Non-anatomic Liver Resection for Colorectal Metastases Liver...2006/01/17 · Overview • Liver...

Non-anatomic Liver Resection for Colorectal Metastases Kseniya Roudakova, MD

www.downstatesurgery.org

Case from KCH • 57F who was diagnosed with metastatic colorectal cancer in May 2016

• S/p neoadjuvant chemotherapy followed by an LAR in January 2017 in Coney Island Hospital

• She subsequently underwent 4 cycles of adjuvant chemotherapy

• Presented on 4/26/2017 for elective hepatectomy for liver metastases


PresenterPresentation NotesAs usual we’re going to start with a case…this one cames from KCH…It’s a case of a 57 y/o woman with pmhx of HTN, who was diangosed with metastatic rectosigmoid cancer in May of 2016…She underwent LAR for her primary in January of 2017 at coney island hospital..followed by four cycles of adjuvant chemotherapy..Pt was referred to KCH for surgical management of her liver mets…


PresenterPresentation NotesHer pre-operative work up included an MRI which demonstrated Multiple hepatic lesions the largest of which is seen here…measured 3x2.9 cm located in in segments 6/7, as well as a 7 and 9 mm lesions in segment 7and 1.4x1.1 cm in segment 5The lesions demonstrated a slightly increased T2 signal, rim enhancement with central hypovascularity compatible with colon mets…portal and hepatic veins were patent and there was no intrahepatic or extrahepatic dilatationPt was scheduled for elective right hepatectomy…


PresenterPresentation NotesHowever, intra-operatively the liver was noted to have an abnormal dark purple apparence…the concern was that the patient had suffered signficaint hepatic injury due to her prolonged chemotherapy treatment. For this reason, the original plan of performing a formal right hepatectomy was aborted (which would have included the whole of segments V, VI, VII and VIII). Instead…IOUS was used to localize the metastatic lesions and right lateral bisegmentectomy and as well as metastasectomy of segment 5 was performed instead…


PresenterPresentation NotesCrush clamp manuver and ligasure device was used to transect the liver parenchyma…once the speciment was resected..it was taken to patholgoist who determiend that there was no tumor at the margin


PresenterPresentation NotesAfter segment 5 metastatectomy was performed IOUS was once again used to demonstrate absence of any remaining lesions…Pt did not have any singiicnat blood loss during the case and the pringle maneuver was not employed…she did not receive any blood transfusion and was taken to the SICU post op in a stable condition…Her post op course was uncoplicated and she was discharged home after appropriate post op management…

Overview • Liver anatomy and hepatic resection terminology

• Colorectal liver metastases Incidence Prognosis Management

• Goals of hepatectomy for CRLM and patient selection

• Non-anatomic or parenchymal-sparing resection

• Questions


PresenterPresentation NotesThe goal of my talk today is to go over basic liver anatomy as well as the terminology used to describe specific hepatic resections as it pertains to the topic of anatomic vs non-anatomic resectionI’ll also discuss the incidenence, prognoss and management of colorectal liver metsI’ll go over the goals of hepatectomy in the setting of colorectal liver mets as well as appropriate patient selection…Most importantly ill go over the evidence which supports the use of non-anatomic or parenchymal sparing resection for colorectal liver mets as opposed to traditional major hepatectomies

