PATIENTS AND METHODS
This prospective study was conducted in General Surgery department, Benha University and National liver institute ,Menofia University from Sept. 2011 to Oct. 2013 on 60 patients.
Patients were diagnosed to have HCC based on typical radiological features of HCC by two imaging techniques (US and spiral contrast enhanced CT) plus or minus alpha fetoprotein level higher than 400ng/ml.
Inclusion criteria:
• Solitary HCC smaller than 5 cm in diameter.
• No extra-hepatic metastasis.
• No radiological evidence of invasion into the major portal/ hepatic vein branches.
• Good liver function with Child Class A, with no history of encephalopathy, ascites refractory to diuretics, or variceal bleeding.
• Platelet count of >50,000/mm3 and prothrombin activity higher than 60%.
• No previous treatment of HCC.
• Patient generally fit for either surgical resection or local radiofrequency ablation therapy.
Patients were randomized into 2 groups:
• Resection group (n=28 patients ) assigned to undergo hepatic resection .
• Radiofrequency group (n=32patients) assigned to undergo radiofrequency thermal ablation.
Written informed consent was obtained before surgery from all patients after explanation & discussion of the procedure and its possible complications. Patients & Methods 155
All patients were subjected to:
• History taking
• Thorough clinical examination including hepatomegaly,splenomegaly or ascites.
• Laboratory investigations :
Hepatitis viral markers, complete blood count,liver function tests and serum alpha fetoprotein.
• Imaging studies:
- Abdominal ultrasound for assessment of hepatic focal lesion: site, size, number, echopattern, and detection of splenomegaly or ascites.
- Colour-Doppler detection of intralesional arterial signal .
- Spiral contrast-enhanced CT to detect hepatic lesion with contrast uptake in early arterial phase and rapid wash-out in late venous (portal) phase
Resection Group:
During the study period, 28 patients (subdivided into patients with HCC < 3cm and patients with HCC > 3cm - < 5cm ) were submitted to surgical resection of HCC. Resection aiming at a free resection margin of at least 1 cm over the tumour by visual estimation was performed intraoperatively.
All surgical resections had negative resection margins confirmed with histopathology. Surgical specimen examination confirmed the presence of liver cirrhosis in all patients. Nonanatomic resections were performed in 17 cases, in the other 11 cases anatomic resections were performed [four lefts lateral lobectomy (segments2,3); five bisegmentectomies (segments 5,6);and two segmentectomies (segment 5)].
Anatomic resection was defined as resection of the lesion together with the portal vein branch related to the lesion and the corresponding hepatic territory. Nonanatomic resection was defined as resection of a lesion without regard to segmental, sectional, or lobar anatomy . Patients & Methods 156
Surgery was carried out under general anaesthesia using a bilateral subcostal incision. Formal abdominal exploration was done to exclude other intra-abdominal pathology.
After mobilization of the lobe with the lesion, attention was then turned to the porta-hepatis which was dissected, followed by extrahepatic pedicle occlusion of the respective portal and hepatic artery branch in anatomic resections.
In nonanatomic resections hilar dissection was omitted and direct parenchymal transaction along an estimated plane 1 cm over the tumour using scalpel or cutting current diathermy after application of bipolar radiofrequency device (which consists of 2x2 array of needles arranged in a rectangle, introduced perpendicular into the liver along the intended transection line producing coagulative necrosis of liver parenchyma and sealing biliary radicles and blood vessels); or using ultrasonic activated scalpel with application of hemostatic sponge over the raw liver surface to assure haemostasis. Ligation of the Intra-parenchymatous pedicles was routinely done in all cases.. Suction drains were left after hepatic resection, Fig 1-9.
RFA Group:
During the study period, 32 (subdivided into patients with HCC < 3cm and patients with HCC > 3cm - < 5cm ) were submitted to RFA with percutaneous approach under ultrasound guidance in an room setting under conscious sedation .Subcostal approache was used patient was in an anti- Trendelenburg position.
Either 3 or 5cm expandable electrode needles, according to tumour size, with multiple retractable lateral-exit J-hooks on the tip were introduced into the centre of the tumour enabling a substantial and reproducible enlargement of the volume of thermal necrosis produced with single needle insertion and offer the potential of large volume coagulation necrosis. RF thermal ablation was performed with a gradual increase in power until either the power roll off was Patients & Methods 157
achieved or 15 minutes of treatment time had elapsed. Thermal coagulation of the track was performed during needle withdrawal.
Immediately after the procedure, sterile dressings were applied on the site of puncture; the patients were asked to lie down on the site of puncture for at least 2 hours with observation of vital signs every half an hour.
Assessment of patients after treatment and follow up:
HCC treatment was ended when the entire tumour appeared echogenic with ultrasound and disappearance of intralesional arterial Colour-Doppler signals with the next strategy of follow up:
• Abdominal ultrasound to detect the change of echopattern of hepatic focal lesion, one week after treatment, 1 and 3 months later then every 6 months.
• Spiral CT one month after treatment, response was considered complete if there is no contrast enhancement of hepatic lesions in arterial phase and partial if there were areas of enhancement within the original lesion.
• Serum alpha-fetoprotein 3 months later and every 6 months.
The morbidity, hospital stay, overall survival, and disease-free survival for both groups were accounted. Psychological and physical welfare of the patients were assessed on a 4- point (4: normal, 3: partially disturbed, 2: disturbed and 1: distressing) questionnaire of three subscales including: physical wellbeing; relational life and psychological well-being; and total psychological and physical welfare.
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