Electromagnetic Interference with Protocolized Electrosurgery Dispersive Electrode Positioning in Patients with Implantable Cardioverter Defibrillators.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Electromagnetic interference from monopolar electrosurgery may disrupt implantable cardioverter defibrillators.Current management recommendations by the American Society of Anesthesiologists and Heart Rhythm Society are based on expert clinical opinion since there is a paucity of data regarding the risk of electromagnetic interference to implantable cardioverter defibrillators during surgery. WHAT THIS ARTICLE TELLS US THAT IS NEW: With protocolized electrosurgery dispersive electrode positioning in patients with implantable cardioverter defibrillators, the risk of clinically meaningful electromagnetic interference was 7% in above-the-umbilicus noncardiac surgery and 0% in below-the-umbilicus surgery. In cardiac surgery, clinically meaningful electromagnetic interference with use of an underbody dispersive electrode was 29%.Despite protocolized dispersive electrode positioning, the risk of electromagnetic interference in above-the-umbilicus surgery is high, supporting recommendations to suspend antitachycardia therapy when monopolar electrosurgery is used above the umbilicus.With protocolized dispersive electrode positioning, the risk of electromagnetic interference in below-the-umbilicus surgery is negligible, implying that suspending antitachycardia therapy might be unnecessary in these cases.With an underbody dispersive electrode, the risk of electromagnetic interference in cardiac surgery is high. BACKGROUND: The goal of this study was to determine the occurrence of intraoperative electromagnetic interference from monopolar electrosurgery in patients with an implantable cardioverter defibrillator undergoing surgery. A protocolized approach was used to position the dispersive electrode. METHODS: This was a prospective cohort study including 144 patients with implantable cardioverter defibrillators undergoing surgery between May 2012 and September 2016 at an academic medical center. The primary objectives were to determine the occurrences of electromagnetic interference and clinically meaningful electromagnetic interference (interference that would have resulted in delivery of inappropriate antitachycardia therapy had the antitachycardia therapy not been programmed off) in noncardiac surgeries above the umbilicus, noncardiac surgeries at or below the umbilicus, and cardiac surgeries with the use of an underbody dispersive electrode. RESULTS: The risks of electromagnetic interference and clinically meaningful electromagnetic interference were 14 of 70 (20%) and 5 of 70 (7%) in above-the-umbilicus surgery, 1 of 40 (2.5%) and 0 of 40 (0%) in below-the-umbilicus surgery, and 23 of 34 (68%) and 10 of 34 (29%) in cardiac surgery. Had conservative programming strategies intended to reduce the risk of inappropriate antitachycardia therapy been employed, the occurrence of clinically meaningful electromagnetic interference would have been 2 of 70 (2.9%) in above-the-umbilicus surgery and 3 of 34 (8.8%) in cardiac surgery. CONCLUSIONS: Despite protocolized dispersive electrode positioning, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with surgery above the umbilicus were high, supporting published recommendations to suspend antitachycardia therapy whenever monopolar electrosurgery is used above the umbilicus. For surgery below the umbilicus, these risks were negligible, implying that suspending antitachycardia therapy is likely unnecessary in these patients. For cardiac surgery, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with an underbody dispersive electrode were high. Conservative programming strategies would not have eliminated the risk of clinically meaningful electromagnetic interference in either noncardiac surgery above the umbilicus or cardiac surgery.

Value of top-hat procedure in management of squamous intraepithelial lesion.

