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The optimal adjuvant therapy for uterine leiomyosarcoma (uLMS) remains uncertain. We analyzed the utilization of adjuvant chemotherapy and radiation therapy for stage II and III uLMS and explored the association between use of adjuvant therapy and survival.Patients with stage II or III uLMS treated from 2004 to 2016 and recorded in the National Cancer Database were identified. Multivariable regression models were fit to estimate predictors of use of either adjuvant radiation therapy or chemotherapy. To analyze the impact of chemotherapy on all-cause mortality, an inverse probability of treatment weighted (IPTW) propensity score method was used to account for measured confounders, and the receipt of radiation therapy was adjusted in the outcome model. The process was repeated to analyze the impact of radiation therapy on all-cause mortality by using an IPTW propensity score method and adjusting for the receipt of adjuvant chemotherapy.A total of 890 patients were identified. Adjuvant chemotherapy use increased from 62.2% in 2010 to 70.4% in 2016, whereas radiation usage decreased from 26.7% in 2010 to 10.4% in 2016. Patients with stage III (vs. stage II) disease were less likely to receive radiation therapy. After propensity score weighting, chemotherapy was associated with a 30% decreased risk of all-cause mortality in stage III patients (HR 0.70, 95% CI 0.45-0.98) but had no effect on mortality for stage II patients (HR 0.93, 95% CI 0.70-1.20). Radiation therapy was associated with a 26% decreased risk of mortality for stage II tumors (HR 0.74; 95% CI, 0.53-0.99) and a 57% decrease in mortality for stage III disease (HR 0.43, 95% CI 0.18-0.99).Among women with stage II-III uLMS, use of chemotherapy is increasing while use of radiation therapy is decreasing. Radiation therapy is associated with improved survival in both stage II and III disease, while there was no association between use of adjuvant chemotherapy and survival in stage II patients.

Objectives To determine the impact of frailty on postoperative readmission, morbidity, and mortality among patients undergoing surgery for endometrial cancer. Methods Patients with endometrial cancer undergoing hysterectomy between 2010 and 2014 were identified using the Nationwide Readmissions Database. Frailty was classified using criteria outlined by the Johns Hopkins Adjusted Clinical Groups Frailty Diagnoses Indicators. Primary outcomes were divided by index surgical admission (intensive level of care, mortality, non-routine discharge), 30-days (readmission and mortality), and 90-days (readmission and mortality) after discharge. Multivariable log linear regression models were fit to analyze the effect of frailty on these outcomes, adjusting for patient, hospital, and clinical factors. Results From 2010 to 2014, there were 144,809 surgical endometrial cancer cases with a 1.8% frailty rate. Frailty was associated with an increased risk of intensive level of care (aRR = 3.61, 95% CI: 2.95, 4.42), non-routine discharge (aRR = 1.59, 95% CI: 1.51, 1.68), and inpatient mortality (aRR = 2.05, 95% CI: 1.68, 2.51) during index admission. Frail patients were more likely to be readmitted within 30 days (RR 1.33, 95% CI 1.22–1.47) and 90-days (RR 1.21, 95% CI 1.12, 1.32), and were at increased risk of mortality during their 30-day readmission (aRR = 1.75, 95% CI: 1.28–2.39). Frailty was not associated with 90-day mortality. Hospitalization costs for frail patients were significantly higher than for non-frail patients during index admission and readmissions within 30 and 90 days (p Conclusions Frailty affects postoperative outcomes in endometrial cancer patients and is associated with an increased rate of readmission and 30-day mortality among those who are readmitted. Gynecologic cancer providers should screen for frailty and consider outcomes in frail patients when counseling them for surgery.

To explore trends of ovarian conservation (OCN) over time in young women with early stage leiomyosarcoma (LMS) and examine the association between OCN and survival.Patients under the age of 50 who were diagnosed with stage I LMS who underwent hysterectomy with and without oophorectomy between 2010 and 2016 were identified in the National Cancer Database (NCDB). Performance of oophorectomy vs. OCN was determined using surgery codes. Trends of OCN were reported. Multivariable regression models were fit to estimate predictors of OCN. An inverse probability of treatment weighted propensity score method was used to examine the association between all-cause mortality and OCN.Overall, 225 patients (28%) underwent OCN. Rates of OCN decreased from 41.2% (2010) to 14.3% (2016); this finding was consistent across age groups:35, 35-39, 40-44, and 45-49 years. Race, insurance, and stage did not affect performance of OCN. Women with poorly differentiated tumors were less likely to undergo OCN compared to well-differentiated tumors (aRR 0.59; 95% CI 0.40-0.86). After propensity score weighting, there was no association between OCN and mortality (HR 1.19, 95% CI 0.80-1.77). Five-year survival for the OCN group was 67.1% (95% CI 59.8-75.2%) compared to 72.2% for the oophorectomy group (95% CI 67.2-77.5%).OCN for early stage LMS in premenopausal women has decreased over time. There was no association between OCN and mortality among women with stage I LMS. OCN should be considered in premenopausal women with stage I LMS given the health benefits.

