Hepatic artery infusion pumps: cannulation techniques and other surgical considerations.

Long term hepatic artery chemotherapy for metastatic disease to the liver has been made practical by technologic advances in pumps and catheters. The surgical placement of these pumps and catheters can be associated with a significant morbidity unless careful attention is given to variations in hepatic arterial anatomy and to eliminating collateral arterial supply to the distal stomach and duodenum. Gastroduodenal devascularization should be performed in all patients and should be confirmed both with intra-operative fluorescein injection and postoperative scintigraphy scanning. Routine cholecystectomy avoids the complication of chemical cholecystitis. Exact placement of the catheter tip at the junction of the gastroduodenal artery and the hepatic artery with fixation of the catheter in this position by placement of bidirectional ligatures around the catheter bead will reduce the incidence of hepatic artery thrombosis and catheter migration. Intrahepatic arterial collateralization in most patients allows for ligation of variant lobar vessels with total liver perfusion through the remaining lobar arterial supply. This again can be confirmed intra-operatively with fluorescein injection and postoperatively with scintigraphy scanning. Strict attention to these technical details will allow continued use of this important therapeutic modality in the treatment of hepatic metastases and by minimizing surgical complications will encourage continued trials to improve the efficacy of long term hepatic arterial chemotherapy.