Anatomy


PresenterPresentation NotesJust to review the basic anatomy of the liver…it is the largest organ in the body…It resides in the right upper abdominal cavity beneath the diaphragm and is protected by the rib cage…It is nornally reddish brown in color (and not purple as was the case in our patient..) and is surrouned by glisson’s capsule. The liver is held in place by several ligaments The round ligament is the remnant of the obliterated umbilical vein and enters the left liver hilum at the front edge of the falciform ligament. The falciform ligament separates the left lateral and left medial segments and anchors the liver to the anterior abdominal wall….what seperated the right and left lobes of the liver is actually a line extending from IVC to gallbladder fossa …and this is where the middle hepatic vein usually lies…the falciform ligament does not separate the two lobes…which can be a common source of confusion… The left and right triangular ligaments secure the two sides of the liver to the diaphragm. Extending from the triangular ligaments anteriorly on the liver are the coronary ligaments. These ligaments (round, falciform, triangular, and coronary) can be divided in a bloodless plane to fully mobilize the liver to facilitate hepatic resection. Centrally and just to the left of the gallbladder fossa, the liver attaches via the hepatoduodenal and the gastrohepatic ligaments. The hepatoduodenal ligament is known as the porta hepatis and contains the common bile duct, the hepatic artery, and the portal vein. The hepatoduodenal ligament can be clamped during surgery using the Pringle maneuvery to allow for vascular inflow control

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwi-zOf6kpPUAhWI6iYKHQHSA6gQjRwIBw&url=https://clinicalgate.com/normal-anatomy-and-flow-during-the-complete-examination-extracardiac-anatomy/&psig=AFQjCNHDnDCk5aZn5fqDnSgznG5MhsN2iQ&ust=1496079715091600

Vascular Supply


PresenterPresentation NotesThe liver has a dual blood supply consisting of the hepatic artery and the portal vein. The hepatic artery delivers approximately 25% of the blood supply, and the portal vein approximately 75%. The hepatic artery arises from the celiac axis (trunk), which gives off the left gastric, splenic, and common hepatic arteries . The common hepatic artery then divides into the gastroduodenal artery and the hepatic artery proper. The right gastric artery typically originates off of the hepatic artery proper, but this is variable. The hepatic artery proper divides into the right and left hepatic arteries. This “classic” or standard arterial anatomy is present in only approximately 76% of cases, with the remaining 24% having variable anatomy.

Vascular Supply


PresenterPresentation NotesApproximately 10% to 15% of the time, there is a replaced or accessory right hepatic artery arising from the (SMA). When there is a replacement or accessory right hepatic artery, it travels posterior to the portal vein and then takes up a right lateral position before diving into the liver parenchyma. This can be recognized visually on a preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scan, and confirmed by palpation in the hilum where a separate right posterior pulsation is felt distinct from that of the hepatic artery proper that lies anteriorly in the hepatoduodenal ligament to the left of the common bile duct. In approximately 3% to 10% of cases, there exists a replacement (or accessory) left hepatic artery coming off of the left gastric artery

Vascular Supply


PresenterPresentation NotesThe portal vein is formed by the confluence of the splenic vein and the superior mesenteric vein. The main portal vein traverses the porta hepatis before dividing into the left and right portal vein branches. There are three hepatic veins (right, middle, and left) that pass obliquely through the liver to drain the blood to the suprahepatic IVC and eventually the right atrium (Fig. 31-8). The right hepatic vein drains segments V through VIII; the middle hepatic vein drains segment IV as well as segments V and VIII; and the left hepatic vein drains segments II and III. The caudate lobe is unique because its venous drainage feeds directly into the IVC. In addi- tion, the liver usually has a few small, variable short hepatic veins that directly enter the IVC from the undersurface of the liver. The left and middle hepatic veins form a common trunk approximately 95% of the time before entering the IVC, whereas the right hepatic vein inserts separately (in an oblique orientation) into the IVC. There is a large inferior accessory right hepatic vein in 15% to 20% of cases that runs in the hepatocaval ligament. This can be a source of major bleeding if control of it is lost during right hepatectomy. The hepatic vein branches bisect the portal branches inside the liver parenchyma (i.e., the right hepatic vein runs between the right anterior and posterior portal veins; the middle hepatic vein passes between the right anterior and left portal vein; and the left hepatic vein crosses between the segment II and III branches of the left portal vein). Within the hepatoduodenal ligament, the common bile duct lies anteriorly and to the right. It gives off the cystic duct to the gallbladder and becomes the common hepatic duct before dividing into the right and left hepatic ducts. In general, the hepatic ducts follow the arterial branching pattern inside the liver. The left hepatic duct typically has a longer extrahepatic course before giving off segmental branches behind the left portal vein at the base of the umbilical fissure. Considerable variation exists, and in 30% to 40% of ases, there is a nonstandard hepatic duct confluence with accessory or aberrant ducts (Fig. 31-9). The cystic duct itself also has a variable pattern of drainage into the common bile duct. This can lead to potential injury or postoperative bile leakage during cholecystectomy or hepatic resection, and the surgeon needs to expect these variants. The gallbladder sits adherent to hepatic segments IVB (left lobe) and V (right lobe).

