Surgical approaches of resectable synchronous colorectal liver metastases: Timing considerations

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 or staged resection of synchronous colorectal cancer liver metastases: a 13-year institutional follow-up

BACKGROUND

This study compared postoperative outcomes and survival rates of patients who underwent simultaneous or staged resection for synchronous colorectal cancer liver metastases.

METHODS

Between 2005 and 2018, 126 patients were registered prospectively at a university hospital in Sweden, 63 patients who underwent simultaneous resection were matched against 63 patients who underwent staged resection.

RESULTS

The length of hospital stay was shorter for the simultaneous resection group, at 11 vs 16 days, p = <0.001. Fewer patients experienced recurrence in the simultaneous resection group 39 vs 50 patients, p = 0.012. There were no significant differences in disease-free survival and overall survival between the groups. Age (hazard ratio [HR] 1.72; 95% CI 1.01-2.94; p = 0.049) and Clavien-Dindo score (HR 2.22; 95% CI 1.06-4.67; p = 0.035) had impact on survival.

CONCLUSION

Colorectal cancer with synchronous liver metastases can be resected simultaneously, and enables a shorter treatment time without jeopardizing oncological outcomes.

Perioperative Outcomes Following Combined Versus Isolated Colorectal and Liver Resections: Insights From a Contemporary, National, Propensity Score-Based Analysis

Our objective was to compare outcomes following combined versus isolated resections for metastatic colorectal cancer and/or liver metastases using a large, contemporary national database.

Background

Controversy persists regarding optimal timing of resections in patients with synchronous colorectal liver metastases.

Methods

We analyzed 11,814 patients with disseminated colorectal cancer and/or liver metastases who underwent isolated colon, rectal, or liver resections (CRs, RRs, or LRs) or combined colon/liver or rectal/liver resections (CCLRs or CRLRs) in the National Surgical Quality Improvement Program Participant Use File (2011-2015). We examined associations between resection type and outcomes using univariate/multivariate analyses and used propensity adjustment to account for nonrandom receipt of isolated versus combined resections.

Results

Two thousand four hundred thirty-seven (20.6%); 2108 (17.8%); and 6243 (52.8%) patients underwent isolated CR, RR, or LR; 557 (4.7%) and 469 (4.0%) underwent CCLR or CRLR. Three thousand three hundred ninety-five patients (28.7%) had serious complications (SCs). One hundred forty patients (1.2%) died, of which 113 (80.7%) were failure to rescue (FTR). One thousand three hundred eighty-six (11.7%) patients experienced unplanned readmission. After propensity adjustment and controlling for procedural complexity, wound class, and operation year, CCLR/CRLR was independently associated with increased risk of SC, as well as readmission (compared with LR). CCLR was also independently associated with increased risk of FTR and death (compared with LR).

Conclusions

Combined resection uniformly confers increased risk of SC and increased risk of mortality after CCLR; addition of colorectal to LR increases risk of readmission. Combined resections are less safe, and potentially more costly, than isolated resections. Effective strategies to prevent SC after combined resections are warranted.

Histopathological prognostic factors for colorectal liver metastases: A systematic review and meta-analysis of observational studies

INTRODUCTION

Resection is the mainstay of treatment for colorectal liver metastases (CRLMs). Many different histopathological factors related to the primary colorectal tumour have been well studied; however, histopathological prognostic factors related to CRLMs are still under evaluation.

OBJECTIVE

To identify histopathological factors related to overall survival (OS) and disease-free survival (DFS) in patients with resected CRLMs.

METHODS

A systematic review was performed with the following databases up to August 2020: PubMed, EMBASE, Web of Science, SciELO, and LILACS. The GRADE approach was used to rate the overall certainty of evidence by outcome.

