Hepatoduodenal fistula formation following transcatheter arterial chemoembolization and radiotherapy for hepatocellular carcinoma: treatment with endoscopic Histoacryl injection

Missing a Lipiodol-laden hepatocellular carcinoma?: Silent iatrogenic hepatoduodenal fistula after transarterial chemoembolization: a case report

RATIONALE

Owing to the abundant collateral blood supply to the duodenum, the development of a hepatoduodenal fistula after transarterial chemoembolization (TACE) is an extremely rare complication that usually requires hospitalization and intensive medical intervention. Here, we report a case of a silent hepatoduodenal fistula following TACE.

PATIENT CONCERNS

A 74-year-old man with a history of alcoholic liver cirrhosis and type 2 diabetes. He had undergone a partial hepatectomy due to hepatocellular carcinoma (HCC) 7 years ago. In addition, he had undergone 4 TACEs for the treatment of recurrent HCCs but still had a viable tumor in S4b of the liver, which abuts the duodenal 1st portion.

DIAGNOSES

HCC.

INTERVENTIONS

The patient underwent a 5th TACE and was discharged from the hospital without major adverse events.

OUTCOMES

Follow-up computed tomography scans showed a 2 cm-sized air cavity instead of a compact Lipiodol-laden tumor in S4b, which had shrunk over time. The patient had experienced a fluctuating nonspecific mild fever for 3 months, with improvements in symptoms and laboratory findings following conservative treatment alone.

LESSONS

Hepatic fistulas may arise following TACE for HCCs near the gastrointestinal tract and may be present with nonspecific symptoms. This case suggests that increased efforts should be directed toward achieving selective embolization when treating HCC adjacent to the gastrointestinal tract, with close monitoring required after treatment.

Duodenal Hemorrhage Due to an Invasive Hepatocellular Carcinoma Controlled by Transarterial Embolization

Upper gastrointestinal (GI) bleeding due to duodenal invasion is a very unusual presentation revealing the initial diagnosis of hepatocellular carcinoma (HCC), especially in patients without cirrhosis. No clear recommendations are available in this setting. A 68-year-old man was admitted to the emergency department with melena. The esophagogastroduodenoscopy (EGD) revealed an oozing hemorrhagic ulcer of the duodenal bulb (Forrest I b) secondary to an invasive, undetermined bulky liver mass that was biopsied. The histopathological examination confirmed an HCC. The patient was started on chemotherapy (Gemcitabine and Oxaliplatin) with good initial response. Nevertheless, after eight months of treatment, there was a recurrence of the ulcer bleeding and a disease progression was identified. Selective transarterial embolization (TAE) was used to control the duodenal bleeding, permitting the patient to receive immunotherapy with a long-lasting control of the disease. Our case report suggests that selective TAE is a therapeutic option that can be used to stop GI bleeding due to invasive HCC in order to allow oncological treatment.

Hepatoduodenal fistula closure diagnosed and characterized Ecoendoscopically (EUS) and managed by OTSC CLIP OVESCO: A case report

Introduction

Gastrointestinal (GI) tract perforations are a significant source of morbidity in clinical practice; therefore, an early diagnosis is fundamental for early management. In management, surgery is the definitive therapy; however, there is evidence of a strong response to conservative measurements.

Presentation of case

A 53-year-old man known for a laparoscopic cholecystectomy with difficult access and postoperative complications was admitted to our emergency department due to a five-day clinical history comprising acute abdominal pain and feverish peaks up to 38.4 °C. Diagnosis methods CT and NMR were performed but did not lead to a clear diagnosis. Therefore, a EUS was performed observing an anechoic path that communicates the duodenal wall with a right subhepatic collection that was in contact with the proximal bile duct, thickening its walls. A 5 mm fistulous orifice was found. The hepatoduodenal fistula was close endoscopically with the over-the-scope-clip OVESCO OTSC. Post endoscopic closure course was uneventful.

Discussion

Duodenal fistulae are considered one of the most serious complications in gastrointestinal surgery, when conventional diagnosis methods do not permit the clinicians to get either a medical diagnosis or the management; the EUS can. Advances in interventional endoscopic techniques offer an alternative management for the closure of GI fistulae.

Conclusion

Whenever the presence of an organized fistula is clinically suspected, EUS can be considered a useful tool that allows not only the characterization of the fistulous path and but also the definition of the minimally invasive endoscopic treatment.

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Duodenal fistulae are considered one of the most serious complications in gastrointestinal surgery.

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Whenever the presence of an organized intestinal fistula is clinically suspected, EUS can be considered a useful tool that allows characterizing the fistulous path and defining the minimally invasive endoscopic treatment.

Recurrent hepatogastric fistula during lenvatinib therapy for advanced hepatocellular carcinoma managed by over-the-scope clip closure: a case report

Objective: Lenvatinib is an oral multitarget tyrosine kinase inhibitor (mTKI) and is recommended for patients with advanced hepatocellular carcinoma (HCC) with Child-Pugh A liver function, who are not amenable to surgical resection, locoregional treatment, or transcatheter arterial chemoembolization. Hepatogastric fistula is a rare complication with a poor prognosis in patients with HCC. Previous reports on fistula formation during mTKI therapy for HCC were all associated with sorafenib. Here, we report the first case of recurrent hepatogastric fistula during lenvatinib therapy for advanced HCC managed using an over-the-scope clip (OTSC). Patient: We present the case of a 73-year-old man with alcoholic liver cirrhosis who was treated for multiple HCC for 7 years. HCC was treated using repetitive transcatheter arterial chemoembolization, radiofrequency ablation, and sorafenib. Owing to disease progression, lenvatinib treatment was started. During lenvatinib treatment, recurrent hepatogastric fistulas developed. An OTSC was useful for fistula closure and prevention of recurrence. Results: The major cause of fistula formation is considered to be the direct invasion of HCC; however, HCC treatment might also be a contributing factor in our case. In addition, OTSC was useful for fistula closure. Conclusion: Clinicians should be aware of the fatal complications during HCC treatment.

Utility of endoscopic ultrasound and endoscopy in diagnosis and management of hepatocellular carcinoma and its complications: What does endoscopic ultrasonography offer above and beyond conventional cross-sectional imaging?

Hepatocellular carcinoma constitutes over 90% of the primary liver tumors, the rest being cholangiocarcinoma. It has an insidious presentation, which is responsible for the delayed presentation. Hence, the management strategy relies on screening to diagnose it an early stage for curative resection and/or treatment with local ablative techniques or chemotherapy. However, even with different screening programs, more than 60% of tumors are still detected at an advanced stage, leading to an unchanged mortality rate, thereby implying a room for improvement in the screening and diagnostic process. In the last few years, there has been evolution of utility of endoscopy, specifically endoscopic ultrasonography along with Fine needle aspiration, for this purpose, which we comprehensively review in this article.