Imaging findings of liver resection using a bipolar radiofrequency electrosurgical device—Initial observations

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Imaging findings of liver resection using a bipolar radiofrequency electrosurgical device—Initial observations

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  EuropeanJournalofRadiology 81 (2012) 663–670 ContentslistsavailableatScienceDirect European    Journal   of    Radiology  journalhomepage:www.elsevier.com/locate/ejrad Imaging   findings   of    liver   resection   using   a   bipolar   radiofrequency   electrosurgicaldevice—Initial   observations Adele   Taibbi a , ∗ ,   Alessandro   Furlan b ,   Luigi   Sandonato c ,   Valentina   Bova a ,Massimo   Galia a ,Daniele   Marin d ,   Giuseppe   Cabibbo e ,   Maurizio   Soresi f  ,   Tommaso   Vincenzo   Bartolotta a ,Massimo   Midiri a ,   Roberto   Lagalla a ,   Giuseppe   Brancatelli a , b , g a DepartmentofRadiology,UniversityofPalermo,Palermo,90127,Italy b DepartmentofRadiology,UniversityofPittsburghMedicalCenter,200LothropStreet,Pittsburgh,PA15213,USA c DepartmentofOncology,DivisionofGeneralandOncologicalSurgery,UniversityofPalermo,Palermo,90127,Italy d DepartmentofRadiology,DukeUniversityMedicalCenter,Box3808,Durham,NC27710,USA e DivisionofGastroenterologyandHepatology,BiomedicalDepartmentofInternalandSpecialisedMedicineandDepartmentofPathobiologyandBiomedicalMethodologies,UniversityofPalermo,Palermo,90127,Italy f  DepartmentofClinicalMedicineandEmergingPathologies,UniversityofPalermo,Palermo,90127,Italy g RadiologyUnit,LaMaddalenaHospital,Palermo,90146,Italy a   r   t   i   c   l   e   i   n   f   o  Articlehistory: Received29December2010Accepted5January2011 Keywords: HepatocellularcarcinomaLiver,metastasesLiver,resectionRadiofrequencyablationCoagulativenecrosis a   b   s   t   r   a   c   t Objective:   Toassess   contrast-enhanced   US   (CEUS),   computed   tomography   (CT)   and   magnetic   resonance(MR)   imaging   findings   and   serial   changes   of    the   treated   area   at   follow-up   in   patients   who   underwentliver   resection   using   a   bipolar   radiofrequency   electrosurgical   device. Methods:   Imaging   findings   of    27patients   with   resected   hepatocellular   carcinomas   (HCCs)   ( n   =   24)   andmetastases   ( n   =3)   (mean   size:   2.6   cm),   were   retrospectively   evaluated.   Two   readers   assessed:   the   (a)   pres-ence,(b)   thickness,   (c)   shape   and   (d)   echogenicity   (CEUS)/attenuation   (CT)/signal   intensity   (MR    imaging)atcoagulated   site   and   the   (e)   presence   of    residual   tumor   of    the   bipolar   radiofrequency   electrosurgicaldevice   resection   margin. Results:   Follow-up   was   performed   with   either   CT   ( n   =20)   or   MR    imaging   ( n   =7)   and   repeated   in   16   patientswith   CT   ( n   =   7),   MR    imaging   ( n   =   4),   or   both   techniques   ( n   =   5).   Four   patients   also   had   a   single   CEUS   exami-nation.   Atfirst   imaging   follow-up   a   peripheral   halo   was   depicted   at   resection   site   (100%).   A   fluid   collectionwithin   the   surgical   area   was   found   in   67%   of    patients.   During   the   following   imaging   examinations   apro-gressive   involution   of    both   findings   was   observed,   respectively,   in   81%   and   62%   of    patients.   