Abstract. Background: Radiofrequency ablation (RFA) is an alternative for the treatment of unresectable hepatic tumors. Tumors beneath the diaphragmatic ...
Surg Endosc (2004) 18: 1672–1674 DOI: 10.1007/s00464-004-8110-z Ó Springer Science+Business Media, Inc. 2004
Transthoracic hepatic radiofrequency ablation N. N. Lee,1 R. W. O’Rourke,2 J. Cheng,3 P. D. Hansen3 1 2 3
Oregon Health & Science University Medical School, Portland, OR, USA Department of Surgery, Oregon Health and Science University, Portland, OR, USA Department of Minimally Invasive Surgery, Legacy Health System, 1040 NW 22 Avenue, Suite 120, Portland, OR, USA
Received: 13 January 2004/Accepted: 30 March 2004/Online publication: 13 October 2004
Abstract Background: Radiofrequency ablation (RFA) is an alternative for the treatment of unresectable hepatic tumors. Tumors beneath the diaphragmatic dome may be difficult to access by laparoscopy. In these cases, a transthoracic transdiaphragmatic approach for delivering RFA can be used. Methods: Three patients with hepatic metastatic disease were treated using a transthoracic transdiaphragmatic approach to deliver RFA therapy for tumors in liver segments 7 and 8. The patients underwent thoracoscopy. The tumors were identified using transdiaphragmatic ultrasound, and transthoracic transdiaphragmatic RFA (TTRFA) was performed. Results: In three patients, TTRFA was successfully used to ablate five lesions. There were no perioperative complications, blood loss was minimal,and postoperative hospital stays ranged from 2 to 8 days. There were no recurrences during a follow-up period of 4 to 20 months. Conclusions: TTRFA is a viable alternative for hepatic tumors located beneath the dome of the diaphragm that are difficult to access by laparoscopy. Key words: Transthoracic — Radiofrequency ablation — Laparoscopic — Transdiaphragmatic
The application of radiofrequency ablation (RFA) to unresectable hepatic tumors has had a significant impact on the conventional approach to treatment for patients with primary liver carcinoma and hepatic metastatic disease. Because 80% to 90% of these patients are not good candidates for surgical resection, RFA represents a viable treatment option. A laparoscopic approach for delivering RFA therapy is effective and associated with short hospital stays
Correspondence to: P. D. Hansen
and recovery times [6]. The feasibility of laparoscopic RFA is dependent on the size, location, and accessibility of the tumor. In particular, tumors located under the dome of the diaphragm in patients with a history of multiple prior laparotomies may be difficult to access using a laparoscopic approach. In such cases, a thoracoscopic approach may offer a solution. We report three cases in which transthoracic transdiaphragmatic RFA (TTRFA) was performed for patients with metastatic lesions to the liver. We discuss the feasibility of a thoracoscopic approach to hepatic lesions, technical considerations for performing these procedures, and patient selection and outcomes.
Patients and methods Patients A retrospective chart review was conducted for all 117 patients who underwent RFA between 1998 and 2002 by one surgeon at Legacy Health System, Portland, Oregon. Three patients who received TTRFA were identified. These patients included two women and one man, ages 50, 55, and 77 years, respectively, who had a total of five metastatic lesions in segments 7 and 8 of the liver. All the patients had received treatment previously for their primary carcinoma and presented with metachronous metastases to the liver. All five lesions were deemed surgically unresectable because of their location and proximity to vasculature. The lesions were identified using computed tomography and ranged in size from 1.5 to 6 cm. Each patient was treated with TTRFA, and one patient also received simultaneous open cryoablation, via laparotomy, of an additional lesion in segments 2 and 3. This lesion was not accessible via a transthoracic route and required cryoablation because of its large size. Laparotomy was required because of extensive adhesions, which made a laparoscopic approach impossible. Patient characteristics and follow-up data are shown in Table 1.
Surgical procedure The procedures were performed with the patients under general anesthesia and in the left lateral decubitus position in two cases and in the supine position with the right side elevated in one case. Ventilation was supported using a single-lumen endotracheal tube in one case and a double-lumen endotracheal tube in two cases. Generally,
1673 Table 1. Patient data
Patient
Sex
Age
Diagnosis
Procedure
1
F
77
M.O. J.H.
F M
55 50
Metastatic colorectal cancer Metastatic melanoma Metastatic cholangiocarcinoma
TTRFA open cryoablation TTRFA TTRFA
Involved segments
Maximum diameter (cm)
No. of lesions
EBL (ml)
OR time (min)
Hospital Stay(days)
7–8, 2–3
4, 5
2
150
500
8
7–8 7
6 1.5
3 1
100 100
390 180
2 3
EBL, estimated blood loss; OR, operating room; TTRFA, transthoracic transdiaphragmatic RFA
three thoracic trocars were placed: a 5-mm port in the fourth intercostal space at the anterior axillary line, a 10-mm port in the sixth intercostal space at the midaxillary line, and a 10-mm port in the eighth intercostal space at the posterior axillary line. Adequate space for visualization of the diaphragm was obtained using insufflation of the chest using carbon dioxide to 10 mmHg, the use of a lung retractor, or both. Transdiaphragmatic thoracoscopic ultrasound was used to guide the transthoracic RFA probe through the diaphragm and into the lesion in segments 7 and 8. A 5-cm-diameter probe (Radionics, Inc., Burlington, MA, or RITA Medical Systems, Mountain View, CA) was inserted through the diaphragm and directly into the lesion. Radiofrequency waves were administered through the needle. Smaller lesions were treated with a single ablation, whereas multiple overlapping areas were used to ablate larger lesions. After ablation, a 24-Fr chest tube was inserted through one of the 10-mm port sites, and the remaining port sites were closed.
