Duodenopleural fistula formation after percutaneous radiofrequency ablation for recurrent hepatocellular carcinoma

Radiofrequency ablation (RFA) is a treatment option in the management of unresectable or recurrent hepatocellular carcinoma (HCC). It can be performed either through laparotomy or in a minimally invasive manner by percutaneous, laparoscopic or thoracoscopic routes. Percutaneous RFA is associated with reduced surgical trauma and thus can be performed in patients with significant comorbidities. The procedure can be repeated after short intervals for sequential ablation of multiple liver lesions. However, the associated risks should not be underestimated. This is the first report of a rare complication of duodeno-pleural fistula after percutaneous RFA of a recurrent subcapsular HCC. The risk of bowel perforation during the ablation of subcapsular HCC requires special attention, since only the position of the tip of the electrode, but not the zone of ablation, can be assessed accurately by imaging during the procedure. Our case demonstrated that there was leakage of bowel content from the duodenal injury site into the pleural cavity through the RFA track. Subsequent uncontrolled infection resulted in empyema thoracis and led to the death of the patient.     

Popliteal vein thrombosis after radiofrequency ablation of greater saphenous vein for varicose vein

Percutaneous endovenous techniques, such as radiofrequency ablation (RFA), have become the preferred method for treatment for varicose veins associated with great saphenous vein (GSV) insufficiency. Reports have shown safety and efficacy of these techniques with relatively few complications. Deep venous thrombosis after RFA is rare and usually involves extension of thrombus from great saphenous vein to common femoral vein, hence the requirement for postoperative ultrasound. We report a case of symptomatic popliteal vein thrombosis after RFA of GSV requiring anti-coagulation.     

Treatment of recurrent hepatocellular carcinoma by radiofrequency thermal ablation

Abstract. Background and aims: The treatment of choice for hepatocellular carcinoma is surgical resection. Recurrence occurs in most patients. Aggressive treatment of liver recurrence increases patients' survival, but most frequently, these patients are not suitable for surgery. The aim of this study was to analyze the indications for and results of radiofrequency thermal ablation (RFTA) in the treatment of intrahepatic recurrences of hepatocellular carcinoma after surgical resection or after RFTA. Patients and methods: Seventy-nine patients with HCC were treated by RFTA (17 during laparotomy, 1 in video-laparoscopic surgery, and 61 percutaneously). Five (5/79) of these patients had recurrences after surgical resection and 1 patient had a recurrence (new lesion) after percutaneous RFTA. Fifteen of the 79 patients were treated for recurrence after transarterial chemoembolization (TACE) and, for the remaining 58 patients, RFTA was the first treatment. We used a radiofrequency generator with an expandable needle with four, seven, or nine hooks at its end. We followed up all patients with enhanced computed tomography (CT) scans and α-fetoprotein sampling 1 month after RFTA, and then every 4 months. Results: All 5 patients treated for recurrence after resection are alive, after a mean period of 43 months from liver resection. One patient is disease-free, 1 patient has controlled disease, and 3 patients are in progression. The patient treated for recurrence after RFTA is disease-free after 4 months. Conclusions: We treated all our patients with intrahepatic recurrence after surgical resection by a multimodal approach. We regard RFTA as the treatment of first choice in the management of intrahepatic recurrence. For superficial tumors, surgical resection is still the best treatment. For multifocal recurrence, TACE is needed. RFTA can be useful as a complementary technique for lesions not completely treated by TACE. Received: February 14, 2001 / Accepted: March 24, 2001     

复发性小肝癌再次手术和消融栓塞治疗的探讨

目的：探讨复发性小肝癌的外科治疗方法。
方法：回顾性分析2004年1月—2007年12月第1次手术后复发的小肝癌47例患者的临床资料。分为再次手术组和消融栓塞组,比较两组术后3年生存及复发情况。
结果：再次手术组24例,均行局部切除加肝动脉化疗泵植入行化疗栓塞。消融栓塞组23例,均行局部射频消融治疗加股动脉穿刺肝动脉插管化疗栓塞。再次手术组3年无瘤存活率（66.7%,16/24）高于消融栓塞者（47.8%,11/23）（P＜0.05）,手术切除肿瘤局部复发率（25.0%,6/24）低于消融栓塞（34.8%,8/23）（P＜0.05）。直径<3 cm的肿瘤,采用手术或消融栓塞治疗者3年生存率和复发率差异无统计学意义(P＞0.05)。但3~5 cm肿瘤采用手术治疗者3年生存率高于消融栓塞治疗,复发率低于消融栓塞治疗（均P＜0.05）。
结论：临床医生在为复发性小肝癌患（<3 mm）者提供治疗方案时应当根据患者的具体情况并充分考虑患者意愿。对肿瘤为3~5 mm者则以手术为宜。

