Simultaneous resection of synchronous colorectal liver metastasis: Feasibility and development of a prediction model

Is It Worth Performing Intersphincteric Resection in Patients Having Rectal Adenocarcinoma with Oligometastasis

Intersphincteric resection (ISR) is being increasingly performed in metastatic rectal adenocarcinoma (with oligometastasis) patients. There has been a trend towards worse prognosis in this group. This study compares the oncological and surgical outcomes of patients with and without pre-operative oligometastasis who underwent ISR. The outcomes compared include prognostic factors like margin positivity, recurrence rates, stoma reversal rate, and surgical failure rate (defined as a combination of one or more of the aforestated factors). The demographic pattern, American Society of Anaesthesia grade (ASA), treatment received, clinical and histopathological T and N stage, grade, type of minimally invasive surgery (MIS) approach, neoadjuvant therapy, and pathological high-risk features are also studied. Patients who underwent minimally invasive ISR over 10 years at a high-volume tertiary cancer center were selected for the study. Factors used for the assessment of oncological outcomes were margin positivity (circumferential resection and distal margin), recurrence (both local and systemic), and stoma reversal rate. A descriptive and comparative analyses were performed. Four hundred and eight patients underwent minimally invasive ISR of which 25 (6.12%) patients were oligometastatic. While R0 resection was similar in both groups, higher overall recurrence (24% versus 18.5%) and low stoma reversal rate (36.8% versus 67.3%) were observed in the oligometastatic group with statistically significant differences. No local recurrence was seen in the oligometastatic group, and the difference compared to non-metastatic group was not statistically different. This study indicates that oligometastatic patients who underwent ISR experienced lower stoma reversal rates, maintaining similar local control but facing higher rates of systemic recurrence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-02117-3.

Advancement in the Management of Synchronous Colorectal Liver Metastasis: A Comprehensive Review of Surgical, Systemic, and Local Treatment Modalities

Synchronous colorectal liver metastases (sCRLMs) present a complex therapeutic challenge requiring multimodal management strategies due to their complex tumor biology, variable disease progression, and the need to balance oncologic control with liver function preservation. This systematic review evaluates recent advancements in surgical approaches, systemic therapies, and local treatment modalities. A comprehensive literature search was conducted across major databases (PubMed, EMBASE, and Cochrane) for studies published between 2013 and 2024. Studies evaluating surgical techniques, perioperative outcomes, systemic therapy integration, and local treatments for sCRLM were included. Quality assessment was performed using the Newcastle-Ottawa Scale for observational studies and the Cochrane risk-of-bias tool for randomized controlled trials (RCTs). Analysis of nine primary studies encompassing 3,856 patients revealed evolving treatment paradigms. This review includes English-language studies (2013-2024) on adult patients (≥18 years) with sCRLM, covering RCTs, cohort, and case-control studies reporting survival, perioperative outcomes, or quality of life (≥12 months follow-up). Exclusions include case reports (<10 patients), metachronous metastases, conference abstracts, reviews without data, unclear methodology, duplicates, and animal/in-vitro studies. Staged resection demonstrated superiority over the simultaneous approach in recent analyses (win ratio 1.59, 95%CI 1.47-1.71). This indicates that patients undergoing staged resection had a 59% higher likelihood of achieving better outcomes (such as survival or fewer complications) compared to those undergoing simultaneous resection. The narrow confidence interval suggests strong statistical reliability of this finding. Minimally invasive techniques showed comparable outcomes to open surgery, with acceptable morbidity rates (21.7%) even in simultaneous resections. Neoadjuvant chemotherapy with targeted agents achieved high resectability rates (97%) and significant response rates (66%). The presence of liver metastases negatively impacted immunotherapy efficacy, suggesting the need for tailored approaches. Management of sCRLM has evolved toward a more personalized approach incorporating advanced surgical techniques, targeted therapies, and novel treatment sequencing. While staged resection may offer advantages in selected cases, treatment decisions should be individualized based on patient and disease characteristics. Future research should focus on optimizing patient selection and treatment sequencing through prospective trials.

Extent of resection and underlying liver disease influence the accuracy of the preoperative risk assessment with the American College of Surgeons Risk Calculator

BACKGROUND

Liver surgery is associated with a significant risk of postoperative complications, depending on the extent of liver resection and the underlying liver disease. Therefore, adequate patient selection is crucial. This study aimed to assess the accuracy of the American College of Surgeons Risk Calculator (ACS-RC) by considering liver parenchyma quality and the type of liver resection.

