Outcome following repeat liver resection for colorectal liver metastases.

AIM: Our aim was to determine independent predictors of survival after second liver resection and to confirm whether the type of first resection influences survival after repeat resection. METHODS: Fifty-four patients who underwent a second liver resection for colorectal liver metastases were analyzed. To find independent predictors of survival, possible prognostic factors regarding the primary tumor, and the first and second resections were used in the Cox regression analysis. RESULTS: There were three postoperative deaths within 90 days of surgery. The 3- and 5-year overall survival rates were 53% and 46%, respectively. The size of the tumor (>50mm) (p=0.005), serum carcinoembryonic antigen level (>30microg/L) (p=0.002), and the presence of a positive surgical margin at the second resection (p=0.006) were independent predictors of poor survival following the second resection. The type of first resection was not associated with survival but was associated with the ability to achieve a histological negative surgical margin at the second liver resection (p=0.01). CONCLUSION: Three independent predictors of survival were identified. Major initial liver resection was associated with a reduced ability to achieve surgical clearance at the second resection. For colorectal liver metastases, major resection should only be performed if a negative margin cannot be achieved by minor resection.     

Routine staging laparoscopy has no place in the management of colorectal liver metastases

Aims

Staging laparoscopy has been recommended in the management of patients with colorectal liver metastases prior to hepatectomy in order to reduce the incidence and associated morbidity of futile laparotomies. The utility of staging laparoscopy has not been assessed in patients undergoing CT, PET-CT and MRI as standard preoperative staging.

Methods

All patients undergoing attempted open hepatectomy for colorectal liver metastases between 1/4/2008 and 31/3/2012 were identified from a prospectively maintained research database. All patients who underwent futile laparotomy were identified, with demographics and operative notes subsequently analysed.

Results

A total of 274 patients underwent attempted open hepatectomy during the study period. At laparotomy 12 (4.4%) patients were found to have irresectable disease. There were no unifying demographic factors within the patients undergoing futile laparotomy.

Conclusions

With modern imaging, the potential yield of staging laparoscopy is low. Staging laparoscopy should not be used routinely, but may have a role in the case of specific clinical concerns.     

Elevated preoperative neutrophil to lymphocyte ratio predicts survival following hepatic resection for colorectal liver metastases

Background

The neutrophil–lymphocyte ratio (NLR) provides an indicator of inflammatory status. An elevated NLR has been shown to be a prognostic indicator in primary colorectal malignancy. The aim of this study was to establish whether NLR predicts outcome in patients undergoing resection for colorectal liver metastasis.

Design

Retrospective analysis of the white cell and differential counts for 440 patients undergoing liver resections for colorectal liver metastasis between January 1996 and January 2006. An NLR ≥ 5 was considered to be elevated.

Results

Two hundred and eighty-nine males and 151 females were included. Seventy-eight patients (18%) had an elevated NLR, 55 of whom died, giving elevated NLR a positive predictive value (PPV) for death of 71%. Sixty of the 78 patients had recurrent disease giving raised NLR an PPV for recurrence of 78%. The 5-year survival for patients undergoing resection with high NLR was significantly worse than that for patients with normal NLR (22% vs. 43%, p < 0.0001). Univariate analysis of factors affecting survival revealed raised NLR, number of metastases >8, tumour size >5 cm and age >70 significantly affected outcome. All factors except tumour size remained significant predictors of term survival on multivariate analysis (NLR:HR = 2.261, CI = 1.654–3.129, p < 0.0001, metastases >8:HR = 1.611, CI = 1.006–2.579, p = 0.047, age >70:HR = 1.418, CI = 1.049–1.930, p = 0.027). Elevated NLR was found to be the sole positive predictor of recurrence on univariate analysis (HR = 4.521, CI = 2.475–8.257, p < 0.0001).

Conclusion

Elevated NLR increases both risk of death and the risk of recurrence in patients who undergo surgery for CRLM. Preoperative NLR measurement may therefore provide a simple method of identifying patients with a poorer prognosis.     

