Non-Thermal Liver Ablation: Existing and New Technology.

Cancer has and continues to be a complex health crisis plaguing millions around the world. Alcohol ablation was one of the initial methods used for the treatment of liver lesions. It was surpassed by thermal ablation which has played a big role in the therapeutic arsenal for primary and metastatic liver tumors. However, thermal ablation has several shortcomings and limitations that prompted the development of alternative technologies including electroporation and histotripsy. Percutaneous alcohol injection in the liver lesion leads to dehydration and coagulative necrosis. This technology is limited to the lesion with relative sparing of the surrounding tissue, making it safe to use adjacent to sensitive structures. Electroporation utilizes short high-voltage pulses to permeabilize the cell membrane and can result in cell death dependent on the threshold reached. It can effectively target the tumor margins and has lower damage rates to surrounding structures due to the short pulse duration. Histotripsy is a novel technology, and although the first human trial was just completed, its results are encouraging, given the sharp demarcation of the targeted tissue, lack of thermal damage, and potential for immunomodulation of the tumor microenvironment. Herein, we discuss these techniques, their uses, and overall clinical benefit.

Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature.

Endoscopic access to the gastric remnant and pancreatobiliary tree is technically difficult after Roux-en-Y gastric bypass even when facilitated by the use of specialized techniques such as balloon enteroscopy and the use of overtubes. Furthermore, such techniques are not universally available at all medical centers. We describe a case series of 13 patients with a history of Roux-en-Y gastric bypass for the treatment of morbid obesity who underwent laparoscopic transgastric endoscopy through the gastric remnant to access the duodenum or biliary tree. Charts of these patients were reviewed for demographics, indications for procedure, length of stay, morbidity, and mortality. Four of the patients had failed prior attempts to access the excluded anatomy through traditional transoral endoscopy. Two patients underwent transgastric endoscopy for evaluation of gastrointestinal bleeding. Of the 11 patients for whom endoscopic retrograde cholangiopancreatography was planned, all underwent successful biliary cannulation and sphincterotomy. There were no conversions to an open procedure or complications during the follow-up period. Laparoscopic transgastric endoscopy is a safe and reliable method to access the excluded stomach and biliary tree in patients with a history of Roux-en-Y gastric bypass.