Segmental Anatomy


PresenterPresentation NotesA significant advance in our understanding of liver anatomy cames from French surgeon and anatomist Couinaud in the early 1950s. Couinaud divided the liver into eight segments, numbering them in a clockwise direction beginning with the caudate lobe as segment I. You can think of these liver segments going clockwise starting from 2 pm position at segment II.

Segment IV can be subdivided into segment IVA and segment IVB. Segment IVA is cephalad Segment IVB is caudad and adjacent to the gallbladder fossa. Many anatomy textbooks also refer to segment IV as the quadrate lobe. Quadrate lobe is an outdated term,…Most surgeons still refer to segment I as the caudate lobe,. The right lobe is comprised of segments V, VI, VII, and VII… Additional functional anatomy was highlighted by Bismuth based on the distribution of the hepatic veins. The three hepatic veins (right, middle and left) run in corresponding scissura (fissures) and divide the liver into four sectors. The right hepatic vein runs along the right scissura and separates the right posterolateral sector from the right anterolateral sector. The main scissura contains the middle hepatic vein and separates the right and left livers as I meantioned earlier. The left scissura contains the course of the left hepatic vein and separates the left posterior and left anterior sectors.

Resection Terminology www.downstatesurgery.org

PresenterPresentation NotesThere is a lot of variation and overlap when it comes to namenclature of hepatic resections…which can be confusing…In 2000 there was a meeting in Brisbane, Australia of international hepato-pancreato-biliary association and they come to a concensus on the nameclature that should be used to avoid any confusion…This is outlined in the graph here…Based on this classification a right hepatectomy is a resection of segments V, VI, VII and VIII…extended right hepatectomy is a resection of segments V, VI, VII, VIII plus IVleft hepatectomy is resection of segments II, III, IVLeft lateral sectionectomy is resection of segments II and III…and so forth

Segmental Anatomy


PresenterPresentation NotesThis is to reiterate segmental anatomy as seen on a CAT scan

Colorectal liver metastases • Colorectal cancer is one of the leading causes of mortality in the Western

world with nearly 1.23 million new cases diagnosed each year

• 50% of patients with colorectal cancer will develop liver-metastatic disease

• Fewer than 30% have surgically resectable disease at diagnosis

• Major hepatectomy offers a high rate of R0 resection with 50% 5-year survival rate

• Liver resection – gold standard Many large series of patients undergoing major hepatectomy now report mortality

rates of

Adjuncts to surgical resection • Neoadjuvant chemotherapy

• Portal vein embolization

• Two-stage hepatectomy

• Simultaneous ablation Radiofrequency ablation Ethanol ablation Cryoablation Microwave ablation

• Resection of extrahepatic tumors in select patients


PresenterPresentation NotesUse of neoadjuvant chemotherapy, portal vein embolization, two-stage hepatectomy, simultaneous ablation, and resection of extrahepatic tumor in select patients have increased the number of patients eligible for a surgical approach.


PresenterPresentation NotesNew techniques and devices for dividing liver parenchyma and achieving hemostasis have made the surgery safer by reducing operative time and blood loss…

Colorectal liver metastases • Predictors of poor outcome

Node-positive primary Disease-free interval 5 cm CEA level >200 ng/mL


PresenterPresentation NotesThere are predictors of poor outcome including node-positive primary, disease-free interval 5 cm, and carcinoembryonic antigen level >200 ng/mL. and Traditional teaching suggested that hepatic resection for metastatic colorectal cancer to the liver, if technically feasible, should be performed only for fewer than four metastases.

