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Diagnostic and Therapeutic Endoscopy, 1996, Vol. 2, pp. 207-210Reprints available directly from the publisherPhotocopying permitted by license only

(C) 1996 OPA (Overseas Publishers Association)Amsterdam B. V. Published in The Netherlands

by Harwood Academic Publishers GmbHPrinted in Singapore

Endobronchial Electrocautery Using Snare

MASAAKI KAWAHARA, KIYOYUKI FURUSE, NAGAHISA KODAMA, MITSUMASA OGAWARA,SHINJI ATAGI, TAKAO KAMIMORI, MITSUNOBU NAKAO, and NOBUYUKI NAKA

National Kinki Central Hospitalfor Chest Diseases, Osaka, Japan

(Received May 22, 1995; infinalform October 26, 1995)

Between May 1987 and March 1994, upper airway and tracheobronchial electrosurgery with snarewas performed in 13 patients (10 men and 3 women), ranging in age from 18 to 87 years. Four pa-tients had benign lesions, and nine had malignant tumors. Total eradication has been achieved in thetwo patients with benign lesions. Electroexcision of the endobronchial portion of the tumor helpedto clear the respiratory airways in all cases with malignant tumors. There has been no major side ef-fects such as bleeding due to this method. Electrocautery is an available economical tool, which helpsto diagnose and treat obstructing airway mass lesions.

KEY WORDS: Lung neoplasms, electrocoagulation, wire snare, bronchoscopy, granuloma, airwayobstruction

INTRODUCTION

Electrocautery using a snare loop is a valuable surgicaland endoscopic tool with the potential for significantupper and lower airway applications, as well as for thegastrointestinal tract. Experience with endobronchialelectrocautery is limited to a few observations (1-3),mainly because of the recent availability of laser therapy.However, laser therapy takes much more time to evapo-rate obstructing endobronchial lesions and produces moregas than electrocautery with snare does. In this article, wereport on 13 cases of electrocautery with snare appliedthrough a fiberoptic bronchoscope to obstructing upperairway and tracheobronchial lesions.

MATERIALS AND METHODS

Between May 1987 and March 1994, upper airway andtracheobronchial electrosurgery with snare was per-formed in 13 patients (10 men and 3 women), in age rang-ing from 18 to 87 years. One patient had electrosurgerytwice and another four times. We used an Olympusfiberoptic bronchoscope (BF- T- 10 or 1T-30), diathermicadult snares (Olympus no. SD-5L), and a high-frequency

Address for correspondence: Masaaki Kawahara, M.D., NationalKinki Central Hospital for Chest Diseases, 1180 Nagasme, Sakai Osaka591, Japan. Tel. 0722-52-3021; Fax. 0722-51-1372.

207

electrosurgical unit (Mera MS-5500N). All patients re-ceived local anesthesia with a transoral fiberoptic bron-choscope. We did not use a rigid bronchoscope.Premedication included 0.4 mg of atropine sulfate and 4mg of oxycodone hydrochloride 30 min before bron-choscopy. A plate electrode was applied to the patient’sthigh. An endotracheal tube was used in all patients withtracheobronchial lesions. The diathermic snare waspassed via the fiberoptic bronchoscope with an instrumentcanal, and the tumor was grasped by the wire loop snare.Electrocrossing of tissue was accomplished by slowlydrawing the wire snare into the catherter. A blended cur-rent ofcutting and coagulation was used for the earlier pa-tients and a coagulation alone was used for the recentpatients. After electrocrossing, the tumor was graspedwith the forceps for the removal of foreign bodies and ex-tracted. Ifthe dissected mass was too large to pass throughthe endotracheal tube, it was grasped by the forceps andextracted with the endotracheal tube. The duration ofelec-trocautery with the diathermic snare was within 30 secs.

