AJR 2003; 181:157-161
© American Roentgen Ray Society
Argon Beam Coagulator Electrode Tip Mimicking a Metallic Foreign Body
Gregory W. Gladish1,
Joel S. Dunnington and
Marvin H. Chasen
1 All authors: Department of Diagnostic Radiology, The University of Texas M. D.
Anderson Cancer Center, 1515 Holcombe Blvd., Box 57, Houston, TX 77030.
Received October 23, 2002;
accepted after revision January 16, 2003.
Address correspondence to G. W. Gladish.
Abstract
OBJECTIVE. Our purpose is to describe the appearance of an argon
beam coagulator electrode tip that may become fractured and detached during
surgery.
CONCLUSION. Knowledge of the potential for fracture and detachment
and recognition of the characteristic radiographic appearance of the argon
beam coagulator electrode tip allows radiographic identification of this
metallic foreign body.
Introduction
The argon beam coagulator is an electrosurgical device introduced in the
late 1980s [1]. It functions by
emitting a stream of ionized argon gas that serves as a conduit for delivery
of radiofrequency energy to the tissue surface. The flowing argon gas also
serves to clear fluids from the operative site and cool the tissue surface.
The argon beam coagulator provides a more uniform more adherent eschar with
less depth of necrosis compared with standard electrosurgical coagulation
[2]. Since its introduction,
the argon beam coagulator has found wide utility, ranging from radical head
and neck surgery to plastic surgery
[1], resection of bullous
disease [3], abdominal
solid-organ resection and repair
[4], and a variety of
endoscopic and laparoscopic applications
[5,
6]. Use of this device has
allowed a decrease in blood loss and transfusion requirements and a decrease
in operative times.
The most significant complication related to the argon beam coagulator is
venous argon embolism
[7–9].
This has occurred with direct application of the argon beam to a large venous
structure and with excess intraabdominal pressure when used during
laparoscopy. Previously reported minor complications have included metaplasia
and inflammatory polyps after endoscopic argon beam coagulator use
[10,
11].
We report the radiologic appearance of the electrode tip from three
Bend-A-Beam Argon Beam Coagulator handpieces (ABC Bend-A-Beam, ConMed, Utica,
NY) that became fractured and detached during surgery.
Materials and Methods
The chest radiographs and CT scans of three patients with metallic foreign
bodies attributed to argon beam coagulator electrode tips were reviewed. Two
women and one man, ages 18–52 years, had surgical indications that
included pulmonary metastasis (Figs.
1A,
1B,
1C,
1D), cholecystitis (Figs.
2A,
2B), and abdominal sarcomatosis
(Figs. 3A,
3B). The argon beam coagulator
was used for lysis of adhesions, cholecystectomy, and hemostasis at multiple
abdominal sites in the respective patients. One patient identified pain at a
site referable to the foreign body after the foreign body was identified. The
other two patients had no symptoms referable to the foreign body. The
examinations were analyzed for the morphologic appearance and location of the
metallic foreign body. This appearance was then compared with that in
radiographs of an argon beam coagulator and its electrode tip.
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Fig. 1A. —18-year-old man with testicular carcinoma after right
thoracotomy for resection of metastases. Posteroanterior (A) and
lateral (B) conventional radiographs show metallic foreign body
(arrows) in midline posterior to heart.
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Fig. 1B. —18-year-old man with testicular carcinoma after right
thoracotomy for resection of metastases. Posteroanterior (A) and
lateral (B) conventional radiographs show metallic foreign body
(arrows) in midline posterior to heart.
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Fig. 1C. —18-year-old man with testicular carcinoma after right
thoracotomy for resection of metastases. Close-up view on conventional
radiograph shows characteristic needlelike configuration with slightly
narrower shaft at base.
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Fig. 1D. —18-year-old man with testicular carcinoma after right
thoracotomy for resection of metastases. CT scan shows foreign body
(arrow) along medial pleural surface adjacent to esophagus and
azygous vein.
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Fig. 2A. —36-year-old woman with acute leukemia after cholecystectomy
for acalculous cholecystitis. Posteroanterior conventional radiograph shows
foreign body with characteristic needlelike appearance of electrode tip
(arrow) in right upper quadrant of abdomen.
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Fig. 3A. —52-year-old woman with abdominal sarcomatosis after resection
of tumor implants. Posteroanterior conventional radiograph shows metallic
foreign body (arrow) in right upper quadrant of abdomen. Note
pneumoperitoneum (arrowheads) related to recent surgery.
