Liver Resection for Hepatocellular Carcinoma in Patients with Cirrhosis: Radiofrequency-Assisted versus Cavitron Ultrasonic Surgical Aspirator

Ke-Fei Chen, Han-Teng Yang, Wei-Hong He, Hong-Yu Li, Yong-Gang Wei, Bin Huang, Bo Li

Ke-Fei Chen, Wei-Hong He, Hong-Yu Li, Yong-Gang Wei, Bin Huang, Bo Li, Division of Liver, Department of Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
Han-Teng Yang, Division of Liver, Department of Surgery, Wu Wei Tumor Hospital, Gansu Province, China

Correspondence to: Bo Li, Department of Surgery, Division of Liver Transplantation, West China Hospital, Sichuan University, 37 Guo Xue Rd, Chengdu 610041, Sichuan Province, China.
Telephone: +86-28-85422476
Fax: +86-28-85423724
Received: December 7, 2011
Revised: January 7, 2012
Accepted: January 14, 2012
Published online: April 21, 2012


AIM: To compare the early postoperative results between Radiofrequency (RF)-assisted and Cavitron Ultrasonic Surgical Aspirator (CUSA) liver resection for HCC in patients with cirrhosis.

METHODS: 18 cirrhotic patients who underwent RF-assisted liver resection for HCC were compared with 18 cirrhotic patients who underwent CUSA liver resection. The two groups were well matched for age, gender, tumor size, and severity of cirrhosis. (Child-Pugh A).

RESULTS: The mean Intraoperative blood loss (RF, 58±61 mL; vs CUSA, 197±75 mL; pr, p=0.001) was statistically less for the RF-assisted group, The mean hospital stay is shorter in the RF-assisted group (RF-assisted, 7±2 days; vs CUSA, 10±3 days; pr, p=0.02).

CONCLUSIONS: RF-assisted liver resection for HCC in properly selected cirrhotic group showed less intraoperative blood loss and shorter hospital stay than the CUSA group.

Key words: Radiofrequency; Liver resection; Hepatocellular carcinoma; Liver cirrhosis

© 2012 The Authors. Published by Thomson research Group Ltd.

Chen KF, Yang HT, He WH, Li HY, Wei YG, Huang B, Li B. Liver Resection for Hepatocellular Carcinoma in Patients with Cirrhosis: Radiofrequency-Assisted versus Cavitron Ultrasonic Surgical Aspirator. Journal of Gastroenterology and Hepatology Research 2012; 1(3): 36-39 Available from: URL: http://www.ghrnet.org/index./joghr/


Hepatocellular carcinoma (HCC) is considered the fifth most common and the third most lethal malignant tumor in the world, and the morbidity and mortality rates of HCC are high[1, 2]. Over 80% patients with HCC are complicated with liver cirrhosis or chronic hepatitis due to infection of hepatitis B virus (HBV) or hepatitis C virus (HCV)[2-4]. Surgical liver resection is the primary treatment method for HCC. However, blood loss during surgery poses a major challenge to surgeons as intraoperative bleeding affects prognosis and mortality[5]. Moreover, liver resection for HCC in cirrhotic patients with esophageal varices (EV) may increase the risk of perioperative bleeding and liver failure[6-8]. Therefore, portal hypertension has been considered a contraindication for hepatic resection in cirrhotic patients with HCC by many surgeons.

Radiofrequency ablation (RFA) has been widely used for unresectable HCC and favorable long-term outcomes have been observed in some cases[9]. RF-assisted liver resection was firstly described by Habib’s group who applied a single needle probe to deploy RFA energy before liver resection, and the mean blood loss during the surgery significantly decreased to 30±10 mL in 15 patients[10]. Since then, this technique has been used in different medical centers and good prognosis has been observed[10-16]. However, short-term outcomes after RF-assisted liver resection for HCC in patients with cirrhosis are still unclear.

The aims of this study were using this technique to reduce intraoperative blood loss during liver resection for HCC in cirrhotic patients and investigating the short-term results.


Between May 2010 and August 2010, 36 cirrhotic patients with HCC underwent liver resection. Of these 36 cases, 18 patients underwent RF-assisted liver resection (RF-assisted group) while the other 18 patients underwent liver resection (CUSA group). All these cohorts have tumors less than 5 cm in diameter and lack intrahepatic metastasis as conformed by preoperative ultrasound, spiral computed tomography and intraoperative ultrasound. The diagnosis of HCC and underlying Child A cirrhosis were conformed by histological examination in these patients. Preoperative preparation was the same as the normal liver resection, including serum biochemistry examination, indocyanine green clearance test, spiral computed tomography or magnetic resonance imaging and exclusion of unresectable extrahepatic diseases. Signed-consent forms were obtained according to the Declaration of Helsinki from all subjects that participated in this study. The protocol of this study was approved by the Ethical Committee of the West China Hospital in Sichuan University.


We used the Valleylab Cool-tip™ RF Multiple Switching controller 3 electrodes ablation system (USA, Valleylab, Boulder CO) to deploy pulsed radiofrequency current during operation in the RF-assisted group. The 3 electrodes were arranged in line at 1cm intervals (Figure 1 A and B). Before resection, the electrodes were inserted into the liver with a depth of 2 cm, and then four steps were carried out to apply RF-assisted liver resection. In step 1, intraoperative ultrasound was performed and an inner line was made on liver surface with diathermy to mark the resection margin. In step 2, an outer line was made 1 cm outside the inner line to mark the location where coagulative necrosis would be achieved with RFA electrodes. In step 3, radiofrequent current was deployed along the outer line and coagulative necrosis was obtained. During this procedure, saline was used to cool the electrodes. In step 4, each application of RFA was deployed 3 to 5 min to obtain a necrotic zone. The liver was transected along the necrotic zone with scalpel. In the CUSA group, the patients underwent normal liver resection by using CUSA (US, Valleylab, Boulder CO) to remove the diseased sections. In our experiments, portal vein obstruction was not performed. The volume of resected liver, the operative time and the intraoperative blood loss were recorded.