RESULTS

Thirty-three studies including 4,641 patients were eligible. We found very low certainty evidence that the following histopathological prognostic factors are associated with a statistically significant decrease in OS: presence of portal vein invasion (HR, 0,50 [95% CI, 0,37 to 0,68]; I²=0%), presence of perineural invasion (HR, 0,55 [95% CI, 0,36 to 0,83]; I²=0%), absence of pseudocapsule (HR, 0,41 [CI 95%, 0,29 to 0,57], p<0,00001; I²=0%), presence of satellite nodules (OR, 0,45 [95% CI, 0,26 to 0,80]; I²=0%), and the absence of peritumoural inflammatory infiltrate (OR, 0,20 [95% CI, 0,08 to 0,54]; I²=0%). Outcome data on DFS were scarce, except for tumour borders, which did not present a significant impact, precluding the meta-analysis.

CONCLUSION

Of the histopathological prognostic factors studied, low- to moderate-certainty evidence shows that vascular invasion, perineural invasion, absence of pseudocapsule, presence of satellite nodules, and absence of peritumoral inflammatory infiltrate are associated with shorter overall survival in CRLMs.

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.

Comparison of sequential, delayed and simultaneous resection strategies for synchronous colorectal liver metastases

Background

The present study aimed to compare the perioperative safety and long-term survival of patients with synchronous colorectal liver metastases undergoing sequential resection (SeR), delayed resection (DeR) and simultaneous resection (SiR).

Methods

From January 2007 to December 2016, data from patients undergoing surgery at Peking University Cancer Hospital for synchronous colorectal liver metastases were retrospectively collected. The above three different surgical strategies were compared.

Results

A total of 233 cases were included, with 49 in the SeR group, 98 in the DeR group and 86 in the SiR group. The incidence of severe complications was 26.7% in the SiR group, higher than that in the DeR group (11.2%, P = 0.007) and the SeR group (16.3%, P = 0.166). The overall survival at 1 and 3 years in the SeR group (93.9 and 50.1%) was lower than that in the DeR group (94.9 and 64.8%, P = 0.019), but not significantly different from that in the SiR group (93.0 and 55.2%, P = 0.378). Recurrence-free survival at 1 and 3 years in the SeR group (22.4 and 18.4%) was lower than that in the DeR group (43.9 and 24.2%, P = 0.033) but not significantly different from that in the SiR group (31.4 and 19.6%, P = 0.275). Cox multivariate analysis indicated that T4, lymph node-positive primary tumour, liver metastases > 30 mm and SiR (compared with DeR) were correlated with poor prognosis.

Conclusion

Simultaneous resection has a relatively higher incidence of severe complications, and with a staged resection strategy, the prognosis of delayed resection was better than that of sequential resection.

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.

Simultaneous Colon and Liver Laparoscopic Resection for Colorectal Cancer with Synchronous Liver Metastases: A Single Center Experience

Background: The one-stage approach for colorectal cancer (CRC) with synchronous liver metastases (SLM) has demonstrated advantages, when feasible, in terms of oncological radicality and reduction in sanitary costs. The simultaneous laparoscopic approach to both colon cancer and liver metastases joins the advantages of mini-invasiveness to the one-stage approach. Methods: During the period from February 2011 to July 2017, a single surgeon performed 17 laparoscopic colorectal operations with simultaneous liver resection for CRC with SLM. Colorectal procedures included 9 rectal resections, 6 left colectomies, and 2 right colectomies. Associated hepatic resections included 1 left hepatectomy, 1 right posterior sectionectomy, 2 segmentectomies, and 13 wedge resections. We analyzed retrospectively the patient's short-term outcome and operative and oncologic results. Results: There was no conversion to open surgery. Six patients (35%) had minor complications (Clavien-Dindo grade I-II), whereas only 2 patients (12%) had major complications (Clavien-Dindo grade III-IV) and no mortality occurred. The median time of discharge was 8.6 (range 5-36) days. We obtained 94% of R0 resection margin on the liver specimen and 100% of negative distal and circumferential margin in case of rectal resection. An average of 20 lymphnodes were retrieved in the colorectal specimen. Conclusions: Simultaneous mini-invasive colorectal and liver resection is a challenging but feasible procedure. The advantages of treating primary cancer and metastases in the same recovery justify the morbidity rate, especially because the most of the complications are minor and no cases of mortality occurred. Further experience is needed to better understand how to reduce the morbidity rate.

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.

