Radiofrequency assisted liver resection: analysis of 604 consecutive cases. Eur J Surg Oncol. 2012;38:274-280. [PMID: 22209064 DOI: 10.1016/j.ejso.2011.12.006]

Ten-year experience of laparoscopic partial splenectomy for patients with splenic benign lesions

BACKGROUND

The increasing comprehension of spleen function has led to the gradual endorsement of laparoscopic partial splenectomy (LPS) as a treatment option for benign spleen lesions. However, it is important to note that the LPS technique remains challenging. This study explores the standardized process and surgical techniques in LPS, aiming to promote the application of this technique.

METHODS

The clinical data of 20 patients with benign cystic or solid spleen lesions who underwent LPS at Shunde Hospital, Southern Medical University were retrospectively collected. Data include age, gender, imaging data, surgical process, and postoperative complications. Additionally, the surgical techniques and standardization process were recorded in detail.

RESULTS

All 20 cases completed LPS without conversion to laparotomy or splenectomy. The surgical time was 162.25 ± 37.96 min, the intraoperative blood loss was 93.00 ± 58.40 mL, no blood products were transfused during the operations, and the removed volume of the spleen was about 34.75 ± 12.19 %. There were no postoperative complications such as intra-abdominal bleeding, intra-abdominal infection, pancreatic fistula, and residual splenic infarction. Postoperative pleural effusion occurred in four cases, and symptoms improved after symptomatic treatment. The postoperative hospital stay was 7.0 ± 1.4 days. There were no perioperative deaths. The residual splenic vessels were normal during the follow-up period, and no vascular embolism occurred.

CONCLUSIONS

LPS is a safe, feasible, and effective surgical method for patients with benign cystic or solid spleen lesions. Subsequently, mastering related surgical techniques and standardized surgical procedures can control the surgical risks in suitable cases, making LPS the standard procedure for treating benign spleen diseases.

One-stage resection of primary colorectal cancer and hepatic metastases using the Habib Device: analysis of 40 consecutive cases treated in a Unit of general surgery

BACKGROUND

More than 50% of patients with colorectal cancer (CRC) present or develop hepatic metastases (HM). The intraoperative use of the Habib 4X® radio frequency probe device is safe in resetting HM and allows a one-stage resection of both CRC and HM with a similar mortality rate than a two-stage surgical treatment.

METHODS

After an exhaustive residential training at the reference center for hepato-biliary surgery of the Imperial College of London, we treated at our unit of general surgery 40 consecutive patients with CRC and HM with the one-stage resection, using the Habib 4X® intraoperative radiofrequency probe device to reset HM.

RESULTS

None of the 40 patients died during the intra-operatory and post-operatory periods, none presented liver failures during the postoperative course nor complication related to the Habib's resection procedure (e.g. bleeding, abscess, bile leak). The amount of intra-operative liver bleeding was minimal. New HM arose in 10 (25%) cases, with a mean disease-free interval of 13 months, but the hepatic tissue close to previous resections remained cancer-free. The 69.7% of patients were disease-free at month 24 of the post-operative follow-up and 5-year rate was about 70%.

CONCLUSIONS

The data suggest that surgeons well trained at a reference center for hepato-biliary surgery may perform with excellent results the one-stage CRC and HM resection with the Habib 4X® device even in a Unit of general surgery.

Gut Barrier Disruption Secondary to Radiofrequency-Assisted Liver Parenchyma Resection in a Porcine Model

BACKGROUND

Radiofrequency-assisted liver resection (RF-LR) techniques minimize intraoperative blood loss, while avoiding the Pringle maneuver. Both surgical excision and radiofrequency ablation of liver parenchyma compromise gut barrier function with subsequent bacterial translocation. The present study sought to investigate in a porcine model the impact of two RF-LR techniques on the integrity and inflammatory response of the gut barrier.

METHODS

Twenty-four pigs were subjected to either (a) partial hepatectomy (PH) employing the "sequential coagulate-cut" technique using a monopolar electrode (SCC group), the one using the bipolar Habib-4X device (group H), or the "crush-clamp" technique (group CC) or (b) sham operation (group Sham). At 48-h post-operation, ileal tissue was excised to be subjected to histopathologic examination, histomorphometric analysis, and immunohistochemical assessment of the mitotic and apoptotic activities and the expression of interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and nuclear factor-κB (NFκΒ).

RESULTS

Histopathologic score increased in all PH groups, being higher in group SCC, while lower in group H. Villous height decreased in group SCC only. Mitotic index decreased, while apoptotic index increased in all PH groups. An increase in tissue expression score was noted for IL-6 in group CC, for TNFα in all PH groups, being lower in group H compared to group CC, and for NFκB in all PH groups.

CONCLUSIONS

The Habib-4X technique for liver resection proved to preserve the integrity of gut barrier, being less injurious in the intestinal mucosa compared to the SCC and CC techniques.

Radiofrequency ablation in the treatment of hepatocellular carcinoma

OBJECTIVE

The purpose of this article is to discuss the use, comparative efficacy, and research progress of radiofrequency ablation (RFA), alone or in combination with other therapies, for the treatment of hepatocellular carcinoma (HCC).

METHOD

To search and summarize the basic and clinical studies of RFA in recent years.

RESULTS

RFA is one of the radical treatment methods listed in the guidelines for the diagnosis and treatment of HCC. It has the characteristics of being minimally invasive and safe and can obtain good local tumor control, and it can improve the local immune ability, improve the tumor microenvironment and enhance the efficacy of chemotherapy drugs. It is commonly used for HCC treatment before liver transplantation and combined ALPPS and hepatectomy for HCC. In addition, the technology of RFA is constantly developing. The birth of noninvasive, no-touch RFA technology and equipment and the precise RFA concept have improved the therapeutic effect of RFA.

CONCLUSION

RFA has good local tumor control ability, is minimally invasive, is safe and has other beneficial characteristics. It plays an increasingly important role in the comprehensive treatment strategy of HCC. Whether RFA alone or combined with other technologies expands the surgical indications of patients with HCC and provides more benefits for HCC patients needs to be determined.

