HEGAZY SURGERY

1. Mohamed Fathy Abdel Ghaffar
Professor of Hepatobiliary Surgery
Ain-Shams University
Transplant surgeon in Wady El-Neel /Ain-Shams
University Hospital

2. • Colorectal cancer is the third most commonly
diagnosed cancer with one million new cases
annually worldwide, representing the
commonest gastrointestinal malignancy and the
second commonest cause of cancer death.¹
• Over half of patients with colorectal cancer will
develop metastatic disease, with a quarter
having distant metastatic lesions at diagnosis. 2
1-CA Cancer J Clin 2005;55(2):74–108
2-J Natl Cancer Inst 2004; 96: 1420–25.

3. What are the options for patients with
colorectal liver metastasis?
• Do nothing
– median survival of 6 to 9 months.
• Chemotherapy
– 14.5-month median survival,
• RFA
– 40% 3-year survival rate,
• Resection
– 5-year survival rate of 45% to 60%

4. Conclusion:
RFA can not be recommended
as an alternative to HR. However
RFA may contribute to local control
of small CLM in patients who are
not candid for liver resection

5. • Radiofrequency ablation (RFA) has been
used for unresectable metastasis,
sometimes in conjunction with the
surgical removal of resectable
metastases, and may have a role in the
treatment of other selected patients
Cancer Care Ontario (CCO) Report Date: June 15, 2012

6. • The use of chemotherapy as an adjunct to
liver resection has resulted in a 5-year
survival in the range of 37 to 58%. ¹
• Ten-year survival is reported to be
between 16 to 30%.²
1. Clin Colon Rectal Surg 2009;22:225–232.
2. Ann Surg Oncol 2008;15(9): 2458–2464

7. Gayowski et al. (1994) -
Pittsburg Medical
Center
0 33 32%
Jamison et al. (1997) -
Mayo Clinic
4 33 27%
Fong et al. (1999) -
Memorial Sloan
Katering
3 42 36%
Choti et al. (2002) -
Johns Hopkins
1 46 40%
Fernandez et al. (2004) -
Washington University
1 – 59%
Pawlik et al. (2005) -
M.D. Anderson
1 74 58%
Hospital A.C. Camargo
(2005)
0 – 51%
Hospital A.C. Camargo
(2010)
0.9 (30 days)
1.8 (90 days) – 66.2%
Author (year) Mortality %
Mean
survival
(months)
Five-year
survival

8. Prior to being considered for surgical
resection it must be shown that:
• The patient has no extrahepatic disease
• The intrahepatic disease is safely
resectable and the patient must also be
in good medical condition.

9. Contraindications to liver resection
• Non-treatable primary tumor.
• Widespread pulmonary disease.
• Peritoneal disease.
• Extensive nodal disease, such as
retroperitoneal or mediastinal nodes.
• Bone or CNS metastases.
Guidelines for resection of colorectal cancer liver metastases. Gut 2006; 55
(Suppl 3):iii1–iii8

10. Clinical Risk Score
• Nodal status of the primary disease
• Free interval from the discovery of the primary to
the discovery of the liver metastases of <12
months
• Number of tumors >1
• Preoperative CEA level of >200 ng/mL
• Size of the largest tumors >5 cm
• Each positive criterion is assigned one point. 5-
year survival is 60% with score of 0 points, and
falls to 14% in patients with 5 points.
• Fong , et al.,Ann Surg 1999;230:309–318; discussion 318–321

11. • In 1986, Ekberg et al defined resectability as less than
four metastases (even if bilobar), absence of
extrahepatic disease, and a resection margin of at
least 1 cm.
• Today, resections are based on the remnant liver. A
sufficient future remnant liver volume (>20% of the
total estimated liver volume) is a prerequisite.
• If R0 with negative surgical margins (≥1mm) is
possible and sufficient liver parenchyma remains to
maintain liver function, resection should be considered
The Role of Liver Resection in Colorectal Cancer Metastases
A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario
(CCO) Report Date: June 15, 2012
What is a Resectable Tumor?

