Fatal ischemic acute pancreatitis complicating trans-catheter arterial embolization of small hepatocellular carcinoma: Do the risks outweigh the benefits?

Abstract

Hepatocellular carcinoma (HCC) is an accepted indication for liver transplantation (LT). Pre-LT adjuvant ablation treatments to prevent tumour progression and drop out from the waiting list have been increasingly adopted at most transplant centers. Trans-catheter arterial chemo-embolization (TACE) is frequently used, but the procedure can be difficult and severe complications may arise. Among them, acute ischemic pancreatitis occasionally occurs and may clinically mimic a post-embolization syndrome. Fatal outcomes of this complication have been reported exceptionally but never in patients awaiting LT. The present case raises concern about the widespread application of TACE and highlights the need for a critical evaluation of the risks and benefits to patients with monofocal small HCC who are scheduled for LT. Superselective embolization of the tumour-feeding artery and systematic monitoring of serum pancreatic enzymes after this radiological procedure are recommended.

Acute recurrent pancreatitis secondary to hepatocellular carcinoma invading the biliary tree

“…The proposed pathway is similar to that described in ischemic pancreatitis by means of regurgitation of embolic agents into the pancreatic arteries [7].…”

The impact of transarterial chemoembolization induced complications on outcomes after liver transplantation: A propensity‐matched study

“…[26][27][28] Bile duct injuries have been described in up to 4% of patients following TACE. 15,29,30 Selective treatment of hepatic artery branches is the recommended technique to minimize side effects, but even with this approach, injuries of adjacent untreated vessels, 27 duodenum, 16,31 and pancreas [32][33][34] are attributed to overflow of the emulsion to nearby arteries or accidental embolization of collaterals and manipulation of the vessels.…”

Acute Pancreatitis After Transarterial Chemoembolization Before Liver Transplantation for Hepatocellular Carcinoma: A Case Report.

“…As reported in the literature, the incidence of acute pancratitis after TACE varies between 2% (clinical pancreatitis) to 40% (biological pancreatitis) and a few cases of necrotizing pancreatitis complicated by abscess formation after TACE have been reported [13,14].It may result from the development of ischemia caused by regurgitation of embolic and chemotherapeutic agents into the pancreatic arteries. Another study suggested that superselective TACE may reduce the risk of pancreatic tissue damage by embolic materials [15].…”