结直肠癌同时性肝转移的同期手术切除

目的探讨同时性结直肠癌肝转移行同期切除原发瘤和肝转移瘤的安全性和有效性。方法回顾性总结分析从1981年5月至2005年11月在我院住院治疗的43例结直肠癌同时性肝转移同期手术的临床病理资料及结果并结合文献复习。结果43例患者中男性21例,女性22例,中位年龄52岁,手术持续中位时间180min。共30例术中输血,中位输血量800ml。术后总住院时间10—50d,中位时间15d。并发症发生率18．6％（8／43）,手术死亡率2．3％（1／43）。全组总的中位生存期为25个月,5年生存率19．1％。R0切除组的中位生存期48个月,5年生存率33．8％;非R0切除组的中位生存期为20个月,5年生存率7．6％。两组的生存时间经LogRank检验差异明显,P=0．002。结论同时性结直肠癌肝转移同期手术的安全性和有效性可以保证。对可切除的同时性结直肠癌肝转移应争取同期手术,并争取R0切除。     

Laparoscopic resection of colon cancer and synchronous liver metastasis

The recommended surgical approach to synchronous colorectal metastasis has not been clarified. Simultaneous open liver and colon resection for synchronous colorectal carcinoma has been shown beneficial when compared to staged resections. A review of the literature has shown the benefits of both laparoscopic colon resection for colorectal cancer and laparoscopic left lateral segmentectomy in liver disease. We present the case of a 60-year-old male with sigmoid colon carcinoma and a synchronous solitary liver metastasis localized to the left lateral segment. Using laparoscopic techniques, we were able to achieve simultaneous resection of the sigmoid colon and left lateral liver segment.     

Totally laparoscopic strategies for the management of colorectal cancer with synchronous liver metastasis

Introduction

Laparoscopy is an accepted treatment for colorectal cancer and liver metastases, but there is no consensus for its use in the management of synchronous liver metastases (SCRLM). The purpose of this study was to evaluate totally laparoscopic strategies in the management of colorectal cancer with synchronous liver metastases.

Methods

Patients presenting to Ninewells Hospital between July 2007 and August 2010, with adenocarcinoma of the colon and rectum with synchronous liver metastases were considered. Patients underwent simultaneous laparoscopic liver and colon cancer resection, a staged laparoscopic resection of SCRLM and colon cancer, or simultaneous colon resection and radiofrequency ablation (RFA) of SCRLM. Primary endpoints were in-hospital morbidity and mortality, total hospital stay, intraoperative blood loss, duration of surgery, and resection margin status.

Results

Twenty-eight patients presented with synchronous colorectal liver metastases. Thirteen patients underwent a simultaneous laparoscopic liver and colon resection (median operating time, 370 (range, 190–540) min; median hospital stay, 7 (range, 3–54) days), seven patients had a staged laparoscopic resection of SCRLM and primary colon cancer (median operating time, 530 (range, 360–980) min; median hospital stay 14, (range, 6–51) days), and eight patients underwent laparoscopic colon resection and RFA of SCRLM (median operating time, 310 (range, 240–425) min; median hospital stay, 8 (range, 6–13) days). There were no conversions to an open procedure. Overall in-hospital morbidity and mortality was 28 and 0?% respectively. An R0 resection margin was achieved in 91?% of the resection group. At a median follow-up of 26 (range, 18–55) months, 19 (90?%) patients remain disease-free.

Conclusions

Totally laparoscopic strategies for the radical treatment of stage IV colorectal cancer are feasible with low morbidity and favorable outcomes. A laparoscopic approach for the simultaneous management of SCRLM and primary colon cancer is associated with reduced surgical access trauma, postoperative morbidity, and hospital stay with no compromise in short-term oncological outcome.     

