Comparison of bipolar scissors and bipolar forceps in tonsillectomy

Bipolar diathermy scissors tonsillectomy is a relatively new surgical technique. We conducted a prospective study of 90 patients to compare this technique with bipolar forceps tonsillectomy. We found that the use of the bipolar scissors required significantly less operating time (mean: 3.03 min less) and allowed patients to resume eating solid food more rapidly (mean: 40.35 min earlier). Bipolar scissors tonsillectomy was safe, and there were no intraoperative complications or primary hemorrhages. A postoperative follow-up telephone survey revealed that patients who underwent scissors tonsillectomy experienced no more morbidity than did the forceps group during the first 2 weeks after surgery. We conclude that bipolar scissors tonsillectomy is a safe and rapid technique that can be used successfully as an outpatient procedure.     

Ligation versus bipolar diathermy for hemostasis in tonsillectomy: a comparative study

Tonsillectomy despite being less performed nowadays still is a very common surgery performed by ENT surgeons. The use of various modalities like bipolar diathermy, laser, cryosurgery, radiofrequency and ionic coblation for hemostasis in tonsillectomy remains controversial so far. A thorough scan of literature comparing the ligation with diathermy has been presented. In this prospective study, we analysed 50 patients undergoing tonsillectomy by dissection method. Right sided tonsillectomies act as study group (bipolar diathermy used) and left sided tonsillectomies as the control group (ligation for hemostasis used). The aim of our study is to compare the amount of blood loss, number of ligatures applied, average time taken and incidence of postoperative haemorrhage following the use of ligation and bipolar diathermy. The study found that diathermy hemostatic technique is associated with a quicker procedure, less intraoperative blood loss, comparable postoperative pain.     

Blunt dissection to bipolar forcep tonsillectomy- a comparision

Conclusion  Bipolar diathermy forcep or scissors dissection is safe and trusted and established procedure now and have an edge over blunt dissection. If monopolar diathermy is used, high voltage current should be used for dissection with fine point and if bipolar is used, low voltage current should be used, diathermy tip should be cleaned with wet gauge piece, fossae should be packed with wet gauge only, minimum required current and only coagulation should be attempted, avoid injury to surrounding tissue resulting to minimum sloughing. Avoiding thermal injury to surrounding tissues leads to lesser post operative pain. Results depends upon the precision of technique and expertise developed over a time especially coagulating the vessel during dissection before spurt. Considering cost effectiveness, bipolar diathermy is much economical than ultrasonic and laser to provide comparable results in terms of better results, duration of surgery, anaesthesia and overall postoperative morbidity.     

Preliminary experiences with microscopic tonsillectomy

Experiences with a modified technique of tonsillectomy are described. The surgery is performed viewing the tonsil through the operating microscope and using the bipolar diathermy forceps for dissection and diathermy of blood vessels. In a pilot-study of 70 patients, the microscopic method was found to be an elegant technique which substantially reduced intra-operative blood loss and did not prolong surgery. Post-operative morbidity will be assessed in a further study.     

Harmonic scalpel tonsillectomy: a prospective study

The harmonic scalpel has been in use for tonsillectomy for the last 5–6 years in western Europe and North America. Although some studies have found this technique to be superior to other conventional methods, its use is still not very popular. In this single-blinded prospective study, the intraoperative events and postoperative morbidity after the use of harmonic scalpel in tonsillectomy (HST) was evaluated in 180 cases in two hospitals and compared with conventional steel tonsillectomy (CST) and hemostasis secured by bipolar diathermy or ligatures in 100 cases. Both bipolar diathermy and ligatures were used to control the intraoperative bleeding in all cases of CST and some cases ( n =9) of HST. The study was done in two hospitals. Patients were randomized irrespectively of their age, sex, past history or indication for surgery. The total number of patients operated on was 180 for HST and 100 for CST. The surgical duration, intraoperative blood loss and postoperative pain were compared between the patients who only had tonsillectomy done in either group ( n =120 in HST and n =70 in CST). The mean operative time in the HST group was not longer than the CST group, but the intraoperative blood loss was significantly less in the HST group. Postoperative pain was present in all patients in the HST group, but to a lesser extent than in the CST group. There was no major postoperative hemorrhage in the HST group that required surgical attention. HST has the advantage over CST when secondary hemorrhage after tonsillectomy is considered. Thus, following the results of the National Prospective Tonsillectomy Audit (NPTA), it may be safe to say that HST is superior to most other conventional methods in reducing secondary hemorrhage. The use of disposable blades in CST certainly reduces the risk of the transmission of Cruetzfield-Jacob disease (CJD).     

