HabibHabib? ? EndoHPB EndoHPB ------雙極射頻消融導(dǎo)管雙極射頻消融導(dǎo)管惡性膽道梗阻治療新技術(shù)惡性膽道梗阻治療新技術(shù)1內(nèi)容提要內(nèi)容提要1.射頻及其在腫瘤臨床中的應(yīng)用；2.Endo-HPB是什么及其操作方法；3.Endo-HPB主要作用及其臨床應(yīng)用；4.Endo-HPB臨床效果；2什么是射頻什么是射頻n射頻（RF，Radio Frequency）就是射頻電流，它是一種高頻交流變化電磁波的簡稱n頻率范圍從300KHz～300GHz之間n每秒變化小于1000次的稱為低頻電流，大于10000次的稱為高頻電流，而射頻就是這樣一種高頻電流?高頻高頻(大于大于10K)；；?射頻（射頻（300K-300G）是高頻的較高頻段；）是高頻的較高頻段；?微波頻段（微波頻段（300M-300G）又是射頻的較高頻段又是射頻的較高頻段3正常組織正常組織急性熱凝固急性熱凝固凝固性壞死凝固性壞死1.1.通過通過460460千赫電流，千赫電流，RFRF射頻能量從發(fā)生射頻能量從發(fā)生器轉(zhuǎn)移到射頻電極器轉(zhuǎn)移到射頻電極2.2.RFRF射頻能量使電極射頻能量使電極附近的細(xì)胞內(nèi)物質(zhì)附近的細(xì)胞內(nèi)物質(zhì)快速振蕩（離子攪快速振蕩（離子攪動）。

動）3.3.離子攪動引起摩擦離子攪動引起摩擦加熱，該熱量又在加熱，該熱量又在電極針臨近的組織電極針臨近的組織上傳遞擴(kuò)散，從而上傳遞擴(kuò)散，從而導(dǎo)致細(xì)胞死亡導(dǎo)致細(xì)胞死亡腫瘤射頻消融原理腫瘤射頻消融原理4溫度與細(xì)胞死亡溫度與細(xì)胞死亡（腫瘤細(xì)胞對溫度更為敏感）（腫瘤細(xì)胞對溫度更為敏感）（腫瘤細(xì)胞對溫度更為敏感）（腫瘤細(xì)胞對溫度更為敏感）5?射頻消融在美國、歐洲、亞太肝病學(xué)會指南，射頻消融可以與手術(shù)射頻消融在美國、歐洲、亞太肝病學(xué)會指南，射頻消融可以與手術(shù)一樣，作為肝癌根治療性治療手段一樣，作為肝癌根治療性治療手段AASLD?PRACTICE?GUIDELINE?2010AASLD?PRACTICE?GUIDELINE?20106射頻在肝癌等腫瘤治療中的地位射頻在肝癌等腫瘤治療中的地位 近年以近年以射頻消融射頻消融為代表的局部治療發(fā)展迅猛，治療小肝癌療為代表的局部治療發(fā)展迅猛，治療小肝癌療效不斷提高，接近手術(shù)切除效不斷提高，接近手術(shù)切除RFARFA已經(jīng)成為繼手術(shù)切除和已經(jīng)成為繼手術(shù)切除和肝移植術(shù)之后小肝癌的肝移植術(shù)之后小肝癌的第三種根治性治療手段第三種根治性治療手段，手術(shù)切除，手術(shù)切除的首選地位受到了挑戰(zhàn)。

的首選地位受到了挑戰(zhàn) 陳敏山陳敏山射頻消融在小肝癌治療中的地位射頻消融在小肝癌治療中的地位Chinese Journal of Cancer,2007,26(5)Chinese Journal of Cancer,2007,26(5)7專家評述專家評述n高溫使腫瘤組織凝固性壞死，最終形成液化灶或纖維化，起到原位滅活腫瘤組織作用；n高溫使腫瘤周圍血管閉塞并形成一個反應(yīng)帶，使之不能向腫瘤組織供血，可防止腫瘤復(fù)發(fā)或轉(zhuǎn)移；n高溫滅活的腫瘤組織由于細(xì)胞免疫表形的變化而具有瘤苗作用，從而發(fā)生特殊的抗腫瘤免疫作用8射頻治療腫瘤射頻治療腫瘤機(jī)制機(jī)制n微創(chuàng)，最大限度地保留靶器官功能；n并發(fā)癥少、恢復(fù)快、患者易接受；n療效確切，可重復(fù)治療；n適應(yīng)癥廣；n操作簡單，定位、溫控可靠9射頻腫瘤消融治療射頻腫瘤消融治療特點(diǎn)特點(diǎn)n原位滅活：微創(chuàng)根治腫瘤n綜合治療：聯(lián)合手術(shù)、TACE、粒子植入、 化療…n姑息治療：緩解癥狀，提高生存質(zhì)量10 提高腫瘤局部控制率提高腫瘤局部控制率射頻在臨床中的應(yīng)用射頻在臨床中的應(yīng)用內(nèi)容提要內(nèi)容提要1.射頻及其在腫瘤臨床中的應(yīng)用；2.Endo-HPB是什么及其操作方法；3.Endo-HPB主要作用及其臨床應(yīng)用；4.Endo-HPB臨床效果；11EndoEndo- -HPBHPB射頻消融導(dǎo)管射頻消融導(dǎo)管?一次性使用一次性使用?0.9m0.9m或或1.8m 1.8m 長長?8Fr (2.6mm) 8Fr (2.6mm) ?.035inch .035inch 英寸導(dǎo)絲英寸導(dǎo)絲?3.2mm 3.2mm 內(nèi)鏡工作管道內(nèi)鏡工作管道?