Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: a case matched study

Perioperative safety and oncological efficacy of simultaneous versus colorectal and liver first two-staged resections in patients with synchronous colorectal liver metastases: a systematic review and network meta-analysis

BACKGROUND

Previous meta-analyses have yielded conflicting results on the optimal surgical treatment strategy in patients with synchronous colorectal liver metastases (sCRLM). This network meta-analysis aims to provide an overview on colorectal-, liver first and simultaneous resections to treat sCRLM.

METHODS

A search was conducted in MEDLINE, Embase and Cochrane CENTRAL (inception-July 11,2023). Pairwise and network meta-analyses were conducted to compare the three strategies, using colorectal-first resections as reference group.

RESULTS

Overall, 46 studies with a total of 20,991 patients were included, a significant portion at a high risk of bias. Simultaneous resections were associated with less blood loss (MD -145.44 ml, 95%CI -239.40 to -51.48) and shorter hospital stays (MD -6.39 days, 95%CI -7.78 to -4.99). Liver-first resections were associated with more transfusions (OR 1.89, 95%CI 1.04 to 3.42) and shorter hospital stays (MD -4.53 days, 95%CI -7.99 to -1.06). Simultaneous resections were associated with less incomplete macroscopic disease clearances (OR 0.33, 95%CI 0.12 to 0.92), while liver-first resections were associated with more incomplete macroscopic disease clearances (OR 2.80, 95%CI 1.16 to 6.73) and less microscopically radical (R0) resections (OR 0.64, 95%CI 0.45 to 0.90). There were no significant differences in morbidity, mortality, disease-free or overall survival.

CONCLUSION

Based on meta-analysis of mainly observational studies, simultaneous resections were associated with less blood loss, shorter length of stay and more complete macroscopic disease clearances.

Colon cancer: the 2023 Korean clinical practice guidelines for diagnosis and treatment

Colorectal cancer is the third most common cancer in Korea and the third leading cause of death from cancer. Treatment outcomes for colon cancer are steadily improving due to national health screening programs with advances in diagnostic methods, surgical techniques, and therapeutic agents.. The Korea Colon Cancer Multidisciplinary (KCCM) Committee intends to provide professionals who treat colon cancer with the most up-to-date, evidence-based practice guidelines to improve outcomes and help them make decisions that reflect their patients' values and preferences. These guidelines have been established by consensus reached by the KCCM Guideline Committee based on a systematic literature review and evidence synthesis and by considering the national health insurance system in real clinical practice settings. Each recommendation is presented with a recommendation strength and level of evidence based on the consensus of the committee.

Safety and long-term prognosis of simultaneous versus staged resection in synchronous colorectal cancer with liver metastasis: a systematic review and meta-analysis

PURPOSE

The optimal time point for surgical resection of synchronous colorectal liver metastases (SCLMs) is still controversial. This meta-analysis evaluated the safety and long-term prognoses of simultaneous and staged resection of SCLM to provide a reference for clinical selection.

METHODS

A systematic literature search for studies published by October 2022 was performed using PubMed, Web of Science, Embase, Scopus and Cochrane Library. The evaluated outcome parameters were total, gastrointestinal and hepatic complications, as well as perioperative mortality, intraoperative blood loss, total hospital stay, 5-year disease-free survival (DFS) and 5-year overall survival (OS).

RESULTS

This meta-analysis included 22 nonrandomised and one randomised study comprising 4862 patients. The patients undergoing simultaneous resection of SCLM had similar total (OR = 0.88, 95% CI [0.66-1.19], P = 0.409), gastrointestinal (OR = 1.19, 95% CI [0.89-1.59], P = 0.241) and hepatic (OR = 1.04, 95% CI [0.83-1.31], P = 0.734) complications, as well as perioperative mortality (OR = 1.79, 95% CI [0.88-3.64], P = 0.108), 5-year DFS (HR = 1.26, 95% CI [0.96-1.66], P = 0.098) and 5-year OS (HR = 1.13, 95% CI [0.95-1.34], P = 0.164). Lower intraoperative blood loss (SMD = - 0.39, 95% CI [- 0.60 to - 0.18], P < 0.001) and shorter total hospital stay (WMD = - 5.43, 95% CI [- 7.29 to - 3.58], P < 0.001) were observed in the simultaneous-resection group versus the staged group.

