Liver Ablation Research Articles

Prognostic Significance of Recurrence and Timing of Recurrence on Survival Among Patients with Early-Stage Hepatocellular Carcinoma in U.S. Clinical Practice.

Many patients with hepatocellular carcinoma (HCC) experience recurrence after curative-intent resection or ablation, with a poor prognosis. Real-world patterns of recurrence and the prognostic significance of early recurrence in U.S. clinical practice have not been well characterized. This retrospective observational study was designed to evaluate the impact of recurrence on overall survival (OS) among patients with HCC following initial curative-intent resection or ablation. We used the Surveillance, Epidemiology, and End Results cancer registry linked with Medicare claims (January 1, 2010-December 31, 2019). Eligible patients (≥66 years) diagnosed with HCC (2010-2017) had liver resection or ablation within 180 days of diagnosis. Patients were stratified by recurrence status using diagnosis- and treatment-based definitions of recurrence. Early or late recurrence was defined as within 1 year or after 1 year, respectively. Adjusted OS analyses used multivariable Cox regression models. A total of 1,146 patients were included. During a median overall follow-up of 35.2 months, 736 (64%) patients had a recurrence, of whom 380 (52%) had early recurrence (within 1 year). In the adjusted analysis, patients with recurrence had a 2.24-fold higher risk of death (95% confidence interval 1.85, 2.71; P < 0.001). Patients with early recurrence had a 1.39-fold higher risk of death (95% confidence interval 1.14, 1.68; P < 0.001) than those with late recurrence. Recurrence and the timing of recurrence are significant predictors of increased mortality risk for patients with HCC following initial curative-intent resection or ablation, highlighting the need for effective adjuvant therapies that may delay or avoid recurrences.

Thermoacoustic CBE imaging for monitoring microwave ablation of the liver: A feasibility study

Microwave ablation is the most commonly used minimally invasive technique for thermal ablation of liver tumors, and accurate monitoring of the ablation area is crucial for evaluating treatment efficacy. While traditional imaging techniques play an important role in clinical monitoring, they still face several insurmountable challenges. Microwave-induced thermoacoustic imaging (TAI) has emerged as a promising modality for ablation detection due to its high resolution and deep imaging capabilities. To further enhance the effectiveness of TAI in ablation monitoring, we propose a technique based on thermoacoustic changes in backscattered energy (CBE) imaging. This method accurately delineates the liver ablation area by monitoring temperature variations before and after ablation. Experimental results show that thermoacoustic CBE imaging offers significant advantages over traditional TAI, achieving accuracies of 97.12% in ex vivo and 93.46% in in vivo experiments. Its superior resolution makes it an ideal choice for monitoring tissue damage during microwave ablation.

Invited Commentary: Sex-Differences in Post-procedural Pain Experiences after Thermal Liver Ablations for Liver Tumors—A Retrospective Study

Invited Commentary: Sex-Differences in Post-procedural Pain Experiences after Thermal Liver Ablations for Liver Tumors—A Retrospective Study

Multi-stage automatic and rapid ablation and needle trajectory planning method for CT-guided percutaneous liver tumor ablation.

Computer-assisted planning methods have increasingly contributed to preoperative ablation planning; however, these methods cannot automatically obtain the final optimal solution within a short time and are rarely validated in practice, greatly limiting their clinical applicability. We aimed to propose a full-automatic multi-stage ablation and needle trajectory planning method for CT-guided percutaneous liver ablation to attain the final optimal plans under multiple clinical constraints rapidly. Our proposed method integrates the ablation zone planning fulfilling complete tumor coverage and critical structure avoidance while reaching a trade-off between ablation number and healthy tissue damage, and needle trajectory planning under multiple clinical constraints. Our needle trajectory planning determines feasible skin entry regions based on hard constraints, where the multi-objective optimization (MOO) considering soft constraints is performed using the Pareto Optimality and Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) methods for the final optimal solution. The performance of our proposed method was evaluated on 30 tumors of various characteristics from 23 patients and clinically validated in five clinical cases. Our proposed method achieved 99.8% treatment zone coverage and 40.5% ablation efficiency without involving critical structures, and completely satisfied multiple clinical constraints in all needle trajectory planning results. The average planning time was 23.6 s for tumors of different sizes. All the plans were considered clinically acceptable by the doctors' evaluation. Our method achieved complete tumor coverage without complications in clinical case validation. Our proposed planning method can generate a final optimal plan satisfying multiple clinical constraints within a short time, potentially facilitating preoperative planning for hepatic tumor ablation.

