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Chirurgische Innovationen in der Therapie des metastasierten kolorektalen Karzinoms

Die Komplexität der Metastasenchirurgie als Beispiel für personalisierte Medizin

Surgical innovations in treatment of metastatic colorectal cancer

Complexity of metastatic surgery as example for personalized medicine

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Zusammenfassung

Hintergrund

Kolorektale Lebermetastasen (KLM) mit extensivem, bilobärem Verteilungsmuster bzw. kritischer intrahepatischer Lage benötigen für eine kurative Zielsetzung komplexe chirurgische Resektionstechniken.

Ziel der Arbeit

In der vorliegenden Arbeit beschreiben wir aktuelle Techniken der hepatoonkologischen Chirurgie, mit denen auch bei vermeintlich grenzwertig kleinem gesundem Leberrest eine kurative Resektionsstrategie verfolgt werden kann. Es werden die Methoden der Pfortaderembolisation/-ligatur, der Kombination aus Resektion und Ablation, der zweizeitigen Resektionsstrategie und der „In-situ-split“-Resektion, auch unter „ALPPS“ („associating liver partition and portal vein ligation for staged hepatectomy“) bekannt, diskutiert. Kurz wird auch auf die extrahepatische oligometastasierte Situation eingegangen.

Material und Methoden

Revision aktueller Literatur und Diskussion des an unserer Klinik entwickelten Verfahrens des „in situ split“.

Ergebnisse

In den letzten Jahren wurden die chirurgischen Techniken, kolorektale Metastasen kurativ zu resezieren, signifikant erweitert, wodurch auch bei extensiver Metastasierung kurative Resektionen möglich wurden.

Diskussion

Eingebettet in ein multimodales Therapiekonzept ist es essenziell, dass die Resektabilität kolorektaler Metastasen auch in vermeintlich „aussichtslosen“ Fällen durch einen erfahrenen, hepatobiliären Chirurgen beurteilt wird.

Abstract

Background

Extensive, bilobular and multifocal colorectal liver metastases (CLM) or metastases that are critically situated require an experienced surgeon and advanced surgical techniques to enable curative resection.

Objective

This article describes the toolbox of hepato-oncologic surgery including functional augmentation of liver segments by portal vein embolization/ligation, combinations of ablation and resection, two-stage resections and in situ split liver resection, also known as associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Furthermore, the curative resection of extrahepatic, oligometastatic disease are briefly discussed.

Material and methods

Review of current literature as well as discussion of the ALPPS procedure, which was developed at our institute.

Results

In recent years, oncologic resections for CLM have been significantly refined, leading to a constant increase of curative resection rates.

Conclusion

In a multimodality treatment setting, surgical resection of CLM remains the gold standard curative approach and even in the event of presumed hopeless cases with extensive metastasis, experienced hepatobiliary surgeons must evaluate the resectability of colorectal metastases.

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Literatur

  1. Cucchetti A, Ferrero A, Cescon M, Donadon M, Russolillo N, Ercolani G, Stacchini G, Mazzotti F, Torzilli G, Pinna AD (2015) Cure model survival analysis after hepatic resection for colorectal liver metastases. Ann Surg Oncol 22:1908–1914

    Article  PubMed  Google Scholar 

  2. Ekberg H, Tranberg KG, Andersson R, Lundstedt C, Hagerstrand I, Ranstam J, Bengmark S (1986) Determinants of survival in liver resection for colorectal secondaries. Br J Surg 73:727–731

    Article  CAS  PubMed  Google Scholar 

  3. Pawlik TM, Scoggins CR, Zorzi D, Abdalla EK, Andres A, Eng C, Curley SA, Loyer EM, Muratore A, Mentha G, Capussotti L, Vauthey JN (2005) Effect of surgical margin status on survival and site of recurrence after hepatic resection for colorectal metastases. Ann Surg 241:715–722 (discussion 722–714)

    Article  PubMed  PubMed Central  Google Scholar 

  4. de Haas RJ, Wicherts DA, Flores E, Azoulay D, Castaing D, Adam R (2008) R1 resection by necessity for colorectal liver metastases: is it still a contraindication to surgery? Ann Surg 248:626–637