CONCLUSIONS

Simultaneous resection is safe and effective for SCLM patients. The long-term prognosis is equivalent to that of the traditional staged resection. Correct selection of resectable SCLM patients for the simultaneous resection of the primary tumour and liver metastases can be the first choice. Owing to the potential heterogeneity, more RCTs should be included to verify our conclusions.

Simultaneous versus staged major hepatectomy (≥3 liver segments) for outcomes of synchronous colorectal liver metastases: A systematic review and meta-analysis

Background

Hepatectomy is an effective treatment for synchronous colorectal liver metastases (SCLM) patients. However, whether to choose simultaneous hepatectomy (SIH) or staged hepatectomy (STH) is still controversial, especially during major hepatectomy (≥3 liver segments).

Aims

Compare the difference between the SCLM patients underwent SIH and STH, especially during major hepatectomy (≥3 liver segments).

Methods and Results

A meta‐analysis was conducted by analyzing the published data on the outcomes of SCLM patients underwent SIH or STH from January 2010 to December 2020 from the electronic databases. A random‐effects model was used to derive pooled estimates of odds ratio (OR) with 95% confidence interval (CI) for the explored outcomes. Eventually, 18 studies, including 5101 patients, were included this study. The result of meta‐analysis showed that SIH did not increase postoperative complications (pooled OR: 1.037; 95% CI: 0.897–1.200), perioperative mortality (pooled OR: 0.942; 95% CI: 0.552–1.607), 3‐year mortality (pooled OR: 1.090; 95% CI: 0.903–1.316) or 5‐year mortality (pooled OR: 1.077; 95% CI: 0.926–1.253), as compared with STH. Subgroup analysis showed that, simultaneous major hepatectomy (SIMH) also did not increase postoperative complications (pooled OR: 0.863; 95% CI: 0.627–1.188) or perioperative mortality (pooled OR: 0.689; 95% CI: 0.290–1.637) as compared with staged major hepatectomy (STMH).

Conclusion

Postoperative complications, perioperative mortality and long‐term prognosis had no significant difference between SIH and STH for SCLM patients. Besides, postoperative complications and perioperative mortality also had no significant difference between SIMH and STMH.

Simultaneous versus staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases: a meta-analysis of outcomes and clinical characteristics

OBJECTIVES

To evaluate the comparative outcomes and clinical characteristics of simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases.

METHODS

We conducted a systematic search of electronic information sources, and bibliographic reference lists. Perioperative morbidity and mortality, anastomotic leak, wound infection, bile leak, bleeding, intra-abdominal abscess, sub-phrenic abscess, reoperation, recurrence, 5-year overall survival, procedure time, and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using random-effects model.

RESULTS

We identified 41 comparative studies reporting a total of 12,081 patients who underwent simultaneous (n = 5013) or staged (n = 7068) resections for colorectal cancer with synchronous hepatic metastases. There were significantly lower use of neoadjuvant chemotherapy (p = 0.003), higher right-sided colonic resections (p < 0.00001), and minor hepatic resections (p < 0.00001) in the simultaneous group. The simultaneous resection was associated with significantly lower rate of bleeding (OR 0.60, p = 0.03) and shorter length of hospital stay (MD - 5.40, p < 0.00001) compared to the staged resection. However, no significant difference was found in perioperative morbidity (OR1.04, p = 0.63), mortality (RD 0.00, p = 0.19), anastomotic leak (RD 0.01, p = 0.33), bile leak (OR 0.83, p = 0.50), wound infection (OR 1.17, p = 0.19), intra-abdominal abscess (RD 0.01, p = 0.26), sub-phrenic abscess (OR 1.26, p = 0.48), reoperation (OR 1.32, p = 0.18), recurrence (OR 1.33, p = 0.10), 5-year overall survival (OR 0.88, p = 0.19), or procedure time (MD - 23.64, p = 041) between two groups.

CONCLUSIONS

Despite demonstrating nearly comparable outcomes, the best available evidence (level 2) regarding simultaneous and staged colorectal and hepatic resections for colorectal cancer with synchronous hepatic metastases is associated with major selection bias. It is time to conduct high-quality randomised studies with respect to burden and laterality of disease. We recommend the staged approach for complex cases.