Temperature Simulation of an Ablation Needle for the Prediction of Tissue Necrosis during Liver Ablation

Background/Objectives: Microwave ablation (MWA) is the leading therapy method for treating patients with liver cancer. MWA simulation is used to further improve the therapy and to help develop new devices. Methods: A water-cooled ablation needle was reconstructed. MWA simulations of a polyacrylamide phantom were carried out and compared with a representative clinical example (tumor diameter: 8.75 mm). The Arrhenius damage model and a critical temperature approach of 60 °C were applied to assess the necrosis zones. Finally, the simulation results were compared to the corresponding MR measurements. Results: Most of the heating in the simulation took place at a distance of 5 mm along the transverse axis and 20 mm along the longitudinal axis above the needle tip. The calculated Dice scores for the Arrhenius model were 0.77/0.53 for the phantom/clinical case. For the critical temperature approach, Dice scores of 0.60/0.66 for the phantom/clinical case were achieved. Conclusions: The comparison between simulated and measured temperature increases showed an excellent agreement. However, differences in the predicted necrosis volume might be caused by omitting consideration of the heat sink effect, especially in the clinical case. Nevertheless, this workflow enables short MWA simulation times (approximately 3 min) and demonstrates a step towards possible integration into daily clinical use.

Precise ablation zone segmentation on CT images after liver cancer ablation using semi‐automatic CNN‐based segmentation

AbstractBackgroundAblation zone segmentation in contrast‐enhanced computed tomography (CECT) images enables the quantitative assessment of treatment success in the ablation of liver lesions. However, fully automatic liver ablation zone segmentation in CT images still remains challenging, such as low accuracy and time‐consuming manual refinement of the incorrect regions.PurposeTherefore, in this study, we developed a semi‐automatic technique to address the remaining drawbacks and improve the accuracy of the liver ablation zone segmentation in the CT images.MethodsOur approach uses a combination of a CNN‐based automatic segmentation method and an interactive CNN‐based segmentation method. First, automatic segmentation is applied for coarse ablation zone segmentation in the whole CT image. Human experts then visually validate the segmentation results. If there are errors in the coarse segmentation, local corrections can be performed on each slice via an interactive CNN‐based segmentation method. The models were trained and the proposed method was evaluated using two internal datasets of post‐interventional CECT images ( = 22, = 145; 62 patients in total) and then further tested using an external benchmark dataset ( = 12; 10 patients).ResultsTo evaluate the accuracy of the proposed approach, we used Dice similarity coefficient (DSC), average symmetric surface distance (ASSD), Hausdorff distance (HD), and volume difference (VD). The quantitative evaluation results show that the proposed approach obtained mean DSC, ASSD, HD, and VD scores of 94.0%, 0.4 mm, 8.4 mm, 0.02, respectively, on the internal dataset, and 87.8%, 0.9 mm, 9.5 mm, and −0.03, respectively, on the benchmark dataset. We also compared the performance of the proposed approach to that of five well‐known segmentation methods; the proposed semi‐automatic method achieved state‐of‐the‐art performance on ablation segmentation accuracy, and on average, 2 min are required to correct the segmentation. Furthermore, we found that the accuracy of the proposed method on the benchmark dataset is comparable to that of manual segmentation by human experts ( = 0.55, ‐test).ConclusionsThe proposed semi‐automatic CNN‐based segmentation method can be used to effectively segment the ablation zones, increasing the value of CECT for an assessment of treatment success. For reproducibility, the trained models, source code, and demonstration tool are publicly available at https://github.com/lqanh11/Interactive_AblationZone_Segmentation.

