Laparoscopic hepatectomy for patients who received enterostomy.

BACKGROUND: Laparoscopic hepatectomy is more conducive to the rapid rehabilitation of patients after surgery compared with open hepatectomy. However, there have been no reports on performing laparoscopic resection for liver metastases in enterostomy patients. MATERIALS: From December 2016 to April 2017, the Liver Surgery Department of the Peking Union Medical College Hospital received three patients who had focal liver lesions after colorectal cancer surgery and enterostomy. We performed laparoscopic hepatectomy for these three patients and reviewed relevant literature.
RESULTS: All of these three patients' post-operative recovery was good. We found three different positions of the stomas and the corresponding abdominal adhesions in these three patients. We also summarised several possible related surgical techniques.
CONCLUSION: For patients with colorectal cancer and enterostomy after an operation, implementation of laparoscopic hepatectomy is feasible. Further research is still required for a more comprehensive assessment of this surgical approach.

INTRODUCTION

Colorectal cancer is a common digestive system tumour and its incidence is 0.023% worldwide, with a yearly increase in incidence.[1] In China, the incidence rate of colorectal cancer has increased more significantly than that in other countries.[2] Surgery-based comprehensive treatment greatly improves the survival of patients with colorectal cancer. About 8.6% of surgical patients require permanent or temporary enterostomy in colon cancer patients, and the figure is 54.5% in rectal cancer patients.[3] In addition, 30% to 50% of these patients undergo liver metastases.[4567] For treatment of patients with colorectal cancer with liver metastases, surgery-based multidisciplinary treatment (MDT) is currently advocated. The MDT model can significantly improve the 5-year survival rate of patients with colorectal cancer and liver metastases.[89] With the progress of laparoscopic hepatectomy, and increasing amount of colorectal cancer liver metastases can be removed under laparoscopy. Laparoscopic hepatectomy is more conducive to rapid rehabilitation of patients after surgery compared with open hepatectomy and improves the long-term survival rate.[10] However, there have been no reports on performing laparoscopic resection for liver metastases in enterostomy patients.

MATERIALS AND RESULTS

From December 2016 to April 2017, the Liver Surgery Department of the Peking Union Medical College Hospital received three patients who had focal liver lesions after colorectal cancer surgery and enterostomy. We implemented laparoscopic hepatectomy for these three patients and raised some surgical techniques according to our experiences. These three cases are described below. Appropriate written consents, permissions and releases were obtained.

Case 1

The patient was a 38-year-old male who had a rectal cancer operation 1 year ago. He was admitted to hospital in December 2016, 1 month after finding a focal liver lesion. One year ago, the patient underwent colonoscopy in another hospital because of changes in bowel habits and blood in the stool. There was irregular uplift in the mucous membrane 6 cm away from the anus. A biopsy showed the pathology of glandular epithelial high-grade intraepithelial neoplasia (glandular epithelial dysplasia and canceration). Therefore, he received abdominal perineal resection of the rectal cancer and sigmoid colon neostomy (Mile's surgery) (3 cm from the lower left area of the navel). Post-operative pathology showed the following: (rectal) ulcer type, adenocarcinoma (moderate differentiation) and cancer tissue invaded into the full intestinal wall layer and surrounding adipose tissues. Cancer tissue was observed within the lymph nodes near the tumour (5 positive lymph nodes in 6 lymph nodes). No cancer tissue was observed in the lymph nodes at the vascular ligation and the upper and lower margins were negative. The patient underwent a six-course fluorouracil, leucovorin and oxaliplatin 4 chemotherapy after the operation. No abnormalities were observed within 6 months after the operation. One month ago, computed tomography (CT) showed a quasi-circular, flaky, low-density lesion with a diameter of 1.6 cm in the left hepatic lateral lobe. The lesion had an unclear border and uneven enhancement, and we considered that it was metastasis [Figure 1a]. When the patient visited our department, he showed improvement in a pre-operative examination, and we performed laparoscopic exploration and left hepatic lateral lobe resection. The surgical observation port was located away from the original incision. We performed open pneumoperitoneum with a pressure of 11 mmHg. There was serious adhesion around the fistula and serious pelvic adhesion. Mild adhesion on both sides of the abdominal wall and around the liver was also observed in the operation [Figure 1b and c]. This adhesion did not affect the liver operation, and thus left hepatic lateral lobe resection was performed. After the operation, the patient recovered well and was discharged on the 4th day after the operation. Post-operative paraffin pathology showed moderately differentiated adenocarcinoma with a large area of necrosis. We considered that this was liver metastatic adenocarcinoma with a large amount of necrosis, but it did not invade the liver capsule, and close to the cross-section. Immunohistochemical results were as follows: alpha-fetoprotein (−), cytokeratin (CK) 20 (+), cell adhesion molecule (CAM) 5.2 (+), CK 19 (+), cluster of differentiation (CD) 34 (blood vessel +), caudal-type homeobox transcription factor 2 (CDX-2) (−), carcinoembryonic antigen (+), CK 7 (partially +), glypican 3 (−), hepatocytes (−), Ki-67 index of 80% and Villin (+) [Figure 1d].