Surgical treatment of stage IV colorectal cancer with synchronous liver metastases: A systematic review and network meta-analysis

BACKGROUND

The ideal treatment approach for colorectal cancer (CRC) with synchronous liver metastases (SCRLM) remains debated. We performed a network meta-analysis (NMA) comparing the 'bowel-first' approach (BFA), simultaneous resection (SIM), and the 'liver-first' approach (LFA).

METHODS

A systematic search of comparative studies in CRC with SCRLM was undertaken using the Embase, PubMed, Web of Science, and CENTRAL databases. Outcome measures included postoperative complications, 30- and 90-day mortality, chemotherapy use, treatment completion rate, 3- and 5-year recurrence-free survival, and 3- and 5-year overall survival (OS). Pairwise and network meta-analysis were performed to compare strategies. Heterogeneity was assessed using the Higgins I2 statistic.

RESULTS

One prospective and 43 retrospective studies reporting on 10 848 patients were included. Patients undergoing the LFA were more likely to have rectal primaries and a higher metastatic load. The SIM approach resulted in a higher risk of major morbidity and 30-day mortality. Compared to the BFA, the LFA more frequently resulted in failure to complete treatment as planned (34% versus 6%). Pairwise and network meta-analysis showed a similar 5-year OS between LFA and BFA and a more favorable 5-year OS after SIM compared to LFA (odds ratio 0.25-0.90, p = 0.02, I2 = 0%), but not compared to BFA.

CONCLUSION

Despite a higher tumor load in LFA compared to BFA patients, survival was similar. A lower rate of treatment completion was observed with LFA. Uncertainty remains substantial due to imprecise estimates of treatment effects. In the absence of prospective trials, treatment of stage IV CRC patients should be individually tailored.

Simultaneous, Delayed and Liver-First Hepatic Resections for Synchronous Colorectal Liver Metastases: A Systematic Review and Network Meta-Analysis

BACKGROUND

Systematic reviews and meta-analyses that compare simultaneous, delayed and liver-first approach for synchronous colorectal liver metastases have found no significant differences. The aim of this study was to determine the best treatment strategy on the basis of effect sizes and the probabilities of treatment ranking by using a network meta-analysis. Moreover, first-time pairwise and network meta-analyses were used to estimate the existing evidence, and their results were compared to detect any discrepancies between them.

METHODS

Systematic review, pairwise meta-analysis and network meta-analysis were performed. The primary and secondary outcomes were 5-year overall survival and postoperative major morbidity, respectively.

RESULTS

No significant differences in long-term survival and major morbidity were found amongst the three approaches. The hazard ratios (95% confidence interval) for 5-year overall survival for the simultaneous, delayed and liver-first approaches were 0.93 (0.69 - 1.24, P = 0.613), 0.97 (0.87 - 1.07, P = 0.596) and 0.90 (0.67 - 1.22, P = 0.499), respectively. Moreover, the liver-first approach with a surface under the cumulative ranking area score of 89% was ranked as the potentially best treatment option based on probabilities of treatment ranking.

CONCLUSIONS

On the basis of the relative ranking of treatments, the liver-first approach ranked first, followed by the delayed and simultaneous approaches. Therefore, a three-arm randomized controlled trial that compares the liver-first, simultaneous and delayed approaches needs to shed further light as to which is the best treatment option.

Population level outcomes and costs of single stage colon and liver resection versus conventional two-stage approach for the resection of metastatic colorectal cancer

BACKGROUND

The objective of the current study was to compare outcomes among patients combined colon (CR) and liver resection (LR) for the treatment of simultaneous colorectal liver metastasis (CRLM) versus patients undergoing two-stage CR and LR.

METHODS

Patients undergoing surgery for CRLM between 2004 and 2014 were identified using the Nationwide Inpatient Sample (NIS). Propensity-score matching was used to compare patients undergoing CR + LR with patients undergoing two-stage CR and LR.

