneficial in preserving limb length and subtalar motion. The complications associated with Blair tibiotalar arthrodesis have led to modifications to improve stability and functional outcomes with rigid internal fixation. We present the case of a 29-year-old female with a history of an open fracture dislocation of the talus 10 years previously, with subsequent development of avascular necrosis of the talus. The purpose of the present case report was to describe the surgical approach and use of an anterior compression plate to augment the modified Blair tibiotalar arthrodesis.

Plasma 25-hydroxyvitamin D3, folate and vitamin B12 biomarkers among international colorectal cancer patients: a pilot study.

Vitamin D and folate are associated with decreased colorectal cancer risk and their association with colorectal cancer prognosis is under investigation. We assessed the levels of plasma 25-hydroxyvitamin D3 (25(OH)D3), folate and vitamin B12 in an international pilot study in order to determine variability of these biomarkers based on geographical location. Plasma 25(OH)D3, folate and vitamin B12 concentrations were measured in 149 invasive, newly diagnosed colorectal cancer cases from Heidelberg (Germany), Seattle (WA, USA), and Tampa (FL, USA) and in ninety-one age- and sex-matched controls. Their associations with potential predictors were assessed using multivariate linear regression analyses. Plasma 25(OH)D3, folate and vitamin B12 concentrations differed by location. Other predictors were season for 25(OH)D3 and tumour stage (vitamin B12). Season-corrected average 25(OH)D3 concentrations were higher in Heidelberg (31·7 ng/ml; range 11·0-83·0 ng/ml) than in Seattle (23·3 ng/ml; range 4·0-80·0 ng/ml) and Tampa (21·1 ng/ml; range 4·6-51·6 ng/ml). In Heidelberg, a strong seasonal variation was observed. Folate (11·1 ng/ml) and vitamin B12 (395 pg/ml) concentrations in Heidelberg were lower than those in Seattle (25·3 ng/ml and 740 pg/ml, respectively) and Tampa (23·8 ng/ml and 522 pg/ml, respectively). Differences in plasma 25(OH)D3 and folate concentrations between Heidelberg and the US sites were observed, probably reflecting variation in outdoor activities and sun-avoidance behaviour during summer as well as in folic acid fortification and supplement use. Intra-site differences at each study location were greater than between-location variability, suggesting that individual health behaviours play a significant role. Nevertheless, the intra-site differences we observed may be due to chance because of the limited sample size. Our pilot study illustrates the value of an international cohort in studying colorectal cancer prognosis to discern geographical differences in a broad range of exposures.