Liver cancer has a high incidence in China, and most of them are found to be in the middle and late stages, and not many patients can be surgically removed. Interventional treatment of liver cancer in China has achieved good results since the 1980s, and is now recognized as the first choice of non-surgical treatment for liver cancer. Therefore, interventional treatment for liver cancer has blossomed in medical institutions all over the country, but due to the uneven level and irregular operation, it has seriously affected the efficacy of patients. However, due to the uneven level and irregular operation, the outcome of patients is seriously affected. This shows the importance of standardized treatment and management. Therefore, we hereby formulate the standardization of interventional treatment and management of hepatocellular carcinoma.
I. Basic requirements for medical institutions.
1.Hospital of Grade IIA or above.
2. Equipped with independent interventional operating room.
3. Hospitals with conditions can set up interventional wards.
II. Interventional operating room requirements: 1.
1, in line with radiation protection and aseptic operating conditions.
2, equipped with more than 500mA medical diagnostic X-ray machine, with image intensifier or DSA (digital subtraction of blood vessels) system.
3, there are stored catheters, guidewires, contrast agents, embolic agents and other items, drugs storage cabinet, a person responsible for the registration of custody.
4. Storage of necessary emergency drugs.
5. Equipped with cardiac monitors and established oxygen channels.
Third, the basic requirements of personnel.
1.Physicians with intermediate title or above who have more than 5 years of experience in radiological diagnosis or liver cancer diagnosis and treatment, with a certain foundation of first aid, and those who have received further training or formal training in domestic or provincial Grade 3 A hospitals before they can work independently.
2.Technical personnel with formal training and large X machine induction certificate.
3.Nurses with more than 5 years of nursing experience and advanced training or training in level 3 hospitals.
IV. Operating procedures of liver cancer interventional therapy.
Indications and contraindications of hepatocellular carcinoma interventional therapy.
1. Indications for hepatic artery chemotherapy (HAI)
① Primary or secondary hepatocellular carcinoma that has lost the opportunity of surgery.
② Those with poor liver function or difficult to super-selective intubation.
③Prophylactic hepatic artery infusion chemotherapy for recurrence of hepatocellular carcinoma after surgery or postoperative.
2. Contraindication to HAI No absolute contraindication should be contraindicated for those with systemic failure, severe liver dysfunction, massive ascites, severe jaundice and white blood cell <3000.
3. Indications for hepatic artery embolization (HAE)
(1) Pre-operative application of hepatic tumor resection can shrink the tumor and facilitate resection, and at the same time can clarify the number of lesions and control metastasis.
② middle and advanced hepatocellular carcinoma that cannot be resected surgically, without severe liver and kidney dysfunction, without complete obstruction of the portal vein trunk and with tumor occupancy rate <70%.
③small hepatocellular carcinoma.
④ those who failed in surgery or recurred after resection.
⑤ control of pain, bleeding and arteriovenous fistula.
⑥Prophylactic hepatic artery chemoembolization after resection of hepatocellular carcinoma.
4. Contraindications for HAE
①Severe liver dysfunction, such as: severe yellow pox [bilirubin>51μmol/L, ALT>120U (depending on the size of the tumor)], hypocoagulation, etc., massive ascites or severe cirrhosis, and liver function of Child C grade.
② portal hypertension with reverse blood flow and complete obstruction of the main trunk of the portal vein, with little formation of collateral vessels.
③Infection, such as liver abscess.
④ cancer occupying 70% or more of the whole liver (if the liver function is basically normal, or if a small amount of iodine oil is used for embolization in stages).
⑤ White blood cells <3000.
(6) Those with extensive metastases throughout the body.
(vii) systemic failure.
Preoperative preparation.
1.Preoperative routine blood, urine, stool and blood biochemical examination should be done.
2.Pre-operative summary should be done according to the condition and relevant examination results to formulate the treatment plan, reasonably select chemotherapy drugs according to the imaging examination, individual patient’s condition and histological typing, and explain to the patient and family members and sign the informed consent form.
3.Prepare the skin at the puncture site.
4.Fast for 6 hours before surgery.
5.Preoperative routine use of diazepam 10MG intramuscularly.
6.Preparation of equipment and careful inspection.
7, Sterilization of interventional operating room, equipment and personnel.
Operating procedures.
1, hepatic arteriography: seldinger technique is used for routine transfemoral puncture cannulation, and the catheter is placed in the abdominal trunk or common hepatic artery for imaging. If it is difficult to reach the target artery by femoral artery cannulation or if a drug cassette needs to be implanted, it can be cannulated by subclavian artery puncture. Image acquisition includes the arterial, parenchymal and venous phases. If there are few or no blood vessels in a certain area of the liver or the number of lesions does not match with the imaging film, other vessels (including superior mesenteric artery, left gastric artery, phrenic artery, internal thoracic artery and right renal artery) should be explored to find ectopic hepatic arteries or arteries supplying blood to the liver tumor and to clarify the tumor site, size, number and blood supply. Also observe whether there is arteriovenous fistula.
2. Perfusion chemotherapy: carefully analyze the imaging performance, super-select the catheter to the target vessel and inject the diluted chemotherapeutic drugs. The chemotherapeutic drug should be diluted to 150-200ml with saline according to the drug dosage, and the infusion should be slow and the infusion time should be not less than 15-20min.
3.Hepatic artery embolization: choose embolization agent reasonably, generally mix super liquefied iodine oil with chemotherapy drug to make emulsion, the amount of iodine oil should be flexible according to the size of tumor, blood supply and patient tolerance, the maximum amount should not exceed 30ml. At this time, central embolization of the tumor blood supply artery or secondary trunk can be performed with gelatin sponge fragments. In case of concomitant hepatic arteriovenous fistula, the arterial trunk should not be occluded by first blocking with gelatin sponge or steel ring, except for obvious hepatic arteriovenous-portal fistula. For the first treatment, try to ensure complete embolization to prevent the formation of collateral arteries, which will cause difficulties in re-embolization.
4.After embolization, hepatic arteriogram again to understand the embolization situation, and remove the tube after satisfaction. Compress the puncture site to stop bleeding for 10-15 min, and apply local pressure bandage. Explain the precautions to the family and escort to the ward by the attending physician. The limb on the punctured side was braked and bedridden for 8-12 h. The vital signs, the presence of bleeding at the puncture site and the pulsation of the dorsalis pedis of both lower limbs were observed. Complete the procedure record in a timely manner.
5. Precautions: Reasonable use of microcatheters to reduce the patient’s burden. For those whose tumor is too large, after reaching a certain embolization dose, even if the iodine oil deposition is incomplete, the embolization should not be overdone to prevent the tumor from rupture and bleeding. If the patient reacts seriously during embolization and cannot be relieved by symptomatic treatment, the treatment should also be stopped. The injection of iodine oil should always be carried out under fluoroscopic surveillance to prevent misembolization.
6.Frequency of follow-up and treatment: Make a good record of patient’s information and feedback of their condition, so as to facilitate the determination of patient’s treatment time again and experience summary. The treatment density can be increased in the first few times, and thereafter the treatment interval can be extended if the tumor does not progress. In principle, the treatment interval should be not less than one month to facilitate the recovery of liver function. If the liver tumor shrinks significantly, surgical resection can be adopted.
V. Standardized interventional treatment and management of hepatocellular carcinoma not only improves the treatment effect of hepatocellular carcinoma patients and reduces medical errors and accidents, but also facilitates the development and promotion of interventional treatment and better serves the patients.