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PubMed1996

Photodynamic therapy in lung cancer. A review.

Photodynamic therapy (PDT) in lung cancer was introduced in 1980 to treat tumours located in the major airways. After systemic injection of photosensitizers, tumour illumination is performed using a laser fibre to transmit light of a specific wavelength. PDT can be performed under local anaesthesia using the flexible fibreoptic bronchoscope. Skin photosensitivity is the most important treatment morbidity caused by the prolonged cutaneous retention of photosensitizer molecules. Ample data have shown that PDT is effective in obtaining tumour necrosis, but the skin photosensitivity issue limits its palliative potential. Moreover, competing bronchoscopic techniques, such as electrosurgery, Nd-YAG laser and brachytherapy, are available and seem to be equally palliative for the debulking of intraluminal obstructive lung tumours. The curative potential of PDT in patients with roentgenologically occult lung cancer is the most interesting aspect of this treatment modality. A significant number of patients with lung cancer have limited pulmonary function. A normal tissue sparing treatment such as PDT may provide an alternative, as patients may also have subsequent multiple lung cancer primaries. Since early lung cancer detection is now becoming feasible, PDT may be applied to treat roentgenologically occult tumours with curative intent. This may optimize treatment efficacy in the near future.

Dihematoporphyrin Ether↗

PubMed2003

Endobronchial post-transplant lymphoproliferative disorder and its management with photodynamic therapy: a case report.

Post-transplant lymphoproliferative disorder (PTLD) is a recognized complication of solid-organ transplantation. We describe a 56-year-old man with end-stage idiopathic pulmonary fibrosis who underwent right-sided single-lung transplantation and who had biopsy-proven PTLD involving the main bronchi 3 months later. The lesions recurred despite endobronchial electrosurgery and systemic therapy with interferon for 3 months. Interferon was deceased and anti-CD20 therapy and photodynamic therapy were performed concurrently using flexible bronchoscopy. The subsequent follow-up endobronchial biopsy specimen results were negative for PTLD. This case is the first reported use of photodynamic therapy combined with anti-CD20 for treating PTLD. Endobronchial PTLD is a rare complication of lung transplantation and can be managed successfully with photodynamic therapy.

Bronchial Diseases↗

PubMed1998

Clinical experience with the (OPERA)StarSL using saline irrigation fluid for OPERA.

Objective: To present clinical results using a new hysteroscopic resectoscope, the (OPERA)Star(SL) with PEARL technology, which cuts and coagulates uterine tissue in a physiologic, conductive fluid environment in order to perform OPERA, Out-Patient Endometrial Resection/Ablation. Use of physiologic normal saline in resectoscopy has not previously been feasible. Use of normal saline prevents complications such as hyponatremia and cerebral edema due to excessive absorption of traditional nonphysiologic fluids.Methods: Patients suffering from abnormal uterine bleeding with or without submucosal fibroids who were scheduled for surgical intervention underwent OPERA for treatment of their condition. The (OPERA)Star(SL) resectoscope with PEARL technology was used with a 0.9% saline distention medium. The PEARL technology insulates the active electrode so that a noninsulating fluid, such as 0.9% saline or lactated ringers, can be used while maintaining the ability to cut and coagulate tissue using a standard monopolar electrosurgery unit.Operative data recorded include uterine size, presence and size of fibroids, pretreatment with endometrial thinning agents, operative time, cutting/coagulating power levels, estimated blood loss, and calculated fluid deficit. Additional data include the ability to cut and coagulate tissue as compared to standard resectoscopes used in the physician's clinical practice.Results: A total of 22 patients underwent operative hysteroscopy with the described resectoscope. Average age of all patients was 45 years (range 30-70), and average weight was 158 pounds (range 106-258). Eighteen (82%) patients underwent OPERA while the remaining 4 (18%) patients underwent fibroid resections. The average uterine size was 7 weeks (range 4-14). Average operative time was 26 minutes, and all procedures were successfully completed without complications. Fluid deficit averaged 480 mL (range 0.0-1.54 L) as reported by the Flo-Stat Fluid Management System.A Likert scale was used to rate the device's ability to cut and coagulate tissue with results indicating the (OPERA)Star(SL) accomplishes the same clinical results to standard resectoscopic devices used in the physician's clinical practice.Conclusion: Complete uterine tissue resection and ablation can now be accomplished in a saline environment. The unique PEARL technology with the (OPERA)Star(SL) resectoscope is effective in cutting and coagulating uterine tissue. Operating in a saline environment eliminates the most prevalent potential complication of operative hysteroscopy when using nonphysiologic irrigation solutions, dilutional hyponatremia, and secondary cerebral edema.