    PubMed  Google Scholar 

  5. Donadon M, Cescon M, Cucchetti A, Cimino M, Costa G, Pesi B, Ercolani G, Pinna AD, Torzilli G (2017) Parenchymal-sparing surgery for the surgical treatment of multiple colorectal liver metastases is a safer approach than major hepatectomy not impairing patients’ prognosis: a Bi-institutional propensity score-matched analysis. Dig Surg. https://doi.org/10.1159/000479336

    PubMed  Google Scholar 

  6. Abdalla EK, Vauthey JN, Ellis LM, Ellis V, Pollock R, Broglio KR, Hess K, Curley SA (2004) Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg 239:818–825 (discussion 825–817)

    Article  PubMed  PubMed Central  Google Scholar 

  7. Petre EN, Sofocleous C (2017) Thermal ablation in the management of colorectal cancer patients with oligometastatic liver disease. Visc Med 33:62–68

    Article  PubMed  PubMed Central  Google Scholar 

  8. van Amerongen MJ, Jenniskens SFM, van den Boezem PB, Futterer JJ, de Wilt JHW (2017) Radiofrequency ablation compared to surgical resection for curative treatment of patients with colorectal liver metastases – a meta-analysis. HPB (Oxford) 19:749–756

    Article  Google Scholar 

  9. Imai K, Benitez CC, Allard MA, Vibert E, Cunha AS, Cherqui D, Castaing D, Bismuth H, Baba H, Adam R (2017) Impact of surgical treatment for recurrence after 2‑stage hepatectomy for colorectal liver metastases, on patient outcome. Ann Surg. https://doi.org/10.1097/sla.0000000000002472

    PubMed  Google Scholar 

  10. Adam R, Aloia TA (2009) Is hepatic resection justified after chemotherapy in patients with colorectal liver metastases and lymph node involvement? J Clin Oncol 27:1343–1345 (author reply 1345)

    Article  PubMed  Google Scholar 

  11. Adam R, Wicherts DA, de Haas RJ, Ciacio O, Levi F, Paule B, Ducreux M, Azoulay D, Bismuth H, Castaing D (2009) Patients with initially unresectable colorectal liver metastases: is there a possibility of cure? J Clin Oncol 27:1829–1835

    Article  PubMed  Google Scholar 

  12. Memeo R, de Blasi V, Adam R, Goere D, Piardi T, Lermite E, Turrini O, Navarro F, de’Angelis N, Cunha AS, Pessaux P, French Colorectal Liver Metastases Working Group AFdC (2017) Margin status is still an important prognostic factor in hepatectomies for colorectal liver metastases: a propensity score matching analysis. World J Surg. https://doi.org/10.1007/s00268-017-4229-7

    Google Scholar 

  13. Miller CL, Taylor MS, Qadan M, Deshpande V, Worthington S, Smalley R, Collura C, Ryan DP, Allen JN, Blaszkowsky LS, Clark JW, Murphy JE, Parikh AR, Berger D, Tanabe KK, Lillemoe KD, Ferrone CR (2017) Prognostic significance of surgical margin size after neoadjuvant FOLFOX and/or FOLFIRI for colorectal liver metastases. J Gastrointest Surg. https://doi.org/10.1007/s11605-017-3557-0

    PubMed  Google Scholar 

  14. Margonis GA, Spolverato G, Kim Y, Ejaz A, Pawlik TM (2015) Intraoperative surgical margin re-resection for colorectal liver metastasis: is it worth the effort? J Gastrointest Surg 19:699–707

    Article  PubMed  Google Scholar 

  15. Adam, R (2015) ASCO 2015, abstract e14602. https://doi.org/10.1200/jco.2015.33.15_suppl.e14602

  16. Moris D, Ronnekleiv-Kelly S, Kostakis ID, Tsilimigras DI, Beal EW, Papalampros A, Dimitroulis D, Felekouras E, Pawlik TM (2017) Operative results and oncologic outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus two-stage hepatectomy (TSH) in patients with unresectable colorectal liver metastases: a systematic review and meta-analysis. World J Surg. https://doi.org/10.1007/s00268-017-4181-6

    Google Scholar 

  17. Adam R, Laurent A, Azoulay D, Castaing D, Bismuth H (2000) Two-stage hepatectomy: a planned strategy to treat irresectable liver tumors. Ann Surg 232:777–785

