Simultaneous cytoreductive surgery, hyperthermic intraperitoneal chemotherapy and hepatectomy for colorectal peritoneal and liver metastases

Abstract

Background and Aim: Emerging publications about cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) for colorectal peritoneal metastases show encouraging outcomes. Simultaneous liver resection could offer a chance of cure to selected patients with liver and peritoneal metastases. Methods: We reported a patient with colorectal liver and peritoneal metastases that was managed with hepatectomy, CRS, and HIPEC to maximize the chance of survival. Results: A 45-year-old gentleman had laparoscopic right hemicolectomy for obstructing carcinoma of ascending colon in 2015. In view of bilobar liver metastases, palliative chemotherapy of XELOX and bevacizumab were given. He was referred to our center for consideration of liver resection in 2017. PET scan showed another metachronous carcinoma of rectum with liver metastases at left lobe and segment 5. In the multidisciplinary meeting, the plan was robotic total mesorectal resection (TME) followed by left hepatectomy. Robotic TME and loop ileostomy were performed uneventfully. Two months later, at the time of elective hepatectomy, diagnostic laparoscopy revealed peritoneal deposits at right flank peritoneum and around the ileostomy. Intraoperative frozen section confirmed metastatic adenocarcinoma; thus, hepatectomy was abandoned. Subsequent PET-CT scan showed static liver metastases 1 month later; therefore, synchronous CRS, HIPEC, closure of ileostomy, and hepatectomy were performed 3 months after rectal resection. Intraoperatively, the peritoneal cancer index was 7. Left lateral sectionectomy, wedge resection of segment 5, peritonectomy, closure of ileostomy, and HIPEC were performed, with complete cytoreduction (CC-0). Post-operatively, he recovered well apart from postoperative ileus. The patient remained disease free for 6 months. His latest PET scan showed small volumes of recurrent liver and peritoneal disease. He declined third line chemotherapy as he was asymptomatic. Conclusion: CRS/HIPEC and hepatectomy could be considered in highly selected patients with colorectal metastases with minimal postoperative morbidities when compared with systemic chemotherapy or biologics.