Selection criteria for colorectal metastasectomy • 1986: Ekberg et al required the following to be present to qualify for

resection: Maximum of three liver lesions Ability to achieve a 10 mm resection margin Absence of extrahepatic metastases

• Present: Ability to attain a negative margin (R0 resection) while preserving liver

parenchyma to avoid liver failure


PresenterPresentation NotesHowever, new studies challenged this paradigm. While in the past limiting criteria such as number of lesions, ability to achieve at least a 1 cm margin and absence of extrahepatic mets precluded hepatic resection…the new dogma for treaetmetn of colorectal liver metastasis is the ability to attain a negative margin while preserving liver parenchyma to avoid future liver failure…The focus has shift from what is being taken out to what is left behind…

Number of nodules • Minagawa et al (Ann Surg 2000): series of 235 patients who underwent

hepatic resection for metastatic colorectal cancer, the 10-year survival rate of patients with four or more nodules was 29%, nearly comparable to the 32% survival rate of patients with only a solitary tumor metastasis

• Kornprat et al (Ann Surg Oncol 2007): series of 98 patients with four or more colorectal hepatic metastases who underwent resection between 1998 and 2002, the 5-year actuarial survival was 33%


PresenterPresentation NotesThe limit to the number of nodules that preclude hepatic resection for colorectal metastasis has been challenged with recent publications…In a series of 235 patients who underwent hepatic resection for metastatic colorectal cancer, the 10-year survival rate of patients with four or more nodules was 29%, nearly comparable to the 32% survival rate of patients with only a solitary tumor metastasis.84 In the Memorial Sloan- Kettering Cancer Center series of 98 patients with four or more colorectal hepatic metastases who underwent resection between 1998 and 2002, the 5-year actuarial survival was 33%.

Resection margins • Dhir et al (Ann Surg 2011): meta-analysis demonstrate that in patients

undergoing resection for CRLM negative margin of 1 cm or more confers a survival advantage

• Kokudo et al (Arch Surg 2002): surgical margin of 2 mm is clinically acceptable minimal requirement (6% risk of margin-related recurrence)

• Inoue et al (J Gastrointest Surg 2012): neither resection margin not type of hepatectomy (anatomic or nonanatomic) for CRCLM was a significant prognostic factor for overall survival or recurrence


PresenterPresentation NotesThe resection margin has for long been debated; some authors stress that an optimal margin should be at least 10 mm, though a sub-centimetric margin should not be a criterion of exclusion. In contrast, various others and large scale studies report that neither overall nor disease free survival nor recurrence is affected by the width of the margin. Widespread acceptance of margins as narrow as 1 mm or less emerges from the realization of the importance of preserving liver volume and function. This is also due to the fact that 58%-78% of patients develop recurrence after initial resection of CRLM, almost 50% being intrahepatic; it is therefore crucial to maintain as much liver volume as possible during the first hepatectomy to widen treatment options in the event of recurrence. Thus the main factor affecting the decision of resection is the FLR and resection potential is determined but what will be left of the liver rather than what is being resected.In 2011 Dhir and colleages performed a meta-analysis and concluded that 1 cm margins confer a survival advantage…while Kokudo and colleagues used genetic and histological techniques and argued that Micrometastases around liver tumors are not common, and most are confined to the immediate vicinity of the tumor border. they propose that a surgical margin of 2 mm is clinically acceptable minimum requirement, which carries approximately a 6% risk of margin-related recurrence. They argues that because liver resection provides the only chance of cure, complete removal of the tumor with a minimum margin is justified when technically unavoidable because of the size, location, number of tumors, or successive resections…therefore inability to achieve 10 mm margin should no longer be used as an exlucison criteria for attempted resection.