RESULTS

Among 83,410 patients, CR + LR was performed in 5659 (6.7%), stage C + LR was performed in 5659 (6.7%), while isolated CR and LR was performed in 70,177 (84.0%) and 7574 (9.3%) patients, respectively. The number of patients undergoing CR + LR increased from 423 in 2004 to 580 in 2014 (Δ = +37%). Patients undergoing CR + LR had lower postoperative morbidity (CR + LR vs. two-staged CR and LR: 38.5% vs. 61.2%), shorter LOS (median LOS: 8 days [IQR: 7-12] vs. 14 days [IQR: 10-21]), and lower postoperative mortality (3.1% vs. 5.9%) versus patients undergoing two-stage CR and LR. Compared with patients undergoing two-staged CR and LR, median hospital costs were $13,093 lower for patients undergoing CR + LR (median costs: $36,775 [IQR: 26,416-54,245] vs. $23,682 [IQR: 16,299-32,996]).

CONCLUSION

CR + LR was increasingly performed for treatment of CRLM. Compared with two-staged CR and LR, CR + LR was associated with improved outcomes and lower costs.

Oncosurgical Management of Liver Limited Stage IV Colorectal Cancer: Preliminary Data and Protocol for a Randomized Controlled Trial

Background

Colorectal cancer is the fourth commonest cancer and second commonest cause of cancer-related death in the United Kingdom. Almost 15% of patients have metastases on presentation. An increasing number of surgical strategies and better neoadjuvant treatment options are responsible for more patients undergoing resection of liver metastases, with prolonged survival in a select group of patients who present with synchronous disease. It is clear that the optimal strategy for the management of these patients remains unclear, and there is certainly a complete absence of Level 1 evidence in the literature.

Objective

The objective of this study is to undertake preliminary work and devise an outline trial protocol to inform the future development of clinical studies to investigate the management of patients with liver limited stage IV colorectal cancer.

Methods

We have undertaken some preliminary work and begun the process of designing a randomized controlled trial and present a draft trial protocol here.

Results

This study is at the protocol development stage only, and as such no results are available. There is no funding in place for this study, and no anticipated start date.

Conclusions

We have presented preliminary work and an outline trial protocol which we anticipate will inform the future development of clinical studies to investigate the management of patients with liver limited stage IV colorectal cancer. We do not believe that the trial we have designed will answer the most significant clinical questions, nor that it is feasible to be delivered within the United Kingdom’s National Health Service at this current time.

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.

BACKGROUND

The optimal strategy for treating liver disease among patients with resectable synchronous colorectal liver metastases (CRLM) is unclear. Simultaneous resection of primary tumour and liver metastases may improve patient experience by reducing the number of interventions. However, there are concerns of increased morbidity compared to delayed resections.

METHODS

A systematic literature search was performed using EMBASE, Medline, Cochrane library and Google scholar databases. Meta-analyses were performed using both random-effects and fixed-effect models. Publication and patient selection bias were assessed with funnel plots and sensitivity analysis.

RESULTS

Thirty studies including 5300 patients were identified. There were no statistically significant differences in parameters relating to safety and efficacy between the simultaneous and delayed hepatectomy cohorts. Patients undergoing delayed surgery were more likely to have bilobar disease or undergo major hepatectomy. The average length of hospital stay was six days shorter with simultaneous approach [MD = -6.27 (95% CI: -8.20, -4.34), p < 0.001]. Long term survival was similar for the two approaches [HR = 0.97 (95%CI: 0.88, 1.08), p = 0.601].

CONCLUSION

In selected patients, simultaneous resection of liver metastases with colorectal resection is associated with shorter hospital stay compared to delayed resections, without adversely affecting perioperative morbidity or long-term survival.

Prognostic Analysis of 102 Patients with Synchronous Colorectal Cancer and Liver Metastases Treated with Simultaneous Resection

Background:

The liver is the most common site for colorectal cancer (CRC) metastases. Their removal is a critical and challenging aspect of CRC treatment. We investigated the prognosis and risk factors of patients with CRC and liver metastases (CRCLM) who underwent simultaneous resections for both lesions.

Methods:

From January 2009 to August 2016, 102 patients with CRCLM received simultaneous resections of CRCLM at our hospital. We retrospectively analyzed their clinical data and analyzed their outcomes. Overall survival (OS) and disease-free survival (DFS) were examined by Kaplan-Meier and log-rank methods.

