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| Journal of the New Zealand Medical Association,
01-June-2007, Vol 120 No 1255
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Hepatocutaneous fistula: a complication after
radiofrequency ablation therapy for hepatocellular carcinoma
Hsu-Kai Huang, Chien-Hua Lin, Chia-Chun Hsu, Jyh-Cherng Yu,
Yao-Chi Liu, Teng-Wei Chen, Chung-Bao Hsieh
Radiofrequency ablation is an alternative therapy for
hepatocellular carcinoma (HCC)—especially for unresectable, small, or
metastatic tumours. The procedure is preferred since it is less invasive than
surgery. Common complications of radiofrequency ablation (RFA) are abdominal
pain, fever, ascites, and pleural effusions.1
Intra-abdominal bleeding and pneumohemothorax are considered
major complications that can be life-threatening. As RFA is becoming popular
worldwide, attention to new complications is necessary. Herein, we report a case
of hepatocutaneous fistula as a complication of radiofrequency ablation for
hepatocellular carcinoma.
Case reportIn September 2006, a 34-year-old man presented to our
hospital with a complaint of poor healing of a previous wound over the upper
abdomen, which was resultant from RFA for recurrent hepatocellular carcinoma.
Laboratory data showed elevation of alpha-fetoprotein (AFP) at 1217 ng/ml.
The patient, who had a history of hepatitis B-related
hepatocellular carcinoma, underwent right lobectomy of the liver 3 years
previously. The patient underwent regular outpatient department follow-up.
Elevation of AFP and recurrent HCC over the left lobe were noted subsequently,
so the patient received transarterial chemoembolisation once in September 2005
and once in June 2006.
The abdominal ultrasound showed another hypoechoic nodule
over the left lobe in this patient (Figure 1).
Figure 1. A hypoechoic nodule, about 2.7 ×
1.5 × 2.2 cm in size, in the left lateral dome of liver compatible with
recurrent hepatocellular carcinoma
 Radiofrequency ablation was performed by a radiologist in
July 2006. Under local anesthesia, RFA was completed with a 16-gauge LeVeen
needle, which was introduced into the recurrent HCC over the lateral segment of
the left lobe. The puncture wound was over the epigastric region, which was
located under ultrasound guidance. Four thermal ablations in the tumour mass
were performed. Most of the tumour revealed a hyperechoic pattern (Figure 2).
Figure 2. The tumour in hyperechoic pattern
after repeated ablation (4 times)
 The treatment and hospital course for this patient were
uneventful. Poor healing with discharge of the puncture wound was noted and
treated at the outpatient department. Due to the elevated AFP level and poor
healing of the RFA puncture wound, the patient underwent positron emission
tomography/computed tomography (PET/CT) scan in August 2006 which showed a 3-cm
F18 deoxyglucose (FDG)-avid lesion compatible
with recurrent HCC.
Exploratory laparotomy with wedge resection of the tumour
and excision of the percutaneous wound was performed. The operative finding
showed a 1.5-cm tumour over segment 3. Additionally, segment 3 was adhered to
the peritoneal wall under the RFA wound over the epigastric region.
A fistula, which extended from the skin wound directly to
the tumour, was discovered (Figure3). Microscopic examination revealed mixed
acute and chronic inflammation with congestion and stromal edema over the
fistula. There was no evidence of recurrence at 2-month follow-up in our
outpatient department.
Figure 3: A hepatocutaneous fistula from the
puncture wound directly to the recurrent tumour
 DiscussionAblative therapies—including transarterial
chemoembolisation, percutaneous ethanol injection (PEI), and radiofrequency
ablation—are effective methods for small HCCs, recurrent HCCs, and liver
metastatic lesions in patients who are not suitable for surgery because of
advanced disease or other morbidities.2
Radiofrequency ablation is the latest procedure, which can
be performed by operative, laparoscopy-assisted, or percutaneous method. The
radiofrequency electrode, which is inserted into the tumours, releases heat.
This, in turn, may cause damage and necrosis of tumour cells. The advantages of
RFA over PEI include more certain necrosis, fewer treatment sessions, and
possible treatment of
metastases.1–3
However, complications of RFA have been reported in the
previous literature. For instance, Livraghi et al studied 3554 lesions in 2320
patients in 2003. Fifty major complications were reported with an incidence of
2.2%; 6 deaths were also noted.
Major complications of RFA included peritoneal hemorrhage,
neoplastic seeding, intrahepatic abscesses, and intestinal perforation. Minor
complications developed in less than 5% of patients, such as self-limiting
bleeding, pain, burn haemobilia, and arterioportal
shunt.4 Bleeding complications of RFA seemed
more common in advanced cirrhosis
patients.5
We described the first case of RFA complicated by
hepatocutaneous fistula with poor healing. This problem is not a major
complication, but is bothersome for the patient. Surgical intervention was
performed to remove the fistula and tumour lesion for estimation of response to
RFA treatment. The possible aetiology of fistula formation was that the puncture
site was close to the scar of the previous laparotomy. The needle tract through
the tissue exhibited scarring and fibrosis. The thermal energy release by RFA
electrode may have injured adjacent tissue and caused severe inflammation.
Moreover, debris and discharge from the tumour necrosis may have leaked through
the needle tract and delayed concrescence.
We suggest that the puncture wound and route of percutaneous
RFA therapy for hepatic tumour should avert the previous surgical scar to reduce
the chance of fistula formation. Detailed evaluation of the patient’s
general condition and image studies such as ultrasound, color Doppler scan, and
CT scan may be helpful to identify the fistula.
Author information: Hsu-Kai Huang,
Registrar1, Chien-Hua Lin, Chief
Registrar1, Chia-Chun Hsu,
Radiologist2, Jyh-Cherng Yu, Surgeon, Chief of
Division of General Surgery1, Yao-Chi Liu,
Surgeon, Professor of Division of General
Surgery1,
Teng-Wei Chen, Surgeon1, Chung-Bao Hsieh, Surgeon1
Correspondence: Dr
Chung-Bao Hsieh, Division of General Surgery, Department of Surgery, Tri-Service
General Hospital, No. 325, Sec 2, Cheng-Kung Rd, Taipei 114, Taiwan. Fax: +886 2
87927372; email: albert0920@yahoo.com.tw
References:
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