Intravenous paracetamol is highly effective in pain treatment after tonsillectomy in adults

Tonsillectomy in adults is associated with significant postoperative pain. Intravenous paracetamol injection (Perfalgan) is marketed for the management of acute pain. This prospective placebo-controlled study was performed to evaluate the analgesic efficacy and safety of intravenous paracetamol in 76 adult patients undergoing elective standard bipolar diathermy tonsillectomy. After tonsillectomy was performed under general anesthesia, the patients were randomized to receive either intravenous paracetamol 1 g (Perfalgan) (n = 38) or 0.9% normal saline as a placebo (n = 38) at 6-h intervals. No other analgesic medication was permitted for postoperative pain during the study. Need for rescue analgesic during the first 24 h after surgery as well as all adverse events were recorded. The intravenous paracetamol group differed significantly from the placebo group regarding pain relief and median time to pethidine rescue. Intravenous paracetamol significantly reduced pethidine consumption over the 24-h period. The worst pain after surgery was also more severe in the placebo group than that in the paracetamol group. There was no significant difference between groups in the incidence of adverse events. Intravenous paracetamol administered regularly in adult patients with moderate to severe pain after tonsillectomy provided rapid and effective analgesia and was well tolerated.     

Scars and satisfaction: do smaller scars improve patient-reported outcome?

Thyroidectomy has few complications, as a result, many patients are concerned about the prominence of their scar. Performing thyroid surgery through excessively small incisions in order to maximise cosmesis may increase the likelihood of complications. This study investigates the relationship between conventional approach thyroidectomy scar length and patient satisfaction. A validation of self-measurement of neck circumference and thyroidectomy scar was carried out with the measurements taken by patients compared with those taken by an investigator. One hundred consecutive patients who had undergone conventional thyroidectomy and total thyroidectomy within 24 months were invited to measure their scars and neck circumference, and to score their satisfaction on a Likert scale of 1–10. Spearman’s correlation was calculated for the relationship between absolute and relative scar length, and patient satisfaction. Thirty-four patients entered the preliminary study and 80 patients entered the main study (80% response rate). Measurements by patients and investigators were closely associated: Spearman’s Rank correlation coefficient for neck circumference and for scar length were ρ = 0.9, p < 0.0001 and ρ = 0.93, p < 0.0001 respectively. No significant correlation was evident between scar length and patient satisfaction (ρ = 0.068, p = 0.55), or between relative scar length ratio and patient satisfaction (ρ = −0.045, p = 0.69). Mean scar length was 6.96 cm [standard deviation (SD) 2.70], and mean satisfaction score 8.62 (SD 2.04). Thyroidectomy scar length appears to have no association with patient satisfaction. Thyroid surgery should, therefore, not be performed through unnecessarily small incisions for purely aesthetic reasons.     

Disección fría y coagulación bipolar versus disección con bisturí armónico en la cirugía de los tumores benignos de la glándula parótida

IntroductionSurgical techniques for extirpation of tumours of the parotid gland have evolved significantly in recent years. Previous data suggest the use of Harmonic Scalpel reduced operative time, intraoperative blood loss, postoperative drain production, and incidence of facial nerve injury, in comparison to cold scalpel dissectionMaterial and methodsretrospective analysis of 2 group of patients operated using harmonic scalpel versus cold knife dissection and bipolar diathermy and compare operative time and post-surgical complication rate:, facial nerve injury, sialocele or salivary fístula formation, after parotidectomy for benign parotid tumours.Results108 patients were included. Regarding surgical time, the mean time to using Harmonic Scalpel was 114 ± 39 (Min: 60/Max: 240), and the mean time using bipolar diathermy was 135 ± 38 (Min: 90/Max: 285) and this was the only significant difference between the 2 techniques (p = .049).ConclusionsHarmonic scalpel is a safe and effective tool to perform parotid surgery in benign tumours. However, a shorter surgical time was the only advantage found over the traditional cold dissection and bipolar dissection method.     

