Unintended stray energy from monopolar instruments: beware the dispersive electrode cord.

BACKGROUND: The monopolar instrument emits stray radiofrequency energy from its cord when activated. This is a source of unintended thermal injury to patients. Stray energy emitted from the dispersive electrode cord has not been studied. The purpose of this study was to determine whether, and to what extent, the dispersive electrode cord contributes to unintentional energy transfer and describe practical steps to minimize risk. METHODS: In a laparoscopic simulator, a monopolar generator delivered radiofrequency energy to an L-hook. Thermal imaging quantified the change in tissue temperature nearest to the tip of a non-electrical instrument following activation. The orientation of the dispersive electrode cord was varied relative to other instruments. RESULTS: When the dispersive electrode cord is parallel to the camera cord, tissue temperature increased at the telescope tip by 46 ± 6 °C from baseline (p < 0.001). Similar heat was generated when the camera cord was oriented parallel to the active electrode cord (46 ± 6 vs. 48 ± 7 °C, respectively, p = 0.48). Adding a second dispersive electrode decreased the temperature change (46 ± 6 vs. 25 ± 9 °C, p < 0.001). Temperature increase was greater with coagulation versus cut mode (33 ± 7 vs. 22 ± 6 °C, p < 0.001). CONCLUSION: Stray energy emitted from the dispersive electrode cord heats tissue >40 °C via antenna coupling; the same magnitude as the active electrode cord. Practical steps to minimize stray energy transfer include avoiding orienting the dispersive electrode cord in parallel with other cords, adding a second dispersive electrode, and using low-voltage cut mode.

Management of low-output pancreatic fistulas with fibrin glue.

BACKGROUND: Despite advances in surgical, endoscopic, and percutaneous therapeutic techniques, pancreatic fistulas remain a source of significant morbidity and long-term patient discomfort. The intraoperative use of fibrin sealant has been used prophylactically to prevent formation of fistula. We recognized the potential use of fibrin glue as a therapeutic modality for successful resolution of low-output pancreatic fistulas. METHODS: Three patients with low (<20 ml per day) output pancreatic fistulas underwent fluoroscopically directed injection of fibrin glue along their fistula tract. RESULTS: All 3 patients underwent successful fibrin glue injection without procedural complication. All fistula output stopped, and the 3 patients remained asymptomatic at 1 year. CONCLUSIONS: Fibrin glue inserted with image-guided catheter delivery systems may be a useful option in selected patients with low-output pancreatic fistulas.

Motion - prophylactic banding of esophageal varices is useful: arguments for the motion.

Variceal hemorrhage is a frequent complication of cirrhosis and is associated with a high mortality rate, especially in patients with decompensated liver disease. Endoscopy is useful in identifying factors that predict a high likelihood of bleeding, including large varices and red colour signs. Endoscopic rubber band ligation has superseded sclerotherapy in the prevention of both recurrent hemorrhage and the first episode of bleeding, because it causes fewer complications and requires fewer sessions to eradicate varices. It has been proven to be more effective than nontreatment in the primary prophylaxis against variceal hemorrhage. There is extensive literature that has found that band ligation is more effective than beta-adrenergic receptor antagonists at preventing the first variceal hemorrhage. There is ongoing debate about the relative merits of these two approaches, but the available evidence supports the conclusion that band ligation is the treatment of choice in the primary prevention of variceal bleeding. Trials of combined medical and endoscopic therapy are eagerly awaited, and the author suspects that it may prove to be more effective than either modality alone.

Electromagnetic interference caused by common surgical energy-based devices on an implanted cardiac defibrillator.

BACKGROUND: Surgical energy-based devices emit energy, which can interfere with other electronic devices (eg, implanted cardiac pacemakers and/or defibrillators). The purpose of this study was to quantify the amount of unintentional energy (electromagnetic interference [EMI]) transferred to an implanted cardiac defibrillator by common surgical energy-based devices. METHODS: A transvenous cardiac defibrillator was implanted in an anesthetized pig. The primary outcome measure was the average maximum EMI occurring on the implanted cardiac device during activations of multiple different surgical energy-based devices. RESULTS: The EMI transferred to the implanted cardiac device is as follows: traditional bipolar 30 W .01 ± .004 mV, advanced bipolar .004 ± .003 mV, ultrasonic shears .01 ± .004 mV, monopolar Bovie 30 W coagulation .50 ± .20 mV, monopolar Bovie 30 W blend .92 ± .63 mV, monopolar instrument without dispersive electrode .21 ± .07 mV, plasma energy 3.48 ± .78 mV, and argon beam coagulator 2.58 ± .34 mV. CONCLUSION: Surgeons can minimize EMI on implanted cardiac defibrillators by preferentially utilizing bipolar and ultrasonic devices.

Frailty predicts increased hospital and six-month healthcare cost following colorectal surgery in older adults.

BACKGROUND: The purpose of this study was to determine the relationship of frailty and 6-month postoperative costs. METHODS: Subjects aged ≥ 65 years undergoing elective colorectal operations were enrolled in a prospective observational study. Frailty was assessed by a validated measure of function, cognition, nutrition, comorbidity burden, and geriatric syndromes. Frailty was quantified by summing the number of positive characteristics in each subject. RESULTS: Sixty subjects (mean age, 75 ± 8 years) were studied. Inpatient mortality was 2% (n = 1). Overall, 40% of subjects (n = 24) were considered nonfrail, 22% (n = 13) were prefrail, and 38% (n = 22) were frail. With advancing frailty, hospital costs increased (P < .001) and costs from discharge to 6-months increased (P < .001). Higher degrees of frailty were related to increased rates of discharge institutionalization (P < .001) and 30-day readmission (P = .044). CONCLUSIONS: A simple, brief preoperative frailty assessment accurately forecasts increased surgical hospital costs and postdischarge to 6-month healthcare costs after colorectal operations in older adults.