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A Disappearing Hepatic Infusion Pump
Gastrointestinal Images A Disappearing Hepatic Infusion Pump Leonard R. Henry, M.D., Elin Sigurdson, M.D., Ph.D., F.A.C.S., Cletus A. Arciero, M.D., James C. Watson, M.D., F.A.C.S. KEY WORDS: Hepatic arterial infusion, complications, metastasis
CASE REPORT An 81-year-old man underwent right hemicolectomy for a T3 N1 colon cancer complicated by the development of a midline incisional hernia. He completed 6 months of adjuvant systemic chemotherapy. Shortly thereafter, he developed a solitary right hepatic lobe metastasis and was referred to our institution for consideration of resection and hepatic arterial pump placement. A right hepatic lobectomy, hepatic pump placement, and incisional hernia repair were performed through a right subcostal incision with a left-sided extension. Through this exposure, a suprafascial pocket for the hepatic pump was fashioned in the left lower quadrant. The incisional hernia was observed during creation of the pocket, the sac was removed, and the fascia was closed without undue tension with interrupted Prolene (Ethicon, Somerville, NJ). The catheter was placed through the abdominal wall, the pump was secured to the fascia with Prolene, and the pocket was closed with chromic suture. The pump pocket was created lateral to the hernia repair. A postoperative abdominal roentgenogram demonstrated the pump to be in the expected location (Fig. 1). The patient’s incisional hernia recurred postoperatively. Despite this, the hepatic pump remained in position, and he received two cycles of fluorodeoxyuridine unremarkably. He began to complain of intermittent abdominal pain in the area of his pump. Four months after placement, the pump could no longer be palpated or accessed. Roentgenograms were obtained (Fig. 2) and demonstrated the pump to be in the patient’s true pelvis. At exploration, a large incisional hernia was found. The pump had subsequently eroded through the
Fig. 1. Abdominal roentgenogram taken immediately after the operation, showing the hepatic arterial infusion pump located in the left lower anterior abdominal wall.
midline hernia sac and descended into the patient’s pelvis. The catheter remained intact. A new pump pocket was made more lateral to the midline with the
From the Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania. Reprint requests: James C. Watson, M.D., F.A.C.S., Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111. e-mail: [email protected]
878
쑖 2005 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/05/$—see front matter doi:10.1016/j.gassur.2005.03.006
Vol. 9, No. 6 2005
Migrating Hepatic Arterial Infusion Pump
879
Fig. 2. Anteroposterior (left) and lateral (right) pelvic roentgenograms, taken 4 months after the operation, show the patient’s infusion pump now to be located in the true pelvis.
pump resecured. The hernia was repaired with mesh. The patient has done well since then, without hernia or disease recurrence. His pump remains functional. DISCUSSION Hepatic arterial infusion of chemotherapy reduces liver recurrence and may provide a survival benefit.1 However, several factors have limited its widespread application: conflicting data regarding the overall survival advantage; the implementation of newer systemic agents with efficacy such as irinotecan, oxaliplatin, and bevacizumab; and metabolic and technical complications associated with hepatic pump placement and utilization. Studies specifically addressing technical complications of hepatic arterial chemotherapy using a continuous-infusion pump report complications in 28%2 to 41% of patients with hepatic pumps, resulting in cessation of therapy in as many as 30% of patients.3 Complications reported with a greater than 5% incidence are dislodgement of the catheter tip, catheter occlusion, pump failure, and pump pocket hematoma, seroma, and infection.2,3 This report describes another complication, viz., pump migration from its initial position in the left anterior abdominal wall into the true pelvis. This case brings attention to several important issues regarding hepatic pump placement and management. It is critical to ensure catheter redundancy
during placement to avoid dislodgement and pseudoaneurysm formation should unforeseen catheter tension occur. Generally, a catheter needs only to be tailored at the tip so that it infuses at the junction of the gastroduodenal artery and common hepatic artery. In addition, the creation of a generous pump pocket away from the midline allows for adequate fascial bites for midline closure, which lessens the risk of catheter entrapment and minimizes the risk of pump migration should an incisional hernia occur. Some favor a separate left lower quadrant incision for this purpose, with the added theoretical decreased risk of concomitant pump infection, should the primary operative wound become infected. Finally, the use of interventional radiology services is validated in diagnosing (and often rectifying) a number of complications associated with hepatic pumps and other chemotherapy delivery systems. REFERENCES 1. Kemeny N, Huang Y, Cohen AM, et al. Hepatic arterial infusion of chemotherapy after resection of hepatic metastasis from colorectal cancer. N Engl J Med 1999;341:2039– 2048. 2. Curley SA, Chase JL, Roh MS, Hohn DC. Technical considerations and complications associated with the placement of 180 implantable hepatic arterial infusion devices. Surgery 1993;114: 928–935. 3. Heinrich S, Petrowsky H, Schwinnen I, et al. Technical complications of continuous intra-arterial chemotherapy with 5-fluorodeoxyuridine and 5-fluorouracil for colorectal liver metastasis. Surgery 2003;133:40–48.