Objectives: Leiomyosarcoma of the uterus (LMS) is an aggressive tumor with a high recurrence rate. For women with stage I disease, NCCN guidelines currently recommend observation after resection of gross intraabdominal disease. However, the role of adjuvant therapy after surgery remains controversial. We analyzed the utilization of adjuvant chemotherapy and radiation therapy for stage I LMS and explored the association between usage of adjuvant therapy and overall survival. Methods: Patients who had pathologically confirmed stage I LMS treated from 2004 - 2016 whose data were recorded in the National Cancer Database (NCDB) were identified. Multivariable regression models were fit to estimate predictors of use of either adjuvant radiation therapy or chemotherapy. To analyze the impact of chemotherapy on all-cause mortality, an inverse probability of treatment weighted (IPTW) propensity score method was used to account for measured confounders and adjust for the receipt of radiation therapy in the outcome model. The process was repeated to analyze the impact of radiation therapy on all-cause mortality by using an IPTW propensity score method to account for measured confounders and adjust for the receipt of adjuvant chemotherapy. Results: A total of 2,426 patients were included in the analysis. Overall the chemotherapy utilization rate was 41.7% and the radiation utilization rate was 9.8%. The usage of chemotherapy remained stable between 39% and 44% between 2010 to 2016 whereas the usage of radiation decreased from 17% in 2010 to 4% in 2016. Adjuvant chemotherapy was more commonly prescribed in younger patients, those with poorly differentiated tumors, and tumors larger than 10cm. Adjuvant radiation was less likely to be utilized for patients living in areas with median socioeconomic status in the highest quartile. Overall 5-year survival for the entire cohort was 57.9% (95% CI 55.1 - 60.6%). After propensity score weighting, patient receiving chemotherapy had a 20% increased risk of all-cause mortality (HR 1.20, 95% CI 1.01 - 1.41, Figure 1A) with a 5-year survival of 53.8% (95% CI 49.4 -58.0%). After propensity score weighting and adjusting for receipt of chemotherapy, radiation therapy was not associated with mortality (HR 0.91, 95% CI 0.68 - 1.21, Figure 1B) with a 5-year survival of 55.0% (95% CI 47.0 - 62.3%). Download : Download high-res image (102KB) Download : Download full-size image Conclusions: In women with stage I LMS, adjuvant chemotherapy is commonly used. There is no association between use of either chemotherapy or radiation and improved survival.

Objectives Frailty, defined as loss of reserve and vulnerability to changes in health, affects many ovarian cancer patients who are planned to undergo surgery. The effect of frailty on postoperative readmissions in ovarian cancer patients remains poorly defined. We investigated the effect of frailty on unplanned readmission, morbidity, and mortality among patients undergoing surgery for ovarian cancer. Study design Patients who underwent laparotomy for ovarian cancer between 2010 and 2014 were identified using the Nationwide Readmissions Database. Frailty was classified using the Johns Hopkins Adjusted Clinical Groups Frailty Diagnoses Indicators. Primary outcomes were divided into index admission (intensive level of care, mortality, non-routine discharge,) 30-days (readmission and mortality), and 90-days (readmission and mortality). Multivariable regression models were fit, adjusting for patient, hospital, and clinical factors. Results From 2010 to 2014, there were 76,441 inpatient laparotomies identified with a 6.1% frailty rate. Frailty was associated with an increased risk of intensive level of care (aRR = 1.76, 95% CI: 1.68, 1.85), non-routine discharge (aRR = 1.39, 95% CI: 1.33, 1.45), and inpatient mortality (aRR = 1.91, 95% CI: 1.63, 2.23) during the index admission. Frail patients were more likely to be readmitted within 90 days (aRR = 1.11, 95% CI: 1.04–1.18), sustain mortality during 90-day readmission (aRR = 1.31, 95% CI 1.01–1.69), and have longer and costlier index hospital stays. Hospital readmission costs did not differ significantly between frail and non-frail patients. Conclusions Frailty affects postoperative outcomes in ovarian cancer patients and is associated with an increased rate of 90-day readmission and mortality among those who are readmitted. Gynecologic oncologists should screen for frailty and consider outcomes in frail ovarian cancer patients when counseling for surgery.

