Keyword
needle tract bleeding - colorectal liver metastasis - reablation hemostasis
Introduction
Colorectal cancer is the fourth most common cancer globally, often leading to liver
metastasis.[1] Surgery is the gold standard for treating colorectal liver metastasis (CRLM), yet
only one-third of patients are candidates.[1] Percutaneous ablation is an alternative for treating unresectable CRLM, providing
comparable outcomes in small lesions.[1] In 0.5 to 1.5% of cases, intra-abdominal bleeding may occur during liver tumor ablation,
controllable through several options.[2] Heat ablation needles are increasingly used to control bleeding, including needle
tract bleeding after percutaneous ablation.[2]
Case Report
We report a 78-year-old woman, postright hemicolectomy for colonic carcinoma (TNM
stage pT3N1aM0) with free surgical margins. She had multiple comorbidities: hypertension,
dyslipidemia, chronic pulmonary embolism on enoxaparin, ischemic heart disease managed
with aspirin, nonvalvular atrial fibrillation, postsurgery pituitary macroadenoma,
chronic cholecystitis, and a history of passing a bile duct stone. Postoperatively,
serum carcinoembryonic antigen level was elevated and magnetic resonance imaging (MRI)
revealed four liver metastases (segment 8/5 junction: 2.2 cm, segment 5: 1.6 cm, segment
7: 1.0 cm, segment 8: 1.5 cm). Surgical resection was unfeasible due to comorbidities,
leading to scheduled percutaneous liver ablation. Preprocedure laboratory tests were
within normal limits, including platelet count and coagulation function. Aspirin and
enoxaparin were withheld appropriately.
Periprocedure liver ultrasound revealed a slight enlargement in the size of four masses
up to 3.1 cm ([Fig. 1]). Using a 13G × 15 cm microwave ablation (MWA) needle (The Emprint Ablation System,
Covidien, Boulder, Colorado, United States), lesions were targeted via two capsular
punctures under local anesthesia. Sedation drugs were administered after placing the
ablation needle in the first lesion. Sequential ablation included segment 8/5 (75W × 5 minutes
and 100W × 3.5 minutes overlapping), segment 5 (100W × 3.5 minutes), segment 7 (75W × 4 minutes),
and segment 8 (75W × 3.5 minutes) ([Fig. 1]). Tract cauterization was performed on the first puncture tract before introducing
the needle into the second puncture tract. Another tract cauterization was performed
at the second puncture tract at the end of the procedure. Immediately postprocedure
(just after removing the ablative needle), ultrasound showed rapid development of
fluid in the hepatorenal and right perihepatic region. Active Doppler color extravasation
from the second puncture tract was found, with pulsations on spectral waveform analysis.
At that time, the patient remained sedated with stable vital signs. The same ablation
needle was reinserted 1.5 cm beyond the liver capsular outline into the bleeding tract.
Reablation was initiated with 70W for 5 minutes. Subsequent ultrasound no longer showed
any active bleeding ([Fig. 2]). Additional external compression was applied for 5 minutes, followed by placement
of a sandbag over the puncture site for 6 hours. Postprocedure computed tomography
angiography abdomen on the same day showed a good ablation zone and no evidence of
active contrast extravasation or gross major vascular injury either on arterial or
portal phase ([Fig. 3]).
Fig. 1 Intraprocedural ultrasound images and subsequent ablation: (A) The segment 8/5 junction lesion and first liver capsular puncture site (arrowhead),
(B) the segment 5 lesion, (C) the segment 7 lesion and second liver capsular puncture site (arrowhead), and (D) the segment 8 lesion.
Fig. 2 Images during ablation of bleeding needle tract. (A) Newly detected hepatorenal and perihepatic fluid (asterisk) after the removal of
the microwave ablation (MWA) needle from the second puncture liver tract. (B) First (arrowhead) and second (arrow) sites of puncture of the liver capsule. (C) Color Doppler shows active extravasation from the second puncture liver tract with
pulsation on spectral analysis. (D) Reinsertion of the MWA needle was done into the bleeding site and the needle tip
is visualized (arrow). (E) After starting reablation of the bleeding tract. (F) No extravasation was detected on color Doppler after complete bleeding tract ablation.
Fig. 3 Computed tomography angiography (CTA) abdomen immediately after completing the procedure
shows perihepatic hematoma and post-liver ablation changes. (A) Second liver capsule puncture site (arrowhead) after reablation without residual
active bleeding with perihepatic hematoma (asterisk) and (B) first liver capsule puncture site (arrowhead).
The patient was admitted for 3 days due to a postprocedure drop in hematocrit from
31.5 to 25.5%, requiring a blood transfusion. Despite this, the overall clinical condition
remained stable, allowing for discharge. The follow-up MRI at 1 month later showed
a well-covered ablation zone over the target tumors with complete resolution of the
perihepatic hematoma.
Discussion
Intra-abdominal hemorrhage after liver tumor ablation is rare.[2]
[3] Limited reports exist on using percutaneous heat ablation for needle tract bleeding.[2]
[4]
[5] Options for immediate bleeding management include external compression for 5 minutes
(54% success) and transvascular embolization (100% effective with a median waiting
time to angiogram of 22 hours).[2]
[3] Few reports show 100% effective control of tract bleeding with heat ablation, despite
abnormal coagulation function, mostly performed under ultrasound guidance.[2]
[4] The target site is active bleeding that can be seen on color Doppler or contrast-enhanced
ultrasound.[2]
[4] The ablative needle is inserted into the outer parts of the bleeding tract to stop
bleeding and minimize parenchymal injury.[2] Although no standard ablative protocol exists, the principle involves delivering
sufficient energy to overcome the heat sink effect at the active bleeding site and
stop the bleeding. Suggested settings for radiofrequency ablation include using power
at 100W or higher for 3 to 5 minutes while maintaining continuous cooling pump operation.[2] For MWA, the reported protocol uses 50 to 100W for 5 to 8 minutes.[4]
[5] The endpoint is the disappearance of active bleeding.[2]
[5] Reevaluation should be conducted after an additional 5 to 10 minutes wait to avoid
gas obscuration.[5] Further contrast media study may be needed to confirm successful hemostasis. No
major complications after tract reablation have been reported such as new intraperitoneal
bleeding, bile duct injury, liver abscess, or nearby organ injury.[2]
[4]
[5]
Conclusion
Reablation under ultrasound promptly stops active needle tract bleeding without extra
tool preparation, proving effective.