A novel internal cold circulation radiofrequency-assisted device for liver transection

PURPOSE

To evaluate the safety and efficacy of a new internal cold circulation bipolar radiofrequency compared with Habib-4X bipolar radiofrequency device in the resection of liver tumors.

METHODS

A total of 85 patients with hepatocellular carcinoma who received radiofrequency-assisted liver resection from February 2017 to January 2020 were retrospectively enrolled in our study, in which 45 patients received the new internal cold circulation bipolar radiofrequency (New-RF) and 40 patients received Habib-4X bipolar radiofrequency (Habib-4X). Primary outcome measures were the speed of liver transection, the width of coagulation tissue, hemorrhage volume, blood transfusion rate, and operation time.

RESULTS

The baseline characteristics of patients in the New-RF and Habib-4X groups had no significant difference (p > 0.05). Compared to Habib-4X, the New-RF had a faster average speed of liver transection (4.81 ± 1.20 cm²/min vs 3.64 ± 1.08 cm²/min, p < 0.001), a narrower width of coagulation tissue (1.42 ± 0.23 cm² vs 1.81 ± 0.20 cm², p < 0.001), a less operation time (55.04 ± 16.12 min vs 64.02 ± 15.09 min, p = 0.010), a lower rate of needle path bleeding (13.3% vs 35.0%, p = 0.019), and a lower carbonization rate of electrode needle (22.2% vs 77.8%, p < 0.001). Hemorrhage during the transection (85.0 ml vs 105.0 ml, p = 0.438) and hemorrhage per square centimeter (3.28 ± 0.86 ml/cm² vs 3.60 ± 1.12 ml/cm², p = 0.141) in the New-RF group were smaller than those in Habib-4X group with no significant difference.

CONCLUSION

The new internal cold circulation bipolar radiofrequency was a safe and efficacious auxiliary device for liver resection with a faster speed of resection, lower carbonization rate of electrode needle, and more precise range of coagulation.

Liver Transection with Precoagulation Therapy in Liver Cirrhosis: Effective Use of an Energy Device at Hepatectomy

Background

Hepatectomy for liver cirrhosis patients requires skillful surgical technique and careful attention because of the fibrotic parenchyma, elevated portal pressure, and impaired coagulation. This report evaluated short- and long-term outcomes for liver cirrhosis patients receiving precoagulation therapy on the parenchymal transection plane, compared with noncoagulation cases.

Methods

Seventy-three patients diagnosed with cirrhosis via postoperative pathological findings were selected after reviewing 887 hepatectomy patient files. They were divided into a precoagulation group (n = 20) and a noncoagulation group (n = 53). There were no significant differences in patient and tumor factors between 2 groups.

Results

The precoagulation group had significantly less blood loss compared with noncoagulation group [282 vs 563g (P &lt; 0.05)], shorter operative time [214 vs 276 min (P = 0.06)], and shorter postoperative hospital stays [14.5 vs 22.5 days (P = 0.12)]. The median recurrence free survival rates time in the pre-coagulation group (733 days) was significantly longer than that in the non-coagulation group (400 days) (P &lt; 0.05). Overall survival rates showed rates showed no difference between the 2 groups (P = 0.62).

Conclusions

Precoagulation therapy may be the a preferred treatment application for hepatectomy patients with severe liver fibrosis.

Local therapies for liver metastases of rare head and neck cancers: a monoinstitutional case series

INTRODUCTION

Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are established procedures for treating hepatocellular cancer and selected malignancies with liver metastasis. The aim of this study is to describe a monoinstitutional case series of local approaches in patients with liver metastases from rare head and neck cancers (HNCs).

METHODS

This is a retrospective series of adult patients with HNC treated with liver locoregional approaches (TACE or RFA) at our institution from 2007 to 2018. In case of chemoembolization, the preferred chemotherapeutic drug was doxorubicin. Response according to RECIST (Response Evaluation Criteria in Solid Tumors) was assessed with contrast-enhanced computed tomography scans.

RESULTS

Thirty-four patients were treated (20 men, median age 58 years) with TACE (27), transarterial embolization (2), or RFA (7). Primary tumours were salivary gland (21), thyroid (6), nasopharyngeal (5), and sinonasal cancers (2). Seventeen patients (50%) had a single metastatic liver nodule; 70% of the remaining 17 patients had at least three liver metastases. The median diameter of the metastatic liver mass undergoing treatment was 39 mm (range 11-100 mm). Median follow-up was 27.6 months. Response rate was 35% (3% complete, 32% partial response). Median progression-free survival and overall survival were 6.9 and 19.6 months, respectively. Treatment-related adverse events occurred in 59% of patients (21% grade ⩾ 3; no grade 5).

DISCUSSION

This retrospective case series demonstrates that locoregional radiologic approaches for rare HNCs with liver metastases are feasible. These procedures deserve further prospective studies before being considered safe and active in these malignancies where the availability of effective systemic treatments is lacking.

Ablative therapies for hepatic and biliary tumors: endohepatology coming of age

Ablative therapies refer to minimally invasive procedures performed to destroy abnormal tissue that may arise with many conditions, and can be achieved clinically using chemical, thermal, and other techniques. In this review article, we explore the different ablative therapies used in the management of hepatic and biliary malignancies, namely hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), with a particular focus on radiofrequency ablation (RFA) and photodynamic therapy (PDT) techniques.

Safety and efficacy of percutaneous microwave ablation for post-procedural haemostasis: a bi-central retrospective study focusing on safety and efficacy

OBJECTIVE

To review safety and efficacy of percutaneous microwave ablation (MWA) for post-procedural haemostasis.

METHODS

Institutional databases retrospective research identified 10 cases of iatrogenic bleeding who underwent percutaneous MWA for post-procedural haemostasis. Ultrasound examination with Doppler and contrast enhancement identified a source of active bleeding prior to ablation; additionally they were used as guiding modality for antenna insertion whilst, post-ablation, assessed the lack of active extravasation. Target locations included liver intercostal space spleen and thyroid gland. Technical success was defined as positioning of the antenna on the desired location. Treatment end point was considered the disappearance of active extravasation in both Doppler imaging and contrast-enhanced ultrasound.

