Safety and efficacy of radiofrequency thermal ablation in advanced liver tumors.

HYPOTHESIS: Radiofrequency thermal ablation (RFA) can be performed safely and effectively to control local disease in patients with advanced, unresectable liver tumors. DESIGN, SETTING, AND PATIENTS: Prospective study of 76 patients with unresectable liver tumors who underwent RFA at a private tertiary referral hospital. INTERVENTIONS: Ninety-nine RFA operations were performed to ablate 328 tumors. MAIN OUTCOME MEASURES: Complications and local recurrence. RESULTS: There was 1 death (1%), major complications occurred in 7 operations (7%), and minor complications occurred in 10 operations (10%). Local recurrence was identified in 30 tumors (9%) at a mean follow-up of 15 months. Size (P<.001), vascular invasion (P<.001), and total volume ablated (P<.001) were associated with recurrence but the number of tumors was not (P =.39). CONCLUSION: Radiofrequency thermal ablation provides local control of advanced liver tumors with low recurrence and acceptable morbidity.

Ultrasound-guided radiofrequency thermal ablation of liver tumors: percutaneous, laparoscopic, and open surgical approaches.

Only 10% to 20% of patients with primary and colorectal metastatic liver tumors are candidates for curative surgical resection. Even after curative treatment, tumors recur commonly in the liver. As a less invasive therapy, radiofrequency thermal ablation (RFA) of primary, metastatic, and recurrent liver tumors was performed under percutaneous, laparoscopic, or open intraoperative ultrasound guidance. The safety and local control efficacy of RFA were investigated. RFA was performed mostly in patients with unresectable hepatomas or metastatic liver tumors. Patients with large tumors, major vessel or bile duct invasion, limited extrahepatic metastases, or liver dysfunction were not excluded. An RFA system with a 15-gauge electrode-cannula with four-pronged retractable needles was used. All patients were followed for more than 8 months to assess morbidity and mortality, and to determine tumor recurrence. Sixty RFA operations were performed in 46 patients: 11 patients underwent repeat RFA once or twice. A total of 204 tumors were treated: 70 hepatomas and 134 metastatic tumors. Tumor size ranged from 5 mm to 180 mm (mean 36 mm). RFA was performed in 29 operations for 81 tumors percutaneously, in seven operations for 14 tumors laparoscopically, and in 24 operations for 109 tumors by open surgery. Combined colorectal resection was carried out in five operations and combined hepatic resection was carried out in three operations. There was one death (1.7%) from liver failure, and there were three major complications (5%): one case of bile leakage and two biliary strictures due to thermal injury. There were no intra-abdominal infectious or bleeding complications. The length of hospital stay ranged from 0 to 2, 1 to 3, and 4 to 7 days for percutaneous, laparoscopic, and open surgical RFA, respectively. During a mean follow-up period of 20.5 months, local tumor recurrence at the RFA site was diagnosed in 18 (8.8%) of 204 tumors. The risk factors for local recurrence included large tumor size and major vessel invasion: recurrence rates for tumors less than 4 cm, 4 to 10 cm, and greater than 10 cm, and for those with vessel invasion were 3.3%, 14.7%, 50%, and 47.8%, respectively. Ten of 18 tumors recurring locally were retreated by RFA, and eight of them showed no further recurrence. Ultrasound-guided RFA is a relatively safe, well-tolerated, and versatile treatment option that offers excellent local control of primary and metastatic liver tumors. The appropriate use of percutaneous, laparoscopic, and open surgical RFA is beneficial in the management of patients with liver tumors in a variety of situations.

The first non-heart-beating organ donor in Hawaii--medical and ethical considerations.

The shortage of organ donors remains a major obstacle in transplantation in Hawaii. Some patients die while waiting for a life-saving organ. Across the nation, "marginal" donors, including non-heart-beating donors are used. The authors describe the first successful non-heart-beating organ donor transplant in Hawaii, and include medical and ethical considerations.

Improved survival with screening for hepatocellular carcinoma.

