Minimally invasive partial fasciectomy for Dupuytren’s contractures

Background

Numerous options exist for the treatment of Dupuytren’s contracture. This study describes the technique and early results of partial fasciectomy through a mini-incision approach as an additional treatment option for Dupuytren’s disease.

Methods

This procedure involves the excision of diseased Dupuytren’s tissue with the use of multiple 1 cm transverse incisions. Patient demographics, digit involvement, the number of incisions required to release each digit, and complications were recorded for all patients. Range of motion data was obtained from a subgroup of patients that had at least 6 months of follow-up. A paired t test was used to compare preoperative and postoperative contracture.

Results

Sixty-seven patients underwent 75 procedures that involved 119 digits. The mean patient age at the time of surgery was 63 years (range, 33–95 years). A total of 32 digits (47 joints) were available for range of motion analysis. After a mean of 2.2 years following surgery, metacarpophalangeal joint contractures maintained correction (34° preoperatively, 19° postoperatively, p = 0.008). After a mean postoperative duration of 2.0 years, proximal interphalangeal joint contractures trended worse than preoperative levels (39° preoperatively, 45° postoperatively, p = 0.319). There was one major complication, which consisted of a nerve laceration that was identified and repaired intraoperatively.

Conclusions

Partial fasciectomy through the described mini-incision approach provides an additional surgical option for patients who desire a less invasive surgical procedure than traditional fascietomy. Although this procedure is safe and effective at achieving immediate cord release, maintenance of correction for proximal interphalangeal joint contractures remains problematic.     

Functional outcome of collagenase injections compared with fasciectomy in treatment of Dupuytren’s contracture

Background

This study was designed to provide comparative information on the safety and efficacy of injection with collagenase clostridium histolyticum (CCH) and fasciectomy for patients with Dupuytren’s contracture (DC).

Methods

A single-center, retrospective, observational, longitudinal chart review was conducted of 25 patients treated with CCH injections and 21 patients undergoing fasciectomy. Patients were assessed at 1 week, monthly for 3 months and then yearly for a minimum of 2 years after treatment for changes in contracture and range of motion, time to return to work/normal activities, patient satisfaction, and Disabilities of Arm, Shoulder and Hand (DASH) score.

Results

Post-procedure follow-up averaged 32 months for the injection group compared with 39 months for fasciectomy group. For the CCH group, the mean postinjection contracture was 3.6° for the metacarpophalangeal and 17.5° for the proximal interphalangeal joints compared with 3.7° and 8.1° in the fasciectomy group, respectively. Patients treated with injections returned to normal activities after a mean of 1.9 days compared with 37.4 days for fasciectomy patients (p < 0.0001). DASH scores for 13 CCH and 15 fasciectomy patients were obtained. The mean DASH score was significantly lower in the injection group in the first 3 months (p < 0.01). At the 2-year follow-up visit, patients were satisfied with their outcomes following either treatment (92 % and 96 % of CCH and fasciectomy patients, respectively).

Conclusion

CCH injections are safe and effective and may be a viable alternative to fasciectomy for treating DC. It also allows earlier return to work and daily activities.     

Surgical outcome of Dupuytren’s disease—no higher self-reported recurrence after segmental fasciectomy

A single-center survey on the patients’ perception of recurrence after Dupuytren’s surgery was conducted. To evaluate the impact of surgical techniques on self-reported recurrence rates, a retrospective analysis of 216 surgically treated patients with a minimum 2-year follow-up was conducted using a postal questionnaire. Reported recurrence rates were somewhat lower in segmental fasciectomy (43%), which was performed in 39% of the patients compared to an overall reported recurrence rate of 54% in all surgical procedures. In total fasciectomy with skin resection and grafting, patients reported a surprisingly high recurrence rate of 63%. By taking the prognostic value of diathesis into account, the difference in recurrence rates between surgical techniques was not statistically significant. Nevertheless, no higher recurrence risk in segmental fasciectomy was noticed and total fasciectomy with or without skin resection did not appear to guarantee indefinite results. At this point, surgical treatment in Dupuytren’s disease is confined to correcting contractures, without curing the patients. Therefore, unless segmental fasciectomy is not feasible due to the severity of the contractures, we suggest to always consider minimal invasive surgery as a surgical option in the treatment of Dupuytren’s disease.     

A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren��s contracture

Background  

Needle aponeurotomy and collagenase injection are alternative treatments of Dupuytren’s contracture to open partial fasciectomy; however, reported data are difficult to interpret without a formal systematic review.     

Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome

Introduction

Boerhaave’s syndrome represents the most lethal of all gastrointestinal perforations. In 2009 a treatment algorithm was published based on current level 4 evidence indicating that all septic patients should be treated surgically, early presentations without sepsis endoscopically and delayed presentations without sepsis conservatively. No provision was made for septic patients unfit for surgical intervention. Using a case series, we demonstrate how minimally invasive endoscopic therapies can be used successfully to manage such a cohort.

Methods

Between September 2008 and January 2010, five patients presented to Wishaw General Hospital with Boerhaave’s syndrome, all with an associated septic profile and none fit for surgery. They were managed using minimally invasive endoscopic therapies including endoscopic placement of oesophageal stents, elimination of mediastinal/pleural contamination using video assisted thorascopic lavage, management of subsequent collections using sinus tract endoscopy and minilaparotomy with transhiatal endoscopic drainage, and closure of oesophagocutaneous fistulas using the Surgisis® (Cook Surgical, Bloomington, IN, US) anal fistula plug sited endoscopically with a rendezvous technique.

Results

Oesophageal re-epithelialisation and resolution of sepsis was achieved in all five cases on days 50, 50, 51, 59 and 103. Four patients are alive today. The fifth died on day 109 in hospital as a consequence of co-morbidity. Two patients required oesophageal dilatation for benign oesophageal strictures.

Conclusions

Minimally invasive endoscopic therapy can be used successfully to achieve oesophageal re-epithelialisation and resolution of sepsis in patients unfit for surgical intervention. It offers a feasible treatment for patients not accounted for in today’s literature and expands on currently described endoscopic therapies.     

Percutaneous fasciotomy for the treatment of Dupuytren��s disease��a systematic review

Background  

Dupuytren’s disease is described as a thickening of the palmar fascia. It typically affects men of Northern European descent in their fifties. The disease process starts as a nodule at the distal palmar crease that progressively gives rise to a cord invading distally toward the finger. Historically, different treatments have been described. Our purpose was to perform a meta-analysis of the evidence published on the percutaneous fasciotomy (PCF) treatment.     

Results of total aponeurectomy for Dupuytren’s contracture in 61 patients: a retrospective clinical study

Introduction  Many surgical techniques have been advocated to treat Dupuytren’s contracture. Partial fasciectomy is often performed to treat the whole spectrum of Dupuytren’s disease. Method  We have reviewed the effectiveness of total aponeurectomy performed on 61 patients [10 women and 51 men (male:female ratio 5.1:1) with a mean age of 63.0 (range 42–79 years) and a mean follow-up of 3.45 years (range 1.03–6.39 years)]. Results  Post-operative complications including haematoma, seroma or necrosis were found in 13.8% of the patients. Recurrence of contracture occurred in 10.8% of the patients and 4.6% of the operated patients presented with a nerve lesion. Nerve irritation occurred in 6.2% of the patients. The mean DASH-score was 3.85 (range 0–52.5). Family pre-disposition was an important risk factor for Dupuytren’s disease with 44.3% of patients having a positive family history. Conclusion  We suggest that total aponeurectomy is a promising alternative to partial fasciectomy with low risk for a recurrence and slightly increased risk for a nerve lesion.     

Nonsurgical treatment of Dupuytren’s contracture: 1-year US post-marketing safety data for collagenase clostridium histolyticum

Background

Collagenase clostridium histolyticum (CCH) is a Food and Drug Administration-approved treatment for adult patients with Dupuytren’s contracture with a palpable cord that has been shown efficacious and safe in clinical trials.

Methods

This paper summarizes the most common post-marketing clinical adverse event (AE) reports received by the manufacturer of CCH and sponsor of the US Biologics License Application (Auxilium Pharmaceuticals, Malvern, PA, USA) during the first 12 months after drug approval and commercialization in the USA.

Results

Of the 115 AE reports describing 270 AEs voluntarily received from patients or health care providers after approximately 5,400 injections of CCH administered, the most common AEs involved local, nonserious reactions to treatment, including skin tears, peripheral edema, and contusion. There were few serious AEs observed (0.6% reporting rate per 1,000 injections), and two flexor tendon ruptures and one flexor pulley injury were reported.

Conclusions

Analysis of post-marketing AEs received for CCH in the first year post-approval supports the safety profile reported earlier during clinical development and did not reveal additional clinical risks or concerns about CCH.     

Minimally invasive percutaneous plate osteosynthesis through fracture site approach for fracture of both tibia and fibula

Objective： To introduce the experience of treating fracture of both tibia and fibula with micro-invasive percutaneous plate internal fixation through fracture site approach. Methods： The data of 15 patients （11 males and 4 females）, including 14 adults （ aged 22-73 years, mean = 40 years） and 1 child （aged 10 years）, with fracture of both tibia and fibula were studied retrospectively in this study. A small incision was made at the fracture site of tibia. Then reposition was made under direct vision, and internal fixation was employed with steel plates inserting through the small incision. Results： Anatomical reduction was obtained. No complication was found. Union occurred on time in 14 patients. One case healed after a second operation. Conclusions ： Micro-invasive percutaneous plate internal fixation is beneficial to the healing of bone and soft tissues. Without X-ray examination, it is also easy to reach anatomical reduction and make tibial internal fixation with both plates with micro-invasive percutaneous plate internal fixation.     

