Post-radiofrequency ablation empyema—a staged multidisciplinary protocol for colonic and diaphragmatic perforation: a case report

Background: Percutaneous radiofrequency ablation (RFA) is a widely accepted, minimally invasive treatment for hepatic tumors. However, it can rarely cause severe complications, including visceral and diaphragmatic perforation leading to acute empyema. Such complex scenarios, particularly in patients with underlying liver cirrhosis and malignancy, require a highly specialized management strategy. We report a successful treatment case utilizing a staged, multidisciplinary approach prioritizing source control. Case Description: A 76-year-old man with Child-Pugh B cirrhosis, previously treated for descending colon cancer and liver metastases, presented with fever and malaise 90 days after his third RFA session. Imaging revealed a right subphrenic abscess contiguous with the transverse colon and right pleural space, suggesting a delayed iatrogenic perforation caused by thermal injury. We diagnosed acute empyema secondary to pleuro-colonic communication. Given the severe infection and extensive adhesions, we executed a three-stage therapeutic strategy. Stage 1 involved thoracic infection control via drainage and thoracoscopic debridement. Stage 2 addressed the abdominal source; a diverting ileostomy was created to mitigate contamination, followed later by a right hemicolectomy and diaphragmatic repair using a Gerota’s fascia patch. Stage 3 managed the residual refractory empyema and persistent air leak through an open window thoracostomy, followed by bronchial occlusion using endobronchial Watanabe spigots. The patient fully recovered, was discharged on day 162, and remains recurrence-free at the 15-month follow-up. Conclusions: Delayed colonic and diaphragmatic perforation is a rare but life-threatening complication of hepatic RFA. A rigorous staged, multidisciplinary approach focused on definitive source control and management of chronic pleural complications is essential for a favorable outcome in such complex cases.