A nephron sparing operation, such as partial nephrectomy and enucleation of renal tumors, has been recently shown to provide extended survival free of disease in selected patients with localized low stage renal cell carcinoma. To verify the possibility of whether the microwave tissue coagulator is applicable to the laparoscopic partial nephrectomy without renal ischemia, we performed the laparoscopic partial nephrectomy with 5 dogs using this coagulator. After the anesthesia, three trocars were inserted into the peritoneal cavity under the laparoscopic monitoring. Using the microwave tissue coagulator inserted into the kidney, the tissue was coagulated and cut off from intact tissue inside its margin. The resected surface left in the intact tissue was also coagulated by the argon beam coagulator. The mean operative time was about 53 minutes without bleeding, while the coagulated margin in the renal remnant was limited to 5-7 mm in thickness. The temperature of the kidney and circumferential organs was elevated soon after the operation ; 40.9 ± 1.2°C (mean ± S.D.) on the surface of the kidney and 39.5 ± 1.2°C in the peritoneal cavity. The results suggest that the application of the microwave tissue coagulation to the laparoscopic partial nephrectomy avoids renal ischemia and results in reduced blood loss, shorter operative time, and minimal risk of the renal remnant. However, it remains unknown whether the renal remnant is damaged by the heat of the microwave tissue coagulator.
We introducted a technique of microwave tissue coagulation during partial nephrectomy, without clamping the renal vessels. In three male and a female, all patients had incidental renal tumor. The tumor size were 2-3 cm and histrogical finding were three renal cell carcinomas and one cortical adenome. They did not require blood transfusion but occured one complication as urinary leakage.
Recently, there has been a trend towards reduction in the use of surgical methods to treat breast cancer in the early stage. We speculated whether it is possible to apply microwave tissue coagulation (MTC) therapy, which is currently being used in the treatment of liver tumor, to the reduction of breast cancer. We first conducted a preliminary histological study to investigating the effect of MTC on mammary gland tissue. When MTC was performed for 60 seconds at a power of over 75W, hyaline degeneration was found in an area with a radius of approximately 5 mm, indicating cell death. There remain many problems to be solved in the future, but MTC therapy may be an effective method of treating non-invasive type breast cancer with a circumference of approximately 1 cm.
The incidence of postoperative complications of the hepatectomy using microwave tissue coagulator (MTC) for hepatocellular carcinoma were investigated. In one hundred and twenty six cases, containing 71 “atypical” hepatectomy and 55 “typical” hepatectomy, operated between January 1981 to December 1993, 21 cirrhotic cases and 2 non-cirrhotic cases represented the sign of hepatic insufficiency such as severe ascites, jaundice and/or death due to hepatic failure. Thirteen cases of “atypical” hepatectomy represented the sign of hepatic insufficiency. Another complications were four cases (3.2%) of stump abscess, 4 cases of massive gastrointestinal bleeding, 3 cases (2.4%) of bile leakage, 2 cases (1.6%) of postoperative pulmonary complication, 2 cases of incisional herniation, 2 cases of postoperative adhesion ileus and 1 case of acute intraabdominal bleeding from the resected stump. There were no significant tendency of stump abscess or bile leakage between, “atypical” or “typical” hepatectomy, cirrhotic or non-cirrhotic liver. The result implies that accurate evaluation of functional reserve is necessary even in the case of “atypical” hepatectomy but all of the complications can be overcome because they are not specific for MTC.
A 69-year-old man with HCC was treated. Abdominal US, CT and angiography revealed three small nodules in S5, S6 and S8 segment of the liver. US pattern and CT density of the nodules were different each other. According to this findings, these nodules were thought to be multicentric growth of HCC. Using microwave tissue coagulator, limited atypical subsegmentectomy to each nodule was performed. Histological examination of resected specimens showed atypical adenomatous hyperplasia (AAH) in S8 segment, and coexistencce of AAH and middle or low grade HCC in each S5, S6 segment. On this histological findings, atypical subsegmentomy applied to this patient was suspected to be a reasonable operative method and radical operation in the result.
Major post-operative complications are often experience after hepatic resection. In particular, abdominal abscess and bile leakage frequently occur. Here we report the complications observed after hepatic resection without using MTC, and also suggest treatment to reduce these post-operative problems. From July 1992 to December 1994, 33 patients with HCC were performed partial hepatectomy without using MTC at the National Cancer Center Hospital East. The above complications occured in 9 patients (31%). Those patients were associated with Clinical stage II, resection of segment 8, and with increased intraoperative blood loss, operative time and tumor size. However none of the patients had liver failure or MOF because we performed US frequently and had adequate drainage after the operation. In conclusion ; for patients with a high risk of complications, there should be more careful management after hepatic resection.
