Simultaneous versus staged liver resection of synchronous liver metastases from colorectal cancer

Background and aims The surgical strategy for treatment of synchronous liver metastases from colorectal cancer remains controversial. This retrospective analysis was conducted to compare the postoperative outcome and survival of patients receiving simultaneous resection of liver metastases and primary colorectal cancer to those receiving staged resection. Materials and methods Between January 1988 and September 2005, 219 patients underwent liver resection for synchronous colorectal liver metastases, of whom, 40 patients received simultaneous resection of liver metastases and primary colorectal cancer, and 179 patients staged resections. Patients were identified from a prospective database, and records were retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on postoperative morbidity and mortality as well as on long-term survival. Results Simultaneous liver resections tend to be performed for colon primaries rather than for rectal cancer (p = 0.004) and used less extensive liver resections (p < 0.001). The postoperative morbidity was comparable between both groups, whereas the mortality was significantly higher in patients with simultaneous liver resection (p = 0.012). The mortality after simultaneous liver resection (n = 4) occurred after major hepatectomies, and three of these four patients were 70 years of age or older. There was no significant difference in long-term survival after formally curative simultaneous and staged liver resection. Conclusion Simultaneous liver and colorectal resection is as efficient as staged resections in the treatment of patients with colorectal cancer and synchronous liver metastases. To perform simultaneous resections safely a careful patient selection is necessary. The most important criteria to select patients for simultaneous liver resection are age of the patient and extent of liver resection.     

Simultaneous vs. staged resection for synchronous colorectal liver metastases: a metaanalysis

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.     

Simultaneous resection of colorectal cancer with synchronous liver metastases; a practice survey

BackgroundWe examined surgeon practice intentions and barriers to performing simultaneous resections for colorectal cancer with synchronous liver metastases.MethodsWe electronically surveyed North American surgeons who provide colorectal cancer care with a pilot-tested questionnaire. Four clinical scenarios of increasing complexity were presented. Perceived outcomes of and barriers to simultaneous resection were assessed on a 7-point Likert scale. We compared results between general and hepatobiliary surgeons.ResultsResponses (rate 20%, 234/1166) included 50 general and 134 hepatobiliary surgeons. High likelihood scores for support of simultaneous resection among general and hepatobiliary surgeons, respectively, included the following for: minor liver and low complexity colon, 83% and 98% (p < 0.001); minor liver and rectal resection, 57% and 73% (p = 0.042); complex liver and low complexity colon resection, 26% and 24% (p = 0.858); and, complex liver and rectal resection, 11% and 7.0% (p = 0.436). Among hepatobiliary surgeons, the most common barriers to simultaneous resections were patient comorbidities and lung metastases, whereas certain general surgeons additionally identified transfer of care.ConclusionsSurgeon support for simultaneous resection was high for cases with minor hepatectomy, and low for cases involving major hepatectomy. These results suggest that clinical trials should involve patients with limited disease to evaluate post-operative complications and cost.     

Simultaneous resection of colorectal carcinoma and synchronous liver metastases in a district hospital

Of 491 patients operated for carcinomas of the colon or rectum between 1984 and 1989, 106 were tumour stage IV, U.I.C.C. (Dukers' D) at time of operation. In 22 of these cases a radical resection of the carcinoma of the colon or rectum and of synchronous liver metastases was performed simultaneoulsy. In 20 patients the metastases were confined to one, in two they were found in both hepatic lobes. In one case a solitary metastasis of the lower lobe of the right lung was resected additionally. Three right-sided hemihepatectomies, one extended right hemihepatectomy, five left-sided hemihepatectomies, three left-sided lateral segmentectomies, seven atypical segmental resections and three wedge resections were performed. The mean operation time for the radical resection of the carcinomas of the colon or rectum as well as of the liver metastases was 3.5 (3–5.2) hour. An average of 3 (0–9) blood units were needed intraoperatively. The major liver resections were performed in complete normothermic vascular ischaemia using the finger fracture method. The time of ischaemia ranged between 8 and 25 min. Only 1 of 22 patients died postoperatively (30 days postoperative hospital mortality rate 4.5%). Five of 17 patients were free of tumour 2 years after operation. Eight of 22 were alive 2 years after operation (non-age corrected 2-year survival rate 36.4%), 2 of them are alive more than 5 years after treatment. Our results demonstrate that simultaneous resection of colon or rectum carcinoma and of synchronous (resectable) liver metastases can be performed successfully, even in a district hospital.

