Percutaneous hepatic melphalan perfusion: Single center experience of procedural characteristics, hemodynamic response, complications, and postoperative recovery

Abstract

Background Percutaneous hepatic melphalan perfusion (PHMP) for the selective treatment of hepatic metastases is known to be associated with procedural hypotension and coagulation disorders. Studies on anesthetic management, perioperative course, complications, and postoperative recovery in the intensive care unit (ICU) have not been published. Methods In a retrospective observational study, we analyzed consecutive patients who were admitted for PHMP over a 6-year period (2016–2021). Analyses included demographic, treatment, and outcome data with regard to short-term complications until ICU discharge. Results Fifty-three PHMP procedures of 16 patients were analyzed. In all of the cases, procedure-related hypotension required the median (range) highest noradrenaline infusion rate of 0.5 (0.17–2.1) μg kg min-1 and fluid resuscitation volume of 5 (3–14) liters. Eighty-four PHMP-related complications were observed in 33 cases (62%), of which 9 cases (27%) involved grade III and IV complications. Complications included airway constriction (requiring difficult airway management), vascular catheterization issues (which resulted in the premature termination of PHMP, as well as to the postponement of PHMP and to the performance of endovascular bleeding control after PHMP), and renal failure that required hemodialysis. Discharge from the ICU was possible after one day in most cases (n = 45; 85%); however, in 12 cases (23%), prolonged mechanical ventilation was required. There were no procedure-related fatalities. Conclusions PHMP is frequently associated with challenging cardiovascular conditions and complications that require profound anesthetic skills. For safety reasons, PHMP should only be performed in specialized centers that provide high-level hospital infrastructures and interdisciplinary expertise.

Analysis of patient’s X-ray exposure in hepatic chemosaturation procedures: a single center experience

“…Therefore, high doses of melphalan can be administered while minimizing systemic side effects [ 1 , 2 ]. In the past years the feasibility and repeatability of CS-PHP in the setting of unresectable hepatic metastasis has been shown in numerous studies [ 2 – 9 ]. Especially in unresectable liver metastases of uveal melanomas CS-PHP has proven to be an effective and save therapeutic option [ 10 ].…”

Percutaneous Hepatic Perfusion (PHP) with Melphalan in Liver-Dominant Metastatic Uveal Melanoma: The German Experience

“…All procedures were performed under general anesthesia due to the length of the procedure and hemodynamic changes that occur with the extracorporeal hemofiltration circuit and inferior caval vein occlusion [ 25 ]. The first day after the PHP, patients received a single shot of antibiotics as well as granulocyte colony-stimulating factor (G-CSF).…”

Chemosaturation of the Liver – an Update

“…The rate of clinically relevant hyperbilirubinemia is reported to be up to 15 % and appears to correlate with tumor burden [13]. A recent study showed that the side effect spectrum does not change even with repeated sessions (up to six) [5], other data show that up to eight repetitions are possible [4]. Ultimately, the majority of reported adverse events were transient in nature or manageable, and treatment-associated deaths occurred very rarely (< 1 %) in the published cohorts (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15).…”

“…In einer aktuellen Studie konnte gezeigt werden, dass sich das Nebenwirkungspektrum auch bei wiederholten Sitzungen (bis zu 6) nicht ändert [5], andere Daten zeigen, dass bis zu 8 Wiederholungen möglich sind [4]. Letztlich war die Mehrheit der berichteten Nebenwirkungen von transienter Natur bzw.…”

“…Abschließend kann die Heparinisierung mittels Protamin antagonisiert werden. Nach Erfahrung der Autoren dauert eine Therapiesitzung ohne Narkoseeinleitung und -ausleitung circa 120–180 Minuten 5 . Der Patient wird bis zum Folgetag auf der Intensivstation überwacht, wo die Schleusen nach vollständiger Normalisierung der Gerinnung gezogen werden.…”