B超引导下硬化剂注射治疗肝囊肿

本文报道了19例共34个肝囊肿应用 B 超引导装置硬化剂(无水乙醇或四环素注射液)注射治疗的效果。结果表明:单纯性囊肿治愈率89.5%,有效率100%,囊肿越小,效果越好,治愈时间越短;多囊肝治疗也取得了满意的效果;一次穿刺成功率100%。本法简单、易行,无严重并发症,是非手术治疗肝囊肿的首选方法,值得临床推广应用。     

Combined hepatic resection and radiofrequency ablation for multiple hepatic adenomas

We describe the novel use of radiofrequency ablation (RFA) in combination with surgical resection for treatment of multifocal hepatic adenoma. We show three cases without recurrent lesions detected in follow-up examination. Two of the patients have subsequently gone on to carry pregnancies successfully to term.     

射频消融治疗肝血管瘤的现状

简述了目前射频消融术治疗肝血管瘤的进展,主要对射频电极、治疗方式、并发症及防治进行介绍,为规范肝血管瘤射频消融治疗奠定基础。射频消融术作为肝血管瘤重要的微创技术,其规范化有助于临床应用推广及发展。     

Percutaneous ultrasound-guided radiofrequency ablation with artificial pleural effusion for hepatocellular carcinoma in the hepatic dome

Background Nodules of hepatocellular carcinoma (HCC) located in the hepatic dome cannot be depicted on ultrasography because of pulmonary air. Therefore, percutaneous treatment is not possible in such cases. The purpose of this study was to clarify the feasibility and safety of percutaneous sonographically guided radiofrequency (RF) ablation with the concurrent use of artificial pleural effusion for HCC located in the right subphrenic region.Methods Between May 2001 and June 2002, 24 patients with 28 HCC nodules located directly below the diaphragm were enrolled in this study. The patient population included 17 men and 7 women (age range, 51–87 years; mean age, 66.5 years). The maximum diameter of the HCC nodules ranged from 1.0cm to 4cm (mean ± SD, 2.1 ± 0.8cm).Results We infused 200–1100ml of 5% glucose solution intrathoracically to separate the lung and liver; thus, obtaining an image of the whole tumor was impossible on gray-scale sonography. Complete tumor necrosis was achieved in a single session of RF ablation in 27 (96.4%) of the 28 lesions, while two sessions of RF ablation were required for the remaining lesion (3.6%). During treatment, no dyspnea or other complications concerned with the respiratory system were observed. Clinical courses have been satisfactory without recurrences at 1–13 months after treatment (mean, 7.9 months).Conclusions Percutaneous RF ablation with artificial pleural effusion in patients with HCC in the hepatic dome may be a safe and feasible therapy.     

Novel laparoscopic bipolar radiofrequency energy technology for expedited hepatic tumour ablation

Background:

Monopolar radiofrequency ablation (RFA) is a well accepted modality for local control of hepatic tumours, but its effectiveness is challenged by prolonged ablation time, an inconsistent ablation zone and susceptibility to energy loss from convective heat loss from adjacent high-velocity blood flows (‘heat sinks’). Bipolar RFA employs a dual parallel electrode array; the energy wave travels unidirectionally between and not around electrodes. This ‘line-of-sight’ delivery streams energy between two fixed points and concentrates energy delivery to the area between the probes. Bipolar RFA is postulated to yield reduced ablation time and to reduce or eliminate convective heat loss from adjacent high-velocity blood flows. The current study evaluated the feasibility, time and safety of this novel FDA-approved bipolar RFA technology using a laparoscopic approach in human liver tumours.

Methods:

Using the prospectively maintained surgical oncology hepatic-pancreatic-biliary database, 17 consecutive patients (26 liver tumours) who underwent laparoscopic bipolar ablations were reviewed. Electrodes were placed using guidance by intraoperative ultrasound and trajectory planning needles. Ablation time was recorded and postoperative computed tomography scans were obtained.

Results:

A total of 18 lesions (in 12 patients) represented metastatic colorectal cancer. Three lesions (in two patients) were hepatocellular carcinoma. Four lesions (in two patients) represented locally advanced symptomatic gallbladder cancer invading the liver bed or symptomatic intrahepatic liver metastases from gallbladder cancer. One lesion was benign hepatic adenoma. Mean tumour size was 3.07 ± 1.42 cm. Mean ablation time was 358 ± 120 sec. No major complications were observed in the ≤30-day or >30-day periods post-RFA.

