Newswise — Electrosurgery, an invaluable surgical technique used in several medical specialties such as neurology, cardiology, and urology, has, in the last 20 years, been accepted as an attractive option for performing tonsillectomy. Compared to scalpel dissection, electrosurgery provides excellent means for conducting rapid hemostasis to address operative bleeding, although its use has been noted to extend postoperative recovery. Consequently, ensuring minimized risk for peri-operative bleeding as well as improving quality of the postoperative experience remains a priority in the effort to optimize the tonsillectomy procedure.
Electrosurgery entails applying an electrical current to produce a desired surgical effect in tissue, most commonly consisting of cutting, ablation, coagulation, desiccation, or hemostasis. The end result is primarily determined by the rate of energy delivery, electrode shape and geometry, and feedback control. Tissue ablation with conventional electrosurgery, like the 'Bovie', is achieved by introducing high voltage sparking, via an electrode pair, across the physical gap between the source electrode and the electrically conductive tissue. Coblation devices offer improved energy delivery over conventional electrosurgery tools. By design,, when used with a common conductive medium, such as saline solution, Coblation devices convert the medium into a stable, controlled, low temperature (~70ºC) plasma energy field. With Coblation technology, the mechanism of action differs from conventional electrosurgery in that tissue excision occurs via molecular dissociation of organic (tissue) molecules, in lieu of the cellular rupture that occurs with conventional electrosurgery at extremely high temperatures (400ºC to 600ºC). This is believed to provide important clinical benefits, such as improved precision in tissue etching and minimal to no thermal damage in tissue adjacent to treatment areas.
Previous research indicates that Coblation electrosurgery (CES) tonsillectomy is associated with less postoperative pain and better quality recovery than conventional electrosurgery (ES). A new study set out to confirm this assertion in a multi-site setting.
The purpose of this study was to determine whether patients who received CES total tonsillectomy would experience less postoperative discomfort over the 30-day follow-up period, with no difference in occurrence or severity of bleeding or complications, than patients who received ES tonsillectomy. The authors of "Pediatric Total Tonsillectomy Using Coblation Electrosurgery Compared To Conventional Electrosurgery: A Prospective, Controlled Single-Blind Study," are Kelly E. Stoker MD, Mountain West Ear, Nose, and Throat, Bountiful, UT; Debra M. Don MD, D. Richard Kang, MD, and Anthony Magit, MD, from the Children's Pediatric Specialists, San Diego, CA; and David N. Madgy DO and Michael S. Haupert, DO at the Michigan Pediatric ENT Association, Detroit, MI. Their findings were presented September 23, 2003, at the American Academy of Otolaryngology-Head and Neck Surgery Foundation http://www.entnet.org Annual Meeting and OTO EXPO, being held September 21-24, 2003, at the Orange County Convention Center, Orlando, FL.
Methodology: All study candidates had a history of tonsillar infection and/or obstructive enlarged tonsils and were between the ages of 3 and 12 years. Patients were ineligible for participation if they had active infection with fever greater than 101.5 degrees F, previous tonsillar surgery, history of peritonsillar abscess, systemic disease potentially causing coagulopathy, craniofacial anomaly, history of easy bruising or bleeding disorders, history of heart disease, diabetes, or hypertension.
In ES patients, the tonsils were removed through subcapsular dissection using a needle tip monopolar radiofrequency probe and electrosurgery controller applied using set point 17±3. In CES patients, tonsils were excised using a blunt dissection technique, performed using the Evac 70 Plasma Wand (ArthroCare Corp., Sunnyvale, CA) at a controller set point between 6 and 9, depending on clinician preference. In patients who required adenoidectomy, surgeons used their preferred method.
Blood loss during both the tonsillectomy and adenoidectomy portions of the procedure was estimated intra-operatively by the surgeon and recorded. The surgeon graded the electrosurgery devices on effectiveness for tissue removal and for hemostasis. Duration of the tonsillectomy portion of the procedure (time from first incision to complete hemostasis of the tonsillar bed) and total time of surgery were noted.
Patients' parents were instructed by study coordinators to complete a daily diary recording assessment of subjective pain, type and frequency of pain medication, return to normal diet and daily activity, and physician contact. A postoperative physical examination was made at the 16-day follow-up visit.
Results: The mean age for patients in both treatment groups was 6±3 years. In the CES (n=44) and ES (n=45) groups, 55 percent and 42 percent, respectively, were female. Most patients required surgery to correct symptoms associated with obstructive hypertrophy; the majority of patients also had a history of chronic or recurrent tonsillitis. Treatment groups did not differ in regard to tonsil size or nasal findings. Key findings included:
"¢ Procedure time, ease for performing the tonsillectomy, and device effectiveness did not differ significantly between treatment groups. Over 90 percent of patients from both groups requested liquids within the first 12 hours after the tonsillectomy and most accepted soft food "¢ During the first 14 days, fewer CES patients contacted or visited the physician for postoperative complications than ES patients (14/44 vs 24/45). The total number of contacts from the ES parents was double the contacts from CES parents. Reasons for postoperative calls or visits (# of patients) included mild bleeding (CES = 3, ES = 1), pain (CES = 6, ES = 11), vomiting (CES = 4, ES = 7), fever, dehydration, or no eating (CES = 6, ES = 7), cough, lethargy, confusion, and dizziness (CES = 0; ES = 8), or miscellaneous (CES = 4, ES = 14). "¢ Significantly fewer CES patients reported nausea during the 14-day postoperative period than ES patients (35 percent vs 62 percent; P=0.013). Mouth odor, ear pain, and mild bleeding were reported less often by CES parents than ES parents (67 percent vs 77 percent; 51 percent vs 64 percent; 7 percent vs 14 percent, respectively) but proportions did not differ statistically."¢ Days until return to solid food, normal diet, and normal activity were similar for treatment groups. Of note, two subjects from each group had not returned to normal diet or normal activity by the end of the 14-day follow-up period. Freedom from analgesics or pain did not differ statistically between treatment modes, but CES patients tended to discontinue prescription narcotics sooner. Of patients who took narcotics, CES patients tended to take half the daily dose of ES patients. "¢ At 32 days, more CES parents rated the postoperative experience as 'better than expected.'
Conclusions: This study asserts that although conventional electrosurgery is considered by most clinicians to be the standard of care for performing tonsillectomy, Coblation electrosurgery appears to provide better quality postoperative recovery.
In summary, during the two weeks after the procedure, fewer CES parents contacted the physician, making half as many contacts. Of children who received narcotic analgesics, CES patients tended to take half the dose and to discontinue them sooner. In addition, CES children reported significantly less incidence of nausea and were less likely to have localized site-specific swelling. Thirty days after the tonsillectomy, more CES parents rated the recovery period as better than expected compared to ES parents. Coblation electrosurgery appears to provide a valuable addition to our surgical armamentarium for optimizing the postoperative tonsillectomy experience in the pediatric population.
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