Choledochojejunostomy: possible risk factor for septic complications after percutaneous hepatic tumor ablation

Indocyanine green fluorescence navigation for hepatocellular carcinoma with bile duct tumor thrombus: a case report

Background

Bile duct tumor thrombus (BDTT) is one of the features of advanced hepatocellular carcinoma (HCC). In the resection of HCC with BDTT, it is important to detect the BDTT tip to decide the appropriate point of bile duct division. In this regard, the efficacy of indocyanine green (ICG) fluorescence navigation has been confirmed for the detection of HCC, whereas its utility for BDTT has not yet been reported. Herein, we describe our experience with right hepatectomy for HCC with BDTT using ICG fluorescence navigation.

Case presentation

A 72-year-old woman had experienced local recurrences of HCC after radiofrequency ablation, with BDTT reaching the confluence of the right anterior branch and posterior branch. Right hepatectomy was planned, and 2.5 mg of ICG was injected one day before surgery. After transection of the liver parenchyma, the right liver was connected with only the right hepatic duct. ICG fluorescence imaging visualized the tip of BDTT in the bile duct with clear contrast; the proximal side (hepatic side) of the right hepatic duct showed stronger fluorescence than the distal side (duodenal side). The bile duct was divided at the distal side of the BDTT border, and the tip of BDTT was recognized into the resected right hepatic duct without laceration. The patient had an uneventful postoperative course and currently lives without recurrences for 6 months.

Conclusions

ICG fluorescence navigation assisted in the precise resection of the bile duct in HCC with BDTT.

Outcomes of resection for hepatocellular carcinoma with macroscopic bile duct tumour thrombus: A propensity score matched study

The incidence of hepatocellular carcinoma (HCC) with bile duct tumour thrombus (BDTT) is low, and related studies, especially studies on long-term survival, are uncommon. The present study aimed to evaluate the clinicopathological characteristics, prognostic factors and postoperative long-term outcomes of BDTT in patients with HCC. The clinicopathological characteristics and postoperative long-term outcomes of patients with HCC both with and without BDTT were compared before and after propensity score matching (PSM). Prognostic risk factors were assessed by Cox proportional hazards regression analyses after PSM. Tumour stages in the BDTT group were significantly higher than those in the group without BDTT (P=0.001). Overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher in the group without BDTT than in the BDTT group before PSM (P<0.001 and P=0.003, respectively). However, no significant difference in OS or RFS was found between the two groups after PSM (P=0.249 and P=0.121, respectively). Moreover, the median OS and RFS times of the BDTT patients who underwent tumour thrombectomy and bile duct resection were not significantly different (P=0.891 and P=0.787, respectively). In the multivariate analysis, macrovascular invasion (HR, 3.701; 95% CI, 1.313-9.10.437; P=0.013) was the only independent predictor of OS. Although the clinicopathological characteristics of the BDTT group suggested more advanced stage disease and poorer oncological outcomes than the group without BDTT, BDTT was not a poor prognostic factor for patients with HCC who underwent liver resection. Curative resection is recommended for patients with HCC and BDTT, even for those with poor liver function, after proper perioperative management in order to achieve good long-term survival.

Surgical Outcomes of Hepatocellular Carcinoma With Bile Duct Tumor Thrombus: A Korea-Japan Multicenter Study

OBJECTIVE

To identify optimal surgical methods and the risk factors for long-term survival in patients with hepatocellular carcinoma accompanied by macroscopic bile duct tumor thrombus (BDTT).

SUMMARY BACKGROUND DATA

Prognoses of patients with hepatocellular carcinoma accompanied by BDTT have been known to be poor. There have been significant controversies regarding optimal surgical approaches and risk factors because of the low incidence and small number of cases in previous reports.

METHODS

Records of 257 patients from 32 centers in Korea and Japan (1992-2014) were analyzed for overall survival and recurrence rate using the Cox proportional hazard model.

RESULTS

Curative surgery was performed in 244 (94.9%) patients with an operative mortality of 5.1%. Overall survival and recurrence rate at 5 years was 43.6% and 74.2%, respectively. TNM Stage (P < 0.001) and the presence of fibrosis/cirrhosis (P = 0.002) were independent predictors of long-term survival in the Cox proportional hazards regression model. Both performing liver resection equal to or greater than hemihepatectomy and combined bile duct resection significantly increased overall survival [hazard ratio, HR = 0.61 (0.38-0.99); P = 0.044 and HR = 0.51 (0.31-0.84); P = 0.008, respectively] and decreased recurrence rate [HR = 0.59 (0.38-0.91); P = 0.018 and HR = 0.61 (0.42-0.89); P = 0.009, respectively].

