Delayed Bile Duct Injury Preceded by Sepsis After Biliary Cooling-Assisted Ablation of Hilar Hepatocellular Carcinoma

An 80-year-old man with hepatitis C was diagnosed with a 12-mm hilar hepatocellular carcinoma and underwent microwave thermosphere ablation with intraductal cooling via endoscopic nasobiliary drainage. The ablation zone was adequate and no early recurrence occurred, but he developed septic shock 6 weeks later without overt biliary dilation. Enterobacter cloacae was isolated and treated successfully. Follow-up imaging revealed biliary dilation, consistent with delayed bile duct injury. In retrospect, this suggests that subclinical ductal injury had preceded and ultimately manifested as septic shock, likely of biliary origin. Delayed biliary injury may occur despite cooling, underscoring the need for long-term surveillance.