Parenchymal-Sparing Hepatectomy Does Not Increase Intrahepatic Recurrence in Patients with Advanced Colorectal Liver Metastases

Strategies for Recurrent Colorectal Liver Metastases Based on Prognostic Factors and Resectability: Potential Benefit of Multidisciplinary Treatment

BACKGROUND

Colorectal liver metastasis (CLM) is classified into technical and oncologic categories, with recommended treatments for each resectability category. However, the classification of recurrent CLM has not been established to date.

METHODS

This study evaluated patients with CLM who underwent initial liver resection between 2006 and 2020 and subsequently experienced liver recurrence. Long-term outcomes and prognostic factors associated with recurrent CLM were investigated.

RESULTS

From 949 patients who underwent an initial liver resection, the analysis included 392 patients with liver recurrence. Repeat liver resection was associated with a significantly longer prognosis than non-resection (5-year overall survival [OS] from initial liver resection: 66.3 % vs 27.2 %, p < 0.0001). Multivariable analysis indicated the following independent prognostic factors: four or more recurrent tumors (p = 0.015), tumor 5 cm or larger in size (p = 0.004), and presence of extrahepatic diseases (p = 0.003). The patients were stratified into resectable, borderline resectable, and unresectable recurrent CLM groups based on these criteria. The prognosis varied significantly across the groups, with 5-year OS rates of 67.3 % for resectable recurrent CLM, 30.8 % for borderline resectable recurrent CLM, and 2.6 % for unresectable recurrent CLM (p < 0.0001). Patients with borderline resectable recurrent CLM who did not receive adjuvant chemotherapy after initial liver resection had a positive prognostic impact of preoperative chemotherapy (p = 0.049).

CONCLUSION

The significant independent predictors of recurrent CLM prognosis were four or more tumors, tumor size of 5 cm or larger, and the presence of extrahepatic diseases at recurrence. It is critical to onsider the current condition and tumor resectability at the time of recurrence, and tailored treatments could further improve recurrent CLM outcomes.

Neoadjuvant chemotherapy for borderline resectable colorectal cancer liver metastases: a single-institution retrospective study

INTRODUCTION

This study aimed to extract prognostic factors in patients undergoing neoadjuvant chemotherapy (NAC) for borderline resectable colorectal liver metastasis (BR-CRLM) (tumor size ≥5 cm, number of tumors ≥4, or resectable extrahepatic diseases) and assess validity of this strategy.

MATERIALS AND METHODS

Since 2010, patients with BR-CRLM were treated with hepatectomy after six cycles of NAC. Prognostic factors of these patients were evaluated using clinicopathological data.

RESULTS

Of 650 patients who underwent initial hepatectomy for CRLM from 2010 to 2018, 246 BR-CRLM cases underwent hepatectomy after NAC (BR-NAC). The 5-year recurrence-free survival rate was 16.7% and the 5-year overall survival rate (5y-OS) was 52.9%. Number of tumors ≥6, carcinoembryonic antigen (CEA) level ≥25 ng/mL, tumor diameter ≥5 cm, and progressive disease (PD) after NAC were identified as independent poor prognostic factors for OS. Patients were divided into four groups according to the number of risk factors, and prognoses of the four groups were well stratified.

CONCLUSION

In patients with BR-NAC, number of tumors ≥6, CEA ≥25 ng/mL, tumor diameter ≥5 cm, and PD after NAC were independent poor prognostic factors. Patients with three or four risk factors showed poor prognosis and may need to switch chemotherapy.

Outcomes of different parenchymal-sparing hepatectomies in patients with colorectal liver metastases and prognostic impact of peritumoral imaging features

OBJECTIVES

Parenchymal-sparing hepatectomy (PSH) is recommended in patients with colorectal liver metastases (CRLM). Based on the principle of PSH, to investigate the impact of anatomical resection (AR) and non-anatomic resection (NAR) on the outcome of CRLM and to evaluate the potential prognostic impact of three peritumoral imaging features.

METHODS

Fifty-six patients who had abdominal gadoxetic acid-enhanced magnetic resonance imaging (MRI) before CRLM surgery were included in this retrospective research. Peritumoral early enhancement, peritumoral hypointensity on hepatobiliary phase (HBP), and biliary dilatation to the CRLM at MRI were evaluated. Survival estimates were calculated using the Kaplan-Meier method, and multivariate analysis was conducted to identify independent predictors of liver recurrence-free survival (LRFS), recurrence-free survival (RFS) and overall survival (OS).

RESULTS

NAR had a lower 3-year LRFS compared with AR (36.6% vs. 78.6%, p = 0.012). No significant differences were found in 3-year RFS (34.1% vs. 41.7%) and OS (61.7% vs. 81.3%) (p > 0.05). In NAR group, peritumoral early enhancement was associated with poor LRFS (p = < 0.001, hazard ratio [HR] = 6.260; 95% confidence interval [CI], 2.322,16.876]) and poor RFS (p = 0.035, HR =2.516; 95% CI, 1.069,5.919). No independent predictors of CRLM were identified in the AR group.

CONCLUSIONS

In patients with CRLM, peritumoral early enhancement was a predictor of LRFS and RFS after NAR according to the principle of PSH.

Clinical outcomes of parenchymal-sparing versus anatomic resection for colorectal liver metastases: a systematic review and meta-analysis

BACKGROUND

The advantages of parenchymal-sparing resection (PSR) over anatomic resection (AR) of colorectal liver metastases (CRLM) remain controversial. Here, we aim to evaluate their safety and efficacy.

METHODS

A systematic review and meta-analysis of short-term perioperative outcomes and long-term oncological outcomes for PSR and AR were performed by searching Pubmed, Embase, the Cochrane Library and Web of Science databases.

