AJR 2005; 184:S120-S122
© American Roentgen Ray Society
Gastric Perforation After Percutaneous Radiofrequency Ablation of a Colorectal Liver Metastasis in a Patient with Adhesions in the Peritoneal Cavity
Lars Frich1,2,
Bjørn Edwin1,2,
Knut Brabrand3,
Arne R. Rosseland2,
Tom Mala2,
Øystein Mathisen2 and
Ivar Gladhaug2
1 The Interventional Centre, Rikshospitalet University Hospital, 0027 Oslo,
Norway.
2 Department of Surgery, Rikshospitalet University Hospital, 0027 Oslo,
Norway.
3 Department of Radiology, Rikshospitalet University Hospital, 0027 Oslo,
Norway.
Received March 4, 2004;
accepted after revision April 19, 2004.
Address correspondence to L. Frich
(lars.frich{at}labmed.uio.no).
Introduction
Radiofrequency ablation is increasingly used for ablation of
malignant liver tumors. Although minor complications are common, the rate of
major complications is low
[1-3].
This report presents a major complication associated with percutaneous
radiofrequency ablation that became clinically evident several weeks after the
patient was discharged.
Case Report
A 67-year-old man was operated on for a cancer of the sigmoid colon in
2001. At the primary surgery, biopsy-proven liver metastases in both liver
lobes were present. The liver metastases were initially considered
in-operable, but the patient was reconsidered for surgical treatment after a
favorable response to fluorouracil and leucovorin. A right hemihepatectomy was
performed 15 months after the primary procedure, thereby removing four
colorectal metastases with free resection margins. Three months later, a
solitary metastasis with a 2.8-cm diameter was detected in segment III in
proximity to the left portal vein. This metastasis was treated by MRI-guided
percutaneous cryoablation.
On a CT examination 10 months later, a new 1.5-cm-diameter tumor was found
caudally in segment III of the left liver lobe close to the wall of the
gastric antrum (Figs. 1A,
1B,
1C). The tumor was considered
eligible for thermal ablation. After written informed consent was obtained,
the patient was included in an ongoing trial of radiofrequency ablation. The
potential risk for thermal damage to the gastric wall was explained to the
patient before the procedure.
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Fig. 1A. —67-year-old man with hepatic metastasis from cancer of
sigmoid colon. Right hemihepatectomy has been performed. Contrast-enhanced
axial CT scans obtained before radiofrequency ablation show hepatic metastasis
(white arrowheads) in close proximity to gastric antrum. Portovenous
phase with 5-mm slice thickness is shown.
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Fig. 1B. —67-year-old man with hepatic metastasis from cancer of
sigmoid colon. Right hemihepatectomy has been performed. Contrast-enhanced
axial CT scans obtained before radiofrequency ablation show hepatic metastasis
(white arrowheads) in close proximity to gastric antrum. Portovenous
phase with 5-mm slice thickness is shown.
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Fig. 1C. —67-year-old man with hepatic metastasis from cancer of
sigmoid colon. Right hemihepatectomy has been performed. Contrast-enhanced
axial CT scans obtained before radiofrequency ablation show hepatic metastasis
(white arrowheads) in close proximity to gastric antrum. Portovenous
phase with 5-mm slice thickness is shown.
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The patient was treated with percutaneous radiofrequency ablation under
general anesthesia. The procedure was performed under sonogram guidance with a
curvilinear multi-frequency probe (Acuson Sequoia 512, Siemens), using a low
mechanical index mode (Cadence CPS). Two 15-cm-long, 1.7-mm-diameter perfusion
radiofrequency electrodes with an unisolated 2-cm tip (Berchtold) were placed
in the tumor using a guide device incorporated into the sonogram transducer.
Using the Elektrotom HiTT 106 radiofrequency current generator (Berchtold),
radiofrequency energy of 30 W for 1 min followed by 50 W for 20 min was
applied to each of the electrodes. The total energy applied was 39,304 J and
47,690 J, respectively. After the treatment sessions, both electrodes were
retracted slowly as 25 W was applied to ablate the needle track.
Gas artifacts prevented estimation of the thermal damage by sonography
immediately after treatment was terminated. After 10-15 min, the artifacts had
regressed and a contrast-enhanced sonogram (SonoVue, Bracco) was performed. A
well-defined area without contrast enhancement with a 5-cm diameter was found,
indicating no intralesional circulation. No residual tumor tissue could be
visualized, and the treatment was considered complete. Two days after the
procedure, the contrast-enhanced sonogram was repeated. An area without
contrast enhancement with a 5-cm diameter was still present. In addition, a
vascular structure could be seen traversing the left anterior part of the
thermal lesion (Fig. 2). The
postoperative course was uneventful. In accordance with our protocol, the
patient was examined using CT 3 days after the procedure and was discharged
from the hospital.
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Fig. 2. —Contrast-enhanced sonogram of liver (L) in the same
67-year-old man 2 days after radiofrequency procedure. Largest diameter of
area without contrast enhancement (RF) was 5 cm. Tumor cannot be identified
within treated area. A vascular structure (white arrowhead) is seen
traversing left anterior part of thermal lesion.
