Electrosurgery in The Gastrointestinal Suite .4

Geri Nelson, RN
Marcia L. Morris, MS
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Electrosurgery in the Gastrointestinal Suite

Knowledge Is Power
ABSTRACT
Electrosurgery allows both cutting and coagulation of tissue and is an essential tool for therapeutic endoscopy. Elec-
trosurgery is also the most commonly used and misunderstood technology by all surgical and medical disciplines. In
other words, everyone uses it, but few understand it! The aims of this article are to (1) present a useful review of the
fundamentals of electrosurgery technology; (2) relate the fundamentals to commonly performed flexible endoscopy
procedures; and (3) provide a review of the safe application of grounding pads, careful management of accessories,
and special patient safety considerations.
T
he ability to both cut and coagulate tissue at same time (Van Gossum, Cozzoli, Adler, Taton, &
the same time defines the technology of elec- Cremer, 1992; Vormbrock & Monkemuller, 2012).
trosurgery and makes it an ideal therapeutic Matched with appropriate accessories, electrosurgi-
tool for flexible endoscopy (Morris, Tucker, cal generators are used for general hemostasis of varied
Baron, & Wong Kee Song, 2009). Electrosurgery is bleeding lesions and for ablating unwanted diseased
also the most commonly used and misunderstood tech- tissue. Producing the best clinical outcome from these
nology by all medical disciplines (Vilos & Rajakumar, procedures—and doing so safely—is enhanced when
2013). everyone involved is well informed of the basic princi-
Endoscopic accessories such as polypectomy snares, ples of how electrosurgery works. The objective of this
sphinctertomes, contact coagulators, hot biopsy for- article is to give the gastrointestinal (GI) nurse a con-
ceps, and argon coagulation (ArC) probes are used cise overview of the principles of electrosurgical tech-
with an electrosurgery generator to produce therapeu- nology as it directly relates to tissue effect outcomes
tic heating. For example, if a wire snare is used alone, and patient and operator safety.
it can mechanically cut through a small polyp (cold
snaring), but for larger polyps, the risk of immediate Electrosurgery Technology
bleeding is greater than if the snare is attached to an Fundamentals
electrosurgery generator that will produce electrosurgi- Electrosurgery allows both cutting and coagulation of
cal cutting instead of mechanical cutting, because elec- tissue by passing a high-frequency alternating electric
trosurgery produces cutting and coagulation at the current through the target area. The generator takes
current from the wall that is alternating (changing
direction) 60 times a second (60 Hertz or “Hz”)—and
speeds it up. Generators produce alternating currents
Received October 17, 2013; accepted January 26, 2014.
between 200 thousand and 1 million Hz. Alternating
About the authors: Geri Nelson, RN, is Endoscopy Staff Nurse, the current rapidly prevents shocks and most neuro-
Minnesota Gastroenterology, St. Paul, Minnesota.
muscular responses by the patient.
Marcia L. Morris, MS, is Founder and CEO of Genii, Inc., St. Paul,
Minnesota.
These high-frequency waveforms are produced in
various electrical waveform patterns (Morris &
Ms. Nelson declares no conflicts of interest. Ms. Morris has a financial
interest in electrosurgery products manufactured by Genii, Inc. No finan- Norton, 2012). As the waveform patterns change, so
cial support was given to support this article. will the corresponding tissue effects. The characteristic
Correspondence to: Marcia L. Morris, MS, 2145 Woodlane Drive, St. that determines whether one waveform causes more
Paul, MN 55125 (marcia_morris@comcast.net). cutting effect and another causes more coagulation is
DOI: 10.1097/SGA.0000000000000167 the rate at which heat is produced in the tissue. By
430 Copyright © 2015 Society of Gastroenterology Nurses and Associates Gastroenterology Nursing
Copyright © 2015 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00101_LR 430 21/11/15 3:34 AM

