Percutaneous radio-frequency ablation of hepatic metastases from colorectal cancer: long-term results in 117 patients

PURPOSE

To describe the results of an ongoing radio-frequency (RF) ablation study in patients with hepatic metastases from colorectal carcinoma.

MATERIALS AND METHODS

In 117 patients, 179 metachronous colorectal carcinoma hepatic metastases (0.9-9.6 cm in diameter) were treated with RF ablation by using 17-gauge internally cooled electrodes. Computed tomographic follow-up was performed every 4-6 months. Recurrent tumors were retreated when feasible. Time to new metastases and death for each patient and time to local recurrence for individual lesions were modeled with Kaplan-Meier analysis. Modeling determined the effect of number of metastases on the time to new metastases and death and effect of tumor size on local recurrence.

RESULTS

Estimated median survival was 36 months (95% CI; 28, 52 months). Estimated 1, 2, and 3-year survival rates were 93%, 69%, and 46%, respectively. Survival was not significantly related to number of metastases treated. In 77 (66%) of 117 patients, new metastases were observed at follow-up. Estimated median time until new metastases was 12 months (95% CI; 10, 18 months). Percentages of patients with no new metastases after initial treatment at 1 and 2 years were 49% and 35%, respectively. Time to new metastases was not significantly related to number of metastases. Seventy (39%) of 179 lesions developed local recurrence after treatment. Of these, 54 were observed by 6 months and 67 by 1 year. No local recurrence was observed after 18 months. Frequency and time to local recurrence were related to lesion size (P < or =.001).

CONCLUSION

RF ablation is an effective method to treat hepatic metastases from colorectal carcinoma.

Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia

The paper describes the technique of 'LLETZ' (large loop excision of the transformation zone), a new method of management for women with an abnormal cervical smear which offers the advantages of conization with those of local destruction. A large loop of thin wire forms a diathermy electrode that allows deep excision of the transformation zone with minimal tissue damage. The tissue removed can be examined histologically. The technique was used to investigate and treat 111 women with abnormal smears referred to the Bristol Royal Infirmary during 1986. Microinvasive disease was revealed in one woman where it was not suspected by cytology or colposcopic examination. Of 102 women followed up for at least 1 year by cytology, colposcopy and, where appropriate, histology, two women were found to have residual/recurrent cervical intraepithelial neoplasia.

Treatment for cervical intraepithelial neoplasia and risk of preterm delivery

CONTEXT

It is unclear whether treatments for cervical intraepithelial neoplasia (CIN) increase the subsequent risk of preterm delivery. Most studies have lacked sufficient sample size, mixed heterogeneous subtypes of preterm delivery, and failed to control for confounding factors.

OBJECTIVE

To determine whether cervical laser and loop electrosurgical excision procedure (LEEP) treatments increase risk of preterm delivery and its subtypes.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study conducted among women evaluated at a colposcopy clinic serving Auckland, New Zealand (1988-2000), comparing delivery outcomes of untreated women (n = 426) and those treated (n = 652) with laser conization, laser ablation, or LEEP. Record linkage using unique health identifiers identified women who had subsequent deliveries.

MAIN OUTCOME MEASURES

Total preterm delivery and its subtypes, spontaneous labor and premature rupture of membranes before 37 weeks' gestation (pPROM).

RESULTS

The overall rate of preterm delivery was 13.8%. The rate of pPROM was 6.2% and the rate of spontaneous preterm delivery was 3.8%. Analyses showed no significant increase in risk of total preterm delivery (adjusted relative risk [aRR], 1.1; 95% confidence interval [CI], 0.8-1.5) or spontaneous preterm delivery (aRR, 1.3; 95% CI, 0.7-2.6) for any treatment. Risk of pPROM was significantly increased following treatment with laser conization (aRR, 2.7; 95% CI, 1.3-5.6) or LEEP (aRR, 1.9; 95% CI, 1.0-3.8), but not laser ablation (aRR, 1.1; 95% CI, 0.5-2.4). Moreover, risk of pPROM and total preterm delivery increased significantly with increasing height of tissue removed from the cervix in conization. Women in the highest tertile of cone height (> or =1.7 cm) had a greater than 3-fold increase in risk of pPROM compared with untreated women (aRR, 3.6; 95% CI, 1.8-7.5).

CONCLUSIONS

LEEP and laser cone treatments were associated with significantly increased risk of pPROM. Careful consideration should be given to treatment of CIN in women of reproductive age, especially when treatment might reasonably be delayed or targeted to high-risk cases.

