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Patient selection and perioperative optimisation in surgery for colorectal liver metastases

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Summary

Background

Clinical decision-making around the management of liver-limited stage IV colorectal cancer involves careful assessment of the potential risks and benefits of surgery. This balance can often be optimised through appropriate patient selection to ensure long-term benefit of any operation, with fastidious perioperative care to minimize risk.

Methods

We reviewed selected relevant articles from the existing literature.

Results

Multi-platform imaging is routinely used to determine distribution of disease and whether lesions are technically resectable, but what remains less clear is how to identify patients in whom resection is likely to deliver long-term benefits. A number of prognostic markers have been identified, with growing interest in direct assessment of tumour biology; genotyping of RAS status is routine in specific situations. Following a multidisciplinary team decision to proceed to surgery, patients undergo perioperative assessment and optimisation. Cardiopulmonary exercise testing helps to stratify perioperative risk: patients with low uptake of oxygen at the anaerobic threshold are known to have worse perioperative outcomes, and prehabilitation may offer the chance to reduce this risk. Intraoperative anaesthetic management is on a patient-by-patient basis but sub-normal hydration, epidural anaesthesia and steroids play a key role. Enhanced recovery after surgery programmes have improved perioperative outcomes while providing a potential economic benefit.

Conclusion

Despite very good perioperative results, surgical management is not curative for the majority of patients, highlighting the need to further refine patient selection and definition of treatment aim on a patient-by-patient basis.

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Authors and Affiliations

  1. Liverpool Hepatobiliary Centre, Aintree University Hospital, Longmoor Lane, L9 7AL, Liverpool, UK

    Benjamin D Jones BMBS, Robert Jones PhD FRCS, Declan FJ Dunne FRCS, Tim Astles MBChB MRCP FRCA FFICM, Stephen W Fenwick FRCS, Graeme J Poston MS & Hassan Z Malik FRCS

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  1. Benjamin D Jones BMBS
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  2. Robert Jones PhD FRCS
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  3. Declan FJ Dunne FRCS
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Correspondence to Benjamin D Jones BMBS.

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Conflict of interest

B.D. Jones, R. Jones, D.F. Dunne, T. Astles, S.W. Fenwick, G.J. Poston and H.Z. Malik declare that they have no competing interests.

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Jones, B.D., Jones, R., Dunne, D.F. et al. Patient selection and perioperative optimisation in surgery for colorectal liver metastases. Eur Surg 50, 87–92 (2018). https://doi.org/10.1007/s10353-018-0539-8

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  • DOI: https://doi.org/10.1007/s10353-018-0539-8

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