Post-trans-arterial chemoembolization hepatic necrosis and biliary stenosis: Clinical charateristics and endoscopic approach

Abstract

Liver cancer is the fifth most common tumor and the second highest death-related cancer in the world. Hepatocarcinoma (HCC) represents 90% of liver cancers. According to the Barcelona Clinic Liver Cancer group, different treatment options could be offered to patients in consideration of tumor burden, liver function, patient performance status and biochemical marker serum concentration such as alpha-fetoprotein. Trans-arterial chemoembolization (TACE) is the treatment of choice in patients with diagnosis of unresectable HCC not eligible for liver transplantation, and preserved arterial supply. TACE is known to be safe and its complications are generally mild such as post-TACE syndrome, a self-resolving adverse event that occurs in about 90% of patients after the procedure. However, albeit rarely, more severe adverse events such as biloma, sepsis, hepatic failure, chemoagents induced toxicities, and post-TACE liver necrosis can occur. A prompt diagnosis of these clinical conditions is fundamental to prevent further complications. As a result, biliary stenosis could be a rare post-TACE necrosis complication and can be difficult to manage. Complications from untreated biliary strictures include recurring infections, jaundice, chronic cholestasis, and secondary biliary cirrhosis.

Keywords: Biliary stenosis; Hepatocarcinoma; Multistenting; Trans-arterial Chemoembolization.

Figure 1

Endoscopic retrograde cholangiopancreatography performed at admission to clarify the radiological findings showed a serrated biliary hilar stenosis (orange circle) and dilatation of intrahepatic bile ducts.

Figure 2

Choledoscopy with Spyglass II revealed the presence of fixed tissue in the hepatic hilum causing bile duct stenosis.

Figure 3

Magnetic resonance imaging cholangiopancreatography showing persistence of bile duct and intrahepatic biliary dilation after endoscopic treatment.