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Asian J Endosc Surg ISSN 1758-5902
MY A P P R OAC H
Percutaneous radiofrequency ablation-assisted laparoscopic hepatectomy Toru Beppu,1,2 Hidetoshi Nitta,1 Masayo Tsukamoto,1 Katsunori Imai,1 Hiromitsu Hayashi,1 Hirohisa Okabe,1 Daisuke Hashimoto,1 Akira Chikamoto,1 Takatoshi Ishiko1 & Hideo Baba1 1 Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan 2 Department of Multidisciplinary Treatment for Gastroenterological Cancer, Innovation Center for Translational Research, Kumamoto University Hospital, Kumamoto, Japan
Keywords Laparoscopic hepatectomy; percutaneous radiofrequency ablation; sonazoid-enhanced ultrasonography Correspondence Toru Beppu, Department of Multidisciplinary Treatment for Gastroenterological Cancer, Innovation Center for Translational Research, Kumamoto University Hospital, 1-1-1 Honjo, Chuo Ku, Kumamoto 860-8556, Japan. Tel: +81 96 373 5211 Fax: +81 96 371 4378 Email: [email protected]
Abstract Metachronous rectal liver metastasis (15 mm in segment 8 ventral) was managed with laparoscopic hepatectomy using segmental blood flow occlusion with radiofrequency ablation. During liver dissection, the ischemic area was visible as a distinct hypoechoic area on intraoperative enhanced ultrasound; with a photodynamic eye camera, it appeared as a discolored lesion. The resection was completed with adequate margins.
Received: 18 September 2013; revised 9 December 2013; accepted 15 December 2013 DOI:10.1111/ases.12088
Introduction Laparoscopic hepatectomy is a curative therapeutic modality for liver tumors and is less invasive than the open approach (1–3). Among the various types of hepatectomy, laparoscopic partial hepatectomy (LPH) is commonly selected. Pure LPH for small tumors located at the deeper site of the liver is relatively challenging (4). Segmental blood flow occlusion with thermal ablation has been developed to assist with the procedure (5–7), and desiccation of arterial and portal vessels can reveal a Doppler ultrasound (US) deficit and marked discoloration on the liver. Recently, we developed a new pure LPH technique. Our team performed an open anatomical resection in which portal pedicle ligation was followed by contrast-enhanced intraoperative ultrasound (CE-IOUS) (ProSound F75, Hitachi Aloka Medical Ltd, Tokyo, Japan) using Sona-
188
zoid (GE Healthcare, Oslo, Norway); this allowed us to visualize a parenchymal dissection line as the margin of a hypo-enhanced image (6). An indocyanine green fluorescence imaging system (photodynamic eye, Karl Storz, Tuttlingen, Germany) was used to recognize the discolored area (6). We used CE-IOUS to monitor the stoppage of blood flow, which was performed by with radiofrequency ablation (RFA). LPH was then performed.
Case Presentation A 68-year-old man with metachronous rectal liver metastases was admitted to Kumamoto University Hospital (Kumamoto, Japan). After induction chemotherapy, the metastases shrunk to 15 mm and 7 mm in segment (S)8 and S4/8, respectively (Figure 1). The former was located at the deeper site, 3.8 cm from the liver surface,
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
(a)
(b)
Figure 1 Preoperative diagnostic images. (a) CT during arterioportography. Tumors were located in S8 and S4/8. The former tumor was adjacent to S8 ventral Glissonean sheath. (b) 3D-CT reconstruction. Portal vein and hepatic vein are presented in pink and blue colors, respectively. S, segment.
(a)
(b)
Figure 2 Laparoscopic IOUS. (a) B-mode US. (b) enhanced-US with Sonazoid. The ischemic area including the tumor was clearly visible as a hypoechoic area in enhanced US with Sonazoid. IOUS, intraoperative ultrasound; US, ultrasound.
and was barely detectable by extracorporeal US using Sonazoid. Therefore, pure LPH following percutaneous RFA was planned. RFA was performed using a 17-G cooled-tip electrode with a 2-cm metallic tip (Radionics, Burlington, MA, USA); the power application was increased to 60 W in the impedance control mode for 10 min. The tumor and the S8 ventral Glissonean sheath were ablated twice. The segmental blood flow stoppage was observed with Doppler US. Laparoscopic CE-IOUS using Sonazoid enabled constant visualization of the hypoechoic area during the liver dissection (Figure 2). The PDE camera revealed a distinct discolored area of the liver. Pure LPH was achieved with five ports plus a port at the eighth intercostal. Liver transection was achieved
using an ultrasonic dissector and energy devices: Sonicision (Covidien, Mansfield, USA) and BiClamp and ball electrode with the VIO soft-coagulation system (ERBE, Elektromedizin, Tübingen, Germany) (Figure 3a– c). Because of the severe intra-abdominal adhesion, no Pringle maneuver was performed. The resected specimen was placed in a plastic bag and removed (Figure 3d). Liver transection time was 70 min for the deep-sited S8 tumor. Blood loss during hepatectomy was 30 mL. The patient was discharged 8 days after surgery without any complications. Written informed consent was obtained from the patient, and the work conformed to the provisions of the 1995 Declaration of Helsinki (fifth revision, 2000).