CASE REPORT An 81-year-old man underwent right hemicolectomy for a T3 N1 colon cancer complicated by the development of a midline incisional hernia. He completed 6 months of adjuvant systemic chemotherapy. Shortly thereafter, he developed a solitary right hepatic lobe metastasis and was referred to our institution for consideration of resection and hepatic arterial pump placement. A right hepatic lobectomy, hepatic pump placement, and incisional hernia repair were performed through a right subcostal incision with a left-sided extension. Through this exposure, a suprafascial pocket for the hepatic pump was fashioned in the left lower quadrant. The incisional hernia was observed during creation of the pocket, the sac was removed, and the fascia was closed without undue tension with interrupted Prolene (Ethicon, Somerville, NJ). The catheter was placed through the abdominal wall, the pump was secured to the fascia with Prolene, and the pocket was closed with chromic suture. The pump pocket was created lateral to the hernia repair. A postoperative abdominal roentgenogram demonstrated the pump to be in the expected location (Fig. 1). The patient’s incisional hernia recurred postoperatively. Despite this, the hepatic pump remained in position, and he received two cycles of fluorodeoxyuridine unremarkably. He began to complain of intermittent abdominal pain in the area of his pump. Four months after placement, the pump could no longer be palpated or accessed. Roentgenograms were obtained (Fig. 2) and demonstrated the pump to be in the patient’s true pelvis. At exploration, a large incisional hernia was found. The pump had subsequently eroded through the
Fig. 1. Abdominal roentgenogram taken immediately after the operation, showing the hepatic arterial infusion pump located in the left lower anterior abdominal wall.
midline hernia sac and descended into the patient’s pelvis. The catheter remained intact. A new pump pocket was made more lateral to the midline with the
From the Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania. Reprint requests: James C. Watson, M.D., F.A.C.S., Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111. e-mail: [email protected]
878
쑖 2005 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/05/$—see front matter doi:10.1016/j.gassur.2005.03.006
Vol. 9, No. 6 2005
Migrating Hepatic Arterial Infusion Pump
879
Fig. 2. Anteroposterior (left) and lateral (right) pelvic roentgenograms, taken 4 months after the operation, show the patient’s infusion pump now to be located in the true pelvis.
pump resecured. The hernia was repaired with mesh. The patient has done well since then, without hernia or disease recurrence. His pump remains functional. DISCUSSION Hepatic arterial infusion of chemotherapy reduces liver recurrence and may provide a survival benefit.1 However, several factors have limited its widespread application: conflicting data regarding the overall survival advantage; the implementation of newer systemic agents with efficacy such as irinotecan, oxaliplatin, and bevacizumab; and metabolic and technical complications associated with hepatic pump placement and utilization. Studies specifically addressing technical complications of hepatic arterial chemotherapy using a continuous-infusion pump report complications in 28%2 to 41% of patients with hepatic pumps, resulting in cessation of therapy in as many as 30% of patients.3 Complications reported with a greater than 5% incidence are dislodgement of the catheter tip, catheter occlusion, pump failure, and pump pocket hematoma, seroma, and infection.2,3 This report describes another complication, viz., pump migration from its initial position in the left anterior abdominal wall into the true pelvis. This case brings attention to several important issues regarding hepatic pump placement and management. It is critical to ensure catheter redundancy
during placement to avoid dislodgement and pseudoaneurysm formation should unforeseen catheter tension occur. Generally, a catheter needs only to be tailored at the tip so that it infuses at the junction of the gastroduodenal artery and common hepatic artery. In addition, the creation of a generous pump pocket away from the midline allows for adequate fascial bites for midline closure, which lessens the risk of catheter entrapment and minimizes the risk of pump migration should an incisional hernia occur. Some favor a separate left lower quadrant incision for this purpose, with the added theoretical decreased risk of concomitant pump infection, should the primary operative wound become infected. Finally, the use of interventional radiology services is validated in diagnosing (and often rectifying) a number of complications associated with hepatic pumps and other chemotherapy delivery systems. REFERENCES 1. Kemeny N, Huang Y, Cohen AM, et al. Hepatic arterial infusion of chemotherapy after resection of hepatic metastasis from colorectal cancer. N Engl J Med 1999;341:2039– 2048. 2. Curley SA, Chase JL, Roh MS, Hohn DC. Technical considerations and complications associated with the placement of 180 implantable hepatic arterial infusion devices. Surgery 1993;114: 928–935. 3. Heinrich S, Petrowsky H, Schwinnen I, et al. Technical complications of continuous intra-arterial chemotherapy with 5-fluorodeoxyuridine and 5-fluorouracil for colorectal liver metastasis. Surgery 2003;133:40–48.