27 Tumor Ablation:
Interventional Management of Complications
Ronald S. Arellano, Debra A. Gervais, and Peter R. Mueller
R. Arellano, MD; D. A. Gervais, MD; P. R. Mueller, MD Department of Radiology, Massachusetts General Hospital, Division of Abdominal Imaging and Intervention, 55 Fruit Street, White 270, Boston, MA 02114, USA
CONTENTS
27.1 Introduction 387 27.2 Complications 388
27.2.1 Hepatobiliary Complications 388 27.2.2 Thoracic Complications 389 27.2.3 Bleeding Complications 390 27.3 Conclusion 391
References 391
27.1
Introduction
After approximately 10 years of clinical experience, radiofrequency ablation has become an established therapeutic option for the treatment of primary or metastatic hepatic malignancies. Whether performed as an open surgical procedure or by percutaneous methods, radiofrequency ablation offers minimally invasive therapy of malignant tumors without the 15%–30% morbidity associated with open surgical resection (Fong et al. 1995; Molmenti et al. 1999;
Steele et al. 1991). Nevertheless, even minimally invasive therapies have associated risks and poten- tial complications. In the case of radiofrequency ablation of the liver, potential complications derive from two broad categories: (a) direct physical injury as a result of placement of the electrode into the liver and (b) thermal-induced injury of the liver or related structures as a result of treatment (Fig. 27.1) (Rhim et al. 2003). In addition, preexisting condi- tions such as prior abdominal surgery or impaired liver function can also adversely affect the outcome of ablative therapy. However, other complications associated with thermal ablation of the liver require treatment and intervention beyond the skill of the interventional radiologist. Thermal injuries of the
skin, for example, can develop from improper place- ment or insufficient surface area of grounding pads and should be managed by a dermatologist or sur- geon who specializes in burn injuries (Goldberg et al. 2000; Steinke et al. 2003; Yamagami et al.
2002). Metabolic derangement such as electrolyte imbalances, liver failure or hepatorenal syndrome can develop following treatment of primary or meta- static liver tumors (Keltner et al. 2001; Shankar et al. 2002; Verhoeven et al. 2002).
Treatment of these conditions requires consulta- tion from medical specialists in hepatology and ne- phrology.
In many cases, complications are minor and do not result in adverse sequelae or prolonged hospital- ization. Major complications, on the other hand, can be life threatening and therefore often require ad- ditional, unplanned or prolonged therapy and hos-
Fig. 27.1 Axial CT image of the liver demonstrating radio- frequency electrode within lesion in VII segment (black ar- row)
pitalization (Burke et al. 2003). The management of some radiofrequency induced major complications, such as hepatic failure or bowel perforation are be- yond the expertise and skill of the interventional ra- diologist. However, several procedure-related major complications can be safely and effectively treated by percutaneous means. Therefore, recognition and experience with interventional management of ra- diofrequency related complications are essential in order to provide optimum patient care. This chapter will discuss the percutaneous management of com- plications associated with image-guided radiofre- quency ablation of hepatic malignancies.
27.2
Complications
Major complication rates for image-guided percu- taneous radiofrequency ablation range from 2.2- 9.6% (Buscarini and Buscarini 2004; Livraghi and Meloni 2002; de Baere et al. 2003; Rhim et al. 2003). While these rates compare favorably with to surgical resection, radiofrequency-induced com- plications can have a significant impact on patient care. Major complications that require additional interventional management include hepatic abscess, biliary-related complications such as bilomas, bili- ary strictures and fistulas, bleeding complications and complications involving the lung and the pleu- ral space. Other complications such as skin burns, metabolic dysfunction and pain require medical management for resolution.
27.2.1
Hepatobiliary Complications
The liver and bile ducts are prone to procedure re- lated complications due to direct injury by place- ment of the radiofrequency electrode and by the cre- ation of devitalized hepatic tissue. Hepatic abscesses and bilomas derive from both mechanisms and must be suspected in any patient who develops significant pain or clinical signs of septicemia (i.e. tachycardia, fever, leukocytosis) beyond the first 2–4 weeks of the procedure. Adherence to strict sterile technique is essential in order to minimize the potentially life- threatening complication of overwhelming septice- mia. Prophylactic intravenous antibiotics may fur- ther minimize the risk of post-procedure infections, though this practice remains controversial.