雙極、不銹鋼雙環(huán)的距離間隔為雙極、不銹鋼雙環(huán)的距離間隔為8 8mmmm?加熱區(qū)域：加熱區(qū)域： 25mm +/-3mm25mm +/-3mm12全球?qū)＠皻W美認(rèn)證全球?qū)＠皻W美認(rèn)證-HPB-HPB?由英國帝國理工大學(xué)著名外科專家由英國帝國理工大學(xué)著名外科專家 Nagy HabibNagy Habib教授發(fā)明教授發(fā)明?20072007年獲得全球?qū)＠戢@得全球?qū)＠? (專利號專利號WO2007135437)WO2007135437)?20092009年獲歐盟年獲歐盟CECE及美國及美國FDAFDA認(rèn)證認(rèn)證?20122012年獲中國年獲中國SFDASFDA認(rèn)證認(rèn)證13Fig. 4 The specimens were resected for the evaluation of microscopic findingsFig. 5 Ablation by lower power and short time (5 W and 60 s) showed insufficient ablationEndoHPB?EndoHPB?消融范圍消融范圍2.52.5* *1cm(1cm(直徑直徑) )14Takao Itoi et al. Evaluation of effects of a novel endoscopically applied radiofrequency ablation biliary catheter using an ex-vivo pig liver。

J Hepatobiliary Pancreat SciDOI 10.1007/s00534-011-0465-7 Takao Itoi et al. Evaluation of effects of a novel endoscopically applied radiofrequency ablation biliary catheter using an ex-vivo pig liver J Hepatobiliary Pancreat SciDOI 10.1007/s00534-011-0465-7 HPBHPB消融范圍與時間、功率間的關(guān)系消融范圍與時間、功率間的關(guān)系15Ablationpower (W)Ablationtime (s)Lengtha (mm)Lengthb (mm)5604.3 ± 0.611.0 ± 1.05905.3 ± 0.613.0 ± 1.751207.3 ± 0.618.0 ± 1.010608.0 ± 1.020.3 ± 0.610908.3 ± 1.221.3 ± 1.61012010.3 ± 0.627.7 ± 1.615608.3 ± 0.623.7 ± 1.2159010.0 ± 1.026.7 ± 0.61512010.3 ± 0.627.7 ± 0.620609.3 ± 0.629.0 ± 1.0209011.3 ± 1.229.0 ± 1.72012011.3 ± 1.229.0 ± 1.0 經(jīng)內(nèi)鏡逆行膽胰管造影經(jīng)內(nèi)鏡逆行膽胰管造影(ERCP) (ERCP) 或經(jīng)皮肝穿刺膽道或經(jīng)皮肝穿刺膽道造影造影 (PTC)(PTC)1.1.插進(jìn)導(dǎo)絲并通過乏特壺腹插進(jìn)導(dǎo)絲并通過乏特壺腹 2.2.在進(jìn)行在進(jìn)行X X光影像判斷和評估膽道梗阻的長度后，將光影像判斷和評估膽道梗阻的長度后，將EndoHPBEndoHPB插進(jìn)至腫瘤的上部。

插進(jìn)至腫瘤的上部3.3.將功率設(shè)置為將功率設(shè)置為8-8-1010瓦特，消融瓦特，消融9090秒秒-2-2分鐘消融組織長度分鐘消融組織長度為為 2.5cm2.5cm，寬度為，寬度為0.5cm0.5cm4.4.可以根據(jù)腫瘤的長度重復(fù)一次或兩次消融可以根據(jù)腫瘤的長度重復(fù)一次或兩次消融5.5.