Conclusions:

Laparoscopic bipolar RFA is a quick, safe technique which adds a new tool to our armamentarium for treating hepatic tumours. Establishing its longterm oncological outcome will require longer follow-up and the exact role of this technique in the current multimodality management remains to be defined.     

Percutaneous radiofrequency ablation of hepatocellular adenoma: Initial experience in 10 patients

Background and Aim:  The purpose of this study was to assess the therapeutic efficacy and safety of percutaneous radiofrequency (RF) ablation for hepatocellular adenoma.
Methods:  We performed percutaneous RF ablation in 10 patients with pathologically proven hepatocellular adenomas. Eight patients were asymptomatic and two patients had a recurrent tumor after surgical resection. The size of the tumors was 2.25 ± 0.76 cm (range: 1.5–4.5 cm) in the largest diameter. All ablation procedures were percutaneously performed with an internally cooled RF electrode system under ultrasound (US) guidance. We evaluated the therapeutic efficacy and safety of the procedure by clinical follow-up data with regular follow-up computed tomography (CT) for 2–35 months (mean, 17.5 months).
Results:  All patients well tolerated percutaneous RF ablation procedure without any incident. Contrast-enhanced CT ( n  = 7) or contrast-enhanced US ( n  = 3) obtained immediately (<24 h) after the procedure revealed complete ablation of the tumor in all cases. There was no case of local tumor progression or new recurrence during the follow-up period. We found neither procedure-related mortality nor major complication requiring specific treatment.
Conclusion:  Percutaneous RF ablation of hepatocellular adenoma without overt complication can be a new potential alternative to close imaging follow-up or elective surgery.     

射频消蚀术前后血清心肌酶变化的研究

对３３例患者射频消蚀术（简称ＲＦＣＡ）前后的血清心肌酶（ＣＫ、ＣＫ－ＭＢ．ＡＳＴ、ＬＤＨ、ＬＤＨ１）进行动态观察。结果表明：ＲＦＣＡ后血清心肌酶活性均有不同程度的升高（Ｐ＜０．０１）；ＣＫ及ＣＫ－ＭＢ于术后６小时达到峰值，２４小时恢复至正常水平，ＡＳＴ于术后１２小时达峰值、时达峰值，７２小时恢复正常，ＬＤＨ及ＬＤＨ，的达峰及恢复时间分别为２４小时和１２０小时；多元线性相关分析显示心肌酶活性的升高程度与消蚀靶点个数呈高度正相关（ｒ＝０．８１３６，Ｐ＜０．００１）．揭示ＲＦＣＡ对心肌组织有不同程度的损伤，影响心肌损伤范围的主要因素是消蚀靶点的多少。因此，在ＲＦＣＡ中，应力求标测定位准确，尽量减少试探性放电，以最大限度地减少心肌损伤。     

射频消融治疗快速性心律失常的体会

临床安全应用射频导管消融（ＲＦＣＡ）治疗各类快速性心律失常７８０例，总成功率９７．８％。其中房室折返性心动过速（ＡＶＲＴ）５５４例；房室结折返性心动过速（ＡＶＮＲＴ）１８２例；房扑１５例；房颤５例；特发性室速８例；右室流出道室速、室早１４例；致心律失常性右室心肌病（ＡＲＶＣ）２例。本组患者无一例发生血胸、气胸、心包填塞、动脉拴塞、３°房室传导阻滞、室颤等严重并发症。本文特别强调了术前充分准备、术中精确标测定位、细心轻巧操作、严谨控制消融能量和时间，术中与术后严密监护，可以最大程度地降低并发症的发生率。     

盐酸曲美他嗪对射频消融术所致心肌损伤保护作用的研究

目的通过动态观察盐酸曲美他嗪干预组及非干预组射频消融术前后肌钙蛋白Ⅰ(cTnI)的变化,分析盐酸曲美他嗪对心肌损伤的保护作用。方法对室上性心动过速行射频消融术的77例病人进行cTnI监测,其中男47例,女30例,平均年龄46±10岁,随机分为盐酸曲美他嗪干预组与盐酸曲美他嗪非干预组。77例患者分别于射频消融术前、射频消融术后即刻、3h、6h、12h、24h、48h各采静脉血检测cTnI水平。结果应用盐酸曲美他嗪干预方法使射频消融术后cTnI均有所降低,6h(0.165±0.004ng/mlVS.0.144±0.003ng/ml,P<0.01)和12h(0.136±0.002ng/mlVS.0.132±0.002ng/ml,P<0.05)CTnI降低具有显著性差异。结论盐酸曲美他嗪对射频消融心肌损伤可能有一定的保护作用。     

