Case report: The management of advanced oral cancer in a Jehovah's Witness using the Ultracision Harmonic Scalpel
© Kullar et al; licensee BioMed Central Ltd. 2011
Received: 31 January 2011
Accepted: 3 October 2011
Published: 3 October 2011
We present the first case of a head and neck oncological procedure accomplished in a Jehovah's Witness using the Ultracision Harmonic Scalpel (Ethicon, Cincinnati, OH). Jehovah's Witnesses present a serious challenge to the head and neck cancer surgeon due to their refusal to accept transfusion of any blood products. However, our experience reinforces the view that surgical management of head and neck cancer is possible in these patients. We show the Harmonic Scalpel, an ultrasonic tissue dissector, to be a useful surgical tool in obviating the need for blood transfusion. Preoperative optimisation, intra-operative surgical and anaesthetic techniques are also fully discussed.
A 48 year old female Caucasian JW presented with non-healing ulcerated lower right second and third molar extraction sockets in 2005. Her past medical history was unremarkable. She was a non-smoker and consumed only moderate amounts of alcohol in accordance with her religious beliefs. Biopsy was performed confirming a moderately differentiated squamous cell carcinoma (SCC), staged by whole body computed tomography (CT) as T4N0M0. She was initially treated with primary chemoradiotherapy as blood products were deemed to be essential for surgical resection at this time. She received 63 Grays of radiation and 5 cycles of cisplatin. Post-treatment she was deemed to be tumor free.
In 2006 she presented with an unstable ulcer on the left lateral tongue. Biopsy revealed early invasive pT1 SCC. This was treated with laser excision.
As the patient was unwilling to accept any blood products all efforts were directed at preoperatively optimisation and minimization of intra-operative blood loss. Preoperative blood tests showed haemoglobin (Hb) of 11 g/dl, platelets 310 × 109/l and a normal clotting profile. She was assessed by a haematologist who prescribed a 2 week preoperative course of oral ferrous sulphate. No further preoperative treatment was instigated.
At operation the patient was premedicated with a statim dose of 1 gram tranexamic acid and anaestethseia was induced with a combination of propofol (120 mg), fentanyl (100 mcg) and vecuronium (8 mg). Anaesthesia was maintained using a remifentanil infusion (50 mcg/ml at 10 ml/hr) and sevofluorane gas inhalation. Hypervolameic hemodilution was performed using preloading with 15 ml/kg cryastalloid fluid in conjunction with the controlled hypotension using remifentanil infusion maintaining a mean arterial pressure of 65 mmHg. The patient was placed in a head up position and meticulous attention to blood loss was performed throughout the whole operation. Blood loss was charted continuously during the operation. Intra-operative blood sampling also provided a guide to blood loss and the Hb did not drop below 9.6 g/dl during the operation. The intraoperative clotting profile revealed a normal prothrombin (PT) and activated partial throboplastin time (APTT).
The entire procedure was accomplished in approximately 11 hours. The total blood loss was under 500 ml. During the operation Hartmann's solution was infused at 100 ml/hr (Total 1.1 L). The urine output was 500 ml giving an intra-operative fluid balance of +0.1 L.
The patient was transferred to the intensive care unit for close monitoring on the first postoperative night. She was then returned to the specialised otolaryngology ward. The patient had a single episode of self resolving supraventricular tachycardia but the rest of the postoperative course was uneventful. She was discharged home able to eat a soft diet and with good speech function 2 weeks postoperatively. Her postoperative haemoglobin did not drop below 10 g/dl on her daily postoperative blood counts. No blood products were used at any time.
The use of a blood transfusion is forbidden under JW doctrine. Doctors have no legal right to transfuse someone against their will even if this may result in their death . After extensive discussion at the MDT meeting and with the patient, a comprehensive literature review was undertaken by the operating surgeons. In conjunction with their previous experience of decreased blood loss whilst using the HS it was decided that salvage surgery was the most appropriate course of action.
Blood transfusion, although potentially life-saving is known to be associated with a number of risks. These must be balanced against the potential benefit of transfusion. Reactions range from the self-limiting febrile non-hemolytic transfusion reaction to life threatening conditions such as Transfusion Related Acute Lung Injury (TRALI). The transmission of blood borne bacteria and viruses (including HIV and hepatitis B/C) also remains a possibility [5, 6]. Specifically in surgical patients there is a documented link between transfusions and postoperative infections and tumor recurrence .