Viable   tissuewas   detected   in   three   patients   (11%). Conclusions:   After   liver   resection   with   bipolar   radiofrequency   electrosurgical   device   successfully   ablatedtumor   is   demonstrated   at   imaging   byan   unenhancing   partial   linear   peripheral   halo,   in   most   cases,surrounding   afluid   collection   reducing   in   size   during   follow-up. © 2011 Elsevier Ireland Ltd. All rights reserved. 1.Introduction Ablativetechniqueshaveemergedoverthepastdecadeasavalidalternativetoliverresectioninpatientswithhepatictumors[1].Inthelate1990s,abipolarradiofrequencyelectrosurgicaldevicethatcombinesthebenefitsofsurgeryandablativetech-niqueshasbeendevelopedandimplementedinthisclinicalsetting[2–8].Usingthistechnique,surgeonsachieveaplaneofcoagulativenecrosisalongapredeterminedlineofliverparenchymaltransec- ∗ Correspondingauthorat:UniversityHospital,DepartmentofRadiology,ViaMontiIblei43–90144Palermo,Italy.Tel.:+39916552385;fax:+39916552337. E-mailaddress: taibbiadele@hotmail.com(A.Taibbi). tionwithonlynegligiblebloodlossandnoneedforhepaticpedicleclampingortotalvascularexclusion[6,7].Duetoitsadvantages, thistechniqueisbeingincreasinglyusedasasafealternativetotheestablishedresectionprocedures[9].Acorrectassessmentoftherapeuticresponseatimagingiscritical,becausecompletetumorresectionsignificantlyincreasespatientsurvival,whereasthepersistenceofviabletissuerequiresadditionaltreatment[10].Contrast-enhancedcomputedtomogra- phy(CT)andmagneticresonance(MR)imagingplayapivotalroleinthistask.Althoughradiologistsarefamiliarwiththeimagingappearanceoflivertumorstreatedwithradiofrequencyablation[11],toourknowledgethereareonlylimiteddataontheimagingfindingsandthenaturalhistoryoftreatedareasafterhepaticresec-tionperformedbymeansofbipolarradiofrequencyelectrosurgicaldevice[12,13]. 0720-048X/$–seefrontmatter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2011.01.015  664  A.Taibbietal./EuropeanJournalofRadiology 81 (2012) 663–670 Therefore,thepurposesofthisstudyweretoinvestigate(1)post-treatmentcontrast-enhancedUS(CEUS),CTandMRimagingfindings,and(2)theserialchangesofthetreatedareaatfollow-upimagingstudiesinpatientswhounderwentliverresectionusingabipolarradiofrequencyelectrosurgicaldevice. 2.Materialsandmethods Institutionalreviewboardpermissionwasobtainedforthisretrospectivestudy.Patientinformedconsentwaswaived.Thestudywasconductedinasingleuniversityhospitalreferralforhepatobiliary-diseases.  2.1.Patients Thestudycoordinatorsearchedtheinstitution’ssurgicalandradiologicaldatabasestoidentifypatientswhounderwentsurgicalresectionofhepaticmasseswithabipolarradiofrequencyelec-trosurgicaldevicebetweenMay   2007andJanuary2009,andhadatleastonecross-sectionalcontrast-enhancedimagingstudy(i.e.,CEUS,CT,orMR    imaging)availableaftertreatment.Foreachpatientincludedinthefinalpopulation,thestudycoordinatorreviewedsurgeryandpathologynotesinordertoobtaindemographicdata,typeofhepaticresectionperformed(wedgeresectionorsegmen-tectomy),diagnosisatsurgicalpathology,andsurgicalcomplica-tions.Throughtherevisionofthesurgical,pathologyandradiologyreports,thestudycoordinatorrecordedlocationandsizeofeachlesion.Allcontrast-enhancedliverimagingstudiesperformedaftersurgery,includingCEUS,CT,andMR    imaging,wereretrievedforimaginganalysis.Thetime-intervalbetweensurgeryandimagingfollow-upandthetotallengthoffollow-upwererecorded.  2.2.Liverresectionwithbipolarradiofrequencyelectrosurgicaldevicetechnique Patientswereconsideredcandidatesforliverresectionwithbipolarradiofrequencyelectrosurgicaldeviceiftheyhadasinglelesion ≤ 5cmindiameterornomorethanthreelesions ≤ 3cmforHCCandasufficientfutureremnantlivervolume(>20%ofthewholeestimatedlivervolume)formetastases[14–16].   