Hepatoduodenal Fistula Successfully Treated With Enteral Metallic Stent: A Rare Complication Following Trans-catheter Arterial Chemoembolization for Hepatocellular Carcinoma

Abstract

A 62-year-old man presented with fever and right upper quadrant pain (RUQ) for 1 week. He was recently diagnosed with chronic hepatitis B cirrhosis and hepatocellular carcinoma (HCC). He underwent several sessions of transcatheter arterial chemoembolization (TACE) as a palliative treatment. On physical examination, body temperature was 39°C. Marked tenderness was observed at RUQ. Laboratory tests revealed white blood cell count 8.5x109/L (neutrophil 78%), total bilirubin 2.6 mg/dL, aspartate aminotransferase 37 U/L, alanine aminotransferase 21 U/L and alkaline phosphatase 110 U/L. Computed tomography (CT) showed a fistulous connection between gas-containing cavity in previous HCC area, suggesting an abscess draining to duodenum (Figure 1). Esophagogastroduodenoscopy (EGD) was done to confirm the fistula through a 1.5-cm hole in the second part of duodenum (Figure 2A). A few days later, a repeat upper endoscopy was performed with a therapeutic duodenoscope and a partially-covered enteral metallic stent was placed between duodenum and pylorus (Figure 2B). Follow-up CT (1 month after the intervention) showed complete obliteration of the fistulous tract (Figure 3). The remaining liver abscess was treated by percutaneous drainage and antibiotics. The patient was discharged 1 month later with a significant improvement of symptoms.2283_A Figure 1. Contrast-enhanced computed tomography (A) axial view (B) coronal view showed fistulous connection (arrow) between lipiodol-staining mass at hepatic segment V/VII and second part of duodenum.2283_B Figure 2. (A) Endoscopic finding of fistula tract at second part of duodenum with failure of closure by endoscopic clipping (B) Fluoroscopic view showed successful enteral metallic stent deployment.2283_C Figure 3. Contrast-enhanced computed tomography (A) axial view (B) coronal view showed metallic stent at duodenum and improvement of hepatoduodenal fistula.Hepatoduodenal fistula is a rare complication of HCC after TACE. Only few reports have been previously described. Abscess formation from necrotic tumor after TACE with local inflammation may lead to abnormal connection to surrounding structures. A direct invasion from advanced HCC is also another possible cause of fistula formation. There are several therapeutic approaches for managing fistula, including, conservative treatment, endoscopic Histoacryl injection and surgery. However, the selection is depended on the case scenario and the availability of special devices. Herein, we report the first case of hepatoduodenal fistula, which was successfully treated with enteral metallic stent after a failure of endoscopic clipping due to a large fibrotic fistula defect. Although rare, hepatoduodenal fistula is a serious and fatal condition. Clinical suspicion along with radiologic and endoscopic findings are crucial clues for diagnosis. Stent placement can be considered as an alternative to surgery in a large and difficult-to-close fistula tract.