Radiofrequency Ablation Device Research Articles

L-Shaped Arthroscopic Posterior Capsular Release in Frozen Shoulder

Background: The inadequate arthroscopic release of the tight posterior capsule in frozen shoulder may result in limited postoperative shoulder internal rotation. Indication: The purpose of this article is to describe an L-shaped arthroscopic posterior capsular release to overcome the limited internal rotation that may be encountered following the standard longitudinal technique. Operative intervention is indicated in patients with refractory shoulder stiffness with limitation of internal rotation of grade 0, +2, +4 (according to the Constant-Murley Score), after failure of conservative measures for 3 to 6 months. The technique is contraindicated if less than 3 months of physical therapy, shoulder stiffness due to osseous deformity, infection, or cuff tear arthropathy. Technique: After performing a standard anterior capsular release, the scope is shifted to the anterior portal to perform posterior capsular release by introducing the radiofrequency ablation device through the posterior portal. Posterior release begins from the glenoid level down to the 6 o’clock position until the back fibers of the infraspinatus muscle appear. Then the hook-tip part of the radiofrequency ablation device is used to perform a transverse release in the posterior capsule, starting from the beginning of the longitudinal limb. The transverse limb is performed in a stepwise manner going step-by-step laterally but ending before reaching the rotator cuff to avoid any damage of the cuff. After that, the shoulder was manipulated according to Codman technique. Results: A comparative study was performed on 43 patients with primary frozen shoulder to compare the standard longitudinal (22 patients) and L-shaped (21 patients) posterior capsular release. At the final follow-up, there was a statistically significant improvement in the internal rotation range of motion in the L-shaped group ( P < .001). There was no loss of function over time. Moreover, there were no infections, instability, or axillary nerve injury in either group. Discussion/Conclusion: Restriction of internal rotation in frozen shoulder has been attributed to posterior capsular tightness. The L-shaped arthroscopic posterior capsular release in patients with primary frozen shoulder significantly improves the postoperative internal rotation range of motion.

Abstract PS1-27: A novel technology for uniform post-lumpectomy radio-frequency ablation for margin extension and local control tested in IRB-approved pilot mastectomy study

Abstract Background: Radio-frequency ablation (RfA) of post-lumpectomy breast cavities has been shown to extend the surgical margin to reduce the need for re-operations and to provide local control without radiation therapy in many Breast Conservation Surgery (BCS) patients. However, all studies to-date have had to use adapted RfA needle electrodes designed for inoperable solid liver/kidney tumor ablation as no devices had been specifically developed for breast lumpectomy application. The SIRA™ device (Innoblative Designs Inc., Chicago, IL) is a first-in-class Saline-coupled Intra-cavitary RfA device specifically designed to fit the post-lumpectomy breast cavity and deliver uniform post-lumpectomy cavity ablation for margin extension and local control. We aimed to evaluate the SIRA device’s ablation performance in human breasts of patients undergoing prophylactic mastectomy. The device settings and ablation dose (i.e., power and duration) were previously optimized within this same model to target a ~1cm ablation depth, where residual cancer cells are most likely to be located. The study was designed to evaluate the repeatability and uniformity of the optimized settings across multiple patients. Methods: This study was approved by the Northwestern University IRB. Immediately following the prophylactic mastectomy, simulated lumpectomies 3-4cm in diameter were removed from the breast specimen by a surgeon. The SIRA device was then inserted and secured in place within the cavity with suture by the surgeon. Once secured, the ablation procedure was performed using the optimized modelled ablation dose (80W for 22min). Following each procedure, 18 representative tissue blocks were taken around each ablation cavity, H&E slides were made, and the resulting ablation zones were analyzed histologically by a board-certified pathologist, including the percent fat per slide. Results: In the 10 procedures performed, a mean ablation depth across all margins of 8mm (SD = 1.3mm) was achieved. The standard deviation within each individual procedure ranges between 0.3mm and 2.8mm, indicating the ablation is relatively uniform around the cavity. 70% of the patients had calculated BIRADs scores of either Heterogeneously Dense or Extremely Dense. Conclusions: The results of this study confirmed the feasibility of the SIRA device to create consistent and effective uniform ablations to targeted depth of ~1cm around a lumpectomy cavity in fresh human breasts undergoing mastectomy. The prophylactic mastectomy model allows for analysis of the SIRA in freshly excised ex vivo tissue to provide nearly identical electrical conductivity, thermal conductive, and mechanical stress-strain properties as in vivo breast tissue. Future studies will provide more statistical clarity on the effect of breast density on ablation depth. Most patients in the study had Heterogeneously Dense or Extremely Dense breasts, which was expected due to the nature of the younger patients receiving prophylactic mastectomy; however, the performance here was consistent across densities and supplemented with a parallel study in older, fattier breasts in a cadaveric model. Ultimately, these data show proof-of-concept for the SIRA device to provide margin extension and local control, which may ultimately reduce the need for reoperations and for adjunctive radiation in select BCS patients. Citation Format: Tyler R Wanke, Thomas Kurth, Alyssa Bailey, Zach Rzeszutek, Luis Blanco, Jr., Kevin Bethke. A novel technology for uniform post-lumpectomy radio-frequency ablation for margin extension and local control tested in IRB-approved pilot mastectomy study [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-27.

