title: Extrahepatic biliary obstruction after percutaneous tumour ablation for hepatocellular carcinoma: aetiology and successful treatment with endoscopic papillary balloon dilatation.
abstract: OBJECTIVE
  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.
  
  
  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.
authors.affiliation: Department of Gastroenterology, University of Tokyo, Japan.
authors.forename: N
authors.initials: N
authors.lastname: Sasahira
authors.forename: M
authors.initials: M
authors.lastname: Tada
authors.forename: H
authors.initials: H
authors.lastname: Yoshida
authors.forename: R
authors.initials: R
authors.lastname: Tateishi
authors.forename: S
authors.initials: S
authors.lastname: Shiina
authors.forename: K
authors.initials: K
authors.lastname: Hirano
authors.forename: H
authors.initials: H
authors.lastname: Isayama
authors.forename: N
authors.initials: N
authors.lastname: Toda
authors.forename: Y
authors.initials: Y
authors.lastname: Komatsu
authors.forename: T
authors.initials: T
authors.lastname: Kawabe
authors.forename: M
authors.initials: M
authors.lastname: Omata
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000628:therapy*; D017115:Catheter Ablation / Q000009:adverse effects*; D002404:Catheterization; D002760:Cholangiopancreatography, Endoscopic Retrograde; D001651:Cholestasis, Extrahepatic / Q000000981:diagnostic imaging / Q000209:etiology*; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome