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Intra-arterial hepatic catheterization and pump placement
Intra-Arterial Hepatic Catheterization and Pump Placement James v. Sitzmann, MD and Leonidas G. Koniaris, MD
I ntra-arterial hepatic catheterization and pump placement provides hepatic-specific, long-term, continuous infusion of chemotherapeutic agents. Generally, pumps are placed for metastatic colorectal cancer and primary hepatocetlular cancer, but successful treatment of other metastatic tumor cell types has also been reported.~ Because of the selective hepatic infusion that this system delivers and the need for abdominal surgery to place these arterial hepatic pumps, certain criteria should be met before their use: 1. There should be a reasonable expectation that the tumor will respond to intra-arterial chemotherapy. 2. The tumor must be confined solely to the liver, with no evidence of extrahepatic disease. 3. The patient must have adequate hepatic reserve to clear and detoxify the chemotherapeutic agent. 4. The chemotherapeutic regimen should use agents that have a high degree of first-pass kinetics to minimize systemic toxicity. Cisplatin, 5-FUDR, mitomycin C, and adriamycin are commonly used for intra-arterial hepatic perfusion. 5. There should be minimal or no evidence of portal hypertension. Patients with significant portal hypertension are poor candidates for hepatic arterial p u m p placement. This is because of the risk of hepatopedal blood flow, which would cause splenic perfusion with chemotherapeutic agent and potential tissue necrosis, as well as intrinsic impaired parenchymal function, which limits the utility of intra-arterial infusion and the ability of nontumor liver cells to tolerate therapy. 6. The patient should have an overall performance status that can tolerate a major operative procedure. When patients are properly selected for hepatic arterial chemotherapy, multiple studies have demonstrated a survival advantage over patients treated with systemic chemotherapy. 2'3
Patient Evaluation The traditional diagnostic radiographic studies for evaluating a patient for hepatic arterial p u m p placement in-
From the Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY. Address reprint requests to James V. Sitzmann, MD, University of Rochester School of Medicine and Dentistry, Department of Surgery, 601 Elmwood Ave, Box SURG, Rochester, NY 14642. Copyright 2002, ElsevierScience(USA).All nghts reserved 1524-153X/02/0401-0008535.00/0 doi:10.1053/otgn.2002.30038
clude abdominal computed tomography (CT) scan and magnetic resonance imaging (MRI). Many surgeons also perform a chest CT scan or positron emission tomography (PET) scan during the initial evaluation to rule out extrahepatic pulmonary metastases. Patients with isolated hepatic disease that is not amenable to hepatic resection or other ablative therapies are considered p u m p candidates. Alternatively, pumps may be placed after surgical resection or ablation of isolated hepatic disease. 3 Early in the experience of hepatic arterial p u m p placement, many surgeons routinely obtained celiac and superior mesenteric arteriograms to define the vascular anatomy of the liver before p u m p placement. Alternatively, MRI angiography was performed. As experience with this procedure has increased, however, some surgeons feel comfortable determining the hepatic arterial anatomy intraoperatively. The question of obtaining an arteriogram or other vascular assessment is based on the fact that "classic" or "standard" hepatic vascular anatomy will be present in only 50% of patients. In the patients with "classic" anatomy the celiac artery gives rise to the left gastric, splenic, and c o m m o n hepatic arteries. The c o m m o n hepatic artery then branches into the gastroduodenal and proper hepatic arteries. The hepatic artery proper, in turn, gives rise to the cystic, right, and left hepatic arteries (Fig 1). But roughly 50% of patients have an anatomic variation of this "classic" anatomy. 4 The most c o m m o n variation is the presence of a replaced right hepatic artery arising as an early branch from the superior mesenteric artery. This "aberrant" vessel generally traverses posterior to the pancreatic head joining the portal triad posterior and lateral to the c o m m o n bile duct and portal vein. The next most c o m m o n anatomic vascular variant is a replaced left hepatic artery, wherein the left hepatic or left lateral segment artery arises from the left gastric artery. Other anomalies include the "arch of Buhler" or "trifurcation" anatomy, wherein the gastroduodenal artery, right hepatic artery, and left hepatic artery all come off as a single cluster from the end of the hepatic artery (Fig 2). Surgeons disagree over whether all vessels to the liver need be cannulated to achieve complete hepatic perfusion. Although "crossover" perfusion of the liver after ligation of ancillary hepatic branches certainly occurs, we believe that ideal uniform perfusion is best achieved with individual catheterization of all vessels supplying lobar perfusion.