Long-term results of catheter ablation of idiopathic right ventricular tachycardia

Ten consecutive patients with recurrent episodes of symptomatic, idiopathic, sustained monomorphic ventricular tachycardia (VT) originating in the right ventricle underwent an attempt at catheter ablation of the ventricular tachycardia. There were seven women and three men, with a mean age of 39 +/- 14 years (+/- SD). None of the patients had any evidence of structural heart disease. The VT had a left bundle branch block configuration and an inferior axis in each patient, and the mean cycle length was 313 +/- 75 msec. Based on the methods of induction of the VT and the response of the VT to verapamil, the VT mechanism was presumed to be reentry in six patients, triggered activity in three patients, and catecholamine-sensitive automaticity in one patient. Sites for ablation were guided by pace mapping, and an appropriate target site was identified in the right ventricular outflow tract in each patient. From one to three shocks of 100-360 J (mean total, 336 +/- 195 J) were delivered from a defibrillator between the tip of the ablation catheter (cathode) and a patch electrode on the anterior chest (anode). An electrophysiology test 7-9 days after ablation demonstrated that VT was still inducible in only one patient, who was treated with amiodarone. One other patient had a recurrence of VT 3 weeks after ablation and was treated with verapamil. Eight of 10 patients were not treated with antiarrhythmic medications and have had no episodes of symptomatic VT during 15-68 months of follow-up (mean follow-up, 33 +/- 18 months). There were no acute or long-term complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Transurethral electrovaporization of the prostate: a novel method for treating men with benign prostatic hyperplasia

OBJECTIVES

To determine the preliminary safety and efficacy of transurethral vaporization of the prostate (TVP) using the VaporTrode as a therapeutic alternative in the management of men with bladder outlet obstruction.

METHODS

Twenty-five men (mean age, 63.5 +/- 3.1 years) with mild to moderate symptoms of prostatism underwent TVP since August 1994. Patients were assessed at baseline for both safety and efficacy and in follow-up at 1 week and 1 and 3 months. Efficacy parameters evaluated included operative time (in minutes), change in hematocrit and serum sodium, postoperative catheterization time, American Urological Association symptom score, peak uroflow (Qmax) and postvoid residual urine. Safety parameters evaluated included incidence of side effects, changes in serum sodium and hematocrit, and evaluation of sexual function.

RESULTS

Symptoms decreased from 17.8 to 5.9 and 4.2 at 1 and 3 months, respectively (P < 0.01). Qmax increased from 7.4 to 15.3 and 17.3 mL/s at 1 and 3 months, respectively (P < 0.02). Mean operative time was 40.3 minutes; mean interval to catheter removal was 14.6 hours. Changes in serum parameters included a 0.9 mL/dL decrease in hematocrit and a 1.1 mEq/L change in sodium. Complications of the procedure included mild hematuria (n = 3) and distal bulbar urethral stricture (n = 1). There were no associated significant postprocedure irritative symptoms and no patient required recatheterization.

CONCLUSIONS

TVP is a new and potentially useful modification of performing transurethral resection of the prostate. In this preliminary study, there has been significant clinical improvement maintained with minimal morbidity. This early clinical experience highlights several potential advantages of TVP, including significantly lower cost and minimal postoperative irritative symptom score. Currently, a multicenter clinical trial is under way to determine the long-term efficacy and safety of TVP.

Complications and recommended practices for electrosurgery in laparoscopy

BACKGROUND

Electrosurgery is one of the most commonly used energy systems in laparoscopic surgery. Two major categories of potential complications related to electrosurgery in laparoscopy are mechanical trauma and electrothermal injury. The latter can result from unrecognized energy transfer in the operational field or, less commonly, to unnoticed stray current outside the laparoscopic field of view. Stray current can result from insulation failure, direct coupling, or capacitive coupling.

METHODS

We reviewed the literature concerning essential biophysics of electrosurgery, including electrosurgical waveform differentiation, tissue effect, and variables that determine tissue effect. The incidence of electrosurgical injuries and possible mechanisms responsible for the injuries are discussed. Different types of injuries may result in different clinical manifestations and histopathological findings. Gross and microscopic pathological check-ups of the injury sites may distinguish between different mechanisms, and thus provide further clues postoperatively.

