top of page

BackTable / VI / Topic / Procedure

Liver Ablation

Liver Ablation Procedure Prep

Learn more on the BackTable VI Podcast

BackTable is a knowledge resource for physicians by physicians. Get practical advice on Liver Ablation and how to build your practice by listening to the BackTable VI Podcast, reading exclusing BackTable Articles, and following the work of our Contributors.

Ep 379 Management of HCC: Focus on Radiation Segmentectomy Part 2 with Dr. Juan Gimenez and Dr. Tyler Sandow
00:00 / 01:04

Stay Up To Date

Follow:

Subscribe:

Sign Up:

Pre-Procedure Prep

Modalities

• Radiofrequency ablation
• Microwave ablation
• Cryoablation - less common for liver
• Irreversible electroporation (IRE): non-thermal ablation

Operator preference
Some prefer microwave because:
• Faster
• Larger ablation volume
• Less susceptible to heat sink
• Multiple probes have synergistic effect
• Microwave ablation travels through all tissues: charred tissue
• Tissue contraction which can work to your advantage

Indications

• HCC - potentially curative for lesions <3 cm. Potential to downstage tumor to fall within Milan criteria
• Unresectable hepatic metastases
• Curative vs. Palliative intent

Ideal patient:
• Size less than 3 cm
• Safe distance from vasculature and vital structures (central bile ducts)
Non-ideal patients:
• Consider other therapy
• Within 2 cm of liver hilum
• Lesions in close proximity to bowel that cannot be effectively hydrodissected

Contraindications

• Life expectancy <6 months
• Child-Pugh class C
• ECOG 3 or 4
• Active infection
• Bile duct or major vessel invasion
• Uncorrectable coagulopathy
• No safe approach

Pre-Operative Evaluation

• H&P
• Labs: coagulation, LFTs
• Prior imaging - CT and/or MRI
Consider involving anesthesia early
• Anesthesia with paralytics can be helpful for breath hold maneuvers

Liver Ablation Podcasts

Listen to leading physicians discuss liver ablation on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #379

VI

In this episode, host Dr. Chris Beck continues the discussion on managing hepatocellular carcinoma (HCC) with Dr. Tyler Sandow and Dr. Juan Gimenez, interventional radiologists at Ochsner Health in New Orleans, Louisiana.

Episode #378

VI

In this episode, Dr. Constantinos (Costi) Sofocleous, Dr. Bruno Odisio, and Dr. William Rilling discuss the history of percutaneous liver tumor ablation, takeaways from past and present clinical studies, and the contemporary role of ablation margin confirmation software for optimizing treatment outcomes.

Episode #377

VI

In this episode, host Dr. Chris Beck interviews Dr. Juan Gimenez and Dr. Tyler Sandow. Juan and Tyler are both interventional radiologists in New Orleans, Louisiana who practice at Ochsner Health System - one of the United States’ leading transplant centers. As a result, both doctors have significant experience in Y-90 radiation segmentectomy and other complex procedures for treatment of hepatocellular carcinoma (HCC).

Episode #257

VI

In this episode, Dr. Chris Beck interviews Interventional Radiologist Dr. Josh Kuban about his liver tumor ablation practice at MD Anderson Cancer Center, including how it's evolved over time with newer technologies. They also discuss patient workup for liver tumors, treatment with microwave ablation, and post-procedure follow up. Dr. Kuban shares why he uses microwave ablation technology, and the advantages of ablation confirmation software for these procedures.

Episode #158

VI

Dr. Christopher Beck talks with Dr. Driss Raissi about his approach to Microwave Ablation of Liver Lesions, including workup, technique, and tips and tricks for a successful ablation treatment.