Sex-Differences in Post-Procedural Pain Experiences After Thermal Liver Ablations for Liver Tumors: A Retrospective Study

IntroductionLiterature shows differences in pain experiences between sexes. The exact influence of thermal liver ablation on experienced pain is still not well-known. This study aims to investigate the maximum pain intensity at the recovery between men and women after percutaneous thermal liver ablation.MethodsPatients treated with percutaneous thermal liver ablation (radiofrequency or microwave ablation) in Maastricht University Medical Center + between 2018 and 2022 for primary or secondary liver tumors were included retrospectively. Outcomes included maximum numerical rating scale (NRS, scale:0–10) score at the recovery room, prevalence of post-procedural pain (defined as NRS score ≥ 4), duration of anesthesia, length of stay at recovery, and complications. Regression analyses were adjusted for age, ASA-score, BMI, tumor type, maximum diameter of lesion, chronic pain in patients’ history, and history of psychological disorder.Results183 patients were included of which 123 men (67%). Results showed higher average maximum NRS scores in women patients compared to men (mean:3.88 versus 2.73), but not after adjustments (aß:0.75, 95%CI:−0.13–1.64). Women suffered more from acute post-procedural pain (59% versus 35%; aOR:2.50, 95%CI:1.16–5.39), and needed analgesics more often at the recovery room (aOR:2.43, 95%CI:1.07–5.48) compared to men. NRS score at recovery arrival did not significantly differ (aß:0.37, 95%CI:-0.48–1.22). No differences were seen in the length of stay at the recovery, duration of anesthesia, procedure time, and complication rate. Location of the tumor (subcapsular or deep), total tumors per patient, and distinction between primary and secondary tumors had no influence on the NRS.ConclusionThis retrospective single-center study shows higher post-procedural pain rates after thermal liver ablation in women, resulting in higher analgesics use at the recovery room. The results suggest considering higher dosage of analgesics during thermal liver ablation in women to reduce post-procedural pain.Level of Evidence 3Non-controlled retrospective cohort study.Graphical

286. TREATMENT WITH CURATIVE INTENT FOR OLIGOMETASTATIC GASTROESOPHAGEAL CANCER-RESULTS OF A PROSPECTIVE MULTICENTER STUDY

Abstract Background Oligometastatic gastroesophageal cancer is a clinical entity with no standard treatment recommendation. Treatment with curative intent has recently emerged as an option in selected patients in contrast to the traditional palliative treatment strategy. This prospective study aimed to assess the safety and efficacy of combined systemic and local treatment with curative intent for patients with oligometastatic gastroesophageal cancer. Methods In a multicenter collaborative study, consecutive patients with gastroesophageal cancer and metastases in the liver and/or extra-regional lymph nodes were screened for inclusion. Eligible patients were offered treatment with combined systemic and local therapy within the study. Primary endpoints were treatment safety and feasibility, secondary outcomes included postoperative mortality, treatment response, progression-free and overall survival. Subgroup analyses were stratified based on oligometastatic location. Results A total of 29/35 patients completed systemic and local treatment with surgical resection, liver ablation or definitive chemoradiotherapy. The majority of postoperative complications were mild-moderate, no patient died due to postoperative complications within 30 days of surgery. Median progression-free survival was 7.1 (interquartile range 4.3-12.4) months and median overall survival was 23.8 (interquartile range 12.3-33.0) months. Conclusion This study found combined systemic and local treatment to be a safe treatment option and to potentially improve long-term survival in strictly selected patients with oligometastatic gastroesophageal cancer.

