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. However, the liver is the chief organ to be investigated by imaging scans (CT, MRI, PET-CT), abdominal echograms, and liver function studies as well as a complete survey of the colorectal system by colonoscopy. 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. Radio immuno-guided detection of recurrent malignancy may be useful in localizing metastasis which otherwise would be missed as well as providing evidence of complete resection of the tumor. The 5-year survival rates following the removal of hepatic metastases tend to be encouraging. The patient should be fully informed of the reasons for the “second look” exploration as well as the uncertainty of being cured of recurrence of malignancy.
Multivitamins and adequate caloric intake are urged during the days of preoperative investigation. Antibiotics are given.
A general intratracheal anesthetic is given. Catheters are placed in both arms for replacement of fluid and blood products if required.
The patient is placed supine on the operating table in a slightly reverse Trendelenburg position.
The skin is prepared over the chest and abdomen down to the pubis.
An extended or bilateral subcostal incision can provide excellent exposure. Alternatively a liberal midline incision beginning over the xiphoid may be used.
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.
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. Sufficient ...