Percutaneous endobiliary ablation of malignant biliary strictures with a novel temperature-controlled radiofrequency ablation device.

We aimed to determine the safety and effectiveness of percutaneous endobiliary radiofrequency ablation of malignant biliary obstructions with a temperature-controlled radiofrequency ablation device. In this single center retrospective study, a total of 62 consecutive patients with malignant biliary obstruction were evaluated. Thirty patients who underwent endobiliary radiofrequency ablation with metallic stent placement were in the study group and 32 patients who underwent only metallic stenting were in the control group. Outcomes of this study were technical success, complications related to the procedure, stent patency, and overall survival. All procedures were technically successful in both groups. There was no procedure-related mortality in either group. Procedural complication rates were similar between the groups. Although statistically not significant, the only two major complications (hemobilia requiring endovascular treatment) were in the control group. Median primary stent patency was significantly longer in the study group than in the control group (223 days vs. 158 days; P = 0.016). Median survival rates were also longer in the study group (246 days vs. 198 days; P = 0.004). Percutaneous endobiliary radiofrequency ablation is safe and feasible with this novel radiofrequency ablation device in patients with malignant biliary obstruction. Percutaneous endobiliary radiofrequency ablation has a potential to improve both stent patency and survival.

Endoscopic treatments for GERD.

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.

Renal denervation: A safe, effective, and long-lasting blood pressure-lowering therapy.

In The Journal of Clinical Hypertension, Tino Naduvathumuriyil and colleagues report the results of their single-center registry on the effects of renal denervation (RDN) in resistant hypertension patients. They report that a total of 50 resistant hypertension patients underwent RDN using three different systems. The data from their registry showed that office blood pressure (BP) reductions following RDN were sustained throughout the follow-up periods of up to 3 years. Mean office BP was reduced from 170.6/93.4 mm Hg at baseline to 144.2/84.6 mm Hg at 36 months. Mean changes in office systolic and diastolic BP after 36 months were −26.4 and −8.8 mm Hg (95% CI: −34.6 to −18.2 and −13.5 to −4.2 mm Hg, n = 28), respectively. Patients at the very highest BP level—greater than 180 mm Hg systolic at baseline—appeared to benefit the most from the procedure at three years. Based on office BP, 100% and 82% of patients with grade 3 hypertension were responders at 24 and 36 months, respectively. Additionally, the proportion of patients with an office systolic BP ≥ 180 mm Hg dropped from 30% at baseline to 7.4% at 3 years. Although plasma creatinine increased from 90.6 μmol/L (95% CI: 82.1-99.0 μmol/L) at baseline to 102.1 μmol/L (95% CI: 95.8-108.3 μmol/L) at 36 months (P = .007), no long-term safety concerns were observed following the RDN procedure. The study is an important evidence around RDN as a safe, effective, and long-lasting BP-lowering therapy. The Global SYMPLICITY Registry is the largest study documenting the long-term safety and effectiveness of the Medtronic renal denervation systems in a real-world setting in patients with uncontrolled hypertension.1 This single-center study, as a useful supplement to the Global SYMPLICITY Registry, reconfirmed the long-term efficacy of lowering blood pressure in RDN. The recently published randomized, sham-controlled SPYRAL HTN-OFF MED (Efficacy of catheter-based renal denervation in the absence of antihypertensive medications [SPYRAL HTN-OFF MED Pivotal]: a multicentre, randomised, sham-controlled trial)2 and (Catheter-based renal denervation in patients with uncontrolled hypertension in the absence of antihypertensive medications [SPYRAL HTN-OFF MED]: a randomised, sham-controlled, proof-of-concept trial),3 SPYRAL HTN-ON MED (Effect of renal denervation on blood pressure in the presence of antihypertensive drugs: 6-month efficacy and safety results from the SPYRAL HTN-ON MED proof-of-concept randomised trial),4 and RADIANCE SOLO (Endovascular ultrasound renal denervation to treat hypertension [RADIANCE-HTN SOLO]: a multicentre, international, single-blind, randomised, sham-controlled trial)5 trials documented significant and consistent reductions in both office and ambulatory BP in patients with and without concomitant antihypertensive medication, while results are short term. Although the sample size is relatively small, the encouraging findings of this single-center registry support to the clinical application of RDN, a legitimate antihypertensive strategy, for uncontrolled hypertension. This single-center registry showed a substantial reduction in office BP after RDN using 3 different catheter-based radiofrequency ablation systems: the Symplicity RDN system from Medtronic, the EnligHTN RDN system from St. Jude Medical/Abbott, and the Vessix RDN system from Boston Scientific. This first comparison of 3 different radiofrequency ablation RDN systems reveals novel findings. Although the average BP reductions were modest and the number of patients was small, head-to-head comparison showed an advantage for Vessix RDN system perhaps because of the more complete renal nerve ablation. At present, there are a variety of RDN devices with different technologies, but different devices should have different effects. Both radiofrequency and ultrasound endovascular RDN systems have proven clinical efficacy for the treatment of hypertension. The Radiosound-HTN comparative trial has shown that RDN using endovascular ultrasound afforded superior reduction in ambulatory systolic BP in comparison with radiofrequency ablation system.6 Questions that remain open and require further evidence in future studies relate to the long-term safety and efficacy of both the radiofrequency ablation devices and that of other devices with different technologies in larger cohorts. A head-to-head comparison may be useful to determine the potential superiority of all the devices. Selection of suitable patients for RDN therapy is the key to the success of RDN. The ultimate litmus test is to identify responders and nonresponders to RDN therapy. The problem remains unresolved. In this small sample study, patients with grade 3 or higher hypertension had a better response, while the BP response was variable. Although more patients demonstrated BP reduction with RDN than with the sham procedure, there were changes seen in either direction for both groups in SPYRAL HTN-OFF MED, SPYRAL HTN-ON MED, and RADIANCE SOLO trials. In any case, following the positive SPYRAL HTN-OFF MED Pivotal data, these new data provide additional evidence on the safety and efficacy of RDN to help manage uncontrolled hypertension, with study patients experiencing meaningful blood pressure reductions out to several years. None disclaimers.

