Staged Hepatectomy for Staged Hepatectomy for Colorectal Metastases to Colorectal Metastases to

LiverLiver

Dr. Steven, Kong Ling TINGDr. Steven, Kong Ling TINGCaritas Medical CentreCaritas Medical Centre

IntroductionIntroduction

Surgical resection is considered as a curative Surgical resection is considered as a curative therapy for colorectal liver metastases (CLM) therapy for colorectal liver metastases (CLM)

5-year overall survival rate - 58%5-year overall survival rate - 58%

Patient with unresectable colorectal liver Patient with unresectable colorectal liver metastases, and no other organs involvedmetastases, and no other organs involved

Chemotherapy? Chemotherapy? Use of preoperative portal vein embolization Use of preoperative portal vein embolization

and ablative therapies?and ablative therapies?

Two stage hepatectomy (TSH)Two stage hepatectomy (TSH)

Selection of patients for resection of CLM: expert Selection of patients for resection of CLM: expert consensus statement. In Ann Surg Oncol 2006consensus statement. In Ann Surg Oncol 2006

To preserve:To preserve: 1. two contiguous liver segments1. two contiguous liver segments 2. adequate vascular supply and biliary drainage2. adequate vascular supply and biliary drainage 3. adequate functional liver volume (FLV) >20%3. adequate functional liver volume (FLV) >20%

Unresectable disease – bilobar CLM, with Unresectable disease – bilobar CLM, with inability to inability to

achieve margin negative (R0) resection of all achieve margin negative (R0) resection of all tumors, tumors,

while preserving the above three criteriawhile preserving the above three criteria

IntroductionIntroduction

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Case DiscussionCase Discussion

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Case DiscussionCase Discussion

Past 5-year studies in PubMed and MEDLINEPast 5-year studies in PubMed and MEDLINE

Two stage hepatectomy with curative Two stage hepatectomy with curative intentionintention

Initially unresectable diseaseInitially unresectable disease Survival outcomes reportedSurvival outcomes reported

Overlapping patient pool seriesOverlapping patient pool series <10 patient number<10 patient number

9 Observational studies9 Observational studies

Review of Current EvidenceReview of Current Evidence

1. Bilobar multiple liver metastases

2. Response to chemotherapy

3. Adequate remnant liver volume(>25 / 30%)

4. Other conditions concerning surgicalstrategy, for example: left hemi-liverclear of metastases during 1st stage

(Tsim et al.)

Review of Current EvidenceReview of Current Evidence

Review of Current EvidenceReview of Current Evidence

Review of Current EvidenceReview of Current Evidence

Case DiscussionCase Discussion

* R0 resection cases included only, DF = disease free

Review of Current EvidenceReview of Current Evidence

Adjuvant modalitiesAdjuvant modalities

Portal vein embolization Portal vein embolization Intra-operative ligation of portal veinIntra-operative ligation of portal vein ALPPS (Associating Liver Partition and ALPPS (Associating Liver Partition and

Portal vein ligation for Staged Portal vein ligation for Staged hepatectomy)hepatectomy)

Ablation (RFA) – Ablation (RFA) – preferably <1cm preferably <1cm tumors away from tumors away from major vesselsmajor vessels

Review of Current EvidenceReview of Current Evidence

Interval chemotherapyInterval chemotherapy Mentha et al. – histologic evidence Mentha et al. – histologic evidence

supporting interval chemotherapy supporting interval chemotherapy

Liver steatosis, Liver steatosis, steatohepatitis, sinusoidal steatohepatitis, sinusoidal liver injury, blue liver liver injury, blue liver syndromesyndrome

Role of intra arterial Role of intra arterial chemotherapy (HAI)chemotherapy (HAI)

Review of Current EvidenceReview of Current Evidence

Factors affect the survival outcomeFactors affect the survival outcome

Response to preoperative chemotherapyResponse to preoperative chemotherapy FLR volume FLR volume Completion of both stages of hepatectomyCompletion of both stages of hepatectomy Presence of extra-hepatic metastasesPresence of extra-hepatic metastases

? Tumor number and size? Tumor number and size ? Resection margin? Resection margin

Review of Current EvidenceReview of Current Evidence

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Case DiscussionCase Discussion

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Case DiscussionCase Discussion

Two stage hepatectomy in selected patients Two stage hepatectomy in selected patients withwith

initially unresectable CLM is associated withinitially unresectable CLM is associated with acceptable operative mortality and survival acceptable operative mortality and survival outcomesoutcomes

Consensus on patient selection, combined Consensus on patient selection, combined adjuvant modalities, interval chemotherapy adjuvant modalities, interval chemotherapy

Data inhomogeneity: synchronous versusData inhomogeneity: synchronous versus metachronous disease, use of biological metachronous disease, use of biological

agents,agents, presence of extra-hepatic diseasepresence of extra-hepatic disease

ConclusionConclusion

Rees M, Tekkis PP, Welsh FKS, et al. Evaluation of long term survival after hepatic resection for metastatic colorectal cancer: a Rees M, Tekkis PP, Welsh FKS, et al. Evaluation of long term survival after hepatic resection for metastatic colorectal cancer: a multifactorial model of 929 patients. Ann Surg 2008 247:125-135multifactorial model of 929 patients. Ann Surg 2008 247:125-135

Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009 62:1-34evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009 62:1-34