RESULTS

Several recommended practices are proposed to avoid electrosurgical injury laparoscopically. To achieve electrosurgical safety and to prevent electrosurgical injuries, the surgical team should have a good understanding of the biophysics of electrosurgery, the basis of equipment and general tissue effects, as well as the surgeon's spatial orientation and hand-eye coordination. Some intraoperative adjuvant procedures and newly developed safety devices have become available may aid to improve electrosurgical safety.

CONCLUSIONS

Knowledge of the biophysics of electrosurgery and the mechanisms of electrosurgical injury is important in recognizing potential complications of electrosurgery in laparoscopy. Procedures for prevention, intraoperative adjuvant maneuvers, early recognition of the injury with in-time salvage treatment, and alertness to postoperative warning signs can help reduce such complications.

The Effect of Loop Electrosurgical Excision Procedure on Future Pregnancy Outcome

OBJECTIVE

To estimate whether the loop electrosurgical excision procedure (LEEP) is associated with an adverse effect on the outcome of subsequent pregnancies.

METHODS

A retrospective cohort study was performed. The study group comprised women who had a LEEP in Halifax County between 1992 and 1999 and then had a subsequent singleton pregnancy of greater than 20 weeks of gestation with delivery at the IWK Health Centre in Halifax, Nova Scotia. The comparison group comprised women with no history of cervical surgery who were matched for age, parity, smoking status, and year of delivery. There were 571 women in each group. The primary outcome was rate of preterm delivery at less than 37 weeks of gestation. Secondary outcomes included delivery at less than 34 weeks and various neonatal and maternal outcomes. The effect of specific LEEP characteristics was analyzed separately.

RESULTS

Women who had a LEEP were more likely to deliver preterm overall (7.9% versus 2.5%; odds ratio [OR] 3.50, 95% confidence interval [CI] 1.90-6.95; P < .001) and to deliver preterm after premature rupture of membranes (PROM) (3.5% versus 0.9%; OR 4.10, 95% CI 1.48-14.09). The increase in delivery at less than 34 weeks was not statistically significant (1.25% versus 0.36%; OR 3.50, 95% CI 0.85-23.49; P = .12). Women with LEEP also delivered more low birth weight (LBW) infants (5.4% versus 1.9%; OR 3.00, 95% CI 1.52-6.46; P = .003). There were no differences in other neonatal or maternal outcomes. No association was found between the characteristics of the LEEP, including depth, and the rate of preterm delivery.

CONCLUSION

Loop electrosurgical excision procedure is associated with an increased risk of overall preterm delivery, preterm delivery after PROM, and LBW infants in subsequent pregnancies at greater than 20 weeks of gestation. Women who are considering future pregnancies should be counseled about these risks during informed consent for LEEP.

LEVEL OF EVIDENCE

II-2.

Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. An in vitro study

BACKGROUND

High-frequency (HF) electrocoagulation and cutting procedures produce smoke by high-temperature pyrolysis of tissues. As distinct from the experience of conventional surgery, electrosurgical smoke is produced in a closed gaseous environment during laparoscopic operations. As a result, toxic chemicals may be absorbed into the circulation. The effects of this absorption are not known. Furthermore, the chemical composition of electrosurgical smoke produced in an anoxic environment may be different from that produced in air.

METHODS

Smoke was produced in vitro by HF electrocutting of fresh porcine liver in helium, CO2, and air-saturated closed environments. Smoke samples were collected and analyzed by gas chromatography-mass spectrometry (GC-MS).

RESULTS

The chemical constituents of electrosurgical smoke produced in air, CO2, and helium were similar. To date, 21 chemicals, some highly toxic, have been identified in the electrosurgical smoke produced in a closed environment. These consist of hydrocarbons, nitriles, fatty acids, and phenols.

CONCLUSIONS

Electrosurgical smoke produced in a closed environment contains several toxic chemicals. The effects of these on cell viability, macrophage, and endothelial cell activation are not known but are being investigated. Meantime, measures to reduce smoke and evacuate it during endoscopic surgery are advisable.

Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery

The potential problems of monopolar electrosurgery relate to unrecognized energy transfer ("stray current") outside the view of the laparoscope. Mechanisms of stray current and unrecognized tissue injury include: (1) insulation breaks in electrodes; (2) capacitive coupling, or induced currents through the intact insulation of the active electrode to surrounding cannulas or other instruments; and (3) direct coupling (or unintended contact) between the active electrode and other metal instruments or cannulas within the abdomen. Capacitive coupling poses the greatest risk for injury when the outer conductor (trocar cannula or irrigation cannula) is electrically isolated from the abdominal wall by a plastic nonconductor. Capacitive coupling is increased by the coagulation mode (versus cut), open circuit (versus tissue contact with the electrode), 5-mm cannulas (versus 11 mm), and higher voltage generators. The safety of electrosurgery can be enhanced by surgical education regarding the biophysics of radio frequency electrical energy, technical choices in instruments using all-metal cannula systems, and engineering developments with a dynamically monitored system for insulation failure and capacitive coupling.