Preoperative selection of patients with colorectal cancer liver metastasis for hepatic resection

Surgical resection of colorectal liver metastases (CRLM) has a well-documented improvement in survival. To benefit from this intervention, proper selection of patients who would be adequate surgical candidates becomes vital. A combination of imaging techniques may be utilized in the detection of the lesions. The criteria for resection are continuously evolving; currently, the requirements that need be met to undergo resection of CRLM are: the anticipation of attaining a negative margin (R0 resection), whilst maintaining an adequate functioning future liver remnant. The timing of hepatectomy in regards to resection of the primary remains controversial; before, after, or simultaneously. This depends mainly on the tumor burden and symptoms from the primary tumor. The role of chemotherapy differs according to the resectability of the liver lesion(s); no evidence of improved survival was shown in patients with resectable disease who received preoperative chemotherapy. Presence of extrahepatic disease in itself is no longer considered a reason to preclude patients from resection of their CRLM, providing limited extra-hepatic disease, although this currently is an area of active investigations. In conclusion, we review the indications, the adequate selection of patients and perioperative factors to be considered for resection of colorectal liver metastasis.

Unresolved issues and controversies surrounding the management of colorectal cancer liver metastasis

Ideally, tumors that might cause morbidity and mortality should be treated, preferably early, with proven, convincing, and effective therapy to prevent tumor progression or recurrence, while maintaining a favorable risk-benefit profile for the individual patient. For patients with colorectal cancer (CRC), this diagnostic, prognostic, and therapeutic precision is currently impossible. Despite significant improvements in diagnostic procedures, a sizable number of patients with CRC have liver metastases either at presentation or will subsequently develop it. And in many parts of the world, most cancer-related deaths are still due to metastases that are resistant to conventional therapy. Metastases to the liver occur in more than 50% of patients with CRC and represent the major determinant of outcome following curative treatment of the primary tumor. Liver resection offers the best chance of cure for metastases confined to the liver. However, due to a paucity of randomized controlled trials, its timing is controversial and a hotly debated topic. This article reviews some of the main controversies surrounding the surgical management of colorectal cancer liver metastases (CRLM).

Rectal cancer: a review

Rectal cancer is the second most common cancer in large intestine. The prevalence and the number of young patients diagnosed with rectal cancer have made it as one of the major health problems in the world. With regard to the improved access to and use of modern screening tools, a number of new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs, management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal tract or even the colon. In this article, we will review the current updates on rectal cancer including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods and latest treatment modalities and approaches will also be discussed in detail.

The effect of a primary tumour resection on the progression of synchronous colorectal liver metastases: an exploratory study

AIM

The objective of this study was to determine the effect of an upfront primary tumour resection on the progression of synchronous colorectal liver metastases.

MATERIALS AND METHODS

Patients with synchronous colorectal liver metastases referred between 2005 and 2010 were identified. Patients were analysed according to the following two groups: 1) an upfront primary tumour resection and 2) neo-adjuvant chemotherapy. A univariate and multivariate analysis was performed to identify factors significantly contributing to progressive disease. Cox regression analysis was undertaken to determine the effect of management on overall survival (OS) and time to tumour progression (TTP).

RESULTS

A total of 116 patients with synchronous colorectal liver metastases were identified of which 49 patients received an upfront primary tumour resection and 67 received neo-adjuvant chemotherapy. Liver resections were performed in 18 (36.7%) and 14 (20.9%) of the patients in the upfront and neo-adjuvant groups respectively (P 0.06). On multivariate analysis, an upfront primary tumour resection significantly affected progressive disease (p < 0.001, OR 5.67; 95% CI 2.71-11.79). An upfront tumour resection was not a significant predictor of overall survival (P = 0.83; HR 1.10; 95% CI 0.48-2.52).

CONCLUSION

Our findings suggest that an upfront primary tumour resection in patients with synchronous colorectal liver metastases results in progressive disease. These preliminary findings need to be validated in a future multi-centre independent study.

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.

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.

