Hemorrhagic complications of percutaneous radiofrequency ablation for liver tumors

Risk Factors for Hospitalization Duration Longer Than 24 Hours Following Percutaneous Radiofrequency Ablation of Liver Tumours

PURPOSE

Prior studies have described complications of radiofrequency ablation (RFA) of liver tumours. The aim of this study was to identify risk factors for hospitalization duration longer than 24 hours following RFA of liver tumours.

METHODS

This retrospective, single-centre study included patients with liver tumours undergoing RFA between October 2017 and July 2020. Medical records were reviewed to collect patient, tumours, and procedure characteristics for each RFA session. The association between potential risk factors and duration of hospitalization (less than or more than 24 hours) was analyzed using univariate and multivariate logistic regressions.

RESULTS

Our study included 291 patients (mean age: 65.2 ± 11.2 [standard deviation]; 201 men) undergoing 324 RFA sessions. Sixty-eight sessions (21.0%) resulted in hospitalization of more than 24 hours. Multivariate analysis identified each additional needle insertion per session (OR 1.4; 95% CI [1.1-1.9]; P = .02), RFA performed in segment V (OR 2.8; 95% CI [1.4-5.7]; P = .004), and use of artificial pneumothorax (OR 14.5; 95% CI [1.4-146.0]; P = .02) as potential risk factors. A history of hepatic encephalopathy (OR 2.6; 95% CI [1.1-6.0]; P = .03) was only significant in univariate analysis. Post-hoc, subgroup analysis of patients with hepatocellular carcinoma (69.8%) did not identify other risk factors.

CONCLUSION

Risk factors for a hospitalization duration longer than 24 hours include a higher number of needle insertions per session, radiofrequency ablation in segment V, and use of an artificial pneumothorax.

Lusutrombopag Reduces the Risk of Hemoperitoneum Caused by Percutaneous Radiofrequency Ablation for Hepatocellular Carcinoma Compared with Platelet Transfusion

INTRODUCTION

Patients with liver cirrhosis develop thrombocytopenia and an increased risk of bleeding events after invasive procedures. Lusutrombopag, a thrombopoietin receptor agonist, can increase the platelet count. This study assessed whether lusutrombopag reduces the risk of hemoperitoneum following percutaneous radiofrequency ablation for hepatocellular carcinoma, compared with platelet transfusion.

METHODS

Participants in the present study comprised patients with severe thrombocytopenia (platelet count <50,000/μL) enrolled between November 2012 and March 2020, excluding patients with idiopathic thrombocytopenia or anticoagulant use. Hemoperitoneum rate, hemostasis rate, hemoglobin reduction rate, rate of achieving a platelet count ≥50,000/μL, and increases in platelet count and factors contributing to hemoperitoneum were retrospectively analyzed.

RESULTS

This study enrolled 41 patients, comprising 18 patients administered lusutrombopag and 23 patients who received platelet transfusion. The major hemoperitoneum rate after RFA was tend to be lower in the lusutrombopag group (0%) than in the platelet transfusion group (21.7%). All of the major hemoperitoneum was observed in the platelet transfusion group. Hemoglobin reduction rate was lower in the lusutrombopag group (-0.17%) than in the platelet transfusion group (6.79%, p = 0.013). Hemostasis rate was lower in the lusutrombopag group (0%) than in the platelet transfusion group (21.7%, p = 0.045). The rate of achievement of platelet counts ≥50,000/μL the day after RFA was higher in the lusutrombopag group (100%) than in the platelet transfusion group (60.9%, p = 0.005).

CONCLUSION

Lusutrombopag may be able to perform RFA more safely with respect to the hemoperitoneum caused by percutaneous radiofrequency ablation compared with platelet transfusion.

Tips for Preparing and Practicing Thermal Ablation Therapy of Hepatocellular Carcinoma

Thermal ablation therapy, including radiofrequency ablation (RFA) and microwave ablation (MWA), is considered the optimal locoregional treatment for unresectable early-stage hepatocellular carcinomas (HCCs). Percutaneous image-guided ablation is a minimally invasive treatment that is being increasingly performed because it achieves good clinical outcomes with a lower risk of complications. However, the physics and principles of RFA and MWA markedly differ. Although percutaneous thermal ablation under image guidance may be challenging in HCC cases with limited access or a risk of thermal injury, a number of ablative techniques, each of which may be advantageous and disadvantageous for individual cases, are available. Furthermore, even when a HCC is eligible for ablation based on tumor selection and technical factors, additional patient factors may have an impact on whether it is the appropriate treatment choice. Therefore, a basic understanding of the advantages and limitations of each ablation device and imaging guidance technique, respectively, is important. We herein provide an overview of the basic principles of tissue heating in thermal ablation, clinical and laboratory parameters for ablation therapy, preprocedural management, imaging assessments of responses, and early adverse events. We also discuss associated challenges and how they may be overcome using optimized imaging techniques.

A study on prevention of bleeding complications using lusutrombopag for safe RFA in patients with hepatocellular carcinoma with low platelet counts: prospective observational study

BACKGROUND

Platelet (PLT) transfusion was the most practical way to increase patients' PLT counts before invasive hepatic procedures such as radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). A novel drug that raises the PLT count by acting on the thrombopoietin receptor has recently become available.