Synchronous resection for colorectal liver metastases: The future

Colorectal Cancer is a common malignancy. Many patients have metastatic disease at presentation and a significant proportion subsequently go onto develop metastatic disease, following surgery for the primary disease.     

Prolonged portal triad clamping during liver surgery for colorectal liver metastases is associated with decreased time to hepatic tumour recurrence

Aims

The aim of this study was to evaluate the oncological outcome of portal triad clamping during hepatectomy in colorectal cancer patients.

Methods

160 patients with colorectal liver metastases underwent a partial hepatectomy with curative intent. Data were collected in a prospective database and were retrospectively analyzed for time to liver recurrence (TTLiR) and time to overall recurrence (TTR). The prognostic significance of portal triad clamping of any type and severe ischemia due to prolonged portal triad clamping was determined by Cox regression models.

Results

TTLiR was reduced after clamping of any type, although not statistically significant (p = 0.061). Severe ischemia due to prolonged portal triad clamping significantly decreased TTLiR (p = 0.022), but not TTR. Furthermore, severe ischemia independently predicted TTLiR in a multivariable analysis (p = 0.038).

Conclusions

Severe ischemia due to prolonged portal triad clamping during hepatic resection for colorectal liver metastases appears to be associated with decreased TTLiR. Further research remains necessary to determine the causative effect of prolonged vascular clamping on liver tumour recurrence.     

A new sequential treatment strategy for multiple colorectal liver metastases: Planned incomplete resection and postoperative completion ablation for intentionally-untreated tumors under guidance of cross-sectional imaging

PurposeWe retrospectively evaluated outcomes of a new sequential treatment strategy for patients with multiple colorectal liver metastases (CLM): planned incomplete resection and postoperative percutaneous completion ablation for intentionally-untreated lesions under cross-sectional imaging guidance.MethodsPatients with CLM who underwent curative-intent hepatectomy and ablation during 2007–2018 were analyzed. Complications, local tumor progression (LTP) rates at ablation site(s), and overall survival (OS) estimated using the Kaplan-Meier method were compared between patients who underwent CLM resection and postoperative percutaneous ablation for intentionally-untreated lesions (completion ablation) and patients who underwent CLM resection and concomitant intraoperative CLM ablation under ultrasound guidance.ResultsNumber and largest diameter of CLM and liver resection complexity did not differ significantly between the completion ablation (n = 23) and intraoperative ablation (n = 92) groups. Microwave (versus radiofrequency) ablation was used more frequently in the completion ablation group than in the intraoperative ablation group (61% [14/23] vs. 6% [6/92], P = 0.001). The complication rate after hepatectomy and ablation was significantly lower in the completion ablation group (21% [5/23] versus 48% [44/92], P = 0.033). No death was observed in either group. The 5-year LTP cumulative incidence was significantly lower in the completion ablation group (31.7% versus 62.4%, P = 0.030). The 5-year OS rate did not differ significantly between groups (53%, completion ablation; 42%, intraoperative ablation; P = 0.407).ConclusionsResection and postoperative percutaneous completion ablation under cross-sectional imaging guidance may be a safe and effective treatment pathway in patients with CLM in whom liver resection alone cannot achieve R0 resection.     

Outcomes following synchronous liver resection,cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases: A bi-institutional study

