Pitfalls of radiofrequency assisted liver resection

BACKGROUND/AIMS: Radiofrequency has been used recently for bloodless liver resection. We studied the safety and feasibility of using RF energy for liver parenchymal transection in 8 patients. METHODOLOGY: We performed eight (n=8) open RF assisted liver resection for various malignancies. There were 5 men and 3 women, with mean age of 56.5 years (range 20-80 years). RESULTS: All patients had successful liver resection. The mean operating time for liver resection was 45 minutes (range 25-60 min). The average blood loss for wedge resections and segmentectomies was 30 mL (range 10-100 mL). None of the patients required postoperative transfusion. Three out of eight patients developed minor complications in the form of intra-abdominal abscesses which were managed by USG guided drainage of abscess in two patients and one patient had open surgical drainage of the subhepatic abscess. CONCLUSIONS: RF assisted liver resection is safe and effective with minimal blood loss for minor liver resections. Though the procedure is slightly more time consuming presently, with further improvement in technology and needles, the operative time may be reduced for this technique. RF assisted liver resection should be avoided in the presence of overt local sepsis.     

Repeated liver resection for recurrent metastases from colorectal cancer

BACKGROUND/AIMS: Repeat hepatectomy is the most effective treatment for recurrent colorectal liver metastases. We aim to assess how repeated liver resections increase survival, without unacceptable surgical risk. METHODOLOGY: Between December 1992 and December 1998, among 19 patients, 5 underwent secondary resection of recurrent metastatic disease. Following the primary liver surgery, three patients had systemic chemotherapy with 5-fluorouracil and two locoregional chemotherapy via Port-a-cath in the gastroduodenal artery. We evaluated survival and we compared time of surgery, duration of Pringle maneuver, blood losses and postoperative stay in the hospital between first and second liver surgery. RESULTS: Perioperative mortality at second liver resection was nil; morbidity minor; mean duration of surgery 320 vs. 260 min; Pringle maneuver 35 vs. 25 min; blood losses 1300 vs. 650 mL; postoperative stay 12.6 vs. 11.5 days. Mean total survival from time of colon resection was 50 months. As an interesting secondary finding, we observed prolonged inhibition of liver regeneration following treatment with Methotrexate. CONCLUSIONS: Repeated hepatic resection is a safe procedure for selected patients. Surgical risk is slightly increased, but the risk/benefit ratio is definitely in favor of as many repeated resections as needed, whenever there is a chance of curative surgery.     

Use of dissecting sealer may affect the early outcome in patients submitted to hepatic resection

Background. Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness. Patients and methods. All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality. Results. Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150 min. Total operative time range was 120–480 min. The average blood loss was 325 ml (range 50–600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients. Conclusion. The water-cooled high frequency monopolar device is useful for reducing ischemia–reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery.     

Hepatic resection in 170 patients using saline-cooled radiofrequency coagulation

Background. Hepatic resection for malignancies or symptomatic benign liver lesions remains the standard of treatment. Historically, the principal cause of mortality during liver resection was intraoperative bleeding. Advances in surgical and anesthetic techniques, along with application of new technologies, have decreased blood loss and dramatically improved the outcomes for major liver surgery.Methods. The purpose of this prospective study was to determine the utility of a saline-cooled radiofrequency coagulation device (TissueLink Medical, Inc.) for hepatic resection. Intraoperative bleeding, blood transfusion, postoperative bile leak, and other complications were noted.Results. The results are described for 170 patients undergoing hepatic resection over a three-year period. There were no intraoperative or postoperative deaths. Six patients in the series received blood transfusions for a transfusion rate of 3.5%. Four patients experienced a transient postoperative bile leak. Three of the four closed spontaneously prior to discharge home, and the fourth closed promptly after ERCP. There were no episodes of postoperative hemorrhage, hepatic failure, liver abscess, or reoperation.Conclusions. The saline-cooled radiofrequency coagulation device is very effective in achieving intraoperative hemostasis and facilitates liver parenchymal transection during hepatic resection.     