Endoscopic treatment of symptomatic insulinoma with a new EUS-guided radiofrequency ablation device.

Endoscopic treatment of symptomatic insulinoma with a new EUS-guided radiofrequency ablation device.

Endobronchial Ultrasound-Guided Radiofrequency Ablation of Lung Tumors and Mediastinal Lymph Nodes: A Preclinical Study in Animal Lung Tumor and Mediastinal Adenopathy Models

Radiofrequency ablation (RFA) can be a therapeutic option in medically inoperable lung cancer patients. In this study, we evaluated a prototype bipolar RFA device applicator that can be deployed from a standard endobronchial ultrasound (EBUS) bronchoscope to determine feasibility and histopathological analysis in animal models. Rabbit lung cancers were created by transbronchial injection of VX2 rabbit cancer cells. Once the tumors were developed, they were ablated transpleurally, under EBUS guidance using the prototype RFA device. The animals were then sacrificed for specimen resection. Pig inflammatory lung pseudo-tumors and lymphadenopathy were created by transbronchial injection of a talc paste and ablated transbronchially under EBUS guidance. Pigs were evaluated at 5 days, 2 weeks, and 4 weeks following ablation by bronchoscopy and cone beam computed tomography before necropsy. Nicotinamide adenine dinucleotide hydrogen diaphorase staining was employed to measure the ablation area. Twenty-four VX2 rabbit tumors were ablated. The total ablated area ranged from 0.6 to 3.0 cm2 (mean: 1.8 cm2), corresponding to a total energy range of 1 to 6 kJ. Six pig lung pseudo-tumors and 5 mediastinal lymph nodes were ablated. Adjacent airway ulceration was observed in 3 ablations of lymph nodes. These airway complications resolved within 4 weeks of RFA without any treatment. There was no hemoptysis, air embolism, respiratory distress, or other serious complication noted. In these 2 animal models, we provide evidence that EBUS-guided bipolar RFA is feasible and histopathology shows that can ablate lung tumors and mediastinal lymph nodes under real-time ultrasound guidance.

