Laparoscopic Radiofrequency Research Articles

Laparoscopic Radiofrequency Ablation in the Caudate Lobe for Hepatocellular Carcinoma Before Liver Transplantation

The caudate lobe, because of its location and its highly unpredictable vascular anatomy, is one of the most surgical challenging segment of the liver. Hepatocellular carcinoma (HCC) of the caudate lobe in cirrhotic patients is not easily amenable to surgical resection. In order to treat HCC and to down-stage these patients within accepted criteria for liver transplantation (LT), laparoscopic radiofrequency ablation (RFA) can be performed. We present three cases of laparoscopic RFA for caudate lobe HCC. All three patients were successfully treated with laparoscopic RFA. The computed tomography scans 1 month postsurgery revealed complete necrosis of the lesion. No postoperative complications occurred, and all patients had a short postoperative stay. All three patients underwent, thereafter, LT from a deceased donor. Laparoscopic RFA is the treatment of choice in patients with HCC who could be scheduled for LT. Furthermore, a laparoscopic technique with an accurate ultrasound examination of liver parenchyma can allow for a complete exclusion of hepatic lesions undetectable at the preoperative imaging and provides the minimal onset of adhesions, both approaches that are extremely useful in patients undergoing liver transplantation.

Commentary on “Laparoscopic Radiofrequency Ablation in the Caudate Lobe for Hepatocellular Carcinoma Before Liver Transplantation”

Commentary on “Laparoscopic Radiofrequency Ablation in the Caudate Lobe for Hepatocellular Carcinoma Before Liver Transplantation”

Laparoscopic approach for treatment of multiple hepatocellular carcinomas

The aim of this study is to evaluate clinical and oncologic outcomes after laparoscopic surgery for patients with multiple hepatocellular carcinoma (HCC). Among the 260 patients who underwent laparoscopic procedures, including laparoscopic liver resection and laparoscopic radiofrequency ablation (LRFA), between September 2003 and December 2009, 107 patients with HCC were included in this retrospective study. According to tumor multiplicity, patients were divided into multiple lesion (n = 23) and single lesion (n = 84) groups. We compared the operative outcomes after the laparoscopic procedures between the single and multiple tumor groups. There was no difference in the clinicopathologic characteristics between the two groups, except the multiple group had more frequent previous history of preoperative transarterial chemoembolization. LRFA was more frequently used in the multiple group as compared with the single group. There was no postoperative mortality in either group. Application of laparoscopic surgery in the multiple group did not increase the operative time, rate of intraoperative transfusion, length of postoperative hospital stay, or postoperative complications, as compared with the single group. After median follow-up of 33.7 months, there was no statistically significant difference of the survival rates between the two groups, although there was a better disease-free survival rate in the single group. This study shows that laparoscopic surgery, including LH and LRFA, can be safely applied to patients with multiple HCCs, and the survival outcomes are acceptable.

Cost comparison of nephron-sparing treatments for cT1a renal masses

ObjectivesTreatment options for small renal tumors have evolved from radical nephrectomy (RN) to partial nephrectomy (PN), thermal ablation, or active surveillance. With the advancement of techniques, costs differences are unclear. The objective of this study is to compare the 6-month costs associated with nephron-sparing procedures for cT1a renal tumors. Materials and methodsWe performed a review of patients diagnosed with a solitary cT1a renal mass who underwent surgical treatment from June 2008 to May 2011. Open partial nephrectomy (OPN), robot-assisted partial nephrectomy (RLPN), laparoscopic radio-frequency ablation (LRFA), or computed tomography guided radio frequency ablation (CTRFA) was performed on 173 patients. Cost data were collected for surgical costs, associated hospital stay, and the 6-month postoperative period. ResultsPatients underwent surgery, including 52 OPN, 48 RLPN, 44 LRFA, and 29 CTRFA. Median total costs associated were $17,018, $20,314, $13,965, and $6,475, for OPN, RLPN, LRFA, and CTRFA, respectively. When stratified by approach differences were noted for total cost (P < 0.001), operating room (OR) time (P < 0.001), surgical supply (P < 0.001), and room and board (P < 0.001) in univariable analysis. Multivariable linear regression (R2 = 0.966) showed surgical approach (P = 0.007), length of stay (P < 0.001), and OR time (P < 0.001) to be significant predictors of total cost. However, tumor size (P = 0.175), and Charlson comorbidity index (P = 0.078) were not statistically significant. ConclusionsSix-month cost of nephron-sparing surgery is lowest with radio frequency ablation (RFA) by either laparoscopic or computed tomography (CT)-guided approach compared to RLPN and OPN. As oncologic and safety outcomes improve and become comparable in all nephron-sparing surgery (NSS) approaches, cost of each procedure will start to play a stronger role in the clinical and healthcare policy setting.