Predicting liver ablation volumes with real-time MRI thermometry

Background & AimsMRI guidance offers better lesion targeting for microwave ablation of liver lesions with higher soft-tissue contrast, as well as the possibility of real-time thermometry. This study aims to evaluate the correlation of real-time MR thermometry-predicted lesion volume with the ablation zone in postprocedural first-day images. Materials and MethodsThis single center retrospective analysis evaluated prospectively collected patients who underwent MRI-guided microwave ablation with real-time thermometry between December 2020 and July 2023. All procedures were performed in general anesthesia on a 1.5T MRI scanner. Real-time thermometry data were acquired using multi-slice gradient-echo EPI sequences, and thermal dose (CEM43 of 240 minutes as a threshold) maps were created. The volume of tissue exposed to lethal thermal dose in MR thermometry (thermal dose) was compared with the ablation zone volume in portal phase T1w MRI on postprocedural first-day using Pearson correlation test, and visual quantitative assessment by radiologists was performed to evaluate the similarity of shapes and volumes. ResultsOut of 30 patients with 33 lesions with thermometry images, six (18.1%) lesions were excluded due to artifacts limiting interpretation of thermal dose volume. Twenty-four patients with 27 lesions (20 male, age 63.1±9.1) were evaluated for the volume correlation. The volume of thermal dose-predicted lesions and the postprocedural first-day ablation zones showed a strong correlation (R=0.89, p<0.001). Similarly, visual similarity of MR thermometry-predicted shape and the ablation zone shape was graded as perfect in 23 (85.1%) lesions. ConclusionsReal-time thermal dose-predicted volumes show very good correlation with the ablation zone volumes in images obtained one day after the procedure, which could reduce the local recurrence rates with the possibility of reablating lesions within the same procedure.

Epidemiology, pathophysiology and clinical aspects of Hepatocellular Carcinoma in MAFLD patients.

Hepatocellular carcinoma (HCC) is undergoing a transformative shift, with metabolic-associated fatty liver disease (MAFLD) emerging as a dominant etiology. Diagnostic criteria for MAFLD involve hepatic steatosis and metabolic dysregulation. Globally, MAFLD prevalence stands at 38.77%, significantly linked to the escalating rates of obesity. Epidemiological data indicate a dynamic shift in the major etiologies of hepatocellular carcinoma (HCC), transitioning from viral to metabolic liver diseases. Besides the degree of liver fibrosis, several modifiable lifestyle risk factors, such as type 2 diabetes, obesity, alcohol use, smoking, and HBV, HCV infection contribute to the pathogenesis of HCC. Moreover gut microbiota and genetic variants maycontribute to HCCdevelopment.The pathophysiological link between MAFLD and HCC involves metabolic dysregulation, impairing glucose and lipid metabolism, inflammation and oxidative stress. Silent presentation poses challenges in early MAFLD-HCC diagnosis. Imaging, biopsy, and AI-assisted techniques aid diagnosis, while HCC surveillance in non-cirrhotic MAFLD patients remains debated.ITA.LI.CA. group proposes a survival-based algorithm for treatmentbased on Barcelona clinic liver cancer (BCLC) algorithm. Liver resection, transplantation, ablation, and locoregional therapies are applied based on the disease stage. Systemic treatments is promising, with initial immunotherapy results indicating a less favorable response in MAFLD-related HCC.Adopting lifestyle interventions and chemopreventive measures with medications, including aspirin, metformin, and statins, constitute promising approaches for the primary prevention of HCC.Prognosis is influenced by multiple factors, with MAFLD-HCC associated with prolonged survival. Emerging diagnostic biomarkers and epigenomic markers, show promising results for early HCC detection in the MAFLD population.

Hepatic arterial chemotherapy infusion combined with tyrosine kinase inhibitors and PD-1 inhibitors for advanced hepatocellular carcinoma with high-risk: A propensity score matching study.

To ascertain the therapeutic efficacy and safety of FOLFOX (oxaliplatin, fluorouracil, and leucovorin)-based hepatic arterial infusion chemotherapy (HAIC) combined with tyrosine kinase inhibitors (TKI) and programmed cell death protein-1 inhibitors (PD-1 inhibitors) (triple therapy), as a first-line treatment in high-risk advanced hepatocellular carcinoma (aHCC with Vp4 portal vein invasion or/and tumor diameter ≥ 10cm). This retrospective multicenter study included 466 high-risk aHCC patients treated with either triple therapy (n = 245) or dual therapy (TKI and PD-1 inhibitors, n = 221). The overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and safety were compared between the two groups. Propensity score matching (PSM) was performed to reduce bias between the two groups. After PSM (1:1), 194 patients in each group were analyzed. The triple-therapy group showed a longer median OS (24.6 months vs. 11.9 months; HR = 0.43, P < 0.001) and a longer median PFS (10.0 months vs. 7.7 months; HR = 0.68, P = 0.002) than the dual-therapy group. The survival rates at 6, 12, and 24 months were 94.2%, 71.0%, and 50.8% for triple therapy and 75.9%, 49.9%, and 26.8% for dual therapy. The ORR in the triple-therapy group was significantly higher (57.7% vs. 28.9%, P < 0.001). In the triple-therapy group, more patients converted to non-high-risk (68.0% vs. 36.6%, P < 0.001) and received salvage liver resection or ablation after downstaging conversion (16.5% vs. 9.2%, P = 0.033). The grade 3/4 adverse events were 59.2% and 47.4% in the triple-therapy group and dual-therapy group, respectively (P = 0.022). FOLFOX-based HAIC plus TKI and PD-1 inhibitors significantly improve survival prognosis compared with TKI plus PD-1 inhibitors. This is a potential first-line treatment for high-risk aHCC, with a relatively controlled safety profile.