FIGURE 1. A survey of polypectomy practices among clinical gastroenterologists in the United States showed that for
electrosurgical snare resections, 46% chose a coagulation current (left) and 46% chose a blended current (right) (7% chose
a cut or a mixed current). From “A Survey of Colonoscopic Polypectomy Practices Among Clinical Gastroenterologists,” by
N. Singh, M. Harrison, and D. K. Rex, 2004, Gastrointestinal Endoscopy, 60(3), pp. 414–418. Used with permission.
design, some types of waveforms promote very rapid, and some outputs that are the same have different
intense heating, whereas others are designed to heat names and some that are different have similar names.
tissue more slowly. Users must learn about the particular waveforms avail-
The change in heating rate applies directly to the able with each generator. The generator’s user manual
clinical result. Very intense, rapid heating causes the and the American Society of Gastrointestinal Endoscopy
water within cells to heat so quickly that it turns to (ASGE) Technology Status Evaluation Report 2013 are
steam and the cell wall explodes. The resulting explod- good places to start (ASGE, 2013). It is the responsibil-
ed path along a wire separates the tissue and is called ity of the operator to know which waveforms are rec-
“electrosurgical cutting.” When tissue is heated more ommended for each procedure using their particular
slowly, cells tend to dry out before they burst. This is generator. Also, the waveform is only one of the tissue
seen as tissue coagulation. Waveform designs can be density variables. The operator will start with a wave-
made to promote more cutting, more coagulation, or a form that is likely to produce a good therapeutic result
variable blend of the two effects (Barlow, 1982; Morris for that procedure, but must also choose appropriately
et al., 2009).
Besides the selection of waveform, the choice of
accessory (i.e., a thin wire vs a wide cupped forceps),
the amount of tissue in the current path (large polyp or
small), and the time that current is applied all affect the
final clinical outcome. This is due to the principle of
current density-–how much the heat is concentrated
into one area. Spreading the current over a larger
amount of tissue lowers the current density and slows
the heating of the tissue. Understanding the principle
of current density and that waveforms are designed to
promote various tissue effects is fundamental to an
understanding of electrosurgical technology. Being able
to confidently employ the best available waveform
FIGURE 2. Most physicians chose waveforms with more cut
with the most appropriate electrosurgical accessory is and less coagulation for sphincterotomy. Types of cut wave-
the key to the safest and most effective clinical out- forms that “pulse” or fractionate the cut are also widely
come (Blackwood & Silvis, 1971; Van Way & Hinrichs, used. These help prevent uncontrolled “zipper” complica-
2000). Figures 1 and 2 are examples of common wave- tions where the cut is extended beyond what the endoscopist
form choices for common endoscopic procedures. intends. This may lead to increased bleeding and an
increased risk of perforation. American Society of
Many names such as “Coag,” “TouchSoft,” “Blend Gastrointestinal Endoscopy (2013); Elta, Barnett, Wille
3,” “Endocut,” and so forth are given to waveforms by (1998); Kohler et al. (1998); and Perini et al. (2005). Used
the manufacturers. Most names are not standardized with permission.
VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015 431

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FIGURE 3. A bipolar circuit.
the accessory, power setting, and time of application accessory (a snare, for example), takes a direct path of
(Carr-Locke et al., 1996). least resistance through the patient, and is dispersed
over a “grounding pad.” The current leaves the pad to
Bipolar and Monopolar be returned to the generator to complete the circuit
Electrosurgery uses electricity that must flow in a com- (Morris, 2006; Tucker, 2000; Veck, 1996). Grounding
plete circuit. Gastrointestinal accessories are catego- pads may also be called patient return, dispersive, or
rized by how they let flowing current complete the neutral electrodes.
circuit. Being mindful of the monopolar circuit can help
A bipolar accessory (e.g., Bicap or GoldProbe) has at prevent some of the most common types of electrosur-
least two poles (Figure 3). The accessory has both a flow gical injuries. Once a monopolar snare, for example,
“out” and a flow “in.” The current flows out from the is attached to an active cord inserted into the genera-
positive pole of the accessory, travels only through a bit tor socket and the generator is on, it is a potential
of tissue, and is returned by the opposite electrode “active electrode.” If the grounding pad has also been
within the same probe to the generator. This is why placed on the patient, it is imperative not to place that
grounding pads are not necessary for bipolar procedures active electrode (snare) on the bed next to the patient
(Morris, 2012; Wong Kee Song & Marcon, 2000). while turning your attention elsewhere. If someone
Monopolar accessories have only one pole or direc- were to activate the footswitch, the patient could be
tion out (Figure 4). The current flows out of the burned wherever they were in contact with the snare
FIGURE 4. A monopolar circuit current path.
GNJ-D-13-00101_LR 432 21/11/15 3:34 AM

lying on the bed. The best practice rule is to carefully

manage all active electrodes. Disconnect the accessory
from the active cord, or place the generator in
“Standby” mode, if available, until everyone is actu-
ally ready for the electrosurgical procedure. Carefully
managing active cords and accessories can also pre-
vent shocks and burns to staff. Handle active elec-

