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Background: Health care burden attributable to Dupuytren disease (DD) is largely unknown. The authors determined (1) the prevalence and incidence of DD, (2) the incidence of first surgical intervention, and (3) the lifetime risk of surgical intervention in the United Kingdom National Healthcare Service.Methods: In this population-based dynamic cohort analysis, data of the Clinical Practice Research Datalink was linked to Hospital Episode Statistics, to characterize the diagnosis and surgical treatment of DD. Secular trends of incidence of DD diagnosis and first surgical treatment were calculated for 2000 to 2013. A multistate Markov model was designed to estimate the lifetime risk of first surgical intervention.Results: A total of 10,553,454 subjects were included in the analyses, 5,502,879 (52%) of whom were women. Of these, 38,707 DD patients were identified. Point prevalence in 2013 was 0.67% (99% CI, 0.66 to 0.68). The incidence of DD almost doubled from 0.30 (99% CI, 0.28 to 0.33) per 1000 person-years in 2000, to 0.59 (99% CI, 0.56 to 0.62) per 1000 person-years in 2013. The incidence of first surgical intervention similarly increased from 0.29 (99% CI, 0.23 to 0.37) to 0.88 (99% CI, 0.77 to 1.00) in the same period. A man or woman newly diagnosed with DD at age 65 has a lifetime risk of surgical intervention of 23% and 13%, respectively, showing only a very subtle decrease when diagnosed later in life.Conclusions: DD is an important health condition in the older population, because prevalence and incidence rates have almost doubled in the past decade. Estimated lifetime risk of surgical treatment is relatively low, but almost twice in men compared with women. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

This study assesses the diagnostic accuracy of ultrasound and magnetic resonance imaging (MRI) in diagnosing Stener lesions of the thumb. MEDLINE, PubMed, Embase and Cochrane CENTRAL were searched for studies using ultrasound or MRI to detect Stener lesions following suspected thumb ulnar collateral ligament injuries. The reference standard was surgical exploration or clinical joint stability. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. A random-effects bivariate meta-analysis was used to estimate pooled sensitivity and specificity. Forest plots were generated. Nine ultrasound (315 thumbs) and six MRI (107 thumbs) studies were included in meta-analysis (all high risk of bias). Pooled sensitivity and specificity for ultrasound were 95% and 94%, and for MRI were 93% and 98%. Both ultrasound and MRI demonstrate high diagnostic accuracy in detecting Stener lesions. Ultrasound is an appropriate first-line imaging modality.

Objectives Intra-articular steroid injection is commonly used to treat base of thumb osteoarthritis (BTOA), despite a lack of large-scale data on safety and effectiveness. We estimate the incidence of serious complications and further procedures following BTOA injection, including the risk of post-operative serious surgical site infection for subsequent operative intervention. Methods Hospital Episode Statistics data linked to mortality records from 1 April 1998 to 31 March 2017 were used to identify all BTOA injections undertaken in adults in the National Health Service secondary care in England. Patients were followed up longitudinally until death or 31 March 2017. A multivariable regression with a Fine and Gray model adjusting for the competing risk of mortality in addition to age, sex and socioeconomic deprivation was used to identify factors associated with progression to further procedure. Secondary outcomes included serious complications after injection and subsequent surgical site infection. Results A total of 19 120 primary injections were performed during the 19-year period in 18 356 patients. Of these 76.5% were female; mean age 62 years (s.d. 10.6); 50.48% underwent further procedure; 22.40% underwent surgery. Median time to further intervention was 412 days (IQR 110–1945). Female sex was associated with increased risk of proceeding to surgery. Serious complication rate following injection was 0.04% (0.01–0.08) within 90 days. Of those proceeding to surgery 0.16% (0.06–0.34) presented with a wound infection within 30 days and 90 days, compared with an overall post-operative wound infection rate of 0.03% (0.02–0.05). Conclusions Very low rates of serious complications were identified following BTOA injections performed in secondary care; only one in five patients proceeded to subsequent surgery. Clinical trial registration clinicaltrials.gov, https://www.clinicaltrials.gov, NCT03573765

Background Carpal tunnel decompression surgery to treat carpal tunnel syndrome is a common procedure, yet data on safety and effectiveness of the operation in the general population remain scarce. We aimed to estimate the incidence of reoperation and serious postoperative complications (requiring admission to hospital or further surgery) following carpal tunnel decompression in routine clinical practice and to identify the patient factors associated with these adverse outcomes. Methods We did a nationwide cohort analysis including all carpal tunnel decompression surgeries in patients aged 18 years or older, done in the National Health Service in England between April 1, 1998, and March 31, 2017, using the Hospital Episode Statistics dataset linked to mortality records. Patients were followed-up until death or until the end of the study (March 31, 2017). Primary outcomes were the overall incidence of carpal tunnel decompression reoperation and serious postoperative complications (surgical site infection or dehiscence, or neurovascular or tendon injury, requiring admission to hospital or further surgery) within 30 days and 90 days after surgery. Multivariable Cox regression analysis was used to identify factors influencing complications and reoperation, and the Fine and Gray method was used to adjust for the competing risk of mortality. This study is registered with ClinicalTrials.gov, NCT03573765. Findings 855 832 carpal tunnel decompression surgeries were done between April 1, 1998, and March 31, 2017 (incidence rate 1·10 per 1000 person-years [95% CI 1·02–1·17]). 29 288 procedures (3·42%) led to carpal tunnel decompression reoperation (incidence rate 3·18 per 1000 person-years [95% CI 3·12–3·23]). Of the 855 832 initial surgeries, 620 procedures (0·070% [95% CI 0·067–0·078]) led to a serious complication within 30 days after surgery, and 698 procedures (0·082% [0·076–0·088]) within 90 days. Local complications within 90 days after surgery were associated with male sex (adjusted hazard ratio 2·32 [95% CI 1·74–3·09]) and age category 18–29 years (2·25 [1·10–4·62]). Male sex (adjusted subhazard ratio 1·09 [95% CI 1·06–1·13]), old age (>80 years vs 50–59 years: 1·09 [1·03–1·15]), and greater levels of comorbidity (Charlson score ≥5 vs 0: 1·25 [1·19–1·32]) and socioeconomic deprivation (most deprived 10% vs least deprived 10%: 1·18 [1·10–1·27]) were associated with increased reoperation risk. Interpretation To our knowledge, this is the largest national study on carpal tunnel decompression to date, providing strong evidence on serious postoperative complication and reoperation rates. Carpal tunnel decompression appears to be a safe operation in most patients, with an overall serious complication rate (requiring admission to hospital or further surgery) of less than 0·1%. Funding Versus Arthritis; Medical Research Council; Royal College of Surgeons of England and National Joint Registry research fellowship; University of Oxford; National Institute for Health Research; and National Institute for Health Research Biomedical Research Centre, Oxford.