According to the literature, blood transfusion is required in 14-80% of all head and neck cancer operations . However, within our unit only 16% of major head and neck operations required blood transfusion (11 of 68 cases transfused between August 2008-August 2009). We have also noted a significant decline in the use of transfusion since we began to use the HS (unpublished data).
In the preoperative and intra-operative periods hypervolameic/normovolemic hemodiltion , hypotensive anaesthesia  and cell scavenging  have all been described to minimize blood loss. Acute normovolemic hemodilution is the process of removing one or more units of blood before the operation for transfusion to the patient either during or at the end of the operation. This was not acceptable to our patient as blood cannot be reused once taken out of circulation. On discussion with our patient cell scavenging was also ruled out as it involves the reinfusion of blood which has left the circulation. We decided on a strategy of hypervolemic hemodilution. Here considerable fluid is administered intravenously to the patient reducing the patient's hematocrit and hence the blood's oxygen carrying capability. This reduces the number of red blood cells lost intra-operatively. The hematocrit is restored with a postoperative diuresis. This strategy is not suitable for patients with cardiovascular or renal dysfunction . We also used controlled hypotension with a mean arterial pressure of 65 mmHg maintained with an opiate infusion. Similarly, the use of controlled hypotension is only recommended in patients known to be free of cardiovascular and respiratory problems .
The use of aprotinin and tranxemic acid have also been employed to reduce intra-operative bleeding . Previous surgery in JW have used aprotinin, a bovine derived inhibitor of trypsin and plasmin. However, this was withdrawn in May 2008 due an increased risk of death in cardiac surgical patients . Therefore we followed the recommendation of Henry et al to use the antifibrinolytic agent tranxemic acid. Their meta-analysis showed this to be the most effective antifibinolytic since the withdrawl of aprotinin .
There are only a few documented cases of JWs undergoing major head and neck surgery previously presented in the literature. Genden et al present the case of a 35 year old male with a T3N0M0 anterior floor of mouth SCC who successfully underwent a segmented mandibulectomy and staged fibula free flap reconstruction with osseointegrated dental implants without use of allogenic blood . Van Hemelen et al present two JWs with oral cancer requiring neck dissection and free flap transfer without use of blood transfusion . Skoner et al's presentation of 5 JWs with head and neck cancers requiring 7 free flap reconstructions is the largest series in the literature so far . However, our case is the first presentation of the use of the HS in this patient population.
Preoperative planning requires extensive discussion between all parties involved. Particularly, the patient must be aware that refusal of blood products may have life endangering consequences. Our patient was fully optimized before surgery. A full medical and surgical history was taken to identify any risk factors adversely affecting hemostasis. We restricted pre- and post-operative phlebotomy to a minimum. Preoperative haemoglobin was optimized by a course of ferrous sulphate. We considered the use of recombinant erythropoientin (EPO), to raise preoperative haemoglobin levels. EPO is a glycosylated polypeptide released by the kidney in response to hypoxia which increases erythropoietic precursors in the bone marrow and has been shown to be a useful in avoiding transfusion in surgical specialties including head and neck [17, 18]. Remmers et al suggested the use of EPO and iron 2 to 3 weeks before elective surgery in JW .
However, the use of EPO has been associated with increased recurrence in head and neck cancer patients . Janecka speculates that this may be due to EPO promoting thrombogenesis and hence tumor hypoxia and angiogenesis . Conversely, a more recent trial failed to shown any negative impact of EPO therapy on patient survival or tumor recurrence . We decided against the use of EPO in this case. The use of recombinant clotting factors and DDAVP was also thought inappropriate in a patient with a physiologically normal clotting profile.
With our unit's experience of the HS and a comprehensive literature review we felt the use of the HS would allow meticulous hemostatis and thus reduce the chances of requiring blood products. The traditional surgical method for head and neck cancer resections is 'cold steel' dissection. Here blood loss is controlled using pressure or ligatures. Monopolar and bipolar electrosurgery are newer methods of dissection which use heat to cauterise bleeding vessels. The HS is a surgical cutting device which concurrently coagulates tissues. The basic principle of this device is converting an ultrasonic wave into high frequency mechanical energy, vibrating the cutting surfaces at 55.5 Khz. The cutting blade is able to denature proteins into a coagulum which acts as a haemostatic seal around blood vessels . This allows optimal surgical visibility in a near bloodless operating field . The harmonic scalpel operates at lower temperatures (50-100 C) compared to mono- or bipolar devices (100-600 C) hence there is less tissue damage and the subsequent inflammatory response is also lessened. The lower operating temperatures mean that neighbouring structures are at less risk of damage hence allowing the surgeon to work around delicate structures .
