Radiofrequency on the liver remnant after liver resection to reach the haemostasis not otherwise achievable with conventional techniques.

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International

Journal

of

Surgery

Case

Reports

jo u r n al ho m e p ag e :w w w . e l s e v i e r . c o m / l o c a t e / i j s c r

Radiofrequency

on

the

liver

remnant

after

liver

resection

to

reach

the

haemostasis

not

otherwise

achievable

with

conventional

techniques

Benedetta

Pesi

_,

_Francesca

_Leo

_,

_Gadiel

_Liscia

_,

_Giovanni

_Alemanno

_,

Daniela

Zambonin

_,

_Massimo

_Falchini

_,

_Giacomo

_Batignani

a_{DigestiveSurgeryUnit,DepartmentofSurgeryandTraslationalMedicine,UniversityofFlorenceMedicalSchool,CareggiUniversityHospital,Florence,Italy} b_{DiagnosticandInterventionalRadiologyUnit,UniversityofFlorenceMedicalSchool,CareggiUniversityHospital,Florence,Italy}

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Articlehistory:

Received14February2013 Accepted18February2013 Available online 4 April 2013

Keywords: Radiofrequency Haemostasis Liverresection Intra-operativebleeding

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INTRODUCTION:Duringliverresection,insamecaseofinflamed, steatoticorneo-vascularizedliver parenchyma,reachingofhaemostasisontheliverresectionsurfacecouldbeverydifficultforthesurgeon becauseofthepresenceoffragiletissuethatdoesnotallowstheproperplacementofstitches,andthe conventionalmethodfail.

PRESENTATIONOFCASE:Theauthorsdescribeanoveltechniqueinwhich,afteraformalliverresection, liverhaemostasisisachievedusingradiofrequencyenergyontheresectedsurface.Apatientaffectedby ahystiocyticsarcomalocalizedontheVI-VandIVasegmentswasscheduledforliverresection.During theresectionadiffusebleedingfromtheresectedsurfacestartedwithlittlesuccessobtainedwith con-ventionalmethod.Sowedecidedtousethecoagulativenecrosisgeneratedbytheradiofrequency,using acooltypeclusterneedle,hand-piecewith3needle,bending2needlesinawayresemblinga“fork”,to reachacompleteanddefinitivehaemostasis.

DISCUSSION:Haemostasisremainsacriticalissueinliversurgerynotonlyforthecatastrophiceffect ofhaemorrhagebutalsobecauseitiscorrelatedtocomplicationsrateandtosurvival.Thecoagulative necrosisgeneratedbytheradiofrequencycouldbeusedtofacilitatethecreationofanecroticplaneto betransacted.

CONCLUSION:Theuseoftheradiofrequencyenergy,deliveredthroughneedles,issuggestedwhenthe conventionaltechniquesfailtoreachaproperhaemostasisafteraliverresectionor,toconsideritsuse, priortoresecttheliverinpresenceoffragileparenchyma.

© 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Haemostasisontheliverresectionsurfaceisusuallyachieved usingsutureligations,clips,coagulation(eithermonoorbipolar), argonbeamcoagulationandhaemostaticagentsinmany prepara-tionssuchassponge,powderorsealantglue.

Whenproperhaemostasiscannotbeachievedamattresssuture or“u”stitchesusingpledgesthatcompresstheparenchymamay beused.

Onanormallivertextureoreveninpresenceofacirrhoticliver, post-resection haemostasisis usually achievedusing theabove mentionedtechniques.Somecases,mostrare,ofinflamed,steatotic orneo-vascularizedliverparenchymamayrepresentachallenge forthesurgeoninorder toobtaina properhaemostasisaftera liverresection.Theengorgedfragiletissueinfact,doesnotallow

Abbreviation:RF,radiofrequency.

∗ Correspondingauthorat:CareggiHospital,DigestiveSurgeryUnit,Largo Bram-billa3,50134Florence,Italy.Tel.:+390557947449;fax:+390557947449.