We performed Mendelian randomization analyses of body mass index and waist–hip ratio adjusted for body mass index in Dupuytren’s disease using summary statistics from genome-wide association study meta-analyses. We found that adiposity is causally protective against Dupuytren’s disease, with the inverse-variance weighted Mendelian randomization analysis estimating that a 1 standard deviation increase in body mass index (equivalent to 4.8 kg/m2) leads to 28% (95% confidence interval: 18–37%) lower relative odds of developing Dupuytren’s disease, and a 1 standard deviation increase in waist–hip ratio adjusted for body mass index (equivalent to a waist–hip ratio of 0.09) leads to 26% (95% confidence interval: 6–42%) lower relative odds of developing Dupuytren’s disease. We conclude from this study that regardless of the well-established negative health effects of obesity, the raised body mass index is associated with a lower risk of Dupuytren’s disease and may be causally protective for the development of the disease.

Background Upper limb arthroplasty is an increasingly used treatment modality for end-stage joint disease of the shoulder, elbow and wrist. Whilst complications have been reported, the risk of venous thromboembolism has received less attention when compared to the lower limb. Guidance to aid clinical decision-making remains limited. This review aims to ascertain whether venous thromboembolism prophylaxis is beneficial after upper limb major joint replacement surgery. Methods A systematic review was performed in April 2019, utilising EMBASE, MEDLINE, Cochrane and Google Scholar. All clinical studies reporting venous thromboembolism incidence and risk reduction (after prophylaxis) in upper limb joint replacement were included. Results Twenty-four observational studies were identified. The reported incidence of venous thromboembolism ranged from 0.2% to 16% (weighted mean 0.68%) and 0.2% to 0.8% (weighted mean 0.49%) in shoulder and elbow arthroplasty, respectively. No records for wrist arthroplasty were found. In the literature, baseline venous thromboembolism risk of patients without an operation is reported as 0.5%. Discussion There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery. We recommend further research, ideally formal randomised controlled trials to guide recommendations. Although venous thromboembolism is rare in upper limb surgery, surgeons should remain vigilant to this possibility.

We aimed to assess the association between bariatric surgery and incident Dupuytren's disease (DD) using propensity score-matched cohort studies among Swedish nationwide healthcare registries. Patients aged 30-79 years who underwent bariatric surgery 2006-2019 were matched on their propensity scores, up to two obese bariatric surgery-free (unexposed) patients. We applied Cox proportional hazard regression to calculate hazard ratios (HR) with 95% confidence intervals (CI) for the risk of DD overall, in subgroups of age, sex, bariatric surgery type and duration of follow-up. Among 34,959 bariatric surgery patients and 54,769 propensity score-matched obese patients, the risk of DD was increased in bariatric surgery patients compared with obese unexposed patients (HR 1.30, 95% CI 1.02-1.65), among women (HR 1.36; 1.00-1.84); those undergoing gastric bypass (HR 1.33; 1.04-1.71) and those with >5 years follow-up (HR 1.63; 1.14-2.34). Our results suggest that substantial weight loss is associated with an increased risk of DD in an obese population., Journal of Hand Surgery (European Volume), 47 (3), ISSN:1753-1934, ISSN:2043-6289

Aim To elucidate the genetic architecture of haemorrhoids and identify genes and biological pathways central to their pathobiology. Method We report the first ever genome-wide association study of haemorrhoids in 31,652 cases and 369,931 controls from UK Biobank. Genes and biological pathways were prioritised using several bioinformatic approaches, and potential therapeutic targets were identified in the Open Targets Platform. A weighted genetic risk score (wGRS) for haemorrhoids was constructed to compare genetic susceptibility in surgical vs non-surgical haemorrhoids patients. Results Twelve novel genome-wide significant susceptibility loci were discovered to be associated with haemorrhoids. Seventeen genes were mapped to these loci, and gene sets in biological pathways relating to extracellular matrix regulation and TGF-β signalling were strongly implicated. Seven gene-products (41.2%) were predicted tractable to antibody and/or small molecule targeting, and three products (17.6%) have known pharmaceutical interactions (ACHE, ADRA2B, ELN). The wGRS analysis demonstrated that haemorrhoid patients requiring surgery have a higher inherent genetic susceptibility than those managed non-surgically (P = 4.58 × 10-27). Conclusions This study has advanced our understanding of haemorrhoids pathobiology with the identification of several biologically plausible genes and pathways, many of which demonstrate strong therapeutic potential. The wGRS correlated with disease severity, representing a first step in personalised medicine approaches to haemorrhoids.

Aim To elucidate the genetic architecture of varicose veins (VVs) and identify genes and biological pathways central to their pathobiology. Method We performed hitherto the largest two-stage genome-wide association study of VVs in 401,656 subjects from UK Biobank, and replication in 408,969 subjects from 23andMe, Inc (total 135,514 VVs cases and 675,111 controls). Genes and biological pathways were prioritised using several bioinformatic approaches, and potential therapeutic targets were identified in the Open Targets Platform. A weighted genetic risk score (wGRS) for VVs was constructed to compare genetic susceptibility in surgical vs non-surgical VVs patients. Results 109 genome-wide significant (P ≤ 5 × 10-8) loci were identified in UK Biobank, 46 of which successfully replicated in the 23andMe cohort. Twenty-eight loci have not been previously reported. We mapped 237 genes to these loci, many of which are biologically relevant and tractable to therapeutic targeting or repurposing (notably VEGFA, COL27A1, EFEMP1, PPP3R1 and NFATC2). Tissue enrichment analyses implicated vascular tissue, and several genes were enriched in biological pathways relating to extracellular matrix biology, inflammation, angiogenesis, lymphangiogenesis, vascular smooth muscle cell migration, and apoptosis. The wGRS analysis demonstrated that VVs patients requiring surgery have a higher inherent genetic susceptibility than those managed non-surgically (P = 2.46 × 10−13). Conclusions This study has advanced our understanding of VVs pathobiology with the identification of several biologically plausible genes and pathways, many of which demonstrate strong therapeutic potential. The wGRS correlated with disease severity, representing a first step in personalised medicine approaches to VVs.

