A Comparison of Thermal Plasma Energy Versus Argon Beam Coagulator-Induced Intestinal Injury After Vaporization in a Porcine Model

Plasma Device Functions and Tissue Effects in the Female Pelvis-A Systematic Review

Medical use of (non-)thermal plasmas is an emerging field in gynaecology. However, data on plasma energy dispersion remain limited. This systematic review presents an overview of plasma devices, fields of effective application, and impact of use factors and device settings on tissues in the female pelvis, including the uterus, ovaries, cervix, vagina, vulva, colon, omentum, mesenterium, and peritoneum. A search of the literature was performed on 4 January 2023 in the Medline Ovid, Embase, Cochrane, Web of Science, and Google Scholar databases. Devices were classified as plasma-assisted electrosurgery (ES) using electrothermal energy, neutral argon plasma (NAP) using kinetic particle energy, or cold atmospheric plasma (CAP) using non-thermal biochemical reactions. In total, 8958 articles were identified, of which 310 were scanned, and 14 were included due to containing quantitative data on depths or volumes of tissues reached. Plasma-assisted ES devices produce a thermal effects depth of <2.4 mm. In turn, NAP effects remained superficial, <1.0 mm. So far, the depth and uniformity of CAP effects are insufficiently understood. These data are crucial to achieve complete treatment, reduce recurrence, and limit damage to healthy tissues (e.g., prevent perforations or preserve parenchyma). Upcoming and potentially high-gain applications are discussed, and deficits in current evidence are identified.

The effects of neutral argon plasma versus electrocoagulation on tissue in advanced-stage ovarian cancer: a case series

BACKGROUND

The aim of surgery for advanced-stage ovarian cancer is a complete cytoreduction, because this is the most important independent prognostic factor for prolonged survival. Yet this can be difficult to achieve when there are micrometastases on the intestinal mesentery or intestines. The PlasmaJet device is an instrument to remove these micrometastases, but little is known about the depth of damage in human tissue compared to electrocoagulation devices.

METHODS

A prospective study was performed for the ex-vivo comparison of the histological depth of thermal damage of neutral argon plasma (PlasmaJet®) and electrocoagulation devices, in a series of 106 histological slides of 17 advanced-stage ovarian cancer patients. Depending on the tissue types resected during complete cytoreductive surgery, samples were collected from reproductive organs (uterus, ovaries), intestines (ileum, colon, rectum) and omentum, intestinal mesentery and peritoneum.

RESULTS

Average thermal damage depth was 0.15 mm (range 0.03-0.60 mm) after use of neutral argon plasma and 0.33 mm (range 0.08-1.80 mm) after use of electrocoagulation (p < 0.001). Greater disruption of the tissue surface was often observed after electrocoagulation.

CONCLUSION

Our case series suggests that the use of neutral argon plasma during cytoreductive surgery produces significantly less thermal damage than electrocoagulation treatment. It is therefore considered a thermally safe alternative, aiding in the achievement of cytoreductive surgery.

A New Technique for Breast Pocket Adjustment: Argon Beam Thermal Capsulorrhaphy

Implant malposition remains one of the main complications of aesthetic breast augmentation and alloplastic breast reconstruction with expanders and implants. Many capsulorrhaphy techniques have been described to adjust the breast pocket and correct the malposition. In this study, we tested the efficacy of the argon beam coagulator (ABC) for lateral capsulorrhaphy on breast reconstruction patients at the time of expander replacement with a permanent implant. We also experimentally compared the effects of the ABC and the standard electrocautery on fragments of healthy breast capsule. We noted a 69.5% capsule shrinkage with the ABC versus 46.8% with the standard electrocautery. We concluded that breast capsulorrhaphy using the ABC is a safe and efficient technique for the correction of breast implant malposition in both reconstructive and aesthetic breast surgery.

