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Hajibandeh S, Hajibandeh S, Sultana A, Ferris G, Mwendwa J, Mohamedahmed AYY, Zaman S, Peravali R. Simultaneous versus staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases: a meta-analysis of outcomes and clinical characteristics. Int J Colorectal Dis 2020; 35:1629-1650. [PMID: 32653951 DOI: 10.1007/s00384-020-03694-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To evaluate the comparative outcomes and clinical characteristics of simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases. METHODS We conducted a systematic search of electronic information sources, and bibliographic reference lists. Perioperative morbidity and mortality, anastomotic leak, wound infection, bile leak, bleeding, intra-abdominal abscess, sub-phrenic abscess, reoperation, recurrence, 5-year overall survival, procedure time, and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using random-effects model. RESULTS We identified 41 comparative studies reporting a total of 12,081 patients who underwent simultaneous (n = 5013) or staged (n = 7068) resections for colorectal cancer with synchronous hepatic metastases. There were significantly lower use of neoadjuvant chemotherapy (p = 0.003), higher right-sided colonic resections (p < 0.00001), and minor hepatic resections (p < 0.00001) in the simultaneous group. The simultaneous resection was associated with significantly lower rate of bleeding (OR 0.60, p = 0.03) and shorter length of hospital stay (MD - 5.40, p < 0.00001) compared to the staged resection. However, no significant difference was found in perioperative morbidity (OR1.04, p = 0.63), mortality (RD 0.00, p = 0.19), anastomotic leak (RD 0.01, p = 0.33), bile leak (OR 0.83, p = 0.50), wound infection (OR 1.17, p = 0.19), intra-abdominal abscess (RD 0.01, p = 0.26), sub-phrenic abscess (OR 1.26, p = 0.48), reoperation (OR 1.32, p = 0.18), recurrence (OR 1.33, p = 0.10), 5-year overall survival (OR 0.88, p = 0.19), or procedure time (MD - 23.64, p = 041) between two groups. CONCLUSIONS Despite demonstrating nearly comparable outcomes, the best available evidence (level 2) regarding simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases is associated with major selection bias. It is time to conduct high-quality randomised studies with respect to burden and laterality of disease. We recommend the staged approach for complex cases.
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Affiliation(s)
- Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Abida Sultana
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Gabriella Ferris
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Josiah Mwendwa
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rajeev Peravali
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Gavriilidis P, Katsanos K, Sutcliffe RP, Simopoulos C, Azoulay D, Roberts KJ. Simultaneous, Delayed and Liver-First Hepatic Resections for Synchronous Colorectal Liver Metastases: A Systematic Review and Network Meta-Analysis. J Clin Med Res 2019; 11:572-582. [PMID: 31413769 PMCID: PMC6681858 DOI: 10.14740/jocmr3887] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 06/17/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Systematic reviews and meta-analyses that compare simultaneous, delayed and liver-first approach for synchronous colorectal liver metastases have found no significant differences. The aim of this study was to determine the best treatment strategy on the basis of effect sizes and the probabilities of treatment ranking by using a network meta-analysis. Moreover, first-time pairwise and network meta-analyses were used to estimate the existing evidence, and their results were compared to detect any discrepancies between them. METHODS Systematic review, pairwise meta-analysis and network meta-analysis were performed. The primary and secondary outcomes were 5-year overall survival and postoperative major morbidity, respectively. RESULTS No significant differences in long-term survival and major morbidity were found amongst the three approaches. The hazard ratios (95% confidence interval) for 5-year overall survival for the simultaneous, delayed and liver-first approaches were 0.93 (0.69 - 1.24, P = 0.613), 0.97 (0.87 - 1.07, P = 0.596) and 0.90 (0.67 - 1.22, P = 0.499), respectively. Moreover, the liver-first approach with a surface under the cumulative ranking area score of 89% was ranked as the potentially best treatment option based on probabilities of treatment ranking. CONCLUSIONS On the basis of the relative ranking of treatments, the liver-first approach ranked first, followed by the delayed and simultaneous approaches. Therefore, a three-arm randomized controlled trial that compares the liver-first, simultaneous and delayed approaches needs to shed further light as to which is the best treatment option.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Konstantinos Katsanos
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, 26504 Patras, Greece
| | - Robert P. Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Constantinos Simopoulos
- The 2nd Department of Surgery, Medical School, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Daniel Azoulay
- Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, 94010 Creteil, France
| | - Keith J. Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
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Bizzoca C, Delvecchio A, Fedele S, Vincenti L. Simultaneous Colon and Liver Laparoscopic Resection for Colorectal Cancer with Synchronous Liver Metastases: A Single Center Experience. J Laparoendosc Adv Surg Tech A 2019; 29:934-942. [PMID: 30925103 DOI: 10.1089/lap.2018.0795] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: The one-stage approach for colorectal cancer (CRC) with synchronous liver metastases (SLM) has demonstrated advantages, when feasible, in terms of oncological radicality and reduction in sanitary costs. The simultaneous laparoscopic approach to both colon cancer and liver metastases joins the advantages of mini-invasiveness to the one-stage approach. Methods: During the period from February 2011 to July 2017, a single surgeon performed 17 laparoscopic colorectal operations with simultaneous liver resection for CRC with SLM. Colorectal procedures included 9 rectal resections, 6 left colectomies, and 2 right colectomies. Associated hepatic resections included 1 left hepatectomy, 1 right posterior sectionectomy, 2 segmentectomies, and 13 wedge resections. We analyzed retrospectively the patient's short-term outcome and operative and oncologic results. Results: There was no conversion to open surgery. Six patients (35%) had minor complications (Clavien-Dindo grade I-II), whereas only 2 patients (12%) had major complications (Clavien-Dindo grade III-IV) and no mortality occurred. The median time of discharge was 8.6 (range 5-36) days. We obtained 94% of R0 resection margin on the liver specimen and 100% of negative distal and circumferential margin in case of rectal resection. An average of 20 lymphnodes were retrieved in the colorectal specimen. Conclusions: Simultaneous mini-invasive colorectal and liver resection is a challenging but feasible procedure. The advantages of treating primary cancer and metastases in the same recovery justify the morbidity rate, especially because the most of the complications are minor and no cases of mortality occurred. Further experience is needed to better understand how to reduce the morbidity rate.
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Affiliation(s)
- Cinzia Bizzoca
- General Surgery "Balestrazzi" Polyclinics of Bari, Bari, Italy
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Gavriilidis P, Sutcliffe RP, Hodson J, Marudanayagam R, Isaac J, Azoulay D, Roberts KJ. Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:11-19. [PMID: 28888775 DOI: 10.1016/j.hpb.2017.08.008] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/30/2017] [Accepted: 08/08/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This was a systematic review and meta-analysis to compare outcomes between patients undergoing simultaneous or delayed hepatectomy for synchronous colorectal liver metastases. BACKGROUND The optimal strategy for treating liver disease among patients with resectable synchronous colorectal liver metastases (CRLM) is unclear. Simultaneous resection of primary tumour and liver metastases may improve patient experience by reducing the number of interventions. However, there are concerns of increased morbidity compared to delayed resections. METHODS A systematic literature search was performed using EMBASE, Medline, Cochrane library and Google scholar databases. Meta-analyses were performed using both random-effects and fixed-effect models. Publication and patient selection bias were assessed with funnel plots and sensitivity analysis. RESULTS Thirty studies including 5300 patients were identified. There were no statistically significant differences in parameters relating to safety and efficacy between the simultaneous and delayed hepatectomy cohorts. Patients undergoing delayed surgery were more likely to have bilobar disease or undergo major hepatectomy. The average length of hospital stay was six days shorter with simultaneous approach [MD = -6.27 (95% CI: -8.20, -4.34), p < 0.001]. Long term survival was similar for the two approaches [HR = 0.97 (95%CI: 0.88, 1.08), p = 0.601]. CONCLUSION In selected patients, simultaneous resection of liver metastases with colorectal resection is associated with shorter hospital stay compared to delayed resections, without adversely affecting perioperative morbidity or long-term survival.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK; Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, 94010 Créteil, France.