METHODS

Lusutrombopag 3 mg was administered daily for 7 days to patients who underwent RFA for liver tumors with low PLT counts (< 50,000 PLT µL^- 1). We collected demographic data concerning the patients' liver function and PLT counts.

RESULTS

Lusutrombopag was administered to 91 patients, with a median age of 71 years (range 51-86). Forty-two patients had hepatitis C, 12 had hepatitis B, 21 had alcoholic liver disease, 11 had nonalcoholic steatohepatitis, and five had other diseases. The median Child-Pugh score was 7 (range 5-11). Thirty-seven patients had stage I tumors, 41 had Stage II, 12 had stage III, and one had stage IV. PLT count was elevated from 4.4 × 10⁴ ± 1.4 × 10⁴ to 8.6 × 10⁴ ± 2.5 × 10⁴ PLT µL^- 1. Lusutrombopag administration prevented PLT transfusions in 84/91 patients (92%). No patient had bleeding complications after RFA. One had portal thrombosis after lusutrombopag administration. Patients who achieved PLT counts of > 50,000 PLT µL^- 1 had higher PLT counts before lusutrombopag administration. The degree of splenomegaly did not affect the rate of PLT count elevation. There was no specific adverse effect by administrating lusutrombopag for patients with PLT counts of around 50,000 µL^- 1 but > 50,000 µL^- 1.

CONCLUSIONS

Lusutrombopag administration before RFA was effective and seemed to be relatively safe for hepatocellular carcinoma patients with low PLT counts.

TRIAL REGISTRATION

This study was approved by Japanese Red Cross Medical Center Institutional Reseach Comittie (#862, 07/03/2016), and was registered in a publically accessible primary register (#UMIN000046629, registered date: 14/01/2022).

Indian College of Radiology and Imaging Guidelines on Interventions in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies and a significant cause of cancer-related death. Treatment of HCC depends on the stage of the tumor. As many patients with HCC are not deemed fit for surgical resection or liver transplantation, locoregional therapies play an essential role in the management. Image-guided locoregional treatments include percutaneous ablative therapies and endovascular therapies. The choice of an individual or a combination of therapies is guided by the tumor and patient characteristics. As the outcomes of image-guided locoregional treatments depend on the ability to achieve necrosis of the entire tumor along with a safety margin around it, it is mandatory to follow standard guidelines. In this manuscript, we discuss in detail the various aspects of image-guided locoregional therapies to guide interventional radiologists involved in the care of patients with HCC.

Complications after Thermal Ablation of Hepatocellular Carcinoma and Liver Metastases: Imaging Findings

Tumour ablation is a strategy of treatment of hepatic tumours in patients with small hepatocellular carcinoma (HCC) (<3 cm) or in patients unfit for surgical resection. Moreover, tumor ablation can be used as an adjuvant therapy or may be used in association with resection in case of patients with poor functional liver disease. These types of treatment usually could be performed percutaneously under image guidance. The most clinically verified and used ablation modalities are Radiofrequency Ablation (RFA) and microwave ablation (MWA). However, despite both of them are considered minimally invasive techniques, they could be related to post-procedural complications. The International Working Group on Image-Guided Tumor and the Society of Interventional Radiology (SIR) identified major and minor post-ablative complications. Major complications, as vascular complications, occur in 2.2% to 3.1% of cases and include all the high risk pathological conditions which could increase the level of care or result in hospital admission or substantially prolonged hospital stay (SIR classifications C−E). Minor complications, as biliary complications, occur in 5% to 8.9% and include self-limiting conditions that are considered to be of low risk for the patient’s outcome. The purpose of this review is to summarise the main pathological ultrasound (US) and Computed Tomography (CT) findings, that may arise after ablative treatment. To simplify the analysis, the pathological pictures are divided according to the site of damage into vascular, biliary and extrahepatic complications.

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis

The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.

Haemobilia secondary to an arterio-biliary fistula: A rare complication of intra-operative microwave ablation of hepatocellular carcinoma

A rare case of arterio-biliary fistula and haemobilia complicating intra-operative microwave ablation of hepatocellular carcinoma in a 58-year-old woman with cirrhosis.

Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia

BACKGROUND

Gaps of knowledge still exist about the potential association between severe thrombocytopenia and increased risk of procedure-associated bleeding in patients with liver disease.

METHODS

In this narrative review, we aimed at examining the association between procedure-related bleeding risk and platelet count in patients with cirrhosis and severe thrombocytopenia in various settings. We updated to 2020 a previously conducted literature search using MEDLINE/PubMed and EMBASE. The search string included clinical studies, adult patients with chronic liver disease and thrombocytopenia undergoing invasive procedures, any interventions and comparators, and haemorrhagic events of any severity as outcome.

RESULTS

The literature search identified 1276 unique publications, and 15 studies met the inclusion criteria and were analysed together with those identified by the previous search. Most of the new studies included in our analysis did not assess the association between post-procedural bleeding risk and platelet count alone in patients with chronic liver disease. Furthermore, some results could have been biased by prophylactic platelet transfusions. A few studies found that severe thrombocytopenia may be predictive of bleeding following percutaneous liver biopsy, dental extractions, percutaneous ablation of liver tumours and endoscopic polypectomy.

