Applications of radiofrequency in day care proctology surgery
Gupta Pravin J.


Consultant Surgeon, Colo-Proctology.
Corrospondence:
Pravin J.Gupta, Gupta Nursing Home, D/9, Laxminagar, NAGPUR- 440 022, India.
Phone: 91712 2231047; Fax: 91 712 2547837; E-mail:drpjg_ngp@sancharnet.in / drpjg@yahoo.co.in

Abstract:
Background- Modalities like Cryosurgery, Photocoagulation, Electro surgery and Lasers are being used in the field of proctology since long. A machine that generates ultra-high frequency current waveform [radiofrequency] has emerged as a new tool to deal with many of the common ano rectal conditions.

Objective- The purpose of this paper is to enumerate the benefits of radiofrequency with emphasis on its advantages over conventional procedures. Based on extensive personal experience of using radiofrequency surgery in the performance of various anal pathologies, an attempt is made here to relay in narrative form the procedures from a “how-we-do-it” perspective.

Conclusion- Our experience indicates that radiofrequency surgery not only facilitates but also improves the performance of surgical procedures in treating anal fistula, hemorrhoids, pilonidal sinus, anal papillae, anal polyps, anal warts, anal condylomas, anal antibiomas and papillomas. It significantly shortens operative time, causes negligible intra-operative bleeding, facilitates faster recovery by allowing rapid healing and minimizes the chances of postoperative complications. It permitted us to perform most of the above procedures as a day care surgery.
Add to this, its cost-effectiveness coupled with better patient acceptance, radiofrequency surgery, applied judicially, could significantly improve the performance of a proctologist. The technique could be effectively applied in conjunction with conventional maneuvers to better the results of these procedures.

Keywords- Radiofrequency, Proctology, Conventional procedures, Day care procedures.
To cite this article:
Gupta Pravin J. The Indian scenario of Day Care Surgery in Proctology. Day Surg J India, 2008, 4:8-14

Introduction to Radio surgery

Radiofrequency surgery, to begin with, was used for treatment of snoring and is now being extensively used in the practice of dermatology1, cosmetology, neurosurgery, hepatology and ENT procedures. It has multi-faceted usages in the respective medical fields. 2,3,4.

However, to-date, proctologists have used this instrument very sparingly and that too out of curiosity rather than being serious. For a surgeon practicing proctology, there are two important goals to achieve. Whenever a new technique is adapted, it should aim at minimizing tissue damage and obtaining hemostasis during reconstruction, excision or ablation process. Radiofrequency is a refined type of electro surgery that utilizes a wave of electrons at a frequency between 2 and 4MHz, to incise, excise, ablate or coagulate tissue.

Radio surgery can simply be termed as an electro surgery at radiofrequency. It is necessary to eliminate any possible misconception about radio surgery by other older modality ‘electrocautery’ which is quite
different from radio surgery.

The word ‘cautery’ is derived from the Greek word kauterion, a branding iron, and, as its name suggests, electrocautery acts like an electric branding iron. In electrocautery, the heat [rather than the radio wave] is transferred to the soft tissue by convection. A massive cell destruction result from the application of cautery and the destruction caused by this cauterization is equivalent to that of a third degree burn 5.

The high frequency radio surgery and its results also should not be confused with diathermy. Such electro surgical generators are sometimes called by other names. In Europe, it is called as “Surgical Diathermy” while in the United States; they are termed as “Bovie” or “Electro cauterization machine.” With radiofrequency, the targeted tissue temperatures stay localized within a 38-70°C range thus limiting heat dissipation and damage to adjacent tissue. In contrast, electrocautery, diathermy or laser temperatures are significantly higher (750-900°C) which result in significant heat propagation in excess of the desired therapeutic need 6.
Electro surgical machines operating at frequencies below 3 MHz cause the electrode itself to heat and it has been found that these electrodes, if made of steel, melt away with use. It has been determined that the ideal frequency for achieving effortless cutting of tissues is approximately 4 MHz7.

