Liver surgery for colorectal liver metastases. Keith Roberts, Consultant Liver Transplant and Liver/Pancreas Surgeon University Hospitals Birmingham

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1 Liver surgery for colorectal liver metastases Keith Roberts, Consultant Liver Transplant and Liver/Pancreas Surgeon University Hospitals Birmingham

2 Introduction: what do we do? UHB Liver Unit: Liver resections , by diagnosis n=1802 Other malignancy, 241, 13% Other benign, 189, 10% CRC mets Cholangiocarcinoma HCC Other malignancy Other benign HCC, 174, 10% Cholangiocarcinoma, 99, 5% CRC mets, 1099, 62%

3 Normal Liver very forgiving to the surgeon and patient Large hepatic reserve Segmental anatomy Life long regeneration

4 Liver and blood supply

5 Anatomy

6 Making liver surgery fair

7 Liver surgery postcode lottery? Variation in liver surgery for colorectal metastases throughout England

8 Making liver surgery safe

9 units of FFP Units of platelets Change in blood use liver transplant 70 Units of blood transfused by year YEAR 40 Use of FFP during transplant procedure 50 Use of platelets during transplant procedure N = N = Slide No. 9

10 Near patient monitoring PT, PTT, TEG Slide No. 10

11 What can we treat with surgery?

12 Historical perspective Recognition that liver could be resected safely paved the way for liver resection for colorectal liver metastases common disease first time that cure was possible Initial experience included high rates of morbidity and mortality reduced by understanding and controlling for central venous pressure pringle manoevre Boundaries regarding what was acceptable have changed ie. Bilobar metastases were a contraindication to resection

13 Definition of resectability: changing limits Metachronous detection Unilobar disease <4 metastases <5 cm largest metastasis >1 cm resection margin If we accepted these criteria then less than 10% of patients were eligible for surgery Disease confined to liver +/- resectable extrahepatic disease Resectable with adequate margins Adequate future remnant liver (25-30%) Preservation of functional liver anatomy 2017 Rees et al 1997

14 What evidence is there for liver resection of colorectal liver metastases? Experience base vs. evidence base! Therefore our practice is based upon intuition and providence: This has been formalised 2004, 2011 NICE guidelines Systematic review* no randomised trials Bias selection of biologically less aggressive disease! More effective chemotherapy available Liver is the first filter *Simmonds et al, Br J Cancer 2006, 94:982

15 The limit..

16 What counts is what remains Technical resectability Functional resectability Type of resection Liver remnant

17 Current focus with colorectal liver metastases Not what is removed but what is left behind! R0 resection adequate volume of liver Gonzalez and Figueras 2007

18 %RLV Critical relative residual liver volume of 26.6%: associated with increased incidence of severe liver dysfunction no Severe liver dysfunction 10/11 (90.9%) correctly identified, but 12/76 (13.6%) allocated at risk without severe liver dysfunction yes Schindl et al Gut 2005, 54:

19 can be modified

20 Future Liver Volume too small? Portal vein embolisation (PVE)

21 BEFORE AFTER Volume of a sphere V= 4 3 πr3 So an increase in radius of the left liver from 4 to 5cm is a change from 268ml to 524ml (increase of 96% in volume)

22 Measuring liver volumes

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25 Effects of chemotherapy upon the liver Liver injury occurs in patients receiving oxaliplatin and irinotecan chemotherapy Increased buffer of safety recommended for resection after chemotherapy 6 weeks break before surgery 30-35% liver volume to remain not 25%

26 Treatment options Liver surgery Combined liver and bowel surgery Two stage liver surgery Complex surgery Ablation Liver transplantation

27 Surgery

28 Right hepatectomy ~60% Extended Right hepatectomy ~75%

29 Non anatomical resections 1-30%

30 Two stage surgery Operation 1 clear the liver that will stay 2. Increase the volume of the liver that will stay 3. Check it is still healthy (4-8 weeks later) 4. Operation 2 remove the rest of the disease

31 Combined liver and bowel surgery

32 Ablation

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34 Conclusions Remarkable outcomes for secondary cancer Better than for other primary cancers There are ever increasing options for surgeons and patients Chemotherapy plays a huge role Close working relationship between colon team and liver team

35 Thank you