Laparoscopic Microwave Coagulation Therapy Research Articles

Cerebellar hemorrhage in patients treated with edoxaban for portal vein thrombosis after hepatobiliary surgery: a report of two cases

BackgroundThe standard therapeutic agent administered for portal vein thrombosis (PVT) in patients with or without cirrhosis is warfarin or low-molecular weight heparin. However, therapy with edoxaban appears to be one of the most promising treatments for patients who require anticoagulation therapy. We encountered two cases of cerebellar hemorrhage in patients treated with edoxaban for PVT after hepatobiliary surgery during the past 2 years.Case presentationCase 1 A 67-year-old male underwent cholecystectomy and choledocholithotomy with choledochoduodenostomy to treat choledocholithiasis after cholangitis. Enhanced computed tomography (CT) on the 1st postoperative day (POD) revealed thrombosis in the left and anterior segment of the portal vein branches. We administered antithrombin III concentrate with heparin for 5 days; thereafter, we switched to 60 mg edoxaban. A sudden decrease in the patient’s level of consciousness was observed due to cerebellar hemorrhage on POD 27. Cerebellar hemorrhage was successfully treated with craniotomy hematoma evacuation and ventricular drainage; however, the patient died from aggravation of hepatic failure due to PVT and intra-abdominal infection. Case 2 A 67-year-old male received laparoscopic microwave coagulation therapy for two hepatic nodules suggestive of hepatocellular carcinoma in the left lobe of the liver due to alcoholic hepatitis. Enhanced CT on POD 5 revealed a thrombosis in the 4th segment branch of the portal vein, and the patient was treated with 60 mg edoxaban. Cerebellar hemorrhage with ventricular perforation occurred on POD 15. Cerebellar hemorrhage was successfully treated by craniotomy hematoma evacuation with ventricular drainage. Prolonged consciousness disorder persisted, and the patient was transferred to another medical facility for rehabilitation 49 days after brain surgery.ConclusionsAlthough edoxaban is recently described to be one of the options for patients with PVT who require anticoagulation therapy instead of heparin or warfarin, it should be used with caution, given its propensity to induce severe hemorrhagic adverse events in cases such as those described above. The monitoring of hepatic dysfunction and decision for continuation of drug may be required during edoxaban use for PVT, especially after hepatobiliary surgery.

Initial experiences with MR Image-guided laparoscopic microwave coagulation therapy for hepatic tumors.

Percutaneous thermal ablation is used for treating hepatic tumors. Recent advances in laparoscopy and imaging modalities have led to the development of a novel image-guided minimally invasive loco-regional treatment. The aim of this trial was to apply laparoscopic assistance to magnetic resonance (MR) image-guided thermoablation instead of ultrasonography, because of its various advantages. Patients with hepatic tumors and liver cirrhosis underwent magnetic resonance (MR) image-guided laparoscopic microwave coagulation therapy using a borescope and endoscopic forceps. Six cases of laparoscopic microwave coagulation treatment using MR image guidance were successfully performed between January 2000 and December 2008. Tumors were detected, punctured, and ablated in an open-configured MR scanner. A total of nine hepatocellular carcinoma nodules were preoperatively identified in S3, S5 and S6 (mean diameter=20.8±5.4mm). MR-guided microwave coagulation was laparoscopically achieved in all patients without any significant complications that required invasive treatment. The mean length of the operation was 275.3±60.5min, and the mean postsurgical hospital stay was 10.0±2.3days. Postoperative confirmation scanning was performed without moving the patients. MR-guided laparoscopic microwave coagulation therapy is an effective treatment for hepatic tumors adjacent to other organs, as it allows for more accurate detection of lesions and for tumors to be treated safely while avoiding adjacent organs. It is less invasive than conventional procedures, because the MR real-time guidance enabled continuous monitoring throughout the procedure.

