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CORRESPONDENCE
Year : 2016  |  Volume : 12  |  Issue : 7  |  Page : 221-224

Percutaneous intraductal radiofrequency ablation combined with biliary stent placement for malignant biliary obstruction: A case report and review of the literature


Department of Interventional Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, P.R. China

Date of Web Publication21-Feb-2017

Correspondence Address:
Renyou Zhai
Department of Interventional Radiology, Beijing Chao-Yang Hospital, 8 Gongren Tiyuchang Nan Road, Beijing 100020
P.R. China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.200604

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 > Abstract 

Percutaneous management of unresectable malignant biliary obstruction remains challenging. Biliary radiofrequency ablation (RFA) using the Habib EndoHBP catheter is a new palliation therapy for malignant biliary obstruction. We report our initial experience of RFA for the management of malignant biliary obstruction. A 58-year-old male was diagnosed with gallbladder cancer. Intraductal bipolar RFA was delivered at power of 10 W for 120 s, followed by stent placement. The patient had immediate stricture improvements after RFA. No severe adverse event occurred. Percutaneous RFA seems to be safe and feasible for the treatment of malignant biliary obstruction. Further studies are warranted.

Keywords: Malignant biliary obstruction, radiofrequency ablation, stent


How to cite this article:
Guan L, Wang J, Gao K, Zhai R. Percutaneous intraductal radiofrequency ablation combined with biliary stent placement for malignant biliary obstruction: A case report and review of the literature. J Can Res Ther 2016;12, Suppl S3:221-4

How to cite this URL:
Guan L, Wang J, Gao K, Zhai R. Percutaneous intraductal radiofrequency ablation combined with biliary stent placement for malignant biliary obstruction: A case report and review of the literature. J Can Res Ther [serial online] 2016 [cited 2021 Mar 1];12:221-4. Available from: https://www.cancerjournal.net/text.asp?2016/12/7/221/200604


 > Introduction Top


Patients with gallbladder cancer or extrahepatic cholangiocarcinoma present with malignant biliary obstruction. The diagnosis is usually made when the disease is already in an advanced stage and cure rates are low.[1] In such cases, palliation with drainage of the biliary duct is important to improve the quality of life. Stent placement using endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiodrainage (PTCD) has become the favored palliative drainage procedure.[2],[3] The tumor may grow through the mesh of the stent, leading to in-stent occlusion.[4] A stent's patency period is crucial for both the patient's quality of life and the procedure's cost-effectiveness.

Percutaneous radiofrequency ablation (RFA) has been accepted as a curative therapy for small hepatocellular carcinoma and can provide better local control of the disease than transarterial chemoembolization treatment and a similar long-term survival to surgical resection.[5] Percutaneous intraluminal RFA with Habib EndoHBP catheter (EMcision UK, London, UK) is a newly developed technique, which heats up local tumor tissues, leads to coagulation necrosis, and reduces tumor burden. This new palliative treatment might be useful for delaying tumor progression, prolonging stent patency, and improving quality of life. Several studies have looked into the feasibility and safety of this procedure.[6],[7],[8],[9] We report a patient with malignant biliary obstruction who was treated with intraductal RFA and stent placement using percutaneous approach.


 > Case Report Top


A 58-year-old male was admitted to our hospital with upper abdominal discomfort and jaundice. He had not received any clinical treatment before this admission. Physical examination revealed jaundice. Vague right upper quadrant fullness was present, but the gallbladder was not palpable. No ascites or peripheral edema was evident. Laboratory tests showed alkaline phosphatase, 632 IU/L; γ-glutamyl transpeptidase, 902 IU/L; aspartate aminotransferase, 206 IU/L; alanine aminotransferase, 181 IU/L; total bilirubin, 278.9 µmol/L; direct bilirubin, 266.9 µmol/L; and the serum level of carbohydrate antigen 19-9 significantly elevated at 3008.5 U/mL. The levels of carcinoembryonic antigen and α-fetoprotein were within their normal ranges.

Contrast-enhanced computed tomography scan showed a mass replacing the gallbladder fossa with irregular peripheral enhancement, suggestive of gallbladder carcinoma. Invasion of the adjacent liver and bile duct were also suggested [Figure 1]. Magnetic resonance cholangiopancreatography (MRCP) showed dilated intrahepatic ducts and common bile duct [Figure 2]. Ultrasound-guided liver biopsy indicated gallbladder adenocarcinoma.
Figure 1: Contrast-enhanced computed tomography scan showed a mass replacing the gallbladder fossa with irregular peripheral enhancement, suggestive of gallbladder carcinoma

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Figure 2: Magnetic resonance cholangiopancreatography showed dilated intrahepatic biliary ducts and common bile duct

