Ezekiel.egan: Created page with "'''Histotripsy''' is a procedure that uses high amplitude, very short pulse ultrasound waves to create a “bubble cloud” that destroys targeted tumorshttps://histosonics.com/fda-awards-histosonics-clearance-of-its-first-of-a-kind-edison-histotripsy-system-2/. Unlike most other liver tumor therapies, the procedure is completely noninvasive - no incision or puncture is made. The technology uses focused sound energy to produce contro..."

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Created page with "'''Histotripsy''' is a procedure that uses high amplitude, very short pulse ultrasound waves to create a “bubble cloud” that destroys targeted tumors<ref name=":0"><nowiki>https://histosonics.com/fda-awards-histosonics-clearance-of-its-first-of-a-kind-edison-histotripsy-system-2/</nowiki></ref>. Unlike most other liver tumor therapies, the procedure is completely noninvasive - no incision or puncture is made. The technology uses focused sound energy to produce contro..."

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'''Histotripsy''' is a procedure that uses high amplitude, very short pulse ultrasound waves to create a “bubble cloud” that destroys targeted tumors<ref name=":0"><nowiki>https://histosonics.com/fda-awards-histosonics-clearance-of-its-first-of-a-kind-edison-histotripsy-system-2/</nowiki></ref>. Unlike most other liver tumor therapies, the procedure is completely noninvasive - no incision or puncture is made. The technology uses focused sound energy to produce controlled acoustic cavitation that mechanically destroys and liquifies targeted tissue while sparing collagenous structures such as blood vessels and bile ducts<ref name=":1">Mendiratta-Lala M, Wiggermann P, Pech M, Serres-Créixams X, White SB, Davis C, Ahmed O, Parikh ND, Planert M, Thormann M, Xu Z, Collins Z, Narayanan G, Torzilli G, Cho C, Littler P, Wah TM, Solbiati L, Ziemlewicz TJ. The #HOPE4LIVER Single-Arm Pivotal Trial for Histotripsy of Primary and Metastatic Liver Tumors. Radiology. 2024 Sep;312(3):e233051. doi: 10.1148/radiol.233051. PMID: 39225612; PMCID: PMC11427859.</ref>. Other locoregional therapies (LRTs) - such as radiofrequency ablation (RFA), microwave ablation (MWA), hepatic arterial infusion chemotherapy (HAIC), transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), and stereotactic body radiotherapy (SBRT) - are more invasive and carry their own risks, generally related to thermal energy, radioactivity, or invasive nature of procedures<ref name=":0" /><ref name=":2">Wehrle CJ, Sayed Ahmed AF, Knott E, Hong H, Uysal M, Schlegel A, Berber E, Walsh RM, Kim J, Aucejo F, Kwon DCH. The first full year of histotripsy for liver tumors: Local tumor control and preliminary oncologic efficacy. Surgery. 2026 Mar;191:109898. doi: 10.1016/j.surg.2025.109898. Epub 2025 Dec 6. PMID: 41353073.</ref>. For histotripsy, the sound waves must be precisely targeted to destroy tumors and avoid injuring healthy tissue. To ensure immobility and allow for control of ventilation, the procedure is typically performed under general anesthesia.

The Edison Histotripsy System by Histosonics is the only FDA approved devices. It is a mobile system about the size of a C-arm so these procedures can be performed in a myriad of locations from a procedure room to an operating room. The procedure can be performed by surgical oncologists, interventional radiologists, and, potentially, other subspecialties.{{Infobox surgical procedure
| anesthesia_type =General
| airway =ETT (potentially double lumen)
| lines_access =PIV
| monitors =Standard
| considerations_preoperative =Liver function (e.g., Child Pugh, VOCAL Penn)
| considerations_intraoperative =Immobility, one lung ventilation
| considerations_postoperative =Liver function, comorbidity management
}}
==Overview==
===Indications===

* Curative, complete treatment, or palliative treatment of liver tumors<ref name=":2" />
* Tumors can be primary hepatic (e.g., HCC) or metastatic of almost any origin<ref name=":2" />

===Surgical procedure===
The procedure is well described by Mendiratta-Lala et al<ref name=":1" />

The patient is put under general anesthesia with an endotracheal tube. The patient’s skin is prepared to remove hair, excess oils and debris per standard clinical practices where the treatment head is to be positioned. A skin marker is used to mark the target location and other relevant landmarks. The treatment head, which sits in a basin filled with degassed water, is positioned over the target tumor in contact with the patient's skin. The imaging and targeting system are calibrated to deliver treatment and treatment is delivered.