Figure 1

(a) The computed tomography image of the case 1. (b) The intraperitoneal condition observed by laparoscopy. ① ligamentum teres hepatis, ② adhesive tissue, ③ liver, ④ omentum tissue. (c) The intraperitoneal condition observed by laparoscopy. ⑤ observation trocar, ⑥ the sigmoid colon with a stoma ⑦ the adhesive omentum around the stoma. (d) The postoperative paraffin pathology of the liver lesion in case 1

Case 2

The patient was a 57-year-old woman in her 4th year after a rectal cancer operation. She was admitted to hospital in December 2016, 3 years after finding a focal liver lesion. Four years ago, the patient underwent colonoscopy in another hospital because of an anal bulge. A ring cavity neoplasm was observed in the rectum 5 cm to 8 cm away from the anus, accounting for two-thirds of the enteric cavity. The neoplasm was crisp and easily bled after contact. A biopsy of the neoplasm showed the pathology of moderately differentiated adenocarcinoma. Rectal cavity ultrasound showed that the adenocarcinoma was 7 cm to 8 cm from the anus, with a size of 4.22 cm × 0.50 cm. The adenocarcinoma was relatively even in internal echo and had a relatively smooth surface, suggesting UT3N1. Neoadjuvant therapy was performed with 25 times of radiotherapy and two courses of capecitabine and oxaliplatin (XELOX) regimen. A review of rectal cavity ultrasound showed that the original lesion size was 2.42 cm × 0.68 cm, suggesting UT3N1. Therefore, laparoscopic radical resection of rectal cancer and transverse colostomy was performed between the navel and xiphoid. Post-operative pathology showed slightly poorly differentiated residual adenocarcinoma in the intestines, which invaded into the deep muscular layer. In the intestinal wall, a large number of foam cells with calcification were present, as well as multinucleated giant cells. No cancer was observed on the upper, lower and side incisal margins as well as another sampled specimen. The lymph nodes showed chronic inflammation. Post-operative recovery was smooth and the stoma defecation was smooth. Six-course XELOX chemotherapy was then applied. With an obvious scar reaction near the rectal anastomosis opening, obstruction may have been present locally; therefore, no stoma apothesis was applied. In a follow-up 3 years ago, CT showed a new low-density lesion in the left hepatic lobe, and a regular review showed slow growth of the low-density lesion. In a follow-up 1 month ago, the lesion had increased to 2.6 cm, with mild arterial enhancement. There appeared to be oedema in the surrounding area, weak portal-phase enhancement [Figure 2a-c] and transverse colostomy was observed in the abdominal wall under the liver [Figure 2d]. Liver magnetic resonance imaging (MRI) showed slightly long T1 and slightly long T2 signal nodule in the IVa segment of the liver, mild enhancement in the arterial-phase and weak in the portal-phase. The patient had a history of gallstones for longer than 10 years. After the patient visited our department and showed improvement pre-operative examination, a laparoscopic exploration was carried out, along with left liver tumour resection and cholecystectomy. A surgical observation port was made at 2 cm from the upper right of the navel. We performed open pneumoperitoneum with a pressure of 11 mmHg. After entering the abdominal cavity, adhesion around the transverse colon stoma was observed, similar to a curtain blocking the liver. Appropriate adjustment of the laparoscope, we enabled to pass through the adhesive area to observe the liver. After appropriately separating the adhesion around the liver, a trocar was placed in the appropriate location to conduct liver neoplasm resection [Figure 3]. The patient's post-operative recovery was smooth and she was discharged at day 5 after the operation. Post-operative paraffin pathology showed chronic cholecystitis with cholesterol polyps and gallstones, and the liver neoplasm was in line with the colon cancer liver metastasis.