To identify use and outcomes of simple hysterectomy compared with radical hysterectomy for women with early-stage cervical cancer.The National Cancer Database was used to review the cases of women with stage IA2 and IB1 (2 cm or less) cervical cancer from 2004 to 2015. Patients were classified based on whether they underwent simple or radical hysterectomy. Survival was examined after propensity score weighting.Simple hysterectomy was performed in 44.6% of women with stage IA2 (n=1,530) and 35.3% of those with stage IB1 (n=3,931) tumors. Rates of simple hysterectomy increased from 37.8% to 52.7% from 2004 to 2014 for stage IA2 cancers and from 29.7% to 43.8% between 2004 and 2013 for stage IB1 cancers. For stage IA2 cancers, younger women and those treated at an academic medical center were less likely to undergo simple hysterectomy. For stage IB1 cancers, black women were more likely to undergo simple hysterectomy, and those treated at an academic medical center were less likely to undergo simple hysterectomy. After propensity score weighting, there was no association between route of hysterectomy and survival for stage IA2 cancers (hazard ratio [HR] 0.70, 95% CI 0.41-1.20, 5-year survival 95.1% for radical hysterectomy vs 97.6% for simple hysterectomy). For stage IB1 cancers, patients who underwent simple hysterectomy were at 55% increased risk of death (HR 1.55, 95% CI 1.18-2.03, and 5-year survival was 95.3% for radical hysterectomy vs 92.4% for simple hysterectomy).Although there was no association between surgical radicality and survival for women with stage IA2 tumors, there was a 55% increase in mortality for women with stage IB1 neoplasms who underwent simple compared with radical hysterectomy. Radical hysterectomy is the treatment of choice for women with stage IB1 cervical cancer.

Objectives: Uterine leiomyosarcoma (LMS) is a rare and extremely aggressive tumor with a high recurrence rate and low disease-specific survival. Treatment involves surgical resection of all visible disease. Adjuvant therapy, however, remains controversial as clinical trial accrual has been low given the rarity of the tumor. NCCN guidelines currently recommend consideration of systemic chemotherapy and/or consideration of external beam radiation therapy after completion of hysterectomy for women with stage II-III LMS. We analyzed the utilization of adjuvant chemotherapy and radiation therapy for stage II and III LMS and explored the association between use of adjuvant therapy and survival. Methods: Patients who had pathologically confirmed stage II or III LMS treated from 2004 - 2016 and recorded in the National Cancer Database (NCDB) were identified. Multivariable regression models were fit to estimate predictors of use of either adjuvant radiation therapy or chemotherapy. To analyze the impact of chemotherapy on all-cause mortality, an inverse probability of treatment weighted (IPTW) propensity score method was used to account for measured confounders. The IPTW outcome model was fit adjusting for the receipt of radiation therapy. The process was repeated to analyze the impact of radiation therapy on all-cause mortality by using an IPTW propensity score method and adjusting for the receipt of adjuvant chemotherapy in the outcome model. Results: A total of 852 patients were identified. Adjuvant chemotherapy and radiation therapy were utilized in 67% and 16% of patients, respectively. Adjuvant chemotherapy use grew from 62% in 2010 to 70% in 2016, whereas radiation usage decreased from 27% in 2010 to 10% in 2016. Patients with stage III (vs stage II) disease and tumors larger than 10 cm were less likely to receive radiation therapy. Overall 5-year survival for the entire cohort was 27.9% (95% CI 24.0 - 31.9%). After propensity score weighting and adjusting for receipt of chemotherapy, radiation therapy was associated with 41% decreased risk of all-cause mortality (HR 0.59, 95% CI 0.41 - 0.88, Figure 1A). In contrast, after propensity score weighting and adjusting for receipt of radiation therapy, chemotherapy was not associated with mortality (HR 0.88, 95% CI 0.71 - 1.07, Figure 1B). Five-year survival for patients undergoing adjuvant radiation was 40.4% (95% CI 30.2 - 50.3%) whereas 5-year survival for patients undergoing adjuvant chemotherapy was 25.9% (95% CI 21.0 - 31.1%). Download : Download high-res image (131KB) Download : Download full-size image Conclusions: Among women with stage II-III uterine LMS, use of chemotherapy is common and increasing while use of radiation therapy is decreasing. Radiation therapy is associated with improved survival while there was no association between use of adjuvant chemotherapy and survival. Prospective trials are needed to determine the optimal adjuvant therapy for women with stage II-III LMS.