Does surgical management still play a role in the management of ectopic lingual thyroid: Institutional experience and systematic review of the literature

ObjectiveManagement of ectopic lingual thyroid (ELT) must balance the morbidity of disease with the morbidity of treatment. We investigate clinical outcomes associated with modern treatment options and analyze the role of transoral surgery in the treatment algorithm for ELT.MethodsThis was a retrospective chart review of ELT patients treated at a tertiary care center from 1/1/1979 to 12/31/2019. In addition, a systematic review of the literature from 1979 to 2021 for reports of ELT was performed. Symptoms defined as high-risk were dysphagia, dysphonia, dyspnea, neck swelling, bleeding, and obstructive sleep apnea (OSA).Results36 patients within the institutional cohort (IC) and 224 cases in the systematic review (SRC) met criteria. The most common presenting symptoms for both cohorts were dysphagia, globus sensation, and dysphonia. One third of each cohort were hypothyroid, while 3% (n = 1) and 9% (n = 21) of the IC and SRC, respectively, had clinical suspicion of malignancy at presentation. 27% (n = 10) of the IC and 55% (n = 121) of the SRC underwent surgical therapy. There was a 4% (3/72) transoral bleed rate for all patients undergoing transoral surgery. Other reported complications were minor. There were no tracheostomies, and no deaths. Among observed, medically treated, and surgically treated patients, symptoms improved during follow up for 43% or 68% in the IC and SRC, respectively. Following surgery, symptoms improved or resolved for 86% or 93% in the IC and SRC, respectively.ConclusionsAsymptomatic ELTs with no concern for malignancy can be managed with observation. Patients with mild symptoms or hypothyroidism may trial thyroid suppressive therapy or RAI. RAI can be considered for patients with high-risk symptoms. For patients with symptoms resistant to conservative therapy, concern for malignancy or high-risk symptoms not conducive to RAI, surgery should be considered. Transoral approaches offer acceptable morbidity, and most patients experience resolution of symptoms following this approach.     

Increased post-tonsillectomy secondary haemorrhage with disposable instruments: an audit cycle

The objective of the audit was to examine the increased morbidity associated with elective tonsillectomy with single-use instruments in a district general hospital in England. Retrospective audit of consecutive case notes of 145 patients who underwent tonsillectomy in a 6-week period after the introduction of single-use instruments was carried out. The main outcome measure was incidence of secondary haemorrhage. In total, 9.5% of patients required re-admission indicated by secondary haemorrhage, 4% required emergency surgery and 43% of the total group had haemostasis achieved with ties. None of these was re-admitted. Out of the total group, 57% had haemostasis achieved with single-use bipolar forceps; 16.8% of these patients were re-admitted, with 7% of this group requiring emergency surgery to control the haemorrhage. Animal tissue experiments and design analysis of the single-use bipolar diathermy highlighted the deficiencies of the initial single-use bipolar diathermy. This was replaced by a new design of single-use diathermy forceps. A second audit was performed which revealed a significant reduction in postoperative morbidity. Complications associated with the introduction of new instruments can be identified by repeated audit cycles.     

Expanded use of telemedicine for thyroid and parathyroid surgery in the COVID-19 era and beyond

BackgroundThe COVID-19 pandemic has greatly expanded the use of telemedicine in healthcare. Surgical thyroid and parathyroid diseases are uniquely suited for comprehensive telemedicine. The objective of this study was to compare the safety and efficacy of telemedicine with in-person preoperative visits in patients undergoing thyroid and parathyroid surgery.MethodsProspective cohort study of patients undergoing thyroid and parathyroid surgery at a tertiary care center in a COVID-19 hotspot from March 2020 to October 2020. Patients were divided into a telemedicine cohort, with preoperative consultation and surgical decision-making conducted via telemedicine, and a conventional in-person cohort.ResultsOf 94 patients, 28 were enrolled in the telemedicine cohort and 66 were enrolled in the conventional cohort. Telemedicine patients were more likely to have parathyroid disease (50% versus 24%, p = 0.02) compared with the conventional cohort, but there was no significant difference in surgery for malignancy (43% versus 56%, p = 0.27). There were no significant differences in surgical outcomes or postoperative complications between cohorts, including intraoperative blood loss (19.4 mL versus 35.5 mL, p = 0.06), postoperative length of stay (1.3 days versus 1.2 days, p = 0.93), persistent hypocalcemia (3.6% versus 0%, p = 0.30), and true vocal fold paresis (0% versus 4.5%, p = 0.55).ConclusionsWith careful selection, many patients undergoing thyroid and parathyroid surgery may be safely treated using comprehensive telemedicine.     