Results In three patients, TTRFA was successfully used to ablate a total of five lesions. Each procedure was performed with no perioperative complications or mortality. Estimated blood loss was minimal (100– 150 ml). The chest tube was removed on postoperative day 1 for two patients, and on postoperative day 4 for one patient. The postoperative hospital courses were uneventful in all cases. All three patients were followed with repeat computed tomography (CT) scans within 4 months of the procedure that showed no recurrences of the ablated lesions. Long-term followup evaluation ranged from 4 to 20 months. One patient was lost to follow-up evaluation after 4 months, and the other two patients died of progressive metastatic disease 8 and 20 months, respectively, after the TTRFA procedure.
Discussion Currently, the only curative treatment for patients with primary or metastatic liver cancer is surgical resection. However, 80% to 90% of such patients are not candidates for resection because of poor medical status, tumor location, extrahepatic disease, or hepatic insufficiency [1]. An alternative to surgical resection is therefore necessary. Current alternatives include ablation therapy including microwave coagulation, cryoablation, and radiofrequency ablation. In the United States, RFA has become the predominant ablation therapy [3, 5]. A variety of approaches have been used to deliver RFA, including percutaneous and minimally invasive
approaches as well as an open approach via laparotomy. A percutaneous approach is the least invasive method, but its disadvantages include inability to stage disease, poorer resolution of transabdominal ultrasound than with laparoscopic ultrasound, and an increased risk of collateral injury to nearby organs. Percutaneous RFA is therefore generally reserved for patients unable to tolerate an open or laparoscopic procedure [2, 6], or for patients who have had prior staging via laparoscopy or laparotomy. A laparoscopic approach to RFA allows for the benefits of a minimally invasive procedure (short hospital stays and recovery times) while providing accurate cancer staging and probe placement as well as a minimal risk of collateral thermal injury. Despite its advantages over both open and percutaneous RFA, however, the laparoscopic approach has limitations. In particular, tumors located in segments 7 and 8 may be difficult to access, especially in patients who have had a prior laparotomy. A thoracoscopic approach provides improved access to the dome of the liver and may offer a solution in such patients. A review of the literature yielded only two reports of a thoracoscopic approach to hepatic ablation therapy. Yamashita et al. [8] delivered thoracoscopic transdiaphragmatic microwave coagulation for primary and secondary hepatic tumors to six patients with no perioperative complications and no recurrence after a median follow-up of 17 months. Ishikawa et al. [4] performed thoracoscopic RFA for nine patients with similar good results. These reports suggest that thoracoscopic ablation is technically feasible and safe. Our experience confirms this and supports the thoracoscopic approach as an alternative in a subset of patients. Our criteria for selecting patients to undergo TTRFA are evolving, but this procedure is best suited to patients with lesions in the dome of the liver that are difficult to access via a transabdominal approach. Patients with dense intra-abdominal adhesions, especially those who have undergone prior hepatic resection, may be best approached via a transthoracic method. A combined thoracoscopic and laparoscopic approach also is an option and may provide a solution for the patient with multiple tumors. Finally, we do not consider prior thoracic surgery to be a contraindication to TTRFA, although we have yet to encounter such a patient. One of our patients had prior chest radiation and required extensive thoracoscopic adhesiolysis. Nevertheless, good exposure of the diaphragm was achieved. Full left lateral decubitus positioning provides excellent exposure of the right hemidiaphragm. In pa-
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tients selected for a combined thoracoscopic and laparoscopic approach, the sequence of procedures and positioning is dependent on the locations of the lesions. In general, we prefer to begin with thoracoscopy, simply for ease of repositioning later in the case. Alternatively, supine positioning with the right chest slightly elevated on a roll provides good exposure during both thoracoscopic and laparoscopic procedures without the need for intraoperative repositioning. This is, however, suboptimal when the lesions approached through the chest are relatively posterior. In such cases, we prefer full decubitus positioning followed by repositioning to supine. Whatever the sequence of events chosen, in most cases, the lesion expected to be the most difficult to ablate because of its depth or proximity to the vasculature or bile ducts should be ablated first. It also is important to realize that once ablated, tissue becomes hyperechoic and can block transmission of ultrasound waves. Therefore, to allow for ultrasound visualization, the lesions ablated first should lie deep to lesions targeted for subsequent ablation. The TTRFA procedure is performed using three or four thoracic trocars. One trocar is placed in the seventh intercostal space in the midaxillary line, then two or three trocars are placed lateral and caudad to the first. Carbon dioxide chest insufflation, a lung retractor, or single-lung ventilation is used to expose the diaphragm. We use each of these techniques and find that singlelung ventilation usually is unnecessary because good exposure can be accomplished by insufflation of the chest with Carbon dioxide at a pressure of 10 mmHg. Alternatively, or in addition, the use of a flexible snake or fan lung retractor aids exposure. Once the diaphragm is exposed, TTRFA requires expertise in the use of ultrasound [7]. The ultrasound probe is placed directly on the diaphragm, and frequencies of 3 to 7 MHz provide excellent visualization. After identification of the lesion and probe placement, ablation is performed. Minor collateral thermal injury to the diaphragm is occasionally observed, and the RFA
probe tines sometimes penetrate diaphragmatic muscle, but we have noticed no significant diaphragmatic injury or adverse clinical sequelae. After ablation, a chest tube is placed in one of the trocar sites and usually removed on postoperative day 1. For patients with unresectable primary and secondary hepatic malignancies, RFA is a viable treatment option. Although a laparoscopic approach offers the advantages of a minimally invasive procedure to a debilitated group of patients, many lesions amenable to ablation therapy are difficult to access laparoscopically. For such patients, TTRFA provides a safe, effective alternative approach.
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