Cholecystostomy in radiofrequency ablation of lesions next to the gallbladder: protective effect

Posted By Andre Azevedo
Cholecystostomy in radiofrequency ablation of lesions next to the gallbladder: protective effect

Radiofrequency ablation (RFA) is considered a simple and safe modality for treatment of hepatic lesions. The benefits related to RFA include low morbidity, performance on an outpatient basis and the possibility to repeat the procedure when necessary due to recurrences. However, minor and major complications related to mechanical and thermal damage may occur, especially in cases of tumors adjacent to extra hepatic organs. This case report is about a 48 years old female patient with previous history of uterine sarcoma, on clinical and radiological monitoring, who presented with two metastatic subcapsular hepatic nodules (segments V and IV), neighbouring the gallbladder, without a safe cleavage plane from it, measuring 2,4 cm and 2,0 cm. Percutaneous RFA was decided to be performed. In order to protect the gallbladder from thermal injury, once one of these nodules was adjacent to the gallbladder fundus, it was previously perform a US guided cholecystostomy. A Dawson Muller drainage catheter 8,5 Ga was implanted in the gallbladder and bile was aspirated followed by continuous irrigation with cooled saline solution. Another concern was the subcapsular location of the lesions and their proximity to the abdominal wall. Thus, in order to increase this space, a percutaneous hydrodissection with dextrose solution and contrast, using a Turner needle (22 Ga x 20 cm), was performed. After these thermal protection techniques, the RFA was safely performed. Tomographic images immediate after the procedure showed adequate ablation zone no signs of complications. Follow-up MRI two months after the procedure demonstrates the gallbladder usual appearance and effective ablation zone without residual hypervascular areas or signs of inflammation, showing these are effective techniques to prevent thermal injury. Figure 1: MRI (GE 1,5 Tesla Magnet) Axial postcontrast T1 WI demonstrates two metastatic hipervascular nodules (arrows) adjacent to the gallbladder. Figure 2: Noncontrast axial CT scan demonstrates two metastatic hipodense nodules (arrows). Patient was positioned in slight left lateral decubitus and the percutaneous access was planned. Figure 3: US guided percutaneous cholecystostomy: (a) a transhepatic access was performed using a Turner needle 18 Ga (Arrow). (b) an 8,5 Ga Dawson Muller catheter (arrowhead) was implanted in the gallbladder; bile was aspirated and a continuous irrigation with cooled saline solution was initiated. Figure 4: Noncontrast axial CT scan: In order to increase the space between the liver and the abdominal wall, hydrodissection with dextrose solution and contrast was performed; Turner needle 22Ga (arrow). Figura 5: Noncontrast axial CT scan: the second probe at a justavesicular localization (arrow). Note the catheter of cholecystostomy (arrowhead). Figure 6: Postcontrast axial CT scans; images immediate (a) and one month (b) after the procedure demonstrate ablation zones (arrows) without residual hypervascular

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