What is the recommended resection strategy for an elderly patient with sigmoid colon cancer and multiple metastases in the right liver lobe?

Staged Resection Strategy for Elderly Patients with Sigmoid Colon Cancer and Multiple Right Liver Lobe Metastases

For elderly patients with sigmoid colon cancer and multiple metastases in the right liver lobe, a staged approach with primary tumor resection followed by liver resection (option D) is the recommended strategy to minimize perioperative morbidity and mortality. 1

Rationale for Staged Approach

• The staged approach reduces physiological stress, which is particularly important in elderly patients with potentially reduced functional reserve 2
• Simultaneous resection carries higher risk of major morbidity and 30-day mortality compared to staged approaches, especially when major hepatectomy is required 2
• Multiple metastases in the right lobe typically require major hepatectomy, which increases surgical risk when performed simultaneously with colorectal resection 1

Preoperative Assessment and Planning

• Complete staging with CT of chest, abdomen, and pelvis is essential to evaluate both primary tumor and metastatic disease 2
• Liver-specific imaging should be performed according to protocols agreed with the hepatobiliary unit 2
• Assessment of patient's physiological status and fitness for surgery is crucial, as the liver surgeon and anesthetist should make the clinical decision regarding fitness for surgery 2

Surgical Strategy Algorithm

1. First Stage: Resection of sigmoid colon primary with appropriate lymphadenectomy

   • Ensures removal of symptomatic primary tumor
   • Allows patient recovery before major liver surgery
   • Consider laparoscopic approach when feasible to reduce surgical trauma 2

2. Interval Period:

   • Consider systemic chemotherapy between surgeries to control disease
   • Monitor for disease progression with imaging
   • Allow for patient recovery and optimization

3. Second Stage: Liver resection for metastases

   • Goal is to remove all macroscopic disease with clear margins while preserving sufficient functioning liver (approximately one-third of standard liver volume) 2
   • Consider portal vein embolization if extensive right lobe resection is planned to induce hypertrophy of the future liver remnant

Special Considerations for Elderly Patients

• Older patients (>70 years) have 2-3 fold increased risk of postoperative mortality following liver resection compared to younger patients 2
• Despite increased mortality risk, disease-free survival is comparable between age groups, supporting surgical intervention when appropriate 2
• Laparoscopic approach for liver resection has shown significantly lower postoperative morbidity in elderly patients compared to open surgery 2

Potential Contraindications

• Uncontrollable extrahepatic disease 2
• Insufficient future liver remnant (less than one-third of standard liver volume) 2
• Medical unfitness for surgery (in which case, consider ablative therapy) 2

Pitfalls to Avoid

• Undertreatment based solely on chronological age - advanced age should not be regarded as a medical contraindication to liver resection for colorectal metastases 2
• Simultaneous major resections in elderly patients, which significantly increases perioperative risk
• Inadequate preoperative assessment of both primary and metastatic disease extent
• Failure to involve a multidisciplinary hepatobiliary team in treatment planning

By following a staged approach with primary tumor resection followed by liver resection, elderly patients with sigmoid colon cancer and multiple right liver lobe metastases can achieve optimal oncological outcomes while minimizing perioperative risks.