While surgical resection and chemotherapy have remained mainstays in the treatment of both primary and metastatic liver cancers, various minimally invasive techniques have been developed to treat patients for whom traditional approaches either are not available or have failed. Percutaneous ablation techniques such as radiofrequency, microwave, cryoablation, and irreversible electroporation are considered as potentially curative treatments in patients with hepatocellular carcinoma with early-stage tumors. Transarterial chemoembolization (TACE) and radioembolization with yttrium-90 (Y-90) are palliative treatments that have improved survival in patients with unresectable disease. In this chapter, we discuss these minimally invasive techniques, the criteria for selecting appropriate candidates for treatment, and potential limitations to their use.
Part of the book: Updates in Liver Cancer
Although percutaneous cholecystostomy historically is an alternative to cholecystectomy, it is typically performed as a bridge to gallbladder removal. As a low mortality procedure, it proves itself a valuable tool in morbid patients such as the elderly and the critically ill who present with acute cholecystitis and as an alternate route for biliary access. In high-risk patients, PC can be performed at the patient’s bedside in patients who are too unstable to be transported outside the ICU. PC is performed using ultrasound, CT, or fluoroscopic guidance; however, bedside PC can only be performed using ultrasound. Ultrasound is readily available and portable and allows for real-time imaging. A 2010 study performed by Donkol et al. demonstrated success rates for CT (93%), US (46%), and fluoroscopy (62%). Though US had the lowest success rate, it remains the only option for those critically ill who cannot tolerate transportation or an immediate cholecystectomy. Contraindications of PC include hemorrhage, pericholecystic abscess, gallbladder tumor, etc. Complications include bile leak, hemorrhage, sepsis, bowel perforation, etc. The gallbladder is a small organ with much pathology. Having the knowledge and skill to adequately perform this procedure is essential, especially in patients with septic shock in need of source control.
Part of the book: Bedside Procedures
Minimally invasive treatments for hepatocellular carcinoma (HCC) are a cornerstone in the management of this challenging disease. For many years, percutaneously guided ablative techniques, such as radiofrequency ablation (RFA), cryoablation, and microwave ablation (MWA), have successfully treated many different solid malignancies including HCC. Since the initial implementation of these ablative techniques, there have been many advances in the design, technique, and patient selection as well as investigation into the body’s response to treatment. The mechanisms of thermal-based ablative techniques, advantages and disadvantages of each technique, subsequent immunologic response following ablation, and advances in care that utilize combination therapy to potentiate the immunologic response creating a robust and long-term immunity to HCC are outlined in this chapter.
Part of the book: Hepatocellular Carcinoma