New Endoscopic Surgical Treatment-Thoracoscopic Microwave Coagulo-Necrotic Therapy for small hepatocellular carcinoma

Percutaneous local ablative therapy for hepatocellular carcinoma: a review and look into the future

OBJECTIVE

To review and compare treatment result for percutaneous local ablative therapy (PLAT) with surgical resection in the treatment of small hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

PLAT is indicated for small unresectable HCC localized to the liver. From the use of ethanol to the latest technology of radiofrequency ablation, ablative techniques have been refined and their role in the management of HCC established. This review aims to give an overview of various ablative methods, including their efficacy, indications, and limitations, and also tries to look into the future of clinical trials in PLAT.

METHODS

The authors reviewed recent papers in the English medical literature about the use of local ablative therapy for HCC. Focus was given to the results of treatment in terms of local control, progression-free survival, and overall survival, and to compare treatment results with those of surgery.

RESULTS

PLAT for small HCC (<5 cm) with thermal ablation (radiofrequency ablation or microwave coagulation) can achieve effective local control of disease and is superior to ethanol injection. Progressive disease in untreated areas is a common reason for failure. Overall progression-free survival is similar to that of surgical resection.

CONCLUSIONS

Thermal ablation gives good local control of small HCC, is superior to ethanol, and may be comparable to surgical resection in long-term outcome.

Transoesophageal echocardiography shows high risk of gas embolism during laparoscopic hepatic resection under carbon dioxide pneumoperitoneum

BACKGROUND

The ultrasonically activated scalpel (UAS) enables safe and effective laparoscopic tissue dissection, making hepatic resection feasible. This study compared blood loss and risk of gas embolism using the UAS during open hepatic resection and laparoscopic hepatic resection.

METHODS

Female pigs were divided into two groups for laparoscopic (n = 7) and open (n = 5) left hepatic lobectomy. The UAS was used for both tissue cutting and coagulation. Laparoscopic liver resection was performed under carbon dioxide pneumoperitoneum (intraperitoneal pressure 12 mmHg). During surgery animals were monitored haemodynamically by an arterial line and Swan-Ganz catheter. Two-dimensional transoesophageal echocardiography (2D-TEE) was used to detect gas emboli with special attention to the right atrium and ventricle. Gas emboli were graded according to size, and correlated with haemodynamic and blood gas data.

RESULTS

During open and laparoscopic hepatic resection the UAS resulted in minimal blood loss and effective tissue dissection. No air embolism was seen during open surgery. With laparoscopic hepatic resection 2D-TEE revealed gas embolism in all animals. Gas embolism was accompanied by cardiac arrhythmia in four of seven animals. No direct correlation was observed between embolism episodes and blood gas variables. There were no deaths after episodes of embolization. A significant decrease in arterial partial pressure of oxygen was seen at the end of the laparoscopic procedure in all animals.

CONCLUSION

The UAS causes minimal blood loss during both open and laparoscopic hepatic resection. Laparoscopic liver dissection under carbon dioxide pneumoperitoneum carries a high risk of gas embolism.

Radiofrequency interstitial thermal ablation of hepatocellular carcinoma in liver cirrhosis. Role of the laparoscopic approach

BACKGROUND

The laparoscopic approach to radiofrequency interstitial thermal ablation (RITA) of hepatocellular carcinoma (HCC) with intraoperative ultrasound guidance has been proposed with the aim of obtaining additional information for a better neoplastic staging and a complete and effective treatment of the liver lesions in patients with a difficult percutaneous approach.

METHODS

In this pilot study, 29 patients with HCC in liver cirrhosis were submitted to laparoscopic RITA under sonographic guide. Most of these patients were in Child's A class of liver function. Patients with large tumors (> 5 cm), portal vein thrombosis, or severe liver disease (Child's C class) were excluded from the study.

RESULTS

The laparoscopic RITA procedure was completed in 27 of 29 patients (93% feasibility rate). The laparoscopic ultrasound examination identified new malignant liver nodules in five patients (18.5%). A total of 44 lesions were treated. The mean operative time was 75.8 +/- 20.5 min (range, 45-120 min), and the mean RITA time was 18 +/- 10 min (range, 10-56 min). There was no operative mortality, and postoperative morbidity was low (four cases) without any mortality. A complete tumor necrosis was observed in 90% of the patients via spiral computed tomography (CT) 1 month after treatment.

CONCLUSIONS

Laparoscopic RITA of hepatocellular carcinoma proved to be a safe and effective technique, at least in the short term. Its role in the treatment of HCC needs to be defined in larger series.

Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series

BACKGROUND

Technical difficulties have impeded the development of laparoscopic hepatectomy. This article describes a new technique for performing partial hepatectomy and left lateral segmentectomy by means of laparoscopy, and the results in a series of 11 consecutive patients are reported.

METHODS

A microwave tissue coagulator is used in combination with an ultrasonic surgical aspirator to divide hepatic parenchyma without pneumoperitoneum. Branched vessels and ducts are clipped and transected. The largest vessels were suture ligated in some cases. The endoscopic linear stapler was used to transect the left hepatic vein for left lateral segmentectomy. The resected liver was maneuvered into a specimen bag and removed. The argon beam coagulator was used to secure hemostasis of the plane of transection.

RESULTS

Eleven patients underwent laparoscopic hepatic resection. Indications included isolated metastatic lesion, hepatocellular carcinoma, hemangioma, Wilson's disease, and hemochromatosis. Three patients underwent left lateral segmentectomy, and eight underwent partial hepatectomy. Ten procedures were performed uneventfully; one patient required conversion to open hepatectomy because of excessive bleeding. Notable differences were seen in blood loss compared with open hepatectomy, and no operative complications occurred. Postoperative pain was minimal.

CONCLUSIONS

The laparoscopic hepatectomy, especially partial or left lateral segmentectomy, appears to be a viable surgical alternative in selected cases.