A Review of 1228 In-Office Hand Surgery Procedures With Wide Awake Local Anesthesia No Tourniquet (WALANT) at a Single Private Practice.

BACKGROUND: This study examined the complication rate of Wide Awake Local Anesthesia No Tourniquet (WALANT) technique in the clinic setting with field sterility at a single private practice. We hypothesized that WALANT is safe and effective with a low complication rate. METHODS: This retrospective chart review included 1228 patients who underwent in-office WALANT hand procedures at a single private practice between 2015 and 2022. Patients were divided into groups based on type of procedure: carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, foreign body removal, and needle aponeurotomy. Patient demographics and complications were recorded; statistical comparisons of cohort demographics and risk factors for complications were completed, and P < .05 was considered significant for all statistical comparisons. RESULTS: The overall complication rate for all procedures was 2.77% for 1228 patients including A1 pulley release (n = 962, 2.7%), mass excision (n = 137, 3.7%), extensor tendon repair (n = 23, 4.3%), and first dorsal compartment release (n = 22, 8.3%). Carpal tunnel release, foreign body removal, and needle aponeurotomy groups experienced no complications. No adverse events (e.g. vasovagal reactions, digital ischemia, local anesthetic toxicity, inadequate vasoconstriction) were observed in any group. Patients with known autoimmune disorders and those who were currently smoking had a statistically significant higher complication rate. CONCLUSIONS: Office-based WALANT procedures with field sterility are safe and effective for treating common hand maladies and have a similar complication profile when compared to historical controls from the standard operating room in an ambulatory center or hospital.

Five-year outcome of a staged giant Shamblin type III carotid body tumor excision.

Giant carotid body tumors, defined as those >8 cm in size, are extremely rare. Definitive surgical management is a complex undertaking because these large tumors tend to have grown to envelop cranial nerves and the carotid artery, and few data exist regarding the long-term outcomes for these patients. We present the case of a patient with bilateral giant carotid body tumors who underwent staged embolization and excision of a >10-cm carotid body tumor. After 5 years of follow-up, we demonstrated that elective open repair can provide long-term symptomatic relief. We describe and illustrate the crucial steps and considerations regarding the excision of complex Shamblin type III carotid body tumors.

Recurrent Diffuse Pigmented Villonodular Synovitis in the Hand of a Pediatric Patient: A Case Report.

Diffuse pigmented villonodular synovitis is characterized by synovial inflammation and hemosiderin deposition. It mainly occurs in adults, with the hip and knees being the most common sites of involvement. It is associated with high recurrence rates, with open synovectomy being the most common treatment method to avoid recurrences. Few cases of diffuse pigmented villonodular synovitis have been reported in pediatric patients, especially in uncommon locations such as the hand. This case presents pathology-confirmed diffuse pigmented villonodular synovitis in the hand of a pediatric patient with multiple recurrences despite adequate surgical margins. The patient underwent mass excision with adjuvant radiation treatment after his last recurrence, with excellent functional outcomes and no recurrence at the five-year follow-up.

Surgical management of eyelid lesions in adult-onset asthma and periocular xanthogranuloma.

Medical therapy is the mainstay of initial treatment for periocular xanthogranulomas. Here we depict surgical management of biopsy-proven adult-onset asthma and periocular xanthogranuloma (AAPOX). This 27-year-old female presented with seven years of progressive bilateral periorbital swelling, weight gain, and severe asthma refractory to immunosuppressive therapy including methotrexate, rituximab, and cyclophosphamide. Pre-operative and post-operative photos show excellent resolution of lesions. Orbitotomy with excision involved an upper eyelid crease incision marked at 9 mm centrally. A flap was dissected between the skin and orbicularis-involving xanthogranuloma, extended superiorly to orbital rim and laterally and medially until normal orbicularis was encountered. The xanthogranuloma was excised en-bloc. Infiltrated preaponeurotic fat and portions of the orbital lobe of the lacrimal gland were resected. After achieving hemostasis, the skin was closed with 6-0 polypropylene suture. Surgical pathology was consistent with the diagnosis of AAPOX.

Vocal Fold Paresis and Voice Outcomes following Vocal Fold Mass Excision.

