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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Ablation Therapy of Liver Tumors
Laparoscopic approach
Step1
Positioning of the patient and access
Depending on the location of the tumor or tumors, the patient is placed in the supine or le lateral
decubitus position. A minimum of two laparoscopic trocars are placed: a 12-mm periumbilical
camera port and a 12-mm laparoscopic ultrasound port in the right ank. e RFA or MWA
probe can be placed percutaneously, through a sheath, or through a 5-mm right subcostal port.
More ports may be required if additional procedures are to be performed (e. g., liver mobilization,
partial resection) (. Fig. 53.4).
. Fig.53.4
Section III • Liver: Nontransplant Procedures
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Step2
Assessment of tumors and ablation
Laparoscopic intra-abdominal ultrasound is performed by either rigid or exible IOUS probes to
identify/conrm the location and the size of the lesions.
e abdomen is explored for the presence of extrahepatic disease. As described for the
open technique, the probe is oriented parallel with the IOUS crystal to facilitate probe guidance
(
. Fig. 53.5a and 53.5b). Limited mobility can make this more dicult than with the open tech-
nique. e ablation process and monitoring are otherwise performed as described for the open
approach.
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. Fig.53.5
Chapter • Ablation Therapy of Liver Tumors
Postoperative Evaluation
Follow-up post-ablation imaging (CT or MRI) is performed 3 to 30days aer the procedure to
assess the completeness of ablation.
Postoperative Complications
z Short-term
Pleural eusion
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Regional hemorrhage into needle track or into RFA lesion
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Fever
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Hepatic abscess (more common with enterobiliary anastomosis)
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Biliary stricture secondary to ablation near major bile duct
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Grounding pad burns
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z Long-term
Biloma
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Biliary stula
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Ascites
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Hepatic insuciency
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Arteriovenous stula
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Indications
Non-thermal Ablation: Irreversible Electroporation (IRE)
is novel technology oers the possibility for non-thermal ablation procedure for unresectable
tumors in the liver, hilum, and pancreas. It uses an electric eld to change the electrochemical
potential of the membrane, forming nanopores leading to cell membrane instability followed by
cell death. It is applied using short pulses of high energy (1,500–3,000 V), applying electrical eld
to tissue between the probes. Access is either laparotomic or percutaneous.
Indications and Contraindications
IRE is indicated for unresectable malignant tumors located on surrounding hepatic veins or perihilar area (. Fig. 53.6).
IRE seems not to damage connective tissue, preserving vascular structures and bile ducts.
is is the most relevant advantage of IRE compared to other ablative techniques. Of note, lesions
located in areas other than the hilum and hepatic veins should be treated by thermal ablation
(MWA or RFA).
. Fig.53.6
Section III • Liver: Nontransplant Procedures
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Contraindications
Step1
z Access
Open: under intraoperative ultrasound (IOUS) guidance
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Laparoscopic: multiple needle insertion under IOUS guidance may be demanding, as
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needles usually bend and must be re-inserted
Percutaneous: under CT guidance
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Similar to RFA and MWA: coagulopathy, ascites, and tumor progression under chemotherapy.
(atrial brillation), recent myocardial infarction, and presence of any metal in the proximity of
the ablation area.
Preoperative Investigation and Preparation for the Procedure
MRI, MDCT, and PET-CT: same preoperative image as used for thermal ablation.
Procedures
General anesthesia
is is mandatory for all IRE cases (either via laparotomy or percutaneous access). Neuromuscular
blockade with level0 paralysis is paramount to avoid patient movement while pulses are delivered.
Before starting, place the external synchronization device lids for ECG synchronization. e leads
should be placed before draping and debrillator pads.
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Step2
Step3
Ablation planning
Treatment plan is based on preoperative tumor dimensions, which should be further conrmed
by IOUS. is information of tumor width, length and depth, as well as the tumor free desirable
margin goes into the Ablation Zone estimator soware. e IRE generator will calculate the
number and spacing probes to ablate the tumor.
Probe selection
Monopolar electrode probe is a 19-gauge needle with a depth-map echogenic surface. e active
length ranges from 0.5 cm to 4.0 cm and should be adjusted for tissue type. Usually in the liver,
2 cm can be used (
. Fig.53.7
. Fig. 53.7).
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Chapter • Ablation Therapy of Liver Tumors
Step4
Needle placement
Needle placement is guided by US or CT direct visualization e number of monopolar probes
depends on tumor size, adequate margin, and area of ablation. .
ablation area using four needles.
Figure 53.8
demonstrates an
. Fig. 53.8
One important fact for needle placement to achieve irreversible electroporation is the position of
needles. ey must be parallel, avoiding convergent or divergent-needled tips.
Section III • Liver: Nontransplant Procedures
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Step4 (continued)
Procedure summary
General anesthesia with full muscle relaxation is required for all cases
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Image guide of the liver to assess 3D tumor size
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Plan needle placement (. Fig. 53.8). Needle insertion is around the tumor. When overlap-
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ping is requiring for lesions larger than 4 cm, active needle can be placed centrally. For
lesions larger than 3 cm, pullbacks are required.