Laparoscopic Habib 4X: a bipolar radiofrequency device for bloodless laparoscopic liver resection

Background. In recent years the progress of laparoscopic procedures and the development of new and dedicated technologies have made laproscopic hepatic surgery feasible and safe. In spite of this laparoscopic liver resection remains a surgical procedure of great challenge because of the risk of massive bleeding during liver transection and the complicated biliary and vascular anatomy in the liver. A new laparoscopic device is reported here to assist liver resection laparoscopically. Methods. The laparoscopic Habib™ 4X is a bipolar radiofrequency device consisting of a 2x2 array of needles arranged in a rectangle. It is introduced perpendicularly into the liver, along the intended transection line. It produces coagulative necrosis of the liver parenchyma sealing biliary radicals and blood vessels and enables bloodless transection of the liver parenchyma. Results. Twenty-four Laparoscopic liver resections were performed with LH4X out of a total of 28 attempted resections over 12 months. Pringle manoeuvre was not used in any of the patients. None of the patients required intraoperative transfusion of red cells or blood products. Conclusion. Laparoscopic liver resection can be safely performed with laparoscopic Habib™ 4X with a significantly low risk of intraoperative bleeding or postoperative complications.     

Liver resection with bipolar radiofrequency device: Habib 4X

Background. Intraoperative blood loss has been shown to be an important factor correlating with morbidity and mortality in liver surgery. In spite of the technological advances in hepatic parenchymal transection devices, bleeding remains the single most important complication of liver surgery. The role of radiofrequency (RF) in liver surgery has been expanded from tumour ablation to major hepatic resections in the last decade. Habib^TM 4X, a new bipolar RF device designed specifically for liver resection is described here. Methods. Habib^TM 4X is a bipolar, handheld, disposable RF device and consists of two pairs of opposing electrodes which is introduced perpendicularly into the liver, along the intended transection line. It produces controlled RF energy between the electrodes and the heat produced seals even major biliary and blood vessels and enables resection of the liver parenchyma with a scalpel without blood loss or biliary leak. Results. Three hundred and eleven patients underwent 384 liver resections from January 2002 to October 2007 with this device. There were 109 major resections and none of the patients had vascular inflow occlusion (Pringle''s manoeuvre). Mean intraoperative blood loss was 305 ml (range 0–4300) ml, with less than 5% (n=18) rate of transfusion. Conclusion. Habib^TM 4X is an additional device for hepatobiliary surgeons to perform liver resections with minimal blood loss and low morbidity and mortality rates.     

Current role of bloodless liver resection

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. Recently new technologies are applied in the field of liver surgery, having one goal： safer and easier liver operations. The aim of this article is to address the issue of bloodless liver resection using radiofrequency energy. Radionics, Cool-tip^TM System and Tissue Link are some of the devices which are using radiofrequency energy. All information included in this article, refers to these devices in which we have personal experience in our unit of liver surgery. These devices take advantage of its unique combination of radiofrequency current and internal electrode cooling to perform sealing of the small vessels and biliary radicals. Dissection is also feasible with the cool-tip probe. For the purposes of this study patient sex, age, type of disease and type of surgical procedure in association with the duration of parenchymal transection, blood loss, length of hospital stay, morbidity and mortality were analyzed. Cool-tip RF device may provide a unique, simple and rather safe method of bloodless liver resections if used properly. It is indicated mostly in cirrhotic patients with challenging hepatectomies （segment Ⅷ, central resections）. The total operative time is eliminated and the average blood loss is significantly decreased. It is important to note that this technique should not be applied near the hilum or the vena cava to avoid damage of these structures.     

Postoperative day one serum alanine amino-transferase does not predict patient morbidity and mortality after elective liver resection in non-cirrhotic patients

Serum aminotransferases have been used as sur-rogate markers for liver ischemia-reperfusion injury that fol-lows liver surgery. Some studies have suggested that rises in serum alanine aminotransferase (ALT) correlate with patient outcome after liver resection. We assessed whether postopera-tive day 1 (POD 1) ALT could be used to predict patient mor-bidity and mortality following liver resection. We reviewed our prospectively held database and included consecutive adult patients undergoing elective liver resection in our in-stitution between January 2013 and December 2014. Primary outcome assessed was correlation of POD 1 ALT with patient’s morbidity and mortality. We also assessed whether concurrent radiofrequency ablation, neoadjuvant chemotherapy and use of the Pringle maneuver signiifcantly affected the level of POD 1 ALT. A total of 110 liver resections were included in the study. The overall in-hospital patient morbidity and mortality were 31.8% and 0.9%, respectively. The median level of POD 1 ALT was 275 IU/L. No correlation was found between POD 1 serum ALT levels and patient morbidity after elective liver resection, whilst correlation with mortality was not possible because of the low number of mortalities. Patients undergoing concur-rent radiofrequency ablation were noted to have an increased level of POD 1 serum ALT but not those given neoadjuvant chemotherapy and those in whom the Pringle maneuver was used. Our study demonstrates POD 1 serum ALT does not cor-relate with patient morbidity after elective liver resection.     