Radiofrequency energy has been used extensively in many different medical applications and specialties for its ability to achieve a precise and controlled thermal ablation of soft tissue. The heat is not generated by the electrode itself as in standard electrocautery but is caused by resistance of the tissue falling in the path of the waves sent through the electrode tip 8.

Soft tissue resistance to these radio waves causes the cellular water in the soft tissue to heat, which produces steam and results in cellular molecular dissolution of individual tissue cells. The tissue cells absorb heat because of a natural resistance when in contact with waves of high frequency which are converted from the current. The surrounding cell layers, therefore, remain unaffected.
9-10

The radiofrequency unit- While there are different radiofrequency units in the market, we found the Ellman dual frequency 4MHz unit, which has a long successful history and which comes with a multitude of electrode tips very handy for a large variety of surgical maneuvers. The unit produces output power of 100 Watts at two different frequencies i.e. 4MHz and 1.7MHz. While the frequency of 4MHz is used for four standard settings like 1. Cutting, 2. Cutting and Coagulation, 3. Pure coagulation and 4. Fulguration, the frequency of 1.7MHz is used for bipolar coagulation. The unit has a digital display and audible signal to indicate when the unit is activated. The amount of energy to be delivered through the electrode can be preset between 1 and 10011.

An ‘antenna’ is used to focus the “radio wave” which unlike traditional electro surgical units, does not have to be in skin contact with the patient, rather it needs to be in the close proximity of the operating field. The antenna plate is not a passive electrode as is used in electro surgery. This antenna avoids the risk of electrical burns to the patient12-13. The unit is activated by a foot pedal. The ‘active’ or patient electrode is interchangeable.

Since last 8 years, we have been working with this equipment with satisfactory results. The procedure is suitable in all age group of patients [Table 1]. We have routinely used this unit to perform most of the proctological surgeries.

The advantage of simultaneous cutting and coagulation achieved by this machine has attracted us most. According to us, such versatility of the tool is the prime need of procedures within the ano rectal area, which is vascular and has only limited accessibility. During many procedures, the area of operation is blurred due to frequent
bleeding. This problem makes the procedure more difficult and time-consuming.
surgery for common anal patholoies [Figure 1]:

Hypertrophied anal papillae.
External piles.
Sentinel tags in fissure in ano.
Perianal warts and condylomata.
Rectal polyps.
Fibrous anal polyps.
Perianal and pilonidal sinuses.
Post fissure antibiomas.
Perianal papillomas.
Biopsies.
Fistula-in-ano.
Hemorrhoids.
Rectal prolapse.

Techniques:

Most applications are accomplished with under local anesthesia, short general anesthesia or under a caudal block.

Although, different types of electrodes are available with the unit, we could perform most of the procedures using a loop, a ball and a fine needle electrode.

Hypertrophied Anal Papilla:

It is a common finding in more than 50% of the cases of chronic anal fissure and is responsible for minor but disturbing complaints like discharge, pruritus or a foreign body sensation. They are trapped in the tight sphincter at times to cause severe pain. They immediately disappear when touched with the ball electrode in a coagulation mode. 14.

External Piles:

They either are in an isolated form with no internal pathology or may be a part of interno-external hemorrhoids. If small, they are coagulated with the ball electrode. However, a large sized mass is required to be shaved off with a round loop electrode.


Sentinel Piles in Fissure in Ano:

Sentinel pile or tags are a common accompaniment of chronic anal fissures. In our opinion, these must be removed for two reasons. First, they may interfere with the healing of the fissure and second, they become a cause of concern for the patient that ‘something’ was still left behind.

If the tag is small, it can be directly coagulated with a ball electrode, but if it is large, then it is excised with the round loop, securing the bleeding points and coagulating them later. 15.

Perianal Warts and Condylomata:

Perianal warts and condylomata are not very common. These are mostly the result of perverted sexual practice and cause perianal soiling and pruritus. They may reach within the anal canal and can bleed at times.

These could be shaved off using a loop electrode in a cut and coagulation mode. Once all of them are removed, the operated area is ‘sterilized’ by rolling a ball electrode on coagulation mode to ensure removal of invisible warts and the viral colony. The intra-anal warts can simply be coagulated rather than being excised.

