Microwave-assisted liver resection vs. clamp crushing liver resection in cirrhosis patients with hepatocellular carcinoma

Figures & data

Figure 1. Study flow chart.

Figure 2. MW-LR procedure. (A) Parenchymal transection after precoagulation with a microwave probe along the intended line marked 2 cm away from the edge of a tumour on the liver capsule. (B) Dissection and ligation of vessels across the transection plane. (C) The sample and surgical margin after transection.

Table 1. Comparison of the clinicopathological features between the MW-LR and CC-LR groups.

	CC-LR (N = 191)	MW-LR (N = 112)	p
Gender (M/F), n	140/51	82/30	0.905
Age (years)	51.1 ± 14.2	52.4 ± 13.1	0.419
Surgical period			0.060
2005–2010	65	32
2011–2015	126	80
Tumour size, cm	5.7 ± 3.7	5.6 ± 4.2	0.834
Tumour number, n			0.471
Uninodular	131	82
Multinodular	60	29
Etiology, n			0.711
HBV	163	93
HCV	29	19
Albumin (g/L)	38 ± 7.1	39 ± 6.2	0.199
Alpha fetoprotein			0.795
>400 ng/ml	110	62
<400 ng/ml	81	50
Platelet (10^9/L)	165.2 ± 64.3	147.3 ± 54.6	0.249
Edmondson grade, n			0.952
I, II	103	60
III, IV	88	52
Alanine aminotransferase (U/L)	48.2 ± 24.5	47.3 ± 32.3	0.798
Total bilirubin (µmol/L)	17.5 ± 4.9	18.3 ± 6.7	0.270
Prothrombin time, s	13.5 ± 2.1	13.3 ± 2.4	0.463

HBV: hepatitis B virus; HCV: hepatitis C virus.

Values with “±” are written as the mean ± SD.

Table 2. Comparison of operative variables and postoperative outcomes between the MW-LR and CC-LR groups.

	CC-LR (N = 191)	MW-LR (N = 112)	p
Blood loss, ml	752 ± 976.0	253 ± 289.6	<0.001
Blood transfusion, n (%)	129 (67.5)	21 (18.7)	<0.001
Operative time, min	234 ± 76.5	282 ± 87.2	<0.001
Pringle manoeuvre, n (%)	181 (94.7)	33 (29.4)	<0.001
Pringle clamping time, min	45 ± 34.3	7 ± 6.3	<0.001
Type of resection			0.248
Minor resection, n (%)	162 (84.8)	101 (90.1)
Major resection, n (%)	29 (15.2)	17 (9.9)
Resection margin			<0.001
Narrow margin, n (%)	90 (47.1)	89 (79.5)
Wide margin, n (%)	101 (52.9)	23 (20.5)
R1 resection, n (%)	24 (12.5)	6 (5.3)	0.020
Complications^a
Overall morbidity, n (%)	63 (32.9)	28 (25.0)	0.282
Class II, n (%)	21 (10.9)	10 (8.9)	0.706
Class III, n (%)	23 (12.0)	9 (8.0)	0.367
Classes IV–V, n (%)	19 (9.9)	9 (8.0)	0.726
Abdominal abscess, n (%)	6 (3.1)	10 (8.9)	0.029
Bile leakage, n (%)	7 (2.3)	8 (7.1)	0.903
Surgical wound infection, n (%)	15 (7.8)	5 (4.4)	0.364
Pleural effusion, n (%)	20 (10.4)	3 (2.6)	0.024
Uncontrolled ascites, n (%)	10 (5.2)	3 (2.6)	0.443
Postoperative bleeding, n (%)	7 (3.6)	3 (2.6)	0.895
30-Day mortality, n (%)	3 (1.5)	1 (0.8)	0.982

^a Postoperative complications were graded according to the Clavien-Dindo classification, and complications of grade 2 or above were analysed. Values with “±” are written as the mean ± SD.

Figure 3. OS and DFS curves of patients in the MW-LR and CC-LR groups. (A) MW-LR provided a survival benefit over CC-LR at 1, 3 and 5 years (93.5% vs. 87.0%, 77.0% vs. 62.5% and 50.0% vs. 36.5%, respectively; p = 0.003). (B) MW-LR has a similar DFS benefit to that of CC-LR (p = 0.103).