Operative Techniques in General Surgery, Vol 4, No i (March), 2002: pp 99-110
99
1 O0
Sitzmann and Koniaris
CHA
Abdominal
Caudate lobe
CHA
SDA
Pancreas
I Classic hepatic-vascular anatomy after division of the gastrohepatic omentum. The origin of the celiac artery is shown with its branches, the splenic artery (SA), left gastric artery (LGA), and common hepatic artery (CHA). The gastroduodenal artery (GDA) and proper hepatic artery (PHA) are shown branching off the CHA. Note the anatomic relationship to the caudate lobe of the liver and the superior margin of the pancreas.
101
Intra-Arterial Hepatic Catheterization and Pump Placement
LGA
RLHA
GD/
3A
Cystic F
LHA RH
;A
I.a
2 Nonclassic anatomic variants of hepatic arterial inflow. (A) the replaced right hepatic artery (RRHA) arising from the superior mesenteric artery (SMA). (B) Replaced left hepatic artery (RLHA) arising from the left gastric artery (LGA). C, Trifurcation anatomy demonstrating a common origin of the RHA, LHA, and GDA.
102
Sitzmann and Koniaris
SURGICAL TECHNIQUE Catheter Placement
/ k
3 The liver can be approached via either a midline (A) or a right subcostal (B) incision. The hepatic pump is placed in the left lower quadrant (C); if two pumps are used, they are placed in the left and right (D) lower quadrants. The advantage of a right subcostal approach is that it provides excellent exposure of the porta hepatis in a nonenlarged liver and allows for a twoqayer abdominal closure. The disadvantage of a subcostal incision is that patients with an extensive bulky hepatic tumor burden will have displacement of the liver and porta hepatis significantly below the costal margin. Midline incisions have the advantages of simplicity, offering full exposure of the abdomen, and facilitating exploration to rule out extrahepatic disease. In general, we prefer a midline incision. Laparoscopic catheter placement in a seIect group of patients with classic anatomy has also been reported. 5
103
Intra-Arterial Hepatic Catheterization and Pump Placement
.=patic im
/
4 The decision to place a hepatic arterial infusion catheter is made after exploration of the abdomen and confirmation of isolated liver disease. To provide optimal exposure of this region, a retractor is placed on the left lateral and left medial sectors, exposing the porta hepatis and the gastrohepatic omentum in its entirety. The stomach and duodenum are retracted to the left, and the right colon and transverse colon are retracted inferiorly. With this exposure, the superior border of the pancreas should be clearly visible after the gastrohepatic omentum is divided. The gastrohepatic omentum is divided along its whole length, taking care to avoid a replaced left hepatic artery, freely exposing the caudate lobe, which extends to the right diaphragmatic crux. We also carefully dissect free all of the adventitial tissue in the portal triad to prevent the possibility of visceral misperfusion. All hepatoduodenal ligament tissue except the common bile duct, portal vein, and common hepatic artery is divided. The common hepatic, gastroduodenal, and proper hepatic arteries are clearly identified. This illustration shows the exposure of the porta hepatis. Cholecystectomy is always performed at some point during this procedure, because chemotherapeutic infusion will cause acalculus or chemical cholecystitis in a large proportion of patients.
104
Sitzmann and Koniaris
A
B
.
..Y
5 Typically, cannulation in patients with "classical" anatomy of the liver should be performed with a single catheter placed via the gastroduodenal artery (GDA), as shown. (A) After the common hepatic artery (CHA) is dissected and the gastroduodenal origin identified, the vessel from the gastroduodenal artery to the liver is dissected and skeletonized so that any back branches leading to the intestinal viscera can be individually ligated and divided. This is a critical step to prevent misperfusion injuries. (B) After dissection, noncrushing vascular clamps are applied proximal and distal to the origin of the gastroduodenal artery.
