The Truth About Radiofrequency Ablation and Laparoscopic Liver Resection

Comparison of Transarterial Chemoembolization Combined with Radiofrequency Ablation Therapy versus Surgical Resection for Early Hepatocellular Carcinoma

Both radiofrequency ablation (RFA) and surgical resection (SR) are radical treatment recommended for early hepatocellular carcinoma (HCC). Transarterial chemoembolization (TACE) is a palliative treatment for intermediate HCC, and TACE1RFA combined therapy is considered superior to TACE or RFA alone for management of early HCC. This systematic review compared the efficacy and safety of TACE1RFA combined therapy with SR for early HCC. Web of Science, PubMed, EMBASE, and the Cochrane Library were searched for literatures related with our topic. The primary endpoint was overall survival (OS), and the secondary endpoint was the recurrence-free survival (RFS) rate; safety was measured by the rate of major complications. The effect sizes of OS, RFS, and local progression rates were expressed by odds ratio (OR), while the effect size of complications was presented using relative risk. TACE1RFA combined therapy and SR had a similar 1-year OS rate [OR: 1.84; 95% confidence interval (CI): 0.82, 4.14; P > 0.05], 3-year OS rate (OR: 0.84; 95% CI: 0.43, 1.67; P > 0.05), 1-year RFS rate (OR: 0.77; 95% CI: 0.53, 1.11; P > 0.05), and 3-year RFS rate (OR: 0.88; 95% CI: 0.48, 1.42; P > 0.05) for early HCC. However, the 5-year OS rate (OR: 0.54; 95% CI: 0.40, 0.73; P < 0.05) and 5-year RFS rate (OR: 0.49; 95% CI: 0.27, 0.90; P < 0.05) were lower in patients with TACE1RFA than in those with SR. SR is associated with better long-term survival outcomes and a lower recurrence rate than TACE1RFA for patients with early HCC and is the optimal choice for patients with early HCC.

[Modern diagnostics and stage-oriented surgery: therapy of adenocarcinoma of the esophagogastric junction]

The basis for decision-making about an individualized surgical treatment of adenocarcinoma of the esophagogastric junction is tumor staging and exact evaluation of the topography of the tumor in the small junctional area. The diagnostics mainly comprise endoscopy, biopsy, endosonography, computed tomography and partially diagnostic laparoscopy. This results in a clinical TNM staging and an evaluation according to the AEG classification from oral to aboral in type I (esophagus), type II (cardia) and type III (subcardia). Endoscopic resection is only appropriate for the infrequent mucosal carcinomas whereas the majority of the junctional carcinomas are treated by surgical resection. This is combined with neoadjuvant treatment in case of T3 or resectable T4 carcinomas. A type I carcinoma is removed by radical transthoracic en bloc esophagectomy with high intrathoracic esophagogastrostomy after gastric pull-up. In case of type II or III carcinomas, a transhiatal extended gastrectomy including distal esophageal resection is performed with reconstruction by Roux en Y esophagojejunostomy in the lower mediastinum. However, some advanced type II carcinomas which cannot be resected R0 at the esophagus need esophagectomy and gastric pull-up. This surgical strategy is justified by the topography of the lesion and the corresponding lymphatic drainage. Very rare indications are seen for a limited resection with interposition of small bowel in some mucosal carcinomas or total esophagogastrectomy with colon interposition in very advanced tumors. The neoadjuvant treatment comprises especially chemoradiation for type I and chemotherapy for type II and III carcinomas and leads to a significant survival benefit compared to surgery alone.

Laparoscopic resection of the liver for cancer

Although most laparoscopic hepatic procedures are performed for benign disease, an increasing fraction is for malignant disease, including primary and metastatic liver tumors. Data suggest that minor and major hepatic resections are feasible and can be performed safely. The limited data currently available suggest that survival in patients with hepatocellular carcinoma and colorectal metastatic disease may be comparable to that achieved with open hepatectomy. The benefits of the laparoscopic approach seem to be shorter hospitalization, smaller incisions, and less blood loss. Despite the progress to date, concern continues about the potential for significant intraoperative hemorrhagic complications and oncologic outcomes.

Laparoscopic liver resection: an examination of our first 300 patients

BACKGROUND

Laparoscopic liver resection is a procedure in evolution. In the last decade it has evolved from a novel procedure to a standard part of the hepatic surgeon's armamentarium. Few data exist on the development of a laparoscopic resection program.

STUDY DESIGN

With IRB approval, a retrospective review of 300 consecutive laparoscopic liver resections was undertaken. To determine changing results and patterns of practice, the cohort was divided into 3 consecutive groups of 100 patients. Patient demographics, indications for operation, operative factors, and in-hospital outcomes were examined. Continuous variables were analyzed with the Kruskal-Wallis test; continuous variables were compared with Fisher's exact test. Univariate and multivariate analyses of major complications (≥grade 3) were performed using logistic regression.

RESULTS

Of the 300 patients, 173 (61.6%) were female, with a median age of 54 years. There were 133 (44.3%) major resections. The median number of segments resected increased (3 vs 2, p = 0.015), as did the percentage of repeat hepatectomies (13.0% vs 2.0%, p = 0.001). At the same time, median operative time decreased (2.25 vs 3.0 hours, p < 0.001).and estimated blood loss was similar (150 mL vs 150 mL, p = 0.635). Morbidity was similar (11% vs 14%, p = 0.300), as was mortality (1% vs 3%, p = 0.625).

CONCLUSIONS

Laparoscopic liver resection has evolved from a novel procedure to a vital technique in liver surgery. Our group has demonstrated the ability over time to perform more difficult resections with similar morbidity and decreased operative length.