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Catheter placement for intra-arterial hepatic chemotherapy
Journal of Visceral Surgery (2012) 149, 389—394
Available online at
www.sciencedirect.com
SURGICAL TECHNIQUE
Catheter placement for intra-arterial hepatic chemotherapy C. Honoré ∗, D. Goéré , F. Dumont , D. Elias Département de Chirurgie Oncologique, Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
Introduction The administration of intra-arterial hepatic chemotherapy (IAHC) permits an increase in the local concentration of cytotoxic chemotherapy by a factor of 20 to 400× without any increase in systemic chemotoxicity, thanks to the ‘‘first pass’’ phenomenon in the hepatic circulation [1]. At present, this mode of administration has been used with promising results in curative and palliative treatment of hepatic metastases from colorectal cancer [2,3]. The fundamental principle for administration of IAHC is to preserve only a single hepatic arterial branch after division of all other afferent arterial branches; this allows arterialization of the entire liver by the almost immediate opening of intraparenchymal arterial shunts from the single arterial branch that has been cannulated. The catheter is then connected to an implantable subcutaneous port to allow repeated sessions of chemotherapy. Several technical stratagems may be needed to achieve this goal, particularly when the patient has anatomic variations. The catheter can be either placed by an open approach during laparotomy or by a radiology-guided percutaneous route, which is the favored approach when no hepatic resection is planned. Even if not substituting for an accurate intraoperative assessment, the interpretation of the early arterial phase after IV contrast injection of an abdominopelvic CT scan allows accurate preoperative analysis of the hepatic artery anatomy. It is no longer necessary to perform selective angiography preoperatively. We will first describe the technique of IAHC catheter placement in patients with ‘‘normal’’ anatomy; this is applicable to 60% of the general population.
∗
Corresponding author. E-mail address: [email protected] (C. Honoré).
1878-7886/$ — see front matter © 2012 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2012.10.015
390
1
C. Honoré et al.
Surgical approach and exposure
The surgical incision is governed by the surgical procedures that are to be performed in association with catheter placement. When catheter placement is the only anticipated procedure, a short right subcostal incision allows adequate exposure. The liver edge is elevated with a malleable retractor. The hepatic pedicle and the lesser omentum are palpated to detect the right or left hepatic artery. The lesser omentum is incised along its entire width from the hepatic pedicle to the right diaphragmatic pillar. An antegrade cholecystectomy is performed to prevent the risk of toxic cholecystitis during the chemotherapy infusion.
Exposure and dissection of the 2 gastroduodenal artery
All the branches of the gastroduodenal artery serving the pylorus, duodenum, and pancreas that lie anterior to the hepatic pedicle, to the left of the common bile duct, and below the common hepatic artery are divided to avoid extrahepatic perfusion of chemotherapy agents, which may cause severe pain and/or gastroduodenal ulceration. The right gastric artery is ligated. The bifurcation of the common hepatic artery (CHA) into the hepatic artery (HA) and the gastroduodenal artery (GDA) is exposed and dissected.
Catheter placement for intra-arterial hepatic chemotherapy
3
Preparation of the gastroduodenal artery
4
Insertion of the catheter
The GDA is freed up circumferentially over a length of 2 cm from its origin and all collateral branches are ligated (no clips). The distal end of the GDA is ligated with absorbable suture (Vicryl® 2/0). The GDA is encircled proximally close to its origin with a non-absorbable suture (Prolene® 3/0).
A small atraumatic curved bulldog clamp is applied to the origin of the GDA. A 3-mm longitudinal arteriotomy is made about 1 cm from its origin. The tip of a Celsite® type catheter (T202F 6,5F, B BRAUN), pre-flushed with heparinized saline and with the distal spur excised, is inserted so that its tip just reaches the level of the origin of the GDA without protruding into the CHA or the HA. The catheter is fixed in place by ligation of the prolene suture just downstream of the proximal spur. The use of a vein pick may help in introducing the catheter into the artery.
