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General Surgery
Hepatic Colorectal Metastases Resection, Pumps, and Ablation
Built from Maingot's Abdominal Operations
What’s inside
10 sections · 145 slides
Overview
- Topics covered
Burden of colorectal liver metastases
How often the bowel cancer reaches the liver, and what removing it achieves
- Colorectal cancer in the United States
- Pattern of spread to the liver
- Survival benefit of complete resection
- 3rd
- Liver-directed treatment options
Preoperative evaluation
Deciding who can be helped by an operation, before the abdomen is opened
- Purpose of preoperative staging
- How much staging each patient needs
- Computed tomography for extrahepatic disease
- Limits of computed tomography
- Magnetic resonance imaging
- Positron emission tomography: principle
- Positron emission tomography in practice
- Assessing the extent of disease inside the liver
- Advanced image processing
- Goal of preoperative evaluation
Intraoperative assessment
What the surgeon looks for, feels for and scans for once the abdomen is open
- Abdominal exploration before resection
- Significance of periportal nodal disease
- Palpation of the liver
- Intraoperative ultrasonography
- Metastasis seen on intraoperative ultrasound
- Echogenicity of the index lesion and extra findings
- Yield of intraoperative ultrasound
- How intraoperative ultrasound changes the operation
- Staging laparoscopy
- Staging laparoscopy in colorectal liver metastases
Surgical resection
Selecting the patient, doing the operation, and what the long-term results look like
- Questions to settle before hepatic resection
- Place of resection among the treatments
- Shift in what counts as resectable
- Features that no longer bar resection
- Definition of resectability
- Four conditions for resectable liver disease
- Health of the liver that is left behind
- Assessing hepatic functional reserve
- Imaging clues to cirrhosis
- Future liver remnant volume
- Portal vein embolization
- Sequence of portal vein embolization
- Patient comorbidity and operative risk
- Objectives of a liver resection
- Types of liver resection
- Major hepatic resection
- Controlling the inflow
- Wedge resection
- Segmental resection
- Pringle maneuver
- Dividing the liver substance
- Choosing a transection technique
- Perioperative mortality
- Hospital volume and outcome
- Complications of liver resection
- ~1%
- Long-term survival after resection
- Largest series of curative-intent surgery for colorectal liver metastases
- Outcomes in the largest published series
- Reading the outcomes table
- Why prognostic factors are studied
- Features of the primary bowel tumour
- Features of the liver deposits
- Number of metastases and the decision to operate
- Surgical margin status
- How wide should the margin be
- Type of resection and recurrence
- Extrahepatic disease and prognosis
- What does not count as extrahepatic disease
- Lung metastases
- Combined lung and liver resection
- Perihepatic lymph node metastases
- Peritoneal metastases
- Resecting liver and extrahepatic disease together
- Using prognostic factors correctly
- Liver-directed pathways by disease status
Systemic chemotherapy around surgery
Drugs before the operation, after it, and to turn inoperable disease operable
- Modern chemotherapy for metastatic disease
- Where chemotherapy sits relative to surgery
- Three settings for chemotherapy
- Adjuvant chemotherapy in earlier-stage colon cancer
- Adjuvant chemotherapy after liver resection
- The two European randomised trials
- The Portier trial
- Limits of the adjuvant evidence
- Adjuvant hepatic arterial infusion
- Why adjuvant pumps are little used
- Arguments for chemotherapy before surgery
- Advantages and disadvantages of chemotherapy before hepatectomy
- Weighing chemotherapy before resection
- Risk of progression on neoadjuvant therapy
- Chemotherapy-associated liver injury
- Disappearing liver metastases
- Size of metastases that disappear on chemotherapy
- Residual disease behind a complete radiologic response
- The EORTC 40983 trial design
- Results of the EORTC 40983 trial
- Interpreting the EORTC 40983 trial
- Converting unresectable disease
- Bulky liver disease converted to resectable by chemotherapy
- Reading the conversion scans
- How often conversion succeeds
- Outcome after conversion surgery
- Unanswered questions in conversion therapy
- Managing a complete radiologic response
Ablative therapies
Destroying a tumour where it sits, with cold or with heat
- Why ablation is used
- Hepatic cryosurgery
- Radiofrequency ablation
- How radiofrequency ablation destroys a tumour
- Radiofrequency ablation versus cryotherapy
- Newer ablative methods
- Planning the zone of destruction
- Tumour features that limit ablation
- Radiofrequency ablation under ultrasound guidance
- Monitoring during ablation
- Imaging after ablation
- Recognising local recurrence after ablation
- Quality of the evidence for ablation
- Reported results of ablation
- Ablation compared with resection
Regional chemotherapy: hepatic arterial infusion
Delivering the drug straight into the artery that feeds the tumour
- Rationale for regional chemotherapy
- Blood supply of liver tumours
- Why hepatic arterial infusion concentrates the drug
- Drugs used for hepatic arterial infusion
- Older randomised trials of hepatic arterial infusion
- The Kerr trial
- The Kemeny trial
- Current place of hepatic arterial pumps
Summary and outlook
What is settled, what is still being argued about
- Summary of surgical therapy
- Ways to widen the reach of resection
- Outlook
- Take-home points
References
The source list printed with this topic
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- Maingot's Abdominal Operations, 12th Edition