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Résumé 106 parmi les 491 malades opérés pour cancer du colon ou du rectum entre 1984 et 1989 avaient une tumeur du stade IV de la classification UICC (Dukes D.) au moment de leur opération. Dans 22 cas une résection radicale du cancer du colon ou du rectum et de métastases hépatiques synchrones a été réalisée simultanément. Ces métastases étaient localisées dans un seul lobe chez 20 patients alors que chez 2 autres il existait des métastases dans les 2 lobes. De plus, dans un cas une métastase solitaire du lobe inférieur du poumon droit a été réséquée. 3 hépatectomies droite, une hépatectomie droite élargie, 5 hépatectomies gauches, 3 segmentectomies latérales gauche, 7 résections segmentaires atypiques et 3 résections cunéiformes ont été effectuées. Le temps moyen d'intervention pour la résection radicale des cancers du colon ou du rectum aussi que es métastases hépatiques a été de 3,5 heures (3–5,2). Une moyenne de 3 (0–9) unités de sang a été nécesaire pendant l'intervention. Les résections hépatiques majeures ont été effectuées sous complète normothermie et ischémie vasculaire utilisant la méthode de Ton-Than-Tung. Le temps moyen d'ischémie était de 8 à 25 minutes. 1 seul malade sur 22 est mort dans la période post-opératoire (mortalité post-opératoire à l'hôpital pendant les 30 premiers jours: 4,5%). 5 des 17 malades étaient indemnes de toute tumeur 2 ans après l'opération. 8 des 22 malades étaient vivants 2 ans après l'opération (taux de survie à 2 ans 36,4%), 2 d'entre eux étaient vivants plus de 5 ans après traitement. Nos résultats démontrent que la résection simultanée des cancers du colon et du rectum et des métastases hépatiques synchrones réséquables peut être effectuée avec succés même dans un hôpital de district.

     

Meta‐analysis of simultaneous versus staged resection for synchronous colorectal liver metastases

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.     

Repeat liver resection for recurrent colorectal metastases: a single-centre, 13-year experience

Objectives: Isolated intrahepatic recurrence is noted in up to 40% of patients following curative liver resection for colorectal liver metastases (CLM). The aims of this study were to analyse the outcomes of repeat hepatectomy for recurrent CLM and to identify factors predicting survival.Methods: Data for all liver resections for CLM carried out at one centre between 1998 and 2011 were analysed.Results: A total of 1027 liver resections were performed for CLM. Of these, 58 were repeat liver resections performed in 53 patients. Median time intervals were 10.5 months between the primary resection and first hepatectomy, and 15.4 months between the first and repeat hepatectomies. The median tumour size was 3.0 cm and the median number of tumours was one. Six patients had a positive margin (R1) resection following first hepatectomy. There were no perioperative deaths. Significant complications included transient liver dysfunction in one and bile leak in two patients. Rates of 1-, 3-and 5-year overall survival following repeat liver resection were 85%, 61% and 52%, respectively, at a median follow-up of 23 months. R1 resection at first hepatectomy (P = 0.002), a shorter time interval between the first and second hepatectomies (P = 0.02) and the presence of extrahepatic disease (P = 0.02) were associated with significantly worse overall survival.Conclusions: Repeat resection of CLM is safe and can achieve longterm survival in carefully selected patients. A preoperative knowledge of poor prognostic factors helps to facilitate better patient selection.     

Primary resection and synchronous regional hepatic chemotherapy or cryotherapy for colorectal cancer with liver metastases

Twenty-two patients with colorectal cancer and synchronous unresectable hepatic metastases were treated by resection the primary tumour with concurrent insertion of an Infusaid infusaport system for regional chemoperfusion (hepatic arterial 20, portal venous 2). Four patients in addition had cryotherapy the liver metastases. Morbidity from the synchronous procedures was minimal. Median survival was 10 months. Four patients with poorly-differentiated tumours had a poor response, with a median survival of 3.75 months.

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Résumé Vingt-deux patients porteurs d'un cancer colorectal et de métastases hépatiques synchrones non réséquables ont été traités par résection première de la tumeur avec mise en place simultanée d'un système INFUSAIDINFUSAPORT pour assurer une chimiothérapie régionale (20 fois dans l'artère hépatique et 2 fois dans la veine porte). Par ailleurs, 4 patients ont subi une cryothérapie de métastases hépatiques. La morbidité de ces interventions synchrones est minimale. La survie moyenne est de 10 mois. Quatre patients porteurs de tumeurs peu différenciées ont eu une mauvaise réponse thérapeutique avec une survie moyenne de 3,75 mois.