OP-01 Laparoscopic and percutaneous microwave coagulation therapy of hepatic malignancies: feasibility, efficiency and risk factors for tumor recurrence

s of the 3rd ITLT Essen 2013 / Digestive and Liver Disease 45S (2013) S233–S260 S249 Scientific Abstracts

Argon gas embolism in the application of laparoscopic microwave coagulation therapy

A major concern in the use of the argon beam coagulator system is the potential risk of argon gas embolism. Seven cases with argon gas embolism in the English literature were reviewed along with the current case. The latter case was a 77-year-old female having laparoscopic hepatectomy after application of the microwave coagulation system on the cutting planes. Immediately following shots of an argon beam to control local bleeding at the needle hole in the liver caused by microwave coagulation, the end-tidal carbon disappeared, followed by cardiovascular collapse. After 18 min of cardiovascular resuscitation, the tumors were resected under laparotomy. After reviewing the cases, pneumoperitoneum (57.1%), hepatic needle punctures (42.8%) and direct application of the argon beam to the liver (28.6%) can be considered as risky processes in such events. Caution is necessary in the use of an argon beam in liver surgery to avoid life-threatening gas embolism.

婦人科領域における内視鏡下治療

In consideration of women's quality of life, the surgery in gynecologic fields is replaced from laparotomy to endoscopic surgery. An operation of uterine leiomyoma is also changing from an abdominal hysterectomy into minimally invasive conservative surgery. The methods include a laparoscopic myomectomy and hysteroscopic myomectomy. Additionally we device and investigate laparoscopic microwave coagulation therapy and MR-guided transcervical microwave coagulation therapy for uterine leiomyoma. Clinically, a therapy should be selected after explaining an indication, a merit, a demerit and a possible complication of the therapy to a patient intelligibly, and having got enough understanding.

Five-year Survival of Patients with Hepatocellular Carcinoma Treated with Laparoscopic Microwave Coagulation Therapy

Hepatocellular carcinomas (HCCs) that are located near the liver surface are difficult to treat with percutaneous locoregional therapies, so we have performed laparoscopic microwave coagulation therapy (LMCT) for these HCCs. We assessed the long-term survival of patients with HCCs treated with LMCT, the factors related to their survival, and the rates and causes of local and distant recurrences. Participants were 68 patients with HCC treated in the past 8 years with LMCT under local or general anesthesia. LMCT was done using microwave electrodes with tips ranging from 15 to 45 mm in length; the effectiveness of LMCT was confirmed using contrast-enhanced computed tomography (CT) within 2 weeks of the LMCT procedure while patients were still in hospital, and within 1-3 months after the procedure in an outpatient setting; and the follow-up study was performed periodically by CT, ultrasonography, or magnetic resonance imaging (MRI) in addition to estimation of alpha fetoprotein. Factors contributing to survival were analyzed statistically. The mean lengths of the major and minor axes of the 71 HCC nodules in 68 patients were 20 mm and 18 mm, respectively, and the mean lengths of the major and minor axes of the coagulated areas were 43 mm and 29 mm, respectively. At dynamic CT after the LMCT procedure, treatment in 62 of the 68 patients (91%) was judged to have been completely effective; the remaining six patients underwent additional therapy while still in hospital. Eight of the 68 patients (12%) had local recurrences, 39 of them (57%) had distant recurrences, and 21 of them (31%) had no recurrence up to December 31, 2003. A total of 14 patients (21%) died during the 16-56 months after LMCT. When the survival rate was assessed for all patients treated with LMCT, 1-year survival was 97 %, 3-year survival was 81%, and 5-year survival was 43%. Whether the therapy was for primary or secondary HCC strongly influenced survival. LMCT is a useful modality in clinical practice for treatment of HCC nodules located near the liver surface, and it can be safely performed, in its entirety, under direct visual guidance.

