Aggressive liver resection including major-vessel resection for colorectal liver metastases

Table 1 Outcomes of patients undergoing major vessel resection/reconstruction

Patient No.	Resected vessel (s)	Reconstruction	No. of Hx	Age	Gender	Tumor distribution	No. of tumors	Maximum size (mm)	Resection margin	Outcome month	Status
1	IVC	Primary closure	1	72	F	Bilobar	2	42	Negative	45	DDT
2	IVC	Primary closure	1	70	M	Unilobar	2	15	Negative	67	DDT
3	IVC	Primary closure	1	61	M	Unilobar	1	33	Positive	12	DDT
4	IVC	Primary closure	1	64	M	Bilobar	5	58	Positive	39	DDT
5	IVC	Primary closure	1	70	F	Bilobar	3	75	Negative	33	DDT
6	IVC	Primary closure	1	54	M	Bilobar	27	75	Positive	4	DDT
7	IVC	Primary closure	1	61	F	Bilobar	6	110	Positive	37	DDT
8	IVC	Primary closure	1	72	M	Bilobar	5	20	Negative	11	DDT
9	IVC	Primary closure	1	69	F	Unilobar	1	35	Negative	34	NED
10	IVC	Primary closure	1	71	M	Unilobar	1	55	Positive	31	NED
11	IVC	Primary closure	1	68	F	Unilobar	2	74	Positive	4	NED
12	IVC	Graft replacement	1	70	F	Bilobar	6	63	Negative	16	AWD
13	IVC	Primary closure	2	73	M	Unilobar	1	40	Negative	125	DOD
14	IVC	Primary closure	2	47	F	Bilobar	4	38	Negative	75	DOD
15	IVC	Primary closure	2	65	M	Unilobar	1	42	Positive	38	DDT
16	IVC	Primary closure	2	61	M	Unilobar	1	29	Negative	22	DDT
17	IVC	Patch closure	2	53	F	Bilobar	3	40	Negative	59	DDT
18	IVC	Graft replacement	2	56	M	Unilobar	1	50	Negative	3	NED
19	IVC	Primary closure	3	57	F	Unilobar	1	36	Negative	25	DDT
20	IVC-LHV	Primary closure	3	54	F	Unilobar	1	23	Positive	45	DDT
21	MHV	Graft replacement	1	62	M	Bilobar	4	45	Positive	55	DDT
22	MHV	Graft replacement	1	60	M	Bilobar	2	56	Negative	52	AWD
23	MHV	Graft replacement	2	80	M	Unilobar	1	45	Negative	13	DDT
24	RHV	End-to-end	1	60	F	Unilobar	1	19	Negative	24	DDT
25	RHV	Patch closure	1	55	M	Bilobar	5	17	Positive	71	DDT

Hx: Hepatectomy; IVC: Inferior vena cava; LHV: Left hepatic vein; MHV: Middle hepatic vein; RHV: Right hepatic vein; F: Female; M: Male; N: No; Y: Yes; NED: No evidence of disease; AWD: Alive with disease; DDT: Died of disease treated; DOD: Died of other disease.

Table 2 Feasibility of combined resection

Variable	Patients (n = 25)
Resected liver volume (g)	386 ± 242
(median, range)	(360, 21-972)
Operative time, mean ± SE (min)	488 ± 130
(median, range)	(460, 270-735)
Total blood loss, mean ± SE (L)	1.6 ± 1.3
(median, range)	(1.4, 0.3-5.7)
Patients transfused	17 (68%)
Hospital stay, in days, mean ± SE	19 ± 8
(median, range)	(18, 10-41)
Morbidity	4 (16%)
Ascites	2
Hyperbilirubinemia	1
Bile leakage	1
Intra-abdominal abscess	1

Table 3 Univariate analysis of predictive factors for combined major-vessel resection

