Homayounfar K, Liersch T, Schuetze G, Niessner M, Goralczyk A, Meller J, Langer C, Ghadimi B M, Becker H, Lorf T
Department of General and Visceral Surgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
Int J Colorectal Dis. 2009 Apr;24(4):409-18. doi: 10.1007/s00384-008-0620-z. Epub 2008 Dec 16.
Patients with bilobular colorectal liver metastases (CRLM) experience poor prognosis, especially when curative resection cannot be achieved. However, resectability in these patients is often limited by low future remnant liver volume (FRLV). The latter can be enhanced by a two-stage liver resection, using portal vein ligation to induce liver hypertrophy. The aim of this prospective pilot study was to evaluate safety, secondary resectability, and time to recurrence of two-stage hepatectomy with portal vein ligation (PVL) and complete surgical clearance of the FRLV in patients with bilobular CRLM.
Out of 24 patients (63+/-8.26 years) with extended bilobular CRLM (metachronous n=10, synchronous n=14), 18 received preoperative 5-FU-based chemotherapy combined with oxaliplatin or irinotecan. Staging included thoracoabdominal computed tomography and (18)F-fluorodeoxyglucose-positron emission tomography scans. First-stage procedure consisted of PVL, resection of all CRLM in the FRLV, and radiofrequency ablation (RFA) of CRLM situated near the future resection plane.
During first-stage procedure, 7x RFA, 4x non-anatomical resections, and 4x bisegmentectomies were performed additionally to PVL. FRLV/body-weight ratio increased from 0.4% to 0.6% within 55 days (median) after PVL. Second-stage hepatectomy was performed in 19 patients without tumor progression. R0 resection was possible in 14 patients. During a median follow-up of 17 months, intrahepatic recurrence occurred in two, and extrahepatic recurrence in nine out of 14 patients.
Two-stage hepatectomy with PVL and complete surgical clearance of FRLV is safe even after intensified systemic chemotherapy resulting in a curative resection rate of 58.3% (73.7% of re-explored cases).
双叶结直肠癌肝转移（CRLM）患者预后较差，尤其是无法进行根治性切除时。然而，这些患者的可切除性常受未来残余肝体积（FRLV）过小的限制。通过两阶段肝切除，利用门静脉结扎诱导肝肥大，可增加FRLV。本前瞻性试点研究的目的是评估双叶CRLM患者行门静脉结扎（PVL）两阶段肝切除及FRLV完全手术清除的安全性、二次可切除性和复发时间。
24例（63±8.26岁）广泛双叶CRLM患者（异时性10例，同时性14例）中，18例接受了术前基于5-氟尿嘧啶的化疗联合奥沙利铂或伊立替康。分期检查包括胸腹部计算机断层扫描和（18）F-氟脱氧葡萄糖-正电子发射断层扫描。第一阶段手术包括PVL、FRLV内所有CRLM的切除以及位于未来切除平面附近的CRLM的射频消融（RFA）。
在第一阶段手术中，除PVL外，还额外进行了7次RFA、4次非解剖性切除和4次双段切除术。PVL后55天（中位数）内，FRLV/体重比从0.4%增加到0.6%。19例无肿瘤进展的患者接受了第二阶段肝切除。14例患者实现了R0切除。在中位随访17个月期间，14例患者中有2例发生肝内复发，9例发生肝外复发。
即使在强化全身化疗后，PVL两阶段肝切除及FRLV完全手术清除也是安全的，根治性切除率为58.3%（再次手术病例的73.7%）。
