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Transcript of SYNCHRONOUS COLORECTAL AND LIVER RESECTION J Peter A Lodge MD FRCS HPB and Transplant Unit St...
![Page 1: SYNCHRONOUS COLORECTAL AND LIVER RESECTION J Peter A Lodge MD FRCS HPB and Transplant Unit St James’s University Hospital Leeds LS9 7TF 2006 Association.](https://reader035.fdocuments.in/reader035/viewer/2022062518/56649ee65503460f94bf6632/html5/thumbnails/1.jpg)
SYNCHRONOUS COLORECTAL AND LIVER
RESECTION
SYNCHRONOUS COLORECTAL AND LIVER
RESECTION
J Peter A Lodge MD FRCS
HPB and Transplant Unit
St James’s University Hospital
Leeds LS9 7TF
2006 Association of Coloproctology
M62 Course - March 30, 2006
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HEPATIC METASTASESLIVER RESECTION
HEPATIC METASTASESLIVER RESECTION
• GI tract tumour• Colorectal• Stromal tumours (GIST - sarcoma) • Neuroendocrine (Carcinoid)• Gastro-oesophageal
• Metastases from other sites• Sarcoma• Renal• Breast• ? Others
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LIVER RESECTION FOR COLORECTAL METASTASIS
DOCTRINE
LIVER RESECTION FOR COLORECTAL METASTASIS
DOCTRINE
• Metachronous• Observe for 3 months before resecting
• Solitary• Unilobar and not more than four metastases• Anatomical limitations• 1 cm margin
• No lymphadenopathy• No other extrahepatic disease
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COLORECTAL METASTASESCOLORECTAL METASTASES
METASTASECTOMY
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SEGMENTAL ANATOMYSEGMENTAL ANATOMY
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SEGMENTAL RESECTIONSEGMENTAL RESECTION
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RIGHT HEPATECTOMY WITH MULTIPLE
METASTASECTOMIES
RIGHT HEPATECTOMY WITH MULTIPLE
METASTASECTOMIES
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HEPATIC RESECTIONHEPATIC RESECTION
Hepatic ischaemia techniques• Pringle manoeuvre
– Intermittent– Continuous
• Hepatic vascular exclusion• In situ hypothermic perfusion• Ante situm procedure • Ex vivo hepatic resection
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IN SITU HYPOTHERMIC PERFUSION
IN SITU HYPOTHERMIC PERFUSION
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HEPATIC VEIN RECONSTRUCTIONHEPATIC VEIN RECONSTRUCTION
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CLINICAL SCORE FOR PREDICTING RECURRENCE AFTER HEPATIC RESECTION FOR METASTATIC COLORECTAL
CANCER - ANALYSIS OF 1001 CONSECUTIVE CASES
CLINICAL SCORE FOR PREDICTING RECURRENCE AFTER HEPATIC RESECTION FOR METASTATIC COLORECTAL
CANCER - ANALYSIS OF 1001 CONSECUTIVE CASES
Fong et al, Annals of Surgery 1999; 230: 309
• Nodal status of primary• Disease-free interval from primary to discovery of the liver metastases
of < 12 months• Number of tumours > 1• Preoperative CEA level > 200 ng/ml• Size of largest tumour > 5 cm
• Overall actuarial survival 37% at 5 years, 22% at 10 years • Clinical Risk Score (CRS) predictive of long term outcome (p<0.0001)• Actuarial survival 60% if CRS =1, 14% if CRS = 5
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LIVER RESECTION FOR COLORECTAL METASTASIS
DOCTRINE
LIVER RESECTION FOR COLORECTAL METASTASIS
DOCTRINE
• Metachronous• Observe for 3 months before resecting
• Solitary• Unilobar and not more than four metastases• Anatomical limitations• 1 cm margin
• No lymphadenopathy• No other extrahepatic disease
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SYNCHRONOUS COLORECTAL LIVER METASTASES
SYNCHRONOUS COLORECTAL LIVER METASTASES
• Detected in 15-25% of colorectal cancer cases
• Have been presumed to represent more aggressive tumour
• No evidence that these patients do worse after liver resection
• Should these patients have concurrent or staged liver resection?