RESULTS

Technical success (i.e. positioning of the antenna on the desired location) was achieved in all cases. No complications were noted. All patients post MWA remained haemodynamically stable with no need for transfusion and were discharged from the hospital the next morning. Imaging and clinical follow-up in all patients before exiting the hospital did not depict any sign of active extravasation or bleeding.

CONCLUSION

Our limited experience reports preliminary data showing that MWA could be added in the armamentarium of percutaneous therapies for iatrogenic bleeding. More prospective studies with larger patient samples are necessary for verification of this technique as well as for drawing broader conclusions in order to evaluate the place of percutaneous ablation in the treatment algorithm of haemorrhage.

ADVANCES IN KNOWLEDGE

Percutaneous ablation might have a role in haemostasis in well-selected cases.

A Systematic Review and Meta-Analysis Comparing Liver Resection with the Rf-Based Device Habib™-4X with the Clamp-Crush Technique

Liver cancer is the sixth most common cancer and third most common cause of cancer-related mortality. Presently, indications for liver resections for liver cancers are widening, but the response is varied owing to the multitude of factors including excess intraoperative bleeding, increased blood transfusion requirement, post-hepatectomy liver failure and morbidity. The advent of the radiofrequency energy-based bipolar device Habib™-4X has made bloodless hepatic resection possible. The radiofrequency-generated coagulative necrosis on normal liver parenchyma provides a firm underpinning for the bloodless liver resection. This meta-analysis was undertaken to analyse the available data on the clinical effectiveness or outcomes of liver resection with Habib™-4X in comparison to the clamp-crush technique. The RF-assisted device Habib™-4X is considered a safe and feasible modality for liver resection compared to the clamp-crush technique owing to the multitude of benefits and mounting clinical evidence supporting its role as a superior liver resection device. The most intriguing advantage of the RF-device is its ability to induce systemic and local immunomodulatory changes that further expand the boundaries of survival outcomes following liver resection.

The impact of R1 resection for colorectal liver metastases on local recurrence and overall survival in the era of modern chemotherapy: An analysis of 1,428 resection areas

BACKGROUND

It is still unclear whether a positive surgical margin after resection of colorectal liver metastases remains a poor prognostic factor in the era of modern perioperative chemotherapy. The aim of this study was to evaluate whether preoperative chemotherapy has an impact on reducing local recurrence after R1 resection, and the impact of local recurrence on overall survival.

METHODS

Between 2000 and 2014, a total of 421 patients underwent resection for colorectal liver metastases at our unit after preoperative chemotherapy. The overall number of analyzed resection areas was 1,428.

RESULTS

The local recurrence rate was 12.8%, significantly higher after R1 resection than after R0 (24.5% vs 8.7%; P < .001). These results were also confirmed in patients with response to preoperative chemotherapy (23.1% after R1 vs 11.2% after R0; P < .001). At multivariate analysis, R1 resection was the only independent risk factor for local recurrence (P < .001). At the analysis of the 1,428 resection areas, local recurrence significantly decreased according to the increase of the surgical margin width (from 19.1% in 0 mm margin to 2.4% in ≥10 mm). At multivariable logistic regression analysis for overall survival, the presence of local recurrence showed a significant negative impact on 5-year overall survival (P < .001).

CONCLUSION

Surgical margin recurrence after modern preoperative chemotherapy for colorectal liver metastases was still significantly higher after R1 resection than it was after R0 resection. Local recurrence showed a negative prognostic impact on overall survival. R0 resection should be recommended whenever technically achievable, as well as in patients treated by modern preoperative chemotherapy.

Radiofrequency-assisted liver resection: Technique and results

BACKGROUND

Radiofrequency (RF)-assisted liver resection allows non-anatomical liver resection with reduced blood loss and offers the opportunity for a combination of resection and ablation. However, there are still concerns with regard to postoperative complications related to this technique. In the present study, we discuss the technical aspects of RF-assisted liver resections and analyse the rate of perioperative complications, focusing on post-hepatectomy liver failure (PLF), bile leak and abscess, and mortality.

METHODS

Between 2001 and 2015, 857 consecutive open and laparoscopic elective RF-assisted liver resections for benign and malignant liver tumours were reviewed retrospectively to assess perioperative outcomes.

RESULTS

Median intraoperative blood loss was 130 mL, with 9.8% of patients requiring blood transfusion. Intra-abdominal collections requiring percutaneous drainage developed in 8.7% of all patients, while bile leak at resection margin developed in 2.8% of the cases. Major liver resection was performed in 34% of patients and the incidence of PLF was 1.5% with one directly related mortality (0.1%).

CONCLUSION

RF-assisted liver resection has evolved into a feasible and safe technique of liver resection with an acceptable incidence of perioperative morbidity and a low incidence of PLF and related mortality.

A new technique for hepatic parenchymal transection using an articulating bipolar 5 cm radiofrequency device: results from the first 100 procedures

BACKGROUND

Parenchymal transection(PT) still remains a challenge in liver resection. The outcomes of the first experience of a novel vessel-sealer for hepatic transection were assessed.

METHODS

A bipolar articulating vessel-sealer (Caiman^®, Aesculap Inc., Center Valley, PA) was used in 100 liver resections through both open (OLR) and laparoscopic (LLR) approaches. All data were prospectively collected into an IRB-approved department database, and clinical, surgical and perioperative parameters were analyzed.

RESULTS

Fifty patients underwent OLR and 50 patients underwent LLR. Eighty hepatectomies were performed for malignancy. Median number of tumors was 1, with the largest focus measuring an average of 5.1 cm. Forty-nine of the procedures were major liver resections. Parenchymal transection time was 29.9 ± 3.1 min in OLR and 29.9 ± 3.6 min in LLR. Median estimated blood loss was 300 cc (Inter-quartile range (IQR) 100-575 cc). Median hospital stay was 6 days for open and 3 days for laparoscopic procedures. Ninety-day complication rate was 8% without any mortality. Bile leak rate was 4%. Staplers were used for parenchymal transection in 16 cases.

