Safety and efficacy of laparoscopic radiofrequency ablation of hepatocellular carcinoma in patients with liver cirrhosis

The value of intra-operative ultrasonography on safety margin and outcome during liver resection and radio-frequency ablation in the management of hepatocellular carcinoma patients

Background

Hepatocellular carcinoma (HCC) is an important health issue worldwide. Liver resection is the optimal management for early compensated HCC patients, but the majority of HCC patients are not candidates for resection. Several nonsurgical treatment modalities such as radio-frequency ablation (RFA), microwave ablation (MWA), trans-arterial chemoembolization, and immune therapy have been established. Intra-operative ultrasound (IOUS) is essential for accurate staging and secures both resection and RFA. We aimed to detect the value of using IOUS on safety margin and outcome during liver resection and RFA in the management of HCC patients. In the current study, 76 HCC patients, 58 males and 18 females, were included. Patients' age ranged from 49 to 69 years. Patients were divided into two groups: 52 open surgery liver resections (open resection group) and 24 laparoscopic-assisted RFA guided with laparoscopic IOUS (LARFA group). The open resection group was further subdivided into 32 cases for whom IOUS was performed and 20 patients studied retrospectively without IOUS. Surgical decisions were based on preoperative ultrasonography, computed tomography, and/or magnetic resonance imaging (MRI). We determined the size, number of lesions, and location by IOUS and compared them with preoperative imaging. Histopathology was done for resected lesions and follow-up CT for all patients.

Results

In the open resection group, the 32 cases of 52 for whom IOUS was performed, all had free surgical margin (100%) while 18 of 20 patients studied retrospectively without IOUS had free surgical margin (90%). Patients operated guided by IOUS had less morbidity and mortality with less operative time and hospital stay. In the LARFA group (24 patients with 37 lesions), the one-month follow-up showed complete ablation for all lesions in the 24 patients, while 12-month follow-up proved two cases of recurrence.

Conclusions

IOUS is a cornerstone in liver surgery. It improves outcomes with less morbidity and mortality and helps to achieve free surgical margin. Using IOUS allows the performance of radical but conservative hepatic resection.

Early experience with laparoscopic treatment of liver tumors using a separable cluster electrode with a no-touch technique

Introduction

Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Laparoscopic RFA has the benefit of direct visual control of the RFA procedure. Cluster electrodes (Octopus RF electrodes) can create a common ablation zone.

Aim

Using these two methods (laparoscopic approach and no touch technique), this present study evaluated the technical and clinical outcomes of early experience with laparoscopic RFA and a no-touch technique.

Material and methods

Between November 2015 and November 2018, 21 patients underwent laparoscopic RFA for hepatocellular carcinoma with a no-touch technique using cluster electrodes. Laparoscopic RFA is recommended for patients with a contraindication for surgical resection, patients wants and a relative contraindication for conventional percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct, or heart.

Results

In the 21 tumors, 2 were treated with a single electrode, 12 with 2 electrodes, and 7 tumors with 3 electrodes. The mean time of ablation per lesion was 20.43 ±8.77 min. There was no mortality, local tumor progression, delayed destructive biliary damage, or liver abscess at the follow-up computed tomography. No technical failures occurred.

Conclusions

Laparoscopic RFA can access lesions for which percutaneous RFA is contraindicated or risky. Cluster electrodes can create sufficient ablation zones without contact and can achieve a sufficient margin with a low complication rate and no tumor dissemination. Therefore, laparoscopic RFA with a no-touch technique might be a safe and feasible treatment for HCC tumor in selected patients.

Individualized laparoscopic B-ultrasound-guided microwave ablation for multifocal primary liver cancer

Introduction

Liver cancer is one of the most common malignancies of the digestive system. Minimally invasive ablation procedures have become one of the major means for treating unresectable multifocal liver cancer and have been extensively applied in primary and metastatic liver cancer treatment. Laparoscopic B-ultrasound-guided microwave ablation is an example of the progress made in this field.

Aim

To analyze and summarize the results of and experience with laparoscopic B-ultrasound-guided microwave ablation for multifocal primary liver cancer; moreover, the ablation effects were compared between tumors of different sizes.

Material and methods

Laparoscope-guided needle ablation was conducted on 84 lesions from 32 patients with primary liver cancer based on tumor size, quantity, and location. Moreover, the perioperative data, ablation effects according to tumor size, and long-term follow-up results were analyzed.

Results

Among the 84 nodules treated via microwave ablation, tumors measuring ≤ 3 cm demonstrated complete ablation upon imaging analysis conducted 1 month after surgery. Moreover, 5 of the tumors measuring > 3 cm demonstrated incomplete ablation. In these cases, a second procedure was performed, until imaging studies confirmed that complete ablation was achieved.

Conclusions

Laparoscopic microwave ablation allows for precise puncture positioning, an effective ablation range, and safe and feasible surgery, which is especially suitable for liver tumors located in sites difficult to access.

Advantages of Laparoscopic Radiofrequency Ablation Over Percutaneous Radiofrequency Ablation in Hepatocellular Carcinoma

BACKGROUND

Inoperable hepatocellular carcinoma (HCC) can be treated with laparoscopic radiofrequency ablation (LRFA), which is generally a more accurate and accessible procedure than percutaneous RFA (PRFA). However, few studies have compared survival outcomes between LRFA and PRFA in patients with HCC.

AIMS

This study aimed to compare the efficacy of LRFA and PRFA for HCC treatment.

METHODS

Patients who underwent PRFA or LRFA as an initial treatment modality between April 2005 and April 2016 were enrolled in this study. The overall and recurrence-free survival rates were examined for each patient. Additionally, propensity score matching was performed for both groups.

RESULTS

The baseline characteristics of patients in the PRFA and LRFA groups showed several minor differences. Multivariate analysis showed that the RFA method was not a critical determinant of recurrence-free or overall survival (p = 0.069 and p = 0.406). Among patients who underwent RFA as the initial treatment modality, there was no significant effect between either RFA procedures on survival. After propensity score matching, univariate analysis showed a significant difference in overall survival between PRFA and LRFA (p = 0.031). Multivariate analysis showed that LRFA is a strong factor that contributed to an improved overall survival in HCC patients (hazard ratio 0.108, p = 0.040). Furthermore, our data showed that LRFA was able to limit multiple intrahepatic recurrences, as well as prevent marginal recurrence.

