Colorectal metastases how far can we go

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Colorectal metastases- how far can we go?

• Professor James Garden
• Regius Professor of Clinical Surgery
• University of Edinburgh

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Colorectal metastases- where have we come from?

• Berta, 1716
• - amputated protruding liver following abdominal
  injury
• Von Bruns 1870
• - resection of lacerated portion of liver
  (Franco-Prussian War)
• Luis, 1886
• - removal of adenoma (patient died)
• Langenbuch, 1888
• - left lobectomy (constriction by corsets)

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History of liver resection

• Lucke, 1891
• - first removal of cancer from left lobe
• Keen, 1892
• - liver resection finger fracture technique
  (digitoclasie)
• - 1899 first left hepatic lobectomy
• Pringle, 1908
• - portal triad clamping, liver sutures
• Wendell, 1911
• - right lobectomy
• Cattell, 1940
• - first successful removal of liver metastases
• Modern era, 1960s and beyond
• - Couinaud, Lortat-Jacob, Ton That Tung,
  Starzyl, Bismuth

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Natural History of Unresected Untreated
Colorectal Metastases
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Survival Following Hepatic Resection for CRLM
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Outcome in 1001 hepatic resections for colorectal
cancer
all resections lobectomy ltlobectomy Numbe
r 1001 631 370 Hospital
stay 9 (0-70) 10(1-70) 8(4-35)
(median days) 30-day mortality 28(2.8)
26(4.1) 2(0.5) Complications ()
31 37 20 1-yr survival
() 89 85 93 3-yr
survival () 57 53
75 5-yr survival () 37 33
40 median survival (mo) 42
39 46
Fong et al, Ann Surg, 1999
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Size lt5cm v gt5cm
Unilobar v Bilobar
Fong et al, Ann Surg, 1999
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Resection of CRL metastases impact of positive
resection margins
Cady et al, Ann Surg, 1998
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Survival after primary or secondaryresection of
CRLM
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PET Scan and liver resection
?
Fernandez et al, Ann Surg 2402004438-50
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Colorectal metastases- how far can we go?

• Factors influencing survival after resection of
  pulmonary metastases from colorectal cancer-
  Vogelsangm, Br J Surg, 2004
• Surgical treatment for extrahepatic recurrence
  after hepatectomy for colorectal metastases-
  Yoshidome, Hepatogastroenterology. 2004

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Tumours borderline for resection

• portal vein embolisation
• two stage hepatectomy
• ablative therapy
• chemotherapy

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Neoadjuvant Chemotherapy
Unresectable tumours may be converted to
resectable lesions by high dose
chemotherapy - 53 patients initially
unresectable - 5-FU Folinic acid
oxaliplatin ? resection - 40 5 year
survival
Bismuth, Ann Surg, 1996
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Neoadjuvant Chemotherapy

• Large lesion
• Ill-located lesions
• Multiple, bilateral lesions
• Extra-hepatic tumour

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Challenging patients challenging livers
Fat!
Chemotherapy
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prothrombin index lt50 (INR gt1.7) serum
bilirubin gt450 mmol/L (2.9 mg/dL) on
post-operative day 5 When fulfilled- 59 risk
of mortality versus 1.2 not met - sensitivity
69.6 - specificity 98.5
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• Virtual hepatic resection using
  three-dimensional reconstruction of helical
  computed tomography

Wigmore et al Ann Surg 2001
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Relative residual liver volume (RLV) in patients
with no, mild, moderate, and severe hepatic
dysfunction following liver resection
Schindl, M J et al. Gut 200554289-296
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Metabolic adaptation in the liver
Preop
Postop
Liver volume
100
50
Van de Poll, Am J Physiol 2007
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99Tc albumin clearance and volume of residual
liver following resection
Schindl et al, Ann Surg 2006
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• When there is around 25 residual liver volume
  the liver is at a critical point of compensation
• Small volume of liver determines the difference
  between liver failure and recovery
• Improve our understanding of impact of steatosis
  on liver dysfunction

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Laparoscopic liver resectional surgery

• feasible and safe in selected patients
• advantages in recovery
• long-term results awaited

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Hypothesis - goal directed (fast track)
programme which optimised peri-operative care
reduces accelerates recovery, reduces hospital
stay and shortens hospital stay
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Enhanced Recovery After Surgery

• same day admission
• oral carbohydrate loading 2 hours prior to
  anaesthesia
• thoracic epidural and short-acting anaesthetic
  agent
• no nasogastric tube or intra-abdominal drain
• recovery area or surgical HDU before transfer to
  ward
• commence fluids/diet and mobilisation on same day

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Enhanced recovery protocol
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Enhanced recovery after liver surgery

• Patients informed regarding protocol at
  preadmission counselling session
• importance of early mobilization and oral intake
  explained
• Patients were discharged only if they met the
  discharge criteria and follow-up within 3 days
  was possible
• Patients were given the mobile telephone number
  of the operating consultant surgeon
• direct communication and safe deployment of
  protocol.
• Maastricht only

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Outcomes
Median (range) number of days all others
incidence (percentage)
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ERALS - markers of recovery

• 92 of patients resumed oral intake
• within 4 hours
• Normal diet resumed by day 1
• (0-3) median (range)
• 2 patients required NG tube reinsertion
• 85 of patients fully mobile by day 3
• 48 discharged within 5 days

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Colorectal metastases- how far can we go?

• Improved selection and staging of patients for
  resection
• Better understanding of residual liver volume and
  post resection liver failure
• Improvements in systemic (neoadjuvant)
  chemotherapy
• - response to treatment
• - biological markers
• Extending conventional boundaries of
  resectability
• - radiological, surgical and ablative
• - definitive treatment