Percutaneous liver puncture radiofrequency thermocoagulation for hepatocellular carcinoma

Hepatocellular carcinoma with percutaneous transhepatic radiofrequency thermocoagulation is an ablation therapy for liver cancer. RF equipment: RF2000 type RF transmitter from PTC of the United States, RF electrode needle is a multi-pole special needle-needle printer Le VeenTM series of RTC, USA, clustered radial needle group (with 10 electrodes, Figure 1.10.8.1-1 The developed diameter is 2.5 cm, 3 cm, 3.5 cm, and the length is 10 cm, 15 cm, and 20 cm. Treating diseases: liver cancer Indication 1. <5cm, especially <3cm, no surgical indication or primary liver cancer because the tumor is located in the central region of the liver and the hilar region makes surgery difficult and has poor efficacy. 2. Surgical resection of difficult recurrent small liver cancer. 3. Secondary small liver cancer that has been cured by the primary tumor, the number of tumors is <5. 4. For large liver cancer without surgical indications, hepatic arterial chemoembolization should be performed first, followed by PRFA. 5. Liver function is Child-Pugh A or B, no ascites. Preoperative preparation Preoperative examination First of all, you should inquire about the medical history and comprehensive physical examination of patients, especially attention should be paid to the presence or absence of hypertension, heart disease, emphysema, diabetes, bleeding from upper gastrointestinal varices, and history of abdominal surgery. Routine examinations performed before surgery: blood, urine, fecal routine tests, liver function, renal function, blood glucose, electrolytes, prothrombin time, hepatitis B and hepatitis C serum markers, tumor markers (such as Fetal protein), chest X-ray, electrocardiogram, gastroscope or upper gastrointestinal barium meal, CT or MRI. The surgeon should personally observe the B-ultrasound before surgery to understand the size, number and location of the tumor, especially the relationship with the important blood vessels in the liver. According to the size and location of the lesion, consider the needle route, according to the lesion range single or divided. , segmentation treatment. In this way, the diagnosis can be more clearly defined, and the patient's general condition and surgical tolerance can be correctly estimated. It has important clinical significance for the consideration of surgical indications, anesthesia, control of thermocoagulation range and prevention of surgical complications. 2. Preoperative treatment According to the preoperative examination, the active and targeted treatment is carried out in a short time before the operation. 1 improve blood coagulation function, such as the administration of vitamin K11, so that the preoperative examination of prothrombin time and the contrast is no more than 3s. Because prothrombin time is an important indicator of liver function and coagulation function. At present, most of the liver malignant tumors in China are primary liver cancer and are associated with different degrees of cirrhosis. Coagulation dysfunction exists to varying degrees. Therefore, it is necessary to improve the coagulation function of patients before surgery, and should be strengthened during and after surgery. Coagulation function to prevent possible internal bleeding. 2 improve liver reserve function, for patients with poor liver function should strengthen liver protection treatment, so that liver function is not lower than Child-Pugh B grade. 3 For patients with jaundice, liver and choleretic treatment should be given to make total bilirubin less than 35mol/L. For obstructive jaundice, if there is a secondary bile duct blockage, the bile duct can be given drainage, and the jaundice is relieved and PRFA is given. 4 for the treatment of patients with ascites. Because the outer diameter of the RF needle is about 2.2cm, if there is ascites, the pinhole left after the puncture does not have bleeding between the abdominal wall and the liver. Therefore, diuresis should be promoted on the basis of strengthening liver protection and increasing plasma albumin protein, so that ascites subsides. 3. Basic anesthesia Due to the high temperature generated by radiofrequency thermocoagulation, the vagus reflex caused by the liver capsule and intrahepatic vagus nerve stimulation can cause heart rate slowing, arrhythmia, blood pressure drop, and severe death, so you can give atropine or mountain before surgery. Scopolamine prevents vagal reflexes. We gave subcutaneous routine 1ml (including morphine 10mg, atropine 0.5mg) before surgery, in which atropine can prevent vagal reflex, morphine can calm the pain. However, patients with contraindications to atropine should be banned. Surgical procedure 1. All treatment procedures should be performed under strict aseptic procedures. 