According to the National Comprehensive Cancer Network (NCCN) guidelines, RFA is recommended for patients with HCC whose liver function or systemic conditions are poor and are not suitable for surgical resection, with an expected survival comparable to the surgery and fewer complications[9]. Previous literature reports[7, 10], the complications of RFA are mainly associated with needle damage or local thermal damage. While DH after RFA is mainly caused by the injury of the diaphragm by puncture needle, which causes local high temperature in the working state and further aggravates the injury of the diaphragm. After many months, the local diaphragm tension is reduced, and under the attraction of continuous negative pressure of the thoracic cavity, the viscera will penetrate into the thoracic cavity through the local weak place of the diaphragm, resulting to DH.
In this case, a DH with acute intestinal obstruction and necrosis occurred 52 months after RFA, after emergency surgery, the patient recovered and was discharged successfully. According to previous literature reports[11–22], the occurrence time of DH after RFA is 7–96 months (median 18 months), combined with our case, DH is considered to be a long-term complication of RFA, which is consistent with the occurrence mechanism of acquired diaphragmatic hernia, suggesting that for patients after RFA, the occurrence of DH should be vigilant during long-term follow-up.
In some patients with cirrhosis, as the liver atrophy, the space between the liver and the diaphragm gradually becomes larger, and the intestine embedded in it, which is known as Chilaiditi Syndrome. When the diaphragm is locally weak due to RFA, the intestines in this space can herniate into the chest from it, causing diaphragmatic hernia. In this case, the presence of Chilaiditi Syndrome was consistently observed during CT follow-up after RFA, which eventually led to DH. In a review of previous literature[11–22], we found that Chilaiditi Syndrome was present in most cases of DH after RFA. Therefore, high vigilance should be paid to the occurrence of subsequent DH when Chilaiditi Syndrome was shown on CT during the follow-up of RFA.
A review of the previous 12 cases of DH[11–22] showed that 2 cases chose conservative treatment, including diuresis and albumin supplementation, while 10 cases chose emergency surgery. Among them, 3 cases underwent bowel resection due to necrosis, and most of them had good prognosis. Only 2 cases died, the cause of death was tumor recurrence and liver failure (Table 1). The patient in this case was in good preoperative condition, with Child-Pugh A, although intestinal necrosis had been complicated, the patient had a good body tolerance and recovered well after surgery. By reviewing the literature, for patients with DH after RFA, when there is no bowel incarcerated or the patient's general condition is poor, the doctors can consider to conservative treatment, although the short-term curative effect, but in the long run, because failing to repair the diaphragm local weak place, under the condition of prolonged negative pressure in the thoracic cavity, DH is prone to persist and recurring attacks, to avoid the possibility of emergency surgery in the next attack, we recommend that diaphragmatic repair should be performed in time after the general condition of the patient is improved, and laparoscopic surgery can be considered when conditions permitted to reduce injury.