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Acute necrotizing pancreatitis after transarterial chemoembolization in candidates for a liver transplant
G Model
ARTICLE IN PRESS Med Clin (Barc). 2017;xxx(xx):xxx–xxx
www.elsevier.es/medicinaclinica
Letter to the Editor
Acute necrotizing pancreatitis after transarterial chemoembolization in candidates for a liver transplant夽 Pancreatitis aguda necrosante secundaria a quimioembolización transarterial en pacientes candidatos a trasplante hepático Dear Editor, Transarterial chemoembolization (TACE) is a procedure primarily applied to patients who are liver transplantation (LT) candidates who have liver lesions compatible with hepatocellular carcinoma (HCC) without indication of resection and who do not meet LT criteria. In case of reduction in size or number of lesions, the patient can be included in the list of LT due to meeting the Milan criteria, with TACE acting as a bridge treatment. TACE has been associated with complications such as acute cholecystitis, gastrointestinal mucosal lesions, pulmonary thromboembolism, or acute pancreatitis.1 We describe 2 cases of LT candidates who developed necrotizing pancreatitis secondary to TACE for HCC. Case 1. 59-year-old male with alcoholic cirrhosis and HBV infection, Child-B9/MELD-10 functional grade and HCC in segment VIII (14 mm) and V (12 mm), evaluated as a candidate for LT. A selective TACE session was performed with adriamycin and lipiodol particles, without immediate complications. The patient was discharged on the second day, being readmitted through the Emergency Department after six days for abdominal pain and vomiting. Laboratory results highlighted: 11,000 white blood cells/mm3 ; bilirubin 2.5 mg/dl; GOT 72 UI/l; GPT 80 UI/l and amylase 100 UI/l. A decreased uptake in the head of the pancreas was observed in the abdominal CT, mainly of the uncinate process, compatible with necrotizing pancreatitis. He entered the ICU with antibiotic treatment and TPN. The subsequent progression was favourable. 20 days after TACE, a new CT scan was performed, with improvement of pancreatic lesions, so his discharge was decided. Currently, the patient is pending re-evaluation for inclusion on the LT waiting list. Case 2. A 55-year-old male, diagnosed with HCV cirrhosis, Child6/MELD-6, with portal hypertension and 3 HCC, included in the list of LT. 2 TACE had been previously performed due to SOL in segments II and IV. In the control CT scan, a lesion recurrence was observed in segment II and a new one, doubtful, in segments V-VI, so it was decided to perform a third TACE, with selective canalization of the left liver artery, injecting adriamycin and lipiodol. 20 days
夽 Please cite this article as: Nutu OA, Marcacuzco Quinto AA, Jiménez Romero LC. Pancreatitis aguda necrosante secundaria a quimioembolización transarterial en pacientes candidatos a trasplante hepático. Med Clin (Barc). 2017. http://dx.doi.org/10.1016/j.medcli.2017.02.005
post-TACE, the patient was re-admitted for abdominal pain, vomiting and digestive intolerance. Admission lab tests showed the following data: 11,500 white blood cells/mm3 ; prothrombin activity 52%; bilirubin 0.8 mg/dl; GOT 35 UI/l; GPT 45 UI/l; GGT 98 UI/l; amylase 800 UI/l and CRP 20 mg/dl. CT scan showed findings compatible with necrotizing pancreatitis, with involvement of more than 60% of the pancreas. In the ICU, the patient showed a favourably course, being discharged with CAT evidence of pancreatic lesion improvement. In addition, a new lesion was detected in segment VIII, pending radiofrequency and subsequent inclusion in LT list, once the pancreatitis was resolved. Post-TACE pancreatitis usually occurs during the first 24 h in 1.7–2% of the cases, and 40% of patients have signs compatible with pancreatic inflammation, although they do not develop pancreatitis as such.2 In our patients, it appeared after several weeks, worsening when treatment was not established early. When the symptoms occur the first day, ischemia is usually due to the microspheres, and if it starts several days later, it is caused by chemotherapy.3 90% of patients may develop a post-TACE syndrome with symptoms similar to pancreatitis. Measuring serum pancreatic enzymes helps with diagnosis, especially if there is pain.2,3 Embolism material regurgitation, non-selective TACE, use of microsphere vials or lipiodol, and