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.     

Staged or simultaneous resection of synchronous liver metastases from colorectal cancer – a systematic review

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.     

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。     

Major Liver Resections Synchronous with Colorectal Surgery

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.     

The management of solitary colorectal liver metastases

Surgical resection of solitary colorectal liver metastases is associated with long-term survival. Radiofrequency ablation used as the primary treatment option of solitary resectable colorectal liver metastases is associated with an increased risk of local recurrence that generally leads to worse survival compared to resection. In contrast with treatment of other hepatic malignancies, radiofrequency ablation is not equivalent to resection for colorectal liver metastases and should not be used as an alternative but limited to inoperable patients. Although overall survival rate after resection can be up to 71% at 5 years, the majority of patients develop recurrence. Preoperative chemotherapy contributes to decrease the risk of recurrence after resection of colorectal liver metastases. In patients with advanced solitary colorectal liver metastasis initially non suitable for resection, chemotherapy and portal vein embolization contribute to increase the number of surgical candidates whereas radiofrequency is rarely an option.     

Comparison between hepatic wedge resection and anatomic resection for colorectal liver metastases

Some investigators have suggested that wedge resection (WR) confers a higher incidence of positive margins and an inferior survival compared with anatomic resection (AR) of colorectal liver metastases (CLM). We sought to investigate the margin status, pattern of recurrence, and overall survival of patients with CLM treated with WR or AR. We identified 253 consecutive patients, in a multi-institutional database from 1991 to 2004, who underwent either WR or AR. WR was defined as a nonanatomic resection of the CLM, and AR was defined as single or multiple resections of one or two contiguous Couinaud segments. Clinicopathologic factors were analyzed with regard to pattern of recurrence and survival. One hundred six WRs were performed in 72 patients and 194 ARs in 181 patients. There was no difference in the rate of positive surgical margin (8.3%), overall recurrence rates, or patterns of recurrence between patients treated with WR vs. AR. Patients who had a positive surgical resection margin were more likely to recur at the surgical margin regardless of whether they underwent WR or AR. The median survival was 76.6 months for WR and 80.8 months for AR, with 5-year actuarial survival rates of 61% and 60%, respectively. AR is not superior to WR in terms of tumor clearance, pattern of recurrence, or survival. WR should remain an integral component of the surgical treatment of CLM. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

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).     

Repeat hepatic resection as effective treatment for recurrent colorectal liver metastases

Background: Approximately 20–40% of patients who undergo liver resection for colorectal metastases develop recurrent disease confined to the liver. The goals of this study were to determine whether the survival benefit of repeat hepatic resection justified the potential morbidity and mortality. Methods: A retrospective review was performed on all patients who underwent liver resection for colorectal cancer metastases between 1983 and 1995 (N=202). Repeat liver resections were performed on 23 patients for recurrent metastases. Results: There were no operative deaths in the 23 patients, and the postoperative morbidity rate was 22%. The 5-year actuarial survival rate after repeat resection was 32%, with a median length of survival of 39.9 months. There were three patients who survived for >5 years after repeat resection. Sixteen patients (70%) developed recurrent disease at a median interval of 11 months after the second resection; 10 of these 16 patients (62%) had new hepatic metastases. No clinical or pathological factors were significant in predicting long-term survival. Conclusions: Repeat liver resection for recurrent colorectal metastases (a) can be performed safely with acceptable mortality and morbidity rates and (b) may result in long-term survival in some patients.Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

Management of potentially resectable colorectal cancer liver metastases

Colorectal cancer is a very common malignancy worldwide and development of liver metastases,both synchronous or metachronous,is a common event.Of all patients with metastatic colorectal cancer,up to 77% have a liver-only disease and approximately 10%-20% of patients with colorectal liver metastases are considered resectable at the time of diagnosis.Surgical resection of liver metastases remains the best treatment option and it is associated with a survival plateau and a 20%-25% of long-term survivors.Perioperative chemotherapy for resectable liver metastases may improve resecability of liver metastases and disease free survival,but its impact on overall survival is still unclear and more studies are needed.Moreover,preoperative chemotherapy can increase postoperative complications.Further studies are needed to define the role of adjuvant chemotherapy after a R0 resection of liver metastases and to define the criteria for a better selection of patients candidate to hepatectomy.New strategies such as targeted therapies are emerging with promising results.Optimal management requires a multidisciplinary approach,local and systemic,but it is a still pending question.Colorectal liver metastases represent a major challenge for oncologists and surgeons.In this review will be analyzed available data about assessment and management of the patients with potentially resectable colorectal liver metastases.     