Hepatocellular cancer (HCC) is a frequent cause of cancer death worldwide. Although successful screening programs exist in Asian countries, the role for screening in the United States is not clear. The purpose of this study is to determine if screening has an effect on survival in a predominantly Asian population in Hawaii. We retrospectively reviewed cases of HCC from 1993 to 1998 for demographic data, risk factors, symptoms, stage, treatment, and survival. Patients were divided into 3 groups according to presentation: symptomatic (S), asymptomatic (A), and asymptomatic but screened for disease (A/Sc). Kaplan-Meier analysis was performed on overall survival by group. Ninety-one patients were referred for HCC. There were 56 patients in group S, 19 patients in group A, and 16 patients in group A/Sc. Patients in group A/Sc survived significantly longer than those in group S (P =.009), with the former group having a median survival of 1,399 versus 234 days for group S. Median survival for group A was 545 days and did not differ significantly from the other groups. Patients who are asymptomatic and screened for HCC have an increased survival compared with those patients who present with symptoms. This may justify the use of a formal screening program for HCC in Hawaii, but we would need to investigate this prospectively.

Attitudes on organ donation among Hawaii physicians.

A survey of physicians attending the recent Hawaii Medical Association meeting was conducted in order to assess physician attitudes on organ donation. Physicians were asked 6 questions and demographics were collected. Results indicate that Hawaii physicians generally support organ donation and are aware of some of the current federal legislation regarding donation.

Hepatic cryosurgery: early experience in Hawaii.

Liver cancer, both primary and metastatic, is often deemed hopeless and patients with advanced disease cannot be offered a treatment that is completely effective. Surgical resection is the treatment of choice, but less than 20% of patients are candidates for this treatment. Hepatic cryosurgery is a relatively new procedure in which the tumor is localized intraoperatively with ultrasound guidance and exposed to liquid nitrogen at -196 degrees C. Nine cases have been performed in Hawaii, and we present the first four cases here. Of these cases, there were no mortalities and only one patient required blood transfusion. All patients currently are alive with up to 11-month follow-up. Long-term studies will be necessary to assess the effectiveness of this modality.

A salvage technique for continuous ambulatory peritoneal dialysis catheters with exit-site infections.

Catheter infection is a major complication of continuous ambulatory peritoneal dialysis (CAPD) therapy for end-stage renal disease. Catheter exist-site infections were treated with a new surgical technique consisting of dissection and removal of the existing catheter in the subcutaneous layer, insertion of a catheter connector and new catheter piece, and creation of a new subcutaneous tunnel. The new surgery can be performed on an outpatient basis and allows for the continuation of CAPD, thereby avoiding the cost associated with inpatient admission and interim hemodialysis.

25 years of kidney transplantation in Hawaii.

The first kidney transplant in Hawaii was performed in August 1969. In the following 25 years, more than 433 kidney transplants were performed. The most common etiology leading to transplantation was chronic glomerulonephritis. Patient and graft survivals after a kidney transplant have progressively improved, particularly after the introduction of cyclosporine in 1984. The overall one-year patient and graft survival rates now are 96% and 85%, respectively; these results exceed the national averages.

Liver transplantation in Hawaii.

The first liver transplant performed in Hawaii was on May 17, 1993 in a patient with end-stage liver disease caused by autoimmune hepatitis. Liver transplantation is a well-accepted treatment for end-stage liver disease with a 1-year patient survival of 80% to 85%. Early recognition of the appropriate candidate by primary care physicians and prompt referral to a liver transplant center are essential for optimal results. The indications, contraindications, organ procurement and allocation, complications, and results of liver transplantation are described. Finally, several controversial areas will be introduced, including liver transplant for alcoholic cirrhosis and hepatitis B, and use of transjugular intrahepatic portosystemic shunts (TIPS).

Pancreas transplantation for diabetic patients in Hawaii.

Diabetes mellitus is a common disease affecting a large population in Hawaii. Over the past 20 years, pancreas transplantation has evolved into a viable therapeutic option for selected patients with diabetes mellitus. This report describes the first combined pancreas-kidney transplant performed in Hawaii on June 28, 1993 on a patient with juvenile-onset diabetes mellitus and diabetic nephropathy. The patient has remained off insulin and off dialysis since the transplant. The history, indications, techniques, and potential complications related to this procedure are discussed.

The need for organ donation in Hawaii.

Donor organ availability is the primary limiting factor in organ transplantation. The number of patients on the national organ waitlist has increased to more than 32,000, while the number of donors has remained fairly constant at approximately 4,500 per year. In Hawaii, there are 98 patients awaiting organ transplants, and for the past 5 years, the average number of donors per year was 15. The criteria for organ donation, brain death, approaches to donation request, and the management of the multiple organ donor are discussed.