CONCLUSION

This study introduces a new multifunctional device into the armamentarium of the liver surgeon. In our experience, this device facilitated the parenchymal transection by adding speed and consolidating the amount of instrumentation used in liver resection without increasing complications.

HabibTM 4X-assisted resection versus clamp-crush resection for hepatocellular carcinoma: a propensity-matching study

Long term outcome of ablation-assisted hepatic resection is unclear for hepatocellular carcinoma (HCC) patients. This study was scheduled to compare the outcome of Habib 4X ablation assisted resection (Habib group) with clamp-crush resection (CC group) for HCC. In this study, we retrospectively enrolled 81 patients from the Habib group and 103 patients from the CC group. Oncologic outcomes were analyzed using a propensity score matching (PSM) method. Compared with the CC group, the Habib group had higher levels of γ-glutamyltransferase (P=0.044) and albumin (P=0.001), larger tumor sizes (P=0.007), shorter operation times (P=0.001), less blood loss (P=0.005), and less blood transfusions (P=0.038). There were no significant differences in complications (P=0.310), recurrence-free survival rates (RFS, P=0.112), or overall survival rates (OS, P=0.203) between the two groups. For the 67 patient pairs selected from the PSM analysis, the Habib group had better RFS and OS (P=0.033 and P=0.014, respectively). A Cox proportional hazards analysis revealed that Habib-assisted resection was an independent factor for RFS and OS (P=0.008 and P=0.016, respectively). Furthermore, for the 42 patients with central and large tumors, the Habib group had better RFS and OS than the CC group (P=0.035 and P=0.038, respectively). However, the differences of RFS and OS (P=0.117 and P=0.126, respectively) were not significant among 92 patients with peripheral or small tumors. Hence, Habib^TM 4X-assisted resection is safe and provides better survival for HCC patients, particularly those with central and large tumors.

Microwave-assisted liver resection vs. clamp crushing liver resection in cirrhosis patients with hepatocellular carcinoma

PURPOSE

This study aimed to evaluate the safety and effectiveness of microwave-ablation-assisted liver resection (MW-LR) and clamp crushing liver resection (CC-LR) in cirrhotic patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From July 2005 to January 2015, cirrhotic HCC patients who underwent CC-LR (n = 191) or MW-LR (n = 112) were retrospectively analysed. We compared morbidity, mortality, disease-free survival (DFS) time and overall survival time between the CC-LR and MW-LR groups.

RESULTS

The blood loss volume was significantly higher in the CC-LR group (mean of 752 ml) than that in the MW-LR group (mean of 253 ml, p < 0.001). The abdominal abscess rate was higher in the MW-LR group (8.9%) than that in the CC-LR group (3.1%, p = 0.029). The 30-day mortality rate (1.5% vs. 0.8%) and postoperative complication rate (32.9% vs. 25.0%) were both similar between the CC-LR and MW-LR groups. MW-LR provided a survival benefit over CC-LR at 1, 3 and 5 years in the entire population (93.5% vs. 87.0%, 77.0% vs. 62.5% and 50.0% vs. 36.5%, respectively; p = 0.003). In a subgroup analysis, MW-LR provided a survival benefit over CC-LR for Barcelona Clinic Liver Cancer stage A (BCLC-A) HCC (p = 0.026) and stage B (BCLC-B) HCC (p = 0.035) patients and provided DFS benefits for BCLC-A HCC patients (p = 0.036).

CONCLUSIONS

MW-LR is a safe and feasible procedure for HCC patients with a cirrhotic liver history.

Laparoscopic liver resection using a monopolar soft-coagulation device to provide maximum intraoperative bleeding control for the treatment of hepatocellular carcinoma

BACKGROUND

The popularity of laparoscopic liver resection (LLR) is spreading, worldwide, because the intraoperative blood loss is less than for open hepatectomy and it is associated with a shorter hospitalization period [1-6]. During LLR, intraoperative hemostasis is difficult to achieve, unlike during laparotomy where bleeding can be stopped instantly [7-10]. Our LLR method for the treatment of hepatocellular carcinoma (HCC) includes maximal control of intraoperative bleeding using a monopolar soft-coagulation device. Although we use a monopolar soft-coagulation device to control bleeding during LLR, while coagulating the thin blood vessels, we also developed a maneuver (the hepatocyte crush method: HeCM) to allow liver transection to progress while liver parenchymal cells are being crushed.

METHOD

Between January 2008 and March 2016, we performed total LLR on 150 hepatocellular carcinoma patients (144 partial liver resections and six left lateral sectionectomies) using the maneuver shown in the video.

RESULTS

The patients had Child-Pugh Scores of grade A (n = 100), B (42), or C (n = 8) and the localizations of tumor were segment (S) 1(n = 7), S2 (19), S3 (23), S4 (28), S5 (17), S6 (26), S8 (17), and S8 (29). The median blood loss was 30 (range 0-490) g during a median surgical time of 207 (range 127-468) min. One patient required conversion to a laparotomy due to the presence of severe adhesions; none of the patients required conversion due to intraoperative hemorrhage. The peak aspartate aminotransferase (AST) level was 320 (range 57-1964) IU/L. Although some patients showed high AST levels, none showed signs of hepatic failure. The median postoperative hospital stay duration was 6 (range 3-21) days. Postoperative complications occurred in seven cases (4.7%), including intraabdominal abscesses (n = 2), wound infections (2), intraabdominal hemorrhage (1), bile duct stricture (1), and umbilical hernia (1). The mortality was zero.

CONCLUSION

HeCM, combined with the use of a monopolar soft-coagulation device, is a good technique for reducing bleeding during liver resection in patients with HCC.

