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Percutaneous radio-frequency liver tumor ablation: what are the risks?
2564
World Literature Review
tients with strictures that were radiographically malignant were invariably found to have malignant tumors in the esophagus; therefore, endoscopy and biopsy are mandatory for definitive diagnoses in these patients. However, most benign strictures in this series were peptic in nature, resulting from scarring from reflux esophagitis. These peptic strictures may be associated with Barrett’s esophagus, a known premalignant condition (8); thus, patients with peptic stricture often undergo endoscopy and biopsy to confirm the presence of Barrett’s esophagus and to help determine whether these individuals are candidates for endoscopic surveillance. Also, even in the absence of tumor, symptomatic patients with esophageal strictures may require endoscopic dilation procedures to relieve their dysphagia. Consequently, endoscopic evaluation of esophageal strictures that are radiologically benign is often needed for reasons other than suspicion of malignancy. Several important limitations of this investigation warrant discussion. The study was retrospective, with unavoidable selection bias, because of the need for patients to have had both endoscopic and radiological examinations. This limitation likely accounted for more strictures that were equivocal and malignant as assessed radiographically going on to endoscopic and pathological evaluation. In nearly all patients biphasic radiological studies of the esophagus were performed, a method that optimizes detection of lower esophageal narrowings (2, 3, 7, 8); whether this radiological approach reflects that used in the general radiology community is unlikely, and would contribute to less effective detection of esophageal narrowings by using less optimal barium studies. Finally, 27 (36%) of the 75 strictures that were benign on radiological examination were not confirmed at endoscopy and remained unexplained; possibilities would include timing of the two examinations, false positive radiological diagnoses, or endoscopic errors in which more minor strictures were not detected. David J. Ott, M.D., F.A.C.G. Department of Radiology Wake Forest University School of Medicine Winston-Salem, North Carolina
REFERENCES 1. Ott DJ, Gelfand DW, Lane TG, Wu WC. Radiologic detection and spectrum of appearances of peptic esophageal strictures. J Clin Gastroenterol 1982;4:11–5. 2. Creteur V, Thoeni RF, Federle MP, et al. The role of single and double-contrast radiography in the diagnosis of reflux esophagitis. Radiology 1983;147:71–5. 3. Ott DJ, Chen YM, Wu WC, Gelfand DW. Endoscopic sensitivity in the detection of esophageal strictures. J Clin Gastroenterol 1985;7:121–5. 4. DiPalma JA, Prechter GC, Brady CE. X-ray-negative dysphagia: Is endoscopy necessary? J Clin Gastroenterol 1984;6:409 – 11. 5. Hapert RD, Feczko PJ, Spickler EM, Ackerman LV. Radiologic assessment of dysphagia with endoscopy. Radiology 1985;157: 599 –602.
AJG – Vol. 98, No. 11, 2003
6. Levine MS, Chu P, Furth EE, et al. Carcinoma of the esophagus and esophagogastric junction: Sensitivity of radiographic diagnosis. Am J Roentgenol 1997;168:1423–6. 7. Ott DJ, Chen YM, Wu WC, et al. Radiographic and endoscopic sensitivity in detecting lower esophageal mucosal ring. Am J Roentgenol 1986;147:261–5. 8. Luedtke P, Levine MS, Rubesin SE, et al. Radiologic diagnosis of benign esophageal strictures: A pattern approach. RadioGraphics 2003;23:897–909.
Percutaneous Radio-Frequency Liver Tumor Ablation: What Are the Risks? Livraghi T, Solbiati L, Meloni MF, et al. Treatment of Focal Liver Tumors With Percutaneous Radiofrequency Ablation: Complications Encountered in a Multicenter Study. Radiology 2003;226:441–51.