Simultaneous colorectal and hepatic procedures for colorectal cancer result in increased morbidity but equivalent mortality compared with colorectal or hepatic procedures alone: outcomes from the National Surgical Quality Improvement Program

BACKGROUND

Simultaneous colorectal and hepatic surgery for colorectal cancer (CRC) is increasing as surgery becomes safer and less invasive. There is controversy regarding the morbidity associated with simultaneous, compared with separate or staged, resections.

METHODS

Data for 2005-2008 from the National Surgical Quality Improvement Program (NSQIP) were used to compare morbidity after 19,925 colorectal procedures for CRC (CR group), 2295 hepatic resections for metastatic CRC (HEP group), and 314 simultaneous colorectal and hepatic resections (SIM group).

RESULTS

An increasing number of simultaneous resections were performed per year. Fewer major colorectal and liver resections were performed in the SIM than in the CR and HEP groups. Patients in the SIM group had a longer operative time and postoperative length of stay compared with those in either the CR or HEP groups. Simultaneous procedures resulted in higher rates of postoperative morbidity and major morbidity than CR procedures, but not HEP procedures. This difference was driven by higher rates of wound and organ space infections, and a greater incidence of septic shock. Mortality rates did not differ among the groups.

CONCLUSIONS

Hospitals in the NSQIP are performing more simultaneous colonic and hepatic resections for CRC. These procedures are associated with increases in operative time, length of stay and rate of perioperative complications. Simultaneous procedures do not, however, increase perioperative mortality.

Timing of hepatectomy in resectable synchronous colorectal liver metastases (SCRLM): Simultaneous or delayed?

The optimal surgical strategy for treatment of patients with synchronous colorectal liver metastases (SCLRM) remains controversial. We conducted a systematic review and meta-analysis of all observational studies to define the safety and efficacy of simultaneous versus delayed resection of the colon and liver. A search for all major databases and relevant journals from inception to April 2012 without restriction on languages or regions was performed. Outcome measures were the primary parameters of postoperative survival, complication, and mortality, as well as other parameters of blood loss, operative time, and length of hospitalization. The test of heterogeneity was performed with the Q statistic. A total of 2,880 patients were included in the meta-analysis. Long-term oncological pooled estimates of overall survival (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.81-1.14; P = 0.64; I(2) = 0) and recurrence-free survival (HR: 1.04; 95% CI: 0.76-1.43; P = 0.79; I(2) = 53%) all showed similar outcomes for both simultaneous and delayed resections. A lower incidence of postoperative complication was attributed to the simultaneous group as opposed to that in the delayed group (modified relative ratio [RR] = 0.77; 95% CI: 0.67-0.89; P = 0.0002; I(2) = 10%), whereas in terms of mortality within the postoperative 60 days no statistical difference was detected (RR = 1.12; 95% CI: 0.61-2.08; P = 0.71; I(2) = 32%). Finally, selection criteria were recommended for SCRLM patients suitable for a simultaneous resection.

CONCLUSION

Simultaneous resection is as efficient as a delayed procedure for long-term survival. There is evidence that in SCRLM patients simultaneous resection is an acceptable and safe option with carefully selected conditions. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion. (HEPATOLOGY 2013;57:2346-2357).

Laparoscopic resection of colorectal cancer facilitates simultaneous surgery of synchronous liver metastases

AIM

Combined resection of colorectal cancer with surgery for synchronous liver metastases (LM) still remains controversial because of the possible higher morbidity rate, the necessity of an adequate abdominal approach for both resections and the impact on oncological results. However, laparoscopy may be beneficial in terms of operative results and could facilitate this combined procedure. The aim was to assess the benefit of the laparoscopic approach for colorectal cancer resection in patients undergoing simultaneous liver resection for synchronous LM.

METHOD

From 2006 to 2011, all patients with colorectal cancer and resectable synchronous LM, for which the total length of the procedure was suspected to be less than 8 h, underwent colorectal laparoscopic resection combined with open and/or laparoscopic liver surgery. In order to identify selection criteria, a comparative analysis was performed between patients with and without major postoperative morbidity.