AIM: To investigate the features of skip lesions and evaluate value of top-hat procedure in management of squamous intraepithelial lesion. METHODS: We reviewed the records of patients who underwent loop electrosurgical excision procedure (LEEP) in Peking University First Hospital between 2011 and 2016. Patients were confirmed to have CIN1-3. The term 'skip lesion' refers to lesion lying deep in cervical canal discontiguous with other lesions in transformation zone and was confirmed by top-hat. We compared their lesion grade in patients with or without skip lesion using logistic regression. We further reviewed patients who underwent subsequent hysterectomy within 6 months following LEEP and evaluated if top-hat procedure led to less residual lesions or was able to predict residual lesions. RESULTS: A total of 2260 patients were included and 595 underwent top-hat procedure. Thirty-nine out of 595 patients had skip lesions (6.5%), among whom two patients had CIN1 (5.1%), eight had CIN2 (20.5%) and 29 had CIN3 (74.4%). Logistical regression showed CIN3 was associated with higher risk of skip lesions compared to CIN1 (OR = 4.433, 95%CI: 1.036-18.964), while CIN2 was not (OR = 1.762, 95%CI: 0.366-8.471). Sixty-two patients underwent hysterectomy within 6 months following LEEP (CIN1-3), 24 underwent top-hat. Analysis revealed top-hat procedure did not result in less residual lesions. Colposcopy impression or prior HPV test was unable to predict skip lesions. CONCLUSION: About 9.4% patients with CIN3 had skip lesions in the study, which is associated with elevated risk for residual lesion. Top-hat procedure is able to detect skip lesions, but should not be performed on routinely because its prognostic value is not proved.

Surgeons have knowledge gaps in the safe use of energy devices: a multicenter cross-sectional study.

BACKGROUND: Despite the widespread use of surgical energy devices and the potential for rare but serious complications, pilot data from North America suggest that surgeons and surgical trainees have knowledge gaps in their safe use. The purpose of this study was to determine baseline knowledge of general surgeons and surgical trainees regarding the safe use of electrosurgery (ES) across varying levels of experience in Japan. METHODS: Participants completed a 35-item multiple-choice question examination, testing critical knowledge of ES. The examination was developed according to the objectives and blueprints of SAGES' Fundamental Use of Surgical Energy™ curriculum. Sections of the examination included: "principles of ES," "ES-related adverse events," "monopolar and bipolar devices," and "pediatric considerations and interference with implantable devices." Scores were compared between PGY > 5 and PGY 1-5 participants. RESULTS: A total of 145 general surgeons and surgical trainees of all years after medical school (PGY 1-5: 57, PGY > 5: 88) from ten academic and five community hospitals completed the assessment (mean age 35; 91% male). The mean score in the entire cohort was 58 ± 12% (range 23-83%), with significantly higher scores in the PGY > 5 group compared to the PGY 1-5 group (60 ± 11 vs. 53 ± 12%, p < 0.01). Among all participants, 92% were not familiar with best practices when using ES on patients with a pacemaker; 44% believe that ES uses thermal energy from cautery; 19% did not know how to manage an operating room fire; 16% thought that a dispersive electrode should be cut to fit a child; and 27% believe that insulation failure in minimally invasive surgical instruments is mostly visible under careful inspection. CONCLUSIONS: General surgeons and trainees at all levels have knowledge gaps in the safe and effective use of energy devices, regardless of years of experience. There is a need for educational curricula to help address these gaps and contribute to safer surgery.

Comparison of cold knife cone biopsy and loop electrosurgical excision procedure in the management of cervical adenocarcinoma in situ: What is the gold standard?