Tanaka K, Shimada H, Ueda M et al. Perioperative complications after hepatectomy with or without intra-arterial chemotherapy for Tanaka K, Shimada H, Ueda M et al. Perioperative complications after hepatectomy with or without intra-arterial chemotherapy for bilobar colorectal cancer liver metastases. Surgery 2006 139:599-607bilobar colorectal cancer liver metastases. Surgery 2006 139:599-607

Kuniya Tanaka, Takafumi Kumamoto, Kazunori Nojiri, et al. Timing of two stage liver resection during chemotherapy for otherwise Kuniya Tanaka, Takafumi Kumamoto, Kazunori Nojiri, et al. Timing of two stage liver resection during chemotherapy for otherwise unresectable colorectal metastases. World J Surg 2012 36:1832-1841 unresectable colorectal metastases. World J Surg 2012 36:1832-1841

Mohammad H. Jamal, Mazen Hassanin, et al. Staged hepatectomy for bilobar colorectal hepatic metastases. HPB 2012 14:782-789Mohammad H. Jamal, Mazen Hassanin, et al. Staged hepatectomy for bilobar colorectal hepatic metastases. HPB 2012 14:782-789 Tsai S, Marques HP, et al. Two stage stretegy for patients with extensive bilateral colorectal liver metastases. HPB 2010 12:262-269Tsai S, Marques HP, et al. Two stage stretegy for patients with extensive bilateral colorectal liver metastases. HPB 2010 12:262-269 Bowers KA, O’Reilly D, Bond Smith GE, et al. Feasibility study of two stage hepatectomy for bilobar liver metastases. Am J Surg Bowers KA, O’Reilly D, Bond Smith GE, et al. Feasibility study of two stage hepatectomy for bilobar liver metastases. Am J Surg

2011 203:691-6972011 203:691-697 Brouquet A, Abdalla EK, Kopetz S, et al. High survival rate after two stage resection of advanced colorectal liver metastases: response Brouquet A, Abdalla EK, Kopetz S, et al. High survival rate after two stage resection of advanced colorectal liver metastases: response

based selection and complete resection define outcome. J Clin Oncol 2011 29:1083-1090based selection and complete resection define outcome. J Clin Oncol 2011 29:1083-1090 Muratore A, Zimmitti G, Ribero D, et al. Chemotherapy between the first and second stages of a two stage hepatectomy for colorectal Muratore A, Zimmitti G, Ribero D, et al. Chemotherapy between the first and second stages of a two stage hepatectomy for colorectal

liver metastases: should we routinely recommend it? Ann surg Oncol 2011 19:1310-1315liver metastases: should we routinely recommend it? Ann surg Oncol 2011 19:1310-1315 Turrini O, Ewald J, et al. Two stage hepatectomy: who will not jump over the second hurdle? Eur J Surg Oncol 2012 38:266-273Turrini O, Ewald J, et al. Two stage hepatectomy: who will not jump over the second hurdle? Eur J Surg Oncol 2012 38:266-273 Tsim N, Healey AJ, Frampton AE, et al. Two stage resection for bilobar colorectal liver metastases: R0 resection is the key. Ann Surg Tsim N, Healey AJ, Frampton AE, et al. Two stage resection for bilobar colorectal liver metastases: R0 resection is the key. Ann Surg

Oncol 2011 18:1939-1946Oncol 2011 18:1939-1946 Narita M, Jaeck D, et al. Two stage hepatectomy for multiple bilobar colorectal liver metastases. Br J Surg 2011 98:1463-1475Narita M, Jaeck D, et al. Two stage hepatectomy for multiple bilobar colorectal liver metastases. Br J Surg 2011 98:1463-1475 Adam R, Wicherts DA, de Haas RJ, et al. Patients with initially unresectable colorectal liver metastases: is there a possibility of cure? J Adam R, Wicherts DA, de Haas RJ, et al. Patients with initially unresectable colorectal liver metastases: is there a possibility of cure? J

Clin Oncol 2009 27:1829-1835Clin Oncol 2009 27:1829-1835 Mentha G, Terraz S, Morel P, et al. Danerous halo after neoadjuvant chemotherapy and two step hepatectomy for colorectal liver Mentha G, Terraz S, Morel P, et al. Danerous halo after neoadjuvant chemotherapy and two step hepatectomy for colorectal liver

metastases. Br J Surg 2009 96:95-103metastases. Br J Surg 2009 96:95-103 Adam R, Pascal G, Castaing D, et al. Tumor progression while on chemotherapy: a contraindication to liver resection for multiple Adam R, Pascal G, Castaing D, et al. Tumor progression while on chemotherapy: a contraindication to liver resection for multiple

colorectal metastases? Ann Surg 2004 240:1052-1061colorectal metastases? Ann Surg 2004 240:1052-1061 Wicherts DA, Miller R, de Hass RJ et al. Long term results of two stage hepatectomy for irresectable colorectal cancer liver Wicherts DA, Miller R, de Hass RJ et al. Long term results of two stage hepatectomy for irresectable colorectal cancer liver

metastases. Ann Surg 2008 248:994-1005metastases. Ann Surg 2008 248:994-1005 Hemming AW, Reed AI, et al. Preoperative portal vein embolization for extended hepatectomy Ann Surg 2003 237:686-693Hemming AW, Reed AI, et al. Preoperative portal vein embolization for extended hepatectomy Ann Surg 2003 237:686-693 Picture sources: www.Intechopen.com, www.hopkinsmedicine.orgPicture sources: www.Intechopen.com, www.hopkinsmedicine.org

ReferenceReference