repeated TACE contribute to the mechanism of ischemia producing pancreatic inflammation.4 In our patients, TACE were supraselective, a fact that prevents reflux in the superior mesenteric artery and decreases the risk of pancreatic body-tail ischemia, while the head is more exposed. A new TACE may be performed after an episode of pancreatitis, as long as this has been resolved.5 The diagnosis of pancreatitis is based on clinical suspicion and confirmed with enzyme determination and CT images. The treatment of our patients was conservative, similar to that of other pancreatitis. Percutaneous drainage can be used as first-choice, and laparoscopic drainage as second-choice if a necrosectomy is necessary.5 Open surgery is the last option, being left for cases that were refractory to previous treatments. References 1. López-Benítez R, Radeleff BA, Barragán-Campos HM, Noeldge G, Grenacher L, Richter GM, et al. Acute pancreatitis after embolization of liver tumors: frequency and associated risk factors. Pancreatology. 2007;7:53–62. 2. Roullet MH, Denys A, Sauvanet A, Farges O, Vilgrain V, Belghiti J. Acute clinical pancreatitis following selective transcatheter arterial chemoembolization of hepatocellular carcinoma. Ann Chir. 2002;127:779–82. 3. Chey V, Chopin-Ialy X, Micol C, Lepiliez V, Forestier J, Lombard-Bohas C, et al. Acute pancreatitis after transcatheter arterial chemoembolization for liver metastases of carcinoid tumors. Clin Res Hepatol Gastroenterol. 2011;35:583–5. 4. Lo CM, Ngan H, Tso WK, Liu CL, Lam C, Poon RT, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002;35:1164–71. 5. She WH, Chan A, Cheung T, Chok K, Chan S, Poon RT, et al. Acute pancreatitis induced by transarterial chemoembolization: a single-center experience of over 1500 cases. Hepatobiliary Pancreat Dis Int. 2016;15:93–8.
˜ S.L.U. All rights reserved. 2387-0206/© 2017 Elsevier Espana,
MEDCLE-3974; No. of Pages 2
G Model 2
ARTICLE IN PRESS Letter to the Editor / Med Clin (Barc). 2017;xxx(xx):xxx–xxx
Oana Anisa Nutu, Alberto Alejandro Marcacuzco Quinto ∗ , Luis Carlos Jiménez Romero Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
∗ Corresponding author. E-mail addresses: alejandro [email protected], alejandro [email protected] (A.A. Marcacuzco Quinto).
ARTICLE IN PRESS Med Clin (Barc). 2017;xxx(xx):xxx–xxx
www.elsevier.es/medicinaclinica
Letter to the Editor
Acute necrotizing pancreatitis after transarterial chemoembolization in candidates for a liver transplant夽 Pancreatitis aguda necrosante secundaria a quimioembolización transarterial en pacientes candidatos a trasplante hepático Dear Editor, Transarterial chemoembolization (TACE) is a procedure primarily applied to patients who are liver transplantation (LT) candidates who have liver lesions compatible with hepatocellular carcinoma (HCC) without indication of resection and who do not meet LT criteria. In case of reduction in size or number of lesions, the patient can be included in the list of LT due to meeting the Milan criteria, with TACE acting as a bridge treatment. TACE has been associated with complications such as acute cholecystitis, gastrointestinal mucosal lesions, pulmonary thromboembolism, or acute pancreatitis.1 We describe 2 cases of LT candidates who developed necrotizing pancreatitis secondary to TACE for HCC. Case 1. 59-year-old male with alcoholic cirrhosis and HBV infection, Child-B9/MELD-10 functional grade and HCC in segment VIII (14 mm) and V (12 mm), evaluated as a candidate for LT. A selective TACE session was performed with adriamycin and lipiodol particles, without immediate complications. The patient was discharged on the second day, being readmitted through the Emergency Department after six days for abdominal pain and vomiting. Laboratory results highlighted: 11,000 white blood cells/mm3 ; bilirubin 2.5 mg/dl; GOT 72 UI/l; GPT 80 UI/l and amylase 100 UI/l. A decreased uptake in the head of the pancreas was observed in the abdominal CT, mainly of the uncinate process, compatible with necrotizing pancreatitis. He entered the ICU with antibiotic treatment and TPN. The subsequent progression was favourable. 20 days after TACE, a new CT scan was performed, with improvement of pancreatic lesions, so his discharge was decided. Currently, the patient is pending re-evaluation for inclusion on the LT waiting list. Case 2. A 55-year-old male, diagnosed with HCV cirrhosis, Child6/MELD-6, with portal hypertension and 3 HCC, included in the list of LT. 2 TACE had been previously performed due to SOL in segments II and IV. In the control CT scan, a lesion recurrence was observed in segment II and a new one, doubtful, in segments V-VI, so it was decided to perform a third TACE, with selective canalization of the left liver artery, injecting adriamycin and lipiodol. 20 days