Background Dupuytren disease (DD) is a common fibroproliferative disease of the palmar fascia. The mainstay of DD treatment in England is surgery with either percutaneous needle fasciotomy, limited fasciectomy, or dermofasciectomy. This study aimed to investigate the temporal trends and geographical variation of primary DD surgery in England. Methods A longitudinal population-based cohort study was perfomed using the Hospital Episode Statistics database from April 1, 2007, to March 31, 2017. Directly standarized rates were estimated over time (between financial years 2007-2008 and 2016-2017) and by geographic region (by clinical commissioning groups [CCGs]; financial years 2010-2011, 2013-2014, and 2016-2017). The Office for National Statistics midyear population estimates were used as the reference population. Main findings Primary DD surgery was undertaken at a steadily increasing rate from financial year 2007 to 2008, to 2016 to 2017 in England. There was a striking 3.6-fold variation in the rates of primary DD surgery among National Health Service CCGs in England place of residence. Conclusions This significant variation in DD surgical treatment in England suggests a need for the development of standardized surgical practice across all CCGs and National Health Service hospitals, promoting equality of access to cost-effective health care.

Aim Develop a prediction model for incident radiographic IPJ osteoarthritis when multiple clinical risk factors are present. Methods This study used secondary analysis from the Chingford 1000 Women Study, a prospective cohort of women aged 45 to 64 years. At baseline, anthropometric, clinical, and lifestyle measured had been collected. Hand radiographs had been taken at baseline and 10 years, read using the Kellgren-Lawrence atlas. For the current study, participants with osteoarthritis (Kellgren-Lawrence ≥2) in any IPJ at baseline were excluded. Risk factors were selected from baseline based on biological plausibility, a published systematic review, and a Delphi study of Hand Surgeons. Incident osteoarthritis was diagnosed at 10 years if ≥ 1 IPJ was Kellgren-Lawrence ≥2. The model was built with logistic regression and elastic net penalisation, and performance assessed through discrimination (c-statistic) and calibration (c-slope). Complete case analysis was used. Results Of 1,003 participants, 459 participants were included in this study (median age: 51 years, 202 (44%) with IPJ osteoarthritis at follow-up). Manual occupation (P Conclusions Osteoarthritis at the base of thumb and IPJs might be a continuum of the same disease. Knowledge of these modifiable and non-modifiable risk factors can inform prevention strategies.

Secondary lymphedema is a common side effect of breast cancer treatment, with significant impact on patients' physical and psychological well-being. Conservative therapies are the gold standard treatment, however surgical options are becoming more popular. Lymphaticovenular anastomosis (LVA) is a supermicrosurgical procedure that aims to restore lymphatic flow by anastomosing damaged lymphatics to subcutaneous venules. We aimed to assess the effects of LVA on patients' limb volume and quality of life. Pre- and postoperative limb volumes and LYMQOL scores were collected for patients undergoing LVA for lymphedema secondary to breast cancer. Thirty-seven patients underwent LVA. A significant reduction was seen in median excess limb volume postoperatively (13.3%-6.6%, P < 0.005), with volumetric improvement seen in 78% of patients. Thirteen patients were able to discontinue compression garment use. Eighty-six percent of patients reported improved quality of life postoperatively with median LYMQOL score increasing from 90 to 104 points (P < 0.005). LVA is a minimally invasive surgical option for patients with early stage lymphedema. It can lead to significant volumetric improvements and in select patients, freedom from compression therapy. LVA can also lead to significant improvements in quality of life, in particular patients' mood and perception of their appearance.

ObjectivePrioritisation of important treatment uncertainties for ‘Common Conditions Affecting the Hand and Wrist’ via a UK-based James Lind Alliance Priority Setting Partnership.SettingThis process was funded by a national charitable organisation and based in the UK.ParticipantsAnyone with experience of common conditions affecting the adult hand and wrist, including patients, carers and healthcare professionals. All treatment modalities delivered by a hand specialist, including therapists, surgeons or other allied professionals, were considered.InterventionsEstablished James Lind Alliance Priority Setting Partnership methods were employed.Electronic and paper questionnaires identified potential uncertainties. These were subsequently confirmed using relevant, up-to-date systematic reviews. A final list of top 10 research uncertainties was developed via a face-to-face workshop with representation from patients and clinicians. Impact of research was sought by surveying hand clinicians electronically.Outcome measuresThe survey responses and prioritisation—both survey and workshop based.ResultsThere were 889 individually submitted questions from the initial survey, refined to 59 uncertainties across 32 themes. Eight additional uncertainties were added from published literature before prioritisation by 261 participants and the workshop allowed the final top 10 list to be finalised. The top 10 has so far contributed to the award of over £3.8 million of competitively awarded funding.ConclusionsThe Common Conditions in the Hand and Wrist Priority Setting Partnership identified important research questions and has allowed research funders to identify grant applications which are important to both patients and clinicians

Introduction Varicose veins (VV) impact a third of the UK adult population; 10% of patients develop lipodermatosclerosis and ulceration. VV often requires surgical management, however, there is a high-risk of recurrence. VV is a complex disease, where genetic and non-genetic components contribute to overall phenotypic expression. The genetic architecture of VV is poorly understood; we aimed to uncover its genetic basis. Method We conducted hitherto the largest genome-wide association study of VV. In stage one, using UK Biobank, we compared 22,473 VV patients and 379,183 controls. In stage two, replication and meta-analysis were performed in an independent cohort of 113,041 VV cases and 295,928 controls from 23&Me (California, USA). In-silico analysis was conducted in FUMA, MAGMA, and XGR. Result 109 genome-wide significant (P≤ 5×10-8) loci were identified in UK Biobank, 45 of which successfully replicated in the 23&Me cohort. Twenty-seven loci have not been previously reported. FUMA positionally-mapped 128 genes at the replicated loci, with 84 having a combined annotation-dependent depletion score (CADD) >12.37, suggesting functional, deleterious variants. MAGMA analysis implicated pathways involved in cardiovascular system development (P=1.57×10-08) and tube morphogenesis (P=9.35×10-08). Furthermore, XGR revealed enriched pathways in downstream signalling in naive CD8+ T cells (P=0.0017), and encoding structural and core extracellular glycoproteins (both P=0.007). Conclusion We identified 45 variants conferring risk of VV, which provide insights into disease biology. Implicated genes are enriched in pathways involved in vascular development, immune cell activity and extracellular matrix function, and provide new targets for therapeutic development. Take-home message Unravelling the genetic architecture of varicose veins may facilitate our understanding of the disease and guide therapeutic approaches.