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Connection of the catheter to the implanted reservoir
The catheter is connected to the reservoir leaving a sufficient length so that the tubing lies in place with a comfortable curve but without kinking. The reservoir, pre-flushed with heparinized saline, is implanted in a subcutaneous pocket overlying the fascia and the right costal margin. The system is tested with a low-pressure injection of fluorescein to verify that the entire liver is perfused and that there is no extrahepatic perfusion. Too-rapid injection may result in result in backflow into the hepatic artery trunk resulting in dye coloration of the pancreas, duodenum, and stomach. One should never aspirate blood back into the IAHC catheter to avoid the risk of thrombosis.
Adjustments of technique for anatomical variations The different technical stratagems described below allow achievement of in toto hepatic perfusion by implantation of a catheter into a single hepatic artery.
6
Aberrant right hepatic artery arising from the superior mesenteric artery or left hepatic artery arising from the left gastric artery
It has been shown that ligation of a right (or left) hepatic artery is followed by re-arterialization of the entire right (or left) liver from the CHA, due to opening of intraparenchymal arterial shunts [4]; the aberrant right or left hepatic artery can therefore be ligated with placement of the catheter as described above.
Catheter placement for intra-arterial hepatic chemotherapy
7
Trifurcation of the hepatic artery
8
Single right hepatic artery
In some cases, the AHC trifurcates into three arteries; the GDA, a right HA and a left HA. In this case, there is a risk of preferential flow to one or the other hepatic lobes when the catheter is placed in the GDA. At the time that perfusion is verified by fluorescein injection, if only the right liver is colored, the left hepatic arterial branch should be clamped. Injection should be repeated (perhaps using a blue dye to obtain sufficient color contrast), to confirm that the intraparenchymal arterial shunts have opened leading to perfusion of the entire liver. The left branch is then ligated. An analogous technique can be used if the perfusion favors the left liver.
In this anatomical configuration, there are usually no collateral arteries of sufficient caliber to allow catheter insertion. After dissection of the hepatic hilum, the catheter is introduced retrograde into the left hepatic branch, which is then ligated distally; the catheter should be positioned so that its tip lies just at the origin of the left hepatic branch but does not penetrate into the HA or the right hepatic branch [5].
393
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C. Honoré et al.
Single left hepatic artery
When the left hepatic artery is the only arterial supply to the liver, the catheter should be introduced via the left gastric artery so that its tip just reaches the level of origin of the left hepatic artery.
Postoperative examinations
References
Before using the catheter for chemotherapy, a scintigraphy with Technetium-99 injection is performed to verify good catheter function and absence of extrahepatic perfusion. Angiography is also routinely performed before the first course of chemotherapy and is repeated every 2—3 courses. If the patient develops symptoms of severe abdominal pain or if there is any difficulty with injection, a new angiogram should be performed. If this shows no evidence of catheter thrombosis or extrahepatic perfusion, a new scintigraphy with Technetium-99 injection should be performed; this is the only test sensitive enough to demonstrate abnormal microperfusions, especially in the late phase after injection.
