SSAT - Robotic Hepatic Artery Infusion Pump Placement

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Robotic Hepatic Artery Infusion Pump Placement
Motaz Qadan^*, Michael D'Angelica, Peter Allen, Ronald P. DeMatteo, William R. Jarnagin, Nancy E. Kemeny, Peter Kingham
Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY

Introduction
Hepatic artery infusion pump (HAIP) placement is associated with improved outcomes in the treatment of colorectal liver metastases in both the adjuvant setting and in patients with unresectable disease. Its use in cholangiocarcinoma is also promising. In this study, we examined outcomes following robotic HAIP placement, which were compared with open and laparoscopic outcomes.
Methods
A retrospective review of HAIP placements by 2 surgeons at a single institution was carried out from a prospectively maintained institutional cancer database. The institutional review board approved this HIPAA-compliant study. All statistical tests were 2-sided and p < 0.05 was considered significant.
Results
There were a total of 53 open HAIP cases, 21 laparoscopic cases, and 17 robotic cases. There were no statistically significant differences between the 3 groups in gender, age, body mass index, aberrant arterial anatomy, disease process being treated, or prior treatment, including chemotherapy, radiation therapy, or prior abdominal or hepatic surgical intervention.
Robotic HAIP placement was associated with a significantly lower conversion rate to open operation than laparoscopic pump placement (22 vs. 67%; p = 0.01). When cases with concomitant resections were excluded in order to evaluate the effect of pump placement alone, mean operative time was highest during robotic HAIP placement, followed by laparoscopic placement, and then open placement (283 vs. 237 vs. 154 minutes; p < 0.0001). Similarly, when cases with concomitant resections were excluded, there was a trend towards longer length of hospital stay with open HAIP placement compared with both laparoscopic and robotic placement (6.3 vs. 5.2 vs. 5.1 days; p = 0.21). Complication rates were equivalent among the 3 groups.
When robotic cases without concomitant procedures were divided equally into 2 chronological time-periods, early cases (n = 6) vs. late cases (n = 6), there was a trend towards shorter hospitalization (6.3 days vs. 3.8 days, respectively; p = 0.09) as well as shorter mean operative time (315 vs. 250 minutes, respectively; p = 0.15), as familiarity with the procedure increased.
Conclusion
Robotic HAIP placement is a safe minimally-invasive procedure that is associated with a significantly lower conversion rate to open operation compared with laparoscopic placement and trend towards shorter hospitalization. This procedure is one where the visualization and wristed instruments included in the robotic system make a minimally-invasive approach more feasible compared to laparoscopy.
Preoperative, Intraoperative, and Postoperative Data for Open vs. Laparoscopic vs. Robotic Hepatic Artery Infusion Pump Placement
Parameter Open HAIP Laparoscopic HAIP Robotic HAIP p-Value
Total Patients (n = 53) (n = 21) (n = 17)
Total Patients HAIP Alone (n = 22) (n = 20) (n = 12)
Preoperative Data
Mean Age (Years) 57.0 54.4 60.2 0.37
Mean BMI 28.0 26.9 28.8 0.64
CRLM:ICC:Breast:HCC Ratio 42:10:1:0 14:4:2:1 11:5:1:0 0.35
Prior Chemotherapy/Radiation 38 (71.7%) 12 (57.1%) 9 (52.9%) 0.26
Prior Abdominal Surgery 31 (58.5%) 17 (81.0%) 10 (58.8%) 0.17
Prior Hepatic Surgery 6 (11.3%) 0 (0.0%) 1 (5.9%) 0.25
Aberrant Arterial Anatomy 17 (32.1%) 4 (19.0%) 6 (35.3%) 0.46
Intraoperative Data
Conversions to Open N/A 14 (66.7%) 4 (22.2%) 0.01*
Mean OR Time HAIP Alone (Minutes) 154.00 237.35 282.50 < 0.0001*
Mean EBL HAIP Alone (mL) 199.50 168.42 95.83 0.26
Simultaneous Hepatic Resection 24 (45.3%) 0 (0.0%) 3 (17.6%) < 0.001*
Simultaneous Colon Resection 9 (17.0%) 1 (4.8%) 1 (5.9%) 0.24
Simultaneous Other Resection 3 (5.7%) 0 (0.0%) 1 (5.9%) 0.53
Postoperative Data
Mean LOS HAIP Alone (Days) 6.31 5.20 5.08 0.21
Total Patients with Complications 30 (56.6%) 5 (23.8%) 10 (58.8%) N/A
Total Patients with Grade 1-2 Complications 21 (70.0%) 5 (100%) 7 (70.0%) N/A
Total Patients with Grade 3-4 Complications 9 (30.0%) 0 (0.0%) 3 (30.0%) N/A
Total Complications 40 5 16 N/A
Total Grade 1-2 Complications 27 (67.5%) 5 (100%) 13 (81.3%) 0.14
Total Grade 3-4 Complications 13 (32.5%) 0 (0.0%) 3 (18.8%) 0.15

BMI = body mass index; CRLM = colorectal liver metastases; ICC = intrahepatic cholangiocarcinoma; HCC = hepatocellular carcinoma; OR = operating room; EBL = estimated blood loss; HAIP = hepatic arterial infusion pump; LOS = length of stay.
“HAIP Alone” refers to no concomitant procedure with pump placement.
* indicates statistical significance (p < 0.05)

Robotic hepatic arterial infusion pump catheter placement in the gastroduodenal artery

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