Long-Term Outcomes of Renal Tumor Radio Frequency Ablation Stratified by Tumor Diameter: Size Matters

Renal tumor size influences the efficacy of radio frequency ablation but identification of confident size cutoffs has been limited by small numbers and short followup. We evaluated tumor size related outcomes after radio frequency ablation for patients with adequate (greater than 3 years) followup. We identified 159 tumors treated with radio frequency ablation as primary treatment. Disease-free survival was defined as the time from definitive treatment to local recurrence, detection of metastasis or the most recent imaging showing no evidence of disease. Patients were evaluated with contrast enhancing imaging preoperatively, and at 6 weeks, 6 months and at least annually thereafter. Median tumor size was 2.4 cm (range 0.9 to 5.4) with a median followup of 54 months (range 1.5 to 120). Renal cell carcinoma was confirmed in 72% of the 150 tumors that had pre-ablation biopsy (94%). The 3 and 5-year disease-free survival was comparable at 92% and 91% overall, and was dependent on tumor size, being 96% and 95% for tumors smaller than 3.0 cm and 79% and 79%, respectively, for tumors 3 cm or larger (p=0.001). Most failures (14 of 18) were local, either incomplete ablations or local recurrences. This is an intent to treat analysis and, therefore, includes patients ultimately found to have benign tumors, although outcomes were comparable in patients with cancer. Radio frequency ablation treatment success of the small renal mass is strongly correlated with tumor size. Radio frequency ablation provides excellent and durable outcomes, particularly in tumors smaller than 3 cm. Of tumors 3 cm or larger, approximately 20% will recur such that alternative treatment techniques should be considered. However, most treatment failures are local and are often successfully treated with another ablation session.

Hemodynamic effects of laparoscopic radiofrequency ablation of liver tumors versus laparoscopic hepatic ultrasound examination

Study ObjectiveTo compare the hemodynamic changes that occur during laparoscopic radiofrequency ablation of liver metastases with those occurring during laparoscopic ultrasound hepatic examination alone. DesignProspective, observational study. SettingOperating rooms of a university-affiliated hospital. Patients40 ASA physical status 2 and 3 patients with liver metastases. Interventions20 patients underwent laparoscopic radiofrequency ablation of liver tumors following laparoscopic ultrasound examination, and 20 had laparoscopic ultrasound examination alone. The anesthetic technique was standardized. MeasurementsThe primary endpoint of the study was the number of episodes of mean arterial pressure (MAP) < 70 mmHg. Secondary endpoints were significant differences between the groups in MAP, heart rate, cardiac index, ejection fraction (EF; both measured with thoracic bioimpedance), calculated systemic vascular resistance index (SVRI), and central venous pressure. Main ResultsThe number of episodes of MAP < 70 mmHg did not differ between groups: there were 9 episodes in the ultrasound alone group and 7 in the radiofrequency group (P = 0.668). Cardiac index, EF, and SVRI were similar between groups. Central venous pressure was slightly higher in the radiofrequency group [11.99 (10.8-13.2) mmHg vs. 10.3 (9.2-11.4) mmHg, P = 0.04]. ConclusionsHemodynamic profiles were similar when comparing laparoscopic radiofrequency ablation of liver metastases with laparoscopic ultrasound hepatic examination alone.

Preoperative patient counseling for diagnostic renal biopsy and complications with renal radiofrequency ablation

To identify preoperative factors associated with surgical complications and successful diagnostic renal biopsy in both laparoscopic and percutaneous radiofrequency ablation (RFA) of renal masses in order to help aid in preoperative patient counseling for renal RFA. We reviewed our Institutional Review Board approved database from November 2001 to January 2011, containing 335 tumors treated with either laparoscopic (LRFA) or percutaneous RFA (CTRFA). Preoperative patient demographics, tumor characteristics, and intraoperative surgical data were collected along with biopsy results and clinicopathologic outcomes. RFA was performed on 335 renal tumors (124 LRFA, 211 CTRFA). Non-diagnostic biopsy occurred in 18 (5.5%) tumors. Of the 317 procedures performed, 121 complications occurred in 103 (30.7%) procedures. Multivariate analysis only showed CTRFA (vs LRFA) to increase the likelihood of non-diagnostic biopsy (OR 5.1, 95% CI 1.2-22, p = 0.032). Increased tumor size (p = 0.007) and synchronous ablations (p = 0.019) increased the risk for major complications, while decreased surgeon experience (p = 0.003) and tumors close to the collecting system (p = 0.005) increased the risk of any complication. Preoperative recommendations can be made to patients in the future. We suggest counseling patients that when undergoing RFA, percutaneous approach increases the risk of non-diagnostic biopsy, increased tumor size increases the risk of major complications, having more than 1 tumor ablated increases the risk of a major complication, and tumors close to the collecting system may increase the risk of complications.