PurposeSynchronous liver resection, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal liver (CRLM) and peritoneal metastases (CRPM) has traditionally been contraindicated. However, latest practice promotes specialist, multidisciplinary-led consideration for select patients. This study aimed to evaluate the perioperative and oncological outcomes of synchronous resection in the management of CRLM and CRPM from two tertiary referral centres.MethodThis bi-institutional, retrospective, cohort study included patients undergoing simultaneous liver resection, CRS and HIPEC for metastatic colorectal cancer from 2013 to 2020. Patients treated with ablative liver techniques, staged operative approaches and extra abdominal disease were excluded. Overall survival (OS) and disease-free survival (DFS) rates were assessed. Univariate and multivariate analyses identified variables associated with survival and major morbidity (Clavien-Dindo grade III/IV).ResultsTwenty-three patients were included. The median peritoneal carcinomatosis index (PCI) was 9 (range 0–22). There were two major liver resections and 21 minor resections. CC-0 resections were achieved in all patients. Major morbidity occurred in 7 patients. There were no deaths at 90 days. PCI was independently associated with morbidity (p = 0.04). PCI >10 (p = 0.069), major morbidity (p = 0.083) and presence of KRAS mutation (p = 0.052) approached significance for poor OS. Median follow up was 21 months (4–54 months). Median OS was 37 months, 3-year survival 54%, and median DFS 18 months.ConclusionSynchronous liver resection, cytoreductive surgery and HIPEC is feasible in selected patients with low-volume CRPM and CRLM. Increasing PCI is associated with postoperative major morbidity, and should be considered during operative planning.     

Advanced image analytics predicting clinical outcomes in patients with colorectal liver metastases: A systematic review of the literature

BackgroundTo better select patients with colorectal liver metastases (CRLM) for an optimal selection of treatment strategy (i.e. local, systemic or combined treatment) new prognostic models are warranted. In the last decade, radiomics has emerged as a field to create predictive models based on imaging features. This systematic review aims to investigate the current state and potential of radiomics to predict clinical outcomes in patients with CRLM.MethodsA comprehensive literature search was conducted in the electronic databases of PubMed, Embase, and Cochrane Library, according to PRISMA guidelines. Original studies reporting on radiomics predicting clinical outcome in patients diagnosed with CRLM were included. Clinical outcomes were defined as response to systemic treatment, recurrence of disease, and survival (overall, progression-free, disease-free). Primary outcome was the predictive performance of radiomics. A narrative synthesis of the results was made. Methodological quality was assessed using the radiomics quality score.ResultsIn 11 out of 14 included studies, radiomics was predictive for response to treatment, recurrence of disease, survival, or a combination of outcomes. Combining clinical parameters and radiomic features in multivariate modelling often improved the predictive performance. Different types of individual features were found prognostic. Noticeable were the contrary levels of heterogeneous and homogeneous features in patients with good response. The methodological quality as assessed by the radiomics quality score varied considerably between studies.ConclusionRadiomics appears a promising non-invasive method to predict clinical outcome and improve personalized decision-making in patients with CRLM. However, results were contradictory and difficult to compare. Standardized prospective studies are warranted to establish the added value of radiomics in patients with CRLM.     

Time-varying prognostic effects of primary tumor sidedness and grade after curative liver resection for colorectal liver metastases

BackgroundThe veracity of the proportional hazards (PH) requirement is rarely scrutinized in most areas of cancer research, although fulfilment of this assumption underpins widely-used Cox survival models. We sought to critically appraise the existence of prognostic factors with time-dependent effects and to characterize their impact on survival among CLM patients.MethodsConsecutive patients who underwent liver resection with curative intent for CLM at the Singapore General Hospital were identified from a prospectively-maintained database. We evaluated PH of 55 candidate variables, and parameters which departed significantly from proportionality were included in Cox models that incorporated an interaction term to account for time-dependent effects. As sensitivity analyses, we fitted Weibull mixture ‘cure’ models to handle long plateaus in the tails of survival curves, and also analyzed the restricted mean survival time.Results318 consecutive patients who underwent curative liver resection for CLM between Jan 2000 and Nov 2016 were included in this analysis. Hazard ratios for tumor grade (poorly-versus well- and moderately-differentiated) were found to decrease from 3.135 (95% CI: 1.637–6.003) at 12 months to 2.048 (95% CI: 1.038–4.042) after 24 months, and ceased to be significant at 26 months. Compared to left-sided tumors, a right-sided tumor location was found to portend worse prognosis for the first 10 months after resection but subsequently confer a survival benefit due to a crossing of survival curves. Corroborating this observation, long-term cure fractions were estimated to be 25.5% (95% CI: 17.4%–33.6%) and 34.2% (95% CI: 17.4%–50.9%) among patients with left-sided and right-sided primary disease respectively.ConclusionPrimary tumor sidedness and grade appear to exert time-varying prognostic effects in CLM patients undergoing curative liver resection.     