Use of Laparoscopic and Laparotomic J-Plasma Handpiece in Gynecological Malignancies: Results From A Pilot Study in A Tertiary Care Center

Introduction

The J-Plasma has recently been introduced into the surgical community with different intrinsic characteristics aimed to further reduce the thermal effect and enhance precision when compared to standard radiofrequency. This study aimed to investigate the role of this new technology in different conditions of gynecological carcinomatosis characterized by the indication for regional peritonectomy and/or ablation, either in laparotomy (LPT) or in laparoscopy (LPS), in the context of a modern personalized approach to the surgical management of gynecological malignancies.

Material and Methods

From January 2019 to April 2019, 12 patients were selected for this prospective pilot study at the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. In this single surgeon experience, the inclusion criteria were: histologically proven advanced ovarian/endometrial cancer, primary or interval debulking surgery, and intraoperative indication for regional peritonectomy. Six patients were treated by LPS (Group 1) and 6 by LPT (Group 2).

Results

In Group 1 the indication for debulking surgery was in 4 cases an interval debulking surgery and 2 advanced endometrial cancer. All patients in Group 2 underwent primary debulking surgery for advanced ovarian cancer. The whole cohort achieved a complete tumor excision after surgery. The median OT and median EBL were 195 min and 100 ml in Group 1, and 420 min and 500 ml in Group 2. The median hospital stay was 4 days in Group 1 and 13 days in Group 2, respectively. No intra and postoperative complications were registered within 60 days after surgery.

Conclusions

J-Plasma allows to approach delicate maneuvers on viscera, mesentery, and blood vessels with a high degree of safety and precision thanks to its limited vertical and lateral thermal spread, favoring the surgeon to push ever higher the cytoreduction/morbidity tradeoff. The use of J-Plasma in cytoreductive surgery could also increase the range of possible minimally invasive procedures, narrowing the technical distance with the open technique and thus contributing to designing a personalized surgical strategy for each patient in different scenarios of peritoneal carcinomatosis.

Adjuvant Use of PlasmaJet Device During Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: Results of the PlaComOv-study, a Randomized Controlled Trial in The Netherlands

Objective

Standard surgical treatment of advanced-stage ovarian carcinoma with electrosurgery cannot always result in complete cytoreductive surgery (CRS), especially when many small metastases are found on the mesentery and intestinal surface. We investigated whether adjuvant use of a neutral argon plasma device can help increase the complete cytoreduction rate.

Patients and Methods

327 patients with FIGO stage IIIB–IV epithelial ovarian cancer (EOC) who underwent primary or interval CRS were randomized to either surgery with neutral argon plasma (PlasmaJet) (intervention) or without PlasmaJet (control group). The primary outcome was the percentage of complete CRS. The secondary outcomes were duration of surgery, blood loss, number of bowel resections and colostomies, hospitalization, 30-day morbidity, and quality of life (QoL).

Results

Complete CRS was achieved in 119 patients (75.8%) in the intervention group and 115 patients (67.6%) in the control group (risk difference (RD) 8.2%, 95% confidence interval (CI) –0.021 to 0.181; P = 0.131). In a per-protocol analysis excluding patients with unresectable disease, complete CRS was obtained in 85.6% in the intervention group and 71.5% in the control group (RD 14.1%, 95% CI 0.042 to 0.235; P = 0.005). Patient-reported QoL at 6 months after surgery differed between groups in favor of PlasmaJet surgery (95% CI 0.455–8.350; P = 0.029). Other secondary outcomes did not differ significantly.

Conclusions

Adjuvant use of PlasmaJet during CRS for advanced-stage ovarian cancer resulted in a significantly higher proportion of complete CRS in patients with resectable disease and higher QoL at 6 months after surgery. (Funded by ZonMw, Trial Register NL62035.078.17.)

Trial Registration

Approved by the Medical Ethics Review Board of the Erasmus University Medical Center Rotterdam, the Netherlands, NL62035.078.17 on 20-11-2017. Recruitment started on 30-1-2018.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11763-2.