Journal Article↗

PubMed2004

Hysteroscopic training: the butternut pumpkin model.

Operative hysteroscopy involves significant hand-eye coordination, utilizing energy sources, video imaging, and the safe control of distending media. We describe a safe, effective, inexpensive, and reproducible method of developing the skills and hand-eye coordination for diagnostic and operative hysteroscopy. In this inanimate model, advanced surgical skills can be practiced, and realistic, simulated electrosurgery including resection of the endometrium and rollerball ablation can be performed.

Australia↗

PubMed2001

Comparison of tissue injury between laparosonic coagulating shears and electrosurgical scissors in the sheep model.

STUDY OBJECTIVE: To compare laparosonic coagulating shears (LCS), which use ultrasonic energy, and unipolar diathermy scissors with respect to depth of tissue injury. DESIGN: Prospective observational study (Canadian Task Force classification I). SETTING: A reproduced surgical setting. SUBJECTS: An anesthetized sheep. INTERVENTION: We laparoscopically harvested uterine horn and bowel tissue. MEASUREMENTS AND MAIN RESULTS: Tissue was transected while hemostasis was maintained. Two pathologists examined tissue independently, and each was blinded as to the instrument used for harvesting. Clinical characteristics and tissue injury created by the instruments were compared. CONCLUSION: Subjectively, LCS appeared to produce less smoke plume than diathermy scissors. It also produced greater tissue damage than unipolar electrosurgery on settings of 35 W cut and 30 W coagulate.

Animals↗

PubMed1993

Buttonhole ulceration and perforation of the rectum.

Three laparoscopies were performed with treatment of cul-de-sac endometriosis near the rectum Two patients had a subsequent laparotomy for rectal perforation. The bowel damage appears to have been from a combination of failure to appreciate the position of the bowel with anatomy distorted by endometriosis, dissecting into healthy tissue with a carbon dioxide laser, desiccating healthy tissue with bipolar electrosurgery, and thermal spread into healthy tissue from the desiccated endometriotic tissue. Gynecologists must be aware of this potential complication when treating endometriosis near the rectum.

Adult↗

PubMed1993

Laparoscopic ablation of endometriosis using the cavitational ultrasonic surgical aspirator.

Surgical modalities such as electrosurgery and lasers have been used for many years to treat endometriosis. They are relatively unselective with wide scatter, however, leading to the potential for significant tissue damage and injury. As an alternative, a technique for performing laparoscopic excision and adhesiolysis using a cavitational ultrasonic surgical aspirator (CUSA) was developed and studied in 15 patients. Endometriosis was removed using a prototype titanium probe developed for a 10-mm laparoscopic port. The ultrasonic laparoscopic probe consisted of an acoustic vibrator, a coupling device, a removable tip, and a protective flue. Vibrations from the acoustic vibrator (magnetostrictive device) were conveyed to the operating tip through a coupling piece. The magnetostrictive device consisted of nickel alloy laminations 10.8 cm in length that transformed electrical energy into mechanical motion at the hollow titanium tip, vibrating at a frequency of 23 kHz. The excursion of the tip (amplitude setting) was arbitrarily set, with a fixed stroke of 200 microm in all cases to remove tissue with a 1- to 2-mm radius of the vibrating tip. The tip was tapered to obtain greater amplitude and ablation efficiency. When placed in contact with the endometriotic implants and adhesions, it destroyed and emulsified the cell membranes, which were irrigated and removed through a built-in suction tube. The resulting debris and irrigating fluid were removed through the hollow central portion of the probe. The vibrating tip was moved over the surgical site in a back-and-forth motion to allow continuous, controlled removal. Vessels larger than 0.5 mm in diameter, nerves, and fibrous tissue capsules rebounded with the ultrasonic vibration waves emitted by the CUSA, and thus were unimpaired by the procedure. The consistency of tissues was sensed accurately when the tip of the device was in contact with them. This tactile feedback was helpful in enabling the surgeon to differentiate target tissues. The future application of this instrument awaits the outcome of research.

Adult↗

PubMed1996

Laparoscopic myomectomy in African-American women.