Figure 2

The computed tomography images of the case 2. (a) It shows a low-density lesion at the interface of the left and right hepatic lobe in plain phase. (b) The lesion is mild enhanced in arterial phase. (c) The enhancement declined in portal phase than arterial phase and is weak. (d) the image of the transverse colostomy in the computed tomography scan

Figure 3

The intraoperative images of the case 2

Case 3

The patient was a 62-year-old woman. Within 1 year after a rectal cancer operation, and 1 month after finding a focal liver lesion, she was admitted to hospital in April 2017. Because of blood in the stool 1 year ago, the patient underwent electronic colonoscopy. This procedure showed huge iati polyps in the rectum approximately 5 cm away from the anus, and this was 3.5 cm × 4 cm and the top was sunken and erosive. Lesion tissue biopsy showed rectal highly/moderately differentiated adenocarcinoma. Neoadjuvant therapy was performed, with 25 times of radiotherapy and three courses of XELOX regimen. Laparoscopic low rectal anterior resection and ileostomy (3 cm below the navel) were then performed. The patient had a regular post-operative follow-up and received a five-course XELOX regimen chemotherapy. In a 1-month follow-up, CT suggested a nonsignificantly enhanced, slightly low-density flaky lesion in the left hepatic lobe, with a diameter of approximately 2.0 cm. An enhanced scan showed mild enhancement in three phases. Moreover, a low-density lesion of approximately 1 cm was also observed in the VI segment of the liver. The lesion was mildly enhanced with peripheral area in arterial phase and an apparently mildly enhanced in portal phase. We considered that all of these signs indicated metastasis. Dynamic MRI of the liver showed long T1 and slightly long T2 signal nodules in the IVa and VI segments of the liver. The larger nodule was located in the IVa segment, with a size of 2.0 cm × 2.3 cm. Diffusion-weighted imaging showed a high signal. The apparent diffusion coefficient value was decreased. Moreover, a dynamic enhanced scan showed ring enhancement, with blurred edges [Figure 4a-d]. After the patient visited our department and showed improvement in a pre-operative examination, we performed laparoscopy, ultrasound-guided radiofrequency ablation, and hepatic segmentectomy of the right liver. After intra-operative anaesthesia was completed, ultrasound-guided IVa tumour radiofrequency ablation (Olympus T40; energy of 29 KJ, needle was inserted twice) was applied. Open pneumoperitoneum was conducted at 2 cm from the right side of the navel, with a pressure of 11 mmHg. After entering the abdominal cavity, mild adhesion was observed at the pelvic cavity near the stoma, with mild adhesion on both sides of the abdominal wall and no obvious adhesion near the liver. Therefore, segment VI resection was performed. Post-operative recovery was successful and the patient was discharged on the 4th day after the operation. Post-operative paraffin pathology showed moderately differentiated adenocarcinoma in the liver (mostly mucinous adenocarcinoma), which was close to the liver capsule and did not involve cross section. The patient's history and immunohistochemical results suggested a rectal source of the adenocarcinoma. Immunohistochemical results were as follows: CAM5.2 (partially +), CD 10 (−), CK 20 (+), CK 7 (−), CDX-2 (+) and CK19 (partially +).

Figure 4

The dynamic magnetic resonance imaging of the liver in case 3. It shows a neoplasm at the interface of the left and right hepatic lobe. (a) It shows a long T1 signal of the neoplasm in T1 phase. (b) It shows a long T2 signal of the neoplasm in T2 phase. (c) The neoplasm shows a ring enhancement in arterial phase. (d) The neoplasm shows a ring enhancement in portal phase similar to the arterial phase

DISCUSSION

Colorectal cancer is a common malignant tumour of the digestive system, and its incidence increases yearly.[11] In 2012, approximately 1.36 million people worldwide were diagnosed with colorectal cancer, and approximately 690,000 people died of colorectal cancer. In 2015, the incidence of colorectal cancer in China was approximately 376,000 and approximately 190,000 patients died.[12] In treating colorectal cancer, approximately 8.6% of patients with colon cancer and 54.5% of patients with rectal cancer require permanent or temporary enterostomy.[3] In China, approximately 100,000 new cases of permanent enterostomy are found each year, with approximately 1 million cases at present.[13]

