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Liver Ablation

Liver Ablation Procedure Prep

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Ep 257 Microwave Ablation for Liver Lesions with Dr. Josh Kuban
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Pre-Procedure Prep

Modalities

• Radiofrequency ablation
• Microwave ablation
• Cryoablation - less common for liver
• Irreversible electroporation (IRE): non-thermal ablation

Operator preference
Some prefer microwave because:
• Faster
• Larger ablation volume
• Less susceptible to heat sink
• Multiple probes have synergistic effect
• Microwave ablation travels through all tissues: charred tissue
• Tissue contraction which can work to your advantage

Indications

• HCC - potentially curative for lesions <3 cm. Potential to downstage tumor to fall within Milan criteria
• Unresectable hepatic metastases
• Curative vs. Palliative intent

Ideal patient:
• Size less than 3 cm
• Safe distance from vasculature and vital structures (central bile ducts)
Non-ideal patients:
• Consider other therapy
• Within 2 cm of liver hilum
• Lesions in close proximity to bowel that cannot be effectively hydrodissected

Contraindications

• Life expectancy <6 months
• Child-Pugh class C
• ECOG 3 or 4
• Active infection
• Bile duct or major vessel invasion
• Uncorrectable coagulopathy
• No safe approach

Pre-Operative Evaluation

• H&P
• Labs: coagulation, LFTs
• Prior imaging - CT and/or MRI
Consider involving anesthesia early
• Anesthesia with paralytics can be helpful for breath hold maneuvers

Liver Ablation Podcasts

Listen to leading physicians discuss liver ablation on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #257

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In this episode, Dr. Chris Beck interviews Interventional Radiologist Dr. Josh Kuban about his liver tumor ablation practice at MD Anderson Cancer Center, including how it's evolved over time with newer technologies. They also discuss patient workup for liver tumors, treatment with microwave ablation, and post-procedure follow up. Dr. Kuban shares why he uses microwave ablation technology, and the advantages of ablation confirmation software for these procedures.

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Episode #158

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Dr. Christopher Beck talks with Dr. Driss Raissi about his approach to Microwave Ablation of Liver Lesions, including workup, technique, and tips and tricks for a successful ablation treatment.

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Procedure Steps

Antibiotic Prophylaxis

• Recommended, especially for high-risk patients (biliary-enteric anastomosis, cirrhosis, diabetes)
• For low risk patients: 1-2 g cefazolin (Ancef) IV
• Multiple regimens for high risk patients: 1.5 g ampicillin/sulbactam (Unasyn) IV is simplest
• Vancomycin or clindamycin for Gram-positive coverage (PCN allergy) and gentamicin for Gram-negative coverage

Margins Are Key

• Circumferential: Example: 2 cm met needs 4 cm ablation zone
• 10 mm for metastatic lesions
• 5 mm for HCC
Can use US, CT, angiography with cone beam CT or combination of modalities

Percutaneous Approach

• Plan ahead to make procedure easier
• Using combination of US and CT often faster than using each modality alone
Mark skin site and prep large area

Insert probes
• Depending on lesion size, strongly consider multiple probes and bracketing tumor
• If one the fence about extra probe, use extra probe
• Try and maintain parallel probe orientation
• Probes cannot be too close or too far apart
• Probes typically need to be within 1-2 cm from each other
• Know equipment and ablation zone which will vary between manufacturer and probes

Protective techniques if needed
• Hydrodissection most common: can use D5W, sterile water, 0.9% normal saline
• Pneumodissection: CO2
• Balloon interposition
• Gallbladder or stomach lavage

Ablate
• Can use intermittent CT scans to check ablation zones
• Can watch live with US if lesion visible and watch ablation zones coalesce
Ablate tract with probe removal

Following ablation, helpful to obtain diagnostic CT (outside of US, contrast enhanced US)
• Evaluate ablation zones
• Evaluate adjacent structures
• Establish new baseline
• Retreat if necessary

• Will depend on tumor location, orientation, vital structures and size
• Largest ablation zone will be along long axis of probe. Can use to operator advantage by orienting probe along long axis of the tumor
• Target temperature: 60° for microwave

• Plan ahead to make procedure easier
• Using combination of US and CT often faster than using each modality alone
• Mark skin site and prep large area

Insert Probes

• Depending on lesion size, strongly consider multiple probes and bracketing tumor
• If one the fence about extra probe, use extra probe
• Try and maintain parallel probe orientation
• Probes cannot be too close or too far apart
• Probes typically need to be within 1-2 cm from each other
• Know equipment and ablation zone which will vary between manufacturer and probes

Protective Techniques if Needed

• Hydrodissection most common: can use D5W, sterile water, 0.9% normal saline
• Pneumodissection: CO2
• Balloon interposition
• Gallbladder or stomach lavage

Ablate

• Can use intermittent CT scans to check ablation zones
• Can watch live with US if lesion visible and watch ablation zones coalesce
Ablate tract with probe removal

Following Ablation

• Helpful to obtain diagnostic CT (outside of US, contrast enhanced US)
• Evaluate ablation zones
• Evaluate adjacent structures
• Establish new baseline
• Retreat if necessary

Liver Ablation Articles

Read our exclusive BackTable VI Articles for quick insights on liver ablation, provided by physicians for physicians.

