We report the successful treatment of a patient with malignant neoplasm of the ampulla of Vater by radiofrequency ablation plus stent placement. For biliary malignancies not amenable to curative surgical resection, stent has been commonly used for alleviating obstructive jaundice. However, tumor regrowth often causes stent blockage; thus, inhibiting tumor growth and prolonging stent patency are critical in management of biliary malignancies. Recently, radiofrequency ablation has been used to treat biliary malignancies.[10–13]
The number of living patients with liver transplant has increased over the recent years given improvement in survival and emergence of gastrointestinal tumors has been reported recently.[10,11] We searched PubMed, and Chinese databases Wangfang and CNKI for literature on emergent neoplasms postliver transplant. Between January, 1993, and June, 2012, 47 papers were published on emergent neoplasms postliver transplant. Among 27,301 liver transplant recipients, gastrointestinal tract tumors were found in 208 cases with an incidence rate of 0.76%, including 1 case of biliary tract carcinoma, 16 cases of pancreatic cancer, and 3 cases of periampullary cancer. Our patient developed periampullary cancer 4 years after liver transplant with involvement of the portal vein. Because the tumor was inoperable, we treated the patient with radiofrequency ablation in combination with FCSEMS placement. The patient saw marked improvement in biochemical markers including CA-199 and rapid decline in jaundice. Though the condition of the patient remained satisfactory at 10 months of follow-up, the longer term outcome of the treatment awaits further evaluation. Endoscopic ultrasound remains a valuable diagnostic modality in the diagnosis of periampullary tumor. Unfortunately, the endoscopic ultrasound examination was not performed in our patient as it was not available at our hospital.
Radiofrequency ablation can remove tumor tissues and achieve reduction in tumor volume in patients with inoperable biliary tract cancer, with demonstrable survival benefit. Moreover, endobilliary radiofrequency ablation prolongs patency of FCSEMS, thus avoiding the suffering from and the cost of repeated endoscopic therapies and changes of stents. Reduction in tumor volume allows placement of larger stents, which facilitates better draining and prolongs patency. This is particularly beneficial for patients with severe stricture of the bile duct that precludes the use of larger stents. For these patients, endobilliary radiofrequency ablation provides a second chance for stenting, thus avoiding complications of percutaneous transhepatic cholangial drainage.
Endobilliary radiofrequency ablation may cause thermal injury-associated fistula, hemorrhaged , and pancreatitis.[11,14] It is critical that the radiofrequency ablation electrode be properly positioned in the bile duct and the area to be ablated fall within the stenosed segment of the bile duct. In addition, the electrode should not come into contact with the stent. The electrode should be kept immobile for 1 minute at the end of ablation to facilitate biliary tract remodeling. In case of bleeding, hemostasis can be achieved by compression with balloon or FCSEMS. No bile duct fistula as a result of radiofrequency ablation has been reported so far and our patient also did not develop bile duct fistula. Bile duct fistula might ensue as a result of that the ablation power is too high or the ablation time is too long. Currently, it is considered safe when radiofrequency ablation is performed at a power of 5 to 10 W for 90 s to 120 s. On the other hand, pancreatitis most commonly occurs when the lower segment of the bile duct is ablated. Thermal conduction may cause injury in the pancreas, leading to blockage of the pancreatic duct. Pancreatitis may be managed with conventional antibiotic therapy and preventive measures such as stent placement may also be taken.
In conclusion, we report the first case of a liver transplant patient with inoperable periampullary carcinoma who was successfully managed by radiofrequency ablation plus FCSEMS placement. Postliver transplant periampullary carcinoma is extremely uncommon and our experience will be useful to other surgeons in managing similar patients in the future.
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