RESULTS

Fifty-one patients underwent combined surgery with laparoscopic colectomy (n = 31) and proctectomy (n = 20). The conversion rate was 8%. Liver resections included major surgery (n = 10) and minor surgery (n = 41). Extraction of the colorectal specimen was performed through an incision used for open liver resection, except in seven patients who underwent a total laparoscopic procedure. Overall and major morbidity rates were 55% and 25%, respectively. Median (range) hospital stay was 16 (6-40) days. Regarding patient and tumour characteristics, no independent criteria of major morbidity risk were identified.

CONCLUSION

This study showed that laparoscopic colorectal resection combined with liver resection for synchronous LM was feasible and safe. Moreover, laparoscopy facilitates the surgical abdominal approach for combined colorectal and liver resection.

Meta-analysis of simultaneous versus staged resection for synchronous colorectal liver metastases

AIM

  There is no clear consensus on the optimal timing of surgical resection for synchronous colorectal liver metastases (SCLM). This study is a meta-analysis of the available evidence.

METHODS

  Systematic review and meta-analysis of trials comparing outcomes following simultaneous resection with staged resection for SCLM published from 1990 to 2010 in PubMed, Embase, Ovid and Medline. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either the fixed effects or random effects model.

RESULTS

  Nineteen non-randomized controlled trials (NRCT) studies were included in this analysis. These studies included a total of 2724 patients: 1116 underwent simultaneous resection and 1608 underwent staged resection. Meta-analysis showed that shorter hospital stay (P < 0.001) and lower total complication rate (P < 0.001) were observed in patients undergoing simultaneous resection group. The overall survival rate in the simultaneous resection group did not statistically differ with that in the staged resection group at 1 year (P = 0.13), 3 years (P = 0.26), 5 years (P = 0.38), as well as the 1, 3 and 5 years disease-free survival rates (respectively, P = 0.55; P = 0.16; P = 0.12). No significant difference was noted between the two groups in terms of mortality (P = 0.16), intraoperative blood loss (P = 0.06) and recurrence (P = 0.47).

CONCLUSION

  Simultaneous resection is safe and efficient in the treatment of patients with SCLM while avoiding a second laparotomy. In selected patients, simultaneous resection might be considered as the preferred approach. However, the findings have to be carefully interpreted due to the lower level of evidence and the existence of heterogeneity.

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.

Embolization of liver tumors: Past, present and future

Curative therapies for hepatocellular carcinoma (HCC), such as resection and liver transplantation, can only be applied in selected patients with early tumors. More advanced stages require local or systemic therapies. Resection of HCC offers the only hope for cure. Even in patients undergoing resection, recurrences are common. Chemoembolization, a technique combining intra-arterial chemotherapy with selective tumor ischemia, has been shown by randomized controlled trials to be efficacious in the palliative setting. There is now renewed interest in transarterial embolization/transarterial chemoembolization (TACE) with regards to its use as a palliative tool in a combined modality approach, as a neoadjuvant therapy, in bridging therapy before transplantation, for symptomatic indications, and even as an alternative to resection. There have also been rapid advances in the agents being embolized trans-arterially (genes, biological response modifiers, etc.). The current review provides an evidence-based overview of the past, present and future trends of TACE in patients with HCC.

Synchronous resection of colorectal cancer and liver metastases: comparative views of colorectal and liver surgeons

AIM

The optimal management of patients presenting with colorectal cancer and synchronous liver metastases is controversial. This survey was intended to summarize the opinions of UK colorectal and liver surgeons on the specific issues pertaining to synchronous resection.

METHOD

A validated electronic survey was sent to the consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgeons (AUGIS). The questions were structured to allow direct comparison between the two groups of the responses obtained.

RESULTS

Four hundred and twenty-four specialist colorectal surgeons and 52 specialist hepatobiliary surgeons were identified from the register of their respective associations. Responses were obtained from 133 (31%) colorectal and 22 (42%) liver surgeons. A majority of both groups of surgeons felt that synchronous resection was a valid therapeutic option. A majority of both groups believed that synchronous resection was justified despite the options of laparoscopic surgery and enhanced recovery programmes for each discipline. Agreed possible advantages of synchronous resections were: a decrease in the overall length of hospital stay, cost and patient anxiety. The major concern about synchronous resections was an excessive overall physiological insult. Specific scenarios indicated that synchronous resection was favoured for major/complex major colorectal resection with minor liver resection or most colorectal resections not involving an anastomosis with either a minor or major liver resection.

