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The Clinical Application of Cryocare Surgery System in the Treatment for Rear Peritoneum Leiomyoma's Recurrence After Operation

Wu Qing, Wu Xueyong , Feng Jianping
Department of Oncology , Jing'an Elder People Hospital , Shanghai

(Abstract) objects: to eveluate the clinical application of cryocare surgery system (Argon - Helium Scalpel) in the treatment for rearperitoneum leiomyoma's recurrence after operation, observe its effectiveness as well as its influences on the prognosis. Methods: Using local anesthesia,under B-ultrasonography or computer tomography monitoring,6 patients were treated by targeted Ar-He cryoablation. Results: The operation is simple and safe, no mortality. All of the six cases are appeasement refrigeration. After the following-up of more than six months, the range of the refrigeration is over 75%. The effectiveness is significant, the clinical symptom has been improved and the quality of the patients' life has been elevated. Conclusion: if the resecting is not need again, Targeted Cryoablation is a feasible and effective method for treating rear peritoneum leiomyoma's recurrence after operation.

(Key Words) rear peritoneum leiomyoma, Cryocare surgery system, Targeted Cryoablation

Concerning rear peritoneum leiomyom, operation is still the main treatment method on clinical oncology; however, the recurrence rate is high after operation, the ratio of resecting again cases is very small as well as the effectiveness of radiation or chemical treatment is very poor. The authors applied the Cryocare surgery system, ultra low temperature refrigeration (namely Ya-He Targeted Cryoablation) during the period between March and August of 2000 to treat six cases, which have no need to resect the cancer again, and have made preliminary effectiveness. The details are presented as following:

1 Clinical Data
⑴General Information:Four male cases, two female cases with the age between 60 and 75 years old (the aeverage age is 68 years old). Among which, four cases are right-middle-up abdomen ones and two are left-middle abdomen ones. The six cases are all the recurrence cases after operation among which two cases are the second time recurrence after twice operations, one case can not accept the second resecting, because the gut and the cancer are conglutinated together and the vessels on the cancer's surface are congested, two cases' cancer has influenced the veins of below cavity, as well as one case's cancer has penetrated into cavity main artery, spleen artery and pancreas with pressing the duodenum, which causes the incomplete ileus. The shortest recurrence time is three months and the longest is 8 months. Six cases have been proved as Peritoneum Leiomyoma by operation and all have the symptoms of stomachache, weight losing etc. According to the CT examination, the size of the smallest cancer is 8×7×5cm3, and the largest is 14.7×14×10.5cm3. All six cases are not suitable for accepting the resecting operations once more.

⑵ The Anaesthesia Method: De to relatively older ages of the cases, the consistent anaesthesia outside the scirrhus is adopted.

⑶The preparation and the simulated orientation: CT examination identifies the size and the surroundings of the cancer. If the cancer has penetrated into the organs, the range of refrigeration should be controlled strictly. The CT simulated orientation is adopted before the operation. According to the cancer's shape and the surroundings detected by CT as well as the specifications of the targeted cryoablation, the multiple-scalpel operation plan should be designed, as the reference for the authentic operation, to specify the number of the cryoprob, directions, angles, depth, distances, ranges etc to avoid hurting other organs , to provide reference for the ultra B short wave inducing during the operation as well as to avoid the serious syndrome. Diagram 1 indicates the CT simulated orientation refrigeration designing blueprint before the operation. Because the cancer has penetrated into the intestine and can not be separated, the refrigeration is conducted from the center of the cancer to the peripheral to ensure that the surface of intestine will not be frozen dead. Altogether, four cryoprob are used including three 3mm ones and one 2mm. The operation spot is marked on the skin as the reference of the operation. Since one week before the operation, the TPN supporting shall be given to the patient to rectify the negative nitrogen balance and the electrolyte balance as well as to supply vitmin K1 in order that the patient can elevate his endurance of the operation.

⑷ The Method of the Operation(1-2): Cutting from the abdomen, separating abundantly and exposing the cancer. During the operation, using the ultra B short wave to detect the size of the cancer as well as the surroundings of the cancer together with pre-operation CT orientation's result. Under the ultra B short wave's inducing, the puncture is conducted with a thin cannulation. After arriving the aimed spot, dilate with a steel wire and insert the cryoprobs to fix temporarily. After re-examination, cryocare surgery system should be started off. The cycles of "refrigeration-calefaction- refrigeration-calefaction" should be finished then. Each time, the refrigeration duration is about 15 minutes. The first calefaction temperature is 0-5℃,as well as the second calefaction temperature is about 15℃左右。As soon as the frozen cancer becomes flexible, the scalpel can be withdrawn. The lowest frozen temperature is approximate‐150℃. If the cancer is very huge, the second time refrigeration can be conducted after withdrawing the cryoprob 3-3.5 cm till the cancer thoroughly becomes a huge ice-ball. The ultra B short wave indicates the boundary of the ice-ball clearly and this can be used to judge the effective refrigeration range primarily. After withdrawing the scalpel, the specialized hemostatic gauze should be used to jam the wound to avoid the bleeding. After the hemostasia, drainage should be conducted and no clean out needed. After the operation, measures should be conducted to diminish inflammation Also, some immunity treatments are needed like thymus peptide and bcg vaccine. If necessary, the chemical treatment and artery intervention treatment could be adopted.

