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Long-term outcome of hepatocellular carcinoma patients who underwent liver resection using microwave tissue coagulation
Abstract
Our policy for the surgical treatment of hepatocellular carcinoma (HCC) has been to minimize the extent of liver resection using a microwave tissue coagulator (MTC) and to not perform Pringle's maneuver for the prevention of ischemic injury to the liver routinely. We verify the safety of liver resection using MTC in HCC patients with poor liver functional reserve, and clarify the long-term outcome of HCC patients who underwent curative resection using MTC.
One hundred sixty-eight patients who underwent curative resection using MTC between 1992 and 2001 were divided into two groups according each patient's score in the Indocyanin Green Retension 15 Test (ICG-R15 test). The high (ICG-R15 values>20) and low ICG-R15 groups (ICG-R15 values<20) included 100 and 68 HCC patients, respectively. Clinical characteristics of each group were evaluated, and operative mortality and morbidity, as well as overall and disease-free survival rates, were compared between the two groups to determine risk factors for overall and disease-free survival.
Although there were significant differences in liver function-related parameters between the low and high ICG-R15 groups, no differences in surgical or tumor factors were found. No patients in this study developed post-operative liver failure, and there was no significant difference in morbidity between the low and high ICG-R15 groups. The overall survival rate of the low ICG-R15 group was significantly longer than the high ICG-R15 group (p=0.0003). Cox's multivariate analysis showed that an ICG-R15 value less than 20 was the only significant independent factor for overall survival. Disease-free survival rates in the low ICG-R15 group were significantly longer than in the high ICG-R15 group (p=0.0007). Multivariate analysis showed that serum albumin level and number of tumors were significant independent factors for disease-free survival.
The long-term outcome of HCC patients with low ICG-R15 following curative resection using MTC was acceptable. This procedure was safe even for patients with high ICG-R15.
... According to a recent study, ICG-R15 was of significance for predicting HCC recurrence (30). Besides, previous studies reported that elevated ICG-R15 was significantly linked to poor DFS (31,32). In this study, we found estimated ICG-R15 >10% showed a significant correlation with higher HCC recurrence and disease-free survival in the estimated ICG-R15≤10% group were significantly longer than in the estimated ICG-R15 >10% group. ...
Purpose
The indocyanine green retention rate at 15 min (ICG-R15) is of great importance in the accurate assessment of hepatic functional reserve for safe hepatic resection. To assist clinicians to evaluate hepatic functional reserve in medical institutions that lack expensive equipment, we aimed to explore a novel approach to predict ICG-R15 based on CT images and clinical data in patients with hepatocellular carcinoma (HCC).
Methods
In this retrospective study, 350 eligible patients were enrolled and randomly assigned to the training cohort (245 patients) and test cohort (105 patients). Radiomics features and clinical factors were analyzed to pick out the key variables, and based on which, we developed the random forest regression, extreme gradient boosting regression (XGBR), and artificial neural network models for predicting ICG-R15, respectively. Pearson's correlation coefficient (R) was adopted to evaluate the performance of the models.
Results
We extracted 660 CT image features in total from each patient. Fourteen variables significantly associated with ICG-R15 were picked out for model development. Compared to the other two models, the XGBR achieved the best performance in predicting ICG-R15, with a mean difference of 1.59% (median, 1.53%) and an R -value of 0.90. Delong test result showed no significant difference in the area under the receiver operating characteristic (AUROCs) for predicting post hepatectomy liver failure between actual and estimated ICG-R15.
Conclusion
The proposed approach that incorporates the optimal radiomics features and clinical factors can allow for individualized prediction of ICG-R15 value of patients with HCC, regardless of the specific equipment and detection reagent (NO. ChiCTR2100053042; URL, http://www.chictr.org.cn ).
... Moreover, there was no significant difference in the RFS rates between both groups. The absence of surgical margin recurrence in the MLH group could be caused by the eradication of possible satellite cancer nodules and small tumor emboli along the surgical margin by microwave ablation [37,38]. Alternatively, the closure of small hepatic and portal vein branches by precoagulation can also block potential metastases. ...
Purpose: In this study, we evaluated the efficacy of microwave ablation-assisted laparoscopic hepatectomy (MLH) for the management of hepatocellular carcinoma (HCC) in cirrhotic patients.
Methods: Data from HCC patients with liver cirrhosis who underwent laparoscopic hepatectomy (LH) or MLH in Shengjing Hospital (Shenyang, China) were retrospectively analyzed from January 2013 to June 2017. The demographic characteristics, clinical features, intraoperative parameters and surgical outcomes were analyzed and compared. Propensity scores matching (PSM) analysis was used to minimize bias.
Results: A total of 54 patients were enrolled in the MLH group and 39 patients in the LH group. Following 1:1 matching by PSM analysis, 26 patients were selected from each group. Compared to the LH group, patients in the MLH group had significantly decreased intraoperative bleeding (48.0 vs. 203.9 ml, p < .0001) and reduced demand for hepatic inflow occlusion (0 vs. 6, p = .009). No significant difference was observed in average operation time (155.7 vs. 148.5 min) and postoperative hospitalization time (8.3 vs. 9.3 d) between the MLH and LH groups. Similarly, the 1-year and 3-year recurrence-free survival (RFS) rates as well as the 1-year and 3-year overall survival (OS) rates of the MLH and LH groups were not significantly different (83.1 vs. 82.4% and 64.6 vs. 36.6% as well as 100 vs. 95.8% and 93.8 vs. 59.1%, respectively: p > .05).
Conclusions: MLH significantly decreased intraoperative bleeding and reduced the need for hepatic occlusion without compromising the surgical outcome. Therefore, microwave ablation could be a valuable tool for LH in HCC patients with cirrhosis.
... Although the usefulness of MTC has been reported by several investigators 1)-6) 9) , MTC may cause postoperative bleeding, bile leakage from injury of the bile ducts, and intraabdominal abscesses because MTC produces coagulonecrotic tissue along the cut surface of the liver. In fact, these complications have been reported in previous studies 4) 6) . ...
In order to evaluate the effects of microwave tissue coagulation (MTC) on postoperative complications, the number of incidences of postoperative bleeding, bile leakage, intraabdominal infection, wound infection, and intractable pleural effusion and ascites were compared between 142 patients who underwent liver resection using MTC (MTC group) and 60 other patients (non-MTC group). The liver was coagulated with a microwave tissue coagulator along the resection line by puncture of the needle applicator (15-mm length) before the transection of the liver. MTC was not used near the thick Glisson′s sheath, major hepatic veins, or the hepatic hilum in order to prevent injury to major vessels or bile ducts. There were no differences in the number of incidences of these complications between the groups. In addition, there were no differences in the characteristics of the bacteria isolated between the groups. Thus, MTC does not affect the development of postoperative complications in liver resections when MTC is used appropriately.