There is also less eschar formation and hence less smoke production. Due to the lower temperatures of the harmonic scalpel as compared to conventional thermal surgical instruments less tissue sticks to the blades. This decreases tissue damage and wasted time cleaning and exchanging instruments [26, 27].
A number of studies have shown that operative time, blood loss and hospital stay are shortened in a wide range of head and neck such as tonsillectomy  and thyroidectomy [25–27], general  and gynaecological surgery . Initial results have been favourable with less postoperative pain, lower blood loss, shortened operative time and lack of impairment of histopathologic evaluation.
Salami et al present a non-randomized study comparing 40 pharyngolarygectomy, 40 total laryngectomy, 40 unilateral neck dissections and 40 superficial parotidectomies with either the harmonic scalpel or 'cold steel' dissection . The evaluation demonstrated a significant decrease in operative time, intra-operative blood loss, total hospital stay, postoperative seroma formation and subjective pain scores for patients treated with the HS.
In summary, JW present a major challenge to the head and neck cancer surgeon. We believe preoperative optimisation with ferrous sulphate, the use of hypervolameic hemodilution with the addition of tranexamic acid and meticulous attention to intra-operative hemostasis with the HS are the cornerstones of management for these patients. We found the use of the HS in conjunction with our anaesthetic techniques created an almost bloodless operating field and enabled a large cancer resection and reconstruction to be performed without recourse to blood transfusion. We feel the HS will play an important role in bloodless surgery in the future.
Written informed consent was obtained from the patient's next of kin for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Watchtower: What is God's Law on blood?. 2011, [cited 2011 2011]; Available from: http://www.watchtower.org/Google Scholar
- McInroy A: Blood transfusion and Jehovah's Witnesses: the legal and ethical issues. Br J Nurs. 2005, 14 (5): 270-4.View ArticlePubMedGoogle Scholar
- Goff L: Re F (Mental Patient: Sterilisation). 1990Google Scholar
- Williamson LM: Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. BMJ. 1999, 319 (7201): 16-9.PubMed CentralView ArticlePubMedGoogle Scholar
- Regan F, Taylor C: Blood transfusion medicine. BMJ. 2002, 325 (7356): 143-7. 10.1136/bmj.325.7356.143.PubMed CentralView ArticlePubMedGoogle Scholar
- Stainsby D: Reducing adverse events in blood transfusion. Br J Haematol. 2005, 131 (1): 8-12. 10.1111/j.1365-2141.2005.05702.x.View ArticlePubMedGoogle Scholar
- Amato A, Pescatori M: Reported noncausal effect of blood transfusions on colorectal cancer recurrence. Ann Surg. 1997, 225 (1): 129-30.PubMed CentralView ArticlePubMedGoogle Scholar
- Krupp NL: Validation of a transfusion prediction model in head and neck cancer surgery. Arch Otolaryngol Head Neck Surg. 2003, 129 (12): 1297-302. 10.1001/archotol.129.12.1297.View ArticlePubMedGoogle Scholar
- Kreimeier U, Messmer K: Hemodilution in clinical surgery: state of the art 1996. World J Surg. 1996, 20 (9): 1208-17. 10.1007/s002689900184.View ArticlePubMedGoogle Scholar
- Hack H, Mitchell V: Hypotensive anaesthesia. Br J Hosp Med. 1996, 55 (8): 482-5.PubMedGoogle Scholar
- Nieder AM: Intraoperative cell salvage during radical prostatectomy is not associated with greater biochemical recurrence rate. Urology. 2005, 65 (4): 730-4. 10.1016/j.urology.2004.10.062.View ArticlePubMedGoogle Scholar
- Henry DA: Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2001, CD001886-1Google Scholar