CONCLUSIONS

LRFA appears to be superior to PRFA in terms of survival. LRFA may help reduce mortality in HCC patients.

Comparison of laparoscopic hepatectomy, percutaneous radiofrequency ablation and open hepatectomy in the treatment of small hepatocellular carcinoma

OBJECTIVE

Three mainstream techniques--laparoscopic hepatectomy (LH), percutaneous radiofrequency ablation (pRFA), and open hepatectomy (OH)--were compared in this study, in terms of their efficacies in the treatment of small hepatocellular carcinoma (HCC).

METHODS

A comparative study was performed within a total of 94 patients diagnosed with small HCC in our hospital from 2005 to 2010, who underwent LH (28), RFA (33), or OH (33). They had either a single tumor lesion of less than or up to three nodules with diameters of less than each. Outcomes were carefully evaluated throughout a 3-year follow-up interval and statistically interpreted.

RESULTS

The pRFA group had a significantly lower disease-free survival rate compared with the two surgical groups (P=0.001) and significantly shorter overall survival (P=0.005), while the LH group and the OH group had no difference in survival results. For patients younger than 60 years old, surgical approaches offered a better long-term overall survival prognosis (P=0.008). There were no statistically significant differences among the three groups in overall survival for elderly patients (P=0.104).

CONCLUSIONS

Among patients with small HCC, LH may provide better curative effects than pRFA without increasing complication rates. pRFA leads to faster recurrence than surgical resections. LH has similar therapeutic effects to OH and causes less trauma. For patients younger than 60 years old, LH may be the best curative treatment. Elderly patients may choose either surgery or pRFA.

Results of laparoscopic radiofrequency ablation for HCC. Could the location of the tumour influence a complete response to treatment? A single European centre experience

INTRODUCTION

In selected patients, radiofrequency ablation (RFA) is a well-established treatment for hepatocellular carcinoma (HCC). However, subcapsular or lesions close to adjacent viscera preclude a percutaneous approach. In this setting laparoscopic-RFA (LRFA) is a potential alternative. The aim of this study was to analyse the safety and feasibility of LRFA in patients with HCC.

PATIENTS AND METHODS

Retrospective study of patients with HCC meeting strict inclusion criteria who underwent LRFA at a single Institution from December 2000 to March 2013.

RESULTS

Forty-one patients underwent 42 LRFA of 51 nodules. The median size of the nodule was 2.5 (range 1.2-4.7) cm. Thirty-one tumours were subcapsular and 17 located near the gallbladder. Major complications occurred in 17 patients. The initial complete response (ICR) rate was 94% and was lower among tumours located adjacent to the gallbladder. At the end of the follow-up period, the sustained complete response (SCR) rate was 70% and was lower in tumours adjacent to the gallbladder while increased for subcapsular tumours. The 1-, 3- and 5-year overall survival rate was 92.6%, 64.5% and 43%, respectively.

CONCLUSION

LRFA of HCC is safe, feasible and achieves excellent results in selected patients. LRFA should be the first-line technique for subcapsular lesions as it minimizes the risk of tumoural seeding and improves ICR. Proximity to gallbladder interferes in treatment efficacy (lower rate of ICR and lower rate of SCR).

[Percutaneous ablation of hepatocellular carcinoma in older patients in clinical practice]

INTRODUCTION

A high percentage of older patients with early-stage hepatocellular carcinoma (HCC) are potential candidates for percutaneous ablation.

MATERIAL AND METHODS

We prospectively assessed data from patients older than 70 years with HCC. We determined their demographic and clinical characteristics, the treatment provided and the response, complications and survival among those treated with radiofrequency ablation (RFA) and/or percutaneous ethanol injection (PEI).

RESULTS

Of 194 patients with HCC, 84 were older than 70 years (43.3%). The mean age was 76.8 ± 4.5 years. Seventy-five percent were male and 91.7% had cirrhosis. Cancer was initially identified by a surveillance program in 61.9%. According to the Barcelona Clinic Liver Cancer staging system, 60.7% were classified as having early stage cancer (0-A), 19% as stage B, 12% as stage C, and 8.3% as stage D. Potentially curative initial treatment was provided in 38.2% (surgical resection in 4.8%, PEI in 22.6%, RFA in 4.8%, PEI+RFA in 6%), transarterial chemoembolization in 20.2%, and sorafenib in 3.6%. Twenty-five percent of patients were not treatment candidates and 13% refused the recommended treatment. The median follow-up after percutaneous ablation was 23 months (IQR 14.2-40.6). The mean number of sessions was 3.5 ± 2.2 for PEI and 1.8 ± 1.6 for RFA. The complications rate per session was 4%. Remission was achieved in 35.7%. The overall median survival was 45.7 months (95% CI 20.8-70.6).

CONCLUSIONS

Almost half of the patients with HCC in our sample were elderly and more than half were diagnosed at an early stage. Percutaneous ablation was performed in one-third of the sample, achieving remission in 37.5%. There were few complications. Therefore, these patients should be assessed for percutaneous ablation.

Comparative analysis of Laparoscopic versus open surgical radiofrequency ablation for malignant liver tumors

Backgrounds/Aims

This study aims to evaluate the comparative effectiveness of two surgical approaches on the treatment outcomes of radiofrequency ablation (RFA) for malignant liver tumors.

Methods

Fifty-seven patients with malignant liver tumors, hepatocellular carcinoma, cholangiocarcinoma and liver metastases, who were candidates for RFA, underwent laparoscopic or open surgical treatments.

Results

The patients' characteristics were comparable in the two groups that received open (n=33, 57.9%) and laparoscopic (n=24, 42.1%) surgical treatments. There were no statistically significant differences between the two groups in terms of recurrence rate (p=0.337) and overall survival (p=0.423). However, patients in the laparoscopic RFA group had significantly shorter hospital stay (14.1 vs. 5.9 days, p<0.05) and experienced fewer complications (Grade I: 62.5% vs. 26.3%, p=0.102).

Conclusions

Laparoscopic RFA can be performed for malignant liver tumors with lower morbidity rates, less invasiveness and lower expense compared to open surgical approach.