Efficacy and long‐term outcome of laparoscopic microwave coagulation or radiofrequency ablation therapy for surface‐type hepatocellular carcinoma

Background: Microwave or radiofrequency ablation therapy has been widely perfomed for hepatocellular carcinoma (HCC). Whereas ablation therapy is effective treatment, it cannot be perfomed easily, as is evident in several reports of severe complications. We treated surface‐type HCC under laparoscopy in avoidance of complications from March 1996. In the present study, we examined the efficacy and long‐term outcome of laparoscopic ablation therapy.Patients and Methods: The patients were 47 cases (58 lesions) of HCC treated by laparoscopic ablation therapy under general anesthesia in our Center from March 1996 until March 2003.Results: The surface‐type HCC to which the therapy was applicable accounted for approximately 15% of all cases. The overall 5‐year survival rate was 62%. Hepatic reserve and rate of intrahepatic recurrences in the remnant liver after curative treatment were the limiting factors on the survival rate. There was no serious complication in the treatment. It was well tolerated and brought about good quality of life.Conclusion: Laparoscopic ablation therapy was considered to be an easy and effective approach, and its utility was also recognized in the avoidance of the problems of percutaneous treatment, such as bleeding or damage to the adjacent organs.

The analysis of the usefulness of laparoscopic microwave coagulation therapy for hepatocellular carcinoma in patients with poor hepatic reserve by serial measurements of IL-6, cytokine antagonists, and C-reactive protein.

Little is known about the effectiveness of laparoscopic microwave coagulation therapy (L-MCT) for hepatocellular carcinoma (HCC) in patients with liver cirrhosis and poor hepatic reserve. Here, we analyzed the usefulness of laparoscopic MCT by comparing the serum levels of IL-6, cytokine antagonists, and C-reactive protein (CRP) following L-MCT with those following MCT with the open method (O-MCT). Sixteen patients with hepatocellular carcinoma (HCC) were separated into L-MCT and O-MCT groups according to ICGR15 (ICGR15 30%<:L-MCT, 30%> :O-MCT). Nine patients with poorer hepatic reserve received L-MCT, while seven patients with relatively good hepatic reserve received O-MCT. Serum levels of cytokine antagonists (interleukin-6, IL-6; interleukin-1 receptor antagonist, IL-1ra; soluble tumor necrosis factor receptor type I, sTNF-R55) and C-reactive protein (CRP) were simultaneously measured on serial postoperative days (POD) by immunoassay. Postoperative serum levels of IL-6, IL-1ra, and CRP were significantly elevated on POD-1 and returned to the preoperative levels on POD-7 in both L-MCT and O-MCT groups. In contrast, no significant elevation of sTNF-R55 was found during the period in both groups. In addition, no statistical differences were found in the levels of IL-6, IL-1ra, sTNF-R, and CRP between the groups, except that the level of IL-6 on POD-1 in L-MCT group was significantly lower than that in the O-MCT group. These results suggested that the surgical stress by L-MCT in patients with poorer hepatic reserve were almost equal to that by O-MCT in patients with relatively good hepatic reserve, indicating the usefulness of L-MCT for HCC patients with poorer hepatic reserve. We recommend the laparoscopic approach for future patients with the criterion that ICGR15 is over 30%.

Laparoscopic microwave coagulation therapy for small hepatocellular carcinoma on the liver surface

Six patients with small size (< or =2.0 cm in diameter) hepatocellular carcinoma (HCC) on their liver surface underwent laparoscopic microwave coagulation therapy (LMCT) in our institute. All cases showed complete necrosis after LMCT alone and there were no major complications during the LMCT. During the follow-up period, one patient had recurrent HCC at the LMCT-treated lesion site and two patients had lesions at sites distant to the LMCT-treated site. Two out of these three patients had presented with severe liver dysfunction at admission and died within the follow-up period. LMCT is believed to be a useful and safe treatment for small size HCC on the liver surface, and treatment can achieve complete tumor necrosis. However, in severe liver dysfunction, the use of LMCT may have a negative influence on patient survival.