When an abscess is suspected, cross-sectional im- aging with computed tomography imaging is neces- sary to localize and define the extent of disease.
Intralesional air that is generated within the lesion during treatment should resolve within 1 month of the treatment (Lim et al. 2001). Therefore, any fluid, air, or air-fluid levels within the treated lesion beyond the normal expectation should be regarded with clinical suspicion, especially accompanied by clinical signs and symptoms of infection (Fig. 27.2) (Titton et al.
2003). Hepatic abscesses develop in up to 3% patients who undergo radiofrequency ablation for hepatic tu- mors (de Baere et al. 2000). Patients with preexist- ing biliary-enteric anastomoses may be more prone to develop postablation abscesses. Retrograde enteric flow into the biliary tree, altered lymphatic periportal drainage and vascular resection may all limit the ef- fectiveness natural mechanisms to control spread of infectious organisms (Shibata et al. 2003). Patients with preexisting bile duct biliary stones or strictures may also be predisposed to hepatic abscess formation (Zagoria et al. 2002). Biliary strictures and obstruc- tion have been described following radiofrequency treatment and centrally located lesions may result in clinically significant biliary complications (Mulier et al. 2002; Rhim et al. 2003). Treatment of hepatic abscesses or bilomas involves the combination of per- cutaneous drainage and intravenous antibiotics.
Drainage catheters of sufficient size (i.e. 8–14 F) to effectively drain purulent material can be placed us- ing computed tomography, ultrasound or a combina- tion ultrasound and fluoroscopic guidance (Fig. 27.3).
Drainage catheters should be flushed on a daily basis
Fig. 27.2. Axial CT scan of the liver that demonstrates a low attenuation fluid collection 1 month following radiofre- quency ablation (black arrows)
in order to ensure patency and to prevent encrusta- tion of debris at the catheter tip. A sudden drop in the daily output may indication tube malposition, kink- ing or clogging, all of which require tube replace- ment or repositioning in order to restore drainage.
Alternatively, persistently high output may be due to communication with the bile ducts in the setting of central obstruction (Figs. 27.4, 27.5) (Titton et al.
2003). In such cases, a combination of percutaneous and endoscopic drainage may be necessary to achieve complete resolution (Curley et al. 2004; Shankar et al. 2003; Shibata et al. 2003; Stippel et al. 2003).
27.2.2
Thoracic Complications
Thoracic complications can result from treatment of subcapsular lesions situated high in the hepatic dome. Treatment of hepatic dome lesions is techni- cally challenging and potentially risky due to several factors, including the proximity of the diaphragm and lung, long trajectory from the skin to the lesion and difficulty in localizing lesions with imaging, especially when using ultrasound guidance. In order to overcome these limitations, several authors have described various techniques, which aid in detect- ing and isolating domes lesions in order to avoid potentially fatal complications (Curley et al. 2004;
Shankar et al. 2003; Shibata et al. 2003; Stippel et al. 2003). Transpleural or transthoracic treatment of hepatic dome lesions can result in hemothorax, pleural effusions or pneumothorax (Fig. 27.6).
Small, non-expanding pneumothoraces seldom lead to adverse clinical consequences and therefore can be treated conservatively. This is true as long as oxy- genation is unaffected and the patient remains he- modynamically stable. On the other hand, patients who have severe or chronic underlying pulmonary disease often cannot tolerate even minor changes in respiratory dynamics. In this subgroup of patients, evacuation of the pleural air with needle aspiration or catheter drainage is necessary in order to restore normal respiration. Similarly, symptomatic pleural effusions and/or hemothoraces can be treated with thoracentesis using with small bore catheters or with thoracostomy.
Fig. 27.3. Axial CT scan of the liver following percutaneous drainage of hepatic abscess, which developed following ra- diofrequency ablation (arrow)
Fig. 27.4. Axial CT scan of the liver demonstrates large bi- loma, which developed following radiofrequency ablation for hepatocellular carcinoma (arrow)
Fig. 27.5 Axial CT scan of the liver demonstrating drainage catheter within the biloma (arrow)
27.2.3
Bleeding Complications
Bleeding complications arise as a result of needle puncture across the hepatic capsule (Fig. 27.7).