Intra-Arterial Hepatic Catheterization and Pump Placement
105
PHA
f
~HA
/
~-~.
--,.
19
,, (
a
E
(continued) (C) The gastroduodenal artery is skeletonized for a least i or 2 cm, then ligated with a 2-0 silk near the head of the pancreas. A transverse arteriotomy is then made with a 11 blade. The blunt tip catheter is cut at a 45-degree angle, very close to the last bead. The distance from the last bead to the end of the catheter must be equal to the distance from the arteriotomy to the juncture of the gastroduodenal artery with the common hepatic artery. This is to ensure that the catheter can be positioned into the gastroduodenal artery with one bead located inside the vessel, while keeping the catheter tip from protruding into the lumen of the common hepatic artery. There should be no possibility that the catheter can enter the common hepatic artery, to prevent catheter-induced common hepatic artery thrombosis. (D, E) After the beaded catheter is placed into the gastroduodenal artery, the artery is secured around the catheter using a 4-0 or 5-0 Prolene suture. Care must be taken when taking bites of the vessel to ensure that the vessel is tied securely around the catheter. The catheter is then anchored to the remaining gastroduodenal artery with several sutures of 4-0 Prolene, with each suture taking a small bite of adventitia. Typically, these sutures are placed just distal to each bead so that if traction were placed on the catheter, the bead would be anchored by the suture. Alternatively, some surgeons divide the catheter straight across, just past the last bead. This bead is placed just outside of the hepatic artery, and ties are placed around the gastroduodenal artery just behind two or three beads.
106
Sitzmann and Koniaris
Cystic duct
\
6 In the presence of a replaced right hepatic artery, two catheterization sites are required. The first catheter is placed in the gastroduodenal artery, as previously described, and a second tapered catheter is used to cannulate the replaced right hepatic artery. (A) The beaded catheter anchored in the gastroduodenal artery alongside a replaced right hepatic artery. The replaced right hepatic artery is immediately posterior to the common bile duct and portal vein. (B, C) The vessel is cleared along the entire length from the head of the pancreas to just under the gallbladder fossa. It is held both proximally and distally with vessel loops, and two vascular clamps are then placed. In this case a very fine, tapered catheter is used to minimize the risk of occlusion or thrombosis of the replaced right hepatic artery. The tapered tip is cut on a 45-degree bevel before insertion. A longitudinal arteriotomy is made, and the tapered catheter is inserted with the bead on the outside of the arteriotomy. (A bead should never be placed intraluminally into a replaced right hepatic artery.) With the catheter inserted, the bead should rest immediately flush with the outside of the artery.
Intra-Arterial Hepatic Catheterization and Pump Placement
107
E
F 6 (continued) (D, E, F) A pursestring suture with 6-0 or 5-0 Prolene is used to close the arteriotomy around the tapered catheter. The catheter is then anchored to the artery with a series of 5-0 or 4-0 Prolene sutures, with each suture taking a small bite of adventitia and the catheter tied down just distally to each bead.
] 08
Sitzmann and Koniaris
Fluorescein
7 Successful placement of a tapered catheter in a replaced right hepatic artery and a second catheter in the gastroduodenal artery. This illustration also shows the injection of fluorescene to assess perfusion. If the trifurcation anatomy is encountered, the gastroduodenal artery is ligated and the common hepatic artery is directly catheterized well proximal to the bifurcation of the right and left hepatic arteries, as described for a replaced right hepatic artery. Placement below the bifurcation of the common hepatic artery is critical to ensure free and adequate mixing of drug and equal perfusion of the liver. The last arterial variant, a replaced left hepatic artery or left hepatic requires cannulation of the gastroduodenal artery and then a second pump cannulation at the left gastric artery as described for a replaced right hepatic artery. However, some authors advocate ligating accessory vessels rather than placing multiple pumps.