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - James Hodson
- Statistician at the Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK
| | - Ravi Marudanayagam
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - John Isaac
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - Daniel Azoulay
- Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, 94010 Créteil, France
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
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Takorov I, Belev N, Lukanova T, Atanasov B, Dzharov G, Djurkov V, Odisseeva E, Vladov N. Laparoscopic combined colorectal and liver resections for primary colorectal cancer with synchronous liver metastases. Ann Hepatobiliary Pancreat Surg 2016; 20:167-172. [PMID: 28261695 PMCID: PMC5325152 DOI: 10.14701/ahbps.2016.20.4.167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 09/24/2016] [Accepted: 09/26/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUNDS/AIMS Synchronous liver metastases (SLMs) are found in 15-25% of patients at the time of diagnosis with colorectal cancer, which is limited to the liver in 30% of patients. Surgical resection is the most effective and potentially curative therapy for metastatic colorectal carcinoma (CRC) of the liver. The comparison of simultaneous resection of primary CRC and synchronous liver metastases with staged resections is the subject of debate with respect to morbidity. Laparoscopic surgery improves postoperative recovery, diminishes postoperative pain, reduces wound infections, shortens hospitalization, and yields superior cosmetic results, without compromising the oncological outcome. The aim of this study is therefore to evaluate our initial experience with simultaneous laparoscopic resection of primary CRC and SLM. METHODS Currently, laparoscopic resection of primary CRC is performed in more than 53% of all patients in our surgical department. Twenty-six patients with primary CRC and a clinical diagnosis of SLM underwent combined laparoscopic colorectal and liver surgery. Six of them underwent laparoscopic colorectal resection combined with major laparoscopic liver resection. RESULTS The surgical approaches were total laparoscopic (25 patients) or hybrid technique (1 patients). The incision created for the extraction of the specimen varied between 5 and 8cm. The median operation time was 223 minutes (100 to 415 min.) with a total blood loss of 180 ml (100-300 ml). Postoperative hospital stay was 6.8 days (6-14 days). Postoperative complications were observed in 6 patients (22.2%). CONCLUSIONS Simultaneous laparoscopic colorectal and liver resection appears to be safe, feasible, and with satisfying short-term results in selected patients with CRC and SLM.
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Affiliation(s)
- Ivelin Takorov
- Clinic of Hepato-pancreato-biliary Surgery and Transplantology, Military Medical Academy, Sofia, Bulgaria
| | - Nikolay Belev
- Surgical Department, Eurohospital, Plovdiv, Bulgaria
| | - Tsonka Lukanova
- Clinic of Hepato-pancreato-biliary Surgery and Transplantology, Military Medical Academy, Sofia, Bulgaria
| | | | | | | | - Evelina Odisseeva
- Department of Anesthesiology and Intensive Care, Military Medical Academy, Sofia, Bulgaria
| | - Nikola Vladov
- Clinic of Hepato-pancreato-biliary Surgery and Transplantology, Military Medical Academy, Sofia, Bulgaria
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Simultaneous Minimally Invasive Treatment of Colorectal Neoplasm with Synchronous Liver Metastasis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9328250. [PMID: 27294144 PMCID: PMC4884597 DOI: 10.1155/2016/9328250] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
Purpose. To analyse perioperative and oncological outcomes of minimally invasive simultaneous resection of primary colorectal neoplasm with synchronous liver metastases. Methods. A Medline revision of the current published literature on laparoscopic and robotic-assisted combined colectomy with hepatectomy for synchronous liver metastatic colorectal neoplasm was performed until February 2015. The specific search terms were "liver metastases", "hepatic metastases", "colorectal", "colon", "rectal", "minimally invasive", "laparoscopy", "robotic-assisted", "robotic colorectal and liver resection", "synchronous", and "simultaneous". Results. 20 clinical reports including 150 patients who underwent minimally invasive one-stage procedure were retrospectively analysed. No randomized trials were found. The approach was laparoscopic in 139 patients (92.7%) and robotic in 11 cases (7.3%). The rectum was the most resected site of primary neoplasm (52.7%) and combined liver procedure was in 89% of cases a minor liver resection. One patient (0.7%) required conversion to open surgery. The overall morbidity and mortality rate were 18% and 1.3%, respectively. The most common complication was colorectal anastomotic leakage. Data concerning oncologic outcomes were too heterogeneous in order to gather definitive results. Conclusion. Although no prospective randomized trials are available, one-stage minimally invasive approach seems to show advantages over conventional surgery in terms of postoperative short-term course. On the contrary, more studies are required to define the oncologic values of the minimally invasive combined treatment.
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Comparison between simultaneous resection and staged resection of synchronous colorectal cancer with resectable liver metastases: a meta-analysis. Eur Surg 2014. [DOI: 10.1007/s10353-014-0286-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Castellanos JA, Merchant NB. Strategies for Management of Synchronous Colorectal Metastases. CURRENT SURGERY REPORTS 2014; 2:62. [PMID: 25431745 DOI: 10.1007/s40137-014-0062-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of synchronous presentation of colorectal cancer and liver metastases has long been a topic of debate and discussion for surgeons due to the unique dilemma of balancing operative timing along with treatment strategy. Operative strategies for resection include staged resection with colon first approach, "reverse" staged resection with liver metastases resected first, and one-stage, or simultaneous, resection of both the primary tumor and liver metastases approach. These operative strategies can be further augmented with perioperative chemotherapy and other novel approaches that may improve resectability and patient survival. The decision on operative timing and approach, however, remains largely dependent on the surgeon's determination of disease resectability, patient fitness, and the need for neoadjuvant chemotherapy.
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Affiliation(s)
- Jason A Castellanos
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nipun B Merchant
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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"Liver-first" approach for synchronous colorectal liver metastases: is this a justifiable approach? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:263-70. [PMID: 23325126 DOI: 10.1007/s00534-012-0583-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND To review the outcomes of patients with synchronous colorectal liver metastases (CRLM) treated by the "liver-first" approach. METHODS Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords "colorectal cancer", "liver-first", "reverse strategy", "liver metastases", "liver resection" and "hepatectomy". RESULTS There have been four retrospective studies that have reported the outcomes of patients with synchronous CRLM following the reverse strategy. The number of patients included ranged from 16 to 27. One study included patients with advanced rectal cancer and synchronous liver metastases only. None of the studies defined resectability for the CRLM. Overall, the morbidity and mortality rates were low. The recurrence rate ranged from 25 to 70 %. One study did not report survival data, and the overall 5 year survival ranged from 31 to 41 %. CONCLUSION The "liver-first" approach may be beneficial to a selected group of patients with synchronous CRLM. Patient selection is likely to be determined by their response to down-staging chemotherapy with or without biological agents.