Dupuytren’s disease (DD) is a common fibro-proliferative disorder of the palm. We estimated the risk of serious local and systemic complications and re-operation after DD surgery. We queried England’s Hospital Episode Statistics database and included all adult DD patients who were surgically treated. A longitudinal cohort study and self-controlled case series were conducted. Between 1 April 2007 and 31 March 2017, 121,488 adults underwent 158,119 operations for DD. The cumulative incidence of 90-day serious local complications was low at 1.2% (95% CI 1.1–1.2). However, the amputation rate for re-operation by limited fasciectomy following dermofasciectomy was 8%. 90-day systemic complications were also uncommon at 0.78% (95% CI 0.74–0.83), however operations routinely performed under general or regional anaesthesia carried an increased risk of serious systemic complications such as myocardial infarction. Re-operation was lower than previous reports (33.7% for percutaneous needle fasciotomy, 19.5% for limited fasciectomy, and 18.2% for dermofasciectomy). Overall, DD surgery performed in England was safe; however, re-operation by after dermofasciectomy carries a high risk of amputation. Furthermore, whilst serious systemic complications were unusual, the data suggest that high-risk patients should undergo treatment under local anaesthesia. These data will inform better shared decision-making regarding this common condition.

Proximal phalangeal fractures have traditionally been fixed via either Kirschner wires or dorsal plating. Concerns regarding lack of compression and potential for infection with wire fixation, and adhesion formation and stiffness with plating, have lead to alternative fixation methods, such as intramedullary screw fixation. However, the literature regarding this modality is limited. Methods: A systematic review was performed to review the literature regarding intramedullary screw fixation for proximal phalangeal fractures. English language studies that reported original data and commented on at least one postoperative measure of function were eligible for inclusion. 4 studies were eligible for inclusion, with a further 3 studies assessing proximal and middle phalanges analysed separately. Total active motion was greater than 240° in all proximal phalangeal studies; mean post-operative DASH was 3.62. 6% of patients sustained a major complication. Intramedullary screw fixation of proximal phalangeal fractures is safe, providing stable fixation to allow early motion.

Background Dupuytren's disease is a common complex disease caused by genetic and nongenetic factors. The role of many nongenetic risk factors is still unclear and debatable. This study aimed to systematically review the association between Dupuytren's disease and nongenetic risk factors. Methods A search strategy was developed based on the Population, Exposure, Comparison, Outcomes and Study framework. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search was conducted in MEDLINE, Embase, Scopus, Web of Science, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to November of 2018. Title and abstract and then full-text screening against eligibility criteria was performed independently by two reviewers, and consensus was achieved by a third reviewer. The Effective Public Health Practice Project and the Oxford Centre for Evidence Based Medicine tools were used to assess study quality and to evaluate the level of evidence of included studies, respectively. Results Reviewers identified 4434 studies, of which 54 were included in the analysis. There was strong evidence for the association between Dupuytren's disease and advanced age, male sex, family history of Dupuytren's disease, and diabetes mellitus. Furthermore, heavy alcohol drinking, cigarette smoking, and manual work exposure showed a significant dose-response relationship. The quality of the included studies was mainly low or moderate, and most studies were level 3 or 4 on the Oxford Centre for Evidence Based Medicine scale. Conclusions The study results show a strong association between Dupuytren's disease and advanced age, male sex, family history of Dupuytren's disease, diabetes mellitus, heavy alcohol drinking, cigarette smoking, and manual work exposure. Further studies are required to explain the causal relationship of these associations.

Summary Background The prevalence of chronic wrist pain and subsequent functional decline is increasing. Diagnosis is challenging, with non-surgical treatment frequently failing. Recently, partial wrist denervation (PWD) has gained popularity as a procedure to alleviate chronic pain. Methods A systematic review was performed in April 2019. Inclusion criteria involved clinical studies with a minimum of ten wrists, focusing on PROMs, objective measures of function and complications. Papers investigating complete or mixed denervation procedures were excluded. Results Nine studies were included (292 wrists), all of which were observational in study design and limited in patient numbers, evaluation techniques and follow-up length. PWD appears to be associated with a reduction in pain, and functional improvement. Further surgery was required in 54 (24%) wrists at an average follow-up of 18 months. PWD was not found to complicate further surgery. Conclusion PWD is associated with improvement in short-term pain relief and functional status, yet carries a high re-operation rate without contraindicating further salvage surgery. Further research is required to evaluate the benefits, duration of relief and long-term complications of PWD.

Background Computerised adaptive testing (CAT) has the potential to transform plastic surgery outcome measurement by making patient-reported outcome measures (PROMs) shorter, individualised and more accurate than pen-and-paper questionnaires. Objectives This paper reports the results of two optimisation studies for the CLEFT-Q CAT, a CAT intended for use in the field of cleft lip and/or palate. Specifically, we aimed to identify the optimal score estimation and item selection methods for using this CAT in clinical practice. These represent two major components of any CAT algorithm. Method Monte Carlo simulations were performed using simulated data in the R statistical computing environment and incorporated a range of score estimation and item selection techniques. The performance and accuracy of the CAT was assessed by mean items administered, correlation between CAT scores and paired linear assessment scores, and the root mean squared deviation (RMSD) of these score pairs. Results The accuracy of the CLEFT-Q CAT was not significantly affected by the choice of score estimation or item selection method. Sub-scales which originally contain more items were amenable to greater item reduction with CAT. Conclusion This study shows that score estimation and item selection methods that need minimal processing power can be used in the CLEFT-Q CAT without compromising accuracy. This means that the CLEFT-Q CAT could be administered quickly and efficiently with basic hardware demands. We recommend the use of less computationally intensive techniques in future CLEFT-Q CAT studies.