... However, there has been limited experience with earlier forms of microwave energy for liver transection. [12][13][14][15][16] These reports differ from the current series in that the antennae wavelength was different (915 GHz in our series) and the previously described probes have not been FDAapproved in the United States. The current report is the largest case series using currently FDA-approved technology in the United States. ...
Hepatic surgery has evolved significantly in the past decade. The current article describes the largest series of patients in United States undergoing liver resective therapy with the use of microwave technology for liver precoagulation. Glisson's capsule was incised after securing inflow and outflow control. Two antennae, 2 cm apart, connected to a 915-MHz generator, were inserted 5 cm into liver parenchyma at a 130° angle. Once the parenchyma was firm and changed its color to gray, the antennae were advanced along the line of transection. The parenchyma was divided with electrocautery. Intra- and postoperative data were analyzed. Thirty-five patients (24 men) underwent liver resections. Diseases treated were colorectal metastases (n = 9), hepatic adenoma (n = 3), gallbladder cancer (n = 3), hepatocellular carcinoma (n = 4), neuroendocrine tumor (n = 2), cholangiocarcinoma (n = 5), hemangioma (n = 2), focal nodular hyperplasia (n = 2), metastatic gastrointestinal stromal tumor (n = 1), hydatid cyst (n = 1), hepatoid carcinoma (n = 1), hepatolithiasis (n = 1), and suspected metastatic breast cancer (n = 1). Resections done were right hepatectomy (n = 19), segmental resection (n = 5), left hepatectomy (n = 4), extended right hepatectomy (n = 4), Segment IVb and Segment V resections during radical cholecystectomy (n = 2), and left lateral sectionectomy (n = 1). Median operative time for major resection was 188 and 251 minutes for minor resection. There was one postoperative mortality. Bile leak needing stenting occurred in one patient. Median blood loss for major resection was 500 mL and 265 mL for minor resection. Intraoperative transfusion was required in nine major and one minor resections. Other complications were ileus in four, deep vein thrombosis in two, intra-abdominal abscess in one, and cardiac events in two patients. Liver precoagulation with microwave technology is a novel and efficient technique with minimal morbidity and mortality for liver transection.
This report presents a systematic literature review and economic evaluation of MTA for the treatment of primary and secondary liver tumours. This assessment has been undertaken in order to inform MSAC’s decision making regarding whether the proposed medical service should be publicly funded.
In surgical treatment of liver tumors, it is important to consider the balance between the liver volume to be resected and the liver functional reserve. The technique of microwave tissue coagulation (MTC) has been applied clinically for transection of hepatic parenchyma with or without underlying liver cirrhosis. Use of MTC has been reported to reduce blood loss and to enable nonanatomical liver resection, even in patients with poor liver functional reserve. This type of hepatic transection is easy to perform and does not require special surgical techniques. In this chapter, we describe the MTC device, surgical indications, and surgical technique, illustrated with photographs and video on the use of MTC for open hepatic transection.
Aim of this work was to analyze retrospectively two groups of patients who underwent hepatic resection using two different techniques, to determine whether exists a difference in hepatic tolerance and in the early outcome.
We retrospectively analyzed seventy-one patients divided into group 1, treated with kellyclasia and Pringle maneuver, and group 2 treated with a radiofrequency device. The following parameters were analyzed: age; sex; type of disease, number of major/minor resections; total operative time and transection time; number and time of clampings; blood loss; pre- and postoperative transaminases and total bilirubin; length of hospitalization; morbidity and mortality.
Median total operative time and median hospital stay were similar in both groups but median median blood loss was higher in group 1. ALT levels in group 1 were higher than in group 2. Morbidity and mortality were observed only in group 1.
Kelly-crush is related to a lower parenchymal tolerance as shown by the higher increase in postoperative alanine aminotransferase levels.
Microwave energy is another energy source than can be used to precoagulate hepatic tissue during hepatic resection. The aim of this study was to develop an optimal microwave precoagulation technique in a porcine model and then validate the technique during hepatic resection in patients.
Institutional Animal Care and Use and Institutional Review Board (IRB)-approved protocols were utilized for hepatic resection in a porcine model and validation in patients using microwave energy for precoagulation. Different numbers of antennas (one, two or three; spaced 5 mm apart) and ablation times (20, 30, 40, and 60 s) were evaluated to identify an optimal technique that effectively provided precoagulation.
Animal studies: Two antennas for 30 s provided the optimal ablation time, ablation width, mean size of largest vessel coagulated, and minimal bleeding when compared with other techniques. However, given that this is not an optimal technique for laparoscopic precoagulation, one antenna for 60 s was found to provide similar precoagulation success. Patient validation: To validate these techniques, three patients underwent open hepatectomy using two antennas with 5 mm spacing for 30 s, demonstrating successful precoagulation up to inflow/outflow vessels of 10 mm size or greater, which were controlled with a vascular stapler. In addition three patients underwent laparoscopic hepatectomy using one antenna for 60 s and demonstrated successful precoagulation up to inflow/outflow vessels of 8 mm or greater, which were controlled with a vascular stapler.
Microwave energy is a safe and effective precoagulation device to achieve good hemostasis during hepatic resection with both open and laparoscopic technique.
Objective:
This study aimed to evaluate the long-term results of treatment and prognostic factors in patients with intrahepatic recurrence after curative resection of hepatocellular carcinoma (HCC).
Summary background data:
Recent studies have demonstrated the usefulness of re-resection, transarterial oily chemoembolization (TOCE), or percutaneous ethanol injection therapy (PEIT) in selected patients with intrahepatic recurrent HCC. The overall results of a treatment strategy combining these modalities have not been fully evaluated, and the prognostic factors determining survival in these patients remain to be clarified.
Methods:
Two hundred and forty-four patients who underwent curative resection for HCC were followed for intrahepatic recurrence, which was treated aggressively with a strategy including different modalities. Survival results after recurrence and from initial hepatectomy were analyzed, and prognostic factors were determined by univariate and multivariate analysis using 27 clinicopathologic variables.
Results:
One hundred and five patients (43%) with intrahepatic recurrence were treated with re-resection (11), TOCE (71), PEIT (6), systemic chemotherapy (8) or conservatively (9). The overall 1-year, 3-year, and 5-year survival rates from the time of recurrence were 65.5%, 34.9%, and 19.7%, respectively, and from the time of initial hepatectomy were 78.4%, 47.2%, and 30.9%, respectively. The re-resection group had the best survival, followed by the TOCE group. Multivariate analysis revealed Child's B or C grading, serum albumin < or = 40 g/l, multiple recurrent tumors, recurrence < or = 1 year after hepatectomy, and concurrent extrahepatic recurrence to be independent adverse prognostic factors.