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de Rosa A, Gomez D, Hossaini S, Duke K, Fenwick SW, Brooks A, Poston GJ, Malik HZ, Cameron IC. Stage IV colorectal cancer: outcomes following the liver-first approach. J Surg Oncol 2013; 108:444-9. [PMID: 24009161 DOI: 10.1002/jso.23429] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 08/12/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND To date, there is limited data on the liver-first approach in the management of colorectal liver metastases (CRLM). The aim of the study was to assess the outcomes of the liver-first approach for patients with synchronous CRLM in two tertiary referral centers. METHODS Patients with stage IV colorectal cancer selected for the liver-first approach from January 2009 to December 2012 in two tertiary referral centers were included. Data collated included demographics, chemotherapy, operative findings, histo-pathological features, and survival. RESULTS Thirty-seven patients with synchronous CRLM were considered for the liver-first approach. Twenty-five patients had rectal cancer. All patients underwent induction chemotherapy. Thirty patients underwent hepatic resections with no post-operative deaths. Following liver resection, five patients failed to proceed to colorectal resection and one patient had complete response to chemo-radiotherapy. Of the 25 patients that completed the liver-first approach, 13 patients had recurrent disease, of which 12 patients died. The overall 1- and 3-year survival rates were 65.9% and 30.4%, respectively. CONCLUSION The liver-first approach is a feasible strategy for patients with synchronous CRLM and may improve survival in selected patients. The selection of patients should be incorporated in a multidisciplinary approach to achieve the best possible outcomes.
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Affiliation(s)
- Antonella de Rosa
- Department of Hepatobiliary Surgery and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Hamed OH, Bhayani NH, Ortenzi G, Kaifi JT, Kimchi ET, Staveley-O'Carroll KF, Gusani NJ. Simultaneous colorectal and hepatic procedures for colorectal cancer result in increased morbidity but equivalent mortality compared with colorectal or hepatic procedures alone: outcomes from the National Surgical Quality Improvement Program. HPB (Oxford) 2013; 15:695-702. [PMID: 23458152 PMCID: PMC3948537 DOI: 10.1111/hpb.12031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 11/12/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Simultaneous colorectal and hepatic surgery for colorectal cancer (CRC) is increasing as surgery becomes safer and less invasive. There is controversy regarding the morbidity associated with simultaneous, compared with separate or staged, resections. METHODS Data for 2005-2008 from the National Surgical Quality Improvement Program (NSQIP) were used to compare morbidity after 19,925 colorectal procedures for CRC (CR group), 2295 hepatic resections for metastatic CRC (HEP group), and 314 simultaneous colorectal and hepatic resections (SIM group). RESULTS An increasing number of simultaneous resections were performed per year. Fewer major colorectal and liver resections were performed in the SIM than in the CR and HEP groups. Patients in the SIM group had a longer operative time and postoperative length of stay compared with those in either the CR or HEP groups. Simultaneous procedures resulted in higher rates of postoperative morbidity and major morbidity than CR procedures, but not HEP procedures. This difference was driven by higher rates of wound and organ space infections, and a greater incidence of septic shock. Mortality rates did not differ among the groups. CONCLUSIONS Hospitals in the NSQIP are performing more simultaneous colonic and hepatic resections for CRC. These procedures are associated with increases in operative time, length of stay and rate of perioperative complications. Simultaneous procedures do not, however, increase perioperative mortality.
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Affiliation(s)
| | | | | | | | | | | | - Niraj J Gusani
- Correspondence Niraj J. Gusani, Program for Liver, Pancreas and Foregut Tumors, Section of Surgical Oncology, Department of Surgery, Penn State College of Medicine, 500 University Drive, Mail Code H070, PO Box 850, Hershey, PA 17033-0850, USA. Tel: + 1 717 531 5965. Fax: + 1 717 531 3649. E-mail:
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Yin Z, Liu C, Chen Y, Bai Y, Shang C, Yin R, Yin D, Wang J. Timing of hepatectomy in resectable synchronous colorectal liver metastases (SCRLM): Simultaneous or delayed? Hepatology 2013; 57:2346-2357. [PMID: 23359206 DOI: 10.1002/hep.26283] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 01/06/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED The optimal surgical strategy for treatment of patients with synchronous colorectal liver metastases (SCLRM) remains controversial. We conducted a systematic review and meta-analysis of all observational studies to define the safety and efficacy of simultaneous versus delayed resection of the colon and liver. A search for all major databases and relevant journals from inception to April 2012 without restriction on languages or regions was performed. Outcome measures were the primary parameters of postoperative survival, complication, and mortality, as well as other parameters of blood loss, operative time, and length of hospitalization. The test of heterogeneity was performed with the Q statistic. A total of 2,880 patients were included in the meta-analysis. Long-term oncological pooled estimates of overall survival (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.81-1.14; P = 0.64; I(2) = 0) and recurrence-free survival (HR: 1.04; 95% CI: 0.76-1.43; P = 0.79; I(2) = 53%) all showed similar outcomes for both simultaneous and delayed resections. A lower incidence of postoperative complication was attributed to the simultaneous group as opposed to that in the delayed group (modified relative ratio [RR] = 0.77; 95% CI: 0.67-0.89; P = 0.0002; I(2) = 10%), whereas in terms of mortality within the postoperative 60 days no statistical difference was detected (RR = 1.12; 95% CI: 0.61-2.08; P = 0.71; I(2) = 32%). Finally, selection criteria were recommended for SCRLM patients suitable for a simultaneous resection. CONCLUSION Simultaneous resection is as efficient as a delayed procedure for long-term survival. There is evidence that in SCRLM patients simultaneous resection is an acceptable and safe option with carefully selected conditions. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion. (HEPATOLOGY 2013;57:2346-2357).
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Affiliation(s)
- Zi Yin
- General Surgery Department of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Safety of Simultaneous Bowel and Liver Resections for Colon and Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2013. [DOI: 10.1007/s11888-013-0168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Colorectal cancer with synchronous liver metastases: does global management at the same centre improve results? Clin Res Hepatol Gastroenterol 2013; 37:56-63. [PMID: 22537902 DOI: 10.1016/j.clinre.2012.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 01/31/2012] [Accepted: 02/14/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Synchronous liver metastases (SLM) occur in 20% of colorectal cancers (CRC). Resection of SLM and CLC can be undertaken at different centres (separate management, SM) or at the same centre (global management, GM). METHODS Retrospective study of SLM and CRC resections carried out during 01/2000 - 12/2006 by SM or GM, using a combined or delayed strategy. RESULTS Morphologic characteristics and type of CRC and SLM resection were similar for the GM (n = 45) or SM (n = 66) groups. In patients with delayed liver resection (62 SM, 17 GM), chemotherapy prior to liver surgery was used in 92% and 38% of SM and GM patients (P < 0.0001) and the median delay between procedures was 212 and 182 days, respectively (P = 0.04). First step of liver resection was more often performed during colorectal surgery in the GM group (62 vs. 6% for SM, P < 0.0001) and the mean number of procedures (CRC+SLM) was lower (1.6 vs. 2.3, P = 0.003). Three-month mortality was 3% for GM and 0% for SM (n.s.). Overall survival rates were 67% and 51% for SM and GM at 3 years (n.s.), and 35 and 31% at 5 years (n.s.). Disease-free survival to 5 years was higher in SM patients (14% vs. 11%, P = 0.009). CONCLUSIONS GM of CRC and SLM was associated with fewer procedures but did not influence overall survival. SM was associated with a longer delay and increased use of chemotherapy between procedures, suggesting that more rigorous selection of SM patients for surgery may explain the higher disease-free survival after SLM resection.