Microwave tissue coagulation (MTC) therapy was applied to 11 cases with liver cancer. With irradiation at 70 watts for 60 seconds, the extent of heating in cancerous regions (5 cases with hepatocellular carcinoma) and non-cancerous regions (6 cases) was measured. In the area 12.5 mm from the electrode, in both cancer and non-cancerous regions, the temperature exceeded about 50°C. In the same area, severe histological degeneration was found. From this result, the extent of thermal damage caused by this microwave energy may reach 25 mm in maximal diameter regardless of cellularity or vascularity.
The three directional percutaneous microwave coagulation therapy, which is the new procedure, under general anesthesia was performed for 67 y.o. male patient with HCC of 1.5 cm in diameter, in the Couinaud's segment 7 after transcatheter arterial embolization. The needle electrodes of the microwave tissue coagulator were induced through 14 gauge tru-cut biopsy needles which had been punctured from the point of 8th intercostal space (i.c.s.), from the point of 9th i.c.s. and from the point of subcostal area under ultrasonographic guidance. The microwave irradiation with dissociation electric current simultaneously was started after all the needle electrodes had been inserted. The total microwave irradiation time for this tumor counted 30 minutes. There were no intraoperative and postoperative complications. The CT findings, 36 days after treatment, revealed that the low density area was 3.1 cm in diameter and 15.1 cm3 in volume. Angiography and CT scan demonstrated the recurrence free 9 months after treatment. In conclusions, this new procedure is reliable and safe for postoperative recurrent HCC.
Intraoperative microwave tissue coagulation (MTC) therapy was applied to 9 hepatocellular carcinoma (HCC) lesions in 5 patients. Magnetic resonance (MR) imaging was used to evaluate changes before and at two and four weeks after treatment. Two weeks after treatment, all coagulated lesions had mildly hyper-intensity with a hypo-intensity rim on T1-WI and mixed signal intensity with a hyper-intensity rim on T2-WI. Enhanced T1-WI displayed an enhanced rim corresponding to hypo-intensity rim on T1-WI (and a hyper-intensity rim on T2-WI). Four weeks after treatment, the MR image characteristics of these coagulated lesions had not changed noticeably compared with those two weeks after treatment. Histologic changes correlated well with changes in MR signal intensity. These findings suggested that MR imaging was useful for evaluation of changes after MTC therapy for HCC.
We report a case of laparoscopic microwave coagulo-necrotic therapy (L-MCNT) for metastatic liver tumor. The patient was 62-year-old male who received Miles operation due to rectal cancer. 6 months after Miles operation, liver metastasis was pointed out. The tumor was solitary, 4.5 cm in diameter. It was thought that resection was possible. But the patient rejected the therapy, so that we selected L-MCNT. L-MCNT was safety done because of no adhesion in the upper abdominal cavity. The radiation time of MCNT was totally 120 minutes. He discharged without complication at the 15th postoperative day. Coagulated area involving tumor and surrounding tissue was not enhanced on post MCNT dynamic CT scan. But 6th months after L-MCNT, multiple lung metastasis was found. He underwent chemotherapy in out patient. After chemotherapy, CEA level was decreased. L-MCNT is useful method in the treatment of metastatic liver tumor.
Subsegmentectomy using a flow dilated balloon catheter and microwave tissue coagulation was carried out in 14 cases with hepatocellular carcinoma. This procedure prevented postoperative liver dysfunction by maintaining blood flow in the residual liver and minimizing stripping of the hepato-duodenal ligament. Correct anatomical diagnosis of the tumor sites was achieved by means of US Angiography (in these cases, the injection of a CO2 bubble in to the portal vein through the catheter) during the operation. Additionally, prevention of intrahepatic metastasis via the portal vein can be anticipated because of the balloon catheter blockade of the regional portal branch. This procedure is easy to perform, it reduce intraoperative bleeding and thus blood transfusion, and addition of this procedure dose not extent the total time required for the operation.
Laparoscopic microwave coagulation therapy (LMCT) for two hepatocellular carcinoma (HCC) s was performed after basic experiment. Since LMCT is carried out under laparoscopic ultrasonography, not only superficial HCC but also HCC located deep in the liver can be treated. Because LMCT is carried out under local anesthesia, it is less stressful and allows earlier recovery of patients as compared to conventional laparotomy. With this technique, adequate necrosis of tumors can be induced by thermocoagulation. It can be applied repeatedly on the same patient. LMCT is very useful in treating HCC.