Conclusions:
Aggressive treatment with a multimodality strategy could result in prolonged survival in patients with intrahepatic recurrence after curative resection for HCC. Prognosis was determined by the liver function status, interval to recurrence, number of recurrent tumors, any concurrent extrahepatic recurrence, and type of treatment.
Liver transplantation is proposed as the best therapy for early hepatocellular carcinoma in cirrhotic patients. However, the confrontation with the results obtained by surgical resection has never been done on an intention-to-treat basis. Between 1989 and 1997, 164 out of 1,265 patients with hepatocellular carcinoma were evaluated for surgery. Seventy-seven (48 men, mean 61 years of age, 74 Child-Pugh class A, size 33 +/- 18 mm) were resected (first line option) and 87 (65 men, mean 55 years of age, 50 Child-Pugh class B/C, size 24 +/- 14 mm) were selected for transplantation. The 1-, 3-, and 5-year "intention-to-treat" survival was 85%, 62%, and 51% for resection and 84%, 69%, and 69% for transplantation (8 drop-outs on waiting list). Bilirubin and clinically relevant portal hypertension were independent survival predictors after resection. Thereby, the 5-year survival of the best candidates (absence of clinically relevant portal hypertension, n = 35) was 74%, whereas it was 25% for the worst candidates (portal hypertension and bilirubin >/=1 mg/dL, n = 27) (P <.00001). The variable "drop-out on waiting list" was the sole survival predictor after transplantation. The 2-year survival rate of patients evaluated for transplantation was 84% in the 1989 to 1995 period (mean waiting time, 62 days; no drop-outs) and 54% during 1996 to 1997 (mean waiting time, 162 days; 8 drop-outs)(P <.003). This outcome was significantly lower than that of the best candidates for resection (P =.002). In conclusion, a proper selection of candidates for resection promotes better results than transplantation, in which the results are significantly hampered by the growing incidence of drop-outs because of the increasing waiting time.
The authors used new ultrasonically activated scissors and blades in open and laparoscopic liver resections to investigate their capabilities.
Despite standardized techniques for liver resection, the surgical death rate ranges from 4% to 20%. Dissection of liver parenchyma may cause considerable blood loss. Further complications include liver failure, hematoma, infections, and bile leakage. The surgical technique is an important factor in preventing intraoperative and postoperative complications. Various techniques have been developed for safe and careful dissection of the liver parenchyma. In addition to blunt dissection using the "finger fracture" technique, various ultrasonic dissectors, water jet dissectors, laser systems, and specially prepared suction devices have been used, but none of these techniques can achieve complete hemostasis during dissection.
The instrument was used in open and laparoscopic liver resections. It works by means of a longitudinally vibrating blade or scissors in tissue dissection, coagulation, and preparation. Denaturation of protein and coagulation of vessels up to 2 to 3 mm is possible as a result of the vibration. In this prospective study of a consecutively sampled case series of 41 patients, the author sought to gain experience in handling this instrument and in its capabilities, and they also measured the extent of intraoperative and postoperative blood loss.
The UltraCision was used for 64 open liver resections in 39 patients and for 2 laparoscopic liver resections in 2 patients. Blood loss in laparoscopic resections was less than 50 mL; in open resections it averaged 820 mL. Eleven patients (28%) needed blood transfusions. There were no biliary leakages or abscesses. One patient died after postoperative bleeding leading to fatal liver failure after 4 weeks. Handling of the instrument and cutting and coagulation quality were satisfactory.
The advantages over other resection techniques are limited heat and smoke generation and the lack of current flow through the patient. The handling and coagulation and cutting quality of the UltraCision appeared satisfactory and safe. The new instrument can be recommended for laparoscopic and open resections of the liver.
Active hexose correlated compound (AHCC) is a newly developed functional food. In vitro experiments have shown that AHCC enhances natural killer cell activity, and may be considered a potent biological response modifier in the treatment of cancer patients. However, the effects of AHCC in a clinical setting have not been reported. We seek to determine whether AHCC can improve the prognosis of hepatocellular carcinoma (HCC) patients following surgical treatment.
A prospective cohort study was performed from February 1, 1992 to December 31, 2001. A total of 269 consecutive patients with histologically confirmed HCC were studied. All of the patients underwent resection of a liver tumor. Time to treatment failure (disease recurrence or death) and ten parameters related to liver function after surgery were examined.
Of the 269 patients, 113 received AHCC orally after undergoing curative surgery (AHCC group). The AHCC group had a significantly longer no recurrence period (hazard ratio (HR), 0.639; 95% confidence interval (CI), 0.429-0.952; P=0.0277) and an increased overall survival rate (HR, 0.421; 95% CI, 0.253-0.701; P=0.0009) when compared to the control group by Cox's multivariate analysis.
This study suggests that AHCC intake can improve the prognosis of postoperative HCC patients.
We hypothesized that no-margin resections for hepatocellular carcinoma do not negatively affect patient outcomes.
Inception cohort study.
Department of surgery at a university hospital.
From January 1992 to December 2005 at our institute, 465 consecutive patients with a preoperative diagnosis of hepatocellular carcinoma with curative potential were evaluated.
Liver resection performed with or without surgical margins.
Overall survival and no-recurrence survival.
Of the 465 patients, 62 underwent resections with exposure of the tumor surface at the cut stump (the cut surface of the remnant liver) with no surgical margins (exposure group), because the tumor adhered to the major hepatic vascular structures. The remaining 365 patients underwent resections without exposure of the tumor surface (nonexposure group). There were no significant differences between the 2 groups regarding the recurrence and overall survival rates. There were also no significant differences between the 2 groups with respect to the recurrence rate at the cut stump or the number and the location of intrahepatic recurrences, despite the less favorable clinical histories in the exposure group.
Limited resection with no margin seems to be the best procedure for patients with tumors close to the major hepatic vessels and with hepatic functions that do not permit wide-margin resections.