CONCLUSIONS

Currently available literature cannot support definitive conclusions about the appropriate target platelet counts to improve the risk of bleeding in cirrhotic patients who underwent invasive procedures; moreover, it showed enormous variability in the use of prophylactic platelet transfusions.

Radiofrequency Ablation of Liver Tumors in Patients on Antithrombotic Therapy: A Case-Control Analysis of over 10,000 Treatments

PURPOSE

To evaluate the safety of radiofrequency ablation (RFA) for liver tumors in patients on antithrombotic therapy.

MATERIALS AND METHODS

A total of 10,653 consecutive RFA treatments in 3,485 patients with liver tumors were analyzed. The incidence of complications was analyzed on a treatment basis. The treatments for patients who had received antithrombotic medication up to 1 week prior to RFA comprised the antithrombotic therapy group (n = 806), and the others comprised the control group (n = 9,847). Antithrombotic agents were ceased prior to RFA (aspirin, ticlopidine, clopidogrel, and prasugrel ceased 7 days before RFA; cilostazol, 2 or 3 days before RFA; warfarin, 3 days before RFA; and direct oral anticoagulants, 1 day before RFA) and resumed as soon as possible after RFA. Logistic regression analysis was performed to assess whether the antithrombotic therapy increased the risk of hemorrhagic complications.

RESULTS

Hemorrhagic complications were diagnosed after 6 treatments (0.7%) in the antithrombotic group and 48 (0.5%) in the control group, and there was no significant difference between the groups (P = .30). In 3 treatments, hemorrhage was diagnosed on or after 8 days of RFA, all of which were in the antithrombotic group. Thrombotic complications were diagnosed after 2 treatments (0.2%) in the antithrombotic group and after 5 (0.1%) in the control group. In a multivariate analysis, receiving antithrombotic therapy was not an independent risk factor for hemorrhagic complications (adjusted odds ratio, 1.52; 95% confidence interval, 0.60-3.87; P = .38).

CONCLUSIONS

RFA of liver tumors in patients on antithrombotic therapy is generally safe with appropriate cessation and resumption. Late-onset hemorrhage should be noted in the patients on antithrombotic therapy.

The development of a predictive risk model on post-ablation hemobilia: a multicenter matched case-control study

Objective:

This study aimed to develop a predictive risk model for post-ablation hemobilia.

Methods:

This was a retrospective, multicenter, matched case–control study. The case group comprised patients with hepatocellular carcinoma who developed post-ablation hemobilia (n = 21); the control group (n = 63) comprised patients with hepatocellular carcinoma but no post-ablation hemobilia; for each case, we included three controls matched for age, sex, platelet count, year of ablation therapy, and center. Univariate and multivariate regression analyses were performed to identify the risk factors for hemobilia. A risk score model was developed based on adjusted odds ratios (ORs).

Results:

The independent risk factors for occurrence of post-ablation hemobilia were maximum tumor diameter >47 mm [OR = 5.983, 95% CI (1.134–31.551)] and minimum distance from the applicator to the portal trunk ≤8 mm [OR = 4.821, 95% CI (1.225–18.975)]. The risk model was developed using the adjusted ORs; thus a score of 6 was assigned to the former and a score of 5 for the latter. The area under the curve of this risk model was 0.76. Significant hemodynamic instability and inaccurate embolization might increase the risk of recurrence of hemobilia.

Conclusion:

Tumor size >47 mm and distance of the applicator from the portal trunk ≤8 mm are independent risk factors for hemobilia. A predictive risk model for post-ablation hemobilia was developed using these risk factors.

Advances in knowledge:

This is the first study that developed a risk score model of post-ablation hemobilia. Risk factors of the recurrence of post-ablation hemobilia were also been identified.

Radiofrequency ablation and stereotactic body radiotherapy for hepatocellular carcinoma: should they clash or reconcile?

Until a few decades ago, surgical resection was the only valid option for treating hepatocellular carcinoma (HCC). However, various locoregional modalities including arterial-directed therapy, radiofrequency ablation (RFA), and radiotherapy have been recently shown to be effective. RFA is now established as a standard treatment for small localized HCCs, showing oncological results comparable to those of surgical resection in randomized studies. Stereotactic body radiotherapy (SBRT) is a modern radiotherapeutic modality that targets tumors with precision and delivers high radiation doses over a short period of time; it has particularly attracted clinical interest after its therapeutic efficacy was found to be similar to that of surgery in early-stage lung cancer. Given its potent disease control capability, SBRT has also been applied to early HCCs and demonstrated promising results in recent studies. It has also been noted for its suitability to treat tumors located in anatomical locations where RFA would be challenging. However, since its effectiveness has not been compared to that of RFA in randomized studies of patients eligible for RFA, the use of SBRT has been debated. This review was conducted to guide physicians from all fields involved in the treatment of early HCC. The therapeutic characteristics and indications of both SBRT and RFA are described, and recent comparative studies between the two modalities are discussed. In addition, we examined the factors that should be considered when selecting the appropriate treatments, and offer our recommendations.

Safety and efficacy of percutaneous radiofrequency ablation for hepatocellular carcinoma patients with haemophilia

Haemophilia is an X-linked inherited bleeding disorder caused by coagulation factor deficiency. Hepatocellular carcinoma (HCC) is a major complication associated with the disease. No study thus far has investigated the safety and efficacy of percutaneous radiofrequency ablation (RFA) for HCC in patients with haemophilia.