Table 3. Subgroup analyses of the effects of resection margin width on 5-year disease-free survival.

Group	5-Year DFS	p
CC-LR		0.112
Wide margin (n = 101)	33.6%
Narrow margin (n = 90)	28.3%
MW-LR		0.181
Wide margin (n = 23)	34.2%
Narrow margin (n = 89)	36.7%

DFS: disease-free survival.

Figure 4. OS and DFS curves of patients with BCLC-A HCC in the MW-LR and CC-LR groups. (A) MW-LR provided a survival benefit over CC-LR (p = 0.026). (B) MW-LR provided a DFS benefit over CC-LR (p = 0.036).

Figure 5. OS and DFS curves of patients with BCLC-B HCC in the MW-LR and CC-LR groups. (A) MW-LR provided a survival benefit over CC-LR (p = 0.035). (B) MW-LR has a similar DFS to that of CC-LR (p = 0.060).

Table 4. Comparison of recurrence patterns in CC-LR and MW-LR patients who suffered from recurrence.

Variable	CC-LR (n = 134)	MW-LR (n = 63)	p
Site of recurrence			0.472
Intrahepatic only	78 (58.2%)	40 (63.5%)
Intrahepatic + extrahepatic	36 (26.9%)	12 (19.0%)
Extrahepatic only	20 (14.9%)	11 (17.5%)
Intrahepatic recurrence			0.212
Resection plane	26 (22.8%)	6 (11.5%)
Other than resection plane	66 (57.9%)	34 (65.4%)
Advanced recurrence	22 (19.3%)	12 (23.1%)

Advanced recurrence was defined as multiple recurrences with four or more lesions and/or portal vein invasion.

Table 5. Comparison of published outcomes of precoagulated-assisted liver resection for hepatocellular carcinoma patients with underlying cirrhosis.

Device	N	Study period	Cirrhosis (%)	Operative blood loss (ml, mean)	Tumour size (cm, mean)	Bile leakage (%)	Abdominal abscess (%)	5-Year DFS/OS (%)	Author
RFH	55	2001–2007	100	165	<5^a	1.8	9.0	–/–	Curro et al. [19]
MW	1118	1990–2013	59	497	2.2	3.1	4.4	40/78	Sasaki [15]
RFH	100	2010–2013	100	300	>5^a	7.0	3.0	–/–	Zhang et al. [31]
RFTL	61	2004–2007	100	350	4.9	4.9	–	–/–	Xia et al. [17]
RFH	22	2004–2010	100	22	2.7	0	0	–/–	Sandonato et al. [18]
RFH	38	2009–2010	100	365	∼5^a	10.5	2.6	–/–	Li et al. [16]
MW	112	2005–2015	100	310	5.6	7.1	8.9	50/72	This study

RFH: radiofrequency coagulator with a needle or bipolar needle designed by Habib; MW: microwave coagulator; RFTL: TissueLink with radiofrequency energy.

^a Tumour size was estimated by data; DFS: disease-free survival; OS: overall survival.

Curro G, Jiao L, Scisca C, et al. (2008). Radiofrequency-assisted liver resection in cirrhotic patients with hepatocellular carcinoma. J Surg Oncol 98:407–10.

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Sasaki K. (2015). Liver resection for hepatocellular carcinoma using a microwave tissue coagulator: experience of 1118 cases. WJG 21:10400.

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Zhang F, Yan J, Feng XB, et al. (2015). Efficiency and safety of radiofrequency-assisted hepatectomy for hepatocellular carcinoma with cirrhosis: a single-center retrospective cohort study. WJG 21:10159–65.

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Xia F, Wang S, Ma K, et al. (2008). The use of saline-linked radiofrequency dissecting sealer for liver transection in patients with cirrhosis. J Surg Res 149:110–14.

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Sandonato L, Soresi M, Cipolla C, et al. (2011). Minor hepatic resection for hepatocellular carcinoma in cirrhotic patients: Kelly clamp crushing resection versus heat coagulative necrosis with bipolar radiofrequency device. Am Surg 77:1490–5.

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Li M, Zhang W, Li Y, et al. (2013). Radiofrequency-assisted versus clamp-crushing parenchyma transection in cirrhotic patients with hepatocellular carcinoma: a randomized clinical trial. Dig Dis Sci 58:835–40.

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