Indications and Contraindications in Surgical Therapy

The indications for resection of hepatic metastases are obtained from the analysis of the prognostic elements described above. The pre-operative evaluation of the patient should consider general examinations for abdominal general surgery and evaluation of liver function [36]. In patients with normal liver function, resections of 70-80% of the total hepatic mass can be safely performed. In patients submitted to per-oper-ative chemotherapy or with chronic liver disease, resection should be limited to 50-60% of total liver volume to reduce the risk of post-operative liver failure.

Surgical indications for metachronous metastases are related to the possibility of performing a hepatic radical resection and the absence of extrahepatic metastases.

Synchronous metastases are found in 20-30% of patients; among these only 10-25% are resectable. Surgical management of this group of patients is still controversial and debated.

If both rectal cancer and liver metastases are resectable, two different strategies might be chosen: simultaneous resection both of the rectal cancer and metastases, or resection of the rectal cancer with a delayed hepatic resection. The debate about these different strategies is still underway: many Authors in the literature report high percentages of mortality and complications due to simultaneous resection of colon and liver and advise simultaneous resection only for small metastases that require limited resection; for major hepatic resection they suggest waiting to perform resection at least two months after rectal resection. Nordlinger et al. [20] report a post-operative mortality of 7% in simultaneous resections, in comparison with 2% of delayed resections. Bolton

Table 3. Published results of simultaneous vs. staged resection for synchronous colorectal hepatic metastases

Authors

Year

n

Type of resection

Morbidity (%)

Mortality (%)

Vogt et al. [42]

1991

36

19 simultaneous

5.2

O

17 staged

17.6

Scheele et al. [15]

1991

98

60 simultaneous

n.r.

2

38 staged

Elias et al. [39]

1995

53

53 simultaneous

19

O

Jaeck et al. [43]

1996

41

20 simultaneous

2O

O

21 staged

1O

Nordlinger et al. [2O]

1996

1OO8

115 simultaneous

n.r.

7

893 other

2

Jenkins et al. [44]

1997

46

22 simultaneous

n.r.

n.r.

24 staged

Bolton, Fuhrman [37]

2OOO

165

50 simultaneous

n.r.

12

115 other

4

Fujita, Takayuki [4O]

2OOO

97

83 simultaneous

58

O

14 staged

Lyass et al [45]

2OO1

112

26 simultaneous

27

O

86 staged

35

2.3

n.r., not recorded; other, staged and metachronous resections n.r., not recorded; other, staged and metachronous resections and Fuhrman [37] report a post-operative mortality of 24% in simultaneous resections that require major hepatic resections. Other Authors report that the simultaneous resection of the primitive tumour and hepatic metastases is safe with recent improvements and progress in rectal and hepatic surgery [38]. Elias et al. [39] and Fujita and Takayuki [40] reported an operative mortality near to 0%, and morbidity rates ranging from 19 to 33%. Some Authors suggest a different behaviour according to the site of colonic cancer; a right colon resection may be associated to major hepatic resection while left colon resection should be associated only to minor hepatic resections. Martin and Paty [41] emphasised that the site of the primitive tumour (rectum or colon) and the extent of the hepatic involvement do not represent risk elements for the outcome of the surgical intervention. They stressed the importance of the experience of the surgical team. Post-operative complications and mortality reported by these Authors are comparable with those of the delayed operation (Table 3).

When multiple small (<1-2 cm) metastases are discovered at the time of colonic surgery, some authors suggest waiting at least 3 months before liver resection, with ultrasound monitoring every 4 weeks to monitor tumour progression.

If the rectal tumour is not resectable, the hepatic resection, even if it is technically feasible, is con-traindicated, because patients do not have any improvement in survival. When the rectal cancer is resectable with unresectable hepatic metastases, it is advisable to proceed with rectum resective surgery, associated with systemic chemotherapy for hepatic metastases, whether or not associated with locore-

Table 4. Principles of surgery. Criteria for resectability of metastases (NCCN Practice Guidelines in Oncology, 2005 [47])

Liver

• Complete resection must be feasible based on anatomic grounds and the extent of disease, maintenance of noble hepatic function is required

• There should be no unresectable extrahepatic sites of disease

• Re-evaluation for resection can be considered in otherwise unresectable patients after neoadjuvant therapy

• Hepatic resection is the treatment of choice for resectable liver metastases from colorectal cancer

• Ablative techniques should be considered in conjunction with resection in unresectable patients

Lung

• Complete resection based on the anatomic location and extent of disease with maintenance of adequate function is required

• Resectable extrapulmonary metastases do not preclude resection

• The primary tumour must be controlled

• Re-resection can be considered in selected patients

Table 5. Models for multimodality treatment of NCCN Practise Guidelines in Oncology, 2005 [47]

Table 5. Models for multimodality treatment of NCCN Practise Guidelines in Oncology, 2005 [47]

Nccn Guideline Renal Mass
Table 6. Complications after surgical procedures

Type of complication

Liver

Bile leak

Perihepatic abscesses Liver failure Post-operative bleeding Renal failure Portal thrombosis

Infection

Wound infection Sepsis

General complications

Pleural effusions Pneumonia Myocardial infarction Gastrointestinal bleeding Deep vein thrombosis Pulmonary embolism

gional chemotherapy, or with interstitial therapies. If the primary tumour and the hepatic metastases cannot be resected, there is no suggestion to perform surgery, but only supporting palliative medical therapy is advised. In patients with hepatic and lung metastases, associated treatment is advisable in patients suffering from resectable hepatic and only 1 or 2 lung metastases, which have been stabilised for 6 months after per-operative evaluation.

The absolute contraindications to surgical resection are determined both by the technical inability to resect all metastases and by the presence of extrahep-atic metastases that cannot be radically resected; therefore when it is not possible to perform an R0 radical resection.

The presence of metastatic lymph nodes at the hepatic hilum is associated with a poor prognosis even after a complete lymph node resection [46]. In selected patients complete hepatoduodenal ligament and hepatic artery lymph node resection with adjuvant chemotherapy might have good results. However, some Authors failed to observe any prognostic advantage of this strategy [32].

Distant extrahepatic metastases are usually considered as an absolute contraindication to surgery, but there are advantages of en-bloc resection of hepatic and extra-hepatic metastases for patients with tumour invasion of adjacent structures.

Many guidelines are reported in the literature and those published by the National Comprehensive Cancer Network [47] are frequently utilised in clinical practice. These guidelines have defined criteria for surgery resectability and actual models for multi-modality treatment including adjuvant or neoadju-vant chemotherapy (Tables 4, 5).

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