2 The Results
In all the 6 cases, no mortality appears during the operation or due to the syndrome. One case had incomplete ileus due to the cancer's oppression. After the operation, large abscess occurred and the hemostasia was not successful. The patient refused a second time operation and died of exhaustion four months later. Other five cases, after more than six months' following-up, their stomachache has got lysis significantly ,the quality of their lives has been improved and their weights have increased 1-3 Kg. According to the re-examination, the caner neither grows nor transfers. All the cases have got fever after the operation with a temperature between 38-39℃, which lasts approximate one week. One case, with huge cancer, had been getting fever for two weeks. The fever is often related to the refrigeration range and the necrotic tissues. The refrigeration ranges of all the six cases have not reached 100% with a maximum of 90% and a minimum of 60%. Diagram indicates the cancer dies after refrigeration and forms a low-density area in CT picture, whose CT numerical value has decreased from 72Hu to 1~ 10Hu.

3 Discussion
The size of the effective refrigeration range is closely related to the results. Theoretically, all the cancer should be frozen and the range of the refrigeration should be 1~1.5cm surpassing the brim of the cancer to ensure the zero rudimental cancer. However, in the actual practice, due to the limitation of connections between the cancer and other important organs, doctors have to consider more about the security and the ideal refrigeration range can not be attained. Especially in cases of recrudescent cancers, the refrigeration operation has more difficulties. Therefore what refrigeration range is really effective is an issue requires research(3-5). According to our preliminary observation, if the range is more than 85%, the effectiveness is significant and if the range is less than 60%, the effectiveness is insignificant. Hence, the rudimental rate should be as low as possible with the security as the premise. Research result indicates that no rudimental cancer cleaning out can stimulate the immunity response and is helpful for shrinking the cancer as well as controlling the transferring.(1)One case with huge cancer 14.7×14×10.5cm3,as indicated by diagram 1 and 2, adopts "four croprobs combination" and "two withdrawing", totally 6 refrigeration circles. Therefore, a huge ice column forms in the celio-cavity; however, the no ice-crystal forms on the surface of the cancer. And the intestine is not hurt by refrigeration. After the operation, the recovery goes smoothly. According to the CT's reexamination, it indicates that the refrigeration range has reached approximate 75%. After the operation, absolute alcohol, HCPT and DDP are injected into the cancer and the left kidney artery intervention chemical treatments are conducted twice. Based on the seven months' following up, tumidness has been significant released, the healthy condition has been improved as well as the weight has increased 2Kg. Presently, we are still continuing to follow up this case. Concerning the refrigeration of the main vessels, the author holds the cautious attitude. The animal experiments indicate that if the diameter of the vessel is beyond 4mm, due to the fast speed of the blood stream, the temperature transmission is fairly quick, namely the "warm pool" effect, and after refrigeration the embolism and blood stream block may not happen.(2)Also, experiments indicate that the fiber content of main artery is more than that of the vein, therefore the artery's endurance ability of refrigeration is better than the vein. Though the author has conducted the refrigeration on important vessels and no negative effects occurred after the operation; however, the author still does not advocate the refrigeration on main vessels, such as the abdomen main artery and the below cavity vein. Currently, no systematical parameter is available. At the same time, it may cause angioma, which will threaten the patient's life. For the Rear Peritoneum Leiomyoma's Recurrence cases, which can not be cut, there is not effective treatment available. The targeted Argon and Helium cryoablation treatment under the inducing of ultra B short wave has the advantage of simplicity, less bleeding and less hurt, as well as no more cancer tissues are needed to be dissociated. Combine CT orientation before the operation with the ultra B short wave inducing during the operation, the border of the cancer as well as the nearby tissues can be indicated. During the process of the operation, the temperature detecting probe is adopted, which can avoid hurting or frostbite of the vessels and organs successfully. The operation is relatively safe, the recovery period is short as well as there is less syndrome. After the operation, the immune system is strengthened. Therefore, this is a new treatment for cancer patients(6).
Based on out preliminary observation, the operation is safe and feasible with decent effectiveness. However, the number of the surveyed cases is limited, the following-up time is relatively short, the effectiveness needs further observation and the comparison research of its influences on the patients' life-span is not abundant. .

REFERENCES
1. Seming Wang, Jiren Zhang. Qiuping Reng, et al. The treatment of irresectable Liver Tumors by percutaneous targeted Ar-He Cryoablation. International Journal of Modern Cancer Therapy. 2000;3:16-18
2. Cryogenic Medical, Beijing, edited by Liu Jingang and Liu Zuobin, published by People's Hygiene Press 1993;Page 319-349
3. Onik CM,Alkinson B,Zemel R Weaver ML.Cryosurgery of lung cancer.Semm Sury Oncol 1993;9 .309
4. Steele G Jr. Cryoablation in hepatic surgery. Semin liver Dis 1994;14;120 125.
5. Morrs DL, Horton.AC, Dilley A V, et al. The treatment of hepatic metastasis by cryotherapy and regional cytotoxic perfusion.Gut,1993,34:1156.
6. Zhang jiren, et al. The Argon and Helium targeted ablation technology for tumor ( in press)
( Paper was accepted at March, 2001)
 

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