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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 16
| Issue : 7 | Page : 1686-1690 |
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General versus local anesthesia for percutaneous radiofrequency ablation of hepatocellular carcinoma at unusual regions
Yan-Hua Bai1, Gang Chen2, Yong Xu3, Li Cui1, Xiao-Hui Li1, Xiu-Qi Wang1, Mao-Qiang Wang1, Feng Duan1
1 Department of Interventional Radiology, The First Medical Centre of Chinese PLA General Hospital, Beijing, China
2 Anesthesia and Operation Center, The First Medical Centre of Chinese PLA General Hospital, Beijing, China
3 Second Department of Hepatopancreatobiliary Surgery, The First Medical Centre of Chinese PLA General Hospital, Beijing, China
| Date of Submission | 15-Aug-2020 |
| Date of Decision | 03-Dec-2020 |
| Date of Acceptance | 31-Dec-2020 |
| Date of Web Publication | 9-Feb-2021 |
Correspondence Address:
Feng Duan
28 Fuxing Road, Haidian District, Beijing
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrt.JCRT_1187_20
Aims: The aim of this study is to compare the efficacy and safety of percutaneous radiofrequency ablation (RFA) under general anesthesia or local anesthesia plus intraoperative analgesia in the treatment of hepatocellular carcinoma (HCC) at unusual regions.
Subjects and Methods: From July 2012 to October 2019, 83 consecutive patients with 107 HCC lesions were treated with interventional radiology therapy. The lesions were located at some unusual regions such as diaphragmatic surface, hepatic hilum, hepatic subcapsular region, tissues near inferior vena cava, and tissues near the colon. General anesthesia was applied in 57 cases (general anesthesia group) and local anesthesia plus intraoperative analgesia was used in 26 cases (local anesthesia group). All patients were treated with transcatheter arterial chemoembolization, followed immediately by RFA. The rate of tumor inactivation, time used for placing RF needles to the scheduled sites, pain score, and complications were analyzed.
Statistical Analysis Used: All continuous variables were tested for the normal/nonnormal distribution by Kolmogorov–Smirnov test. The t-test was used to analyze the normal distribution variables; the Mann–Whitney U-test was used to measure nonnormal distribution variables; and the Chi-square test for categorical variables. P < 0.05 was considered statistically significant.
Results: The treatments were successful in all patients, including 51 cases of complete response (CR) and 6 cases of partial response (PR) in the general anesthesia group and 18 cases of CR and 8 cases of PR in the local anesthesia group (P = 0.049). The time used for placing the needles to the scheduled sites was 1–5 min (mean 2 min) in the general anesthesia group and 2–9 min (mean 4 min) in the local analgesia group (P < 0.001). The pain scores ranged from 0 to 2 points (mean 1 point) in the general anesthesia group and 2–9 points (mean 5 points) in the local anesthesia group (P < 0.001). With regard to complications, seven cases had pneumothorax and four cases had slight hepatic subcapsular hemorrhage in the general anesthesia group and four cases of pneumothorax and three cases of slight hepatic subcapsular hemorrhage in the local anesthesia group, and the difference was not statistically significant between the two groups (P = 0.715).
Conclusions: For HCC located at unusual regions, general anesthesia is superior to local anesthesia plus intraoperative analgesia in percutaneous RFA in reducing the difficulty of the procedure and improving the safety of RFA.
Keywords: Anesthesia, hepatocellular carcinoma, interventional radiology, radiofrequency ablation
How to cite this article:
Bai YH, Chen G, Xu Y, Cui L, Li XH, Wang XQ, Wang MQ, Duan F. General versus local anesthesia for percutaneous radiofrequency ablation of hepatocellular carcinoma at unusual regions. J Can Res Ther 2020;16:1686-90 |
How to cite this URL:
Bai YH, Chen G, Xu Y, Cui L, Li XH, Wang XQ, Wang MQ, Duan F. General versus local anesthesia for percutaneous radiofrequency ablation of hepatocellular carcinoma at unusual regions. J Can Res Ther [serial online] 2020 [cited 2021 Mar 8];16:1686-90. Available from: https://www.cancerjournal.net/text.asp?2020/16/7/1686/308756 |
| > Introduction | |  |
Percutaneous ablation is one of the radical treatments for hepatocellular carcinoma (HCC) and has increasingly been applied in the clinical practice.[1],[2] However, for HCC lesions located at some unusual regions such as diaphragmatic surface, hepatic hilum, hepatic subcapsular region, tissues near the inferior vena cava, and tissues near colon, percutaneous radiofrequency ablation (RFA) remains difficult and risky. For these patients, there is still no consensus on which the anesthesia method can reduce difficulty in the procedure and achieve better efficacy and safety.[3] In the present study, we report the clinical data of patients with HCC lesions located at unusual regions and compare the efficacy and safety of percutaneous RFA using two different anesthetic methods (general anesthesia versus local anesthesia plus intraoperative analgesia).