ABSTRACT The purpose of this investigation is to report complications encountered by members of a large collaborative group who performed radio-frequency (RF) ablation in patients with focal liver cancer. Members of 41 Italian centers used a percutaneous, internally cooled RF ablation technique and a standardized protocol for follow-up of treated patients. A questionnaire was used to determine complications and mortality, and their relationship to the RF procedure. Enrollment included 2320 patients with 3554 liver lesions (mean size, 3.1 cm); of these patients 1610 had hepatocellular carcinoma, 693 had metastases, and 17 had cholangiocarcinoma. All 3554 hepatic tumors were treated. Six deaths (0.3%) were noted. These included two deaths caused by multiorgan failure after intestinal perforation; one case each of septic shock after peritonitis caused by Staphylococcus aureus, massive hemorrhage after tumor rupture, liver failure after stenosis of the right bile duct; and one case of sudden death of unknown cause 3 days after the procedure. A total of 50 patients (2.2%) had additional major complications; the most frequent of these were peritoneal hemorrhage, neoplastic seeding, intrahepatic abscesses, and intestinal perforation. An increased number of RF sessions were related to a higher rate of major complications (p ⬍ 0.01), whereas the number of complications was not significantly different when tumor size or electrode type were compared. Minor complications were observed in ⬍5% of patients. The authors conclude that RF ablation is a relatively low risk procedure for the treatment of focal liver tumors. (Am J Gastroenterol 2003;98:2564 –2565. © 2003 by Am. Coll. of Gastroenterology)
COMMENT Percutaneous RF ablation for the treatment of focal liver tumors is a relatively new image-guided procedure that is rapidly gaining acceptance in the radiological and surgical communities, particularly for treating patients with inoper-
AJG – November, 2003
able tumors (1, 2). This procedure is now being favored over other minimally invasive therapies such as percutaneous ethanol injection (3, 4), and it is being chosen over surgery in some patients because of comparative potential benefits such as reduced morbidity and mortality, or in those patients who may not be candidates for surgery. Preliminary reports suggest that RF ablation of the liver is both safe and effective, but only a limited number of studies have been published (3– 6). Many of these published investigations are also limited by the small numbers of patients treated and do not allow a clear assessment of complications and mortality in this procedure. Also, the complication rate of RF ablation must be compared with the 15–30% morbidity and the approximately 5% mortality of surgery (7, 8). Thus, the purpose of this current study is to report the complications encountered by a large collaborative group whose members have performed RF ablation in a large number of patients with focal liver cancer. Four different complications from RF ablation were reported in this study: thermal damage from heating; and mechanical, septic, and other unexplained causes. The latter three types of complications cannot be attributed directly to RF thermal ablation alone but are likely related to performance of any image-guided needle procedure. Thermal damage included cases of GI perforation, biliary stenosis, and grounding pad burns. The most important major complication resulting from thermal damage was perforation of the GI wall, which occurred in 0.7% of patients. Overall, major complications in this series were small (2.2%) and mortality was extremely low (0.3%). The complications and mortality relating to RF ablation were much lower than those reported for surgery and were equivalent to that for single-shot ethanol injection. Additional experiences in the use of this technique will likely lead to further improvement in outcomes and to reduction in complications and deaths. David J. Ott, M.D., F.A.C.G. Department of Radiology Wake Forest University School of Medicine Winston-Salem, North Carolina
REFERENCES 1. Gazelle GS, Goldberg SN, Solbiati L, Livraghi T. Tumor ablation with radio-frequency energy. Radiology 2000;217:633– 46. 2. McGahan PJ, Dodd DB, III. Radio-frequency ablation of the liver: Current status. Am J Roentgenol 2001;176:3–16. 3. Lencioni R, Goletti O, Armillotta N, et al. Radio-frequency thermal ablation of liver metastases with a cooled-tip electrode needle: Results of a pilot clinical trial. Eur J Radiol 1998;8: 1205–11. 4. Livraghi T, Goldberg SN, Lazzaroni S, et al. Small hepatocellular carcinoma: Treatment with radiofrequency ablation versus ethanol injection. Radiology 1999;210:661–5. 5. Wood TF, Rose DM, Chung M, et al. Radiofrequency ablation of 231 unresectable hepatic tumors: Indications, limitations, and complications. Ann Surg Oncol 2000;7:593–600. 6. Buscarini L, Buscarini E, Di Stasi M, et al. Percutaneous
World Literature Review
2565
radiofrequency ablation of small hepatocellular carcinoma: Long-term results. Eur J Radiol 2001;11:914 –21. 7. Fong Y, Blumgart LH, Cohen AM. Surgical treatment of colorectal metastases to the liver. CA Cancer J Clin 1995;45:50 –62. 8. Molmenti EP, Marsh JW, Dvorchik I, et al. Hepatobiliary malignancies: Primary hepatic malignant neoplasms. Surg Clin North Am 1999;79:43–57.
