Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go?

Abstract

Colorectal cancer is the third most common cancer worldwide, and up to 50% of all patients diagnosed will develop metastatic disease. Management of colorectal liver metastases (CRLM) has been constantly improving, aided by newer and more effective chemotherapy agents and the use of multidisciplinary teams. However, the only curative treatment remains surgical resection of the CRLM. Although survival for surgically resected patients has shown modest improvement, this is mostly because of the fact that what is constantly evolving is the indication for resection. Surgeons are constantly pushing the limits of what is considered resectable or not, thus enhancing and enlarging the pool of patients who can be potentially benefited and even cured with aggressive surgical procedures. There are a variety of procedures that have been developed, which range from procedures to stimulate hepatic growth, such as portal vein embolization, two-staged hepatectomy, or the association of both, to technically challenging procedures such as simultaneous approaches for synchronous metastasis, ex-vivo or in-situ perfusion with total vascular exclusion, or even liver transplant. This article reviewed the major breakthroughs in liver surgery for CRLM, showing how much has changed and what has been achieved in the field of CRLM.

Keywords: ALPPS; colorectal metastases; liver resection; liver transplant; parenchyma sparring surgery.

Figure 1

The case of a 70-year-old patient with synchronous bilobar CRLM. (a) CT volumetry of the FLR (red outline) is insufficient (FLR 20%, SPECT 20% and HIBA index of 8%); thus, a portal embolization with venous deprivation is performed. (b) The blue star marks the embolization material. The blue outline shows the exponential growth of the FLR after portal embolization (SPECT 58%, HIBA index 16%).

Figure 2

The patient of Figure 1 was subjected to a simultaneous approach after successful embolization. (a) The cut-edge surface of the hypertrophied FLR is marked with the green star, the IVC with the stapled right hepatic vein (blue arrow), and the sewn-over stump of the right portal branch with a black arrow. (b) The surgical specimens consist of right hepatectomy and a right colectomy, with a scalpel handle for scale.

Figure 3

First stage of a simultaneous approach + Mini ALPPS in a patient with synchronous CRLM. (a) The transection line is shown on the right hemiliver. (b) The FLR has been cleared of multiple metastases. (c) The patient’s abdomen is shown for the sake of trocar placement. mini-ALPPS provides the benefit of a laparoscopic procedure, and can even assist in cannulation of the inferior mesenteric vein for PVE (red arrow). (d) Post-PVE portography that shows embolization material in all right portal branches.

Figure 4

Second stage of a Mini-ALPPS in the patient previously described in Figure 3. (a) Ten days after a successful first stage, a conventional second stage was performed. Transection line and the deportalized right lobe can be observed. (b) Completion of the second stage with the cut edge of the FLR with neithr signs of bleeding nor bile leak.

Figure 5

Parenchyma sparing surgery on a patient with multiple tumors. (a,b) The multiple bilobar resections with red arrows are shown. An intra arterial catheter for local chemotherapy was placed as well (blue arrow). (c) A tumor (red star) was in close proximity to the right hepatic vein (blue arrow). (d) It was removed with an R1 vasc approach, with preservation of the middle hepatic vein (blue arrow).

Figure 6

Parenchyma sparing surgery in a patient with a tumor located in the hepatocaval confluence. (a) Careful separation of the tumor from the surrounding tissue was performed. A red vascular loop was placed around the hepatic vein confluence in case clamping was required, and the tumor was marked by several stay sutures to allow for better exposure. (b) Due to the tumor’s proximity to the middle hepatic vein, a partial resection was necessary, and a Kelly clamp was used for hemostasis. (c) The tumor was completely removed, the middle hepatic vein has been ligated, and the right hepatic vein repaired using a patch of falciform ligament, as shown in (d) with a blue arrow.

Figure 7

The ante situm procedure in a patient with a large CRLM invading the hepatocaval confluence. (a) Portotomy is performed and cannulated for cold perfusion with Wisconsin University Solution (black arrow). (b) The liver is rotated in a counterclockwise fashion to expose the hepatocaval confluence. A piggy-back type clamping of the hepatic veins is performed, and the left hepatic vein is opened (black arrow). (c) Reconstruction of the IVC with a prosthetic graft (arrowhead) and reimplantation of the left hepatic vein using a deceased donor iliac vein graft (blue arrow) are performed.

Figure 8

A patient with a large tumor invading the IVC. (a) The already resected and exposed endothelium of the IVC is shown. (b) The autologous peritoneal patch (black arrowhead), which will be used to close the defect, is shown. It should be noted that the epithelized side of the patch should always face inwards into the vascular lumen.