E-mailaddress:[email protected](B.Pesi).

conventionalplacementofsuturesinthesesituationsandthe oth-erstechniquesmayfailaswell,despitetheircorrectutilization.

Recently a new kind of bloodless liver resection has been describedusingradiofrequency(RF)energydeliveredintheliver parenchymabymeansofcooled-tipneedles.1_{RFisabletosealall}

kindsofvesselsandbile-ductsneartheneedletipthen,ifmultiple needlesareplacedinrow,anecroticplanemaybecreatedwhere ascalpelmaycutthroughinabloodlessfield.2,3

Wedescribehereanoveltechniqueinwhichthepost-resection liverhaemostasisisachievedusingRFenergyontheresected sur-face.

2. Presentationofthecase

A 69 years old man affected by a hystiocytic sarcoma with multiplelivertumourslocalizedontheanteriorsegments(VI-V andIVa)wasscheduledforliverresection.Ontheopeningofthe abdomenthroughabilateralsubcostalincisionweperformeda Pringlemanoeuvreresectingtheaffectedsegmentsasforan ante-riorhepatectomyusingKelly-crushtechniqueusingsilktieand clips.Afterthereleasingoftheclampsforliverreperfusionafteran

2210-2612/$–seefrontmatter © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

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B.Pesietal./InternationalJournalofSurgeryCaseReports4 (2013) 558–560 559

Fig.1.Intra-operativeviewoftheradiofrequencyenergydeliveredontheresected surfacebymeansofahand-piecemultipleneedlesbentinawayresemblinga“fork”.

ischaemiatimeof30min,adiffusebleedingfromtheresected

sur-facestartedwithlittlesuccessobtainedwithconventionalmethod

suchasprolenestitches,argonbeamcoagulation,coagulatoragents

andglues.APringlemanoeuvrelasting5minwasre-usedtwicein

ordertobetterplacethestitches.Themanoeuvrewasfollowed

by10minofde-clamping time.Sincebleeding wasongoingwe

decidedtoperformapackingthatwasremoved48hlater.At

re-operationtherewasnobloodintheabdominalcavitybutafterthe

removalofthepackingtheresectedsurfacestartedtobleedagain.

Wedecidedthentoresectalsotherightposteriorsegmentswhere

thebleedingseemedtocomefrom,completingaformalright

hemi-hepatectomy.Legatingandcuttingtherighthepaticartery,and

righthepaticvein.TheparenchymabelongedtosegmentVIIand

VIIIwasthenremovedusingKelly-crushtechniquelegatingand

clippingsmallvesselsinthemainfissureunderPringlemanoeuvre

lasting20min.Uponreperfusionwewereinthesameconditionsas

inthepreviousprocedurebecauseofthecontinuousbleedingfrom

theresectedsurface.Weusedagainstitches,argonbeamand

coag-ulants/gluewithoutdefinitivebleedingcontrol.Thistimeitwas

possibletoplacearowof“U”stitchesthroughtheliverparenchyma

1cm.apartfromtheresectedsurface.The“U”stitcheswereplaced

usingPTFEpledgesthat,whentied,compressedtheparenchyma.

Withthistechniquethebleedingreducedbutdidnotstopandfor

thisreasonwehadtopackagaintheliver.Atthispoint,wedecided

tousearadiofrequencyfortissuecoagulationandforthispurpose

weusedacooltypeclusterneedle(RF-cooltypeneedle,Valleylab,

USA)hand-piecewith3needle,bending2needlesinaway

resem-blinga“fork”witheveryneedlespacedfrom1cmapartfromthe

other(Fig.1).

Needlewereconnectedtoaradiofrequencygenerator(CoolTip RFsystem,Valleylab,USA)withenergyoutputrangingfrom0to 200Watts. Automatedalgorithmofenergy outputismodulated ontissueimpedance variation;increasingimpedancerelatedto reduceenergydelivered.

Thetipoftheneedleismaintainedcooledbycontinuoussaline perfusiontopreservetissuefromscarringwithoptimalenergy dif-fusiontothesurroundingtissue.