It has been suggested that Dupuytren’s disease has an origin in Norse countries. We harnessed data from a genome-wide association study of Dupuytren’s disease and the People of the British Isles study to determine evidence for a Norse origin of Dupuytren’s disease. We computed Wright’s Fixation Index between Orkney (Norse ancestry), Wales (ancient British) and South East England (Anglo-Saxons); compared mean Wright’s Fixation Index in cases versus controls; used permutation to determine any excess of Norse inheritance in disease associated variants; constructed a genetic risk score for Dupuytren’s disease and applied this to the People of the British Isles dataset to look for systematic differences between counties with known high and low levels of Norse ancestry. Finally, chromosome painting was used to see whether Dupuytren’s disease-associated single nucleotide polymorphisms are geographically structured. In all analyses, no evidence was found for an excess of Norse ancestry in Dupuytren’s disease. We conclude that there is no genetic evidence for a ‘Viking origin of Dupuytren’s disease’.

The exponential increase in the volume and complexity of healthcare data presents new challenges to researchers and clinicians in analysis and interpretation. The requirement for new strategies to extract meaningful information from large, noisy datasets has led to the development of the field of big data analytics. Artificial intelligence (AI) is a general-purpose technology in which machines carry out tasks traditionally thought to be only achievable by humans. Machine learning (ML) is an approach to AI in which machines can “learn” to perform tasks in an automated process, rather than being explicitly programmed by a human. Research aiming to apply ML techniques to classification, prediction and decision-making problems in healthcare has increased 61-fold from 2005 to 2019, mirroring this sense of early promise. The field of healthcare ML is relatively young, and many critical steps are needed before adoption into clinical practice, including transparent, unbiased development and reporting of algorithms. Articles claiming that machines can outperform, or replace, doctors in high-level tasks, such as diagnosis or prognostication, must be carefully appraised. It is critical that surgeons have an understanding of the principles and terminology of AI and ML to evaluate these claims and to take an active role in directing research. This article is an up-to-date review and primer for surgeons covering the core tenets of ML applied to surgical problems, including algorithm types and selection, model training and validation, interpretation of common outcome metrics, current and future reporting guidelines and discussion of the challenges and limitations in this field.

Background:Dupuytren disease (DD) is multifactorial, with several genetic and environmental risk factors contributing to disease susceptibility. High body mass index, however, was suggested to be protective of DD.1 The impact of weight loss among obese patients on DD has not been assessed to date.Objectives:To assess the association between bariatric surgery and DD in a secondary care setting.Methods:We performed a propensity score (PS)-matched cohort study using data from Swedish nationwide healthcare registries (patient registry [secondary care], causes of death registry, prescribed drug registry). Patients aged 30-79 years who underwent bariatric surgery between 2006 and 2019 were matched to up to 2 obese bariatric surgery-free patients (called unexposed patients) based on their PS. PS-matching was carried out in risk set sampling to reduce selection bias, within 4 sequential cohort entry blocks to account for time trend biases. The outcome DD was defined as a diagnosis of DD in secondary care or partial or total fasciotomy of wrist or hand. After a 1-year run-in period, patients were followed in an “as-treated” approach. We applied Cox proportional hazard regression to calculate hazard ratios (HR) with 95% confidence intervals (CIs) of incident DD among bariatric surgery patients when compared to obese unexposed patients overall, and in subgroups of age, sex, bariatric surgery type, and by duration of follow-up.Results:A total of 34 959 bariatric surgery patients were PS-matched to 54 769 obese unexposed patients. A total of 71.6% of bariatric surgery patients were women. Bariatric surgery patients had a mean age of 45.5 years and a mean follow-up of 6.9 years. All patient characteristics in obese unexposed patients were highly similar. We observed 126 and 136 severe DD cases among bariatric surgery and obese unexposed patients, respectively. The risk of DD was significantly increased in bariatric surgery patients compared to obese unexposed patients (HR = 1.30, 95% CI 1.02-1.65). The risk of DD was higher in women (HR = 1.36, 95% CI 1.00-1.84) than in men (HR = 1.05, 95% CI 0.70-1.58). Age did not modify the risk of DD among bariatric surgery patients compared to obese unexposed patients. Malabsorptive bariatric surgery yielded an increased risk of DD when compared to obese unexposed patients (HR = 1.33, 95% CI 1.04-1.71), while restrictive bariatric surgery yielded a null result. The risk of DD increased with duration of follow-up (>5 years of follow-up: HR = 1.63, 95% CI 1.14-2.34, null result in earlier follow-up).Conclusion:Our results suggest that substantial weight loss is associated with a latent increased risk of severe DD in an obese population. This observation further strengthens current evidence that high body mass index is protective against DD. The latency of risk increase of DD after bariatric surgery may suggest that slowly adapting metabolic changes may be part of the mechanism of DD emergence.References:[1]Hacquebord JH, Chiu VY, Harness NG. The Risk of Dupuytren Surgery in Obese Individuals. J Hand Surg Am. 2017, 42: 149–55.Acknowledgements:We thank Prof. Dr. Jesper Lagergren (Karolinksa Institutet, Stockholm, Sweden) for hosting Dr. Theresa Burkard for a research stay at the Upper Gastrointestinal Surgery Group and making the data available for use. Furthermore, we thank Dr. Giola Santoni (Karolinksa Institutet, Stockholm, Sweden) for her technical support.Disclosure of Interests:None declared

