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