结直肠癌同时性肝转移同期与分期手术切除疗效比较

目的：比较结直肠癌同时性肝转移患者原发灶和肝转移灶同期与分期切除的近期和远期结局。方法回顾性分析北京肿瘤医院肝胆胰外一科2003年1月至2011年12月间的64例结直肠癌合并同时性肝转移患者的临床及术后随访资料,其中行原发灶和肝转移灶同期切除者20例（同期切除组）,分期切除者44例（分期切除组）。结果同期切除组Clavien-Dindo 1、2和3级并发症发生率分别为10．0％（2/20）、15．0％（3/20）和15．0％（3/20）,分期切除组分别为13．6％（6/44）、13．6％（6/44）和22．7％（12/44）,差异无统计学意义（P＞0．05）。同期切除组1、2和3年总体生存率分别为85．0％、59．6％和37．2％,分期切除组分别为90．9％、68．2％和47．1％,差异亦无统计学意义（均P＞0．05）。两组中位无病生存时间分别为6月和7月,差异亦无统计学意义（P＞0．05）。多因素预后分析显示,原发灶淋巴结阳性（P=0．020）和肝切除术前CEA水平大于20μg/L（P=0.017）是影响患者总体生存的独立危险因素;复发后有机会接受根治性局部治疗联合化疗则是一项保护性因素（P=0.001）;而手术时机（同期或分期切除）与患者总体生存无关（P＞0．05）。结论对于结直肠癌同时性肝转移,选择同期或分期切除并不影响患者的术后并发症发生率和远期生存率。     

结肠癌同时性肝转移同期手术与分期手术的疗效比较

目的：对比结肠癌同时性肝转移行同期手术与分期手术切除转移灶的疗效。方法：回顾性分析36例结肠癌同时性肝转移患者的临床资料,其中16例行结肠癌根治术同时切除肝转移病灶（同期手术组）;20例先行结肠癌根治性切除、二期行肝转移病灶切除（分期手术组）。比较两组患者的1,3,5年生存率。结果：同期手术组患者1,3,5年生存率分别为87.5%,37.5%,18.8%,分期手术组患者1,3,5年生存率分别为65%,10.0%,0.0%。两组比较,1年生存率差异无统计学意义（P>0.05）,同期手术组3,5年生存率明显高于分期手术组（均P<0.05）。结论：结肠癌同时性肝转移行同期手术可延长患者生存时间。

     

结直肠癌同时性肝转移行一期和二期肝切除术安全性的荟萃分析

目的 评估结直肠癌同时性肝转移患者一期和二期肝切除术的安全性.方法 通过检索PubMed/Medline,ISI Web of Knowledge,Springer link,Ebscohost,Elsevier Wiley Interscience和Google Scholar,搜集1989年1月至2009年3月关于结直肠癌同时性肝转移患者行一期和二期肝切除术的对照研究,对一期和二期手术组患者的手术并发症发生率和围手术期死亡率进行荟萃分析.结果 检索到7篇文献共计1390例结直肠癌同时性肝转移行肝切除术的患者,其中一期手术者495例,二期手术者895例.一期手术者围手术期死亡率（2.4%）高于二期手术者（1.1%）,差异有统计学意义（Peto OR 3.39,95% CI 1.29～8.93,P=0.01）;两组手术并发症发生率分别为33.9%和29.8%,两组比较差异无统计学意义[OR（随机）0.88,95% CI 0.51～1.51,P=0.64].结论 同时性结直肠癌肝转移患者有选择地行二期手术是合理和安全的.     

ͬʱ�Խ�ֱ������ת����һ�ںͶ��ڸ��г�����ȫ�Լ���Ч���ͷ���

??Safety and efficacy of simultaneous resection and staged resection for synchronous colorectal liver metastases??A Meta analysis WEI Meng??GENG Xiao-ping??ZHAO Hong-chuan??et al. Department of Organ Transplantation??the First Affiliated Hospital of Anhui Medical University??Hefei 230022??China
Corresponding author??GENG Xiao-ping??E-mail??xp_geng@163.net
Abstract Objective To evaluate the safety and efficacy of simultaneous resection and staged resection for synchronous colorectal liver metastasis (SCLM). Methods Medline??Cochrane Library and Google Scholar were searched from December 1999 to May 2012 to identify the case-control studies comparing outcomes following simultaneous resection and staged resection for SCLM. Results Fourteen case-control studies with a total of 2588 patients of SCLM undergone curative hepatic resection were reviewed. There were 931 simultaneous and 1657 staged resections. Complication incidence in simultaneous resection group was lower than that in staged resection group (41.1% vs. 44.8%)??and the difference was statistically significant (OR 0.79??95%CI??0.65??0.95??P=0.01). Less blood loss (P=0.02) and shorter hospital stay (P=0.00) were observed in simultaneous resection group. No significant difference was found in perioperative mortality rate (P=0.26), 3 years tumor-free survival rate (P=0.19), 5 years overall survival rate (P=0.86) and operative time (P=0.05) between two groups. Particularly??for major liver resections (resection of three or more segments)??the surgical complication incidence (P=0.26) and perioperative mortality rate (P=0.26) in the simultaneous resection group have not statistical difference compared with that in the staged resection group. Conclusion Simultaneous resection is safe and efficient in the treatment of patients with SCLM who can undergo staged resection. In appropriately selected patients??simultaneous resection might be considered as the preferred treatment.     