| > Subjects and Methods | | |
Patient data
From July 2012 to October 2019, 83 consecutive patients with 107 HCC lesions were treated with interventional radiology therapy. Informed consent was obtained from all individual participants included in the study. The baseline characteristics of these patients are shown in [Table 1]. This study was approved by the Ethics Committee of the Hospital (protocol number: 20120039). Decision of treatment strategies was jointly made by a multidisciplinary team composed of specialists from the departments of hepatobiliary surgery, medical imaging, interventional therapy, and oncology. | Table 1: Baseline characteristics of patients undergoing percutaneous radiofrequency ablation under general anesthesia or local anesthesia
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Selection of anesthesia methods
Local anesthesia plus intraoperative analgesia was applied in patients who were not feasible for general anesthesia due to a previous history of heart disease or other conditions, as assessed by an anesthesiologist, or if the operating room is not qualified for the general anesthesia and the other patients all underwent general anesthesia.
The procedure of general anesthesia was as follows: Mask oxygen inhalation and intravenous injection of midazolam 0.05 mg/kg, propofol 1–2 mg/kg, sufentanil 0.4 μg/kg, and rocuronium 1 mg/kg were administered. After the eyelash reflex disappeared in 3 min, an endotracheal tube was inserted. Anesthesia was maintained by a combination of oxygen inhalation and intravenous infusion. Inhalation of 1%–2% sevoflurane was given, followed by pump infusion of remifentanil 0.1–0.3 μg/kg/min. During the procedure, rocuronium 0.15 mg/kg was intravenously infused to maintain muscle relaxation, if required. Assisted ventilation was provided with an anesthesia machine with a tidal volume of 3–8 ml/kg and a respiratory rate of 10–12 breaths/min, and the end-tidal carbon dioxide partial pressure was maintained at 35–40 mmHg. The ventilation might be suspended during the procedure for the RF needle positioning if necessary.
Local anesthesia was performed by the local injection of lidocaine solution through puncture; in addition, 5–10 mg of morphine was injected intravenously for analgesia during RFA.
Simultaneous transcatheter arterial chemoembolization and radiofrequency ablation
After the completion of preoperative preparation, simultaneous transcatheter arterial chemoembolization (TACE) plus RFA was performed. The procedure was basically the same as we had described before.[4],[5] TACE was performed first. A 4F hepatic artery catheter (HA; Terumo Corp., Japan) was used for hepatic and superior mesenteric arteriography. After the arteries that directly fed the tumor were identified, maximum catheter selectivity was achieved using a microcatheter (Progreat; Terumo Corp., Japan), an emulsion of mixtures of lipiodol and chemotherapeutic drugs were administrated. Drug dosages per procedure varied, ranging from 5 to 20 mL for lipiodol (Guerbet Corp., France), 30–50 mg of doxorubicin (Pfizer Pharmaceuticals Ltd, USA), 100 mg oxilaplatin (Sanofi Pharmaceuticals Co., Ltd, France), depending on the size of the tumor lesion and laboratory results. Percutaneous RFA was immediately performed following TACE under the guidance of CT or digital subtraction angiography combined with cone-beam computed tomography (CBCT). A single-electrode RF probe (Celon POWER, Olympus, Japan) with a maximum ablation diameter of 3 cm and a cluster electrode RF probe (RITA, AngioDynamics Inc, USA) with a maximum ablation diameter of 5 cm were used during RFA. Guided by 16-slices spiral CT combined with the positioning mesh grids preattached to the corresponding body surface area of the tumor, the puncture site and puncture path were determined. Mechanical ventilation was suspended for patients under general anesthesia and patients under local anesthesia could keep their respiratory phases consistent with the respiratory phases during the CT scanning. The RF probe was introduced according to the prescheduled puncture site and puncture path, and a second CT scan was performed to ensure the position of the probe was accurate. Guided by fluoroscopy, the RF probe was introduced into the lesion by repeating frontal and lateral projection with reference to the positioning of the lipiodol deposited on the lesion. CBCT was then performed to confirm the position of the RF probe [Figure 1] and [Figure 2]. After the positioning was confirmed to be correct, RFA was performed using the corresponding parameters. Puncture tract ablation was carried out to avoid bleeding and tumor seeding. | Figure 1: In a 69-year-male patient, preoperative coronal magnetic resonance imaging showed that hepatocellular carcinoma was located at the diaphragmatic surface, about 4.6 cm in size
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 | Figure 2: (a and b) The radiofrequency ablation probe was punctured to the predetermined position accurately under cone-beam computed tomography guidance
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The patients were followed up with enhanced magnetic resonance imaging (MRI) 1–2 months after the procedure to evaluate the tumor response [Figure 3]. A decision of further treatment or follow-up was made based on the MRI findings. | Figure 3: Coronal magnetic resonance imaging showed complete necrosis of the lesion 6 months after operation
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Statistical analysis
SPSS for Windows, Version 15, 2007 (SPSS Inc., Chicago) was used for analyzing the data.