CONCLUSION

Although significant concerns relating to synchronous resection remain amongst colorectal and liver surgeons, a majority of them felt that synchronous resections could be offered to appropriately selected patients.

Totally laparoscopic strategies for the management of colorectal cancer with synchronous liver metastasis

INTRODUCTION

Laparoscopy is an accepted treatment for colorectal cancer and liver metastases, but there is no consensus for its use in the management of synchronous liver metastases (SCRLM). The purpose of this study was to evaluate totally laparoscopic strategies in the management of colorectal cancer with synchronous liver metastases.

METHODS

Patients presenting to Ninewells Hospital between July 2007 and August 2010, with adenocarcinoma of the colon and rectum with synchronous liver metastases were considered. Patients underwent simultaneous laparoscopic liver and colon cancer resection, a staged laparoscopic resection of SCRLM and colon cancer, or simultaneous colon resection and radiofrequency ablation (RFA) of SCRLM. Primary endpoints were in-hospital morbidity and mortality, total hospital stay, intraoperative blood loss, duration of surgery, and resection margin status.

RESULTS

Twenty-eight patients presented with synchronous colorectal liver metastases. Thirteen patients underwent a simultaneous laparoscopic liver and colon resection (median operating time, 370 (range, 190-540) min; median hospital stay, 7 (range, 3-54) days), seven patients had a staged laparoscopic resection of SCRLM and primary colon cancer (median operating time, 530 (range, 360-980) min; median hospital stay 14, (range, 6-51) days), and eight patients underwent laparoscopic colon resection and RFA of SCRLM (median operating time, 310 (range, 240-425) min; median hospital stay, 8 (range, 6-13) days). There were no conversions to an open procedure. Overall in-hospital morbidity and mortality was 28 and 0 % respectively. An R0 resection margin was achieved in 91 % of the resection group. At a median follow-up of 26 (range, 18-55) months, 19 (90 %) patients remain disease-free.

CONCLUSIONS

Totally laparoscopic strategies for the radical treatment of stage IV colorectal cancer are feasible with low morbidity and favorable outcomes. A laparoscopic approach for the simultaneous management of SCRLM and primary colon cancer is associated with reduced surgical access trauma, postoperative morbidity, and hospital stay with no compromise in short-term oncological outcome.

Totally laparoscopic strategies for the management of colorectal cancer with synchronous liver metastasis

INTRODUCTION

Laparoscopy is an accepted treatment for colorectal cancer and liver metastases, but there is no consensus for its use in the management of synchronous liver metastases (SCRLM). The purpose of this study was to evaluate totally laparoscopic strategies in the management of colorectal cancer with synchronous liver metastases.

METHODS

Patients presenting to Ninewells Hospital between July 2007 and August 2010, with adenocarcinoma of the colon and rectum with synchronous liver metastases were considered. Patients underwent simultaneous laparoscopic liver and colon cancer resection, a staged laparoscopic resection of SCRLM and colon cancer, or simultaneous colon resection and radiofrequency ablation (RFA) of SCRLM. Primary endpoints were in-hospital morbidity and mortality, total hospital stay, intraoperative blood loss, duration of surgery, and resection margin status.

RESULTS

Twenty-eight patients presented with synchronous colorectal liver metastases. Thirteen patients underwent a simultaneous laparoscopic liver and colon resection (median operating time, 370 (range, 190-540) min; median hospital stay, 7 (range, 3-54) days), seven patients had a staged laparoscopic resection of SCRLM and primary colon cancer (median operating time, 530 (range, 360-980) min; median hospital stay 14, (range, 6-51) days), and eight patients underwent laparoscopic colon resection and RFA of SCRLM (median operating time, 310 (range, 240-425) min; median hospital stay, 8 (range, 6-13) days). There were no conversions to an open procedure. Overall in-hospital morbidity and mortality was 28 and 0 % respectively. An R0 resection margin was achieved in 91 % of the resection group. At a median follow-up of 26 (range, 18-55) months, 19 (90 %) patients remain disease-free.

CONCLUSIONS

Totally laparoscopic strategies for the radical treatment of stage IV colorectal cancer are feasible with low morbidity and favorable outcomes. A laparoscopic approach for the simultaneous management of SCRLM and primary colon cancer is associated with reduced surgical access trauma, postoperative morbidity, and hospital stay with no compromise in short-term oncological outcome.

Treatment dilemmas in patients with synchronous colorectal liver metastases

Approximately 20 % of patients with colorectal cancer have synchronous liver metastases at the time of diagnosis. In some instances it is difficult to determine the best treatment strategy in these patients. For example, should the primary tumor be removed in those patients with unresectable liver metastases and who do not have any symptoms of the primary tumor? Or which operation should be performed first in patients with rectal cancer and synchronous resectable liver metastases? Unfortunately, there are no clear answers to these questions from prospective randomized trials. In the present article retrospective studies are analyzed in order to define the best possible treatment strategy for patients with synchronous colorectal liver metastases.

Colorectal liver metastases

The diagnosis and management of CRLM is complex and requires a multidisciplinary team approach for optimal outcomes. Over the past several decades, the 5-year survival following resection of CRLM has increased and the criteria for resection have broadened substantially. Even patients with multiple, bilateral CRLM, previously thought unresectable, may now be candidates for resection. Two-stage hepatectomy, repeat curative-intent hepatectomy, and even selected resection of extrahepatic metastases have further increased the number of patients who may be treated with curative intent. Multiple liver-directed therapies exist to treat unresectable, incurable patients with adequate survival benefit and morbidity rates.

Simultaneous vs. staged resection for synchronous colorectal liver metastases: a metaanalysis

PURPOSE

The optimal timing of surgical resection for synchronous colorectal liver metastases (SCLMs) remains controversial. The aim of this metaanalysis was to compare outcomes between simultaneous resection and staged resection from all published comparative studies in the literature.

MATERIALS AND METHODS

Databases, including PubMed, Embase, Cochrane Library, Ovid, and Web of Science, were searched to identify studies comparing outcomes following simultaneous resection with staged resection for SCLM. The metaanalysis was performed by RevMan 4.2.

RESULTS

Fourteen comparative studies comprising 2,204 patients were identified. Patients undergoing simultaneous resection were found to have similar operative time (weighted mean difference [WMD], -34.19; 95% confidence interval [CI], -81.32-12.95, P = .16) and intraoperative blood loss (WMD, -161.33; 95% CI, -351.45-28.79, P = .10). Shorter hospital stay (WMD, -4.77; 95% CI, -7.26-2.28, P < .01) and lower morbidity rate (odds ratio [OR], 0.71; 95% CI, 0.57-0.88, P = .002) were observed in simultaneous resection group. The survival rate in the simultaneous resection group did not statistically differ with that in the staged resection group at 1 year (OR, 0.77; 95% CI, 0.51-1.16, P = .21), 3 years (OR, 1.12; 95% CI, 0.85-1.47, P = .43), and 5 years (OR, 1.14; 95% CI, 0.86-1.50, P = .37) postresection, respectively.

CONCLUSIONS

Simultaneous resection is safe and efficient in the treatment of patients with SCLM while avoiding a second major operation. In appropriately selected patients, simultaneous resection might be considered as the preferred treatment. Since heterogeneity was detected, caution is needed in interpretation of the results. Better designed, adequately powered studies are required for addressing this issue.