     

以射频消融为主的微创方式治疗肝癌术后复发

目的 评价以射频消融为主的微创方式治疗肝细胞癌切除术后复发的疗效及安全性.方法 回顾性分析1999年8月至2008年2月间接受以经皮射频消融为主的微创方式治疗的84例肝癌切除术后复发患者的临床资料.结果 未见治疗相关性死亡,严重并发症发生率为2.4%(2/84),完全消融率为94.0%(79/84),治疗后1、3、5年总生存率分别为74.9%、54.%、48.2%.肿瘤最大径≤3 cm和>3 cm的患者治疗后1、3、5年总生存率分别为83.2%、67.7%、67.7%和59.1%、24.2%、12.1%(P=0.003),术后复发间隔时间≤1年和>1年的患者治疗后1、3、5年总生存率分别为72.1%、36.2%、24.2%和76.8%、70.6%、65.1%(P=0.040).结合和未结合瘤内无水酒精注射的患者术后1、3、5年总生存率分别为76.5%、57.3%、57.3%和66.7%、33.3%、22.2%(P=0.017);结合和未结合经导管肝动脉栓塞化疗的患者治疗后1、3、5年总生存率分别为81.6%、66.0%、57.5%和55.6%、24.7%、24.7%(P=0.001).结论 射频消融是治疗肝癌切除术后复发安全、有效的手段,肿瘤大小和复发间隔是其疗效的重要影响因素.联合瘤内无水酒精注射或肝动脉栓塞化疗有助于提高射频消融对复发性肝癌的疗效.     

Selective portal vein clamping for radiofrequency ablation of hepatocellular carcinoma with portal vein invasion

Surgical resection provides potential cure for patients with hepatocellular carcinoma. Unfortunately, resection is suitable in only about 10-37% of patients because of the limited hepatic functional reserve from the underlying chronic liver disease in the majority of patients. Survival of patients with unresectable diseases, especially those with portal vein tumor invasion, remains very poor. Radiofrequency ablation (RFA) is a form of locoregional therapy that allows a selected group of previously inoperable patients to be treated. However, problems with RFA leading to induced portal vein thrombosis have been reported in the literature. Nevertheless, patients with portal vein tumor invasion may be considered for radiofrequency tumor ablation to improve survival. We report the case of a patient with hepatocellular carcinoma with left portal vein invasion. Complete tumor ablation was achieved after RFA with left portal vein clamping. He remained disease free both radiologically and biochemically 6 months after the operation. Supported by a grant from Sun C.Y. Research Foundation for Hepatobiliary and Pancreatic Surgery of the University of Hong Kong.     

Percutaneous thermal ablation for recurrent hepatocellular carcinoma after hepatectomy

BACKGROUND: Tumour ablation using a thermal energy source has shown promising results, and is particularly suitable for recurrent hepatocellular carcinoma (HCC). The present study evaluated long-term outcomes after percutaneous thermal ablation for recurrent HCC following liver resection. METHODS: Radiofrequency ablation or microwave ablation was used to treat a total of 124 tumour nodules (0.9-7.0 cm in diameter) in 72 patients with recurrent HCC. RESULTS: Complete ablation of 119 (96.0 per cent) of 124 tumour nodules was achieved. There was no treatment-related death and the major complication rate was 4 per cent. During a mean(s.d.) follow-up of 27.9(17.8) months, local recurrence developed in 16 (13.6 per cent) of 118 successfully treated tumour nodules. Distant recurrence developed in 60 (85 per cent) of 71 patients, of whom 26 had repeat metachronous distant recurrence. With repeated ablation for both local and distant recurrence, the 1-, 3- and 5-year overall survival rates after initial ablation were 75, 43 and 18 per cent respectively. Patients with a serum alpha-fetoprotein level greater than 200 ng/ml before treatment had significantly poorer survival than those with a lower level (P = 0.034) and multivariate analysis identified preablation AFP level as an independent prognostic factor (P = 0.054). CONCLUSION: With their advantages of preservation of non-tumorous liver tissue and easy repetition, percutaneous thermal ablative therapies were particularly suitable for recurrent HCC and improved long-term survival.     

