Selection of Patients for Resection of Colorectal Metastases to the Liver Using Diagnostic Laparoscopy and Laparoscopic Ultrasonography

Abstract

ObjectiveTo assess the value of diagnostic laparoscopy (DL) and laparoscopic ultrasonography (LUS) in the staging and selection of patients with colorectal liver metastasis. Summary Background DataPreoperative imaging modalities such as ultrasound, computed tomography, and magnetic resonance imaging are limited in the assessment of the number and exact location of hepatic metastases and in the detection of extrahepatic metastatic disease. Consequently, the surgeon is often faced with a discrepancy between preoperative imaging results and perioperative findings, resulting in either a different resection than planned or no resection at all. MethodsFifty consecutive patients were planned for DL and LUS in a separate surgical sitting to assess the resectability of their liver metastases. All patients were considered to be candidates for resection on the basis of preoperative imaging studies. ResultsLaparoscopy could not be performed in 3 of the 50 patients because of dense adhesions. The remaining 47 patients underwent DL. On the basis of DL and LUS, 18 (38%) patients were ruled out as candidates for resection. Of the 29 patients who subsequently underwent open exploration and intraoperative ultrasonography, another 6 (13%) were deemed to have unresectable disease. ConclusionsThe combination of DL and LUS significantly improves the selection of candidates for resection of colorectal liver metastases and effectively reduces the number of unnecessary laparotomies.Resection of colorectal metastases in selected patients is a worthwhile undertaking: a survival advantage has been shown if metastases are resected with curative intent. 1,2However, 62% to 85% of patients will not survive beyond 5 years after resection of liver metastases.3-6 Tumor recurrence after resection of the liver metastases occurs in 48% to 88% of patients who die of their metastatic disease, 7-9 and most often within the first year after resection.Only a small proportion of patients with hepatic colorectal metastases are candidates for resection with curative intent. Accurate staging is mandatory in the selection process. Preoperative imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are limited in the assessment of the number and exact location of hepatic metastases and in the detection of extrahepatic metastatic disease. Consequently, the surgeon is often faced with a discrepancy between preoperative imaging results and perioperative findings, resulting in either a different resection than planned or no resection at all. 10Laparoscopy may reveal extrahepatic intraabdominal dissemination, such as peritoneal implants and lymph node metastases, that is often not seen on a preoperative CT scan. When necessary, guided biopsies can be taken. Direct contact intraoperative ultrasonography (IOUS) has proven to be more sensitive in detecting liver metastases than preoperative imaging.11-13 Laparoscopic ultrasonography (LUS) therefore seems to be a logical addition to diagnostic laparoscopy (DL) to dete...

Laparoscopic intra-operative ultrasound in liver and pancreas resection: Analysis of 93 cases

“…In another study, LIOUS identified 17% of all undetected HCC nodules in patients undergoing liver resection [9] and allowed 38% of patients with hepatic metastases to avoid needless surgery [10]. Laparotomy was avoided in 63% of patients with unresectable hepatocellular carcinomas [11].…”

Resource and manpower calculations for the provision of hepatobiliary surgical services in the UK

“…8 It is useful to note that while surgical resection of other gastrointestinal cancers is commonly performed in the UK and accepted as standard treatment, the survival rates for these cancers can be considerably lower than those for patients undergoing hepatectomy for colorectal metastases. For example, patients undergoing pancreatoduodenectomy for pancreatic cancer l2 or oesophagectomy for oesophageal cancer 13 have a mean 5-year survival of 10% and 20%, respectively, at best.…”

Laparoscopic Radiofrequency Ablation of Liver Tumors

“…Some authors consider that every liver resection must be preceded by abdominal laparoscopic assessment of the disease [9]. By identifying extrahepatic lesions, laparoscopy can up-stage the patients with cancer and can deem these as unresectable or untreatable with in situ ablation procedures (except those with neuroendocrine tumors).…”