trodes by their plastic insulated areas only and never
attempt to connect or disconnect accessories while
current is flowing (Veck, 1996).
Current that will boil water if concentrated onto
one square millimeter of area will not even feel warm
when spread over 1 cm2 (Tucker, 2000). This principle
is well demonstrated by the grounding pad and snare
in a typical monopolar polypectomy application. The
current is very concentrated along the snare wire but
dispersed over the much larger area of the grounding
pad when it exits the patient’s body. Along the snare
loop, the high current density causes rapid heating of
the water in cells, causing them to burst while cells
farther away shrink and dry. This results in some elec-
trosurgical cutting as well as adequate coagulation.
Luckily, when dispersed over a properly applied
grounding pad as the energy exits the patient, the same
amount of current produces no noticeable rise in skin
FIGURE 5. Best placement sites for grounding pads in gas-
temperature. This is why it is important to place troenterology. From “Electrosurgery in the Gastroenterology
grounding pads correctly and to ensure the best possi- Suite: Principles, Practice, and Safety,” M. L. Morris, 2006,
ble contact over the entire pad to promote the even Gastroenterology Nursing, 29(2), pp. 126–134. Used with
dispersion of the current (Slivka et al., 2003). permission.
3M research confirmed a phenomenon called the
“leading edge effect” (S. Netherly and H. Carim, US
pad and might produce a burn. Figure 6 shows how to
Patent No. 5,836,942, November 17, 1998). This
recognize “split/dual/sensing/smart” pads.
effect occurs when current dispersing over a grounding
pad is slightly more concentrated on the edge facing
Best Practices for the Use of Grounding
the treatment site. While the measured increase in tem-
Pads
perature on the leading edge is small and not enough
to cause a patient burn, it has led to the advice from • Place grounding pads in the most suitable position
some pad manufacturers that rectangular pads should that is closest to the treatment site. Refer to the
be placed with the long edge facing the treatment site, instructions on the pad label for each manufacturer’s
such as crosswise on the patient’s thigh as shown in advice.
Figure 5. For the same reason, it is best not to skew the • Choose a site that is muscular (not overly fatty) and
pad so that one corner is the closet point toward the well vascularized. Make sure that the entire area of
treatment site. the grounding pad is smoothly and reliably in con-
While a published report of an electrosurgical pad tact with the patient’s skin.
burn during a flexible endoscopic procedure is • Make sure that the grounding pad remains properly
unknown, it is still wise to take advantage of the inex- attached throughout the procedure. Check the pad if
pensive, well-studied safety advantages of using “split/ the patient has been moved or repositioned. If the
dual/sensing” grounding pads. When using any of the pad must be removed midprocedure for any reason,
many generators that include pad safety and tissue consider discarding it in favor of a fresh disposable
sensing technology in their design, these pads are able pad.
to communicate with the generator’s computer and • Never attach the pad over implants, metal, bony
alarm system and produce both a visual and audible protuberances, broken skin, or scar tissue.
warning to the operator that the pad is sensing an Circumstances may require the skin to be cleaned or
impedance situation that, if not corrected, could result shaved to get even contact.
in a temperature rise on the patient’s skin under the • If possible, avoid placing pads over tattoos.

GNJ-D-13-00101_LR 433 21/11/15 3:34 AM

manufacturer recommends discarding unused multi-

pack pads after 14 days of opening.
Another common question in endoscopy is, “Why
won’t the pad light go green right away on some
patients?” The author estimates the frequency of this in
her free-standing center to occur about once or twice
per month. In hospital-based settings, where electrosur-

gical use is more frequent, this delay will likely be more
frequent. An understanding of how dual/sensing/split
pads work (known by trade names such as REM,
CQRM, PSS, and NESSY) can help with troubleshoot-
ing. These “smart” sensing pads are able to send a sig-
nal to the generator that gives a baseline reading of the
FIGURE 6. How to recognize a “split/dual/sensing” pad: In
impedance at the pad site on that individual patient.
addition to the label, notice the communication pin and the Working with the tissue sensing software in the genera-
characteristic “split” design. (Arrows) Single or “nonsplit” tor, the pad continues to monitor the impedance safety
pads are NOT able to communicate with a generator. Single limits during the entire procedure. Generators are pro-
(nonsensing) pads will not enable the warning alarms in the grammed not to give the “green” light until the imped-
generator to function.
ance is within an acceptable limit at the start, and to
alarm if this limit is exceeded at any time during the
procedure (Tucker, Hurdlik, Silvis, & Ackerman, 1981).
• Never use pads with a damaged or dried gel layer.
The baseline impedance at the pad/patient skin
Never cut pads in an attempt to resize them.
interface is dependent on several factors. Skin integrity,
• If reusable grounding pad cables are used, be sure
skin dryness, excess hair, or oily lotions can all play a
that they are properly attached. Be sure that the
role. The gel in pads has a high water content so that
attachment clip covers the gel free connecting lugs or
as the gel “sits” on the patient’s skin, it moisturizes the
tabs so that they do not make contact with the
underlying skin and gives good adherence—and hope-
patient’s skin. Replace cables when worn.
fully a starting baseline impedance reading that the
• Extend the grounding pad connecting cables away
generator will accept. The “see the need, slap on a pad
from the patient and do not align or entwine the
and go” rush in typical endoscopic settings sometimes
cable with other cables such as the active cord or
does not give the pad enough time to adequately estab-
cables leading to patient monitoring equipment.
lish this connection. To lessen the number of times this
Current will follow a path of least resistance happens, use the overall good pad safety advice to
directly toward the pad. In gastroenterology proce- avoid placing pads over scars or excessive hair on a
dures, placements on the flank and the upper thigh muscular area with good blood flow. Remove excess
are preferred sites, but some individual consideration skin lotion. If the pad light does not turn green quickly
is often necessary. For example, if the patient is posi- in spite of this careful placement, rub the surface of the
tioned on his or her left, the right thigh may be most pad gently for a moment.
convenient to access, but if the patient has a right hip Not green yet? Unplug the pad from the generator,
implant, choose either the right flank or the left but leave the pad on the patient. Use a second pad and
thigh. If necessary, the upper arm can serve, but place it in an appropriate alternate site. Does this sec-
never choose arm placement if the patient has an ond pad “go green”? If yes, remove the first pad and
implanted cardiac device. Do not overlap the pad, if continue. If not, leave the second pad in place but
the upper arm is thin. Always be familiar with the unplug it. Now replug in the first pad. Is it green now?
manufacturer’s recommendations supplied with your (Enough time may have passed that the area under the
pads and generators (Anonymous, 2000; Spruce & first pad is now in good low impedance contact.) If
Braswell, 2012). green, remove the second pad and continue.
If this issue is causing too frequent disruptions, con-
Frequent Concerns About Grounding sider trying different brands of grounding pads.
Pads Different generators and pads have different measure-
Pads packed individually should not be opened until ment thresholds and different pads have different
needed. In the lead author’s endoscopy center, ground- shapes, sizes, and gel water content. While it is rarely
ing pads are purchased in a multipack. These pads true that you can only use a grounding pad brand that
should not be removed from the package in advance as matches the brand of your generator, it may be helpful
this helps prevent the gel from drying out. At least one to try to find a more compatible mix of brands.
GNJ-D-13-00101_LR 434 21/11/15 3:34 AM