AIM

This study aimed to evaluate the safety and efficacy of RFA for HCC in haemophilia patients.

METHODS

From July 2008 to June 2019, 217 patients with HCC underwent 300 RFA sessions. Of these, 18 sessions were performed in ten haemophilia patients (H group) and 282 in 207 non-haemophilia patients (NH group). The patients' characteristics, incidence of haemorrhagic complications and rates of local tumour recurrence were compared between the groups.

RESULTS

A majority of the haemophilia patients received clotting factor concentrate replacement therapy before and after RFA treatment, with the aim of reaching a plasma clotting factor level of higher than 60%-80%. Twelve haemorrhagic complications were observed in the NH group (4.2%; 12/282). Major bleeding requiring control procedures was observed in two patients and minor bleeding with careful observation was noted in ten patients. No bleeding complications were observed in the H group (0/18). There were no significant differences in the 5-year local tumour recurrence rates after RFA treatment between the groups (35.0% in the H group and 32.1% in the NH group).

CONCLUSION

RFA could be an effective and a safe method for HCC treatment in patients with haemophilia.

Massive abdominal hemorrhage after radiofrequency ablation of recurrent hepatocellular carcinoma with successful hemostasis achieved through transarterial embolization: a case report

Acute massive abdominal hemorrhage after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is an infrequent and severe complication. Delayed diagnosis and treatment may be life-threatening. We herein describe a 60-year-old man with a history of postoperative HCC. A new nidus of HCC was found in his right liver lobe after abdominal magnetic resonance imaging and intraoperative angiography. The patient then underwent computed tomography-guided RFA. However, 7 hours after RFA, he suddenly developed dizziness, nausea, abdominal distension, hematuria, a decreased blood pressure, and an increased heart rate. Diagnostic abdominal puncture produced bloody liquid, and angiography demonstrated hemorrhage in the right hepatic artery. Transarterial embolization was performed following the administration of an appropriate amount of tissue emulsion to embolize the source of hemorrhage. Following this treatment, the patient had no further bleeding. Neither the hemorrhage nor the HCC lesions had recurred after 3 months of follow-up.

Factors Associated With Local Tumor Control and Complications After Thermal Ablation of Colorectal Cancer Liver Metastases: A 15-year Retrospective Cohort Study

INTRODUCTION

The purpose of this study was to identify risk factors associated with local tumor progression-free survival (LTPFS) and complications after colorectal liver metastases (CLM) thermal ablation (TA).

PATIENTS AND METHODS

This retrospective analysis included 286 patients with 415 CLM undergoing TA (radiofrequency and microwave ablation) in 378 procedures from January 2003 to July 2017. Prior hepatic artery infusion (HAI), bevacizumab, pre-existing biliary dilatation, ablation modality, minimal ablation margin (MM), prior hepatectomy, CLM number, and size were analyzed as factors influencing complications and LTPFS. Statistical analysis included the Kaplan-Meier method, Cox proportional hazards model, competing risk analysis, univariate/multivariate logistic/exact logistic regressions, and the Fisher exact test. Complications were reported according to modified Society of Interventional Radiology guidelines.

RESULTS

The median follow-up was 31 months. There was no LTP for MM > 10 mm. Smaller tumor size, increased MM, and prior hepatectomy correlated with longer LTPFS. The major complications occurred following 28 (7%) of 378 procedures. There were no biliary complications in HAI-naive patients, versus 11% in HAI patients (P < .001), of which 7% were major. Biliary complications predictors in HAI patients included biliary dilatation, bevacizumab, and MM > 10 mm. In HAI patients, ablation with 6 to 10 mm and > 10 mm MM resulted in major biliary complication rates of 4% and 21% (P = .0011), with corresponding LTP rates of 24% and 0% (P = .0033). In HAI-naive patients, the LTP rates for 6 to 10 mm and > 10 mm MM were 27% and 0%, respectively.

CONCLUSIONS

No LTP was seen for MM > 10 mm. Biliary complications occurred only in HAI patients, especially in those with biliary dilatation, bevacizumab, and MM > 10 mm. In HAI patients, MM of 6 to 10 mm resulted in 76% local tumor control and 4% major biliary complications incidence.

SN, Kulkarni S, Shetty NS, Gupta A, Gupta S. Indian Society of Vascular and Interventional Radiology Expert Consensus Statements for Ablation in Hepatocellular Carcinoma: Part I

Locoregional therapies play an important role in the management of hepatocellular carcinoma (HCC). Percutaneous ablation is one of the most commonly employed nonsurgical methods for treating very early and early HCC. For small HCCs, ablation is potentially curative and competes with surgical resection. The widespread availability and the spectrum of ablative techniques mandate uniform approach among interventional radiologists. Thus, it is desirable to have a consensus regarding various aspects of liver ablation. This article represents a consensus document of the experts from the Indian Society of Vascular and Interventional Radiology involved in the care of patients with HCC. The statements are presented in two parts.

Single-centre retrospective review of risk factors for local tumour progression and complications in radiofrequency ablation of 555 hepatic lesions

INTRODUCTION

This study aimed to assess safety, local tumour progression (LTP) and risk factors for LTP after radiofrequency ablation (RFA) of liver tumours in a single centre.