Single portal endoscopic carpal tunnel release: modification of Menon��s technique and data from 65 cases

The purpose of our study is to make a follow-up evaluation of endoscopic carpal tunnel release under focal anesthesia using the Wolf single portal system. A total of 65 patients with a mean age of 50 years undergoing 79 procedures were retrospectively studied. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were recorded. Follow-up was conducted at 1, 5, 12, and 24 weeks and at 1 year postoperatively. Wound pain, analysis of satisfaction, Levine functional status scales, and surgical complications were included. No patients sustained iatrogenic neurovascular injury or hematoma formation. The average Levine functional severity score decreased from 2.82 points preoperatively to 1.2 points at the most recent survey. One case recurred at 1 year after the surgery and subsequently underwent open release. Surgery using the Wolf single portal system under focal anesthesia is a safe and efficacious option for endoscopic carpal tunnel release.     

Minimally invasive excision of gynaecomastia �C a novel and effective surgical technique

INTRODUCTION

More aesthetically acceptable treatment options have been sought to minimise the morbidity associated with open surgery for gynaecomastia. This study investigated the use of a vacuum-assisted biopsy device (VABD) and liposuction to provide minimally invasive approach.

PATIENTS AND METHODS

Patients diagnosed with idiopathic benign gynaecomastia referred to the Breast Care Unit of Castle Hill Hospital between June 2002 and April 2007 and requesting surgical intervention underwent VABD excision and liposuction. All patients underwent thorough investigations to exclude any underlying cause for their gynaecomastia. The procedure was carried out by a single consultant surgeon with special interest in breast surgery. An 8-G mammotome probe was advanced through a 4-mm incision positioned in the corresponding anterior axillary line to excise the glandular disc. Liposuction was performed through the same incision. Incision wounds were closed with Steristrips. A pressure dressing was applied over wound by corset and an inflatable device.

RESULTS

Thirty-six male patients with grade I and II gynaecomastia were recruited (22 bilateral, 14 unilateral). Average age was 33.3 years (range, 16–88 years). All underwent mammotome excision and liposuction. There were no conversions to an open procedure. The average procedure time was 50.3 min (range, 30–80 min). One intra-operative complication was recorded. The minimum follow-up time was 2 months. Thirty-four patients reported excellent satisfaction, two patients had residual gynaecomastia and needed a re-do procedure. Three patients developed small haematomas that resolved spontaneously.

CONCLUSION

This novel, minimally invasive, surgical approach for gynaecomastia gives excellent results with minimal morbidity.     

Reversal of Hartmann’s procedure through the stomal side: a new even more minimal invasive technique

Background  Several minimal invasive, mainly laparoscopic-assisted, techniques for reversal of Hartmann’s procedure (HP) have been published. The purpose of this pilot study was to assess a minimal invasive procedure through the stomal site that may compare favorably with open or laparoscopic-assisted procedures in terms of operative time, hospital stay and postoperative complications. Methods  HP reversal through the stomal side was attempted in 13 consecutive patients. Lysis of intra-abdominal adhesions was done manually through an incision at the formal stoma side, without direct vision between thumb and index finger. The rectal stump was identified intra-abdominally using a transanal rigid club. A manually controlled stapled end-to-end colorectal anastomosis was created. Results  Mean duration of operation was 81 min (range 58–109 min); mean hospital stay was 4.2 days (range 2–7 days). In two patients the procedure was converted because of strong adhesions in the lower pelvic cavity around the rectal stump that could not be lysed manually safely. No complications occurred in the patients in whom reversal was completely done through the stomal site. Conclusions  In our opinion, restoration of intestinal continuity through the stomal side after HP is a feasible operation, without need for additional incisions. In the hands of a specialist gastrointestinal surgeon this technique can be attempted in all patients, as conversion to a laparoscopic-assisted or an open procedure can be performed when necessary.     

Examining the efficacy and maintenance of contracture correction after collagenase clostridium histolyticum treatment for Dupuytren’s disease

Background

This study examined the efficacy, complications, and contracture recurrence in patients who received injectable collagenase clostridium histolyticum (CCH) for Dupuytren’s-induced metacarpophalangeal (MP) and proximal interphalangeal (PIP) joint contractures.