From October 1983 to January 1995, we performed microwave coagulo-necrotic therapy (MCN) in 21 patients in whom another cancer nodules were detected intraoperatively or liver resection was dangerous due to severe cirrhosis. Seven were treated with MCN alone, other 13 cases were treated with MCN combined with partial hepatic resection, and one case was done with portal vein ligation. Preoperative results of fifteen minutes retention rate of indocyanine green were 6.4 to 45.8 (mean ; 27.0) %. The needle-electrode was punctured into various site of the tumor one to fifty times, and coagulations with microwave energy of 80 watts for 30 seconds at 15 seconds intervals were done. The treated lesions changed to avascular areas on dynamic CT at 1 and 6 postoperative months, and these lesions were completely necrotic histologically. The postoperative courses of 7 patients who received MCN therapy alone were uncomplicated except for one patient with severe cirrhosis. Long term prognosis after MCN were almost the same as that after liver resection. MCN is useful for treatment of unresectable HCC with minimal invasiveness.
The case is 76-year-old male whose chief complaint was terminal miction pain. A urinalysis showed microscopic hematuria and pyuria, and KUB revealed a 5.0 × 3.3 cm sized vesical calculus. Transurethral vesical lithotripsy using a pyeloscope was performed. Microwave coagulation therapy was applied to hemostasis which was interrupted the lithotripsy. The coagulation was performed with a microwave energy of 100 watts for 30 seconds. There was not any inconvinience, when the microwave applicator was inserted through the pyeloscope. The operation was able to be performed safely to the end. It supposed that the microwave coagulation therapy was a useful combined procedure for the endoscopic treatment of urinary tracts calculi.
Resectability of a liver tumor is influenced by the functional reserve of the liver, tumor size and location. In a case of severely limited functional reserve of the liver with a tumor close to the main vessels of the residual liver, successful resection of the tumor is not always possible. For such a situation percutaneous ethanol injection or percutaneous microwave coagulation therapy (MCT) have limited applicability a restricted application from the point of view of effect or safety. The indications of MCT can be expanded when performed laparotomy. The present case report shows that effective and safe coagulation can be successfully performed after surgical isolation of the tumoral mass from the surrounding liver tissue with the unablated part of the tumor close to the vessel to be preserved and that the needle in the tumor should be maintained a distance of 7 of 8 mm from the vessel.
We reported a 55 years old female with a unresectable giant metastatic liver tumor from malignant thymoma who underwent percutaneous microwave coagulo-necrotic therapy (MCT). She underwent thymectomy for thymoma 15 years ago, and right nephrectomy and left partial nephrectomy for metastasis from thymoma 3 years ago. During the follow-up, she was found to have a giant metastatic liver tumor and we performed the MCT three points of the tumor per 60W 60s, because of her poor general condition. No complications were observed. Two months later, a biopsy was done, showing necrosis of the tumor. A pertinent literature was reviewed.
A case of advanced multiple hepatocellular carcinoma (HCC) was reported, which could be treated successfully by microwave coagulation method under laparotomy and chemo-hyperthermia. A 71-year old man with HCC combined with severe liver cirrhosis was admitted, who reccured with a protruding tumor of S4 and tumor thrombus into the left main portal vein after 4-times of transarterial emborization. Tumor and tumor thrombus were treated by microwave coagulation method under laparotomy, using microwave tissue coagulator (Microtaze®) and thereafter chemo-hyperthermia therapy was added continuously. He is alive keeping good quality of life 20 months later. Hepatoma was well controlled. The coagulated regions were persistent without local growth. On the literature, this is the first case that microwave coagulation method was applied to the treatment of tumor thrombus of portal vein.
A self-expandable metallic stent, Gianturco-Rösch Z-stent (Cook), was used to the patient of the left bronchial stenosis due to recurrent esophageal cancer. The stent was inserted easily with fiberoptic bronchoscopy under local anesthesia, following immediate improvement of atelectasis of the left lung. After 10 days, it became again obstructed because the tumor grew up through the spaces between the wires. The tumor was easily cauterised and removed by endoscopic tissue coagulation. Thereafter another stent was inserted within the initial stent (stent in stent) to prevent more ingrowth of the tumor. The patency of the airway continued for a few months until the patient deceased from worsening of the general condition.