Case Presentation

Prof. Daniel Candinas

Klinik für Viszerale Chirurgie und Medizin

The long and winding road

• 76 y female Pat• Fit, plays golf, no specific complaints• Check-up for anemia• Large, non-stenosing Sigmoid Cancer• Staging

– CT, PET, Colonoscopy, EUS: – T3, Nx, M1

How would you proceed? A: Needs more tests

B: Needs Chemotherapy and Reassessment

C: Needs right sided PV Embolisation

D: Needs Hemicolectomie, Chemotherapy and Reassessment

E: needs Extended Right Hepatectomy

Chemotherapy and Reassessment

• Chemotherapy: 6 Cycles Oxaliplatin, CPT11 /Irinotecan, Capecitabine (OCX)

• Chemo well tolerated, no bowel symptoms (no obstruction), weight stable

• Referral and Reassessment

Volumes Volume (relative)(in ml) (% of total)

----------------------------------------Resection 1049 ( 73.4%)----------------------------------------Remnant 360 ( 25.2%)----------------------------------------Cutting Plane 21 ( 1.5%)========================================Total 1430 (100.0%)

How would you proceed? A: Needs more Chemotherapy

B: Perform R-Hepatectomy plus L-Hemicolectomy

C: Perform L-Hemicolectomy plus R-PV Ligation

D: Perform L-Hemicolectomy, then continue Chemo

E: Perform L-Hemicolectomy plus RF Ablation

C: L-Hemicolectomy plus R-PV Ligation

• Safe L-Hemicolectomy• PV Pressures upon clamping

– R PV: 28 mm Hg– R posterior PV: 17 mm Hg– R post. + 50% tapering R anterior: 20mm Hg

• Postop. ascites manageable and reversible

3 weeks postop

7 weeks postop

How would you proceed? A: Forget it - TLC

B: Start Anticoagulation - Reassess

C: Perform R-Hepatectomy with Mesocaval Shunt

D: Perform R-Hepatectomy

E: Attempt PV recanalisation

8 weeks with oral anticoagulation

Modified R-Hepatectomy • No hilar dissection• Intrahepatic Glissonian approach to R Pedicle• Modified R-Hepatectomy• R-0 Resection

• Uneventul recovery• Readmitted 3 weeks postop for small bilioma• Percutaneous drainage

3 mts postop

Follow-up• Pulmonary Metastasis• Ongoing Chemotherapy• Progression of disease• Dies at 38 mts