Evaluation of the performance of ultrasonography and 99mTc-sestamibi scintigraphy for primary hyperparathyroidism surgery

IntroductionMinimally invasive surgery has become the standard surgical attitude in primary hyperparathyroidism. It requires precise preoperative lesion localization. The aim of the present study was to evaluate the performance of ultrasonography and 99mTc-sestamibi scintigraphy in minimally invasive surgery for primary hyperparathyroidism.Materials and methodsA retrospective study included all patients managed surgically for primary hyperparathyroidism between January 2008 and November 2017 in the University Hospital of Brest (France). Two hundred and seventy-three patients underwent ultrasonography and 99mTc-sestamibi scintigraphy. Results determined intrinsic (sensitivity and specificity) and extrinsic (positive and negative predictive values) performance on per-patient and per-gland analysis. Demographic, preoperative, interventional and cure data were compared according to ultrasonography and scintigraphy results, distinguishing 3 patient groups: concordant n = 156, discordant n = 99, negative n = 18.ResultsOn per-gland analysis, sensitivity was 70% for ultrasound, 74% for 99mTc-sestamibi scintigraphy and 81% for associated ultrasound-scintigraphy; positive predictive values were 89%, 91% and 96%, respectively. Gland volume and concomitant thyroid pathology rates differed significantly (both p = 0.003) between the 3 imaging results groups.ConclusionThe performance of associated ultrasound-99mTc-sestamibi-scintigraphy provided a positive predictive value of 96%. Combining the two techniques reduced surgical morbidity.     

Increased post‐tonsillectomy secondary haemorrhage with disposable instruments: an audit cycle

The objective of the audit was to examine the increased morbidity associated with elective tonsillectomy with single‐use instruments in a district general hospital in England. Retrospective audit of consecutive case notes of 145 patients who underwent tonsillectomy in a 6‐week period after the introduction of single‐use instruments was carried out. The main outcome measure was incidence of secondary haemorrhage. In total, 9.5% of patients required re‐admission indicated by secondary haemorrhage, 4% required emergency surgery and 43% of the total group had haemostasis achieved with ties. None of these was re‐admitted. Out of the total group, 57% had haemostasis achieved with single‐use bipolar forceps; 16.8% of these patients were re‐admitted, with 7% of this group requiring emergency surgery to control the haemorrhage. Animal tissue experiments and design analysis of the single‐use bipolar diathermy highlighted the deficiencies of the initial single‐use bipolar diathermy. This was replaced by a new design of single‐use diathermy forceps. A second audit was performed which revealed a significant reduction in postoperative morbidity. Complications associated with the introduction of new instruments can be identified by repeated audit cycles.     

CT comparison of primary snoring and obstructive sleep apnea syndrome: role of pharyngeal narrowing ratio and soft palate-tongue contact in awake patient

Soft palate-tongue contact and automatically calculated pharyngeal narrowing ratio (PNR), defined as a ratio between the airway cross-section at the hard palate level and the narrowest cross-section from the hard palate to the epiglottis, could assist in earlier identification of potential obstructive sleep apnea syndrome (OSA) patients even on awake individuals. Parameters were studied on carotid CTA images from 67 consecutively included awake Caucasians who were later classified by second independent physician into the primary snorers (SNORE, n = 34) or obstructive sleep apnea syndrome patient (OSA, n = 33) group according to the clinical examination, laboratory testing and a full-night video polysomnography (PSG) in the sleep laboratory. Imaging and clinical data were statistically compared between groups. The odd’s ratio calculation showed a 2.95 (P = 0.0354) higher risk for OSA development in snoring person with a PNR greater than 8.6. The loose-contact subgroup among OSA patients showed significantly (P = 0.002) higher values of AHI in contrast to the in-contact subgroup. Authors didn’t have any financial relationship concerning presented study.     