Laparoscopic microwave ablation in patients with hepatocellular carcinoma: a prospective cohort study

OBJECTIVES

There are no prospective studies of laparoscopic microwave (MW) ablation in patients with hepatocellular carcinoma (HCC). The aim of this study was to demonstrate the safety and efficacy of laparoscopic MW ablation.

METHODS

A prospective study group of consecutive HCC patients considered ineligible for liver resection and/or percutaneous ablation was conducted from December 2009 to December 2010. Short-term (3-month) outcomes included a centralized revision of radiological response, mortality and morbidity. Mid-term (24-month) outcomes included time to recurrence in the study group compared with that in a cohort of consecutive patients treated with laparoscopic radiofrequency (RF) ablation using propensity score analysis.

RESULTS

A total of 42 patients were enrolled. Their median age was 64 years; 67% were positive for hepatitis C virus; 33% were of Child-Pugh class B status; the median tumour diameter was 2.5 cm, and 48% of patients had multinodular HCC. In 47 of 50 (94%) nodules treated with MW ablation, a complete radiological response was observed at 3 months. There was no perioperative mortality. The overall morbidity rate was 24%. The 2-year survival rate was 79% and the 2-year recurrence rate was 55%. Using propensity score analysis (in 28 MW ablation patients and 28 RF ablation controls), 2-year recurrence rates were 55% in the MW ablation group and 77% in the control group (P = 0.03).

CONCLUSIONS

Laparoscopic MW ablation is a safe and effective therapeutic option for selected HCC patients who are ineligible for liver resection and/or percutaneous ablation.

A case of small hepatocellular carcinoma treated with laparoscopic multipolar radiofrequency ablation with a no-touch ablation procedure

A 77-year-old man with hepatocellular carcinoma was admitted to our institution. Computed tomography revealed two nodules, one at the surface and one within the liver, ≤3 cm in diameter. We performed laparoscopic radiofrequency ablation using a bipolar system with a "no-touch ablation" procedure using multiple applicators for insertion, not into the tumor directly, but to the perimeter of the tumor. A sufficient ablated area was obtained regardless of tumor location. No operative complications were encountered and adequate therapeutic effect was achieved safely. Laparoscopic multipolar radiofrequency ablation is a feasible procedure for treating hepatocellular carcinoma.

Position paper of the Italian Association for the Study of the Liver (AISF): the multidisciplinary clinical approach to hepatocellular carcinoma

Patients with hepatocellular carcinoma should be managed with a multidisciplinary approach framed in a network where all the diagnostic techniques and therapeutic resources are available in order to provide the optimal level of care. Given this assumption, the Coordinating Committee of the Italian Association for the Study of the Liver nominated a panel of experts to elaborate practical recommendations for the multidisciplinary management of hepatocellular carcinoma aiming to provide: (1) homogeneous and efficacious diagnostic and staging work-up, and (2) the best treatment choice tailored to patient status and tumour stage at diagnosis. The 2010 updated American Association for the Study of Liver Disease Guidelines for hepatocellular carcinoma were selected as the reference document. For each management issue, the American Association for the Study of Liver Disease recommendations were briefly summarised and discussed, according to both the scientific evidence published after their release and the clinical expertise of the Italian centres taking care of these patients. The Italian Association for the Study of the Liver expert panel recommendations are finally reported.

Laparoscopic ablation of hepatocellular carcinoma in cirrhotic patients unsuitable for liver resection or percutaneous treatment: a cohort study

The aim of this study was to demonstrate the safety and efficacy of laparoscopic ablation for cirrhotic HCC patients. Between January 2004 and December 2009, laparoscopic ablation was applied prospectively in 169 consecutive HCC patients (median age 62 years, 43% hepatitis C positive) considered ineligible for liver resection and/or percutaneous ablation. There was clinically relevant portal hypertension in 72% of cases. A significant proportion of subjects (50%) had multinodular tumors or nodules larger than 25 mm. The main ablation techniques used were radiofrequency in 103 patients (61%), microwave ablation in 8 (5%), and ethanol injection in 58 (34%). The primary endpoint was 3-year survival. There was no perioperative mortality. The overall morbidity rate was 25%. The median postoperative hospital stay was 3 days (range 1–19 days). Patients survived a median 33 months with a 3-year survival rate of 47%. Cox's multivariate analysis identified patient age, presence of diabetes, albumin ≤37 g/l, and alpha-fetoprotein >400 µg/l as significant preoperative predictors of survival, while the chance to undergo liver transplantation and postoperative ascites were the only independent postoperative predictor of survival. Laparoscopic ablation is a safe and effective therapeutic option for selected HCC patients ineligible for liver resection and/or percutaneous ablation.

A randomized controlled trial of radiofrequency ablation and surgical resection in the treatment of small hepatocellular carcinoma

BACKGROUND & AIMS

The aim of this study was to compare the efficacy of radiofrequency ablation (RFA) with surgical resection (RES) in the treatment of small hepatocellular carcinoma (HCC).

METHODS

A total of 168 patients with small HCC with nodular diameters of less than 4 cm and up to two nodules were randomly divided into RES (n=84) and RFA groups (n=84). Outcomes were carefully monitored and evaluated during the 3-year follow-up period.

RESULTS

The 1-, 2-, and 3-year survival rates for the RES and RFA groups were 96.0%, 87.6%, 74.8% and 93.1%, 83.1%, 67.2%, respectively. The corresponding recurrence-free survival rates for the two groups were 90.6%, 76.7%, 61.1% and 86.2%, 66.6%, 49.6%, respectively. There were no statistically significant differences between the two groups in overall survival rate (p=0.342) or recurrence-free survival rate (p=0.122). Multivariate analysis demonstrated that the independent risk factors associated with survival were multiple occurrences of tumors at different hepatic locations (relative risk of 2.696; 95% CI: 1.189-6.117; p=0.018) and preoperative indocyanine green retention rate at 15 min (ICG-15) (relative risk of 3.853; 95% CI: 1.647-9.015; p=0.002).

CONCLUSIONS

In patients with small hepatocellular carcinomas, percutaneous RFA may provide therapeutic effects similar to those of RES. However, percutaneous RFA is more likely to be incomplete for the treatment of small HCCs located at specific sites of the liver, and open or laparoscopic surgery may be the better choice.

Safety and efficacy of laparoscopic radiofrequency ablation for hepatic malignancies

Purpose

Radiofrequency 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.

