Transcript Document 7293614

Curettage and Cautery
www.bradfordvts.co.uk
Curette
From the Latin curare, to care for
or to cure.
Then to the French curer, to cure.
Bronze curettes have been found
in Egyptian tombs!
11/7/01
Bruce Davies
2
Cautery
From the Latin cauterium, a
branding iron.
An old usage is a cauterant, a
chemical used to burn!
Used for several thousand years
11/7/01
Bruce Davies
3
Cautery
One of the earliest surgical
techniques and one that is
still very useful especially in
a general practice setting.
It is often quick to perform
and provided simple
precautions are observed it
is safe and effective.
11/7/01
Bruce Davies
4
Cautery
As a additional incentive the "Minor
surgery" scheme allows most forms of
cautery to be a claimable "minor op".
The regulations are not specific as to
what constitutes claimable cautery so
the interpretation can be fairly broad.
11/7/01
Bruce Davies
5
Cautery
There are 3 types of cautery relevant to
general practice, the use of specialist
operating theatre type equipment is out
side the normal scope of general practice.
These are Cryocautery, Chemical cautery
and Electro cautery [ hot wire - DC types ].
All have uses in general practice.
11/7/01
Bruce Davies
6
Cautery
By definition cautery does not produce a tissue
sample for histology ( unless used as a adjuvant in
another procedure) so it must Never be used if there
is any doubt as to the nature of the lesion.
Medical records must be meticulous as to the
procedure and the diagnosis of the lesion concerned.
As in all things there is no substitute for practical
experience, Good sources of practical training are
Dermatology outpatients, ENT outpatients, A&E and
gynae - but your training practice may the best bet!
11/7/01
Bruce Davies
7
Cryocautery
Works by causing cellular
lysis after freeze thaw cycle,
relatively painless with liquid
nitrogen but stings with
warmer techniques.
There are 4 different
techniques, carbon dioxide
snow(now rarely used), liquid
nitrogen, nitrous oxide and
commercial freezing mixtures
11/7/01
(e.g. Histofreeze). Bruce Davies
8
Liquid Nitrogen
11/7/01
Very cold and causes lots of tissue destruction can
be over applied and cause full thickness skin loss.
Only one application usually needed. Applied with
cotton wool buds or proprietary sprays.
Can be kept in a Dewar flask(fancy thermos) for 2
days.
BOC won't sell small amounts so need to arrange
supply from local hospital or industry.
This means saving up suitable patients and
arranging a special session.
Bruce Davies
9
Nitrous Oxide
Used to cool special heads via gun.
Difficult to over treat lesion, may need 2-3
goes to clear thicker lesions - about 10-14
days apart.
Always to hand from cylinder, gas
prescribable on FP10.
Convenient and to hand but more painful and
needs more treatment, less skill needed.
11/7/01
Bruce Davies
10
What for?
Suitable for surface skin lesions
of known type, e.g. viral warts,
seb. warts, small moles,
Keratoacanthoma, solar
keratosis etc.
11/7/01
Bruce Davies
11
Warnings to Patients
11/7/01
The patient should be warned that the treated
lesion will throb for up to 12 hours, paracetamol
may be suitable.
The lesion will blister, the blister should not be
"popped" if possible but allowed to dry off as
"natural" dressing.
This area of dead skin will slough off 7-14 days
after treatment leaving a red area.
The red area will fade to normal colour after up
Bruce Davies 6.
12
to 12 weeks - usually
Electro-cautery
11/7/01
Works by simple
burning of tissue via DC
current. Needs local
anaesthesia.
Cheap machines readily
available.
Quick to use.
Very easy to cause
marked scars, good
Bruce Davieshaemostasis.
13
Electro-cautery
Unsuitable for viral warts as highest
recurrence rate of any wart therapy.
May be useful adjuvant to straight
scalpel surgery for stopping bleeding.
Needle point tips available for the
treatment of spider naevi and capillary
flares.
11/7/01
Bruce Davies
14
Chemical Cautery
11/7/01
The chemical destruction of a
surface lesion.
Usually employs silver
nitrate.
This comes in the forms of
pencils - sold to the public (!)
for shaving cuts, but a simple
cheap source for certain
applications.
Bruce Davies
15
Chemical Cautery
It is also available on sticks - looking like a
very long match with a black head.
These are very cheap.
They need storage in a dry dark place.
Silver nitrate stains clothing, worktops and
skin, WARN the patients and always wear
gloves when handling.
11/7/01
Bruce Davies
16
Chemical Cautery
The stain will go as the top layer of
skin is shed.
The lesion or the head of the stick
needs to be moist to work, it is usual
to dip in a galipot with some water
and knock off excess water before
use.
11/7/01
Bruce Davies
17
Nasal Cautery
Cautery to Little's area
for recurrent nose
bleeds is a quick and
simple procedure, well
within the remit of
general practice.
It should only be done
when the practitioner
has had supervised prior
experience.
11/7/01
Bruce Davies
18
Nasal Cautery
The area needs to well visualized with
good lighting.
It should also only be done if a obvious
vessel is seen to cauterise - one is not
trying to burn the whole nasal septum!
The technique is not suitable when there is
active bleeding.
11/7/01
Bruce Davies
19
Nasal Cautery
The area needs to be free of debris and large
clots, washing the area with Adrenaline
diluted to about 1 in 10,000 from a syringe
without a needle will remove debris and will
usually temporarily stop bleeding.
The upper lip should be covered with
Vaseline to prevent chemical burns to the
upper lip - medico-legally important
11/7/01
Bruce Davies
20
Nasal Cautery
And the patient warned to leave the Vaseline
on over night.
The procedure may need to be repeated.
It is unsuitable for nasal bleeding other than
from Little's area.
After preparation the area is simply touched
with the stick using a rolling movement.
11/7/01
Bruce Davies
21
Granuloma cautery
Post op, bits of
granuloma tissue in
wounds can be simply
touched to induce
involution.
Pyogenic granuloma can
be easily and quickly
treated. The pressure
required on the lesion
may be quite painful.
11/7/01
Bruce Davies
22
Adjuvant
Can usefully be employed to
stop bleeding from a raw area,
particularly useful after a shave
excision.
MUST not be used to stop
bleeding if the treated area is in
a wound - the silver nitrate
incorporated into deeper layers
will cause considerable damage.
11/7/01
Bruce Davies
23
Curettage
11/7/01
Allowable under the minor surgery
scheme.
Usually needs some sort of anaesthetic.
Produces tissue for cytology, NOT
histology.
Quick and simple.
Surface lesions only.
Often blunt.
Possible to sharpen them!
Bruce Davies
24
Curettage
Disposable curettes cost £2-3 each. Very
sharp!
– A joy to use!
– 4mm and 7mm ring sizes available.
Any surface skin lesions that one is pretty
sure of!
May need to apply haemostatic.
Avoid on possible carcinomas!
11/7/01
Bruce Davies
25
Curettage
Specially good for:
– Seborrhoeic warts
– Kerato-acanthomas
– Skin tags
– Facial warts
– Pyogenic granuloma
• (Chalazions)
11/7/01
If it extends beyond the dermis –
excise it!
Bruce Davies
26
Curettage
Basal cell carcinomas.
– Said to be good.
– 90% cure with selected
lesions.
– Maybe a place in elderly and
infirm.
– I don’t do it intentionally!
11/7/01
Bruce Davies
27