[1] Kemeny N, Conti JA, Cohen A, et al. Phase II study of hepatic arterial floxuridine, leucovorin, and dexamethasone for unresectable liver metastases from colorectal carcinoma. J Clin Oncol 1994;12(11):2288—95. [2] Ducreux M, Ychou M, Laplanche A, et al. Hepatic arterial oxaliplatin infusion plus intravenous chemotherapy in colorectal cancer with inoperable hepatic metastases: a trial of the gastrointestinal group of the Fédération Nationale des Centres de Lutte Contre le Cancer. J Clin Oncol 2005;23(22):4881—7. [3] Boige V, Malka D, Elias D, et al. Hepatic arterial infusion of oxaliplatin and intravenous LV5FU2 in unresectable liver metastases from colorectal cancer after systemic chemotherapy failure. Ann Surg Oncol 2008;15(1):219—26. [4] Chuang VP, Wallace S. Hepatic arterial redistribution for intraarterial infusion of hepatic neoplasms. Radiology 1980;135(2):295—9. [5] Elias D, Lasser P. Simplified technic of implanting a catheter in a case of single right hepatic artery. J Chir (Paris) 1988;125(1):54.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
Available online at
www.sciencedirect.com
SURGICAL TECHNIQUE
Catheter placement for intra-arterial hepatic chemotherapy C. Honoré ∗, D. Goéré , F. Dumont , D. Elias Département de Chirurgie Oncologique, Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
Introduction The administration of intra-arterial hepatic chemotherapy (IAHC) permits an increase in the local concentration of cytotoxic chemotherapy by a factor of 20 to 400× without any increase in systemic chemotoxicity, thanks to the ‘‘first pass’’ phenomenon in the hepatic circulation [1]. At present, this mode of administration has been used with promising results in curative and palliative treatment of hepatic metastases from colorectal cancer [2,3]. The fundamental principle for administration of IAHC is to preserve only a single hepatic arterial branch after division of all other afferent arterial branches; this allows arterialization of the entire liver by the almost immediate opening of intraparenchymal arterial shunts from the single arterial branch that has been cannulated. The catheter is then connected to an implantable subcutaneous port to allow repeated sessions of chemotherapy. Several technical stratagems may be needed to achieve this goal, particularly when the patient has anatomic variations. The catheter can be either placed by an open approach during laparotomy or by a radiology-guided percutaneous route, which is the favored approach when no hepatic resection is planned. Even if not substituting for an accurate intraoperative assessment, the interpretation of the early arterial phase after IV contrast injection of an abdominopelvic CT scan allows accurate preoperative analysis of the hepatic artery anatomy. It is no longer necessary to perform selective angiography preoperatively. We will first describe the technique of IAHC catheter placement in patients with ‘‘normal’’ anatomy; this is applicable to 60% of the general population.
∗
Corresponding author. E-mail address: [email protected] (C. Honoré).
1878-7886/$ — see front matter © 2012 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2012.10.015
390
1
C. Honoré et al.
Surgical approach and exposure
The surgical incision is governed by the surgical procedures that are to be performed in association with catheter placement. When catheter placement is the only anticipated procedure, a short right subcostal incision allows adequate exposure. The liver edge is elevated with a malleable retractor. The hepatic pedicle and the lesser omentum are palpated to detect the right or left hepatic artery. The lesser omentum is incised along its entire width from the hepatic pedicle to the right diaphragmatic pillar. An antegrade cholecystectomy is performed to prevent the risk of toxic cholecystitis during the chemotherapy infusion.
Exposure and dissection of the 2 gastroduodenal artery
All the branches of the gastroduodenal artery serving the pylorus, duodenum, and pancreas that lie anterior to the hepatic pedicle, to the left of the common bile duct, and below the common hepatic artery are divided to avoid extrahepatic perfusion of chemotherapy agents, which may cause severe pain and/or gastroduodenal ulceration. The right gastric artery is ligated. The bifurcation of the common hepatic artery (CHA) into the hepatic artery (HA) and the gastroduodenal artery (GDA) is exposed and dissected.
Catheter placement for intra-arterial hepatic chemotherapy
3
Preparation of the gastroduodenal artery
4
Insertion of the catheter
The GDA is freed up circumferentially over a length of 2 cm from its origin and all collateral branches are ligated (no clips). The distal end of the GDA is ligated with absorbable suture (Vicryl® 2/0). The GDA is encircled proximally close to its origin with a non-absorbable suture (Prolene® 3/0).
A small atraumatic curved bulldog clamp is applied to the origin of the GDA. A 3-mm longitudinal arteriotomy is made about 1 cm from its origin. The tip of a Celsite® type catheter (T202F 6,5F, B BRAUN), pre-flushed with heparinized saline and with the distal spur excised, is inserted so that its tip just reaches the level of the origin of the GDA without protruding into the CHA or the HA. The catheter is fixed in place by ligation of the prolene suture just downstream of the proximal spur. The use of a vein pick may help in introducing the catheter into the artery.
