One-lung ventilation to treat hepatic dome lesion - a further step towards minimally invasive surgery: a case report

Colorectal Liver Metastases: A Literature Review of Viable Surgical Options with a Special Focus on Microwave Liver Thermal Ablation and Mini-Invasive Approach

Colorectal cancer (CRC) is the third most common tumor worldwide and it is characterized in 20-30% of cases by liver involvement, which strongly affects the long-term patient outcome. There are many available therapies for liver colorectal metastases (CRLMs); the current standard of care is represented by liver resection, and when feasible, associated with systemic chemotherapy. Microwave thermal ablation (MWA) is a viable option in unresectable patients or to achieve treatment with a parenchymal spearing approach. A literature review was performed for studies published between January 2000 and July 2022 through a database search using PUBMED/Medline and the Cochrane Collaboration Library with the following MeSH search terms and keywords: microwave, ablation, liver metastases, colorectal neoplasm, and colon liver rectal metastases. The recurrence rate and overall patients' survival were evaluated, showing that laparoscopic MWA is safe and effective to treat CRLMs when resection is not feasible, or a major hepatectomy in fragile patients is necessary. Considering the low morbidity of this procedure, it is a viable option to treat patients with recurrent diseases in the era of effective chemotherapy and multimodal treatments.

Pulsed Microwave Liver Ablation: An Additional Tool to Treat Hepatocellular Carcinoma

Simple Summary

Hepatocellular carcinoma (HCC) is the seventh most frequent neoplasm and the second most common oncologic cause of death, mostly in patients with end-stage liver disease. HCC treatment is complex and different solutions are available, ranging from liver transplants to local therapies. In this study, we analyze the role of pulsed microwave liver ablation as an additional treatment option.

Abstract

This study aimed to analyze the outcomes of HCC patients treated with a novel technique—pulsed microwave ablation (MWA)—in terms of safety, local tumor progression (LTP), intrahepatic recurrence (IHR), and overall survival (OS). A total of 126 pulsed microwave procedures have been performed in our center. We included patients with mono- or multifocal HCC (BCLC 0 to D). The LTP at 12 months was 9.9%, with an IHR rate of 27.8% at one year. Survival was 92.0% at 12 months with 29.4% experiencing post-operative complications (28.6% Clavien–Dindo 1–2, 0.8% Clavien–Dindo 3–4). Stratifying patients by BCLC, we achieved BCLC 0, A, B, C, and D survival rates of 100%, 93.2%, 93.3%, 50%, and 100%, respectively, at one year, which was generally superior to or in line with the expected survival rates among patients who are started on standard treatment. The pulsed MWA technique is safe and effective. The technique can be proposed not only in patients with BCLC A staging but also in the highly selected cases of BCLC B, C, and D, confirming the importance of the concept of stage migration. This procedure, especially if performed with a minimally invasive technique (laparoscopic or percutaneous), is repeatable with a short postoperative hospital stay.

Combined utility of one lung ventilation and artificial pneumothorax in thermal ablation of hepatic dome tumor: a technical note

Radiofrequency ablation and microwave ablation are established treatment modalities for smaller (<3 cm) or isolated hepatic tumors. Transthoracic ablation of hepatic dome lesions is a well described technique. We report the use of one lung ventilation to facilitate the successful percutaneous transthoracic microwave ablation of a segment 8 hepatic dome lesion after induction of artificial pneumothorax. This involved the use of general anesthesia and insertion of a double lumen endotracheal tube to allow isolated ventilation of one lung, followed by creation of an artificial pneumothorax under computed tomography (CT) guidance. Complete ablation of the lesion was confirmed on CT liver at 1 and 7 months with no local recurrence. The combined techniques of one lung ventilation and artificial pneumothorax enabled a safe and accurate transthoracic targeting of the hepatic dome lesion.

Thoracoscopic Ablation of Critically Located Liver Tumors: A Safety and Efficacy Cohort Study

Background: Liver resection represents the first curative treatment to treat primary and secondary hepatic tumors. Thoracoscopic liver ablation is a viable and minimally invasive alternative treatment, especially for patients with previous multiple abdominal surgeries. The aim of the study was to evaluate the safety and efficacy of thoracoscopic ablation for liver tumors. Methods: Retrospective analysis of a prospective database of patients with liver tumors, treated with thoracoscopic trans-diagrammatic ablation (MWA or RFA) at our institution from 2012 to 2018. The primary endpoint was post-operative mortality at 30 days, while secondary endpoints were morbidity and efficacy of ablation (i.e., response rate evaluated according to mRECIST criteria, and overall patient survival). Patient demographics, operational characteristics, and complications were recorded. Results: A total of 13 nodules were treated in 10 patients with a median age of 65.5 years. Post-operative mortality was 0%, and overall morbidity was 40% (Clavien-Dindo I complications 30%, II 0%, III 10%, IV 0%). Complete radiological response was obtained in 83.3% of nodules at 3 months. After a median follow-up of 20.95 months, the local tumor progression rate was 30%, with an intra-segmental-recurrence of 30%, and an intra-hepatic-recurrence of 30%. The overall 1-, 2-, and 3-years survival rates were 80%, 58%, and 58%. Conclusion: Thoracoscopic trans-diaphragmatic ablation proved to be a safe and effective way to treat liver tumors when abdominal approach is not feasible. Considering the low morbidity, it is a viable option to treat patients with recurrent disease and/or previous multiple abdominal surgeries.

One-lung ventilation for percutaneous thermal ablation of liver tumors in the hepatic dome

Purpose: To investigate the feasibility, efficacy and safety of one-lung ventilation for percutaneous thermal ablation of liver tumors in the hepatic dome.Materials and methods: From 5 January 2017 to 16 April 2019, 64 patients who underwent ultrasound-guided thermal ablation with a total of 75 liver malignant tumors located in the hepatic dome were enrolled in the present study. One-lung ventilation was employed to improve the acoustic window and protect the lung and diaphragm. If the one-lung ventilation was unsuccessful, artificial pleural effusion was added. The technical efficacy was confirmed by contrast-enhanced computed tomography/magnetic resonance imaging (CT/MRI) 1 month later. After that, CT/MRI was performed every 3-6 months.Results: Among the enrolled patients, the technical success rate of one lung ventilation was 92.2% (59/64). The visibility scores of tumors were improved significantly after one-lung ventilation compared to those before one-lung ventilation (p < .001). Finally, 78.6% (55/70) of the tumors achieved clinical success of one-lung ventilation to become clearly visible and underwent thermal ablation. Fourteen of the remaining 15 tumors achieved a satisfactory acoustic window after combination of artificial pleural effusion. One lesion remained inconspicuous and partly affected by pulmonary gas. The follow-up period was 8 months (3-30 months). The technical efficacy rate was confirmed to be 100% (75/75). During the follow-up period, local tumor progression occurred in 2 patients (2/75, 2.7%). Major complications occurred in two patients (2/64, 3.1%) receiving one-lung ventilation.Conclusions: One-lung ventilation is a promising noninvasive method for the thermal ablation of hepatic dome tumors due to its efficacy and safety.