Methods

Between 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).

Results

Among 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.

Conclusion

LRFA 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 approach for treatment of multiple hepatocellular carcinomas

BACKGROUND

The aim of this study is to evaluate clinical and oncologic outcomes after laparoscopic surgery for patients with multiple hepatocellular carcinoma (HCC).

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Single-port laparoscopic hepatectomy: technique, safety, and feasibility in a clinical case series

BACKGROUND

The recent use of single-port-access surgery in cholecystectomy and other abdominal surgeries has confirmed its safety and validity as a treatment option. However, few reports have described the use of complete single-port access surgeries in hepatectomy for neoplasms.

METHODS

The authors performed single-port laparoscopic hepatectomy (SLH) for eight patients (5 patients with hepatocellular carcinoma, 1 patient with metastatic liver tumor, 1 patient with endocrine liver tumor, and 1 patient with hemangioma). Furthermore, in terms of Child-Pugh classification, five patients were in category A, two in category B, and one in category C. The patients were eligible for SLH if they had solitary tumors measuring 3 cm or smaller on the caudal surface of the liver. The lesion was approached through a 20-mm supraumbilical incision using a single-port access device.

RESULTS

No patient experienced intraoperative complications that required additional port access and conversion to laparotomy. The operative time was 148 min (range, 141-235 min). The postoperative course of the patients was uneventful, and they were discharged an average of 6.2 days (range, 3-11 days) after the operation. Approximately 2 weeks after discharge, the patients experienced no wound pain or liver dysfunction.

CONCLUSION

The SLH technique is a safe and feasible procedure for a specific group of candidates, including patients with high-grade liver dysfunction.

Pure laparoscopic hepatectomy for hepatocellular carcinoma patients with severe liver cirrhosis

Hepatocellular carcinoma often arises in cirrhotic livers. Patients with severe liver cirrhosis who undergo hepatectomy often develop postoperative liver failure, even if the hepatectomy is limited. Here, we report six patients with severe liver cirrhosis (Child-Pugh B/C and indocyanine green retention rate at 15 min ≥ 40%) who underwent pure laparoscopic hepatectomy. Their perioperative course was favorable and comparable to that of other hepatocellular carcinoma patients with mild-moderate liver cirrhosis. In patients with severe liver cirrhosis, pure laparoscopic hepatectomy minimizes the disturbance in collateral blood and lymphatic flow caused by laparotomy and liver mobilization, as well as the mesenchymal injury caused by compression of the liver. It limits complications such as massive ascites, which can lead to severe postoperative liver failure. Good candidates for the procedure include patients with severe liver cirrhosis who have tumors on the liver surface and in whom adaptation to ablation therapy is difficult and/or who experience local recurrence after repeat treatments.

Radiofrequency ablation of hepatocellular carcinoma: Current status

Ablation therapy is one of the best curative treatment options for malignant liver tumors, and can be an alternative to resection. Radiofrequency ablation (RFA) of primary and secondary liver cancers can be performed safely using percutaneous, laparoscopic, or open surgical techniques, and RFA has markedly changed the treatment strategy for small hepatocellular carcinoma (HCC). Percutaneous RFA can achieve the same overall and disease-free survival as surgical resection for patients with small HCC. The use of a laparoscopic or open approach allows repeated placements of RFA electrodes at multiple sites to ablate larger tumors. RFA combined with transcatheter arterial chemoembolization will make the treatment of larger tumors a clinically viable treatment alternative. However, an accurate evaluation of treatment response is very important to secure successful RFA therapy. Since a sufficient safety margin (at least 0.5 cm) can prevent local tumor recurrences, an accurate evaluation of treatment response is very important to secure successful RFA therapy. To minimize complications of RFA, clinicians should be familiar with the imaging features of each type of complication. Appropriate management of complications is essential for successful RFA treatment.

Newly designed flexible electrode for laparoscopic radiofrequency ablation: ex vivo and in vivo comparative studies with needle electrode in a porcine liver as technical study

BACKGROUND

To compare the efficiency of radiofrequency ablation (RFA) using the newly designed flexible laparoscopic radiofrequency electrode and the internally cooled needle electrode for creating an ablation zone in ex vivo and in vivo porcine livers.

MATERIALS AND METHODS

In the ex vivo ablation zone, 40 ablation areas were created using the flexible electrode (group A, n=5) and the needle electrode of the Cool-tip RF system (group B, n=5). These were done in an excised porcine liver with a 200 W generator. In each group, ablation durations were 3, 6, 9, and 12 min, respectively. The volume was compared in each group. In the in vivo ablation zone, under laparoscopy, we divided the surface of the porcine liver into four areas: anterior, cranial, right lateral, and caudal. At each area, a couple of RFA using the flexible and needle electrodes with 6 min ablation duration was performed, respectively, in line with 3 cm intervals in five porcine livers. A flexible electrode was administered in the peritoneal cavity via a laparoscopic cannula, and a needle electrode was administered via a transcutaneous route, which avoided a pulmonary injury. The volumes and shapes of the ablation zones in each group and area were compared in the excised liver.

RESULTS

In the ex vivo experiments, the ablation volumes using the flexible and needle electrodes with 3, 6, 9, and 12 min ablation duration were 3.19±0.41 cm(3), 6.36±0.48 cm(3), 7.66±0.51 cm(3), 8.72±0.78 cm(3) (Group A) and 3.40±0.35 cm(3), 6.83±0.66 cm(3), 7.79±0.56 cm(3), 8.85±0.54 cm(3) (Group B). There was no statistical significance among all the ablated volumes in each group at the same duration. In the in vivo experiment, the differences in the short diameter and the volume of ablated zones in the caudal and right lateral areas were statistically significant (P<0.05). In the cranial, right lateral, and caudal areas, the shape of the ablated zone using the needle electrode was elliptical. However, the ablated zone using the flexible electrode was spherical. The difference of the long and short diameter ratio in the cranial and right lateral areas was statistically significant (P<0.05).

CONCLUSION

The newly designed flexible laparoscopic RF electrode shows similar efficacies compared with the needle electrode in the ex vivo study. However, it shows superiority in efficacy and predictability with the increased volume and predictable shape of coagulation necrosis at the laparoscopic RFA in the porcine liver.