     

Simultaneous colorectal and parenchymal-sparing liver resection for advanced colorectal carcinoma with synchronous liver metastases: Between conventional and mini-invasive approaches

The optimal timing of surgery in case of synchronous presentation of colorectal cancer and liver metastases is still under debate. Staged approach, with initial colorectal resection followed by liver resection (LR), or even the reverse, liver-first approach in specific situations, is traditionally preferred. Simultaneous resections, however, represent an appealing strategy, because may have perioperative risks comparable to staged resections in appropriately selected patients, while avoiding a second surgical procedure. In patients with larger or multiple synchronous presentation of colorectal cancer and liver metastases, simultaneous major hepatectomies may determine worse perioperative outcomes, so that parenchymal-sparing LR should represent the most appropriate option whenever feasible. Mini-invasive colorectal surgery has experienced rapid spread in the last decades, while laparoscopic LR has progressed much slower, and is usually reserved for limited tumours in favourable locations. Moreover, mini-invasive parenchymal-sparing LR is more complex, especially for larger or multiple tumours in difficult locations. It remains to be established if simultaneous resections are presently feasible with mini-invasive approaches or if we need further technological advances and surgical expertise, at least for more complex procedures. This review aims to critically analyze the current status and future perspectives of simultaneous resections, and the present role of the available mini-invasive techniques.     

Laparoscopic and robot-assisted one-stage resection of colorectal cancer with synchronous liver metastases: a pilot study

Background/purpose

One-stage resection of primary colon cancer and synchronous liver metastases is considered an effective strategy of cure. A laparoscopic approach may represent a safe and advantageous choice for selected patients with the aim of improving the early outcome.

Methods

Between January 2008 and October 2008, 7 patients underwent one-stage laparoscopic resection for primary colorectal cancer combined with laparoscopic or robot-assisted liver resection.

Results

A total of five laparoscopic left-colon, one right-colon, and one rectal resections were performed. Three patients underwent preoperative left-colon stenting and two received neoadjuvant chemotherapy. The patient with rectal cancer underwent neoadjuvant radiotherapy. Liver procedures included one bisegmentectomy (segments 2, 3), 3 segmentectomies, 6 metastasectomies, and four laparoscopic ultrasound-guided radiofrequency ablations (LUG-RFAs). One patient with multiple liver metastases was managed by a two-stage hepatectomy partially conducted by a totally laparoscopic approach. The overall postoperative morbidity was null. The median hospital stay was 10 days (range 7–10 days).

Conclusions

This pilot study suggests that laparoscopic one-stage colon and liver resection is feasible and safe. Robot assistance may facilitate liver resection, increasing the number of patients who may benefit from a minimally invasive operation.     

Simultaneous laparoscopic resection of primary colorectal cancer and associated liver metastases: a systematic review

As many as 25 % of colorectal cancer (CRC) patients have liver metastases at presentation. However, the optimal strategy for resectable synchronous colorectal liver metastasis remains controversial. Despite the increasing use of laparoscopy in colorectal and liver resections, combined laparoscopic resection of the primary CRC and synchronous liver metastasis is rarely performed. The potential benefits of this approach are the possibility to perform a radical operation with small incisions, earlier recovery, and reduction in costs. The aim of this study was to review the literature on feasibility and short-term results of simultaneous laparoscopic resection. We conducted a systematic search of all articles published until February 2013. Search terms included: hepatectomy [Mesh], “liver resection,” laparoscopy [Mesh], hand-assisted laparoscopy [Mesh], surgical procedures, minimally invasive [Mesh], colectomy [Mesh], colorectal neoplasms [Mesh], and “colorectal resections.” No randomized trials are available. All data have been reported as case reports, case series, or case–control studies. Thirty-nine minimally invasive simultaneous resections were identified in 14 different articles. There were 9 (23 %) major hepatic resections. The most performed liver resection was left lateral sectionectomy in 26 (67 %) patients. Colorectal resections included low rectal resections with total mesorectal excision, right and left hemicolectomies, and anterior resections. Despite the lack of high-quality evidence, the laparoscopic combined procedure appeared to be feasible and safe, even with major hepatectomies. Good patient selection and refined surgical technique are the keys to successful simultaneous resection. Simultaneous left lateral sectionectomy associated with colorectal resection should be routinely proposed.     