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Wicherts DA, Miller R, de Haas RJ, Bitsakou G, Vibert E, Veilhan LA, Azoulay D, Bismuth H, Castaing D, Adam R (2008) Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases. Ann Surg 248:994–1005

    Article  PubMed  Google Scholar 

  19. Brouquet A, Abdalla EK, Kopetz S, Garrett CR, Overman MJ, Eng C, Andreou A, Loyer EM, Madoff DC, Curley SA, Vauthey JN (2011) High survival rate after two-stage resection of advanced colorectal liver metastases: response-based selection and complete resection define outcome. J Clin Oncol 29:1083–1090

    Article  PubMed  PubMed Central  Google Scholar 

  20. Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, Horbelt R, Kroemer A, Loss M, Rummele P, Scherer MN, Padberg W, Konigsrainer A, Lang H, Obed A, Schlitt HJ (2012) Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2‑staged extended right hepatic resection in small-for-size settings. Ann Surg 255:405–414

    Article  PubMed  Google Scholar 

  21. de Santibanes E, Clavien PA (2012) Playing Play-Doh to prevent postoperative liver failure: the “ALPPS” approach. Ann Surg 255:415–417

    Article  PubMed  Google Scholar 

  22. Eshmuminov D, Raptis DA, Linecker M, Wirsching A, Lesurtel M, Clavien PA (2016) Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy. Br J Surg 103:1768–1782

    Article  CAS  PubMed  Google Scholar 

  23. Schadde E, Ardiles V, Robles-Campos R, Malago M, Machado M, Hernandez-Alejandro R, Soubrane O, Schnitzbauer AA, Raptis D, Tschuor C, Petrowsky H, De Santibanes E, Clavien PA, Group AR (2014) Early survival and safety of ALPPS: first report of the international ALPPS registry. Ann Surg 260:829–836 (discussion 836–828)

    Article  PubMed  Google Scholar 

  24. Linecker M, Bjornsson B, Stavrou GA, Oldhafer KJ, Lurje G, Neumann U, Adam R, Pruvot FR, Topp SA, Li J, Capobianco I, Nadalin S, Machado MA, Voskanyan S, Balci D, Hernandez-Alejandro R, Alvarez FA, De Santibanes E, Robles-Campos R, Malago M, de Oliveira ML, Lesurtel M, Clavien PA, Petrowsky H (2017) Risk adjustment in ALPPS is associated with a dramatic decrease in early mortality and morbidity. Ann Surg 266:779–786

    Article  PubMed  Google Scholar 

  25. Schlitt HJ, Hackl C, Lang SA (2017) “In-Situ Split” (ISS) liver resection (also termed “ALPPS”) – historical development and current practice. Visc Med. https://doi.org/10.1159/000479850

    PubMed  Google Scholar 

  26. Lodge JP, Ammori BJ, Prasad KR, Bellamy MC (2000) Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases. Ann Surg 231:471–479

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Moris D, Tsilimigras DI, Chakedis J, Beal EW, Felekouras E, Vernadakis S, Schizas D, Fung JJ, Pawlik TM (2017) Liver transplantation for unresectable colorectal liver metastases: a systematic review. J Surg Oncol 116:288–297

    Article  PubMed  Google Scholar 

  28. Hagness M, Foss A, Egge TS, Dueland S (2014) Patterns of recurrence after liver transplantation for nonresectable liver metastases from colorectal cancer. Ann Surg Oncol 21:1323–1329

    Article  PubMed  Google Scholar 

  29. Hagness M, Foss A, Line PD, Scholz T, Jorgensen PF, Fosby B, Boberg KM, Mathisen O, Gladhaug IP, Egge TS, Solberg S, Hausken J, Dueland S (2013) Liver transplantation for nonresectable liver metastases from colorectal cancer. Ann Surg 257:800–806

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Franz Josef Strauss Allee 11, 93053, Regensburg, Deutschland

    C. Hackl, S. M. Brunner, K. M Schmidt &  H. J. Schlitt

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Correspondence to H. J. Schlitt.

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C. Hackl, S. M. Brunner, K. M. Schmidt und H. J. Schlitt geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Hackl, C., Brunner, S.M., Schmidt, K.M. et al. Chirurgische Innovationen in der Therapie des metastasierten kolorektalen Karzinoms. Chirurg 89, 191–196 (2018). https://doi.org/10.1007/s00104-017-0583-0

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