RESULTS

Twenty-two studies were considered eligible (totally 7228 patients: AR, n = 3154 (43.6%) vs. PSR, n = 4074 (56.4%)). Overall survival (OS, HR = 1.08, 95% CI: 0.95-1.22, P = 0.245) and disease-free survival (DFS, HR = 1.09, 95% CI: 0.94-1.28, P = 0.259) were comparable between the two groups. There were no significant differences in 3-year OS, 5-year OS, 3-year DFS, 5-year DFS, 3-year liver recurrence-free survival (liver-RFS) and 5-year liver-RFS. In terms of perioperative outcome, patients undergoing AR surgery were associated with prolonged operation time (WMD = 51.48 min, 95% CI: 29.03-73.93, P < 0.001), higher amount of blood loss (WMD = 189.92 ml, 95% CI: 21.39-358.45, P = 0.027), increased intraoperative blood transfusion rate (RR = 2.24, 95% CI: 1.54-3.26, P < 0.001), prolonged hospital stay (WMD = 1.00 day, 95% CI: 0.34-1.67, P = 0.003), postoperative complications (RR = 2.28, 95% CI: 1.88-2.77, P < 0.001), and 90-day mortality (RR = 3.08, 95% CI: 1.88-5.03, P < 0.001). While PSR surgery was associated with positive resection margins (RR = 0.77, 95% CI: 0.61-0.97, P = 0.024), intrahepatic recurrence (RR = 0.90, 95% CI: 0.82-0.98, P = 0.021) and repeat hepatectomy (RR = 0.64, 95% CI: 0.55-0.76, P < 0.001).

CONCLUSION

Considering relatively acceptable heterogeneity, PSR had better perioperative outcomes without compromising oncological long-term outcomes. However, these findings must be carefully interpreted, requiring more supporting evidence.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023445332.

Optimizing the selection of technically unresectable colorectal liver metastases

BACKGROUND

The prediction of conversion surgery in patients with technically unresectable colorectal liver metastases has not been generalized or well-established. We developed a predictive model for conversion surgery and assessed the long-term outcomes of patients with technically unresectable colorectal liver metastases.

METHODS

In this single-center, retrospective study, we analyzed the perioperative parameters and outcomes of 892 consecutive patients (2014-2021). Conversion surgery was indicated when the chemotherapy response allowed the complete resection of colorectal liver metastases with negative margins and adequate remnant liver volume.

RESULTS

Of the 892 patients, 122 had technically unresectable colorectal liver metastases; 61 underwent conversion surgery (conversion surgery group) and 61 did not (nonconversion surgery group). The median overall survival was significantly higher in the conversion surgery group than in the nonconversion surgery group (5.6 vs 1.8 years, P < .001). After univariate and multivariate analyses, the predictive model for conversion surgery was constructed using 4 predictive factors: Rat sarcoma viral oncogene homolog status (mutant, +2 points), tumor number (≥15, +1), hepatic vein contact (≥2 hepatic veins, +1), and the presence of preservable sections (absence of preservable sections, +2). The area under the curve for conversion surgery was 0.889. Patients were graded according to the scores (A [0-2], B [3-4], and C [5-6]), and the conversion rates were 91.5% (A), 32.6% (B), and 10.3% (C) (P < .001). Grade A patients (median survival time, 5.7 years) had significantly better overall survival than grade B and C patients (median survival time, 2.2 and 1.6 years, respectively; P < .001).

CONCLUSION

Patients who underwent conversion surgery for technically unresectable colorectal liver metastases had better prognoses, and our novel predictive model was useful in predicting conversion surgery and prognosis.

Colorectal Cancer Liver Metastases: Multimodal Therapy

Despite a steady decline in incidence and mortality rates, colorectal cancer (CRC) remains the second most common cancer diagnosis in women and the third most common in men worldwide. Notably, the liver is recognized as the most common site of CRC metastasis, and metastases to the liver remain the primary driver of disease-specific mortality for patients with CRC. Although hepatic resection is the backbone of curative-intent treatment, management of CRLM has become increasingly multimodal during the last decade and includes the use of downstaging chemotherapy, ablation techniques, and locoregional therapy, each of which are reviewed herein.

Clinical strategy of conversion therapy and surgical treatment for liver metastases from colorectal cancer

Colorectal cancer is one of the common malignant tumors of the digestive system in clinical practice. Due to the anatomical characteristics of the colorectum itself, colorectal cancer is prone to liver metastasis. Approximately 15%-25% of colorectal cancer cases are complicated with liver metastasis at diagnosis, 15%-25% are complicated with liver metastasis after radical resection of colorectal cancer, and 80%-90% with liver metastasis cannot undergo radical resection initially. The 5-year survival rate is less than 5%, and liver metastasis is the main cause of death in patients with colorectal cancer. In recent years, with the clinical application of effective chemotherapy and molecular targeted drugs, as well as the rapid development of surgical techniques, an individualized safe, efficient, fast, treatment plan can be formulated according to patients' age, primary colorectal tumor location, degree of differentiation, Ras and B-Raf gene status, tumor size, number and distribution of metastases in the liver. By shrinking the tumor volume in the liver and increasing the residual liver volume, liver metastatic tumors can undergo surgical resection or disease-free status can be achieved in patients with liver metastasis. As a result, patients with colorectal liver metastases can achieve a 5-year survival rate of 30%-57%, which greatly improves the prognosis after operation. According to the postoperative adverse factors, individualized preventive measures are worked out to reduce the impact of adverse factors and improve the prognosis of patients with colorectal liver metastases. In this paper, we systematically discuss the clinical strategy of conversion therapy and surgical treatment for unresectable colorectal cancer liver metastases by reviewing the relevant domestic and foreign literature, so as to provide a theoretical reference for the selection of clinical treatment and program for patients with unresectable colorectal cancer liver metastases.

Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?

Liver resection for malignant tumors should respect oncological margins while ensuring safety and improving the quality of life, therefore tumor staging, underlying liver disease and performance status should all be attentively assessed in the decision process. The concept of parenchyma-sparing liver surgery is nowadays used as an alternative to major hepatectomies to address deeply located lesions with intricate topography by means of complex multiplanar parenchyma-sparing liver resections, preferably under the guidance of intraoperative ultrasound. Regenerative liver surgery evolved as a liver growth induction method to increase resectability by stimulating the hypertrophy of the parenchyma intended to remain after resection (referred to as future liver remnant), achievable by portal vein embolization and liver venous deprivation as interventional approaches, and portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy as surgical techniques. Interestingly, although both strategies have the same conceptual origin, they eventually became caught in the never-ending parenchyma-sparing liver surgery vs. regenerative liver surgery debate. However, these strategies are both valid and must both be mastered and used to increase resectability. In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors. In addition, liver volume-manipulating regenerative surgery should be employed when resectability needs to be extended beyond the possibilities of parenchyma-sparing liver surgery.

