Cardiovasc Intervent Radiol DOI 10.1007/s00270-015-1110-7

CASE REPORT

Digestive Tract Complications of Renal Cryoablation Kanichiro Shimizu1 • Takuji Mogami2 • Kenkichi Michimoto1 • Yoshihiko Kameoka1 Tadashi Tokashiki1 • Naoki Kurata1 • Jun Miki3 • Koichi Kishimoto3



Received: 19 January 2015 / Accepted: 23 March 2015 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2015

Abstract We report a case each of duodenorenal and colorenal fistula that arose after computed tomographyguided percutaneous cryoablation (PCA) for renal cell carcinoma and use imaging and endoscopic findings to analyze their causes and mechanisms. Both complications occurred though the edge of the iceball did not touch the intestinal wall, and patients’ symptoms and fistula formation occurred several days after the PCA procedure. Based on imaging and endoscopy findings, we suspected the colorenal fistula resulted from bowel injury caused by ischemia from the occlusion of small vessels at the procedure’s low temperature. Both cases were resolved conservatively without surgical intervention. Keywords Colorenal fistula  Duodenorenal fistula  Percutaneous cryoablation  Renal cell carcinoma

Introduction The most common complication after percutaneous cryoablation (PCA) for renal cell carcinoma (RCC) is bleeding or hematuria. The reported rates of any

& Kanichiro Shimizu [email protected] 1

Department of Radiology, Kashiwa Hospital, The Jikei University School of Medicine, Chiba, Japan

2

Department of Radiology, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan

3

Department of Urology, Kashiwa Hospital, The Jikei University School of Medicine, Tokyo, Japan

complication after PCA range between 6.0 and 12.9 % [1–3]. Gastrointestinal complications are rare and comprise less than 10 % of all complications [2, 3], and few cases are reported [4, 5]. We report two cases of gastrointestinal complication after PCA for RCCs.

Case 1 An 83-year-old man underwent transcatheter arterial embolization (TAE) to avoid hemorrhage prior to computer tomography (CT)-guided PCA for RCC of 39-mm diameter adjacent to the duodenum and ascending colon. We performed PCA using an argon-based cryoablation unit (CryoHit; Galil Medial, Yokneam, Israel) and four 17-gauge cryoneedles (IceRod; Galil Medial, Yokneam, Israel), with the patient placed on the CT table in left lateral position to displace the colon and duodenum and better expose the RCC. Under CT guidance, we targeted the tumor and monitored iceball formation. Using an 18-gauge coaxial needle, we performed hydrossection, injecting several milliliters of contrast medium mixed with saline in a ratio of one part contrast to 50 parts saline between the renal tumor and duodenum. We then inserted two cryoneedles into the tumor, retracted them to pull away the tumor and duodenum, and then inserted the other two cryoneedles. We performed ablation in two freeze–thaw cycles of 15 and 5 min. CT during the procedure confirmed formation of an iceball that avoided the duodenum using the hydrodissection technique. The total freezing time was 30 min. The day after the PCA procedure, the patient showed no symptoms, and CT confirmed no complication. The next day, he was discharged from the hospital without problem. However, 1 month later, follow-up contrast-enhanced CT (CECT) demonstrated a duodenorenal fistula, and an upper

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gastrointestinal series demonstrated a diverticulum-like lesion in the duodenum. The urinary tract was not visualized. We treated the patient conservatively because he had no symptom. Two months after the procedure, CECT and an upper gastrointestinal series confirmed spontaneous resolution of the fistula without treatment (Fig. 1). Four months after the initial procedure, CECT revealed a small enhancing nodule that we suspected was residual viable lesion, it was treated by repeat PCA, and complete ablation was achieved without complication.