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Li ZQ, Liu K, Duan JC, Li Z, Su CQ, Yang JH. Meta-analysis of simultaneous versus staged resection for synchronous colorectal liver metastases. Hepatol Res 2013; 43:72-83. [PMID: 22971038 DOI: 10.1111/j.1872-034x.2012.01050.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIM There is no clear consensus on the optimal timing of surgical resection for synchronous colorectal liver metastases (SCLM). This study is a meta-analysis of the available evidence. METHODS Systematic review and meta-analysis of trials comparing outcomes following simultaneous resection with staged resection for SCLM published from 1990 to 2010 in PubMed, Embase, Ovid and Medline. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either the fixed effects or random effects model. RESULTS Nineteen non-randomized controlled trials (NRCT) studies were included in this analysis. These studies included a total of 2724 patients: 1116 underwent simultaneous resection and 1608 underwent staged resection. Meta-analysis showed that shorter hospital stay (P < 0.001) and lower total complication rate (P < 0.001) were observed in patients undergoing simultaneous resection group. The overall survival rate in the simultaneous resection group did not statistically differ with that in the staged resection group at 1 year (P = 0.13), 3 years (P = 0.26), 5 years (P = 0.38), as well as the 1, 3 and 5 years disease-free survival rates (respectively, P = 0.55; P = 0.16; P = 0.12). No significant difference was noted between the two groups in terms of mortality (P = 0.16), intraoperative blood loss (P = 0.06) and recurrence (P = 0.47). CONCLUSION Simultaneous resection is safe and efficient in the treatment of patients with SCLM while avoiding a second laparotomy. In selected patients, simultaneous resection might be considered as the preferred approach. However, the findings have to be carefully interpreted due to the lower level of evidence and the existence of heterogeneity.
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Affiliation(s)
- Zhi-Qing Li
- Medical College of Soochow University, Suzhou City, Jiangsu ProvinceDepartments of Hepatic Surgery Molecular Oncology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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Slesser AAP, Simillis C, Goldin R, Brown G, Mudan S, Tekkis PP. A meta-analysis comparing simultaneous versus delayed resections in patients with synchronous colorectal liver metastases. Surg Oncol 2012; 22:36-47. [PMID: 23253399 DOI: 10.1016/j.suronc.2012.11.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 11/25/2012] [Accepted: 11/26/2012] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The traditional surgical management for patients presenting with synchronous colorectal liver metastases (SCLM) has been a delayed resection. However, in some centres, there has been a shift in favour of 'simultaneous' resections. The aim of this study was to use a meta-analytical model to compare the short-term and long-term outcomes in patients with synchronous colorectal liver metastases (SCLM) undergoing simultaneous resections versus delayed resections. METHOD Comparative studies published between 1991 and 2010 were included. Evaluated endpoints were intra-operative parameters, post-operative parameters, post-operative adverse events and survival. A random-effects meta-analytical model was used and sensitivity analysis performed to account for bias in patient selection. RESULTS Twenty-four non-randomized studies were included, reporting on 3159 patients of which 1381 (43.7%) had simultaneous resections and 1778 (56.3%) had delayed resections. The bilobar distribution (P = 0.01), size of liver metastases (P < 0.001) and the proportion of major liver resections (P < 0.001) was found to be higher in the delayed resection group compared to the simultaneous resection group. There was no significant difference in operative blood loss (95% CI, -279.28, 22.53; P = 0.1) or duration of surgery (WMD -23.83, 95% CI, -85.04, 37.38; P = 0.45). Duration of hospital stay was significantly reduced in simultaneous resections by 5.6 days (95% CI: 2.4-8.9 days, P = 0.007) No significant differences in post-operative complications (36% vs 37%, P = 0.27), overall survival (HR 1.00, 95% CI 0.86-1.15, P = 0.96) or disease free survival (HR 0.85, 95% CI 0.71-1.02, P = 0.08) were found. Sensitivity analysis revealed that these findings were consistent for the duration of hospital stay, post-operative complications, overall survival and disease free survival. CONCLUSION This study demonstrates that the selection criteria for patients undergoing simultaneous or delayed resections differs resulting in a discrepancy in the metastatic disease severity being compared between the two groups. The comparable intra-operative parameters, post-operative complications and survival found between the two groups suggest that delayed resections may result in better outcomes. Similarly, the reduced length of hospital stay in simultaneous resections may only be as a result of the reduced disease severity in this group. Simultaneous resections can only be recommended in patients with limited hepatic disease until prospective studies comparing similar disease burdens between the two resection groups are available.
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Affiliation(s)
- A A P Slesser
- Department of Colorectal Surgery, The Royal Marsden Hospital, Fulham Road, London, UK
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Is there a role for simultaneous hepatic and colorectal resections? A contemporary view from NSQIP. J Gastrointest Surg 2012; 16:2074-85. [PMID: 22972010 DOI: 10.1007/s11605-012-1990-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 07/25/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The optimal timing of primary and metastatic tumor management in patients with synchronous hepatic colorectal metastases remains controversial. We aimed to compare perioperative outcomes of simultaneous colorectal/liver resection (SCLR) with isolated resections utilizing a national clinical database. METHODS NSQIP data from 2005 to 2009 were examined to construct risk-adjusted generalized linear models and to calculate group-specific predicted estimates. These were used to compare 30-day perioperative outcomes among patients undergoing SCLR with colorectal (CR) and liver resections (LR) only in patients with metastatic colorectal cancer. RESULTS A total of 3,983 patients were identified, who underwent SCLR (192), LR (1,857), or CR (1,934). Rectal resection was performed in 45 (23.4 %) SCLR patients and 269 (13.9 %) CR patients (p < 0.001). Major hepatectomy was performed in 69 (35.9 %) SCLR patients and 774 (41.7 %) LR patients (p = 0.12). Median adjusted operation time (SCLR: 273 min, 95 % CI: 253-295; CR: 172, CI: 168-177; LR: 222, CI: 217-228; p < 0.001) and median adjusted length of hospital stay (SCLR: 9.5 days, CI: 8.8-10.4; CR: 8.1, CI: 7.9-8.3; LR: 6.4, CI: 6.3-6.6; p < 0.001) were longer for SCLR compared to CR and LR. Adjusted predicted risks for at least one postoperative complication were higher in SCLR (36.3 %) than in CR (26.6 %) and LR (19.8 %) (p < 0.003), mostly due to infectious/cardiopulmonary issues. DISCUSSION In SCLR patients, the risk of 30-day adverse outcomes is higher, and median operation time as well as length of hospital stay is longer compared to CR and LR patients. However, the expected combined morbidities of staged procedures though likely favor SCLR in carefully selected patients undergoing even complex hepatic and colorectal resections and should be considered.