[Current state of laparoscopic hepatic surgery: results of a survey of DGAV-members]

BACKGROUND

To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008.

MATERIALS AND METHODS

A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously.

RESULTS

A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551).

CONCLUSION

Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.

Intraoperative ultrasound score to predict recurrent hepatocellular carcinoma after radical treatments

Despite the high complete necrosis rate of radio-frequency ablation (RFA) or the complete removal following curative hepatic resection (HR), recurrent hepatocellular carcinoma (HCC) remains a significant problem. The aim of the study is to identify some intraoperative ultrasound (IOUS) patterns, predicting intrahepatic recurrences. From January 1997 to July 2009, 410 patients with HCC were treated (162 HR and 248 RFA through a surgical access). All patients were submitted to IOUS examination: 148 IOUS were performed during the laparotomic access while 262 IOUS were performed during the laparoscopic access. Primary HCC was classified according to diameter, HCC pattern (nodular or infiltrative), echogenicity (hyper- or hypo-echoic), echotexture (homogeneous or inhomogeneous), capsular invasion, mosaic pattern, nodule in nodule aspect and infiltration of portal vessels. Number of HCC nodules was also considered. Multivariate analysis (Cox model) was performed to determine features associated with recurrent HCC using IOUS patterns that independently predicted recurrent HCC, a IOUS score was developed. The patients were followed for 3-127 months, (median follow-up: 21.5 months). In 220 patients (54%), intrahepatic recurrences occurred. In 155 patients (38%), distant intrahepatic recurrences arose in different segments at the primary tumor site. In 65 HCC cases (16%), local recurrences were found. At multivariate analysis, multiple nodules, HCC diameter (>20 mm), HCC pattern (infiltrative), hyperechoic nodule and portal infiltration were statistically significant for risk factor of intrahepatic recurrences. Therefore, a IOUS scoring system was calculated on the basis of multivariate analysis and identified three risk categories of patients: in group 1 recurrences occurred in 37%, group 2 in 46% and group 3 in 66% (p = 0.0001). IOUS is an accurate staging tool during "surgical" procedures. This study showed an added value of IOUS: it permitted to identify ultrasound patterns, which can predict the risk of HCC recurrences. The calculated IOUS score permits to intraoperatively evaluate the actual surgical choice and to program the best treatment strategies during the follow-up period.

Radiofrequency ablation of hepatocellular carcinoma: Current status

Ablation therapy is one of the best curative treatment options for malignant liver tumors, and can be an alternative to resection. Radiofrequency ablation (RFA) of primary and secondary liver cancers can be performed safely using percutaneous, laparoscopic, or open surgical techniques, and RFA has markedly changed the treatment strategy for small hepatocellular carcinoma (HCC). Percutaneous RFA can achieve the same overall and disease-free survival as surgical resection for patients with small HCC. The use of a laparoscopic or open approach allows repeated placements of RFA electrodes at multiple sites to ablate larger tumors. RFA combined with transcatheter arterial chemoembolization will make the treatment of larger tumors a clinically viable treatment alternative. However, an accurate evaluation of treatment response is very important to secure successful RFA therapy. Since a sufficient safety margin (at least 0.5 cm) can prevent local tumor recurrences, an accurate evaluation of treatment response is very important to secure successful RFA therapy. To minimize complications of RFA, clinicians should be familiar with the imaging features of each type of complication. Appropriate management of complications is essential for successful RFA treatment.

Surgical resection versus laparoscopic radiofrequency ablation in patients with hepatocellular carcinoma and Child-Pugh class a liver cirrhosis

BACKGROUND

This study compared two homogeneous groups of patients submitted to either surgical resection (HR) or laparoscopic radiofrequency ablation (LRFA) for the treatment of hepatocellular carcinoma (HCC). When compatible with the liver functional reserve, HR remains the treatment of choice for HCC, while LRFA seems to be a promising, less invasive alternative. We thus compared HR or LRFA for short- and long-term outcomes in patients with a single HCC nodule and Child-Pugh class A liver cirrhosis.

METHODS

We enrolled 152 cirrhotic patients out of 372 cases consecutively evaluated for HCC. Enrolled patients with similar baseline characteristics underwent HR (n = 78) or LRFA (n = 74), in both cases with intraoperative ultrasonography, and they were then followed for similar durations (mean +/- standard deviation, 36.2 +/- 23.5 months for HR vs. 38.2 +/- 28.4 for LRFA). Outcomes included short- and long-term morbidity, HCC recurrence, and overall survival.

RESULTS

Short-term morbidity was far higher in the HR group while, during follow-up, HCC recurrence (mainly local) was more frequent in patients treated with LRFA. More importantly, baseline alfa-fetoprotein levels and early HCC recurrence after treatment greatly influenced overall survival, while the use of HR or LRFA did not predict it. On the other hand, HCC recurrence was found to be determined by the surgical approach and ultrasound characteristics of the tumor.

CONCLUSIONS

Our data were obtained from a large number of HCC cases and support similar survival rates after HR or LRFA for single HCC nodules on Child-Pugh class A liver cirrhosis, despite a marked increase in HCC recurrence rates after LRFA.

Laparoscopic radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Although the percutaneous approach is less invasive and is considered the first choice, RFA with laparoscopic guidance is highly recommended for patients with a relative contraindication for percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct and heart. Recent advances in laparoscopic ultrasound have widened the indication for laparoscopic ablation. In the present paper, we review the indications, advantages, prognosis and safety of laparoscopic RFA for hepatocellular carcinoma.

Efficacy of laparoscopic radiofrequency ablation for hepatocellular carcinoma compared to percutaneous radiofrequency ablation with artificial ascites

AIM

Hepatocellular carcinoma (HCC) nodules close to the liver surface exhibit high recurrence compared to those in distal parts of the liver. Moreover, when nodules remain adjacent to the gastrointestinal tract or gallbladder, severe complications such as perforation of those organs may occur due to invasive therapy. Percutaneous radiofrequency ablation (PRFA) with artificial ascites or laparoscopic radiofrequency ablation (LRFA) are used to treat these patients to avoid complications. The purpose of the present study was to assess the efficacy and safety of these two methods.

