Bipolar Diathermy Forceps May Not be Responsible for Post-Tonsillectomy Hemorrage

In January 2001, the British government advised against the use of re-usable instruments for tonsil and adenoid surgery. This advisory addressed concerns that re-usable surgical instruments presented a theoretical risk of transmission of variant Creutzfeldt-Jacob Disease (vCJD) or human "mad cow disease." The British medical authorities advised that single-use instruments, including single-use bipolar diathermy forceps, which are used to seal the surgical wounds, should be adopted.

After their introduction, a series of operating room problems occurred, and hospitals were ordered to return to the use of traditional, reusable tools. This decision was influenced by a London Times report that the 25 Pounds (British) throwaway bipolar diathermy kit caused hundreds of cases of secondary hemorrhaging (occurring one to ten days following surgery) and the deaths of a 33-year-old woman and a two-year-old boy.

The British surgical community hailed the decision, stating that the return to reusable bipolar diathermy forceps (where two electrodes are combined in the instrument (e.g. forceps) and a current passes between tips and not through the patient) improved postoperative care. But a new study from a department of otolaryngology in the United Kingdom finds that withdrawing the use of bipolar diathermy for dissection in adult tonsillectomy led to no significant reduction in adult secondary post-tonsillectomy haemorrhage rates. Changing to "cold dissection," or use of a scalpel, had no impact on the haemorrhage rates at all.

A previous prospective study over one year (November 1999 -- 2000) assessed the rate of reactionary and secondary post-tonsillectomy haemorrhage using 'cold' and bipolar diathermy dissection in adults and children in the same hospital department. Adult tonsillectomy by bipolar diathermy dissection was found to have a statistically significant higher secondary haemorrhage rate than cold dissection. This result prompted a change in departmental practice to the exclusive use of cold dissection tonsillectomy in adults.

This study aims to assess the consequences of that decision to abandon tonsillectomy by bipolar diathermy dissection in adults on post-tonsillectomy haemorrhage rates. The authors of "Post-tonsillectomy Haemorrhage -- Impact of Altered Practice" are Mary-Louise Montague MRCS, Michael S.W. Lee FRCS, and S.S. Musheer Hussain FRCS, all from the Department of Otolaryngology, Ninewells Hospital and Medical School, Dundee, United Kingdom. Their findings were presented at the Annual Meeting and OTO EXPO of the American Academy of Otolaryngology--Head and Neck Surgery Foundation, held September 22-25, 2002, at the San Diego Convention Center, San Diego, CA.

Methodology: This is a prospective study of all patients undergoing tonsillectomy between August 2001 and August 2002 in a university department of otolaryngology. Adult tonsillectomy was performed exclusively by cold dissection. Pediatric tonsillectomy was performed either by cold dissection or by bipolar diathermy dissection according to surgeon preference.

The haemostasis technique comprised bipolar diathermy with or without ties during cold dissection tonsillectomy. Bipolar diathermy alone was used to complete haemostasis during bipolar diathermy dissection tonsillectomy. Patient identity, age and sex, date of surgery, method of tonsillectomy, and skill level of the surgeon were recorded at the time of surgery. The occurrence of post-tonsillectomy haemorrhage, its interval from surgery and its management were measured. The occurrence of both reactionary haemorrhage (within 24 hours) and secondary haemorrhage (between one to 10 days) was recorded.

The overall reactionary and secondary post-tonsillectomy haemorrhage rates in adults and children were calculated. Specific attention was given to the secondary haemorrhage rate in adults to allow an assessment of the impact of the department's altered practice to be made. Fisher's exact test was used to determine statistical significance. Confidence intervals were established for the differences observed in post-tonsillectomy haemorrhage rates between the two study periods.

Results: Some 385 patients (124 male and 261 female) with a mean patient age of 17.0 years underwent tonsillectomy between August 2001 and August 2002. Tonsillectomy was performed in 216 adults and 169 children. Cold dissection was the method of tonsillectomy in all but three adults. Bipolar diathermy dissection was deemed necessary by the operating surgeon in the three cases where dissection failed to proceed using a cold dissection technique. Of the 169 tonsillectomies in children cold dissection was used in 110 cases and bipolar diathermy dissection in 59 cases.

The overall reactionary haemorrhage rate was 0.8 percent (n=3). The overall secondary haemorrhage rate was 9.4 percent (n=36). The reactionary and secondary post-tonsillectomy haemorrhage rates in adults and children are shown in Tables 1 and 2. The overall reactionary and secondary haemorrhage rates in adults were 1.4 percent (n=3) and 12.0 percent (n=26) respectively. Abandoning the use of bipolar diathermy for dissection in adult tonsillectomy resulted in a fall in the adult secondary post-tonsillectomy haemorrhage rate from 12.7 percent to 12.0 percent.

Conclusions: The overall secondary post-tonsillectomy haemorrhage rate did not change significantly despite the change in practice. A 0.7 percent fall in the adult secondary post-tonsillectomy haemorrhage rate observed after abandoning bipolar diathermy dissection in adults in favour of cold dissection was not statistically significant. The differences in haemorrhage rates observed in children before and after the change in practice also were not statistically significant. Changing the practice in adult tonsillectomy by avoiding the use of bipolar diathermy for dissection has had no impact on the rate of secondary post-tonsillectomy haemorrhage in the adults undergoing tonsillectomy.

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