Background:Carpal tunnel syndrome (CTS) is a chronic compression neuropathy caused by entrapment of the median nerve in the wrist causing pain and sensory loss. Prior observational research suggested that obesity increased the risk of CTS. However, the impact of weight loss among obese patients on CTS has not been assessed to date.Objectives:To assess the association between bariatric surgery and CTS in a secondary care setting.Methods:We performed a propensity score (PS)-matched cohort study using data from Swedish nationwide healthcare registries (patient registry [secondary care], causes of death registry, prescribed drug registry). Patients aged 18-79 years who underwent bariatric surgery between 2006 and 2019 were matched to up to 2 obese bariatric surgery-free patients (called unexposed patients) based on their PS. PS-matching was carried out in risk set sampling to reduce selection bias, within 4 sequential cohort entry blocks to account for time trend biases. The outcome CTS was defined as a diagnosis of CTS in secondary care or carpal tunnel decompression surgery. After a 1-year run-in period, patients were followed in an “as-treated” approach. We applied Cox proportional hazard regression to calculate hazard ratios (HR) with 95% confidence intervals (CIs) of CTS among bariatric surgery patients when compared to obese unexposed patients overall, and in subgroups of age, sex, bariatric surgery type, and by duration of follow-up.Results:A total of 40 619 bariatric surgery patients were PS-matched to 63 540 obese unexposed patients. A total of 72.3% of bariatric surgery patients were women. Bariatric surgery patients had a mean age of 41.7 years and a mean follow-up of 6.8 years. All patient characteristics in obese unexposed patients were highly similar. We observed 1 356 and 1 938 severe CTS cases among bariatric surgery and obese unexposed patients, respectively. Bariatric surgery was not associated overall with CTS (HR of 0.98, 95% CI 0.91-1.05). However, the risk of CTS seemed to decrease with age at bariatric surgery – the lowest CTS risk was observed among bariatric surgery patients aged 18-34 years (HR of 0.87, 95% CI 0.74-1.01), when compared to obese unexposed patients. Sex did not modify the risk of CTS among bariatric surgery patients compared to obese unexposed patients. Restrictive bariatric surgery yielded lower risks of CTS (HRs of 0.81, 95% CI 0.69-0.88) than did malabsorptive bariatric surgery (HR of 0.95, 95% CI 0.88-1.02) when compared to obese unexposed patients. The risk of CTS increased with duration of follow-up. The lowest risk was observed 1-3 years after bariatric surgery (HR of 0.77, 95% CI 0.68-0.88) and the highest risk 6-13 years after bariatric surgery (HR of 1.20, 95% CI 1.05-1.36) when compared to obese unexposed patients.Conclusion:Our results suggest that substantial weight loss is not overall associated with severe CTS in an obese patient population. However, bariatric surgery was associated with an initial decreased risk of CTS after bariatric surgery followed by an increased risk in later follow-up. Furthermore, restrictive bariatric surgery but not malapsorptive bariatric surgery was associated with a decreased risk of CTS.Acknowledgements:We thank Prof. Dr. Jesper Lagergren (Karolinksa Institutet, Stockholm, Sweden) for hosting Dr. Theresa Burkard for a research stay at the Upper Gastrointestinal Surgery Group and making the data available for use. Furthermore, we thank Dr. Giola Santoni (Karolinksa Institutet, Stockholm, Sweden) for her technical support.Disclosure of Interests:None declared.

Background One of the complications of lymphoedema is recurrent cellulitis. The aim was to determine whether lymphaticovenous anastomosis (LVA) was effective at reducing cellulitis in patients with lymphoedema. Methods This was a retrospective review of patients with arm/leg lymphoedema who underwent LVA. The frequency of cellulitis was compared before and after surgery. The diagnostic criteria for cellulitis were a fever of 38·5°C or higher, and warmth/redness in the affected limb(s). Results A total of 95 patients were included. The mean number of episodes of cellulitis in the year preceding surgery was 1·46, compared with 0·18 in the year after surgery (P < 0·001). Conclusion LVA reduced the rate of cellulitis in these patients with lymphoedema.

The role of cooling in the acute management of burns is widely accepted in clinical practice, and is a cornerstone of basic first aid in burns. This has been underlined in a number of animal models. The mechanism by which it delivers its benefit is poorly understood, but there is a reduction in burns progression over the first 48 h, reduced healing time, and some subjective improvements in scarring when cooling is administered after burning. Intradermal temperature normalises within a matter of seconds to a few minutes, yet the benefits of even delayed cooling persist, implying it is not simply the removal of thermal energy from the damaged tissues. Animal models have used oedema formation, preservation of dermal perfusion, healing time and hair retention as indicators of burns severity, and have shown cooling to improve these indices, but pharmacological or immunological blockade of humoural and cellular mediators of inflammation did not reproduce the benefit of cooling. More recently, some studies of tissue from human and animal burns have shown consistent, reproducible, temporal changes in gene expression in burned tissues. Here, we review the experimental evidence of the role and mechanism of cooling in burns management, and suggest future research directions that may eventually lead to improved treatment outcomes.