Procedure Steps

Antibiotic Prophylaxis

• Recommended, especially for high-risk patients (biliary-enteric anastomosis, cirrhosis, diabetes)
• For low risk patients: 1-2 g cefazolin (Ancef) IV
• Multiple regimens for high risk patients: 1.5 g ampicillin/sulbactam (Unasyn) IV is simplest
• Vancomycin or clindamycin for Gram-positive coverage (PCN allergy) and gentamicin for Gram-negative coverage

Margins Are Key

• Circumferential: Example: 2 cm met needs 4 cm ablation zone
• 10 mm for metastatic lesions
• 5 mm for HCC
Can use US, CT, angiography with cone beam CT or combination of modalities

Percutaneous Approach

• Plan ahead to make procedure easier
• Using combination of US and CT often faster than using each modality alone
Mark skin site and prep large area

Insert probes
• Depending on lesion size, strongly consider multiple probes and bracketing tumor
• If one the fence about extra probe, use extra probe
• Try and maintain parallel probe orientation
• Probes cannot be too close or too far apart
• Probes typically need to be within 1-2 cm from each other
• Know equipment and ablation zone which will vary between manufacturer and probes

Protective techniques if needed
• Hydrodissection most common: can use D5W, sterile water, 0.9% normal saline
• Pneumodissection: CO2
• Balloon interposition
• Gallbladder or stomach lavage

Ablate
• Can use intermittent CT scans to check ablation zones
• Can watch live with US if lesion visible and watch ablation zones coalesce
Ablate tract with probe removal

Following ablation, helpful to obtain diagnostic CT (outside of US, contrast enhanced US)
• Evaluate ablation zones
• Evaluate adjacent structures
• Establish new baseline
• Retreat if necessary

• Will depend on tumor location, orientation, vital structures and size
• Largest ablation zone will be along long axis of probe. Can use to operator advantage by orienting probe along long axis of the tumor
• Target temperature: 60° for microwave

• Plan ahead to make procedure easier
• Using combination of US and CT often faster than using each modality alone
• Mark skin site and prep large area

Insert Probes

• Depending on lesion size, strongly consider multiple probes and bracketing tumor
• If one the fence about extra probe, use extra probe
• Try and maintain parallel probe orientation
• Probes cannot be too close or too far apart
• Probes typically need to be within 1-2 cm from each other
• Know equipment and ablation zone which will vary between manufacturer and probes

Protective Techniques if Needed

• Hydrodissection most common: can use D5W, sterile water, 0.9% normal saline
• Pneumodissection: CO2
• Balloon interposition
• Gallbladder or stomach lavage

Ablate

• Can use intermittent CT scans to check ablation zones
• Can watch live with US if lesion visible and watch ablation zones coalesce
Ablate tract with probe removal

Following Ablation

• Helpful to obtain diagnostic CT (outside of US, contrast enhanced US)
• Evaluate ablation zones
• Evaluate adjacent structures
• Establish new baseline
• Retreat if necessary

Liver Ablation Articles

Read our exclusive BackTable VI Articles for quick insights on liver ablation, provided by physicians for physicians.

Hepatocellular Carcinoma in Practice: Optimizing Workflows & Treatment Decisions

Dr. Juan Gimenez and Dr. Tyler Sandow explain how they built their hepatocellular carcinoma practice, the finer points of their patient workflows, and how they make treatment decisions favoring a high volume of Y90 radioembolization.

The NeuWave Microwave Ablation System: A Guide for IRs

Interventional radiologist Dr. Josh Kuban shares his workflow with the NeuWave microwave ablation system & his review of the system interface, the ability to draw customizable margins, & more!

Evolving Practices: Microwave Ablation with Multiple Probes & Ablation Confirmation Software

Along with the speed and efficiency associated with microwave ablation, the introduction of NeuWave’s ablation confirmation software significantly modifies the microwave ablation procedure workflow, allowing the use of multi-probe techniques, and larger ablation zones.

Physician opening microwave liver ablation device to create ablation zones

The standard liver ablation zone for hepatocellular carcinoma is half a centimeter to one centimeter, but where does this standard come from? This article discusses the current liver ablation zone guidelines and explores an alternative approach.

Post-Procedure

Complications

• Hemorrhage
• Vascular complications: portal vein thrombosis, hepatic venous thrombosis, infarct, AV fistula and pseudoaneurysm
• Pain
• Abscess formation/Infection
• Biloma or bile leak
• Post-ablation syndrome - fever, fatigue, nausea, myalgia 7-10 days following procedure. Occurs 30-60% of patients.
• Extrahepatic complications: depends on location. Examples: diaphragm injury, bowel injury

Post-Operative Care

• Many patients can be discharged same day
• Monitor patient for at least 2 hours for development of pain, signs of bleeding, or extrahepatic injury
• Schedule follow up clinic visit and imaging.
• For liver tumor follow up CT or MRI in 1-2 months.
• Helpful to maintain consistency with pre and post imaging. MR often preferred over CT
• Follow tumor markers and LFTs

Liver Ablation Demos

Watch video walkthroughs of liver ablation on the BackTable VI expanded content network.

