www.clinicalrobotics.com Videopresentaiton Houston 2011 Clinical Robotic Surgery Association Giulianotti Pier Cristoforo

1. PC GIULIANOTTI, MD, FACS

4. PC GIULIANOTTI, MD, FACS
ROBOTIC LIVER RESECTION FOR
NEUROENDOCRINE HEPATIC METASTASIS

5. Neuroendocrine liver metastases (NLMs)
46%–93% of patients with Neuroendocrine Tumors shows NLMs at
the time of diagnosis
Liver involvement is related to significantly worse prognosis
Surgical interventions forNLMs have consistently been shown to
have superior outcomes to nonoperative therapies
HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
MAYO SC ET AL. ANN SURG ONCOL. EPUB JUN 17 2011
FRILLING A ET AL. HPB, 12(6); 2010

6. NLMs
PROGNOSTIC FACTORS:
Tumor grade
Tumor size
Number
Location
In 2008, the ENETS (European Neuroendocrine Tumor Society) proposed
guideline for surgical resection based on the 3 distinct patterns of liver
involvement:
1.SIMPLE pattern of metastasis located in one or two contiguous lobes
(20–25%)
2.COMPLEX pattern where there is one major focus and other lesions are
contained in the contralateral lobe (10–15%)
3.DIFFUSE disease in both lobes (60–70%) SAXENA A ET AL. J SURG ONCOL. EPUB OCT 17 2011
YANG Z ET AL. AM J SURG PATH 35(6); 2011
FRILLING A ET AL. BR J SURG 96(2); 2009
STEINMULLER T ET AL. NEUROENDOCRINOLOGY 87(1); 2007

7. NLMs
Resection alone is supported by favorable long-term outcomes in large
retrospective trials
Complete surgical R0 treatment is an option for only 10 % of these
patients
Surgery remains the only potential for cure in patients with NLMs
Even in the setting of incurable disease, surgery offers the best chance for
prolonged survival
OPTIONS:
1. Surgery
2. Other Liver directed therapies
3. Non-Liver-Directed Therapies
HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
MAYO SC ET AL. ANN SURG ONCOL. EPUB JUN 17 2011

8. 1. Surgery
FIVE-YEAR SURVIVAL: greater than 60%, 80% in some selected series
Minimal mortality (<5%) and morbidity (<30%) reported
Cytoreductive surgery can be usually recommended only in cases where
>90% of the tumor volume can be excised
Recent review of 74 cases demonstrated a greater than 60% 5-year survival in all
patients underwent resection
FRILLING A ET AL. BR J SURG 96(2); 2009
GLAZER ES ET AL. HPB 12(6); 2010
FRILLING A ET AL. HPB, 12(6); 2010
SAXENA A ET AL. J SURG ONCOL. EPUB OCT 17 2011

9. 1. OLTx
Liver transplantation for neuroendocrine tumors is one of the only
accepted indications for metastatic disease
185 liver transplants performed for metastatic neuroendocrine tumors in
the United States at March 2011
The overall 5-year survival: 57.8%
- worse than the 74% 5-year survival for all other patients
- good for this group of patients
OLTx criteria:
(1) not a resection candidate
(2) identification and complete resection of primary
malignancy at least one year prior to evaluation
(3) no evidence of extrahepatic disease demonstrated on
cross-sectional imaging or nuclear medicine scan
(4) evidence of stability of disease for at least one year
(5) failure of nonoperative treatments
TREUT YP ET AL. AM J TRANSPL 8(6); 2008
MATHE Z ET AL. TRANSPLANTATION 91(5); 2011
HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011

10. 2. Other Liver directed therapies
NETs are predisposed to form highly vascular metastatic lesions in the
liver and derive more than 90% of their oxygenation and nutrition from
the hepatic artery
1. Radiofrequency Ablation
2. Hepatic Artery Embolization
3. Hepatic Artery Radioembolization
4. Selective Radiation Therapy
HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011

11. 3. Non-Liver-Directed Therapies
Lack of consensus on a nonsurgical treatment algorithm
No comparative studies
OPTIONS:
1. Chemotherapy
2. Peptide Receptor Radionuclide Therapy
3. Somatostatin Analogs
4. Interferon-α
5. Targeting mTOR Pathway
6. Targeting Vascular Endothelial Growth Factors

12. NLMs Algorithm
Modified from: HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011

13. Minimally invasive approach
STATEMENTS
Recent studies have shown similar perioperative and
long-term outcomes of anatomic and non-anatomic
liver resection
Multiple simultaneous parenchyma-sparing resections
should be preferred over single major resection
in case of multiple lesions
LAPAROSCOPIC TECHNIQUE
Facilitate concomitant multiple resections as well as repeated
resections due to minimal adhesion formation
BUT
The parenchyma-sparing liver resection is challenging in laparoscopy,
principally for posterosuperior segments
KING J ET AL. CANCER 113(5); 2008
STROSBERG JR ET AL. CANCER CONTROL 18(2); 2011
KHASRAW MJ ET AL. CLIN GASTROENT 43(9); 2009

14. Minimally invasive approach
From: EDWIN B. SC J SURG; 2011

15. Robotic Liver Resection
No metanalysis, no randomized controlled comparisons
2010

16. Robotic Liver Resection

17. Our Experience
113 Robotic Liver resections
55 males and 58 females
Mean age 55.3 yrs (range 20 – 84)
Major Hepatectomies: 48
Right hepatectomy 32 pts
Left hepatectomy 5 pts
Extended right hepatectomy 4 pts
Extended left hepatectomy 3 pts
Trisegmentectomy or multiple (>3 segments) resections 4 pts
Minor Resections: 65
Segmentectomy 21 pts
Bisegmentectomy 19 pts
Left lateral sectionectomy 11 pts
Wedge resections 14 pts

18. Case report
70- year old lady
bowel obstruction from an intussusception at the ileum in March 2008
associated with liver mass (CT scan)
Emergency laparotomy, ileocolic resection and liver biopsy
Pathology report: metastatic carcinoid tumor of the distal ileum
PLAN:
- Robotic segmentectomy of segments 5 versus right hepatectomy
- CT Liver volumetry

19. Case report
VOLUME:
865 cc total liver
595 cc right liver
1.9 x 1.7 cm low attenuating lesion within the inferior right hepatic lobe

20. Case report
Wedge resection V segment
Total Operative Time: 180 minutes
Estimated Blood Loss: 350 cc
Hospital stay: 4 days
Follow up:
Alternating CT scan and PET scan
Alive without evidence of recurrence at 40 months

21. Parenchymal-sparing surgery

22. Parenchymal-sparing surgery

23. Conclusions
Minimally invasive liver resections for neuroendocrine mets have a
role in the treatment of this disease.
Minimally invasive surgery presents a lot of advantages for this
application and also have some limitations.
Robotic surgery seems to overcome the limitations of laparoscopy
and expands the role of minimally invasive approachs