Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis
Summary
This protocol describes the laparoscopic resection of colorectal cancer liver metastases combined with ultrasound-guided microwave ablation. This technique can safely, effectively, and accurately treat refractory liver metastases <3 cm, reduce postoperative complications, and accelerate the postoperative rehabilitation of patients.
Abstract
Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to be maintained during laparoscopic hepatectomy, with a residual liver volume of >40% in cirrhotic patients and >30% in non-cirrhotic patients. The high incidence of complications such as bleeding, bile leakage, or liver failure due to the exposure and difficulty of the resection of specific liver segments such as S2 and S7 reduces the success rate of liver resection. At present, microwave ablation is mainly applied in the treatment of liver metastasis using a percutaneous approach, which makes it difficult to identify hidden parts or small lesions. For some liver segments, the percutaneous puncture of liver segment 7 (S7) is likely to pass through the thoracic cavity, and the percutaneous puncture of liver segment 2 (S2) adjacent to the diaphragm is likely to injure the diaphragm and heart; these issues restrict the application of percutaneous ablation in colorectal cancer liver metastasis. Considering multiple lesions, laparoscopic microwave ablation combined with hepatectomy was performed in this study. The location of the lesions was determined by contrast-enhanced ultrasound under laparoscopy, and small lesions that were difficult to detect before the operation were identified. For the scattered lesions, which had diameters less than 3 cm and were difficult to resect, ablation was adopted to substitute hepatectomy. This technique helped to more explicitly locate the tumors, simplified the operation procedures, reduced the risk of complications such as bleeding and bile leakage, shortened the operation time, accelerated the postoperative recovery, significantly improved the success rate of operation, and enhanced the clinical prognosis of colorectal cancer liver metastasis by surgical resection.
Introduction
Colorectal cancer is the third most common cause of cancer-related death worldwide1, and the most common site of hematogenous metastases from colorectal cancer is the liver; this metastasis occurs in up to 50% of colorectal patients and is the leading cause of death in colorectal cancer patients2. For colorectal cancer patients without liver metastases, survival can be prolonged by surgical resection and postoperative adjuvant chemotherapy, and interventional techniques. In the case of resectable liver metastases, those with a diameter of less than 3 cm can be treated by surgical local excision, radiological intervention, cryotherapy, radiofrequency ablation, and microwave ablation to improve the survival rate of patients3. For unresectable colorectal cancer liver metastases, conventional chemotherapy, interventional therapy, and other treatment strategies have limited survival benefits for the vast majority of patients.
Surgery is the gold standard for liver metastases from colorectal cancer, with a 5 year survival rate of 40%. Only 20%-30% of patients with colorectal liver metastases can benefit from surgical treatment, and most patients with unresectable colorectal liver metastases experience limited benefit from traditional conservative treatment4. An important method in the treatment of colorectal cancer liver metastases is thermal ablation, including microwave ablation and radiofrequency ablation; these two techniques induce cell death through coagulation necrosis caused by local hyperthermia. The main indications of thermal ablation include (i) unresectable liver lesions; (ii) combination with hepatectomy; (iii) patients with severe comorbidities or poor performance status (PS); (iv) small (<3 cm) solitary lesions otherwise requiring segmentectomy; and (v) patient preference5. Among them, microwave ablation (MWA) is a safe and effective treatment that can prolong the survival of patients. It has a wide range of active heating areas and does not depend on electrical conduction in the tumor tissue. This energy transfer is not limited by tissue scorching. Compared with radiofrequency ablation, microwave ablation has a higher temperature in the tumor tissue, shorter treatment time, and larger treatment range6.
Multiple intrahepatic metastases often occur in colorectal cancer liver metastases. In conventional treatment, chemotherapy, immunotherapy, interventional therapy, microwave therapy, radiofrequency ablation, and other methods can improve the survival rate of patients. The 5 year survival rate is 50%, but the survival rate is still low7. Surgical resection is still an important method for the treatment of liver metastases. Due to multiple liver metastases, small residual liver volume, postoperative bleeding, bile leakage, and inflow or outflow tract obstruction, which lead to the risk of liver failure, the surgical resection of multiple liver metastases is difficult. Three-quarters of patients are diagnosed with unresectable liver metastases8. Laparoscopic hepatectomy combined with microwave ablation in the treatment of colorectal cancer liver metastases can avoid the small amount of residual liver limiting the operation, reduce the adverse reactions of systemic chemotherapy, and overcome the electrical conduction barrier of radiofrequency ablation, thereby improving the success rate of surgery, prolonging the survival time of patients, and achieving a better prognosis of colorectal cancer liver metastases3,9.
This protocol describes the precision treatment of laparoscopic hepatectomy combined with microwave ablation for tumors <3 cm, occult liver metastases, and multiple liver metastases with positioning using laparoscopic ultrasound.
Protocol
Representative Results
Discussion
The main metastatic site of colorectal cancer metastasis is the liver. Liver resection is the treatment for colorectal cancer liver metastases, and liver resection can improve the survival rate of patients11. As colorectal cancer metastasizes to the liver through the blood, resulting in multiple liver metastases in both lobes, and the remaining liver volume is small, about 75% of liver metastases in colorectal cancer patients cannot be surgically removed12. Systemic chemoth…
Divulgazioni
The authors have nothing to disclose.
Acknowledgements
This work does not have any funding sources.
Materials
| 0.9% sodium chloride solution | Foshan Shuanghe Commercial Co., Ltd | H20013095 | Dilute antibiotics, irrigate. |
| 2-0 polyglactin 910 sutures | Johnson & Johnson Medical Devices | W8400 | Close the Trocar hole. |
| 3 D laparoscopic | STORZ | 26605BA | Surgical treatment under direct vision, minimally invasive |
| Absorbable Hemostat | ETHICON | 1962 | wound hemostasis |
| BiClamp E Lap | ERBE Elektromedizin GmbH | 20195-136 | Intraoperative wound hemostasis |
| Cefoperazone Sulbactam Sodium | Pfizer Pharmaceuticals Ltd | H20020597 | infection prevention |
| Laparoscopic ultrasound probe | HITACHI | ALOKA-UST5418 | Intraoperative localization of liver metastases |
| LIGACLIP Multiple Clip Applier and Ligating Clips | Ethicon Endo – Surgery, LLC | ER320 | Clamp tiny blood vessels and bile ducts |
| Microwave ablation System | Nanjing Yigao Microwave System Engineering Co., Ltd, China | ECO-100A110 | Microwave ablation of liver metastases |
| Polymer ligation clips | Teleflex Medical, USA | Hem-lock544233 | Clipping of broken ends of blood vessels and bile ducts |
| Silica gel drainage tube | BAINUS MEDICAL | YY-Fr16 | Drainage of peritoneal fluid |
| Ultrasonic knife | Johnson & Johnson Medical Devices | HAR36 | Tissue cutting, microvascular hemostasis |
Riferimenti
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