A Case of Needle-Track Implantation of Hepatocellular Carcinoma in the Chest Wall after Laparoscopic Radiofrequency Ablation

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Laparoscopic Radiofrequency Thermal Ablation of Hepatocellular Carcinoma in Liver Cirrhosis Patients.

BackgroundLaparoscopic radiofrequency ablation (LRFA) for hepatocellular carcinoma (HCC) under guidance of intra-operative laparoscopic ultrasound (IOLUS) aiming of obtaining additional information for liver situation, better tumor staging and effective treatment of hepatic focal lesion (HFL) in patients with a difficult percutaneous approach.MethodsBetween September 2010 and July 2012, 301 patients with HCC in liver cirrhosis were referred from HCC clinic at National Hepatology and Tropical Medicine Research Institute (NHTMRI). Twenty nine patients were submitted to LRFA with IOLUS guidance. Operation time, hospital stay, post procedure complication were recorded. Spiral CT scan one month postoperative was mandatory during follow up.ResultsLRFA was completed in all patients. The IOLUS examination identified new HFL in three patients. A total of 32 lesions were treated. The mean operative time was 120 minutes; eight procedures were associated in six patients: cholecystectomy (6) and adhesiolysis (2). A complete tumor ablation was observed in all patients which were documented via spiral computed tomography (CT scan) one month after treatment.ConclusionLRFA of HCC proved to be a safe and effective technique. IOLUS is superior on spiral CT scan in detection a small HCC.

腹腔鏡下ラジオ波焼灼術におけるNon-Trocar Techniqueの有用性

We have developed a novel insertion method, a non-trocar technique for laparoscopic radiofrequency ablation, whereby an ablation needle is accurately and easily punctured into the target tumor in the liver using the 13-mm echo probe, PVM-787LA (TOSHIBA, Tokyo). By exiting methods, an ablation needle must be inserted into the abdominal cavity through the puncture hole at a distance from the echo probe due to the existence of 15-mm trocar. Under these circumstances, it is difficult to attach and slide an ablation needle along the groove of the probe in the abdominal cavity because of the large longitudinal dissociation between the needle and the probe. In order to avoid this dissociation, the echo probe is inserted directly through the hole from which the 12-mm trocar was pulled out and an ablation needle is inserted directly into the abdominal cavity through the puncture hole very adjacent to the probe. Then, an ablation needle can be easily slid along the groove of the probe.

Safety and efficacy of laparoscopic radiofrequency ablation for hepatic malignancies

PurposeRadiofrequency ablation (RFA) is an accepted treatment option for primary and metastatic liver tumors. As percutaneous RFA has some limitations, laparoscopic RFA (LRFA) has been used as a therapeutic alternative for the treatment of hepatic malignancies.MethodsBetween March 2006 and September 2009, thirty patients with hepatic malignancies that were contraindicated for resection or percutaneous RFA underwent LRFA. Indications for this procedure were hepatocellular carcinoma (HCC, 21 patients), metastatic liver tumor (8 patients) and intrahepatic cholangiocarcinoma (1 patient).ResultsAmong the 30 patients who underwent LRFA, 5 patients underwent concomitant laparoscopic liver resection. Intraoperative laparoscopic ultrasound detected new malignant lesions in 4 patients (13.3%). A total of 46 lesions were ablated by LRFA. There was no postoperative mortality. The three-year overall survival rate was 83.7% for the HCC group and 64.3% for the metastatic group.ConclusionLRFA for hepatic malignancies proved to be a safe and effective treatment. Also, this procedure is indicated for lesions that are not amenable to percutaneous RFA or liver resection.