Study Objective The objective of this video is to provide an overview of the variety of different specimen retrieval bags available in the United States, offer practice guidelines for bag selection, and review bag terminology to highlight important concepts for bag selection. Design Although a number of companies manufacture laparoscopic bags to assist in removal of specimens from the body cavity, differences in size, shape, and labeling of the bags lead to confusion when attempting to choose the best laparoscopic bag for one's needs. Setting Laparoscopic Surgery Requiring Specimen Removal. Patients or Participants N/A Interventions N/A Measurements and Main Results To assist viewers, we include a review table comparing various specifications of the most common laparoscopic bags in the United States. We talk viewers through steps on how to choose a bag during laparoscopic surgery. These steps include first determining the specimen size, type and shape. These specimen characteristics will dictate the required bag size and type of bag, and which ultimately will influence laparoscopic trocar size. Finally, we demonstrate the bagging of various tissue specimens with different sizes and shapes of laparoscopic bags. Conclusion To maximize operating room efficiency, we recommend starting off by thinking about the characteristics of the pathology, which will dictate bag size and bag type, which finally will influence trocar size. Starting off with an appropriate laparoscopic bag will reduce operating room efficiency and allow for safe laparoscopic removal of specimens from the body cavity.

Study Objective The objective of this video is to highlight the benefits of the bipolar resectoscope loop for hysteroscopic myomectomy and to review surgical techniques to optimize outcomes. Design Hysteroscopic mechanical morcellators have gained popularity given their ease of use. As a result, resectoscope loops are being used less frequently, resulting in less resident training with this device. Although the bipolar resectoscope loop has a steeper learning curve than mechanical morcellators, the bipolar device offers distinct advantages such as the ability to produce both cutting and coagulation tissue effects with electrosurgery. The ability to achieve electrosurgical hemostasis is unique to the resectoscope loop and may result in less blood loss, less extravasation of intrauterine distention media, and improved visibility allowing for a more efficient and safer surgery. Setting Patients should be in lithotomy position in the operating room. Standard hysteroscopic resectoscope setup is required. Patients or Participants N/A Interventions N/A Measurements and Main Results In this video, we review specific surgical techniques for optimizing outcomes and safety with the bipolar resectoscope loop including the “bow and arrow” technique, identification of the fibroid anatomy (pseudocapsule plane), cold loop blunt dissection, the “push and tuck“ method, and efficient electrosurgical hemostasis. Conclusion The bipolar resectoscope loop is an important tool that offers gynecologic surgeons a wider range of techniques for fibroid removal while still being able to achieve hemostasis. It is important to train residents to learn to use both hysteroscopic mechanical morcellators and resectoscope loops.

Infection with Mycobacterium marinum is often difficult to diagnose. Infection with M. marinum in the upper extremity may involve the tendon sheaths, producing clinical manifestations such as tenosynovitis and symptoms of carpal tunnel syndrome. We report 3 cases of M. marinum infection of the hand associated with carpal tunnel syndrome during an outbreak in New York City's Chinatown. A combination of carpal tunnel release, flexor tenosynovectomy, and appropriate antibiotics yielded complete resolution of symptoms in all cases.

Objective To determine whether a surgical interest group run entirely by preclinical students can influence medical students to enter general surgery residency programs. Design Matriculation rates into general surgery and affiliated subspecialties from Columbia University College of Physicians and Surgeons residency match lists were compared to National Residency Match Program data for all U.S. senior students from 2006 to 2014. Setting The Columbia University College of Physicians and Surgeons. Results After establishing the interest group, entrance rates into general surgery programs tripled from the early 2000s to more than 12% of 2006 Columbia University College of Physicians and Surgeons graduates. After 8 years, our data illustrate sustained results, with more than 8% of students entering surgical residencies, significantly higher than the National Residency Match Program's average (p Conclusions Surgical interest groups spark early and lasting interest in surgery that may influence residency decisions. Moreover, these programs can be successfully run entirely by preclinical students and implemented in other institutions.

Endothelial cell (EC) loss and regeneration are important aspects of the response to vascular injury leading to atherosclerosis in vein grafts (VG). EC regeneration is known to be impaired in diabetes mellitus (DM) leading to an accelerated atherosclerosis, however the mechanism remains unclear. Given the increased oxidative stress in DM, we hypothesized that protein s-glutathiolation, the reversible covalent addition of glutathione to cysteine on target proteins was a candidate mechanism. Overall s-glutathiolation of proteins measured by immunoblot was significantly increased in human DM atherosclerotic plaque compared to non-DM (4-fold, P