CRC Liver metastasis management

1. Surgical management of Colorectal
Liver Metastasis
Dr Malinda Wijerathne
Registrar in General Surgery
National Cancer Institute – Maharagama
17/04/2023

2. 1. Colorectal Cancer – 3rd Common cancer
2. 50% develop liver mets - 25 % @ diagnosis of CRC
3. 70 – 90 % Unresectable 60 % Resectable
4. > 50 % will have new mets after treatments
Neoadjuvent
Similar 5yS

3. Principles of Surgery
1. Should preserve
• Artery
• Portal Vein
• Bile duct
• As much as possible parenchyma (1 mm margin is sufficient)
2. Future Liver Remnant (FLR)
Prediction of the FLR could be
problematic because
Volume = Function

4. Pathways
Resectable
Not Resectable at diagnosis
Resectable
Neoadjuvent
Surgery
R0 R1 Not Resectable

5. Neoadjuvent chemotherapy
1.Tumour biology can be assessed
2.Occult disease treated
3.Identify aggressive disease not
amenable to surgery.
• Options
1. Double therapy - 5-fluorouracil (5-FU) and Oxaliplatin or
Irinotecan
2. Triple therapy - 5-fluorouracil (5-FU), Oxaliplatin and
Irinotecan
3. Immunotherapy – Cetuximab (EGFR)
Bevacizumab (VEGF)
Fundamental key for better prognosis

7. Surgical Options
1. Anatomical resections vs Non Anatomical resections
2. Staged Resections
3. Portal venous ligation or embolization
4. ALPPS - Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)
5. LVD
6. ultrasound guided enhanced one stage hepatectomy (e-OSH)
7. Intraoperative ablation techniques
8. Liver transplantation
9. Redo surgeries
10. Salvage ALPPS

11. Parenchymal sparing

12. Tricks of parenchymal sparing

13. Tumour vessel detachment & R1 resections

14. Portal venous ligation / embolization
• 90 % suitable for PVE
• Whist some studies have claimed that PVL is less effective than PVE because of
intrahepatic Porto-portal shunting
• two recent met analyses have shown the techniques to be equal in terms of
• hypertrophy of the FLR
• time to hepatectomy
• morbidity and mortality
There was also no difference in the number of patients who had to be cancelled
because of disease progression.

15. Timing of liver & CRC resection
1. CRC first vs Liver first
2. After Neoadjuvent
3. Staged
4. Simultaneous Is the patient fit?
Can you achieve R0 of both?

16. • A simultaneous approach was not associated with worse overall
survival or morbidity compared to a liver-first approach.
653 patients
Simultaneous N = 92
Liver-first N = 163
Colorectal-first N = 403

17. Repeat surgery
• Preserve parenchyma in first surgery
• 1 mm margin is adequate
• Similar outcome as 5yS
• Can consider R1 resection – e.g. on vessels

18. Genetic Profiling
• Those who have KRAS and BRAF mutations derive no
benefit from the anti-EGFR antibodies cetuximab and panitumumab.

19. Minimally invasive resections

20. Robotic surgery
overcome some limitations of the laparoscopic
approach
better dexterity
less fatigue
better access to postero-superior segments
similar or even reduced blood loss compared to
open or laparoscopic approaches
Similar oncological outcomes in terms of margin
status

22. References
1. Shifting concepts in the management of colorectal
liver metastases – The Surgeon 2022
2. A comparison of the simultaneous, liver-first, and colorectal-
first strategies for surgical treatment of synchronous colorectal liver
metastases at two major liver-surgery institutions in Sweden HPB 2023
3. Parenchymal preserving surgery in CRC Liver Metastasis – Tools and
Statergy – 2021 IHPBA V REACH Programme
4. The IASGO Textbook of Multi-Disciplinary Management of Hepato-
Pancreato-Biliary Diseases
5. Cancers Metastatic to the Liver - Surg Clin North America 2020