Tonsillectomy findings favour cold steel without diathermy
Aug 21, 2004 - 8:59:00 AM
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By Ashwin, UK Correspondent,
[RxPG] The report in this weeks issue of The Lancet (Tonsillectomy technique as a risk factor for postoperative haemorrhage) is based on the National Prospective Tonsillectomy Audit being carried out by the Royal College of Surgeons Clinical Effectiveness Unit and the British Association of Otorhinolaryngologists, Head and Neck Surgeons.
The data collection for the Audit, which started in July 2003, is due to be completed in October this year.
Tonsillectomy is one of the most common surgical procedures. The Audit is investigating occurrence of haemorrhages and other complications after tonsillectomy; risk factors of the complications, including type of instruments used, surgical technique, surgical experience and patient factors; and whether these risk factors can explain variations in complications. Data is being collected from all NHS Trusts and independent hospitals in England and Northern Ireland.
The Audits interim findings, reported in The Lancet by a team led by Jan van der Meulen of The Royal College of Surgeons and the London School of Hygiene and Tropical Medicine, are that tonsillectomies carried out using hot techniques such as diathermy and coblation could increase postoperative haemorrhages.
Dr van der Meulen says, Although our findings favour cold steel without diathermy, we do not think that hot techniques should be stopped on the basis of current evidence. Further clinical research is needed to support the results of our study.
In response to the results of this Audit, the National Institute of Clinical Excellence (NICE) issued interim guidance in March this year to all ENT surgeons in England on the use of diathermy in tonsillectomy. In an accompanying letter, surgeons were advised by Professor Richard Ramsden, chairman of the Audits Steering Group and President-Elect of the British Association of Otorhinolaryngologists, Head and Neck Surgeons, that:
Hot techniques should not be stopped on the basis of the current evidence. However, the Audit found particularly high postoperative haemorrhage rate with monopolar diathermy, and the use of this technique should be carefully considered.
The extent to which diathermy is used in a patient seems to be linked to the amount of thermal damage to surrounding tissues. This indicates that diathermy should always be used with caution, and the power setting, frequency and duration of diathermy use should be carefully controlled.
The training in ENT may need to be more stringent than in the past. We should emphasise that excessive use of diathermy whilst readily controlling bleeding during surgery may lead to increased postoperative haemorrhage. The technique of tying blood vessels should be taught to all trainees.
Coblation may be a particularly difficult technique to learn, and that must b e reflected in the way this technique is taught.
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