Laparoscopic versus open hepatectomy for hepatocellular carcinoma following conversion therapy: A systematic review and meta-analysis.

e16272 Background: Conversion therapy for hepatocellular carcinoma (HCC) has emerged as a novel strategy allowing patients with previously unresectable HCC to transition to a resectable disease through a combination of therapies. Laparoscopic hepatectomy is associated with reduced blood loss and early recovery without compromising oncological results in cirrhotic patients. However, the specific benefits of laparoscopic hepatectomy in patients who have undergone conversion therapy are not clear. Methods: We searched PubMed, Embase, and Cochrane Central for any studies that compared laparoscopic versus open hepatectomy after the use of conversion therapy (transarterial chemoembolization, portal vein embolization, hepatic arterial infusion chemotherapy, or liver ablation) in patients with hepatocellular carcinoma. The outcomes of interest were length of hospital stay, blood loss, operative time, pedicle clamping, postoperative complications, and transfusion. Statistical analysis was performed using R statistical software 4.2.1. Heterogeneity was assessed with I². Results: We included 535 patients from 4 retrospective nonrandomized studies. The mean age in the laparoscopic group was 60.33, ranging from 29 to 83. Length of hospital stay was significantly reduced in the laparoscopic group (MD -5.01; 95% CI -9.76–-0.27; p = 0.04; I² = 92%), as well as the blood loss (MD -97.26; 95% CI -200.54–6.01; p = 0.06; I² = 76%). Postoperative complications also favored the laparoscopic group (OR 0.40; 95% CI 0.17–0.94; p = 0.035; I² = 0%). The endpoints of pedicle clamping (OR 0.7; 95% CI 0.11–4.36; p = 0.70; I² = 91%), transfusion (OR 0.69; 95% CI 0.36–1.33; p = 0.273; I² = 0%), and operative time (MD 34.21; 95% CI -36.68–105.10; p = 0.34; I² = 97%) did not favor any of the groups. Conclusions: In this meta-analysis, laparoscopic hepatectomy after conversion therapy was proven to be safe and feasible, without significant differences compared to open hepatectomy regarding pedicle clamping, transfusion, and operative time. Furthermore, the laparoscopic group presented less blood loss and a significantly reduced length of hospital stay. These findings suggest that laparoscopic resection could be safely used after conversion therapy and may improve surgical outcomes in these patients.

Imaging Guidelines during Percutaneous Liver Ablation to Optimize Outcomes and Patient Safety.

Image-guided ablation procedures have become a mainstay in cancer therapy. Typically performed from a percutaneous approach, thermal-based ablation procedures rely heavily on imaging guidance both prior to and during the procedure itself. Advances in imaging as they relate to ablation procedures are as important to successful treatments as advancements in the ablation technology itself. Imaging as it relates to procedural planning, targeting and monitoring, and assessment of procedural endpoint is the focus of this article.

Development of a contrast-enhanced ultrasound guided high intensity focused ultrasound system for coagulation of liver parenchyma.