METHODS

All consecutive patients treated with RFA for liver tumours between January 2009 and October 2012 were included. Previously treated lesions that progressed were excluded. Using electronic medical records, the following data was captured: patient demographics, pre-procedural laboratory results, Child-Pugh status, tumour characteristics, development of tumoral seeding, RFA complications and LTP. Possible risk factors for LTP were identified using Cox regression.

RESULTS

In total, 555 liver tumours were treated in 337 patients. 483 (87.0%) hepatocellular carcinomas, 52 (9.4%) colorectal metastases and 20 (3.6%) other tumour types were treated. Mean tumour size was 2.1 ± 1.1 (range 0.4-6.8) cm. Mean follow-up duration was 387 days. 416 (75.0%) lesions had no LTP at the last imaging. 70 (12.6%) patients had minor complications requiring observation, while 7 (1.3%) patients had significant complications requiring prolonged hospitalisation or further interventions. Only one case of tumour seeding was detected. Using multivariate Cox regression, the following factors were statistically significant in predicting LTP: hilar location (relative ratio [RR] 3.988), colorectal metastases (RR 2.075), size (RR 1.290) and younger age (RR 0.982).

CONCLUSION

RFA of liver tumours is safe and effective, with a low significant complication rate of 1.3%. Hilar lesions are most prone to LTP, followed by lesions that were larger in size and colorectal metastases. 75.0% of patients showed no LTP at the last follow-up.

Percutaneous Radiofrequency Ablation for Liver Tumors: Technical Tips

Percutaneous radiofrequency ablation (RFA) has been accepted as a minimally invasive therapeutic treatment for liver malignancies. Although RFA is usually applied for the treatment of small liver tumors (<3 cm), several technical developments have expanded the use of RFA. RFA is now used for the treatment of large liver tumors, and the number of complications associated with this treatment has decreased. These refinements may ultimately lead to better long-term prognosis. Here, we review recent refinements of liver RFA and provide technical tips.

Impact of an ultrasound-guided radiofrequency ablation training program on the outcomes in patients with hepatocellular carcinoma

PURPOSE

The aim of this study was to retrospectively evaluate the impact of a training program on the safety and efficacy of percutaneous ultrasound-guided radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 227 patients with 296 HCC nodules who underwent percutaneous RFA with or without transcatheter arterial chemoembolization at our institution were included. There were 163 men and 64 women with a mean age of 74.2±8.3 (SD) years (range: 41-89 years). Percutaneous ultrasound-guided RFA was performed by three trainees (205 HCC nodules in 157 patients) or a mentor (91 HCC nodules in 70 patients) after preprocedural preparation including planning ultrasonography. We compared background-related, tumor-related, and treatment-related factors, and local recurrence and complication rates between the trainee group and the mentor group. Similarly, we compared these variables among the years 2015, 2016, and 2017 for trainee group.

RESULTS

The proportion of easy-to-treat tumors in the trainee group (109/205; 53.2%) was greater than that in the mentor group (33/91; 36.3%) (P=0.020). No significant differences were observed in procedure difficulty among the years 2015, 2016, and 2017 for trainee group (easy-to-treat HCC nodules: 25/47; 53.2% vs. 39/79; 49.4% vs. 45/79; 57.0%. P=0.775). The local recurrence rate in the trainee group was 8.8% (18/205 HCC nodules) which was equivalent to 7.7% in the mentor group (7/91 HCC nodules). No significant differences were observed in local recurrence rate (8.8% vs. 7.7%, respectively; P=0.621) and major complication rate (1.3% vs. 1.4%, respectively; P=0.999) between the trainee group and the mentor group. No significant differences were observed in local recurrence rates ([5/47; 10.6%] vs. [11/79; 13.9%] vs. [2/79; 2.5%]) (P=0.109) and major complication rates ([1/36; 2.8%] vs. [1/62; 1.6%] vs. [0/59; 0%]) (P=0.701) between the years 2015, 2016, and 2017 for trainee group.

CONCLUSION

A well supervised training program that includes planning ultrasonography fosters the efficacy and treatment quality of RFA for HCC.

Hemobilia after CT-guided radiofrequency ablation of liver tumors: frequency, risk factors, and clinical significance

PURPOSE

The purpose of the study is to evaluate the frequency, risk factors, and clinical significance of hemobilia after percutaneous computed tomography (CT)-guided radiofrequency ablation (RFA) of liver tumors.

MATERIALS AND METHODS

From January 2013 to September 2016, 195 patients received 267 sessions of CT-guided RFA for liver tumors at our institution. The CT images during and immediately after the RFA were retrospectively reviewed. The frequency of hemobilia development and clinical outcome of patients with hemobilia were studied. Risk factors were identified by comparison between the hemobilia and non-hemobilia groups using univariate and multivariate analysis. The clinical courses of patients with hemobilia were also reviewed.

RESULTS

The frequency of CT detected hemobilia after RFA was 8.2% (22/267). The majority of the clinical courses were self-limited. Univariate analysis showed that the tumor numbers (p = 0.015), the central type puncture track (p < 0.001), the length of the puncture track (p = 0.033), and the platelet count (p = 0.026) were significantly associated with the development of hemobilia. Multivariate analysis demonstrated that the central type puncture track (p < 0.024) and the platelet count (p = 0.023) were significant independent risk factors.