OBJECTIVE: To correlate the surgical results of vocal fold mass excision with pre-operative existence of vocal fold paresis. METHODS: Data were collected on 66 patients who underwent excision of benign vocal fold masses from 2015 to 2020. The pre- and post-operative strobovideolaryngoscopy (SVL) examinations for all patients included were evaluated blindly by three otolaryngologists using THE Voice-Vibratory Assessment with Laryngeal Imaging (VALI) Form for scar severity, mucosal wave, free edge contour, glottal closure, and phase closure. The success of mass excision surgery was determined based on the presence of the following criteria post-operatively: 1) improved mucosal wave motion 2) improved phase closure or glottic closure 3) improved free edge contour and 4) lack of worsening of vocal fold scar severity. Surgery was considered successful if 3 or 4 criteria were met, partially successful if 1 or 2 criteria were met, and unsuccessful if no criteria were met. The percent recruitment of the thyroarytenoid, posterior cricoarytenoid (PCA), and cricothyroid muscles were used evaluated the severity of paresis as mild (70-99% recruitment), moderate (40-60% recruitment), or severe (0-39% recruitment). VHI-10 scores were used as subjective measures of pre- and post-operative voice. RESULTS: Sixty-six patients (26 male, 40 female) were included in this study, with a mean age of 37.25 ± 16.6 (range 18-78). Twelve patients had no evidence of VF paresis noted during the initial clinical evaluation; and 52 patients had paresis and had undergone laryngeal EMG. 81% of these patients had mild paresis, 12.8% had moderate paresis, and 5.8% had severe paresis. Based on pre- and post-operative strobovideolaryngoscopy, there was improvement in mucosal wave in 44.9% of cases, improvement of phase or glottic closure in 85.4% of cases, improved free edge contour in 95.5% of cases, and worsening of scar in 38.5% of cases. 39.6% of surgeries were fully successful, 33.3% of surgeries were partially successful, and 27.1% were not successful. There was a significant correlation between female gender and vocal fold paresis (P = 0.048). Paresis severity did not correlate with complete or partial surgical success (P = 0.956), pre-operative VHI-10 scores (P = 0.519), post-operative VHI-10 scores (P = 0.563), or strobovideolaryngoscopy parameters. Unilateral and bilateral paresis did not correlate with any other parameter of surgical success (P >0.05). CONCLUSION: This study suggests that there is no correlation between pre-operative vocal fold paresis and voice outcomes after mass excision surgery, that the majority of mass excision surgeries (72.9%) are successful based on improvement in stroboscopic parameters, and that the proportion of patients with moderate and severe paresis is consistent across all laryngeal nerves.

Rare glomus tumor formation following trauma to the first digit.

INTRODUCTION: Glomus tumors are rare and few cases are reported in the literature. They typically occur in females on the digits of the hands. CASE PRESENTATION: We report a case of a 30 year-old woman who presented with a mass that developed on the distal tip of her right thumb after traumatic injury. Magnetic resonance imaging (MRI) was conducted and mass resection was performed. Histopathology confirmed that the mass was a glomus tumor. CLINICAL DISCUSSION: Clinical presentations of glomus tumors are typically non-specific, mainly consisting of a small mass with chronic pain, with a lengthy time to diagnosis and potentially improper management. MRI is the preferred diagnostic step, followed by curative surgical excision and pathological confirmation. CONCLUSION: Glomus tumors can cause significant discomfort for patients, and clinicians should be aware of the rare diagnosis when treating painful masses on the extremities, as surgical excision is often curative.

Cellular solitary fibrous tumor in the mental area: a case report and literature review.

Solitary fibrous tumors (SFTs) are rare benign mesenchymal tumors that occur mainly in the pleura. We herein report the first case of a cellular SFT located in the mental region of the head and neck in a 46-year-old woman. Facial computed tomography revealed a mass measuring 0.8 cm with clear boundaries in the right mental region. After excision of the mass, expert pathologists diagnosed a cellular SFT. To our knowledge, this is the first case of a cellular SFT identified in the subcutaneous tissue of the mental region of the head and neck. Because the postsurgical prognosis of SFTs is unpredictable, long-term follow-up and further studies are necessary to determine the characteristics of cellular SFTs in the head and neck region.