Exclusioncriteriaconsistedofthefollowing:(a)extrahepaticmetastases;(b)portalveinthrombosis;(c)theneedtoperformamajorliverresectionincirrhoticpatientswithhepatocellularcarcinoma(duetotheriskofliverfailure);(d)proximityofthelesiontohepaticvessels(i.e.,inferiorvenacava,mainbranchesoftheportalorhep-aticveins),gallbladderorhepatichilum;(e)plateletcountoflessthan50,000/  L;and(f)internationalnormalizedratio>1.5.Liversurgerywasperformedusingabipolardevice(Habib4XAngiody-namics,NY,USA)connectedtoaspecialradiofrequencygenerator(Model1500XRITAMedicalSystem,MountainView,CA).Undergeneralanaesthesia,throughprogressiveandsequentialapplica-tionofthedevicealongapredeterminedlineatintraoperativeUS,a1cmthickcoagulativenecrosiswasobtained.Accordingtothesectionlineandtotheparenchymalthicknesstobecoagulated,thesurgeonpre-coagulatedbyintroducingthedevicefromonesidetotheotherorproceededgradually.Inthelattercase,aftercoagulatingandsectioningtheparenchymafor2–4cm,   theoper-atorcontinuedwiththecoagulationalongthepredeterminedlineandcompletedthesectionassuringthattheneedle’stipsdidnotstickoutfromtheliverparenchyma,thereforedamagingthesur-roundingstructures.Incaseofexophyticorsubcapsularlesionsthesurgeonperformedacircumferentialresection.Theresectionwasmadealongtheexternaledgeofthepre-coagulatedareaandmostofthecoagulatedtissuewasleftinthehepaticareabyusingascalpel(Fig.1).Metalclipswereusedinpatientswithpersistent bloodloss[17]. Fig.1. 53-year-oldman   undergoingresectionofsubcapsularhepatocellularcarci-nomawithbipolarradiofrequencyelectrosurgicaldevice.Theradiofrequencydeviceis   insertedintotheparenchymaalonglandmarksdrawnontheliversurface(a).Viewof    theoperativefieldattheendofresection(b).  2.3.Imagingtechnique 2.3.1.CT  AllCTstudieswereperformedona64-sectionscanner(Bril-liance64;PhilipsMedicalSystems,Eindhoven,theNetherlands),withtheimagingparametersdetailedinTable1.Allpatients received1.5mL/kgtotalbodyweightof400mgI/mLnon-ioniccon-trastagent(Iomeron400;BraccoImaging,Milan,Italy)infusedbyusinganautomatedinjector(Medrad,Indianola,Pa)atarateof 4mL/sthroughanintravenousantecubital18–20gaugecatheterinsertedintoanarmvein.CTwas   performedimmediatelybeforecontrastmediumadministrationandduringhepaticarterial,hep-aticvenous,anddelayedphases.Todeterminethescanningdelayforthehepaticarterialphase,thetime-to-peakaorticenhance-mentwas   assessedbyusinganautomaticbolus-trackingtechnique  Table1 Multidetector64-rowCTscanningparameters.Detectorconfiguration64 × 0.625Peak   kilovoltage(kVp)120Tubecurrent–timeproduct(mAs)250–300Gantryrevolutiontime(s)0.33–1Beampitch1.0–1.1ScanningdirectionCraniocaudalScantime(s)4Reconstructedsectionthickness(mm) 3.0Sectionoverlap(mm)   –Reconstructionkernel Softtissue(B)   A.Taibbietal./EuropeanJournalofRadiology 81 (2012) 663–670 665  Table2 MR    Imagingsequencesandparameters.MRsequenceTR/TE(ms)Flipangle( ◦ )Sectionthickness(mm)MatrixsizeFieldof view(cm)IntravenouscontrastmaterialprotocolT2-weighted2DFSE4000/761506224 × 32030–50PrecontrastimagesDual-echoT1-weighted 150/4.2-2.1804256 × 19230–50PrecontrastimagesT1-weighted2DGRE150/2.2-4.4805256 × 25630–50PrecontrastimagesT1-weighted3DGRE(LAVA)4.2/2.0123196 × 32030–50Pre-andpostcontrastimages withautomatedscan-triggeringsoftware(BolusProUltra,PhilipsMedicalSystems).Hepaticarterialphasescanningwasstartedautomatically18safterthetriggerthreshold(150HU)wasreachedatthelevelofthesuprarenalabdominalaorta.Thehepaticvenousanddelayedphaseswereacquired,respectively,40safterthebeginningofarterialphase,and180safterinjectionofcontrast.  