Rectal Polyp:

A child is often found to be the common sufferer of rectal polyps. Sometimes adults may also have a large polyp slipping down during defecation and needing a manual repositioning.

These are vascular, delicate structures and can easily be detached if manipulated. If the polyp is large enough to be delivered out of the anus, then its pedicle is caught in a hemostat and the polyp is shaved off with loop electrode and then the base is coagulated with ball electrode. A small polyp can be coagulated in-situ.

Fibrous anal polyps:

These are exaggerated anal papillae. Over a period, they attain excessive fibrous thickening, and acquire a rounded expanded tip, which can even be felt on digital examination.

These are either coagulated in situ using the ball electrode, or if found large enough, could be shaved off with a loop electrode after coagulation of the base. 16.

Perianal and Para sacral Sinuses:

These include the pilonidal sinuses, post anal sinuses and post-traumatic sinuses. These are a source of constant pain, edema and pus discharge.

The patient is operated in a left lateral position. Methylene
blue dye mixed with hydrogen peroxide is injected in the sinus opening, which spreads out in the sinus tract. The tracts so identified, are then incised and laid opened with the needle electrode. The bleeding points are coagulated with the ball electrode in coagulation mode. The wound is left open for secondary healing. 17.

The wound healing in this procedure is excellent and the scarring is minimal. 18.

Perianal Papillomas:
These are coincidentally found while performing proctological procedures for some other pathology. These can precisely be removed using a loop electrode of a suitable size. The raw area left behind may require a touch of a ball electrode in coagulation mode to arrest any oozing from the base.

Perianal Antibiomas:

It follows an inadequate or delayed drainage of the anal abscess, which assumes chronicity. The abscess is treated with antibiotics to result in being walled off with fibrotic tissue and forming into an ‘antibioma’ [antibiotic granuloma, organized abscess, sterile abscess].

The aim of treatment is to curette the complete cavity, which could be achieved by incising the center of the lump using a needle electrode in cut and coagulation mode. All the granulation tissues, which feel hard with little bleeding, are scrapped out with a round loop electrode until a soft red base is reached.

Biopsies:

Biopsies can be performed for suspected growths in and out of the anus. A round loop electrode is best tool, which is used on a cutting mode so that the histology is not distorted due to lateral heat. A brisk bleeding is encountered from the base, which could be compressed for a few minutes or else coagulated with ball electrode.

There is no distortion of the resected edges of biopsy specimens. Histologically, it has been shown that tissue damage with radio surgery is actually less than with a conventional scalpel. 19.

Fistula in Ano:

The Ellman Dual Frequency has been found to be the most exciting and effective tool in operating fistula-in- ano. 20.

The versatility of this instrument is its biggest asset in performing this surgery. The ease of operation, minimal bleeding, a short procedure time and early recovery of the patient are but few of the highlights of radiofrequency fistulotomy. 21.

The patient is operated either under a short general
anesthesia or under caudal block. The procedure is performed keeping the patient in a lithotomy position. While viewing through an anoscope, methylene blue dye mixed with hydrogen peroxide is injected through the external opening. The dye emerges out from the internal opening. A probe is gently passed through the external opening and is brought out of the anal canal through the internal opening. The blue spot of the dye emerging from the internal opening is a good guide in this maneuver. Keeping the probe in the fistula tract, the skin overlying the probe is coagulated by moving the ball electrode over its complete length. This reduces the amount of bleeding during incision of the tract.

With a needle electrode the tract is then slit opened over the probe. The edges of the wound are shaved off by the loop electrode to create a pear shaped wound tapering towards the anus. The bleeding points are held in the hemostat and are coagulated. 22-23.

Hemorrhoids:

Radio surgery is useful in both early and advanced hemorrhoids. The non- prolapsing internal hemorrhoids could be directly coagulated in-situ with the ball electrode of a sufficient length under a surface anesthesia as an office procedure. 24.