Liver resection or cryotherapy for colorectal liver metastases

Background and aims While there is promising survival data for cryosurgery of colorectal liver metastases, local recurrence following cryoablation remains a problem. We aimed to compare morbidity and mortality, as well as the recurrence pattern and survival after liver resection and cryotherapy (alone or in combination with resection) for liver metastases.Patients and methods Between 1996 and 2002, 168 patients underwent liver resection alone and 55 patients had cryotherapy (25 in combination with liver resection) for colorectal liver metastases. The patient, tumour and operative details were recorded prospectively and the two patient groups were compared regarding morbidity, survival and recurrence.Results More patients had a prior liver resection, liver metastases were smaller and less frequently synchronous, morbidity was significantly lower and hepatic recurrence was significantly more frequent in the cryotherapy group. Five-year survival rates following resection and cryotherapy were comparable (23 and 26% respectively), while overall and hepatic recurrence-free survival was inferior following cryotherapy.Conclusion Cryotherapy is a valuable treatment option for some patients with non-resectable colorectal liver metastases. While survival is comparable to that after resection, higher hepatic recurrence rates following cryotherapy should caution against the use of cryotherapy for resectable disease until the results of randomized controlled trials are available.     

Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis

Objective

This was a systematic review and meta-analysis to compare outcomes between patients undergoing simultaneous or delayed hepatectomy for synchronous colorectal liver metastases.

The prognosis of colorectal cancer with synchronous liver metastases]

Between January 1985 and December 1989, 583 patients with carcinoma of the colon and rectum have been studied. In 85 with synchronous liver metastases discovered at laparotomy and followed-up, median survival time has been 5.8 months and 1 and 3 year survival 23 and 6 percent respectively. Favorable factors for survival were rectosigmoid location, single metastasis in the right hepatic lobe, normal values of alkaline phosphatase, resection of the tumor as well as stage II of Duke's classification.     

Treatment of colorectal cancer with synchronous bilobar liver metastases with simultaneous bowel and liver resection plus radiofrequency ablation

Patients with synchronous bilobar colorectal liver metastases usually have an extent or distribution of the metastases that precludes curative resection. Recently radiofrequency ablation has been proved to safely control liver metastases but a combination of radiofrequency ablation with more than liver resection is rarely performed. We report two patients with colorectal primary and synchronous classically unresectable bilobar liver metastases treated with a combination of bowel and liver resection plus radiofrequency ablation. In the first patient we performed left colectomy, left hepatic lobectomy and radiofrequency ablation of lesions in segments I and VII. In the second patient we performed low anterior resection, wedge resections for three superficially placed lesions in segments V and VIII, and radiofrequency ablation of five more deeply located lesions in segments III, IV, VI and VII. Both patients recovered uneventfully. At the eighth month, the first patient developed three new liver metastases that were treated with subsequent radiofrequency ablation and at the tenth and seventh months of follow-up respectively, both patients are disease free. In conclusion, combination of bowel and liver resection plus radiofrequency ablation expands the possibilities to treat more patients with colorectal cancer having synchronous bilobar unresectable liver metastases.     

Chemotherapy and resection for gastric cancer with synchronous liver metastases

AIM: To investigate the effect of surgery and chemotherapy for gastric cancer with multiple synchronous liver metastases (GCLM). METHODS: A total of 114 patients were entered in this study, and 20 patients with multiple synchronous liver metastases were eligible. After screening with preoperative chemotherapy, 20 patients underwent curative gastrectomy and hepatectomy for GCLM; 14 underwent major hepatectomy, and the remaining six underwent minor hepatectomy. There were 94 patients without aggressive treatment, and they were in the non-operative group. Two regimens of perioperative chemotherapy were used: S-1 and cisplatin (SP) in 12 patients, and docetaxel, cisplatin and 5-fluorouracil (DCF) in eight patients. These GCLM patients were given preoperative chemotherapy consisting of two courses chemotherapy of SP or DCF regimens. After chemotherapy, gastrectomy and hepatectomy were preformed. Evaluation of patient survival was by follow-up contact using telephone and outpatient records. All patients were assessed every 3 mo during the first year and every 6 mo thereafter. RESULTS: Twenty patients underwent gastrectomy and hepatectomy and completed their perioperative chemotherapy and hepatic arterial infusion before and after surgery. Ninety-four patients had no aggressive treatment of liver metastases because of technical difficulties with resection and severe cardiopulmonary dysfunction. In the surgery group, there was no toxicity greater than grade 3 during the course of chemotherapy. The response rate was 100% according to the Response Evaluation Criteria in Solid Tumors Criteria. For all 114 patients, the overall survival rate was 8.0%, 4.0%, 4.0% and 4.0% at 1, 2, 3 and 4 years, respectively, with a median survival time (MST) of 8.5 mo (range: 0.5-48 mo). For the 20 patients in the surgery group, MST was 22.3 mo (range: 4-48 mo). In the 94 patients without aggressive treatment, MST was 5.5 mo (range: 0.5-21 mo). There was a significant difference between the surgery and unresectable patients (P = 0.000). Thr     