室性心律失常的射频治疗

目的 :观察射频治疗室性心律失常的疗效 ,以替代抗心律失常药物。方法 :利用体表心电图 12导联定位及心内电生理标测进行射频消融治疗室性早搏 2 1例。结果 :体表心电图可基本确定其发生部位 ,射频电极标测室性早搏提前时间在 2 0～ 40 ms,并局部起搏图形与室性早搏一致 ,采用 12～ 40 W,3～ 7m in消融 ,成功率 86%。根据Holter随访具有统计学意义 （ P<0 .0 1）。结论 :只要标测定位准 ,其疗效是肯定的 ,可部分或基本替代抗心律失常药物 ,并避免药物所致的副作用     

A prospective study of in-line radiofrequency ablation in hepatic parenchymal transection--its efficacy and complications

Background. Bleeding during liver transection remains a potential hazard. This study aims to report the efficacy and complications of in-line radiofrequency ablation (ILRFA)-assisted liver resection. Patients and methods. The blood loss of 25 consecutive patients who underwent ILRFA-assisted liver resection was obtained by weighing swabs and measuring suction jar contents during liver resection and calculated in ml per cm² of the transection surface area. Postoperative complications were recorded. Five clinical variables, which might affect blood loss, were analyzed. Results. The mean blood loss during parenchymal dissection for the ILRFA group was 3.4±3.2 ml/cm². Three patients had intra-abdominal collections, including one patient with bile leakage after ILRFA-assisted liver resection. Age, gender, extent of liver resection, liver quality and Pringle maneuver did not demonstrate significant impact on blood loss. Conclusions. This study showed that ILRFA-assisted liver resection was associated with very low blood loss. This is likely to improve the operative safety of liver resection for hepatic tumors. There were no significant postoperative sequelae.     

Coronary ischemia induced by radiofrequency ablation in the left atrium

INTRODUCTION: We report three cases of transient, reversible coronary ischemia occurring after radiofrequency ablation in the left atrium. METHODS AND RESULTS: A 56-year-old man with a left atrial tachycardia that was mapped to the septum and roof of the atrium using a noncontact mapping developed 5-mm ST elevation in the anterolateral leads. Coronary angiography showed an occluded diagonal that was opened using intracoronary nitrate, which led to resolution of the ST changes. A 57-year-old man undergoing right upper pulmonary vein ablation developed 6-mm ST elevation in leads V1-V4, II, III, and aVF. Coronary angiography showed normal coronaries with slow flow into the left anterior descending artery, which resolved with nitrates. A 50-year-old man undergoing left lower pulmonary vein ablation developed 3-mm reversible inferior ST elevation. All patients were adequately anticoagulated after transseptal access to the left atrium. CONCLUSION: Ablation in the left atrium, at the roof, septum, and left inferior wall, can cause transient coronary ischemia, possibly due to spasm, which can be reversed with intracoronary nitrates. This phenomenon has not been previously described.     

A novel hybrid transcatheter ablation system that combines radiofrequency and cryoenergy

Introduction: Radiofrequency (RF) and cryoenergy are largely considered independent modalities for the transcatheter ablation of cardiac arrhythmias. There are numerous theoretical advantages to engineering a system capable of delivering both energy forms.
Methods and Results: We designed a hybrid steerable catheter capable of delivering RF and cryoenergy independently, sequentially, and simultaneously. The novel catheter system was tested pre-clinically by creating a total of 180 ablation lesions in 20 mongrel dogs. Right atrial and right and left ventricular sites were preselected by a randomized factorial design devised to compare sequential and simultaneous RF and cryoenergy applications to standard RF, irrigated RF, and standard cryoablation. A steerable 4-mm electrode-tip hybrid catheter ("Fire and Ice") was created by modifying a 7 F cryocatheter (Freezor™, CryoCath Technologies, Montreal, Canada). RF energy was injected via a copper wire, thermocouples were isolated to reduce RF interference, and 100 KHz band pass filters and RF chokes were added. Sequential low-dose RF (20 W, 60 seconds) preceding or following cryoablation resulted in larger lesions (P = 0.0010). The addition of RF energy did, however, produce more thrombus than cryoenergy alone, with clot detected on 82.4% versus 12.1% of ablation lesions, P < 0.0001. Simultaneously applying the two energy modalities (45 W, 10 or 30°C, 60 seconds) created more voluminous lesions than standard RF ablation (median 288.1 vs 126.1 mm³, P = 0.0333) of similar dimension to irrigated RF ablation.
Conclusion: A versatile catheter system was fashioned capable of creating standard cryoablation lesions, standard RF lesions, and simultaneous lesions of similar dimension to irrigated RF.     