METHODS

Subjects comprised 74 patients (48 men, 26 women; mean age, 68.5 +/- 8.0 years; range, 46-89 years) with 86 HCC nodules. PRFA with artificial ascites was carried out for 37 patients (44 nodules) and LRFA was used for 37 patients (42 nodules). Clinical profiles were compared between groups.

RESULTS

No significant differences in clinical profiles were found between patients treated by PRFA or LRFA. Mean number of treatments was significantly lower for LRFA (1.0 +/- 0.0) than for PRFA (2.1 +/- 1.0, P < 0.001). Mean number of PRFA treatments was 2.2 +/- 1.0 in patients with HCC nodules >2 cm in diameter, whereas all tumors were completely ablated with only one session of LRFA. The safety margin was significantly wider for LRFA than for PRFA.

CONCLUSION

LRFA is a better treatment option for ablation of HCC nodules >2.0 cm in diameter.

Percutaneous radiofrequency ablation of liver cancer in the hepatic dome using the intrapleural fluid infusion technique

BACKGROUND

Intrapleural fluid infusion improves ultrasonographic visualization of tumours in the hepatic dome. The aim of this study was to assess the safety and long-term efficacy of ultrasonographically guided percutaneous radiofrequency ablation for tumours in the hepatic dome with intrapleural infusion.

METHODS

Of 2575 patients with hepatocellular carcinoma or hepatic metastases treated with radiofrequency ablation, intrapleural fluid infusion was performed in 587 patients for tumours in the hepatic dome. After the tip of a 14-G metallic needle was positioned in the pleural cavity under ultrasonographic guidance, 500-1000 ml of 5 per cent glucose solution was infused in 5-15 min. Radiofrequency ablation was performed using an internally cooled electrode. Long-term results were evaluated in 347 patients with a single hepatocellular carcinoma who were naive to any treatment.

RESULTS

Intrapleural fluid infusion was successfully performed in all 587 patients. The major complication rate on a per tumour basis was similar for patients treated with and without intrapleural infusion (1.6 versus 1.6 per cent; P = 0.924). The overall and recurrence-free survival were both similar for naive patients with a single hepatocellular carcinoma treated with and without intrapleural infusion (P = 0.429 and P = 0.109 respectively). Intrapleural infusion was not associated with lower overall survival in multivariable analysis.

CONCLUSION

With intrapleural fluid infusion, radiofrequency ablation for tumours in the hepatic dome was safe and effective, resulting in satisfactory overall and recurrence-free survival.

The evolving influence of laparoscopy and laparoscopic ultrasonography on patients with hepatocellular carcinoma

BACKGROUND

With the recent introduction of laparoscopic partial hepatectomy and laparoscopic/open radiofrequency ablation for hepatocellular carcinoma (HCC), the role of preoperative laparoscopic staging may be expanded. The objective of this study was to determine the role of preoperative laparoscopy and laparoscopic ultrasonography (USG) in patients with HCC.

METHODS

From January 2001 to April 2007, a cohort of 122 consecutive patients with a diagnosis of potentially resectable HCC underwent staging laparoscopy with laparoscopic USG before performing a major laparotomy in a tertiary referral center. The patients' data were collected prospectively. We have retrospectively analyzed the effect of implementation of this staging technique in our center.

RESULTS

Preoperative laparoscopy and laparoscopic USG was successful in 119 patients (97.5%). Forty-four patients were found to be unresectable after laparoscopic staging, whereas 2 patients were found to be unresectable after exploratory laparotomy. The total number of patients who underwent curative liver resection was 73 (laparoscopic partial hepatectomy, 22 patients; open partial hepatectomy, 51 patients). The median hospital stay of the laparoscopic liver resection group was significantly shorter than that of the open resection group (8 vs 13 d; P = .002). Intraoperative treatment for patients with unresectable HCC, including local ablative therapy, or combined liver resection and local ablative therapy, was performed in 27 of 45 inoperable patients (60%) (laparoscopic approach, 8 patients; open approach, 19 patients). The median hospital stay of the laparoscopic treatment group was significantly shorter than for the open treatment group for patients with unresectable HCC (5 vs 7 d; P = .003). In this study, a laparoscopic treatment approach for HCC was performed in 25.2% of the study population.

CONCLUSIONS

Laparoscopy and laparoscopic USG have a significant effect both on identifying surgically untreatable disease and in selecting the optimal treatment strategy. Some patients will benefit from a laparoscopic therapy approach. Therefore, it argues for more widespread use in laparoscopic staging procedures for patients with potentially resectable HCC.

Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis?

BACKGROUND

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection.

METHODS

A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound.

RESULTS

From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8).

CONCLUSION

Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.

Influence of approach on outcome in radiofrequency ablation of liver tumors

In this article some recent data concerning the approach on radiofrequency ablation (RFA) of liver tumors are reviewed. Specifically, several critical statements between surgical and percutaneous approach are raised and discussed: (1) Open approach may lead to a higher complication rate; (2) Temporary occlusion of hepatic inflow during surgical approach may lead to a higher rate of ablation of the liver tumors; (3) Surgical approach may permit better targeting of the tumor to be ablated. (4) Surgical approach may discover additional liver tumors. Finally, several conclusions and recommendations are also addressed.

Laparoscopic radiofrequency ablation of hepatocellular carcinoma: A critical review from the surgeon's perspective

BACKGROUND

The treatment of choice for hepatocellular carcinoma (HCC) is surgical resection but only a small percentage of patients are operative candidates. Percutaneous radiofrequency interstitial thermal ablation (RFA) has proved to be effective in the treatment of unresectable HCC. However, there is a sub-group of patients who may benefit from a laparoscopic rather than a percutaneous approach. Laparoscopic RFA offers the combined advantages of improved tumor staging based on the intracorporeal ultrasound examination and safer access to liver lesions that are difficult or impossible to treat with a percutaneous approach. The aim of our review was to evaluate the advantages and limitations of the laparoscopic approach, according to the criteria of evidence-based medicine.

CONCLUSIONS

Laparoscopic RFA of HCC proved to be a safe and effective technique, at least in terms of the short- and mid-term results. This technique may be indicated in selected cases of HCC when percutaneous RFA is very difficult or contraindicated.