Results:

Median follow-up time was 22.7 months; no perioperative death or serious complications were observed. Median OS was 55.5 months; postoperative OS rates were 1-year: 93.8%, 3-year: 60.7%, and 5-year: 46.4%. Median DFS was 9.0 months; postoperative DFS rates were 1-year: 43.1%, 3-year: 23.0%, and 5-year 21.1%. Independent risk factors found in multivariate analysis included carcinoembryonic antigen ≥100 ng/ml, no adjuvant chemotherapy, tumor thrombus in liver metastases, and bilobar liver metastases for OS; age ≥60 years, no adjuvant chemotherapy, multiple metastases, and largest diameter ≥3 cm for DFS.

Conclusions:

Simultaneous surgical resection is a safe and effective treatment for patients with synchronous CRCLM. The main prognostic factors are pathological characteristics of liver metastases and whether standard adjuvant chemotherapy is performed.

Simultaneous hepatic resection benefits patients with synchronous colorectal cancer liver metastases

Objective

The safety of the simultaneous resection of synchronous colorectal cancer liver metastases (SCRLM) is still being debated. However, this simultaneous operative approach is more commonly adopted at present than in the past. Therefore, we compared simultaneous hepatic resection with delayed hepatic resection in this study.

Methods

All patients with SCRLM diagnosed before initial treatment between January 2009 and September 2013 were retrospectively included in our study. Short-term and long-term outcomes were compared in patients who underwent simultaneous colorectal and hepatic resection and those treated by delayed hepatectomy.

Results

Among the 73 patients diagnosed with SCRLM, simultaneous colorectal and hepatic resection was performed in 60 patients (82.2%), while delayed hepatic resection was performed in 13 patients (17.8%). The mortality rate was zero. The postoperative complication rate after delayed resection was higher than, but not significantly different from, that after simultaneous resection (46% vs. 23%, P=0.166). The duration of operating time (240 vs. 420 min, P<0.05) and postoperative hospital stay time (11 vs. 18 days, P<0.05) were shorter in the simultaneous resection group. After the initial treatments were given, the 1-, 2-, and 3-year survival rates in the simultaneous resection group were 77%, 59%, and 53%, respectively, whereas those in the delayed resection group were 67%, 42%, and 10%, respectively. The 5-year survival rate in the simultaneous resection group was 23%; overall survival differed significantly between the two groups (P=0.037). Median disease-free survival (DFS) times were 19.1 months in the simultaneous resection group and 8.8 months in the delayed resection group. DFS differed significantly between the two groups.

Conclusions

Simultaneous colorectal and hepatic resection is safe and exhibits advantages in the long-time survival of patients.

Intermittent clamping of the hepatic pedicle in simultaneous ultrasonography-guided liver resection and colorectal resection with intestinal anastomosis: is it safe?

PURPOSE

In patients with colorectal cancer (CRC) and synchronous colorectal liver metastases (CRLM) potentially candidates to combined liver (LR) and colorectal resection (CRR), the extent of LR and the need of hepatic pedicle clamping (HPC) in selected cases are considered risk factors for the outcome of the intestinal anastomosis. This study aimed to determine whether intermittent HPC is predictive of anastomotic leakage (AL) and has an adverse effect on the clinical outcome in patients undergoing combined restorative CRR and LR.

METHODS

One hundred six LR have been performed for CRLM in our unit from July 2005. Patients who received CRR with anastomosis and simultaneous intraoperative ultrasonography (IOUS)-guided LR/ablation for resectable CRLM were included in this study. CRR was performed first. Intermittent HPC was decided at the discretion of the liver surgeon. The perioperative outcome was evaluated according to occurrence of AL and overall postoperative morbidity and mortality.

RESULTS

Thirty-eight patients underwent simultaneous IOUS-guided LR/ablation and CRR with intestinal anastomosis; 19 underwent intermittent HPC (group ICHPY) while 19 did not (group ICHPN); the mean ± SD (range) duration of clamping in group ICHPY was 58.6 ± 32.2 (10.0-125.0) min. Postoperative results were similar between groups. One asymptomatic AL occurred in group ICHPY (5.2 %). Major postoperative complications were none in group ICHPY and one (5.2 %) in group ICHPN, respectively. One patient in group ICHPY died postoperatively (5.2 %).