Parenchymsparende Operationen oder anatomische Resektionen bei Lebermetastasen des kolorektalen Karzinoms?

Darmkrebs ist eine der häufigsten Todesursachen in der westlichen Welt. Die Hälfte der Patienten entwickelt kolorektale Lebermetastasen (CRLM), dabei weisen weniger als 30% der Patienten zum Zeitpunkt der Diagnose eine chirurgisch resektable Metastasierung auf. Im Falle einer Resektabilität bietet die klassische anatomische (Major-)Hepatektomie eine hohe R0-Resektionsrate, allerdings bei gleichzeitig erhöhter Morbidität und Mortalität. In den letzten 2 Jahrzehnten wurden die potenziellen Vorteile der parenchymsparenden Hepatektomie (PSH) in Bezug auf die onkologischen Gesamtergebnisse, das Überleben und die Re-Resektion im Falle eines Rezidivs („Salvageability“) nachgewiesen. Der Beitrag fasst die aktuellen Erkenntnisse zur PSH als chirurgische Therapieoption zusammen und diskutiert den aktuellen „state of the art“ in verschiedenen Szenarien.

Limited Prognostic Value of KRAS in Patients Undergoing Hepatectomy for Colorectal Liver Metastases

BACKGROUND

RAS mutation status is considered a powerful prognostic factor in patients undergoing hepatectomy for colorectal liver metastases (CLM). However, whether its prognostic power is robust regardless of administration of preoperative chemotherapy or tumor burden remains unclear.

METHODS

Consecutive patients who underwent initial hepatectomy for CLM from April 2010 through March 2017 in two hospitals were included. The prognostic value of KRAS was compared based on whether patients received preoperative chemotherapy and their tumor burden score (TBS).

RESULTS

We included 409 patients (median follow-up 38 months). In the preoperative chemotherapy group, patients with mutant KRAS (mt-KRAS) CLM had poorer overall survival (OS) than those with wild KRAS (wt-KRAS; 5-year OS: 37.7% vs 53.8%, p = 0.024), although their OS was not different from patients undergoing upfront surgery. Similarly, patients with mt-KRAS had poorer OS than those with wt-KRAS in TBS of 3-9 (5-year OS: 33.1% vs 63.2%, p = 0.001), although their OS was not different from patients with TBS < 3 or ≥ 9. In multivariate analysis, mt-KRAS was an independent prognostic factor of OS among patients receiving preoperative chemotherapy (hazard ratio [HR] 1.61, 95% confidence interval [CI]: 1.034-2.491; p = 0.035) and patients with TBS of 3-9 (HR 1.836, 95% CI 1.176-2.866; p = 0.008). However, it was not a prognostic factor in patients who underwent upfront surgery or with TBS > 3 or ≥ 9.

CONCLUSIONS

In patients undergoing hepatectomy for CLM, the prognostic value of KRAS depends on their history of preoperative chemotherapy or tumor burden.

Parenchyma-sparing hepatectomy improves salvageability and survival for solitary small intrahepatic cholangiocarcinoma

BACKGROUND

This study aimed to investigate the prognostic impact of parenchyma-sparing hepatectomy (PSH) on solitary small intrahepatic cholangiocarcinoma (ICC).

METHODS

A total of 184 patients with solitary small ICC (≤ 5 cm) from 2009 to 2017 were included. Short- and long-term outcomes were compared between PSH and Non-PSH approach.

RESULTS

95 (51.6%) patients underwent PSH and 89 (48.4%) patients underwent Non-PSH for solitary small ICC. PSH was associated with less intraoperative blood loss (212.9 mL versus 363.5 mL, P=0.038), lower transfusion rate (7.4% versus 16.9%, P=0.048), without increasing the frequency of tumor recurrence (60.0% versus 58.4%). No significant differences were observed in overall survival (OS), recurrence-free survival (RFS) and liver RFS (P = 0.627, 0.769 and 0.538, respectively). 109 (59.2%) patients experienced recurrence, of these, 67 (36.4%) were intrahepatic recurrence. Subgroup analysis of patients with liver-only recurrence demonstrated an increased likelihood of repeat hepatectomy for PSH compared to Non-PSH (21.2% versus 2.9%, P = 0.031), thus resulting in improved liver OS (P = 0.016).

CONCLUSION

PSH was associated with improved perioperative outcomes but it did not increase liver recurrence rates. PSH offered an increased rate of salvage hepatectomy for recurrent tumor, thus improving long-term survival in cases in which liver recurrence occurred.

Accuracy of Modern Clinical Risk Score Including RAS Status Changes Based on Whether Patients Received Perioperative Chemotherapy for Colorectal Liver Metastases

BACKGROUND

A modified Fong clinical score (m-Fong CS) that includes the RAS mutation status has recently been proposed and offered an improved survival stratification of patients who undergo surgery and systemic chemotherapy for colorectal liver metastases (CLM). The aim of this study is to assess whether a CS that includes RAS status is influenced by whether patients receive perioperative chemotherapy.

METHODS

We created a new CS using multivariate analysis of data of patients who underwent hepatectomy for CLM for the first time between 2010 and 2016 at a single hospital (n = 341, 79% received perioperative chemotherapy). The resulting CS and m-Fong CS were then validated in the patient cohort at three other hospitals (n = 309). Furthermore, the applicability of the two CS in the total cohort (n = 650) was tested according to whether the patients received perioperative chemotherapy.

RESULTS

The new CS comprised mutant RAS status, ≥4 CLMs, and a CA19-9 level ≥100 U/mL (1 point per factor). Both the new CS and m-Fong CS failed to stratify the survival of the 309 patients in the validation cohort, including those who did not receive perioperative chemotherapy (29%). Both of the CS accurately stratified the survival of patients who underwent perioperative chemotherapy but not of those who underwent surgery alone.

CONCLUSION

A CS that includes the RAS mutation status can stratify the survival of patients who undergo hepatectomy combined with perioperative chemotherapy, but it has limited value for patients who undergo surgery alone.