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
189
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
(a)
(b)
(c)
(d)
Figure 3 Intraoperative findings. (a) Liver dissection was performed with laparoscopic coagulating shears. (b) The resecting liver was lifted with surgical thread. (c) The intercostal port made it easier to transect the cranial portion of the liver. (d) The resected specimen was placed in a plastic bag and removed from the body.
Discussion A laparoscopic non-anatomical liver resection is sometimes challenging when there are small tumors located in the deeper sites of the liver. Such tumors gradually become unclear during liver transection, even with continuous monitoring by laparoscopic CE-IOUS using Sonazoid. Manual interventions are not possible, particularly during pure LPH. To maintain adequate surgical margins, extensive resection or unnecessary anatomical dissection is occasionally selected. Therefore, we developed a new pure LPH procedure that is performed after RFA of the Glissonean sheath. To create an appropriate ischemic area, RFA should be performed using a percutaneous approach, not a laparoscopic approach. To avoid the risk of bile leakage, liver dissection should include the site of ablated Glissonean sheath.
190
This LPH technique offers several benefits. First, this procedure aids in the clear visualization of the liver parenchyma to be resected. Second, because the ischemic liver parenchyma is transected, blood loss is reduced. Intravascular administration of Sonazoid can indicate loss of blood flow, as observed by hypo-enhanced image for over 1–2 hours (6). Third, during surgery, the accurate direction of liver transection can always be verified, particularly the bottom of the resected plane, to achieve adequate surgical margins from the tumor. Histopathological examination confirmed that the hypoechoic area was an ischemic area, which included the ablated area as well (Figure 4). Although this technique is useful in hybrid or open hepatectomy, it is most useful in a pure laparoscopic approach. This technique allows anatomical resection to transect the entire ischemic area. In conclusion, this technique can achieve
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
(a)
(b)
(c)
Figure 4 Macroscopic and microscopic findings of resected specimen. (a) The cut surface of the resected specimen. The tumor was in contact with the S8 ventral Glissonean sheath and was surrounded with the yellowish coagulative area. (b) Hematoxylin-and-eosin staining of boundary region of coagulative and ischemic area (×40). (c) Hematoxylin-and-eosin staining of ischemic area (×200). The RFA-coagulation area was demonstrated around the tumor histologically, and ischemic changes were histologically proven in the area fed by S8 ventral vessels. RFA, radiofrequency ablation; S, segment.
accurate liver dissection as well as decrease blood loss, and metastases may be avoided via portal flow during the liver transection.
Acknowledgment The authors have no conflicts of interest to disclose and received no financial support for this study.
References 1. Buell JF, Cherqui D, Geller DA et al. World Consensus Conference on Laparoscopic Surgery. The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009; 250: 825–830. 2. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients. Ann Surg 2009; 250: 831–841.
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
191
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
3. Beppu T, Horino K, Komori H et al. Advances in endoscopic surgery for hepatocellular carcinoma. J Microwave Surg 2008; 26: 67–72. 4. Takagi S, Kaneko H, Ishii T et al. Laparoscopic hepatectomy for extrahepatic growing tumor. Surgical strategy based on extrahepatic growing index. Surg Endosc 2002; 16: 1573– 1578. 5. Imura S, Shimada M, Utsunomiya T et al. Ultrasound-guided microwave coagulation assists anatomical hepatic resection. Surg Today 2012; 42: 35–40.
192
6. Uchiyama K, Ueno M, Ozawa S et al. Combined intraoperative use of contrast-enhanced ultrasonography imaging using a sonazoid and fluorescence navigation system with indocyanine green during anatomical hepatectomy. Langenbecks Arch Surg 2011; 396: 1101–1107. 7. Navarra G, Bartolotta M, Scisca C et al. Ultrasound-guided radiofrequency-assisted segmental arterioportal vascular occlusion in laparoscopic segmental liver resection. Surg Endosc 2008; 22: 1724–1728.
