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

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.

Hepatocellular Carcinoma Intrinsic Cell Death Regulates Immune Response and Prognosis

Ablative and locoregional treatment options, such as radiofrequency, ethanol injection, microwave, and cryoablation, as well as irreversible electroporation, are effective therapies for early-stage hepatocellular carcinoma (HCC). Hepatocyte death caused by ablative procedures is known to increase the release of tumor-associated antigen, thus enhancing tumor immunogenicity. In addition, the heat ablative resection induces pyroptotic cell death accompanied by the release of several inflammatory factors and immune-related proteins, including damage-associated molecular patterns (DAMPs), heat shock proteins (HSPs), ficolin 3, ATP, and DNA/RNA, which potentiate the antitumoral immune response. Surgical approaches that enhance tumor necrosis and reduce hypoxia in the residual liver parenchyma have been shown to increase the disease-free survival rate by reducing the host’s immunosuppressive response. Scalpel devices and targeted surgical approach combined with immune-modulating drugs are an interesting and promising area to maximize therapeutic outcomes after HCC ablation.

Water-cooled microwave ablation array for bloodless rapid transection of the liver

BACKGROUND

Microwaves (MWs) deliver relatively high temperatures into biological tissue and cover a large ablation zone. This study aims to evaluate the efficacy and effectiveness of water-cooled double-needle MW ablation arrays in assisting the hepatic transection of an in vivo pig model.

METHODS

Our research program comprised computer modeling, tissue-mimicking phantom experiments, and in vivo pig liver experiments. Computer modeling was based on the finite element method (FEM) to evaluate ablation temperature distributions. In tissue-mimicking phantom and in vivo pig liver ablation experiments, the performances of the water-cooled MW ablation array and conventional clamp crushing liver resection were compared.

RESULTS

FEM showed that the maximum lateral ablation diameter at 100 W output and a duration of 60 s was 3 cm (assessed at 50 °C isotherm). In the phantom, the maximum transverse ablation diameter of the double-needle MW ablation increased rapidly to 3 cm in 60 s at 50 W. The blood loss and blood loss per transection area in Group A were significantly lower than those in Group B (18 (7-26) ml vs. 34 (19-57) ml, and 2.4 (2-3.1) ml/cm² vs. 6.9 (3.2-8.3) ml/cm², respectively) (p < 0.05). The transection speed in Group A (2.6(1.9-3.8) cm²/min) was significantly faster than that in Group B (1.7(1.1-2.2) cm²/min) (p < 0.05).

CONCLUSION

In this experimental model, the new water-cooled MW array-assisted liver resection (LR) has the potential advantage of less blood loss and rapid removal than the conventional LR.

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.

Efficiency of a radiofrequency sealer (Aquamantys) for parenchymal transection during laparoscopic hepatectomy

INTRODUCTION

The methods of liver parenchymal transection vary across institutions. In this study, we used a radiofrequency (RF) sealer (Aquamantys) as a hemostatic device during laparoscopic liver transection; we also evaluated the usefulness of RF sealers.

METHODS

From April 2016 to May 2019, 113 consecutive laparoscopic hepatectomy patients, excluding patients with combined resection of other organs, were examined. Patient characteristics, operative factors, and postoperative complications were compared between the Cavitron ultrasonic surgical aspirator (CUSA) + soft coagulation system (VIO) group; (n = 32) and the CUSA + Aquamantys group; (n = 81). The former underwent liver transection by CUSA and VIO from April 2016 to March 2017, while the latter underwent liver transection using CUSA and Aquamantys from April 2017 to May 2019.

RESULTS

The median difficulty score was significantly higher in the CUSA + VIO group (5.5 points vs 5.0 points; P = .04). Blood loss per unit area and the liver parenchymal transection speed were not significantly different between the groups. After propensity score matching, blood loss per unit area was similar between the groups, but the parenchymal transection speed of the CUSA + Aquamantys group was significantly higher (0.92 cm² /min vs 0.64 cm² /min; P = .017). Postoperative complications were similar between the groups.