CONCLUSIONS

This study suggests that intermittent HPC during LR is not predictive of AL and has no adverse effect on the overall clinical outcome in patients undergoing combined restorative colorectal surgery and hepatectomy for advanced CRC.

Timing of hepatectomy for resectable synchronous colorectal liver metastases: for whom simultaneous resection is more suitable--a meta-analysis

BACKGROUND

The optimal timing of resection for synchronous colorectal liver metastases is still controversial. Retrospective cohort studies always had baseline imbalances in comparing simultaneous resection with staged strategy. Significantly more patients with mild conditions received simultaneous resections. Previous published meta-analyses based on these studies did not correct these biases, resulting in low reliability. Our meta-analysis was conducted to compensate for this deficiency and find candidates for each surgical strategy.

METHODS

A systemic search for major databases and relevant journals from January 2000 to April 2013 was performed. The primary outcomes were postoperative mortality, morbidity, overall survival and disease-free survival. Other outcomes such as number of patients need blood transfusion and length of hospital stay were also assessed. Baseline analyses were conducted to find and correct potential confounding factors.

RESULTS

22 studies with a total of 4494 patients were finally included. After correction of baseline imbalance, simultaneous and staged resections were similar in postoperative mortality (RR = 1.14, P = 0.52), morbidity (RR = 1.02, P = 0.85), overall survival (HR = 0.96, P = 0.50) and disease-free survival (HR = 0.97, P = 0.87). Only in pulmonary complications, simultaneous resection took a significant advantage (RR = 0.23, P = 0.003). The number of liver metastases was the major factor interfering with selecting surgical strategies. With >3 metastases, simultaneous and staged strategies were almost the same in morbidity (49.4% vs. 50.9%). With ≤3 metastases, staged resection caused lower morbidity (13.8% vs. 17.2%), not statistically significant.

CONCLUSIONS

The number of liver metastases was the major confounding factor for postoperative morbidity, especially in staged resections. Without baseline imbalances, simultaneous took no statistical significant advantage in safety and efficacy. Considering the inherent limitations of this meta-analysis, the results should be interpret and applied prudently.

Strategies for Management of Synchronous Colorectal Metastases

The management of synchronous presentation of colorectal cancer and liver metastases has long been a topic of debate and discussion for surgeons due to the unique dilemma of balancing operative timing along with treatment strategy. Operative strategies for resection include staged resection with colon first approach, "reverse" staged resection with liver metastases resected first, and one-stage, or simultaneous, resection of both the primary tumor and liver metastases approach. These operative strategies can be further augmented with perioperative chemotherapy and other novel approaches that may improve resectability and patient survival. The decision on operative timing and approach, however, remains largely dependent on the surgeon's determination of disease resectability, patient fitness, and the need for neoadjuvant chemotherapy.

Laparoscopic resection of colorectal cancer liver metastases

AIM: To investigate the application of laparoscopic resection in the management of colorectal cancer liver metastases.

METHODS: Between March 2008 and September 2013, 21 patients underwent laparoscopic resection of colorectal cancer liver metastases at Huashan hospital and Pudong Hospital. Their clinical data were retrospectively analyzed.

RESULTS: All laparoscopic resections for colorectal cancer liver metastases were successful with no conversion. There were no severe postoperative complications except one case of bile leakage. The median surgical margin was 12 mm. The overall 1-, 2- and 3-year survival rates were 86%, 67% and 57%, respectively, while the 1-, 2- and 3-year disease-free survival rates were 81%, 62% and 47%, respectively.

CONCLUSION: Laparoscopic resection of colorectal cancer liver metastases is safe and effective.

Systematic review of surgical management of synchronous colorectal liver metastases

BACKGROUND

The optimal management of colorectal cancer with synchronous liver metastases has not yet been elucidated. The aim of the present study was systematically to review current evidence concerning the timing and sequence of surgical interventions: colon first, liver first or simultaneous.

METHODS

A systematic literature review was performed of clinical studies comparing the timing and sequence of surgical interventions in patients with synchronous liver metastases. Retrospective studies were included but case reports and small case series were excluded. Preoperative and intraoperative data, length of hospital stay, perioperative mortality and morbidity, and 1-, 3- and 5-year survival rates were compared. The studies were evaluated according to a modification of the methodological index for non-randomized studies (MINORS) criteria.

