Use of radiofrequency hepatic parenchymal transection device in hepatic hemangioma resection: early experience and lessons learned.
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ABSTRACT: BACKGROUND: Control of intraoperative hemorrhage represents a significant challenge in hepatic surgery, particularly during resection of large, hypervascular hepatic hemangiomata (HH). Various devices to minimize blood loss from hepatic parenchymal transection are currently under investigation. Herein, we present our experience with a radiofrequency (RF)-powered multiarray for resection of HH. PATIENTS AND METHODS: From September 2005 to January 2006, we conducted a retrospective review of our hepatobiliary database to identify patients with symptomatic giant cavernous HH undergoing resection with a RF multiarray device. The purpose of this review was to assess the technical aspects of using RF energy to assist in the resection of HH. RESULTS: The extent of operation varied depending on the size and location of the tumor. Two patients underwent two atypical subsectionectomies and two underwent trisectionectomies. The Habib sealer provided a safe and effective method for hepatic parenchymal transaction. No patients required blood transfusion, and no injuries to major biliary or vascular strictures were observed at 1 year follow-up. A seroma developed in one patient 6 months postoperatively, but was drained percutaneously. CONCLUSIONS: Hepatic parenchymal transection with the Habib sealer device is a feasible approach to resect HH. Further study is needed to objectively compare the efficacy of RF-assisted parenchymal transection with that of traditional parenchymal transection techniques.
Project description:BackgroundPure laparoscopic liver resection (LLR) of segment 8 (S8) is still rarely performed due to the lack of an appropriate surgical approach. This article discusses the technical tips and operation methods for LLR of S8 via a hepatic parenchymal transection-first approach.MethodsClinical data of 22 patients who underwent LLR of S8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein (MHV) in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from May 2017 to February 2020 were retrospectively analyzed.ResultsThe mean age was 51.1 ± 11.6 years; mean operation time, 186.6 ± 18.4 min; median blood loss, 170.0 ml (143.8-205.0 ml); and median length of hospital stay, 8.0 days (7.0-9.0 days). There was no case of open conversion. Pathologic findings revealed all cases of hepatocellular carcinoma (HCC). Pathology showed free surgical margins. Post-operative complications included liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding and bile leak. All the complications responded well to conservative treatment. No other abnormality was noted during outpatient follow-up examination. All patients survived tumor-free.ConclusionsLLR of S8 is still quite challenging at present, and it is our goal to design a reasonable procedure with accurate efficacy and high safety. We use hepatic parenchymal transection-first approach guided by the MHV for LLR of S8. This technique overcomes the problem of high technical risk, greatly reduces the surgical difficulty and achieves technological breakthroughs, but there are still many problems worth further exploration.
Project description:ABSTRACT Infantile hemangiomas are the most common tumors seen in pediatrics. Recent clinical research has led to marked advances in understanding, including the recognition that a wide spectrum of clinical severity exists and that these tumors are significantly more complex than originally thought. This article addresses some of the most common clinical questions and scenarios surrounding infantile hemangiomas, based on the most recent research to date.
Project description: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 cm(2) 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/cm(2). 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.
Project description:Liver transection is the most challenging part of liver resection due to the risk of massive blood loss which is associated with increased postoperative morbidity and mortality, as well as reduced long-term survival after resection of malignancies. Among the devices used for open parenchyma transection, ultrasonic dissection with bipolar cautery forceps is one of the most widely used technique worldwide. We identified four retrospective comparative studies and three randomized controlled trials dealing with the efficacy of ultrasonic dissector (UD) compared with other techniques including the historical clamp crushing technique. UD is associated with similar blood loss and slower resection time compared with water-jet or clamp crushing technique. However, it seems to be more precise in dissecting vessels. Its use does not impact on morbidity and hospital stay compared with other techniques. From an economic point of view, UD is the most expensive technique and may be a disadvantage for low centre volume. UD with bipolar cautery is one of the safest and the most efficient device for liver transection, even if its superiority over the clamp crushing technique has not been well established. It is considered as a standard technique for liver transection.
Project description:Insulin bolus calculators have proven effective in improving glycemia and patient safety. Insulin calculators are increasingly being implemented for inpatient hospital care. Multidisciplinary teams are often involved in the design and review of the efficacy and utilization for these calculators. At times, unintended consequences and benefits of utilization are found on review. Integration of our insulin calculator into our electronic health record system was a multidisciplinary effort. During implementation, several obstacles to effective care were identified and are discussed in the following manuscript. We describe the barriers to utilization and potential pitfalls in clinical integration. We further describe benefits in patient education, time of insulin administration versus meal delivery, variations in insulin bolus for ketone correction, variation in care, and maximum bolus administration. Sharing lessons learned from experiences using electronic insulin calculator order sets will further our goals of improved patient care in the hospital setting.
