© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2017Xinyu Qin, Jianmin Xu and Yunshi Zhong (eds.)Multidisciplinary Management of Liver Metastases in Colorectal Cancer10.1007/978-94-017-7755-1_14
14. Laparoscopic Management of Colorectal Liver Metastases
Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France
Colorectal cancer is the third most common cancer worldwide, with a lifetime risk of approximately 5 %. The most common site for haematogenous metastasis is the liver. Approximately 10–20 % of patients with colorectal adenocarcinoma will have synchronous hepatic metastasis at the time of diagnosis, and 20–25 % of the patients will develop metachronous metastasis later in life. Without treatment, the prognosis of colorectal cancer with liver metastasis is poor, and the 5-year survival rate is less than 5 %. At present, liver resection offers the best chance of survival for patients with colorectal cancer liver metastasis. Currently the 5-year survival rate following curative resection of colorectal liver metastasis approaches 45–60 %. Many reasons have contributed to the better results of colorectal liver metastasis. Improved patient selection in a multidisciplinary team setting, increased understanding of liver surgery and anaesthesia, technological improvements, advances made in diagnostic and interventional radiology and advances made in the field of chemotherapy are to name a few contributory factors.
Since the initial laparoscopic liver resection in the early 1990s, there has been a slow progress in the number of liver resections performed laparoscopically. Increasing expertise and experience in liver and laparoscopic surgery and advances in technology, there has been an exponential rise in the number of liver resections performed laparoscopically. Recent world review suggests that there are almost 3,000 laparoscopic liver resections reported in the world literature.
The use of laparoscopy in colorectal liver metastasis also includes staging of the disease to look for peritoneal disease and with the use of laparoscopic ultrasound to identify and confirm the location and number of lesions as suggested by the preoperative imaging. This would be a valid tool as it would prevent patients from having an unnecessary laparotomy if the metastatic lesions are deemed unresectable. There is also a role for laparoscopy in radiofrequency ablation in the treatment of colorectal liver metastasis. Laparoscopic ablation is found to have less local recurrence than percutaneous with the obvious advantages over open ablation. Laparoscopic radiofrequency ablation of the liver metastasis can be done as an adjunct to resection of other lesions in order to preserve functional residual liver volume. Current evidence does not support the use of radiofrequency ablation as the primary treatment for fit patients who have lesions which are amenable to resection.
This chapter would discuss mainly about laparoscopic liver resection for colorectal liver metastasis.
14.2 Preoperative Imaging
This is the same as in open hepatic resection for colorectal liver metastasis and involves ultrasound with or without contrast, triple-phase contrast CT scan, MRI scan and PET scan.
14.2.1 Ultrasound Scan (USS)
Ultrasonography is cheap and provides detailed information about the number, size and relation of metastatic lesions with the hepatic vasculature. The sensitivity can be increased by the use of contrast-enhanced ultrasound. However, ultrasound is operator dependent.
14.2.2 CT Scan
Computed tomography is routinely performed as part of staging for patients with colorectal liver metastasis. CT scans of the chest, abdomen and pelvis with intravenous contrast are obtained. A triphasic CT scan of the liver will further characterize the hepatic metastasis. Arterial phase images are useful in cases of neuroendocrine metastasis, primary hepatomas, hepatic adenomas and haemangiomas. This phase also outlines the arterial anatomy of the liver. Portal venous phase is the most useful for the evaluation of colorectal liver metastasis. Metastasis from colorectal cancer usually respects the liver capsule and intersegmental planes and pushes structures away rather than invades directly into them. However, one should be aware that there are reports of colorectal liver metastasis with intrabiliary growth. Invasion of the vena cava and diaphragm is rare, and even if imaging studies suggest invasion of these structures, surgical exploration is indicated.
14.2.3 Magnetic Resonance Imaging (MRI)
MRI is most useful to evaluate the relationship of the tumours to the hepatic vasculature and biliary system. MRI is particularly used to characterize benign lesions like hepatic adenoma, haemangioma and focal nodular hyperplasia. In cases of fatty infiltration due to obesity or prior chemotherapy and in cases of cirrhosis, MRI might be able to delineate lesions better than a contrast CT scan.