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The first 25 slides, exactly as they appear. The full deck has 145 content slides.
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