Baseline characteristics of the study participants were listed in Table 1. The mean age of the patients was 57 years (range 42 to 73 years) and the patients were comprised of 30 men and 6 women. Diagnosis of all the patients was conformed by histological examination. In the RFA group, anterior right lobes (n=10), posterior right lobes(n=3), left hemiliver(n=1), left lateral lobe(n=4), were performed (Figure1 C,D,EandF), as compared with anterior right lobes(n=8), posterior right lobes(n=4), lef themiliver(n=2), left lateral lobe(n=4) in the CUSA group. The resected volumes of the RF-assisted group and the CUSA group were 103±37 cm3 and 118±36 cm3, respectively, and no than that in the CUSA group (42±10 min vs 76±50 min p=0.04). The intraoperative blood loss significantly differ between the RF-assisted statistically significant difference was found between the two groups. The operative time was significantly shorter in the RF-assisted group group and the CUSA group (58±61 mL and 197±75 mL p=0.001). None of the patients in the RF-assisted group required intraoperative blood transfusion whereas 4 patients in CUSA group did require intraoperative blood transfusion (RF-assisted, 0%; vs CUSA, 22.2%; p=0.05). Serum AST levels were significantly higher in the RF- assisted roup than those in the CUSA group on the 3d postoperation (RF-assisted, 223±91U/L; vs CUSA, 123±55 U/L; p=0.001), but they decreased to normal level in one week. No difference were observed in Postoperative TB and ALB levels between the two groups. Postoperative bile leakage occurred in 1 patient in the RF-assisted group and healed spontaneously 10d postoperation. The mean length of hospital stay of the RF- assisted group was shorter than the that of the CUSA group (RF-assisted, 7±2 days; vs CUSA, 10±3 days; p =0.02). The 1-year overall survival rates for the RF-assisted group and the CUSA group after hepatic resection were 83.3% and 88.9%, respectively, and the difference was not statistically significant (P=0.35, Table1).


In clinical management of HCC and surgical liver resection, the factors including tumor and cirrhosis should be both evaluated since about 80% HCC cases are accompanied by cirrhosis in China, and overall survival rate and recurrence rate should be primarily considered as censor because any treatment would be meaningless if it reduced the survival rate[17]. Cirrhosis and EV may increase intraoperative blood loss in liver resection for HCC. Although portal vein obstruction can reduce bleeding during surgery, it may cause liver ischemia which would lresult in postoperative liver failure. By using CUSA, liver resection can be performed without occluding portal vein. However, cirrhosis may increase liver stiffness, which would increase liver resection time and blood loss duirng CUSA. In our study, applying RF-assisted liver resection significantly reduced blood loss, avoided portal vein occlusion and prevented ischemia-reperfusion damage to residual liver. Therefore, RF-assisted liver resection has a promising future in liver resection for HCC patients with cirrhosis and EV.

In this study, all the tumors were smaller than 5 cm in diameter and the resected liver volumes were similar between groups. Postoperative complications such as bile leakage, hemorrhage, and wound inflammation were rare. Although serum AST levels in the RF-assisted liver resection group were significantly higher than those in the CUSA group on the 3rd postoperation, they decreased to normal level rapidly in one week. Heat injury around the necrotic region caused by RF may be the reason of temporary increase of serum AST levels, and the amount of heat produced by RF determined the damage levels. The larger the tumor was, the more RF energy deployed and the more residual liver damage occurred. Therefore, the severity of cirrhosis and the volume of residual liver should be carefully evaluated[18]. If excess liver was resected in the surgery, the risk of postoperative liver failure would be increased due to weak regenerative capability of cirrhotic liver. We strongly recommend that cirrhotic level of tumor should be ascertained strictly before operation and the periphery of tumor should be marked precisely before resection by using intraoperative ultrasound. Moreover, achieving a 1 cm width necrotic zone surrounding the tumor can reduce the unnecessary loss of residual liver without increasing the risk of residual tumor presence.

Recently, attention has been increasingly given to the intraoperative blood loss and perioperitive blood transfusion which have been considered to be closely associated with HCC recurrence[19, 20]. In this study, no significant differences were observed in the 1-year overall survival rates between the RF-assisted liver resection group and the CUSA group. The cancer cells in the paratumor liver tissues may be killed by the heat produced by the RF, which may result in the similar short-time survival rates between the two groups. However, the long-time outcomes are still unclear and further investigation is needed.

In conclusion, HCC, which smaller than 5 cm in diameter, can be resected by using RF-assisted liver resection with shorter operative time, less blood loss and shorter hospital stay. Although RF-assisted liver resection therapy temporarily increased serum AST levels, it did not affect the recovery of the patients, and the early postoperative complications and the 1-year overall survival rate were the same for RF-assisted liver resection and the CUSA groups.


We thank Dr. Lu-Nan Yan (Department of Surgery, West China Hospital, Sichuan University) for the assistance of data collection and Ding Yuan for data analysis.


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Peer reviewer: Prof. Luis Rodrigo, Department of Gastroenterology University Hospital Central of Asturias, c/ Celestino Villamil s. nº, 33.006, Oviedo, Spain.


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