O'Connell Robert Michael, Hoti Emir
Department of Hepatopancreaticobiliary and Transplantation Surgery, Saint Vincent's University Hospital, D04 T6F4 Dublin, Ireland.
Cancers (Basel). 2024 Jun 28;16(13):2379. doi: 10.3390/cancers16132379.
The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery-the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient-is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function.
由于环境和遗传因素的相互作用，全球范围内结直肠癌和结直肠癌肝转移（CRLM）的发病率正在上升。少数CRLM患者有手术可切除的疾病，但对于那些将手术作为疾病多模式治疗一部分的患者，已显示出长期生存的情况。精准手术——即仔细选择患者并针对手术干预进行靶向治疗，使在人群水平上已被证明有益的治疗方法成为每个个体患者的最佳治疗方法——是新的护理模式。关键在于了解肿瘤分子生物学和临床相关突变，如KRAS、BRAF和微卫星不稳定性（MSI），这些可以预测总体预后较差和对全身治疗的反应较差。免疫疗法和肝动脉灌注（HAI）泵的出现，除了已有的全身和局部区域疗法外，还显示出将先前不可切除的疾病转化为可切除疾病的潜力，但外科医生必须警惕肝脏质量差和肝切除术后肝衰竭（PHLF）的风险。容积调节是一代肝脏手术的基石，随着肝静脉耗竭（LVD）的出现，它得到了有力推动，可确保未来肝残余（FLR）显著更多地肥大。对于同步性疾病患者，肝切除的最佳时机尚未真正确定，但有证据表明，那些需要进行复杂结直肠手术和大肝切除的患者，采用分期方法效果最佳。在手术室中，保留实质的微创手术（MIS）可以显著减少对患者的手术创伤，带来更好的围手术期结果，功能恢复也更快。
