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Ann Thorac Surg 1998;66:308
© 1998 The Society of Thoracic Surgeons
a President & CEO, Surgical Laser Technologies, 147 Keystone Dr, Montgomeryville, PA 18936-9638, USA
To the Editor
Surgical Laser Technologies, Inc, has read the article entitled "Pathogenesis of Systemic Air Embolism During Bronchoscopic Nd:YAG Laser Operations" [1] that was published in your journal. We appreciate Tellides and associates’ effort to educate the surgical community about the risks of air embolism, and we applaud the candor with which these experiences are shared with other surgeons. Surgical Laser Technologies, Inc, agrees that it is important that surgeons understand how to use the laser systems both to achieve the best possible clinical effect and to reduce or eliminate potential safety risks. But of these twin goals, our overriding concern, first and foremost, is patient safety.
We believe that the proper use of any product is critical to patient safety. With this in mind, we have reviewed our own labeling, instructions for use, and recommendations for bronchoscopic applications to confirm the parameters we provide to our customers for safe and effective use of our products. The instructions for use, warnings, and precautions included with our fiber delivery systems, coolant cartridges, probes and scalpels, and laser systems provide the following:
Warnings: "In procedures where a risk of gas embolism exists, do not use coaxial CO2 or air as a coolant for the fiber distal end or the junction between the fiber distal end and the probe/scalpel. Such risk exists, for instance, in intrauterine procedures (e.g., endometrial ablation) or narrow-luminal procedures." Indeed, if the bronchus becomes nearly occluded, it may act like a narrow lumen, and present a risk of embolism.
"Contact Laser Probes or Scalpels should never be embedded into tissue, so as to force air, CO2 or fluid coolant into the tissue. This can cause ... gas embolism ... In procedures where a gas coolant is permitted and used, do not embed more than one-third of the distal portion of the probe or scalpel into tissue" [emphasis added]. It should never be necessary to bury the probe into the tissue, such that the coolant ports communicate directly with the tissue. The principal mechanism for tissue removal is the infrared-absorbing means that is on the contact surface of the probe. All that is necessary is to bring the contact tip in touch with the tissue and allow the energy in the tip to do the work.
Precautions: " ... The highest clinically prudent coolant flow for the clinical situation should be used ... . Operation at higher than recommended power levels can result in overheating." Although we recommend use of the highest flow rate that the surgeon deems clinically prudent, we recommend in our product labeling the following rates for gas or air coolant: 0.3 L/min minimum for endoscopic procedures and 1.0 L/min for open procedures. These flow rates are based on the assumption that recommended power levels will not be exceeded.
The SMTR 1.5 Round Probe is a quartz probe that has infrared-absorbing means on the distal contact surface. Given the size of the probe and the amount of surface treatment on it, we recommend in our labeling that the probe should be used at power settings of 12 to 14 watts for bronchoscopic applications. Higher power levels do not increase tissue removal commensurately. In fact, higher power settings have primarily the effect of merely overheating the probe-fiber junction.
We hope that Tellides and associates’ report achieves the goal of increasing awareness of the risk of embolism, and of the need to use laser equipment in a safe and effective manner. To that end, we request publication of this letter to amplify the instructions, warnings, and precautions that can be found in our labeling.
In regard to the use of our system to debulk or vaporize large masses of tissue, we believe that an alternate solution may be to use a contact probe that has a larger contact surface area and therefore has a capacity for higher power settings. Also, the use of fluid coolant may be appropriate. This solution has proven satisfactory in Contact Laser prostatectomy procedures. In particularizing our product to tumor masses in thoracic applications, we would welcome any comments or suggestions from the clinical community.
References
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