Anatomical Left Hepatectomy Extended to Caudate Lobe due to Colorectal Metastasis with Intrabiliary Growth: Securing Optimal Margins with a Laennec's Capsule Approach and Vein-Guided Resection

INTRODUCTION
Metastases of colorectal cancer (CRLM) present in up to 15% of cases an intrabiliary growth pattern (IGP) resembling cholangiocarcinoma behavior. An appropriate diagnosis is paramount, as IGP modifies the surgical strategy.

PATIENT AND METHODS
We present the case of a patient diagnosed with sigmoid cancer and synchronous liver metastases. Magnetic reso- nance imaging confirmed a solitary metastasis in segment II with dilatation of the segment II/Spiegel lobe radicals and delay in contrast washing, suggesting IGP. Due to the uncertainty of the extension of the IGP, neoadjuvant chemo- therapy was chosen.

Due to the IGP, an anatomical left hepa- tectomy extended to the Spiegel lobe was recommended. To obtain an optimal biliary duct margin, a double strategy was designed: the hilar bifurcation was optimally exposed begin- ning with a hilar plate cholecystectomy (helpful maneuver to access and expose the hilar plate, furthermore, since the patient did not have cirrhosis, this minimizes the risk of entering the liver), combined with an intraglissonian indi- vidual division of the elements. The “proper” tumor margin was secured with a vein-guided resection following the mid- hepatic vein as a reference.

RESULTS
Operative time was 400 min with minimal blood loss. The patient was discharged on the fourth postoperative day. Path- ological examination confirmed a moderately differentiated CRLM with IGP and a surgical-free margin, and 10 months after liver surgery, the patient is free of disease.

CONCLUSIONS
IGP influences the spread of disease, conditioning a greater probability of local recurrence if not treated cor- rectly. Complete anatomical resection is the treatment of choice to provide the best oncological results.

CITA DEL ARTÍCULO  Ann Surg Oncol. 2024 Mar 22.  doi: 10.1245/s10434-024-15174-3