Tissue welding tonsillectomy provides an enhanced recovery compared to that after monopolar electrocautery technique in adults: a prospective randomized clinical trial

Postoperative recovery: how and when is it assessed: a scoping review

BACKGROUND

There is no consensus about the type of instrument with which to assess postoperative recovery or the time points when assessments are most appropriate. It is also unclear whether instruments measure the four dimensions of postoperative recovery, that is physical, psychological, social, and habitual recovery. This scoping review had three objectives: (1) to identify and describe instruments used in clinical trials to assess postoperative recovery; (2) to determine how, when, and the number of times postoperative recovery was measured; and (3) to explore whether the four dimensions of postoperative recovery are represented in the identified instruments.

METHODS

A literature search was conducted in CINAHL, MEDLINE, and Web of Science. The search terms were related to three search strands: postoperative recovery, instrument, and clinical trials. The limits were English language and publication January 2010 to November 2021. In total, 5015 studies were identified.

RESULTS

A total of 198 studies were included in the results. We identified 20 instruments measuring postoperative recovery. Different versions of Quality of Recovery represented 81.8% of the included instruments. Postoperative recovery was often assessed at one time point (47.2%) and most often on postoperative day 1 (81.5%). Thirteen instruments had items covering all four dimensions of postoperative recovery.

CONCLUSIONS

Assessing recovery is important to evaluate and improve perioperative care. We emphasise the importance of choosing the right instrument for the concept studied and, if postoperative recovery is of interest, of assessing more than once. Ideally, instruments should include all four dimensions to cover the whole recovery process.

Comparison of outcomes between thermal welding forceps, controlled ablation and monopolar electrosurgery for tonsillectomy in children

OBJECTIVE

To compare recovery from tonsillectomy using thermal welding forceps (TWF), controlled ablation (CA), and monopolar electrosurgery (MES) in children.

METHODS

This was a prospective single blinded observational study using data from electronic medical record (EMR) and caregiver completed patient diary, conducted at a community-based children's hospital within an academic program with tonsillectomy performed by attending surgeons. Children aged 3-17 years undergoing tonsillectomy or adenotonsillectomy by TWF, CA, or MES over a 4-year period were included. Demographics, intraoperative time for tonsillectomy, blood loss, patient diary documentation of pain levels, analgesic doses, diet type and events per day were recorded. In addition, EMR documentation of morbidity events (bleeding, visits for bleeding, return to operating room [OR], total visits or admissions, poor oral intake or dehydration) were noted. To assess for differences in baseline characteristics, we utilized analysis of variance and Pearson's χ² test. To determine primary outcomes, we used a multilevel mixed-effect linear regression model.

RESULTS

A total of 369 children were enrolled, and 346 who met inclusion criteria underwent tonsillectomy. The children were categorized by the instrument used by the surgeons: CA 32.4% (n = 112), MES 36.7% (n = 127), and TWF 30.9% (n = 107). Mean age overall was 6.8 ± 3.2 years, with 57.4% female and 42.6% male. Diary return rate was 52.3% (n = 181) overall, with CA at 48.2% (n = 54), MES at 44.8% (n = 57), and TWF at 65.4% (n = 70). Average pain on the day of surgery was different between instruments with CA having the lowest level of 2.0 compared to 2.7 for TWF and MES (p = 0.001). Maximum pain level for day of surgery were lowest for CA at 2.7 compared to 3.4 for MES and 3.5 for TWF (p = 0.003). Pain levels were lowest for TWF after postoperative day (POD) 6. Overall rate of bleeding was 9.3%, with 2.6% return to surgery for control of bleeding. TWF had the lowest rate of bleeds (4.7% versus CA 11.6% and MES 11.0%), return to surgery (0.0% versus CA 2.7% and MES 4.7%), the earliest and final return to regular diet at POD 5.8 and 8.1, respectively without reaching statistical significance.

CONCLUSION

CA had significantly lowest early pain levels on day 0-1 and trended lowest up to POD 6, after which TWF was lowest but did not reach statistical significance. TWF had the earliest return to regular diet. Children undergoing CA and MES are more likely to have a postoperative bleed and a return to the OR than TWF suggesting improved ability to seal vessels with the latter instrument. Further study with a larger sample is needed.

Comparison of outcomes and cost in patients undergoing tonsillectomy with electrocautery and thermal welding

PURPOSE

To assess the morbidity and efficacy of thermal tissue welder instrument for tonsillectomy and compare it with monopolar electrocautery.

MATERIALS AND METHODS

IRB approval was obtained at the Wexner Medical Center at Ohio State University for a prospective, randomized, single-blinded, controlled clinical study of 48 healthy adult volunteers undergoing tonsillectomy for chronic tonsillitis and tonsil hypertrophy. Subjects were randomized to the TW or EC group. Post-operative pain, pain medication use, return to normal oral intake, return to normal activity, and bleeding were measured on the post-operative log. We recorded operative time, operating room time, and blood loss. All procedures were performed by one surgeon to eliminate variations in time and experience. Operative and patient data were analyzed using a Student T-test and evaluated by cost analysis.

RESULTS

There was a statically significant increase in operative time with the TW taking an average of 4min longer per procedure, p<0.001. However, when total anesthesia time was compared, this did not translate into a statistically significant increase in total operating room time and therefore did not translate into additional cost. The remaining categories were not significantly different between the two groups. In 3/23 TW cases, suction cautery was required for hemostasis. Two patients had 3 occurrences of secondary bleeding in the electrocautery group and none in the tissue welder group. TW cost increase per case was $167 per instrument but averaged $700 per case.