在將射頻電極移走后，放入金屬支架在將射頻電極移走后，放入金屬支架操作方法操作方法16經(jīng)皮經(jīng)肝膽管內(nèi)射頻消融經(jīng)皮經(jīng)肝膽管內(nèi)射頻消融1718Insertion of a 0.0035” guidewire經(jīng)經(jīng)ERCPERCP膽管內(nèi)射頻消融膽管內(nèi)射頻消融1819Insertion of the Habib EndoHPB into bile ductInsertion of the Habib EndoHPB into bile duct經(jīng)經(jīng)ERCPERCP膽管內(nèi)射頻消融膽管內(nèi)射頻消融1920Insertion of the Habib EndoHPB into bile duct經(jīng)經(jīng)ERCPERCP膽管內(nèi)射頻消融膽管內(nèi)射頻消融2021Insertion of the Habib EndoHPB into bile duct經(jīng)經(jīng)ERCPERCP膽管內(nèi)射頻消融膽管內(nèi)射頻消融21222 electrodes separated for total ablation 經(jīng)經(jīng)ERCPERCP膽管內(nèi)射頻消融膽管內(nèi)射頻消融22233 or 4 application times according to stricture經(jīng)經(jīng)ERCPERCP膽管內(nèi)射頻消融膽管內(nèi)射頻消融23內(nèi)容提要內(nèi)容提要1.射頻及其在腫瘤臨床中的應(yīng)用；2.Endo-HPB是什么及其操作方法；3.Endo-HPB主要作用及其臨床應(yīng)用；4.Endo-HPB臨床效果；24EndoHPBEndoHPB主要作用及臨床應(yīng)用主要作用及臨床應(yīng)用?臨床應(yīng)用：臨床應(yīng)用：?解決目前管道支架容解決目前管道支架容易出現(xiàn)的再閉塞問題易出現(xiàn)的再閉塞問題?放置支架前對腫瘤進(jìn)放置支架前對腫瘤進(jìn)行射頻消融行射頻消融?對膽道腫瘤進(jìn)行射頻對膽道腫瘤進(jìn)行射頻消融后不放置支架消融后不放置支架25?主要作用：主要作用：?通過射頻直接殺死膽管內(nèi)通過射頻直接殺死膽管內(nèi)腫瘤細(xì)胞腫瘤細(xì)胞?可有效延長支架暢通期可有效延長支架暢通期?延長患者生存時間延長患者生存時間?改善患者生存質(zhì)量改善患者生存質(zhì)量PTCDPTCD造影明確梗阻部位造影明確梗阻部位腫瘤腔內(nèi)導(dǎo)管射頻消融腫瘤腔內(nèi)導(dǎo)管射頻消融膽道支架植入膽道支架植入完成消融減完成消融減瘤，達(dá)到解瘤，達(dá)到解除梗阻、改除梗阻、改善患者生存善患者生存質(zhì)量目的。

質(zhì)量目的26HPBHPB消融減瘤，解除梗阻消融減瘤，解除梗阻膽道支架放置前射頻消融術(shù)后即刻效果膽道支架放置前射頻消融術(shù)后即刻效果-PTCD-PTCD27膽道支架放置前射頻消融術(shù)后即刻效果膽道支架放置前射頻消融術(shù)后即刻效果-ERCP-ERCP膽管內(nèi)射頻消融前后膽管內(nèi)射頻消融前后膽管內(nèi)射頻消融前后膽管內(nèi)射頻消融前后 (Reddy)(Reddy)(Reddy)(Reddy)28胰腺癌放療術(shù)后胰腺癌放療術(shù)后3 3月，月，支架阻塞獲得再通支架阻塞獲得再通29胰腺癌支架阻塞再通處理胰腺癌支架阻塞再通處理30胰腺癌支架置入前射頻消融胰腺癌支架置入前射頻消融射頻電極被插進(jìn)膽總管在進(jìn)行射頻消融后，金屬支架被放進(jìn)右肝膽管31胰頭腺癌射頻消融胰頭腺癌射頻消融患有胰腺腺癌的病人，膽管造影顯示膽總管下段狹窄射頻電極穿過狹窄處胰頭腺癌射頻消融胰頭腺癌射頻消融32壺腹腺癌射頻消融，電極穿過腫瘤壺腹腺癌射頻消融，電極穿過腫瘤壺腹腺癌射頻消融壺腹腺癌射頻消融3334支架內(nèi)阻塞射頻消融支架內(nèi)阻塞射頻消融Metal stent金屬支架金屬支架Endoablator in situ射頻導(dǎo)管定位射頻導(dǎo)管定位Ablation with 10W 2min x 2消融：消融：10瓦特，瓦特， 2分鐘分鐘× 2次次Ablation with 30W 3min 消融：消融：30瓦特，瓦特，3分鐘分鐘支架內(nèi)阻塞射頻消融支架內(nèi)阻塞射頻消融---PTCD---PTCD3536支架內(nèi)阻塞射頻消融支架內(nèi)阻塞射頻消融---ERCP---ERCP37支架內(nèi)阻塞射頻消融支架內(nèi)阻塞射頻消融---ERCP---ERCP內(nèi)容提要內(nèi)容提要1.射頻及其在腫瘤臨床中的應(yīng)用；2.Endo-HPB是什么及其操作方法；3.Endo-HPB主要作用及其臨床應(yīng)用；4.Endo-HPB臨床效果；38膽道支架阻塞后射頻消融臨床研究膽道支架阻塞后射頻消融臨床研究39Table 1 Patient characteristicsTotal number of patients9Age (median), yr72 (39–78)Male:female ratio7:2Cholangiocarcinoma6 Bismuth type I1 Bismuth type II1 Bismuth type IIIA1 Bismuth type IV 3Pancreatic adenocarcinoma 2Metastatic disease1M. Pai et al.: Intraductal Radiofrequency Ablation for Clearance of Occluded Metal Stent。