Locoregional recurrences are frequent after radiofrequency ablation for hepatocellular carcinoma

BACKGROUND: Enthusiasm for radiofrequency ablation (RFA) therapy for patients with unresectable hepatocellular carcinoma (HCC) has increased. The data for recurrence after RFA for patients with HCC is not well documented. The purpose of this study was to evaluate tumor recurrence patterns after RFA in patients with unresectable HCC. STUDY DESIGN: Over a 3-year period, 50 patients having RFA for unresectable HCC were identified at a single institution. Medical records and radiologic studies were reviewed and outcomes factors analyzed. RESULTS: Of the entire cohort, 46 patients underwent RFA by a percutaneous approach under CT guidance. Most patients underwent either one (n = 22) or two ablations (n = 23). At the time of this report, 14 patients (28%) were tumor-free by radiologic and biochemical (alpha-fetoprotein) parameters. Eighteen additional patients had persistence of tumor at the ablation site and 14 patients had recurrence in the liver at sites different from the ablation site. An additional four patients had recurrence in extrahepatic sites. Twelve patients underwent orthotopic liver transplantation after RFA. Of these 12, 5 (42%) demonstrated no viable tumor in the explanted liver. Independent predictors of tumor recurrence included tumor size, serum AFP levels, and the presence of hepatitis. CONCLUSIONS: These data suggest that factors such as tumor size should be considered before employing RFA therapy. In addition to treating the primary tumor, other therapies aimed at the liver's inflammatory state might also be important in achieving a durable response after RFA.     

Surgically treated diaphragmatic perforation after radiofrequency ablation for hepatocellular carcinoma

We review 6 cases of diaphragmatic perforation, with and without herniation, treated in our institution. All patients with diaphragmatic perforation underwent radiofrequency ablation(RFA) treatments for hepatocellular carcinoma(HCC) performed at Kurume University Hospital and Tobata Kyoritsu Hospital. We investigated the clinical profiles of the 6 patients between January 2003 and December 2013. We further describe the clinical presentation, diagnosis, and treatment of diaphragmatic perforation. The change in the volume of liver and the change in the Child-Pugh score from just after the RFA to the onset of perforation was evaluated using a paired t-test. At the time of perforation, 4 patients had herniation of the viscera, while the other 2 patients had no herniation. The majority of ablated tumors were located adjacent to the diaphragm, in segments 4, 6, and 8. The average interval from RFA to the onset of perforation was 12.8 mo(range, 6-21 mo). The median Child-Pugh score at the onset of perforation(8.2) was significantly higher compared to the median Child-Pugh score just after RFA(6.5)(P = 0.031). All patients underwent laparotomy and direct suture of the diaphragm defect, with uneventful post-surgical recovery. Diaphragmatic perforation after RFA is not a matter that can be ignored. Clinicians should carefully address this complication by performing RFA for HCC adjacent to diaphragm.     

射频消融治疗复发性肝癌的应用价值

目的：评价经皮射频消融术（RFA）治疗复发性肝癌的疗效及安全性。
　　方法：回顾性分析2008年5月—2014年3月期间79例行经皮RFA治疗的肝癌复发患者临床资料,79例患者复发病灶共106个,病灶大小0.8~5.0cm,平均（2.8±1.0）cm。
　　结果：消融治疗成功率为98.1%,肿瘤完全消融率94.2%。术后常见不良反应为发热（72.7%）、肝区疼痛（90.9%）、胃肠道症状（20.8%）、黄疸（6.5%）,无肝功能衰竭、胆瘘、感染、出血等严重并发症,无围手术期死亡病例。术后住院时间1~5d,平均（2.2±1.0）d。术后随访7~64个月,平均（38±14）个月,54例出现复发,复发率70.1%。术后1、3年生存率分别为89.6%、66.2%。
　　结论：经皮RFA治疗复发性小肝癌是一种安全有效的微创治疗方法,可优先考虑作为该病治疗的术式选择。     

Delayed portal vein thrombosis after experimental radiofrequency ablation near the main portal vein