The liver is the most common organ injured in blunt abdominal trauma and makes up roughly 5% of all trauma admissions. Current treatments are invasive and resource-intensive, which may delay care. We aim to develop and validate a contrast-enhanced ultrasound (CEUS)guided noninvasive tool to treat liver lacerations at the bedside. Two 1.8 MHz high-intensity focused ultrasound (HIFU) elements were coupled to a C1-6 diagnostic ultrasound probe and a Logiq E10 scanner (GE HealthCare) utilizing a custom enclosure for co-registered imaging and ablation. A phantom was created from polyacrylamide gel combined with thermochromic ink whose color changes above biological ablative temperatures (60 °C). The HIFU wave was focused approximately 0.5 cm below the surface utilizing a 50% duty cycle generating 11.9 MPa for 20, 30, 40, 50, and 60s. Experiments were repeated on ex vivo chicken livers in a water bath. Finally, the livers of 4 live swine underwent up to 6 CEUS-guided treatments using parameters optimized from in vitro work. Treatment of the phantom between 20-60s, produced ablation sizes from 0.016 to 0.4 cm 3 . The relationship between time and size was exponential (R 2 = 0.992). Ablation areas were also well visualized on with ultrasound imaging. The ex vivo liver ablation size at 20s was 0.37 cm 3 , at 30s was 0.66 cm 3 , and at 100 s was 5.0 cm 3 . For the in-vivo swine experiments, the average ablation area measured 2.0x0.75 cm with a maximum of 3.5x1.5 cm. CEUS was utilized with the contrast agent Definity (Lantheus) for identification of lacerations as well as immediate post operative evaluation of therapy. These experiments demonstrate the feasibility of CEUS guided transdermal HIFU ablation and the time-dependent size of ablation. This work warrants future investigations into using ultrasound to detect active bleeding and HIFU to coagulate grade III and IV liver laceration. Therapeutic/care management.

Catheter-Directed Ionic Liquid Embolic Agent for Rapid Portal Vein Embolization, Segmentectomy, and Bile Duct Ablation.

Embolic materials currently in use for portal vein embolization (PVE) do not treat the tumor, which poses a risk for tumor progression during the interval between PVE and surgical resection. Here, is developed an ionic-liquid-based embolic material (LEAD) for portal vein embolization, liver ablation, and drug delivery. LEAD is optimized and characterized for diffusivity, X-ray visibility, and cytotoxicity. In the porcine renal embolization model, LEAD delivered from the main renal artery reached vasculature down to 10 microns with uniform tissue ablation and delivery of small and large therapeutics. In non-survival and survival porcine experiments, successful PVE is achieved in minutes, leading to the expected chemical segmentectomy, and delivery of a large protein drug (i.e., Nivolumab) with LEAD. In cholangiocarcinoma mouse tumor models and in ex vivo human tumors, LEAD consistently achieved an effective ablation and wide drug distribution. Furthermore, various strains of drug-resistant patient-derived bacteria showed significant susceptibility to LEAD, suggesting that LEAD may also prevent infectious complications resulting from tissue ablation. With its capabilities to embolize, ablate, and deliver therapeutics, ease of use, and a high safety profile demonstrated in animal studies, LEAD offers a potential alternative to tumor ablation with or without PVE for FLR growth.

Safety and efficacy of percutaneous image-guided ablation for soft tissue sarcoma metastases to the liver.

To evaluate outcomes following percutaneous image-guided ablation of soft tissue sarcoma metastases to the liver. A single-institution retrospective analysis of patients with a diagnosis of metastatic soft tissue sarcoma who underwent percutaneous image-guided ablation of hepatic metastases between January 2011 and December 2021 was performed. Patients with less than 60 days of follow-up after ablation were excluded. The primary outcome was local tumor progression-free survival (LPFS). Secondary outcomes included overall survival, liver-specific progression-free survival. and chemotherapy-free survival. Fifty-five patients who underwent percutaneous ablation for 84 metastatic liver lesions were included. The most common histopathological subtypes were leiomyosarcoma (23/55), followed by gastrointestinal stromal tumor (22/55). The median treated liver lesions was 2 (range, 1-8), whereas the median size of metastases were 1.8 cm (0.3-8.7 cm). Complete response at 2 months was achieved in 90.5% of the treated lesions. LPFS was 83% at 1 year and 80% at 2 years. Liver-specific progression-free survival was 66% at 1 year and 40% at 2 years. The overall survival at 1 and 2 years was 98% and 94%. The chemotherapy-free holiday from the start of ablation was 71.2% at 12 months. The complication rate was 3.6% (2/55); one of the complications was Common Terminology Criteria for Adverse Events grade 3 or higher. LPFS subgroup analysis for leiomyosarcoma versus gastrointestinal stromal tumor suggests histology-agnostic outcomes (2 years, 89% vs 82%, p=.35). Percutaneous image-guided liver ablation of soft tissue sarcoma metastases is safe and efficacious.