Simultaneous resection for colorectal cancer and synchronous liver metastases

Purposes

The correct timing of hepatectomy in patients with synchronous colorectal liver metastases is unclear. The aim of this study was to assess the clinical value of simultaneous resection (SR) for patients with colorectal cancer and synchronous liver metastases.

Methods

Between January 2006 and December 2013, 158 patients underwent resection of primary colorectal cancer and liver metastases. Sixty-three patients possessed synchronous colorectal liver metastases. Of those with synchronous colorectal liver metastases, 41 patients (65 %) underwent SR, and 22 (35 %) underwent delayed resection (DR). The clinicopathologic and operative data and the surgical outcomes of the patients in the SR and DR groups were retrospectively analyzed.

Results

The type of primary/liver resection, liver resection time, total blood loss volume, R0 resection rate, and morbidity rate were similar between the two groups. The SR group was associated with a shorter total postoperative hospital stay (21 vs 32 days, p < 0.001). However, the overall survival rate was similar between the two groups (3-year survival, 65.6 % in the SR group versus 66.8 % in the DR group, p = 0.054).

Conclusion

Simultaneous resection of colorectal cancer and synchronous liver metastases is associated with a comparable morbidity rate and shorter hospital stay, even when following rectal resection and major hepatectomy.

     

大肠癌伴肝转移同期切除的预后分析

目的分析大肠癌(结肠癌和直肠癌)伴肝转移行同期切除影响患者预后的相关因素。方法采用多因素回归分析方法回顾性分析3 7例大肠癌伴肝转移患者行同期切除的临床资料;选取11项相关因素进行分析。结果年龄,门静脉化疗泵内局部化疗,组织学分型,淋巴结转移,肝转移灶位置,大小,数目对患者的生存时间有影响。结论大肠癌伴肝转移行同期切除术中术后行门静脉化疗泵内局部化疗可以改善患者的预后,延长其生存期,并且后者是惟一可控因素。     

Selection criteria for simultaneous resection in patients with synchronous liver metastasis

HYPOTHESIS: While simultaneous resection has been shown to be safe and effective in patients with synchronous metastasis, neoadjuvant chemotherapy followed by hepatectomy has gradually gained acceptance for both initially nonresectable metastasis and resectable metastasis. The boundary between these treatments is becoming unclear. We hypothesized that factors associated with colorectal cancer may play an important role in the prognosis of patients with synchronous metastasis and may be useful for identifying patients who can be expected to have adequate results following simultaneous resection. DESIGN: Outcome study. SETTING: Tertiary referral center. PATIENTS: From January 1980 to December 2002, 187 patients underwent curative resection for synchronous liver metastasis from colorectal cancer. One hundred forty-two patients received simultaneous resection, 18 underwent staged resection, and 27 underwent delayed hepatic resection. Twenty-one clinicopathological factors were analyzed, and long-term prognosis was assessed. MAIN OUTCOME MEASURES: Prognostic factors and patient survival. RESULTS: There was no in-hospital death. In a multivariate analysis, the factors that significantly affected the prognosis of synchronous metastasis were 4 or more lymph node metastases around the primary cancer (P<.001) and multiple liver metastases (P = .003). In patients with 3 or fewer lymph node metastases around the primary cancer, the 5-year survival rates of those with 1, 2 to 3, and 4 or more liver metastases were 63%, 33%, and 40%, respectively, but these rates were 15%, 22%, and 0%, respectively, in patients with 4 or more lymph node metastases around the primary cancer. CONCLUSIONS: The results support the application of simultaneous resection in patients with 0 to 3 colorectal lymph node metastases. However, in patients with 4 or more colorectal lymph node metastases, biological selection by neoadjuvant chemotherapy may be more suitable.     

Sequence of colorectal and liver resection in patients with surgically-treatable stage IV colorectal cancer

Approximately 25-30% of patients with colorectal cancer develop hepatic metastases. For patients diagnosed with resectable colorectal hepatic metastases, variation exists regarding the timing of resection of the colorectal primary and the hepatic metastases including three approaches: (1) the “classical” colorectal-first staged approach, (2) the “combined” or simultaneous/synchronous approach, and (3) the “reverse” or liver-first staged approach. The purpose of this chapter is to review the current literature regarding the timing of colorectal and hepatic resection in patients with surgically treatable colorectal adenocarcinoma hepatic metastases. There are inadequate data at the current time to provide definitive recommendations as to the optimal timing and sequence of surgery. Our recommendations based on existing data favor delivery of neoadjuvant therapy followed by either: (1) the combined approach for low-risk resections, (2) the liver-first staged strategy for high-risk hepatic resections or mid- to distal rectal tumors that may benefit from total neoadjuvant therapy, or (3) the colorectal-first approach for symptomatic primary colon tumors.     