Supplemental Digital Content is available in the text., Background: Dupuytren’s disease is a common, chronic, fibroproliferative disease of the palmar fascia. The cause is unclear but includes genetic predisposition alongside environmental factors. Several studies have suggested an association between Dupuytren’s disease and excess mortality. The authors aimed to evaluate this association in adult patients in the United Kingdom and identify the causes of mortality. Methods: The authors used a large primary care database (Clinical Practice Research Datalink) linked to the Office of National Statistics to identify patients with Dupuytren’s disease between January 1, 1995, and December 31, 2013. Each patient was matched by age, sex, and general practitioner to five control patients without the disease. Cox regression models were used to study the association between Dupuytren’s disease and all-cause and cause-specific mortality, adjusting for confounders. Results: A total of 41,965 Dupuytren’s disease patients and 209,825 control patients were identified. The all-cause mortality rate was increased in both unadjusted (hazard ratio, 1.48; 99% CI, 1.29 to 1.70; p < 0.0001) and multivariable adjusted (hazard ratio, 1.43; 99% CI, 1.25 to 1.65; p < 0.0001) models in patients with Dupuytren’s disease, 12 years after diagnosis. Excess mortality was secondary to a wide range of causes, including cancer (hazard ratio, 1.66; 99% CI, 1.27 to 2.17; p < 0.0001), an effect that persisted after adjustment for confounders. Conclusions: There is excess mortality associated with Dupuytren’s disease that can be partially explained through environmental factors. From time of diagnosis in primary care, there is a 12-year window of opportunity for intervention to reduce the impact of these factors. The authors observed an increased risk of cancer mortality independent of confounders, and hypothesize a shared genetic risk between Dupuytren’s disease and cancer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Burn injuries are a major cause of morbidity and mortality worldwide. Cooling is widely practised as a first aid measure, but the efficacy of cooling burns in human skin has not been demonstrated. A safe, consistent, ethically acceptable model of burning and cooling in live human skin in vivo was developed, and used to quantify the effects of cooling.Novel apparatus was manufactured to create and cool burns in women who were anaesthetized for breast reconstruction surgery using a deep inferior epigastric artery perforator flap. Burns were excised between 1 and 3 h after creation, and analysed using histopathological assessment.All 25 women who were approached agreed to take part in the study. There were no adverse events. Increased duration of contact led to increased burn depth, with a contact time of 7·5 s at 70°C leading to a mid-dermal burn. Burn depth progressed over time following injury, but importantly this was modified by cooling the burn at 16°C for 20 min. On average, cooling salvaged 25·2 per cent of the dermal thickness.This study demonstrated the favourable effects of cooling on human burns. Public heath messaging should emphasize cooling as first aid for burns. This model will allow analysis of the molecular effects of cooling burns, and provide a platform for testing novel therapies aimed at reducing the impact of burn injury.Las lesiones por quemadura son una causa importante de morbilidad y mortalidad en todo el mundo. El enfriamiento de las quemaduras se practica ampliamente como medida de primeros auxilios, pero no se ha demostrado su eficacia en la piel de los seres humanos. Para cuantificar los efectos del enfriamiento, se desarrolló un modelo de quemadura y enfriamiento en piel humana in vivo, seguro, estable y éticamente aceptable. MÉTODOS: Se construyó un dispositivo nuevo para crear y enfriar quemaduras en pacientes que fueron anestesiadas para una reconstrucción mamaria utilizando un colgajo perforante de la arteria epigástrica inferior profunda. Las quemaduras se extirparon entre una y tres horas después de su producción y se analizaron por evaluación histopatológica. Para determinar la significación estadística entre grupos se utilizó las pruebas de ANOVA o de t pareadas, según correspondiera.Aceptaron participar en el estudio las 25 pacientes a las que se propuso. No hubo efectos adversos. La mayor duración del contacto conllevó un aumento en la profundidad de la quemadura: con un tiempo de contacto de 7,5 segundos a 70°C se obtuvo una quemadura dérmica de segundo grado. La profundidad de la quemadura aumentó con el tiempo de exposición, pero mejoró de forma sustancial al enfriar la quemadura a 16°C durante 20 minutos. El enfriamiento salvó el 25% del espesor dérmico como promedio. CONCLUSIÓN: Este es el primer estudio que demuestra los efectos favorables del enfriamiento sobre las quemaduras humanas. Los consejos de salud deberían hacer más énfasis en el enfriamiento como forma de primeros auxilios en las quemaduras. Este modelo permitirá identificar los efectos moleculares del enfriamiento en las quemaduras y proporcionará una plataforma para probar nuevos tratamientos encaminados a reducir el impacto de las lesiones por quemadura.

Objective As survival from cancer continues to improve, greater importance is placed on quality of life after surgery.Lymphoedemais a common and disabling complication of cancer treatment. Lymphaticovenularanastomosis(LVA) is a supermicrosurgical treatment option for lower limb lymphoedema. The aim of this study was to assess the effectiveness of LVA in reducing limb volume and its effect on quality of life of patients with secondary leg lymphoedema following treatment for cancer, includinggynaecological cancers. Methods Limb volume and patient rated quality of life were collected prospectively pre-operatively and at every post-operative appointment in this case series. All patients presenting to the clinic with stable or progressive leg lymphoedema despiteconservative therapywho were suitable candidates for LVA over a three-year period were included. Results Twenty-nine patients were treated with LVA, 19 for unilateral lymphoedema and 10 for bilateral. In unilateral cases median limb excess volume reduced from 27% to 16% post-operatively (pp Conclusions In selected patients with early stagelymphoedema secondaryto cancer treatment, LVA offers a minimally invasive surgical option that can achieve significant volumetric and quality of life improvements.

Hospital Episode Statistics (HES) include freely accessible records of all hospital episodes in England. We analysed HES from 1998–1999 to 2014–2015 for diagnoses of hand fractures, tendon injuries, nerve injuries, blood vessel injuries, traumatic amputations and nail bed injuries. Population data were used to calculate the incidence. The overall incidence of the injuries increased from 70 to 110 per 100,000. There were especially large increases in the incidence of fractures in the over 75 years age group and nail bed injuries in the 0–14 years age group. The incidence of nerve injuries also increased. We conclude from this study that HES is a useful tool. The information from HES may help plan service provision and also highlight important clinical problems that may benefit from further research.

Introduction Recurrent cellulitis is a frequent and challenging complication of lymphoedema. British Lymphology Society cellulitis guidelines state that decongestive lymphatic therapy reduces the frequency of cellulitis attacks, but do not mention the effect of surgical interventions. This systematic review aims to assess whether surgical interventions for lymphoedema reduce the frequency of attacks of cellulitis. Materials and methods Embase, Medline, and the Cochrane database were searched for relevant articles from database inception to January 2016. Four hundred and thirty-six abstracts were retrieved. Studies were included which contained quantitative data on cellulitis incidence before and after a surgical intervention. Two independent reviewers applied selection criteria, selecting 27 papers for full text review. Two were unavailable in the UK from any source. Results A variety of surgical techniques were utilized in the 25 papers included: lymphaticovenous anastomosis, superficial-to-deep lymphaticolymphatic anastomosis, lymph node transfer, Charles procedure, muscle flap transfer, Homan's procedure, and subcutaneous tissue excision below skin flaps. Five studies combined techniques. One study compared the intervention to a control group (physical therapy). Cellulitis incidence was decreased following surgical intervention in 24/25 studies included. Eight had quantifiable reductions in cellulitis over a set follow-up period; in the other 16 preoperative incidence was not precisely defined. Conclusion Surgery appears effective at reducing cellulitis incidence in lymphoedema. However, high quality evidence from randomized controlled trials is lacking. Future research should concentrate on comparison with control groups, for example compression alone versus compression with surgical intervention, in patients with lymphoedema and greater than two attacks of cellulitis per year.

