Simultaneous resection of colorectal carcinoma and synchronous liver metastases in a district hospital
Of 491 patients operated for carcinomas of the colon or rectum between 1984 and 1989, 106 were tumour stage IV, U.I.C.C.(Dukes' 'D') at time of operation. In 22 of these cases a radical resection of the carcinoma of the colon or rectum and of synchronous liver metastases was performed simultaneously. In 20 patients the metastases were confined to one, in two they were found in both hepatic lobes. In one case a solitary metastasis of the lower lobe of the right lung was resected additionally. Three right-sided hemihepatectomies, one extended right hemihepatectomy, five left-sided hemihepatectomies, three left-sided lateral segmentectomies, seven atypical segmental resections and three wedge resections were performed. The mean operation time for the radical resection of the carcinomas of the colon or rectum as well as of the liver metastases was 3.5 (3-5.2)hours. An average of 3 (0-9) blood units were needed intraoperatively. The major liver resections were performed in complete normothermic vascular ischaemia using the finger fracture method. The time of ischaemia ranged between 8 and 25 min. Only 1 of 22 patients died postoperatively (30 days postoperative hospital mortality rate 4.5%). Five of 17 patients were free of tumour 2 years after operation. Eight of 22 were alive 2 years after operation (non-age corrected 2-year survival rate 36.4%), 2 of them are alive more than 5 years after treatment. Our results demonstrate that simultaneous resection of colon or rectum carcinoma and of synchronous (resectable) liver metastases can be performed successfully, even in a district hospital.
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ABSTRACT: Colorectal cancer remains one of the most common malignancies worldwide. As liver metastases are found in approximately 50% of patients with colorectal cancer, colorectal liver metastases (CLM) concern a major health issue. Hepatic resection is the only treatment option providing long-term survival for patients with CLM, with 5-year survival rates up to 67% in highly selected patients. However, when using traditional criteria, hepatic resection can only be offered to 10-20% of patients presenting with CLM. To increase the number of patients amenable for surgery, several strategies have been developed, including the use of modern chemotherapy regimens which downsize CLM to allow surgery, portal vein embolization which stimulates growth of liver tissue, two-stage hepatectomy, vascular resection and reconstruction, and in situ hypothermic liver perfusion. Taken together, the modern treatment of CLM should be multidisciplinary, necessitating a close collaboration between surgeons and oncologists, with frequent re-evaluations and adequate timing to optimize therapeutic strategies on an individual basis. The central theme of this thesis is the multidisciplinary treatment of CLM, with special emphasis on factors which determine outcome following hepatic resection and the place of surgery in patients with both CLM and extrahepatic disease. The research described in this thesis shows that an aggressive multidisciplinary treatment approach, consisting of perioperative chemotherapy en (repeat) surgery, can result in significant long-term outcome in patients with CLM. Also, well-selected patients with both CLM and extrahepatic disease can undergo surgical resection with reasonable expectations of long-term survival. However, these patients should be treated in specialized hepatobiliary centers, offering them a multidisciplinary treatment approach, as this is the only chance of long-term survival and even cure.
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ABSTRACT: In patients with newly diagnosed colorectal cancer, a significant proportion of patients will present with disseminated disease. In the presence of a symptomatic primary tumor, resection may be required to alleviate the symptoms of obstruction, bleeding, or perforation. Historically, resection of the primary asymptomatic tumor was advocated because a large portion of patients eventually developed symptoms or complications related to their primary tumors. Resection was followed by adjuvant chemotherapy with 5FU and survival was modest. However, with the improved response rates to the newer cytotoxic systemic therapies the role of prophylactic resection of the primary tumor in unresectable stage IV colorectal cancer has been questioned. Newer data suggest that routine palliative resection of the synchronous primary lesion should not be performed in the absence of symptoms. Several questions remain and ongoing prospective randomized trials will likely address many of the limitations of currently available literature.
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ABSTRACT: Colorectal liver metastases (CRLM) develop within 5 years of primary tumor diagnosis in up to 50% of patients and are diagnosed
on preoperative imaging or at primary tumor resection in 15–25% of patients. Modern criteria for resectability of CLRM emphasize
the ability to achieve (1) a negative hepatic resection margin; (2) a future liver remnant of at least two contiguous segments
with intact biliary drainage, vascular inflow/outflow, and adequate size to provide sufficient hepatic function after resection;
and (3) the ability to completely resect and/or ablate extrahepatic disease (EHD). Recent studies have shown that the inability
to achieve a 1-cm negative resection margin or the presence of resectable EHD is no longer contraindications to resection.
Oxaliplatin and irinotecan-based chemotherapy may serve to both augment the resectability of CRLM by shrinking previously
unresectable lesions and render disease unresectable via injury to the nontumor bearing liver. Portal vein embolization (PVO)
has been employed to broaden the criteria for resectability by increasing the volume and synthetic function of the future
liver remnant. Two-stage hepatectomy is an effective resection strategy for select patients with multiple bilateral colorectal
liver metastases that would otherwise be unresectable. Prospective trials and retrospective studies with extensive follow-up
demonstrate long-term survival benefits after resection CRLM. Indications for radiofrequency ablation (RFA) include (1) unresectability
of liver disease due to location, size, number, or patient comorbidity such that the hepatic reserve provided by the future
liver remnant would not be sufficient for patient survival or (2) as an adjunct to hepatic resection to clear the liver remnant
of disease while preserving liver function (Abdalla et al, Ann Surg Oncol 13:1271–1280, 2006). While RFA does not provide
comparable long-term survival to that provided by resection, outcomes after RFA are superior to that after systemic chemotherapy
alone. These developments underscore the need for the early involvement of hepatobiliary surgeons in the multidisciplinary
care of patients with CRLM.
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