Outcome of arthroscopic radiofrequency denervation of the patella in the management of resistant patellofemoral pain syndrome

Background Patellofemoral pain syndrome is common in females as well as young active adults. The aim of the current study was to assess the outcome of arthroscopic radiofrequency denervation of the patella in patients with resistant patellofemoral pain syndrome. Patients and methods Thirty-two patients with patellofemoral pain syndrome were included, after failure of conservative treatment for at least 6 months. Exclusion criteria included lower limb malalignment, patellofemoral instability, or associated meniscal or knee ligamentous injuries. Arthroscopic patellar denervation was performed using a radiofrequency ablation device. Results The average duration of follow-up was 36.8 months (range, 24–48 months). At the final follow-up, the postoperative pain visual analog score improved from 7.4 (range, 5–9) preoperatively to 2.3 (range, 1–4). The postoperative Lysholm score improved significantly from 63.5 (range, 56–71) to 90.5 (range, 86–95) (P<0.0001), while the Kujala score improved significantly from 70.75 (range, 62–81) to 88.5 (range, 81–96) (P<0.0001). Conclusion Arthroscopic patellar denervation is a simple procedure that yields good results and no complications in the management of resistant patellofemoral pain syndrome.

Non-surgical blepharoplasty with the novel plasma radiofrequency ablation technology.

Surgical blepharoplasty is one of the most common plastic surgical procedures performed worldwide. It is carried out for treating both aesthetic and functional indications. As with any surgical procedures, the technique is not free from complications. The growing request for non-invasive, effective procedures, and safe technology for aesthetic treatments of eyelids has implied the research for novel treatment strategies marked by a good efficacy and less collateral effects when compared to surgical procedures. The choice fell on the relatively recent plasma skin regeneration technique. The aim of this study is to evaluate the effectiveness of plasma radiofrequency ablation in non-surgical blepharoplasty performed with DAS Medical device (Technolux), a tool working with long-wave plasma radiofrequency principles. Ten patients affected by aesthetically unpleasant dermatochalasis, excess of tissue and fine wrinkles of the eyelids, were enrolled for non-surgical blepharoplasty with long-wave plasma radiofrequency ablation device. The treatment consisted of two sessions carried out at interval of 30days. Treatments were well tolerated by all patients with no adverse effects and optimal aesthetic results. The technique consists of a modeling of the eyelids that must be sculpted reducing excess of skin, improving the appearance of eyelids, rejuvenating the eyes, and reducing eyelid heaviness. Long-wave plasma radiofrequency ablation could be an effective treatment for non-surgical blepharoplasty, and could offer an alternative choice to surgical procedures for aesthetic treatments of eyelids.

Comparison of two radiofrequency ablation devices for atrial fibrillation concomitant with a rheumatic valve procedure.

Background:Perioperative and median-term follow-up outcomes have not been compared among procedures using radiofrequency ablation devices for permanent atrial fibrillation with concomitant rheumatic valve disease. We compared the sinus rhythm restoration efficacy of “non-irrigation” ablation forceps and an “irrigation” ablation device in patients with rheumatic valve disease undergoing a modified Cox maze radiofrequency ablation procedure due to permanent atrial fibrillation.Methods:Data of 278 patients with rheumatic valve disease from the Cardiac Surgery Department of Sichuan Provincial People's Hospital who underwent the modified Cox maze radiofrequency ablation procedure between May 2013 and May 2017 were reviewed. The procedure was performed using “non-irrigation” ablation forceps (AtriCure, group A) in 149 patients and an “irrigation” ablation device (Medtronic, group M) in 129 patients. Data were collected prospectively, and follow-up was documented and compared between the groups.Results:The radiofrequency procedure duration was 28.9 ± 3.8 min in group A and 29.5 ± 2.8 min in group M (t = 1.623, P = 0.106). The predicted radiofrequency time to the left atrium diameter was (Ya = 0.4964 X + 0.3762, R2 = 0.74) in group A and (Ym = 0.4331 X + 4.3563, R2 = 0.8435) in group M. The sinus rhythm (SR) conversion rate without use of anti-arrhythmic drugs was similarly good in groups A and M, with 75.2%, 72.5%, and 70.5% vs. 73.6%, 71.3%, and 69.8% at discharge, 6 and 12 months, respectively (F = 0.084, F = 0.046, F = 0.046, P > 0.05, respectively).Conclusion:Two types of radiofrequency ablation devices characteristic of “non-irrigation” and “irrigation” bipolar ablation forceps were similarly efficient at SR restoration.