2.3.2.MR   imaging  MR    imagingwasperformedwith1.5-Tscanner(Signa;Gen-eralElectricsHealthcare,Milwaukee,WI,   USA)withtheimagingparametersdetailedinTable2.T1-weighted3DGREimageswere obtainedimmediatelybeforeandaftertheintravenousadmin-istrationofabolusof0.2mL/kgofgadobenatedimeglumine(MultiHance ® ,Bracco,Milan,Italy)injectedintothearmataflowrateof2mL/sthrougha20gaugeintravenouscatheterbymeansof apowerinjector(MR    Spectris;Medrad,Pittsburgh,PA),followedby20mL    ofsterilesalinesolution,atthesameinjectionrate.Imageswereacquiredusingautomatedbolusdetectiontechnique(Smart-preptechnique,GEHealthcare)duringthearterial(11safterbolusdetection),hepaticvenousanddelayedphase(60sand180safterbolusinjection,respectively).  2.3.3.CEUS  USandCEUSstudywereperformedusingascanner(iU-22,PhilipsUltrasound,Bothell,Wash,USA)equippedwithaC5-2con-vexarrayprobeandPulseInversionimagingsoftware.Abaselineexamination,includingacolor/powerandpulsedDoppleranalysis,wasperformed.TheUSscanparameters–suchasfocalzoneandtimegaincompensation– werenotchangedthroughoutthestudy.TheUScontrastagentusedinthepresentstudywasSonoVue ® (Bracco,MilanItaly),whichwas   injectedintravenouslyasa2.4mL    bolus(equivalenttoa0.003mL/kgfor70kgbodyweight)followedby5mL    ofnormalsalineflushbyusinga20-or22-gaugeperipheralintravenouscannula.Alowframe-rate(5Hz)andaverylowmechanicalindex(MI),rangingfrom0.05to0.08,wereusedforrealtimeimaging.Digitalcine-loopswerereg-isteredbothduringbaselineandpost-contrastUSscanningduringthehepaticarterial(i.e.,10–40sfrombeginningofcontrastagentbolusinjection),hepaticvenous(i.e.,55–90sfrombeginningof injection),anddelayed(i.e.,180–240sfrombeginningofinjection)phases.  2.4.Imageanalysis Tworadiologists(M.G.andA.T.,with8yearsand7yearsof experienceinabdominalimaging,respectively)retrospectivelyand jointlyreviewedCT,MR    andCEUSimages.Thereadoutsessionswereconductedindependentlythroughtheevaluationofaxialimagesonapicturearchivingandcommunicationsystem(IMPAX,Agfa,RidgefieldPark,NJ)overapproximately2weeksandinfourdifferentsessions.Disagreementsbetweenthetwoobserverswereresolvedbyconsensus.Readersevaluatedoneachavailableimagingstudy,thepresence,thickness,shapeandechogenicity(CEUS)/attenuation(CT)/signalintensity(MR    imaging)ofthebipolarradiofrequencyelectrosurgicaldeviceresectionmargin.Theshapeoftheresectionmarginswasevaluatedqualitatively.Themarginsweredefinedascircumferentialwhentheboundariesoftheresectionmarginsformedacompletecircle(360 ◦ ),andaspartialwhenthecirclewasincomplete.Basedonthepresenceofnodularity,resectionmarginsweredefinedaslinear,nodular,ormixed.Furthermore,readersqualitativelyassessedthepresenceofanyremainingtumorviabletissue.Forthediagnosisofviabletissuethereaderslookedforanappearancethatwassimilartopre-treatmentfindings,directlyarisingfromoradjacenttotheresectionplane.Specifically,viabletissueforhepatocellularcarcinomawas   definedasanareaofhypervascularityinthearterialphasewithrespecttotheadjacentparenchyma,followedbywash-outinthedelayedphase.Viabletissuefornon-hepatocellularcarcinomalesionswasdefinedasahypoechoic/hypoattenuating/hypointenseareainthehepaticvenousanddelayedphasewithrespecttotheadjacentparenchyma,butwithhigherechogenicity/attenuation/intensitythanthetreatedarea.Treatmentresponsewas   consideredcom-pleteaccordingtothefollowingcriteria:(i)aclearlydemarcatednonenhancingareaoflowechogenicity/attenuation/intensityvisu-alizedatmultiphasicimagingafterintravenouscontrastinjection;(ii)anarealargerthanthelesionbeforetreatment.ReadersalsocomparedthefindingsfromretrospectivereviewofCEUS,CTandMRimageswiththediagnosisrenderedatthetimeoftheoriginalimageinterpretation.Moreover,readersreportedanyprocedure-relatedcomplica-tions,suchaspresenceoffluid(lowdensityunenhancingareaatCTandmarkedlyhyperintenseT2-weightedandhypointenseT1-weightedunenhancingareaatMR    imaging);aircollections( − 1000HUvaluesatCT),andhemorrhage(moderatelyandunen-hancinghyperattenuatingareaatCTanddifferentappearanceatMRimagingdependingondifferentstagesofbloodbreakdownproducts)[18]. 