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MAYO CLINIC EXPERIENCEMAYO CLINIC EXPERIENCE
• 96 consecutive patients (1986-1999)• 64 concurrent vs 32 staged• Perioperative morbidity 53% vs 41%• Disease free survival 13 vs 13 months• Overall survival 27 vs 34 months
(p=0.52)
• Hospitalisation 11 vs 22 day (p<0.001)
Chua et al (Nagorney). Dis Colon Rectum 2004; 47: 1310-6
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YOKOHAMA EXPERIENCEYOKOHAMA EXPERIENCE
• 39 consecutive patients• 39 concurrent – multivariate analysis for safety and
success rate• Risk factor for morbidity – volume of resected liver
– 350g vs 150g (p<0.05)• Poor overall survival with poorly differentiated and
mucinous adenocarcinomas (p<0.05)• Conclusion: 1 stage resection desirable except in
patients over 70 years of age and those with poorly differentiated and mucinous adenocarcinomas
Tanaka K et al. Surgery 2004; 136: 650-9.
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STRASBOURG EXPERIENCESTRASBOURG EXPERIENCE
• 97 consecutive patients (1987-2000)• 35 concurrent vs 62 staged• Concurrent resection if <4 unilobar metastases• Morbidity 23% vs 32%• Location of primary did not influence morbidity• Overall survival 1yr 94% vs 92%
3 yr 45% vs 45% 5 yr 21% vs 22%
• Synchronous resection does not increase morbidity or mortality rates
Weber JC et al. (Jaeck) Br J Surg 2003; 90: 956-62.
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MSKCC EXPERIENCEMSKCC EXPERIENCE
• 240 consecutive patients (1984-2001)• 134 concurrent vs 106 staged• Concurrent resection: more right colon primaries
(p<0.001), smaller (p<0.001) and fewer (p<0.001) liver metastases, and less extensive liver resection (p<0.001)
• Complications: 49% vs 67% (p<0.003)• Median 10 vs 18 days in hospital (p<0.001)• Mortality n=3 vs n=3• Simultaneous resection safe and efficient, with reduced
morbidity and shorter treatment time
Martin R et al. (Blumgart) J Am Coll Surg 2003; 197: 233-42.
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CURRENT LEEDS DATA
CURRENT LEEDS DATA
January 1993-December 2001
294 consecutive patients - assessed in October 2003
Actuarial survival: 1 year 82% 3 years 58% 5 years 44%
10 years 36%
• New data – the 1 cm clearance rule needs to be reappraised: If clearance is achieved, the resection margin alone has no influence on survival or recurrence rate: 1mm is enough
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Median Survival
1 Year Survival
3 Year Survival
5 Year Survival
10 Year Survival
47 mo (18 – 49)
82%
58%
44%
36%
Months
140120100806040200
Sur
viva
l %
1.1
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
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Median Disease Free Survival
1 Year Recurrence Rate
3 Year Recurrence Rate
5 Year Recurrence Rate
22 mo (9 – 37)
30%
61%
78%
Months
120100806040200
Re
curr
en
ce %
.8
.6
.4
.2
0.0
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REDO RESECTIONREDO RESECTION
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COLORECTAL METASTASES IMPACT OF REDO HEPATIC RESECTION
COLORECTAL METASTASES IMPACT OF REDO HEPATIC RESECTION
86420
100
80
60
40
20
0
No. at risk (survival rate)
54 14 6 50
Median survival (months)
Year
Sur
viva
l
(%)
53%
46%
3 5
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HEPATIC RESECTIONIMPROVING RESULTS
HEPATIC RESECTIONIMPROVING RESULTS
• Adjuvant therapies• Careful follow up
• Tumour markers• Complex radiology
• Further surgery• Redo hepatic surgery• Recurrent colorectal cancer excision• Lung surgery
• Further chemotherapy / radiotherapy
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HEPATIC RESECTIONIMPROVING RESULTS
HEPATIC RESECTIONIMPROVING RESULTS
• Neoadjuvant therapies• What is the evidence?• Could we miss the window of opportunity for surgery?• Who is making the decision?
• Earlier referral and rapid assessment
• Larger cancer centres • Ability and capacity to plan simultaneous resection
• Logistics and capacity prevent concurrent resection in all but a very few cases in the U.K.