Objective: This study aimed to evaluate the long-term results of treatment and prognostic factors in patients with intrahepatic recurrence after curative resection of hepatocellular carcinoma (HCC). Summary Background Data: Recent studies have demonstrated the usefulness of re-resection, transarterial oily chemoembolization (TOCE), or percutaneous ethanol injection therapy (PEIT) in selected patients with intrahepatic recurrent HCC. The overall results of a treatment strategy combining these modalities have not been fully evaluated, and the prognostic factors determining survival in these patients remain to be clarified. Methods: Two hundred and forty-four patients who underwent curative resection for HCC were followed for intrahepatic recurrence, which was treated aggressively with a strategy including different modalities. Survival results after recurrence and from initial hepatectomy were analyzed, and prognostic factors were determined by univariate and multivariate analysis using 27 clinicopathologic variables. Results: One hundred and five patients (43%) with intrahepatic recurrence were treated with re-resection (11), TOCE (71), PEIT (6), systemic chemotherapy (8) or conservatively (9). The overall 1-year, 3-year, and 5-year survival rates from the time of recurrence were 65.5%, 34.9%, and 19.7%, respectively, and from the time of initial hepatectomy were 78.4%, 47.2%, and 30.9%, respectively. The re-resection group had the best survival, followed by the TOCE group. Multivariate analysis revealed Child's B or C grading, serum albumin ≤ 40 g/l, multiple recurrent tumors, recurrence ≤ 1 year after hepatectomy, and concurrent extrahepatic recurrence to be independent adverse prognostic factors. Conclusions: Aggressive treatment with a multimodality strategy could result in prolonged survival in patients with intrahepatic recurrence after curative resection for HCC. Prognosis was determined by the liver function status, interval to recurrence, number of recurrent tumors, any concurrent extrahepatic recurrence, and type of treatment.
We have developed a new technique to resect hepatic parenchyma without inflow occlusion by using the Cavitron Ultrasonic
Surgical Aspirator (CUSA®) and bipolar cautery with a saline irrigation system. The significance of this method in hepatectomy
was analyzed in comparison with historical control of hepatectomy using Pringle's maneuver. An ordinary bipolar cautery was
remodeled with an infusion line to bring saline droplets down the inner surface of one arm of the tweezers through an opening
about 1.5 cm proximal to its tip. The optimal flow rate of saline was approximately one drop per second. The power of bipolar
cautery was adjusted to 50 watts. When the tweezer blades were approximated to 1 or 2 mm, saline droplets were directed to
the tip of tweezers and could be immediately evaporated. After sonicating parenchymal cells, the tissue of small branches
of Glisson's tree or small tributaries of the hepatic vein were coagulated by bipolar cautery. The coagulated cords were then
easily cut by scissors. The impact of this technique on ordinary liver resections was evaluated by analyzing the postoperative
clinical course in relation to the hepatic functional reserve necessary for major hepatectomy, duration of hepatectomy, and
intraoperative blood loss. Hepatic resection without vascular occlusion using this technique could decrease the morbidity
in patients who have less hepatic functional reserve. It could also decrease intraoperative blood loss. This new technique
effectively decreased the surgical load of the remnant liver during parenchymal resection by avoiding ischemic stress. Consequently
it extends the safety limits of major hepatectomy.
• Liver resections were performed in 18 pigs with an inexpensive disposable plastic suction knife, an ultrasonic dissector, or a contact neodymium (Nd)–YAG laser. Technical aspects and intraoperative and postoperative data were compared. Intraoperative blood loss was less with the suction knife (112±28 mL) than with the ultrasonic dissector (149±45 mL) or Nd-YAG laser (174±25 mL). Operating time was similar in all groups. The number of ligatures used in the Nd-YAG laser group (12±1) was significantly less than in the ultrasonic dissector (27±2) or suction knife (32±2) groups. In the ultrasonic dissector group, there was an increase in postoperative white blood cell count and liver enzyme levels compared with the other two groups. Light microscopy revealed dilated bile ducts in the ultrasonic dissector resection group, which may reflect biliary stasis. There were no significant differences in mortality among the three experimental groups. Results indicated that the ultrasonic dissector and the contact laser method were not substantially better than an inexpensive, easily modified plastic suction catheter in performing a major nonanatomic liver resection in piglets.
(Arch Surg 1987;122:1166-1171)
The microwave tissue coagulator has been applied clinically with satisfactory results. In our system, 2,450-MHz microwaves for medical use are generated and transmitted to a monopolar-type needle electrode. This electrode is thrust directly into the liver tissue and this is repeated along the line where incision is anticipated. Between July 1980, and May 1983, this device was used in 60 patients having major hepatic resections for a variety of conditions. The average amounts of blood loss and blood transfusion were 860 ml and 416 ml, respectively. Seventeen patients did not need blood transfusions, and all cases were free from postoperative bleeding from the resected liver stump. Besides the complications similar to those occurring with other major operations, pyrexia and abdominal pain developed in some cases 2-3 weeks after this surgical procedure. These symptoms were thought to be ascribed to the microwave surgery. However, they remitted soon and the subsequent course was uneventful. All patients with benign or inflammatory diseases had a satisfactory postoperative course, and are well. Of the patients subjected to liver resection for malignant diseases, 4 (6.7%) died within a month after the operation. These findings led us to conclude that this new operative technique can be utilized safely, surely, and easily in the field of hepatic surgery.
Intrahepatic dissection in ablative liver surgery can be accomplished easily and safely with a jet of normal saline generated by a standard agricultural electric sprayer. The jet washes away the intrahepatic parenchyma leaving the ducts and vessels undamaged and easily controlled during dissection. The technique, applied in 45 lobectomies in the dog and in 4 liver resections in man, reduced blood loss.
The microwave tissue coagulator (2450 MHz) has been used clinically in the treatment of hepatocellular carcinoma (HCC) to transection of the liver parenchyma and has proven an excellent method for hemostasis. There are, however, few reports on the application of this coagulator to the induction of tumor necrosis.
Microwave tissue coagulation (MTC) was applied at laparotomy in eight patients with nonresectable multiple HCCs. All patients were treated with a combination of resection or intrahepato-arterial chemotherapy and MTC. A total of 222 bouts of MTC were applied to 21 tumors, the largest of which was 65 mm in largest dimension. The monopolar needle electrode was inserted directly into the tumor and the procedure was repeated at approximately 5 mm intervals.
Levels of alpha-fetoprotein in serum were found to have decreased in all patients one month after surgery with MTC. Contrast-enhanced computerized tomography (CT) showed the complete absence of blood flow in all tumors subjected to MTC. Needle biopsy one month after MTC confirmed tumor necrosis in all cases. All patients are alive at the time of this report, with the longest survival period being 24 months. In three of eight patients, new tumors were confirmed by angiographic CT at sites separate from the treated tumors. MTC resulted in fewer adverse effects on liver function and less extensive inflammatory reactions than liver resection.
Intraoperative MTC appears to be an effective method for inducing local tumor necrosis, and may be of use in combination with palliative surgery for multiple HCC when radical liver resection is not feasible.