Extensive resections for colorectal liver metastases

Background/Purpose Mortality and morbidity rates after liver resections have decreased with better surgical techniques and perioperative care. The aim of this study was to evaluate the short- and longterm results in patients who had undergone extensive hepatectomies.Methods From January 1985 to December 2000, 237 patients underwent 275 liver resections for colorectal metastases. Extensive liver resections were defined as follows: technical reasons (extended hepatectomies, associated vascular resections); disease extent (diameter, 10cm; number, 5; associated extrahepatic resection). The total number of extensive liver resections was 74. There were 51 radical resections (68.9%), while in the nonextensive resections group, 152 resections were radical (90.7%; P = 0.1).Results Postoperative mortality (60 days) was 1.6% (1.3% in the extensive resections group; P = 0.3), while morbidity was 22.7% (31% in the extensive resections group vs 19% in the nonextensive resections group; P = 0.1). One-, 3-, and 5-year overall actuarial survival rates were 91.8%, 44.9%, and 25.3%. The survival rates of patients who underwent an extensive resection were similar to those in the nonextensive resections group.Conclusions Technical difficulties and neoplastic extension are not, nowadays, a contraindication for hepatectomy for colorectal liver metastases, unless a radical resection is performed.     

Intraoperative ultrasound for the colorectal surgeon: current trends and barriers

Up to two thirds of patients diagnosed with colorectal cancer (CRC) develop colorectal liver metastases (CRLMs) and one quarter of patients present with synchronous metastases. Early detection of CRLM widens the scope of potential treatment. Surgery for CRLM offers the best chance of a cure. Current preoperative staging of CRC relies on computerized tomography and magnetic resonance imaging. Intraoperative ultrasound (IOUS) scans and contrast‐enhanced IOUS (CE‐IOUS) have been demonstrated to detect additional metastases not seen on routine preoperative imaging. IOUS is not widely used by colorectal surgeons during primary resection for CRC. Confident use of IOUS/CE‐IOUS during primary resection of CRC may improve decision‐making by providing the most sensitive form of liver staging even when compared with magnetic resonance imaging. This may be particularly important in the era of laparoscopic resections, where the colorectal surgeon loses the opportunity to palpate the liver. There are several implied barriers to the routine use of IOUS/CE‐IOUS by colorectal surgeons. These include time pressure, familiarity with techniques, a perceived learning curve, cost implications and limitation of the modality due to operator variations. Inclusion of IOUS in the training of colorectal surgeons and further investigation of potential benefits of IOUS/CE‐IOUS could potentially reduce these barriers, enabling usage during primary resection for CRC to become more widespread.     

Impact of parenchymal preserving surgery on survival and recurrence after liver resection for colorectal liver metastasis

Background

This study aimed to investigate the impact of non‐anatomical liver resection (NAR) versus anatomical resection (AR) in patients with colorectal liver metastasis (CRLM), with regard to perioperative and long‐term outcomes.

Methods

Analysis of prospectively collected data for patients with CRLM who underwent either AR or NAR between January 1993 and August 2011 was performed. The impact of AR and NAR on morbidity, mortality, margin positivity, redo liver resections, overall survival (OS) and disease free survival (DFS) was analysed.