Systematic review and meta-analysis of local ablative therapies for resectable colorectal liver metastases

IntroductionLocal ablative therapies (LAT) have shown positive but heterogenous outcomes in the treatment of colorectal liver metastases (CRLM). The aim of this systematic review is to evaluate LAT and compare them with surgical resection.MethodsIn accordance with PRISMA guidelines, Medline, EMBASE, Cochrane and Web of Science databases were searched for reports published before January 2019. We included papers assessing radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (CA) and electroporation (IRE) treating resectable CRLM with curative intention. We evaluated LAT related complications and oncological outcomes as tumour progression (LTP), disease-free survival (DFS) and overall survival (OS).ResultsThe literature search yielded 6767 records; 20 papers (860 patients) were included. No included studies related mortality with LAT. Median adverse events percentage was 7%: (8% RFA;7% MWA). Median 3y-DFS was 32% (24% RFA; 60% MWA); 5y-DFS was 27%: (18% RFA; 38.5% MWA). Median 3y-OS was 59% (60% RFA; 70% MWA; 34% CA), 5y-OS was 44.5% (43% RFA; 55% MWA; 20% CA).Surgical resection showed decreased LTP, improved DFS and OS than those reported with LAT, with RFA accounting for reduced 1y-DFS (RR 0.83, 95%CI 0.71–0.98), 3y-DFS (RR 0.5, 95%CI 0.33–0.76), 5y-DFS (RR 0.53, 95%CI 0.28–0.98) and 5y-OS (RR 0.76, 95%CI 0.58–0.98) in comparison with surgical resection.ConclusionsLow quality evidence suggests that both RFA and MWA seem superior to CA. MWA presents similar adverse events when compared to RFA with a possible increase in DFS and OS. Surgical resection still seems to provide superior DFS and OS in comparison with LAT.     

Systematic review of outcomes of patients undergoing resection for colorectal liver metastases in the setting of extra hepatic disease

BackgroundSurgical resection for patients with colorectal liver metastases (CRLM) can offer patients a significant survival benefit. We hypothesised that patients with CRLM and extra hepatic disease (EHD) undergoing metastasectomy had comparable survival and describe outcomes based on the distribution of metastatic disease.MethodsA systematic search using a predefined registered protocol was undertaken between January 2003 and June 2012. Primary exposure was hepatic resection for CRLM and primary outcome measure was overall survival. Meta-regression techniques were used to analyse differences between patients with and without extra hepatic disease.FindingsFrom a pool of 4996 articles, 50 were retained for data extraction (3481 CRLM patients with EHD). The median survival (MS) was 30.5 (range, 9–98) months which was achieved with an operative mortality rate of 0–4.2%. The 3-year and 5-year overall survival (OS) were 42.4% (range, 20.6–77%) and 28% (range, 0–61%) respectively. Patients with EHD of the lungs had a MS of 45 (range, 39–98) months versus lymph nodes (portal and para-aortic) 26 (range, 21–48) months versus peritoneum 29 (range, 18–32) months. The MS also varied by the amount of liver disease – 42.2 months (<two lesions) versus 39.6 months (two lesions) versus 28 months (⩾three lesions).InterpretationIn the evolving landscape of multimodality therapy, selective hepatic resection for CRLM patients with EHD is feasible with potential impact on survival. Patients with minimal liver disease and EHD in the lung achieve the best outcome.     

Influence of the primary tumour location in patients undergoing surgery for colorectal liver metastases

Background

The prognosis of patients undergoing liver resection for colorectal liver metastases (CLM) seems to be altered when the primary tumour is right-sided. However, data are lacking and conflicting. We aimed to evaluate the influence of the primary tumour location on oncologic outcomes following such surgery.