12. Two main problems
• Tumor burden: make a small number of
patients who are candid for curative
resection.
• Synchronous tumor: what is the best
approach?

13. How to increase RESECTABILITY
• Portal Vein Occlusion
• Two-Stage Hepatectomy
• Tailored hepatectomy
• Downstaging chemotherapy
• Local Ablation Techniques

14. Large right lobe lesion

15. CT Volumetery

16. 1 months after embolization

17. 6 months after resection

18. Two-Stage Hepatectomy

19. Tailored hepatectomy

20. Downstaging chemotherapy

21. Local Ablation Techniques

22. Synchronous tumors
What are the possible options?
• Colon first: Staged approach
• Colon and liver: Simultaneous
approach
• “Reverse Strategy”

23. Factors determine the decision:
1. The presence of symptoms.
2. Location of primary tumor and
liver metastases.
3. Extent of tumor (both primary
and metastatic).
4. Patient performance status, and
underlying comorbidities.

24. Surgical incisions according to primary
tumor and liver metastases

25. Advantages of simultaneous resection
• The performance of only a single
surgical procedure.
• Reduced length of hospital stay
• The removal of all neoplastic foci and
interruption of the “metastatic cascade”.
• The avoidance of immunodepression
after isolated primary tumor resection
• No delay in initiating systemic treatment

26. Disadvantages of simultaneous resections
• The combination of a “clean” and a
“contaminated” surgical procedure and
thus the higher risk of septic
complications, which could cause or
worsen a liver dysfunction
• The increased risk of anastomotic leak
due to splanchnic congestion if
prolonged pedicle clamping is needed.
• The inadequate surgical exposure
through a single incision.

27. Disadvantages of simultaneous resections,
cont.,
• The need for a double surgical team for
liver and colorectal surgery/inadequate
treatment if a single team performs the
entire procedure.
• Small occult metastases may not be
evident during the evaluation and
therefore not addressed during the
operation.

28. “Test of time”
• Scheele et al suggested a “test of time”
approach of waiting up to 6 months to
observe the tumor biology and evolution
of metastases as a means of natural
selection for operable disease.
• World J Surg 1995;19:59-71.

29. Tumor doubling time
• Mean tumor doubling time has been
assessed using serial computed
tomography to be 155 ± 34 days for
overt metastases and 86 ± 12days for
occult lesions not evident at laparotomy.
• Br J Surg 1988;75:641-4.

30. Criteria for synchronous approach
• Age<70 years
• good surgical fitness.
• an adequate tumor-free margin,
• lesions that are not advanced(T4),
• less than 4 colorectal lymph node metastases
• histology that is not poorly differentiated or
mucinous adenocarcinoma.
• 3 or fewer liver metastases.
• a minor liver resection (less than 3 segments)
is planned
Ann Acad Med Singapore 2010;39:719-33

31. “Reverse Strategy”
• Brouquet et al. and the group from M.D.
Anderson Cancer Center
• preoperative chemotherapy is followed
by resection of the hepatic metastases
and then by resection of the colorectal
primary at a second operation.
• J Am Coll Surg 2010;210:934-41.

32. The rationale for this approach
• complications related to the primary
colorectal tumor are rare and treatment
of metastatic disease is not delayed by
local therapy for the primary tumor or
complications associated with treatment
of the primary tumor
• It can be considered as an alternative
option in patients with advanced hepatic
metastases and an asymptomatic
primary.

33. It is a multidisciplinary approach

34. • Team work
– Patients should be treated at a designated
HPB Centre that has appropriate physical
resources (diagnostic equipment, operating
rooms, ICU, staffing (surgeons with advanced
training in HPB and colorectal surgery,
nurses, radiologists, medical and radiation
oncologists), and a high volume of HPB
surgeries (a minimum of 50 index HPB cases
per year).
A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care
Ontario (CCO) Report Date: June 15, 2012

35. THANK YOU