Determinants of short- and long-term outcome in patients undergoing simultaneous resection of colorectal cancer and synchronous colorectal liver metastases

Purpose  

The optimal surgical strategy for patients presenting with colorectal liver metastases has yet to be determined. Short- and long-term outcomes must be considered if simultaneous resection of primary and liver metastases is to gain acceptance. We examine the prognostic value of patient and tumour characteristics in predicting short- and long-term outcomes following simultaneous resection for synchronous disease.     

结直肠癌同时性肝转移患者原发灶切除的预后分析

目的 原发灶切除能否使结直肠癌肝转移患者生存获益,目前仍有争议.本研究探讨接受原发灶切除结直肠癌肝转移患者的生存状况及预后的影响因素.方法 回顾性分析2010年1月～2018年2月在国家癌症中心/中国医学科学院肿瘤医院治疗的371例结直肠癌同时性肝转移患者的病例资料.根据治疗方式分为单纯化疗组和原发灶切除组,分析两组患...     

Repeated liver resection for recurrent metastases from colorectal cancer

BACKGROUND/AIMS: Repeat hepatectomy is the most effective treatment for recurrent colorectal liver metastases. We aim to assess how repeated liver resections increase survival, without unacceptable surgical risk. METHODOLOGY: Between December 1992 and December 1998, among 19 patients, 5 underwent secondary resection of recurrent metastatic disease. Following the primary liver surgery, three patients had systemic chemotherapy with 5-fluorouracil and two locoregional chemotherapy via Port-a-cath in the gastroduodenal artery. We evaluated survival and we compared time of surgery, duration of Pringle maneuver, blood losses and postoperative stay in the hospital between first and second liver surgery. RESULTS: Perioperative mortality at second liver resection was nil; morbidity minor; mean duration of surgery 320 vs. 260 min; Pringle maneuver 35 vs. 25 min; blood losses 1300 vs. 650 mL; postoperative stay 12.6 vs. 11.5 days. Mean total survival from time of colon resection was 50 months. As an interesting secondary finding, we observed prolonged inhibition of liver regeneration following treatment with Methotrexate. CONCLUSIONS: Repeated hepatic resection is a safe procedure for selected patients. Surgical risk is slightly increased, but the risk/benefit ratio is definitely in favor of as many repeated resections as needed, whenever there is a chance of curative surgery.     

同时性结直肠癌肝转移患者的生存分析

目的分析结直肠癌合并同时性肝转移患者的生存状况和相关影响因素。 方法回顾性分析2000年至2010年复旦大学附属中山医院收治的1061例结直肠癌合并同时性肝转移患者的病例。收集所有患者的临床资料、病理特征、治疗策略、住院费用、随访状况等,进行生存状况分析,并采用单因素和Cox比例风险回归模型等分析影响结直肠癌肝转移生存的相关因素。 结果肝转移灶可切除患者中,同期切除肠道原发灶和肝转移灶与分期切除患者的住院费用分别为25693元、34129元(P<0.05),手术并发症(分别为24.5%、20.5%)和总生存期方面(分别为48.5月、47.0月)无显著差异。肝转移灶不可切除且原发灶无症状的患者中,原发灶切除的患者总体中位生存时间明显好于原发灶未切除的患者(分别为19.0月、9.3月,P<0.001)。肠道原发灶分化Ⅲ～Ⅳ级、肝转移灶≥4个、最大肝转移灶直径≥5 cm、肝外转移、肠道原发灶未手术切除和肝转移灶非手术治疗是影响肠癌同时性肝转移患者预后的独立危险因素。将上述6个危险因素各设定为1分,所有患者分为低风险组(0～1分)、中风险组(2～3分)和高风险组(4～6分),5年存活率分别为51%、16%和0%(P<0.001)。 结论结直肠癌合并同时性肝转移患者中,原发灶和转移灶均可切除的可予以同期切除,原发灶可切除且无出血梗阻症状的不可切除的肝转移仍建议在合适时机切除肠道原发灶。根据上述6个独立预后因素所建立的预测模型可以指导临床采取合适的治疗方案。