Risk of cervical stenosis after large loop excision or laser conization

OBJECTIVE

To assess the frequency of cervical stenosis in patients treated by laser conization or the loop electrosurgical excision procedure and to determine the preoperative and therapeutic factors associated with its occurrence.

METHODS

Two hundred fifty-five women treated by laser conization and 277 treated by loop electrosurgical excision procedure were followed regularly by postoperative colposcopy for mean periods of 38 and 16 months, respectively. Stenosis was defined as cervical narrowing that prevented insertion of a 2.5-mm Hegar dilator.

RESULTS

Thirty-eight cases of cervical stenosis, of which seven were complete, were diagnosed up to 28 months after treatment. The risk of postoperative cervical stenosis was higher for patients over 50 years of age (relative risk [RR] 3.07, 95% confidence interval [95% CI] 1.30, 7.26; P = .031), for those with a totally endocervical lesion (RR 3.79, 95% CI 1.88, 7.62; P = .001), for those with an excision 20 mm high or greater (RR 2.96, 95% CI 1.63, 5.38; P = .005), and for those with laser conization (RR 2.35, 95% CI 1.24, 4.46; P = .009). Parity, menopause, previous treatment for cervical intraepithelial neoplasia, satisfactory colposcopy, size of the lesion, its histologic diagnosis, and the extent of excision did not increase the risk for cervical stenosis. Excision was not as high with loop electrosurgical excision as with laser conization (14.3 +/- 5.0 mm versus 20.2 +/- 6.0 mm). The height of excision (RR 1.95, 95% CI 1.02, 3.76; P = .04) and a totally endocervical lesion (RR 5.07, 95% CI 1.96, 14.44; P = .001) were the only independent factors associated with postoperative stenosis identified by a multivariate analysis using logistic regression.

CONCLUSION

The height of excision and a totally endocervical lesion were the main factors associated with cervical stenosis. The decreased risk associated with the loop electrosurgical excision procedure seems to be due to a shorter endocervical excision.

Developments, complications and limitations of catheter-mediated electrical ablation of posterior accessory atrioventricular pathways

Nineteen patients with posterior accessory pathways and disabling, refractory arrhythmias, underwent catheter ablation using standard defibrillator pulses at energy settings of 150 to 400 J. Accessory pathway ablation was successful in 13 of 19 (68%). Effective catheter ablation correlated with local ventriculoatrial (VA) intervals determined from the coronary sinus catheter at the site of earliest retrograde atrial activation during orthodromic reciprocating tachycardia. In 12 of the 13 successfully ablated patients, the local VA interval was less than 80 ms. In 4 of the 6 unsuccessfully treated patients, the local VA interval was greater than or equal to 80 ms, p less than 0.01. Transient abnormalities noted with the procedure included sinus bradycardia (3 patients), atrioventricular block (5), accelerated junctional rhythm (3), ectopic atrial tachycardia (2), myocardial depression (1), "ischemic" appearing T-wave inversions (10) and hemodynamically insignificant small pericardial effusions (5) Creatine kinase-MB increased from 3 +/- 2 U/liter to 26 +/- 18 U/liter (p less than 0.001), 4 to 8 hours after ablation. In addition, electrical shorts occurring during the ablation procedure in 2 patients were identified and corrected only with oscilloscopic monitoring of voltage and current waveforms. Significant adverse sequelae were seen in 4 patients. Three patients required sternotomy for control of cardiac tamponade secondary to a ruptured coronary sinus and 1 patient had a small posterior left ventricular infarction related to spasm of a right coronary artery extension branch. Coronary sinus rupture correlated with the ratio of catheter diameter to coronary sinus diameter.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrosurgery in Otolaryngology???Head and Neck Surgery: Principles, Advances, and Complications

OBJECTIVES/HYPOTHESIS

Electrosurgical instruments are routinely used in many applications by otolaryngologist-head and neck surgeons; and a complete description of their historical development, physics of operation, histological effects, and technological advancements is necessary for our specialty to take full advantage of this instrumentation. Because of the electrical current, heat production, and common use associated with these instruments, compounded by the complex environments in which they are used, potential complications must be considered and are likely underreported in the literature. This thesis describes the important aspects of electrosurgery along with a study of complications so otolaryngologists can use these instruments to their fullest potential while limiting complications.

