PC GIULIANOTTI, MD, FACS
PC GIULIANOTTI, MD, FACS   ROBOTIC LIVER RESECTION FORNEUROENDOCRINE HEPATIC METASTASIS
Neuroendocrine liver metastases (NLMs)46%–93% of patients with Neuroendocrine Tumors shows NLMs atthe time of diagnosisLiv...
NLMsPROGNOSTIC FACTORS:    Tumor grade    Tumor size    Number    LocationIn 2008, the ENETS (European Neuroendocrine Tumo...
NLMsResection alone is supported by favorable long-term outcomes in largeretrospective trialsComplete surgical R0 treatmen...
1. SurgeryFIVE-YEAR SURVIVAL: greater than 60%, 80% in some selected seriesMinimal mortality (<5%) and morbidity (<30%) re...
1. OLTxLiver transplantation for neuroendocrine tumors is one of the onlyaccepted indications for metastatic disease185 li...
2. Other Liver directed therapies NETs are predisposed to form highly vascular metastatic lesions in the liver and derive ...
3. Non-Liver-Directed Therapies Lack of consensus on a nonsurgical treatment algorithm No comparative studies OPTIONS:    ...
NLMs Algorithm       Modified from: HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
Minimally invasive approachSTATEMENTS         Recent studies have shown similar perioperative and         long-term outcom...
Minimally invasive approach                          From: EDWIN B. SC J SURG; 2011
Robotic Liver ResectionNo metanalysis, no randomized controlled comparisons   2010
Robotic Liver Resection
Our Experience                 113 Robotic Liver resections                       55 males and 58 females                 ...
Case report70- year old ladybowel obstruction from an intussusception at the ileum in March 2008associated with liver mass...
Case report   VOLUME:        865 cc total liver        595 cc right liver1.9 x 1.7 cm low attenuating lesion within the in...
Case reportWedge resection V segmentTotal Operative Time: 180 minutesEstimated Blood Loss: 350 ccHospital stay: 4 daysFoll...
Parenchymal-sparing surgery
Parenchymal-sparing surgery
ConclusionsMinimally invasive liver resections for neuroendocrine mets have arole in the treatment of this disease.Minimal...
Houston 2011 - Robotic liver resection for neuroendocrine metastatic tumors
Houston 2011 - Robotic liver resection for neuroendocrine metastatic tumors
Upcoming SlideShare
Loading in …5
×

Houston 2011 - Robotic liver resection for neuroendocrine metastatic tumors

641 views

Published on

www.clinicalrobotics.com
Videopresentaiton Houston 2011
Clinical Robotic Surgery Association
Giulianotti Pier Cristoforo

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
641
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
0
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Houston 2011 - Robotic liver resection for neuroendocrine metastatic tumors