A systematic review on radiofrequency assisted laparoscopic liver resection: Challenges and window to excel

Laparoscopic liver resection has progressively gained acceptance as a safe and effective procedure in the treatment of benign and malignant liver neoplasms. However, blood loss remains the major challenge in liver surgery. Several techniques and devices have been introduced in liver surgery in order to minimize intraoperative haemorrhage during parenchymal transection. Radiofrequency (RF)-assisted liver resection has been shown to be an effective method to minimize bleeding in open and laparoscopic liver resection. A number of RF devices for parenchymal transection have been designed to assist laparoscopic liver resections. Here we have reviewed the results of various RF devices in laparoscopic liver resection. A total 15 article were considered relevant for the evaluation of technical aspects and outcomes of RF-assisted liver resections in laparoscopic procedures. In these studies, 176 patients had laparoscopic liver resection using RF-assisted parenchymal coagulation. Two monopolar and three bipolar devices were employed. Blood loss was limited in most of the studies. The need of blood transfusions was limited to two cases in all the series. Conversion was necessary due to bleeding in 3 cases. Operative and transection times varied between studies. However, RF-assisted resection with bipolar devices appeared to have taken less time in comparison to other RF devices. RF-related complications were minimum, and only one case of in-hospital death due to hepatic failure was reported. Although RF has been used in a small minority of laparoscopic liver resections, laparoscopic RF-assisted liver resection for benign and malignant disease is a safe and feasible procedure associated with reduction in blood loss, low morbidity, and lower hospital mortality rates.

Impact of monopolar radiofrequency coagulation on intraoperative blood loss during liver resection: a prospective randomised controlled trial

PURPOSE

To evaluate the impact of using monopolar thermal coagulation based on radiofrequency (RF) currents on intraoperative blood loss during liver resection.

MATERIALS AND METHODS

A prospective randomised controlled trial was planned. Patients undergoing hepatectomy were randomised into two groups. In the control group (n = 10), hemostasis was obtained with a combination of stitches, vessel-sealing bipolar RF systems, sutures or clips. In the monopolar radiofrequency coagulation (MRFC) group (n = 18), hemostasis was mainly obtained using an internally cooled monopolar RF electrode.

RESULTS

No differences in demographic or clinical characteristics were found between groups. Mean blood loss during liver resection in the control group was more than twice that of the MRFC group (556 ± 471 ml vs. 225 ± 313 ml, p = .02). The adjusted mean bleeding/transection area was also significantly higher in the control group (7.0 ± 3.3 ml/cm² vs. 2.8 ± 4.0 ml/cm², p = .006). No significant differences were observed in the rate of complications between the groups.

CONCLUSIONS

The findings suggest that the monopolar electrocoagulation created with an internally cooled RF electrode considerably reduces intraoperative blood loss during liver resection.

Precoagulation-assisted parenchyma-sparing laparoscopic liver surgery: rationale and surgical technique

BACKGROUND

For the treatment of both primary and metastatic liver tumors, laparoscopic parenchyma-sparing surgery is advocated to reduce postoperative liver failure and facilitate reoperation in the case of recurrence. However, atypical and wedge resections are associated with a higher amount of intraoperative bleeding than are anatomical resections, and such bleeding is known to affect short- and long-term outcomes. Beyond the established role of radiofrequency and microwave ablation in the setting of inoperable liver tumors, the application of thermoablative energy along the plane of the liver surface to be transected results in a zone of coagulative necrosis, possibly minimizing bleeding of the cut liver surface during parenchymal transection.

METHODS

From January 2013 to March 2016, a total of 20 selected patients underwent laparoscopic ultrasound-guided liver resection with thermoablative precoagulation of the transection line.

RESULTS

During a period of 38 months, 50 laparoscopic thermoablative procedures were performed. Colorectal liver metastases were the most frequent diagnosis. Seventy-two percent of the nodules were removed using parenchymal transection with radiofrequency-precoagulation, while microwave-precoagulation was performed for 20 % of the resected nodules. The remaining 8 % of the nodules were treated by thermoablation alone. The hepatic pedicle was intermittently clamped in six patients. The mean blood loss was 290 mL, and four patients required perioperative transfusions.

CONCLUSIONS

Precoagulation-assisted parenchyma-sparing laparoscopic liver surgery can get minimal blood loss during parenchymal transection and lower the need for perioperative transfusions, providing a nonquantifiable margin of oncological safety on the remaining liver. Additional results from larger series are advocated to confirm these preliminary data.

Expert opinion on advanced techniques for hemostasis in liver surgery

BACKGROUND

Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this.

METHODS

An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss.

RESULTS

All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery.

CONCLUSIONS

This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.

The Feasibility of Hepatic Resections Using a Bipolar Radiofrequency Device (Habib®)

The bipolar radiofrequency device (Habib®) has been recently introduced in order to reduce intraoperative bleeding for a safe hepatic resection as an alternative to the conventional tools. However, indications, perioperative findings, and outcome of the device for hepatic resections remain and deserve to be analyzed. The current study aims to analyze the feasibility of the bipolar radiofrequency device (Habib®) for hepatic resections. Information of the patients that underwent hepatic resection using with the Habib® device between 2007 and 2011 was abstracted. Patient, disease, and operation-related findings and perioperative data were investigated. A total of 71 cases (38 [53.5 %] males, mean age was 56.8 ± 11.9) were analyzed. Metastatic disease (n = 55; 77.5 %) was the leading indication followed by primary liver and biliary malignancies (n = 7; 9.9 %), hemangioma (n = 5; 7 %), hydatid disease (n = 3; 2.8 %), and hepatic gunshot trauma (n = 1; 1.4 %). Metastasectomy was the most commonly performed procedure (n = 31; 56.3 %), but in 24 (77.4 %) cases, it was performed in addition to extended resections. Other procedures in the study patients include segmentectomy in 17, bisegmentectomy in 19, trisegmentectomy in 17, right or left hepatectomy in 8, and extended right/left hepatectomy in 3. The mean (±SD) operation time was 241.7 ± 78.2 min. The median amount of bleeding was 300 cc (range 25-2500), and 23 (32.4 %) cases required perioperative transfusion. The median hospitalization period was 5 days (range 1-47). Lengthened drainage (n = 9, 12.7 %) and intraabdominal abscess (n = 8, 11.23 %) were the most common problems. Hepatic resections using the Habib® device seem to be feasible in cases with primary and metastatic hepatic lesions and benign liver masses and even those with hepatic trauma. It may lessen the amount of intraoperative hemorrhage, although lengthened drainage and intraabdominal abscess were the major postoperative problems in these cases.