Simultaneous laparoscopic resection of colorectal cancer and synchronous metastatic liver tumor

Laparoscopic colorectal resection has been applied to advanced colorectal cancer. Synchronous liver metastasis of colorectal cancer would be treated safely and effectively by simultaneous laparoscopic colorectal and hepatic resection. Seven patients with colorectal cancer and synchronous liver metastasis treated by simultaneous laparoscopic resection were analyzed retrospectively. Three patients received a hybrid operation using a small skin incision, 2 patients underwent hand-assisted laparoscopic surgery using a small incision produced for colonic anastomosis, and 2 patients were treated with pure laparoscopic resection. The mean total operation duration was 407 minutes, and mean blood loss was 207 mL. Negative surgical margins were achieved in all cases. Mean postoperative hospital stay was 16.4 days. No recurrence at the surgical margin was observed in the liver. For selected patients with synchronous liver metastasis of colorectal cancer, simultaneous laparoscopic resection is useful for minimizing operative invasiveness while maintaining safety and curability, with satisfying short- and long-term results.     

Simultaneous colorectal and liver resections for synchronous colorectal metastases.

BACKGROUND: The surgical strategy for the treatment of colorectal cancer and synchronous hepatic metastases remains controversial. Many surgeons fear anastomotic leakage and intraperitoneal abscesses when performing a one-step procedure. They prefer a two-step procedure with a liver resection 2 to 3 months after resection of the colorectal primary lesion. SUBJECTS AND METHODS: We analysed medical records from April 1994 to April 2002 for a total of 42 patients with colorectal cancer and synchronous liver metastases who underwent simultaneous liver and colorectal resections with a primary anastomosis. Special attention was paid to data on surgical procedures, postoperative morbidity, and mortality. RESULTS: Forty-two patients, 24 men and 18 women, were studied. Median operating time was 6.50 hours (3.75-11.0 hours), and median blood loss was 1522 ml (range 288 to 5650 ml). Postoperative complications included pleural effusion in 4 patients, ileus in 3, anastomotic leakage in 2, intraperitoneal pelvic abscesses in 1, pneumonia in 1, bile leakage in 1, atelectasis in 1, and wound infection in 1. There was no perioperative mortality. CONCLUSION: Simultaneous colorectal resection with a primary anastomosis and hepatectomy for synchronous liver metastases is considered a safe procedure.     

Predictive Factors for Anastomotic Leakage after Simultaneous Resection of Synchronous Colorectal Liver Metastasis

Background  

The optimal surgical strategy for resectable, synchronous, colorectal liver metastases remains unclear. The objective of this study was to determine which patients could benefit from staged resections instead of simultaneous resection by identifying predictive factors for postoperative morbidity and anastomotic leakage after simultaneous resection of synchronous, colorectal liver metastases and the primary colorectal tumor.     

结直肠癌肝转移综合治疗体会

目的总结分析综合疗法控制结直肠癌肝转移的效果和体会。方法回顾性分析1996．1-2004．12结直肠癌肝转移106例临床资料。结果术前发现肝转移者行同期肝转移灶切除16例，门静脉化疗泵植入5例；术后发现肝转移灶者85例行手术切除、全身化疗、射频消融（PRFA）、无水酒精注射（PEI）、经导管肝动脉化疗栓塞（TACE）等综合治疗。无手术死亡。治疗后CEA转阴29．2％，下降56．9％。随访率92．5％，随访期8个月至5年。缓解率（CR＋PR）为92．9％。病人1，3，5年生存率分别为96．9％、51．8％和23．2％。结论积极手术切除，配合局部消融和全身化疗的综合治疗是控制结直肠癌肝转移的有效方案。     

Major hepatectomy in patients with synchronous colorectal liver metastases: whether or not a contraindication to simultaneous colorectal and liver resection?

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.     