Comparison of the h index with standard bibliometric indicators to rank influential otolaryngologists in Europe and North America

The Hirsch (h) index is an original and simple new bibliometric measure incorporating both quantity and quality. In this study, our aim was first to present characteristics of the statistical correlation between the h index and several standard bibliometric indicators and secondly we compared the h index between otolaryngologists from Europe and US. We used the Institute of Scientific Information (ISI) Web of Knowledge to identify citation reports from a random sample of influential editors from six otolaryngology journals: Journal of Laryngology and Otology (n = 21), Clinical Otolaryngology (n = 16), European Archives of Oto-Rhino-Laryngology (n = 49), The Laryngoscope (n = 66), Otolaryngology-Head and Neck Surgery (n = 15), and Archives of Otolaryngology-Head and Neck Surgery (n = 15). The following data were gathered: Number of publications (P), total citations received by P(C), total citations received by P without self-citations (Cs), average number of citations per publication (CPP), and Hirsch index (h). Statistical analysis was used to correlate the above data and we also compared the h index of European and North American editors. There were 182 randomly selected editors. We observed a good correlation between the h index and other standard bibliometric indicators. Using the non-parametric Mann–Whitney test, the median P between Europe and US was not statistically significant. However, the median C, CS and h were statistically significant. In conclusion, the h index is a simple yet powerful indicator as it combines productivity and impact. Overall, the US editorial panel have a higher h index.     

Detection of anomalous vertebral arteries by ultrasound as an alternative to radiological methods

In order to examine ‘ultrasound’ approach in detecting the course of the vertebral artery (VA) and its anomalies important for neck surgery. An observational study with retrospective analysis of ultrasound images. 500 VAs on 250 3D CT angiographies and 500 ultrasound images performed on the same set of patients were analyzed. The relationship between the extraosseous portions of the VA to the neck organs with a special emphasis to the thyroid gland area, and the abnormal position of the VA were detected. Ultrasound and CT 3D images were compared. Ultrasound detected that 29 out of 500 VAs were anomalous (5.8%), 3D CT detected 30 cases. These anomalies were found in 22 patients (8.8%) (23 for 3D CT; 9.2%), in 7 (31.8%) of them bilaterally. An abnormal level of entrance (C3, C4, and C5) was observed in all anomalous cases. An additional case detected by 3D CT indicated C7 level of entrance. The ultrasound data correspond the CT data in 96.7% of cases. In ten cases (33.3%) the anomalous VA run close to the thyroid gland even touching the lower pole (16.7%; n = 5) or the upper pole (10.0%; n = 3) of the gland. In ten cases (33.3%) the anomalous VA crossed common carotid artery and the internal jugular vein by a way of a median loop. The incidence of anatomic variations of the VA is significant. Preoperative ultrasound investigation allows precise identification of anomalous VAs. Radiation-free ultrasound investigation of blood vessels is as precise as CT 3D imaging.     

Peritonsillar infiltration with tramadol improves pediatric tonsillectomy pain

Pain control in pediatric patients undergoing tonsillectomy remains a dilemma. Tramadol is reported to be an effective analgesic. This prospective, double-blinded, placebo-controlled study was performed to evaluate the analgesic efficacy and safety of submucosal infiltration of tramadol on postoperative pain in children after standard bipolar diathermy tonsillectomy. Following standard bipolar diathermy tonsillectomy was performed, 40 patients were randomized to receive submucoasl infiltration with 2 mg kg⁻¹ tramadol in 3 ml of normal saline (1.5 ml per tonsil) or normal saline only. The patients in each group were compared postoperatively with regard to the quality of pain control using the objective pain scale (OPS), sedation score and their analgesic requirements. Peritonsillar infiltration of tramadol (group 2) provided superior postoperative analgesia to placebo (group 1) for 4 h after surgery. In addition, group 1 received significantly more doses of paracetamol than group 2 in order to maintain analgesia in the first 12 h after recovery from anesthesia. Peritonsillar infiltration of tramadol appears to be an effective method of providing superior analgesia in the postoperative period when compared to placebo.     