RESULTS

Eighteen papers were included and 21 entries analysed. Five entries favoured the simultaneous approach regarding duration of procedure, whereas three showed no difference; five entries favoured simultaneous treatment in terms of blood loss, whereas in four there was no difference; and all studies comparing length of hospital stay favoured the simultaneous approach. Five studies favoured the simultaneous approach in terms of morbidity and eight found no difference, and no study demonstrated a difference in perioperative mortality. One study suggested a better 5-year survival rate after staged procedures, and another suggested worse 1-year but better 3- and 5-year survival rates following the simultaneous approach. The median MINORS score was 10, with incomplete follow-up and outcome reporting accounting primarily for low scores.

CONCLUSION

None of the three surgical strategies for synchronous colorectal liver metastases appeared inferior to the others.

A meta-analysis comparing simultaneous versus delayed resections in patients with synchronous colorectal liver metastases

INTRODUCTION

The traditional surgical management for patients presenting with synchronous colorectal liver metastases (SCLM) has been a delayed resection. However, in some centres, there has been a shift in favour of 'simultaneous' resections. The aim of this study was to use a meta-analytical model to compare the short-term and long-term outcomes in patients with synchronous colorectal liver metastases (SCLM) undergoing simultaneous resections versus delayed resections.

METHOD

Comparative studies published between 1991 and 2010 were included. Evaluated endpoints were intra-operative parameters, post-operative parameters, post-operative adverse events and survival. A random-effects meta-analytical model was used and sensitivity analysis performed to account for bias in patient selection.

RESULTS

Twenty-four non-randomized studies were included, reporting on 3159 patients of which 1381 (43.7%) had simultaneous resections and 1778 (56.3%) had delayed resections. The bilobar distribution (P = 0.01), size of liver metastases (P < 0.001) and the proportion of major liver resections (P < 0.001) was found to be higher in the delayed resection group compared to the simultaneous resection group. There was no significant difference in operative blood loss (95% CI, -279.28, 22.53; P = 0.1) or duration of surgery (WMD -23.83, 95% CI, -85.04, 37.38; P = 0.45). Duration of hospital stay was significantly reduced in simultaneous resections by 5.6 days (95% CI: 2.4-8.9 days, P = 0.007) No significant differences in post-operative complications (36% vs 37%, P = 0.27), overall survival (HR 1.00, 95% CI 0.86-1.15, P = 0.96) or disease free survival (HR 0.85, 95% CI 0.71-1.02, P = 0.08) were found. Sensitivity analysis revealed that these findings were consistent for the duration of hospital stay, post-operative complications, overall survival and disease free survival.

CONCLUSION

This study demonstrates that the selection criteria for patients undergoing simultaneous or delayed resections differs resulting in a discrepancy in the metastatic disease severity being compared between the two groups. The comparable intra-operative parameters, post-operative complications and survival found between the two groups suggest that delayed resections may result in better outcomes. Similarly, the reduced length of hospital stay in simultaneous resections may only be as a result of the reduced disease severity in this group. Simultaneous resections can only be recommended in patients with limited hepatic disease until prospective studies comparing similar disease burdens between the two resection groups are available.

Synchronous resection of colorectal primary and hepatic metastasis

Up to 50% of the over 140,000 new colorectal cancer patients will present with synchronous colorectal cancer and liver metastasis. Surgical management of patients with resectable synchronous colorectal hepatic metastasis is complex and must consider multiple factors, including the presence of symptoms, location of primary tumor and liver metastases, extent of tumor (both primary and metastatic), patient performance status, and underlying comorbidities. Possible approaches to this select group of patients have included a synchronous resection of the colorectal primary and the hepatic metastases or a staged resection approach. The available literature regarding the safety of synchronous versus staged approaches confirms that a simultaneous resection may be performed in selected patients with acceptable morbidity and mortality. Perioperative mortality when minor hepatectomies are combined with colorectal resection is consistently ≤5%. Perioperative morbidity varies considerably following both synchronous and staged resections. However, the bulk of the existing literature confirms that simultaneous resections are both feasible and safe when hepatic resections are limited to <3 segments. Data regarding the oncologic outcomes following synchronous versus staged resections for Stage IV colorectal cancer are more limited than those available regarding postoperative morbidity and mortality. The available data suggest equivalent overall and disease-free survival regardless of timing of resection. Experience with minimally invasive combined colorectal and hepatic resections is extremely limited to date and consists exclusively of small single center series. The potential benefits of a minimally invasive approach will await the results of larger studies.