Parenchymal sparing hepatectomy • Parenchymal sparing resection offers an alternative to major hepatectomy

allowing to achieve complete tumor resection while salvaging liver parenchyma


PresenterPresentation NotesMany groups now consider volume of future liver remnant and the health of the background liver, and not actual tumor number, as the primary determinants in selection for an operative approach.Parenchymal sparing resection or non-anatomic resection which involves resection of the metastases with a margin of uninvolved tissue offers an alternative to major hepatectomy allowing to achieve complete tumor resection while salvaging liver parenchyma

This philosophy gathers various surgical strategies aiming to offer the minimum sufficient margins in order to preserve as much liver parenchyma as possible. Preoperative planning and intraoperative ultrasound (US) are key factors for success. This technique intends to avoid major liver resections and eventually the need of using techniques to induce FLR hypertrophy

initial resistance to PSH was due to assumption that PSH may lead to increased rate of recurrence due to closer margins and a greater amount of at-risk future liver remnant in which metastases could seed. Thus turned out no to be the case however…

Parenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver Metastases: a Systematic Review J Gastrointest Surg 2017 Jun • 2,505 patients in 12 studies:

PSH (n=1087 pts) AR (n=1418)

• Median tumor number 1-2 regardless of PSH or AR; majority had primary tumor that originated in the colon

• Results: No difference between EBL; PSH (100-896 mL) vs AR (200-1489 mL); p=0.248 No difference in median length of stay following PSH (6-17 days) vs AR (7-15 days);

p=0.747 No difference in incidence of R0 resection in PSH (66.7-100%) vs AR (71.6-98.6%)

p=0.58 No difference in overall survival whether resection of CLM was performed with PSH

(5 years OS: mean 44.7%) or AR (5 years OS: mean 44.6%) p=0.97


PresenterPresentation NotesIn fact in a recently published systematic review there was no difference in overall survival in patients undergoing parenchymal sparing hepatectomy vs anatomic resection… additionally there was no statistical difference in incidence of R0 resections, no difference in the length of stay and no difference in EBL

Parenchymal-Sparing Hepatectomy Does Not Increase Intrahepatic Recurrence in Patients with Advanced Colorectal Liver Metastases Ann Surg Oncol. 2016 Oct • 145 patients underwent curative hepatectomy for advanced CLMs (>/=4

nodules and

Parenchymal-sparing Hepatectomy in Colorectal Liver Metastasis Improves Salvageability and Survival Annals of Surgery 2016 Jan • 300 patients

144 PSH 156 non-PSH

• Results: PSH did not impact negatively on overall, recurrence-free, and liver-only

recurrence-free survival, compared with non-PSH Liver-only recurrence was observed in 22 patients (14%) in PSH and 25

patients (17%) in non-PSH group (p=0.44) Repeat hepatectomy was more frequently performed in the PSH group

(68% vs 24%, p

Future liver remnant • Ability to calculate the future liver remnant (FLR) is a crucial factor in

patient selection

• Healthy liver will tolerate reducing its volume to 20%

• Cirrhotic liver will require a FLR of at least 30-40% Portal vein embolization may be utilized in cirrhotic livers when FLR is

Future liver remnant • Liver volumetry is commonly calculated via CT

• Regenerative capacity of the FLR can be measured by assessing liver’s response to portal vein embolization >5% hypertrophy during first 3 wks acceptable

• Indocyanine green clearance


PresenterPresentation NotesBoth the volume and function of the future remnant provide invaluable information. Liver volumetry offers a quantitative means[75]; this is commonly calculated via CT, which is both reproducible[78] and accurate[79]. Functional assessment of the regenerative capacity of the FLR can be measured by assessing the liver’s response to portal vein embolization (PVE)[75]. Despite the fact that the liver continues to hypertrophy over time after PVE, the majority of the hypertrophic response happens during the first 3 wk, where a minimum of 5% degree of hypertrophy is considered acceptable[80]. Another less commonly used method of measuring the functional capacity of the FLR is indocyanine green (ICG) clearance, which is utilized widely in Southeastern countries[81]. In spite of the inverse relationship between the number and size of hepatic metastases and patient survival[36,82], it has become the general rule that if an adequate FLR can be achieved by resection, this relationship should not be considered a reason for exclusion[62].PSH can increase the number of patients eligible for an operation by halving the resection volume and by increasing the chance of direct operative treatment in patients with ill-located CLM