Case 2

Fig. 1 Case 1, an 83-year-old man with right renal cell carcinoma (RCC). A Contrast-enhanced computed tomography (CECT) revealed RCC of 39-mm diameter adjacent to the duodenum. B CT-guided percutaneous cryoablation (PCA) performed after transcatheter arterial embolization (TAE). The patient was placed on the CT table in left lateral position. Hydrodissection to avoid injury to adjacent organs was performed using an 18-gauge coaxial needle (arrow). Two cryoneedles were used to puncture the tumor (arrowhead) and retracted to create a safe margin between the tumor and the duodenum (probe retraction technique). Finally, four cryoneedles were used to

target lipiodol accumulated in the RCC. The iceball was visualized as hypoattenuation around tumor. We successfully avoided extension of the iceball to the duodenum. C CT the day after PCA revealed no complication. D Follow-up CECT 1 month after PCA revealed less than normal enhancement of the duodenal wall and the presence of a duodenorenal fistula. E An upper gastrointestinal series demonstrated a diverticulum-like lesion in the duodenum (arrow). The urinary tract was not visualized. F CECT 2 months after PCA revealed spontaneous resolution of the duodenorenal fistula

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An 84-year-old man underwent TAE prior to CT-guided PCA for exophytic RCC of 38-mm diameter. We placed the patient on the CT table in right lateral position to displace the small intestine from in front of the tumor. Because the tumor was also adjacent to the descending colon, we utilized hydrodissection during the PCA procedure according to the same ablation protocol used for Case 1. Four cryoneedles were used, and total freezing time was

K. Shimizu et al.: Digestive Tract Complications of Renal Cryoablation b Fig. 2 Case 2, an 84-year-old man with left renal cell carcinoma

(RCC). A Contrast-enhanced computed tomography (CECT) revealed renal cell carcinoma (RCC) of 38-mm diameter adjacent to the descending colon and small intestine. B The patient was placed on the CT table in left lateral position to displace the descending colon and small intestine to the inside. An 18-gauge coaxial needle was inserted between the tumor and descending colon for hydrodissection (arrowhead). Four cryoneedles were used for PCA (arrow). C CECT the day after PCA revealed less than normal enhancement of the descending colon (arrow). D Sagittal image. E Endoscopy showed an ulcer ranging up to 10 cm that mimicked ischemic colitis without perforation. F CECT 2 weeks after PCA confirmed a colorenal fistula. G Barium colonography demonstrated a diverticulum-like lesion without visualization of the urinary tract. CECT 2 months after PCA demonstrated resolution of the colorenal fistula. H Axial image. I Sagittal image

was chosen as conservative treatment because the patient had no symptom. Two weeks after PCA, CECT demonstrated a colorenal fistula, which resolved spontaneously by 2 months after the initial procedure. The patient’s only symptom, pneumaturia, appeared several days after PCA. Barium colonography performed 2 months later demonstrated a diverticulum-like lesion without visualization of the urinary tract (Fig. 2). The patient was discharged from the hospital 2 months after PCA without additional surgical intervention.

Discussion

30 min. Iceball formation, monitored under CT, did not reach the descending colon. However, the day after PCA, CECT revealed less than normal enhancement of the descending colon wall, and endoscopic findings showed an ulcer of about 10 cm without perforation that mimicked ischemic colitis. Fasting

The most common complication after PCA for RCC is bleeding or hematuria; the reported rate of bowel injury is less than 10 % of all complications [1–3]. Blute and associates described the dependence of complication incidence on tumor diameter, number of cryoneedles used, and tumor location (central position) [2]. We believe the risk factors for bowel injury have not been described, but bowel perforation, cholecystitis, pancreatitis, and hypertensive crisis from injury of adjacent organs have been reported after ablation therapy and commonly after radiofrequency ablation [6, 7]. In obese patients with renal tumors, gastrointestinal complications may be less likely because fat adjacent to the renal wall protects the critical structures. However, 2 studies examining the relation between body mass index (BMI) and rate of complications concluded there was no association between them in cases of ablation therapy for renal tumors [2, 8], though incomplete ablation may result from long skin-to-tumor distance [2]. Thus, we concluded that obese patients had no advantage in renal ablation. Our ablation protocol consisted of two 15-min freezing cycles, each followed by a 5-min thawing cycle. The most widely used protocol for renal PCA consists of two 10-min freezing cycles, both followed by either an 8- [1] or 10-min