3.Results  3.1.Patients Thirty-fivepatientsunderwentliverresectionwithbipolarradiofrequencyelectrosurgicaldeviceduringthestudyperiod.Amongthem,27patients(16men,11women;age-range:42–75years,mean:66.1years)hadatleastoneimagingstudyperformedatourinstitutionaftertreatmentandwerethereforeincludedinourfinalstudypopulation.Demographicandsurgicaldataofthese27patientsandthetimetofollowuparelistedinTable3.The resectedlesionswerehepatocellularcarcinomain24patientsandmetastasesfromcolo-rectalcancerinthreepatients.Lesionsizerangedfrom0.8cmto5cm(meansize:2.6cm,   SD:1cm).Therewasnoperioperativemortalityormorbidityexceptforonecaseinwhichinfectiveevolutionwithabscessdevelopmentwas   observedbutresolvedafterantibiotictherapy.Metalclipswereusedinsixof27patients(22%)duetopersistentbloodlossafterliverresection.Imagingfollow-upaftersurgerywasperformedwitheitherCT( n =20patients)orMR    imaging( n =7)afterameanof223days(range:30–870days;SD:254days),andrepeatedin16patientswithCT( n =7),MR    imaging( n =4),orbothtechniques( n =5),aftera  666  A.Taibbietal./EuropeanJournalofRadiology 81 (2012) 663–670  Table3 Demographicsandsurgicaldataof27patientstreatedwithbipolarradiofrequencyelectrosurgicaldevice.PatientAgeSexLiversegmentLesionsize(cm)Surgicalmodality a Lesiontype b Firstfollow-up:typeofexam/timetoexamsaftersurgeryFurtherfollow-up:typeofexams/timetoexamsaftersurgery1 67FIV2.1WR    HCCCT/26monthsMR/38months2   75MVI4.1WR    HCCMR/29monthsNone3   73MVI5WR    MTS   CT/23monthsNone4   67MII–IV2.5S(segment3)HCCCT/15monthsCT/28monthsCT-CEUS/31months5 66 F VI–VII   3.1WR HCC MR/26monthsNone6 64 F VI–VII1.9WR    HCCMR/11monthsCT/14monthsMR/20months7 63   MV1.5WR    HCCCT/9monthsMR/24months8   69MIII3.1WR    HCCCT/6monthsCT/18monthsCT/25monthsCT/31months9   58FVI–VII2.1WR    HCCCT/3monthsCT/6months10   64MVIII3.1WR    MTS   CT/1monthCT/1011   75MVIII1.8WR    HCCCT/1monthCT/7monthsMR/10months12   60MV–VIII3.5WR    HCCMR/10monthsMR/15monthsMR/18monthsMR/20months13 74   MII–III4.1S(segment3)HCCCT/3monthsNone14   67FVI2.5WR    HCCCT/3monthsMR/7monthsCT-CEUS/17months15 60 F VI–VII–VIII 1.2WR    MTS   CT/1monthNone16   69MVI0.8WR    HCCCT/2monthsCT/8months17 69MIII4.5WR    HCCCT/2monthsMR/2months18   75FII2.5WR    HCCMR/6monthsNone19   66MVI1.4WR    HCCCT/1monthMR/5monthsCT/9monthsMR/12months20   42FIII1.5WR    HCCMR/2monthsCT/10monthsMR/12months21   67FII1.4WR    HCCCT/1monthMR/5monthsCT-CEUS/10months22 53 M III 2.5WR    HCCMR-CEUS/4monthsNone23   68MII3.2WR    HCCCT/2monthsCT/5months24 68FIII2.7WR    HCCCT/5monthsNone25   70MVI–VII2.6WR    HCCCT/1monthNone26   62MIII2WR    HCCCT/3monthsNone27 74 F III–IV1.8WR    HCCCT/5monthsNone a WR:   wedgeresection;S:segmentectomy. b HCC:hepatocellularcarcinoma;MTS:metastasis. meanof470days.FourpatientsalsohadasingleCEUSexaminationafterameanof465days(range:120–930days;SD:302days).  