CASE REPORTS

Case 3

A 58-year-old woman had been operated on for renalcell carcinoma 3 years before this procedure. She had apolypoid tumor at the right truncus superior, which had

208 M. KAWAHARA et al.

almost completely obstructed the right main bronchus.She had complained of dyspnea on effort and a febrileepisode. Her symptoms began 3 months before admis-sion. Bronchoscopy was performed under local anes-thesia. The right main bronchus was almost completelyobstructed by a polypoid tumor (Fig. 1, left). A wire loopcautery snare was passed through a flexible broncho-scope. A polypoid tumor, measuring 6 mm by 8 mm indiameter, was removed without difficulty. A blendedcurrent was used. The time required for the removal waswithin 30 secs. The tumor was grasped with forceps forthe removal of foreign bodies and extracted. Figure(right) shows the patency of the right main bronchus justafter electrocautery. There was no problem with bleed-ing or smoke. The histologic diagnosis of this tumor wasendobronchial metastatic renal cell carcinoma. After theprocedure, the patient had no complaints of dyspnea orfever due to the obstruction of the right main bronchus.However, the patient died of dissemination of renal cellcarcinoma with a patent airway 31 months after theprocedure.

RESULTS

The results of electrocautery with snare in all patients arelisted in Table 1. Complete removal of upper airway(epipharynx) and endotracheobronchial mass was possi-ble in 3 (cases 1, 5, and 9) of 13 patients. These patientshad granulomas in the epipharynx (case 1), trachea (case5), and the fight upper lobe bronchus (case 9), respectively.One patient (case 1) with pulmonary tuberculosis, whocomplained of hemosputum, had a granuloma in theepipharynx. This granuloma was found during broncho-scopic examination for the evaluation of hemosputum andwas removed completely by electrocautery with snare.Another patient (case 5) was treated with concurrent

chemoradiotherapy for squamous cell lung cancer in theright upper lobe. After the induction therapy, bron-chofiberscopi examination was performed for the evalu-ation of tumor response to therapy. Then a polypoid masswas found in the right upper lobe bronchus. The histologicdiagnosis ofthis polypoid mass removedby electrocauterywith snare was granuloma. The other patient (case 9) with

Figure Case 3. Renal cell carcinoma protruding into the right main bronchus before (left) and after (right) endobronchial electrocautery with snare.

ELECTROCAUTERY WITH SNARE 209

Table 1 Results of Electrocautery Using Snare

Patient Age (yr.) Sex Histology Location Type ofRemovalNo. of

Treatments

Results:Eradication of

Lesion

18 M Granuloma Epipharynx Snare2 55 F Granuloma Rt main br Laser+

Snare3 58 F Renal cell ca Rt main br Snare

4 70 M Squamous Rt inf br Snarecell ca (lung)

5 50 M Granuloma Rt tr sup Snare6 66 M Colon ca Rt main br Laser+

Snare7 66 M Squamous Lt main br Snare

cell ca (lung)8 87 M Squamous Rt tr inf Snare

cell ca (lung)9 38 F Granuloma Trachea Laser+

Snare10 64 M Squamous Lt main br Snare

cell ca (lung)11 52 M Large cell ca Larynx Snare12 67 M Squamous Rt main br Snare

cell ca (lung)13 63 M Thyoid ca Rt int m br Snare

Rt tr inf Snare

Abbreviations: M,male; F,female; ca,carcinoma; rt,right; It,left; br,bronchus; tr,truncus; inf,inferior; int m,intermediate

CompletePartial

Complete

Partial

CompleteComplete

Partial

Partial

Complete

2 Partial

CompletePartial

3 PartialComplete

pulmonary tuberculosis had a granuloma in the trachea,which developed after the T-tube removal. More than 75%of the endobronchial malignant tumor was removed in 10other patients with 11 lesions. Because oftumor regrowth,one patient (case 10) required another use of the snare andanother patient (case 13) needed two more snare proce-dures. The Cd-YAG laser was used before electrosurgerywith snare in three patients (cases 2, 6, and 9). In one pa-tient (case 6), this use of the Cd-YAG laser proved effec-tive to debulk the polypoid tumor and to allow for the snareto go beyond the tumor and grasp it. Bronchoscopic elec-trosurgery with snare was not accompanied by massivehemorrhage in any cases and no other complication, suchas perforation or tracheal fire, was observed.

