Laparoscopic radiation spacer for unresectable liver tumors

Abstract

Background: Radiation therapy is an option for localized, unresectable, hepatic malignancies (both primary and metastatic). The ability to deliver optimized doses of radiation can be hindered by adjacent structures, most typically bowel. For patients in this situation, we have adopted an approach consisting of placement of a customized biologic mesh-based spacer to move adjacent viscera away from the radiation field. This video demonstrates our approach. Methods: Following IRB approval, patients undergoing surgical placement of spacers to facilitate radiation therapy were identified. A single case was video-taped and we describe the clinical case corresponding to this video. Case: The patient is a 59 year old male with Child-Pugh A compensated alcoholic cirrhosis who was being monitored and found to have a 7-mm enhancing lesion in the liver in May of 2014, which was enlarging on surveillance imaging in October 2014, up to 2.7 cm. Radiographic features were consistent with hepatocellular carcinoma. Results: Liver transplant evaluation was performed and the overall consensus was for locoregional therapy at that time. Initial attempt for RFA was made, however, on CT scan the lesion was in close proximity to the duodenum. RFA was not performed and instead alcohol ablation followed by transarterial chemoembolization was undertaken. Recurrent disease in August and November 2015 was treated with TACE. He continued to have progressive disease in the form of enlarging lesion. After multidisciplinary discussion, repeat locoregional radiation therapy was agreed upon. Given the proximity of the duodenum, he was referred to HPB surgery for spacer placement to facilitate safe administration of radiation. The video shows the technique of laparoscopic spacer placement. Shown in the video is the site of HCC in segment 4 of the liver as well as its proximity to the duodenum and colon. An open Hasson technique was used to gain entry into the abdomen and three 5 mm ports were placed based on the location of the target lesion. After sizing the area needed for spacer placement, Surgimend mesh was folded and a pocket created with a running #1 prolene suture. The spacer was introduced by extending the supraumbilical port and was positioned underneath the liver followed by a single tacking suture between the stomach and the liver and a single tacking suture between the spacer and mesentery of the right colon to secure the mesh in appropriate position. Fiducials were placed using a clip applier surrounding the visualizable lesions within the liver. Postoperative scan shows full expansion of the spacer. The patient had no complications following surgery and started radiation therapy 11 days after surgery (50 Gy in 5 fractions, photon). Conclusion: For patients with unresectable tumors, that are amenable to radiation therapy, placement of a spacer to allow for safe administration of full doses of radiation is a feasible strategy to address proximity of adjacent organs and critical structures. There is minimal morbidity associated with these procedures in our limited experience, including in patients with cirrhosis.