Feasibility of Right Upper Transversal Hepatectomy in the Absence of an Inferior Right Hepatic Vein: New Insights regarding This Complex Procedure

Background

Right upper transversal hepatectomy (RUTH) is defined as the removal of liver segments 7, 8, and 4A with ligature of the right and middle hepatic veins and is considered one of the most complex techniques of parenchymal-sparing hepatectomies. This procedure can be performed, without venous reconstruction, if collateral veins are present communicating within remnant liver segments to a large inferior right hepatic vein and/or to the left hepatic vein. This venous network could maintain outflow from the inferior right segments (S5, S6) to the left liver when a RUTH is performed, even in the absence of an inferior right hepatic vein. The aim of this study is to present our experience with RUTH without venous reconstruction in patients with and without the presence of an inferior right hepatic vein (IRHV).

Methods

Patients submitted to RUTH for treatment of liver metastases were selected from our database. The presence of an IRHV, clinical and surgical characteristics of the patients, immediate outcomes, viability of liver segments 5 and 6, and long-term survival were analyzed.

Results

RUTH was successfully performed in four patients. In two patients, IRHV was not present, but intrahepatic communicating veins between proximal right and middle hepatic veins and left hepatic vein were present. No venous reconstructions were performed. Mild congestion of the inferior right segments occurred in the patients where there was no IRHV but no immediate, early, or late complications were observed.

Conclusions

RUTH is feasible and can be performed even in the absence of an IRHV, without venous reconstruction. Some degree of congestion of the right inferior liver segments might occur when an IRHV is absent, yet this is not clinically significant when communicating veins are present. Maximum parenchyma preservation might prevent postoperative liver failure and allow repeated resections in case of hepatic recurrence.

Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021

BACKGROUND

Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors.

METHODS

Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy.

CONCLUSIONS

These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.

Recurrence at surgical margin following hepatectomy for colorectal liver metastases is not associated with R1 resection and does not impact survival

BACKGROUND

Resection margin status has traditionally been associated with tumor recurrence and oncological outcome following liver resection for colorectal liver metastases. Previous studies, however, did not address the impact of resection margin on the site of tumor recurrence and did not differentiate between true local recurrence at the resection margin and recurrence elsewhere in the liver. This study aimed to determine whether positive resection margins determine local recurrence and whether recurrence at the surgical margin influences long-term survival.

METHODS

Clinicopathological data and oncological outcomes of patients who underwent curative resection for colorectal liver metastases between 2012 and 2017 at 2 major hepatobiliary centers (Bern, Switzerland, and Berlin, Germany) were assessed. Cross-sectional imaging following hepatectomy was reviewed by radiologists in both centers to distinguish between recurrence at the resection margin, defined as hepatic local recurrence, and intrahepatic recurrence elsewhere. The association between surgical margin status and location of tumor recurrence was evaluated, and the impact on overall survival was determined.

RESULTS

During the study period, 345 consecutive patients underwent hepatectomy for colorectal liver metastases. Histologic surgical margins were positive for tumor cells (R1) in 63 patients (18%). After a median follow-up time of 34 months, tumor recurrence was identified in 154 patients (45%). Hepatic local recurrence was not detected more frequently after R1 than after R0 resection (P = .555). Hepatic local recurrence was not associated with worse overall survival (P = .436), while R1 status significantly impaired overall survival (P = .025). Additionally, overall survival was equivalent between patients with hepatic local recurrence and patients with any intrahepatic and/or extrahepatic recurrence. In patients with intrahepatic recurrence only, oncological outcomes improved if local hepatic therapy was possible (resection or ablation) in comparison to patients treated only with chemotherapy or best supportive care (3-year overall survival: 85% vs 39%; P < .0001).

CONCLUSION

The incidence of hepatic local recurrence after hepatectomy for colorectal liver metastases is independent of R1 resection margin status. Additionally, hepatic local recurrence at the resection margin is not associated with worse overall survival compared with any other intra- or extrahepatic recurrence. Therefore, R1 status at hepatectomy seems to be a surrogate factor for advanced disease without influencing location of recurrence and thereby oncological outcome. This finding may support decision-making when extending the indication for surgery in borderline resectable colorectal liver metastases.

The impact of personalized nutritional support on postoperative outcome within the enhanced recovery after surgery (ERAS) program for liver resections: results from the NutriCatt protocol

BACKGROUND

Malnutrition in liver surgery is correlated with higher postoperative complications and longer length of hospital stay (LOHS), the same items that ERAS programs try to optimize. However, to date, standardized dietary protocols have not been defined within ERAS programs. Aim of this study was to evaluate the impact on LOHS and postoperative complications, of a personalized nutritional protocol (NutriCatt) with diet and oral branched-chain amino acid (BCAA) supplementation, adopted within the ERAS program.

METHODS

1960 consecutive liver resections were performed from January 2000 to September 2018.

EXCLUSION CRITERIA

perihilar cholangiocarcinoma, simultaneous colorectal and liver resections. Four groups for analysis: resections before 2009 (1st period); from 2009 to 2016 (2nd period, including laparoscopic resections); between 2016 and September 2017 (ERAS); after September 2017 (ERAS + NutriCatt).

RESULTS

LOHS declined (p < 0.0001), from a median of 10 days (1st period) to 8, 7 and 6 in 2nd period, ERAS and ERAS + NutriCatt groups, respectively. At multivariable analysis for risk of LOHS > 8 days, the 2nd period, ERAS and ERAS + NutriCatt groups showed a protective effect. These results were confirmed for both minor and major resections. LOHS was significantly lower in ERAS + Nutricatt group than in ERAS group, without increasing risk of postoperative complications, although the rate of laparoscopic resections was similar in these two groups and complexity of liver resections was significantly higher in the last period.

CONCLUSIONS

Adoption of a personalized nutritional protocol with BCAA supplementation within the ERAS program for liver resections was a safe and effective approach that may impact on reducing the LOHS.

Clinical significance of subcentimeter pulmonary nodules in patients undergoing hepatectomy for colorectal liver metastases

BACKGROUND AND OBJECTIVES

The clinical significance of lung metastases regarded as subcentimeter pulmonary nodules (SPN) before hepatectomy for colorectal liver metastases (CLM) has not been assessed well.

METHODS

The data from 569 patients undergoing hepatectomy for CLM from 2010 to 2016 were reviewed. The presence and final diagnosis of SPN were analyzed for their association with overall survival (OS).