109
Intra-Arterial Hepatic Catheterization and Pump Placement
Pump Pocket Placement
.A. Midline
13
8 Once fluorescein injection documents good perfusion of both liver lobes without visceral perfusion, the surgeon makes pockets for the pumps. Pump pocket location is controversial. We prefer to place the pump in the left lower quadrant of the abdomen. This placement keeps the pump free of the enlarging liver and allows subsequent free palpation of the right upper quadrant. Moreover, even if the liver is enlarged and massive, it will not press on the lower abdominal wall in the left lower quadrant. If a patient needs two pumps, as in the case of the replaced hepatic artery we recommend bilateral lower quadrant pump placements. Before the pump is placed, it is primed with heparinized saline solution, and adequate pump flow is verified. (A) To create a pocket for the pump, we make a transverse abdominal incision at the level of the umbilicus and dissect through subcutaneous tissue, including Scarpa's fascia, to the anterior rectus sheath and external oblique fascia. In very obese patients, it is necessary to resect subcutaneous fat underneath Scarpa's fascia to "thin" the abdominal wall and facilitate subsequent percutaneous needle access to the pump. The pump pocket should extend laterally almost to the iliac crest, inferiorly to just above the inguinal ligament, and medially it should neither extend to the midline or communicate with the laparotomy incision. (B) The pump is placed in the pocket, and its anchors are sewn to the fascia with 3-0 nylon. The hepatic artery perfusion catheter is passed transabdominally by direct puncture and then connected to the pump. The pump pocket is closed in two layers, with interrupted 3-0 polyglycolic reabsorbable suture used for Scarpa's fascia reconstruction and a 4-0-intracuticular reabsorbable stitch used for skin closure. The abdominal incision is typically closed with interrupted number 1 or 2 nonabsorbable monofilament suture, and the skin is closed with either 4-0 intracuticular absorbable suture or staples.
1 10
Sitzmann and Koniaris
9
..........
_
/ l
"Ghosted" liver
t
r
J Postoperative Care The patient does not require a nasogastric tube and is able to start a normal diet within 1 to 3 days postoperatively. Occasionally, liver function tests results are elevated, even after a short hepatic arterial occlusion of less than 5 minutes for catheter insertion. Minor ischemic injury may be marked by elevated AST, ALT, and then alkaline phosphatase. Markedly elevated or prolonged elevation of these enzymes implies a hepatic arterial thrombosis, which should be ruled out with either a HAPS scan or ultrasonography.
Placement of two intra-abdominal catheters. In the postoperative period, adequate perfusion is once again documented with a hepatic arterial perfusion scan (HAPS).6 This involves injection of macro-aggregate radiolabeled albumin through the side port of the pump. HAPS scan should clearly document complete perfusion of both lobes of the liver with no perfusion of the stomach. Once the macro-aggregate albumin is cleared, a technetium-labeled sulfur colloid is used to perform a liver-spleen scan. Subtraction comparison. of the liver-spleen scan images with the HAPS scan images should show complete overlap of the liver with the liver scan and HAPS scan, thus documenting complete hepatic perfusion. (' Occasionally, arteriography is attempted through side port injections. This is generally not usefut, because it does not confirm the adequacy of perfusion, and injecting enough dye through the side port to delineate the arterial anatomy is difficult even with digital subtraction arteriography techniques.
