Surgery of colorectal liver metastasis

1
Surgery of colorectal liver metastasis

• Juozas Pundzius
• Surgery clinic of Kaunas university of medicine

2
Incidence of liver metastasis in colorectal cancer

• At the time of diagnosis of primary colorectal
  cancer
• in 15-20 liver metastases are detectable
• In 15 udetectable liver metastases present
• (Synchronous disease)
• Sasson A.R., Sigurdson E.R. et al Seminars in
  Oncology Vol 29, No 2, 2002
• After curative surgery in 20-30 developing
  subsequent spread to the liver
• (Metachronous disease)
• Weinreich D Semin Oncol 29136144, 2002
• 50 of IV stage patients, liver is the only
  site of metastatic process
• 30 of patients with liver metastases are
  suitable for curative surgery.
• Sasson A.R., Sigurdson E.R. et al Seminars in
  Oncology Vol 29, No 2, 2002

3
Methods of treatment of liver metastasis

• Curative
• Surgical hepatic resection
• With or without adjuvant therapy
• Palliative
• Medical chemoterapy (systemic or regional)
• Surgical
• Ablative techniques
• RFA
• Ethanol injections
• Cryotherapy
• Vesel ligation, embolization
• Chemoembolization
• Radiation

4
Curative possibilities of colorectal liver
metastases

• Hepatic resection is the only form of treatment
  that offers a long-term survival for patients
  with liver metastases from colorectal cancer,
  with 5-year survival ranging from 25 to 39.
• Tanaka K, Shimada H. et al Surgery Vol.
  137156-163, 2005

5
Long term results after CRC liver metastases
surgery
6
Long term results our data
7
Prognostic factors influencing long term results
after curative surgery

• Extrahepatic disease
• Primary tumor stage
• Number and size of liver matastases
• Disease free interval
• Margins
• Other ( age, CEA).

8
Prognostic factors for long term results-
extrahepatic disease

• Mayo Clinic
• 0 5 year survival with extrahepatic disease
  (22 patients)
• Memorial Sloan-Kettering Cancer Center
• Patients with and without extrahepatic disease 5
  year survival 18 vs 38(1.001pts)
• Fong Y, Fortner J et al Ann Surg 230309-318,
  1999
• Elias D, Lasser P, De/Cl/Nouveche, Dec, 1991
• Registry of Hepatic Metastases
• Metastatic lymphadenopathy (portal and celiac
  nodes) markedly decreased survival with no 5 year
  survival reported (850 patients, retrospective
  study)
• Registry of Hepatic Metastases, Surgery,
  103278-288, 1988

9
Restrictions for surgery in case of extrahepatic
disease

• Liver resection restricted in
• Presence of metastasis in two or more organs -
  lung, liver, colon (recurence) in case of
  multiple metastasis in one of them
• Carcinomatosis, pleuritis, ascitis
• Presence of portal or celiac lymph node
  metastasis proved by biopsy and extra pathology?

10
Prognostic factors for long term results primary
tumor stage

• Patients with lymphatic spread have a decreased
  survival compared to patients without lymphatic
  spread, 41 vs 32 ( p 0.05 analysis of
  1.001 patients)
• Fong Y, Fortner J et al Ann Surg 230309-318,
  1999
• Stage II primary have an improved outcome
  compared to patients with stage III primary
• Scheele J., Stangl R. et al World J Surg,
  1959-71,1995
• Nordliger B., Guiget M et al Cancer
  771254-1262,1996

11
Suggestions for therapy in case of primary tumor
spread

• Node positive patients candidates for adjuvant
  therapy

12
Prognostic factors for long term results number
of liver metastases

• Increasing number of metastases decreasing
  survival
• Experience-
• 155 patients who had 4 and more lesions
• 5 year survival after 9 to 20 metastases
  resected - 14.
• increasing number of metastases and positive
  resection margin - independent prognostic factors
  (multivariate analysis).
• Weber SM, Jarnagin WR et al Ann Surg
  Oncol7643-650, 2000
• Statement-
• increased number of metastasis increasing
  likelihood of undetectable metastasis

13
Restrictions for surgery in case of multiple
liver metastases

• 1- 3 metastasis in one liver lobe are suitable
  for curative liver resection
• Patients with 4 and more mts in one or both liver
  lobes are candidates for neoadjuvant treatment
• after 2 months chemotherapy in case of no
  manifestation of new metastasis possibilities of
  surgery should be discussed

