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Case Report |
1 Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115.
2 Department of Radiology, Dana-Farber Cancer Institute, 44 Binney St., Boston,
MA 02115.
Received August 13, 2002;
accepted after revision January 8, 2003.
Address correspondence to E. vanSonnenberg.
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Six months later, and approximately 4 years after his initial presentation, he was referred for radiologic tumor ablation. He had two lesions in the remnant liver, one at the posterior surgical resection margin that measured 4.5 cm and another lesion more laterally that was 1.3 cm in greatest diameter. The patient underwent two sessions of percutaneous CT-guided radiofrequency ablation 6 weeks apart. Follow-up contrast-enhanced CT and MR imaging 1 week after the second ablation showed an increase in residual tumor in the lesion that had been ablated first and two smaller additional untreated lesions in the medial aspect of the liver. Subsequently, he underwent reablation for the residual tumor and the two new tumors in two more sessions. Findings of a positron emission tomography scan 1 month after the last ablation were negative, showing no new sites of disease in the liver and no metabolic activity in the treated areas.
Three months later, he developed jaundice with a bilirubin level that
reached 8.5 mg/dL. CT and MR imaging studies at that time revealed a 13
x 10 cm fluid collection in the liver in the region of the largest
ablated tumor, with irregular nodules along the walls (Fig.
1A,
1B,
1C,
1D). The collection impinged on
the region of the porta hepatis and caused mild biliary dilatation.
Percutaneous catheter drainage of the collection was performed with an
8-French catheter. The contents were bilious fluid (
600 mL), along with a
large amount of debris. The bilirubin level in the fluid was 12.5 mg/dL. Bile
continued to drain for 10 days, approximately 300–400 mL per day. A
subsequent CT scan, 1 week after the drainage procedure revealed resolution of
the previously dilated biliary system. No communication to the bile ducts was
found at that time. Simultaneously, his serum bilirubin level slowly declined
from a peak of 12.5 to 3.5 mg/dL over 10 days. His alkaline phosphatase,
alanine aminotransferase, and aspartate aminotransferase levels at admission
and discharge showed improvement from 1375, 113, and 175 U/L to 1134, 21, and
51 U/L, respectively.
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Bile continued to drain from the catheter for 1 week, at which time the patient developed a fever; culture of the draining fluid revealed infection with multiple organisms including Enterococcus and Staphylococcus (coagulase-negative) organisms and Stenotrophomonas maltophilus. Treatment with IV levofloxacin, vancomycin, and metronidazole was instituted. The patient also developed a right-sided pleural effusion that was drained with a percutaneous 8-French catheter. ERCP, performed to attempt internal biliary drainage, was unsuccessful. The patient recovered from the fever spikes and was discharged home after 26 days of hospitalization. The chest catheter was removed, and the percutaneous biloma drainage catheter was left in place.
After 3 weeks of drainage, ERCP was reattempted and drainage of the bile duct was achieved. A large leak from a main left branch duct was found. The leaking duct was treated with a plastic stent that extended into the biloma cavity. After 2 days, the patient was discharged home with the percutaneous biloma drainage catheter and plastic stent in place. A visiting nurse cared for the patient at home.
After slowly decreasing drainage for 6 weeks, the patient inadvertently pulled out his external drainage catheter. A CT scan obtained 2 days later did not show any significant increased collection in the cavity. His serum bilirubin level had returned to normal. The patient unfortunately died 6 months later from chronic debilitation, with the internal stent still in place.
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The cause of the biloma in our patient was likely to have been injury to one of the main bile ducts by the radiofrequency ablation itself, the consequent sloughing of necrotic tissue, and leaking bile accumulating in the cavity. This sequence of events probably led to the slow accumulation of bile in the ablated tissue and adjacent liver, forming a collection within the necrotic tumor. MR imaging and CT revealed compression of the bile ducts by the collection at the porta hepatis. The patient presented with increasing obstructive jaundice that was slowly relieved over a period of several days after percutaneous drainage of the biloma. Complete necrosis of the treated tumor was evidenced by negative findings on positron emission tomography scans, both at the time of discovery of the biloma and at a later follow-up scan.
Large or symptomatic bilomas are treated by percutaneous drainage, in some cases coupled with a biliary drainage procedure to divert bile from the site of injury. External biloma drainage is continued until the biliary output through the drain ceases. Catheter injection often shows the site of leakage. Some patients may require percutaneous transhepatic cholangiography and percutaneous biliary drainage or ERCP to identify the site of the bile leak along with drainage to divert bile for definitive treatment [1, 4, 5].
Radiofrequency ablation is capable of causing tissue necrosis of large volumes of tumor and normal parenchyma [7], and this may result in injury to major bile ducts. Hence, the possibility of an intrahepatic biloma might be anticipated when ablation of large volumes of tumor tissue in the liver is performed, particularly when it is close to major bile ducts. The complicated course of our patient, both before diagnosis and after treatment of the biloma, acts as a warning to radiologists who perform this procedure. Biloma should be considered if a large low-density (on CT) or hypoechoic (on sonography) collection is seen after ablation. This case also shows the importance of the multidisciplinary approach to address this fortunately uncommon complication.
Acknowledgments
We thank Kristin Rancourt for help in preparing the manuscript.
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