Lung Decortication With Argon Plasma Energy for the Treatment of Chronic Pleural Empyema

Lung decortication for the treatment of chronic pleural empyema remains a technically challenging procedure that is associated with bleeding and air leak. The recent advent of pure argon plasma has provided thoracic surgeons with an electrically neutral energy source for dissection and coagulation of pulmonary tissue with minimal depth of necrosis. In this article, we describe the technique of lung decortication with argon plasma energy (PlasmaJet, Plasma Surgical, Roswell, GA, USA) for the treatment of chronic pleural empyema. With appropriate application, the PlasmaJet can facilitate the removal of fibrous cortex with satisfactory hemostasis and aerostasis. Argon plasma energy can potentially be a useful adjunct in lung decortication. Controlled trials are needed to determine its role in the surgical management of advanced pleural empyema.

Experience with PlasmaJet™ in debulking surgery in 87 patients with advanced-stage ovarian cancer

OBJECTIVE

The aim was to evaluate the effectiveness and safety of PlasmaJet™ in cytoreductive surgery in patients with advanced-stage ovarian cancer.

METHODS

All patients between September 2013 and January 2018 undergoing surgical cytoreduction for advanced-stage ovarian cancer with the help of PlasmaJet™ were identified and analyzed retrospectively.

RESULTS

Eighty-seven patients diagnosed with advanced-stage ovarian cancer underwent surgery with PlasmaJet™. Primary debulking surgery was performed in 15 cases. Fifty-seven patients underwent interval debulking after neoadjuvant chemotherapy. Secondary and tertiary debulking was done in, respectively, 11 and three patients, and one patient underwent quaternary debulking using PlasmaJet™. In all 87 patients but one, complete resection of all macroscopic disease was obtained. PlasmaJet™ was used to remove carcinomatosis on the peritoneum, bowel serosa, intestinal mesentery, and lesions in the upper abdomen (diaphragm and liver surface). No damage to the bladder or ureter was noted in relation to the use of PlasmaJet™. Three patients developed a bowel leakage postoperatively. In one of these patients, PlasmaJet™ was used to treat tumoral implants in the affected region.

CONCLUSIONS

Our series suggests that the use of PlasmaJet™ is efficient and safe in obtaining complete resection of all macroscopic tumoral lesions in advanced-stage ovarian cancer.

Use of ablation and ultrasonic aspiration at primary debulking surgery in advanced stage ovarian, fallopian tube, and primary peritoneal cancer

OBJECTIVES

Ovarian cancer patients with miliary disease have the lowest rates of complete surgical resection and poorest survival. Adjunct surgical techniques may potentially increase rates of complete surgical resection. No studies have evaluated the use of these techniques in primary debulking surgery for ovarian cancer patients with miliary disease. The aim of this study was to examine the use of adjunct surgical techniques during primary debulking surgery for patients with advanced epithelial ovarian, fallopian tube, and primary peritoneal cancer with miliary disease.

METHODS

Medical records of patients with International Federation of Gynecology and Obstetrics (FIGO) stages IIIC-IVB epithelial ovarian, fallopian tube, or primary peritoneal cancer with miliary disease undergoing primary debulking surgery from January 2010 to December 2014 were reviewed. Adjunct surgical techniques were defined as ultrasonic surgical aspiration, argon enhanced electrocautery, thermal plasma energy, and traditional electrocautery ablation. Patients undergoing surgery with and without these devices were compared with respect to demographics, operative characteristics, postoperative complications, residual disease, progression free survival and overall survival.