癌结节对结直肠癌肝转移同期切除术预后的影响

目的探讨癌结节对初始可切除同时性结直肠癌肝转移患者同期切除术预后的影响。 方法回顾性分析2003年7月至2015年7月复旦大学附属中山医院行同期切除的212例同时性结直肠癌肝转移患者资料,分析癌结节和临床病理因素的相关性,采用Kaplan-Meier生存分析和Cox回归模型分析癌结节对预后的影响。 结果癌结节的阳性率为43.9%（93/212）,癌结节和肿瘤分化、淋巴结转移、血管浸润和神经浸润显著相关（P=0.044、0.001、0.035、<0.001）,是低DFS的独立预后因素。癌结节阳性患者的OS和DFS明显低于癌结节阴性患者,差异有统计学意义（P=0.003、<0.001）。淋巴结阳性的135例患者中,癌结节阳性和阴性患者的OS比较,差异无统计学意义（P=0.608）,癌结节阳性患者DFS更低（P=0.003）;在淋巴结阴性的77例患者中,癌结节阳性患者的OS和DFS均显著低于癌结节阴性患者（P<0.001、0.010）。 结论对于结直肠癌肝转移同期切除术后患者,癌结节和肿瘤分化、淋巴结转移以及神经浸润显著相关,且预示不良预后。     

Simultaneous resection for rectal cancer with synchronous liver metastasis is a safe procedure

Background

One quarter of colorectal cancer patients will present with liver metastasis at the time of diagnosis. Recent studies have shown that simultaneous resections are safe and feasible for stage IV colon cancer. Limited data are available for simultaneous surgery in stage IV rectal cancer patients.

Methods

One hundred ninety-eight patients underwent surgical treatment for stage IV rectal cancer. In 145 (73%) patients, a simultaneous procedure was performed. Fifty-three (27%) patients underwent staged liver resection. A subpopulation of 69 (35%) patients underwent major liver resection (3 segments or more) and 30 (44%) patients with simultaneous surgery.

Results

The demographics of the 2 groups were similar. Complication rates were comparable for simultaneous or staged resections, even in the group subjected to major liver resection. Total hospital stay was significantly shorter for the simultaneously resected patients (P < .01).

Conclusions

Simultaneous resection of rectal primaries and liver metastases is a safe procedure in carefully selected patients at high-volume institutions, even if major liver resections are required.     

结直肠癌伴同时性肝转移的治疗

目的 探讨结直肠癌伴同时性肝转移患者的临床相关病理因素以及手术治疗.方法 回顾性分析1994年8月至2006年12月收治患者的临床资料及随访结果,比较结直肠癌无肝转移和有同时性肝转移患者的病理特点及不同程度肝转移患者和不同手术处理的预后.结果 2019例原发性结直肠癌患者中发生同时性肝转移者166例(8.10%).多因素分析显示:术前CEA水平、Ducks分期、肿瘤分化程度与浆膜浸润是同时性肝转移发生的高危因素;同时性肝转移术后1、3、5年生存率分别为69%、21%、9%;不同程度肝转移(H1、H2、H3)组间预后差异有统计学意义(X2=23.35,P<0.01).根治性手术切除组总体生存率明显高于姑息切除和未能切除组生存率(X2=21.18,P<0.01);姑息切除组和未切除组近期生存率差异有统计学意义(P<0.01),远期生存率差异无统计学意义(P=0.13).结论 结直肠癌伴同时性肝转移患者肝转移程度不同预后也不同.能够根治性切除的结直肠癌伴同时性肝转移预后较好,姑息切除原发病灶可提高近期预后和生活质量.     

Importance of response to neoadjuvant chemotherapy in patients undergoing resection of synchronous colorectal liver metastases

The purpose of this study was to compare the treatment and outcome in patients referred for staged re section of synchronous colorectal liver metastases. The records of patients who had undergone colon or rectal resection and were then referred for evaluation of clinically resectable synchronous liver metastases between January 1995 and January 2000 were reviewed. Comparisons were made between patients who did not receive neoadjuvant chemotherapy and had exploratory operations after recovery from colon re section and patients who did receive chemotherapy before liver resection. A total of 106 patients were treated during the 5-year period. Neoadjuvant chemotherapy was given to 52 of the patients; in 29 of them the disease did not progress, but in 17 patients the disease progressed while they were receiving treatment. Median follow-up was 30 months. Patient- and tumor-related variables were similar between groups. Five-year survival was statistically similar between patients who did and those who did not receive neoadjuvant chemotherapy (43% vs. 35%, P = 0.49). Patients within the neoadjuvant group whose dis ease did not progress while they were receiving chemotherapy experienced significantly improved sur vival as compared to patients who did not receive chemotherapy (85% vs. 35%, P = 0.03). In the setting of synchronous colorectal liver metastases, the response to neoadjuvant chemotherapy may be a prognos tic indicator of survival and may assist in the selection of patients for conventional or experimental adju vant therapies. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).