MON-LB096 Methodical Aspects of Using New Low-cost Device for Bipolar Radiofrequency Ablation: Thyrablator

The rising incidence and optimization of management of nodular goiter and thyroid cancer are actual problems for many countries. In last decade radiofrequency ablation (RFA) is becoming more useful treatment option helping to avoid an overtreatment and surgical complications. This technique was developed in 2002 in South Korea and many European countries (Italy, Denmark, Spain, Germany, Austria) are offering RFA in special thyroid clinics. The first study of the effectiveness and feasibility of thyroid nodule RFA in the USA was conducted at Mayo Clinic in 2013, however number of patients and experience until now are very limited. Currently both monopolar and bipolar RFA techniques are used. To ablate small thyroid nodules (less than 2 cm in diameter), in 2017, in framework of american-belarusian clinical trial we started to use a new, originally developed, and patented, low-cost device for bipolar RFA - «Thyrablator». In comparison to a conventional monopolar electrode for RFA, Thyrablator, was designed as a sterile, disposable needle for the fine needle biopsy (20-gauge). It can be used with any type electrosurgical unit, operating in bipolar mode, attached to the generator with a removable connector and no need for a grounding pad. Thyrablator can also be used for drainage of cysts and for injection of liquids to enhance the ablative effect or for anesthetic instillation. Methodically ultrasound-guided percutaneous bipolar RFA was performed with local anesthesia, "moving-shot" technique, with the power of 3 to 5 Watt for duration of 30 to 60 seconds. It requires less time and power for successful ablation of nodes than stated in reports for monopolar electrode. An average reduction of nodule volume was approximately up to 60% after 3 months of follow-up. Conclusion. The first clinical trial showed a promising methodical approach of the new low-cost bipolar RFA device - Thyrablator. More studies are needed for active implementation bipolar RFA in clinical practice in the USA and training programs should begin preparing experienced interventional thyroidologists to treat patients, achieving good results and low complications rate. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Safety and Efficacy of Bipolar Radiofrequency Ablation Device in Hemostasis during Thyroidectomy in Comparison with Ultrasonic Scalpel: A Comparative Study.

Aim:Ultrasonic scalpel is one of the recent advances in surgical technology. The main limitation of their use is the cost. However, radiofrequency ablation device is a refined type of electrosurgical cautery that can be used with conventional reusable bipolar cautery forceps. This study aims to compare the efficacy of bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps for hemostasis and dissection during thyroidectomy with that of ultrasonic scalpel.Materials and Methods:Sixty patients underwent total thyroidectomy were recruited at Alshiffa General Hospital, Basrah, Iraq from March 2016 to June 2017. The participants were divided into two equal groups: in the first group thyroid dissection was done with ultrasonic scalpel, and in the second group thyroid dissection was done with bipolar radiofrequency ablation device. Outcome and complications of both procedures were analyzed statistically and compared.Results:The bipolar radiofrequency ablation device significantly reduced the mean operative time by (−15.35 min) in comparison to ultrasonic scalpel. The Bipolar Radiofrequency Ablation Device (BRFA) group reported a mean operative time of 50.13 ± 14.16 compared to 65.49 ± 7.78 in the US group with, P value = 0.001. There was no statistically significant difference in the other outcome parameters and the rate of complications reported between the two devices during this study.Conclusion:The bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps is a simple, safe, and time-saving adjunct for thyroid surgeries and equally effective as compared to costly instruments like ultrasonic scalpel.Clinical Significance:The bipolar radiofrequency device can be used in thyroid surgery to secure hemostasis, save time, and cost.

Development of radiofrequency ablation devices with neuromonitoring system to detect recurrent laryngeal nerve in thyroid nodule

Background Radiofrequency ablation (RFA) is an emerging minimally invasive treatment modality of benign thyroid nodule and limited small papillary thyroid cancer. Among the RFA related complications, the recurrent laryngeal nerve (RLN) damage is one of the most concerned complications. To reduce the RLN injury during RFA, we developed a RFA device with intraoperative neuromonitoring system (IONM) to detect recurrent laryngeal nerve. Furthermore, to avoid a use of EMG tube requiring general anesthesia, we developed an accelerometer sensor that can be attached on the anterior neck skin. In this study, we examined the feasibility of neuromonitoring system to detect RLN during RFA in thyroid gland. Methods Three beagles (six thyroid glands) underwent the RFA under general anesthesia. Tip of the RF electrode acted as a neurostimulator probe and its location was ultrasonographically monitored. Stimulation current was set based on NIM-Response 3.0 system. During the procedure, nervemonitoring was performed simultaneously using NIM® standard EMG reinforced tube, needle electrode and accelerometer. Results When the tip of the RF electrode was placed near the tracheoesophageal groove, RLN was successfully identified with EMG tube, needle electrode and accelerometer sensor. After RFA near the tracheoesophageal groove, nerve injury was detected in EMG tube, needle electrode and accelerometer sensor. Conclusion Neuromonitoring system to detect RLN using RF electrode was feasible in the animal study. Like both EMG tube and needle electrode, the accelerometer sensor can detect laryngeal muscle twitching during RLN stimulation. Accelerometer sensor for detecting RLN is expected to make the RFA procedure safer without any invasive monitoring system.