Cardiovasc Intervent Radiol DOI 10.1007/s00270-013-0688-x，膽道支架阻塞后射頻消融臨床研究膽道支架阻塞后射頻消融臨床研究40Table 2 Procedure detailsLength of stricture (cm)a5.2 ± 1.6No. of ablations2 (1–3)Duration of ablation (min)6 (2–20)Ablation energy (watts)10 (10–20)Preablation diameter (mm)1.6 (0–4)Postablation diameter (mm)8 (3–10)Preablation bilirubin (lmol/L)109 ± 43Postablation bilirubin (lmol/L)60 ± 27M. Pai et al.: Intraductal Radiofrequency Ablation for Clearance of Occluded Metal StentCardiovasc Intervent Radiol DOI 10.1007/s00270-013-0688-x，膽道支架阻塞后射頻消融臨床研究膽道支架阻塞后射頻消融臨床研究41M. Pai et al.: Intraductal Radiofrequency Ablation for Clearance of Occluded Metal Stent.Cardiovasc Intervent Radiol DOI 10.1007/s00270-013-0688-x，F(xiàn)ig. 2 A. Preablation holangiogram shows stent blockage. B. Cholangiogram shows radiofrequency ablation with the HabibTM HPB inside the blocked stent. C, D Postablation cholangiogram shows patent stent經(jīng)皮膽道射頻消融治療的安全性及臨床療效研究經(jīng)皮膽道射頻消融治療的安全性及臨床療效研究42Table 1 Patient characteristics Total number of patients39 Age (median), yr67.5 (42–87) Male:female ratio22:17 Cholangiocarcinoma17 Bismuth type I5 Bismuth type II1 Bismuth type IIIA4 Bismuth type IV 7 Pancreatic adenocarcinoma 11 Gallbladder adenocarcinoma4 Metastatic disease5 epatocellular carcinoma1 Ampullary adenocarcinoma1Malkhaz Mizandari ? Madhava Pai ?et al. Percutaneous Intraductal Radiofrequency Ablation is a Safe Treatment for Malignant Biliary bstruction: Feasibility and Early Results. Cardiovasc Intervent Radiol DOI 10.1007/s00270-012-0529-3經(jīng)皮膽道射頻消融治療的安全性及臨床療效研究經(jīng)皮膽道射頻消融治療的安全性及臨床療效研究43Table 2 Procedure details Length of stricture (cm)a 3.39 ± 1.06 No. of ablations 1 (1–4) Duration of ablation (min) 2 (2–20) Ablation energy (watts) 10 (8–15) Preablation diameter (mm) 1 (0–2) Postablation diameter (mm) 7 (3–10)Malkhaz Mizandari ? Madhava Pai ?et al. Percutaneous Intraductal Radiofrequency Ablation is a Safe Treatment for Malignant Biliary bstruction: Feasibility and Early Results. Cardiovasc Intervent Radiol DOI 10.1007/s00270-012-0529-3經(jīng)皮膽道射頻消融治療的安全性及臨床療效研究經(jīng)皮膽道射頻消融治療的安全性及臨床療效研究44ParametersPreablationPostablation(day 2)Normal rangeBilirubin (lmol/L)129 ± 6152 ± 32a0–21ALP (IU/L)1,154 ± 8641,032 ± 79730–130ALT (IU/L)108 ± 6578 ± 42＜40GGT (IU/L)755 ± 739760 ± 632＜55LDH (IU/L)384 ± 89313 ± 520–250AST (IU/L)96 ± 6081 ± 39＜40Malkhaz Mizandari ? Madhava Pai ?et al. Percutaneous Intraductal Radiofrequency Ablation is a Safe Treatment for Malignant Biliary bstruction: Feasibility and Early Results. Cardiovasc Intervent Radiol DOI 10.1007/s00270-012-0529-3ERCP?ERCP?射頻消融治療惡性膽道梗阻治療的安全性射頻消融治療惡性膽道梗阻治療的安全性45TABLE 1. Demographics (N22)Sex: male11Age, y, mean (range)70 (56-84)Pancreatic/cholangiocarcinoma, no. 16/6Metastatic, no. 10Locally advanced, no. 17Metastatic and locally advanced, no. 7Hilar strictures, no. 6Plastic stent before SEMS, no. 16Sepsis at RFA ERCP, no. 7Bilirubin, mol/L, median (range)26 (4-286)Karnofsky score, median (range)55 (40-100)Alan W. Steel, MD, MRCP, Aymer J. Postgate，，etal Endoscopically applied radiofrequency ablation appears to be safe inthe treatment of malignant biliary obstruction；Volume 73, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY，149-153ERCP?ERCP?射頻消融治療惡性膽道梗阻治療的安全性射頻消融治療惡性膽道梗阻治療的安全性46TABLE 2. Radiofrequency ablation procedure details (N21)Procedure time, min, mean (range)43 (22-68)Fluoroscopic screening time, min, median (range)5 (3-36)No. of applications, median (range)2 (1-4)Length of stricture, mm, mean (range)37 (20-60)Stricture diameter before RFA, mm, median (range)0 (0-1)Stricture diameter after RFA, mm, median (range)4 (3-6)After ERCP day stay, d, median (range)1 (1-24)Median stent patency at day 90 offinal subject, d, median (range)114 (0-498)Alan W. Steel, MD, MRCP, Aymer J. Postgate，，etal Endoscopically applied radiofrequency