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thawing cycle [9]. Although, long freezing time may induce complication, some authors have used 10- to 20-min freezing cycles according to tumor size [10]. The important thing is to perform two cycles because both thawing and freezing damage cells [11]. Moreover, we believe that the essence of treatment is not the length of freezing time but the coverage of the entire tumor by the iceball [10]. In our cases, we could cover the entire tumor with the iceball using a 15-min freezing cycle. Such techniques as balloon catheter placement, infusion of carbon dioxide gas (carbodissection), and hydrodissection to avoid injury of adjacent organs from freezing have been described. Balloon catheter placement is relatively invasive, expensive, and technically challenging, and carbodissection also demonstrates a good insulating effect, but hydrodissection is widely used. We employed hydrodissection following the technique Campbell and colleagues described, using a ratio of one part contrast medium to 50 parts saline as an optimal balance to increase contrast between the fluid and surrounding tissues with minimal beam-hardening artifacts [12]. Our two cases were RCCs located anterolaterally. Schmit’s group treated 38 such tumors with high success and few complications, using hydrodissection in up to twothirds of patients [13]. They also described the importance of patient positioning [13]. The tumor in our first case was adjacent to the ascending colon and duodenum, so we chose left lateral positioning of the patient for puncture, which displaced the ascending colon that was located around the tumor. This positioning displaced the duodenum, allowed us to avoid organ injury, and shortened the route of puncture. The tumor in our second case was adjacent to the descending colon and small intestine, and lateral positioning of the patient successfully displaced the small intestine from in front of the tumor. Some authors have described the use of probe retraction to avoid injury to adjacent organs [9, 14]. In Case One, we used two cryoneedles to puncture the tumor and retracted them to create a safe margin between the tumor and duodenum. Our patients underwent TAE prior to PCA to reduce hemorrhagic complication and permit accurate visualization of tumor distribution. Miller’s group has recently described the significant reduction of complications using TAE without impacting renal function [15]. Some authors have described bowel injury after PCA in large numbers of patients [2, 3], but few case reports detail bowel injury after PCA. Morgan’s group reported a case of colorenal fistula after ultrasonography-guided PCA for RCC, and Vanderbink’s group reported a case of colorenal fistula after CT-guided PCA for RCC [4, 5]. In each of these cases, such symptoms as pneumaturia and flank pain occurred within one or 2 months after the procedure and

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were conservatively resolved. Gangi’s team reported rectal perforation after PCA for prostate cancer, which also conservatively resolved [13]. One of our patients developed a duodenorenal fistula even when the edge of the iceball did not reach the duodenal wall; CT the day after PCA demonstrated no complication, and the patient had no symptoms. The duodenorenal fistula was diagnosed by follow-up CECT 1 month after the procedure, at which time the patient had no symptom. Although the tumor was adjacent to both the ascending colon and duodenum, complication occurred in only the duodenum. The duodenorenal fistula developed in the opposite side of the mesenteries, in which blood flow was insufficient, whereas the tumor was adjacent to the mesenteric side with rich blood flow in the right colon. Blood flow in adjacent organs is considered an important factor in digestive complication following PCA. In our patient who developed a colorenal fistula, pneumaturia occurred several days after PCA, and CECT 2 weeks after PCA confirmed the lesion. CT the day after the procedure demonstrated less than normal enhancement of the descending colon wall, and endoscopy confirmed an ulcer of about 10 cm without perforation that mimicked ischemic colitis. The ulcer was much wider than the surface of the iceball. This is the first report of a case demonstrating a natural course of bowel injury discovered endoscopically after PCA. Freezing blood vessels damages vascular endothelial cells. Reperfusion after thawing aggregates platelets in the damaged endothelium and causes thrombus formation and ischemia [11]. We attribute fistula formation to ischemia resulting from the occlusion of small vessels caused by the low temperature of the cryoablation procedure as well as to the direct influence of the iceball. Both cases resolved conservatively without additional surgical intervention. PCA requires accurate hydrodissection using enough saline to protect adjacent organs. Ischemia resulting from the occlusion of small vessels is believed to be one cause of digestive complication after PCA. Delayed appearance or improvement of symptoms is usual. Once fistula formation occurs, conservative treatment is feasible. Conflict of interest of interest.