  1. 1. PC GIULIANOTTI, MD, FACS
  2. 2. PC GIULIANOTTI, MD, FACS ROBOTIC LIVER RESECTION FORNEUROENDOCRINE HEPATIC METASTASIS
  3. 3. Neuroendocrine liver metastases (NLMs)46%–93% of patients with Neuroendocrine Tumors shows NLMs atthe time of diagnosisLiver involvement is related to significantly worse prognosisSurgical interventions forNLMs have consistently been shown tohave superior outcomes to nonoperative therapies HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011 MAYO SC ET AL. ANN SURG ONCOL. EPUB JUN 17 2011 FRILLING A ET AL. HPB, 12(6); 2010
  4. 4. NLMsPROGNOSTIC FACTORS: Tumor grade Tumor size Number LocationIn 2008, the ENETS (European Neuroendocrine Tumor Society) proposedguideline for surgical resection based on the 3 distinct patterns of liverinvolvement:1.SIMPLE pattern of metastasis located in one or two contiguous lobes (20–25%)2.COMPLEX pattern where there is one major focus and other lesions are contained in the contralateral lobe (10–15%)3.DIFFUSE disease in both lobes (60–70%) SAXENA A ET AL. J SURG ONCOL. EPUB OCT 17 2011 YANG Z ET AL. AM J SURG PATH 35(6); 2011 FRILLING A ET AL. BR J SURG 96(2); 2009 STEINMULLER T ET AL. NEUROENDOCRINOLOGY 87(1); 2007
  5. 5. NLMsResection alone is supported by favorable long-term outcomes in largeretrospective trialsComplete surgical R0 treatment is an option for only 10 % of thesepatientsSurgery remains the only potential for cure in patients with NLMsEven in the setting of incurable disease, surgery offers the best chance forprolonged survivalOPTIONS: 1. Surgery 2. Other Liver directed therapies 3. Non-Liver-Directed Therapies HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011 MAYO SC ET AL. ANN SURG ONCOL. EPUB JUN 17 2011
  6. 6. 1. SurgeryFIVE-YEAR SURVIVAL: greater than 60%, 80% in some selected seriesMinimal mortality (<5%) and morbidity (<30%) reportedCytoreductive surgery can be usually recommended only in cases where>90% of the tumor volume can be excised Recent review of 74 cases demonstrated a greater than 60% 5-year survival in all patients underwent resection FRILLING A ET AL. BR J SURG 96(2); 2009 GLAZER ES ET AL. HPB 12(6); 2010 FRILLING A ET AL. HPB, 12(6); 2010 SAXENA A ET AL. J SURG ONCOL. EPUB OCT 17 2011
  7. 7. 1. OLTxLiver transplantation for neuroendocrine tumors is one of the onlyaccepted indications for metastatic disease185 liver transplants performed for metastatic neuroendocrine tumors inthe United States at March 2011The overall 5-year survival: 57.8% - worse than the 74% 5-year survival for all other patients - good for this group of patients OLTx criteria: (1) not a resection candidate (2) identification and complete resection of primary malignancy at least one year prior to evaluation (3) no evidence of extrahepatic disease demonstrated on cross-sectional imaging or nuclear medicine scan (4) evidence of stability of disease for at least one year (5) failure of nonoperative treatments TREUT YP ET AL. AM J TRANSPL 8(6); 2008 MATHE Z ET AL. TRANSPLANTATION 91(5); 2011 HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
  8. 8. 2. Other Liver directed therapies NETs are predisposed to form highly vascular metastatic lesions in the liver and derive more than 90% of their oxygenation and nutrition from the hepatic artery 1. Radiofrequency Ablation 2. Hepatic Artery Embolization 3. Hepatic Artery Radioembolization 4. Selective Radiation Therapy HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
  9. 9. 3. Non-Liver-Directed Therapies Lack of consensus on a nonsurgical treatment algorithm No comparative studies OPTIONS: 1. Chemotherapy 2. Peptide Receptor Radionuclide Therapy 3. Somatostatin Analogs 4. Interferon-α 5. Targeting mTOR Pathway 6. Targeting Vascular Endothelial Growth Factors
  10. 10. NLMs Algorithm Modified from: HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
  11. 11. Minimally invasive approachSTATEMENTS Recent studies have shown similar perioperative and long-term outcomes of anatomic and non-anatomic liver resection Multiple simultaneous parenchyma-sparing resections should be preferred over single major resection in case of multiple lesionsLAPAROSCOPIC TECHNIQUEFacilitate concomitant multiple resections as well as repeatedresections due to minimal adhesion formationBUTThe parenchyma-sparing liver resection is challenging in laparoscopy,principally for posterosuperior segments KING J ET AL. CANCER 113(5); 2008 STROSBERG JR ET AL. CANCER CONTROL 18(2); 2011 KHASRAW MJ ET AL. CLIN GASTROENT 43(9); 2009
  12. 12. Minimally invasive approach From: EDWIN B. SC J SURG; 2011
  13. 13. Robotic Liver ResectionNo metanalysis, no randomized controlled comparisons 2010
  14. 14. Robotic Liver Resection
  15. 15. Our Experience 113 Robotic Liver resections 55 males and 58 females Mean age 55.3 yrs (range 20 – 84)Major Hepatectomies: 48Right hepatectomy 32 ptsLeft hepatectomy 5 ptsExtended right hepatectomy 4 ptsExtended left hepatectomy 3 ptsTrisegmentectomy or multiple (>3 segments) resections 4 ptsMinor Resections: 65Segmentectomy 21 ptsBisegmentectomy 19 ptsLeft lateral sectionectomy 11 ptsWedge resections 14 pts
  16. 16. Case report70- year old ladybowel obstruction from an intussusception at the ileum in March 2008associated with liver mass (CT scan)Emergency laparotomy, ileocolic resection and liver biopsyPathology report: metastatic carcinoid tumor of the distal ileumPLAN: - Robotic segmentectomy of segments 5 versus right hepatectomy - CT Liver volumetry
  17. 17. Case report VOLUME: 865 cc total liver 595 cc right liver1.9 x 1.7 cm low attenuating lesion within the inferior right hepatic lobe
  18. 18. Case reportWedge resection V segmentTotal Operative Time: 180 minutesEstimated Blood Loss: 350 ccHospital stay: 4 daysFollow up: Alternating CT scan and PET scan Alive without evidence of recurrence at 40 months
  19. 19. Parenchymal-sparing surgery
  20. 20. Parenchymal-sparing surgery
  21. 21. ConclusionsMinimally invasive liver resections for neuroendocrine mets have arole in the treatment of this disease.Minimally invasive surgery presents a lot of advantages for thisapplication and also have some limitations.Robotic surgery seems to overcome the limitations of laparoscopyand expands the role of minimally invasive approachs

×