INTRODUCTIONRadiofrequency ablation (RFA) for unresectable primary or secondary hepatic malignancies have gained widespread availability and acceptance over the past 5 years. Complication rates have been reported to range from 0% to 27%.

CLINICAL PICTUREWe report a patient with symptomatic right pleural effusion due to a diaphragmatic fistula and another with biliptysis post-RFA, for recurrent hepatoma.

TREATMENTPercutaneous drainage of both the pleural effusion and biloma was performed. However, surgical repair of the diaphragmatic fistula was only required for the former for persistent drainage.

OUTCOMEBoth patients were successfully treated with minimal morbidity.

CONCLUSIONHigh index of suspicion is required for the early diagnosis and treatment of diaphragmatic fistulas. Simple catheter drainage can potentially obviate the need for surgery.

Adult ; Aged ; Carcinoma, Hepatocellular ; surgery ; Catheter Ablation ; adverse effects ; Diaphragm ; physiopathology ; Fistula ; etiology ; Humans ; Liver Neoplasms ; surgery ; Male ; Neoplasm Recurrence, Local ; surgery ; Pleural Effusion ; etiology

INTRODUCTION: Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery-the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery. METHODS: A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency. RESULTS: There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68-0.69) and 1.0m/s (0.88-1.10m/s), respectively. CONCLUSION Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success.
Adult ; Anastomosis, Surgical ; Hepatic Artery/surgery* ; Humans ; Liver Transplantation ; Living Donors ; Prospective Studies