STUDY DESIGN

National survey of electrosurgical complications.

METHODS

A survey addressing potential complications of electrosurgery was developed based on a review of the electrosurgical and complications literature. The electrosurgical complications were organized in the following categories: 1) unanticipated direct burns as a result of the active electrode contacting some tissue unintentionally; 2) unintentional burns as a result of capacitive coupling where radiofrequency (RF) current passes through a metallic instrument (such as forceps) and burns tissue in contact with that metallic instrument; 3) fires occurring as a result of electrosurgical instruments; 4) electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device; and 5) other complications not included in the previous categories. The survey was mailed to the 620 members of the Society of University of Otolaryngologists.

RESULTS

Of the 620 surveys mailed, 35 were returned by the post office for lack of a forwarding address and 296 were returned completed for a response rate of 49.7%. The respondents performed a total of 99,664 cases in the previous year. During that year, 324 complications related to electrosurgical instruments were reported. These included 219 unanticipated direct burns, 48 burns as a result current flow through a metallic retractor or instrument (capacitative coupling), 13 grounding pad burns, 11 fires, 32 cases of electromagnetic interference, and 1 hair loss at an incision site as a result of a cutting electrosurgical instrument. Information regarding the circumstances surrounding these complications and outcome are presented.

CONCLUSIONS

Electrosurgery has proliferated since its original application by William T. Bovie and Harvey Cushing in the 1920s. Because surgeons use this technology frequently, a thorough understanding of these instruments and their potential complications is critical to their safe and successful use. Electrosurgical units operate on basic fundamental principles of physics and involve the passage of electrical current through tissue to create the desired tissue effect. With knowledge of the history, physics, techniques, histological effects, and safety issues of electrosurgery, the field will continue to proliferate and electrosurgery will continue to assist surgeons in alleviating human suffering.

Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of septate uterus: A prospective randomized study

STUDY OBJECTIVE

To compare 2 procedures for metroplasty: resectoscopy with monopolar knife versus small-diameter hysteroscopy fitted with a Versapoint device.

DESIGN

Prospective randomized study (Canadian Task Force classification I).

SETTING

Endoscopic gynecology units at tertiary care university hospitals.

PATIENTS

One hundred-sixty patients with septate uterus and a history of recurrent abortion or primary infertility undergoing hysteroscopic metroplasty from 2001 to 2005.

INTERVENTIONS

Hysteroscopic resection of the uterine septum performed with either a 26F resectoscope with unipolar knife (80 women, group A) or a 5-mm diameter hysteroscope with Versapoint device (80 women, group B). All patients were managed expectantly, with follow-up lasting 1 year.

MEASUREMENTS AND MAIN RESULTS

Operative parameters (operative time, fluid absorption, complications, need for second intervention) and reproductive outcome parameters (pregnancy, abortion, term and preterm delivery, modality of delivery, cervical cerclage) were measured. Operative time and fluid absorption were significantly greater in group A than in group B (23.4 +/- 5.7 vs 16.9 +/- 4.7 minutes and 486.4 +/- 170.0 vs 222.1 +/- 104.9 mL, respectively). The cumulative complication rate was significantly lower in group B than in group A. No difference in any of the reproductive parameters was observed between the 2 groups: pregnancy and delivery rates were 70% and 81.6% in group A vs 76.9% and 84% in group B. Nine women (18.4%) from group B and 8 women (16%) from group B experienced spontaneous abortions. Most patients (54/82) delivered by cesarean section without differences according to the hysteroscopic technique used for metroplasty (65% in group A vs 67.7% in group B) or to the gestational age (65.1% of term and 68.7% of preterm deliveries).

CONCLUSIONS

Small-diameter hysteroscopy with bipolar electrode for the incision of uterine septum is as effective as resectoscopy with unipolar electrode regarding reproductive outcome and is associated with shorter operating time and lower complication rate.

Pregnancy outcome after cervical cone excision: a case-control study

BACKGROUND

To investigate the effect of cervical laser conisation (CLC) or loop electrosurgical excision procedure (LEEP) on the outcome of subsequent pregnancies. Methods. Multi-centre, retrospective, case-control study, which included a cohort of 742 women, who, after treatment with LEEP or CLC, gave birth or suffered second trimester miscarriage. Control women (n=742) were extracted from the respective hospital birth registries and matched by age and parity. Outcome measures were perinatal mortality, length of gestation, birth weight and preterm premature rupture of membranes (pPROM).