For grade III hemorrhoids, these are first ablated with a ball electrode on coagulation mode and then the ablated pile mass is plicated with catgut to ensure fixation of the anal cushions to the underlying structures. It is observed that with this procedure, the hospital stay is minimized, postoperative pain in less, recurrence rate is low and return to work is faster. The results are more assuring when compared with conventional hemorrhoidectomy. 25.

In-situ radiofrequency ablation of advanced grades of hemorrhoids has also been found to be effective in controlling prolapse and bleeding. 26-27.

Rectal Prolapse:

Radiofrequency has been used as an adjuvant therapy in elderly patients with rectal prolapse. A circumferential coagulation of the anoderm is made with the ball electrode and then a Thiersch’s stitch is tied to encircle the anal verge. The radiofrequency coagulation was found to induce fibrosis and a zone of band helping in tightening the anal opening and preventing prolapse. 28.

Post-Operative Care:

Almost all the abovementioned procedures are carried out as day care surgeries. Patients are routinely discharge on the evening of the procedure. Only patients having post anesthesia symptoms like nausea, vomiting, urinary retention etc. are watched in the hospital overnight. Analgesics, antibiotics and stool softeners are prescribed according to the departmental protocol. No specific wound
care is found needed, except a warm water Sitz bath two times a day.

Complications:

No major complications were encountered.
Few minor ones include:-
- Deep dissection causing more scarring and longer time for healing.
- Excessive release of power causing more smoke and charring.
- Accidental burns either on the patient or on operator due to unintended activation of hand piece.

The only way that a radiofrequency surgery could result in tissue damage is when heat is allowed to accumulate in the tissue to the point where excessive dehydration occurs and the tissue is destroyed. Preventing the accumulation of such heat is the basic objective of radio surgical technique. The two factors, which are to needed to make this a good technique, are the power setting on the unit and the swiftness of the cutting stroke.

Precautions to be taken while operating with radiofrequency unit— The human body reacts as an electrolyte liquid. The more hydrated the tissue, the more easily the electric current passes through the body, and the more dehydrated the tissue, the less easily current passes through the body. If the surface of the skin is very dry, current will not pass from the electrode tip to the tissue cells due to the very high resistance caused by the dryness acting as an insulator. Nonetheless, the area should not be wet but just moist, as too much moisture on the tissue surface will cause the current to spread29. Radiofrequency should not be used by, or on anyone who wears a pacemaker. The instrument should not be used in the presence of flammable or explosive liquids or gases. The skin should not be prep with alcohol.

If proper settings are not known, the operator should start with low power setting and cautiously increase power until an ideal cut is accomplished, with no tissue drag and minimum sparking. The finer the electrode used, the less lateral heat spread and the least damage to adjacent tissue is achieved30. A skilled application of radiofrequency surgery does result in great patient satisfaction while achieving a best possible time management in the whole exercise. 31.

The radio surgical generators and needle electrodes used in this study, however, do not measure tissue impedance and temperature. The electrodes are reusable and may be kept in cold sterilization solution when not in use.

Conclusion:

Based on our personal experience and weighing the pros and cons of the technique, we are of the opinion that radiofrequency surgery could certainly prove to be a safe and convenient alternative to many of the conventional ano rectal procedures.
23.Gupta PJ. Novel technique: radiofrequency coagulation—a treatment alternative for early-stage hemorrhoids. MedGenMed. 2002; 4: 1.
24.Gupta PJ. Radiofrequency ablation and plication of hemorrhoids. Tech Coloproctol. 2003; 7: 45-50; discussion 50.
25.Gupta PJ. Radio-ablation of advanced grades of hemorrhoids with radiofrequency. Curr Surg. 2003; 60: 452-458.
26.Gupta PJ.Randomized trial comparing in-situ radiofrequency ablation and Milligan-Morgan hemorrhoidectomy in prolapsing hemorrhoids. J Nippon Med Sch. 2003; 70: 393-400.
27.Gupta PJ.Radiofrequency coagulation with Thiersch’s
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30.Kainz C, Tempfer C, Sliutz G, Breitenecker G, Reinthaller A. Radio surgery in the management of cervical intraepithelial neoplasia. J Reprod Med 1996; 41: 409-411.