Strategies for Management of Synchronous Colorectal Metastases

Minimally invasive robotic-assisted combined colorectal and liver excision surgery: feasibility, safety and surgical technique in a pilot series

Different strategies may be adopted in patients with synchronous colorectal liver metastases (LM). The role of laparoscopy has been investigated to define the benefits of minimally invasive surgery in a single-stage operation. In our study, we report our experience of 28 Minimally Invasive Robotic-Assisted combined Colorectal and Liver Excision Surgery (MIRACLES). From October 2012 to December 2019, 135 Robotic liver resections and 218 Robotic Colorectal resections were performed in our center. Twenty-eight patients underwent MIRACLES resection with 37 nodules removed. Fifty-two lesions in 28 patients were resected in minimally invasive robot-assisted surgery. Eighteen lesions were located in postero-superior liver segments (eight in segment VII, two in segment VIII, eight in segment IVa). Nine right colectomies, seven left colectomies, ten anterior rectal resections, one Hartmann and one MILES procedures were performed. The median surgical time of MIRACLES procedures was 332 min. Two conversions to open approach were necessary. Four major complications (> III) were observed. No postoperative mortality was recorded. The median hospital stay was 8 days. The median overall survival was 27.5 months. The MIRACLES approach is feasible and safe for colorectal resection and hepatic nodules located in all segments, with a low rate of postoperative complications. Surgical technique is demanding and should be reserved, presently, to tertiary centers.

Comparison of the effects and prognosis of concurrent and staged resections for the treatment of resectable colorectal cancer liver metastasis

OBJECTIVE

To compare the effects and prognosis of concurrent and staged resections for the treatment of resectable colorectal cancer liver metastasis (CRLM).

METHODS

A prospective study was conducted on 118 patients with CRLM. The 59 cases in the observation group received concurrent resections, while the 59 cases in the control group received staged resections. The operation time, intraoperative blood loss, length of hospital stay, hospital cost, postoperative complications, 5-year survival rate and 3-year progression-free survival rate were recorded for all patients. Factors that affect the prognosis of CRLM patients were analyzed.

RESULTS

The length of hospital stay, operation time, intraoperative blood loss, hospital cost were significantly lower in the observation group than in the control group (P<0.001). The two groups were equivalent with respect to postoperative complications, 5-year survival rate and 3-year progression-free survival rate (P>0.05). Independent risk factors affecting the prognosis of CRLM included the number of liver metastasis, whether resection is feasible after recurrence, and RAS genotype (P<0.05).

CONCLUSION

Compared to staged resection for CRLM, concurrent resection has shorter operation time, less blood loss, and shorter length of hospital stay, while postoperative complications, long-term efficacy and survival benefits are comparable. Furthermore, the study has found that the number of liver metastasis, whether or not resection is feasible after recurrence, and RAS genotype are risk factors affecting the prognosis of CRLM.

Synchronous Resection of Colon Adenocarcinoma and Bisegmentectomy of Liver Metastases

Colorectal cancer is one of the main neoplasms worldwide; at the time of diagnosis about 25% of cases already have an advanced stage with the presence of metastases. A 58-year-old female presented with nausea, vomiting, and black stools and diffuse abdominal pain associated with 7% weight loss. She was referred to our hospital with signs of digestive tract bleeding and anemic syndrome. Panendoscopy revealed body and fundus gastropathy and presence of Helicobacter pylori, and colonoscopy showed a neoplastic lesion at the ascending colon level. A synchronous resection was performed in a single surgical time of colorectal cancer and liver metastases with a duration of 4 h and bleeding of 900 mL. The oral feeding started 24 h after surgery, presenting gas channeling at 24 h and evacuations at 48 h. The total intrahospital stay was 5 days. Synchronous resection of hepatic metastases in colorectal cancer is still rarely performed, despite the fact that in recent years the number of cases has increased because of better surgical techniques. Synchronous resection of colorectal cancer and liver metastases can be performed safely, without increasing transoperative mortality when performed in specialized centers with a multidisciplinary team; however, it is essential to emphasize the importance of negative surgical margins (R0) of the primary tumor and later to be complemented with adjuvant treatment with chemotherapy.