Radiofrequency versus microwave ablation for intraoperative treatment of colorectal liver metastases

IntroductionIntraoperative radiofrequency ablation (RFA) and the newer technique of microwave ablation (MWA) can both be of additional value in parenchyma preserving surgical treatment of colorectal liver metastases (CRLM). MWA is less influenced by the heat-sink effect of surrounding vessels and can generate more heat in less time but RFA is still widely used. True comparing studies are scarce.MethodsThis single centre retrospective cohort study analyzed patients who underwent ultrasound guided intraoperative ablation as a part of the surgical treatment of CRLM between 2013 and 2018. In September 2015, MWA was substituted for RFA. Outcomes included unsuccessful ablation rates at 1-year postoperative, 30-days major complication rates, progression free survival (PFS) and overall survival (OS). Logistic regression models were used for univariable and multivariable analyses to identify predictors of unsuccessful ablation.ResultsForty-one patients underwent RFA of 98 lesions (median 2) and 79 patients underwent MWA of 193 lesions (median 2). The median diameter of the ablated lesions was 9 mm for both RFA and MWA. Unsuccessful ablation was observed in 7 metastases (7.1%) after RFA and 14 metastases (7.3%) after MWA (p = 1.000). Complications requiring re-intervention were observed after 8 procedures, 2 complications in the RFA group (4.9%) versus 6 complications in the MWA group (7.6%, p = 0.714), of which 6 were liver-related. Ninety-day mortality did not occur. Ablation technique was not associated with unsuccessful ablations. CRLM size was associated with unsuccessful ablation in the per lesion analysis (p < 0.001).ConclusionIntraoperative RFA and MWA were equally effective for treatment of small CRLM.     

Population-based study on practice variation regarding preoperative systemic chemotherapy in patients with colorectal liver metastases and impact on short-term outcomes

IntroductionDefinitions regarding resectability and hence indications for preoperative chemotherapy vary. Use of preoperative chemotherapy may influence postoperative outcomes. This study aimed to assess the variation in use of preoperative chemotherapy for CRLM and related postoperative outcomes in the Netherlands.Materials and methodsAll patients who underwent liver resection for CRLM in the Netherlands between 2014 and 2018 were included from a national database. Case-mix factors contributing to the use of preoperative chemotherapy, hospital variation and postoperative outcomes were assessed using multivariable logistic regression. Postoperative outcomes were postoperative complicated course (PCC), 30-day morbidity and 30-day mortality.ResultsIn total, 4469 patients were included of whom 1314 patients received preoperative chemotherapy and 3155 patients did not. Patients receiving chemotherapy were significantly younger (mean age (+SD) 66.3 (10.4) versus 63.2 (10.2) p < 0.001) and had less comorbidity (Charlson scores 2+ (24% versus 29%, p = 0.010). Unadjusted hospital variation concerning administration of preoperative chemotherapy ranged between 2% and 55%. After adjusting for case-mix factors, three hospitals administered significantly more preoperative chemotherapy than expected and six administered significantly less preoperative chemotherapy than expected. PCC was 12.1%, 30-day morbidity was 8.8% and 30-day mortality was 1.5%. No association between preoperative chemotherapy and PCC (OR 1.24, 0.98–1.55, p = 0.065), 30-day morbidity (OR 1.05, 0.81–1.39, p = 0.703) or with 30-day mortality (OR 1.22, 0.75–2.09, p = 0.467) was found.ConclusionSignificant hospital variation in the use of preoperative chemotherapy for CRLM was present in the Netherlands. No association between postoperative outcomes and use of preoperative chemotherapy was found.     