Should Enteral Feeding Be the Standard of Care for Acute Pancreatitis? Abou-Assi S, Craig K, O’Keefe SJD Hypocaloric Jejunal Feeding Is Better Than Total Parenteral Nutrition in Acute Pancreatitis: Results of a Randomized Comparative Study. Am J Gastroenterol 2002;97:2255– 62.
ABSTRACT This study was performed prospectively to define outcomes including length of hospital stay, duration of feeding, complications, hospital costs, and indications for nutritional support in patients admitted with acute pancreatitis (AP). Patients who failed to improve after 48 h of conservative treatment or who could not tolerate an oral diet were randomized to receive either nasojejunal (NJ) or total parenteral (TPN) feeding. The majority of cases were related to alcohol consumption or gallstones. The goal feeding rates were intended to provide 1.5 g protein/kg/day and 25–30 Kcal/kg/day. The two nutritionally supported groups were compared on an intention to treat basis. In all, 75% of patients admitted for AP improved after conventional therapy within 48 h and did not require nutritional support. Of the patients, 27 patients were randomized to TPN and 26 to NJ feeding. Three patients in the NJ group were switched to TPN (two needed surgery and one could not tolerate the NJ feeds), and two in the TPN group were converted to NJ feeding because of sepsis. The average length of hospital stay was shorter in the NJ group versus the TPN group (14 vs 18 days) but the difference was not significant. The introduction of oral feeding was tolerated better in the NJ group, with 80% advancing to an oral diet without difficulty in comparison to 63% in the TPN group. The average length of nutritional support was significantly shorter in the enteral nutrition (EN) patients who were fed by NJ tube than in patients on TPN (6.7 vs 10.8 days, p ⬍ 0.001). However, the EN group received fewer calories (49% vs 85%) and protein (42% vs 85%) in comparison to the TPN group (p ⬍ 0.005). The disease severity as well as the serum pancreatic enzyme levels on admission and thereafter were comparable between the groups. Nutrition associated complications were significantly more common in the TPN group. These included hyperglycemia, septic complications, and catheterrelated infections requiring prolonged therapy. The incidence of severe complication and death was similar in the two groups. A post hoc analysis of patients with severe
World Literature Review
tients with strictures that were radiographically malignant were invariably found to have malignant tumors in the esophagus; therefore, endoscopy and biopsy are mandatory for definitive diagnoses in these patients. However, most benign strictures in this series were peptic in nature, resulting from scarring from reflux esophagitis. These peptic strictures may be associated with Barrett’s esophagus, a known premalignant condition (8); thus, patients with peptic stricture often undergo endoscopy and biopsy to confirm the presence of Barrett’s esophagus and to help determine whether these individuals are candidates for endoscopic surveillance. Also, even in the absence of tumor, symptomatic patients with esophageal strictures may require endoscopic dilation procedures to relieve their dysphagia. Consequently, endoscopic evaluation of esophageal strictures that are radiologically benign is often needed for reasons other than suspicion of malignancy. Several important limitations of this investigation warrant discussion. The study was retrospective, with unavoidable selection bias, because of the need for patients to have had both endoscopic and radiological examinations. This limitation likely accounted for more strictures that were equivocal and malignant as assessed radiographically going on to endoscopic and pathological evaluation. In nearly all patients biphasic radiological studies of the esophagus were performed, a method that optimizes detection of lower esophageal narrowings (2, 3, 7, 8); whether this radiological approach reflects that used in the general radiology community is unlikely, and would contribute to less effective detection of esophageal narrowings by using less optimal barium studies. Finally, 27 (36%) of the 75 strictures that were benign on radiological examination were not confirmed at endoscopy and remained unexplained; possibilities would include timing of the two examinations, false positive radiological diagnoses, or endoscopic errors in which more minor strictures were not detected. David J. Ott, M.D., F.A.C.G. Department of Radiology Wake Forest University School of Medicine Winston-Salem, North Carolina
REFERENCES 1. Ott DJ, Gelfand DW, Lane TG, Wu WC. Radiologic detection and spectrum of appearances of peptic esophageal strictures. J Clin Gastroenterol 1982;4:11–5. 2. Creteur V, Thoeni RF, Federle MP, et al. The role of single and double-contrast radiography in the diagnosis of reflux esophagitis. Radiology 1983;147:71–5. 3. Ott DJ, Chen YM, Wu WC, Gelfand DW. Endoscopic sensitivity in the detection of esophageal strictures. J Clin Gastroenterol 1985;7:121–5. 4. DiPalma JA, Prechter GC, Brady CE. X-ray-negative dysphagia: Is endoscopy necessary? J Clin Gastroenterol 1984;6:409 – 11. 5. Hapert RD, Feczko PJ, Spickler EM, Ackerman LV. Radiologic assessment of dysphagia with endoscopy. Radiology 1985;157: 599 –602.
