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Discussion
Deep brain stimulators have been effective in
treating movement disorders since 1997. The reported
harmful side effects of using diathermy in a patient
with DBS range from “electrical shock” sensation to
severe brain injury leading to a vegetative state. The
former patient underwent Mohs microsurgery for left
cheek basal cell carcinoma removal. He described a
lancinating electrical shock sensation through his left
arm and leg during the use of monopolar diathermy.
The latter patient had diathermy treatment after teeth
extraction, during which his neurological status
deteriorated, and investigations revealed permanent
diencephalic and brainstem lesions.
DBS guidelines recommend avoiding the use of
diathermy in patients with implanted devices, as it may
lead to thermal injury to tissue, or device damage with
reprogramming of its settings. In Harmonic scalpels,
electrical energy from the generator unit is converted
into mechanical energy by the transducer to create
high frequency vibrations which cut and coagulate
tissue. Thus, electrical current will not travel through
the patient’s body.
Meyring K et al described a series of patients with
DBS undergoing lung lobectomy. Similarly to our case,
the DBS devices were switched off before anaesthesia.
In these cases, bipolar cautery was used for skin
incision. Harmonic scalpel was used in hilar structures
and lymph node dissection in one case and argon
plasma coagulation for pleural haemostasis for the
other two. In our case, Harmonic scalpel alone was
utilized throughout the surgery.
Surgical Management of Non-Small Cell Lung Cancer in Patient
with Deep Brain Stimulator –A Challenge for Safe Haemostasis
M Abbas, R Weedle, A Soo
Department of Cardiothoracic Surgery, Galway University Hospital
Introduction
Achieving haemostasis using electrocautery is an
integral part of any surgical procedure, including
thoracic surgery. Deep brain stimulators (DBS) use
electrical current to reduce symptoms of
movement disorders. Electrocautery may damage
the device or surrounding tissues such as chest wall
or brain, presenting a challenge for haemostasis
during surgery.
Ultrasonic surgical instruments, such as Harmonic
scalpel, ensure haemostasis via high frequency
vibrations around 55.5 KHz.
The Case
A73-year-old lady who had a left-sided DBS
implanted 9 months previously for treatment of
essential tremor, refractory to medical treatment.
The DBS was implanted by a specialist
neurosurgeon with good symptomatic response.
She subsequently developed a cough, and
investigation revealed early stage NSCLC.
She underwent left upper lobectomy. DBS
precluded the use of electrocautery during
surgical management. Her device was switched
off by her neurologist 16 hours preoperatively.
A left posterolateral thoracotomy, tissue
dissection, left upper lobectomy, mediastinal
lymph node dissection, and thoracotomy closure
were entirely performed using Harmonic scalpel.
Total blood loss was negligible. Electrocautery
was avoided for the whole procedure.
The DBS was reactivated postoperatively, and
functioned normally, with no complications for
the patient. The patient had an uneventful
recovery and was reviewed by the neurologist
before discharge.
Conclusion
Harmonic scalpel can be safely used as an alternative
for diathermy in patients with DBS undergoing thoracic
surgery, with no complications. More studies are
necessary to develop guidelines to assist in
management of this growing group of patients.
Figure 1: Pre-discharge chest x-ray of
patient showing deep brain stimulator
in situ
Figure 2: Harmonic Scalpel