Results

A total of 1574 resections for CRLM were performed. A total of 249 were redo resections and 334 patients underwent combined AR and NAR, hence, 583 were excluded. In total, 582 AR and 409 NAR were performed. The median age was 66 years (range 23.8–91.8). Median follow up was 32.2 months (interquartile range 17.5–56.9). The need for postoperative transfusion (11.6% versus 2.2%, P = <0.0001), overall complications (25% versus 10.7%, P < 0.0001) and 90‐day mortality (4.9% versus 1.2%, P < 0.0001) was higher in the AR group. R0 and R1 resection rates (AR 26.2% NAR 25%, P = 0.69) and number of patients with intrahepatic recurrence was similar between the two groups (AR 17.5% NAR 22%, P = 0.08). However, the need for redo liver surgery was higher in NAR group 15.4% versus 8.7% (P < 0.001). The OS (NAR 34.1 months versus AR 31.4 months, P = 0.002) and DFS were longer in the NAR group (NAR 18.8 months versus AR 16.9 months, P = 0.031).

Conclusions

A parenchymal preserving surgery (NAR) is associated with lower complication rates and better OS and DFS when compared with AR without compromising margin status. However, NAR increases the need for repeat liver resections.     

腹腔镜下结直肠癌合并肝转移癌一期同时切除术的临床分析

目的探究腹腔镜下结直肠癌合并肝转移癌一期同时切除术的安全性及可行性。方法选取68例2012年11月~2015年6月至我院以及中山大学孙逸仙纪念医院胃肠外科二区就诊的结直肠癌合并肝转移癌患者,将所有患者分为两组,观察组34例,对照组34例。观察组采取腹腔镜下结直肠癌合并肝转移癌同期切除术,对照组采取传统的开腹结直肠癌合并肝转移癌同期切除术。记录两组患者术中出血量、手术时间、术后排气时间、总住院时间、术后并发症,对两组疗效、总生存期和无瘤生存期进行分析。结果观察组术中出血量、手术时间、术后排气时间、总住院时间与对照组相比,有统计学意义(P0.05);虽然观察组的术并发症比对照组低,但两组术后并发症比较无统计学意义(P0.05)。结论全腹腔镜下结直肠癌合并肝转移癌一期联合切除安全可行,总体临床效果优于开腹手术。     

Hepatic resection for colorectal metastases - a national perspective

BACKGROUND: Many consultant surgeons are uncertain about peri-operative assessment and postoperative follow-up of patients for colorectal liver metastases, and indications for referral for hepatic resection. The aim of this study was to assess the views the consultant surgeons who manage these patients. METHODS: A postal questionnaire was sent to all consultant members of the Association of Coloproctology of Great Britain and Ireland and of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The questionnaire assessed current practice for preoperative assessment and follow-up of patients with colorectal malignancy and timing of and criteria for hepatic resection of metastases. Number of referrals/resections were also assessed. RESULTS: The response rate was 47%. Half of the consultants held joint clinics with an oncologist and 89% assessed the liver for secondaries prior to colorectal resection. Ultrasound was used by 75%. Whilst 99% would consider referring a patient with a solitary liver metastasis for resection, only 62% would consider resection for more than 3 unilobar metastases. The majority (83%) thought resections should be performed within the 6 months following colorectal resection. During follow-up, 52% requested blood CEA levels and 72% liver ultrasound. Half would consider chemotherapy prior to liver resection and 76% performed at least one hepatic resection per year with a median number of 2 resections each year. CONCLUSIONS: A substantial proportion of patients are assessed for colorectal liver metastases preoperatively and during follow-up though there is spectrum of frequency of assessment and modality for imaging. Virtually all patients with solitary hepatic metastases are considered for liver resection. Patients with more than one metastasis are likely to be not considered for resection. Many surgeons are carrying out less than 3 resections each year.     

The timing of liver resection in patients with colorectal cancer and synchronous liver metastases: a population‐based study of current practice and survival

Aim

There is uncertainty regarding the optimal sequence of surgery for patients with colorectal cancer (CRC) and synchronous liver metastases. This study was designed to describe temporal trends and inter‐hospital variation in surgical strategy, and to compare long‐term survival in a propensity score‐matched analysis.

Method

The National Bowel Cancer Audit dataset was used to identify patients diagnosed with primary CRC between 1 January 2010 and 31 December 2015 who underwent CRC resection in the English National Health Service. Hospital Episode Statistics data were used to identify those with synchronous liver‐limited metastases who underwent liver resection. Survival outcomes of propensity score‐matched groups were compared.

