Segmental removal of infected frontalis sling.

Congenital ptosis is one of the most common oculoplastic diseases of infancy. Where there is poor levator function, a frontalis sling is the procedure of choice. Here, we describe 2 cases of frontalis sling extrusion that were managed by segmental sling removal, with favorable results. In case 1, an infant developed silicone extrusion 2 months after bilateral frontalis sling implantation. The exposed segment was excised, and the area healed quickly without recurrence of infection and lid height remained optimal. Case 2 developed recurrent brow abscesses during the 3 years following bilateral frontalis sling. Surgical revision involved excision of the involved sling segment for definitive control of the chronic recurrent infection. Adjustment at the time of segmental excision resulted in improved eyelid position. These cases demonstrate that postoperative infection with implant exposure can be managed by partial sling removal, which may be the preferred procedure in children in order to minimize the number of procedures and exposure to general anesthesia.

The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy.

OBJECTIVES: To evaluate the effects of an enhanced recovery after minimally invasive surgery (MIS-ERAS) protocol on opioid requirements and post-operative pain in patients undergoing minimally invasive hysterectomy on a gynecologic oncology service. METHODS: For this retrospective study, opioid use (oral morphine equivalents (OME)) and post-operative pain scores were compared between patients undergoing minimally invasive hysterectomy pre and post MIS-ERAS protocol implementation. Patients with chronic opioid use or chronic pain were excluded. Opioid use and pain scores were compared between groups using Wilcoxon Rank Sum, Student's t-test, and multiple linear regression. Compliance and factors associated with opioid use and pain scores were assessed. RESULTS: The MIS-ERAS cohort (n = 127) was compared to the historical cohort (n = 99) with no differences in patient demographic, clinical or surgical characteristics observed between groups. Median intra-operative and inpatient post-operative opioid use were lower among the MIS-ERAS cohort (12.0 vs 32.0 OME, p < .0001 and 20.0 vs 35.0 OME, p = .02, respectively). Pain scores among MIS-ERAS patients were also lower (mean 3.6 vs 4.1, p = .03). After controlling for age, BMI, operative time, length of stay, cancer diagnosis, and surgical approach, the MIS-ERAS cohort used 10.43 fewer OME intra-operatively (p < .001), 10.97 fewer OME post-operatively (p = .019) and reported pain scores 0.56 points lower than historical controls (p = .013). Compliance was ≥81% for multimodal analgesia elements and ≥75% overall. CONCLUSIONS: Enhanced recovery after minimally invasive surgery protocol implementation is an effective means to reduce opioid use, both in the intra-operative and post-operative phases of care, among gynecologic oncology patients undergoing minimally invasive hysterectomy.

The addition of metformin to progestin therapy in the fertility-sparing treatment of women with atypical hyperplasia/endometrial intraepithelial neoplasia or endometrial cancer: Little impact on response and low live-birth rates.

OBJECTIVE: Our objectives were 1) to compare the efficacy of progestin therapy combined with metformin (Prog-Met) to Prog alone as primary fertility sparing treatment in women with atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN) or early-stage endometrioid carcinoma (EC), and 2) to analyze the proportion of women achieving live birth following treatment. METHODS: A retrospective cohort study of all reproductive-aged women with AH/IN or EC treated with Prog ± Met from 1999-2018 was conducted. Complete response (CR) was assessed and Kaplan-Meier analysis used to calculate time to CR. Comparison of potential response predictors was performed with multivariable Cox regression models. RESULTS: Ninety-two women met criteria; 59% (n = 54) were treated for AH/EIN and 41% (n = 38) for EC. Their median age, body mass index, and follow up time was 35 years, 37.7 kg/m2, and 28.4 months, respectively. Fifty-eight women (63%) received Prog and 34 (37%) received Prog-Met. Overall, 79% (n = 73) of subjects responded to treatment with a CR of 69% (n = 63). There was no difference in CR (p = 0.90) or time to CR (p = 0.31) between the treatment cohorts. Overall, 22% experienced a disease recurrence. On multivariable analysis, EC histology was the only covariate associated with a decreased Prog response (HR 0.48; p = 0.007). Only 17% of the cohort achieved a live-birth pregnancy, the majority of which required assisted reproductive technologies (81%) and occurred in the Prog treatment group. CONCLUSIONS: Our study does not support the use of Prog-Met therapy for treatment of AH/EIN or EC. Additionally, fewer than 20% of women achieved a live-birth pregnancy during the study period, with most requiring ART.

The Utility of Postoperative Computed Tomography Imaging Following Isolated Orbital Blowout Fracture Repair.

