Laparoscopic radiofrequency ablation of unresectable hepatocellular carcinoma : evolution of technique and long-term results

The optimal treatment for hepatocellular carcinoma (HCC) is either surgical resection or liver transplantation. However, only a small percentage of patients are operative candidates. Percutaneous radiofrequency ablation (RFA) has been performed with promising results in patients with HCC. Our objective was to assess an operative combination of laparoscopic ultrasound with laparoscopic RFA in the treatment of complex patients with HCC not amenable to liver resection or percutaneous RFA. Methods: 393 patients with HCC in liver cirrhosis were submitted to laparoscopic RFA which was indicated in patients not amenable to liver resection that had at least one of the following criteria (all patients were discussed at a weekly multidisciplinary meeting at which surgeons, hepatologists and radiologists exchanged opinions): a) severe impairment of the coagulation tests (55 pts); b) multiple lesions requiring repeated punctures (145 pts); c) superficial lesions adjacent to visceral structures or adjacent to peri-hilar structures (105 pts); d) deep-sited lesions with a very difficult or impossible percutaneous approach (237 pts). An insulated 18 gauge internally cooled tip electrode was used and inserted into the tumour under laparoscopic sonographic guidance An operative combination of laparoscopic RFA with a selective intra-hepatic vascular occlusion (SIHVO) has been accomplished in 74 patients from 2005 and microwave technology (MWA) has been used in 84 patients from 2009. Results: There was one post-operative death (0.26%) due to cardiac failure. Three- hundred and seven patients had no complication (78%): a IIIB grade complication according to Clavien classification occurred in only 5 patients (1.3%). In BCLC stage A group (374 pts), a complete ablation (at 1-month computed tomography evaluation) was achieved in 346 patients (92.5%) (90% after MWA and 100% after SIHVO). During the follow-up (mean follow-up: 32.1 + 30 months), 228 Abstract ID: CE45 patients (61%) (39% after MWA and 61% after SIHVO) developed new malignant nodules (local recurrences: 26% after overall RFA; 20% after MWA and 19% after SIHVO). Actuarial 5-year survival after laparoscopic RFA was 35%. Conclusions: Laparoscopic RFA of HCC proved to be a safe and effective technique: in fact it permits to successfully treat lesions not treatable with the percutaneous approach with a low morbidity rate. New techniques and technology could further improve these results.