CONCLUSION

In laparoscopic hepatectomy, hemostasis of the transection plane with an RF sealer did not reduce blood loss during parenchymal transection. However, the liver parenchymal transection speed was increased.

Recent Advances: The Imbalance of Immune Cells and Cytokines in the Pathogenesis of Hepatocellular Carcinoma. Diagnostics (Basel). 2020;10. [PMID: 32466214 PMCID: PMC7277978 DOI: 10.3390/diagnostics10050338]

Recent advancement in the immunological understanding of genesis of hepatocellular carcinoma (HCC) has implicated a decline in anti-tumour immunity on the background of chronic inflammatory state of liver parenchyma. The development of HCC involves a network of immunological activity in the tumour microenvironment involving continuous interaction between tumour and stromal cells. The reduction in anti-tumour immunity is secondary to changes in various immune cells and cytokines, and the tumour microenvironment plays a critical role in modulating the process of liver fibrosis, hepatocarcinogenesis, epithelial-mesenchymal transition (EMT), tumor invasion and metastasis. Thus, it is considered as one of primary factor behind the despicable tumour behavior and observed poor survival; along with increased risk of recurrence following treatment in HCC. The primary intent of the present review is to facilitate the understanding of the complex network of immunological interactions of various immune cells, cytokines and tumour cells associated with the development and progression of HCC.

Immunological Basis of Genesis of Hepatocellular Carcinoma: Unique Challenges and Potential Opportunities through Immunomodulation

A majority of hepatocellular carcinoma (HCC) develops in the setting of persistent chronic inflammation as immunological mechanisms have been shown to play a vital role in the initiation, growth and progression of tumours. The index review has been intended to highlight ongoing immunological changes in the hepatic parenchyma responsible for the genesis and progression of HCC. The in-situ vaccine effect of radiofrequency (RF) is through generation tumour-associated antigens (TAAs), following necrosis and apoptosis of tumour cells, which not only re-activates the antitumour immune response but can also act in synergism with checkpoint inhibitors to generate a superlative effect with intent to treat primary cancer and distant metastasis. An improved understanding of oncogenic responses of immune cells and their integration into signaling pathways of the tumour microenvironment will help in modulating the antitumour immune response. Finally, we analyzed contemporary literature and summarised the recent advances made in the field of targeted immunotherapy involving checkpoint inhibitors along with RF application with the intent to reinstate antitumour immunity and outline future directives in very early and early stages of HCC.

Vertical interval between hepatic segment of inferior vena cava and right atrium predicts intraoperative blood loss during hemi-hepatectomy

BACKGROUND

Intraoperative bleeding is a major issue for hepatic surgeons because large intraoperative blood loss causes poor patient outcome. The aim of this study was to identify predictors of intraoperative bleeding during hemi-hepatectomy. Methods This study enrolled 45 living donors for liver transplantation (cohort 1) and 44 patients with various conditions (cohort 2) who underwent hemi-hepatectomy at Ehime University Hospital between January 2010 and March 2019 (Approval number: 1810024). The gap between the ventral horizontal line of the inferior vena cava (IVC) confluent with the right atrium (RA) and the dorsal horizontal line of the hepatic segment of the IVC (IVC-RA gap) was determined from preoperative images. Cardiopulmonary and liver functions were investigated as potential predictors of intraoperative estimated blood loss (iEBL). Results The IVC-RA gap positively correlated with iEBL in cohorts 1 and 2 (r = 0.453, P = 0.002 and r = 0.443, P = 0.003, respectively), and multivariate analysis selected the IVC-RA gap as an independent predictor of iEBL >400 ml in cohorts 1 and 2 (odds ratios 1.177 and 1.115; 95% confidence intervals 1.041-1.330 and 1.007-1.234; P = 0.009 and P = 0.036, respectively). Conclusions The IVC-RA gap is a novel and simple predictor of iEBL.