DISCUSSION

There are two methods used for endobronchial electro-surgery: excision of tumors with a diathermic snare, andelectrodestruction of tumors with a cautery probe. As de-scribed by Gerasin and Shafirovsky (1), electrodestructionby the probe may be replaced by laser coagulation becausethe latter has proven to be more effective. However, for re-moval ofpolypoid lesions, laser or electrodestruction withthe probe requires destruction of the whole mass by va-porization, takes more time to accomplish, generateshigher thermal output, and produces more gaseous

byproducts (2). Mainly, electrosurgery with a diathermicsnare has been used as a palliative treatment to remove amajor part of the tumor or mass and restore air passage.In addition, this procedure is also applicable for the diag-nosis of a polypoid mass in the major bronchi. Althoughthis procedure is usuallyused via arigid brochoscopic tubeunder general anesthesia (1,4,5), we were able to effec-tively use this via a flexible bronchoscopic tube underlocalanesthesia without complications. The decision whetheror not to use, rigid tube may depend on the size of tissuefragment resected.

Considering the easy availability ofthis method, we alsoapplied it to the removal of tumors located in the epiphar-ynx and larynx. In these cases, snaring the mass by thebronchoscope was more effective than by direct vision be-cause ofthe magnified view ofthe tumor through the bron-choscope.The duration of the effectiveness after electrocautery

compared to that after laser treatment remains to be de-termined. This may largely depend on the characteristicsof the tumor, rather than the procedure.As for the disadvantages ofelectrocautery, hemorrhage,

perforation, fire and difficulty in shielding the instrumenthave been listed (1,2,6). However, we did not experienceany of these disadvantages.

Initially, a blended current of cutting and coagulationwas used; however, for the most recent patients coagula-tion alone was used, because the coagulation mode was

210 M. KAWAHARA et al.

enough to cut the lesion with the snare. Concerning bleed-ing, this mode may be safer than blended current. Somefailure to perform electrocautery was experienced, withthe major cause being the inability to pass the snare loopbeyond the polypoid tumor. In such patients, laser treat-ment followed by electrocautery may be useful.

In conclusion, electrocautery with snare is a readilyavailable, economical tool that can assist in the diagnosisand therapy of obstructing airway lesions.

ACKNOWLEDGMENTS

The authors wish to express their appreciation to YukiHirochi and Edna Hatashita for their assistance with thepreparation of this paper.

REFERENCES

1. Gerasin VA, Shafirovsky BB. Endobronchial electrosurgery. Chest1988;93:270-274.

2. Hooper RG, Jackson F. Endobronchial electrocautery. Chest1985;87:712-714.

3. Taguchi H, Nagata T, Kawai H, et al. High-frequency electrosurgi-cal treatment of tracheal obstruction using the flexible bronchofiber-scope. In: Bronchology: research, diagnostic and therapeutic aspects.The Hague: Martinus Nijhoff Publishers, 1981:563-565.

4. Spinelli P, Pizzetti P, Lo Gullo C, et al. Resection of obstructingbronchial fibrolipoma through the flexible fiberoptic bronchoscope.Endoscopy 1982; 14:61-63.

5. Pedersen U, Kristensen S, Ilium P. Palliative resection with high-fre-quency cutting loop in malignant tracheobronchial diseases.Bronchol 1994;1:23-25.

6. Hooper RG, Spratling L, Beechler C, et al. Endobronchial electro-cautery: a role in bronchogenic carcinoma? Endoscopy1994;16:67-70.

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