14
Prognostic factors for long term results
disease free interval

• Experience-
• Difference of median survival in
• synchronous vs. metachronous disease
• 27 months vs. 37 months
• Scheele J., Stangl R. et al World J Surg,
  1959-71,1995
• Statements
• Increasing disease-free interval associated with
  improved survival.
• Fong Y, Fortner J et al Ann Surg 230309-318,
  1999
• Synchronous or early manifestation of liver
  metastases are poor prognostic factors

15
Suggestions after liver resection in case of
short disease free interval

• Strong follow up protocol of resected patients
  with intent to detect new manifestation of
  metastasis
• Neoadjuvant, adjuvant chemotherapy

16
Prognostic factors for long term results size of
liver metastases

• Controversial opinions
• Increasing tumor size poor prognostic factor
• Iwatsuki S, Dvorchik I et al, J Am Coll Surg 189
  291-299,1999
• Tumor size no influence on survival
• Cady B, Jenkins RL et al Ann Surg 227566-571,
  1998
• Clinical consideration (hypothesis)
• Large and solitary tumor because of long growing
  period should decrease likelihood of
  manifestation of new metastasis,
• Current consensus
• There is no absolute metastasis size limit for
  surgical resection

17
Prognostic factors for long term results - margins

• Studies
• Patients with positive resection margins (
  noncurative) had a life expectancy similar to
  that of patients with unresectable disease
• Steele G Jr, Bleday R et al J Clin Oncol
  91105-112, 1991
• Patients with minimally negative microscopic
  margins (1 to 9 mm) compared to patients with
  margins greater than 10 mm
• 1. decreased 5-year survival
• 34 vs 41 (p 0.009)
• Scheele J., Stangl R. et al World J Surg,
  1959-71,1995
• 23 vs 47 (p lt 0.01)
• Registry of Hepatic Metastases, Surgery,
  103278-288, 1988
• 2. Increase in hepatic recurrence
• Hughes KS et al Surgery 100278-284, 1986

18
Obligations and Suggestions for surgeon in
aspect of margins

• Obligation-
• to resect with minimally clear margins gt 10mm
• Suggestion-
• To try expand clear margins to 30mm

19
Poor prognostic factorsAs guidelines for
patient selection
20
Actuality of surgical resection (I)

Short term results
21
Short term results after liver resection

• morbidity - lt25
• mortality - lt4

22
Morbidity and Mortality after liver resection

• General complications
• cardiovascular, pulmonary, etc.
• Infection, abscess
• Hemorrhage.
• Specific complications
• bile leak, biliary fistula,
• Liver failure
• ( can be decreesed lt 5 with proper patient
  selection despite agresive surgical treatment).

23
Low morbidity and mortality depends on patient
selection

• Preoperative evaluation
• Medical condition
• similar to other major abdominal surgery (
  particular attention to pulmonary and cardiac
  systems).
• 2. Preoperative Hepatic function

24
Main contraindication for expanded liver
resection

• Inability to preserve an adequate reserve of
  functional hepatic tissue

25
Chance for survival after liver resection with
normal liver function

• 70-75 of the liver can be resected without
  increasing the risk of postoperative liver
  failure in the absence of cirrhosis or fatty
  liver.
• Sasson A.R., Sigurdson E.R. et al Seminars in
  Oncology Vol 29, No 2, 2002

26
Patient selection preoperative evaluation of
Hepatic function

• Main question extent of the operation?
• Clinical evaluation (Child Pugh)
• Level of Bilirubinaemy
• Indocianine green (ICG-5)
• CT volumetry.

27
Clinical evaluation (Child Pugh) 1964m
28
Liver resection volume guides
No ascites or easy control
Bilirubinaemy
normal
18.8-25.6 µmol/l
27.4-32.5 µmol/l
gt 34.2 µmol/l
Limited resection
Enucleation
Not resectable
ICG-5
10-19
20-29
gt 40
normal
30-39
Major surgery
Bisegment- ectomy
Segment- ectomy
Limited resection
Enucleation
29
CT volumetry of liver
30
Preoperative procedures to increase volume of
the liver

• Decreasing of blood supply to diseased part of
  the liver with intent to enlarge normal liver
  lobe
• Portal vein embolisation
• Embolisation of hepatic artery

31
Intent to enlarge normal liver before surgery

• Transhepatic portal vein embolisation

32
Transileocolic portal vein embolisation scheme
Intent to enlarge normal liver before surgery
RPV
SMV
Laparotomy and catheterisation of ileocolic vein