Guidance imaging by IOUS or CT around the tumor (percutaneous ablation)
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IRE delivery: using deep paralytic upstart with 10pulses test all needle pairs to assess tissue
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resistance, followed by 80pulses for ecacy
Check amperage graphic to verify IRE ecacy
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Aer ablation therapy, US Doppler or CT (percutaneous ablation) should conrm patency
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of vascular structures (
CT/MRI should be performed before discharge to exclude complications
. Fig. 53.9)
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. Fig.53.9
Postoperative Testing
MDCT or MRI at the time of discharge to exclude complications
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Every 3months for assessing ablation completeness using PET-CT (CT with contrast) or
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MRI or MDCT
Postoperative Complications
z Short term
Cardiac arrhythmia
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Cardiac arrest
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Bleeding
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Fever
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Portal vein thrombosis
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Fistula/stenosis when probe placed in contact with metal stents
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z Long term
Tumor recurrence
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z Summary
IRE (NanoKnife system) is more expensive than RFA and MWA
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Uses electric pulse energy
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Can be applied on bile ducts and large vessels
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Promising novel technology, however ecacy still under investigation
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Chapter • Ablation Therapy of Liver Tumors
Tricks of the Senior Surgeon
Thermal ablation
When the lesion lies near a major blood vessel, thermal energy from the probe may be drawn
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away from the ablation zone, limiting ablation ecacy. This is known as the “heat sink” eect.
This eect can be limited using in-ow occlusion techniques (e. g., Pringle maneuver) or
repositioning the array closer to the vascular structure. The heat sink eect appears to aect
RFA more than MWA.
In case of a deployable probe, stabilization of the ablation probe at the skin or liver surface
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should be done during deployment to avoid “push back”.
Depending on the device, monitoring of the impedance pattern and tine deployment shape
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by ultrasound can conrm success of the ablation in real time.
With some devices, temperature proles can also be helpful in conrming successful abla-
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tion, including consistent tine temperatures and adequately slow cool-down temperatures.
Non-thermal ablation: irreversible electroporation
Probes too far apart may result in low current and cause an inecient ablation treatment.
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The optimal probe distance is from 1.5–1.8 cm.
If the generator does not recognize the ECG signal, change the lead pair; check if the cable is
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properly connected.
In case of troubleshooting, re-image needle placement and inter-probe distance.
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Selective Hepatic Intra-arterial Chemotherapy
Diane Goéré, Dominique Elias
Placement of a hepatic intra-arterial infusion pump (HAIP) provides liver-specic, continuous
infusion of chemotherapeutic agents. e chemotherapeutic agents selected for use with the
HAIP should exhibit a high degree of rst-pass kinetics, to minimize systemic toxicity. Agents
used include uorodeoxyuridine (FUDR), oxaliplatin, cisplatin, 5-uorouracil, mitomycin C,
and Adriamycin.
Indications and Contraindications
Indications
Contraindications
Unresectable hepatic metastatic colorectal carcinoma (to make lesions resectable)
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Liver-specic adjuvant chemotherapy following resection of colorectal metastases, in
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patients at high risk of hepatic recurrence (≥ 4 liver metastases or disappeared and missing
metastases)
Hepatocellular carcinoma and other metastatic carcinomas, under certain circumstances
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Portal hypertension (portal pressure > 12 mm Hg)
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Known extrahepatic malignancy
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Poor liver reserve (e. g., Child class B or C cirrhosis)
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Severe coagulopathy (e. g., platelets < 30,000/mL)
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Active hepatitis
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Preoperative Studies
History: Specic for hepatic function (e. g., alcohol use, hepatitis)
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Clinical evaluation: To rule out obvious extrahepatic malignancy (lymph node exam) and
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underlying liver dysfunction (ascites, nutrition status, signs of portal hypertension)
Imaging:
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Triple-phase CT scan: For denition of tumor and arterial anatomy
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CT angiogram or MRI of abdomen
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Chest CT scan: To rule out pulmonary metastases, except for colorectal carcinoma
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FDG-PET: In cases of metastatic colorectal carcinoma
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Hepatic arteriogram: Mandatory if HAIP will be placed laparoscopically and CT or MR
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angiograms have not been performed. Not mandatory if HAIP is to be placed via laparotomy (but it may decrease operative time)
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_54, © Springer-Verlag Berlin Heidelberg 2016
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Step1
Section III • Liver: Nontransplant Procedures
Procedure
Incision and exposure
A right subcostal approach or a midline incision can be used. e falciform ligament is divided
and the porta hepatis is exposed further by gentle superior retraction of the liver. Usually, a cholecystectomy is performed to eliminate the postoperative complication of chemical cholecystitis
induced by infusional chemotherapy. (Cholecystectomy is not performed when the catheter is radiologically inserted.) e gastrohepatic ligament is divided with care to avoid injury to a replaced
le hepatic artery (if present). All duodenal and antral vessels must be ligated to eliminate the
possibility of reux of chemotherapy into these regions, which may lead to chemical duodenitis
or gastritis. e common hepatic, gastroduodenal, and proper hepatic arteries are identied by
dissection of the hepatoduodenal ligament and marked with vessel loops (
. Fig. 54.1).
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. Fig.54.1
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Chapter • Selective Hepatic Intra-arterial Chemotherapy
Step2
Determination of arterial anatomy
At this point it is imperative to accurately determine the hepatic arterial anatomy if no preoperative arteriogram was performed. e more common variants in hepatic arterial anatomy are
shown in the gures:
e common hepatic artery may originate from the celiac trunk (typical) (. Fig. 54.2a).
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A replaced right hepatic artery may arise directly from the superior mesenteric artery
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(
. Fig. 54.2b).
A replaced le hepatic artery may arise directly from the le gastric artery (. Fig. 54.2c).
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Common origin of the right hepatic artery, le hepatic artery, and gastroduodenal artery
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(
. Fig. 54.2d), commonly referred to as “trifurcation anatomy.”
. Fig.54.2