Preoperative preparation (I): examination
Detailed medical history and comprehensive physical examination.
Any hypertension, heart disease, emphysema, diabetes mellitus, upper gastrointestinal variceal bleeding, and any history of thoracic surgery and medication use
Routine examination.
1, three major routine, liver function, kidney function, blood sugar, electrolytes, prothrombin time, tumor markers
2, chest CT, electrocardiogram
Special examinations
1.The operator should personally observe the CT before operation to understand the size, number and location of the tumor, especially the relationship between the tumor and important intrapulmonary structures and surrounding tissues.
2. Preliminary ablation plan should be made according to the preoperative CT film: preliminary determination of needle entry point, puncture path, ablation site; decision of single or fractionated or segmented treatment according to the extent of lesion ……
To explain the condition, talk and sign, and comfort the patient ……
Preoperative preparation (II): treatment
According to the preoperative examination, a short period of active and targeted treatment is given before RF
1.Improve coagulation function. Prothrombin time, platelets
2.Elimination of pleural fluid
3, for patients with thrombocytopenia, platelets should be at least 40,000/mm3 by medication or platelet transfusion.
4.Basic anesthesia: Since the high temperature generated by radiofrequency can stimulate the pleura and vagus nerve to produce vagal reflex, to prevent possible slowing of heart rate, arrhythmia and drop of blood pressure, atropine or sanguinarine can be considered before surgery.
Sign the informed consent form before surgery and fast from food and water for 2 h.
Pre-anesthetic medication
About half an hour before radiofrequency ablation, the following drugs can be applied according to the situation
1.Anti-emetic drugs: such as desulfiram, etc., to reduce intraoperative nausea and vomiting causing bleeding in the needle tract.
2.Anti-hemostatic drugs: such as lithotripsin and prothrombin complex, etc., to minimize the occurrence of bleeding in the needle tract, especially for those with incomplete coagulation mechanism.
3, prophylactic antibiotics: such as three generations of cephalosporin, etc. Mainly used for those who have had surgery or stent implantation of esophagus and lung, especially with bronchial dilatation in the lung; larger tumors; with diabetes and other diseases that reduce human immune function; long-term application of hormones or chemotherapy drugs that reduce human immune function
4.Analgesic drugs: such as dulcolax, tramadol injection, etc., especially for tumors located under the pleura, near the heart, esophagus or large bronchus and using local anesthesia.
Preoperative pain relief program.
1.Pethidine 70mg, promethazine 12.5mg, diazepam 5mg, atropine 0.5mg intramuscularly (30min before surgery).
2.NS 250ml plus tramadol 200mg IV (30min before surgery).
3.Add additional painkillers as appropriate according to the pain situation during the operation.
4.Reduce the dosage in elderly and frail patients, and be alert to the occurrence of respiratory depression.
Intraoperative management
1.Fast heart rate, sweating and fever: generally no special treatment is needed
2, chest pain: analgesics (morphine, dulcolax), ineffective → lower the target temperature → gradually to the target temperature
3.Pleural reaction: immediately stop ablation, symptomatic treatment
4.Coughing up blood: hemostatic drugs
5.Coughing: inject lidocaine into the injection hole
Postoperative treatment principles
1.Postoperative calm supine for 2 hours, monitor vital signs and chest signs for 6 hours.
2.Chest X-ray every 12 or 24 hours to exclude any complications such as pneumothorax until discharge
3.Routine oxygen inhalation (4 L/min) for 6 h
4.General postoperative hemostatic drugs can be given once
5.After the operation, the routine broad-spectrum antibiotics can be given for 2-3 d
6.If the one-time ablation tumor is large in volume and number, dexamethasone 10mg can be given for 2-3 days after surgery; on the same day, increase the amount of liquid, alkalinize urine, prostaglandin and other kidney preservation treatment.
7.Give acid control drugs for 1-2 days after surgery for larger tumors.
8.Comprehensive treatment of anti-tumor, immunity, support, etc.
Complications
1.Pneumothorax, incidence 35%, closed drainage 18%
2.Pleural effusion, incidence 5%
3.Hemorrhage, incidence 2%
4.Pulmonary infection, incidence 1%
Postoperative evaluation and follow-up
CT and serum tumor markers will be reviewed about 1 month after surgery
Serum tumor markers were reviewed every 3 months for 1 year; chest enhancement CT or FDG-PET was examined (follow-up chest CT was reviewed at 1, 3, 6, 12, 18, 24 and 30 months after treatment, and intensive scans were used for comparison in all cases without contraindication); enhancement CT: if the swelling was enhanced by 15 HU compared with CT before treatment, it indicated that there was local residual and a second RFA was needed.
Combined treatment
Radiotherapy: For larger tumors or central lung cancer. Radiotherapy is very effective for oxygen-rich cells at the edge of tumor, but less effective for oxygen-depleted cells in the central area of tumor, which can be killed by heating (radiofrequency ablation), so RFA combined with radiotherapy can increase the therapeutic effect
Systemic treatment: chemotherapy, targeted therapy
Particle implantation regional radiotherapy