Special Patient Considerations cardiac pacemaker implant patients who are depend-
ent on their pacemaker for moment-to-moment main-
Electrosurgery With Implanted Cardiac tenance of adequate rhythm and hemodynamics
Devices (Petersen, 2007).
Implanted cardiac pacemakers and cardioverter defi- To minimize risks with patients who have implanted
brillators (ICDs) are designed to sense and react to cardiac devices, the following steps should be taken.
electric signals from the heart. This makes them vul-

nerable to interference from electrical signals that are Preprocedure

not cardiac in origin, and it has long been known that
extra care must be taken when using electrosurgery 1. Attempt to identify the type of implanted cardiac
for treating these patients. Patients with these device, its location, the reason for the patient’s
implanted devices can safely undergo electrosurgery need for the device and their dependence on the
as long as certain precautions are taken (Fiek et al., device. Advice on how to accomplish this includes
2004; Madigan et al., 1999; Morris, 2006; Petersen asking the patient to produce the information
et al., 2007). card that was provided with their device and
Newer pacemakers have been engineered to be have available the technical support phone num-
resistant to electric interference, and alteration in func- ber of the manufacturer. Use this information to
tion from electrosurgery is extremely rare in gastroen- help determine characteristics of an individual
terology (Choukalas, 2005; El-Gamal, Dufresne, & pacemaker, and to determine if an ICD will need
Saddler, 2001; Petersen, 2007). However, the risk to be reprogrammed to the asynchronous (pacing
exists, and if interruption of the implanted device but not sensing) mode during the procedure.
would occur, the effects could be highly variable and With the exception of some dual function pace-
dependent not only on the source and character of the maker/ICD devices, the placement of a ring mag-
interfering signal, but on the design of the device itself. net directly over a pacemaker site forces a con-
Pacemakers can be temporarily inhibited from output- tinuous paced beat. This should be used only
ting a signal, or the interference might be interpreted briefly for the few minutes during which electro-
by the device as noise, which can cause the device to surgery is actually being delivered (Petersen,
revert to an asynchronous pacing mode (a mode in 2007). Note during the patient evaluation any
which the device paces but does not sense) at a rate factors that may predispose the patient to cardiac
preset by the manufacturer. The interference might be instability.
interpreted by the device as a programming signal 2. Determine whether the patient is pacemaker
leading to inappropriate programming of the device. dependent and attempt to predict whether pro-
Sometimes the battery life might be affected, or in the longed electrosurgery current will be needed. If
case of ICDs, they may trigger an inappropriate thera- the patient is not pacemaker dependent, the soci-
py shock to the patient. Most ventricular assist devices eties’ consensus is that no reprogramming is
have sensitive components contained in external con- necessary. If the patient is pacemaker dependent
trollers and are not usually affected by electrosurgery, and prolonged electrosurgical energy may be
but checking the manufacturer’s recommendation is required, see the specific recommendations of the
advisable for these devices as well (Morris, 2006; manufacturer and the established protocol.
Parekh, Buerlein, Shams, Herre, & Johnson, 2013).
During the Procedure
Current recommendations for the management of
patients with these cardiac devices are based on con- 1. Continually monitor cardiac function, and have
sensus statements published by individual societies appropriate resuscitation equipment available.
such as the American College of Cardiology Foundation/ 2. When possible, use bipolar accessories. (The
American Heart Association, the Heart Rhythm Society energy travels only the short distance between
and the American Society of Anesthesiologists), and electrodes and is less likely to pass near the
the ASGE. While agreement between societies is not implanted device.)
completely consistent, there is universal agreement that 3. If monopolar energy is used, make sure the active
it is recommended that each endoscopy practice have a electrode will be at least 6 inches away from the
protocol in place that will be followed when a patient cardiac device and its lead system. Apply the
with an implanted device is scheduled. These protocols grounding pad as close as possible to the treat-
should be initiated and reviewed by qualified personnel ment site and placed so that current is drawn
trained in the operation of implanted cardiac devices away from the pacemaker and the heart. Activate
(Parekh et al., 2013). All societies agree that it is the generator in short bursts with pauses in
imperative to identify the approximately 20% of the between to minimize continuous interruption of