Design and development of adapters for electromagnetic trackers to perform navigated laparoscopic radiofrequency ablation

Background

Laparoscopic radiofrequency ablation (RFA) is an accepted approach to treat unresectable liver tumours distinguishing itself from other techniques by combining minimal invasiveness and the advantages of a surgical approach. The major task of laparoscopic RFA is the accurate needle placement to achieve complete tumour ablation. The use of an ultrasound-based, laparoscopic online-navigation system could increase the safety and accuracy of punctures. To connect such a system with the laparoscopic ultrasound (LUS) transducer or the RFA needle especially designed adapters are needed. In this article we present our first experiences and prototypes for different sterilizable adapters for an electromagnetic navigation system for laparoscopic RFA.

Methods

All adapters were constructed with the help of a standard 3D CAD software. The adapters were built from medical stainless steel alloys and polyetherketone (PEEK). Prototypes were built in aluminium and polyoxymethilen (POM). We have designed and developed several adapters for the connection of electromagnetical tracking systems with different RFA needles and a laparoscopic ultrasound transducers.

Results

Based on earlier experiences of the initial version of the adapter, sterilisable adapters have been developed using biocompatible materials only. After short introduction, the adapters could be mounted to the laparoscopic ultrasound probe and the RFA needle under sterile conditions without any difficulties. Laboratory tests showed no disturbance of laparoscopic navigation system by the adapters. Anatomic landmarks in the liver could be safely reached. The adapters showed good feasibility, ergonomics, sterilizability and stability.

Conclusion

The development of usable adapters is the prerequisite for accurate tracking of a RFA needle for laparoscopic navigation purposes as well as 3D navigated ultrasound data acquisition. We designed, tested and used different adapters for the use of a laparoscopic navigation system for the improvement of laparoscopic RFA.

Bimodal electric tissue ablation-long term studies of morbidity and pathological change

BACKGROUND

Radiofrequency ablation is a popular method of treating unresectable liver tumors but tumors greater than 3 cm in diameter have a much greater risk of local recurrence after treatment. Bimodal electric tissue ablation is a modified form of radiofrequency ablation that creates significantly larger ablations by the addition of extra direct current circuitry. This may help to reduce the risk of local recurrence in these larger tumors. Prior to use in a clinical setting, a long term study was performed to assess associated morbidity and the pathological changes in the ablations.

METHODS

In eight pigs, six ablations were performed in each liver. Pigs were euthanized at 2 d, 2 wk, 2 mo, and 4 mo, and the ablations were assessed macroscopically and microscopically for pathological change. Regular blood tests were performed to assess changes in liver function. At death, any other abnormalities detected were reported.

RESULTS

Histopathological examination of ablation zones revealed tissue death by coagulative necrosis and healing by fibrotic scarring. Transient rises in serum liver enzymes were seen in the postoperative period. Skin necrosis was noted at the site of the positive electrode of the direct electrical current but no other form of morbidity was seen associated with the procedure.

CONCLUSIONS

Although the positive electrode placement requires further consideration, bimodal electric tissue ablation appears to be safe and behaves in a similar fashion to other thermal therapies such as standard radiofrequency ablation.

Development of a perfused ex vivo tumor-mimic model for the training of laparoscopic radiofrequency ablation

BACKGROUND

Laparoscopic radiofrequency ablation (RFA) is a safe and effective method for tumor destruction in patients with unresectable liver tumors. However, accurate probe placement using laparoscopic ultrasound guidance is required to achieve complete tumor ablation. This study aimed to develop a perfusable ex vivo tumor-mimic model for laparoscopic radiofrequency ablation training.

METHODS

After rinsing the prepared liver vessels with anticoagulants, porcine livers were perfused. Tumor-mimics were created by injecting a mixture consisting of 3% agarose, 3% cellulose, 7% glycerol, and 0.05% methylene blue, creating hyperechoic lesions in ultrasound. Heparinized porcine blood was used as perfusion medium. Continuous perfusion of the porcine liver was provided by connection of a pump system to the portal vein and the vena cava inferior. Laparoscopic RFA techniques were taught using a laparoscopic pelvi-trainer.

RESULTS

A total of 30 laparoscopic ablations were performed in four porcine livers. The simulated "tumors" were clearly visible on laparoscopic ultrasound and not felt during placement of the RFA probe. In addition, color duplex ultrasound showed clear signals indicating for a sufficient liver perfusion.

CONCLUSION

Laparoscopic RFA requires advanced laparoscopic ultrasound skills for an accurate placement of the RFA probe. The perfused tumor-mimic model presented is a safe, easy, effective, and economic method to improve and train laparoscopic RFA skills on porcine liver tissue.

Technical Aspects And Feasibility of Laparoscopic Ultrasound Navigation in Radiofrequency Ablation of Unresectable Hepatic Malignancies

PURPOSE

Laparoscopic radiofrequency ablation is safe, practicable, and combines minimally invasive surgery with the advantages of laparotomy. However, application of the laparoscopic freehand puncture is restricted because of capnoperitoneum and the consequent fixation of the needle on two different points. The use of a laparoscopic ultrasound probe with a canal for puncture can solve this problem and improve precision. However, a stiff needle limits the necessary angulation that is needed to reach right-lateral and cranial liver metastases. Therefore we present a new navigation tool for laparoscopic interventions.

MATERIALS AND METHODS

The US Guide 2000 (Ultra Guide, Tirat Hacarmel, Israel) is an independent navigation system compatible with all ultrasound machines and has six degrees of freedom. After proper evaluation of this system under operating room conditions during transcutaneous radiofrequency ablation, we used this technique in laparoscopic radiofrequency ablation. A special adapter was developed to attach the ultrasound-based navigation system to a laparoscopic ultrasound probe. After calibrating the system with an ultrasound phantom, laparoscopic navigation in a liver organ model was studied.

RESULTS

Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Anatomic landmarks in the liver could be safely reached. No interaction between the navigation system and the laparoscopic ultrasound probe or operating instruments was observed.

CONCLUSION

Our preliminary results show the feasibility of this technique in laparoscopic radiofrequency ablation. The use of an ultrasound-based laparoscopic inline navigation system offers the possibility of out-of-plane needle placement and could combine the flexibility of freehand puncture with the accuracy of a canal for puncture. This could increase the safety and accuracy of punctures.