STUDY OBJECTIVE: To evaluate the effectiveness of laparoscopic myomectomy in an ethnic group with a statistically increased frequency of uterine leiomyomata. DESIGN: Retrospective chart review. SETTING: Private practice of one surgeon, and Department of Obstetrics and Gynecology, Rush Medical College, Chicago, Illinois. PATIENTS: Forty-one consecutive African-American women who underwent laparoscopic myomectomy and were followed for 12 to 26 months. INTERVENTIONS: The women received a modified protocol for gonadotropin-releasing hormone agonist treatment before laparoscopic surgery. Laparoscopic myomectomies were performed under general anesthesia using energy sources of monopolar and bipolar electrosurgery and ultrasonic coagulation-cutting (harmonic scalpel). MEASUREMENTS AND MAIN RESULTS: Seventy percent (70%, 29 women) of procedures were completed on an outpatient basis. Twelve patients were hospitalized for an average of 1.3 days. No significant operative or postoperative complications occurred, and none of the women required blood transfusions or readmission. The conversion rate was zero. Forty patients (91%) reported complete resolution or significant reduction of their symptoms. CONCLUSIONS: Outpatient laparoscopic myomectomy is safe and effective in African-American women with symptomatic uterine leiomyomata of 20 weeks' size or less.

Adult↗

PubMed1996

Enterocele as a consequence of laparoscopic resection of deeply infiltrating endometriosis.

Laparoscopic excision of deeply infiltrating endometriosis in the cul-de-sac or the rectovaginal septum by means of electrosurgery or laser is performed frequently. Little is known about the long-term results or complications of this surgery. We suggest that enterocele could be a complication of the procedure. A patient developed a large enterocele 3 years after a laparoscopic excision of a deep endometriotic nodule with resection of the uterosacral ligaments. We question whether routine preventive measures should not be taken after excision of a deep endometriotic nodule from the rectovaginal septum.

Adult↗

PubMed1996

Argon Beam Coagulator in Laparoscopic Gynecologic Surgery

Forty-one women underwent laparoscopic argon-enhanced electrosurgery, 17 for ovarian endometriomas and peritoneal endometriosis, 5 for dermoids, 11 for deep endometriosis of uterosacral ligaments, and 8 for tubal infertility. Argon-enhanced coagulation was used to treat the bed of peeled endometrioma walls and superficial endometriotic lesions, for hemostasis after adhesions dissection and excision of endometriosis from uterosacral ligaments, and for tubal ampulla eversion. The settings used were 4.0 SPLM with 30 to 50 W coagulation current. Argon-enhanced coagulation provided both quick and safe hemostasis, and caused minimal damage to adjacent tissues without smoke and carbonizing of tissues. Better visualization due to the absence of smoke and minimal tissue trauma will probably help reduce blood loss and operating time, and enhance long-term outcomes of surgery.

Journal Article↗

PubMed1996

Advantages of Total Laparoscopic Hysterectomy

We compared 112 total laparoscopic hysterectomies (TLH) with 72 laparoscopic hysterectomies (LH) performed from January 1, 1995, to September 30, 1995. Patient characteristics (age, weight, parity) and indications for surgery were similar between the groups. All surgeries were performed with electrosurgery or suture ligature, or both. Average uterine weight was slightly lower with TLH (193.1 ± 96.2 g) versus LH (237.4 ± 84.5 g). Thirty-three women (29.46%) undergoing TLH had had previous pelvic surgery, versus 12 having LH (16.67%). Operating time was significantly shorter for TLH (117.6 ± 38.2 min) than LH (134.9 ± 37.4 min). Less bleeding, as indicated by decreased postoperative hemoglobin, was noted with TLH (1.3 ± 0.7 g/ml) versus LH (1.7 ± 1.1 g/ml). Fewer cases of serious complications, such as genitourinary tract damage, and less formation of granulation tissues on the vaginal cuff associated with persistent leukorrhea and postcoital bleeding occurred with TLH, probably because more precise surgery can be done under direct vision. We believe TLH can be performed more safely and quickly than LH by an experienced surgeon. A potential advantage of TLH is less postoperative infection due to less vaginal manipulation. Other advantages are the lengthening of the vagina, less postoperative prolapse of the vagina, and less enterocele development because of more precise anatomic restoration of the pelvic structures under direct visualization. Since detailed pelvic structures can be visualized, excised, and restored, TLH has all the possible benefits of subtotal hysterectomy, if any, due to the maximum preservation of supporting structures (cardinal, uterosacral ligaments) and nerve plexus, thus making subtotal hysterectomy obsolete. Further studies and long-term follow-up are required.