Laparoscopic left lateral section resection for hydatid cyst of the liver

Background: Hydatid cyst of the liver is still a relatively common problem in endemic regions. Surgery is one of the most effective way of treatment, and it can be performed using both open and laparoscopic routes. Here, we are presenting a video showing left lateral section resection performed for hydatid liver disease. Methods: A 42-year old male patient was admitted to clinic complaining with abdominal pain. Physical examination was normal. His bilirubin levels were slightly high. Abdominal ultrasonography, contrast enhanced abdominal computed tomography revealed a 10 cm, partially exofitic cyst, localized in left lateral section of the liver, reported as hydatid cyst. An ERCP was performed. There was a communication between the left lateral biliary ducts and the cyst. Sphincterotomy was performed. Laparoscopic left lateral sectionectomy was decided. Abdominal exploration was performed using a supraumbilical 10 mm port. After hilar disection and mobilization of the left lateral section, transection line was marked using hook cautery just lateral to the falciform ligament. Paranchymal transection was performed using, bipolar vessel sealing and bipolar radiofrequency ablation devices, clips and endoscopic staplers. Results: Operative time was 70 minutes and estimated blood loss was 100 ml. Postoperative period was uneventful and the patient was discharged on postoperative second day. Conclusion: Laparoscopic surgery is a feasible treatment option depending on the localization and type of the liver hydatid cyst.

Laparoscopic left lateral section resection for hydatid cyst of the liver

Background: Hydatid cyst of the liver is still a relatively common problem in endemic regions. Surgery is one of the most effective way of treatment, and it can be performed using both open and laparoscopic routes. Here, we are presenting a video showing left lateral section resection performed for hydatid liver disease. Methods: A 42-year old male patient was admitted to clinic complaining with abdominal pain. Physical examination was normal. His bilirubin levels were slightly high. Abdominal ultrasonography, contrast enhanced abdominal computed tomography revealed a 10 cm, partially exofitic cyst, localized in left lateral section of the liver, reported as hydatid cyst. An ERCP was performed. There was a communication between the left lateral biliary ducts and the cyst. Sphincterotomy was performed. Laparoscopic left lateral sectionectomy was decided. Abdominal exploration was performed using a supraumbilical 10 mm port. After hilar disection and mobilization of the left lateral section, transection line was marked using hook cautery just lateral to the falciform ligament. Paranchymal transection was performed using, bipolar vessel sealing and bipolar radiofrequency ablation devices, clips and endoscopic staplers. Results: Operative time was 70 minutes and estimated blood loss was 100 ml. Postoperative period was uneventful and the patient was discharged on postoperative second day. Conclusion: Laparoscopic surgery is a feasible treatment option depending on the localization and type of the liver hydatid cyst.

No-touch ablation in hepatocellular carcinoma has the potential to prevent intrasubsegmental recurrence to the same degree as surgical resection.

The aim of this study was to clarify the utility of a no-touch pincer ablation procedure that uses bipolar electrodes to prevent intrasubsegmental tumor recurrence after radiofrequency ablation (RFA) for patients with hepatocellular carcinoma (HCC) compared to surgical resection. We evaluated 175 consecutive patients with HCC (single nodule, tumor diameter ≤ 30mm) who underwent surgical resection (146 received partial resection) and 313 patients who received RFA; 277 patients received touch ablation using a monopolar or bipolar RFA device, and 36 received no-touch ablation using a bipolar RFA device. Pretreatment arterial and portal phase dynamic computed tomography (CT) or magnetic resonance imaging (MRI) images were classified into four enhancement patterns: Type 1 and Type 2 are homogeneous enhancement patterns without or with increased arterial blood flow, respectively; Type 3 is a heterogeneous enhancement pattern with a septum-like structure; and Type 4 is an irregularly shaped ring structure enhancement pattern. Cumulative recurrence rates significantly differed between procedures (surgical resection, 7.5%; no-touch ablation, 2.9%; and touch ablation, 17.7% at the third year; P = 0.005). Multivariate Cox proportional hazards analysis revealed that enhancement pattern type (Type 3: hazard ratio [HR], 2.95; P = 0.002; and Type 4: HR, 3.88, P = 0.002), treatment procedure (touch ablation: HR, 3.36; P < 0.001), and serum α-fetoprotein level (≥30μg/L: HR, 1.87; P = 0.009) were significant predictors of intrasubsegmental recurrence. No significant differences between no-touch ablation and surgical resection were observed. The no-touch pincer ablation procedure has the potential to prevent intrasubsegmental recurrence after RFA for patients with HCC to the same degree as partial resection.

