Synchronous colorectal liver metastases

Colorectal cancer is one of the most common malignancies worldwide and ranks second in cancer-related deaths in many parts of the Western world. Once in the lymph or blood vessels, colorectal cancer can quickly spread and the liver is known to be a favourable site for metastases. The presence of colorectal liver metastasis (CLM) is associated with a poor outcome. In last centuries new developments in techniques and anatomical knowledge have improved the outcome for this group of patients. Kousnetzoff and Pensky (1896) suggested the use of haemostasis by electrocautery, tourniquet, and suturing with flexible needles for controlling bleeding. The Pringle manoeuvre (1908), a technical advance which established the vascular control of the liver by compressing the portal triad, was a major step in surgery. Different techniques to reduce bleeding followed, including ligation, vascular and aortic clamping. Topographic liver anatomy generally describes the liver in terms of four lobes: right, left, quadrate, and caudate. However, the veins, arteries, and bile ducts of the liver do not conform to this anatomic division. Healey (1953) used the hepatic arteries and bile ducts as the basis of division and Couinaud (1957) the portal and hepatic veins. In 1999 Couinaud described that the portal and hepatic vein segmentation has to be preferred over the arteriobiliary segmentation. Throughout the world, liver surgeons used different terms. In 2000, a group of international liver surgeons proposed a standardized Nomenclature. The use of Brisbane 2000 terminology of hepatic anatomy and resection has led to better communication among surgeons. Many technical tools in the last 20-30 years further refined hepatic surgery: the concept of routine intraoperative ultrasonography for liver surgery, vena portal embolization (VPE) and the introduction of the ultrasonic dissector for division of the hepatic parenchyma. The introduction of low central venous pressure anaesthesia and vascular inflow and outflow control were essential to minimize blood loss during hepatectomy. Today, resection for liver metastasis provides favourable outcomes compared with the natural history.

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