2. Attach the electrode plate to the patient's lower back and connect the electrode lead. 3. Conventional disinfection of the chest and abdomen surgery field. 4. Cut the skin of the puncture point to about 2mm. Under the guidance of B-ultrasound or CT, the RF electrode needle penetrates into the tumor, and the electrode is released according to the tumor size to open the radio frequency. The initial power is 30 ~ 50W (determined according to the size of the release electrode), and then increase 10W every 1 minute, gradually increase to 90W, until the impedance rises above 300, the RF power automatically drops below 10W, it can stop. In order to avoid incomplete thermocoagulation between the 10 electrode tip parts, a coagulation necrotic leakage area appears, the electrode is retracted in situ but the RF needle is not pulled out, rotated a little angle, and again as before, can be repeated 1 or 2 In order to minimize the incomplete thermocoagulation of the tumor. 5. Different thermocoagulation methods for tumors of different sizes (1) For tumors <2 cm, the radiofrequency electrode acupunctures into the center of the lesion to release the electrode, and the outer diameter of the deployed electrode may depend on the size of the tumor. For example, a patient with severe cirrhosis is attached to a cavernous vein of about 2 cm of hepatocellular carcinoma. The radiofrequency needle directly penetrates the center of the tumor to release the electrode, and the electrode is about 2 cm. (2) For a lesion of about 3 cm, the radiofrequency electrode acupunctures into the center of the lesion near the bottom and releases the electrode. If the in situ thermocoagulation is performed 2 or 3 times, the radiofrequency needle is pulled out 1 cm, and the treatment is repeated as before. In this way, the spherical tissue having a diameter of about 5 cm can be coagulated and necrotic, and the coagulation and necrosis range can be about 1 cm beyond the edge of the tumor to achieve the purpose of curing the tumor. For example, a patient with normal liver function has a hepatocellular carcinoma of about 3 cm in the center of the right hepatic lobe. One month after the treatment, the alpha-fetoprotein was reduced to normal from 49 g/L before surgery, and normal work was performed after 2 months. (3) For tumors of about 5 cm, hepatic arterial chemoembolization can be given according to the liver function of the patient. On the one hand, tumor necrosis may be reduced, on the other hand, tumor blood vessels may be embolized to reduce tumor blood flow and carry away heat to expand thermocoagulation. range. (4) For tumors >5 cm: radiofrequency thermocoagulation can be combined with transcatheter arterial chemoembolization. According to the size of the tumor, it can be divided into upper, lower or left and right segments. It can also be divided into upper, middle, lower or left, middle and right segments to do 2 or 3 times of thermal coagulation. At each treatment, according to the size of the tumor, multiple radiofrequency needles can be pre-punched into different parts of the tumor at the same time, so as to prevent the B-ultrasound from increasing the echo after the thermocoagulation and affecting the radiofrequency needle puncture into other tumors. The RF needle first penetrates into the bottom of the tumor near the edge and gradually solidifies (coagulated part of the near-tumor liver tissue) to the top. This can kill a small part of the near-tumor liver tissue, cut off the blood supply of the tumor, and prevent tumor metastasis, because the active part of the tumor is mainly at the edge. Since the gas generated during the treatment affects the ultrasound image, each operation can only be directed to a part of the lesion, and the large tumor needs to be segmented and fractionally coagulated. Due to the possible occurrence of hot-condensed leaky areas in three dimensions, although tumors of >5 cm can be thermocoagulated multiple times, they often fail to completely completely decoagulate the tumor. In theory, the effect of tumor burden on the body can be reduced, but the necrotic tissue produced by thermocoagulation of a large amount of tumor tissue and normal liver tissue also has a negative impact on the body, and its clinical effect remains to be further studied. Therefore, for tumors >5cm, radiofrequency thermocoagulation should be combined with other treatments, rather than a preferred method. For patients with surgical resection, hepatectomy is preferred. Because the maximum diameter of the RF electrode currently used for thermocoagulation is about 5 cm, the above-mentioned thermocoagulation methods for tumors of different sizes are proposed. If the electrothermal technique is further improved in the future, the range of single thermocoagulation is further expanded, and the thermocoagulation method for tumors of different sizes is also Will change. complication 1. Prevention and treatment of