We carried out a systematic review to determine the incidence of infection for hand surgery done in settings other than the operating theatre. Databases were searched and a PRISMA chart created by three independent reviewers. From 1200 studies identified, 46 full text articles were reviewed and six were included (two Level 3 studies and four Level 4). In three studies there were no infections after surgery in an office, procedure room or emergency department. Two studies with a combined number of 1962 procedures reviewed carpal tunnel decompressions and reported identical infection rates of 0.4%. Although the current evidence is of poor quality, it suggests that some types of hand surgery may be done outside the operating theatre without increasing the risk of infection.Level of evidence: IV

Background Despite numerous studies over the past few decades, the optimum strategy for deciding when to remove drains following axillary lymphadenectomy remains unknown. This meta-analysis aims to compare time-limited and volume-controlled strategies for drain removal. Methods A total of 584 titles were identified following a systematic literature search of EMBASE, MEDLINE, Cinahl and the Cochrane library; 6 titles met our eligibility criteria. Data were extracted and independently verified by two authors. Time-limited drain removal was defined as drain removal at Results In all the studies, the time-limited approach resulted in earlier drain removal. Development of a seroma is 2.54 times more likely with early drain removal (Mantel-Haenszel Fixed Odds Ratio (OR) 2.54, p < 0.00001). However, there is no difference in infection rates between early and late drain removal (OR Z 1.07, p Z 0.76). Conclusions This meta-analysis demonstrates that a strategy of early drain removal following axillary lymphadenectomy is safe, with no difference in infection rates; however, the incidence of seroma is significantly higher, which may necessitate more demanding outpatient care. There is a need for further well-designed clinical trials to address the clinical equipoise in this common area of surgical practice.

Objective To determine the evidence-based optimal strategy for management of drains following axillary dissection. Background Despite randomised control trials addressing the issue over the past 20–30 years, there is no widely accepted consensus as to when drains should be removed post axillary dissection. Methods We searched the electronic databases Medline, Embase, Cinahl, Cochrane Library of Systematic Reviews and Web of Science Citation Index. References within identified studies were also searched. Studies were independently identified and data extracted according to a pre-determined proforma based on the Cochrane Collaboration data extraction template by two independent researchers. Validity was determined according to a published standard. Discrepancies were corrected by consensus. Results There was no difference in infection rates between early and late drain removal, hospital stay was reduced when drains were removed earlier, and higher total volume drainage prior to drain removal predicted subsequent seroma formation. The optimal timing of drain removal post axillary dissection could not be determined from the literature. Conclusion Optimal timing of drain removal following axillary dissection remains unknown after this systematic review due to heterogeneity between included studies leading to an inability to provide evidence-based consensus guidance.

Background Groin dissection is commonly performed for the treatment of a variety of cancers, including melanoma, and squamous cell carcinoma of the skin, penis or vulva. It is uncertain whether insertion of a drain reduces complication rates, and, if used, the optimum time for drain removal after surgery is also unknown. Objectives To assess the current level of evidence to determine whether placement of a drain is beneficial after groin dissection in terms of reducing seroma, haematoma, wound dehiscence and wound infection rates, and to determine the optimal type and duration of drainage following groin dissection if it is shown to be beneficial. Search methods In September 2014 we searched the following electronic databases using a pre-designed search strategy: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library). In November 2013 we searched Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting. Selection criteria We considered all randomised controlled trials (RCTs) comparing wound drainage with no wound drainage in individuals undergoing groin dissection, where the most superior node excised was Cloquet's node (the most superior inguinal lymph node). No limits were applied to language of publication or trial location. Two review authors independently determined the eligibility of each trial. Data collection and analysis Two review authors, working independently, screened studies identified from the search; there were no disagreements. Main results We did not identify any RCTs that met the inclusion criteria for the review. Authors' conclusions There is a need for high quality RCTs to guide clinical practice in this under-researched area.

Inguinal lymphadenectomy, or groin dissection, has a key role in the management of patients with penile, vulval, anal, and cutaneous malignancy. About 500 procedures are performed in the United Kingdom each year by general, gynaecological, plastic, and urological surgeons. Groin dissection is associated with high postoperative morbidity, chiefly related to wound healing and lymphoedema. As the preoperative diagnosis and postoperative care of these patients may also involve general practitioners, oncologists, dermatologists, and specialist nurses, this review is aimed at providing a concise yet comprehensive summary of the key aspects of managing inguinal lymph nodes. We searched the Cochrane Library and Medline online databases, using the terms “inguinal lymphadenectomy”, “groin dissection”, and “sentinel lymph node biopsy”, combined with “melanoma”, or “carcinoma” and either “vulva”, “penis”, or “anus”. We reviewed abstracts and selected relevant articles. ### Tumours of the male genital tract Squamous cell carcinoma is the most common tumour of the penis (table 1, accounting for 95% of primary penile malignancies.w1 Relatively uncommon in developed countries, it accounts for up to 17% of all male malignancies in developing countries.1 2 Penile malignancy affects about 800 men per annum in the United Kingdom.1 The mean age of affected individuals is 64.1 Palpable inguinal lymphadenopathy at presentation may represent metastatic disease or secondary inflammation, so a four to six week course of oral antibiotics is usually prescribed, followed by re-evaluation of the lymphadenopathy. However, studies have shown that up to 20% of patients with no palpable lymphadenopathy will have nodal metastasis.w2 View this table: Table 1 Pathology of tumours commonly metastasising to the inguinal lymph nodes ### Tumours of the female genital tract Tumours arising from the vulva and lower third of the vagina metastasise to the inguinal lymph nodes. Vaginal tumours are rare and will not be considered further here. Squamous cell carcinoma is the most common tumour of the vulva (table 1), and 1996 …

Objective Pelvic lymphocele can be a severe complication associated with surgical procedures such as pelvic lymphadenectomy. Lymphaticovenular anastomosis (LVA) is increasing in popularity as a surgical treatment for lymphedema. The aim of this study was to evaluate whether LVA is an effective treatment for lymphocele, which is caused by an obstruction of the lymphatic flow in a manner similar to the development of lymphedema. Methods Eleven female patients, who presented with lymphocele, were treated with LVA. Before the operation, 3 of them were treated with a percutaneous catheter. Lymphocele size and the volume of daily drainage were measured before and after LVA. Results The lymphocele was completely resolved in 6 patients and partially resolved in the remaining 5 patients. The mean size of the pelvic lymphocele changed from 400 ml (range 50-1050 ml) to 43 ml (range 0-120 ml) (P < 0.01). In the 3 patients who had percutaneous drainage catheters, the volume of fluid drained decreased from 340 ml/day to 20 ml/day after LVA. Conclusions Our technique is minimally invasive and is performed under local anesthesia. LVA is effective regardless of the size of the lymphocele. Therefore, LVA should be considered as a therapy for lymphocele because of its low invasiveness and its effectiveness in re-establishing circulation of lymphatic flow. Further studies should be performed to compare LVA with other minimally invasive techniques, such as percutaneous catheter and sclerotherapy. © 2012 Elsevier Inc. All rights reserved.