In a prospective study 116 patients underwent liver resection. Three different resection techniques, blunt dissection (n = 61), ultrasonic aspirator (CUSA) (n = 27) and jet-cutter (n = 28) were compared. Speed of resection, blood loss, transfusion rate, liver hilus clamping time and tissue damage were evaluated on the basis of area of transected liver surface. Liver resection with the jet-cutter was significantly faster with a resection time of 0.33 min/cm2 in comparison to blunt dissection (0.57 min/cm2) and CUSA (0.50 min/cm2) (P < 0.01) and associated with lower blood loss of 17.7 ml/cm2 (P < 0.01) than the other techniques (blunt dissection 32.5 ml/cm2, CUSA 24.3 ml/cm2). Tissue damage with respect to transaminases SGOT and SGPT was comparable to the other techniques. The jet-cutter is a promising new instrument in liver surgery.
The present study reports on the usefulness of microwave coagulonecrotic therapy (MCT) as a treatment option for hepatocellular carcinoma (HCC) with poor hepatic reserve. From June 1992 to March 1995, MCT using a microwave electrode was employed on 8 patients using laparoscopic control and 19 with the open method, and wedge resection (Hx) was applied to the 23 patients. All patients had HCC with poor hepatic reserve. Radiation output was 100 watts with a mean radiation duration of about 30 minutes. The severity of liver dysfunction and the regional characteristics of the tumor (tumor size, multiplicity, portal invasion, tumor depth) were comparable between the MCT and Hx groups. The operative time was significantly shorter for the MCT group than the Hx group. The mean blood loss was 1570 ml in the Hx group but negligible in the MCT group. There was no operative mortality in the MCT group in contrast to 4.3% (1 of 23) in the Hx group. Complications were observed in 11.1% (3 of 27) and 34.8% (8 of 23), respectively, for the MCT and Hx groups. The postoperative total bilirubin had lower values and the start of diet was earlier in the MCT group than the Hx group. The 3-year crude and disease-free survival rates were 86% and 44%, respectively, for patients who underwent MCT, which were comparable to 75% and 14% for those with Hx. MCT can achieve long-term results equivalent to those obtained by wedge resections, but it is less invasive and technically easier. Therefore it can be an alternative option in place of limited resection for HCC with poor hepatic reserve.
From 1984 through 1994, 99 consecutive patients with hepatocellular carcinoma (HCC) underwent hepa-tectomy with microwave tissue coagulation (MTC). We performed limited resection (Hr0) in 28 patients, subsegmentectomy (HrS) in 25 patients, segmentectomy (Hr1) in 21 patients, and lobectomy or extended lobectomy (Hr2) in 25 patients. The patients were divided into two groups: group A, 86 patients with tumors smaller than 1 kg and no tumor thrombi in the main portal trunk; and group B, 13 patients with a tumor 1 kg or larger, or with macroscopic tumor thrombi in the main portal trunk. In group A, mean blood loss was 838 ml for Hr0, 1948 ml for HrS, 1765 ml for Hr1, and 1325 ml for Hr2. The mean operative time in group A ranged from 3 h 43 min for Hr0 to 4 h 57 min for Hr2. In group B, the mean operative time was 6 h 3 min and mean blood loss was 6053 ml. Our MTC method was associated with an in-hospital mortality rate of 3% and a major complication rate of 13.1%. The 5-year survival and disease-free survival rates were 43.4% and 25.4%, respectively. The 5-year survival rate of patients without portal tumor thrombi (50.9%) was significantly better than that of patients with portal tumor thrombi (11.9%) (P < 0.001). The 5-year survival rate of patients who underwent curative resection (58.1%) was significantly better than that of patients who underwent noncurative resection (22.9%) (P < 0.001). The 5-year survival rates of patients in group A without portal tumor thrombi did not differ between those who had cancer-negative margins (54.0%) and those with cancerpositive margins (49.6%) at resection. Recurrence and local recurrence rates did not differ in patients with cancer-positive margins (63.6% and 7.3%, respectively) and patients with cancer-negative margins (56.5% and 8.7%, respectively). These results suggested that microscopic residual cancer in the resected margin was coagulated by MTC. Blood loss, operative time, and clinical outcome in this series of 99 consecutive hepatectomies were comparable with values in earlier reports in which such hemostatic methods as the Pringle maneuver were used. We conclude that hepatectomy with MTC is useful and safe and produces consistent results.
A microwave tissue coagulator originally developed to control hemorrhage during hepatic resection has recently found widespread use in the field of minimally invasive surgery. This surgical tool is based on the principle that by radiating a 2450-MHz (12-cm wavelength) microwave from a monopolar antenna within tissue, the heat generated will be limited to within the electromagnetic field generated around the antenna, leading to coagulation of protein in that field. It is therefore possible to use this monopolar antenna as a surgical electrode. The coagulation field is determined by the relationship between the wavelength frequency, tissue-specific permittivity, antenna length, waveform and output, and duration of the irradiation. Since this technique has been applied to devise a new method of hepatectomy, it has also found use in various other surgical fields, such as gastrointestinal tract endoscopic surgery, laparoscopic surgery, and percutaneous surgery. It has also enhanced therapeutic results, notably in cancer therapy.
We have previously demonstrated that maintenance of a low central venous pressure (LCVP) combined with extrahepatic control of venous outflow reduced the overall blood loss during major hepatic resections. This study examined the overall outcomes and, in particular, renal morbidity associated with a large series of consecutive major liver resections performed with this approach. In addition, the rationale for the anesthetic management to maintain LCVP was carefully reviewed.
All major hepatectomies performed between December 1991 and April 1997 were reviewed. The prospective Hepatobiliary Surgical Service database was merged with the Memorial Hospital Laboratory and Blood Bank databases to yield the nature of the operation, blood loss, blood product transfusions, outcomes, and levels of preoperative, postoperative, and discharge serum creatinine and blood urea nitrogen.
A total of 496 LCVP-assisted major liver resections were performed, with no intraoperative deaths and an in-hospital mortality rate of 3.8%. The median blood loss was 645 mL. Sixty-seven percent of the patients did not require perioperative blood transfusion during surgery and the immediate 12 hours after surgery. The median number of blood transfusions was 2. Only 3% of the patients experienced a persistent and clinically significant increase in serum creatinine possibly attributable to the anesthetic technique. Renal failure directly attributable to the anesthetic technique did not occur.
Major resection with LCVP allowed easy control of the hepatic veins before and during parenchymal transection. The anesthetic technique, designed to maintain LCVP during the critical stages of hepatic resection, not only helped to minimize blood loss and mortality but also preserved renal function.
The significance of a surgical margin for hepatic resection of hepatocellular carcinoma (HCC) in patients with impaired liver function was evaluated.