PURPOSE: To determine the clinical utility of computed tomography (CT) imaging following isolated orbital blowout fracture (OBF) repair. METHODS: Single-center retrospective review of adult patients undergoing surgical repair of isolated OBFs between November 2008 and August 2016 who received postoperative CT scans. Preoperative and postoperative examination data, postoperative imaging reads, postoperative courses, and any reoperation documentation were collected from electronic medical records. Postoperative imaging findings were categorized as major, indeterminate, or minor by predicted impact on clinical management. Major findings indicated a need for reoperation, indeterminate a potential reoperation, and minor no reoperation. RESULTS: Fifty-two cases met inclusion criteria: 94.2% (n = 49) of postoperative scans included minor findings, 34.6% (n = 18) indeterminate findings, and 19.2% (n = 10) major findings. Three patients returned to the operating room (OR) for surgical revision. All 3 had a significant and concerning change on postoperative examination. Only 1 also had a major finding on postoperative imaging. The remaining 49 patients had benign postoperative examinations, despite 9 (17.3%) with major imaging findings who did not undergo reoperation. CONCLUSIONS: In the majority of OBF repairs, postoperative CT scan findings were not predictive of a need to return to the OR for revision. Reoperation was instead largely prompted by concerning changes in the postoperative clinical examination. Our findings suggest that postoperative imaging in the absence of clinical concern should not be included in the surgical management of isolated OBFs. Instead, targeted imaging will help reduce radiation exposure and health-care costs without sacrificing patient care.

Solitary fibrous tumor of the vulva resulting in spinal metastasis: A case report.

•Solitary fibrous tumors are typically indolent tumors of the pleura.•Primary origin in the female reproductive organs is rare, as are aggressive forms.•We report a case of a vulvar solitary fibrous tumor, notable for extensive spinal metastasis.

Brief Report: A Second Primary Endodermal Sinus Tumor 9 Years after Initial Diagnosis.

BACKGROUND: Ovarian yolk sac tumors (YSTs) are rare malignant germ cell tumors known to present unilaterally, allowing for fertility-sparing surgical treatment with adjuvant chemotherapy. The few published cases of bilateral ovarian involvement were at the time of original diagnosis in patients with widely metastatic disease. We present, to our knowledge, the first case of bilateral ovarian YSTs, diagnosed several years apart, and discuss the implications on recurrence and tumor marker surveillance for these tumors. CASE: This is a case of a young woman who re-presented 9 years after initial treatment, with a YST in the contralateral ovary. SUMMARY AND CONCLUSIONS: YSTs are well established as unilateral tumors, however, in rare cases such as this, they might reappear years later on the contralateral ovary.

Laparoendoscopic single-site surgery for management of adnexal masses in pregnancy: case series.

The incidence of adnexal masses in pregnancy is estimated to be 1% to 4%. In select cases, surgical intervention is required. Recent studies have demonstrated that laparoscopy during pregnancy is safe and confers many advantages over laparotomy. Herein we present a series of nine cases collected prospectively that demonstrate the feasibility, safety, and putative benefits of laparoendoscopic single-site surgery for treatment of adnexal masses in pregnant women.

The risk of umbilical hernia and other complications with laparoendoscopic single-site surgery.

STUDY OBJECTIVE: To estimate the risk of umbilical hernia and other latent complications in women who underwent laparoendoscopic single-site surgery (LESS) for a gynecologic indication. DESIGN: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). SETTING: Four tertiary care academic medical centers. PATIENTS: Women undergoing LESS for a benign or malignant gynecologic indication from 2009 to 2011. INTERVENTIONS: A total of 211 women underwent LESS via a single 1.5- to 2.0-cm umbilical incision. All surgeries were performed by advanced gynecologic laparoscopists. Incisions were repaired with a running, delayed absorbable suture. Subject demographics and clinical variables were collected and surgical outcomes analyzed. MEASUREMENTS AND MAIN RESULTS: Median age and body mass index were 45 years and 30 kg/m(2), respectively. Approximately half of study subjects underwent a hysterectomy with or without salpingo-oophorectomy, and 15% had a diagnosis of cancer. Overall, 0.9% of women were diagnosed with a preoperative umbilical hernia, and 2.4% of women experienced a major perioperative complication. After a median postoperative follow-up time of 16 months, 2.4% had development of an umbilical hernia. However, 4/5 of these women had significant risk factors for fascial weakening independent of LESS, including requirement for a second abdominal surgery in 1 subject and a cancer diagnosis with postoperative chemotherapy administration in 2 subjects. When these subjects deemed "high risk" for incisional disruption were excluded from the analysis, the umbilical hernia rate was 0.5% (1/207). On univariable analysis, obesity was the only factor associated with complications (p = .04). CONCLUSION: When performed by advanced laparoscopic surgeons, laparoendoscopic single-site gynecologic surgery is associated with a low risk of major adverse events. Additionally, the overall umbilical hernia rate was 2.4% and was lower (0.5%) in subjects without significant comorbidities.

Abnormal cervical cytology in the diagnosis of uterine papillary serous carcinoma: earlier detection of a poor prognostic cancer subtype?