REFERENCES 1. SitzmannJV: Conversion o[ unresectable liver cancer: An approach and follow-up study. WorldJ Surg 21:330-342, 1995 2. Wagman LD, Kemeny MM, Leong L, et al: A prospective, randomized evaluation of the treatment of colorectal cancer metastatic to the liver. J Clin Oncol 8:1885-1893, 1990 3. Kemeny N, Huang Y, Cohen A, et al: Hepatic arterial infusion of chemotherapy after resection of hepatic metastases from cotorectal cancer. N EngJ Med 341:2039-2048, 1999 4. McClusky DA, Skandalakis LJ, Colborn GL, et al: Hepatic surgery and hepatic surgical anatomy: Historical partners in progress. WorldJ Surg 21:330-342, 1997 5. Urbach DR, Herron DM, Khajanchee YS, et al: Laparoscopic hepatic artery infusion pump placement. Arch Surg 136:700-704, 2001 6. Civelek AC, SitzmannJV, Chin BB, et al: Misperfusion of the liver during hepatic artery infusion chemotherapy: Value of preoperative angiography and post-operative pump scintigraphy. AmJ Roentgenol 160:865-870, 1993
I ntra-arterial hepatic catheterization and pump placement provides hepatic-specific, long-term, continuous infusion of chemotherapeutic agents. Generally, pumps are placed for metastatic colorectal cancer and primary hepatocetlular cancer, but successful treatment of other metastatic tumor cell types has also been reported.~ Because of the selective hepatic infusion that this system delivers and the need for abdominal surgery to place these arterial hepatic pumps, certain criteria should be met before their use: 1. There should be a reasonable expectation that the tumor will respond to intra-arterial chemotherapy. 2. The tumor must be confined solely to the liver, with no evidence of extrahepatic disease. 3. The patient must have adequate hepatic reserve to clear and detoxify the chemotherapeutic agent. 4. The chemotherapeutic regimen should use agents that have a high degree of first-pass kinetics to minimize systemic toxicity. Cisplatin, 5-FUDR, mitomycin C, and adriamycin are commonly used for intra-arterial hepatic perfusion. 5. There should be minimal or no evidence of portal hypertension. Patients with significant portal hypertension are poor candidates for hepatic arterial p u m p placement. This is because of the risk of hepatopedal blood flow, which would cause splenic perfusion with chemotherapeutic agent and potential tissue necrosis, as well as intrinsic impaired parenchymal function, which limits the utility of intra-arterial infusion and the ability of nontumor liver cells to tolerate therapy. 6. The patient should have an overall performance status that can tolerate a major operative procedure. When patients are properly selected for hepatic arterial chemotherapy, multiple studies have demonstrated a survival advantage over patients treated with systemic chemotherapy. 2'3
Patient Evaluation The traditional diagnostic radiographic studies for evaluating a patient for hepatic arterial p u m p placement in-
From the Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY. Address reprint requests to James V. Sitzmann, MD, University of Rochester School of Medicine and Dentistry, Department of Surgery, 601 Elmwood Ave, Box SURG, Rochester, NY 14642. Copyright 2002, ElsevierScience(USA).All nghts reserved 1524-153X/02/0401-0008535.00/0 doi:10.1053/otgn.2002.30038
clude abdominal computed tomography (CT) scan and magnetic resonance imaging (MRI). Many surgeons also perform a chest CT scan or positron emission tomography (PET) scan during the initial evaluation to rule out extrahepatic pulmonary metastases. Patients with isolated hepatic disease that is not amenable to hepatic resection or other ablative therapies are considered p u m p candidates. Alternatively, pumps may be placed after surgical resection or ablation of isolated hepatic disease. 3 Early in the experience of hepatic arterial p u m p placement, many surgeons routinely obtained celiac and superior mesenteric arteriograms to define the vascular anatomy of the liver before p u m p placement. Alternatively, MRI angiography was performed. As experience with this procedure has increased, however, some surgeons feel comfortable determining the hepatic arterial anatomy intraoperatively. The question of obtaining an arteriogram or other vascular assessment is based on the fact that "classic" or "standard" hepatic vascular anatomy will be present in only 50% of patients. In the patients with "classic" anatomy the celiac artery gives rise to the left gastric, splenic, and c o m m o n hepatic arteries. The c o m m o n hepatic artery then branches into the gastroduodenal and proper hepatic arteries. The hepatic artery proper, in turn, gives rise to the cystic, right, and left hepatic arteries (Fig 1). But roughly 50% of patients have an anatomic variation of this "classic" anatomy. 4 The most c o m m o n variation is the presence of a replaced right hepatic artery arising as an early branch from the superior mesenteric artery. This "aberrant" vessel generally traverses posterior to the pancreatic head joining the portal triad posterior and lateral to the c o m m o n bile duct and portal vein. The next most c o m m o n anatomic vascular variant is a replaced left hepatic artery, wherein the left hepatic or left lateral segment artery arises from the left gastric artery. Other anomalies include the "arch of Buhler" or "trifurcation" anatomy, wherein the gastroduodenal artery, right hepatic artery, and left hepatic artery all come off as a single cluster from the end of the hepatic artery (Fig 2). Surgeons disagree over whether all vessels to the liver need be cannulated to achieve complete hepatic perfusion. Although "crossover" perfusion of the liver after ligation of ancillary hepatic branches certainly occurs, we believe that ideal uniform perfusion is best achieved with individual catheterization of all vessels supplying lobar perfusion.