夽 Please cite this article as: Nutu OA, Marcacuzco Quinto AA, Jiménez Romero LC. Pancreatitis aguda necrosante secundaria a quimioembolización transarterial en pacientes candidatos a trasplante hepático. Med Clin (Barc). 2017. http://dx.doi.org/10.1016/j.medcli.2017.02.005
post-TACE, the patient was re-admitted for abdominal pain, vomiting and digestive intolerance. Admission lab tests showed the following data: 11,500 white blood cells/mm3 ; prothrombin activity 52%; bilirubin 0.8 mg/dl; GOT 35 UI/l; GPT 45 UI/l; GGT 98 UI/l; amylase 800 UI/l and CRP 20 mg/dl. CT scan showed findings compatible with necrotizing pancreatitis, with involvement of more than 60% of the pancreas. In the ICU, the patient showed a favourably course, being discharged with CAT evidence of pancreatic lesion improvement. In addition, a new lesion was detected in segment VIII, pending radiofrequency and subsequent inclusion in LT list, once the pancreatitis was resolved. Post-TACE pancreatitis usually occurs during the first 24 h in 1.7–2% of the cases, and 40% of patients have signs compatible with pancreatic inflammation, although they do not develop pancreatitis as such.2 In our patients, it appeared after several weeks, worsening when treatment was not established early. When the symptoms occur the first day, ischemia is usually due to the microspheres, and if it starts several days later, it is caused by chemotherapy.3 90% of patients may develop a post-TACE syndrome with symptoms similar to pancreatitis. Measuring serum pancreatic enzymes helps with diagnosis, especially if there is pain.2,3 Embolism material regurgitation, non-selective TACE, use of microsphere vials or lipiodol, and repeated TACE contribute to the mechanism of ischemia producing pancreatic inflammation.4 In our patients, TACE were supraselective, a fact that prevents reflux in the superior mesenteric artery and decreases the risk of pancreatic body-tail ischemia, while the head is more exposed. A new TACE may be performed after an episode of pancreatitis, as long as this has been resolved.5 The diagnosis of pancreatitis is based on clinical suspicion and confirmed with enzyme determination and CT images. The treatment of our patients was conservative, similar to that of other pancreatitis. Percutaneous drainage can be used as first-choice, and laparoscopic drainage as second-choice if a necrosectomy is necessary.5 Open surgery is the last option, being left for cases that were refractory to previous treatments. References 1. López-Benítez R, Radeleff BA, Barragán-Campos HM, Noeldge G, Grenacher L, Richter GM, et al. Acute pancreatitis after embolization of liver tumors: frequency and associated risk factors. Pancreatology. 2007;7:53–62. 2. Roullet MH, Denys A, Sauvanet A, Farges O, Vilgrain V, Belghiti J. Acute clinical pancreatitis following selective transcatheter arterial chemoembolization of hepatocellular carcinoma. Ann Chir. 2002;127:779–82. 3. Chey V, Chopin-Ialy X, Micol C, Lepiliez V, Forestier J, Lombard-Bohas C, et al. Acute pancreatitis after transcatheter arterial chemoembolization for liver metastases of carcinoid tumors. Clin Res Hepatol Gastroenterol. 2011;35:583–5. 4. Lo CM, Ngan H, Tso WK, Liu CL, Lam C, Poon RT, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002;35:1164–71. 5. She WH, Chan A, Cheung T, Chok K, Chan S, Poon RT, et al. Acute pancreatitis induced by transarterial chemoembolization: a single-center experience of over 1500 cases. Hepatobiliary Pancreat Dis Int. 2016;15:93–8.
˜ S.L.U. All rights reserved. 2387-0206/© 2017 Elsevier Espana,
MEDCLE-3974; No. of Pages 2
G Model 2
ARTICLE IN PRESS Letter to the Editor / Med Clin (Barc). 2017;xxx(xx):xxx–xxx
Oana Anisa Nutu, Alberto Alejandro Marcacuzco Quinto ∗ , Luis Carlos Jiménez Romero Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
∗ Corresponding author. E-mail addresses: alejandro [email protected], alejandro [email protected] (A.A. Marcacuzco Quinto).