intraoperative complications (1) vagus nerve reflex: due to radiofrequency heat generated by the liver capsule and intrahepatic vagus nerve stimulation caused by vagus reflex, can cause heart rate slowdown, arrhythmia, blood pressure drop, severe cases can lead to death, so can give atropine before surgery 0.5 mg or 10 mg of anisodamine prevent vagal reflex. Dynamically monitor heart rate, heart rate, blood pressure and oxygen saturation during surgery. If intraoperative heart rate slowdown, arrhythmia, blood pressure drop should be considered for vagal reflex, can be given atropine or anisodamine treatment. (2) Injury of the intrahepatic and extrahepatic bile ducts: In order to achieve complete thermocoagulation of the tumor, the range of thermocoagulation is expected to exceed the boundary of the tumor, but it is easy to damage the surrounding tissue. For the liver, it should avoid hurting the larger bile duct. Because the bile flow rate is slow, the heat can not be taken away quickly, and the high temperature generated by the radio frequency easily damages the bile duct. For small liver cancer in the first hilar region, the thermocoagulation range should not be too large. (3) Injury of the perihepatic cavity: For those who have had a history of abdominal surgery or imaging examination and found that the tumor invades the surrounding cavity, radiofrequency thermocoagulation should be cautious, and it is not possible to completely cure the tumor and injure the cavity. The device causes serious complications such as internal or external paralysis. (4) Internal bleeding: For liver tumors that are close to the surface of the liver or protrude from the liver, the tumor on the surface of the tumor is rich in blood vessels, and it is not easy to stop bleeding once bleeding. Therefore, the puncture should not penetrate from the surface of the tumor, but should enter the tumor tissue from the tumor-free liver tissue. For patients with platelets below 30 x 109/L, a small amount of platelets can be considered for intraoperative infusion. In order to avoid hemorrhage at the puncture site, 1 unit of intravenous injection and 1 unit intramuscular injection were routinely given before radiofrequency ablation. After treatment, abdominal abdomen and abdominal abdomen were pressure-wrapped. 2. Prevention and treatment of postoperative complications (1) Internal hemorrhage: routine monitoring of blood pressure and pulse at 6 hours after operation, for platelets below 30×109/L, prolonged prothrombin time, and decreased coagulation function, the application of postoperative enhanced blood coagulation drugs should be closely observed Changes in abdominal signs. (2) Pneumothorax: During the operation, the puncture needle under the guidance of B-ultrasound should avoid penetrating into the chest as much as possible. After surgery, observe whether the breathing is stable. If there is difficulty in breathing, the chest should be diagnosed urgently. If there is a small amount of pneumothorax and the breathing is stable. It can be absorbed by itself. If the lung compression exceeds 30% or the breathing is obvious, the puncture should be given immediately. If the tension pneumothorax is found, the thoracic closed drainage should be given immediately. (3) Liver abscess: routinely given broad-spectrum antibiotics 5 days after surgery, especially for those with susceptibility to diabetes, especially anti-infection. If a liver abscess is found, puncture drainage pus, antibiotics can be used to flush the abscess, and combined with bacterial culture and drug sensitivity test results, sensitive antibiotics are given. (4) damage to the hollow organ: damage to the hollow organ can occur internal leakage or leakage. For those with a history of abdominal organ surgery, excessive coverage of the subcapsular tumor that may adhere to the hollow organ may be avoided during surgery. If there is an internal leakage or leakage of the damaged organ, the gastrointestinal decompression, high-vein nutrition, anti-infection should be given, and according to the nature of gastrointestinal angiography, fistula angiography, leakage, the sputum is clearly defined, and according to the stomach, Different parts of the small intestine and colon were treated with drainage, surgical repair, and surgical resection. (5) fever, vomiting, local pain: these are common complications and can be treated symptomatically. However, for patients with esophageal varices, if there is severe vomiting, it should be controlled in time to avoid the rupture of upper gastrointestinal varices. In short, strict control of indications, proficiency in operating techniques and careful preoperative, intraoperative and postoperative close observation and treatment are the key to prevent complications of percutaneous radiofrequency ablation of liver cancer.

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