- Systematic extended posterior right sectionectomy with
resection of subsegment IX
- A.A. Burlaka, A. Gogo-Abite, A.V. Paliichuk, D.E. Makhmudov, V.V.
Zvirych, A.V. Lukashenko
- Burlaka Anton Anatoliyovych – PhD, Senior Researcher,
Abdominal department of National Cancer Institute, Kyiv, e-mail:
nir.burlaka@gmail.com (044 257 9315)
https://orcid.org/0000-0003-4995-705XGogo-Abite Awofa – MD, Senior Researcher, Taras Shevchenko
National University of Kyiv. Educational and Scientific Centre”
Institute of Biology and Medicine” Department of Anatomy and
Pathological Physiology. Phone: +38044 239-33-33, e-mail:
office.chief@univ.net.ua URL: http://www.univ.kiev.uaPaliichuk Ariadna V. – Medical center ”Omega-Kyiv”: Kyiv,
e-mail: drariadna777@gmail.com https://orcid.org/0000-0002-3393-7874Makhmudov Dmutro E. - MD, PhD, Colorectal cancer department
of National Cancer Institute, Kyiv, e-mail: Dmahmudoff@gmail.com (044
257 9315) https://orcid.org/0000-0002-8405-9258.Zvirych Vitalii V.– MD, PhD, Head of the colorectal Cancer
department of National Cancer Institute, Kyiv, e-mail: zvirvit@ukr.net
(044 257 9315). https://orcid.org/0000-0002-3502-1886.Lukashenko Andrii V.– MD, PhD, Director of science
of National Cancer Institute, Kyiv, e-mail: Mail.Onco@gmail.com (044
257 9315).Corresponding author: Burlaka Anton, Abdominal department of
NCI, Ukraine, Kyiv, Lomonosova 33/43, 03022. Phone: +380678002748;
e-mail:
nir.burlaka@gmail.com
http://unci.org.ua/en/
Key words: parenchyma sparing surgery, extended posterior right
sectionectomy, segment IX.
Abstract: parenchymal sparing surgical (PSS) strategy allowed
to plan a one-stage systemic extended posterior right sectionectomy with
resection of the dorsal subsegment S1 in patient with 11 bilobar CRC
metastases. PSS liver surgery has the greatest potential for
implementation in modern medicine conditions.
Key clinical message: parenchymal sparing surgery should be the
strategy of choice for patients with bilobar liver metastases and
lesions withing the central sites.
Introduction. The history of colorectal cancer (CRC) therapy is
an example of the impact of technological progress on the strategic
paradigm. Despite the rapid development of anticancer therapy over the
past decade, surgical removal of the primary tumor and all sites
affected by metastatic disease remains a priority for such patients’
survival. However, ≥ 50% of CRC patients with a history of liver
resection due to the metastatic lesions, have a risk of recurrent
metastatic organ damage, which further requires 2ndline chemotherapy (CTx) and repeated resection treatment. In our
opinion, taking into account the duration and frequency of CTx and the
resection optimal time, all the attempts to develop an effective
algorithm have now become deadend due to misinterpretation of the CRC
growth biology and metastasis, prompting clinicians to return to
fundamental issues. CRC cells dissemination from the primary tumor
occurs at much earlier stages of the disease (through genetically less
mature malignant cells), and metastatic growth occurs in parallel with
the progression of the primary tumor, due to the more malignant
phenotype [1]. Disseminated CRC adenocarcinoma cells, in which the
process of proliferation gradually continues at the stages of
complex/surgical treatment of primary colon neoplasm, lead to a
predicted early clinical manifestation of distant metastases [2]. It
is argued that the micrometastases diffusion and the dormancy of CRC
cells is currently the main argument against performing a wide resection
margin (≥ 1 cm) and anatomically oriented liver surgery for such
patients [3]. Such a tactic makes it impossible to perform
re-resection of the subsequent waves of micrometastases progression in
the parenchyma. That is why parenchymal sparing surgery (PSS) should be
the strategy of choice for patients with bilobar liver metastases and
lesions withing the central sites [4].
The purpose of our work is to demonstrate our own experience of PSS
strategy adaptation in patients with bilobar metastatic liver injury.
Material and methods. A clinical case of a patient S. with
metachronous bilobar metastatic liver disease (11 metastatic lesions) is
presented. The primary tumor has been localized in the upper rectum.
Previous treatment included total mesorectal excision (performed 11
months prior to the manifestation of metastatic disease). According to
the results of real-time PCR analysis in patient S., the wild type of
K-Ras gene has been determined. Given the bilobar spread and multiple
lesions, 3 cycles of chemo (FOLFOX-6) with subsequent surgical treatment
have been planned to conduct, in circs of the growth stabilization on
the background of systemic anticancer therapy. According to computer
tomography report, after 3 courses of FOLFOX-6, there was a
stabilization of the growth of target lesions (according to RECIST 1.1
criteria). At the time of the last pre-operative CT scan in patient S.,
11 metastatic lesions remained (Table 1).
