Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Dec 27, 2017; 9(12): 281-287
Published online Dec 27, 2017. doi: 10.4240/wjgs.v9.i12.281
Surgically treated diaphragmatic perforation after radiofrequency ablation for hepatocellular carcinoma
Sachiko Nagasu, Koji Okuda, Ryoko Kuromatsu, Yoriko Nomura, Takuji Torimura, Yoshito Akagi
Sachiko Nagasu, Yoshito Akagi, Department of Gastrointestinal Surgery, Kurume University, Fukuoka 8300011, Japan
Koji Okuda, Yoriko Nomura, Department of Hepato-biliary and Pancreatic Surgery, Kurume University, Fukuoka 8300011, Japan
Ryoko Kuromatsu, Takuji Torimura, Department of Gastroenterological Medicine, Kurume University, Fukuoka 8300011, Japan
Author contributions: Nagasu S and Okuda K made substantial contributions to the conception or design of the work, the acquisition, analysis, and interpretation of data for the work; Okuda K, Kuromatsu R, Nomura Y, Torimura T and Akagi Y contributed to the drafting of the work or revising it critically for important intellectual content; all authors provided final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Informed consent statement: This is a retrospective study, as we are taking personal information measures, there is no possibility of suffering disadvantages.
Conflict-of-interest statement: No conflict-of-interest was available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Sachiko Nagasu, PhD, Department of Gastrointestinal Surgery, Kurume University, 67 Asahi-machi Kurume, Fukuoka 8300011, Japan. shiraiwa_sachiko@med.kurume-u.ac.jp
Telephone: +81-942-353311 Fax: +81-942-326278
Received: August 7, 2017
Peer-review started: August 8, 2017
First decision: September 7, 2017
Revised: September 18, 2017
Accepted: November 25, 2017
Article in press: November 25, 2017
Published online: December 27, 2017
Abstract

We review 6 cases of diaphragmatic perforation, with and without herniation, treated in our institution. All patients with diaphragmatic perforation underwent radiofrequency ablation (RFA) treatments for hepatocellular carcinoma (HCC) performed at Kurume University Hospital and Tobata Kyoritsu Hospital. We investigated the clinical profiles of the 6 patients between January 2003 and December 2013. We further describe the clinical presentation, diagnosis, and treatment of diaphragmatic perforation. The change in the volume of liver and the change in the Child-Pugh score from just after the RFA to the onset of perforation was evaluated using a paired t-test. At the time of perforation, 4 patients had herniation of the viscera, while the other 2 patients had no herniation. The majority of ablated tumors were located adjacent to the diaphragm, in segments 4, 6, and 8. The average interval from RFA to the onset of perforation was 12.8 mo (range, 6-21 mo). The median Child-Pugh score at the onset of perforation (8.2) was significantly higher compared to the median Child-Pugh score just after RFA (6.5) (P = 0.031). All patients underwent laparotomy and direct suture of the diaphragm defect, with uneventful post-surgical recovery. Diaphragmatic perforation after RFA is not a matter that can be ignored. Clinicians should carefully address this complication by performing RFA for HCC adjacent to diaphragm.

Keywords: Diaphragmatic perforation, Diaphragmatic hernia, Radiofrequency ablation, Hepatocellular carcinoma

Core tip: Diaphragmatic perforation after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) has been rarely described in the literature; however, it is one of the most serious complications. We conducted a retrospective analysis of 6 cases of diaphragmatic perforation after RFA, and considered the following 3 causative factors for this complication: Location, thermal damage, and liver cirrhosis. Moreover, we found that this complication tends to develop late after RFA. We propose that diaphragmatic perforation after RFA is a rare complication. Clinicians should take steps to prevent thermal injury to the diaphragm by performing RFA for HCC adjacent to the diaphragm and carefully follow up after RFA.