Hand-assisted laparoscopic microwave coagulation therapy for hepatocellular carcinoma

Microwave coagulation therapy has been used for local ablation of hepatocellular carcinoma in the setting of liver cirrhosis. This technique can be performed laparoscopically when the tumor is located on the surface of the liver or attached to other intraabdominal organs. However, a laparoscopic approach becomes difficult when it is necessary to mobilize the liver or lyse adhesions to gain access to the tumor. We used a hand-assisted laparoscopic technique for the applicafion of microwave coagulation therapy in two cirrhotic patients with hepatocellular carcinoma to ensure safe mobilization of the liver and adhesiolysis. The first patient presented with a 4.5-cm mass in the left lobe of the liver that was densely adherent to the lesser omentum. The use of a hand-assist device allowed us to perform a safe exptoration, adhesiolysis, and subsequent tumor ablation. In the second patient, the tumor was located on the posterior aspect of the right lobe of the liver. The handassist device allowed safe mobilization of the liver and exposure of the tumor. No significant postoperative complications were noted in either patient. Complete ablation of the tumors was confirmed with contrastenhanced computed tomography scanning. In conclusion, hand-assisted iaparoscopy is an effective adjunct to microwave ablation therapy in patients with hepatocellular carcinoma and liver cirrhosis. It enables the safe completion of the procedure under laparoscopic guidance, thereby averting laparotomy.

Efficacy of laparoscopic microwave coagulation therapy for hepatocellular carcinoma Comparison of survival rates between laparoscopic microwave coagulation therapy and percutaneous ethanol injection therapy

23 patients with solitary HCC were firstly treated by laparoscopic microwave coagulation (LMC) and 39 were initially treated by percutaneous ethanol injection (PEI). For these 63 cases, we analyzed the survival rates and compared the rates between LMC group and PEI group. Of these patients, the longest diameters of HCC were between 7 and 40 mm. 4-year survival rates were 86% in LMC group and 58% in PEI group. The differences of survival rates were not statistically significant between LMC and PEI group (p=0.15). When HCC were 20 mm or less, 4-year survival rates (82%) in LMC group were almost the same percentage as in those (65%) of PEI group (p=0.88). However, when HCC were larger than 20 mm, 4-year survival rates (90%) of LMC group were significantly higher than those (42%) of PEI group (p=0.04).

The evaluation of efficacy for laparoscopic assisted microwave coagulation therapy for the patients of hepatocellular carcinoma with poor liver function

We have already reported the safety and efficacy of laparotomic microwave coagulation therapy (LMCT) for the patients of hepatocellular carcinoma (HCC) with impaired liver function. The aim of this study is to evaluate less invasiveness of laparoscopic assisted microwave assisted microwave coagulation therapy (LAMCT) compared with LMCT.Method : 18 patients of HCC with poor hepatic reserve underwent since April, 2001. 7 patients received LAMCT (LA group) and 11 patient received LMCT (L group). Clinical data ware analyzed before and after surgery in 18 patients.Results : Operative time, blood loss during surgery, and hospitalization were significant less in the LA group than those in the L group. No significant differences between the groups were recognized after surgery in regard to changes in the time course of levels of liver function (AST, ALT, Total bilirubin, Prothrombin time, and Albumin). The changes in the time course of levels of WBC and CRP, as postoperative inflammatory indicators, in the LA group were significantly lower than those in the L group (pLAMCT might be useful treatment mordality for the patient of HCC with poor liver function, whose tumor number is not multiple and tumor size is 3cm or less, and further more, tumor location is not adjacent to Glissonn's sheath.

Microwave coagulation therapy for liver cancer: laparoscopic microwave coagulation.

A microwave coagulator was developed in 1979 by Tabuse.1 Originally, it was invented as a new cautery device designed to reduce the volume of hemorrhage during hepatectomy. Using the same device, Saitsu et al.2 reported intraoperative and laparoscopic microwave coagulation (MC) therapy for hepatocellular carcinoma (HCC) in 1991. Percutaneous MC was then described by Seki et al.3 in 1994, and the use of MC has rapidly spread since that time. MC for HCC was included in medical insurance coverage in Japan in 1996, and it has since been employed percutaneously, endoscopically (laparoscopy, thoracoscopy), and in open surgery. However, as it has been only 4 years since MC became covered by insurance (and, thus, used widely) in Japan, its clinical value has not yet been established. A representative local therapy for HCC before the advent of MC was percutaneous ethanol injection therapy (PEI), which was introduced around 1983.4,5 Although controversy still continues, there is a general consensus that the results of PEI are comparable to those of surgical resection for HCCs 20mm or less in diameter. Recently, radiofrequency coagulators developed in the United States have been introduced to Japan, and a number of facilities are performing radiofrequency ablation (RA).6–13 The appearance of newer RA devices makes the future position of MC unclear. In particular, as the procedure used for percutaneous MC, which is the most widely performed modality, varies among facilities, and as the criteria for evaluation of its efficacy also differ slightly among facilities, the situation is rather confusing. If the methods differ, the results will also be different. Differences in the approach to cancer are expected to further widen the differences in the results obtained. In this article, we summarize the characteristics and procedures of MC, and review the advantages and disadvantages of MC that have been documented to date, in terms of the approach to cancer. Problems experienced with MC are considered to be similar to those experienced with RA.

