AJR 2000; 174:985-986
© American Roentgen Ray Society
Choledochojejunostomy
Possible Risk Factor for Septic Complications After Percutaneous Hepatic Tumor Ablation
Toshiya Shibata1,
Naritaka Yamamoto2,
Iwao Ikai2,
Yasuyuki Shimahara2,
Yoshio Yamaoka2,
Kyo Itoh1 and
Junji Konishi1
1
Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University
Graduate School of Medicine, 54-Kawaharacho, Shogoin, Sakyoku, Kyoto,
606-8507, Japan.
2
Department of Gastroenterological Surgery, Kyoto University Graduate School of
Medicine, Kyoto, 606-8507, Japan.
Received August 30, 1999;
accepted after revision September 21, 1999.
Address correspondence to T. Shibata.
Introduction
Microwave coagulation therapy and other percutaneous techniques, such as
radiofrequency ablation, are effective treatments for the ablation of liver
tumors
[1,2,3].
These therapies have been considered safe and minimally invasive because most
complications are minor, and severe complications, such as biloma, hemorrhage,
or tumor dissemination, rarely occur. To our knowledge, no report describes
how choledochojejunostomy is related to septic complications after microwave
coagulation therapy. We describe a patient with massive biloma, abscess,
hematoma, and septicemia after microwave coagulation therapy, and we discuss
the risk of septic complications in a patient with choledochojejunostomy.
Case Report
A 61-year-old man with hilar cholangiocarcinoma underwent left hepatic
lobectomy and choledochojejunostomy in October 1998. Abdominal CT performed 6
months after surgery showed three tumors that were 1.2 cm, 1.7 cm, and 2.4 cm
in diameter in the anteroinferior, posterosuperior, and posteroinferior
segments, respectively. The patient was admitted for microwave coagulation
therapy for metastatic nodules. He had no sign of cholangitis or biliary
obstruction on admission. His laboratory data showed WBC, 4.7 x
103/µl; RBC, 4.68 x 106/µl; hemoglobin
level, 13.5 g/dl; aspartate transaminase, 41 U/l; alanine transaminase, 31
U/l; total bilirubin, 0.6 mg/dl.
Sonographically guided percutaneous microwave coagulation therapy was
performed according to the technique described in a previous report
[1]. The microwave electrode (2
mm in diameter, 25 cm in length) was connected to a microwave generator
(Microtaze; Nippon Shoji, Osaka, Japan). Single irradiation was set at 70 W
output for 45 sec. At first, microwave irradiation was performed twice for the
1.2-cm nodule in the anteroinferior segment. During the coagulation therapy
for the 2.4-cm nodule in the posteroinferior segment, the patient complained
of severe abdominal pain and shivering and could not continue the therapy. He
developed a fever of 39.3°C 3 hr later. Abdominal CT performed 1 week
after the coagulation therapy showed air and high- and low-density fluid near
the irradiated nodules and along the intrahepatic bile ducts
(Fig. 1A). The laboratory data
showed WBC, 20.4 x 103/µl; RBC, 2.73 x
106/µl; hemoglobin level, 8.1 g/dl; aspartate transaminase, 1140
U/l; alanine transaminase, 744 U/l; total bilirubin, 9.1 mg/dl. Blood cultures
grew Escherichia coli. Abdominal CT performed 10 days after the
coagulation therapy showed air and huge inhomogeneous lesions in the liver and
subcapsular region (Figs. 1B
and 1C). Percutaneous drainage
was performed, and purulent bloody discharge was evacuated. Although
antibiotics were administered, the patient did not recover. Resection of the
abscess and hematoma was performed 3 weeks after coagulation therapy.
Discussion
Among patients with orthotopic liver transplantation, choledochojejunostomy
appears to be a risk factor for septic complications after liver biopsy.
Enteric bacteria most likely cause septicemia in patients with
choledochojejunostomy [4,
5]. Choledochojejunostomy is
required after surgical procedures in the porta hepatis and hepatoduodenal
ligament. Resection of the epicholedochal plexus will decrease arterial blood
flow to the biliary tracts. In transcatheter arterial embolization for
metastatic liver tumors, the presence of a biliaryenteric anastomosis is a
risk factor for hepatic abscess after embolism
[6]. In a patient with
choledochojejunostomy, low arterial flow may reduce the cooling effect to the
biliary tree, and the close proximity of the biliary tree to the bowel
anastomosis may enhance the risk of infection of necrotic tumors with enteric
flora. Choledochojejunostomy can be a risk factor for septic complications
after percutaneous liver tumor ablation.
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