RESULTS

A total of 143 patients had SPN (25.1%). SPN were proved to be lung metastases in 43 patients (30.1%). Before hepatectomy, lung metastases were suspected in 25 patients (sensitivity: 58%; specificity: 100%). The 5-year OS of patients with lung metastases (45.4%) was worse than that of those with no pulmonary nodules (60.9%, P = .003). There was no significant difference in the 5-year OS between the patients with lung metastases diagnosed after hepatectomy (48.7%) and before hepatectomy (41.2%, P = .432). The 5-year OS of patients who underwent surgery for lung metastases after hepatectomy (60.5%) was similar to that of those with no pulmonary nodules and benign pulmonary nodules (60.9%, P = .6310; 44.0%, P = .899).

CONCLUSION

Although diagnostic sensitivity for SPN before hepatectomy is low, timing of diagnosis does not affect OS. Conclusive lung resection offers OS similar to that of patients without lung metastases.

Anatomic Resection Is Not Required for Colorectal Liver Metastases with RAS Mutation

BACKGROUND

Non-anatomic resection (NAR) has emerged as a safe and effective technique for resection of colorectal liver metastases (CRLM). More recently, RAS mutation has been identified as an important indicator of aggressive disease, which may require anatomic resection (AR). In this retrospective study, we compared the long-term outcomes of AR versus NAR in CRLM patients with and without RAS mutations.

METHODS

Patients with known RAS mutation status who underwent AR or NAR for CRLM between 2006 and 2016 were included. Differences in baseline characteristics were adjusted using 1:1 propensity score matching, including the most important factors that contributed to the decision to use the resection technique. Overall survival (OS), recurrence-free survival (RFS), and liver-specific recurrence-free survival (L-RFS) were compared between cohorts.

RESULTS

Among 622 total patients, 338 (54%) underwent AR and 284 (46%) NAR. There was no difference in OS or L-RFS between the AR and NAR groups, regardless of mutation status. There was increased RFS in the RAS WT patients with NAR (P = 0.034), but no difference in RFS in the whole cohort or RAS mutant group. After propensity score matching, 360 patients were analyzed, and no differences in OS, RFS, or L-RFS rates were seen between any groups. There was also no difference in margin recurrence.

CONCLUSIONS

Similar outcomes can be achieved with both AR and NAR, regardless of RAS mutation status. These data do not support a universal requirement for AR in RAS mutant CRLM when not necessary to achieve an R0 resection.

Minor Hepatectomies: Focusing a Blurred Picture: Analysis of the Outcome of 4471 Open Resections in Patients Without Cirrhosis

OBJECTIVE

To elucidate minor hepatectomy (MiH) outcomes.

SUMMARY BACKGROUND DATA

Liver surgery has moved toward a parenchyma-sparing approach, favoring MiHs over major resections. MiHs encompass a wide range of procedures.

METHODS

We retrospectively evaluated consecutive patients who underwent open liver resections in 17 high-volume centers.

EXCLUSION CRITERIA

cirrhosis and associated digestive/biliary resections. Resections were classified as (Brisbane nomenclature): limited resections (LR); (mono)segmentectomies/bisegmentectomies (Segm/Bisegm); right anterior and right posterior sectionectomies (RightAnteriorSect/RightPosteriorSect). Additionally, we defined: complex LRs (ComplexLR = LRs with exposed vessels); postero-superior segmentectomies (PosteroSuperiorSegm = segment (Sg)7, Sg8, and Sg7+Sg8 segmentectomies); and complex core hepatectomies (ComplexCoreHeps = Sg1 segmentectomies and combined resections of Sg4s+Sg8+Sg1). Left lateral sectionectomies (LLSs, n = 442) and right hepatectomies (RHs, n = 1042) were reference standards. Outcomes were adjusted for potential confounders.

RESULTS

Four thousand four hundred seventy-one MiHs were analyzed. Compared with RHs, MiHs had lower 90-day mortality (0.5%/2.2%), severe morbidity (8.6%/14.4%), and liver failure rates (2.4%/11.6%, P < 0.001), but similar bile leak rates. LR and LLS had similar outcomes. ComplexLR and Segm/Bisegm of anterolateral segments had higher bile leak rates than LLS rates (OR = 2.35 and OR = 3.24), but similar severe morbidity rates. ComplexCoreHeps had higher bile leak rates than RH rates (OR = 1.94); the severe morbidity rate approached that of RH. PosteroSuperiorSegm, RightAnteriorSect, and RightPosteriorSect had severe morbidity and bile leak rates similar to RH rates. MiHs had low liver failure rates, except RightAnteriorSect (vs LLS OR = 4.02).

CONCLUSIONS

MiHs had heterogeneous outcomes. Mortality was low, but MiHs could be stratified according to severe morbidity, bile leak, and liver failure rates. Some MiHs had postoperative outcomes similar to RH.

Repeat Hepatectomy After Major Hepatectomy for Colorectal Liver Metastases

OBJECTIVE

This study assessed predictors of survival after repeat hepatectomy and the feasibility of a repeat hepatectomy after a major hepatectomy in the patients with colorectal liver metastases (CLM).

BACKGROUND

More than half of all patients who receive a curative initial hepatectomy for CLM develop hepatic recurrence, and aggressive indications for a repeat hepatectomy can improve the outcome in selected patients. However, the feasibility of repeat hepatectomy after major hepatectomy remains uncertain, and optimal selection criteria for repeat hepatectomy have not yet been established.

METHODS

Data were collected retrospectively on 296 CLM patients who underwent an initial curative hepatectomy between 2007 and 2017 at our institution. The postoperative outcomes of patients undergoing a repeat hepatectomy after major hepatectomy were assessed, and independent predictors of survival were investigated.

