Laparoscopic Placement of Hepatic Arterial Pumps: A True Advance or a Lot of Effort for a Procedure with a Diminishing Role?

Abstract

In this months issue of the Annals of Surgical Oncology, Cheng et al.1 describe their success at placing hepatic arterial infusion (HAI) pumps in 38 consecutive patients using an entirely laparoscopic approach. In addition to placement of the pump, 68% of patients (N 26) also had laparoscopic radiofrequency ablation (RFA, N 24), liver resection, or both (N 2). The 38 patients in the study group were identified from an initial cohort of 56 patients who were determined to have unresectable metastatic colorectal cancer based on tumor number, bilobar distribution, proximity to major vascular, or biliary structures precluding a negative margin resection, or high risk surgical intervention. After preoperative imaging studies failed to identify extrahepatic disease in any of the 56 patients, all had diagnostic laparoscopy and laparoscopic ultrasound. Of these patients, 32% (N 18) were found to have histopathologic confirmation of peritoneal disease (N 18) or lymph node disease (N 8) that led to planned HAI placement being aborted. The authors do not tell us what imaging studies were used to determine resectability or extrahepatic disease preoperatively; however, a 32% rate of occult M1 disease, although high, is within the range of that reported by others.2 Despite having little to do with the premise of this paper, these results alone should provide additional motivation to all surgeons who do major hepatic resections (particularly for metastatic disease or foregut tumors) to consider initial laparoscopic evaluation to exclude occult M1 disease prior to laparotomy. Although Cheng et al.1 are not the first to describe a laparoscopic approach to HAI pump placement, their review of 38 consecutive cases, performed by wellrecognized expert laparoscopic surgeons, provides a comprehensive view of the technical challenges, overall feasibility, safety, and outcome of this approach. Most notably, HAI pump placement was accomplished in 100% of patients in whom it was attempted. According to their protocol, all patients had preoperative celiac and mesenteric angiography to provide a road map for pump placement. Twenty patients had “normal arterial anatomy” in which a common hepatic artery (CHA) (from the celiac axis) gave rise to a single gastroduodenal artery (GDA) that was cannulated for pump placement. Interestingly, 18 patients had aberrant arterial anomalies: 10 accessory or replaced arteries, a left hepatic artery arising from the CHA, or a variety of other anomalies. Despite these anomalies, the authors were to able to cannulate the GDA in 16 of 18 patients using a combination of preoperative embolization or intraoperative ligation of the accessory or replaced vessels; in two instances, cannulation of the LHA was required. Although not the focus of this paper, the authors remind those surgeons not well initiated in HAI pump placement that nearly all replaced or accessory vessels can be ligated with the expectation that the remaining arterial inflow will provide complete hepatic perfusion. Although the authors of this paper are clearly talented laparoscopic surgeons and have demonstrated the feasibility of this operation, the bigger question is “so what?” By asking “so what,” I am not referring to whether the average surgical oncologist will ever be able to perform this procedure. In fact, I remain confident that over time, as most have mastered laparoscopic RFA alone, they will master laparoscopic HAI pump placement as well. I am also not questioning whether the average surgical oncologist would have the tremendous patience necessary to Received April 5, 2004; accepted April 12, 2004. From the Department of Surgery, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, New York. Address correspondence to: Ronald S. Chamberlain, MD, MPA, FACS, Beth Israel Medical Center, Albert Einstein College of Medicine, 10 Union Square East, Suite 2M, New York, NY 10803; Fax: 212-844-8401; E-mail: rchamber@chpnet.org.

DOI: 10.1245/ASO.2004.04.909

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@article{Chamberlain2004LaparoscopicPO, title={Laparoscopic Placement of Hepatic Arterial Pumps: A True Advance or a Lot of Effort for a Procedure with a Diminishing Role?}, author={MPA FACS Ronald S. Chamberlain}, journal={Annals of Surgical Oncology}, year={2004}, volume={11}, pages={558-559} }