Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma: A case report and review of the literature

Abstract

Background: Radiofrequency ablation (RFA) and microwave ablation (MWA) represent the standard of care for patients with early hepatocellular carcinoma (HCC) who are unfit for surgery. The incidence of reported adverse events is low, ranging from 2.4% to 13.1% for RFA and from 2.6% to 7.5% for MWA. Gastrointestinal tract (GIT) injury is even more infrequent (0.11%), but usually requires surgery with an unfavourable prognosis. Due to its low incidence and the retrospective nature of the studies, the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics, comorbidities and treatment approaches.

Case summary: A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location. He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever. A subcutaneous abscess was diagnosed and treated by percutaneous drainage. A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall. The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulent abdominal collection. An over-the-scope clip (OTSC) was used to successfully close the defect.

Conclusion: This is the first reported case of RFA-related GIT injury to have been successfully treated with an OTSC, which highlights the role of this endoscopic treatment for the management of this complication.

Keywords: Case report; Complications; Endoscopy; Gastrointestinal tract; Hepatocellular carcinoma; Over-the-scope clip; Radiofrequency ablation.

Figure 1

Contrast-enhanced ultrasonography showing the subcapsular 20 mm hepatocellular carcinoma at the 4^th liver segment. A: During wash-in phase; B: During wash-out phase.

Figure 2

Abdominal film with oral water-soluble contrast agent showing a gastric perforation with a gastro-cutaneous fistulous tract (surgical drain in place).

Figure 3

Endoscopic finding of the gastric perforation in communication with a purulent collection. Pylorus can be seen in the lower part of the picture.

Figure 4

Endoscopic closure of the perforation using an over-the-scope clip.

Figure 5

Abdominal film with oral water-soluble contrast agent showing no active leakage from the stomach. The over-the-scope clip can be seen in gastric antrum.