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Slesser AAP, Bhangu A, Brown G, Mudan S, Tekkis PP. The management of rectal cancer with synchronous liver metastases: a modern surgical dilemma. Tech Coloproctol 2012; 17:1-12. [DOI: 10.1007/s10151-012-0888-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Accepted: 08/20/2012] [Indexed: 12/15/2022]
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Spampinato MG, Mandalá L, Quarta G, Del Medico P, Baldazzi G. One-stage, totally laparoscopic major hepatectomy and colectomy for colorectal neoplasm with synchronous liver metastasis: safety, feasibility and short-term outcome. Surgery 2012; 153:861-5. [PMID: 22853855 DOI: 10.1016/j.surg.2012.06.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 06/05/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Simultaneous surgery for primary colorectal tumor with synchronous liver metastasis has been showed to be safe and effective. One-stage, totally laparoscopic colorectal and minor liver resections have been reported, but there are no data regarding patients requiring simultaneous major hepatectomies and colorectal surgery. We aimed to evaluate the safety, feasibility and short-term outcomes of a small cohort of highly selected patients treated by 1-stage, totally laparoscopic major hepatectomy and colorectal resection. METHODS From January 2009 to July 2011, 5 patients (3 women and 2 men) with primary colorectal neoplasm and synchronous monolobar liver metastasis requiring a major hepatectomy underwent attempt of 1-stage, totally laparoscopic approach after neoadjuvant chemotherapy. A retrospective analysis of prospective collected data was performed. RESULTS There were no conversions to open procedures. All the patients but 1 underwent a 1-stage laparoscopic resection. Among these, liver procedures were 3 right and 1 left hepatectomy; colonic procedures were 3 sigmoidectomies and 1 anterior resection of the rectum. Median operative time was 495 minutes, and duration of hospital stay, 6 days. Median estimated blood loss was 475 mL (range, 300-630) with no mortality observed. An R0 resection was always achieved. Median follow-up was 14 months (range, 7-20) with 1 recurrence observed in the liver. CONCLUSION In highly selected patients, a totally laparoscopic approach is a feasible and safe option to treat primary colorectal neoplasm with synchronous liver metastasis requiring major hepatectomies. These results need to be validated by larger, prospective, randomized studies.
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Affiliation(s)
- Marcello Giuseppe Spampinato
- HPB and Advanced Laparoscopic Surgical Unit, Department of General and Minimally Invasive Surgery, Policlinico of Abano Terme, Abano Terme, Italy.
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Abstract
The diagnosis and management of CRLM is complex and requires a multidisciplinary team approach for optimal outcomes. Over the past several decades, the 5-year survival following resection of CRLM has increased and the criteria for resection have broadened substantially. Even patients with multiple, bilateral CRLM, previously thought unresectable, may now be candidates for resection. Two-stage hepatectomy, repeat curative-intent hepatectomy, and even selected resection of extrahepatic metastases have further increased the number of patients who may be treated with curative intent. Multiple liver-directed therapies exist to treat unresectable, incurable patients with adequate survival benefit and morbidity rates.
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Simultaneous vs. staged resection for synchronous colorectal liver metastases: a metaanalysis. Int J Colorectal Dis 2011; 26:191-9. [PMID: 20669024 DOI: 10.1007/s00384-010-1018-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal timing of surgical resection for synchronous colorectal liver metastases (SCLMs) remains controversial. The aim of this metaanalysis was to compare outcomes between simultaneous resection and staged resection from all published comparative studies in the literature. MATERIALS AND METHODS Databases, including PubMed, Embase, Cochrane Library, Ovid, and Web of Science, were searched to identify studies comparing outcomes following simultaneous resection with staged resection for SCLM. The metaanalysis was performed by RevMan 4.2. RESULTS Fourteen comparative studies comprising 2,204 patients were identified. Patients undergoing simultaneous resection were found to have similar operative time (weighted mean difference [WMD], -34.19; 95% confidence interval [CI], -81.32-12.95, P = .16) and intraoperative blood loss (WMD, -161.33; 95% CI, -351.45-28.79, P = .10). Shorter hospital stay (WMD, -4.77; 95% CI, -7.26-2.28, P < .01) and lower morbidity rate (odds ratio [OR], 0.71; 95% CI, 0.57-0.88, P = .002) were observed in simultaneous resection group. The survival rate in the simultaneous resection group did not statistically differ with that in the staged resection group at 1 year (OR, 0.77; 95% CI, 0.51-1.16, P = .21), 3 years (OR, 1.12; 95% CI, 0.85-1.47, P = .43), and 5 years (OR, 1.14; 95% CI, 0.86-1.50, P = .37) postresection, respectively. CONCLUSIONS Simultaneous resection is safe and efficient in the treatment of patients with SCLM while avoiding a second major operation. In appropriately selected patients, simultaneous resection might be considered as the preferred treatment. Since heterogeneity was detected, caution is needed in interpretation of the results. Better designed, adequately powered studies are required for addressing this issue.
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Tranchart H, Diop PS, Lainas P, Pourcher G, Catherine L, Franco D, Dagher I. Laparoscopic major hepatectomy can be safely performed with colorectal surgery for synchronous colorectal liver metastasis. HPB (Oxford) 2011; 13:46-50. [PMID: 21159103 PMCID: PMC3019541 DOI: 10.1111/j.1477-2574.2010.00238.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal strategy for resectable synchronous colorectal liver metastases remains controversial. Although some authors advocate a staged treatment, an increasing number of studies have reported that combined colorectal and liver resection is safe. Laparoscopic combined resection in primary colorectal cancer with synchronous liver metastases has been reported but there are no specific data for major liver resections. In the present study, we evaluated the feasibility of a simultaneous entirely laparoscopic procedure, in the light of the benefits of laparoscopy in both colon and liver surgery, and discussed the benefits of this strategy. METHODS Two cases are presented of totally laparoscopic major liver resections associated with laparoscopic colorectal resections for synchronous liver metastases with the emphasis on the technical aspects. Duration of surgery, blood loss and post-operative outcome were evaluated. RESULTS Laparoscopic right hepatectomy or left hepatectomy with simultaneous colon resection for liver metastasis was feasible and safe with only one suprapubic 5-mm trocar added to the usual trocar sites. The mean duration of surgery was 327 min with a mean estimated blood loss of 200 ml. The post-operative course was uneventful. DISCUSSION In selected patients, laparoscopic major hepatectomies for unilobular synchronous metastases can be safely performed simultaneously with colorectal surgery.