CONCLUSIONS

Clinical outcomes were mostly influenced by tumor stage and underlying liver function, and the impact of BDTT to survival seemed less prominent than vascular invasion. Therefore, an aggressive surgical approach, including major liver resection combined with bile duct resection, to increase the chance of R0 resection is strongly recommended.

Septic Shock and Death after Microwave Ablation of Hepatocellular Carcinoma in a Liver Transplant Patient with a Bilioenteric Anastomosis

Percutaneous thermal ablation of hepatic tumors continues to play an integral role in the treatment of early-stage primary or secondary hepatic malignancies. Interventional radiologists must be familiar with potential complications of this procedure, associated risk factors, and methods for prevention. The authors report a devastating case of septic shock and death following percutaneous microwave ablation of a solitary hepatocellular carcinoma in a liver transplant patient with a bilioenteric anastomosis (BEA). We review the literature regarding prophylactic antibiotic regimens and bowel preparation prior to performing thermal ablation in patients with BEAs.

Adverse effects of irreversible electroporation of malignant liver tumors under CT fluoroscopic guidance: a single-center experience

PURPOSE

We aimed to describe the frequency of adverse events after computed tomography (CT) fluoroscopy-guided irreversible electroporation (IRE) of malignant hepatic tumors and their risk factors.

METHODS

We retrospectively analyzed 85 IRE ablation procedures of 114 malignant liver tumors (52 primary and 62 secondary) not suitable for resection or thermal ablation in 56 patients (42 men and 14 women; median age, 61 years) with regard to mortality and treatment-related complications. Complications were evaluated according to the standardized grading system of the Society of Interventional Radiology. Factors influencing the occurrence of major and minor complications were investigated.

RESULTS

No IRE-related death occurred. Major complications occurred in 7.1% of IRE procedures (6/85), while minor complications occurred in 18.8% (16/85). The most frequent major complication was postablative abscess (4.7%, 4/85) which affected patients with bilioenteric anastomosis significantly more often than patients without this condition (43% vs. 1.3%, P = 0.010). Bilioenteric anastomosis was additionally identified as a risk factor for major complications in general (P = 0.002). Minor complications mainly consisted of hemorrhage and portal vein branch thrombosis.

CONCLUSION

The current study suggests that CT fluoroscopy-guided IRE ablation of malignant liver tumors may be a relatively low-risk procedure. However, patients with bilioenteric anastomosis seem to have an increased risk of postablative abscess formation.

Successful resection of hepatocellular carcinoma with bronchobiliary fistula caused by repeated transcatheter arterial embolizations: Report of a case

Bronchobiliary fistula (BBF) is a rare but life-threatening condition. We herein describe a rescued case of a patient with hepatocellular carcinoma (HCC) who developed BBF as a late complication of transcatheter arterial embolization (TAE). A 66-year-old man underwent repeated TAE for a large HCC during a 3-year period. Massive biliptysis developed after the last treatment and bronchoscopy proved the presence of BBF. Radiological studies exhibited a necrotic HCC in the right liver with a tumor thrombus protruding into the common bile duct. Localized pneumonia was also present in the right lung. A right hemihepatectomy with a bile duct tumor thrombectomy and a right lower lobectomy of the lung were performed. He is presently doing well at 6 months after surgery. Increased intraluminal pressure of the biliary system due to obstruction by the tumor thrombus is considered to have led to the rupture of the liver abscess into the bronchus, thus creating a BBF. This is the first successfully resected case of HCC associated with BBF.

Surgical results for hepatocellular carcinoma with bile duct invasion: a clinicopathologic comparison between macroscopic and microscopic tumor thrombus

BACKGROUND

The aim of this study was to evaluate the prognostic factors and long-term results after surgery in patients with hepatocellular carcinoma (HCC) with bile duct invasion.

METHODS

The records of 38 HCC patients with microscopic (tumor thrombus was found in more than the second order branch of the biliary tree; n = 19) and macroscopic (tumor thrombus was found in no more than the second order branch of the biliary tree; n = 19) bile duct invasion were reviewed in this study. Survival rates were calculated with regard to 18 clinicopathological factors. A log-rank analysis was performed to identify which factors predict the prognosis. The relationships between the degree of bile duct invasion and 17 clinicopathologic factors were also compared.

RESULTS

The overall 1-, 3-, and 5-year survival rates were 79%, 45%, and 33%, respectively. The indicators of a favorable prognosis included no intrahepatic metastases, curative surgical resection, and macroscopic bile duct invasion.

CONCLUSION

We found a favorable long-term postoperative result for HCC patients with macroscopic bile duct invasion. Even if HCC tumor thrombus is recognized in the major branches of bile duct, extensive and curative surgical treatment should be recommended when hepatic functional reserve is satisfactory without intrahepatic metastases.