Physician opening microwave liver ablation device to create ablation zones

The standard liver ablation zone for hepatocellular carcinoma is half a centimeter to one centimeter, but where does this standard come from? This article discusses the current liver ablation zone guidelines and explores an alternative approach.

Post-Procedure

Complications

• Hemorrhage
• Vascular complications: portal vein thrombosis, hepatic venous thrombosis, infarct, AV fistula and pseudoaneurysm
• Pain
• Abscess formation/Infection
• Biloma or bile leak
• Post-ablation syndrome - fever, fatigue, nausea, myalgia 7-10 days following procedure. Occurs 30-60% of patients.
• Extrahepatic complications: depends on location. Examples: diaphragm injury, bowel injury

Post-Operative Care

• Many patients can be discharged same day
• Monitor patient for at least 2 hours for development of pain, signs of bleeding, or extrahepatic injury
• Schedule follow up clinic visit and imaging.
• For liver tumor follow up CT or MRI in 1-2 months.
• Helpful to maintain consistency with pre and post imaging. MR often preferred over CT
• Follow tumor markers and LFTs

• Many patients can be discharged same day
• Monitor patient for at least 2 hours for development of pain, signs of bleeding, or extrahepatic injury
• Schedule follow up clinic visit and imaging.
• For liver tumor follow up CT or MRI in 1-2 months.
• Helpful to maintain consistency with pre and post imaging. MR often preferred over CT
• Follow tumor markers and LFTs

Liver Ablation Demos

Watch video walkthroughs of liver ablation on the BackTable VI expanded content network.

Liver Ablation Tools

Check out liver ablation apps, calculators, and decision aids to assist you in your day to day practice.

Child-Pugh Score Calculator

The Child-Pugh Score calculator can be used to quickly assess the severity of cirrhosis, life expectancy, and risk of perioperative abdominal surgery mortality in patients with liver disease.

MELD Calculator

Model for End-Stage Liver Disease. Stratifies severity of end-stage liver disease, for transplant planning.

References

[1] Glassberg MB, Ghosh S, Clymer JW, Wright GWJ, Ferko N, Amaral JF. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World J Surg Oncol. 2019;17(1):98. Published 2019 Jun 10. doi:10.1186/s12957-019-1632-6
[2] Vogl TJ, Nour-Eldin NA, Hammerstingl RM, Panahi B, Naguib NNN. Microwave Ablation (MWA): Basics, Technique and Results in Primary and Metastatic Liver Neoplasms - Review Article. Mikrowellenablation (MWA): Grundlagen, Technik und Ergebnisse in primären und sekundären Lebertumoren – Übersichtsarbeit. Rofo. 2017;189(11):1055‐1066. doi:10.1055/s-0043-117410
[3] Hinshaw JL, Lubner MG, Ziemlewicz TJ, Lee FT Jr, Brace CL. Percutaneous tumor ablation tools: microwave, radiofrequency, or cryoablation--what should you use and why?. Radiographics. 2014;34(5):1344‐1362. doi:10.1148/rg.345140054
[4] Yu H, Burke CT. Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors. Semin Intervent Radiol. 2014;31(2):129‐137. doi:10.1055/s-0034-1373788
[5] Kim KR, Thomas S. Complications of image-guided thermal ablation of liver and kidney neoplasms. Semin Intervent Radiol. 2014;31(2):138‐148. doi:10.1055/s-0034-1373789
[6] Lubner MG, Brace CL, Ziemlewicz TJ, Hinshaw JL, Lee FT Jr. Microwave ablation of hepatic malignancy. Semin Intervent Radiol. 2013;30(1):56‐66. doi:10.1055/s-0033-1333654
[7] Groeschl RT, Wong RK, Quebbeman EJ, et al. Recurrence after microwave ablation of liver malignancies: a single institution experience. HPB (Oxford). 2013;15(5):365‐371. doi:10.1111/j.1477-2574.2012.00585.x

Disclaimer: The Materials available on https://www.BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Podcasts

Microwave Ablation for Liver Lesions with Dr. Josh Kuban on the BackTable VI Podcast)
Microwave Ablation for Liver Lesions with Dr. Driss Raissi on the BackTable VI Podcast)
New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback on the BackTable VI Podcast)

Articles

Physician opening microwave liver ablation device to create ablation zones

Ready, Aim, Ablate: Optimizing the Liver Ablation Zone

Contributors

Dr. Driss Raissi on the BackTable VI Podcast

Dr. Driss Raissi

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