Sixty-eight patients, each with a solitary HCC, who had not received any prior treatments were divided into 2 groups, according to surgical margin: Group A included 25 patients who underwent resection with no margin (although the tumor was not exposed) and Group B included 43 patients with a sufficient surgical margin (mean distance: 9 mm). There were no significant differences in clinicopathologic variables between the 2 groups. The rate of stump recurrence, survival and recurrence-free survival were analyzed.
Among the 38 patients who had cancer recurrence after a median follow-up of 58 months, 9 (Group A, n=4; Group B, n=5) (24%) had recurrent lesions at the stump. The surgical margin was not a significant factor related to survival or recurrence, irrespective of cirrhosis, capsule formation, cancer spread, or tumor size.
Our results indicated that the HCC-free surgical margin is unlikely to be related to the survival of patients with impaired liver function unless the tumor is exposed on the raw liver surface.
Liver cancer (LC) ranks fifth in frequency in the world with an estimated number of 437,000 new cases in 1990. In developing countries, incidence rates are two- to three-fold higher than in developed countries. The geographic areas at highest risk are located in Eastern Asia, with age-adjusted incidence rates (AAIRs) ranking from 27.6 to 36.6 per 100,000 in men; Middle Africa, with AAIRs ranking from 20.8 to 38.1 per 100,000 in men; and some countries of Western Africa, with AAIRs ranking from 30 to 48 per 100,000 in men. The geographic areas at lowest LC risk are Northern Europe, Australia, New Zealand, and the Caucasian populations in North and Latin America, with AAIRs below 5.0 per 100,000 in men. Excess of LC incidence among men compared to women is universal, with sex ratios between 1.5 and 3.0. Significant variations in LC incidence among different ethnic groups living in the same geographical area and among migrants of the same ethnic groups living in different areas have been extensively described. The variability of LC incidence rates between countries and within countries, strongly suggests differences in exposure to risk factors. The role of chronic infection with the Hepatitis B and hepatitis C viruses (HBV and HCV) in the etiology of LC is well established. The attributable risk estimates for LC for each of these hepatotropic viruses vary among countries but the combined effects of persistent HBV or HCV infections account for well over 80% of LC cases worldwide. Other documented risk factors such as aflatoxin exposure in diets, cigarette smoking, alcohol consumption, and oral contraceptives may explain the residual variation between and within countries. Interactions between some risk factors have been postulated, and are subject of active research. New laboratory techniques and biological markers such as polymerase chain reaction detection of HBV DNA and HCV RNA, as well as specific mutations related to aflatoxin exposure may help to provide quantitative estimates of the risk related to each these factors.
To evaluate the influence of the width and histologic involvement of the resection margin on postoperative recurrence after resection of hepatocellular carcinoma (HCC).
The significance of the resection margin in hepatectomy for HCC remains controversial. A precise evaluation of the effects of the width and histologic involvement of the resection margin on postoperative recurrence is required to clarify the issue.
Two hundred eighty-eight patients with macroscopically complete resection of HCC were divided into groups with narrow (<1 cm) or wide (>/=1 cm) resection margins. The two groups were compared for postoperative recurrence rate and pattern of recurrence. A further analysis was performed to investigate the effects of histologic involvement of the resection margin on postoperative recurrence.
Recurrence rates were similar between 150 patients with a narrow margin and 138 patients with a wide margin; the groups were comparable in other clinicopathologic variables. Most recurrent tumors occurred in the liver remnant at a segment distant from the resection margin or at multiple segments. Thirty-four patients had margin involved histologically by microscopic invasion from the main tumor (n = 13), venous tumor thrombi (n = 13), or microsatellites separate from the main tumor (n = 8). These patients had significantly higher recurrence rates than those with a histologically clear margin. However, a positive histologic margin was not a significant risk factor for recurrence by multivariate analysis. Tumor stage and perioperative transfusion were the only independent risk factors.
The width of the resection margin did not influence the postoperative recurrence rates after hepatectomy for HCC. A positive histologic margin was associated with a higher incidence of postoperative recurrence, but in most patients this was related to the underlying venous invasion or microsatellites. Most intrahepatic recurrences were considered to arise from intrahepatic metastasis by means of venous dissemination, which a wide resection margin could not prevent.
To evaluate the current knowledge on the risk factors for recurrence, efficacy of adjuvant therapy in preventing recurrence, and the optimal management of recurrence after resection of hepatocellular carcinoma (HCC).
The long-term prognosis after resection of HCC remains unsatisfactory as a result of a high incidence of recurrence. Prevention and effective management of recurrence are the most important strategies to improve the long-term survival results.
A review of relevant English articles was undertaken based on a Medline search from January 1980 to July 1999.
Pathologic factors indicative of tumor invasiveness such as venous invasion, presence of satellite nodules, large tumor size, and advanced pTNM stage, are the best-established risk factors for recurrence. Active hepatitis activity in the nontumorous liver and perioperative transfusion also appear to enhance recurrence. Recent molecular research has identified tumor biologic factors such as the proliferative and angiogenic activities of the tumor as new risk factors for recurrence. There is a lack of convincing evidence for the efficacy of neoadjuvant or adjuvant therapy in preventing recurrence. Retrospective studies suggested that postoperative hepatic arterial chemotherapy might improve disease-free survival, but results were conflicting. For the management of postoperative recurrence, studies have consistently indicated that surgical resection should be the treatment of choice for localized recurrence, be it in the liver remnant or extrahepatic organs. Transarterial chemoembolization and percutaneous ethanol injection are widely used to prolong survival in patients with unresectable intrahepatic recurrence, and combined therapy with these two modalities may offer additional benefit.
Knowledge of the risk factors for postoperative recurrence provides a basis for logical approaches to prevention. Minimal surgical manipulation of tumors to prevent tumor cell dissemination, avoidance of perioperative blood transfusion, and suppression of chronic hepatitis activity in the liver remnant are strategies that may be useful in preventing recurrence. The efficacy of postoperative adjuvant regional chemotherapy deserves further evaluation. New concepts on the influence of tumor biologic factors such as angiogenic activity on recurrence of HCC suggest a potential role of novel approaches such as antiangiogenesis for adjuvant therapy in the future. Currently, the most realistic approach in prolonging survival after resection of HCC is early detection and aggressive management of recurrence. Randomized trials are needed to define the roles of various treatment modalities for recurrence and the benefit of multimodality therapy.
Hepatic parenchymal transection is a technical priority in liver surgery. The use of an ultrasonic dissector for hepatectomy may result in less blood loss than conventional clamp crushing.
Randomized controlled trial.
University teaching hospital.
The 132 patients scheduled to undergo partial hepatectomies were randomly assigned to receive hepatic transection by ultrasonic dissector or by clamp crushing (66 patients by each method).