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These patients are not eligible for surgery, and percutaneous drainage procedure was performed following informed consent. The skin was infiltrated with local anesthetic. A 22-gauge Chiba needle was inserted from the right flank toward the 10th vertebral body under fluoroscopic guidance. The needle was slowly withdrawn, and contrast material was injected every 1–2 mm until a bile duct was seen. A 0.018 inch guidewire was placed through the needle. The needle was withdrawn and the 5-French sheath assembly placed over the 0.018 inch guidewire into the bile duct. Cholangiography showed obstructions involving the common bile and hepatic duct but did not extend into the confluence [Figure 3]a. A 0.035 inch J-guidewire placed through the 5-French sheath into the duodenum. The percutaneous track through the liver is dilated with a 7-French dilator and a 9-French peel-away sheath placed.
Figure 3: (a) Cholangiography showed obstructions involved the common bile and hepatic duct but did not extend into the confluence. (b) Intraductal radiofrequency ablation was performed with a percutaneous radiofrequency catheter using a 0.035 inch guidewire. (c) Cholangiography confirmed immediate stricture improvement was achieved after radiofrequency ablation. (d) A self-expanding metallic stent was inserted after the ablation. Cholangiography showed that the obstruction was relieved

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A Habib EndoHPB catheter was used for RFA. The electrode was placed at the site of tumor obstruction under fluoroscopic guidance [Figure 3]b. The ablation procedure started at the distal end of the obstruction, and the target tissue was between the electrodes. RFA was repeated twice. Energy was delivered by an RFA generator (1500 RF generator; RITA Medical Systems Inc., Fremont, USA) at 10 W for 2 min. Cholangiography confirmed immediate stricture improvement was achieved after RFA [Figure 3]c. An 10 mm × 80 mm uncovered self-expanding metal stent (SEMS) (Smart stent, Cordis, Miami, USA) was placed. Following cholangiography documented satisfactory stent placement and free drainage into the duodenum [Figure 3]d. No hemorrhage, bile duct perforation, bile leak, or pancreatitis was observed after the RFA procedure. One week following the stent placement, total and direct bilirubin levels decreased to 106 µmol/L and 98 µmol/L, respectively. The patient was followed up through outpatient visits or telephone interviews. At 289 days postoperatively, the patient had developed recurrent jaundice. He underwent repeat percutaneous transhepatic cholangiography to confirm stent occlusion and received new stents.


 > Discussion Top


Despite advances in various therapeutic managements, surgical resection remains the main cure for gallbladder cancer. Palliative treatment of unresectable gallbladder cancer is required for the different conditions caused by invasion of the bile duct, portal vein, or duodenum either directly or through lymph-node metastases. Metallic biliary stent implantation has become a standard palliative treatment for the patients with obstructive jaundice.[2]

Palliative biliary drainage aims to improve liver function, resolve jaundice, and reduce sepsis risk. Long-term biliary stent patency continues to be a challenge for nonresectable malignant biliary obstruction. During the last two decades, the preferred option has been the use of PTCD- or ERCP-inserted stents.[10] Stents have evolved from plastic bare metallic to covered metallic and drug eluting to increase stent patency and decrease tumor ingrowth. Although metal stents have improved bile duct patency compared to plastic stents, occlusion often occurs within 6–8 months of stent placement due to tumor growth, sludge, or biofilm formation.[2],[4] While covered SEMSs and photodynamic therapy have been reported as alternatives to increase rates of stent patency, each has its additional risks. Covered SEMSs are associated with increased risk of pancreatitis and cholecystitis,[4] and photodynamic therapy is associated with cholangitis and photosensitivity.[11]

RFA is based on the interaction between biological tissue and high-frequency rapidly alternating electric current causing vibrational movement of tissue's water molecules; movement transmission results in frictional energy loss, which is deposited as heat in the biological tissue.[12] The clinical use of RFA has an established role in the ablation of solid organ tumors, especially hepatic malignancies.[13] RFA, because of its theoretical local effect on tumoral tissue, has recently been tested regarding its ability to improve stent patency. The procedure requires a disposable, bipolar, over-the-wire RF catheter, suitable for endoluminal delivery of RF into the biliary tree.

The first clinical study to assess the safety and efficacy of RFA using Habib EndoHPB catheter in management of malignant biliary obstruction was performed by Steel et al.[14] The catheter is a bipolar RFA probe that is 8F (2.6 mm) in diameter and passes over 0.035 inch guidewire. The catheter has two ring electrodes, 8 mm apart from the distal electrode at 5 mm from the leading edge and provides coagulation necrosis for a length of 2.5 cm. The ablation was set at 7–10 W power, with 2 min to achieve the balance between tumor necrosis and thermal injury for adjacent tissues.

After that, several studies have revealed that intraductal RFA combined with biliary stent placement for malignant biliary obstruction is feasible and effectively prolongs stent patency time.[6],[7],[15],[16] Our study also confirms that RFA in combination with stent placement is a safe technique for biliary decompression in patients with either nonresectable malignant biliary obstruction.

