Two-stage hepatectomy aiming for the development of intrahepatic venous collaterals for multiple colorectal liver metastases

Virtual hepatectomy and metastasectomy 3d simulation using an automated and semiautomated tool applied to preoperative CT in the treatment of colorectal cancer metastases

Colorectal cancer represents the most common malignancy of the gastrointestinal tract and the second most frequently diagnosed malignancy in adults. The most common site of metastases is the liver and 40% of patients in stage IV have liver only disease. Hepatic metastases are the major determinants of morbidity and mortality in these patients, with surgery being the treatment of choice or even curative in these cases. Therefore, aggressive surgeries should be considered in patients with liver only disease. In this context, hepatectomy and metastasectomy have emerged as promising techniques for improving survival in patients with metastatic disease, also providing long-term cure. The use of liver volumetrics, tridimensional reconstructions with vessel extraction and 3D virtual surgery simulations allow better surgical planning and potentially decrease transfusions, surgery time and complications. For major hepatectomies (>4 resected segments), surgical planning with computed angiotomography and liver remnant volume calculation potentially increases the safety of surgery. We report a case in which preoperative 3D surgical simulation was crucial for conducting a safe major hepatectomy in a patient with multiple colorectal liver metastases.

Surgical outcomes of two-stage hepatectomy for colorectal liver metastasis: comparison to a benchmark procedure

Background

Two-stage hepatectomy (TSH) with portal vein embolization (PVE) is associated with high morbidity and mortality and may result in liver failure due to insufficient future liver remnant. The objectives of this investigation were to evaluate the short-term outcomes of patients with colorectal cancer liver metastasis who underwent TSH with PVE, and to critically review the selection criteria for TSH-PVE.

Methods

A retrospective review of all patients who were operated due to bi-lobar CRLM during the years 2007-2017 was performed. Patients who underwent TSH-PVE were compared to those who underwent right hepatectomy (RH) only.

Results

Twenty-nine patient underwent TSH, 25 of whom (86.2%) completed both stages. These patients demonstrated a major complication rate of 17%, and a 90-day mortality rate of 3.4%. Most complications (80%) were related to the colonic resection, and one patient developed liver failure. Patients who suffered complications had a trend towards more baseline comorbidities and more liver lesions. Ablative techniques were utilized in 76%. When compared to 35 patients who underwent sole RH, no significant difference was demonstrated in major complication rate (20%) or mortality (0%).

Conclusions

TSH is a relatively safe procedure in selected patients. Ablative techniques can reduce the occurrence of liver insufficiency and should be used liberally when possible. Factors such as number of lesions, comorbidities and the timing of colonic resection should be considered and evaluated in order to improve the outcomes of the procedure.