Investigating the possible association between thyroid nodule location and the malignancy risk of the nodules in FNA samples

IntroductionIn this study we aimed to investigate the association between thyroid nodule location and the malignancy risk of the nodules in FNA samples.MethodsIn this cross sectional study, 400 patients with thyroid nodule size >1.5 cm, thyroid nodule size >1 cm with micro-calcification, and thyroid nodule size <1 cm with sonographic or clinical signs of malignancy who referred to a training hospital, were involved. Morphologic characteristics of nodules, including nodule size, laterality and polarity were recorded. In patients with multinodular goiter, the anatomical location was recorded and analyzed.ResultsIn our study, 345 female patients (86.3 %) and 55 male patients (13.8 %) with thyroid nodule were involved. The majority of thyroid nodules were identified in the right lobe (n = 182, 45.5 %) and left lobe (n = 177, 44.3 %), respectively. A total of 323 nodules were benign and the remaining (n = 77) were malignant. The frequency of malignancy in the upper pole of the thyroid (31.6 %) was higher compared to that in the middle pole (10.7 %), lower pole (19.1 %), and isthmus region (26.8 %), leading to a significant difference (p.value = 0.001). The mean size of thyroid nodules was 15.68 mm in benign nodules and 20.08 mm in malignant nodules.ConclusionOur results showed that thyroid nodules found in the upper lobe carried the greatest risk for malignancy. Accordingly, it seems that the location of thyroid nodules can be an independent risk factor in determining the malignancy risk of thyroid nodules and can be used to enhance clinical decision making in thyroid FNA samples.     

A prospective, randomised, placebo-controlled trial of postoperative oral steroid in allergic fungal sinusitis

The aim of this study is to determine the effectiveness of postoperative oral steroid in controlling disease in patients with allergic fungal sinusitis (AFS). The study design includes prospective, randomised, double-blind, placebo-controlled trial using oral prednisolone. Twenty-four patients diagnosed with AFS underwent sinus surgery (endoscopic sinus surgery with or without open surgery) to completely excise disease. Patients were randomised to receive either oral steroid (n = 12) or placebo (n = 12) soon after surgery. All patients were also administered itraconazole and steroid nasal spray in the postoperative period. Subjective evaluation of symptom relief and objective evaluation by rigid nasal endoscopy at 6 and 12 weeks following surgery was performed. After 12 weeks, the code was broken and the two groups of patients were identified to note their response to treatment. At 6 weeks, complete relief of preoperative symptoms was obtained in eight patients who had received oral steroid and none who had received placebo (p = 0.001). Partial relief of preoperative symptoms was obtained in four who had received oral steroid and eight who had received placebo. Nasal endoscopy revealed that 8 of 12 patients who had received oral steroid and 1 patient who had received placebo were disease free (p = 0.009). At 12 weeks, complete symptom relief was obtained by all patients who received oral steroid but only one who received placebo (p = 0.0001). Nasal endoscopy at 12 weeks revealed that all 12 patients who had received oral steroid and only 1 patient (the same patient) who had received placebo were disease free (p = 0.0001). In conclusion, postoperative oral steroid in a tapering dose produces significant subjective and objective improvement of patients with AFS. It is also effective in preventing early recurrence. Inclusion of postoperative oral steroid therapy for at least 12 weeks is recommended in all patients who undergo excisive surgery for AFS.     

Tissue welding tonsillectomy provides an enhanced recovery compared to that after monopolar electrocautery technique in adults: a prospective randomized clinical trial

We have compared tonsillectomy (TE) with tissue welding (TW) technology using a specially designed forceps versus conventional monopolar electrocautery to evaluate whether this new technology may improve recovery after TE. This was a single-blind, randomized clinical trial with two parallel groups. Sixty healthy adult day-surgery patients were allocated into the TW-TE group (n = 31) and the monopolar electrocautery-TE group (n = 29). We recorded intraoperative events and short- and long-term recovery for 2 weeks postoperatively. The patients and study nurses evaluating patients during recovery were blinded to the operation method used. All patients in the TW-TE group completed the study as per protocol, but in the monopolar electrocautery-TE group, there was one drop-out in the hospital and another after discharge. There was no difference in the perioperative parameters and early recovery between the two groups. After discharge, recovery was significantly faster in the TW group than in the monopolar group: (1) the duration of postoperative pain was 2 days shorter, and (2) activities of normal daily living were less affected, and (3) the need for hospital contacts after discharge, and (4) the incidence of postoperative bleeding was less in the TW group than that in the monopolar group. No patients in the TW group developed secondary bleeding versus three patients in the monopolar group requiring electrocautery to control bleeding. In conclusion; our results indicate that, TW technique may provide reduced pain, faster recovery, and fewer complications compared to electrocautery TE.