CONCLUSION

Detection of hemobilia on CT images immediately after percutaneous RFA for liver tumors was not rare. Low platelet count and central type puncture track are independent risk factors. In most cases, hemobilia presented as a minor complication with favorable prognosis.

Thermal ablation of hepatocellular carcinoma in patients with abnormal coagulation function

OBJECTIVE

To evaluate the safety of thermal ablation for hepatocellular carcinoma (HCC) in patients with abnormal coagulation function.

METHODS

Fifty-seven HCC tumours in 50 patients were treated with thermal ablation. All patients had a meted platelet count <50 × 10⁹/L or international normalised ratio (INR) ≥ 1.7. Gastroscopy before ablation, platelet concentrate or fresh frozen plasma transfusion during ablation and contrast enhanced ultrasoundgraphy (CEUS)-guided ablation to cease needle tract bleeding were performed to reduce haemorrhage. The incidences of haemorrhage and other major complications were recorded and patients were followed up to observe the local tumour progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS) and recurrence-free survival (RFS) rates.

RESULTS

Two incidences of needle tract bleeding and one needle tract bleeding together with bleeding at the suture of the spleen fossa were found. Three needle tract bleeding events were detected by CEUS and ceased after CEUS-guided complementary ablation. CEUS failed to detect bleeding at the suture of the spleen fossa. Therefore, a laparotomy was conducted for haemostasis. No other major complications were found after ablation. The median follow-up periods were 18.7 ± 12.0 months (range 1 ∼ 42 months) and 1 LTP and 15 IDRs occurred. The 1-, 2- and 3-year OS rates were 84.8%, 82.7% and 82.7%, and RFS rates were 67.9%, 64.0% and 64.0%, respectively.

CONCLUSION

With gastroscopy before ablation, platelet concentrate or fresh frozen plasma transfusion during ablation and CEUS-guided ablation to cease needle tract bleeding, thermal ablation is a safe treatment for HCC in patients with abnormal coagulation function.

Embolization for Bleeding after Hepatic Radiofrequency Ablation

PURPOSE

To evaluate safety and clinical efficacy of embolization for management of bleeding after hepatic radiofrequency (RF) ablation.

MATERIALS AND METHODS

From January 2000 to December 2014, 5,196 patients with 9,743 tumors underwent 8,303 RF ablation sessions. Of these patients, 62 experienced bleeding after hepatic RF ablation; 15 patients (12 men and 3 women; mean age 62 y; range, 49-76 y) underwent embolization and composed the final study cohort. Tumors were hepatocellular carcinomas in 13 (87%) patients and metastatic adenocarcinomas from colorectal cancer in 2 (13%) patients. Mean number of tumors was 1.5 (22 nodules; range, 1-3). Tumor locations were segment I (n = 1), segment II (n = 2), segment III (n = 1), segment IV (n = 1), segment V (n = 3), segment VI (n = 5), segment VII (n = 1), and segment VIII (n = 9). Mean tumor size was 2.3 cm (range, 0.9-5 cm).

RESULTS

Median time interval between presentation and angiography was 22 hours (mean 38.4 h; range, 3-168 h). On angiography, contrast extravasation with or without pseudoaneurysm was seen in all 15 patients; 14 patients underwent transarterial embolization, and 1 patient underwent percutaneous transhepatic portal vein embolization. Successful hemostasis was achieved in all patients. There was no rebleeding within 30 days after embolization. No embolization-related major complications were observed.

CONCLUSIONS

Embolization is safe and effective for controlling bleeding related to hepatic RF ablation without the need for surgery.

Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference

Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.

MAFR. Complications of radiofrequency ablation of hepatic tumors: Frequency and risk factors

Radiofrequency ablation (RFA) has become an important option in the therapy of primary and secondary hepatic tumors. Surgical resection is still the best treatment option, but only a few of these patients are candidates for surgery: multilobar disease, insufficient liver reserve that will lead to liver failure after resection, extra-hepatic disease, proximity to major bile ducts and vessels, and co-morbidities. RFA has a low mortality and morbidity rate and is considered to be safe. Thus, complications occur and vary widely in the literature. Complications are caused by thermal damage, direct needle injury, infection and the patient’s co-morbidities. Tumor type, type of approach, number of lesions, tumor localization, underlying hepatic disease, the physician’s experience, associated hepatic resection and lesion size have been described as factors significantly associated with complications. The physician in charge should promptly recognize high-risk patients more susceptible to complications, perform a close post procedure follow-up and manage them early and adequately if they occur. We aim to describe complications from RFA of hepatic tumors and their risk factors, as well as a few techniques to avoid them. This way, others can decrease their morbidity rates with better outcomes.

Frequency of and risk factors for complications after liver radiofrequency ablation under CT fluoroscopic guidance in 1500 sessions: single-center experience

OBJECTIVE

The purpose of this article is to retrospectively evaluate the frequency of and risk factors for complications after liver radiofrequency ablation (RFA).