Short- and long-term outcomes of hepatectomy with or without radiofrequency-assist for the treatment of hepatocellular carcinomas: a retrospective comparative cohort study

The objective of this study was to compare the short- and long-term outcomes of radiofrequency-assisted liver resection (RFLR) and conventional clamp-crushing liver resection (CCLR) and to evaluate the safety and efficiency of RFLR. Between January 2008 and December 2012, a total of 597 patients with hepatocellular carcinoma (HCC) who underwent curative hepatectomy were identified. A total of 272 patients underwent RFLR, and 325 patients received CCLR. The short- and long-term outcomes were compared. The patients in the RFLR and CCLR groups showed similar baseline characteristics. The RFLR group showed less intraoperative blood loss (485.5 vs. 763.2 mL, p = 0.003), a lower transfusion requirement rate (19.1 vs. 31.7%, p ≤ 0.01), shorter surgery duration (211 vs. 296 min, p ≤ 0.01) and a lower vascular inflow occlusion rate (25.7 vs. 33.8%, p = 0.032). No significant postoperative changes in bilirubin or liver enzymes were observed in the two groups. The degree of postoperative complications and morbidity did not significantly differ between the two groups. There were no significant differences in the 1-, 2- and 3-year overall survival rates (73.8%, 58.5%, and 55.7% vs. 80.8%, 65.8%, and 56.2%, respectively) or disease-free rates (51.9%, 47.2%, and 46.0% vs. 54.5%, 44.9%, and 38.5%, respectively) between the RFLR and CCLR groups. These results suggested RFLR was a safe and efficient method for patients with HCC. RFLR was associated with decreased blood loss, fewer blood transfusions, shorter surgery times and less vascular inflow occlusion application. The RFLR group did not show increased liver injury or postoperative morbidity or mortality.

Liver resection for hepatocellular carcinoma using a microwave tissue coagulator: Experience of 1118 cases

AIM: To present our extensive experience of hepatectomy for hepatocellular carcinoma using a microwave tissue coagulator to demonstrate the effectiveness of this device.

METHODS: A total of 1118 cases (1990-2013) were reviewed, with an emphasis on intraoperative blood loss, postoperative bile leakage and fluid/abscess formation, and adaptability to anatomical resection and hepatectomy with hilar dissection.

RESULTS: The median intraoperative blood loss was 250 mL; postoperative bile leakage and fluid/abscess formation were seen in 3.0% and 3.3% of cases, respectively. Anatomical resection was performed in 275 cases, including 103 cases of hilar dissection that required application of microwave coagulation near the hepatic hilum. There was no clinically relevant biliary tract stricture or any vascular problems due to heat injury. Regarding the influence of cirrhosis on intraoperative blood loss, no significant difference was seen between cirrhotic and non-cirrhotic patients (P = 0.38), although cirrhotic patients tended to have smaller tumors and underwent less invasive operations.

CONCLUSION: This study demonstrated outcomes of an extensive experience of hepatectomy using heat coagulative necrosis by microwave tissue coagulator.

Efficiency and safety of radiofrequency-assisted hepatectomy for hepatocellular carcinoma with cirrhosis: A single-center retrospective cohort study

AIM: To assess the efficiency and safety of radiofrequency-assisted hepatectomy in patients with hepatocellular carcinoma (HCC) and cirrhosis.

METHODS: From January 2010 to December 2013, 179 patients with HCC and cirrhosis were recruited for this retrospective study. Of these, 100 patients who received radiofrequency-assisted hepatectomy (RF+ group) were compared to 79 patients who had hepatectomy without ablation (RF- group). The primary endpoint was intraoperative blood loss. The secondary endpoints included liver function, postoperative complications, mortality, and duration of hospital stay.

RESULTS: The characteristics of the two groups were closely matched. The Pringle maneuver was not used in the RF+ group. There was significantly less median intraoperative blood loss in the RF+ group (300 vs 400 mL, P = 0.01). On postoperative days (POD) 1 and 5, median alanine aminotransferase was significantly higher in the RF+ group than in the RF- group (POD 1: 348.5 vs 245.5, P = 0.01; POD 5: 112 vs 82.5, P = 0.00), but there was no significant difference between the two groups on POD 3 (260 vs 220, P = 0.24). The median AST was significantly higher in the RF+ group on POD 1 (446 vs 268, P = 0.00), but there was no significant difference between the two groups on POD 3 and 5 (POD 3: 129.5 vs 125, P = 0.65; POD 5: 52.5 vs 50, P = 0.10). Overall, the rate of postoperative complications was roughly the same in these two groups (28.0% vs 17.7%, P = 0.11) except that post hepatectomy liver failure was far more common in the RF+ group than in the RF- group (6% vs 0%, P = 0.04).

CONCLUSION: Radiofrequency-assisted hepatectomy can reduce intraoperative blood loss during liver resection effectively. However, this method should be used with caution in patients with concomitant cirrhosis because it may cause severe liver damage and liver failure.

[Liver transection: modern procedure: Technique, results and costs]

Liver resection has developed into the current standard procedure due to modern resection techniques, profound knowledge of the liver anatomy and optimized surgical and anesthesiological strategies to allow extended resections with both low morbidity and mortality. Initially major blood loss was the biggest concern with liver resection and a Pringle's manoeuvre was necessary. Nowadays, biliary leakage is the major problem after liver surgery. Besides the classical conventional clamp crushing technique for parenchymal transection, various devices including ultrasound, microwaves and staplers have been introduced. Minimally invasive techniques have become increasingly important for liver resection but are still applied in selected patients only. The selection of the resection technique and device mainly depends on the extent of the resection and also on the liver parenchyma, the liver disease, costs, personal experiences and preferences. This article presents a selection of techniques used in modern parenchymal transection during liver resection with special focus on transection time, blood loss, bile leakage and costs.

Endoscopic ultrasound guided radiofrequency ablation, for pancreatic cystic neoplasms and neuroendocrine tumors

AIM

To outline the feasibility, safety, adverse events and early results of endoscopic ultrasound (EUS)-radiofrequency ablation (RFA) in pancreatic neoplasms using a novel probe.