Operative Techniques in General Surgery, Vol 4, No i (March), 2002: pp 99-110
99
1 O0
Sitzmann and Koniaris
CHA
Abdominal
Caudate lobe
CHA
SDA
Pancreas
I Classic hepatic-vascular anatomy after division of the gastrohepatic omentum. The origin of the celiac artery is shown with its branches, the splenic artery (SA), left gastric artery (LGA), and common hepatic artery (CHA). The gastroduodenal artery (GDA) and proper hepatic artery (PHA) are shown branching off the CHA. Note the anatomic relationship to the caudate lobe of the liver and the superior margin of the pancreas.
101
Intra-Arterial Hepatic Catheterization and Pump Placement
LGA
RLHA
GD/
3A
Cystic F
LHA RH
;A
I.a
2 Nonclassic anatomic variants of hepatic arterial inflow. (A) the replaced right hepatic artery (RRHA) arising from the superior mesenteric artery (SMA). (B) Replaced left hepatic artery (RLHA) arising from the left gastric artery (LGA). C, Trifurcation anatomy demonstrating a common origin of the RHA, LHA, and GDA.
102
Sitzmann and Koniaris
SURGICAL TECHNIQUE Catheter Placement
/ k
3 The liver can be approached via either a midline (A) or a right subcostal (B) incision. The hepatic pump is placed in the left lower quadrant (C); if two pumps are used, they are placed in the left and right (D) lower quadrants. The advantage of a right subcostal approach is that it provides excellent exposure of the porta hepatis in a nonenlarged liver and allows for a twoqayer abdominal closure. The disadvantage of a subcostal incision is that patients with an extensive bulky hepatic tumor burden will have displacement of the liver and porta hepatis significantly below the costal margin. Midline incisions have the advantages of simplicity, offering full exposure of the abdomen, and facilitating exploration to rule out extrahepatic disease. In general, we prefer a midline incision. Laparoscopic catheter placement in a seIect group of patients with classic anatomy has also been reported. 5
103
Intra-Arterial Hepatic Catheterization and Pump Placement
.=patic im
/
4 The decision to place a hepatic arterial infusion catheter is made after exploration of the abdomen and confirmation of isolated liver disease. To provide optimal exposure of this region, a retractor is placed on the left lateral and left medial sectors, exposing the porta hepatis and the gastrohepatic omentum in its entirety. The stomach and duodenum are retracted to the left, and the right colon and transverse colon are retracted inferiorly. With this exposure, the superior border of the pancreas should be clearly visible after the gastrohepatic omentum is divided. The gastrohepatic omentum is divided along its whole length, taking care to avoid a replaced left hepatic artery, freely exposing the caudate lobe, which extends to the right diaphragmatic crux. We also carefully dissect free all of the adventitial tissue in the portal triad to prevent the possibility of visceral misperfusion. All hepatoduodenal ligament tissue except the common bile duct, portal vein, and common hepatic artery is divided. The common hepatic, gastroduodenal, and proper hepatic arteries are clearly identified. This illustration shows the exposure of the porta hepatis. Cholecystectomy is always performed at some point during this procedure, because chemotherapeutic infusion will cause acalculus or chemical cholecystitis in a large proportion of patients.
104
Sitzmann and Koniaris
A
B
.
..Y
5 Typically, cannulation in patients with "classical" anatomy of the liver should be performed with a single catheter placed via the gastroduodenal artery (GDA), as shown. (A) After the common hepatic artery (CHA) is dissected and the gastroduodenal origin identified, the vessel from the gastroduodenal artery to the liver is dissected and skeletonized so that any back branches leading to the intestinal viscera can be individually ligated and divided. This is a critical step to prevent misperfusion injuries. (B) After dissection, noncrushing vascular clamps are applied proximal and distal to the origin of the gastroduodenal artery.