Colorectal liver metastasis surgery: analysis of risk factors predicting postoperative complications in relation to the extent of resection

Background/aims  Despite advances in diagnosis and treatment, the rate of complications after resection for colorectal liver metastases remains high. An awareness of risk factors is essential for the rates of morbidity and mortality to fall to optimal levels. Materials and methods  Of the 240 patients who underwent resection for the first manifestation of colorectal liver metastases, 49 patients with lobectomy or extended hepatectomy (major resections) and 58 with wedge resections within only one liver segment (minor resections) form the basis of this report. A total of 16 variables were analyzed to find the risk factors linked to postoperative morbidity and mortality. Results/findings  Thirty-four patients (31.8%) suffered postoperative complications, and one patient died during the hospital stay (0.9%). In the major resection group, multivariate analysis showed that neoadjuvant chemotherapy [odds ratio (OR): 2.4; p = 0.005], vascular clamping (OR: 1.4; p = 0.008), and intraoperative blood loss with transfusion of three to six packed red cell units (OR: 1.2; p = 0.029) were significantly associated with postoperative morbidity. Vascular clamping was an independent predictor for biliary fistula (OR: 1.2; p = 0.029). Postoperative temporary liver failure was influenced by neoadjuvant chemotherapy (OR: 3.4; p = 0.010), vascular clamping (OR: 1.5; p = 0.015), and requirement of blood transfusion (OR: 2.1; p = 0.016). After minor resections, only a decreased postoperative serum cholinesterase B level was an independent predictor for complications (OR: 2.2; p = 0.001), as well as for hemorrhage (OR: 1.6; p = 0.023). Postoperative mortality was not predicted by any of the factors that were analyzed. Interpretation/conclusion  Factors for complications differ depending on the extent of colorectal liver metastasis resection. Only knowledge and particular consideration of these factors may provide for an optimal postoperative outcome for the individual patient. Ralf Konopke and Stephan Kersting contributed equally to this work     

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.     

Hepatic resection using a bipolar vessel sealing device: technical and histological analysis

Introduction. Blood loss and bile leakage are well-known risk factors for morbidity and mortality during liver resection. Bleeding usually occurs during parenchymal transection, and surgical technique should be considered an important factor in preventing intraoperative and postoperative complications. Objective. Many approaches and devices have been developed to limit bleeding and bile leakage. The aim of the present study was to determine whether a bipolar vessel sealing device allows a safe and careful liver transection without routine inflow occlusion, achieving a satisfactory hemostasis and bile stasis, thus reducing blood loss and bile leak and related complications. Patients and methods. A total of 50 consecutive patients (24 males, 26 females, with a mean age of 57 years) underwent major and minor hepatic resections using a bipolar vessel sealing device. A clamp crushing technique followed by energy application was used to perform the parenchymal transection. Inflow occlusion was used when necessary to control blood loss but not as a routine. No other devices were applied to achieve hemostasis. Results. The instrument was effective in 45 patients and failed to achieve hemostasis in 5 cases, all of whom had a cirrhotic liver. Median blood loss was 490 ml (range 100–2500 ml) and intraoperative blood transfusions were required in eight cases (16%). Mean operative time was 178 min (range 50–315 min). Inflow occlusion was necessary in 16 (32%) patients. The postoperative complication rate was 24%, with a postoperative hemorrhage in a cirrhotic patient. There was no clinical evidence of bile leak or procedure-related abdominal abscess. Conclusion. We conclude that the device is a useful tool in standard liver resection, achieving good hemostasis and bile stasis in patients with normal liver parenchyma, but its use should be avoided in cirrhotic patients.     

Liver resection: 10-year experience from a single institution

BACKGROUND: Liver resection constitutes the main treatment of most liver primary neoplasms and selected cases of metastatic tumors. However, this procedure is associated with significant morbidity and mortality rates. AIM: To analyze our experience with liver resections over a period of 10 years to determine the morbidity, mortality and risk factors of hepatectomy. PATIENTS AND METHODS: Retrospective review of medical records of patients who underwent liver resection from January 1994 to March 2003. RESULTS: Eighty-three (41 women and 42 men) patients underwent liver resection during the study period, with a mean age of 52.7 years (range 13-82 years). Metastatic colorectal carcinoma and hepatocellular carcinoma were the main indications for hepatic resection, with 36 and 19 patients, respectively. Extended and major resections were performed in 20.4% and 40.9% of the patients, respectively. Blood transfusion was needed in 38.5% of the operations. Overall morbidity was 44.5%. Life-threatening complications occurred in 22.8% of cases and the most common were pneumonia, hepatic failure, intraabdominal collection and intraabdominal bleeding. Among minor complications (30%), the most common were biliary leakage and pleural effusion. Size of the tumor and blood transfusion were associated with major complications (P = 0.0185 and P = 0.0141, respectively). Operative mortality was 8.4% and risk factors related to mortality were increased age and use of vascular exclusion (P = 0.0395 and P = 0.0404, respectively). Median hospital stay was 6.7 days. CONCLUSION: Liver resections can be performed with low mortality and acceptable morbidity rates. Blood transfusion may be reduced by employing meticulous technique and, whenever indicated, vascular exclusion.     