Study for recurrences of hepatocellular carcinoma after laparoscopic microwave coagulation therapy

From April 1995 to January 2001, we treated 52 hepatocellular carcinomas (HCC) of 47 patients by laparoscopic microwave coagulation (LMC). The efficacy of LMC was evaluated by dynamic CT and 5 HCC were required for additional therapy. The other 45 HCC seemed to be coagulated sufficiently. The number of firstly treated cases with solitary HCC was 21 among 47 patients treated by LMC. In follow-up observation of these 21 cases, 4 cases developed local recurrences. In two of these four cases, HCC were located near large vessels, and local recurrences ware developed because viable portion of HCC were considered to be resisted near large vessels. Thus, HCC near large vessels is needed for careful coagulation because viable portion of HCC can be resisted near large vessels.

Gasless laparoscopic hepatic resection for cirrhotic patients with hepatocellular carcinoma

Nine cirrhotic patients with liver tumors underwent a gasless laparoscopic hepatic resection with a 5 cm minilaparotomy. To maintain the good visualization and working space during hepatic resections, we developed a simple retraction system. Tumors located in segment II through VI of the liver could be treated by the laparoscopic procedure. In three of the nine patients, laparoscopic microwave coagulation therapy was added for each HCC tumors that were detected by intraoperative sonography. No blood transfusion was necessary during the operations. No serious complications such as air embolism occurred. The procedure was also applicable to cirrhotic patients with some complications. The good indication of the laparoscopic procedure is for the patients with small HCCs associated with liver cirrhosis, who are not candidates for radical hepatic resection.

Value of Laparoscopic Microwave Coagulation Therapy for Hepatocellular Carcinoma in Relation to Tumor Size and Location

The indications for laparoscopic microwave coagulation therapy (LMCT) for hepatocellular carcinoma (HCC) have not yet been adequately evaluated. This study investigated the value of LMCT in the treatment of HCC. Forty-three patients with liver cirrhosis (including five patients in Child Pugh grade C), with 56 HCC lesions, were enrolled in the study. When dynamic computed tomography (CT) showed a loss in HCC enhancement characteristics and a low concentration area after LMCT, a lesion was judged to have undergone complete necrosis. The rate of complete necrosis for lesions measuring 40 mm or less was significantly higher (P<0.01) than for those measuring 41 mm or more. The rate of complete necrosis for lesions located on the liver surface, excluding those located close to the gallbladder or in contact with the diaphragm, was also significantly higher (P<0.01) than for those situated deep within the liver. The outcome for lesions of 40 mm or less was favorable. Intra-abdominal hemorrhage occurred in two patients, pneumothorax in three, and hepatic infarction in one, all associated with LMCT. However, these patients did not suffer any sequelae of clinical significance. This study suggests that there is a strong indication for LMCT for HCCs measuring 40 mm or less in diameter and those located on the liver surface even if they are as large as 50 mm, but not for those located close to the gallbladder or in contact with the diaphragm. LMCT appears to be applicable in patients with impaired liver function.

Laparoscopic microwave coagulation therapy for hepatocellular carcinoma.

