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Gastroenterologie 26. September 2016

Current strategies for preoperative conditioning of the liver to expand criteria for resectability of hepatic metastases

Background: Colorectal cancer (CRC) is among the most commonly  diagnosed  cancers,  and  the  liver  is  its  most  frequent  metastatic   site.   Colorectal   liver   metastases   (CLM)  are  synchronous  in  15–25 %  of  the  CRC  patients  and metachronous in 20–25 %. In recent decades, 5-year-overall survival following curative liver resection of CLM has increased to 35–58 %. This improvement owes largely to advances in CLM multimodality treatment.

Methods: In  recent  years,  the  CLM  resectability  criteria have also shifted, following several encouraging studies reporting the possibility of R0 resection for all tumors while  preserving  a  sufficient  volume  of  residual  liver.  In  this  context,  multimodal  approaches  including  portal  vein embolization (PVE), associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) and two-stage hepatectomy after neoadjuvant chemotherapy were developed to induce hypertrophy of the future liver remnant  (FLR)  to  fulfill  minimal  liver  volume  requirements.  Liver  function  tests  and  scores  could  be  a  helpful  tool  in  patient  selection  and  prediction  limit  of  the  hepatic parenchymal reserve.

Results: Generally,  at  least  20  %  of  the  total  liver  volume  should  be  preserved  in  the  case  of  a  healthy  liver,  whereas  at  least  30–60  %  should  be  preserved  for  livers  impaired by chemotherapy-associated steatosis or hepatitis. Further use of ischemic or pharmacological preconditioning of FLR tissue such as stem cell transplantation could  help  to  prepare  the  liver  for  extended  resections  and to avoid postoperative liver failure.

Conclusion: Because   of   shifting   CLM   resectability   criteria  and  encouraging  survival  rates  following  curative resection in the context of multimodality treatment, extended  liver  surgery  for  CLM  is  increasing.  To  condition the liver for extensive surgery and to ensure adequate postoperative  liver  function,  several  approaches  were  developed and routinely practiced in clinical centers.

H. Hau, H. Tautenhahn, M. Schmelzle, H. Morgul, M. Moche, M. Bartels, Prof. Dr. med. D. Uhlmann, European Surgery 4/2016

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