All resections were performed with inflow occlusion and were guided ultrasonographically. Hepatectomies were graded according to a predefined system based on 6 criteria (blood loss, transection time, technical error, surgical margin, landmark appearance, and postoperative morbidity), each with 3 scores (lower scores indicating higher quality).
Blood loss and hepatectomy grade.
No difference was found between the ultrasonic and clamp groups in median blood loss (515 mL [range, 15-2527 mL] vs 452 mL [range, 17-1912 mL]; P =.63), transection time (61 minutes [range, 16-177 minutes] vs 54 minutes [range, 7-205 minutes]; P =.58), or transection speed (1.1 cm(2)/min [range, 0.4-4.0 cm(2)/min] vs 1.0 cm(2)/min [range, 0.4-3.0 cm(2)/min]; P =.90). Ultrasonic dissection caused more frequent histologically proven tumor exposure at the surgical margin (9 vs 3 patients; P =.09), incomplete appearance of landmark hepatic veins on the cut surface after anatomical resection (12 vs 4 patients; P =.03), and postoperative morbidity (20 vs 14 patients; P =.32) than did clamp crushing. The hepatectomies with clamp crushing had significantly higher grades than those with ultrasonic dissection (P =.05), as indicated by the lower median sum score (4.0 [range, 0-12] vs 5.0 [range, 0-19]; 95% confidence interval for difference, -2.0 to 0; P =.03). The transection method independently influenced hepatectomy grade (adjusted odds ratio = 3.06; 95% confidence interval, 1.35-6.92; P =.01).
Ultrasonic dissection offers no reduction in blood loss compared with clamp crushing for transection of the liver. Clamp crushing results in a higher quality of hepatectomy and is therefore the option of choice.
Surgical margin, i.e., the area of possible local intrahepatic metastasis, is controversial in hepatectomy for hepatocellular carcinoma.
The blood drainage area of tumor was identified preoperatively by abdominal helical computed tomographic scan under hepatic arteriography and excised as surgical margin. The specimens were pathologically examined on the basis of the corresponding computed tomographic images.
University hospital.
From June 2, 1997, to April 24, 2000, 67 patients with hepatocellular carcinoma who underwent curative hepatic resection.
Intrahepatic recurrence.
Blood drainage area of tumor could be classified into the following types. The marginal type (drainage into the peritumorous area) was frequent (50 cases) and excised mostly by nonanatomic, limited resection. Portal vein type (drainage into the portal branches) was less common (12 cases) and resected mostly by anatomically systematic hepatectomy. The remaining 5 cases were of the hypovascular type and underwent limited resection. Multiple nodules were frequently found inside the drainage area (4 of 8 cases) and were moderate or poorly differentiated hepatocellular carcinoma, consistent with intrahepatic metastasis. Solitary nodules were mostly outside the drainage area (11 of 12 cases) and contained well-differentiated hepatocellular carcinoma (7 of 10 cases), suggesting multicentric carcinogenesis. Intrahepatic recurrences were commonly found in bilateral or contralateral lobes (17 of 19 cases) and divided into 2 groups with a few (< or =4) and multiple (> or =8) recurrent nodules.
Surgical margin varied according to tumor hemodynamics. Tumor recurrences may result not only from multicentric carcinogenesis but also from intrahepatic metastasis via systemic circulation.
To evaluate prognostic factors that could affect disease-free survival and recurrence after liver resection for hepatocellular carcinoma (HCC) on cirrhosis.
Tumor recurrence is the main cause of poor survival after liver resection for HCC on cirrhosis.
Two hundred twenty-four liver resections for HCC on cirrhosis were retrospectively reviewed. Univariate and multivariate analyses were performed on several clinicopathologic variables to analyze factors affecting long-term outcome and intrahepatic recurrence. The relation between preoperative aminotransferase level and recurrence rate was evaluated in the overall group, and separately in HCV-positive and in HBsAg-positive patients. Median follow-up was 35.6 months.
The 1-, 3-, and 5-year overall survival rates were 83%, 62.8%, and 42.5%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 70.3%, 43%, and 27.4%, respectively. The 1-, 3-, and 5-year recurrence rates were 20.8%, 38.6%, and 54.4% respectively. Tumor recurrence appeared in 93 patients (41.5%) and was the main cause of death in 51 patients (56%). Number of nodules, tumor capsule, microvascular portal vein thrombosis, and preoperative serum aspartate aminotransferase (AST) level significantly affected disease-free survival and recurrence rates. On multivariate analysis, single nodules and preoperative AST level less than twice normal (2N) were related to a better 5-year disease-free survival and lower tumor recurrence. In particular, among HCV-positive patients the recurrence rate was strongly affected by the preoperative AST level.
Child A patients with single nodules are the best candidates for liver resection. Tumor recurrence is strictly linked to the status of the underlying liver disease, and a preoperative AST level equal to 2N seems to be a sensitive cutoff among patients with different risks of recurrence. HCV-positive patients with AST levels above 2N have the highest risk for intrahepatic recurrence and should be monitored carefully or offered alternative treatments.
Blood loss during liver transection and ischemia-reperfusion injury associated with hepatic inflow occlusion are significant drawbacks during liver surgery. Sixteen patients underwent liver resection using the Monopolar Floating Ball (FB) plus LigaSure (LS) diathermy without occlusion of the hepatoduodenal ligament (group FB-LS). The liver parenchyma was precoagulated using the FB, and the uncovered tiny vessels were sealed using LS. Surgical outcomes were retrospectively compared with 16 well matched patients who underwent liver resection using the conventional clamp crushing method with Pringle's maneuver (group CC). The amount of blood loss during liver transection was significantly less in group FB-LS than in group CC [200 ml (0-990 ml) vs. 480 ml (120-1800 ml); p = 0.006]. The median time it took to complete the liver transection was significantly longer in group FB-LS than in group CC [144 minutes (43-335 minutes) vs. 58 minutes (18-94 minutes); p < 0.0001]. Hepatic inflow occlusion was temporally used in five patients in group FB-LS to achieve hemostasis in hepatic venous tributaries for 6, 10, 19, 26, and 61 minutes, respectively. Using these two electronic devices allows liver resection to be safely performed, with the advantage of minimal blood loss and a reduced inflow occlusion period compared to the conventional method. The major disadvantage may be a slower transection speed. A prospective randomized trial is needed to clarify the clinical benefits of liver resections performed using this novel technique.