Selection for surgery and survival of synchronous colorectal liver metastases; a nationwide study

BackgroundResection of colorectal liver metastases (CRLM) is associated with improved survival but we currently have limited population-based data on selection for surgery.MethodsPatients in the Swedish Colorectal Cancer Register reported with liver metastases at diagnosis in 2007–2011 were identified. Clinical characteristics including American Society of Anesthesiologists classification, type of hospital and health care region were retrieved. Linkage to the National Patient Register and Statistics Sweden provided information on liver resection and socioeconomic variables.ResultsSynchronous CRLM was found in 4243/27,990 (15.2%) patients, of whom 1094 (25.8%) also had concurrent lung metastases. Of 3149 patients with liver-only metastases, 556 (17.8%) were subjected to liver resection. The resection rate varied by subsite; right-sided 11.7%, left-sided 19.7% and rectal cancer 22.7% (p = 0.001). It varied by type of hospital 14.1–23.6%, by region 11.5–22.7%, and was 19.8% in men and 14.9% in women (all p < 0.001).The adjusted odds were 0.74 (0.59–0.93) for females, 0.58 (0.46–0.74) for general district and 0.50 (0.37–0.68) for district hospital patients, and there were large regional differences. Patients >75 years were very unlikely to receive liver surgery 0.22 (0.15–0.32).In patients subjected to liver surgery, median survival was 57 months, 5-year survival rate was 45.4%, and those with left-sided colon cancer had the best outcome (48.8%; p = 0.02). Five-year hazard ratio for patients not subjected to liver surgery was 4.3 (3.7–5.0).ConclusionNationwide outcome after resection of synchronous CRLM was impressing but ambiguous selection mechanisms and inaccessibility need to be resolved. The implications of subsite deserve further attention.     

Nationwide oncological networks for resection of colorectal liver metastases in the Netherlands: Differences and postoperative outcomes

IntroductionWidespread differences in patient demographics and disease burden between hospitals for resection of colorectal liver metastases (CRLM) have been described. In the Netherlands, networks consisting of at least one tertiary referral centre and several regional hospitals have been established to optimize treatment and outcomes. The aim of this study was to assess variation in case-mix, and outcomes between these networks.MethodsThis was a population-based study including all patients who underwent CRLM resection in the Netherlands between 2014 and 2019. Variation in case-mix and outcomes between seven networks covering the whole country was evaluated. Differences in case-mix, expected 30-day major morbidity (Clavien-Dindo ≥3a) and 30-day mortality between networks were assessed.ResultsIn total 5383 patients were included. Thirty-day major morbidity was 5.7% and 30-day mortality was 1.5%. Significant differences between networks were observed for Charlson Comorbidity Index, ASA 3+, previous liver resection, liver disease, preoperative MRI, preoperative chemotherapy, ≥3 CRLM, diameter of largest CRLM ≥55 mm, major resection, combined resection and ablation, rectal primary tumour, bilobar and extrahepatic disease. Uncorrected 30-day major morbidity ranged between 3.3% and 13.1% for hospitals, 30-day mortality ranged between 0.0% and 4.5%. Uncorrected 30-day major morbidity ranged between 4.4% and 6.0% for networks, 30-day mortality ranged between 0.0% and 2.5%. No negative outliers were observed after case-mix correction.ConclusionVariation in case-mix and outcomes are considerably smaller on a network level as compared to a hospital level. Therefore, auditing is more meaningful at a network level and collaboration of hospitals within networks should be pursued.     

Contrast-enhanced intra-operative ultrasound as a clinical decision making tool during surgery for colorectal liver metastases: The ULIIS study

BackgroundDetecting more colorectal liver metastases (CRLMs) during surgery may help optimise strategy and improve outcomes. Our objective was to determine clinical utility (CU) of contrast-enhanced intra-operative ultrasound (CE-IOUS) using sulphur hexafluoride microbubbles during CRLM surgery.MethodA prospective phase II trial performed at two comprehensive cancer research centres. Patients operated for CRLMs were eligible and assessable if intra-operative ultrasound (IOUS) and CE-IOUS had been performed and pathological results were available and/or 3-month imaging. CU was defined as the justified change in planned surgical strategy or procedure using CE-IOUS.ResultsOut of the 68 patients enrolled, 54 were eligible and assessable. 43 patients underwent pre-operative chemotherapy. The median number of CRLMs was 2 (range, 1–11). Pre-operative staging was performed using MRI. IOUS allowed identification of 45 new CRLMs in 13 (24.7%) patients. Compared to IOUS, CE-IOUS allowed identification of 10 additional CRLMs in 9 (16.7%) patients. Surgery was altered and justified in 4 patients only, leading to a CU rate of 7.70% (95 CI, [3.2, 18.6]). No missing CRLMs were identified by CE-IOUS.ConclusionsAlthough the primary endpoint was not met for one protocol violation, secondary endpoints indicate that CE-IOUS has an intermediate added-value for surgeons treating CRLMs.Trial registrationNCT01880554 (https://clinicaltrials.gov/).     