Pulse Pressure Variation-Guided Fluid Therapy during Supratentorial Brain Tumour Excision: A Randomized Controlled Trial.

BACKGROUND: Goal-directed fluid therapy (GDFT) improved patient outcomes in various surgical procedures; however, its role during mass brain resection was not well investigated. AIM: In this study, we evaluated a simple protocol based on intermittent evaluation of pulse pressure variation for guiding fluid therapy during brain tumour resection. METHODS: Sixty-one adult patients scheduled for supratentorial brain mass excision were randomized into either GDFT group (received intraoperative fluids guided by pulse pressure variation) and control group (received standard care). Both groups were compared according to the following: brain relaxation scale (BRS), mean arterial pressure, heart rate, urine output, intraoperative fluid intake, postoperative serum lactate, and length of hospital stay. RESULTS: Demographic data, cardiovascular data (mean arterial pressure and heart rate), and BRS were comparable between both groups. GDFT group received more intraoperative fluids {3155 (452) mL vs 2790 (443) mL, P = 0.002}, had higher urine output {2019 (449) mL vs 1410 (382) mL, P < 0.001}, and had lower serum lactate {0.9 (1) mmol versus 2.5 (1.1) mmol, P = 0.03} compared to control group. CONCLUSION: In conclusion, PPV-guided fluid therapy during supratentorial mass excision, increased intraoperative fluids, and improved peripheral perfusion without increasing brain swelling.

Transoral robotic resection of a retropharyngeal parathyroid adenoma: a case report.

Transoral robotic surgery (TORS) has become an increasingly popular option for early malignancies of the oropharynx. It offers superior visualization and has been proven to have acceptable functional and oncologic outcomes. Additionally, indications in head neck have expanded to manage tumors of the thyroid, neck, parapharyngeal space and salivary glands. A 58-year-old female had an incidental finding on CT imaging of a retropharyngeal mass at the level of the hyoid bone. She was referred to a tertiary medical center for further workup and removal of this mass. Due to the midline position of the mass, favorable access and potentially decreased surgical morbidity, TORS excision of the mass was performed for diagnosis and treatment. Histopathology confirmed this to be a hypercellular parathyroid mass consistent with parathyroid adenoma. We report a relatively unusual location of parathyroid adenoma in an asymptomatic patient with normal parathyroid and calcium levels. TORS proves to be a feasible and safe method for complete surgical excision of retropharyngeal parathyroid adenoma without tumor spillage or violation.

Clinical Decision Making for a Soft Tissue Hand Mass: When and How to Biopsy.

Evaluation of a hand mass and subsequent surgical treatment is a frequent clinical encounter for the practicing hand surgeon. The clinical evaluation of benign and malignant hand tumors has traditionally focused on diagnosis, surgical excision, and reconstruction. There is a paucity of literature discussing the determining factors for a hand mass biopsy, its appropriate technique, and postbiopsy preparation and handling. This review discusses the approaches of the hand surgeon and orthopedic oncologist to a soft tissue mass in the hand and clarifies the term biopsy. Special attention is focused on preoperative decisions and indications for core needle, incisional, and excisional biopsies of hand masses. In addition, we include a discussion of surgical technique for obtaining a specimen, processing a specimen, and sending a specimen for pathological evaluation. This highlights specimen labeling and type of fixative utilized for pathological evaluation. This review features a section detailing clinical strategies to reduce morbidity associated with evaluation and treatment of benign and malignant hand masses and is based on recommendations from a synopsis of expert opinion and literature review.

Ultrasound-Guided Bilateral Greater Occipital Nerve Block for Mass Excision.

Anaesthesiologists must always prefer the safest method to minimize the risk for patients. At present, ultrasound-guided blockage of the greater occipital nerve can be performed in a safe manner. In this report, we presented our experience of ultrasound-guided blockage of the greater occipital nerve that we performed in a patient with a mass at the back of the neck who had risk of general anaesthesia because of comorbidities.

Large Forefoot Schwannoma: A Case Report / 대한족부족관절학회지

A schwannoma is a benign neurogenic tumor derived from Schwann cells. A rare case of a large painful schwannoma in the foot with metatarsal deformity was presented. Due to suspicion of malignancy, amputation had been recommended previously. We report on a rare case of a large forefoot schwannoma causing pain and paresthesia of the forefoot.