Radiofrequency electrodes range in size from 14–15 gauge. Each puncture across the capsule creates the potential for bleeding. In addition, patients with he- patocellular carcinoma frequently have an underly- ing coagulopathy due to cirrhosis and compromised hepatic function. As a result, coagulation factors synthesized by the liver can be chronically low, caus- ing prolongation of the prothrombin time and an in- crease in the international normalized ratio (INR).
Added to this is the frequent finding in cirrhotic patients of hypersplenism and thrombocytopenia, which can lead to chronically low levels of circulat- ing platelets. While no standardized algorithm ex- ists for managing patients with coagulopathy, every effort should be made to correct a bleeding diathesis whenever possible. Intramuscular injections of vi- tamin K and infusions of fresh frozen plasma are indicated to correct a prolonged prothrombin time.
A threshold platelet count of greater than 50,000/
cm
3is recommended prior to puncture across the hepatic capsule.
Procedure related bleeding can occur in several locations: (a) subcapsular, (b) intrahepatic, (c) intra- peritoneal (Buscarini and Buscarini 2004; Curley et al. 2004; de Baere et al. 2003; Mulier et al. 2002;
Rhim et al. 2003; Wood et al. 2000; Zagoria et al.
2002). Subcapsular and intrahepatic hematomas are usually self limiting and seldom require percutane- ous intervention. Transfusions are indicated when sufficiently large subcapsular hematomas lower the hematocrit value to levels where the patient may ex- perience hypotension. In the acute setting, drainage of large subcapsular hematomas may remove a natu- ral tamponading mechanism that controls further bleeding and therefore drainage of fresh hematomas is not recommended. However, chronic hematomas cause pain due to capsular irritation or if they are suspected of becoming superinfected, and then im- age-guided percutaneous drainage is indicated.
Drainage with a 10–14 F catheter is usually sufficient for complete evacuation of liquefied hematomas.
In contrast to subcapsular hematomas, intra- peritoneal bleeding can rapidly evolve into an emergency situation; therefore, close hemodynamic monitoring by the anesthetist or the interventional nurse is essential to detect for signs of intraperito- neal hemorrhage. Clinically suspected acute hemor- rhage can be confirmed by the detection of new high
Fig. 27.6. Axial CT scan of the liver during radiofrequency ablation demonstrates a small pneumothorax that devel- oped following placement of the radiofrequency electrode (arrow). The patient remained asymptomatic during the treatment and no treatment was necessary. In patients with underlying pulmonary disease, even small pneumothoraces can be symptomatic and may require thoracentesis or tho- racostomy
Fig. 27.7. Axial CT scan of the liver immediately following treatment, which demonstrates new fluid adjacent to the liver edge (long black arrow). The small black arrows point to the thermal lesion in the treated liver
density by computed tomography or by the devel- opment of complex fluid by ultrasound (Fig. 27.8).
Immediately life-threatening intraperitoneal hem- orrhage requires volume resuscitation and prompt control of the bleeding source. This subgroup of pa- tients can be evaluated with angiography to identify and control the source of bleeding with emboliza- tion. Slower intraperitoneal bleeding can be man- aged more conservatively by following serial hema- tocrit levels, correcting any existing coagulopathies and by transfusions. Delayed bleeding complica- tions from pseudoaneurysms of the hepatic arteries, have been described following treatment of colorec- tal metastases. These were successfully treated with coil embolization (Bilchik et al. 2001). Transient thrombosis of the portal vein has been described as a consequence of radiofrequency ablation but this does not require interventional management (Ng et al. 2003; Zheng et al. 2003).
27.3 Conclusion
Of the potential complications associated with ra- diofrequency ablation of hepatic tumors, few re-
Fig. 27.8. Axial CT scan of the liver obtained 24 h after ra- diofrequency treatment. The black arrow points to new high density fluid adjacent to the liver, consistent with acute hem- orrhage
quire interventional management for resolution. As described above, these include hepatic abscesses, complications related to the biliary tree or collec- tions, which develop in the pleura space. In almost all cases, resolution can be safely and effectively achieved with simple catheter drainage or other minimally invasive techniques.
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