Current techniques of liver transection

The operative mortality rate of liver resection has decreased from 10% to 20% before the 1980s to <5% in most specialized hepatobiliary centers nowadays. The most important factor for better outcome is reduced blood loss due to improvement in surgical techniques. Liver transection is the most challenging part of liver resection, associated with a risk of massive hemorrhage. Understanding the segmental anatomy of the liver and delineation of the proper transection plane using intraoperative ultrasound are prerequisites to safe liver transection. Clamp crushing and ultrasonic dissection are the two most widely used transection techniques. In recent years, new instruments using different types of energy for coagulation or sealing of vessels have been developed for liver transection. These include radiofrequency devices, Harmonic Scalpel, Ligasure and TissueLink dissecting sealer. Whether these new instruments, used alone or in combination with clamp crushing or ultrasonic dissection, improve the safety of liver transection has not been clearly demonstrated. The use of the vascular stapler for transection of major intrahepatic vascular trunks is also gaining popularity. These new instruments are particularly useful in liver transection during laparoscopic liver resection. Adjunctive measures such as intermittent Pringle maneuver and low central venous pressure anesthesia are also useful measures to reduce the risk of hemorrhage. This article reviews the safety and efficacy of different techniques of liver transection, with particular attention to evidence from randomized controlled trials available in the literature.     

Radiofrequency ablation-assisted liver resection: review of the literature and our experience

Background: Surgical resection is the best established treatment known to provide long-term survival and possibility of cure for liver malignancy. Intraoperative blood loss has been the major concern during major liver resections, and mortality and morbidity of surgery are clearly associated with the amount of blood loss. Different techniques have been developed to minimize intraoperative blood loss during liver resection. The radiofrequency ablation (RFA) technique has been used widely in the treatment of unresectable liver tumors. This review concentrates on the use of RFA to provide an avascular liver resection plane. Methods and results: The following review is based on two types of RFA device during liver resection: single needle probe RFA and the In-Line RFA device. Conclusion: Liver resection assisted by RFA is safe and is associated with very limited blood loss.     

老年人肝癌切除术围手术期肝功能损伤的临床研究

目的 研究老年人原发性肝癌肝切除术围手术期肝功能损伤的原因及防治措施,以提高其临床疗效.方法 回顾性分析原发性肝癌肝切除病例62例,老年组32例,非老年组30例,采用单因素分析和多元逐步回归模型分析围手术期老年组与非老年组、肝门阻断组和非阻断组、出血量多组(≥500 ml)和出血量少组(＜500 ml)肝功能损害的影响因素.结果 老年肝癌切除术后肝功能损伤的发生率为32.6%,肝功能衰竭的病死率为1.6%.单因素分析显示肝门阻断、术中出血、术中输血量及肿瘤大小与术后肝功损伤有关.多元逐步回归模型显示肝门阻断的标准化回归系数0.314,(t=2.272,P＜0.05),肝门阻断是决定术后肝功能损伤的独立因素.结论 老年肝癌肝切除术后肝功能损伤的主要原因是肝门阻断和术中大出血,提高手术技能、缩短肝门阻断时间和减少术中出血是预防老年人肝癌术后肝功能损伤的主要措施.     

Portal venous stasis during liver resection does not affect platelet aggregability

INTRODUCTION: To reduce intraoperative blood loss in liver resections surgical bleeding control is often performed by a complete inflow obstruction of the liver called Pringle manoeuvre leading to a portal venous stasis. Platelet aggregability may be affected by this circulatory stasis. MATERIALS AND METHODS: A study population of 11 patients (37-67 years old, 7 females and 4 males) with hepatic tumours underwent elective liver resection. Pringle manoeuvre of up to 50 min duration was used in 4 patients. The other 7 patients were operated using selective vascular clamping. Platelets were aggregated before and after liver resection with adenosine diphosphate, collagen and ristocetin (according to Born). RESULTS: Mean maximal amplitudes of platelet aggregation were comparable before and after liver resection. Statistic analysis did not detect a significant difference between the values before and after liver resection as well as between Pringle manoeuvre and selective vascular clamping. CONCLUSION: Induced platelet aggregability is not affected by the method of surgical bleeding control used in liver resection. Platelet aggregability seems to be resistant even to portal venous stasis of up to 50 min during Pringle manoeuvre.     