Tolerance of radiofrequency ablation by patients of hepatocellular carcinoma

Background

Radiofrequency ablation (RFA) is currently an effective method for ablation of hepatocellular carcinoma (HCC). Early reports have indicated that RFA is safe and virtually free from major complications. Unlike partial hepatectomy for HCC on patients with cirrhosis, there are no data on the safety limit of RFA. However, information is vital for selection of appropriate patients for the procedure. In this study, we analyzed results from use of RFA on HCC patients and determined the lower limit of liver function with which HCC patients can tolerate RFA.

Method

Preoperative variables of 310 patients who underwent RFA for HCC were analyzed to identify the risk factors in RFA intolerance in terms of morbidity associated with stress-induced complications.

Results

Thirty-nine (12.6%) patients developed intolerance of RFA. Postoperative morbidity was mainly because of intractable ascites (n = 13), hyperbilirubinemia (n = 10), massive pleural effusion (n = 7), and other complications (n = 14). Multivariate analysis revealed that serum albumin level (P = 0.001), serum bilirubin level (P = 0.000), tumor number (P = 0.002), and RFA duration (P = 0.017) all played a role in this issue.

Conclusions

Simple data such as serum bilirubin, serum albumin level, and tumor number can be used to predict HCC patients’ tolerance of RFA. Avoidance of excessive RFA time and careful monitoring of patients at risk are important means of reducing the postoperative morbidity rate.     

射频消融在骨肿瘤切开手术中的应用

目的探讨骨肿瘤切开手术中使用射频消融的安全性和有效性。方法应用射频消融治疗、有完整随访的骨肿瘤患者15例。姑息组为转移癌10例和骨髓瘤1例,共消融13处病灶,切开后先消融,再去除肿瘤;肿瘤全切组为累及髋臼的原发恶性或侵袭性肿瘤4例,先切除大部分肿瘤,只对髋臼区行射频消融,刮除髋臼肿瘤,保留髋臼骨质,以利重建。从手术技术、肿瘤学、并发症、肢体功能等方面综合评价此方法的临床应用效果。结果随访1—29个月、平均17个月。姑息组死亡9例,平均存活10个月（1～24个月）,消融处均无肿瘤复发;肿瘤全切组有1例软骨肉瘤术后13个月复发,复发率25％。1例术中在止血带处发生热损伤,1例术后皮缘坏死。以MSTS评分标准对术后存活超过6个月的11例患者进行功能评定,优良率为81．8％。结论切开后行射频消融术对于骨转移癌和侵及髋臼的侵袭性肿瘤是一种安全有效的方法。     

Cost of radiofrequency ablation in the treatment of hepatic malignancies

OBJECTIVES: Our primary objective was to assess the cost of radio-frequency ablation (RFA) of hepatic malignancies and to compare it to hospital reimbursement paid in the French Prospective Payment System (PPS). PATIENTS AND METHODS: A series of 305 patients were enrolled into a prospective study. All resources used during the RFA-related hospital stay were recorded. Costs were assessed from the perspective of the health care providers and computed for four groups of patients: percutaneous RFA in an outpatient setting (group Ia, N=44), percutaneous RFA in an inpatient setting (group Ib, N=94), laparoscopic RFA (group II, N=44) and intraoperative RFA combined with resection (group III, N=120). RESULTS: Mean hospital costs were estimated at euro 1581 (group Ia), euro 3824 (group Ib), euro 8194 (group II) and euro 12967 (group III). Costs per stay without intensive care in these groups were respectively euro 1581, euro 3635, euro 6622 and euro 10905 and reimbursement (intensive care excluded) was euro 560, euro 3367, euro 9084 and euro 11780. CONCLUSION: In the French PPS, the cost of RFA is covered by lump sums paid to hospitals exclusively for intraoperative and laparoscopic RFA. For percutaneous RFA, which is the most frequent approach, reimbursement is highly insufficient.