Extrahepatic biliary obstruction after percutaneous tumour ablation for hepatocellular carcinoma: aetiology and successful treatment with endoscopic papillary balloon dilatation

Abstract

Background and aims: Percutaneous tumour ablation (PTA), such as ethanol injection and radiofrequency ablation, is now recognised as a primary treatment for hepatocellular carcinoma (HCC). Although PTA is a relatively safe procedure, it can cause biliary obstruction as a rare complication. As patients with cirrhosis undergoing surgery or endoscopic retrograde cholangiopancreatography/sphincterotomy have a high mortality rate from bleeding, we adopted the use of endoscopic papillary balloon dilatation (EPBD) in these patients and now report the results. We retrospectively analysed the incidence of biliary obstruction after PTA and the efficacy of treatment with EPBD. Patients and methods: A total of 1043 patients with HCC were treated by PTA, of whom 538 were treated with transarterial embolisation with up to eight years of follow up.Results: There were 17 (1.6%) cases of hilar obstruction due to tumour progression and 35 (3.4%) cases of extrahepatic obstruction. Apart from the expected causes of biliary obstruction (haemobilia n = 11, gallstones n = 11, and three miscellaneous causes), we found that 10 patients had obstruction due to biliary casts. This is the first description of biliary casts after percutaneous tumour ablation therapy. Extrahepatic biliary obstruction by procedure related haemobilia occurred within three days of PTA while other causes occurred between 0 and 17 (average 4.9) months. Biliary casts occurred more frequently after ethanol injection than after radiofrequency ablation. EPBD successfully dissipated biliary obstruction in 33 of 35 cases, while two died due to hepatic failure despite successful drainage. Conclusions: Extrahepatic biliary obstruction is an uncommon complication after PTA for HCC, and can be safely and effectively treated with EPBD, despite impaired liver function.

Ischemic cholangiopathy

“…Several cases of extensive bile duct injury following HA infusion of ethanol or sodium morrhuate in patients suffering from symptomatic hepatic hemangioma have been described [57,58]. Moreover, 17 cases of cholangiopathy developing after percutaneous ethanol injection (associated with embolization of largesized particles or not) have been reported [59][60][61]. Ethanolrelated arterial injury may be implicated in these cases.…”

Biochemical and Hematologic Changes after Percutaneous Radiofrequency Ablation of Liver Tumors: Experience in 83 Procedures

“…Although the clinical triad of biliary colic, anemia, and jaundice is typical, hemobilia may present with only hyperbilirubinemia (13) and moderately elevated aminotransferase and ALKP levels, as seen in one of our patients. Sasahira et al (14) reported that both serum bilirubin (up to 26.3 mg/dL) and ALKP levels (up to 787 U/L) were severely elevated in patients with hemobilia after percutaneous RF ablation, and in most patients, hemobilia and related hyperbilirubinemia resolved spontaneously within 2 weeks (14). Persistent jaundice in a patient with hemobilia might indicate a biliary stricture, as seen in one of our patients with hemobilia.…”

“…Hemobilia generally occurs early after RF ablation, with the reported incidence in the range of 0%-0.3% (13,14). It is almost certainly caused by a punctured vessel bleeding directly into bile ducts (14). Although the clinical triad of biliary colic, anemia, and jaundice is typical, hemobilia may present with only hyperbilirubinemia (13) and moderately elevated aminotransferase and ALKP levels, as seen in one of our patients.…”

“…Hemobilia generally occurs early after RF ablation, with the reported incidence in the range of 0%-0.3% (13,14). It is almost certainly caused by a punctured vessel bleeding directly into bile ducts (14).…”

Bile duct stones and casts after liver transplantation: Different entities but similar prevention strategy?

“…EPBD, in fact, avoids a permanent loss of the Oddi sphincteral function and still allows the treatment of strictures and removal of concretions. 26,27 The percutaneous transhepatic approach is also an effective Oddi-preserving procedure but requires expertise. Biliary irrigation has been adopted in many experiences to favor removal of difficult concretions.…”