Cholangitis and Liver Abscess after Percutaneous Ablation Therapy for Liver Tumors: Incidence and Risk Factors

PURPOSE

To determine the risk factors of cholangitis and liver abscess occurring after percutaneous ablation therapy for liver tumors.

MATERIALS AND METHODS

Between October 1995 and September 2002, 358 patients with 455 liver tumors underwent a total of 683 ablation procedures, such as percutaneous ethanol injection (PEI), percutaneous microwave coagulation (PMC), and radiofrequency (RF) ablation therapy. With a retrospective review of medical records, the rates and outcomes of cholangitis and/or liver abscess occurring after ablation therapy were evaluated. The relationship between cholangitis and/or liver abscess and multiple variables (age, disease, Child-Pugh class, size of nodules, multiplicity of nodules, history of transcatheter arterial embolization, presence of bilioenteric anastomosis, and lack of prophylactic antibiotics administration) were statistically analyzed.

RESULTS

Cholangitis and/or liver abscess occurred in 10 sessions (1.5%) in 10 patients: six sessions after PEI, three sessions after PMC, and one session after RF ablation. Both cholangitis and liver abscess were noted in seven sessions, cholangitis was noted in two, and liver abscess was noted in one. Six patients recovered, but two developed recurrent cholangitis and liver abscess, one developed lung abscess complicated with liver abscess, and one died of septic shock associated with cholangitis. On stepwise regression analysis, bilioenteric anastomosis was the sole significant predictor of cholangitis and/or liver abscess formation (P <.001; odds ratio = 36.4; 95% CI = 9.67-136.9).

CONCLUSION

Bilioenteric anastomosis strongly correlated with the development of cholangitis and/or liver abscess after percutaneous ablation therapy. Close posttreatment attention should be paid to this subgroup of patients.

Adverse events during radiofrequency treatment of 582 hepatic tumors

OBJECTIVE

We describe the rates and potential risk factors of complications of radiofrequency ablation of hepatic tumors. SUBJECTS AND METHODS. Over a 5-year period, 312 patients underwent 350 sessions of radiofrequency ablation (124 intraoperative and 226 percutaneous) for treatment of 582 liver tumors including 115 hepatocellular carcinomas and 467 metastatic tumors. The chi-square test was used for a group-to-group comparison of the occurrence of adverse events.

RESULTS

Thirty-seven (10.6%) adverse events and five (1.4%) deaths were related to radiofrequency treatment. The deaths were caused by liver insufficiency (n = 1), colon perforation (n = 1), and portal vein thrombosis (n = 3). Portal vein thrombosis was significantly (p < 0.00001) more frequent in cirrhotic livers (2/5) than in noncirrhotic livers (0/54) after intraoperative radiofrequency ablation performed during a Pringle maneuver. Liver abscess (n = 7) was the most common complication. Abscess occurred significantly (p < 0.00001) more frequently in patients bearing a bilioenteric anastomosis (3/3) than in other patients (4/223). We encountered five pleural effusions, five skin burns, four hypoxemias, three pneumothoraces, two small subcapsular hematomas, one acute renal insufficiency, one hemoperitoneum, and one needle-tract seeding. The 6.3% of minor complications did not require specific treatment or a prolonged hospital stay. Among the 5.7% major complications, 3.7% required less than 5 days of hospitalization for treatment or surveillance and 2% required more than 5 days for treatment.

CONCLUSION

Radiofrequency ablation of liver tumors is a well-tolerated technique, but caution should be exercised when treating patients with a bilioenteric anastomosis, and radiofrequency ablation during vascular occlusion in cirrhotic livers should be avoided.

Clinicopathologic evaluation of hepatocellular carcinoma with bile duct thrombi

BACKGROUND

The aim of this study was to evaluate the clinicopathologic characteristics of patients with hepatocellular carcinoma (HCC) and bile duct thrombi (BDT).

PATIENTS

Seventeen patients with HCC and BDT among 671 patients with HCC who underwent hepatic resection were enrolled in this study.

RESULTS

There were no significant differences in the survival rates between patients with and those without BDT, although the rate of stage IV or portal vein invasion was significantly higher in patients with HCC and BDT than in those with HCC but without BDT. In 9 of 17 patients with BDT, preoperative jaundice was observed. Five of the 17 patients underwent a bile duct resection combined with hepatic resection, and 12 patients underwent hepatic resection with removal of the BDT without bile duct resection. None of the patients had histopathologic evidence of direct tumor invasion into the bile duct wall or of any tumor recurrence related to the BDT. There were no significant differences in the survival rates between patients who underwent bile duct resection and those who did not.

CONCLUSION

Hepatic resection and the removal of BDT without bile duct resection were sufficient surgical interventions to treat patients with HCC and BDT.