Several different effective forms of treatment are available, singly or in combination, for patients with hepatocellular carcinoma (HCC). These include surgical resection, transcatheter arterial embolization, percutaneous ethanol injection, and percutaneous microwave coagulation therapy. In this study, we carried out laparoscopic microwave coagulation therapy (LMCT), using laparoscopic microwave electrodes to treat HCC. Under local anesthesia, 24 patients with HCCs located on or near the liver surface underwent LMCT under direct laparoscopic vision, with ultrasound guidance. LMCT was performed using microwave electrodes with tips ranging from 15-45 mm in length, and the effectiveness of the treatment was confirmed using contrast-enhanced computed tomography (CT) within two weeks of the LMCT procedure. The mean longest axis of the 26 HCC nodules in 24 patients was 20 mm, and that of the coagulated areas including the nodules was 40 mm, with additional therapy being required in two patients. Complete efficacy of the treatment was observed in 21 patients (87.5%), but local recurrences were seen in three of them one year after LMCT. The three-year survival rate was 92%, but the number of patients included in the study was small. Hemostasis was complete, but mild pneumothorax occurred in three patients. LMCT under local anesthesia is a minimally invasive and effective therapy when carried out on a single occasion to treat HCCs located near the liver surface, and it can be safely performed under direct visual guidance.

Laparoscopic microwave coagulation therapy under the hepatic blood flow occlusion for hepatocellular carcinoma

A 65-year-old man was diagnosed as having hepatocellular carcinoma (HCC) with liver cirrohosis classified clinical stage, which caused by hepatitis C virus. Abdominal contrast CT showed HCC in the diameter of 2 cm located Segment 4. Laparoscopic microwave coagulation therapy under hepatic blood flow occlusion using clamp was performed. We applied the coagulation time for 10 minutes with an output of 80 watts for 60 seconds at a time. After 2 months the hepatic tumor was completely enclosed within the coagulation area and no recurrence was showed for 14 months after procedure. We have reported that the coagulation areas with the hepatic blood flow occlusion was about twice as big as that without blocking the hepatic blood flow. This suggested that a 3 cm hepatic tumor can be controled by this method. We proposed that laparoscopic microwave coagulation therapy under hepatic blood flow occlusion should be selected for HCC of small size or middle-size hepatic tumor and high risk patients.

Treatment of hepatocellular carcinoma with use of microwave coagulation under laparoscopy

We treated 30 patients with hepatocellular carcinoma (HCC) by laparoscopic microwave coagulation therapy (LMCT) and 5 patients with hepatic tumors by laparoscopic hepatectomy (LH). LMCT : The HCC was between 10 and 35 mm in longest diameter. After observation of the surface of the liver during laparoscopy as usual, the lesions were punctured with a electrode needle, coagulated with 60 to 80 W for 45 seconds. The efficacy of LMCT was evaluated by dynamic CT or dynamic MRI. After LMCT, 3 lesions of 3 patients were thought to be coagulated insufficiently and additional therapy was needed. The lesions of the other patients seemed to be coagulated sufficiently. LH : We treated 5 patients by LH under general anesthesia. The longest diameters of tumors were between 13 mm and 45 mm. All tumors were located at the edge of the liver. We coagulated the surrounding tissues around the tumors with the above mentioned method and resected the coagulated lesions with Laparoscopic Coagulating Shears System. The bleeding were few and no serious complications were not found. Conclusions : Laparoscopic treatment for HCC was useful but the indication was restricted by location of HCC.

Usefulness of laparoscopic microwave coagulation therapy (LMC) for hepatocellular carcinoma

We performed LMC in 58 patients with solitary HCC. Mean tumor size was 24.6 mm (range : 12 to 66 mm) Three cases required postoperative procedures such as PEI or TAE. In 55 cases, HCC was treated by LMC alone. LMC was very effective for HCCs measuring under 4cm in diameter. In most patients, oral intake was started in the evening of the day of LMC. Ambulation was resumed on the day after treatment in all cases. No major complications occurred. The mean postoperative hospital stay in the patients treated by LMC alone was 9.4 days. LMC is minimally invasive and requires only a short convalescence. LMC is excellent in terms of cost / benefit and the quality of life and has great potentiality.