Treatment Approaches for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide, and it is responsible for up to one million deaths annually. Although multiple risk factors for HCC have been identified, and despite preventive measures, the incidence of HCC continues to rise to epidemiologic proportions in the United States. In general, tumor resection and orthotopic liver transplantation are the treatment with the best outcome; however, HCC is generally diagnosed late in its course when patients are not eligible for curative treatment options. HCC is a relatively Chemo-refractory tumor secondary to heterogeneity of the tumor and the high rate of multidrug resistant gene expression. There are no standard treatments for HCC, multiple palliative treatment modalities have been used for patients with unresectable disease. None of these modalities have shown any superiority; and the retrospective nature of these available data has confounded any reasonable conclusions. Different institutions use different treatment schema dependent on the center expertise. Sorafenib, a tyrosine kinase inhibitor, has recently demonstrated a survival advantage in metastatic HCC, and if approved by the FDA, might become the standard of care. In this article we will review the rationale behind the currently available treatment options for HCC.

Evaluation of an online navigation system for laparoscopic interventions in a perfused ex vivo artificial tumor model of the liver

BACKGROUND

Laparoscopic radiofrequency ablation (RFA) is a safe and effective method for tumor destruction in patients with unresectable liver tumors. However, accurate probe placement using laparoscopic ultrasound guidance is required to achieve complete tumor ablation. After evaluation of an ultrasound navigation system for transcutaneous and open RFA, we now intend to transfer this technique to laparoscopic liver surgery. This study aimed to evaluate an electromagnetic navigation system for laparoscopic interventions using a perfusable ex vivo artificial tumor model.

MATERIALS AND METHODS

First a special adapter was developed to attach the ultrasound and electromagnetic tracking-based navigation system to a laparoscopic ultrasound probe. The laparoscopic online navigation system was studied in a laparoscopic artificial tumor model using perfused porcine livers. Artificial tumors were created by injection of a mixture of 3% agarose, 3% cellulose, and 7% glycerol, creating hyperechoic lesions in ultrasound.

RESULTS

This study showed that laparoscopic ultrasound-guided navigation is technically feasible. Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Artificial tumors were clearly visible on laparoscopic ultrasound and not felt during placement of the RFA probe. Anatomic landmarks and simulated 'tumors' in the liver could be reached safely.

DISCUSSION

Laparoscopic RFA requires advanced laparoscopic ultrasound skills for accurate placement of the RFA probe. The use of an ultrasound-based, laparoscopic online navigation system offers the possibility of out-of-plane needle placement and could increase the safety and accuracy of punctures. The perfused artificial tumor model presented a realistic model for the evaluation of this new technique.

Impact of intraoperative ultrasonography in laparoscopic liver surgery

BACKGROUND

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. This mainly includes diagnostic procedures, interstitial therapies, and treatment of liver cysts. However, the authors believe there is room for a laparoscopic approach to the liver in selected cases.

METHODS

A prospective study of laparoscopic liver resections was undertaken with patients who had preoperative diagnoses of benign lesion and hepatocellular carcinoma with compensated cirrhosis. The inclusion criteria required that hepatic involvement be limited and located in the left or peripheral right segments (segments 2-6), and that the tumor be 5 cm or smaller. The location of the tumor and its transection margin were defined by laparoscopic ultrasound (LUS).

RESULTS

From December 1996, 17 (5%) of 313 liver resections were included in the study. There were 5 benign lesions and 12 hepatocellular carcinomas in cirrhotic patients. The mean age of the study patients was 59 years (range, 29-79 years). The LUS evaluation identified the presence of new hepatocellular carcinoma nodules in two patients (17%). The resections included 1 bisegmentectomy, 8 segmentectomies, 3 subsegmentectomies, and 3 nonanatomic resections. The mean operative time, including laparoscopic ultrasonography, was 156 +/- 50 min (median, 150 min; range, 60-250 min), and the perioperative blood loss was 190 +/- 97 ml. There was no mortality. Conversion to laparotomy was necessary for two patients. Postoperative complications were experienced by 3 of 15 patients, all of them cirrhotics. One of the patients had a wall hematoma, and the remaining two patients had bleeding from a trocar access requiring a laparoscopic reexploration. The mean hospital stay for the whole series was 6.9 +/- 4.9 days (median, 6 days; range, 2-25 days) and 5.6 +/-1.4 days (median, 6 days; range, 2-8 days) for the 15 laparoscopic patients.

CONCLUSION

Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver. Evaluation by LUS is indispensable to guarantee precise determination of the segmental tumor location and the relationship of the tumor to adjacent vascular or biliary structures, excluding adjacent or adjunctive new lesions. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations.

Survival and intra-hepatic recurrences after laparoscopic radiofrequency of hepatocellular carcinoma in patients with liver cirrhosis

BACKGROUND

The optimal treatment for hepatocellular carcinoma (HCC) is surgical resection. However, only a small percentage of patients are operative candidates. Percutaneous radiofrequency interstitial thermal ablation proved to be effective, too. Our objective was to assess a novel operative combination of laparoscopic ultrasound (LUS) with laparoscopic radiofrequency (LRF) in the treatment of HCC not amenable to liver resection.

METHODS

One hundred and four patients with HCC in liver cirrhosis were submitted to laparoscopic LRF. A LRF was indicated in patients not amenable to liver resection that had at least one of the following criteria: (a) severe impairment of the coagulation tests; (b) large tumors (but <5 cm) or multiple lesions requiring repeated punctures; (c) superficial lesions adjacent to visceral structures; (d) deep-sited lesions with a very difficult or impossible percutaneous approach; (e) short-term recurrence of HCC following percutaneous loco-regional therapies.

RESULTS

The LRF procedure was completed in 102 out of 104 patients (98% feasibility rate). LUS identified 26 new malignant lesions (25%) undetected by pre-operative imaging. There was no operative mortality. Seventy-six patients had no complication (73%). At 1-month computed tomography (CT) evaluation, a complete response with a 100% necrosis was achieved in 88 out of 101 patients (87%). During the follow-up (mean follow-up: 22.5 +/- 15.9 months), 55 patients (54%) developed new malignant nodules (42% of these recurrences were localized in the same segment of the HCC treated).

CONCLUSIONS

LRF of HCC proved to be a safe and effective technique at least in the short and mid-term: in fact it permits to treat lesions not treatable with the per cutaneous approach, to detect 25% of new HCC nodules and it has a low morbidity rate.