RESULTS

After a median follow-up period of 32 months, 247 patients (83%) developed disease recurrence and 122 patients (49%) underwent repeat hepatectomy. The 5-year overall survival (OS) was significantly higher in patients who underwent a repeat hepatectomy than in those who did not receive repeat hepatectomy (51% vs. 19%, respectively; P < 0.001). In a multivariate analysis, an extrahepatic lesion at the time of the repeat hepatectomy (HR, 2.49; P = 0.001) and 5 or more liver tumors at the time of recurrence (HR, 1.88; P = 0.04) remained as independent factors negatively affecting OS after repeat hepatectomy. The type of operative procedure and the intraoperative and postoperative factors at the time of the initial hepatectomy did not have any significant influence on the OS after repeat hepatectomy. No significant difference in OS was found between patients who received repeat hepatectomy after major hepatectomy (n = 43) and those after non-major hepatectomy (n = 79).

CONCLUSIONS

The operative procedure and the liver tumor status at the time of the initial hepatectomy have little impact on the indications for a repeat hepatectomy for recurrent CLM. Repeat hepatectomy is feasible even if major hepatectomy was initially performed.

Parenchymal-sparing versus extended hepatectomy for colorectal liver metastases: A systematic review and meta-analysis

AIMS

To assess the safety and efficacy of parenchymal-sparing hepatectomy (PSH) as a treatment of colorectal liver metastases (CLM).

METHODS

A comprehensive medical literature search was performed. Perioperative and long-term survival outcomes were pooled. Subgroup analysis and meta-regression analysis were performed to identify potential sources of heterogeneity.

RESULTS

A total of 18 studies comprising 7081 CLM patients were eligible for this study. The PSH was performed on 3974 (56.1%) patients. We found that the OS (overall survival; hazard ratio [HR] = 1.01, 95% confidence interval [CI]: 0.94-1.08) and RFS (recurrence-free survival; HR = 1.00, 95% CI: 0.94-1.07) were comparable between non-PSH and PSH group. The perioperative outcomes were better in PSH than in non-PSH group. Non-PSH group was significantly associated with longer operative time (standard mean difference [SMD] = 1.17, 95% CI: 0.33-2.00), increased estimated blood loss (SMD = 1.36, 95% CI: 0.64-2.07), higher intraoperative transfusion rate (risk ratio [RR] = 2.27, 95% CI: 1.60-3.23), and more postoperative complications (RR = 1.39, 95% CI: 1.16-1.66). Meta-regression analyses revealed that no variable influenced the association between surgical types and the survival outcomes.

CONCLUSIONS

This study shows that PSH is associated with better perioperative outcomes without compromising oncological outcomes. Given the increasing incidence of hepatic parenchyma, the PSH treatment offers a greater opportunity of repeat resection for intrahepatic recurrent tumors. It should be considered as an effective surgical approach for CLM.

Propensity score analysis of non-anatomical versus anatomical resection of colorectal liver metastases

Background

There are concerns that non‐anatomical resection (NAR) worsens perioperative and oncological outcomes compared with those following anatomical resection (AR) for colorectal liver metastases (CRLM). Most previous studies have been biased by the effect of tumour size. The aim of this study was to compare oncological outcomes after NAR versus AR.

Methods

This was a retrospective study of consecutive patients who underwent CRLM resection with curative intent from 1999 to 2016. Data were retrieved from a prospectively developed database. Survival and perioperative outcomes for NAR and AR were compared using propensity score analyses.

Results

Some 358 patients were included in the study. Median follow‐up was 34 (i.q.r. 16–68) months. NAR was associated with significantly less morbidity compared with AR (31·1 versus 44·4 per cent respectively; P = 0·037). Larger (hazard ratio (HR) for lesions 5 cm or greater 1·81, 95 per cent c.i. 1·13 to 2·90; P = 0·035) or multiple (HR 1·48, 1·03 to 2·12; P = 0·035) metastases were associated with poor overall survival (OS). Synchronous (HR 1·33, 1·01 to 1·77; P = 0·045) and multiple (HR 1·51, 1·14 to 2·00; P = 0·004) liver metastases, major complications after liver resection (HR 1·49, 1·05 to 2·11; P = 0·026) or complications after resection of the primary colorectal tumour (HR 1·51, 1·01 to 2·26; P = 0·045) were associated with poor disease‐free survival (DFS). AR was prognostic for poor OS only in tumours smaller than 30 mm, and R1 margin status was not prognostic for either OS or DFS. NAR was associated with a higher rate of salvage resection than AR following intrahepatic recurrence.

Conclusions

NAR has at least equivalent oncological outcomes to AR while proving to be safer. NAR should therefore be the primary surgical approach to CRLM, especially for lesions smaller than 30 mm.

Sub-millimeter surgical margin is acceptable in patients with good tumor biology after liver resection for colorectal liver metastases

BACKGROUND

The definition of R1 resection in colorectal cancer liver metastases (CRLM) remains debatable. This retrospective study was conducted to clarify the impact of R1 margin on patient survival after liver resection for CRLM, taking into consideration tumor biology, including RAS status and chemotherapy response.

METHODS

We retrospectively analysed the clinical and survival data of 214 CRLM patients with initially resectable liver metastases who underwent liver resection after receiving neoadjuvant chemotherapy between January 2006 and December 2016.

RESULTS

R1 resection significantly impacted patients' overall survival (OS) and disease-free survival (DFS) in the overall patient cohort (5-year OS: 53.2% for R0 vs 38.2% for R1, P = 0.001; 5-year DFS: 26.5% for R0 vs 10.5% for R1, P = 0.002). In the RAS wild-type subgroup and respond to chemotherapy (RC) subgroup, R1 reached a similar OS to those who underwent R0 resection (RAS wild-type, P = 0.223; RC, P = 0.088). For the RAS mutated subgroup and no response to chemotherapy (NRC) subgroup, OS was significantly worse underwent R1 resection (RAS mutant, P = 0.002; NRC, P = 0.022). When considering tumor biology combining RAS and chemotherapy response status, R1 resection was only acceptable in patients with both RAS wild-type and RC (5-year OS: 66.4% for R0 vs 65.2% for R1, p = 0.884), but was significantly worse in those with either RAS mutation or NRC.

CONCLUSIONS

Tumor biology plays an important role in deciding the appropriate resection margin in patients with CRLM undergoing radical surgery. R1 resection margin is only acceptable in RAS wild-type patients who respond to chemotherapy.

Actual 10-year survival after hepatic resection of colorectal liver metastases: what factors preclude cure?

BACKGROUND

Hepatic resection of colorectal liver metastases is associated with long-term survival. This study analyzes actual 10-year survivors after resection of colorectal liver metastases, reports the observed rate of cure, and identifies factors that preclude cure.