RESULTS

There was no significant difference in perinatal mortality among women treated with LCL or LEEP compared to controls, 6/742 versus 2/742: odds ratio (OR)=3.1 (95% CI: 0.6-15.2). Excluding second trimester miscarriages, ORs for giving birth before week 37, 32 and 28 after conisation compared to the controls were 3.4 (95% CI: 2.3-5.1), 4.6 (95% CI: 1.7-12.5), and 12.4 (95% CI: 1.6-96.1), respectively, after adjusting for smoking habits during pregnancy, marital status and educational level. Adjusted ORs of birth weight <2,500, <1,500 and <1,000 g after conisation compared to controls were 3.9 (95% CI: 2.4-6.3), 4.4 (95% CI: 1.5-13.6), and 10.4 (95% CI: 1.3-82.2), respectively. The adjusted OR for pPROM was 10.5 (95% CI: 3.7-29.5).

CONCLUSION

Treatment by CLC and LEEP increases the risk of preterm delivery, low birth weight and pPROM in subsequent pregnancies.

Hormonal inhibition of the endometrium for resectoscopic endometrial ablation

Attempts at inhibiting the thickness and vascularity of the endometrium in preparation for endometrial ablation by using different types of hormones have been reported. To evaluate the effects of two different progestins, danazol, and leuprolide acetate on the endometrium, compared with the features of early proliferative endometrium, histologic studies were done for at least five patients treated with each hormone who then underwent resectoscopic endometrial ablation for treatment of abnormal uterine bleeding. Significant and at times dramatic differences among the treatment groups were found, with progestin-prepared endometrium being the least successful and leuprolide-prepared endometrium the most successful. In addition, the prolonged suppression provided for a period of time after the procedure by depot leuprolide is likely to help inhibit endometrial regeneration and provide even better long-term success of the procedure.

Management of cryotherapy-ineligible women in a "screen-and-treat" cervical cancer prevention program targeting HIV-infected women in Zambia: lessons from the field

OBJECTIVE

We demonstrate the feasibility of implementing a referral and management system for cryotherapy-ineligible women in a "screen-and-treat" cervical cancer prevention program targeting HIV-infected women in Zambia.

METHODS

We established criteria for patient referral, developed a training program for loop electrosurgical excision procedure (LEEP) providers, and adapted LEEP to a resource-constrained setting.

RESULTS

We successfully trained 15 nurses to perform visual inspection with acetic acid (VIA) followed by immediate cryotherapy. Women with positive tests but ineligible for cryotherapy were referred for further evaluation. We trained four Zambian physicians to evaluate referrals, perform punch biopsy, LEEP, and manage intra-operative and post-operative complications. From January 2006 through October 2007, a total of 8823 women (41.5% HIV seropositive) were evaluated by nurses in outlying prevention clinics; of these, 1477 (16.7%) were referred for physician evaluation based on established criteria. Of the 875 (59.2% of 1147 referred) that presented for evaluation, 748 (8.4% of total screened) underwent histologic evaluation in the form of punch biopsy or LEEP. Complications associated with LEEP included anesthesia reaction (n=2) which spontaneously resolved, intra-operative (n=12) and post-operative (n=2) bleeding managed by local measures, and post-operative infection (n=12) managed with antibiotics.

CONCLUSION

With adaptations for a resource-constrained environment, we have demonstrated that performing LEEP is feasible and safe, with low rates of complications that can be managed locally. It is important to establish referral and management systems using LEEP-based excisional evaluation for women with cryotherapy-ineligible lesions in VIA-based "screen-and-treat" protocols nested within HIV-care programs in resource-constrained settings.

Does the ultrasonically activated scalpel release viable airborne cancer cells?

BACKGROUND

Viable cancer cells may implant at distant sites and cause tumor recurrence. One possible mechanism is the inadvertent exfoliation of viable tumor cells during dissection. The ultrasonically activated scalpel (UAS) uses ultrasonic energy to disrupt tissues by cavitation and produces a dense cloud of cellular debris that may contain viable cells. This study aimed to investigate the viability of airborne cells released during cancer dissection using the UAS and electrosurgery.