Project description: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 4X, a new bipolar RF device designed specifically for liver resection is described here. METHODS: Habib 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 4X is an additional device for hepatobiliary surgeons to perform liver resections with minimal blood loss and low morbidity and mortality rates.
Project description:PurposeTo report the complications of radiofrequency ablation (RFA) for hepatic hemangioma.Patients and methodsInvestigators from six centers performed RFA for hepatic hemangioma and used a standardized follow-up protocol. Data were collected from 291 patients, including 253 patients with hepatic hemangioma 5 to 9.9 cm in diameter (group A) and 38 with hepatic hemangioma ≥ 10 cm (group B). Technical success, complete ablation, and complications attributed to the RFA procedure were reported. Analysis of variance was used to determine whether the major complication rate was related to tumor size or clinical experience.ResultsA total of 304 lesions were treated in 291 patients. Technical success was achieved without adverse events in all cases. A total of 301 lesions were completely ablated, including 265 of 265 (100%) lesions in group A, and 36 of 39 (92.31%) in group B. The rate of technology-related complications was similar in groups A and B (5.14% (13/253) and 13.16% (5/38), respectively; P = 0.121). Moreover, all technology-related complications occurred during the early learning curve period. The rate of hemolysis-related complications in two groups were 83.40% (211/253) and 100% (38/38) (P =0.007) and the systemic inflammatory response syndrome-related complications in two groups were 33.99% (86/253) and 86.84% (33/38) (P<0.001). There were no delayed complications in either group.ConclusionRFA is minimally invasive, safe, and effective for hepatic hemangiomas 5 to 9.9 cm in diameter. More clinical data are needed to confirm the safety of RFA for hepatic hemangiomas ≥ 10 cm.
Project description:CRISPR is revolutionizing the ability to do somatic gene editing in mice for the purpose of creating new cancer models. Inactivation of the VHL tumor suppressor gene is the signature initiating event in the most common form of kidney cancer, clear cell renal cell carcinoma (ccRCC). Such tumors are usually driven by the excessive HIF2 activity that arises when the VHL gene product, pVHL, is defective. Given the pressing need for a robust immunocompetent mouse model of human ccRCC, we directly injected adenovirus-associated viruses (AAVs) encoding sgRNAs against VHL and other known/suspected ccRCC tumor suppressor genes into the kidneys of C57BL/6 mice under conditions where Cas9 was under the control of one of two different kidney-specific promoters (Cdh16 or Pax8) to induce kidney tumors. An AAV targeting Vhl, Pbrm1, Keap1 and Tsc1 reproducibly caused macroscopic ccRCCs that partially resembled human ccRCC tumors with respect to transcriptome and cell of origin and responded to a ccRCC standard of care agent, axitinib. RNAseq analysis was utilized to evaluate the expression profile produced by the targeted loss of Vhl, Pbrm1, Keap1 and Tsc1 in these mouse tumors. Unfortunately, these tumors, like those produced by earlier genetically engineered mouse ccRCCs, are HIF2-independent.
Project description: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.
Project description:BackgroundHepatic hemangiomas are the most typical benign mesenchymal lesions of the liver. Most of these lesions are asymptomatic. Giant hepatic hemangiomas (GHH) (>10 cm) are often symptomatic and require surgical intervention. This study aimed to describe the clinical findings, risk factors, diagnostic approach and management of GHH.MethodsWe performed a retrospective analysis of patients with GHH treated at our hospital from January 2008 to December 2018. The medical records of each patient were reviewed to obtain the clinical and surgical data.ResultsTwelve patients with GHH were treated during the study period. 9 were female and 3 were male. The mean age of diagnosis was 48,2 years. The most common presenting symptom was abdominal pain. Eight patients presented an abdominal mass. Indications for surgical resections were rupture (n = 2), Kasabach-Merritt syndrome (n = 1) and abdominal pain (n = 9). Right hepatectomy was done in four patients, left lobectomy in four patients, and enucleation in four patients. Embolization was performed in 4 patients, but due to the persistence of symptoms or bleeding, surgery was indicated. The mean operative time was 3.5 h, and median blood loss was 870 ml. The median hospital stay was 5.3 days. For four patients, we registered postoperative complications causing death in one case. All alive patients were asymptomatic at a median follow-up of 55 months.ConclusionDespite limitations and alternative modalities, surgery remains the only effective curative treatment for GHH.