OBJECTIVE: To compare the outcomes of patients with cervical adenocarcinoma in situ (ACIS) treated with cold knife cone (CKC) biopsy or loop electrosurgical excision procedure (LEEP) for the treatment of cervical adenocarcinoma in situ (ACIS). STUDY DESIGN: This is a retrospective, population-based cohort study of Western Australian patients with ACIS diagnosed between 2001 and 2012. Outcomes included pathological margin status and the incidence of persistent or recurrent endocervical neoplasia (ACIS and adenocarcinoma) during follow-up (<12 months) and surveillance (≥12 months) periods. RESULTS: The study group comprised 338 patients including 107 (32%) treated initially by LEEP and 231 (68%) treated by CKC biopsy. The mean age was 33.2 years (range 18 to 76 years) and median follow-up interval was 3.6 years (range <1 year to 11.8 years). Overall, 27 (8.0%) patients had ACIS persistence/recurrence while 9 (2.7%) were diagnosed with adenocarcinoma during the follow-up and surveillance periods. No patient died of cervical cancer within the study period. There were no significant differences in the incidence of persistent and/or recurrent endocervical neoplasia according to the type of excisional procedure. Patients with positive biopsy margins were 3.4 times more likely to have disease persistence or recurrence. CONCLUSION(S): LEEP and CKC biopsy appear equally effective in the treatment of ACIS for women wishing to preserve fertility. Patients undergoing conservative management for ACIS should be closely monitored, particularly if biopsy margins are positive in initial excision specimens. Patients and their clinicians should be aware of the potential risks of residual and recurrent disease.

Is screen-and-treat approach suited for screening and management of precancerous cervical lesions in Sub-Saharan Africa?

The World Health Organization guidelines for screening and management of cervical precancerous lesions updated in 2013 made an emphasis on the use of the 'screen-and-treat' approach for cervical cancer prevention. In order to facilitate scaling-up in low income settings, most of these screen-and-treat strategies do not involve confirmatory biopsy. This yields a certain rate of overtreatment. In other words, a majority of people undergoing screen-and-treat intervention who are treated does not necessarily benefit from the treatment. Therefore, the issue of potential short term and long term complications of the recommended treatment procedures (cryotherapy and Loop Electrosurgical Excision Procedure) arises. This question has seldom been studied in resource poor countries, particularly in Sub-Saharan Africa where Human Immunodeficiency Virus infection is rampant in an epidemic fashion and where the procreative capacities are socially rewarding for women. We draw the attention of the scientific community and policy makers to the fact that the lack of evidence supporting the safety of these treatment procedures in African populations may have an impact on the acceptability of these strategies and therefore on the effectiveness of screening programs.

Loop electrosurgical excision procedure for the treatment of cervical intraepithelial neoplasia: how much excision is enough?

This is a retrospective observational study to compare outcomes in patients with cervical intraepithelial neoplasia (CIN) treated with loop electrosurgical excision procedure (LEEP) using combined ectocervical/endocervical resection vs ectocervical resection alone. We demonstrated that additional endocervical resection during loop electrosurgical excision procedure did not significantly lower the risk of subsequent recurrence compared with ectocervical resection alone, in the treatment of CIN. With current published data supporting subsequent increased adverse effects of LEEP on future obstetrical outcomes, endocervical excision should be applied selectively. We recommend that additional endocervical excision should be reserved only for patients with a strong suspicion of underlying endocervical canal involvement based on colposcopic assessment or in patients with unsatisfactory colposcopy, where it is essential to evaluate the endocervical canal.

European Society of Gastrointestinal Endoscopy (ESGE) guideline: the use of electrosurgical units.

Electrosurgery is used in the majority of endoscopic therapeutic procedures. An understanding of the fundamental electrosurgical principles and various settings available on electrosurgical units is essential for the safe and effective use of electrosurgery during endoscopy. The aims of these technical guidelines are to: (1) expose physical principles relevant to the understanding of electrosurgery during endoscopy; (2) describe and provide practical recommendations regarding electrosurgical units that are commonly in use; (3) discuss the clinical relevance of technologies recently implemented in newer electrosurgical units; and (4) review factors relevant to commonly performed therapeutic procedures, including polypectomy, sphincterotomy, contact thermal hemostasis, and argon plasma coagulation.

Suitability of electrosurgical analysers for routine maintenance testing of electrosurgery units - a technical note.