BACKGROUND: Portal venous blood flow may protect adjacent tumour cells from thermal destruction with radiofrequency ablation (RFA). This study aimed to investigate the local effect of RFA on the main portal vein branch, and the completeness of cellular ablation in its vicinity, with or without a Pringle manoeuvre using a porcine model. METHODS: This was an in vivo study on 23 domestic pigs. RFA using a cooled-tip electrode was performed 5 mm from the left main portal vein branch under ultrasonographic guidance for 12 min with (n = 10) or without (n = 10) a Pringle manoeuvre. Ten pigs were killed 4 h after the procedure to study the early effects of RFA and ten others were killed 1 week later to determine any delayed effect. As a control, sham operations with a Pringle manoeuvre for 12 min were performed on three pigs. The flow velocity changes of portal vein and hepatic artery were measured using Doppler ultrasonography, and the completeness of cellular ablation around the portal vein was assessed qualitatively by histochemical staining and quantitatively by measuring intracellular levels of adenosine 5'-triphosphate (ATP). RESULTS: In the absence of the Pringle manoeuvre, there was no significant change in mean(s.d.) portal vein flow velocity before RFA (20.0(3.5) cm/s) and at 4 h (18.5(2.5) cm/s) (P = 0.210) and 1 week (19.5(2.2) cm/s) (P = 0.500) after the procedure. Gross and histological examination of the portal vein branches showed no damage without the Pringle manoeuvre. In all pigs that underwent RFA with a Pringle manoeuvre, the portal vein was occluded 1 week after the operation; histological examination of the affected portal vein showed severe thermal injury and associated venous thrombosis. The local effect of RFA on the hepatic artery was similar. With intact portal blood flow during RFA, complete ablation of liver tissue around the pedicle was demonstrated by histochemical staining and measurement of the intracellular ATP concentration. CONCLUSION: RFA was safe when applied close to the main portal vein branch without a Pringle manoeuvre, with complete cellular destruction. Use of the Pringle manoeuvre resulted in delayed portal vein and hepatic artery thrombosis and injury to the hepatic artery and bile duct.     

Portal vein thrombosis after splenectomy

BACKGROUND: Portal vein thrombosis (PVT) has been described after splenectomy, but the factors associated with its development and the clinical outcomes are poorly characterized. METHODS: Case logs of four surgeons from 1996 to 2001 were retrospectively reviewed to identify cases of postsplenectomy PVT. RESULTS: Eight cases of PVT (8%) among 101 splenectomies were identified. Indications for splenectomy in patients with PVT were myeloproliferative disease (n = 4), hemolytic anemia (n = 3), and myelodysplastic disorder (n = 1). All patients had splenomegaly (mean 1698 g, range 360 to 3150 g). Among 10 patients with myeloproliferative disease (MP), 4 patients (40%) developed PVT, compared with 4 of 12 patients (25%) with hemolytic anemia. Three of 4 patients (75%) with MP disease and spleen weight greater than 3,000 g developed PVT. Five patients developed PVT despite receiving prophylactic subcutaneous heparin postoperatively. Presenting symptoms included anorexia in 7 (88%), abdominal pain in 6 (75%), and both elevated leukocyte and platelet counts in 8 patients (100%). All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One patient died of intraabdominal sepsis; the others are alive with no clinical sequelae at 38 months of follow-up. CONCLUSIONS: PVT is a relatively common complication of splenectomy in patients with splenomegaly. A high index of suspicion, early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation are key to a successful outcome.     

经皮射频消融治疗复发性肝癌的预后分析

目的 探讨影响经皮射频消融(PRFA)治疗复发性肝癌预后的影响因素.方法 1999年1月至2008年12月共有82例复发性肝癌患者(单个肿瘤最大径≤7 cm;多个肿瘤者最大径≤5 cm且肿瘤数目≤3个)接受PRFA治疗,收集其临床及病理学特征等12项可能影响预后的因素作回顾性单因素与多因素分析.结果 全组患者1、3、5年生存率分别是75.8%、43.9%、34.5%(从PRFA术后算起)和95.1%、63.2%、46.6%(从初次手术算起);单因素分析显示初次肿瘤大小、复发期限长短、复发肿瘤数目、复发肿瘤大小、血清谷氨酰转肽酶(GGT)和白蛋白(ALB)水平与复发性肝癌行PRFA的预后有相关性(P<0.05);进一步行Cox模型多因素分析得出与预后相关因素为复发期限长短、复发肿瘤大小、血清GGT与ALB水平(P<0.05).结论 PRFA治疗复发性肝癌疗效确切,复发期限、复发肿瘤大小、血清GGT与ALB水平为其显著性预后影响因子.     