Journal Article↗

PubMed1996

Major Vessel Injury During Advanced Laparoscopic Surgery

Eight cases of large vessel laceration occurred during operative laparoscopy, but were not related to cannula or Veress needle injury. Four injuries were managed at laparoscopy. One patient was operated on by us. We reviewed four cases for colleagues, and the remainder were subject to litigation. Four women were undergoing lymph node dissection and three others had endometriosis or adhesions that obliterated the normal anatomy. The injury involved the inferior vena cava in two women, the right external iliac artery in four, and the left hypogastric and inferior mesenteric artery in one woman each. Vascular lacerations were caused by unipolar electrosurgery in two patients and by the carbon dioxide laser in two. In the remaining four women the injury to the artery or vein occurred during sharp dissection. The vessel injury was repaired by the conventional open technique in four women. The other four were managed laparoscopically, two by applying metal clips on the vessel wall and one with bipolar electrocoagulation. The outcome in all patients was good except for one, who died.

Journal Article↗

PubMed1996

Is Carbon Monoxide Poisoning a Risk During Prolonged Laparoscopic Surgery?

We evaluated whether prolonged laparoscopic procedures performed with high-flow carbon dioxide (CO2) insufflation, intensive evacuation of intraabdominal smoke, and controlled hyperventilation with 50% to 90% oxygen results in significant elevation in blood carboxyhemoglobin levels. Twenty-seven healthy, nonsmoking women (mean ± SD age 39.1 ± 8.0 yrs, range 22-56 yrs) undergoing laparoscopic procedures in which smoke was generated participated. In all cases both the CO2 laser and bipolar electrosurgery were used extensively. The mean ± SD duration of surgery was 141 ± 72 minutes (range 45-300 min). Blood samples were drawn before and after surgery. Carboxyhemoglobin concentrations were measured using a highly accurate gas chromatography method. The mean ± SD carboxyhemoglobin levels were 0.70% ± 0.15% (range 0.44-1.20%) before and 0.58% ± 0.20% (range 0.30-1.33%) after surgery. The concentrations decreased significantly during surgery (mean ± SD 20% ± 11%, range 3-46%, p <0.001). In only one woman the level increased at the end of surgery. This also occurred when levels exceeded 1% (1.33%). The correlation coefficient (r) between carboxyhemoglobin concentrations and duration of surgery was 0.324. We concluded that carbon monoxide poisoning is not associated with prolonged laparoscopic surgical procedures. This may be attributed to aggressive smoke evacuation that minimized exposure and to elimination of CO2 through hyperventilation.

Journal Article↗

PubMed1996

Bipolar Electrodes in the Treatment of Ectopic Pregnancy

During operative laparoscopy in the management of the ectopic pregnancy, conservative treatment consisting of linear salpingotomy and extraction of trophoblast must be carried out systematically. Until recently, tubal incision was performed with monopolar delivery systems. Bipolar electrosurgery has been used for many years, but is limited to coagulation. We applied bipolar technology in the conservative treatment of ectopic pregnancy. The instrument we used for the salpingotomy consisted of disposable Bilap needle or hook electrodes with shaft diameter of 5 mm and working length 33 cm. The trophoblast was extracted with a hydrodissection pump provided with 10- or 5-mm probes without irrigation holes. The electrodes were connected to an electrosurgical generator with maximum cutting power of 70 W. This system offers cutting in bipolar applications that are designed to eliminate current passing through tissues other than those selected. The conductive electrodes are closely spaced, reducing the energy requirements and power delivered to the surrounding tissue. The operative procedure was performed in 12 women. We had no persistent trophoblastic proliferation, and no patient required additional treatment.

Journal Article↗

PubMed1998

Initial experience with a physiologic morcellating resectoscope.

A new physiologic morcellating resectoscope allows operative hysteroscopy to be performed with a physiologic distention medium, thus reducing the risk of dilutional hyponatremia and cerebral edema secondary to excessive absorption of nonphysiologic fluid. To study this new technology, we gathered in vitro data with the SL resectoscope with dual-function electrode (FemRx, Sunnyvale, CA). Coupled to a standard monopolar electrosurgery unit and operating in normal saline or Ringer's lactate solution, extirpated uteri showed equivalent depth of tissue necrosis with this new physiologic morcellating resectoscope as with a conventional monopolar resectoscope used in an electrically nonconductive fluid.

