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INDICATIONS

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A persistent rise in the carcinoembryonic antigen (CEA) level measured every 2 to 3 months during the postoperative years following resection of a colorectal malignancy is an indication for a thorough search for a possible recurrence. The original operation and pathologic reports are reviewed because they may provide a clue as to where the recurrence is located. A complete survey of the colon and rectum is done and the liver is fully studied with liver function tests and imaging scans (CT, MRI, PET-CT) as it is the principal site for metastatic disease Evidence of metastases to the lungs or diffuse involvement of the abdomen or bone generally contraindicates surgical intervention, but local excision is usually considered in a good risk patient with a definite steady increase in the CEA level. Further, a hepatic lobectomy may be considered for a metastasis too large for local excision. The 5-year survival rates following the removal of hepatic metastases tend to be encouraging. The patient should be fully informed of the uncertainty of being cured of recurrence of malignancy.

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PREOPERATIVE PREPARATION

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Multivitamins and adequate caloric intake are urged during the days of preoperative investigation. Antibiotics are given.

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ANESTHESIA

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A general endotracheal anesthetic is given. Catheters are placed in both arms for replacement of fluid and blood products if required.

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POSITION

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The patient is placed supine on the operating table in a slightly reverse Trendelenburg position.

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OPERATIVE PREPARATION

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The skin is prepared over the chest and abdomen down to the pubis.

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INCISION AND EXPOSURE

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An extended or bilateral subcostal incision can provide excellent exposure. Alternatively a liberal midline incision beginning over the xiphoid may be used.

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DETAILS OF PROCEDURE

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The peritoneum, the small and large intestines, the cul de sac, mesentery, and omentum are all inspected for evidence of metastases. The major concern will be the liver, especially if preoperative studies indicate probable liver involvement. If only one or two very small metastases are found in readily accessible locations, they can be excised or destroyed by cauterization. Diffuse multiple metastases should be considered to contraindicate extensive attempts at surgical excision of many sites of recurrence. Formal lobectomy may be considered in such circumstances.

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The liver is carefully inspected and palpated bimanually. In addition, the use of hand-held intraoperative ultrasound is very useful in the search for deep metastases and to map out the internal anatomy of the liver. Sufficient mobilization of the liver is advisable to visualize the dome and posterior aspects of the liver. The falciform and triangular ligaments are divided to ensure direct vision of all aspects of the liver. Fixation of the liver with tumor invading into the diaphragm posteriorly complicates the resection and should only be undertaken in ...

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