391
392
5
C. Honoré et al.
Connection of the catheter to the implanted reservoir
The catheter is connected to the reservoir leaving a sufficient length so that the tubing lies in place with a comfortable curve but without kinking. The reservoir, pre-flushed with heparinized saline, is implanted in a subcutaneous pocket overlying the fascia and the right costal margin. The system is tested with a low-pressure injection of fluorescein to verify that the entire liver is perfused and that there is no extrahepatic perfusion. Too-rapid injection may result in result in backflow into the hepatic artery trunk resulting in dye coloration of the pancreas, duodenum, and stomach. One should never aspirate blood back into the IAHC catheter to avoid the risk of thrombosis.
Adjustments of technique for anatomical variations The different technical stratagems described below allow achievement of in toto hepatic perfusion by implantation of a catheter into a single hepatic artery.
6
Aberrant right hepatic artery arising from the superior mesenteric artery or left hepatic artery arising from the left gastric artery
It has been shown that ligation of a right (or left) hepatic artery is followed by re-arterialization of the entire right (or left) liver from the CHA, due to opening of intraparenchymal arterial shunts [4]; the aberrant right or left hepatic artery can therefore be ligated with placement of the catheter as described above.
Catheter placement for intra-arterial hepatic chemotherapy
7
Trifurcation of the hepatic artery
8
Single right hepatic artery
In some cases, the AHC trifurcates into three arteries; the GDA, a right HA and a left HA. In this case, there is a risk of preferential flow to one or the other hepatic lobes when the catheter is placed in the GDA. At the time that perfusion is verified by fluorescein injection, if only the right liver is colored, the left hepatic arterial branch should be clamped. Injection should be repeated (perhaps using a blue dye to obtain sufficient color contrast), to confirm that the intraparenchymal arterial shunts have opened leading to perfusion of the entire liver. The left branch is then ligated. An analogous technique can be used if the perfusion favors the left liver.
In this anatomical configuration, there are usually no collateral arteries of sufficient caliber to allow catheter insertion. After dissection of the hepatic hilum, the catheter is introduced retrograde into the left hepatic branch, which is then ligated distally; the catheter should be positioned so that its tip lies just at the origin of the left hepatic branch but does not penetrate into the HA or the right hepatic branch [5].
393
394
9
C. Honoré et al.
Single left hepatic artery
When the left hepatic artery is the only arterial supply to the liver, the catheter should be introduced via the left gastric artery so that its tip just reaches the level of origin of the left hepatic artery.
Postoperative examinations
References
Before using the catheter for chemotherapy, a scintigraphy with Technetium-99 injection is performed to verify good catheter function and absence of extrahepatic perfusion. Angiography is also routinely performed before the first course of chemotherapy and is repeated every 2—3 courses. If the patient develops symptoms of severe abdominal pain or if there is any difficulty with injection, a new angiogram should be performed. If this shows no evidence of catheter thrombosis or extrahepatic perfusion, a new scintigraphy with Technetium-99 injection should be performed; this is the only test sensitive enough to demonstrate abnormal microperfusions, especially in the late phase after injection.
[1] Kemeny N, Conti JA, Cohen A, et al. Phase II study of hepatic arterial floxuridine, leucovorin, and dexamethasone for unresectable liver metastases from colorectal carcinoma. J Clin Oncol 1994;12(11):2288—95. [2] Ducreux M, Ychou M, Laplanche A, et al. Hepatic arterial oxaliplatin infusion plus intravenous chemotherapy in colorectal cancer with inoperable hepatic metastases: a trial of the gastrointestinal group of the Fédération Nationale des Centres de Lutte Contre le Cancer. J Clin Oncol 2005;23(22):4881—7. [3] Boige V, Malka D, Elias D, et al. Hepatic arterial infusion of oxaliplatin and intravenous LV5FU2 in unresectable liver metastases from colorectal cancer after systemic chemotherapy failure. Ann Surg Oncol 2008;15(1):219—26. [4] Chuang VP, Wallace S. Hepatic arterial redistribution for intraarterial infusion of hepatic neoplasms. Radiology 1980;135(2):295—9. [5] Elias D, Lasser P. Simplified technic of implanting a catheter in a case of single right hepatic artery. J Chir (Paris) 1988;125(1):54.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.