GNJ-D-13-00101_LR 435 21/11/15 3:34 AM

pacing. Use the lowest power and lowest voltage because of improvements in technology Spruce &
waveforms appropriate for treatment. Braswell, 2012; Tucker, 2007). Nevertheless, metal
4. If equivalent treatment results are possible, use objects, including jewelry, in the direct path of current
contact monopolar accessories, rather than non- flow can concentrate electrosurgical energy. This is one
contact ArC. (The production of some low-fre- reason that staff should not place grounding pads over
quency currents can cause more interference and metal implants (Anonymous, 2005; ASGE, 2013).
are more frequently present with noncontact Never place the grounding pad directly over any
modes of electrosurgical application.) piece of metal (jewelry or a gown snap). In monopo-
lar electrosurgery, the current flows from the treat-
Postprocedure ment site, following a path of least resistance to the
grounding pad to be collected and returned to the
1. If the pacemaker or ICD was reprogrammed, generator to complete the circuit. In the case of a
restore the baseline function of the device. colon polyp with a grounding pad placed on the
Confirm the correct functioning and program- thigh, ear or finger rings would not be in the current
ming of the device. path and would be of no concern. A genital piercing,
2. Verify the function of the device. There is no however, may have at least a theoretical risk of being
need for further follow-up if the device is inter- in the current path and at risk of some heating
rogated successfully after the procedure although no burns are known to have been reported
(Anonymous, 2000; Morris, 2006; Parekh et al., from this cause. If it is not possible to remove such a
2013; Spruce & Braswell, 2012). genital item, staff may use careful watching and
reporting by a conscious patient to help mitigate the
Other Implanted Devices minor risk. Choose the lowest generator setting pos-
New implanted devices are constantly being intro- sible to successfully complete the procedure. It may be
duced. Some devices are used to treat Parkinson’s dis- of benefit to interrupt the application of energy peri-
ease and other movement disorders, and there are odically to allow for tissue cooling if the procedure is
many others. User materials posted for these devices lengthy (Morris, 2012).
warn that system damage or operational changes can A new piercing style has now appeared: dermal or
occur during the use of electrosurgery. Sometimes flat surface piercings. Dermal piercings, also known as
bipolar applications are recommended (Medtronic, microdermal piercing or single point piercing, are
2013). piercings installed on flat surfaces of the body. Some
Many of these devices are not directly life support- choices for these placements can put them in the direct
ing and can be turned off long enough for electrosurgi- path of current flow or in an area that might have been
cal treatment. Because they are so varied, it is wise for chosen for placement of the grounding pad. A dermal
the GI nurse to simply be aware that they exist and to pierce on a wrist, for example, will not be in the usual
plan ahead to get further information on how best to current path and is not of concern. While no burns are
care for individual patients affected. Implanted devices known to have been reported, and the risk is probably
that cannot be easily inactivated such as a deep brain slight, it is good for nurses to be aware of these trends
electrode stimulator pose a clinical conundrum (ASGE, (Medical hub, 2013).
2013). At present, these devices are still relatively rare, Many of these pierced ornaments are removable
but it is wise for endoscopic scheduling to be aware in (although not always easily) and, if in the area of the
advance of the special needs of these patients and to current path, should be. Do not place the grounding
support calls for further studies so that data can be pad directly over or next to any unremoved ornaments
available for the specialty societies to unify consensus (Figure 7 and 8).
on guidelines on the proper management of patients
with all manner of implanted devices (Parekh et al., Argon Coagulation
2013). Argon coagulation (also referred to as argon plasma
[APC] or argon beam [ABC] coagulation) is a noncon-
Electrosurgery With Jewelry tact monopolar technique that is used primarily for
It is always a good idea for patients to remove (and superficial coagulation. Argon gas is electrically con-
leave at home!) as much of their jewelry as possible. ductive when ionized (excited) with energy provided
Risk of loss, tissue tearing, and swelling are all factors. by specially equipped generators. Voltage supplied by
Many years ago, electrosurgery generators were the generator ionizes the argon gas by “knocking”
plagued by “stray” (leaky) currents and there was fear electrons from their home atoms. This creates an ion-
that this unseen energy could concentrate on jewelry ized pathway for current flow, which tends to propa-
and cause patient burns. This hazard has been removed gate in a chain reaction fashion. Nonionized gas
GNJ-D-13-00101_LR 436 21/11/15 3:34 AM