All continuous variables were tested for normal/nonnormal distribution by the Kolmogorov–Smirnov test. The t-test was used to analyze normal distribution variables; the Mann–Whitney U-test was used to measure nonnormal distribution variables; and the Chi-square test for categorical variables. P < 0.05 was considered statistically significant.
| > Results | | |
The treatment was successful in all patients. Some patients developed fever, fatigue, and transient elevations of aspartate aminotransferase and alanine aminotransferase levels, which were relieved after symptomatic treatments. As shown in [Table 2], the objective response rate was 100% in the whole cohort. Complete response (CR) was achieved in 51 patients and partial response (PR) in 6 in the general anesthesia group and 18 and 8 in the local anesthesia group, respectively (P = 0.049). The proportion of CR was significantly higher in the general anesthesia group than in the local anesthesia group. The RF needle placement time was 1–5 min (mean 2 min) in the general anesthesia group and 2–9 min (mean 4 min) in the local analgesia group (P < 0.001), indicating that the general anesthesia group had significantly higher efficiency of RF needle placement than the local analgesia group. The pain scores were 0-2 points (mean 1 point) in the general anesthesia group and 2–9 points (mean 5 points) in the local anesthesia group (P < 0.001), indicating that the pain was markedly milder in the general anesthesia group than in the local anesthesia group. The main complications included pneumothorax and slight hepatic subcapsular bleeding. There were seven cases of pneumothorax and four cases of slight hepatic subcapsular bleeding in the general anesthesia group and four cases of pneumothorax and three cases of slight hepatic subcapsular bleeding in the local anesthesia group, and the difference was not statistically significant between the two groups (P = 0.715). As no obvious symptoms were observed in these patients, no specific treatment was given. No obvious abnormalities were found during follow-up 1–2 months after the operation.
| > Discussion | | |
RFA for HCC is mostly performed under the guidance of ultrasound. However, HCCs located at some unusual regions may not be clearly visualized on ultrasound due to the interference of air and other factors. Although there were reports on ultrasound-guided HCC RFA assisted by artificial pleural fluid or ascites,[6],[7] ultrasound-guided treatment for lesions near apex of diaphragm or near colon is still challenging. In recent years, it has been suggested that TACE combined with RFA may achieve good outcomes for lesions that are difficult to ablate under the guidance of ultrasound.[8],[9] In the present study, we also performed X-ray-guided TACE followed by immediate RFA.
During the percutaneous puncture and ablation, breathing movement and intraoperative (including puncture and ablation procedures) pain are closely associated with the safety and efficacy of the treatment.[10] In particular, for patients with lesions located in risky regions, breathing movement or involuntary movements due to pain can seriously affect the accuracy of probe placement.[11] General anesthesia is an effective solution to this issue. In the present study, in the general anesthesia group, breathing was suspended through the anesthesia machine during probe placement to ensure that the patient's breathing phases during puncture were consistent with those during CT scanning. The results showed that the general anesthesia group was superior to the local anesthesia group in terms of the accuracy and time duration of RFA probe placement.
However, there are also limitations in the RFA for HCC located at some unusual regions under general anesthesia. (a) Under general anesthesia, it is impossible to see the possible damage caused by RFA to the diaphragm or colon by observing the change in the pain level of the patient.[12] In the present study, we tried to ensure the safety of the treatment by closely monitoring the patient's vital signs and as appropriate, by performing CT to observe the changes of the tumor and its surrounding tissues during ablation.[13],[14] Most RFAs are not performed in an operating room, and nonoperating room anesthesia is not available in all the medical centers. In addition, MORA requires more detailed preoperative assessment of the patients by the anesthetists. Attention should be also paid to the complications associated with general anesthesia itself.[15],[16]
For HCC located at unusual regions, general anesthesia is superior to local anesthesia plus intraoperative analgesia in percutaneous RFA in reducing the difficulty of the procedure and improving the safety of RFA.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgment
This study was supported by the Anesthesia and Operation Center, as well as Second Department of Hepatopancreatobiliary Surgery of Chinese PLA General Hospital. We are thankful to our colleagues, including physicians, nurses, and interns, who took part in the treatments that this study referred to. We have to express our appreciation to the Professor Wang MQ for sharing his pearls of wisdom with us during the course of this research.
Financial support and sponsorship
This study was funded by the first Medical Center, Chinese PLA General Hospital (#2018XXFC-4).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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