ablation appears to be safe inthe treatment of malignant biliary obstruction；Volume 73, No. 1 : 2011 GASTROINTESTINAL ENDOSCOPY，149-153膽道惡性梗阻內(nèi)鏡下射頻消融膽道惡性梗阻內(nèi)鏡下射頻消融------國外回顧性研究國外回顧性研究47Biliary tract cancer (Klatskin tumor, distal CCa, gallbladder carcinoma)Pancreatic cancerCentral HCC, mixed HCC/CCa, mCRCTotalNo. of patients 51 4 3 58Gender (m:f) 27:24 0:4 3:0 31:27Age, years (range) 76 (28–88) 62 (55–82) 70 (63–71) 75 (28–88)Co-therapies CHT 20, S 3, RT 2, PDT 2 CHT 3 CHT 1, S 1, TACE 1 CHT 24, S 4, RT 2,PDT 2, TACE 1RFA sessions 1 *= 37, 2 * = 6, 3 * = 2, 4 * = 4, 5 * =1 1 *=4 1 * =3 1*=44,2*=6,3 *= 2, 4*= 4,5* = 1Werner Dolak ? Florian Schreiber et al.Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications；Surg Endosc DOI 10.1007/s00464-013-3232-9CCa cholangiocarcinoma, CHT chemotherapy, CI confidence interval, HCC hepatocellular carcinoma, mCRC metastatic colorectal cancer, PDT photodynamic therapy, RFA radiofrequency ablation, RT radiotherapy, S surgery, TACE transarterial chemoembolization膽道惡性梗阻內(nèi)鏡下射頻消融膽道惡性梗阻內(nèi)鏡下射頻消融------國外回顧性研究國外回顧性研究48Biliary tract cancer (Klatskin tumor, distal CCa, gallbladder carcinoma)PancreaticcancerCentral HCC, mixed HCC/CCa, mCRCTotalNo. of patients 51 4 3 58InterventionalcomplicationsPartial liver infarction None None (as listed)Adverse events within 30 days post RFACholangitis 5, hemobilia 2, cholangiosepsis 2, hepatic coma 1, left bundle branch block1Gallbladderempyema 1Hemobilia 1 (as listed)Survival after first RFA/initial diagnosis (95% CI)10.9/19.1 m5.0/8.8 m10.5/98.4 m 10.6 m (6.9–14.4)/17.9m (10.3–25.6)Werner Dolak ? Florian Schreiber et al.Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications；Surg Endosc DOI 10.1007/s00464-013-3232-9CCa cholangiocarcinoma, CHT chemotherapy, CI confidence interval, HCC hepatocellular carcinoma, mCRC metastatic colorectal cancer, PDT photodynamic therapy, RFA radiofrequency ablation, RT radiotherapy, S surgery, TACE transarterial chemoembolization49射頻消融延長胰腺癌患者生存期射頻消融延長胰腺癌患者生存期50射頻消融延長胰腺癌患者生存期射頻消融延長胰腺癌患者生存期。