射频消融治疗复发性肝细胞癌疗效分析

目的探讨射频消融对肝细胞癌(HCC)手术切除后复发病例再治疗的效果,比较不同复发时间的疗效差别。方法以行超声引导经皮射频消融(RFA)治疗的手术切除后复发性肝细胞癌(RHCC)患者(RHCC组)和同期行RFA治疗的首发HCC患者(首发HCC组)为研究对象。(1)RHCC组42例患者,男34例,女8例,平均年龄(58±10)岁;复发灶大小1.5~6.6cm,平均(3.8±1.4)cm。RFA治疗前5例伴肝外转移。肝功能A级21例,B级19例,C级2例。手术切除距肝内初次复发时间为1~96个月,平均22.8个月。术后1年内肿瘤复发者20例40灶(RHCC近期组),术后1年以上复发者22例37灶(RHCC远期组)。(2)首发HCC组148例患者,男117例,女31例,平均年龄59岁。肿瘤大小1.2~7.0cm,平均(4.0±1.4)cm。RFA治疗后1个月采用增强CT检查评价消融成功率;比较RHCC近期组、RHCC远期组和首发HCC组的治疗效果、复发转移情况及生存期。结果首发HCC组RFA成功率为87.2%(129例),局部复发率为16.2%(24例),另位复发率为37.8%(56例),平均生存期为(39.0±2.1)个月;RHCC近期组、远期组RFA成功率分别为85.0%和95.5%(P>0.05),局部复发率分别为15.0%和13.6%(P>0.05),另位复发率为60.0%和18·2%(P=0.005),平均生存期为(15.4±2.3)个月和(39.5±4.5)个月(P<0.005)。与首发HCC组相比,RHCC远期组消融成功率与局部复发率均无显著性差异(P>0.05),RHCC近期组生存期低于首发HCC组(P<0.05)。RHCC远期组1例患者治疗后出血,经射频止血、输血等保守治疗缓解。结论RFA治疗RHCC的预后及疗效与复发的时间相关;对于术后远期复发者,行RFA治疗可获得同首发HCC相似的生存期,而手术后近期复发者疗效相对较差。     

Risk of tumour seeding after percutaneous radiofrequency ablation for hepatocellular carcinoma

BACKGROUND: A recent small study reported a high rate of neoplastic seeding after cooled-tip radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in patients who had undergone previous needle biopsy. Tumour seeding was associated with subcapsular tumour location, poorly differentiated tumours and a high alpha-fetoprotein (AFP) level. The aim of the present study was to determine the rate of neoplastic seeding after RFA in a large series of unselected patients with HCC who had a long follow-up. METHODS: A total of 1314 patients with 2542 nodules were treated in three centres. Median follow-up was 37 months. Needle biopsy had been performed before RFA in 241 patients (18.3 per cent). The influence of subcapsular location, high AFP level and previous biopsy on risk of tumour seeding was assessed. RESULTS: Neoplastic seeding was identified in 12 patients (0.9 per cent); the rate was comparable at the three centres (0.9, 0.7 and 1.4 per cent). Only previous biopsy was significantly associated with tumour seeding (P = 0.004). CONCLUSION: RFA with a cooled-tip needle was associated with a low risk of neoplastic seeding, even in unselected patients. The use of biopsy before RFA is to be discouraged, particularly when liver transplantation is a possibility at a later date.     

Delayed colonic perforation after percutaneous radiofrequency ablation of hepatocellular carcinoma

Radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma. Colonic perforation secondary to RFA of the liver is an uncommon complication that has been reported to have an incidence between 0.1% and 0.3%. Lesions adjacent (within 1 cm) to the colonic wall and those in patients with history of upper abdominal surgery or chronic cholecystitis are particularly at risk. More importantly, thermal injury leading to colonic perforation has proved to have a fatal outcome. We present a case of percutaneous RFA in a patient with hepatocellular carcinoma that was abutting the colonic hepatic flexure. Colonic perforation was diagnosed on the eighth day postablation when the patient was readmitted with peritonitis.