Liver surgery for colorectal liver metastases Keith Roberts, Consultant Liver Transplant and Liver/Pancreas Surgeon University Hospitals Birmingham
Introduction: what do we do? UHB Liver Unit: Liver resections 1988 2010, 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%
Normal Liver very forgiving to the surgeon and patient Large hepatic reserve Segmental anatomy Life long regeneration
Liver and blood supply
Anatomy
Making liver surgery fair
Liver surgery postcode lottery? Variation in liver surgery for colorectal metastases throughout England
Making liver surgery safe
units of FFP Units of platelets Change in blood use liver transplant 70 Units of blood transfused by year 60 50 40 30 20 10 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 YEAR 40 Use of FFP during transplant procedure 50 Use of platelets during transplant procedure 30 40 30 20 20 10 10 0 0 N = 61 1982-86 334 1987-91 575 1992-96 666 1997-02 N = 61 1982-86 334 1987-91 575 1992-96 666 1997-2002 Slide No. 9
Near patient monitoring PT, PTT, TEG Slide No. 10
What can we treat with surgery?
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
Definition of resectability: 1997-2017 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
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
The limit..
What counts is what remains Technical resectability Functional resectability Type of resection Liver remnant
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
%RLV Critical relative residual liver volume of 26.6%: associated with increased incidence of severe liver dysfunction 100 80 60 40 20 0 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: 290-297
can be modified
Future Liver Volume too small? Portal vein embolisation (PVE)
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)
Measuring liver volumes
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%
Treatment options Liver surgery Combined liver and bowel surgery Two stage liver surgery Complex surgery Ablation Liver transplantation
Surgery
Right hepatectomy ~60% Extended Right hepatectomy ~75%
Non anatomical resections 1-30%
Two stage surgery 1 2 3 4 1. 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
Combined liver and bowel surgery
Ablation
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
Thank you