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Three weeks later, the patient noted local tenderness and a skin rash where
the electrodes had been placed. An abscess was diagnosed and incised at the
local hospital. Two days later, the patient observed gastric content in the
wound. Perforation of the gastrointestinal tract was suspected and the patient
was admitted to our institution. On admission, he had a normal leukocyte count
but elevated C-reactive protein (48 mg/L). Fistulography showed passage of
contrast material from the abdominal skin wound through a fistulous track to
the gastric antrum. CT examination of the abdomen showed no abscess cavity.
The internal opening of the fistula could not be identified by gastroscopy.
Microbiologic examination of the secretion from the fistula tested positive
for Streptococcus milleri. The patient was treated conservatively
without antibiotics. An ileostomy bag was fitted to allow the fistula to close
spontaneously. At the time of discharge 1 week after admission, secretion from
the fistula was 40 mL/24 hr. Secretion ceased within 3 weeks after discharge.
At the 6-month follow-up, the patient was doing well and had no signs of
remaining fistula or abscess. CT of the abdomen did not show new liver tumors
or a tumor recurrence at the site of the ablation.
Discussion
To our knowledge, this is the first report of a perforation of the gastric
wall after radiofrequency ablation of a liver tumor. Although in-frequent,
intestinal perforation can cause mortality. In a retrospective study of 2,320
patients, two of six deaths were caused by intestinal perforation
[3]. In a retrospective
literature study of 3,670 patients treated with radiofrequency ablation for
liver tumors, visceral damage occurred in 14 of 2,898 percutaneous procedures,
whereas no visceral damage occurred in patients treated with a laparoscopic
approach or by laparotomy
[1].
Patient selection criteria for percutaneous, laparoscopic, or open
procedures have not been established. A laparoscopic or open approach is
usually advocated for subcapsular tumors adjacent to viscera
[4]. However, in a
retrospective study of 14 hepatic tumors adjacent to the gallbladder,
percutaneous radiofrequency ablation was shown to be feasible and safe
[5]. The tumor in our patient
was located in close proximity to the gastric wall. Laparoscopy is the
preferred technique in our institution to mobilize organs abutting the planned
treatment site in the liver to prevent thermal damage. However, laparoscopy
was not considered feasible because of significant adhesions after previous
abdominal surgery, and a percutaneous approach was chosen. The largest tumor
diameter in our patient was 1.5 cm. It is generally accepted that a margin of
at least 1 cm of normal liver tissue surrounding the tumor should be ablated;
hence, a coagulation necrosis with at least a 3.5-cm diameter was necessary
for adequate treatment. The exact size and shape of the thermal lesion can be
difficult to predict even under standardized treatment protocols
[6]. In our patient, the extent
of the thermal damage was assessed after the treatment was completed, when a
thermal lesion with a 5-cm diameter was present. Evaluation of the thermal
tissue damage by a contrast-enhanced sonogram before completion of the
ablation protocol might have allowed the operator to reposition the electrode
or modify the applied energy to prevent thermal damage to adjacent structures
while adequately treating the target area. Intraperitoneal instillation of
saline to insulate viscera from the thermal treatment site
[7] or placement of a balloon
catheter between the tumor and adjacent viscera
[8] has been proposed to
prevent thermal damage to extrahepatic structures during percutaneous ablation
procedures. However, the presence of adhesions may limit the possible
usefulness of these approaches.
In our opinion, the delayed clinical presentation and the fact that
abscesses after transgastric biopsies are rare indicate that thermal injury
and not mechanical trauma during the procedure was the cause of the gastric
wall perforation. Thermal injury to the gastric wall was most likely caused by
direct conduction of heat from the treated site in the liver. However, as the
radiofrequency ablation system used in this patient consists of perfusion
electrodes where isotonic saline is infused into the tissue, we cannot exclude
that thermal injury to the gastric wall could have been caused by diffusion of
heated saline. The gastric perforation was not diagnosed until a
gastrocutaneous fistula developed. Fistulas can be classified depending on the
volume of the secretion. Fistulas producing less than 500 mL/24 hr are
classified as low-output fistulas, and those producing more than 500 mL/24 hr,
high-output. Although high-output fistulas often require surgical
intervention, a conservative approach was successfully used in this patient,
with a low-output fistula producing 40 mL/24 hr.
Although hepatic radiofrequency ablation is considered a technique with low
morbidity, major complications can become clinically evident several weeks
after a procedure. Each patient should be reviewed on a case-by-case basis by
surgeons and interventional radiologists before treatment. Patient safety
should be a major concern when risks versus benefits for the different
approaches are assessed. For patients with tumors in close proximity to
viscera, laparoscopic radiofrequency ablation or an open approach should be
considered to allow insulation of the viscera from the treatment site.
Determining the approach for patients with significant adhesions in the
peritoneal cavity presents special challenges, as laparoscopy is not always
feasible, and the risk for mechanical or thermal perforation of the intestines
may be unacceptable when using a percutaneous approach. For these patients,
laparotomy is usually feasible but associated with increased morbidity.
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Introduction
Case Report