Kallis et al.[17] carried out a retrospective analysis of 23 patients with nonresectable pancreatic carcinoma and malignant biliary obstruction undergoing endoscopic RFA and stents insertion and 46 controls (stents insertion alone). Their results showed that median survival in RFA group was 226 days versus 123.5 days in controls (P = 0.010). Stent patency rates were equivalent in both groups. RFA was well tolerated with minimal side effects. At present, RFA technique is a clinical adjuvant therapy rather than a radical treatment for malignant biliary obstruction. Ablation cannot ensure effective tissue necrosis at depth; therefore, ablation can safely treat only a part of a deep tumor. After insufficient RFA, the recurrence of residual tumor would inevitably occur and eventually influence survival.


 > Conclusion Top


Intraductal RFA combined with biliary stent placement seems to be safe and feasible for nonresectable malignant biliary obstruction. Randomized studies to determine the effect applied RFA therapy on long-term biliary stent patency are mandated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Skipworth JR, Keane MG, Pereira SP. Update on the management of cholangiocarcinoma. Dig Dis 2014;32:570-8.  Back to cited text no. 1
    
2.
Krokidis M, Hatzidakis A. Percutaneous minimally invasive treatment of malignant biliary strictures: Current status. Cardiovasc Intervent Radiol 2014;37:316-23.  Back to cited text no. 2
    
3.
Salgado SM, Gaidhane M, Kahaleh M. Endoscopic palliation of malignant biliary strictures. World J Gastrointest Oncol 2016;8:240-7.  Back to cited text no. 3
    
4.
Nam HS, Kang DH. Current status of biliary metal stents. Clin Endosc 2016;49:124-30.  Back to cited text no. 4
    
5.
Zhang L, Yin X, Gan YH, Zhang BH, Zhang JB, Chen Y, et al. Radiofrequency ablation following first-line transarterial chemoembolization for patients with unresectable hepatocellular carcinoma beyond the Milan criteria. BMC Gastroenterol 2014;14:11.  Back to cited text no. 5
    
6.
Wu TT, Li HC, Li WM, Ao GK, Lin H, Zheng F, et al. Percutaneous intraluminal radiofrequency ablation for malignant extrahepatic biliary obstruction: A safe and feasible method. Dig Dis Sci 2015;60:2158-63.  Back to cited text no. 6
    
7.
Li TF, Huang GH, Li Z, Hao CF, Ren JZ, Duan XH, et al. Percutaneous transhepatic cholangiography and intraductal radiofrequency ablation combined with biliary stent placement for malignant biliary obstruction. J Vasc Interv Radiol 2015;26:715-21.  Back to cited text no. 7
    
8.
Duan XH, Wang YL, Han XW, Ren JZ, Li TF, Zhang JH, et al. Intraductal radiofrequency ablation followed by locoregional tumor treatments for treating occluded biliary stents in non-resectable malignant biliary obstruction: A single-institution experience. PLoS One 2015;10:e0134857.  Back to cited text no. 8
    
9.
Tal AO, Vermehren J, Friedrich-Rust M, Bojunga J, Sarrazin C, Zeuzem S, et al. Intraductal endoscopic radiofrequency ablation for the treatment of hilar non-resectable malignant bile duct obstruction. World J Gastrointest Endosc 2014;6:13-9.  Back to cited text no. 9
    
10.
Lee BH, Choe DH, Lee JH, Kim KH, Chin SY. Metallic stents in malignant biliary obstruction: Prospective long-term clinical results. AJR Am J Roentgenol 1997;168:741-5.  Back to cited text no. 10
    
11.
Lu Y, Liu L, Wu JC, Bie LK, Gong B. Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis. Clin Res Hepatol Gastroenterol 2015;39:718-24.  Back to cited text no. 11
    
12.
Organ LW. Electrophysiologic principles of radiofrequency lesion making. Appl Neurophysiol 1976;39:69-76.  Back to cited text no. 12
    
13.
Kariyama K, Wakuta A, Nishimura M, Kishida M, Oonishi A, Ohyama A, et al. Percutaneous radiofrequency ablation for intermediate-stage hepatocellular carcinoma. Oncology 2015;89 Suppl 2:19-26.  Back to cited text no. 13
    
14.
Steel AW, Postgate AJ, Khorsandi S, Nicholls J, Jiao L, Vlavianos P, et al. Endoscopically applied radiofrequency ablation appears to be safe in the treatment of malignant biliary obstruction. Gastrointest Endosc 2011;73:149-53.  Back to cited text no. 14
    
15.
Rustagi T, Jamidar PA. Intraductal radiofrequency ablation for management of malignant biliary obstruction. Dig Dis Sci 2014;59:2635-41.  Back to cited text no. 15
    
16.
Mizandari M, Pai M, Xi F, Valek V, Tomas A, Quaretti P, et al. Percutaneous intraductal radiofrequency ablation is a safe treatment for malignant biliary obstruction: Feasibility and early results. Cardiovasc Intervent Radiol 2013;36:814-9.  Back to cited text no. 16
    
17.
Kallis Y, Phillips N, Steel A, Kaltsidis H, Vlavianos P, Habib N, et al. Analysis of endoscopic radiofrequency ablation of biliary malignant strictures in pancreatic cancer suggests potential survival benefit. Dig Dis Sci 2015;60:3449-55.  Back to cited text no. 17
    


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