METHODS

A single-institution, prospectively maintained database was queried for all initial resections for colorectal liver metastases for the years 1992-2004. Observed cure was defined as actual 10-year survival with either no recurrence or resected recurrence with at least 3 years of disease-free follow-up. Clinical risk score was dichotomized into low (0-2) and high (3-5). Semiparametric proportional hazards mixture cure model was utilized to estimate probability of cure.

RESULTS

We included 1,211 patients with a median follow-up for survivors of 11 years. Median disease-specific survival was 4.9 years (95% CI: 4.4-5.3). 295 patients (24.4%) were actual 10-year survivors. The observed cure rate was 20.6% (n = 250). Among 250 cured patients, 192 (76.8%) had no recurrence and 58 (23.2%) had a resected recurrence with at least 3 years of disease-free follow-up. Extrahepatic disease (n = 88), carcinoembryonic antigen >200 ng/mL (n = 119), positive margin (n = 109), and >10 tumors (n = 31) had observed cure rates less than 10%. In cure model analysis, patients with both extrahepatic disease and high clinical risk score (n = 31) had an estimated probability of cure of 3.5%.

CONCLUSION

Actual 10-year survival after resection of colorectal liver metastases is 24% with an observed 20% cure rate. Patients with both high clinical risk score and extrahepatic disease have an estimated probability of cure less than 5%. When such factors are identified, strong consideration may be given to preoperative strategies, such as neoadjuvant chemotherapy, to help select patients for surgical therapy.

Surgical Approach to "Right Hepatic Core": Deepest Region Surrounded by Major Portal Pedicles and Right Hepatic Vein

BACKGROUND/AIMS

The resection of hepatic tumors located in the region surrounded by the right hepatic vein (RHV) and the portal pedicles of the right paramedian/lateral sector (the right hepatic core) remains a challenge for liver surgeons. The aim of this study was to demonstrate the surgical techniques and outcomes of our atypical-parenchyma-sparing hepatectomy (atypical-PSH) approach for the removal of tumors in the right hepatic core.

METHODS

Perioperative records of 1,179 consecutive patients who had undergone hepatectomy for hepatocellular carcinoma or colorectal liver metastases from January 2006 to December 2014 were retrospectively reviewed.

RESULTS

Twenty-six patients (2%) had a tumor in the right hepatic core. Among them, 20 patients underwent atypical-PSH, including the anterior approach (resection of the right paramedian hepatic parenchyma, n = 9), posterior approach (resection of the right lateral hepatic parenchyma, n = 10), and transhepatic approach (tumor enucleation from the raw surfaces along the RHV, n = 1). Their postoperative outcomes were similar to the remaining 6 patients who had undergone right hepatectomy.

CONCLUSIONS

Atypical-PSH can be safely applied for the removal of tumors in the right hepatic core. This technique may have potential advantages in preserving hepatic function for postoperative chemotherapy and repeated hepatectomy for future recurrence.

Laparoscopic Parenchyma-sparing Liver Resection for Colorectal Metastases

Background

Laparoscopic liver resection (LLR) of colorectal liver metastases (CLM) is increasingly performed in specialized centers. While there is a trend towards a parenchyma-sparing strategy in multimodal treatment for CLM, its role is yet unclear. In this study we present short- and long-term outcomes of laparoscopic parenchyma-sparing liver resection (LPSLR) at a single center.

Patients and methods

LLR were performed in 951 procedures between August 1998 and March 2017 at Oslo University Hospital, Oslo, Norway. Patients who primarily underwent LPSLR for CLM were included in the study. LPSLR was defined as non-anatomic hence the patients who underwent hemihepatectomy and sectionectomy were excluded. Perioperative and oncologic outcomes were analyzed. The Accordion classification was used to grade postoperative complications. The median follow-up was 40 months.

Results

296 patients underwent primary LPSLR for CLM. A single specimen was resected in 204 cases, multiple resections were performed in 92 cases. 5 laparoscopic operations were converted to open. The median operative time was 134 minutes, blood loss was 200 ml and hospital stay was 3 days. There was no 90-day mortality in this study. The postoperative complication rate was 14.5%. 189 patients developed disease recurrence. Recurrence in the liver occurred in 146 patients (49%), of whom 85 patients underwent repeated surgical treatment (liver resection [n = 69], ablation [n = 14] and liver transplantation [n = 2]). Five-year overall survival was 48%, median overall survival was 56 months.

Conclusions

LPSLR of CLM can be performed safely with the good surgical and oncological results. The technique facilitates repeated surgical treatment, which may improve survival for patients with CLM.

Anatomical Resections Improve Disease-free Survival in Patients With KRAS-mutated Colorectal Liver Metastases

OBJECTIVE

To investigate the potential clinical advantage of anatomical resection versus nonanatomical resection for colorectal liver metastases, according to KRAS mutational status.

BACKGROUND

KRAS-mutated colorectal liver metastases (CRLM) are known to be more aggressive than KRAS wild-type tumors. Although nonanatomical liver resections have been demonstrated as a viable approach for CRLM patients with similar oncologic outcomes to anatomical resections, this may not be the case for the subset of KRAS-mutated CRLM.

METHODS

389 patients who underwent hepatic resection of CRLM with known KRAS mutational status were identified. Survival estimates were calculated using the Kaplan-Meier method, and multivariable analysis was conducted using the Cox proportional hazards regression model.

RESULTS

In this study, 165 patients (42.4%) underwent nonanatomical resections and 140 (36.0%) presented with KRAS-mutated CRLM. Median disease-free survival (DFS) in the entire cohort was 21.3 months, whereas 1-, 3-, and 5-year DFS was 67.3%, 34.9%, and 31.5% respectively. Although there was no difference in DFS between anatomical and nonanatomical resections in patients with KRAS wild-type tumors (P = 0.142), a significant difference in favor of anatomical resection was observed in patients with a KRAS mutation (10.5 vs. 33.8 months; P < 0.001). Five-year DFS was only 14.4% in the nonanatomically resected group, versus 46.4% in the anatomically resected group. This observation persisted in multivariable analysis (hazard ratio: 0.45; 95% confidence interval: 0.27-0.74; P = 0.002), when corrected for number of tumors, bilobar disease, and intraoperative ablations.