- FDA Drug Information: Information for Healthcare Professionals: Aprotinin (marketed as Trasylol). 2007, Available from: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm142720.htmGoogle Scholar
- Genden EM, Haughey BH: Head and neck surgery in the Jehovah's Witness patient. Otolaryngol Head Neck Surg. 1996, 114 (4): 669-72. 10.1016/S0194-5998(96)70268-1.View ArticlePubMedGoogle Scholar
- Van Hemelen G: Management of Jehovah's Witness patients undergoing major head and neck surgery. Head Neck. 1999, 21 (1): 80-4. 10.1002/(SICI)1097-0347(199901)21:1<80::AID-HED12>3.0.CO;2-9.View ArticlePubMedGoogle Scholar
- Skoner JM, Wax MK: Microvascular free-tissue transfer for head and neck reconstruction in Jehovah's Witness patients. Head Neck. 2008, 30 (4): 455-60. 10.1002/hed.20720.View ArticlePubMedGoogle Scholar
- Atabek U: Erythropoetin accelerates hematocrit recovery in post-surgical anemia. Am Surg. 1995, 61 (1): 74-7.PubMedGoogle Scholar
- Sturgis EM: Avoiding transfusion in head and neck surgery: feasibility study of erythropoietin. Laryngoscope. 2000, 110 (1): 51-7. 10.1097/00005537-200001000-00011.View ArticlePubMedGoogle Scholar
- Remmers PA, Speer AJ: Clinical strategies in the medical care of Jehovah's Witnesses. Am J Med. 2006, 119 (12): 1013-8. 10.1016/j.amjmed.2006.04.016.View ArticlePubMedGoogle Scholar
- Henke M: Erythropoietin to treat head and neck cancer patients with anaemia undergoing radiotherapy: randomised, double-blind, placebo-controlled trial. Lancet. 2003, 362 (9392): 1255-60. 10.1016/S0140-6736(03)14567-9.View ArticlePubMedGoogle Scholar
- Janecka IP: Erythropoietin to treat anaemia in patients with head and neck cancer. Lancet. 2004, 363 (9413): 993-4.View ArticlePubMedGoogle Scholar
- Hoskin PJ: Effect of epoetin alfa on survival and cancer treatment-related anemia and fatigue in patients receiving radical radiotherapy with curative intent for head and neck cancer. J Clin Oncol. 2009, 27 (34): 5751-6. 10.1200/JCO.2009.22.3693.View ArticlePubMedGoogle Scholar
- Ethicon: Harmonic technology. 2011, Available from: http://www.ethiconendosurgery.com/Clinician/Product/energyGoogle Scholar
- Carroll T, Ladner K, Meyers AD: Alternative surgical dissection techniques. Otolaryngol Clin North Am. 2005, 38 (2): 397-411. 10.1016/j.otc.2004.10.001.View ArticlePubMedGoogle Scholar
- Siperstein AE, Berber E, Morkoyun E: The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery. Arch Surg. 2002, 137 (2): 137-42. 10.1001/archsurg.137.2.137.View ArticlePubMedGoogle Scholar
- Ortega J: Efficacy and cost-effectiveness of the UltraCision harmonic scalpel in thyroid surgery: an analysis of 200 cases in a randomized trial. J Laparoendosc Adv Surg Tech A. 2004, 14 (1): 9-12. 10.1089/109264204322862289.View ArticlePubMedGoogle Scholar
- Papavramidis TS: UltraCision harmonic scalpel versus clamp-and-tie total thyroidectomy: a clinical trial. Head Neck. 2010, 32 (6): 723-7.PubMedGoogle Scholar
- Neumann C: Harmonic scalpel tonsillectomy: a systematic review of evidence for postoperative hemorrhage. Otolaryngol Head Neck Surg. 2007, 137 (3): 378-84. 10.1016/j.otohns.2007.05.003.View ArticlePubMedGoogle Scholar
- Gelmini R: Laparoscopic cholecystectomy with Harmonic scalpel. JSLS. 2010, 14 (1): 14-9. 10.4293/108680810X12674612014301.PubMed CentralView ArticlePubMedGoogle Scholar
- Kunde D, Welch C: Ultracision in gynaecological laparoscopic surgery. J Obstet Gynaecol. 2003, 23 (4): 347-52. 10.1080/0144361031000119457.View ArticlePubMedGoogle Scholar
- Salami A: New trends in head and neck surgery: a prospective evaluation of the Harmonic Scalpel. Med Sci Monit. 2008, 14 (5): PI1-5.PubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.