Theneedleswereinfixedintheliverparenchyma1cmapart fromtheresectedsurfaceand3cmdeepcreating2cmofnecrotic livertissuealongtheresectedsurface.Ittookfourapplicationsof 10mineachtoreachacompleteanddefinitivehaemostasisthat

allowedustoclosetheabdominalwallinabloodlessfield.Patient slowlyrecoveredfromtheoperationandleftthehospital15days laterwithalowoutputbilefistulathattook1monthtoheal.

3. Discussion

Haemostasisremainsacriticalissueinliversurgerynotonlyfor thecatastrophiceffectofhaemorrhagebutalsobecauseitis corre-latedtocomplicationsrateandtosurvival.4_{Eventhoughthorough}

knowledgeofliveranatomyismandatoryforliverresectionthere aremanytechnicaloptionstochooseinordertoreducethe bleed-ingduringliverresection.5_{Thereareavarietyofdissectordevices,}

ties,clips,staplers,coagulation(monoorbipolar,argon)and coag-ulantagentsorglues.Recentlyanewtechniquehasbeenproposed toresecttheliverparenchymainabloodlessfield.1_{Thistechnique}

derivesfromtheexperiencegainedwiththermalablationofliver tumoursandisbaseduponthecoagulativenecrosisgeneratedby theradiofrequencythatisabletosealsmalltomediumsizeblood vesselsandbileductseventhoughsomeconcernsremainabout theitssafetyandpostoperativecomplications.6_{Thistechniqueis}

currentlyindicatedparticularlyforperipheralresectionscreating a necroticplanetobetransectedsimplywithascalpel without bleedingatall.Tofacilitatethecreationofanecroticplanewhere cutthroughandtopreventunwantedinjuresanewhandpiecehas beendescribedwithmultiplebipolarneedlesplacedinarowwhich isdescribedassafer.3

Furthermore,recently,RFhasbeenusedwiththeaimtotreat bleedingfromliverinjuriesinanexperimentalmodel.7

4. Conclusion

We suggest the useof theradiofrequency energy, delivered throughmultipleneedles,whentheconventionaltechniquesfail toreacha properhaemostasisaftera liverresectionor,to con-sideritsuse,priortoresecttheliverinpresenceofinflamedor neo-vascularizedparenchyma. Conflictofinterest None. Funding None. Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontributions

Allauthorscontributedtothiswork:B.P.,F.L.,collectedthedata, B.P.,F.L.,G.L.,G.A.,D.Z.,analyzedthedata,B.P.,F.L.,M.F.andG.B. wrotethemanuscript,G.B.obtainedinformedconsentand super-visedallthemanuscript.

References

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2.HaghighiKS,WangF,KingJ,DanielS,MorrisDL.In-lineradiofrequencyablation tominimizebloodlossinhepaticparenchymaltransection.AmericanJournalof Surgery2005;190(1):43–7.

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bipolarradiofrequencydevice:Habib4X.HPB(Oxford)2008;10(4):256–60. 4.PoonRT,FanST,LoCM,LiuCL,LamCM,YuenWK,etal.Improving

perioper-ativeoutcomeexpandstheroleofhepatectomyinmanagementofbenignand malignanthepatobiliarydiseases:analysisof1222consecutivepatientsfroma prospectivedatabase.AnnalsofSurgery2004;240(4):698–708.

5.PoonRT.Currenttechniquesoflivertransection.HPB(Oxford)2007;9(3):166–73. 6.MitsuoM,TakahiroT,YasukoT,MasayasuA,KatsuyaO,NozomiS,etal. Radiofre-quency(RF)-assistedhepatectomymayinduceseverepostoperativeliverdamage. WorldJournalofSurgery2007;31(11):2208–12.

7.YaoP,GunasegaramA,LaddLA,DanielS,MorrisDL.Anexperimentalstudyofthe treatmentofliverinjurywithInLineRFA.HPB(Oxford)2007;9(1):37–41.

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