All authors declare that they have no conflicts

Statement of Informed Consent Informed consent was obtained from all individual participants included in the study.

References 1. Georgiades CS, Rodriguez R. Efficacy and safety of percutaneous cryoablation for stage 1A/B renal cell carcinoma: results of a

K. Shimizu et al.: Digestive Tract Complications of Renal Cryoablation

2.

3.

4.

5.

6.

7.

8.

prospective, single-arm, 5-year study. Cardiovasc Intervent Radiol. 2014;37(6):1494–9. Blute ML Jr, Okhunov Z, Moreira DM, et al. Image-guided percutaneous renal cryoablation: preoperative risk factors for recurrence and complications. BJU Int. 2013;111(4 Pt B):E181-5. Atwell TD, Carter RE, Schmit GD, et al. Complications following 573 percutaneous renal radiofrequency and cryoablation procedures. J Vasc Interv Radiol. 2012;23(1):48–54. Morgan AI, Doble A, Davies RJ. Successful conservative management of a colorenal fistula complicating percutaneous cryoablation of renal tumors: a case report. J Med Case Rep. 2012;26(6):365. Vanderbink BA, Rastinehad A, Caplin D, Ost MC, Lobko I, Lee BR. Successful conservative management of colorenal fistula after percutaneous cryoablation of renal-cell carcinoma. J Endourol. 2007;21(7):726–9. Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg SN. Treatment of focal liver tumors with percutaneous radio-frequency ablation: complications encountered in multicenter study. Radiology. 2003;226(2):441–51. Rhim H, Yoon KH, Lee JM, et al. Major complications after radiofrequency thermal ablation of hepatic tumors: spectrum of imaging findings. Radiographics. 2003;23(1):123–34. Froemming A, Atwell T, Farrell M, Callstrom M, Leibovich B, Charboneau W. Probe retraction during renal tumor cryoablation:

9. 10.

11.

12.

13.

14.

15.

a technique to minimize direct ureteral injury. J Vasc Interv Radiol. 2010;21(1):148–51. Erinjeri JP, Clark TW. Cryoablation: mechanism of action and devices. J Vasc Interv Radiol. 2010;21(8 Suppl):S187–91. Miller JM, Julien P, Wachsman A, Van Allan RJ, Friedman ML. The role of embolization in reducing the complications of cryoablation in renal cell carcinoma. Clin Radiol. 2014;69(10): 1045–9. Gangi A, Tsoumakidou G, Abdelli O, et al. Percutaneous MRguided cryoablation of prostate cancer: initial experience. Eur Radiol. 2012;22(8):1829–35. Lian H, Guo H, Zhang G, et al. Single-center comparison of complications in laparoscopic and percutaneous radiofrequency ablation with ultrasound guidance for renal tumors. Urology. 2012; 80(1):119–24. Schmit GD, Atwel TD, Leibovich BC, et al. Percutaneous cryoablation of anterior renal masses: technique, efficacy, and safety. Am J Roentgnol. 2010;195(6):1418–22. Campbell C, Lubner MG, Hinshaw JL, Mun˜oz del Rio A, Brace CL. Contrast media-doped hydrodissection during thermal ablation: optimizing contrast media concentration for improved visibility on CT images. Am J Roentgenol. 2012;199(3):677–82. Georgiades C, Rodriguez R. Renal tumor ablation. Tech Vasc Interv Radiol. 2013;16(4):230–8.

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Digestive Tract Complications of Renal Cryoablation.

We report a case each of duodenorenal and colorenal fistula that arose after computed tomography-guided percutaneous cryoablation (PCA) for renal cell...
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