The patient emerges from anesthesia and is taken to the PACU. Initially patients were observed for 24 hours, but as institutional familiarity increases most patients can likely be discharged same day.
==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Cardiovascular
|Standard cardiopulmonary assessment, special consideration of pulmonary fitness if one lung ventilation is to be used
|-
|Gastrointestinal
|Assessment of liver disease burden and status, patients with ascites may require RSI
|-
|Hematologic
|Chemotherapy and chronic illness may result in anemia, thrombocytopenia, etc
|-
|Other
|Systemic therapies, including anticoagulation, should be continued throughout the perioperative period
|}
===Labs and studies===

* PRN, as indicated by history and physical

===Operating room setup===

* Standard, potentially a double lumen tube

===Patient preparation and premedication===

* Standard

===Regional and neuraxial techniques===

* Generally not indicated

==Intraoperative management==
===Monitoring and access===

* PIV
* Standard monitors
* +/- Arterial line if indicated by patient comorbidity (e.g., severe CAD)

===Induction and airway management===

* Standard
* RSI for large volume ascites

===Positioning===

* Supine
* Histotripsy device will rest on top of patient

===Maintenance and surgical considerations===

* General anesthesia is used to ensure immobility and controlled movement of mechanical ventilation
* To ensure immobility during treatment, patients are paralyzed with a non-depolarizing neuromuscular blocker
* To minimize diaphragmatic movement during treatment, many different techniques have been used, including: double lumen tube to isolate the right lung to minimize diaphragm excursion on the treatment side, high frequency jet ventilation<ref>Winterholler JE, Kisting MA, Falk KL, Kisting AL, Jentink MS, White JK, Lubner MG, Laeseke PF, Knavel Koepsel EM, Swietlik JF, Hinshaw JL, Ferreira TH, Mao L, McCormick T, Cui M, Lee FT Jr, Ziemlewicz TJ. Hepatic Histotripsy: Jet Ventilation Decreases the Effect of Respiratory Motion in A Porcine Liver Model. Cardiovasc Intervent Radiol. 2025 Aug;48(8):1164-1173. doi: 10.1007/s00270-025-04060-4. Epub 2025 Jun 4. PMID: 40468037; PMCID: PMC12325549.</ref>, motion compensation technology<ref>Thomas GPL, Khokhlova TD, Khokhlova VA. Partial Respiratory Motion Compensation for Abdominal Extracorporeal Boiling Histotripsy Treatments With a Robotic Arm. IEEE Trans Ultrason Ferroelectr Freq Control. 2021 Sep;68(9):2861-2870. doi: 10.1109/TUFFC.2021.3075938. Epub 2021 Aug 27. PMID: 33905328; PMCID: PMC8513721.</ref>, or treatment gating (i.e., treatment is only delivered during one phase of the respiratory cycle)<ref>Ponomarchuk EM, Thomas GPL, Song M, Wang YN, Totten S, Schade GR, Khokhlova VA, Khokhlova TD. Respiratory Motion Effects and Mitigation Strategies on Boiling Histotripsy in Porcine Liver and Kidney. IEEE Trans Ultrason Ferroelectr Freq Control. 2025 Jun;72(6):837-846. doi: 10.1109/TUFFC.2025.3559458. PMID: 40202884; PMCID: PMC12208655.</ref>

===Emergence===

* Standard

==Postoperative management==
===Disposition===

* Short stay observation or outpatient

===Pain management===

* Pain is generally limited to mild abdominal discomfort or musculoskeletal complaints likely due to positioning

===Potential complications===

* Unintentional treatment of healthy tissue
* Decompensation of liver disease
* Thrombosis of vessels near treatment area (prevented by prophylaxis)

==References==

[[Category:Surgical procedures]]

Histotripsy - Revision history