Treatment of Small Bowel Angiodysplasia Using a Novel Radiofrequency Ablation Device

Introduction: Gastrointestinal angiodysplasia (GIAD) is the most common cause of small bowel bleeding. Argon plasma coagulation (APC) has been the preferred modality for the treatment of GIAD, though there are limitations to this method. The angulated small bowel can often hinder the passage of the APC catheter, impairing repeated re-insertion through the enteroscope. Additionally, targeting of lesions can be difficult with APC, resulting in incomplete ablation. There is also potential for significant intestinal insufflation during prolonged procedures, as argon gas flow is set at a rate of 0.5 to 2 liters/minute. Ideally, an instrument capable of repetitive use, covering more mucosal area per treatment with low risk of damage to healthy mucosa and improved ablation is desirable. Here we present a case series of 8 patients treated with a novel through-the-scope small bowel radiofrequency ablation (SB RFA) catheter that has many of these advantages over APC. Methods: This was an open label pilot study involving 8 patients with small bowel bleed from GIAD. Informed consent was obtained for the procedure. A novel SB RFA catheter (Medtronic, Minneapolis, MN) with a shaft diameter of 2.5 mm and length of 240 cm; at settings 10 J/cm2 was used to treat small bowel GIAD with an enteroscope with a double or single balloon overtube system (FUJIFILM Medical Systems, Wayne NJ, EN-450BI5, and TS-13140, or Olympus America, Center Valley, PA Olympus SIF Q180, and ST-SB1, respectively). Results: Hemostasis was achieved in all 8 cases. There were no procedural complications, and each lesion only needed 1 treatment. There was wide variation in the number of lesions treated in each procedure, ranging from 1 to 78. The performance characteristics of the SB RFA catheter were excellent, and the RFA catheter was felt to have better targeting and bleeding control than APC. Conclusion: This early pilot study demonstrates the safety and feasibility of a novel SB RFA catheter as a viable treatment modality for small bowel GIAD. Its advantages include a more durable shaft that can tolerate multiple re-insertions and the ability to rotate the catheter, which allows for direct targeting of the lesion. Additional studies are needed to compare this to conventional APC catheters, as well as establish long term durability of treatment.765_A Figure 1. Insertion of RFA catheter through enteroscope765_B Figure 2. Successful ablation of GIAD using RFA catheter

Lightening up the Tunnel of Darkness: Endoscopic Radio Frequency Ablation of Malignant Biliary Stricture: A Novel Technique

INTRODUCTION: Radio frequency ablation (RFA) role is established in the treatment of solid tumors. However, its application in biliary system is novel. A novel endoscopic RFA (ERFA) device is available now to manage malignant biliary obstruction (MBO). We are presenting our experience with this novel device. CASE PRESENTATION: Case is a 79 year old male with diagnosis of incidental gallbladder adenocarcinoma (stage IIB;T2bNxM0) after cholecystectomy for symptomatic cholelithiasis. He refused further work up and returned three months later with obstructive jaundice. Imaging showed biliary outflow tract obstruction. ERCP showed bilateral 2.5cm long right and left hepatic duct strictures (RLHDS) extending to common hepatic duct (CHD). Brushing and biopsies were negative. Two plastic biliary stent were placed in hepatic ducts. One month later, jaundice had resolved, nevertheless due to abdominal pain and suspicion for malignant biliary stricture (BS), ERFA of BS and placement of uncovered self-expanding metallic stents (USEMS) was planned for palliative care. ERCP with cholangioscopy confirmed RLHDS biliary strictures. The novel ERFA catheter with 8 F bipolar probe and two ring electrodes (8 mm long and 6 mm apart), providing local coagulative necrosis over a length of 25mm ± 3mm was advanced over the guidewire under fluoroscopic guidance to the hepatic duct stricture. Total 6 RFA ablations (bipolar energy of 7-10 watts above and below the bifurcation respectively; 90 seconds ablation time, 1 minute stability time) were performed sequentially in RLHDS and in CHD successfully. Post RFA, successful biliary ablation appearance and improved lumen patency was noted. Two novel laser cut USEMS with simultaneous deployment device were placed in right and left hepatic ducts with excellent bile drainage. DISCUSSION: USEMS has application in MBO. However, tissue in growth remains a challenge. ERFA before stent placement can delay tumor ingrowth and frequency of re-intervention. Potential complications include thermal injury followed by late bile leak, duodenal leak, or late bleeding. However, a recent clinical trial with 65 patients by Jianfeng Yang etal showed ERFA combined with stenting can significantly prolong survival and stent patency period without increase in adverse events. Large-scale, prospective multicenter trial with a long-term follow-up may reinforce the benefits of RFA on stent patency and survival rates.1412_A.tif Figure 1: Cholangiocarcinoma with biliary stricture prior to RFA1412_B.tif Figure 2: Biliary image post RFA ablation

