Oncologic aspects of the decision-making process for surgical approach for colorectal liver metastases progressing during chemotherapy.

Colorectal cancer represents the third most diagnosed malignancy in the world. The liver is the main site of metastatic disease, affected in 30% of patients with newly diagnosed disease. Complete resection is considered the only potentially curative treatment for colorectal liver metastasis (CRLM), with a 5-year survival rate ranging from 35% to 58%. However, up to 80% of patients have initially unresectable disease, due to extrahepatic disease or bilobar multiple liver nodules. The availability of increasingly effective systemic chemotherapy has contributed to converting patients with initially unresectable liver metastases to resectable disease, improving long-term outcomes, and accessing tumor biology. In recent years, response to preoperative systemic chemotherapy before liver resection has been established as a major prognostic factor. Some studies have demonstrated that patients with regression of hepatic metastases while on chemotherapy have improved outcomes when compared to patients with stabilization or progression of the disease. Even if disease progression during chemotherapy represents an independent negative prognostic factor, some patients may still benefit from surgery, given the role of this modality as the main treatment with curative intent for patients with CRLM. In selected cases, based on size, the number of lesions, and tumor markers, surgery may be offered despite the less favorable prognosis and as an option for non-chemo responders.

Counter-Clockwise Approach for Robotic Pylorus-Preserving Pancreatoduodenectomy.

PURPOSE: This multi-media article aims to describe a counter-clockwise approach for pancreatoduodenectomy (CCA-PD) in robotic surgery. METHODS: A CCA-PD was used as a strategy for robotic surgery to treat a 69-year-old woman without comorbidities who presented a ductal adenocarcinoma of the head of the pancreas (2.7 cm) in contact with the portal vein (less than 180°), preoperatively treated with FOLFIRINOX. The procedure was entirely done in the abdominal right upper quadrant (RUQ) following the main steps of CCA-PD resection: section of the first portion of the duodenum; biliary duct transection; Kocherization of the duodenum and retropancreatic lymphadenectomy; section of the jejunum; portal vein dissection; transection of the pancreas and uncinate detachment. The reconstruction also followed the counter-clockwise direction with a single jejunal loop with end-to-side anastomoses: pancreato-jejunal; choledoco-jejunal; duodenojejunal. RESULTS: The total operation time was 435 min, and the estimated blood loss was 200 mL. The postoperative course was uneventful without complications, with hospital discharge on the fifth postoperative day. The final pathology was ductal adenocarcinoma (G2), ypT2ypN2 (07/31), with negative surgical margins. DISCUSSION: The entire surgery happens in a unique surgical field, the RUQ, which saves time by avoiding unnecessary mobilization of the bowel and favors a layer-by-layer dissection with enough space for both dissections and sutures on each step of the procedure and improving bleeding control if necessary.

Disappearing colorectal liver metastases: Strategies for the management of patients achieving a radiographic complete response after systemic chemotherapy.

The mainstays of treatment for colorectal liver metastases (CRLMs) are surgery and chemotherapy. Chemotherapeutic benefits of tumor shrinkage and systemic control of micrometastases are in part counterbalanced by chemotoxicity that can modify the liver parenchyma, jeopardizing the detection of CRLM. This review addresses the clinical decision-making process in the context of radiographic and pathologic responses, the preoperative imaging workup, and the approaches to the liver for CRLM, which disappear after systemic chemotherapy.