PRIMARY OBJECTIVE: To evaluate the use of electrosurgical analysers in testing power output and leakage current from an electrosurgery unit and compare this to the manufacturer recommendations for routine testing. METHOD: Two electrosurgical analysers were compared to reference measurements (carried out using non-inductive resistors, a current transformer and oscilloscope) over a range of tests described in IEC 60601-2-2: 1998 measuring power output and leakage currents in different conditions. The analysers used were Metron QA-ES and Fluke 454A. OUTCOMES: Both analysers gave similar results to the reference measurements for power output. The Metron QA-ES gave similar results to the reference measurements for leakage current testing; however the Fluke 454A gave substantially different results when used as described in the manual. CONCLUSIONS: Electrosurgical analysers can be a valuable tool in the workshop, enabling rapid, accurate testing of electrosurgery equipment without needing additional equipment and setting up times. Not all analysers can perform all the tests that may be needed and in some cases the accuracy of the results is questionable. Users must be certain of the capabilities and limitations of the analyser before making decisions based on the results.

Variation in electrosurgical vessel seal quality along the length of a porcine carotid artery.

Electrosurgical vessel sealing has been demonstrated to have benefits for both patients and practitioners, but significant variation in the strength of the seal continues to be a concern. This study aims to examine the variation in electrosurgical seal quality along the length of a porcine common carotid artery and explore the relationships between seal quality, vessel size and morphology. Additionally, the study aimed to investigate the minimum safety threshold for successful seals and the influence of vessel characteristics on meeting this requirement. A total of 35 porcine carotid arteries were sealed using the PlasmaKinetic Open Seal device (Gyrus). Each seal was burst pressure tested and a sample taken for staining with elastin van Gieson's stain, with morphological quantification using image processing software ImageJ. With increasing distance from the bifurcation, there was an increase in seal strength and a reduction in both elastin content and vessel outer diameter. A significant correlation was found between burst pressure with both outer diameter (p < 0.0001) and elastin content (p = 0.001). When considering the safe limits of operation, vessels of less than 5 mm in outer diameter were shown to consistently produce a seal of a sufficient strength (burst pressure > 360 mmHg) irrespective of vessel morphology.

Electrosurgical safety: conducting a safety audit.

ECRI detailed some of the lesser-known risks of electrosurgery in a collection of articles published in the August 2005 Health Devices. However, it's also important to recognize that even hazards that are well understood by clinical personnel can lead to injury if appropriate safety measures aren't applied consistently. In this follow-up to our August 2005 articles, we offer guidance to help healthcare facilities conduct a safety audit that examines critical aspects of the facility's use of electrosurgical technology. ECRI recommends that healthcare facilities periodically conduct such an audit to ensure that the appropriate equipment and procedures are in place to protect patients and staff from injury. This article reviews some of the key questions to ask during a safety audit, and it includes detailed guidance for developing an electrosurgical safety checklist.

Safety technologies for laparoscopic monopolar electrosurgery; devices for managing burn risks.

The use of monopolar electrosurgery during laparoscopy has many benefits. But it also creates the risk that high-frequency leakage currents could travel from the active electrode to patient tissue, causing burns. In some cases, these burns can be serious and even lead to life-threatening complications. In this Evaluation, we review four products designed to reduce the risk of leakage-current burns during these procedures. One of the products is an active-electrode shaft with a brightly colored inner layer of insulation, making it easier to spot insulation breaks that could allow leakage currents. Two of the products use high DC voltage to detect full-thickness breaks in electrode insulation. The other product is an active-electrode shielding system that provides protection during a procedure by conducting potentially dangerous leakage current away from the patient. We rate one product Preferred and the others Acceptable. However, we don't believe that any of these technologies are essential to safe monopolar laparoscopic electrosurgery. If these technologies are used, they should be viewed only as supplemental safety measures, not as a substitute for the general safe practices required during these procedures.

Long-term outcome of a randomized study comparing three techniques of conization: cold knife, laser, and LEEP.

