Objective : In percutaneous ablation procedures, periprocedural pain, unrest and respiratory concerns can be detrimental to achieve a safe and efficacious ablation and impair treatment outcome. The aim of this study was to compare the association between anesthetic technique and local disease control in patients undergoing percutaneous microwave ablation (MWA) of colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC).
Methods : This IRB waived single center comparative analysis of three historical cohorts analyzed 90 patients treated for one or more hepatic malignancies from January 2013 until September 2018. The local tumor progression-free survival (LTPFS), safety and periprocedural pain perception were assessed using uni- and multivariate logistic regression analyses to correct for potential confounders.
Results : In 114 procedures (22 general anesthesia; 32 midazolam; 60 propofol), 171 liver tumors (136 CRLM; 35 HCC) were treated with percutaneous MWA. Propofol and general anesthesia were superior to midazolam sedation and regarding LTPFS (4/94 [4.3%] vs. 19/42 [45.2%] vs. 2/35 [5.7%]; P<0.001; respectively). Propofol versus midazolam (P<0.001), general anesthesia versus midazolam (P=0.016), direct postprocedural visual analogue pain score above 5 (P=0.050) and more than one tumor per procedure (P=0.045) were independent predictors for LTPFS. Multivariate analysis revealed that propofol versus midazolam (HR 7.94 [95% CI 0.04-0.39; P<0.001]) and general anesthesia versus midazolam (HR 6.33 [95% CI 0.04-0.69; P=0.014]) were independently associated with LTPFS. Pain during (P<0.001) and directly after treatment (P<0.001) was significantly worse in patients who received midazolam sedation.
Conclusions : Compared to propofol and general anesthesia, midazolam sedation increases the periprocedural perception of pain and decreases the local tumor progression-free survival. To reduce the number of repeat procedures required to eradicate hepatic malignancies, general anesthesia and propofol sedation should be favored over midazolam.