Laparoscopic liver resection for colorectal liver metastases — short- and long-term outcomes: A systematic review

BACKGROUNDFor well-selected patients and procedures, laparoscopic liver resection (LLR) has become the gold standard for the treatment of colorectal liver metastases (CRLM) when performed in specialized centers. However, little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.AIMTo provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.METHODSA systematic search was performed in PubMed, EMBASE, Web of Science and the Cochrane Library using the keywords “colorectal liver metastases”, “laparoscopy”, “liver resection”, “prognostic factors”, “outcomes” and “survival”. Only publications written in English and published until December 2019 were included. Furthermore, abstracts of which no accompanying full text was published, reviews, case reports, letters, protocols, comments, surveys and animal studies were excluded. All search results were saved to Endnote Online and imported in Rayyan for systematic selection. Data of interest were extracted from the included publications and tabulated for qualitative analysis.RESULTSOut of 1064 articles retrieved by means of a systematic and grey literature search, 77 were included for qualitative analysis. Seventy-two research papers provided data concerning outcomes of LLR for CRLM. Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes. Qualitative analysis of the collected data showed that LLR for CRLM is safe, feasible and provides oncological efficiency. Multiple research groups have reported on the short-term advantages of LLR compared to open procedures. The obtained results accounted for minor LLR, as well as major LLR, simultaneous laparoscopic colorectal and liver resection, LLR of posterosuperior segments, two-stage hepatectomy and repeat LLR for CRLM. Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.CONCLUSIONIn experienced hands, LLR for CRLM provides good short- and long-term outcomes, independent of the complexity of the procedure.     

Impact of biological agents on the prevalence of chemotherapy associated liver injury (CALI): Multicentric study of patients operated for colorectal liver metastases

Background

The prevalence of chemotherapy associated liver injuries (CALI), especially SOS (sinusoidal obstruction syndrome) and NRH (nodular regenerative hyperplasia) might be reduced since the introduction of routine use of biological agents with chemotherapy in colorectal liver metastases (CRLM).

Prognostic models for outcome following liver resection for colorectal cancer metastases: A systematic review

Background

Liver resection provides the best chance for cure in colorectal cancer (CRC) liver metastases. A variety of factors that might influence survival and recurrence have been identified. Predictive models can help in risk stratification, to determine multidisciplinary treatment and follow-up for individual patients.

Aims

To systematically review available prognostic models described for outcome following resection of CRC liver metastases and to assess their differences and applicability.

Methods

The Pubmed, Embase and Cochrane Library databases were searched for articles proposing a prognostic model or risk stratification system for resection of CRC liver metastases. Search terms included ‘colorectal’, ‘liver’, ‘metastasis’, ‘resection’, ‘prognosis’ and ‘prediction’. The articles were systematically reviewed.

Results

Fifteen prognostic systems were identified, published between 1996 and 2009. The median study population was 305 patients and the median follow-up was 32 months. All studies used Cox proportional hazards for multi-variable analysis. No prognostic factor was common in all models, though there was a tendency towards the number of metastases, CRC spread to lymph nodes, maximum size of metastases, preoperative CEA level and extrahepatic spread as representing independent risk factors. Seven models assigned more weight to selected factors considered of higher predictive value.

Conclusion

The existing predictive models are diverse and their prognostic factors are often not weighed according to their impact. For the development of future predictive models, the complex relations within datasets and differences in relevance of individual factors should be taken into account, for example by using artificial neural networks.