Variables		Conventional (n = 346)	Combined (n = 25)	P value
		n (%)	n (%)
Patient-related
Age (yr)	≤ 64	179 (52)	14 (56)	0.84
	≥ 65	167 (48)	11 (44)
Gender	Male	209 (60)	14 (56)	0.68
	Female	137 (40)	11 (44)
Primary-related
Site	Colon	204 (59)	19 (76)	0.14
	Rectum	142 (41)	6 (24)
Histology	Moderate	223 (64)	14 (56)	0.40
	Others	123 (36)	11 (44)
Dukes stage	A/B	120 (35)	4 (16)	0.08
	C	226 (65)	21 (84)
Liver-related
Hepatectomy	Initial	296 (86)	16 (64)	< 0.01
	Repeat	50 (14)	9 (36)
Distribution	Unilobar	213 (62)	12 (48)	0.21
	Bilobar	133 (38)	13 (52)
Number	≤ 2	222 (64)	14 (56)	0.52
	≥ 3	124 (36)	11 (44)
Maximum tumor size (mm)	≤ 30	197 (57)	6 (24)	< 0.01
	> 30	149 (43)	19 (76)
Prehepatectomy CEA (ng/mL)	< 10	175 (54)	17 (68)	0.21
	≥ 10	150 (46)	8 (32)
Treatment-related
Extent of hepatectomy	Major	112 (32)	13 (52)	0.05
	Minor	234 (68)	12 (48)
PVE	Performed	44 (13)	7 (28)	0.06
	Not performed	302 (87)	18 (72)
Staged procedure	Performed	20 (6)	1 (4)	> 0.99
	Not performed	326 (94)	24 (96)
Hepatectomy with ablation	Performed	26 (8)	4 (16)	0.13
	Not performed	320 (92)	21 (84)
Prehepatectomy chemotherapy	Performed	63 (18)	11 (44)	< 0.01
	Not performed	283 (82)	14 (56)

Moderate: Moderately differentiated adenocarcinoma; CEA: Carcinoembryonic antigen; PVE: Portal vein embolization.

Table 4 Multivariate analysis of predictive factors for combined major vessel resection, by logistic regression analysis

Variables	RR	P value
Hepatectomy
Repeat	5.690 (2.053-15.765)	0.0008
Maximum tumor size (mm)
> 30	3.338 (1.224-9.108)	0.0186
Prehepatectomy chemotherapy
Performed	3.485 (1.379-8.807)	0.0083

Values in parentheses are 95% confidence intervals. RR: Risk ratio, followed in parentheses by confidence interval.

Table 5 Outcomes of patients undergoing major vessel resection/reconstruction

		Initial resection			Second resection
Variables		Conventional (n = 296)	Combined (n = 16)	P value	Conventional (n = 37)	Combined (n = 7)	P value
Patient-related
Age, years		64	66	0.6	63	61	0.91
		(30-85)	(54-72)		(32-83)	(47-80)
Gender	Male	186 (63%)	9 (56%)	0.6	19 (51%)	5 (71%)	0.43
	Female	110 (37%)	7 (44%)		18 (49%)	2 (29%)
Primary-related
Site	Colon	169 (57%)	11 (69%)	0.61	27 (73%)	6 (86%)	0.66
	Rectum	127 (43%)	5 (31%)		10 (27%)	1 (14%)
Dukes stage	A or B	103 (35%)	3 (19%)	0.33	13 (35%)	1 (14%)	0.53
	C	193 (65%)	13 (81%)		24 (65%)	6 (86%)
Histology	Well	99 (33%)	7 (44%)	0.62	11 (30%)	2 (29%)	> 0.99
	Moderate	184 (62%)	8 (50%)		26 (70%)	5 (71%)
	Others	13 (4%)	1 (6%)		-	-
Liver-related
Timing	Synchronous	146 (49%)	10 (63%)	0.44
	Metachronous	150 (51%)	6 (38%)
Distribution	Unilobar	175 (59%)	6 (38%)	0.12	27 (73%)	5 (71%)	> 0.99
	Bilobar	121 (41%)	10 (63%)		10 (27%)	2 (29%)
Number		2	3.5	0.11	1	1	0.57
		(1-38)	(1-27)		(1-7)	(1-4)
Maximum tumor size (mm)		28	50	0.02	29	40	0.05
		(5-185)	(15-110)		(10-80)	(29-50)
Extrahepatic disease	Present	40 (14%)	4 (25%)	0.26	8 (22%)	1 (14%)	> 0.99
Prehepatectomy CEA (ng/mL)		8.3	43.9	< 0.01	8.6	21.5	0.45
		(1-10 536)	(2-4498)		(3-360)	(2-559)

Well, well differentiated adenocarcinoma; Moderate, moderately differentiated adenocarcinoma; CEA: Carcinoembryonic antigen.