3.2.Imagingfindings We   detectedaperipheralhalointheresectionmargininallpatients.We   interpretedtheperipheralhaloasaperipheraldemar-cationlineatthecoagulatedsite.Thethicknessofperipheralhalorangedfrom0.1to3.2cm(mean:1.4cm;   SD:0.7cm).Peripheralhalowaspartialin16/27cases(59%)[linear( n =14),nodular( n =1)andmixed( n =1)]andcircumferentialin11/27cases(41%)[linear( n =7),nodular( n =1)andmixed( n =3)].Atfirstpost-treatmentCTscan( n =20),peripheralhalowas   hypoattenuatingwithrespecttothesurroundingnormalliverparenchyma( n =20,100%)(Fig.2).At firstpost-treatmentMR    imaging( n =7),peripheralhaloappearedhyperintense( n =5),isointense( n =1)andhypointense( n =1)onT1-weightedimagesandhypointense( n =6)orisointense( n =1)onT2-weightedimages(Fig.3). Fig.2. Hepatocellularcarcinomatreatedwithbipolarradiofrequencyelectrosurgicaldeviceina75-year-oldman   on7months-CTfollow-up.UnenhancedCTscan(a)revealsa   hypoattenuatingcircumferentialperipheralhalo(arrow)surroundingafluidcollection(asterisk)atcoagulatedsiteinthesubcapsularregion.Atcontrast-enhancedCTscanacquiredinthearterialphase(b)nohypervascularfocusisevident.   A.Taibbietal./EuropeanJournalofRadiology 81 (2012) 663–670 667 Fig.3. Hepatocellularcarcinomatreatedwithbipolarradiofrequencyelectrosurgicaldeviceina53-year-oldman   on4months-MRfollow-up(samepatientof Fig.1).T2- weightedimage(a)revealsmoderatelyhypointenseresectionmargins(arrow)surroundingafluidcollection(arrowhead).OnaxialunenhancedvolumetricT1-weightedimage   (b)resectionmarginappearsslightlyhyperintense(arrow).Nohypervascularfocusisevidentinthearterialphase(c). Atrepeatedimagingfollow-upperipheralhalodecreasedinthicknessin13of16patients(81%,rangeofsizedecrease:0.2–1.9cm,   mean:0.6cm,   SD:0.4cm)   whereasitremainedunchangedintheremainingthreecases(19%)(Fig.4).Viabletis- suewasdetectedattheperipheryofthetreatedareainthreepatients(11%)whounderwentresectionforhepatocellularcar-cinomaatimagingperformed10months,17monthsand28months(mean,18.3months)respectivelyafterablationwithbipo-larradiofrequencyelectrosurgicaldevice(Fig.5).CEUSfollow-up wasperformedinfouroutof27cases.Inoneofthesefourpatientsaperipheral,hypoechoicnodulewasfoundadjacenttotheperipheralhalo.Thisnodulewasisoechoictothesurround-ingliverparenchymainthearterialphase,withwash-outinthehepaticvenousanddelayedphases.Thesefindingswereconsid-eredastumorrecurrence,andthisdiagnosiswas   confirmedbyCT(Fig.6).Inthethreeremainingcasesnofindingsofrecurrencewere depictedbyCEUS,butMR    showedviabletissueinoneofthesethreecases.Acompleteresponsetobipolarradiofrequencyelec-trosurgicaldevicewasobtainedinallmetastases.Therewerenodifferencesbetweenprospectiveandretrospectiveinterpretationwithregardtothenumberofcompleteresponsetotreatmentandthedetectionofviabletissue.Afluidcollectionwithinthesurgi-calareawas   foundin18/27(67%)patients.Duringthefollowingimagingexaminationsaprogressiveinvolutionwas   observedin10/16(62%)patients(partial: n =7;complete: n =3)withmorethanonefollow-upimagingexamination.Smallairbubbleswithinthefluidcollectionwereobservedinonepatientat1month-CTfollow-up. 4.Discussion Surgicalresectionoftenrepresentsthetreatmentofchoiceforeitherprimaryorsecondarylivercancer.Nevertheless,themainpitfallremainsthebloodlossassociatedwithotherlikelypost-procedurecomplicationsasbiliaryleakorliverfunctiondamage[3,4].Forthisreasonnewliverresectiontechniques,employingradiofrequencyenergy,havebeendevelopedimprovingthesafetyoftheprocedureandreducingmorbidityandmortality[5]. Fig.4. Progressiveshrinkageoftheresectionmarginsareaina67-year-oldwomanwithhepatocellularcarcinomatreatedwithbipolarradiofrequencyelectrosurgicaldeviceat   imagingfollow-up.Contrast-enhancedCT(a)andcontrast-enhancedMR(b)ataninterval-timeof5monthsdemonstrateareductioninthicknessoftheperipheralhalo(arrows)locatedinthesecondsegment.
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