Laparoscopic Radiofrequency Ablation of Focal Hepatic Lesions. Technical Aspects

Laparoscopic Radiofrequency Ablation of Focal Hepatic Lesions. Technical Aspects

Resection and radiofrequency ablation in the treatment of hepatocellular carcinoma: a single-center experience

We have been utilizing both resection and laparoscopic radiofrequency ablation (RFA) to treat hepatocellular carcinoma (HCC). The aim of this study is to describe patient characteristics and outcome for each treatment modality from a single institution. Medical records of HCC patients who underwent resection (n = 92) or laparoscopic (RFA) (n = 92) between 1997 and 2010 were reviewed. Univariate Kaplan-Meier and multivariate Cox proportional-hazards model were used to analyze survival. Patients with normal liver function and larger tumors were resected, and those with liver dysfunction, portal hypertension, and multiple tumors were ablated. Tumor size was larger in the Resection group, whereas number of tumors was higher in the RFA group. Child class and Barcelona Clinic Liver Cancer (BCLC) staging were more advanced in the RFA group. Hospital stay was longer, and morbidity and mortality higher in the Resection versus the RFA group. There was no difference in disease-free survival, but the 5-year actual survival was significantly higher (40% versus 21%) in the Resection group. On univariate analysis, number of tumors, tumor size, platelet count, BCLC stage, Child class, and type of surgery were predictors of overall survival. On multivariate analysis, Child class and number of tumors were independent predictors of overall survival. To our knowledge, this is the largest North American series reporting on RFA and resection for HCC from a single institution. Herein, we describe the perioperative and oncologic outcomes to be expected when these modalities are used in a certain treatment algorithm.

Leiomyoma Assessment by Intra-Abdominal Ultrasound Compared to Preoperative Ultrasound and Preoperative Magnetic Resonance Imaging

To compare the findings of preoperative transvaginal ultrasound (TVUS) and preoperative magnetic resonance imaging (MRI) with intra-abdominal (IAUS) myoma assessments during laparoscopic radiofrequency volumetric thermal ablation (RFVTA).

Laparoscopic Partial Nephrectomy Versus Laparoscopic Ablative Therapy: A Comparison of Surgical and Functional Outcomes in a Matched Control Study

Patients who are undergoing laparoscopic ablative therapy (LAT) are often older with more comorbidities in comparison with patients who are undergoing laparoscopic partial nephrectomy (LPN). A matched control study was performed to compare the surgical and functional outcomes of LPN and LAT. A prospectively maintained database of 250 patients who underwent nephron-sparing surgery was explored. Fifty-one LAT patients (21 and 30 laparoscopic radiofrequency and cryoablation, respectively) were matched with 51 LPN patients. A comparison of preoperative, operative, and postoperative outcomes was performed. The groups were similar in age, sex, body mass index, preoperative estimated glomerular filtration rate (eGFR), number of comorbidities and tumor size. Patients who were undergoing LAT had a lower incidence of endophytic tumor and higher incidence of upper pole and midpolar tumors. Hilar vessels clamping was performed in LPN (47/51 patients). Mean estimated blood loss and operative time were higher in those undergoing LPN (P<0.01). There was no significant difference in transfusion rate and hospital stay, however. Mean follow-up was 27 and 18 months in LAT and LPN, respectively (P<0.01). The mean percent decline of eGFR at the last follow-up was 10 (95% confidence interval [CI]: 4-15) and 7.5 (95% CI: 4-11), respectively (P<0.43). In comparison with baseline, eGFR declined significantly (P<0. 01), but there was no difference between the groups. Despite renal ischemia, longer operative time, and higher blood loss associated with LPN, the hospital stay and long-term functional outcomes are similar to those of LAT in a matched control study.

Towards the optimization of management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common neoplasm in the world, closely correlated with viral hepatitis and liver cirrhosis. The vast majority of HCC patients present at a late stage and are unsuitable for surgery due to limited liver functional reserve. Tumors can involve major vessels or hilar structures, necessitating major liver resection and/or rendering liver resection unfeasible. A series of new technologies have been developed to optimise HCC management. Stem cell therapy improves impaired liver functional reserve prior to liver resection. Intravascular radiofrequency ablation recanalises the portal vein invaded by tumour thrombus and endobiliary radiofrequency ablation restores and extends biliary patency of the bile duct invaded by malignancy. Laparoscopic radiofrequency assisted liver resection minimizes blood loss and avoids liver warm ischemia, while increasing parenchymal sparing. These benefits combined maximize the safety of liver resection.