The total functional liver volume, future liver remnant volume (S1c, S2,
S3, S4) and body weight at the resection planning moment were 1522,6
cm3, 561 cm3 and 84 kg,
respectively. The remnant liver volume to body weight ratio was 0,46%
which required a two-stage hepatectomy and in that case associated with
30% “drop-out” due to the tumor progression after the 1-st surgical
stage [5] (Fig. 1).
When choosing a «major liver surgery» strategy, patient S. could
potentially have risk of acute liver failure in the early postoperative
period and would require two-stage hepatectomy and right portal vein
embolization. While PSS strategy allowed to plan a one-stage systemic
extended posterior right sectionectomy with resection of the dorsal
subsegment S1. This is an alternative surgical strategy in the PSS
framework, which involves the implementation of the already described
“Systemic extended right posterior sectionectomy” [5] and based on
the complete mobilization of the IVC subhepatic segment of the
“Piggy-back” type at the level of the dorsal (paracaval) part of S1d
(IX segment by C. COUINAUD) and its subsequent resection [6].
IX segment, the anatomical zone which filled with parenchyma, having an
independent inflow into the system of the right portal vein (Fig. 2) and
is limited by the posterior surface of RHV, MHV and anterior subhepatic
segment of IVC, medially in the oblique plane from PRV level to terminal
divisions of main hepatic veins.
Surgical stage. Surgical access based on the principle of
minimal access involved a J-shaped mini laparotomy to the right with the
intersection of the right rectus abdominis [8], revision and the
right liver lobe mobilization according to the “Piggy back” principles
with short veins ligation, draining the dorsal part of S1 in the IVC.
The next step involved marking the anatomical boundaries of the
posterior section, the projection of RHV, MHV and GP to the anterior
section using intraoperative ultrasonic navigation (Fig. 3).
Liver parenchyma transection has been performed under the Pringle
maneuver conditions, started at edge of the anterior/posterior sections,
followed by the RHV visualization to its middle segment and the GP6 in
the direction of main portal fissure. Using the Gleason unit S6 as a
landmark, the transection has been completed at the level of the right
portal vein confluence. Next, the parenchyma dissection with S8d removal
and the middle hepatic vein (MHV) visualization; then, R1v
skeletonization on the ½ circle of the MHV has been performed.
Completion of parenchyma transsection has been performed at the level of
the main portal fissure by resecting S1d (SIX) with a metastatic lesion
(Fig. 4). RPPV and RHV at the level of their orifices have been ligated
and sutured, using vascular clamps. Upon completion of hemo- and
cholestasis on the plane of transection, the characteristics of
parenchymal blood flow were monitored (porto-fugal character of blood
flow in the portal and lateral systems of parenchyma S5 and S8v has been
excluded).
The total duration of normo-ischemia for patient S. lasted for 65
minutes, blood loss amounted to 275 ml. The postoperative period went
smoothly.
Discussion. Today’s understanding of the metastasis biology and
the process of progression in patients with CRC, has become a trigger
for commencing the search for independent prognostic factors and the
development of personalized surgical treatment of such patients. The
main unresolved problems of modern liver surgery include the study of
the effectiveness of the principles of PSS liver surgery adaptation for
CRC metastatic lesions localized in the central sites, and the
assessment of the R1v strategy of vascular skeletonization of such
patients in different clinical cases.
Recently published data proves that the use of large resections is
accompanied by the challenge of performing R1 in 10-30% [9].
Moreover, the adaptation of intraoperative ultrasound and the
improvement of CT and MRI diagnostics allowed to determine the presence
of true tumor invasion into the intraparenchymal vessels walls with a
high degree of accuracy (main hepatic veins and Gleason structures).
This information allows performing rather alternative than classical
approach of PSS resections, realized by combining US navigation,
orientation in vascular structures of 1-4 order 3D anatomy and the use
of R1 vascular skeletonization. From our point of view, the
above-mentioned approach is an alternative in cases of centrally
localized metastatic lesions (within the portal or caval confluence of
the liver). The method of skeletonization of liver vessels in contact
with metastatic lesions is not included in international standards,
however, according to a number of promising studies published in 2020,
R1v in combination with modern CTx can achieve the oncological effect
equivalent to R0 [110,11].
Conclusions . Adaptation of PSS liver surgery in metastatic
colorectal cancer has the greatest potential for development and
implementation in modern medicine conditions.