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Affiliation(s)
| | | | | | | | | | - Dominique Franco
- Department of General SurgeryAP-HP, Clamart,University Paris-SudOrsay, France
| | - Ibrahim Dagher
- Department of General SurgeryAP-HP, Clamart,University Paris-SudOrsay, France
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Reddy SK, Barbas AS, Clary BM. Synchronous colorectal liver metastases: is it time to reconsider traditional paradigms of management? Ann Surg Oncol 2009; 16:2395-410. [PMID: 19506963 DOI: 10.1245/s10434-009-0372-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 10/14/2008] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with synchronous colorectal liver metastases (CLM) are typically treated with initial colorectal resection followed by arbitrary and prolonged courses of chemotherapy. Partial hepatectomy is considered only for patients without interval disease progression. This review describes the rationale for this treatment approach and the recent developments suggesting that this management paradigm should be reconsidered. RESULTS Because asymptomatic colorectal cancer often does not lead to complications, and given the potential benefit of chemotherapy in downsizing unresectable to resectable liver disease, most patients with asymptomatic primary tumors and unresectable synchronous CLM should be first treated with chemotherapy. In contrast, initial hepatic resection should be considered for resectable synchronous CLM. Survival benefits from prehepatectomy chemotherapy have not been established. Several reports demonstrate morbidity after hepatic resection from extended durations of irinotecan- and/or oxaliplatin-based prehepatectomy chemotherapy. Although shorter treatment periods may not have these deleterious effects on subsequent hepatic resection, prospective studies reveal that most patients with supposedly aggressive disease with short treatment durations will not be identified. Moreover, a complete radiologic response to prehepatectomy chemotherapy is not only rare but also does not equate with a complete pathological response. Finally, several studies suggest that simultaneous colorectal and minor hepatic resections can performed safely with benefits in total morbidity when compared with traditional staged procedures. CONCLUSIONS The traditional treatment paradigm centering on the utility of prehepatectomy chemotherapy for resectable synchronous CLM should be reconsidered. Recent developments underscore the need for prospective randomized controlled trials evaluating the optimal timing of hepatectomy relative to chemotherapy.
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Affiliation(s)
- Srinevas K Reddy
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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Hillingsø JG, Wille-Jørgensen P. Staged or simultaneous resection of synchronous liver metastases from colorectal cancer--a systematic review. Colorectal Dis 2009; 11:3-10. [PMID: 18637099 DOI: 10.1111/j.1463-1318.2008.01625.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE A systematic review of the literature was undertaken to estimate the differences in length of hospital stay, morbidity, mortality and long-term survival between staged and simultaneous resection of synchronous liver metastases from colorectal cancer to determine the level of evidence for recommendations of a treatment strategy. METHOD A Pub-med search was undertaken for studies comparing patients with synchronous liver metastases, who either had a combined or staged resection of metastases. Twenty-six were considered and 16 were included based on Newcastle Ottawa Quality Assessment Scale. All studies were retrospective and had a general bias, because the staged procedure was significantly more often undertaken in patients with left-sided primary tumours and larger, more numerous and bi-lobar metastases. Analyses of primary outcomes were performed using the random effects model. RESULTS For the reason of the heterogeneity of the observational studies, no odds ratios were calculated. In 11 studies, there was a tendency towards a shorter hospital stay in the synchronous resection group. Fourteen studies compared total perioperative morbidity and lower morbidity was observed in favour of a combined resection. Fifteen studies compared perioperative mortality, which seemed to be lower with the staged approach. Eleven studies compared 5-year survival, which seemed to be similar in the two groups. CONCLUSION No randomized controlled trials were identified, and hence a meta-analysis was not performed. The evidence level is II to III with grade C recommendations. Synchronous resections can be undertaken in selected patients, provided that surgeons specialized in colorectal and hepatobiliary surgery are available.
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Affiliation(s)
- J G Hillingsø
- Department of Surgery C, Rigshospitalet, Faculty of Health Services, University of Copenhagen, Denmark.
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[Safety of simultaneous colon and liver resection for colorectal liver metastases]. VOJNOSANIT PREGL 2008; 65:153-7. [PMID: 18365673 DOI: 10.2298/vsp0802153s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIM Surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer (CRC) remains controversial. The aim of this study was to assess safety of simultaneous colon and liver rese cions and the direct effects of this type of treatment upon morbidity and mortality of the patients with synchronus hepatic metastases of CRC. METHODS Intraoperative and postoperative data of 31 patients with simultaneous liver and colorectal resection were compared with the data of 51 patients who had undergone colon and hepatic resection in the staging setting. Analized were demographic data, number of metastases, type of the liver resection, operation time, intraoperative blood loss, percentage of postoperative complications, morbidity and mortality and lenght of hospitalisation. RESULTS In the group of the patients operated simultaneously 5 hepatectomies, 3 sectionectomies, 2 trisegmentectomies, 3 bisegmentectomy, 6 segmentectomies, and 12 metastasectomies were combined with colon resection. In this group operation time (280 vs. 330 minutes) and in traoperative blood loss (450 vs. 820 ml) were lower than those in the two staged operation group. Postoperative complication rate was lower in the simultaneous group (19.35%o) than in the two-staged operation group (19.60%), without statistical significance. There was no hospital mortality in both groups. The patients having simultaneous resection required fewer days in the hospital (median 10.2 days) than the patients undergone operation in the two stage (18.34 days). CONCLUSION By avoiding a second laparotomy, overall operation time, blood loss, hospital stay and complication rate are reduced with no change in hospital mortality, so simultaneous colon and hepatic resection performed by the competent surgeons are safe and efficient for the treatment of synchronous colorectal liver metastases.
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Turrini O, Viret F, Guiramand J, Lelong B, Bège T, Delpero JR. Strategies for the treatment of synchronous liver metastasis. Eur J Surg Oncol 2007; 33:735-40. [PMID: 17400418 DOI: 10.1016/j.ejso.2007.02.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 02/19/2007] [Indexed: 12/12/2022] Open
Abstract
AIM Observe the outcomes after complete simultaneous or delayed resection of synchronous liver metastasis (SLM) from colorectal cancer (CRC). METHODS From 1994 to 2005, 119 patients were diagnosed with CRC and SLM; 57 patients had simultaneous resection (group I) and 62 patients had staged resection (group II). Perioperative chemotherapy was considered completed if all expected cycle were administrated. RESULTS Overall survival rates of group I-group II at 1, 3 and 5 years were respectively 91%-93% (p=0,3), 59%-57% (p=0,09) and 32%-25% (p=0,06). The median survival time of group I-group II were respectively 46 months-40 months (p=0,07). There was no statistical difference on survival regarding location of metastasis (p=0,09) or primary tumor location (p=0,2). Patients with simultaneous or staged resection receiving optimal treatment (R0 liver surgery and complete chemotherapy) were respectively 89% and 67% (p=0,04). Twenty three patients developed isolated liver recurrence with higher frequency in staged patients (26% vs 9% p=0,03) without impairment of survival. CONCLUSIONS Because of postoperative morbidity and prolonged tiring treatment, many patients having staged resection were under treated. However we did not observe statistical difference on survival but we supported that simultaneous resection has to be prefer to achieve an optimal treatment. Lung and bone metastasis are the new challenge for oncologists.