Intra-Arterial Hepatic Catheterization and Pump Placement
105
PHA
f
~HA
/
~-~.
--,.
19
,, (
a
E
(continued) (C) The gastroduodenal artery is skeletonized for a least i or 2 cm, then ligated with a 2-0 silk near the head of the pancreas. A transverse arteriotomy is then made with a 11 blade. The blunt tip catheter is cut at a 45-degree angle, very close to the last bead. The distance from the last bead to the end of the catheter must be equal to the distance from the arteriotomy to the juncture of the gastroduodenal artery with the common hepatic artery. This is to ensure that the catheter can be positioned into the gastroduodenal artery with one bead located inside the vessel, while keeping the catheter tip from protruding into the lumen of the common hepatic artery. There should be no possibility that the catheter can enter the common hepatic artery, to prevent catheter-induced common hepatic artery thrombosis. (D, E) After the beaded catheter is placed into the gastroduodenal artery, the artery is secured around the catheter using a 4-0 or 5-0 Prolene suture. Care must be taken when taking bites of the vessel to ensure that the vessel is tied securely around the catheter. The catheter is then anchored to the remaining gastroduodenal artery with several sutures of 4-0 Prolene, with each suture taking a small bite of adventitia. Typically, these sutures are placed just distal to each bead so that if traction were placed on the catheter, the bead would be anchored by the suture. Alternatively, some surgeons divide the catheter straight across, just past the last bead. This bead is placed just outside of the hepatic artery, and ties are placed around the gastroduodenal artery just behind two or three beads.
106
Sitzmann and Koniaris
Cystic duct
\
6 In the presence of a replaced right hepatic artery, two catheterization sites are required. The first catheter is placed in the gastroduodenal artery, as previously described, and a second tapered catheter is used to cannulate the replaced right hepatic artery. (A) The beaded catheter anchored in the gastroduodenal artery alongside a replaced right hepatic artery. The replaced right hepatic artery is immediately posterior to the common bile duct and portal vein. (B, C) The vessel is cleared along the entire length from the head of the pancreas to just under the gallbladder fossa. It is held both proximally and distally with vessel loops, and two vascular clamps are then placed. In this case a very fine, tapered catheter is used to minimize the risk of occlusion or thrombosis of the replaced right hepatic artery. The tapered tip is cut on a 45-degree bevel before insertion. A longitudinal arteriotomy is made, and the tapered catheter is inserted with the bead on the outside of the arteriotomy. (A bead should never be placed intraluminally into a replaced right hepatic artery.) With the catheter inserted, the bead should rest immediately flush with the outside of the artery.
Intra-Arterial Hepatic Catheterization and Pump Placement
107
E
F 6 (continued) (D, E, F) A pursestring suture with 6-0 or 5-0 Prolene is used to close the arteriotomy around the tapered catheter. The catheter is then anchored to the artery with a series of 5-0 or 4-0 Prolene sutures, with each suture taking a small bite of adventitia and the catheter tied down just distally to each bead.
] 08
Sitzmann and Koniaris
Fluorescein
7 Successful placement of a tapered catheter in a replaced right hepatic artery and a second catheter in the gastroduodenal artery. This illustration also shows the injection of fluorescene to assess perfusion. If the trifurcation anatomy is encountered, the gastroduodenal artery is ligated and the common hepatic artery is directly catheterized well proximal to the bifurcation of the right and left hepatic arteries, as described for a replaced right hepatic artery. Placement below the bifurcation of the common hepatic artery is critical to ensure free and adequate mixing of drug and equal perfusion of the liver. The last arterial variant, a replaced left hepatic artery or left hepatic requires cannulation of the gastroduodenal artery and then a second pump cannulation at the left gastric artery as described for a replaced right hepatic artery. However, some authors advocate ligating accessory vessels rather than placing multiple pumps.