Hand Assisted Laparoscopic Transduodenal Ampullary Mass Excision / 대한내시경복강경외과학회지

Transduodenal ampullectomy may be an alternative procedure, and at times a more appropriate procedure, for the management of benign neoplasms of the ampulla. We describe here our technique for performing the lesser invasive transduodenal ampullectomy. First, the duodenum is mobilized with the left hand, which is inserted via a hand port, and a right Harmonic scarpel(R) (Ethicon. Endo-surgery, Cincinnati, OH, USA) is used for duodenal incision and mass removal via a right subcostal incision. After checking the continuity and that there is no leakage of the pancreatic duct and common bile duct, the operation is finished. For transduodenal mass excision, the hand assisted laparoscopic transduodenal procedure is as good for the duct continuity and anastomosis leakage as that for the open procedure. Furthermore, this procedure is less invasive than the open procedure.

Comparison of General Anesthesia and Thoracic Epidural Anesthesia for Breast Mass Excision Surgery / 대한마취과학회지

BACKGROUND: The purpose of this study is to compare the effectiveness of thoracic epidural anesthesia (TEA) and general anesthesia (GA) in terms of side effects, postoperative pain control and the cost of anesthesia for breast mass excision surgery. METHODS: Forty-three patients rated as ASA physical status class 1 or 2 who underwent breast mass excision surgery were included in the study. In the TEA group (n = 20), 2% lidocaine (3 ml) and 0.5% bupivacaine (3 ml) were administered via the epidural route. Blood pressure and heart rate were measured before and at 3, 6, 9, 12, 15, 18 21, 24, 27 and 30 minutes after epidural injection. In the GA group (n = 23) patients were maintained by general anesthesia with enflurane and 50% nitrous oxide in oxygen. After the operation, patients were given NSAID-diclofenac sodium as they wanted. Analgesic requirement, satisfaction score, and anesthesia-related side effects were recorded 1 day after surgery. Satisfaction scores of the surgeons and patients were recorded as excellent (4 point), good (3 point), fair (2 point), and unacceptable (1 point). RESULTS: Overall satisfaction scores and side effects were not significantly different between the TEA group and the GA group. Anesthesia cost (80,883.2 +/- 3956.9 vs 32,284.8 +/- 1209.4 won) were significantly lower in the TEA group than in the GA group. CONCLUSIONS: There were not significant differences in satisfaction scores and postoperative side effests between the TEA and GA groups. TEA provided lower anesthesia cost than GA for breast mass excision surgery.

Clinical Assessment of Thoracic Epidural Anesthesia for Breast Mass Excision / 대한마취과학회지

BACKGROUND: Thoracic epidural anesthesia(TEA) is not commonly used for the purpose of pure regional anesthesia. To investigate the usefulness of TEA as a method of regional anesthesia, we performed TEA in patients(n=20) with breast mass. METHODS: After placement of thoracic epidural catheter at one of the 3rd, 4th, 5th or 6th thoracic intervertebral space according to the position of the mass, we injected 8ml of 2% plain lidocaine solution as initial dosage and 2~4 ml as additional dosage if necessary. Blood pressure and heart rate were measured before and at 5, 10, 15, 20, 25, 30, 60 and 90 minutes after epidural injection. Fifteen minutes after epidural injection, the extent of sensory block was measured at cephalad and caudad directions. Two-dermatome regression time was recorded postoperatively. We also investigated whether surgeon used lidocaine locally and anesthetist used intravenous analgesics or sedatives. And we observed the occurrence of complications associated with TEA. RESULTS: The induction dose of 2% lidocaine was 10.1+/-2.1 ml and total dose used was 11.4+/-2.1 ml. The extent of sensory block was T1.1+/-1.1 to T9.1+/-2.3 and two-dermatome regression time was 73+/-24 minutes. Blood pressure and heart rate showed stable pattern of change perioperatively. In two of the subjects, the surgeon used 4 ml of 1% lidocaine locally and in one of the subjects, 50 microgram of fentanyl was used intravenously. Another one of the subjects developed Horner's syndrome postoperatively, which soon disappeared without specific treatment. CONCLUSIONS: Above results suggest that TEA is suitable for breast mass excision as a method of regional anesthesia.