& Davolos, 2004; Vargo, 2004; Zlatanic, Waye, Kim,

Baiocco, & Gleim, 1999).
ArC is a monopolar application and uses a ground-
ing pad. The active accessory is a special ArC probe
that is disposable and available in many sizes. All safety
concerns that apply to electrosurgery in general also
apply to ArC with the added admonition to observe the

patient for extra distension (Grund & Farin, 2000).
Since the U.S. introduction of argon-assisted coagu-
lation therapy to flexible endoscopy in 1997, several
generations of commercially available argon-capable
units have been introduced. Some models possess
amplified power profiles (Erbe VIO/APC2 and Conmed
FIGURE 7. Two dermal piercings in the lower back. This is Beamer) and are referred to as “high-power APC.”
an area often chosen for grounding pad placement and is These must use lower power settings to achieve com-
likely to be in the current path for a colon or stomach proce- parable tissue effects found with nonamplified beam
dure. Remove these if possible before using electrosurgery
in this area. units (Erbe ICC/APC300 and Genii GI 4000). In all
cases, users should be familiar with their own units
and the manufacturer’s recommended starting power
outside of the activated argon beam does not conduct ranges (ASGE, 2013; Manner, May, Faerber,
energy to the tissue. Electric arcs within the activated Rabenstein, & Ell, 2006).
ion beam enter the tissue and create a matrix structure Some argon-capable generator units include pulsing
that leads to rapid coagulation. The eschar produced modes of argon beams. These have been associated
remains pliable and resistant to rebleeding. For the saf- with an increased incidence of neuromuscular stimula-
est use of ArC, inadvertent probe-tissue contact and/or tion (patients “twitch” or complain of sensations). If
prolonged coagulation time should be avoided (ASGE, this occurs during pulse argon mode applications, it is
2013; Ginsberg, Barkun, & Bosco, 2002; Rey, recommended that the user change to a “forced” or
Bellenhoff, & Dumonceau, 2010). nonpulse mode (Eickhoff, Hartmann, Eickhoff,
The indications for ArC are hemostasis and tissue Enderle, & Riemann, 2008).
ablation. It is ideal for broad or diffuse lesions where
its noncontact application adds speed. It has an uncan- Electrosurgery Contraindications
ny ability to arc toward the nearest tissue and works Avoid using any electrosurgery if the patient is uncoop-
well in areas that are otherwise difficult to reach. ArC erative with the endoscopy procedure or uncontrolled.
tends to produce an even, fairly superficial, rapidly Operators should avoid activation if it is impossible to
healing eschar. ArC use in treating “watermelon stom- visualize the active electrode. It is extremely important
ach” (gastric antral vascular ectasia syndrome), other not to use any electrosurgery device with an improper
vascular ectasias and malformations (AVM), and other bowel preparation. Catastrophic bowel explosions are a
hemorrhagic conditions, such as radiation proctopathy risk if naturally occurring gases present in some patients,
have been widely reported. It is also widely used for such as hydrogen and methane, are mixed with oxygen
ablating small sessile polyps or remnant adenomatous during sigmoidoscopy and colonoscopy. Complete, full
tissue left after snaring. Tumors can be debulked even length, colon cleansing using approved preparation pro-
if a stent is in place and some physicians have reported tocols is required even if the electrosurgery is to be
using argon-assisted techniques for ablation in Barrett’s performed only in the sigmoid or rectum (Avgerinos
esophagus (Olmos, Marcolongo, Pogorelsky, Varela, et al., 1984; Strocchi, Bond, Ellis, & Levitt, 1990).
FIGURE 8. One dermal piercing method and ornament placement technique.

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Summary and complications experienced by cutaneous surgeons. Derma-

tologic Surgery, 27(4), 385–390.
• Electrosurgery is a safe and vital tool for the endos- Elta, G. H., Barnett, J. L., & Wille, R. T. (1998). Pure cut electro-
copy setting. cautery current for sphincterotomy causes less post-procedure
• Electrosurgery uses high-frequency energy to pro- pancreatitis than blended current. Gastrointestinal Endoscopy,
duce heat in tissue. 47, 149–153.
Fiek, M., Dorwarth, U., Durchlaub, I., Janko, S., Von Bary, C.,
• The energy is electric: current, impedance, voltage,