Upper gastrointestinal and hepatopancreaticobiliary surgery in New Zealand: Balancing the volume-outcome relationship with accessibility in a surgically low volume country.

New Zealand has a population of only 5.5 million meaning that for many surgical procedures the country qualifies as a "low-volume center." However, the health system is well developed and required to provide complex surgical procedures that benchmark internationally against comparable countries. This investigation was undertaken to review regional variation and volumes of complex resection and palliative upper gastrointestinal (UGI) surgical procedures within New Zealand. Data pertaining to patients undergoing complex resectional UGI procedures (esophagectomy, gastrectomy, pancreatectomy, and hepatectomies) and palliative UGI procedures (esophageal stenting, enteroenterostomy, biliary enteric anastomosis, and liver ablation) in a New Zealand hospital between January 1, 2000 and December 31, 2019 were obtained from the National Minimum Dataset. New Zealand is a low-volume center for UGI surgery (229 hepatectomies, 250 gastrectomies, 126 pancreatectomies, and 74 esophagectomies annually). Over 80% of patients undergoing hepatic resection/ablation, gastrectomy, esophagectomy, and pancreatectomy are treated in one of the six national cancer centers (Auckland, Waikato, Mid-Central, Capital Coast, Canterbury, or Southern). There is evidence of the decreasing frequency of these procedures in small centers with increasing frequency in large centers suggesting that some regionalization is occurring. Palliative procedures were more widely performed. Indigenous Māori were less likely to be treated in a nationally designated cancer center than non-Māori. The challenge for New Zealand and similarly sized countries is to develop and implement a system that optimizes the skills and pathways that come from a frequent performance of complex surgery while maintaining system resilience and ensuring equitable access for all patients.

Robotic Assistance in Percutaneous Liver Ablation Therapies: A Systematic Review and Meta-Analysis.

The aim of this systematic review and meta-analysis is to identify current robotic assistance systems for percutaneous liver ablations, compare approaches, and determine how to achieve standardization of procedural concepts for optimized ablation outcomes. Image-guided surgical approaches are increasingly common. Assistance by navigation and robotic systems allows to optimize procedural accuracy, with the aim to consistently obtain adequate ablation volumes. Several databases (PubMed/MEDLINE, ProQuest, Science Direct, Research Rabbit, and IEEE Xplore) were systematically searched for robotic preclinical and clinical percutaneous liver ablation studies, and relevant original manuscripts were included according to the Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines. The endpoints were the type of device, insertion technique (freehand or robotic), planning, execution, and confirmation of the procedure. A meta-analysis was performed, including comparative studies of freehand and robotic techniques in terms of radiation dose, accuracy, and Euclidean error. The inclusion criteria were met by 33/755 studies. There were 24 robotic devices reported for percutaneous liver surgery. The most used were the MAXIO robot (8/33; 24.2%), Zerobot, and AcuBot (each 2/33, 6.1%). The most common tracking system was optical (25/33, 75.8%). In the meta-analysis, the robotic approach was superior to the freehand technique in terms of individual radiation (0.5582, 95% confidence interval [CI] = 0.0167-1.0996, dose-length product range 79-2216 mGy.cm), accuracy (0.6260, 95% CI = 0.1423-1.1097), and Euclidean error (0.8189, 95% CI = -0.1020 to 1.7399). Robotic assistance in percutaneous ablation for liver tumors achieves superior results and reduces errors compared with manual applicator insertion. Standardization of concepts and reporting is necessary and suggested to facilitate the comparison of the different parameters used to measure liver ablation results. The increasing use of image-guided surgery has encouraged robotic assistance for percutaneous liver ablations. This systematic review analyzed 33 studies and identified 24 robotic devices, with optical tracking prevailing. The meta-analysis favored robotic assessment, showing increased accuracy and reduced errors compared with freehand technique, emphasizing the need for conceptual standardization.