SAFETY AND EFFICACY OF THE BIPOLAR RADIOFREQUENCY ABLATION DEVICE FOR HEMOSTASIS IN THYROIDECTOMY IN COMPARISON WITH THE CONVENTIONAL KNOT-TYING TECHNIQUE

SAFETY AND EFFICACY OF THE BIPOLAR RADIOFREQUENCY ABLATION DEVICE FOR HEMOSTASIS IN THYROIDECTOMY IN COMPARISON WITH THE CONVENTIONAL KNOT-TYING TECHNIQUE Sadq Ghaleb Kadem*, Sarmad Manea Habash# & Mohammed Khalaf Raheem@ *#@MB,ChB, FICMS, Department of Surgery, Al-Shiffa General Hospital, Basrah, IRAQ Abstract The conventional method of hemostasis by using knot-tying technique is safe and effective in thyroid surgery but it is time consuming. A new energy devices like ultrasonic scalpel and advanced bipolar electrosurgical cautery have been proven to be safe and effective in shortening the length of thyroid surgery but the high cost of these advanced generators that designed to work only with an expensive disposable hand pieces, make its use difficult to justify in some hospitals. Radiofrequency ablation device is a refined type of electrosurgical cautery that utilizes a wave of electrons at a frequency between 2 and 4MHz to seal and divide the targeted tissue and the ablation property of this device act as an extra vessel sealing effect, it can be used with conventional reusable bipolar electrosurgical cautery hand pieces. The aim is to evaluate the safety and efficacy of a simple bipolar radiofrequency ablation device for hemostasis in thyroidectomy in comparison with the conventional knot-tying technique. This study was conducted in Alshiffa General Hospital following the approval of the local ethical committee. Fifty patients with different thyroid gland pathologies underwent total thyroidectomy in which hemostasis was achieved mainly with bipolar radiofrequency ablation device. The results of this group were compared with results of conventional knot-tying technique by the same surgical team at an earlier period. This study showed that bipolar radiofrequency ablation device significantly reduced; mean operative time, amount of foreign suture material, significant reduction in the mean volume of postoperative drainage, early patient discharge from hospital, and less complications. In conclusion, the use of the bipolar radiofrequency ablation device with conventional reusable bipolar cautery forceps for hemostasis in thyroidectomy is a safe, simple technique and effective in reducing the operative time in comparison with the conventional knot-tying technique.

Surgical linear ablation for ventricular tachycardia with postinfarction ventricular aneurysm

BackgroundLeft ventricular aneurysm (LVA) might be an arrhythmogenic substrate. Endocardiectomy and cryoablation for ventricular tachycardia (VT) with LVA can cause extensive myocardial damage. We aimed to evaluate the feasibility of surgical radial linear ablation for VT with LVA guided by electrophysiological mapping. Materials and methodsPorcine models of VT with LVA were developed. Endocardial and epicardial substrate mapping during sinus rhythm were performed under thoracotomy. Surgical radial linear ablation was achieved by a bipolar radiofrequency ablation device. Outcomes, including procedural success and acute freedom of VT, were analyzed. ResultsFifteen of 20 pigs developed LVA in a 6-wk survival period. A total of 28 sustained monomorphic VTs were initiated in 13 of 15 pigs (86.67%). The number of potential points captured from the endocardium and epicardium were 319 ± 45 and 358 ± 52 per animal, respectively. The ablative targets containing abnormal potentials were located largely on the border zone of LVA. Eight linear lesions from core to border zone of LVA were achieved per animal in a radial and even manner continuously, and ablation was repeated three times to transect border zone. The acute freedom of VT was 84.62%, P < 0.05. ConclusionsSurgical linear endo-epicardial ablation seemed to be feasible in a porcine model with VT and LVA.