The liver is the most important target organ for metastasis of colorectal cancer via blood. Liver metastasis occurs in approximately 30%–50% of patients with colorectal cancer. Colorectal cancer liver metastasis can be divided into simultaneous liver metastasis and metachronous liver metastasis. Liver metastasis occurs in 15%–25% of patients with colorectal cancer after radical resection (i.e., metachronous liver metastasis).[4567] Liver metastasis is the leading cause of death in patients with colorectal cancer. For patients with colorectal cancer and liver metastases, resection of the liver metastasis lesion may be the most effective treatment for prolonged survival. The 5-year survival rate for patients who have no resection of liver metastasis is nearly 0%–4%. The 5-year survival rate is 30%–50% for patients with complete resection of liver metastasis.[141516] With development of the MDT model, an operation-based comprehensive treatment model should be implemented in patients with colorectal cancer and liver metastases. Individualised treatment programmes should also be developed to improve the prognosis of patients and extend the survival period. The MDT model can significantly improve the survival rate of patients with colorectal cancer and liver metastasis, and is an independent factor affecting prognosis.[89]

In the recent two decades, the rate of laparoscopic hepatectomy has gradually increased. For patients with colorectal cancer and liver metastases, laparoscopic hepatectomy is a proven, safe, and effective method of promoting rapid post-operative rehabilitation. Compared with open hepatectomy, laparoscopic hepatectomy has a higher R0 resection rate and 5-year survival rate.[1017] For patients with liver metastases after radical resection of colorectal cancer, when resection of lesions of liver metastasis is applied again, the history of abdominal surgery and serious abdominal adhesions are considered, and laparotomy is usually chosen. Untereiner et al.[18] and Hallet et al.[19] suggested that for patients with colorectal cancer and metachronous liver metastasis, laparoscopic hepatectomy can achieve the same effect as open hepatectomy, and does not increase the incidence of complications. However, for patients with enterostomy after colorectal cancer, there have been no reports on laparoscopic hepatectomy as far as we know. The three patients in this report had colorectal cancer and reserved enteral stomata after surgery. The position of stoma was in the lower left area of the navel in Case 1, between the xiphoid and navel in Case 2, and below the navel in Case 3. For the patient with a stoma below the navel, we found that intra-abdominal adhesion was mainly distributed around the stoma, and mild adhesion occurred in other locations. Adhesions above the navel did not affect liver surgery. For the patient with a stoma between the xiphoid and navel, we found adhesion around the stoma, and adhesion on the intestinal canal was involved in the stoma and the surrounding area similar to a curtain. When the observation mirror just entered, the field of view was tissue, which affected observation. However, after we adjusted the direction of the observation mirror, we could identify the abdominal wall with no adhesion, and safely placed the trocar to separate adhesion. According to our own experiences, for laparoscopic hepatectomy, abdominal adhesion can be divided into three levels. For the first level, adhesion is mainly located under the navel, which does not affect the operation. For the second level, adhesion is mainly located between the liver and navel. Moreover after careful separation, most patients can undergo the operation. For the third level, adhesion is located around the liver, and difficulty of separation increases, which can affect operation on the liver, increasing the probability of laparotomy. With the progress of laparoscopic technology and familiarity of skills, the proportion of successful separation of adhesion has gradually increased. There are also several possible related surgical techniques. Increased abdominal pressure may lead to overflow of intestinal contents. Therefore, appropriate intestinal preparation is conducted on the day before the operation by preoperatively placing gauze into the intestine and covering film on the stoma. When selecting the observational port, we chose a position far away from the stoma and this had a good view. When placing the first trocar, we made a small incision to avoid possible damage caused by blind passing. To avoid tearing of intra-abdominal adhesion caused by pneumoperitoneum, we first reduced the pneumoperitoneum to 10 mmHg to 11 mmHg and then increased it to 13 mmHg after the safety was ensured.

CONCLUSION

These three cases were the first time we attempted to perform laparoscopic hepatectomy for patients who received enterostomy. We found that the positions of the stomas are different in these three patients and the abdominal adhesions can be divided into three levels. We also summarised several possible related surgical techniques according to our own experiences. We believe that for patients with colorectal cancer and enterostomy after an operation, implementation of laparoscopic hepatectomy is a feasible surgery. Further research is still required to obtain objective evidence of benefits of this surgical approach versus open surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was supported by Chinese Academy of Medical Sciences (CAMS) Initiative for Innovative Medicine(CAMS-2017-I2M-4-002).

Conflicts of interest

There are no conflicts of interest.