MATERIALS AND METHODS

This was a retrospective study of 656 patients (with 1755 liver tumors) who underwent 1500 CT fluoroscopy-guided liver RFA sessions. Of those patients, 501 had primary liver tumor and 155 had liver metastases. Mortality and treatment-related complications were documented. Complications were evaluated according to the Common Terminology Criteria for Adverse Events (version 4.0). Major complications were defined as grade 3 or higher adverse events. Factors affecting frequent complications with a frequency of 1% or more were detected using multivariate analysis.

RESULTS

Two deaths (0.1% [2/1500]) occurred. One patient died of liver failure subsequent to hemorrhage, and the other died of liver failure. The major complication rate was 2.8% (42/1500). The most frequent major complication was hemorrhage (1.1% [16/1500]). The absence of arterial embolization before RFA (p < 0.01), low hemoglobin level (p < 0.04), and elevated serum creatinine level (p < 0.04) were identified as significant risk factors for major hemorrhage. The minor complication rate was 17.1% (257/1500). Pneumothorax (7.7% [116/1500]) was the most frequent minor complication, followed by hemorrhage (7.0% [105/1500]). A transthoracic approach (p < 0.01) and subphrenic tumor location (p < 0.01) were significant risk factors for pneumothorax, and the use of a cluster needle (p < 0.02) and multiple tumors (p < 0.01) were significant risk factors for minor hemorrhage.

CONCLUSION

CT fluoroscopy-guided RFA is a safe procedure with an acceptably low rate of major complications for liver tumor treatment. Factors identified in this study will help to stratify high-risk patients.

Life-threatening hemorrhage after liver radiofrequency ablation successfully controlled by transarterial embolization

A 59-year-old man underwent liver radiofrequency ablation under laparotomy for recurrent hepatic carcinoma located in the caudate lobe, however, near-fatal bleeding occurred 1 wk after the operation. The intra-operative ultrasound study during laparotomy revealed left hepatic artery pseudoaneurysm. Suture and packing with ribbon gauze was used to obtain hemostasis. A secondary hemorrhage followed 11 h later and hepatic angiography was performed immediately. Bleeding from the pseudoaneurysm in a branch of the left hepatic artery was found and the artery branch was embolized with coils. Other than slight bile leakage, post-embolization continued satisfactorily. Bleeding did not reoccur. The follow up visit 1 mo later found the pseudoaneurysm disappearing and no tumor recurrence.

Determining a minimal safe distance to prevent thermal injury to intrahepatic bile ducts in radiofrequency ablation of the liver: a study in dogs

PURPOSE

To determine a minimal safe distance between the radiofrequency ablation (RFA) electrode tip and major intrahepatic bile ducts to prevent thermal injury during hepatic RFA in a canine model.

MATERIALS AND METHODS

Forty healthy mongrel dogs were randomised equally into four groups based on the distance between the electrode and large intrahepatic bile ducts during RFA of the liver, as follows: 1.0-2.9 mm, 3.0-4.9 mm, 5.0-7.9 mm, or 8.0-10.0 mm. The RFA electrodes were opened uniformly at 2 cm. During RFA, energy was sequentially raised, starting at 5 W and increasing by 5 W increments every minute to a maximum of 95 W. Animals were monitored for a maximum of 14 days post-RFA for complications and by bilirubin testing, after which they were euthanised and their livers were surgically removed for cholangiographic and pathological examination.

RESULTS

When the electrodes were less than 5.0 mm from the bile ducts during RFA, either full or partial-thickness bile duct necrosis occurred, leading to a variety of serious complications. In contrast, when the distance was more than 5.0 mm between the RFA electrode and bile ducts, serious complications occurred rarely, with pathological examinations showing either normal bile ducts or vacuolar changes of the biliary ductal epithelium.

CONCLUSION

A minimum safe distance of 5.0 mm between the RFA electrode and intrahepatic bile ducts was effective in preventing serious complications secondary to bile duct injury in a canine model.

Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of the literature

OBJECTIVE

Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice.

METHODS

We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia.

RESULTS

Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1-23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications.

CONCLUSION

The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.

Hemothorax an Unusual Complication during Liver RFA

We present a case of a 70-year-old patient with hepatocellular carcinoma treated with RFA. The lesion was located in segment II under the ribs. During RFA pleural effusion is presented. After the procedure a dual phase CT revealed haemothorax and extravasation of the contrast medium from the intercostal vessels.

Interleukin-11-induced capillary leak syndrome in primary hepatic carcinoma patients with thrombocytopenia

Background

Capillary leak syndrome (CLS) is a rare condition characterized by recurrent episodes of generalized edema and severe hypotension associated with hypoproteinemia. Interleukin-11 (IL-11) is a promising therapeutic agent for thrombocytopenia. A direct correlation between IL-11 and CLS has never been reported previously, particularly in patients with hepatic carcinoma.

Case presentation

We describe two cases of CLS after IL-11 administration in two males with thrombocytopenia. Case 1 was a 46-year-old man with recurrence of hepatic carcinoma who was treated with IL-11 (3 mg per day). After four days of therapy, hypotension and hypoproteinemia were detected. The chest X-ray and B ultrasound of the abdomen showed pleural effusion and ascites. IL-11 was then discontinued, fluid resuscitation was performed, and fresh frozen plasma and packed red blood cells were transfused into this patient. The patient had recovered after 19 days of treatment.