OBJECTIVE: Early detection of uterine papillary serous (UPSC), clear cell (CCC), and grade 3 endometrioid carcinomas (G3EC) - all poor prognostic variants of endometrial carcinoma (EC) - is of particular clinical relevance. The study objective was to assess the utility of liquid-based cytology (Pap) in the detection of high-grade EC. STUDY DESIGN: A retrospective, two-institution analysis of patients diagnosed with UPSC, CCC, or G3EC with a preoperative Pap from 1999 to 2010 was conducted. RESULTS: One hundred and one patients were evaluated; 51.5% had UPSC, 27.7% had CCC, and 20.8% had G3EC. Stage I/II disease was found in 69.3% of patients, and 46/101 patients (45.5%) had abnormal Paps. Significantly more patients with UPSC had abnormal Paps (65.7%) than those with CCC (25%) or G3EC (23.8%; p < 0.001). An abnormal Pap was the only presenting clinical finding in a significant number of asymptomatic UPSC patients (26.9%) compared with 4% of patients with CCC and G3EC (p = 0.005). On multivariate analysis, UPSC histology was the only variable associated with an abnormal Pap. CONCLUSIONS: A high incidence of abnormal cervical cytology was observed in women with high-grade EC, particularly in UPSC patients. Although hypothesis generating, a proportion of asymptomatic UPSC patients had abnormal cytology, signifying that Pap smear screening may help detect the disease before the patient develops symptoms.

Laparoendoscopic single-site surgery (LESS) in gynecology: a multi-institutional evaluation.

OBJECTIVE: The study objectives were to determine the surgical outcomes of a large series of gynecology patients treated with laparoendoscopic single-site surgery (LESS). STUDY DESIGN: This was a retrospective, multi-institutional analysis of gynecology patients treated with LESS in 2009. Patients underwent surgery via a single 1.5- to 2.5-cm umbilical incision with a multichannel single port. RESULTS: A total of 74 women underwent LESS. Procedures were performed for benign pelvic masses (n = 39), endometrial hyperplasia (n = 9), endometrial (n = 15) and ovarian (n = 6) cancers, and nongynecologic malignancies (n = 5). Median patient age and body mass index were 47 years and 28, respectively. A Pearson product-moment correlation coefficient was computed and demonstrated a significant linear relationship between the operating time and number of cases for cancer staging (r = -0.71; n = 26; P < .001) and nonstaging (r = -0.78; n = 48; P < .002) procedures. Perioperative complications were low (3%). CONCLUSION: LESS is feasible, safe, and reproducible in gynecology patients with benign and cancerous conditions. Operative times are reasonable and can be decreased with experience.

Three case reports of laparoscopic management of granulosa cell tumor with intraoperative rupture and subsequent upstaging.

Granulosa cell tumors (GCT) of the ovary account for 2% to 5% of all ovarian tumors and typically demonstrate an indolent clinical course. For a young woman with stage IA disease who wishes to preserve fertility, conservative surgery with laparoscopic techniques can be a safe and effective method. Three patients with clinical presumptive stage IA GCT of the ovary were initially treated with conservative laparoscopic surgery with intraoperative rupture of the tumor. On repeat surgical exploration, all 3 patients were found to have peritoneal disease. Postoperative chemotherapy was required. Several important aspects of laparoscopic management of adnexal masses are highlighted by these 3 case reports. A thorough knowledge about GCT is important. Complete and clean removal of an unknown adnexal mass is imperative.

Inguinal node metastasis as the initial presentation of primary fallopian tube cancer.

BACKGROUND: An initial presentation of inguinal metastasis in primary fallopian tube cancer in an asymptomatic patient is uncommon. All previously described palpable lymphadenopathies in fallopian tube cancer have been associated with widely disseminated intra-abdominal disease. CASE: This is the first case of inguinal node metastasis from fallopian tube cancer in a 72-year-old asymptomatic patient with a previous hysterectomy with no evidence of intra-abdominal disease. The metastasis was detected in the contralateral inguinal area. CONCLUSION: Fallopian tube cancer can present with inguinal metastasis, although this is an uncommon occurrence. A high index of suspicion must be maintained, especially in asymptomatic patients with negative imaging studies.

Primary insular carcinoid of the ovary.

BACKGROUND: Primary insular carcinoid tumor of the ovary is a rare tumor and accounts for fewer than 1% of all cases of carcinoid in the body. With the exception of a single reported case, all previously described functioning ovarian carcinoid tumors have measured at least 10 cm in diameter. Thus, there appears to be a good correlation between the size of the tumor and the presence of the carcinoid syndrome. CASE REPORT: We describe a case of a functioning primary insular carcinoid tumor of the ovary measuring just 6 cm in maximal diameter. CONCLUSION: Although primary ovarian carcinoid tumor is very rare, a high clinical index of suspicion must be maintained, especially in a patient presenting with carcinoid syndrome and a small adnexal mass.