METHODS

This is a multi-center, pilot safety feasibility study. The intervention described was radiofrequency ablation (RF) which was applied with an innovative monopolar RF probe (1.2 mm Habib EUS-RFA catheter) placed through a 19 or 22 gauge fine needle aspiration (FNA) needle once FNA was performed in patients with a tumor in the head of the pancreas. The Habib™ EUS-RFA is a 1 Fr wire (0.33 mm, 0.013") with a working length of 190 cm, which can be inserted through the biopsy channel of an echoendoscope. RF power is applied to the electrode at the end of the wire to coagulate tissue in the liver and pancreas.

RESULTS

Eight patients [median age of 65 (range 27-82) years; 7 female and 1 male] were recruited in a prospective multicenter trial. Six had a pancreatic cystic neoplasm (four a mucinous cyst, one had intraductal papillary mucinous neoplasm and one a microcystic adenoma) and two had a neuroendocrine tumors (NET) in the head of pancreas. The mean size of the cystic neoplasm and NET were 36.5 mm (SD ± 17.9 mm) and 27.5 mm (SD ± 17.7 mm) respectively. The EUS-RFA was successfully completed in all cases. Among the 6 patients with a cystic neoplasm, post procedure imaging in 3-6 mo showed complete resolution of the cysts in 2 cases, whilst in three more there was a 48.4% reduction [mean pre RF 38.8 mm (SD ± 21.7 mm) vs mean post RF 20 mm (SD ± 17.1 mm)] in size. In regards to the NET patients, there was a change in vascularity and central necrosis after EUS-RFA. No major complications were observed within 48 h of the procedure. Two patients had mild abdominal pain that resolved within 3 d.

CONCLUSION

EUS-RFA of pancreatic neoplasms with a novel monopolar RF probe was well tolerated in all cases. Our preliminary data suggest that the procedure is straightforward and safe. The response ranged from complete resolution to a 50% reduction in size.

Radiofrequency ablation-assisted liver resection: a step toward bloodless liver resection

BACKGROUND

Liver resection is currently the most efficient curative approach for a wide variety of liver tumors. The application of modern techniques and new surgical devices has improved operative outcomes. Radiofrequency ablation is used more often for liver parenchymal transection. This study aimed to assess the efficacy and safety of radiofrequency ablation-assisted liver resection.

METHODS

A retrospective study of 145 consecutive patients who underwent radiofrequency ablation-assisted liver resection was performed. Intraoperative blood loss, need for transfusion or intraoperative Pringle maneuver, the duration of liver parenchymal transection, perioperative complications, and postoperative morbidity and mortality were all evaluated.

RESULTS

Fifty minor and ninety-five major liver resections were performed. The mean intraoperative blood loss was 251 mL, with a transfusion rate of 11.7%. The Pringle maneuver was necessary in 12 patients (8.3%). The mean duration for parenchymal transection was 51.75 minutes. There were 47 patients (32.4%) with postoperative complications. There is no mortality within 30 days after surgery.

CONCLUSIONS

Radiofrequency ablation-assisted liver resection permits both major and minor liver resections with minimal blood loss and without occlusion of hepatic inflow. Furthermore it decreases the need for blood transfusion and reduces morbidity and mortality.

Combined ultrasonic aspiration and saline-linked radiofrequency precoagulation: a step toward bloodless liver resection without the need of liver inflow occlusion: analysis of 313 consecutive patients

BACKGROUND

Hemorrhage is undoubtedly one of the main factors contributing to morbidity and mortality in liver resections. Vascular occlusion techniques are effective in controlling intraoperative bleeding, but they cause liver damage due to ischemia. We evaluated the effectiveness and safety of using a combined technique for hepatic parenchymal transection without liver inflow occlusion.

METHODS

Three hundred and thirteen consecutive patients who underwent liver resection in four hepato-pancreato-biliary units. Hepatic parenchymal transection was carried out using a combined technique of saline-linked radiofrequency precoagulation and ultrasonic aspiration without liver inflow occlusion.

RESULTS

During the study period 114 minor and 199 major hepatic resections were performed. The mean amount of intraoperative blood loss was 377 ml (SD 335 ml, range 50 to 2,400 ml) and the blood transfusion rate was 10.5%. The median amount of blood loss during parenchymal transection and parenchymal transection time was 222 ml (SD 224 ml, range 40 to 2,100 ml) and 61 minutes (range 12 to 150 minutes) respectively. There were two postoperative deaths (0.6%). Complications occurred in 84 patients (26.8%) and most complications were minor.

CONCLUSIONS

Combined technique of saline-linked radiofrequency ablation and ultrasonic aspiration for liver resection is a safe method for both major and minor liver resections. The method is associated with decreased blood loss, reduced postoperative morbidity, and minimal mortality rates. We believe that this combined technique is comparable to other techniques and should be considered as an alternative.

Value of radiofrequency ablation in the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a malignant disease that substantially affects public health worldwide. It is especially prevalent in east Asia and sub-Saharan Africa, where the main etiology is the endemic status of chronic hepatitis B. Effective treatments with curative intent for early HCC include liver transplantation, liver resection (LR), and radiofrequency ablation (RFA). RFA has become the most widely used local thermal ablation method in recent years because of its technical ease, safety, satisfactory local tumor control, and minimally invasive nature. This technique has also emerged as an important treatment strategy for HCC in recent years. RFA, liver transplantation, and hepatectomy can be complementary to one another in the treatment of HCC, and the outcome benefits have been demonstrated by numerous clinical studies. As a pretransplantation bridge therapy, RFA extends the average waiting time without increasing the risk of dropout or death. In contrast to LR, RFA causes almost no intra-abdominal adhesion, thus producing favorable conditions for subsequent liver transplantation. Many studies have demonstrated mutual interactions between RFA and hepatectomy, effectively expanding the operative indications for patients with HCC and enhancing the efficacy of these approaches. However, treated tumor tissue remains within the body after RFA, and residual tumors or satellite nodules can limit the effectiveness of this treatment. Therefore, future research should focus on this issue.