METHODS

Patients who underwent open or minimally invasive liver resection for benign or malignant indications between January 2019 and March 2023 at the University Hospital Basel were included. Brier score and feature importance analysis were performed to investigate the accuracy of the ACS-RC.

RESULTS

A total of 376 patients were included in the study, 214 (57%) who underwent partial hepatectomy, 89 (24%) who underwent hemihepatectomy, and 73 (19%) who underwent trisegmentectomy. Most patients had underlying liver diseases, with 143 (38%) patients having fibrosis, 75 patients (20%) having steatosis, and 61 patients (16%) having cirrhosis. The ACS-RC adequately predicted surgical site infection (Brier score of 0.035), urinary tract infection (Brier score of 0.038), and death (Brier score of 0.046), and moderate accuracy was achieved for serious complications (Brier score of 0.216) and overall complications (Brier score of 0.180). Compared with the overall cohort, the prediction was limited in patients with cirrhosis, fibrosis, and steatosis and in those who underwent hemihepatectomy and trisegmentectomy. The inclusion of liver parenchyma quality improved the prediction accuracy.

CONCLUSION

The ACS-RC is a reliable tool for estimating 30-day postoperative morbidity, particularly for patients with healthy liver parenchyma undergoing partial liver resection. However, accurate perioperative risk prediction should be adjusted for underlying liver disease and extended liver resections.

Propensity-score matched outcomes of resection of stage IV primary colon cancer with and without simultaneous resection of liver metastases

There is controversy in the best management of colorectal cancer liver metastasis (CLM). This study aimed to compare short-term and survival outcomes of simultaneous resection of CLM and primary colon cancer compared to resection of only colon cancer. This retrospective matched cohort study included patients from the National Cancer Database (2015-2019) with stage IV colon adenocarcinoma and synchronous liver metastases who underwent colectomy. Patients were divided into two groups: colectomy-only (resection of primary colon cancer only) and colectomy-plus (simultaneous resection of primary colon cancer and liver metastases). The groups were matched using the propensity score method. The primary outcome was short-term mortality and readmission. Secondary outcomes were conversion, hospital stay, surgical margins, and overall survival. 4082 (37.6%) of 10,862 patients underwent simultaneous resection of primary colon cancer and liver metastases. After matching, 2038 patients were included in each group. There were no significant differences between the groups in 30-days mortality (3.1% vs 3.8%, p = 0.301), 90-days (6.6% vs 7.7%, p = 0.205) mortality, 30-days unplanned readmission (7.2% vs 5.3%, p = 0.020), or conversion to open surgery (15.5% vs. 13.8%, p = 0.298). Patients in the colectomy plus group had a higher rate of lower incidence of positive surgical margins (13.2% vs. 17.2%, p = 0.001) and longer overall survival (median: 41.5 vs 28.4 months, p < 0.001). Synchronous resection of CLM did not increase the rates of short-term mortality, readmission, conversion from minimally invasive to open surgery, or hospital stay and was associated with a lower incidence of positive surgical margins.

Minimally Invasive Simultaneous Colorectal and Liver Resection for Synchronous Colorectal Liver Metastasis-Short-Term Outcomes

Surgical management of colorectal disease and liver metastatectomy can be staged or synchronous. A minimally invasive approach in synchronous resection in the selected group of patients may improve postoperative outcomes. The present study aimed to explore the safety and feasibility of simultaneous liver and colorectal resection for synchronous metastasis by a minimally invasive approach in terms of major morbidity and R0 resection rates. The present study is a retrospective review of a prospectively maintained database. All patients who underwent minimally invasive simultaneous resection of colorectal malignancy and liver metastases between January 2020 and April 2023 were included. A total of 39 patients were included in the study. The median age was 54 (23-79) years with 28 male (72%) and 11 female (28%) patients. Rectum (n = 21, 54%) was the most common primary location. The most commonly performed procedures were low anterior resection (n = 12) and parenchymal sparing non-anatomical resection (n = 23, 59%). The median surgery duration was 280 (150-520) min, and the median blood loss was 400 (50-2100) ml. The median hospital stay was 7 (5-18) days. Five (12.6%) patients had major complications. With a median follow-up of 12 months, the 2-year overall survival (OS) and disease-free survival (DFS) were 84.6% and 37%, respectively. Simultaneous liver and colorectal resection by minimal access approach is feasible in selected groups of patients depending on the extent of hepatectomy, the patient's general condition, and surgical team experience. A minimal access approach leads to faster recovery without compromising on the oncological radicality.

