A multidisciplinary approach is certainly needed for this decision. In our department we review all cases in a weekly meeting with the participation of medical oncologists, liver surgeons and radiologists. I believe that a liver surgeon should always be involved in the decision for such complex cases, some of which may be successfully downstaged by chemotherapy or SIRT and be suitable for surgery. Another group of patients may also be suitable for surgical clearance of one lobe, then portal vein embolisation of the other lobe and finally second operation for resection of the embolised lobe. Obviously, this complex management cannot be made without the presence of a liver surgeon.

MDT will decide which is the best approach for this particular clinical scenario.

Hepatic surgeon is influencing the decision based on the current evidence based medicine.The decision is undertaking after assessing the case as holistic approach;of course depending on ASA grading,distant mets,size ,number and accessibility.

The hepatic resection for colorectal mets is evolving field and we see more and more patients included in resectional category compared to 10 years ago.

a multidisciplinary approach is used in our hospital, weekly oncology meeting with surgeons, oncologists, radiologists, radiotherapist, nuclear physician, internist (gastro-intestinal specialist), pathologist

Thank you for your comments. OK, multidisciplinary team makes the treatment plan and this is widespread policy. But who is the guy in this team deciding resectability? Is it always HPB surgeon or not?

everybody in the MDT gives arguments and the team decides as a whole. If the interventionalist radiologist thinks he/she can play a role h e gives arguments for that. Decisions are also based upon existing evidence and guidelines. The oncologist is presiding the meeting, decisions are taken with consent of the entire team.

In my center, the case is discussed in the tumor board, with full agreement among surgeons, oncologists and radiologists. However, the final decission is strongly influenced by the liver surgeon opinion.

Good for your patients, Juan. My question is provoked by the existing current conflict between advances in the treatment of CRC metastatic to the liver, and the still widely applicable practice not to offer curative surgery to resectable patients. If you look at the population-based data from different countries you will see, that frequently hepatic resection is not offered even for many easily resectable patients with solitary metastases. All we know is that resection determines the outcome and is still the only curative option for those patients. There is something wrong here – surely those patients also had MDT consultation. So who is responsible about the judgment of resectability in MDTs at your centers? Whose is the final word?

As I mentioned before, although full agreement is aimed, the most important opinion is that of the liver surgeon, in my center. This is probably influenced by the fact that our oncologist are fully aware that R0 resection is the main aspect of the liver metastasis treatment.

I fully agree with all of you in terms of discussion within an MDT. Especially in complicated cases the HPB surgeon must be part of the MDT meeting as latest techniques as ex vivo liver resection, superselective embolization or treatment of metastases, radiofrequency ablation and combined approaches.

Hi, MDT has to make the decision! On the other hand you have to be very aware of the potential of your own center. Probably a good hepatic surgeon is missing, or you can find a better one somewhere else. Based on the concept that the first is the interest of the patient, if your local surgeon consider your patient inoperable, you can always can get a second opinion from somebody else....

At the end of MDT discussion HPB surgeon has the influencing decision to operate .This doesn't mean ignoring other team members opinion,

In vast majority of cases the agreement is achieved bases on the available patients data. In some gray area cases , two options are usually available , the first one is to go for resection provided the patient agree for the risks or to go for second option of other adjuvants to downstage and then resection.Some of these patients ,of course declining major hepatic resection .

I had never seen in past 10 years a resectable patient to refuse hepatectomy after through informing discussion. Actually the mortality from hepatectomy for CRC liver mets in experienced hands is lower than the mortality from toxic events related to modern chemotherapy.

In our centre both oncology and HPB surgery see every patient, even the initially unresectable patients since some of these will become respectable in the future after chemotherapy. This is important since a portal vein embolization or a staged resection can render some of these patients operable but the opportunity may be missed if surgery is not also following these patients. After the initial visits the patients are presented at HPB Tumor Board. The oncologists, surgeons, interventional radiologists, and radiation oncologists are present, every one is trying to determine how many patients can be converted to a resectable state, i.e. everyone believes that a resected patients is better off. There is no question about the patients that is resectable at presentation, barring other medical conditions they will be offered surgery. it is important that every centre bring all the parties to the table and have a discussion driven by the literature and get buy in for an in-house protocol for these patients, this may need to be done every 2-3 years. The protocol should reflect the centres strengths and attempt to boost their weaknesses.

“…The oncologists, surgeons, interventional radiologists, and radiation oncologists are present, every one is trying to determine how many patients can be converted to a resectable state…”. I think that’s the key today Peter. Thank you for your comment.

Dear Peter, is this protocol of your Department available somehow?

It's a blanket policy in our institution that any patient with colorectal liver mets gets discussed in the liver MDT, whether deemed respectable or not. As therapy for such lesions is changing. Multiple/bilateral lesions which were deemed unresectable until recently are being offered liver resections.

In every hospital with a MDT I think it is good clinical practice to discuss these patients and the MDT decides how to treat these. But I am full of doubt, that every decision in MDT's is balanced and rational and is based on the principles of evidence-based medicine! A German proverb simplifies this:" If a man has an hammer, every screw looks like a nail."