Electrocoagulation↗

PubMed1998

Endometrial Na+, K+-ATPase pump function and vasopressin levels during hysteroscopic surgery in patients pretreated with GnRH agonist.

STUDY OBJECTIVE: To investigate the effects of gonadotropin-releasing hormone (GnRH) analog pretreatment on endometrial Na+, K+-adenosine triphosphatase (ATPase) pump function and peripheral blood vasopressin levels, and their role in fluid absorption and mechanisms of hyponatremia in patients undergoing hysteroscopic endometrial ablation. DESIGN: Prospective, randomized, placebo-controlled study (Canadian Task Force classification I). SETTING: University-affiliated hospital. PATIENTS: Seventeen women with dysfunctional uterine bleeding. INTERVENTION: Nine women received a GnRH analog and eight received saline approximately 6 to 8 weeks before hysteroscopic ablation by electrosurgery. MEASUREMENTS AND MAIN RESULTS: Both before randomization and immediately before surgery, endometrial biopsy samples were obtained and numbered consecutively without patient identification. Operative hysteroscopy was performed with glycine 1.5% mixed with 2% alcohol. The amount of irrigant and irrigant deficit; blood levels of albumin and ethanol; hematocrit and hemoglobin; changes in sodium levels; and central venous pressure were compared. The Na+, K+-ATPase pump activity was significantly increased in the GnRH analog group compared with the saline group and correlated with decreased estradiol levels (0.4 +/- 0.08 vs 0.26 +/- 0.06 micro mol/min/ml). Vasopressin levels were significantly lower in the GnRH group (3.2 +/- 0.9 vs 7.6 +/- 1.7 micro mol/L). Mean volume of irrigant used and operating time were similar in both groups. Volume deficit, decrease in protein, and hematocrit were less in GnRH than in the saline group. Blood ethanol levels, decrease in sodium, and irrigant deficit were significantly lower in GnRH group. CONCLUSION: Pretreatment with GnRH analogs may prevent the adverse effects of estradiol on endometrial Na+, K+-ATPase and creates a protective mechanism against iatrogenic hyponatremia, which is more critical in women than men in case of absorption of irrigating fluid. Moreover, created hypoestrogenism may enhance Na+, K+-ATPase activity in brain as well as endometrium, thus decreasing women's susceptibility to hyponatremic complications and brain damage. Suppressed vasopressin levels may be protective against fluid absorption in GnRH analog-treated patients.

Adult↗

PubMed1999

Five-year review of endometrial ablation with the SideFire laser fiber.

STUDY OBJECTIVE: To determine 5-year results of endometrial ablation with the SideFire laser fiber. DESIGN: All women seen in private office who were candidates for this procedure were followed over 5 years (Canadian Task Force classification II-2). SETTING: Patients were pretreated with depot leuprolide acetate in a private office. All procedures were done in an outpatient surgery center, and no patient was admitted to the hospital. PATIENTS: Eighty-six women with increased bleeding. INTERVENTION: Endometrial ablation with the SideFire laser fiber. MEASUREMENTS AND MAIN RESULTS: After follow-up of 12 to 72 months, 100% of patients had excellent results; 70 (82%) had total amenorrhea. Results were not less satisfactory in younger women. CONCLUSION: The SideFire laser fiber seems to be a good alternative that achieves improved outcomes compared with electrosurgery and balloon devices with hot fluid or electrodes. (J Am Assoc Gynecol Laparosc 6(1):65-69, 1999)

Adult↗

PubMed1999

Excision of endometriosis with laparosonic coagulating shears.

Excision of endometriotic lesions allows the diagnosis to be confirmed and may provide long-term relief of symptoms. Laparoscopic excision is generally accepted for treatment of all stages of disease and can be accomplished safely with laser, electrosurgery, or ultrasonic energy. Ultrasonic energy uses the 5-mm hook blade for excision and 5-mm harmonic scalpel ball electrode for coagulation. Disease was excised by laparosonic coagulating shears (LCS) in 14 women. All patients had an uneventful postoperative course, with 13 (93%) remaining pain free 7 to 18 months postoperatively. The LCS is easy to use and allows endometriosis to be excised with an adequate margin of safety. (J Am Assoc Gynecol Laparosc 6(2):195-199, 1999)

Electrocoagulation↗