CONCLUSIONS

While the tissue welder remains a viable option for the adult tonsillectomy procedure, it has not demonstrated in our study the necessary parameters intraoperatively, postoperatively, or via cost analysis to become the choice instrument at our institution. We cannot ignore the increase in cost that may be seen for short and routine procedures without an added benefit to the patient in terms of outcome or safety. A larger study is needed to determine if secondary bleeding rates are lower with this instrument.

High-frequency electric welding: a novel method for improved immediate chorioretinal adhesion in vitreoretinal surgery

PURPOSE

To evaluate high-frequency electric welding (HFEW) as a novel technique for retinopexy with improved immediate chorioretinal adhesion

METHODS

In a prospective, randomized, experimental study, we examined 104 eyes of 52 rabbits randomly assigned to either standard 810 nm endolaser retinopexy, alternating current 14-16 V or 18-20 V HFEW retinopexy. A full-thickness fragment of eye wall tissue containing the retinopexy was isolated 1 h, 3 days, 1 week, or 1 month respectively after the intervention, and fixed to an analytical electronic scale. A nylon suture passed through the retina was elevated by a biomechanical force elongation tester. The reduction in weight at the time of retinopexy rupture was registered as a measure for retinopexy adhesion strength.

RESULTS

One hour post-exposure, adhesive strengths were significantly higher in both HFEW groups than in controls (212 ± 26.6 mg and 122 ± 16 mg vs 104 ± 10 mg; p = 0.0001 and p = 0.024 respectively) while laser retinopexy did not significantly change adhesive strength (114 ± 14.0 mg, p = 0.149). Subsequent adhesive strengths were significantly increased for all retinopexy techniques: 3 days post-op 14-16 V HFEW 224 ± 30.0 mg (p = 0.001), 18-20 V HFEW 128 ± 15.6 (p = 0.001), laser 131 ± 12.7 mg (p = 0.0007); at 1 week 14-16 HFEW 235 ± 24.7 mg, 18-20 V HFEW 213 ± 22.4 mg, laser 188 ± 18.7 mg (all p ≤ 0.001); 1 month post-op 14-16 V HFEW 275 ± 32.0 mg, 18-20 V HFEW 283 ± 31.0 mg, laser 276 ± 21.7 mg, rspectively (all p ≤  0.0001).

CONCLUSION

HFEW represents a novel technique for retinopexy during vitreoretinal surgery. It allows firm chorioretinal adhesion immediately after exposure. In non-vitrectomized eyes, using 14-16 V is particularly effective.

Post-tonsillectomy morbidities: randomised, prospective controlled clinical trial of cold dissection versus thermal welding tonsillectomy

BACKGROUND

New surgical techniques and devices have been described that decrease post-tonsillectomy morbidities. This study aimed to compare the two most popular tonsillectomy techniques.

METHOD

Forty children underwent tonsillectomies using both the thermal welding and cold dissection techniques. In each patient, one side was removed with thermal welding and the other was removed with cold dissection.

RESULTS

There was a significant decrease in intra-operative blood loss, and the mean operation time was significantly lower on the thermal welding side compared with the cold dissection side. On the cold dissection side, tissue healing (i.e. the rate of complete tissue healing) was better and less pain was reported compared with the thermal welding side. However, there were no significant differences between the two techniques in terms of throat pain scores on the 1st, 3rd or 14th day post-operatively, or tissue healing scores on any of the post-operative days assessed.

CONCLUSION

Cold dissection resulted in better tissue healing and lower pain scores than thermal welding, but thermal welding was associated with less intra-operative blood loss and lower mean operation time than cold dissection.

Comparison of pediatric and adult tonsillectomies performed by thermal welding system

Objective. To compare pediatric and adult age groups in terms of postoperative bleeding and pain following tonsillectomy performed by thermal welding system (TWS). Method. The study consisted of 213 patients, of whom 178 were children and 35 were adults. The mean age of the pediatric patients (81 girls and 97 females) was 6.7 ± 2.4 years (range 3-13 years) and the mean age of the adults (20 males and 15 females) was 21.8 ± 7.07 years (range 15-41 years). All of the patients were evaluated in terms of postoperative bleeding and pain following tonsillectomy performed by TWS. Results. Bleeding was detected in the late postoperative period in 11 pediatric and 7 adult patients and of them 2 pediatric and 3 adult patients controlled under general. Postoperative bleeding was significantly less prevalent in the pediatric age group compared to the adult age group (P = 0.04). Likewise, postoperative pain was significantly less prevalent in the pediatric age group as compared to the adult age group (P < 0.001). Conclusion. Both postoperative bleeding and pain following tonsillectomy performed by TWS were more prevalent in the adult age group compared to the pediatric age group.

Comparison of three techniques in adult tonsillectomy

This study aimed at investigating the thermal welding (TW), classic dissection (CD) and bipolar cautery dissection (BCD) tonsillectomy in adults. 120 adults with chronic tonsillitis, who were scheduled for elective tonsillectomy between January 2009 and April 2012, were randomized to tonsillectomy with the TW, CD and BCD methods. Operation time, intraoperative blood loss, post-operative haemorrhage rate and especially post-operative pain were evaluated. The difference between operative time of the TW and BCD groups against CD group was statistically significant (p < 0.05). The difference between intraoperative blood loss of the TW and BCD groups against CD group was statistically significant (p < 0.05). No significant difference was found in the incidence of post-tonsillectomy haemorrhage between the three groups (p > 0.05). The difference between post-operative pain score between CD and TW was not statistically significant (p > 0.05). The difference between post-operative pain score of the two groups against BCD group was statistically significant (p < 0.05). TW technique is a relatively safe and reliable method with significantly less post-operative morbidity than CD and BCD tonsillectomy. When we compared TW with the CD and BCD tonsillectomy, we found significant reduction in the surgical time and the intraoperative blood loss without any increase in the post-operative pain.