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Affiliation(s)
- O Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
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Capussotti L, Ferrero A, Viganò L, Ribero D, Lo Tesoriere R, Polastri R. Major liver resections synchronous with colorectal surgery. Ann Surg Oncol 2007; 14:195-201. [PMID: 17080238 DOI: 10.1245/s10434-006-9055-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical strategy in liver metastases synchronous to colorectal cancer remains controversial. The aim of this study was to evaluate feasibility and short-term outcomes of major hepatectomies synchronous to colorectal surgery. METHODS Between January 1985 and December 2004, 79 patients underwent major hepatectomy for metastases synchronous to colorectal cancer; 31 underwent synchronous hepatectomy and colorectal surgery, and 48 underwent delayed liver resection. RESULTS The synchronous group had a higher rate of right colectomy (38.7% vs. 18.8%, P = .0499) and larger metastases (8 vs. 5.3 cm, P = .0032). Mortality (one patient in synchronous group), morbidity, and anastomotic leak rates were similar in the two groups. Colon-related morbidity did not cause adjunctive liver complications. Hospitalization in delayed hepatectomies was shorter (10.4 days vs. 13.9 days, P = .0021). Blood and plasma transfusions were higher in synchronous resections (41.9% vs. 16.7%, P = .0131 and 54.8% vs. 31.3%, P = .0370); no differences were found in the last 10 years. Considering both surgical procedures (colorectal + liver resection), in delayed hepatectomies, morbidity was higher (56.3% vs. 32.6%, P = .0369) and hospitalization was longer (20.5 vs. 13.9 days, P = .00001). Nine patients underwent major hepatectomy at the same time as anterior rectal resection with no mortality (morbidity 22.2%, mean hospitalization 12.4 days). CONCLUSIONS Major hepatectomies can be safely performed at the same time as colorectal surgery in selected patients with synchronous metastases with similar short-term results, even in the presence of rectal cancer.
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Affiliation(s)
- Lorenzo Capussotti
- Unit of Surgical Oncology, Institute for Cancer Research and Treatment, Strada Provinciale 142 km 3, 95 10060, Candiolo, Torino, Italy.
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Vassiliou I, Arkadopoulos N, Theodosopoulos T, Fragulidis G, Marinis A, Kondi-Paphiti A, Samanides L, Polydorou A, Gennatas C, Voros D, Smyrniotis V. Surgical approaches of resectable synchronous colorectal liver metastases: Timing considerations. World J Gastroenterol 2007; 13:1431-4. [PMID: 17457976 PMCID: PMC4146929 DOI: 10.3748/wjg.v13.i9.1431] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the safety and efficacy of simultaneous versus two stage resection of primary colorectal tumors and liver metastases.
METHODS: From January 1996 to May 2004, 103 colorectal tumor patients presented with synchronous liver metastases. Twenty five underwent simultaneous colorectal and liver surgery and 78 underwent liver surgery 1-3 mo after primary colorectal tumor resection. Data were retrospectively analyzed to assess and compare the morbidity and mortality between the surgical strategies. The two groups were comparable regarding the age and sex distribution, the types of liver resection and stage of primary tumors, as well as the number and size of liver metastases.
RESULTS: In two-stage procedures more transfusions were required (4 ± 1.5 vs 2 ± 1.8, pRBCs, P < 0.05). Chest infection was increased after the two-stage approach (26% vs 17%, P < 0.05). The two-stage procedure was also associated with longer hospitalization (20 ± 8 vs 12 ± 6 d, P < 0.05). Five year survival in both groups was similar (28% vs 31%). No hospital mortality occurred in our series.
CONCLUSION: Synchronous colorectal liver metastases can be safely treated simultaneously with the primary tumor. Liver resection should be prioritized over colon resection. It is advisable that complex liver resections with marginal liver residual volume should be dealt with at a later stage.
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Affiliation(s)
- Ioannis Vassiliou
- 2nd Department of Surgery, Aretaieion Hospital, University of Athens, School of Medicine, FACS, 29 El. Venizelou str., GR-154 51 Athens, Greece.
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Jovine E, Biolchini F, Talarico F, Lerro FM, Mastrangelo L, Selleri S, Landolfo G, Martuzzi F, Iusco DR, Lazzari A. Major hepatectomy in patients with synchronous colorectal liver metastases: whether or not a contraindication to simultaneous colorectal and liver resection? Colorectal Dis 2007; 9:245-52. [PMID: 17298623 DOI: 10.1111/j.1463-1318.2006.01152.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Synchronous hepatic lesions account for 15-25% of newly diagnosed colorectal cancer and its optimal timing to surgery is not completely defined, but simultaneous colorectal and liver resection is recently gaining acceptance, at least in patients with a right colonic primary and liver metastases that need a minor hepatectomy to be fully resected. METHOD From September 2002 to December 2004, 16 patients underwent simultaneous resection as treatment of synchronous colorectal liver resection; in 10 patients (62.5%) a major hepatectomy was performed. RESULTS The mean duration of intervention was 322.5 +/- 59.5 min, operative mortality and morbidity rates was 0% and 25% respectively; the hospitalization was 14.4 (range 8-60) days on average. Mean follow-up was 14 months and actuarial survival was 76.5% at 1 year and 63.5% at 2 years. CONCLUSION We concluded that simultaneous colonic and liver resection should be undertaken in selected patients with synchronous colorectal liver resection regardless of the extent of hepatectomy; major liver resection, in fact, seems capable of providing better oncological results, allowing resection of liver micrometastases that, in almost one-third of the patients, are located in the same liver lobe of macroscopic lesions, without increased morbidity rates.
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Affiliation(s)
- E Jovine
- Surgical Department, Maggiore Hospital, Bologna, Italy.
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Capussotti L, Vigano' L, Ferrero A, Lo Tesoriere R, Ribero D, Polastri R. Timing of resection of liver metastases synchronous to colorectal tumor: proposal of prognosis-based decisional model. Ann Surg Oncol 2007; 14:1143-50. [PMID: 17200913 DOI: 10.1245/s10434-006-9284-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Revised: 10/31/2006] [Accepted: 11/01/2006] [Indexed: 01/10/2023]
Abstract
BACKGROUND Timing of hepatectomy for synchronous metastases of colorectal cancer is still debated. The aim of this retrospective study was to analyze prognostic factors after synchronous and delayed liver resections to define selection criteria for choosing timing of hepatectomy. METHODS The study was performed on 127 patients with synchronous metastases undergoing radical hepatectomy. We divided patients according to the timing of hepatectomy: 70 synchronous (group A) and 57 delayed (group B). RESULTS Overall survival was similar between the two groups (5-year survival 30.8% vs. 32.0% A vs. B, P = .406). The multivariate analysis evidenced four independent prognostic factors in group A: male sex (P = .04), T4 (P = .0035), more than three metastases (P = .0001), and metastatic infiltration of nearby structures (P < .0001). There were no statistically significant prognostic factors in group B. Patients with more than three metastases had a significantly worse survival in group A than in group B (3-year survival, 15.0% vs. 34.3%, P = .007); similarly, borderline significant difference was encountered in patients with T4 primary tumor (3-year survival, 16.7% vs. 60%, P = .064) CONCLUSIONS Patients with liver metastases synchronous with colorectal cancer with T4 primary tumor, metastasis infiltration of neighboring structures, and especially with more than three metastases should receive neoadjuvant chemotherapy before liver resection.
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Affiliation(s)
- Lorenzo Capussotti
- Unit of Surgical Oncology, Institute for Cancer Research and Treatment, Strada Provinciale 142 km 3,95 10060, Candiolo, Torino, Italy.