CONCLUSIONS

Nonanatomical tissue-sparing hepatectomies are associated with worse DFS in patients with KRAS-mutated tumors. Because of the aggressive nature of KRAS-mutated CRLM, more extensive anatomical hepatectomies may be warranted.

Surgical salvage of recurrence after resection of colorectal liver metastases: incidence and outcomes

Surgical resection remains the primary curative treatment option for patients with colorectal liver metastases. While the majority of patients will develop tumor relapse within or outside of the liver after hepatic metastasectomy, a subset of these patients may be amenable to salvage surgical resection. However, outcomes for this approach are not well defined. In this article, we summarize the current evidence for the incidence, feasibility and outcomes of salvage resection for recurrence after initial resection of colorectal liver metastases.

Parenchymal-Sparing Versus Anatomic Liver Resection for Colorectal Liver Metastases: a Systematic Review

INTRODUCTION

Colorectal liver metastases develop in 50% of patients diagnosed with colorectal cancer. Surgical resection for colorectal liver metastasis typically involves either anatomical resection (AR) or parenchymal-sparing hepatectomy (PSH). The objective of the current study was to analyze data on parenchymal versus non-parenchymal-sparing hepatic resections for CLM.

METHODS

A systematic review of the literature regarding parenchymal-sparing hepatectomy was performed. MEDLINE/PubMed, Cochrane, and EMBASE databases were searched for publications containing the following medical subject headings (MeSH): "Colorectal Neoplasms," "Neoplasm Metastasis," "Liver Neoplasms" and "Hepatectomy". Besides, the following keywords were used to complete the literature search: "Hepatectomy," "liver resection," "hepatic resection," "anatomic/anatomical," "nonanatomic/ nonanatomical," "major," "minor," "limited," "wedge," "CRLM/CLM," and "colorectal liver metastasis." Data was reviewed, aggregated, and analyzed.

RESULTS

Two thousand five hundred five patients included in 12 studies who underwent either PSH (n = 1087 patients) or AR (n = 1418 patients) were identified. Most patients had a primary tumor that originated in the colon (PSH 52.2-74.4% vs. AR 53.9-74.3%) (P = 0.289). The majority of studies included a large subset of patients with only a solitary tumor with a reported median tumor number of 1-2 regardless of whether the patient underwent PSH or AR. Median EBL was no different among patients undergoing PSH (100-896 mL) versus AR (200-1489 mL) for CLM (P = 0.248). There was no difference in median length-of-stay following PSH (6-17 days) versus AR (7-15 days) (P = 0.747). While there was considerable inter-study variability regarding margin status, there was no difference in the incidence of R0 resection among patients undergoing PSH (66.7-100%) versus AR (71.6-98.6%) (P = 0.58). When assessing overall survival, there was no difference whether resection of CLM was performed with PSH (5 years OS: mean 44.7%, range 29-62%) or AR (5 years OS: mean 44.6%, range 27-64%) (P = 0.97).

CONCLUSION

PSH had a comparable safety and efficacy profile compared with AR and did not compromise oncologic outcomes. PSH should be considered an appropriate surgical approach to treatment for patients with CLM that facilitates preservation of hepatic parenchyma.

Bilobar versus unilobar multiple colorectal liver metastases: a propensity score analysis of surgical outcomes and recurrence patterns

BACKGROUND

Bilobar multiple colorectal liver metastases (MCLM) are often considered incurable or associated with a poor prognosis even after R0 resection. This study was designed to compare the long-term outcomes and recurrence patterns after one-stage resection in patients with bilobar versus unilobar MCLM.

METHODS

The records of patients undergoing parenchymal-sparing intent hepatectomy between 1994 and 2015 were reviewed. Survival and recurrence patterns were analyzed by propensity score matching.

RESULTS

The study population included 140 patients: 81 patients with bilobar MCLM versus 59 patients with unilobar MCLM. In the propensity score matching analysis (bilobar, n = 35 vs. unilobar, n = 35), the short-term outcomes did not differ between the two groups. Five-year overall survival (54.8% in bilobar vs. 51.2% in unilobar; P = 0.388) and recurrence-free survival (28.5% in bilobar vs. 36.2% in unilobar; P = 0.261) also did not differ. No significant differences were found in liver-only recurrence (22.9% in bilobar vs. 25.7% in unilobar; P = 1.000) and other recurrence patterns.

CONCLUSIONS

The clearance of bilobar MCLM by one-stage resection of parenchymal-sparing intent provided comparable long-term survival to unilobar MCLM.

Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases

BACKGROUND

The feasibility of parenchymal-sparing hepatectomy has yet to be assessed based on the tumor location, which affects the choice of treatment in patients with colorectal liver metastases.

METHODS

Sixty-three patients underwent first curative hepatectomy for deep-placed colorectal liver metastases whose center was located >30 mm from the liver surface. Operative outcomes were compared among patients who underwent parenchymal-sparing hepatectomy or major hepatectomy (≥3 segments).

RESULTS

Parenchymal-sparing hepatectomy and major hepatectomy were performed for deep-placed colorectal liver metastases in 40 (63%) and 23 (37%) patients, respectively. Resection time was longer in the parenchymal-sparing hepatectomy than in the major hepatectomy group (57 vs 39 minutes) (P = .02) and cut-surface area was wider (120 vs 86 cm²) (P < .01). Resected volume was smaller in the parenchymal-sparing hepatectomy than in the major hepatectomy group (251 vs 560 g) (P < .01). No differences were found between the 2 groups for total operation time (306 vs 328 minutes), amount of blood loss (516 vs 400 mL), rate of major complications (10% vs 13%), and positive operative margins (5% vs 4%). Overall, recurrence-free, and liver recurrence-free survivals did not differ between the 2 groups. Direct major hepatectomy without portal venous embolization could not have been performed in 40% of the parenchymal-sparing hepatectomy group (16/40) because of the small liver remnant volume.

CONCLUSION

Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases was performed safely without compromising oncologic radicality. Parenchymal-sparing hepatectomy can increase the number of patients eligible for an operation by halving the resection volume and by increasing the chance of direct operative treatment in patients with ill-located colorectal liver metastases.