Results

Of 1830 patients, 270 (14.8%) underwent a liver‐first approach, 259 (14.2%) a simultaneous approach and 1301 (71.1%) a bowel‐first approach. The proportion of patients undergoing either a liver‐first or simultaneous approach increased over the study period from 26.8% in 2010 to 35.6% in 2015 (P < 0.001). There was wide variation in surgical approach according to hospital trust of diagnosis. There was no evidence of a difference in 4‐year survival between the propensity score‐matched cohorts according to surgical strategy: bowel first vs simultaneous [hazard ratio (HR) 0.92 (95% CI: 0.80–1.06)] or bowel first vs liver first [HR 0.99 (95% CI: 0.82–1.19)].

Conclusion

There is evidence of wide variation in surgical strategy in dealing with CRC and synchronous liver metastases. In selected patients, the simultaneous and liver‐first strategies have comparable long‐term survival to the bowel‐first approach.     

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.     

完全腹腔镜下直肠癌根治合并肝左叶转移癌规则左半肝

目的 总结腹腔镜下一期行直肠癌根治、前入路左半肝切除的适应症和手术技巧。方法 分析我院一例直肠癌合并左肝多发转移的患者采用腹腔镜下直肠癌根治、规则性左半肝切除术。结果 手术时间190 min,术中出血300ml,无明显手术并发症,切口一期愈合。术后14d给予化疗。术后随访5个月,无局部复发、远处转移、及切口处肿瘤种植发生。结论一期行腹腔镜直肠癌根治合并左半肝规则切除,局限在单叶的肝多发转移灶行规则肝切除是安全可行的。     

combined hepatic and inferior vena cava resection for colorectal metastases

Surgical resection continues to offer the only hope for cure of colorectal cancer metastatic to the liver. Tumor involvement of the vena cava is often viewed as a contraindication to surgical resection. Whereas proven technically feasible, the survival advantages of en bloc liver and vena cava resection remain unclear. We reviewed all patients at a tertiary care center who had resection of colorectal liver metastases, including those with vena cava resections. Eleven patients had en bloc liver and vena cava resection between 1988 and 2002; during the same time period, 97 patients underwent isolated liver resection. There were no perioperative deaths in the 11 patients. All resections had negative histological margins. Mean follow-up was 33 months from the date of surgery. Median disease-free survival of the group having caval resections was 9 months, whereas median survival was 34 months. When compared to the cohort of isolated hepatic resections, the group undergoing caval resections experienced a significantly reduced diseasefree survival of 18.6 vs. 9.1 months, respectively (P = 0.03); however, there was no difference in overall survival between the two groups at 55.2 vs. 34.3 months, respectively (P = 0.20). Colorectal liver metastases involving the vena cava should be considered for surgical resection. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

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.     

Hepatic resections for bilobar liver metastases from colorectal cancer

The present study was performed to assess survival benefits in patients who underwent a hepatic resection for isolated bilobar liver metastases from colorectal cancer. Thirty-eight patients underwent a curative hepatic resection for isolated colorectal liver metastasis. Among them, 11 patients had bilobar liver metastases and 19 had a solitary metastasis. The remaining 8 patients had unilobar multiple lesions. We investigated survival in two groups those with bilobar and those with solitary metastatic tumors. Survival and disease-free survival were 36% and 18% at 5 years, respectively, in the patients with bilobar liver metastases, while these survivals were 43% and 34% in the patients with solitary liver metastasis. In the 38 patients, repeated hepatic resections were performed in 15 patients with recurrent liver disease. The 5-year survival and disease-free survival rates for these patients were 38% and 27%, respectively, after the second hepatic resections. Of the 11 patients with bilobar liver metastases, 5 underwent a repeated hepatic resection, and they all survived for over 42 months. Based on our observations, a hepatic resection was thus found to be effective even in selected patients with either bilobar nodules or recurrence in the remnant liver. Received: February 7, 2000 / Accepted: April 26, 2000