Steinbeck, G., & Hoffmann, E. (2004). Application of radiof-

and circuits are all important.
requency energy in surgical and interventional procedures: Are
• Grounding pads disperse energy and complete the
there interactions with ICD’s? Pacing and Clinical Electrophysi-
circuit with monopolar accessories. ology: PACE, 27(3), 293–298.
• The intensity of heating can be regulated by chang- Ginsberg, G., Barkun, A. N., & Bosco, J. (2002). Technology status
ing the waveform, the power setting, the electrode, evaluation report: The argon plasma coagulator. Gastrointesti-
and/or the time the energy flows. nal Endoscopy, 55(7), 807–810.
• Rapid, intense, local heating creates more cutting Grund, K. E., & Farin, G. (2000). Clinical application of argon
effect, whereas slower heating or heating over a plasma coagulation in flexible endoscopy. In:Tytgat, G. N. J,
larger area produces more coagulation. Classen, M., Waye, J. D., & Nakazawa, S. (Eds.), Practice of
• Argon-assisted coagulation is a monopolar method therapeutic endoscopy (Vol. 5.3, pp. 87–100). London: Saun-
that allows for the application of the energy in a ders/Harcourt.
Kohler, A., Maier, M., Benz, C., Martin, W. R., Farin, G., & Riemann,
noncontact mode.
J. F. (1998). A new HF current generator with automatically
• Safety is enhanced when users are knowledgeable
controlled system (Endocut mode) for endoscopic sphincteroto-
about the technology. my-preliminary experience. Endoscopy, 30, 351–355.
Of note, BiCap and ABC are registered trademarks Madigan, J. D., Asim, F., Choudhri, B. S., Spotnitz, H. M., Oz, M.
of Conmed. EndoCut is a registered trademark of Erbe C., & Edwards, N. (1999). Surgical management of the patient
with an implanted cardiac device. Annals of Surgery, 230(5),
Electromedizn. Gold Probe, APC, and TouchSoft are
639–647.
trademarks claimed by Boston Scientific, Erbe
Manner, E., May, A., Faerber, M., Rabenstein, T., & Ell, C. (2006).
Electormedizn, and Genii, Inc. respectively. ✪ Safety and efficacy of a new high power argon plasma coagu-
lation system (hp-APC) in lesions of the upper gastrointestinal
REFERENCES tract. Digestive and Liver Disease, 38(7), 471–478.
Anonymous. (2000). Part 4: Electrosurgery/coagulation. In:Morris, M. Medical hub. (2013, July). http://emedicalhub.hubpages.com/hub/
(Ed.), SGNA Manual of GI Procedures (4th ed., pp. 131–135). Dermal-Piercing-Types-Pictures-Procedures
Chicago, IL: Society of Gastroenterology Nurses and Associates. Medtronic. (2013, July 19). Medtronic gastric electrical stimulation:
Anonymous. (2005). Recommended practices for electrosurgery. Indications and safety. Shoreview, Minnesota, 55126. http://pro-
AORN Journal, 81(3), 616–642. fesional.medtronic.com/pt/gastro/ges/ind/index.htm
American Society from Gastrointestinal Endoscopy. (2013, August). Morris, M. L. (2006). Electrosurgery in the gastroenterology suite:
Technology status evaluation report: Electrosurgical generators. Principles, practice, and safety. Gastroenterology Nursing,
Gastrointest Endoscopy, 78(2), 197–208. 29(2), 126–134.
Avgerinos, A., Kalantzis, N., Rekoumis, G., Pallikaris, G., Arapakis, Morris, M. L. (2012). Electrosurgery, jewelry and GI: The real story.
G., & Kanaghinis, T. (1984). Bowel preparation and the risk of ex- Endonurse 12(4), 20.
plosion during colonoscopic polypectomy. Gut, 25(4), 361–364. Morris, M. L., & Norton, I. D. (2012). Electrosurgery in thera-
Barlow, D. E. (1982). Endoscopic applications of electrosurgery: peutic endoscopy. In Ginsberg, G., Gostout, C., Kochman,
A review of basic principles. Gastrointestinal Endoscopy, 28, M., & Norton, I. (Eds.), Clinical gastroenterologic endoscopy
73–76. (2nd ed., pp. 77-85). Philadelphia, PA: W.B. Saunders/
Blackwood, W. D., & Silvis, E. (1971). Gastropic electrosurgery. Elsevier.
Gastroenterology, 61, 305–314. Morris, M. L., Tucker, R. D., Baron, T. H., & Wong Kee Song, L. M.
Carr-Locke, D. L., Al-Kawas, F. H., Branch, M. S., Edmundowicz, (2009). Electrosurgery in gastrointestinal endoscopy: Principles
S. A., Jamidar, P. A., Petersen, B. T., & Stein, T. (1996). ASGE to practice. The American Journal of Gastroenterology, 104(6),
technology assessment status evaluation: Bipolar and multipolar 1563–1574.
accessories. Gastrointestinal Endoscopy, 44(6), 779–782. Olmos, J., Marcolongo, M., Pogorelsky, V., Varela, E., & Davolos,
Choukalas, P. M. (2005). CRM Technical Services Standard Letter, J. (2004). Argon plasma coagulation for prevention of recurrent
Rev A Electrosurgery. Cardiac rhythm management manager- bleeding from GI angiodysplasias. Gastrointestinal Endoscopy,
technical services (pp. 55126). Shoreview, MN: Medtronic. 60(6), 881–886.
Eickhoff, A., Hartmann, D., Eickhoff, J. C., Enderle, M., & Riemann, Parekh, P. J., Buerlein, R. C., Shams, R., Herre, J., & Johnson, D. A.
J. F. (2008). Pain sensation and neuromuscular stimulation dur- (2013). An update on the management of implanted cardiac de-
ing argon plasma coagulation in gastrointestinal endoscopy. Sur- vices during electrosurgical procedures. Gastrointestinal Endos-
gical Endoscopy, 22(7), 1701–1707. copy, 78(6), 836–841.
El-Gamal, H. M., Dufresne, R. G., & Saddler, K. (2001). Perini, R., Sadursk, R., Cotton, P., Patel, R., Hawes, R., & Cunningham,
Electrosurgery, pacemakers, and ICDs: A survey of precautions J. (2005). Post-sphincterotomy bleeding after the introduction of
GNJ-D-13-00101_LR 438 21/11/15 3:34 AM