RESULTS

A total of 135 patients with miliary disease underwent primary debulking surgery, of which 30 (22.2%) patients used adjunct surgical techniques. The most common devices were ultrasonic surgical aspiration (40%) and argon enhanced electrocautery (36.7%). The most common sites of use were diaphragm (63.3%), pelvic peritoneum (30%), bowel mesentery (20%), and large bowel serosa (20%). There were no differences in age, stage, primary site, histology, operative time, surgical complexity, or postoperative complications for patients operated on with or without these devices. Volume of residual disease was similar (0.1-1 cm: 60% with adjunct techniques versus 68.6% without; complete surgical resection: 16.7% with adjunct techniques versus 13.3% without; p=0.67). For patients with ≤1 cm residual disease, median progression free survival (15 versus 15 months, p=0.65) and median overall survival (40 versus 55 months, p=0.38) were also similar.

CONCLUSION

Adjunct surgical techniques may be incorporated during primary debulking surgery for patients with advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer with miliary disease; however, these do not improve the rate of optimal cytoreduction.

The Emerging Role of Neutral Argon Plasma (PlasmaJet) in the Treatment of Advanced Stage Ovarian Cancer: A Systematic Review

Objective. To evaluate the contribution of PlasmaJet application in achieving optimal cytoreduction in advanced ovarian cancer. Methods. We systematically searched for articles published up to June 2019 using MEDLINE, Scopus, Google Scholar databases and clinicaltrials.gov along with the references of the articles retrieved in full text. Observational studies and case reports addressing cases of women with peritoneal spread due to advanced stage ovarian cancer who were treated with application of PlasmaJet device were considered eligible for inclusion. Results. Three studies were excluded from further analysis when they were retrieved in full text. Five studies (2 retrospective, 1 prospective, and 2 case reports) that comprised 77 patients with age range from 38 to 85 years were included. Forty-three women underwent interval debulking surgery, 24 patients primary debulking surgery, and 6 had optimal debulking surgery, while in the remaining 4, a secondary debulking surgery was performed. Incidence of intraoperative complications was 32% (8/25), but none of them was due to the application of PlasmaJet. Complete macroscopic resection was achieved in 59 out of 70 (84.3%) women. Postoperatively, 17 out of 72 patients (23.6%) developed complications such as pneumothorax due to diaphragmatic resection, systemic infections, or wound-related complications. No postoperative mortality was recorded. Conclusions. Preliminary data on the use of PlasmaJet for ablation of ovarian cancer implants in the peritoneal cavity showed its safety and presented with promising outcomes in achieving complete cytoreduction.

Effectiveness and safety of the PlasmaJet® Device in advanced stage ovarian carcinoma: a systematic review

About 80 % of all women affected by ovarian cancer present with advanced stage disease at the time of diagnosis. Achieving complete cytoreduction is complicated when many small tumor spots are found. Yet, complete cytoreduction is the most important determinant of survival.

Application of a thermal plasma energy device to standard surgical instruments may help achieve complete cytoreduction. The ‘PlasmaJet® Device’ (Plasma Surgical, Inc., Roswell, GA, USA) is an electrically neutral device which emits a high–energy jet of argon plasma for direct tissue effects. We performed a literature review to investigate whether the use of the ‘PlasmaJet® Device’ in surgery of advanced stage ovarian carcinoma (FIGO IIIB-IV) is effective and safe.

The primary outcome was the proportion of complete cytoreductions. The secondary outcomes were: complication rate, proportion of colostomies applied, histological findings, disease-free survival and overall survival.

Five case series or reports were found, including a total of 77 patients with FIGO stage IIIC-IV ovarian cancer in whom the PlasmaJet® device was used for primary or interval debulking. Complete cytoreduction was obtained in 79% of the patients. Apart from one pneumothorax after extensive surgery, but no harm or additional complications related to the use of the PlasmaJet® Device were reported. Data on disease-free survival or overall survival were not reported.

These findings suggest that the PlasmaJet® Device is an efficient and safe innovative surgical device for debulking surgery with encouraging results. We have proposed an RCT in which we will compare feasibility, safety and effectiveness aspects of the use of the PlasmaJet® versus conventional electrosurgery in advanced stage epithelial ovarian cancer (FIGO IIIB-IV).