Case 2 was a 66-year-old man who had undergone radiofrequency ablation (RFA) for hepatic carcinoma. He was treated with IL-11 (3 mg per day) for thrombocytopenia. After two days of therapy, this patient complained of dyspnea with bilateral edema of the hands. Laboratory values showed hypoproteinemia. IL-11 was stopped and human albumin was transfused at a rate of 10 g per day. On the 4^th day, fluid resuscitation was performed. The patient had recovered after treatment for two weeks.

Conclusions

The detection of IL-11-induced CLS supports the hypothesis that CLS could be a severe side effect of IL-11 treatment in some patients. These two case reports also demonstrate that patients with hepatic carcinoma who experience this rare form of CLS after treatment with IL-11 seem to respond to a therapeutic regimen that involves hydroxyethyl starch, albumin, and diuretic therapy. Liver cancer patients might be more susceptible to CLS because of poor liver function and hypersplenia. In addition, bleeding after RFA might be a further inducer of CLS.

Intrahepatic bile duct dilatation after percutaneous radiofrequency ablation for hepatocellular carcinoma: impact on patient's prognosis

BACKGROUND

Percutaneous radiofrequency ablation (RFA) has been widely accepted as an alternative to surgery for small hepatocellular carcinoma (HCC). In RFA, a portion of liver tissue surrounding tumour is also ablated to achieve a safety margin. The intrahepatic bile duct may be injured and result in chronic bile duct dilatation upstream of the injured site. However, the impact of such an injury on the overall prognosis has been unclear.

METHODS

Patients who showed bile duct dilatation following RFA were identified by a retrospective review of imaging studies. Each dilatation was classified as mild (limited to one hepatic subsegment) or severe (affecting two or more subsegments). The relation between the incidence of intrahepatic bile duct dilatation and HCC recurrence or survival was analysed using proportional hazard models.

RESULTS

Among 589 consecutive HCC patients treated with RFA, 70 (11.9%) and 21 (3.6%) patients showed mild and severe bile duct dilatation respectively. Patients with severe dilatation, but not those with mild dilatation, had lower survival and higher HCC recurrence than patients without dilatation. Severe dilatation, but not mild dilatation, was significantly associated with death [hazard ratio (HR) 2.17, P=0.035] and recurrence (HR 2.89, P<0.001).

CONCLUSION

Whereas mild bile duct dilatation after RFA is clinically negligible, bile duct dilatation affecting two or more subsegments should be regarded as a complication that may affect the prognosis and should be observed carefully.

Radiofrequency ablation of colorectal hepatic metastases

Radiofrequency ablation (RFA) may be performed intraoperatively, laparoscopically, or percutaneously. The percutaneous approach is associated with the least procedural risk and may be performed under local anesthesia. Percutaneous RFA should be considered a primary treatment option for patients with unresectable hepatic tumors or conditions that prohibit general anesthesia or abdominal surgery. Continually improving thermal ablation and imaging technologies are likely to further increase tumor ablation efficacy and expand its role in treatment of hepatic metastases.

Recent advances of radiofrequency ablation for early hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of death in the malignant neoplastic diseases in the world. Surgical operation is sometimes not indicated because of complicated liver cirrhosis and extrahepatic disorders. Radiofrequency ablation has been developed as a less invasive treatment for HCC since 1999, and long-term outcome has been shown. There are several complications which should be paid attention, and to improve the prognosis, combination treatment with transarterial chemoembolization should be discussed. Overall survival after between RFA and surgical resection should be compared prospectively. Establishment of staging system for treatment allocation of HCC and prevention of HCC recurrence is important issue to be examined.

Hemobilia

Hemobilia is an uncommon medical problem that presents in a varied fashion and is increasingly of iatrogenic origin. The diagnosis of hemobilia needs to be considered in patients presenting with upper gastrointestinal bleeding, particularly if they are jaundiced with abdominal pain in the setting of recent or previous percutaneous liver intervention or abdominal trauma. Multislice computed tomographic angiography is increasingly being used in the investigation, but transcatheter arterial embolization remains the cornerstone of managing those patients requiring intervention. The majority of patients with hemobilia will be managed supportively or with radiologic intervention; most do not require surgical intervention.

Life-threatening hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy: report of a case

BACKGROUND

Hemobilia is a rare but lethal biliary tract complication. There are several causes of hemobilia which might be classified as traumatic or nontraumatic. Hemobilia caused by pseudoaneurysm might result from hepatobiliary surgery or percutaneous interventional hepatobiliary procedures. However, to our knowledge, there are no previous reports pertaining to hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy.

CASE PRESENTATION

A 65-year-old male was admitted to our hospital because of acute calculous cholecystitis and cholangitis. He underwent cholecystectomy, choledocholithotomy via a right upper quadrant laparotomy and a temporary T-tube choledochostomy was created. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Imaging studies confirmed the diagnosis of pseudoaneurysm associated hemobilia. The probable association of T-tube choledochostomy with pseudoaneurysm and hemobilia is also demonstrated. He underwent emergent selective microcoils emobolization to occlude the feeding artery of the pseudoaneurysm.

CONCLUSIONS

Pseudoaneurysm associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and upper gastrointestinal bleeding after liver or biliary surgery.