Cryoablation

cryoablation

Cryoablation

There are many tumor ablation techniques. Radiofrequency ablation (RFA) has been around for the last 16 years and we have used it for bone tumors such as osteoid osteoma, osteoblastoma and chondroblastoma and liver, and lung malignancies, with good success. However, RFA uses thermal energy and the exact diameter of ablation always remains a guestimate.

Cryoablation is a new technique where freezing temperatures are used to kill tumor cells by creating ice-balls within the tumors. 

Liquid nitrogen or argon is used depending on the system. With liquid nitrogen, the temperate at the centre of the ice-ball can reach up to minus 196 degrees Celsius with lethal temperatures of minus 20 to minus 40 degrees in the rest of the ice-ball (Fig. 1). More importantly, the ice-ball can be visualized on USG, CT or MRI as the case may be, allowing accurate monitoring of the ablation area (Figs. 2, 3).

The machine is compact and sits in the CT scan room (Fig. 4). The procedure is easily done on an out-patient basis in day-care, mostly under local anesthesia (Fig. 3), some patients needing intravenous sedation if the tumors are inherently painful (Fig. 2).

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Preparation/Instructions

Pre-Cryoablation Assessment

  1. First, it is necessary to do a proper assessment of the recent scans that may include MRI, PET/CT or CT scan to plan the cryoablation properly.
  2. For this, it is necessary to submit all recent scans in advance. The front-desk will guide you. Please note that there is a charge of Rs. 4,500 for the pre-assessment, which will be absorbed in the total cost of the cryoablation procedure. However, if the cryoablation is not possible, not indicated or not to be done for any reason, then an opinion report will be given against the charge taken for the pre-assessment.
  3. The cost of the cryoablation is Rs. 2.0 lakhs.
  4. In most instances, a detailed pre-procedure counselling will be done with the patient and relatives a few days prior to the procedure. Please note that the patient needs to and must understand the procedure in detail. Only if the patient is below 18 years of age and/or unable to understand or not in her/his senses, will the counselling be done only with the relatives

Instructions Prior to the cryoablation

  1. Minimum 4-hours fasting.
  2. Please wear comfortable and loose clothing.
  3. The PT/INR report should be carried along, so that the values can be re-verified.
  4. If diabetic, then the appropriate medication / food should be carried along. Any other medications to be taken in the morning should be brought along.
  5. One relative / friend at least should accompany the patient. Preferably not more than 3 relatives should come along – there isn't enough space in the waiting room.

Pre-Procedure Steps on the Day of the Cryoablation

  1. All cryoablations are done in the morning between 8:00 am and 10:00 am.
  2. There will be a detailed explanation given by Dr. Bhavin Jankharia to the patient and the accompanying relatives and friends, if a pre-counselling has not already been done.
  3. Following this or at the same time, the patient will change into appropriate clothing.
  4. An intravenous needle will also be placed as standard protocol.
  1.  

Blood Tests

    1. It is important to make sure that the body's ability to clot the blood is normal. Normal PT, PTT and INR test results, done within 1 week of the procedure are needed.
    2. If the patient is on any blood-thinners (anti-coagulants), then these have to be stopped for between 3 to 5 days. The common blood thinners are aspirin etc... Please give us a list of blood thinners you are or maybe on.

Cryoablation Procedure

  1. This is done inside the CT scanner using a CT fluoroscopy unit.
  2. In most instances, an anesthetist / intensivist will be present. Most studies are done with intravenous conscious or unconscious sedation administered by the anesthetist / intensivist.
  3. The cryoablation involves the following steps (usually 30-60 minutes)
    1. Cleaning and draping
    2. Injecting local anesthesia
    3. The actual cryoablation
  4. Following the cryoablation, the patient will be kept on table for 2-10 minutes to ensure everything is
  5. Once the patient is out of the CT scanner, he/she will either be resting on a bed or trolley for between 1-3 hours, usually till the effect of the anesthetic wears off.

Complications

There are two complications that can occur
  1. Bleeding. If the INR is normal, then this is not a problem. Sometimes, there may be a little discomfort for 1 day which will reduce on an hourly basis. With liver cryoablations, the bleeding may not potentially stop, causing an emergency, but this hasn’t occurred with Dr. Bhavin Jankharia for over 25 years performing different liver procedures.
  2. Pneumothorax (air leak) (in case of a lung cryoablation)
    a. Whenever a needle is passed through the lungs, there is a 20-100% chance of an air leak. Usually, if the air leak occurs, it stops in 1-2 minutes and the air (10-200cc) is absorbed in 2-3 days.
    b. Sometimes, if the air leak does not stop, which we would know right then or over 2-3 hours, we may put a tube inside the chest to remove the air. The patient has to bear the inconvenience of having a tube in the chest for 2-3 days, either at home or admitted for observation to a hospital, as the case may be.

Post-cryoablation Instructions

  1. It is a good idea not to work that day, irrespective of which organ cryoablation it is.
  2. For lung, liver and kidney cryoablations, the patient should take bed rest overnight.
  3. Once the patient leaves the premises, he/she can otherwise resume his/her normal daily routine related to food, water, medicines, etc. 
If you have any more questions, feel free to ask the front-desk or the staff nurse / sister.
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Machine 

Prosense Cryoablation System from Israel along with the new Siemens Defination CT Scanner with TwinBeam
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Time taken

15-60 minutes
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Primary Expert Radiologist

Dr. Bhavin Jankharia
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Report Given

A report of procedure will be give
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    Case 53: Cryoablation of Extra-Abdominal Thoracic Wall Fibromatosis

    Case 52: Cryoablation of Liver Metastasis

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