Joint Hospital Surgical Grand Round 26 April 2014

Joint Hospital Surgical Grand Round 26 April 2014 Staged Hepatectomy for Colorectal Metastases to Liver Dr. Steven, Kong Ling TING Caritas Medical Centre

Introduction n n n Surgical resection is considered as a curative therapy for colorectal liver metastases (CLM) 5 -year overall survival rate - 58% Patient with unresectable colorectal liver metastases, and no other organs involved Chemotherapy? Use of preoperative portal vein embolization and ablative therapies? Two stage hepatectomy (TSH)

Introduction n Selection of patients for resection of CLM: expert consensus statement. In Ann Surg Oncol 2006 To preserve: 1. two contiguous liver segments 2. adequate vascular supply and biliary drainage 3. adequate functional liver volume (FLV) >20% Unresectable disease – bilobar CLM, with inability to achieve margin negative (R 0) resection of all tumors, while preserving the above three criteria

Case Discussion 1 2 3 4

Case Discussion 1 2 3 4

Review of Current Evidence n Past 5 -year studies in Pub. Med and MEDLINE n Two stage hepatectomy with curative intention Initially unresectable disease Survival outcomes reported n n n Overlapping patient pool series <10 patient number n 9 Observational studies n

Review of Current Evidence 1. Bilobar multiple liver metastases 2. Response to chemotherapy 3. Adequate remnant liver volume (>25 / 30%) 4. Other conditions concerning surgical strategy, for example: left hemi-liver clear of metastases during 1 st stage (Tsim et al. )

Review of Current Evidence

Review of Current Evidence

Case Discussion

Review of Current Evidence * R 0 resection cases included only, DF = disease free

Review of Current Evidence n Adjuvant modalities n Portal vein embolization Intra-operative ligation of portal vein ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) n n n Ablation (RFA) – preferably <1 cm tumors away from major vessels

Review of Current Evidence n n Interval chemotherapy Mentha et al. – histologic evidence supporting interval chemotherapy n Liver steatosis, steatohepatitis, sinusoidal liver injury, blue liver syndrome n Role of intra arterial chemotherapy (HAI)

Review of Current Evidence n Factors affect the survival outcome n n Response to preoperative chemotherapy FLR volume Completion of both stages of hepatectomy n Presence of extra-hepatic metastases n ? Tumor number and size ? Resection margin n n

Case Discussion 1 2 3 4

Case Discussion 1 2 3 4

Conclusion n Two stage hepatectomy in selected patients with initially unresectable CLM is associated with acceptable operative mortality and survival outcomes n Consensus on patient selection, combined adjuvant modalities, interval chemotherapy n Data inhomogeneity: synchronous versus metachronous disease, use of biological agents, presence of extra-hepatic disease

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