Preprocedural Video Education on Liver Ablation Treatment

BackgroundAnxiety is a common problem in patients scheduled for a procedure, and their level of anxiety increases as the procedure date approaches; pre-procedural anxiety is observed in hepatocellular carcinoma (HCC) patients scheduled for liver ablation treatment. There is currently a lack of standardized education provided to patients about liver ablation treatment, which may contribute to patients’ anxiety. PurposeTo test the effectiveness of a pre-procedural video educational tool to reduce patient anxiety and increase knowledge in HCC patients in an interventional radiology clinic setting. MethodsThis was a quasi-experimental, single-arm study, with a pre-test/post-test. Participant recruitment was based on a convenience sample. Inclusion criteria included: patients ages 18 and older; have biopsy-proven HCC or have a liver mass suspicious for HCC based on LI-RADS criteria imaging; no prior liver ablation treatment within three months of study onset. Participants watched a 7:04 minutes video and completed a 40-item State-Trait Anxiety Inventory and 10-item Knowledge Questionnaire before and after the video intervention to assess changes in anxiety and knowledge. Demographic variables evaluated included age, gender, education, and primary language. ResultsThere were 16 participants who met inclusion criteria. The state anxiety scores were significantly lower after the intervention (Md = 33.50, n = 16) compared to before (Md = 47.50, n = 16), z = −2.67, p = .009, with a medium effect size, r = 0.47. The trait anxiety scores did not show sufficient evidence for a difference after the intervention (Md = 40.00, n = 16) compared to before (Md = 39.50, n = 16), z = 0.71, p = .50, with a small effect size, r = 0.13. The knowledge scores were significantly higher after the intervention (Md = 9.00, n = 16) compared to before (Md = 2.00, n = 16), z = −3.53, p = .0005, with a large effect size, r = 0.62. A nonparametric bootstrap and nonparametric permutation test also showed evidence for a difference in mean between the distributions of the state anxiety and knowledge pre- and post-intervention scores. DiscussionThe results of this study showed evidence for the effectiveness of video education in decreasing anxiety and increasing knowledge in HCC patients. A standardized pre-procedural video educational tool can be a useful practice across all interventional radiology departments as it is associated with improved quality of care and positive health outcomes.

The Added Value of Transcatheter CT Hepatic Angiography (CTHA) Image Guidance in Percutaneous Thermal Liver Ablation: An Experts' Opinion Pictorial Essay.

With the rapidly evolving field of image-guided tumor ablation, there is an increasing demand and need for tools to optimize treatment success. Known factors affecting the success of (non-)thermal liver ablation procedures are the ability to optimize tumor and surrounding critical structure visualization, ablation applicator targeting, and ablation zone confirmation. A recent study showed superior local tumor progression-free survival and local control outcomes when using transcatheter computed tomography hepatic angiography (CTHA) guidance in percutaneous liver ablation procedures. This pictorial review provides eight clinical cases from three institutions, MD Anderson (Houston, TX, USA), Gustave Roussy (Paris, France), and Amsterdam UMC (Amsterdam, The Netherlands), with the intent to demonstrate the added value of real-time CTHA guided tumor ablation for primary liver tumors and liver-only metastatic disease. The clinical illustrations highlight the ability to improve the detectability of the initial target liver tumor(s) and identify surrounding critical vascular structures, detect 'vanished' and/or additional tumors intraprocedurally, differentiate local tumor progression from non-enhancing scar tissue, and promptly detect and respond to iatrogenic hemorrhagic events. Although at the cost of adding a minor but safe intervention, CTHA-guided liver tumor ablation minimizes complications of the actual ablation procedure, reduces the number of repeat ablations, and improves the oncological outcome of patients with liver malignancies. Therefore, we recommend adopting CTHA as a potential quality-improving guiding method within the (inter)national standards of practice.