In the 15th Nationwide follow-up survey of primary liver cancer, 18,843 newly registered patients (1998-1999) and 18,405 follow-up patients from 791 hospitals in Japan were analyzed. Of the newly registered patients, approximately 95% were patients with hepatocellular carcinoma (HCC) and 3.3% had intrahepatic cholangiocarcinoma (ICC). The patients were assessed using 194 items that were related to epidemiological and clinicopathological factors, diagnosis, and treatment. Furthermore, the survival rates of all of the newly registered patients in the 10th-15th follow-up survey were calculated for each histological type, background factor(s) and treatment, respectively. In patients with hepatocellular carcinoma, the survival rates of patients who underwent hepatectomy, ethanol injection therapy, microwave coagulation therapy, or transcatheter arterial embolization were calculated by tumor size, tumor number, and clinical stage. This follow-up survey will be helpful to assess the progress of research and medical practice in the treatment of primary liver cancer.
To assess a new bloodless technique using radiofrequency energy for segmental liver resection of hepatic tumors.
Liver resection remains a formidable surgical procedure; safe performance requires a high level of training and skill. Intraoperative blood loss during liver resection remains a major concern because it is associated with a higher rate of postoperative complications and shorter long-term survival.
From January 2000 to June 2001, 15 patients with various hepatic tumors were operated on using radiofrequency energy to remove the tumor in its entirety. Radiofrequency energy was applied along the margins of the tumor to create "zones of necrosis" before resection with a scalpel.
No blood transfusions were required. The mean blood loss during resection was 30 +/- 10 mL. No mortality or morbidity was observed. The median postoperative stay was 8 days (range 5-9). No liver recurrence was detected in patients undergoing resection with this technique during follow-up periods ranging from 2 to 20 months.
Segmental and wedge liver resection assisted by radiofrequency is safe. This novel technique offers a new method for transfusion-free resection.
Liver resection is the most effective form of treatment for patients with hepatocellular carcinoma. The use of a microwave tissue coagulator has been reported to enable limited liver resections for the patients with poor hepatic reserve. Herein, we report the clinical outcome of 214 patients with HCC who underwent non-anatomical liver resection using MTC in accordance with the tumor size.
A consecutive series of 214 patients who underwent liver resections using MTC were observed over a 10-year study period. The clinical characteristics of patients were evaluated. The operative mortality and morbidity, overall patient survival and disease-free survival were calculated.
Seventy-two percent of patients suffered from type C hepatitis and 47% of patients had pathologically proven liver cirrhosis. The overall patient survival rates were 91, 72, and 58% at 1, 3 and 5 years, respectively. Disease-free survival rates were 74, 46, and 28% at 1, 3 and 5 years, respectively. Postoperative morbidity was 36% and hospital mortality was 2.8%. Complications in most patients were well controlled.
Non-anatomical liver resections using MTC, in accordance with tumor sizes, can be achieved safely with acceptable results and without the need to use special techniques.
To identify the most efficient parenchyma transection technique for liver resection using a prospective randomized protocol.
Liver resection can be performed by different transection devices with or without inflow occlusion (Pringle maneuver). Only limited data are currently available on the best transection technique.
A randomized controlled trial was performed in noncirrhotic and noncholestatic patients undergoing liver resection comparing the clamp crushing technique with Pringle maneuver versus CUSA versus Hydrojet versus dissecting sealer without Pringle maneuver (25 patients each group). Primary endpoints were intraoperative blood loss, resection time, and postoperative liver injury. Secondary end points included the use of inflow occlusion, postoperative complications, and costs.
The clamp crushing technique had the highest transection velocity (3.9 +/- 0.3 cm/min) and lowest blood loss (1.5 +/- 0.3 mL/cm) compared with CUSA (2.3 +/- 0.2 cm/min and 4 +/- 0.7 mL/cm), Hydrojet (2.4 +/- 0.3 cm/min and 3.5 +/- 0.5 mL/cm), and dissecting sealer (2.5 +/- 0.3 cm/min and 3.4 +/- 0.4 mL/cm) (velocity: P = 0.001; blood loss: P = 0.003). Clamp crushing technique was associated with the lowest need for postoperative blood transfusions. The degree of postoperative reperfusion injury and complications were not significantly different among the groups. The clamp crushing technique proved to be most cost-efficient device and had a cost-saving potential of 600 to 2400 per case.
The clamp crushing technique was the most efficient device in terms of resection time, blood loss, and blood transfusion frequency compared with CUSA, Hydrojet, and dissecting sealer, and proved to be also the most cost-efficient device.
To compare the results of percutaneous local ablative therapy (PLAT) with surgical resection in the treatment of solitary and small hepatocellular carcinoma (HCC).
PLAT is effective in small HCC. Whether it is as effective as surgical resection in the long-term survivals remains unknown.
We conducted a prospective randomized trial on 180 patients with a solitary HCC <or=5 cm to receive either PLAT or surgical resection. The patients were regularly followed up after treatment with physical examination, blood, and radiologic tests.
Of the 90 patients who were randomized to PLAT, only 71 received PLAT because 19 withdrew their consent. Of the 90 patients who were randomized to surgical resection, a single Couinaud liver segment resection was carried out in 69 patients, 2 segments in 16 patients, and 3 or more segments in 3 patients. Ethanol injection was given during open surgery in 2 patients. Only 1 patient died after surgical resection within the same hospital admission. Posttreatment complications were more often and severe after surgery than PLAT. The 1-, 2-, 3-, and 4-year overall survival rates after PLAT and surgery were 95.8%, 82.1%, 71.4%, 67.9% and 93.3%, 82.3%, 73.4%, 64.0%, respectively. The corresponding disease-free survival rates were 85.9%, 69.3%, 64.1%, 46.4% and 86.6%, 76.8%, 69%, 51.6%, respectively. Statistically, there was no difference between these 2 treatments.
PLAT was as effective as surgical resection in the treatment of solitary and small HCC. PLAT had the advantage over surgical resection in being less invasive.
We introduced an ultrasonic surgical aspirator with electrosurgical coagulation to increase safety of the liver resections performed for hepatocellular carcinoma.
This system was evaluated by analyzing the intraoperative blood loss, the duration of hepatectomy, the ischemia time, and the postoperative clinical course and comparing these same parameters with the traditional forceps' fracture method.
There was no significant difference in the duration of surgery and the mean liver resection time between the two methods. The mean blood loss by using this system was 2458 +/- 4742 mL and by forceps' fracture method 956 +/- 252 mL. The mean ischemia time was 44.4 +/- 35.9 min by using this system and 23.9 +/- 29.1 min in forceps' fracture method. There was a significant decrease in intraoperative blood loss and ischemia time using the new system. This may decrease postoperative complications.
This system may enable all surgeons to perform liver resection easily and safely.
New technique for liver resection using heat coagulative necrosis
- Weber