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Asian J Endosc Surg ISSN 1758-5902
MY A P P R OAC H
Percutaneous radiofrequency ablation-assisted laparoscopic hepatectomy Toru Beppu,1,2 Hidetoshi Nitta,1 Masayo Tsukamoto,1 Katsunori Imai,1 Hiromitsu Hayashi,1 Hirohisa Okabe,1 Daisuke Hashimoto,1 Akira Chikamoto,1 Takatoshi Ishiko1 & Hideo Baba1 1 Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan 2 Department of Multidisciplinary Treatment for Gastroenterological Cancer, Innovation Center for Translational Research, Kumamoto University Hospital, Kumamoto, Japan
Keywords Laparoscopic hepatectomy; percutaneous radiofrequency ablation; sonazoid-enhanced ultrasonography Correspondence Toru Beppu, Department of Multidisciplinary Treatment for Gastroenterological Cancer, Innovation Center for Translational Research, Kumamoto University Hospital, 1-1-1 Honjo, Chuo Ku, Kumamoto 860-8556, Japan. Tel: +81 96 373 5211 Fax: +81 96 371 4378 Email: [email protected]
Abstract Metachronous rectal liver metastasis (15 mm in segment 8 ventral) was managed with laparoscopic hepatectomy using segmental blood flow occlusion with radiofrequency ablation. During liver dissection, the ischemic area was visible as a distinct hypoechoic area on intraoperative enhanced ultrasound; with a photodynamic eye camera, it appeared as a discolored lesion. The resection was completed with adequate margins.
Received: 18 September 2013; revised 9 December 2013; accepted 15 December 2013 DOI:10.1111/ases.12088
Introduction Laparoscopic hepatectomy is a curative therapeutic modality for liver tumors and is less invasive than the open approach (1–3). Among the various types of hepatectomy, laparoscopic partial hepatectomy (LPH) is commonly selected. Pure LPH for small tumors located at the deeper site of the liver is relatively challenging (4). Segmental blood flow occlusion with thermal ablation has been developed to assist with the procedure (5–7), and desiccation of arterial and portal vessels can reveal a Doppler ultrasound (US) deficit and marked discoloration on the liver. Recently, we developed a new pure LPH technique. Our team performed an open anatomical resection in which portal pedicle ligation was followed by contrast-enhanced intraoperative ultrasound (CE-IOUS) (ProSound F75, Hitachi Aloka Medical Ltd, Tokyo, Japan) using Sona-
188
zoid (GE Healthcare, Oslo, Norway); this allowed us to visualize a parenchymal dissection line as the margin of a hypo-enhanced image (6). An indocyanine green fluorescence imaging system (photodynamic eye, Karl Storz, Tuttlingen, Germany) was used to recognize the discolored area (6). We used CE-IOUS to monitor the stoppage of blood flow, which was performed by with radiofrequency ablation (RFA). LPH was then performed.
Case Presentation A 68-year-old man with metachronous rectal liver metastases was admitted to Kumamoto University Hospital (Kumamoto, Japan). After induction chemotherapy, the metastases shrunk to 15 mm and 7 mm in segment (S)8 and S4/8, respectively (Figure 1). The former was located at the deeper site, 3.8 cm from the liver surface,
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
(a)
(b)
Figure 1 Preoperative diagnostic images. (a) CT during arterioportography. Tumors were located in S8 and S4/8. The former tumor was adjacent to S8 ventral Glissonean sheath. (b) 3D-CT reconstruction. Portal vein and hepatic vein are presented in pink and blue colors, respectively. S, segment.
(a)
(b)
Figure 2 Laparoscopic IOUS. (a) B-mode US. (b) enhanced-US with Sonazoid. The ischemic area including the tumor was clearly visible as a hypoechoic area in enhanced US with Sonazoid. IOUS, intraoperative ultrasound; US, ultrasound.
and was barely detectable by extracorporeal US using Sonazoid. Therefore, pure LPH following percutaneous RFA was planned. RFA was performed using a 17-G cooled-tip electrode with a 2-cm metallic tip (Radionics, Burlington, MA, USA); the power application was increased to 60 W in the impedance control mode for 10 min. The tumor and the S8 ventral Glissonean sheath were ablated twice. The segmental blood flow stoppage was observed with Doppler US. Laparoscopic CE-IOUS using Sonazoid enabled constant visualization of the hypoechoic area during the liver dissection (Figure 2). The PDE camera revealed a distinct discolored area of the liver. Pure LPH was achieved with five ports plus a port at the eighth intercostal. Liver transection was achieved
using an ultrasonic dissector and energy devices: Sonicision (Covidien, Mansfield, USA) and BiClamp and ball electrode with the VIO soft-coagulation system (ERBE, Elektromedizin, Tübingen, Germany) (Figure 3a– c). Because of the severe intra-abdominal adhesion, no Pringle maneuver was performed. The resected specimen was placed in a plastic bag and removed (Figure 3d). Liver transection time was 70 min for the deep-sited S8 tumor. Blood loss during hepatectomy was 30 mL. The patient was discharged 8 days after surgery without any complications. Written informed consent was obtained from the patient, and the work conformed to the provisions of the 1995 Declaration of Helsinki (fifth revision, 2000).