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Results
The foreign body was identified as a 1 x 22 mm needlelike metallic
object with a slightly narrower shaft at the base. On conventional
radiography, the length of the foreign body varied from 22 to 24 mm because of
differences in magnification. In the two patients who underwent abdominal
operations, the foreign body was identified in the right upper quadrant. In
the patient who underwent thoracic surgery, the object was identified along
the medial pleural surface. In all three patients, the object was present on
the first examination, which was performed between 0 days and 6 months 27 days
postoperatively. The object was not identified or described on the first
postoperative study in any patient. It was identified on the second
examination in two patients, one 2 days and the other 7 months
postoperatively. In the third patient, the object was reported 10 months 16
days after surgery only after numerous postoperative radiographs. In the
latter patient, the object was directed posteriorly and, on the frontal
radiographs, had a small profile, appearing to represent a surgical clip
similar to others nearby. However, on the lateral chest images, a
characteristic appearance was identifiable.
CT features are less helpful because the marked artifact produced by the
metallic foreign body limits morphologic evaluation. The scout view commonly
obtained on CT is of too low resolution to provide the characteristic
morphologic appearance. CT more clearly shows the position of the foreign
body. In our three patients, the foreign body was found in a position that was
dependent at the time of surgery.
Discussion
The nature of the foreign body was not determined until the object was
identified in the third patient on the second postoperative portable
radiograph. After determining that the object was not outside the patient, we
obtained posteroanterior and lateral images to definitively localize it. After
repeated consultation with the operative team, we finally suggested that this
might be a part of the argon beam coagulator. A new instrument was opened,
disassembled, and scanned on radiography; the electrode tip was then confirmed
to correspond exactly to the foreign body (Figs.
4A,
4B,
4C,
4D). Because the appearance
and size of the foreign bodies on the conventional radiographs exactly matched
those of the disassembled electrode device, it appears that the fracture
always occurs at the same site. The instrument used in these patients has a
malleable extension to allow the device to be used in poorly accessible areas.
Apparently, the fractured electrode tip became detached during the operation
and fell unobserved into the operative field. Because the electrode tip is
normally completely enclosed in the outer sheath of the device, it is visible
only by direct inspection down the bore of the device. Therefore, the absence
of the electrode tip is not readily apparent. It is not clear whether the
absence of this electrode tip completely deactivates this device. It was not
previously known that this component could become detached; therefore, its
presence was not assessed at the time of surgery. Although the frequency of
this complication is not known, nearly 1000 of these devices have been used at
our institution over the 4 years during which these three cases occurred.
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Fig. 4B. —ABC Bend-A-Beam argon beam coagulator device (ConMed, Utica,
NY). Conventional radiographs of intact (B) and fractured (C)
tip of device show site of fracture (arrow, B) and appearance
of needle fragment (C). Part of supporting sheath was removed during
disassembly of device for radiography.
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Fig. 4C. —ABC Bend-A-Beam argon beam coagulator device (ConMed, Utica,
NY). Conventional radiographs of intact (B) and fractured (C)
tip of device show site of fracture (arrow, B) and appearance
of needle fragment (C). Part of supporting sheath was removed during
disassembly of device for radiography.
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Fig. 4D. —ABC Bend-A-Beam argon beam coagulator device (ConMed, Utica,
NY). Photograph of electrode tip shows size of fragment and characteristic
needlelike appearance with slightly narrower shaft at base.
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In two of these patients, the electrode tip was determined to be causing no
symptoms and creating little risk to the patients. The risk of surgery was
thought to be greater than any risk associated with leaving the object in
place. In the other patient, symptoms of pain attributed to the electrode tip
were thought to be significant enough to warrant removal of the device. The
removal was performed at the time of open liver biopsy to evaluate
graft-versus-host disease in this patient. The foreign body was located in
Morison's pouch adherent to the edge of the liver in scar tissue. The patient
reported resolution of symptoms after removal of the foreign body. The surgeon
and pathologist did not recognize the foreign body at the time of removal,
although it was clearly not a needle used for suture or injection.
Foreign bodies are a common finding on postoperative radiographs. Most of
these are left intentionally at the time of surgery, including clips, pacing
electrode wires, and other devices. Needles, sponges, and instruments are
generally counted at surgery, and frequently the radiologist is alerted if one
of these is unexpectedly missing at the end of the procedure. In addition,
these items have characteristic radiologic appearances well known to
radiologists. The foreign body we describe has an appearance similar to that
of needles used outside the operative theater and might be assumed to be
outside the patient. The identification of any unexpected foreign body should
prompt an examination of the patient, gowns, and sheets to ascertain that the
object is actually inside the patient. Further investigation with upright
posteroanterior and lateral radiographs and CT may be needed to exactly
localize the structure. The knowledge of the possibility of the detachment and
of the characteristic radiographic appearance of the argon beam coagulator
electrode tip will allow its rapid radiologic identification. After the tip
has been identified, the surgeon must assess the hazard of retrieving the
device by comparing the risk to the symptoms and risks associated with leaving
the device in place.
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Abstract
Introduction
