Electrocautery -- Sacred Cow or Valuable Asset?

Electrocautery is the process of burning or destroying tissue by use of a small probe with an electric current running through it. It has become a routine surgical means of burning unwanted or harmful tissue and is also used to diminish or stop hemorrhaging.¹ But rather than being applied as a universal solution for all endoscopy-related excisions, it should be weighed carefully against its alternatives to minimize patient discomfort and adverse events.

The concept of hot cautery is millennia old. Despite the obvious pain associated with the ancient methods -- hot iron instruments being introduced into open wounds -- the concept was effective and incorporated during the last 5,000 years.²

But the idea of an iron poker heated in an open flame is long gone. The modern version of cautery can be performed not only with heat, but also with cold, corrosive chemicals, electricity or a laser.³ It can be used to stop bleeding, to treat wounds that are at high risk for infection, or to destroy scar tissue.

Electrocautery has become a mainstay in the endoscopic suite. Its applications range from the more obvious stemming of blood flow to lesser-known applications for craniotomy, peripheral nerve repair, aneurisms and cataract extraction.⁴

Electrocautery even has relevance in the treatment of malignancies. In surgery to excise cancer of the bladder, for example, cautery can be used to remove the cancer, if it is small enough.⁵

AN OLDIE BUT GOODIE

Electrocautery's wide range of applications makes it a popular adjunct to any endoscopy suite. But there are other options that may be just as effective.

In a letter to the editor of Gastrointestinal Endoscopy, Charles J. Lightdale, MD, notes that in the era of an "innovative" endoscopic approach to treating Barrett's esophagus, it is crucial to determine which weapons work best -- and sometimes older methods can be as effective as the newer, highly-touted techniques.⁶

In his letter, Lightdale observes that a multipolar electrocautery probe is a feasible option for ablation of long segments of Barrett's esophagus; combined with proton pump inhibitors for acid suppression -- albeit in higher-than-normal doses -- multipolar electrocautery has brought about healing with squamous mucosa.

"The major problem is getting an even ablation using a contact method where the depth of injury is dependent in part on the duration of contact and the force applied," writes Lightdale. He remarks that even noncontact methods (such as lasers or argon plasma coagulators) appear to have the same issue. And, he comments, a clear advantage of the argon plasma method over multipolar electrocautery has yet to be shown.

When compared to photodynamic therapy, current electrocautery, argon plasma and thermal laser are all more effective for short segments of Barrett's esophagus, because these methods "involve a limited area with each firing." However, for longer segments -- greater than 2 cm in length -- photodynamic therapy appears to be a better option, Lightdale adds.

A multicenter study published in 2001 also upholds the theory that electrocoagulation combined with high-dose acid inhibition is an effective treatment for the reversal of Barrett's esophagus. In this study, the treatment was demonstrated to be safe in the majority of patients with 2 cm to 6 cm of nondysplastic Barrett's esophagus. The authors recommend long-term follow-up to ensure the durability of the new squamous epithelium.⁷

ASSOCIATED RISKS

Electrocautery does carry several risks. If, for example, a laparoscopic vagotomy is being performed, electrocautery injury may lead to gastric perforation. This, however, can be avoided by "careful dissection and isolation of the branches of the nerve of Latarjet as well as by avoiding the use of electrocautery. The power setting of the electrocautery should be low but sufficient to coagulate tissue," according to the SAGES Manual: Fundamentals of Laparoscopy and GI Endoscopy.⁸

The manual also notes that low-power electrocautery or suture ligation should be used to control bleeding on the lesser curvature of the stomach. Of note, a delayed perforation may be caused by excessive use of cautery; in this case, within two to five days after the procedure, a patient might present with intra-abdominal sepsis. The manual recommends that a Gastrografin study be used to confirm the perforation, and that nasogastric decompression may be adequate if no leak is seen and the patient is stable or improving.

However, if a leak is demonstrated or suspected, the patient is not improving and there is evidence of peritonitis, exploratory laparotomy should be performed with oversewing of the area of perforation, the manual recommends. "If the area is too inflamed to close or if distal obstruction is present, a gastric resection and gastrojejunostomy is usually needed," concludes the recommendation.

Another risk associated with electrocautery is that of interference with an implanted pacemaker or cardioverter defibrillator.⁹ A technology assessment by the ASGE explored the use of electrocautery in patients with pacemakers and found that although pacemakers have been shown to malfunction during surgery, there is no evidence of such malfunction during gastrointestinal endoscopy.¹⁰

Because implantable cardioverter defibrillators (ICD) are so widely used, physicians will find themselves performing endoscopies that incorporate electrocautery more and more frequently on patients with these devices. Thus, the ASGE's technology assessment committee has published recommendations to reduce the potential risk to such patients.

Their suggestions include the following:

• Deactivate any ICD before the endoscopy, and ensure that it is working properly at the end of the endoscopy
• Carefully observe the patient's cardiac rhythm; also keep the necessary resuscitation equipment nearby
• Locate the grounding pad on the buttock or thigh, remote from the ICD
• Use electrocautery only in short, repetitive bursts to lessen the time an ICD might be inhibited
• Use bipolar electrocautery (if possible) if it is necessary to use electrocautery near the ICD. This, the panel notes, is most applicable to lesions in the distal esophagus, proximal stomach, and near the splenic flexure of the colon.

Injuries associated with electrosurgery in general are related to many complications from laparoscopy. This leads to legal complications as well as medical issues. Such injuries have spurred the formation of a sub-society of attorneys who focus only on laparoscopic surgery. Large settlements have been made in cases involving electrosurgical complications, especially those related to delayed bowel burn.¹¹

Damage of this type can be circumvented by the incorporation of active end point electrode monitoring for laparoscopic instruments, says James F. Daniell, MD. In a letter to the editor of the newsletter for the International Society for Gynecologic Endoscopy, Daniell notes that laparoscopic active electrode end point monitoring has been available in North America for more than five years -- in 1999 -- but that despite this, it is seldom used in laparoscopy.

Daniell makes several recommendations for electrosurgery:

• Never use plastic or hybrid trocars
• Never activate the electrode unless it is touching the tissue to be coagulated
• Use cutting current whenever possible. This minimizes the high coagulation current which can increase the risk of discharging electricity into alternate burn sites.
• Incorporate laparoscopic active electrode monitoring to eradicate the risks of capacitive coupling and insulation failure

The active electrode monitoring is strongly recommended by many medical malpractice insurance companies, including the State Volunteer Mutual Insurance Company, which offers physicians a 10 percent discount off their premiums for participating in its seminar on complications in laparoscopy.¹²

Carefully considering these risks, taking proper precautions, and weighing risks against the benefits of electrocautery should allow surgeons to make informed decisions about their patients' needs and appropriate treatments.