Application of stapling devices in liver surgery: Current status and future prospects

The liver is a vascular-rich solid organ. Safe and effective dissection of the vessels and liver parenchyma, and control of intraoperative bleeding are the main concerns when performing liver resection. Several studies have confirmed that intraoperative blood loss and postoperative transfusion are predictors of postoperative morbidity and mortality in liver surgery. Various methods and instruments have been developed during hepatectomy. Stapling devices are crucial for safe and rapid anastomosis. They are used to divide hepatic veins and portal branches, and to transect liver parenchyma in open liver resection. In recent years, laparoscopic liver surgery has developed rapidly, and is now preferred by many surgeons. Stapling devices have also been gradually introduced in laparoscopic liver surgery, from dividing vascular and biliary structures to parenchymal transection. This may be because staplers make manipulation more simple, rapid and safe. Even in single incision laparoscopic surgery, which is recognized as a new minimally invasive technique, staplers are also utilized, especially in left lateral hepatectomy. For safe application of stapling devices in liver surgery, more related designs and modifications, such as application of a suitable laparoscopic articulating liver tissue crushing device, a staple line reinforcement technique with the absorbable polymer membrane or radiofrequency ablation assistance, are still needed. More randomized studies are needed to demonstrate the benefits and find broader indications for the use of stapling devices, to help expand their application in liver surgery.     

Evaluation of total hepatic vascular exclusion and pringle maneuver in liver resection

BACKGROUND/AIMS: The effects of total hepatic vascular exclusion and Pringle maneuver on intraoperative course and postoperative recovery were retrospectively studied. METHODOLOGY: Records of 42 patients who underwent a major hepatectomy and six who had a minor hepatectomy were reviewed. Patients with chronic liver disease or obstructive jaundice were excluded. Hepatic vascular exclusion was used in 5 patients who were at high risk for back flow bleeding from the hepatic veins. Pedicular clamping was used in the other 43 patients. Intergroup differences in intraoperative blood loss, postoperative liver function, the serum interleukin-6 concentrations, and clinical outcome were compared. RESULTS: In four patients of the hepatic vascular exclusion group (n = 5), intraoperative blood loss was less than 2000 mL, and 6000 mL in the remaining patient. However the hepatic vascular exclusion group had longer hepatic ischemia time (45.2 +/- 10.3 min vs. 30.6 +/- 10.9 min), a greater blood loss (2304 +/- 2106 L vs. 913 +/- 1130 mL), a higher serum interleukin-6 concentration (347 +/- 320 pg/mL vs. 93 +/- 58 pg/mL), and a higher morbidity rate (80 vs. 7.1%) compared with the pedicular clamping group (n = 43) (P < 0.05). Postoperative liver function tests were comparable, and no patient developed postoperative hepatic failure. In the pedicular clamping group, intermittent pedicular clamping with periods of 15 minutes (n = 12) increased blood loss (662 +/- 421 mL vs. 1427 +/- 1890 mL), but did not reduce serum interleukin-6 concentration, liver cell damage, or morbidity rate postoperatively, compared with continuous or intermittent clamping of longer periods. CONCLUSIONS: Hepatic vascular exclusion is an effective way to limit blood loss in hepatic resection without causing sever liver injury. However, the interleukin-6 production is increased and the morbidity rate is high. Paradoxically, periodic release of pedicular clamping increases the blood loss but does not reduce liver cell injury or interleukin-6 production.     

A multicentre controlled study of the InLine radiofrequency ablation device for liver transection

Background. Surgical resection is the most effective therapy for liver cancer. Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine radiofrequency ablation device (ILRFA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated. Patients and methods. A total of 108 patients underwent liver resections in 4 medical centres; the prospective sequential cohort study consisted of 54 ILRFA and 54 ultrasonic surgical aspirator transections as the control group. Results. The type of liver resection performed was very similar in both groups. The median number of RFA deployments was 3 (range 1–12) with a median coagulation time of 9 (range 3–36) min. Median blood loss was 165±20 ml (range 5–675) in the ILRFA and 654±83 ml (range 80–3600) in the control group (p<0.001). The median transection time was 27 (2–219) min in the ILRFA group and 35 (5–62) min in controls. Conclusions. Our study indicates that ILRFA device for liver transection is effective in reducing blood loss and is safe. Precoagulation before parenchymal transection appears to be a valid concept in liver surgery. The avoidance of vascular inflow occlusion during parenchymal transection could also be of value.