A Review of Clinical Studies and Practical Guide for the Administration of Triplet Chemotherapy Regimens with Bevacizumab in First-line Metastatic Colorectal Cancer

Colorectal cancer is the third most common cancer worldwide. A significant proportion of patients presents with unresectable metastatic disease or develops metachronous metastases following surgical resection of the primary tumor. The prognosis of the disease has improved over the past two decades, with extended multimodality treatment options and the development of increasingly intensified chemotherapy regimens that now typically include targeted biologics. A recent advance in therapy is a treatment regimen composed of three chemotherapeutic agents (i.e., triplet chemotherapy: 5-fluorouracil [5-FU]/leucovorin [LV], oxaliplatin, and irinotecan; FOLFOXIRI) in combination with the vascular endothelial growth factor inhibitor bevacizumab. This regimen has been shown to elicit significantly improved objective response rates and median progression-free survival compared with 5-FU/LV and irinotecan in combination with bevacizumab. However, triplet chemotherapy has been associated with increased rates of chemotherapy-related adverse events, and treatment-emergent adverse events should be properly managed to minimize treatment interruption or discontinuation. We present herein a review of clinical studies evaluating the safety and efficacy of FOLFOXIRI with bevacizumab in metastatic colorectal cancer, and propose a practical guide for the management of adverse events associated with the regimen.

Robotic simultaneous resection of rectal cancer and liver metastases

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic‐assistance has been rarely reported. We demonstrate that robotic‐assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.

Simultaneous Minimally Invasive Treatment of Colorectal Neoplasm with Synchronous Liver Metastasis

Purpose. To analyse perioperative and oncological outcomes of minimally invasive simultaneous resection of primary colorectal neoplasm with synchronous liver metastases. Methods. A Medline revision of the current published literature on laparoscopic and robotic-assisted combined colectomy with hepatectomy for synchronous liver metastatic colorectal neoplasm was performed until February 2015. The specific search terms were "liver metastases", "hepatic metastases", "colorectal", "colon", "rectal", "minimally invasive", "laparoscopy", "robotic-assisted", "robotic colorectal and liver resection", "synchronous", and "simultaneous". Results. 20 clinical reports including 150 patients who underwent minimally invasive one-stage procedure were retrospectively analysed. No randomized trials were found. The approach was laparoscopic in 139 patients (92.7%) and robotic in 11 cases (7.3%). The rectum was the most resected site of primary neoplasm (52.7%) and combined liver procedure was in 89% of cases a minor liver resection. One patient (0.7%) required conversion to open surgery. The overall morbidity and mortality rate were 18% and 1.3%, respectively. The most common complication was colorectal anastomotic leakage. Data concerning oncologic outcomes were too heterogeneous in order to gather definitive results. Conclusion. Although no prospective randomized trials are available, one-stage minimally invasive approach seems to show advantages over conventional surgery in terms of postoperative short-term course. On the contrary, more studies are required to define the oncologic values of the minimally invasive combined treatment.

Role of a liver-first approach for synchronous colorectal liver metastases

AIM: To evaluate the feasibility and survival outcomes of a liver-first approach.

METHODS: Between January 2009 and April 2013, 18 synchronous colorectal liver metastases (sCRLMs) patients with a planned liver-first approach in the Hepatopancreatobiliary Surgery Department I of the Beijing Cancer Hospital were enrolled in this study. Clinical data, surgical outcomes, morbidity and mortality rates were collected. The feasibility and long-term outcomes of the approach were retrospectively analyzed.

RESULTS: Sixteen patients (88.9%) completed the treatment protocol for primary and liver tumors. The main reason for treatment failure was liver disease recurrence. The 1 and 3 year overall survival rates were 94.4% and 44.8%, respectively. The median survival time was 30 mo. The postoperative morbidity and mortality were 22.2% and 0%, respectively, following a hepatic resection, and were 18.8% and 0%, respectively, after a colorectal surgery.

CONCLUSION: The liver-first approach appeared to be feasible and safe. It can be performed with a comparable mortality and morbidity to the traditional treatment paradigm. This approach might offer a curative opportunity for sCRLM patients with a high liver disease burden.