Table 6 Univariate analysis for prognostic factors of the initial resection

			Survival (%)
Variables		n	3 years	5 years	P value
Patient-related
Age (yr)	≤ 64	158	66.9	53.1	0.83
	≥ 65	154	64.9	52.3
Gender	Male	195	68.2	53.0	0.77
	Female	117	62.4	51.9
Primary-related
Site	Colon	180	67.7	53.7	0.87
	Rectum	132	63.5	50.9
Histology	Moderate	192	67.1	52.1	0.41
	Others	120	64.1	53.5
Dukes stage	A/B	104	72.2	59.9	0.11
	C	208	62.7	48.8
Liver-related
Timing	Synchronous	156	63.7	48.5	0.17
	Metachronous	156	68.1	56.5
Distribution	Unilobar	181	72.2	59.0	< 0.01
	Bilobar	131	57.2	43.6
Number	≤ 2	188	72.6	61.2	< 0.01
	≥ 3	124	55.6	39.1
Maximum tumor size (mm)	≤ 30	169	75.0	61.7	< 0.01
	> 30	143	55.3	41.5
Prehepatectomy CEA (ng/mL)
	< 10	158	72.6	60.8	0.01
	≥ 10	145	60.1	44.5
Extrahepatic metastases	Present	44	40.9	26.7	< 0.01
	Absent	268	70.6	57.3
Treatment-related
Extent of hepatectomy	Major	113	57.9	39.8	< 0.01
	Minor	199	70.6	59.8
Tumor-free margin	Not exposed	256	70.5	58.7	< 0.01
	Exposed	56	46.6	27.9
PVE	Performed	49	51.0	37.4	< 0.01
	Not performed	263	68.8	55.2
Staged procedure	Performed	21	33.2	22.1	< 0.01
	Not performed	291	68.5	55.0
Hepatectomy with ablation	Performed	27	60.5	34.1	0.08
	Not performed	285	66.5	54.2
Prehepatectomy chemotherapy
	Performed	68	56.0	35.1	0.01
	Not performed	244	68.4	56.0
Adjuvant chemotherapy	Performed	257	67.0	54.6	0.02
	Not performed	55	63.1	42.0
Combined resection	Performed	16	55.4	24.6	0.02
	Not performed	296	66.5	54.0
Major vessel invasion	Positive	7	66.0	52.9	0.10
	Negative	305	66.0	52.9

Moderate, moderately differentiated adenocarcinoma; CEA: Carcinoembryonic antigen; PVE: Portal vein embolization.

Table 7 Univariate analysis for prognostic factors of the second resection

			Survival (%)
Variables		n	3 years	5 years	P value
Patient-related
Age (yr)	≤ 63	23	95.0	62.9	0.03
	≥ 64	21	67.9	34.5
Gender	Male	24	85.6	56.5	0.21
	Female	20	77.8	43.5
Primary-related
Site	Colon	33	82.9	49.1	0.80
	Rectum	11	80.0	54.9
Histology	Moderate	31	85.9	52.3	0.40
	Others	13	72.7	45.5
Dukes stage	A/B	14	71.4	38.1	0.15
	C	30	87.9	57.7
Liver-related
Distribution	Unilobar	32	79.1	46.5	0.63
	Bilobar	12	90.0	60.0
Number	1	24	76.1	40.0	0.61
	≥ 2	20	88.9	62.3
Maximum tumor size (mm)	≤ 30	22	73.3	47.5	0.41
	> 30	22	90.2	52.4
Prehepatectomy CEA (ng/mL)
	< 9	18	76.0	53.2	0.56
	≥ 9	18	93.8	67.7
Extrahepatic metastases	Present	9	77.8	62.2	0.99
	Absent	35	83.2	47.2
Treatment-related
Extent of hepatectomy	Major	10	90.0	64.3	0.02
	Minor	34	79.7	46.1
Tumor-free margin	Not exposed	37	81.2	53.9	0.39
	Exposed	7	85.7	34.3
Hepatectomy with ablation	Performed	3	66.7	33.3	0.98
	Not performed	41	83.3	52.2
Prehepatectomy chemotherapy
	Performed	6	50.0	50.0	0.73
	Not performed	38	80.0	50.0
Adjuvant chemotherapy	Performed	37	86.1	52.9	0.03
	Not performed	7	0.0	0.0
Combined resection	Performed	7	66.7	33.3	0.09
	Not performed	37	84.6	53.8
Major vessel invasion	Positive	4	33.3	0.0	< 0.01
	Negative	40	85.9	54.8

Moderate, moderately differentiated adenocarcinoma; CEA: Carcinoembryonic antigen.