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Invited Critique
Nov 2012

Another Club in the Bag : Comment on “Irreversible Electroporation for the Ablation of Liver Tumors”

Author Affiliations

Author Affiliation: Liver Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California.

Arch Surg. 2012;147(11):1061. doi:10.1001/jamasurg.2013.493

In the event that you have had any difficulty keeping up with the near explosion of new technologies and techniques that continue to rapidly change the nature of hepatobiliary surgery, in this article,1 Kevin P. Charpentier, MD, has graciously provided a timely, comprehensive, and thoughtful review of yet another new treatment option.

With the increasing incidence of primary hepatic malignancies, such as hepatocellular carcinoma and cholangiocarcinoma, as well as a host of secondary tumors, including colorectal and neuroendocrine tumors, there is certainly a need for new options. Improvements in imaging, surgical tools and techniques, catheter-based treatments, and ablative technologies have all converged to expand the locoregional treatment alternatives. Indeed, the concepts of unresectable and untreatable tumors are undergoing continuous redefinition. With more on the horizon, irreversible electroporation (IRE) represents one relatively new such modality. I may be horrible at golf, but I do understand the concept: choose the best club based on where the ball lies. Unfortunately, relative to critical anatomy, sometimes tumors in the liver lie in very unfortunate locations. In this article, Charpentier gives us a perspective on soft-tissue tumor ablation, explains the underlying mechanisms, and describes the role potentially filled by IRE. I especially appreciated learning about the IDEAL (Innovation, Development, Exploration, Assessment, and Long-term study) framework for assessing surgical innovation and the place currently held by the IRE technology. In its current state, IRE is costly and indicated for a relatively small niche, but it certainly has promise for an expanded role as more is learned. To answer Charpentier's question, I doubt whether we are there yet; however, as we play the course, it certainly cannot hurt to have a new, albeit expensive, club in the bag.

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