AJG – Vol. 98, No. 11, 2003
6. Levine MS, Chu P, Furth EE, et al. Carcinoma of the esophagus and esophagogastric junction: Sensitivity of radiographic diagnosis. Am J Roentgenol 1997;168:1423–6. 7. Ott DJ, Chen YM, Wu WC, et al. Radiographic and endoscopic sensitivity in detecting lower esophageal mucosal ring. Am J Roentgenol 1986;147:261–5. 8. Luedtke P, Levine MS, Rubesin SE, et al. Radiologic diagnosis of benign esophageal strictures: A pattern approach. RadioGraphics 2003;23:897–909.
Percutaneous Radio-Frequency Liver Tumor Ablation: What Are the Risks? Livraghi T, Solbiati L, Meloni MF, et al. Treatment of Focal Liver Tumors With Percutaneous Radiofrequency Ablation: Complications Encountered in a Multicenter Study. Radiology 2003;226:441–51.
ABSTRACT The purpose of this investigation is to report complications encountered by members of a large collaborative group who performed radio-frequency (RF) ablation in patients with focal liver cancer. Members of 41 Italian centers used a percutaneous, internally cooled RF ablation technique and a standardized protocol for follow-up of treated patients. A questionnaire was used to determine complications and mortality, and their relationship to the RF procedure. Enrollment included 2320 patients with 3554 liver lesions (mean size, 3.1 cm); of these patients 1610 had hepatocellular carcinoma, 693 had metastases, and 17 had cholangiocarcinoma. All 3554 hepatic tumors were treated. Six deaths (0.3%) were noted. These included two deaths caused by multiorgan failure after intestinal perforation; one case each of septic shock after peritonitis caused by Staphylococcus aureus, massive hemorrhage after tumor rupture, liver failure after stenosis of the right bile duct; and one case of sudden death of unknown cause 3 days after the procedure. A total of 50 patients (2.2%) had additional major complications; the most frequent of these were peritoneal hemorrhage, neoplastic seeding, intrahepatic abscesses, and intestinal perforation. An increased number of RF sessions were related to a higher rate of major complications (p ⬍ 0.01), whereas the number of complications was not significantly different when tumor size or electrode type were compared. Minor complications were observed in ⬍5% of patients. The authors conclude that RF ablation is a relatively low risk procedure for the treatment of focal liver tumors. (Am J Gastroenterol 2003;98:2564 –2565. © 2003 by Am. Coll. of Gastroenterology)
COMMENT Percutaneous RF ablation for the treatment of focal liver tumors is a relatively new image-guided procedure that is rapidly gaining acceptance in the radiological and surgical communities, particularly for treating patients with inoper-
AJG – November, 2003
able tumors (1, 2). This procedure is now being favored over other minimally invasive therapies such as percutaneous ethanol injection (3, 4), and it is being chosen over surgery in some patients because of comparative potential benefits such as reduced morbidity and mortality, or in those patients who may not be candidates for surgery. Preliminary reports suggest that RF ablation of the liver is both safe and effective, but only a limited number of studies have been published (3– 6). Many of these published investigations are also limited by the small numbers of patients treated and do not allow a clear assessment of complications and mortality in this procedure. Also, the complication rate of RF ablation must be compared with the 15–30% morbidity and the approximately 5% mortality of surgery (7, 8). Thus, the purpose of this current study is to report the complications encountered by a large collaborative group whose members have performed RF ablation in a large number of patients with focal liver cancer. Four different complications from RF ablation were reported in this study: thermal damage from heating; and mechanical, septic, and other unexplained causes. The latter three types of complications cannot be attributed directly to RF thermal ablation alone but are likely related to performance of any image-guided needle procedure. Thermal damage included cases of GI perforation, biliary stenosis, and grounding pad burns. The most important major complication resulting from thermal damage was perforation of the GI wall, which occurred in 0.7% of patients. Overall, major complications in this series were small (2.2%) and mortality was extremely low (0.3%). The complications and mortality relating to RF ablation were much lower than those reported for surgery and were equivalent to that for single-shot ethanol injection. Additional experiences in the use of this technique will likely lead to further improvement in outcomes and to reduction in complications and deaths. David J. Ott, M.D., F.A.C.G. Department of Radiology Wake Forest University School of Medicine Winston-Salem, North Carolina