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
189
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
(a)
(b)
(c)
(d)
Figure 3 Intraoperative findings. (a) Liver dissection was performed with laparoscopic coagulating shears. (b) The resecting liver was lifted with surgical thread. (c) The intercostal port made it easier to transect the cranial portion of the liver. (d) The resected specimen was placed in a plastic bag and removed from the body.
Discussion A laparoscopic non-anatomical liver resection is sometimes challenging when there are small tumors located in the deeper sites of the liver. Such tumors gradually become unclear during liver transection, even with continuous monitoring by laparoscopic CE-IOUS using Sonazoid. Manual interventions are not possible, particularly during pure LPH. To maintain adequate surgical margins, extensive resection or unnecessary anatomical dissection is occasionally selected. Therefore, we developed a new pure LPH procedure that is performed after RFA of the Glissonean sheath. To create an appropriate ischemic area, RFA should be performed using a percutaneous approach, not a laparoscopic approach. To avoid the risk of bile leakage, liver dissection should include the site of ablated Glissonean sheath.
190
This LPH technique offers several benefits. First, this procedure aids in the clear visualization of the liver parenchyma to be resected. Second, because the ischemic liver parenchyma is transected, blood loss is reduced. Intravascular administration of Sonazoid can indicate loss of blood flow, as observed by hypo-enhanced image for over 1–2 hours (6). Third, during surgery, the accurate direction of liver transection can always be verified, particularly the bottom of the resected plane, to achieve adequate surgical margins from the tumor. Histopathological examination confirmed that the hypoechoic area was an ischemic area, which included the ablated area as well (Figure 4). Although this technique is useful in hybrid or open hepatectomy, it is most useful in a pure laparoscopic approach. This technique allows anatomical resection to transect the entire ischemic area. In conclusion, this technique can achieve
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
(a)
(b)
(c)
Figure 4 Macroscopic and microscopic findings of resected specimen. (a) The cut surface of the resected specimen. The tumor was in contact with the S8 ventral Glissonean sheath and was surrounded with the yellowish coagulative area. (b) Hematoxylin-and-eosin staining of boundary region of coagulative and ischemic area (×40). (c) Hematoxylin-and-eosin staining of ischemic area (×200). The RFA-coagulation area was demonstrated around the tumor histologically, and ischemic changes were histologically proven in the area fed by S8 ventral vessels. RFA, radiofrequency ablation; S, segment.
accurate liver dissection as well as decrease blood loss, and metastases may be avoided via portal flow during the liver transection.
Acknowledgment The authors have no conflicts of interest to disclose and received no financial support for this study.
References 1. Buell JF, Cherqui D, Geller DA et al. World Consensus Conference on Laparoscopic Surgery. The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009; 250: 825–830. 2. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients. Ann Surg 2009; 250: 831–841.
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
191
RFA-assisted laparoscopic hepatectomy
T Beppu et al.
3. Beppu T, Horino K, Komori H et al. Advances in endoscopic surgery for hepatocellular carcinoma. J Microwave Surg 2008; 26: 67–72. 4. Takagi S, Kaneko H, Ishii T et al. Laparoscopic hepatectomy for extrahepatic growing tumor. Surgical strategy based on extrahepatic growing index. Surg Endosc 2002; 16: 1573– 1578. 5. Imura S, Shimada M, Utsunomiya T et al. Ultrasound-guided microwave coagulation assists anatomical hepatic resection. Surg Today 2012; 42: 35–40.
192
6. Uchiyama K, Ueno M, Ozawa S et al. Combined intraoperative use of contrast-enhanced ultrasonography imaging using a sonazoid and fluorescence navigation system with indocyanine green during anatomical hepatectomy. Langenbecks Arch Surg 2011; 396: 1101–1107. 7. Navarra G, Bartolotta M, Scisca C et al. Ultrasound-guided radiofrequency-assisted segmental arterioportal vascular occlusion in laparoscopic segmental liver resection. Surg Endosc 2008; 22: 1724–1728.
Asian J Endosc Surg 7 (2014) 188–192 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
