Laparoscopic Microwave Coagulation 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.

Minimally Invasive Liver Surgery for Hepatic Colorectal Metastases.

Minimally invasive surgery has been cautiously introduced in surgical oncology over the last two decades due to a concern of compromised oncological outcomes. Recently, it has been adopted in liver surgery for colorectal metastases. Colorectal cancer is a major cause of cancer-related death in the USA. In addition, liver metastasis is the most common site of distant disease and its resection improves survival. While open resection was the standard of care, laparoscopic liver surgery has become the standard of care for minor liver resections. Laparoscopic liver surgery provides equivalent oncological outcomes with better perioperative results compared to open liver surgery. Robotic liver surgery has been introduced as it is believed to overcome some of the limitations of laparoscopy. Finally, laparoscopic radio-frequency ablation and microwave coagulation can be used as adjuncts in minimally invasive surgery to complement or replace surgical resection when not possible.

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

A comparative study of therapeutic effect between laparoscopic microwave coagulation and laparoscopic radiofrequency ablation.

We retrospectively compared the therapeutic effect of microwave coagulation needle (Lap-MCT) and radiofrequency ablation needle (Lap-RFA). Between January 2001 and May 2012, 71 patients underwent laparoscopic ablation therapy for HCC with no extra hepatic metastasis. These patients were divided into 3 groups, according to the surgical strategies: Lap-MCT (n=40), Lap-MCT+RFA (n=13) and Lap-RFA (n=18). The patient background, tumor characteristics, cumulative survival rate, recurrence-free survival rate, time of operation and duration of hospitalization were compared between the groups. The maximal tumor size, the number of tumors and the hepatic reserve from each group had no significant difference. Likewise, the time of operation and the duration of hospitalization had no significant difference. However, the number of needle punctures in the Lap-MCT group was significantly larger than that in the Lap-RFA group (p<0.05). Postoperative liver function had no significant difference between the groups. The 5-year cumulative survival rate was 71.5% (Lap-MCT), 66.7% (Lap-MCT+RFA) and 80.0% (Lap-RFA) showing no significant difference. Also, the recurrence-free survival rate and the local recurrence rate had no significant difference. In the laparoscopic setting, MCT and RFA are equally effective in terms of short- and long-term results.

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.

肝細胞癌における熱凝固療法の適応と成績

We analyzed the rates of survival, non-local recurrence, and non-another recurrence of 89 patients with solitary hepatocellular carcinoma who underwent thermal ablation therapies as primary treatment (naive patients). Thirty five cases were ablated by percutaneous radiofrequency ablation (PRFA), 32 and 22 were treated by laparoscopic microwave coagulation (LMCT) and by percutaneous microwave coagulation (PMCT), respectively. Five-year survival rates were 87%, 60%, and 82% in PRFA, LMCT, and PMCT, respectively, with no statistical significance. Rates of 5-year non-local recurrence were 60%, 74%, and 51% in PRFA, LMCT, and PMCT, respectively, with no statistical significance. Those of 5-year non-another recurrence were 0%, 19%, and 20%, with no statistical significance.Thus, PRFA, LMCT, and PMCT had same effectiveness for the local treatment of HCC.

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.

肝細胞癌における局所熱凝固療法の適応と成績

We analyzed the survival rates, local recurrence rates, and another recurrence rates for patients with solitary hepatocellular carcinoma who received thermal ablation therapies as primary treatment (naive patients). In these 89 patients, 35 cases were ablated by percutaneous radiofrequency ablation (PRFA), 32 were treated by laparoscopic microwave coagulation (LMCT), and 22 were treated by percutaneous microwave coagulation (PMCT). 5-year survival rates were 87% in PRFA, 56% in LMCT, 76% in PMCT. The differences of survival rates were not statistically significant among PRFA, LMCT, and PMCT. 5-year local recurrence rates were 49%, 26%, and 44%, consecutively. No differences were found between therapies. 5-year another recurrence rates were 100%, 81%, and 80%, consecutively. No differences were found statistically.