High-intensity focused ultrasound as a treatment for colorectal liver metastasis in difficult position

High-intensity focused ultrasound as a treatment for colorectal liver metastasis in difficult position

Robot-assisted parenchymal-sparing liver surgery including lesions located in the posterosuperior segments

The aim of the study is to describe techniques of robot-assisted parenchymal-sparing liver surgery. Laparoscopy provides the same oncologic outcomes as open liver resection and better early outcome. Limitations of laparoscopy remain resections in posterior and superior liver segments, frequently approached with laparoscopic right hepatectomy, bleeding from the section line, and prolonged operative times when a combined procedure is needed. We retrospectively analyzed our series of robot-assisted liver resections between 2008 and September 2010 to evaluate whether robot assistance can overcome the limitations of laparoscopy. A total of 23 patients underwent robot-assisted liver resection for a total of 21 subsegmentectomies, 6 segmentectomies, 2 segmentectomies S6 + subsegmentectomies S7, 1 bisegmentectomy S2-3, and 2 pericystectomies. In ten cases (47.8%) liver nodules were located in the posterior and superior liver segments. In three cases the tumor was in contact with a main portal branch and in two cases with a hepatic vein. In one case the tumor had contact with both hepatic vein and portal branch. In the latter cases a no-margin resection was carried out. In 16 cases (65.5%) liver resection was associated with a concomitant procedure (10 laparoscopic colectomies, 1 robotic rectal resection, 3 laparoscopic radiofrequency ablations, and 2 extensive adhesiolyses). Mean operative time was 280 ± 101 min, blood loss was 245 ± 254 ml, and mean hospital stay was 8.9 ± 9.4 days. Mortality was nil. One case of biliary leakage and two of intraoperative hemorrhage requiring transfusion were the main complications encountered. Robot assistance allows optimal access to all liver segments and facilitates parenchymal-sparing surgery also for lesions located in the posterosuperior segments or in contact with main liver vessels.

Chyluria After Radiofrequency Ablation of Renal Tumors

Purpose To assess the incidence of chyluria after radiofrequency (RF) ablation of renal tumors and attempt to identify predictors of this phenomenon. Materials and Methods Over a 3-year period, 62 consecutive patients with renal tumors were treated by percutaneous computed tomography (CT)–guided or laparoscopic RF ablation, of which 41 underwent at least three posttreatment CT studies and were evaluated in this study. Three radiologists reviewed the pretreatment and posttreatment CT images for the presence or absence of fat-fluid levels in the bladder, the location of the tumor, and the size of the postablation defect. A logistic regression model was used to assess whether ablation defect size or tumor location predicted chyluria. Results Chyluria was detected at a mean time of 44.5 weeks in 17 (41%) of 41 patients with renal tumors treated by RF ablation. A pretreatment biopsy specimen showed renal cell carcinoma in 74%. Mean tumor size was 2.77 cm, and mean initial ablation size was 4.2 cm. Chyluria persisted in seven patients. Zone of ablation defect size and tumor location were not significant predictors of chyluria ( P = .64 and P = .42). Mean follow-up was 77 weeks. Conclusions Chyluria is a common and asymptomatic finding in a significant proportion of patients undergoing RF ablation for renal tumors. Tumor location and zone of ablation defect size were not predictors of chyluria. The presence of a fat-fluid level should not be mistaken for an air-fluid level.

Surgical management of breast cancer liver metastases

IntroductionSelected patients with isolated breast cancer liver metastases (BCLM) may benefit from surgical management; however, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis. MethodsBetween 1998 and 2006, 17 patients diagnosed with BCLM were considered for surgical management (<4 tumours, tumour <4cm in diameter and no/stable extrahepatic metastases). Peri-operative and outcomes data were analysed and compared. ResultsEight patients were found to have extensive or untreatable disease on staging laparoscopy and intra-operative ultrasound (SL/IOUS). The remaining nine patients underwent surgical management [seven laparoscopic radiofrequency ablations (RFA) and two hepatic resections]. Median length of follow-up for patients treated surgically was 40.0 months, median disease-free survival (DFS) was 32.2 months and median time to disease progression was 17.7 months. Of the eight patients not amenable to surgery, median length of follow-up was 21.8 months. ConclusionSL/IOUS prevented unnecessary laparotomy in half of the patients taken to the operating room for surgical treatment of BCLM. In patients with BCLM, SL/IOUS should be considered standard of care before surgical intervention. The small number of patients and short follow-up may be inadequate to determine the true value of surgical management in this group of patients with BCLM.