METHODS

Flank tumors (n = 8) measuring 1 cm3 were induced in male WAG rats by subcutaneous injection of 2 x 10(6) CC531s colon cancer cells. Dissection was performed in cutting mode using the maximum power output of the respective devices. Electrosurgery was performed using a standard monopolar electrosurgical unit and a needle probe, and ultrasonic dissection was performed with the Harmonic Scalpel utilising the open surgical handset and the hooked spatula tip. The smoke plume was aspirated by a vacuum pump and bubbled under Hank's balanced salt solution to trap particulate matter. The viability of the cellular material was blindly assessed with the trypan blue test and by in vitro culture. The morphology of the cellular debris was studied by examination of cytospin preparations.

RESULTS

Large quantities of cellular debris was trapped in the plume from both devices. However, no viable cells were isolated, nor did in vitro cell growth occur with either device. Examination of the debris from the UAS demonstrated a characteristic mixture of amorphous forms and very few morphologically intact cells. The cauterized tumor produced charred cells and tissue fragments.

CONCLUSIONS

In conclusion, this study demonstrates that viable airborne cancer cells are not released after tumor ablation with the UAS or electrosurgery.

Plasmakinetic resection of the prostate versus standard transurethral resection of the prostate: a prospective randomized trial with 1-year follow-up

The aim of this study was to compare the clinical results of plasmakinetic resection of the prostate (PRP) with standard transurethral resection (TUR) of the prostate (TURP). A total of 240 patients (mean age 63.5; age range 52-90 years), with symptomatic benign prostatic hyperplasia were randomized into two groups and treated with two different techniques (TURP and PRP). We evaluated pre-operative, per-operative and post-operative (first and 12th months) findings of all patients. The mean catheterization time was 3 and 4.5 days in the PRP and standard TURP groups, respectively (P<0.001). We observed the improvements in maximum flow rates in PRP group were significantly higher than TURP group (P<0.001). TUR of the prostate using plasmakinetic energy seems to be a promising treatment alternative to conventional TURP. It has the advantages of low intraoperative and post-operative complications, short convalescence, excellent intraoperative hemostasis, absence of fluid absorption and TUR syndrome.

A prospective, randomized trial comparing conventional transurethral prostate resection with PlasmaKinetic vaporization of the prostate: physiological changes, early complications and long-term followup

PURPOSE

We compared standard transurethral prostate resection with bipolar PlasmaKinetic prostate vaporization for bladder outflow obstruction using a Gyrus PlasmaKinetic Plasma V bar.

MATERIALS AND METHODS

A total of 160 men were enrolled in a prospective, randomized trial. Those at higher risk for cancer were excluded by prostate specific antigen and digital rectal examination with or without transrectal ultrasound biopsy. A total of 81 men underwent prostate vaporization and 79 underwent transurethral prostate resection. Preoperative International Prostate Symptom Score and quality of life score, uroflowmetry, post-void residual urine and transrectal ultrasound prostate volume were recorded. Preoperative and postoperative serum hemoglobin, hematocrit and sodium were measured. Perioperative fluid absorption was calculated using weighing on table and blood loss using the Hemocue system. Longer followup of International Prostate Symptom Score and quality of life score, uroflowmetry and post-void residual urine was available in 149 men, including 76 who underwent prostate vaporization and 73 who underwent transurethral prostate resection. Data were analyzed using the 1 or 2-sample t and chi-square tests.

RESULTS

The 2 groups were comparable in all preoperative parameters. Perioperative fluid absorption, intraoperative blood loss, preoperative and postoperative serum hematocrit, and sodium changes were not statistically different. Mean resection time was 4 minutes shorter for transurethral prostate resection (28.5 vs 32.6 minutes, p = 0.08). Patients with transurethral prostate resection showed a greater hemoglobin decrease (1.39 vs 0.8 gm/dl, p = 0.002) and required more irrigation postoperatively (28.3 vs 20.4 l, p = 0.001). Four patients with transurethral prostate resection required transfusion compared with none who underwent prostate vaporization. After transurethral prostate resection hospital stay was longer (3.36 vs 3.02 days, p = 0.03). Cancer was detected in 8 patients with transurethral prostate resection (10%), of whom 7 are under prostate specific antigen surveillance and 1 received radical radiotherapy. Mean long-term followup was 258 days (range 82 to 884). Prostate vaporization and transurethral prostate resection were equally effective at followup, as evidenced by changes in maximum urine flow, International Prostate Symptom Score, quality of life score and post-void residual urine.

CONCLUSIONS

The 2 operations are highly effective in experienced hands. PlasmaKinetic prostate vaporization resulted in less postoperative bleeding and a slightly shorter hospital stay. The lack of a histological specimen with this version of PlasmaKinetic prostate vaporization may mean that clinically significant cancers are missed.

