Some patients with liver tumours benefit from liver-resection surgery. Radiofrequency energy can be applied as part of the operation, to help minimise bleeding from the surgery.

The National Institute for Health and Clinical Excellence is examining radiofrequency-assisted liver resection and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about radiofrequency-assisted liver resection.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the preliminary recommendations
  
• the identification of factual inaccuracies
  
• additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
  
• The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales, Scotland and Northern Ireland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 28 November 2006
Target date for publication of guidance: February 2007

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Limited evidence on the safety and efficacy of radiofrequency (RF)-assisted liver resection appears adequate to support the use of this procedure as one of the options for performing liver-resection surgery, provided that the normal arrangements are in place for consent, audit and clinical governance.

RF-assisted liver resection is one method that may be used in surgery for primary or secondary liver cancer. Liver metastasis (secondary cancer) occurs as part of the disease process of many primary cancers and is particularly common with colorectal cancer.

Treatment strategies for liver cancer depend on the site, number and size of tumours and, for metastatic disease, the origin of the tumour. Liver tumours can be removed surgically in some patients. Bleeding during surgery is a particular problem associated with liver resection. There are various methods to control bleeding during surgery including the Pringle manoeuvre (continuous or intermittent), vascular clamping, inflow occlusion, and total hepatic vascular exclusion.

A randomised controlled trial comparing RF-assisted liver resection (n = 40) with a clamp crushing method (n = 40) found that there was no significant difference in total blood loss during the procedure; mean blood losses were 665 ml and 733 ml, respectively (p = 0.450). The mean transection time was 79 minutes with RF-assisted resection and 80 minutes with clamp crushing (p = 0.740). The mean length of hospital stay was 16 days and 18 days, respectively (p = 0.941).

In a non-randomised controlled trial and four case series, mean operative blood loss during RF-assisted liver resection was 30 ml (in two studies), 46 ml, 100 ml and 120 ml. Across these same studies, the mean operative time was between 90 and 220 minutes, although operative techniques differed between studies.

A case series of 15 patients undergoing RF-assisted liver resection, followed up for a mean of 7 months (range 2-20 months), reported that there was no local recurrence of liver tumours on either imaging or clinical examination, when treating secondary lesions.

In a randomised controlled trial, there were three incidents of major biliary leakage and two other incidents of major morbidity in 40 patients undergoing RF-assisted liver resection; there were two major biliary leaks but no other major morbidity in the 40 patients having clamp crushing resection. There were no operative deaths in either group.

Bile leaks occurred in 2% (4/170) of patients in one case series of patients undergoing RF-assisted liver resection. One patient had a pulmonary embolus 2 weeks after surgery, but there were no postoperative bleeds, and no reoperations were required. In another case series, one of 42 patients (2%) developed a biliary leak from a hepaticojejunostomy soon after surgery, requiring intensive care and a blood transfusion. Another patient in the same case series developed a subphrenic abscess, and another developed a chest infection. In a third case series, significant intraoperative bleeding occurred in 1 of 8 patients being treated by RF-assisted liver resection, which required pressure and repeat RF coagulation. One patient developed an abscess at the resection site, and one experienced worsening of heart failure symptoms.

The Specialist Advisers stated that potential adverse effects associated with RF-assisted liver resection include inadvertent tumour cell spillage, and an increased risk of postoperative infection and bile leakage. They also noted a risk of injury to major vascular and biliary structures if the procedure is used for centrally located tumours.

It was noted that this procedure is one of several options for surgical resection of the liver; however, it was not clear whether RF-assisted resection offers any advantage compared with other methods.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

• 'Interventional procedure overview of radiofrequency-assisted liver resection', August 2006.