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.

Long‐term outcomes for patients with solitary hepatocellular carcinoma treated by laparoscopic microwave coagulation

Although many reports on the treatment of hepatocellular carcinoma (HCC) by microwave coagulation have been published recently, none have incorporated data for the long-term therapeutic efficacy of laparoscopic microwave coagulation (LMC). In the current study, the efficacy of LMC was assessed. The authors performed LMC under local anesthesia in 69 previously untreated patients with solitary HCCs < or = 4.0 cm in greatest dimension. The maximum diameter for the tumors averaged 22.6 +/- 7.4 mm. Long-time survival rate was evaluated according to the size and histologic grade of the tumor. The 5-year overall cumulative survival rate for the 69 patients was 63.9%. The 5-year overall survival rate for patients with well differentiated HCC was 78.9%, whereas patients with moderately or poorly differentiated HCC had a 5-year overall survival rate of 38.9%. The 5-year cumulative survival rate for patients with HCCs < or = 2.0 cm in diameter was 76.0%, and 56.3% for patients with HCCs >2.0 cm. Twelve patients (17.4%) showed local tumor recurrence during the follow-up period. Local tumor recurrence was observed in 6 of 21 patients with moderately or poorly differentiated HCCs (28.6%) and in 6 of 40 patients with well differentiated HCCs (15.0%). The 3-year cancer-free survival rate for patients with well differentiated HCC was 44.4%, whereas it was 12.2% for patients with moderately or poorly differentiated HCC. A major factor that influenced outcome in LMC was tumor cell differentiation. LMC procedures were best suited for treatment of well differentiated HCC.

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.

Comparison of survival rates for patients with hepatocellular carcinoma among laparoscopic microwave coagulation, percutaneous microwave coagulation and percutaneous ethanol injection

25 patients with solitary HCC were firstly treated by laparoscopic microwave coagulation (LMC), 14 were firstly treated by percutaneous microwave coagulation (PMC), and 39 were initially treated by percutaneous ethanol injection (PEI). For these 78 cases, we analyzed the survival rates and compared the rates among LMC, PMC, and PEI group. 5-year survival rates were 52% in LMC group, 46% in PMC group, and 58% in PEI group. The differences of survival rates were not statistically significant among LMC, PMC, and PEI group. Next, we analyzed survival rates between microwave coagulation (MC) and PEI. When HCC were 20mm or less, 5-year survival rates (45%) in MC group were almost the same percentage as in those (65%) of PEI group (p=0.48). However, when HCC were larger than 20mm, 5-year survival rates (80%) of MC group were significantly higher than those (40%) of PEI group (p=0.011).

Laparoscopic local treatment for hepatocellular carcinoma under general anesthesia

In our department, indication of laparoscopic treatment for hepatocellular carcinoma (HCC) was that the long diameter of HCC was 4 cm or less, the number of HCC was 3 or less, the clinical stage was Child-Pugh A or B, and the vascular invasion was absent.The peculiar feature of laparoscopic treatment is that the objects of treatment and both HCCs on the liver surface and HCCs located deep in the liver using laparoscopic ultrasonography (LUS). The puncture methods of the tumor located deep in the liver were guide needle and immersion method using normal saline solution into the abdominal cavity. Recently convex-type LUS was developed in order to puncture the tumor located deep in the liver.From February 1998, until September 2002, 263 tumors of 197 cases underwent laparoscopic treatment. The mean long diameter of tumors was 24.0 (12-60) mm. One hundred and ninety tumors of 141 cases underwent laparoscopic radiofrequency ablation (LRA) and 73 tumors of 56 cases underwent laparoscopic microwave coagulation (LMC). Local recurrence rate was 6.1% and the recurrence rate of the other lesion was 27.4%. The survival rate was 86% in three year, and 71% in four year.

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.