Hepatoduodenal fistula formation following transcatheter arterial chemoembolization and radiotherapy for hepatocellular carcinoma: treatment with endoscopic Histoacryl injection
A 71-year-old male patient was readmitted to our hospital 1 month after discharge because of relapse of abdominal pain. One year prior, he had been diagnosed with HCC associated with chronic hepatitis B. He could not undergo surgical resection because of invasion of the hepatic and main portal veins. Therefore, he underwent TACE as a palliative treatment. Although he underwent five sessions of TACE over 10 months, newly viable HCC was found in the left lobe of the liver with thromboses of the portal vein, hepatic vein, and inferior vena cava. Palliative RT was administered to the HCC in the left lobe of the liver and area of left portal vein thrombosis using a dose of 33 Gy comprising daily doses of 3 Gy. He then underwent two additional TACE sessions. One month after the seventh TACE session, the patient presented to our institution with a complaint of persistent abdominal pain. He also had intermittent fever, chills, and weight loss. Abdominal computed tomography (CT) showed a gas-containing cavity suggestive of an abscess within a necrotic mass in the left lateral segment of the liver (). He was hospitalized, received intravenous empirical antibiotics, and underwent ultrasound-guided abscess aspiration, which produced 0.5 mL of turbid yellowish fluid with a foul odor. Percutaneous drainage catheter insertion was difficult because of the small size of the abscess pocket. Prevotella oralis and Clostridium bifermentans/sporogenes were isolated from the aspirated specimen. The patient's symptoms, including abdominal pain, fever, and chills, resolved completely after 2 weeks of intravenous antibiotic therapy, and he was discharged with oral antibiotics. Although he continued to take oral antibiotics, his abdominal pain recurred only 2 weeks after discharge, and the frequency of abdominal pain gradually increased. He was readmitted to our hospital 1 month after discharge. He complained of persistent abdominal pain; however, other generalized symptoms, including fever and chills, did not reappear. On physical examination, right upper quadrant tenderness was observed, and his serum C-reactive protein level was higher than that during the previous hospitalization. Follow-up CT was performed. Although the abscess had decreased in size, we detected a new communication between the remaining abscess and the duodenal bulb (). He received total parenteral nutrition and broad-spectrum antibiotics. Gastroduodenoscopy was performed to confirm the fistula through a 0.3-cm hole in the proximal portion of the duodenal bulb (). At that time, endoscopic clipping was attempted to close the fistula opening. Follow-up endoscopy was performed 2 days after clipping; however, there was still a fistula opening beside the clips (). The next approach to the fistula was by endoscopic retrograde cholangiopancreatography (ERCP). A ~1-cm fistulous tract was confirmed by guidewire insertion from the fistula hole of the duodenal lumen. A 1:3 mixture of Histoacryl and lipiodol solution (0.5 mL) was injected into the fistula. Follow-up endoscopy performed 2 days after this intervention revealed that the previous fistula orifice was filled with Histoacryl (). The patient was then discharged from the hospital because he had no abdominal pain after starting oral intake. One month after the intervention, a follow-up abdominal CT scan showed obliteration of the fistulous tract and a decrease in the extent of the abscess (). Eight months later, he underwent four sessions of additional TACE without abscess recurrence (). The most recent CT scan, taken 7 months after Histoacryl injection, showed advanced HCC without abscess or fistula formation. The patient is still alive and has been followed up at the outpatient clinic.