109
Intra-Arterial Hepatic Catheterization and Pump Placement
Pump Pocket Placement
.A. Midline
13
8 Once fluorescein injection documents good perfusion of both liver lobes without visceral perfusion, the surgeon makes pockets for the pumps. Pump pocket location is controversial. We prefer to place the pump in the left lower quadrant of the abdomen. This placement keeps the pump free of the enlarging liver and allows subsequent free palpation of the right upper quadrant. Moreover, even if the liver is enlarged and massive, it will not press on the lower abdominal wall in the left lower quadrant. If a patient needs two pumps, as in the case of the replaced hepatic artery we recommend bilateral lower quadrant pump placements. Before the pump is placed, it is primed with heparinized saline solution, and adequate pump flow is verified. (A) To create a pocket for the pump, we make a transverse abdominal incision at the level of the umbilicus and dissect through subcutaneous tissue, including Scarpa's fascia, to the anterior rectus sheath and external oblique fascia. In very obese patients, it is necessary to resect subcutaneous fat underneath Scarpa's fascia to "thin" the abdominal wall and facilitate subsequent percutaneous needle access to the pump. The pump pocket should extend laterally almost to the iliac crest, inferiorly to just above the inguinal ligament, and medially it should neither extend to the midline or communicate with the laparotomy incision. (B) The pump is placed in the pocket, and its anchors are sewn to the fascia with 3-0 nylon. The hepatic artery perfusion catheter is passed transabdominally by direct puncture and then connected to the pump. The pump pocket is closed in two layers, with interrupted 3-0 polyglycolic reabsorbable suture used for Scarpa's fascia reconstruction and a 4-0-intracuticular reabsorbable stitch used for skin closure. The abdominal incision is typically closed with interrupted number 1 or 2 nonabsorbable monofilament suture, and the skin is closed with either 4-0 intracuticular absorbable suture or staples.
1 10
Sitzmann and Koniaris
9
..........
_
/ l
"Ghosted" liver
t
r
J Postoperative Care The patient does not require a nasogastric tube and is able to start a normal diet within 1 to 3 days postoperatively. Occasionally, liver function tests results are elevated, even after a short hepatic arterial occlusion of less than 5 minutes for catheter insertion. Minor ischemic injury may be marked by elevated AST, ALT, and then alkaline phosphatase. Markedly elevated or prolonged elevation of these enzymes implies a hepatic arterial thrombosis, which should be ruled out with either a HAPS scan or ultrasonography.
Placement of two intra-abdominal catheters. In the postoperative period, adequate perfusion is once again documented with a hepatic arterial perfusion scan (HAPS).6 This involves injection of macro-aggregate radiolabeled albumin through the side port of the pump. HAPS scan should clearly document complete perfusion of both lobes of the liver with no perfusion of the stomach. Once the macro-aggregate albumin is cleared, a technetium-labeled sulfur colloid is used to perform a liver-spleen scan. Subtraction comparison. of the liver-spleen scan images with the HAPS scan images should show complete overlap of the liver with the liver scan and HAPS scan, thus documenting complete hepatic perfusion. (' Occasionally, arteriography is attempted through side port injections. This is generally not usefut, because it does not confirm the adequacy of perfusion, and injecting enough dye through the side port to delineate the arterial anatomy is difficult even with digital subtraction arteriography techniques.
REFERENCES 1. SitzmannJV: Conversion o[ unresectable liver cancer: An approach and follow-up study. WorldJ Surg 21:330-342, 1995 2. Wagman LD, Kemeny MM, Leong L, et al: A prospective, randomized evaluation of the treatment of colorectal cancer metastatic to the liver. J Clin Oncol 8:1885-1893, 1990 3. Kemeny N, Huang Y, Cohen A, et al: Hepatic arterial infusion of chemotherapy after resection of hepatic metastases from cotorectal cancer. N EngJ Med 341:2039-2048, 1999 4. McClusky DA, Skandalakis LJ, Colborn GL, et al: Hepatic surgery and hepatic surgical anatomy: Historical partners in progress. WorldJ Surg 21:330-342, 1997 5. Urbach DR, Herron DM, Khajanchee YS, et al: Laparoscopic hepatic artery infusion pump placement. Arch Surg 136:700-704, 2001 6. Civelek AC, SitzmannJV, Chin BB, et al: Misperfusion of the liver during hepatic artery infusion chemotherapy: Value of preoperative angiography and post-operative pump scintigraphy. AmJ Roentgenol 160:865-870, 1993