An 85-year-old woman developed locally recurrent hepatocellular carcinoma (HCC) after previous radiofrequency ablation combined with transarterial chemoembolization (TACE). Dynamic computed tomography (CT) and magnetic resonance imaging revealed a hypovascular tumor, which was suspected as poorly differentiated HCC. TACE was performed using a microballoon catheter. First, a suspension of miriplatin mixed with iodized oil (miriplatin-lipiodol suspension [MLS]) was injected without balloon occlusion. When the tumor-feeding artery was near stasis, the balloon was inflated and MLS was forcefully injected. CT after TACE showed accumulation of iodized oil throughout the tumor. The tumor had been controlled without recurrence for 22 months, at the time of writing this manuscript. The therapeutic efficacy of conventional TACE (C-TACE) for poorly differentiated hypovascular HCC is generally limited. In the present case, a good therapeutic result was achieved when balloon-occluded TACE was used in addition to C-TACE.
A 60-year-old man with a history of rheumatoid arthritis experienced bloody stool and presented in a state of shock. Emergency endoscopy showed upper gastrointestinal bleeding from a duodenal ulcer. Endoscopic hemostasis was attempted but failed. Gastroduodenal angiography revealed an extravasation from a duodenal branch of the anterior superior pancreaticoduodenal artery (ASPDA). Hemostasis was achieved by subsequent selective transarterial embolization (TAE) with N-butyl-2-cyanoacrylate (NBCA) performed via the duodenal branch. Although no recurrent bleeding was observed, walled-off necrosis (WON) developed twice at 1 and 8 months after TAE due to localized necrotizing pancreatitis. WON is a rare but potentially serious complication of TAE with NBCA from a branch of the ASPDA.
We report a case of bile duct injury at the bile duct confluence after right hepatectomy for metastatic colonic carcinoma. The leak and stricture failed to heal despite the placement of a 10-16-F transhepatic biliary drainage catheter for 8 weeks to bridge the leak site. Subsequently, two bare metallic stents were placed; however, the leak and stricture recurred 282 days after stent placement. Even a covered metallic stent did not function well because of stent kinking, and an additional bare stent was required to support the kinked stented lumen. After final stent placement, the stents were patent, and the patient had maintained a favorable course for 10 years and 1 month, at the time of writing this manuscript.
A 70-year-old woman, who had previously undergone a hepatectomy for hepatocellular carcinoma (HCC), developed a solitary metastasis in the sacral bone with the symptom of limb pain. The tumor had been in remission for 2 years, after radiotherapy and chemotherapy with sorafenib; however, it recurred locally. Although we performed transcatheter arterial embolization (TAE) on the patient, her limb pain worsened gradually. We treated the patient further with percutaneous cryoablation. On the day after she underwent cryoablation, the patient developed a disturbance in gait with a dorsiflexion disorder of the left ankle. These symptoms were believed to be caused by a cryoinjury to the L5 nerve root, which was adjacent to the sacral tumor. After rehabilitation training for several days, the patient became ambulatory with an ankle brace. At her most recent follow-up visit, 18 months after the treatment, the patient did not exhibit the presence of either local tumor progression nor new metastases.
Two patients suffered from repeated cholangitis. Follow-up computed tomography showed dilatation of the intrahepatic bile ducts due to internal plastic stents that had migrated into the intrahepatic bile ducts after choledochojejunostomy. Endoscopic approaches were initially attempted in both cases; however, they failed because of complete migration of the internal plastic stents into the hepatic ducts. Both patients were successfully treated with percutaneous transhepatic removal of the internal plastic stents and balloon cholangioplasty in a single session, without any complications. After the procedure, the patients remained well, without any evidence of cholangitis or dilatation of bile ducts.
Removal of internal plastic stents is crucial in the management of patients with morbidity caused by residual stents, and this interventional procedure should be recognized as a treatment option in such challenging cases.