REFERENCES 1. Gazelle GS, Goldberg SN, Solbiati L, Livraghi T. Tumor ablation with radio-frequency energy. Radiology 2000;217:633– 46. 2. McGahan PJ, Dodd DB, III. Radio-frequency ablation of the liver: Current status. Am J Roentgenol 2001;176:3–16. 3. Lencioni R, Goletti O, Armillotta N, et al. Radio-frequency thermal ablation of liver metastases with a cooled-tip electrode needle: Results of a pilot clinical trial. Eur J Radiol 1998;8: 1205–11. 4. Livraghi T, Goldberg SN, Lazzaroni S, et al. Small hepatocellular carcinoma: Treatment with radiofrequency ablation versus ethanol injection. Radiology 1999;210:661–5. 5. Wood TF, Rose DM, Chung M, et al. Radiofrequency ablation of 231 unresectable hepatic tumors: Indications, limitations, and complications. Ann Surg Oncol 2000;7:593–600. 6. Buscarini L, Buscarini E, Di Stasi M, et al. Percutaneous
World Literature Review
2565
radiofrequency ablation of small hepatocellular carcinoma: Long-term results. Eur J Radiol 2001;11:914 –21. 7. Fong Y, Blumgart LH, Cohen AM. Surgical treatment of colorectal metastases to the liver. CA Cancer J Clin 1995;45:50 –62. 8. Molmenti EP, Marsh JW, Dvorchik I, et al. Hepatobiliary malignancies: Primary hepatic malignant neoplasms. Surg Clin North Am 1999;79:43–57.
Should Enteral Feeding Be the Standard of Care for Acute Pancreatitis? Abou-Assi S, Craig K, O’Keefe SJD Hypocaloric Jejunal Feeding Is Better Than Total Parenteral Nutrition in Acute Pancreatitis: Results of a Randomized Comparative Study. Am J Gastroenterol 2002;97:2255– 62.
ABSTRACT This study was performed prospectively to define outcomes including length of hospital stay, duration of feeding, complications, hospital costs, and indications for nutritional support in patients admitted with acute pancreatitis (AP). Patients who failed to improve after 48 h of conservative treatment or who could not tolerate an oral diet were randomized to receive either nasojejunal (NJ) or total parenteral (TPN) feeding. The majority of cases were related to alcohol consumption or gallstones. The goal feeding rates were intended to provide 1.5 g protein/kg/day and 25–30 Kcal/kg/day. The two nutritionally supported groups were compared on an intention to treat basis. In all, 75% of patients admitted for AP improved after conventional therapy within 48 h and did not require nutritional support. Of the patients, 27 patients were randomized to TPN and 26 to NJ feeding. Three patients in the NJ group were switched to TPN (two needed surgery and one could not tolerate the NJ feeds), and two in the TPN group were converted to NJ feeding because of sepsis. The average length of hospital stay was shorter in the NJ group versus the TPN group (14 vs 18 days) but the difference was not significant. The introduction of oral feeding was tolerated better in the NJ group, with 80% advancing to an oral diet without difficulty in comparison to 63% in the TPN group. The average length of nutritional support was significantly shorter in the enteral nutrition (EN) patients who were fed by NJ tube than in patients on TPN (6.7 vs 10.8 days, p ⬍ 0.001). However, the EN group received fewer calories (49% vs 85%) and protein (42% vs 85%) in comparison to the TPN group (p ⬍ 0.005). The disease severity as well as the serum pancreatic enzyme levels on admission and thereafter were comparable between the groups. Nutrition associated complications were significantly more common in the TPN group. These included hyperglycemia, septic complications, and catheterrelated infections requiring prolonged therapy. The incidence of severe complication and death was similar in the two groups. A post hoc analysis of patients with severe