Methods

A retrospective chart review at one center compared the degree of MP and PIP joint contracture pre-injection, post-cord rupture, and at final follow-up after a minimum duration of 6 months. Recurrence was defined as a 20 ° or greater increase in contracture above the minimum value achieved.

Results

Of 102 eligible patients, 48 patients (47 %) (31 males, 17 females) were available for review. 53 digits and 64 joints (46 MP joints and 18 PIP joints) were studied. The mean patient age was 66 years (range, 48–87 years) and mean follow-up duration was 15 months (range, 6 to 25 months). The mean MP joint contracture was 51 ± 20 ° at baseline, 4 ± 8 ° post-cord rupture, and 9 ± 15 ° at latest follow-up. The mean PIP joint contracture was 39 ± 23 ° at baseline, 14 ± 14 ° at cord rupture, and 29 ± 20 ° at latest follow-up. Of the 46 MP joints and 18 PIP joints, 11 MP (24 %) and 7 (39 %) PIP joints met the recurrence criteria. Of 102 patients, 1 patient had a small finger flexor tendon rupture.

Conclusions

Despite the dramatic initial reduction in contracture, recurrence developed in a high proportion of patients over the study period. While initially effective, CCH may not provide durable contracture reduction. However, CCH remains a viable nonsurgical treatment for Dupuytren’s disease.     

Minimally invasive congenital diaphragmatic hernia repair: a 7-year review of one institution’s experience

Background  Minimally invasive surgery (MIS) has been described for the repair of congenital diaphragmatic hernias (CDH) in neonates, infants, and children. This report evaluates patient selection, operative technique, and clinical outcomes for MIS repair of CDHs from a single center’s experience. Methods  All cases of CDH at a tertiary care pediatric hospital with an initial attempt at MIS repair from January 2001 to December 2007 were reviewed. Results  A total of 22 children underwent an initial attempt at MIS repair of their CDH (5 Morgagni and 17 Bochdalek hernias). The children ranged in age from 1 day to 6 years (mean, 13.9 ± 23 months) and weighed 2.2 to 21 kg (mean, 7.4 ± 5.50 kg) at the time of the operation. All five Morgagni hernias were managed successfully with laparoscopic primary repair. Six of the Bochdalek hernias were found in infants and children (age range, 6–71 months). All these were managed successfully with primary repair by an MIS approach (2 by laparoscopy and 4 by thoracoscopy). The remaining 11 Bochdalek hernias were found in neonates (age range, 1 day to 8 weeks). Four of the Bochdalek hernias were right-sided. Nine of the Bochdalek hernias in neonates were repaired thoracoscopically. One neonate required conversion to laparotomy, and another underwent conversion to thoracotomy. Four of the neonates with Bochdalek hernias required a prosthetic patch. Two of the neonates also had significant associated congenital cardiac defects. Overall, there were two recurrences involving one 3-day-old who underwent a primary thoracoscopic repair and another 3-day-old who underwent a thoracoscopic patch repair. The follow-up period ranged from 5 months to 5 years. Conclusions  Morgagni hernias can be managed successfully by laparoscopy, whereas thoracoscopy is preferred for neonatal Bochdalek hernias. Either approach can be successful for infants and children with Bochdalek hernias. Additionally, patients with congenital cardiac defects and those requiring prosthetic patches can undergo a MIS CDH repair with a successful outcome.     

Modified technique of transforaminal lumbar interbody fusion for segmental correction of lumbar kyphosis: a safe alternative to osteotomies?

Background

Sagittal rebalancing of a fixated lumbar hypolordosis (kyphosis) is very important to gain satisfactory results. To correct a misalignment vertebral column resection or pedicle subtraction osteotomies are favored, disregarding the relatively high complication rates. The aim of this study was to evaluate the efficiency and safety of a new modified transforaminal lumbar fusion technique as an alternative.

Methods

We conducted a retrospective review (06/2011-06/2015 ) of a prospective database at an University hospital. Inclusion criteria were adult patients with a fixated lumbar hypolordosis and the need of monosegmental correction of more than 10° with an mTLIF. Exclusion criteria consisted of minor aged patients and polysegmental corrections. Study parameters were the perioperative complications and the achieved postsurgical lordosis. The follow up period was 6 months.

Results

A total of 11 patients could be included. The mean segmental lordosis was -2.3° ± 12.4° (range -22° to 14°) preoperative and 15.5° ± 10.5° (range 0° to 29°) postoperative. The degree of correction was 17° ± 5.7° in mean per treated segment (range 12° to 29°). No neurologic or vascular complications occurred. No substantial loss of correction or implant failure was noted during the 6-month follow-up.

Conclusion

The modified transforaminal lumbar fusion technique is a safe method to correct a fixated lumbar kyphosis. The potential of segmental correction is comparable to pedicle subtraction osteotomies but sparing potentially healthy segments.