Additional benefits of PSH • Reliable choice in setting of bilateral colorectal liver metastases

Gold et al (2008 Ann Surg): increased use of PSH approach is associated with decreased mortality without compromise in cancer related outcomes

• Appropriate for deep-placed metastases Matsuki et al (Surg 2016): resection of deep placed colorectal metastases whose

center was located >30 mm from liver surface could be safely achieved with PSH without compromising oncologic radicality


PresenterPresentation NotesAdditional benefirs of PSH is that it seems to be a reliable choice in the setting of bilateral colorectal liver mets..In one study..incrased use of PSH was assocaited with decreased mortaliyt wihotu comprimising cancer related outcomes.. Their center’s operative technique changed over time toward a parenchymal-sparing approach as evidenced by the greater use of multiple simultaneous liver resections, wedge resections, and ablations. Similarly, there was a decrease in the use of major hepatectomies. This correlated with decreased mortality without change in disease-specific survival or liver recurrence.

Another study demonstrated that parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases was performed safely without compromising oncologic radicality. Concluding that parenchymal-sparing hepatectomy can increase the number of patients eligible for an operation by halving the resection volume and by increasing the chance of direct operative treatment in patients with ill-located colorectal liver metastases.

Conclusion • PSH is compatible to the current standard-of-care of CLM in terms of

oncological outcomes and survival

• Increases the number of potential candidates for resection

• Provides greater chance at re-operation in cases of recurrence (salvageability)


PresenterPresentation NotesTo sum…Lastest studies suggest that non-anatomic or PSH are compatible and might even be superior to the current standard-of-care of CLM in termsn of oncological outcomes and survival..Allows for more patients to be candidates for resection by preserving the future liver remnant Provides greater chance at re-operation in cases of recurrence

Questions • What is the acceptable % volume of future liver remnant after resection in

an otherwise healthy liver?

• A. 10%

• B. 20%

• C. 50%

• D. 80%


True or False • When compared to anatomic liver resection, parenchymal sparing approach

for colorectal liver mets increases the rate of recurrence.

• True

• False


References • Parenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver

Metastases: a Systematic Review J Gastrointest Surg 2017 Jun

• Parenchymal-Sparing Hepatectomy Does Not Increase Intrahepatic Recurrence in Patients with Advanced Colorectal Liver Metastases Ann Surg Oncol. 2016 Oct

• Parenchymal-sparing Hepatectomy in Colorectal Liver Metastasis Improves Salvageability and Survival Annals of Surgery 2016 Jan

• Brunicardi, C. Scwartz’s Principles of Surgery 10th edition. McGraw Hill. 2015


Non-anatomic Liver Resection for Colorectal MetastasesCase from KCHSlide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7OverviewAnatomyVascular SupplyVascular SupplyVascular SupplySegmental AnatomyResection TerminologySegmental AnatomyColorectal liver metastasesAdjuncts to surgical resectionSlide Number 18Colorectal liver metastasesSelection criteria for colorectal metastasectomyNumber of nodulesResection marginsParenchymal sparing hepatectomyParenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver Metastases: a Systematic Review�J Gastrointest Surg 2017 JunParenchymal-Sparing Hepatectomy Does Not Increase Intrahepatic Recurrence in Patients with Advanced Colorectal Liver Metastases�Ann Surg Oncol. 2016 OctParenchymal-sparing Hepatectomy in Colorectal Liver Metastasis Improves Salvageability and Survival�Annals of Surgery 2016 JanFuture liver remnantFuture liver remnantAdditional benefits of PSHConclusionQuestionsTrue or FalseReferences

Non-anatomic Liver Resection for Colorectal Metastases Liver...2006/01/17 · Overview • Liver...

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