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Weber T, Link KH. Radikale Chirurgie bei primär metastasierten kolorektalen Karzinomen. Visc Med 2007; 23:360-366. [DOI: 10.1159/000110482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
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González HD, Figueras J. Practical questions in liver metastases of colorectal cancer: general principles of treatment. HPB (Oxford) 2007; 9:251-8. [PMID: 18345300 PMCID: PMC2215392 DOI: 10.1080/13651820701457992] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Indexed: 12/12/2022]
Abstract
Liver metastases of colorectal cancer are currently treated by multidisciplinary teams using strategies that combine chemotherapy, surgery and ablative techniques. Many patients classically considered non-resectable can now be rescued by neoadjuvant chemotherapy followed by liver resection, with similar results to those obtained in initial resections. While many of those patients will recur, repeat resection is a feasible and safe approach if the recurrence is confined to the liver. Several factors that until recently were considered contraindications are now recognized only as adverse prognostic factors and no longer as contraindications for surgery. The current evaluation process to select patients for surgery is no longer focused on what is to be removed but rather on what will remain. The single most important objective is to achieve a complete (R0) resection within the limits of safety in terms of quantity and quality of the remaining liver. An increasing number of patients with synchronous liver metastases are treated by simultaneous resection of the primary and the liver metastatic tumours. Multilobar disease can also be approached by staged procedures that combine neoadjuvant chemotherapy, limited resections in one lobe, embolization or ligation of the contralateral portal vein and a major resection in a second procedure. Extrahepatic disease is no longer a contraindication for surgery provided that an R0 resection can be achieved. A reverse surgical staged approach (liver metastases first, primary second) is another strategy that has appeared recently. Provided that a careful selection is made, elderly patients can also benefit from surgical treatment of liver metastases.
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Affiliation(s)
- Héctor Daniel González
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital Josep TruetaGironaSpain
| | - Joan Figueras
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital Josep TruetaGironaSpain
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Weber JC, Bachellier P, Oussoultzoglou E, Jaeck D. Simultaneous resection of colorectal primary tumour and synchronous liver metastases. Br J Surg 2003; 90:956-62. [PMID: 12905548 DOI: 10.1002/bjs.4132] [Citation(s) in RCA: 173] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The surgical strategy for treatment of synchronous colorectal liver metastases remains controversial. The outcome and overall survival of patients presenting with such metastases, treated either by simultaneous resection or by delayed resection, were evaluated. METHODS From 1987 to 2000, 97 patients presented with synchronous colorectal liver metastases, of whom 35 (36 per cent) underwent a simultaneous resection and 62 patients (64 per cent) a delayed resection. Simultaneous resection was considered prospectively for patients with fewer than four unilobar metastases. RESULTS Age, blood transfusion requirements, operating time, duration of inflow occlusion, hospital stay and mortality rate were similar in the two groups. The morbidity rate did not differ significantly (23 per cent after simultaneous resection and 32 per cent after delayed resection). The location of the primary tumour and extent of liver resection did not influence the morbidity rate significantly in the simultaneous resection group. The overall survival rate was 94, 45 and 21 per cent at 1, 3 and 5 years respectively after simultaneous resection, and 92, 45 and 22 per cent after delayed resection. CONCLUSION In selected patients, simultaneous resection of the colorectal primary tumour and liver metastases does not increase mortality or morbidity rates compared with delayed resection, even if a left colectomy and/or a major hepatectomy are required.
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Affiliation(s)
- J C Weber
- Service de Chirurgie Générale, Hépatique et Endocrinienne, Hôpital de Hautepierre, Strasbourg, France
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Kianmanesh R, Farges O, Abdalla EK, Sauvanet A, Ruszniewski P, Belghiti J. Right portal vein ligation: a new planned two-step all-surgical approach for complete resection of primary gastrointestinal tumors with multiple bilateral liver metastases. J Am Coll Surg 2003; 197:164-70. [PMID: 12831938 DOI: 10.1016/s1072-7515(03)00334-x] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Reza Kianmanesh
- Department of Hepato-Biliary and Pancreas Surgery, Clichy, France
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Lyass S, Zamir G, Matot I, Goitein D, Eid A, Jurim O. Combined colon and hepatic resection for synchronous colorectal liver metastases. J Surg Oncol 2001; 78:17-21. [PMID: 11519063 DOI: 10.1002/jso.1117] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES The surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer remains controversial. This study was performed to assess the outcome of combined resection of colorectal cancer and liver metastases. METHODS The perioperative data, morbidity, and survival of the patients who underwent combined colon and liver resections for synchronous colorectal liver metastases from 1988 to 1999 were compared to the parameters of the patients who underwent colon resection followed by resection of liver metastases in a staged setting. RESULTS 198 hepatic resections were performed, of which 112 procedures in 103 patients were done for metastatic colorectal carcinoma. Twenty six patients (25%) had combined hepatic and colon resection and were compared to 86 patients with metachronous metastases who underwent colon and hepatic resection in the staging setting. Postoperative morbidity was 27 and 35%, respectively. There was no hospital mortality in the combined group vs. 2.3% in the staged group. Blood loss, intensive care unit (ICU) stay and length of postoperative stay (LOS) were similar in both groups. The 5 years cumulative survival of the group after combined surgery was 28% vs. 27% of the group after isolated hepatic resections (P = 0.21). CONCLUSION Combined colon and hepatic resection is a safe and efficient procedure for the treatment of synchronous colorectal liver metastases. It can be performed with acceptable morbidity and no perioperative mortality. The survival after combined procedure is comparable to the one achieved after staged procedure of colon resection followed by liver resection.
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Affiliation(s)
- S Lyass
- Department of Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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Bolton JS, Fuhrman GM. Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma. Ann Surg 2000; 231:743-51. [PMID: 10767796 PMCID: PMC1421062 DOI: 10.1097/00000658-200005000-00015] [Citation(s) in RCA: 188] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To define the long-term outcome and treatment complications for patients undergoing liver resection for multiple, bilobar hepatic metastases from colorectal cancer. METHODS A retrospective analysis of 165 consecutive patients undergoing liver resection for metastatic colorectal cancer was performed. Patients were divided into a simple hepatic metastasis group, consisting of patients with three or fewer metastases in a unilobar distribution, and a complex hepatic metastases group, consisting of patients with four or more unilobar metastases or at least two bilobar metastases. RESULTS The 5-year survival rate was 36% for the simple group and 37% for the complex group. Multivariate analysis revealed that the number of hepatic segments involved by tumor and the maximum diameter of the largest metastasis correlated significantly with the 5-year survival rate. The surgical death rate was 4.9% for the simple group and 9.1% for the complex group; this difference was not significant. Multivariate analysis revealed that extended lobar resection and concomitant colon and hepatic resection were significant and independent predictors of surgical death. The combination of extended lobar resection and concomitant colon resection was used significantly more frequently in the complex group than in the simple group. CONCLUSIONS Resection of complex hepatic metastases, as defined in this study, results in a 5-year survival rate of 37% and confers the same survival benefit as does resection of limited hepatic metastases. The surgical death rate for this aggressive approach is significantly higher if extended lobar resections are necessary and if concomitant colorectal resection is performed. Patients who have complex hepatic metastases at the time of diagnosis of the primary colorectal cancer and who would require extended hepatic lobectomy should have hepatic resection delayed for at least 3 months after colon resection.
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Affiliation(s)
- J S Bolton
- Department of General Surgery, Alton Ochsner Medical Institutions, New Orleans, Louisiana, USA.
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