microprocessor-controlled electrosurgery: Does the new technology Tucker, R. D., Hurdlik, T. R., Silvis, S. E., & Ackerman, E.
make the difference? Gastrointestinal Endoscopy, 61(1), 53–57. (1981). Automated impedance: A case study in microproces-
Petersen, B. T. (2007). Implanted electronic devices at endoscopy: Ad- sor programming. Computers in Biology and Medicine, 11,
vice in a gray area. Gastrointestinal Endoscopy, 65(4), 569–570. 153–160.
Petersen, B. T., Hussain, N., Marine, J. E., Trohman, R. G., Carpenter, Van Gossum, A., Cozzoli, A., Adler, M., Taton, G., & Cremer, M.
S., Chuttani, R., … Somogyi, L. (2007). ASGE Technology sta- (1992). Colonoscopic snare polypectomy: Analysis of 1485
tus evaluation report. Endoscopy in patients with implanted resections comparing two types of current. Gastrointestinal
electronic devices. Gastrointestinal Endoscopy, 65(4), 561–568. Endoscopy, 38, 472–475.

Rey, J. F, Bellenhoff, U., & Dumonceau, J. M. (2010). ESGE guide- Van Way, C. W.,III & Hinrichs, C. S. (2000). Electrosurgery 201: Ba-
line: The use of electrosurgical units. Endoscopy, 42, 764–771. sic electrosurgical principles. Current Surgery, 57(3), 261–264.
Singh, N., Harrison, M., & Rex, D. K. (2004). A survey of colono- Vargo, J. J. (2004). Clinical applications of the argon plasma coagu-
scopic polypectomy practices among clinical gastroenterologists. lator. Gastrointestinal Endoscopy, 59(1), 81–88.
Gastrointestinal Endoscopy, 60(3), 414–418. Veck, S. (1996). An introduction to the principles of safety of
Slivka, A., Bosco, J. J., Barkun, A. N, Isenberg, G. A., Nguyen, C. C., electrosurgery. British Journal of Hospice Medicine, 55(1/2),
& Petersen, B. T. (2003). ASGE technology status evaluation re- 27–30.
port: Electrosurgical generators. Gastrointestinal Endoscopy, Vilos, G. A., & Rajakumar, C. (2013). Electrosurgical generators and
58(5), 656–659. monopolar and bipolar electrosurgery. Journal of Minimally In-
Spruce, L., & Braswell, M. (2012). Recommended practices for vasive Gynecology, 20(3), 279–287.
electrosurgery. AORN Journal, 95(3), 373–387. Vormbrock, K., & Monkemuller, K. (2012). Difficult colon polypec-
Strocchi, A., Bond, J. H., Ellis, C., & Levitt, M. D. (1990). Colonic tomy. WJGE, 4(7), 269–280.
concentrations of hydrogen and methane following colonoscopic Wong Kee Song, L. M., & Marcon, N. E. (2000). Modalities for
preparation with an oral lavage solution. Gastrointestinal En- tissue coagulation or ablation: Electrocoagulation. In: G. N. J.
doscopy, 36(6), 580–582. Tytgat, M. Classen, J. D. Waye, & S. Nakazawa (Eds.), Prac-
Tucker, R. D. (2000). Principles of electrosurgery. In:Sivak, M. V. tice of therapeutic endoscopy (Vol. 5.1, pp. 59–74). London:
(Ed.), Gastroenterologic Endoscopy (2nd ed., Vol. 1, pp. 125– Saunders/Harcourt.
135). Philadelphia, PA: W.B. Saunders. Zlatanic, J., Waye, J. D., Kim, P. S., Baiocco, P. J., & Gleim, G. W.
Tucker, R. (2007). Commentary on clinical applications of argon (1999). Large sessile colonic adenomas: Use of argon plasma co-
plasma coagulation in endoscopy. Gastroenterology Nursing, agulator to supplement piecemeal snare polypectomy. Gastroin-
30, 129–130. testinal Endoscopy, 49(6), 731–735.

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Geri Nelson, RN

Electrosurgery in the Gastrointestinal Suite

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VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015 431

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FIGURE 3. A bipolar circuit.

FIGURE 4. A monopolar circuit current path.

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lying on the bed. The best practice rule is to carefully

vent shocks and burns to staff. Handle active elec-

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manufacturer recommends discarding unused multi-

per month. In hospital-based settings, where electrosur-

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electric signals from the heart. This makes them vul-

nerable to interference from electrical signals that are Preprocedure

VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015 435

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& Davolos, 2004; Vargo, 2004; Zlatanic, Waye, Kim,

apply to ArC with the added admonition to observe the

FIGURE 8. One dermal piercing method and ornament placement technique.

VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015 437

GNJ-D-13-00101_LR 437 21/11/15 3:34 AM

Summary and complications experienced by cutaneous surgeons. Derma-

• The energy is electric: current, impedance, voltage,

Steinbeck, G., & Hoffmann, E. (2004). Application of radiof-

GNJ-D-13-00101_LR 438 21/11/15 3:34 AM

electronic devices. Gastrointestinal Endoscopy, 65(4), 561–568. Endoscopy, 38, 472–475.

VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015 439

GNJ-D-13-00101_LR 439 21/11/15 3:34 AM

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