Therapeutic strategies for synchronous and multiple liver metastases from colorectal cancer

Metastasis in the liver is one of the most critical factors in the prognosis of patients with colorectal cancer. The incidence of synchronous liver metastasis has been found to be approximately 20–25%, but the optimal timing of surgical resection remains controversial. Neoadjuvant chemotherapy has also been found to be beneficial not only for initially unresectable but also resectable synchronous metastases and traditional surgical strategies of hepatic resection with past chemotherapeutic regimens have been used less and less over the past several years. This review will discuss treatments in association with the recently developed chemotherapeutic regimens.

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.

METHODS

Forty-six patients undergoing simultaneous resection between April 2002 and June 2010 in a single institution were included. Patient characteristics included preoperative ASA grade and POSSUM. Tumour characteristics included TNM stage, Petersen Index and the Clinical Risk Score.

RESULTS

There were no postoperative deaths. The most common complications were atrial fibrillation (seven patients) and pneumonia (seven patients). Mean hospital stay with an uncomplicated postoperative recovery was 11 days versus 17 days with complicated recovery. Age (p = 0.015), ASA grade (p = 0.010) and POSSUM score (p = 0.032) were associated with postoperative complications. No pathological characteristics of the primary or secondary tumours related to surgical morbidity. Median follow-up was 37 months (5-87) during which 24 patients died, 23 from cancer. Twenty-seven had disease recurrence. N stage of the primary (p = 0.035), high-risk Petersen Index of the primary (p = 0.010) and Clinical Risk Score ≥ 3 (p = 0.005) were associated with poorer recurrence-free and cancer-specific survival.

CONCLUSIONS

Post operative morbidity was determined by patient factors rather than operative or tumour characteristics. In addition to the Clinical Risk Score, pathological characteristics of the primary are important determinants of long-term outcome following simultaneous resection for synchronous disease.

Current state of surgical treatment of liver metastases from colorectal cancer

Hepatic resection is the procedure of choice for curative treatment of colorectal liver metastases (CLM). Objectives of surgical strategy are low intraoperative blood loss, short liver ischemic times and minor postoperative morbidity and mortality. Blood loss is an independent predictor of mortality and compromises, in common with postoperative complications, long-term outcome after hepatectomy for CLM. The type of liver resection has no impact on the outcome of patients with CLM; wedge resections are not inferior to anatomical resections in terms of tumor clearance, pattern of recurrence or survival. Despite the lack of proof of survival benefit, routine lymphadenectomy has been advocated, allowing the detection of microscopic lymph node metastases and with prognostic value. In experienced hands, minimally invasive liver surgery is safe with acceptable morbidity and mortality and oncological results comparable to open hepatic surgery, but with reduced blood loss and earlier recovery. The European Colorectal Metastases Treatment Group recommended treating up front with chemotherapy for patients with both resectable and unresectable CLM. However, neoadjuvant chemotherapy can induce damage to the remnant liver, dependent on the number of chemotherapy cycles. Therefore, in our opinion, preoperative chemotherapy should be reserved for patients whose CLM are marginally resectable or unresectable. A meta analysis of randomized trials dealing with perioperative chemotherapy for the treatment of resectable CLM demonstrated a benefit of systemic chemotherapy but did not answer the question of whether a neoadjuvant or adjuvant approach should be preferred. Analysis of the literature demonstrates that the results of specialized centers cannot be attained in the reality of comprehensive patient care. Reasons behind the commonly poorer results seen in cancer networks as compared with literature-based data are, on the one hand, geographical disparities in access to specialized surgical and medical care. On the other hand, a selection bias in the reports of the literature may be assumed. Studies of surgical resection for CLM derive almost exclusively from case series generally drawn from large academic centers where patient selection or surgical expertise is superior to what is found in many communities. Therefore, we may conclude that the comprehensive propagation of the standards outlined in this paper constitutes a major task in the near future to reduce the variations in survival of patients with CLM.