Clinical Prediction Models for Prognosis of Colorectal Liver Metastases: A Comprehensive Review of Regression-Based and Machine Learning Models

Colorectal liver metastasis (CRLM) is a disease entity that warrants special attention due to its high frequency and potential curability. Identification of "high-risk" patients is increasingly popular for risk stratification and personalization of the management pathway. Traditional regression-based methods have been used to derive prediction models for these patients, and lately, focus has shifted to artificial intelligence-based models, with employment of variable supervised and unsupervised techniques. Multiple endpoints, like overall survival (OS), disease-free survival (DFS) and development or recurrence of postoperative complications have all been used as outcomes in these studies. This review provides an extensive overview of available clinical prediction models focusing on the prognosis of CRLM and highlights the different predictor types incorporated in each model. An overview of the modelling strategies and the outcomes chosen is provided. Specific patient and treatment characteristics included in the models are discussed in detail. Model development and validation methods are presented and critically appraised, and model performance is assessed within a proposed framework.

Simultaneous resection for colorectal cancer with synchronous liver metastases: current state-of-the-art

BACKGROUND

A large proportion of patients with colorectal cancer (CRC) presents with synchronous colorectal liver metastases (sCRLM) at diagnosis. Surgical approaches for patients with sCRLM have evolved over the past decades. Simultaneous resection (SR) of CRC and sCRLM for selected patients has emerged as a safe and efficient alternative approach to traditional staged resections.

METHODS

A comprehensive review of the literature was performed using MEDLINE/PubMed and Web of Science databases with the end of search date October 30, 2023. The MeSH terms "simultaneous resections" and "combined resections" in combination with "colorectal liver metastases," "colorectal cancer," "liver resection," and "hepatectomy" were searched in the title and/or abstract.

RESULTS

SRs aim to achieve maximal tumor clearance, minimizing the risk of disease progression and optimizing the potential for long-term survival. Improvements in perioperative care, advances in surgical techniques, and a better understanding of patient selection criteria have collectively contributed to reducing morbidity and mortality associated with these complex procedures. Several studies have demonstrated that SR are associated with reduced overall length of stay and lower costs with comparable morbidity and long-term outcomes. In light of these outcomes, the proportion of patients undergoing SR for CRC and sCRLM has increased substantially over the past 2 decades.

CONCLUSION

For patients with sCRLM, SR represents an attractive alternative to the traditional staged approach and should be selectively used; however, the decision on whether to proceed with a simultaneous versus staged approach should be individualized based on several patient- and disease-related factors.

Tata Memorial Centre Evidence Based Management of Colorectal cancer

This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.

Simultaneous laparoscopic liver metastasectomy and intersphincteric resection for neuroendocrine tumor of the rectum by natural orifice specimen extraction surgery

Neuroendocrine tumors (NET) are relatively uncommon rectal neoplasms, and the liver is the most common site of distant metastasis. Simultaneous liver and colorectal resections by minimally invasive surgery and natural orifice specimen extraction are gaining popularity, reducing morbidity. We describe a case of rectal NET with liver metastasis operated simultaneously by laparoscopy with both specimens extracted via the anal canal. Transanal or transvaginal natural orifice specimen extraction surgery for suitable cases is underutilized and only isolated case reports for simultaneous resections exist.

Laparoscopic liver metastasectomy, retroperitoneal lymph node dissection and abdominoperineal resection for rectal cancer

Video demonstrating the technical details of minimally invasive, simultaneous liver resection, retroperitoneal lymph node dissection, and abdominoperineal resection for synchronous metastasis.

Staged or Simultaneous Surgery for Colon or Rectal Cancer with Synchronous Liver Metastases: Implications for Study Design and Clinical Endpoints

In patients presenting with colorectal cancer and synchronous liver metastases, the disease burden related to the liver metastasis is the driving cause of limited longevity and, eventually, risk of death. Surgical resection is the potentially curative treatment for colorectal cancer liver metastases. In the synchronous setting where both the liver metastases and the primary tumor are resectable with a relative low risk, the oncological surgeon and the patient may consider three potential treatment strategies. Firstly, a "staged" or a "simultaneous" surgical approach. Secondly, for a staged strategy, a 'conventional approach' will suggest removal of the primary tumor first (either colon or rectal cancer) and plan for liver surgery after recovery from the first operation. A "Liver first" strategy is prioritizing the liver resection before resection of the primary tumor. Planning a surgical trial investigating a two-organ oncological resection with highly variable extent and complexity of resection as well as the potential impact of perioperative chemo(radio)therapy makes it difficult to find the optimal primary endpoint. Here, we suggest running investigational trials with carefully chosen composite endpoints as well as embedded risk-stratification strategies to identify subgroups of patients who may benefit from simultaneous surgery.