Randomised trial comparing LigaSure haemorrhoidectomy with the diathermy dissection operation

The study was designed to compare LigaSure haemorrhoidectomy with open haemorrhoidectomy performed by means of diathermy excision. Fifty-sixty consecutive patients with third- and fourth-degree haemorrhoids were randomly allocated to undergo either LigaSure haemorrhoidectomy (29 patients) or diathermy haemorrhoidectomy (27 patients). All patients were evaluated for operative time, pain, post-operative analgesic requirements, time to first bowel movement, length of hospital stay, wound healing period, time to return to work, and occurrence of early postoperative complications (such as urinary dysfunction, bleeding, soiling, seepage, continence disorders) and late complications (such as stenosis). A statistically significant advantage was observed in the patients who received the LigaSure technique as far as concerns length of operative time (9.2 vs. 12.2 min, p<0.001), post-operative analgesic requirements (14.1 vs. 16.8 administrations, p<0.001), wound healing period (16.3 vs. 37.5 days, p< 0.0001), and time to return to work (8.3 vs. 18.3 days, p<0.01). No significant difference was seen in the postoperative pain score, complications rate, first bowel motion or hospital stay. No recurrence was observed at the 6-month follow-up. In conclusion, our experience shows that the LigaSure haemorrhoidectomy offers definite advantages over the classic diathermy technique. This procedure is easier, safer, and more rapid to perform and is followed by a faster wound healing time, a significantly shorter hospital stay, less postoperative pain and faster wound healing.

Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference?

BACKGROUND

Bleeding as a complication of endoscopic sphincterotomy is influenced by several factors. The objective of this study was to compare rates of bleeding after sphincterotomy performed with two different electrosurgical current generators (Valleylab SSE2L and ERBE ICC200).

METHODS

A total of 6179 consecutive reports of ERCP were analyzed to compare the frequency of endoscopically and clinically evident bleeding after sphincterotomy when using the Valleylab SSE2L generator (from February 1994 to November 1997) and the ERBE ICC200 generator (from December 1997 to September 2000). Relevant risk factors were assessed by univariate analysis and significant predictors were included in a multiple logistic regression model.

RESULTS

A total of 2711 sphincterotomies were performed in 2309 patients (1749 biliary, 962 pancreatic). Endoscopically observed bleeding occurred in 68 patients (5.5%) in the ValleyLab group and 13 (1.2%) in the ERBE group. The ValleyLab generator was independently associated with an increase in endoscopically observed bleeding (OR 4.02: 95% CI[2.13, 7.61], p <0.001). There was no significant difference in clinically evident bleeding between the two groups.

CONCLUSIONS

Use of the microprocessor-controlled ERBE electrosurgical generator for endoscopic sphincterotomy was associated with a significantly lower frequency of endoscopically observed bleeding but not clinically evident bleeding.

Colonoscopic polypectomy with cutting current: is it safe?

BACKGROUND

Coagulation and blended electrosurgical current are currently recommended for colonoscopic polypectomy, whereas pure cut current is believed to be associated with a higher risk of bleeding. However, the outcome of polypectomy performed with a cut current has not been evaluated in a large case series. Our objective was to study the incidence and nature of complications when polypectomy is performed with a pure cut current.

METHODS

Among 9555 colonoscopic examinations, polypectomy cases were retrospectively reviewed for complications. The electrosurgical current applied was always the cutting waveform.

RESULTS

Electrosurgical polypectomy using pure cut current was performed to remove 4735 lesions. Hemoclips were applied to the excision site after polypectomy to prevent bleeding in 12% of the cases. Hemorrhage occurred in 1.1% of the polypectomies (3.1% of patients). The incidence of bleeding with the different methods was snare polypectomy 0.9%, endoscopic mucosal resection 1.6%, "hot" biopsy 0.4%, and piecemeal polypectomy 7.3%. Bleeding was immediate in 66.1% of episodes and delayed in 33.9%. Patients with delayed postpolypectomy bleeding were significantly younger than those with immediate bleeding (50.5 and 64.7 years, respectively, p < 0.001). There was 1 case of transmural burn, but no perforations.

CONCLUSION

Polypectomy can be performed with pure cut current with a bleeding rate comparable to that seen with the use of coagulation or blended current, provided that hemoclip placement can be used readily. Expertise in hemoclip placement is advisable if this method of polypectomy is to be used.