OBJECTIVE: To evaluate the long-term recurrence rates and complication of different techniques of cervical ablation. METHODS: A randomized trial of three techniques of conization (cold knife, laser, and loop electrosurgical excisional procedure (LEEP)) for cervical intraepithelial neoplasia (CIN) in which 110 patients had been recruited. RESULTS: Eighty-six patients were followed-up for more than 3 years. Of these 28 had been treated with the cold knife, 29 with LEEP and 29 by laser. Five recurrences were observed, one in the cold knife group, two in the LEEP group and two in the laser group (P=NS). The only observed complication was cervical stenosis: zero cases in the laser group, one case in the LEEP group and four cases in the cold knife group (laser versus cold knife: P=0.03; LEEP versus cold knife: P=0.06). Fifty pregnancies were observed in 39 patients. First and second trimester outcomes of pregnancy were without complications. One patient treated with the LEEP presented with a premature rupture of membranes and premature labor at 36 weeks. A total of nine cesarean sections were performed with two cases for cervical dystocia. CONCLUSION: There is no major difference in obstetrical outcome between the three techniques.

Outpatient loop electrosurgical excision procedure for cervical intraepithelial neoplasia. Can it replace cold knife conization?

OBJECTIVE: To determine if loop electrosurgical excision procedure (LEEP) can replace cold knife conization. STUDY DESIGN: In a population at high risk for invasive carcinoma, 163 cases of LEEP conization were performed with the same indications as cold knife for cervical conization. RESULTS: Seventy-five percent of LEEP surgical specimens were positive for dysplasia. Six cases showed invasive squamous cell carcinoma. No complications were seen. CONCLUSION: LEEP conization is a quick, simple and economical procedure that can safely replace most cases of cold knife conization.

Postprocedural Pap Smears: a LEEP of faith?

Loop electrosurgical excision procedure (LEEP) is gaining in popularity in the United States as an outpatient alternative to the diagnosis, and potentially the treatment, of cervical intraepithelial neoplasia (CIN). LEEP is fast, simple, performed under local anesthesia, readily learned, and without significant morbidity. As cytopathologists and cytotechnologists, immediate cytologic evaluation of cervico-vaginal smears following LEEP is not the routine; however, there are very specific artifacts, most of which are related to the transfer of thermal energy, which result from the procedure. It is important to recognize these cytomorphologic features for accurate interpretation. The indications and contraindications for LEEP are similar to those for other ablative or excisional procedures. There appears to sacrifice in the efficacy of diagnosing and treating CIN by this method. Factors predictive of disease clearance are as confounding as they are for any other cone procedure. At the University of Iowa Hospital and Clinics (UIHC), immediate post-LEEP endocervical brush (PLEB) is often performed as a method of assessing the endocervical canal for residual disease or skip lesions. The most common cytomorphologic features observed are: "taffy-pulled" nuclei in elongated endocervical cells; cell aggregates with coalesced cytoplasm; hockey stick nuclei; notched and enlarged nuclei; and, smudgy chromatin. The difficulties or most frequent diagnostic dilemmas in interpreting these smears initially include abundant blood and smudgy chromatin, often tempting an interpretation of "unsatisfactory". However, careful study reveals that these changes are related to the nature of the procedure and reproducible. Recognition and familiarization of these features enables more accurate interpretation of PLEB cytology. The significance of abnormal PLEB, with regard to disease clearance, is still uncertain.

[Hazards of electrosurgery]. / Gefahren der Lektrochirurgie

Burn accidents due to the use of electrosurgical instruments (electrotomy, electrocoagulation) are uncommon but generally serious: explosion of inflammable anaesthetics or antiseptics, local tissue necrosis by an uncontrollable current or coagulation necrosis by a high current. An appropriate use of electrosurgical instruments based on the correct range of indications is the basis for the prevention of accidents.

Nail matrixectomies using radio wave technique.

The authors present a successful method for surgically correcting ingrown toenails by using radio wave technique. A review of the literature is also presented.