Liver Ablation Tools

Check out liver ablation apps, calculators, and decision aids to assist you in your day to day practice.

Child-Pugh Score Calculator

Backtable's Child-Pugh score calculator is a comprehensive tool for medical professionals and patients. Assess liver function and determine the severity of liver cirrhosis with ease and accuracy.

MELD Calculator

BackTable's MELD score calculator is a reliable and easy-to-use tool for assessing liver disease severity. Improve diagnostic accuracy today.

References

[1] Glassberg MB, Ghosh S, Clymer JW, Wright GWJ, Ferko N, Amaral JF. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World J Surg Oncol. 2019;17(1):98. Published 2019 Jun 10. doi:10.1186/s12957-019-1632-6
[2] Vogl TJ, Nour-Eldin NA, Hammerstingl RM, Panahi B, Naguib NNN. Microwave Ablation (MWA): Basics, Technique and Results in Primary and Metastatic Liver Neoplasms - Review Article. Mikrowellenablation (MWA): Grundlagen, Technik und Ergebnisse in primären und sekundären Lebertumoren – Übersichtsarbeit. Rofo. 2017;189(11):1055‐1066. doi:10.1055/s-0043-117410
[3] Hinshaw JL, Lubner MG, Ziemlewicz TJ, Lee FT Jr, Brace CL. Percutaneous tumor ablation tools: microwave, radiofrequency, or cryoablation--what should you use and why?. Radiographics. 2014;34(5):1344‐1362. doi:10.1148/rg.345140054
[4] Yu H, Burke CT. Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors. Semin Intervent Radiol. 2014;31(2):129‐137. doi:10.1055/s-0034-1373788
[5] Kim KR, Thomas S. Complications of image-guided thermal ablation of liver and kidney neoplasms. Semin Intervent Radiol. 2014;31(2):138‐148. doi:10.1055/s-0034-1373789
[6] Lubner MG, Brace CL, Ziemlewicz TJ, Hinshaw JL, Lee FT Jr. Microwave ablation of hepatic malignancy. Semin Intervent Radiol. 2013;30(1):56‐66. doi:10.1055/s-0033-1333654
[7] Groeschl RT, Wong RK, Quebbeman EJ, et al. Recurrence after microwave ablation of liver malignancies: a single institution experience. HPB (Oxford). 2013;15(5):365‐371. doi:10.1111/j.1477-2574.2012.00585.x

Disclaimer: The Materials available on https://www.BackTable.com/ are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

backtable-plus-vi-cta.jpg

Podcasts

Management of HCC: Focus on Radiation Segmentectomy Part 2 with Dr. Juan Gimenez and Dr. Tyler Sandow on the BackTable VI Podcast)
Setting the Benchmark: Ablation Confirmation Software for Tumors with Dr. Bruno Odisio, Dr. Constantinos Sofocleous and Dr. William Rilling on the BackTable VI Podcast)
Management of HCC: Focus on Radiation Segmentectomy Part 1 with Dr. Juan Gimenez and Dr. Tyler Sandow on the BackTable VI Podcast)
Microwave Ablation for Liver Lesions with Dr. Josh Kuban on the BackTable VI Podcast)
Microwave Ablation for Liver Lesions with Dr. Driss Raissi on the BackTable VI Podcast)
Iliofemoral Stenting: Decision-Making & Best Practices Explored with Dr. Kush Desai and Dr. Steven Abramowitz on the BackTable VI Podcast)

Articles

Hepatocellular Carcinoma in Practice: Optimizing Workflows & Treatment Decisions

Hepatocellular Carcinoma in Practice: Optimizing Workflows & Treatment Decisions

The NeuWave Microwave Ablation System: A Guide for IRs

The NeuWave Microwave Ablation System: A Guide for IRs

Evolving Practices: Microwave Ablation with Multiple Probes & Ablation Confirmation Software

Evolving Practices: Microwave Ablation with Multiple Probes & Ablation Confirmation Software

Contributors

Dr. Driss Raissi on the BackTable VI Podcast

Dr. Driss Raissi

Related Topics

bottom of page