Microwave liver ablation and dark urine

Microwave assisted liver resection is a useful technique, especially when haemostasis could be difficult to achieve with conventional methods. However, prolonged administration of microwaves can be responsible for intraoperative haemoglobinuria. We describe the first case of acute haemolysis secondary to microwave assisted liver resection.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): the Brazilian experience

BACKGROUND

Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. To induce rapid and significant hepatic hypertrophy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients which tumor is previously considered unresectable.

AIM

To present the Brazilian experience with ALPPS approach.

METHOD

Were analyzed 39 patients who underwent hepatic resection using ALPPS in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation and in situ splitting. In the second operation the right hepatic artery, right bile duct and the right hepatic vein were isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years).

RESULTS

The most common indication was liver metastasis in 32 patients (82.0%), followed by cholangiocarcinoma in three (7.7%). Two patients died (5.2%) during this period and did not undergo the second operation. The mean interval between the first and the second operation was 14.1 days (range: 5-30 days). The volume of the left lateral segment of the liver increased 83% (range 47-211.9%). Significant morbidity after ALPPS was seen in 23 patients (59.0%). The mortality rate was 12.8% (five patients).

CONCLUSION

The ALPPS approach can enable resection in patients with lesions previously considered unresectable. It induces rapid liver hypertrophy avoiding liver failure in most patients. However still has high morbidity and mortality.

Intraoperative margin re-resection for colorectal cancer liver metastases

One of the basic tenets of surgical oncology is the achievement of margin-negative resection. The importance of surgical margins in hepatic resection for colorectal cancer liver metastases (CRCLM) is reflected in the abundance of literature written about this topic. However, the definition of the ideal surgical margin has evolved in parallel with advances in systemic chemotherapy, biologic therapy and surgical technology. A better understanding of the biology of liver metastasis is of critical importance in the context of surgical strategy for CRCLM. The value of intraoperative margin re-resection to achieve R0 status for CRCLM is addressed, taking into consideration current understandings of cancer biology.

Totally laparoscopic left hepatectomy using the Torsional Ultrasonic Scalpel

Minimal invasive techniques have allowed for major surgical advances. We report our initial experience of performing total laparoscopic left hepatectomy (segments II-IV) with the Lotus (laparoscopic operation by torsional ultrasound) Ultrasonic Scalpel. The perioperative and postoperative courses of the young female patient were uneventful and she is in a good general condition without complaints 18 mo after surgery. To the best of our knowledge, this is the first total laparoscopic hemihepatectomy to be performed in Greece, as well as the first laparoscopic liver resection using Lotus shears.

Radiofrequency-assisted versus clamp-crushing parenchyma transection in cirrhotic patients with hepatocellular carcinoma: a randomized clinical trial

BACKGROUND

Surgical resection remains the optimal therapy for cirrhotic patients with hepatocellular carcinoma (HCC) that are not suitable for liver transplantation (LT). Recently, various innovative techniques for liver resection have been developed.

AIM

The aim of the study was to compare radiofrequency-assisted parenchyma transection (RF-PT) with the traditional clamp-crushing (CC) technique to explore the preferred therapy in cirrhotic patients with HCC.

METHODS

From January 2009 to December 2010, 75 cirrhotic patients with HCC who underwent hepatectomy were randomized to RF-PT (group 1, n = 38) or CC-PT (group 2, n = 37) groups. The primary endpoint was intraoperative blood loss. The secondary endpoints included hepatic transection time, total operating time, postoperative morbidity, mortality, length of intensive care unit and hospital stays, and liver function.

RESULTS

The characteristics of the two patient groups were closely matched. The Pringle maneuver was not used in RF-PT patients. The blood loss of the RF-PT group, total or during transection, was significantly lower than that of the CC-PT group (385 vs. 545 ml, p = 0.001; 105 vs. 260 ml, p = 0.000, respectively). Compared with CC-PT patients, the morbidity of the RF-PT group was lower though not statistically significant (28.9 vs. 38.8 %, p = 0.197). One death occurred in the RF-PT group 12 days postoperative due to a large area cerebral embolism.

CONCLUSION

RF-PT is a safe and feasible surgical resection method for patients with cirrhosis and concomitant HCC. In addition, RF-PT results in lower blood loss and lower morbidity than the CC technique during liver resection.

Partial spleen resection with a radiofrequency needle device--a pilot study

INTRODUCTION

Total splenectomy leads to an immunocompromised state, with an increased lifetime risk of infection. The lifetime risk of developing overwhelming postsplenectomy infection is 5 %, with a mortality rate of approximately 50 %. In addition to vaccination and antibiotic prophylaxis, partial splenectomy is believed to improve patient safety.

METHODS

We performed partial splenectomy in seven patients using a radiofrequency (RF) technique with Habib® needles. In seven patients, an open access partial splenectomy was performed. In three patients, a partial splenectomy was performed simultaneously with intraabdominal tumour resection. In two patients, the upper pole of the spleen was removed due to tumours of the spleen. In one patient, a large symptomatic splenic cyst was resected and in another patient, a partial splenectomy was performed due to trauma. RF was applied using Habib® needles (AngioDynamics, Manchester, GA, 31816, USA).

RESULTS

The partial splenectomy procedures were easy and safe in all seven patients. The RF application with the Habib® needles led to primary haemostasis. The blood loss was less than 50 ml in all cases. After a minimum follow-up of 1 year, there were no cases of infections or other adverse events related to the previous partial splenectomy.

CONCLUSION

In our experience, partial splenectomy with Habib® needles is easy to perform and safe for the patient. Thus, radiofrequency resection is a good alternative to total splenectomy in many patients and reduces the risk of postsplenectomy infections.

Bleeding in Hepatic Surgery: Sorting through Methods to Prevent It

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. The parameter "Blood Loss" has a central role in liver surgery, and different strategies to minimize it are a key to improve results. Moreover, recently, new technologies are applied in the field of liver surgery, having one goal: safer and easier liver operations. The aim of this paper is to review the different principal solutions to the problem of blood loss in hepatic surgery, focusing on technical aspects of new devices.