Monitoring instrumentation. Isolated inputs, electrosurgery filtering, burns protection: what does it mean?

1. 50Hz Interference : the patient's body acts as can an antenna picking up several volts of 50 Hz noise from the power line. Differential amplifiers are the key separating the 1 mV E.C.G. signal wanted from 50Hz. Further reduction of this interference is possible with the help of high input impedance amplifiers and proper electrode techniques. 2. Isolated inputs : electrodes internal to the body give rise to potential hazards. Isolated inputs prevent dangerous currents from flowing directly through the patient to ground, should he come into contact with 50Hz AC power. Even micro-shocks caused by leakage currents as low as 50 micro-amps are prevented. These can cause ventricular fibrillation when applied directly to the heart. 3. Electrosurgery interference : electrosurgery machines generate high frequency signals with amplitudes of several hundred volts. This interference is minimized by low-pass filtering, shielding of the input circuitry and using proper monitoring and electrosurgery techniques. (Electrodes, cables, monitor and electrosurgery machine positioning). 4. Patient burns protection :isolated inputs do not protect against high frequency eleectrosurgery currents. Burns occur if the normal return path is interrupted and the current flows to ground through the monitor. Burns can be prevented by making sure that the patient is in intimate contact with the return patient plate, by using high frequency blocks (chokes) close to the E.G.C. electrodes sites and by using isolated-output electrosurgery units. 5. Monitor protection against damage from defibrillator pulses and electrosurgery currents : very sensitive input amplifiers must be able to survive up to 6,000 volt levels. 6. Battery powered monitors have a unique problem : Lack of a connection to ground. Whereas this is most often considered a safety advantage, it can be a hazard if the patient or operator becomes the link from the equipment to ground for a dangerously high current. A very expensive cabinet design could eliminate the above hazard and make the battery powered monitor the ideal operating room instrument.

Electrosurgical loop excision of the cervical transformation zone: the experience of family physicians.

BACKGROUND: Electrosurgical loop excision of the cervical transformation zone (ELECTZ) is an excisional surgical procedure for treatment of premalignant cervical disease and the abnormal transformation zone by wire loop electrodes. The purpose of this study was to describe and assess the clinical experiences and complications of family-physician-performed ELECTZ and ELECTZ conization. METHODS: Women who were scheduled for the ELECTZ or ELECTZ conization procedures were enrolled in the study between March 1992 and March 1993, inclusive. Subjects were recruited from the practices of six family physician colposcopists located at five sites. The ELECTZ and ELECTZ conization procedures were performed on patients with abnormal Papanicolaou (Pap) smears or abnormal histologic results and abnormal colposcopic findings. Procedural complications were documented. Subjects were serially assessed during the first postoperative year by Pap smears, colposcopy, and, when necessary, by biopsy to determine therapeutic cure. RESULTS: Of 198 subjects enrolled in the study, 148 women were assessed at least once in follow-up by Pap smear and colposcopy. Only 7.6% of women were defined as treatment failures by subsequent histologic assessment. Women treated by ELECTZ conization were older (32.2 vs 25.1 years, P = .02), were more likely to develop posttreatment cervical stenosis (25.9% vs 3.8%, P = .001), and were more likely to have the postoperative squamocolumnar junction positioned in the endocervical canal (32.4% vs 8.7%, P = .002) than were women treated by ELECTZ: Loop excision specimen margins demonstrated dysplasia for 27 (13.6%) subjects. Significant operative bleeding (> 25 mL) was noted in 6.8% of subjects. Histologic thermal artifact was reported for 9.6% of specimens. One case of microinvasive cancer and one case of invasive cancer were identified unexpectedly by ELECTZ conization. CONCLUSIONS: Electrosurgical loop excision of the cervical transformation zone and ELECTZ conization may be safely and effectively performed in office settings by family physicians. Complications and treatment failure rates for the ELECTZ and ELECTZ conization procedures were similar to those experienced by other clinicians.