Colorectal Cancer Liver Metastases – Understanding the Differences in the Management of Synchronous and Metachronous Disease

Introduction: Metastatic disease to the liver in colorectal cancer is a common entity that may present synchronously or metachronously. While increasing surgical experience has improved survival outcomes, some evidence suggest that synchronous lesions should be managed differently. This review aims to update current literature on differences between the outcomes and management of synchronous and metachronous disease. Materials and Methods: Systematic review of MEDLINE database up till November 2008. Results: Discrete differences in tumour biology have been identified in separate studies. Twenty-one articles comparing outcomes were reviewed. Definitions of metachronicity varied from anytime after primary tumour evaluation to 1 year after surgery for primary tumour. Most studies reported that synchronous lesions were associated with poorer survival rates (8% to 16% reduction over 5 years). Sixteen articles comparing combined vs staged resections for synchronous tumour showed comparable morbidity and mortality. Benefits over staged resections included shorter hospital stays and earlier initiation of chemotherapy. Suitability for combined resection depended on patient age and constitution, primary tumour characteristics, size and the number of liver metastases, and the extent of liver involvement. Conclusions: Surgery remains the only treatment option that offers a chance of long-term survival for patients amenable to curative resection. Synchronicity suggests more aggressive disease although a unifying theory for biological differences explaining the disparity in tumour behaviour has not been found. Combined resection of primary tumour and synchronous metastases is a viable option pending careful patient selection and institutional experience. Given the current evidence, management of synchronous and metachronous colorectal liver metastases needs to be individualised to the needs of each patient. Key words: Colorectal neoplasms, Liver neoplasms, Neoplasm metastasis, Synchronous Cancer, Metachronous cancer

Comparison of simultaneous or delayed liver surgery for limited synchronous colorectal metastases

BACKGROUND

The optimal surgical strategy for patients with synchronous colorectal liver metastases (CLMs) is still unclear. The aim of this study was to compare simultaneous colorectal and hepatic resection with a delayed strategy in patients who had a limited hepatectomy (fewer than three segments).

METHODS

All patients with synchronous CLMs who underwent limited hepatectomy between 1990 and 2006 were included retrospectively. Short-term outcome, overall and progression-free survival were compared in patients having simultaneous colorectal and hepatic resection and those treated by delayed hepatectomy.

RESULTS

Of 228 patients undergoing hepatectomy for synchronous CLMs, 55 (24.1 per cent) had a simultaneous colorectal resection and 173 (75.9 per cent) had delayed hepatectomy. The mortality rate following hepatectomy was similar in the two groups (0 versus 0.6 per cent respectively; P = 0.557), but cumulative morbidity was significantly lower in the simultaneous group (11 per cent versus 25.4 per cent in the delayed group; P = 0.015). Three-year overall and progression-free survival rates were 74 and 8 per cent respectively in the simultaneous group, compared with 70.3 and 26.1 per cent in the delayed group (overall survival: P = 0.871; progression-free survival: P = 0.005). Significantly more recurrences were observed in the simultaneous group at 3 years (85 versus 63.6 per cent; P = 0.002); a simultaneous strategy was an independent predictor of recurrence.

CONCLUSION

Combining colorectal resection with a limited hepatectomy is safe in patients with synchronous CLMs and associated with less cumulative morbidity than a delayed procedure. However, the combined strategy has a negative impact on progression-free survival.

Management of the hepatic lymph nodes during resection of liver metastases from colorectal cancer: a systematic review

BACKGROUND

Hepatic lymph node involvement is generally considered a contraindication for liver resection performed for colorectal liver metastases. However, some advocate hepatic lymphadenectomy in the presence of macroscopic involvement and others routine lymphadenectomy. The aim of this review is to assess the role of lymphadenectomy in resection of liver metastases from colorectal cancer.

METHODS

Medline, Embase and Central databases were searched using a formal search strategy. Trials with survival data with a minimum follow-up of 1 year were considered for inclusion. Meta-analysis was performed using Revman.

RESULTS

A total of 4230 references were identified. Ten reports of nine studies including 926 patients qualified for the review. The prevalence of nodal metastases after routine lymphadenectomy was 16.3%. The overall 3-year and 5-year survival rates in node-positive patients were 9/151 (11.3%) and 2/137 (1.5%), respectively, compared to 3-year and 5-year survival rates of 424/787 (53.9%) and 246/767 (32.1%) in node-negative patients. The odds ratios for 3-year and 5-year survivals in node positive disease compared to node-negative disease were 0.12 (95% CI 0.06 to 0.24) and 0.08 (95% CI 0.03 to 0.22). There was no randomized controlled trial which assessed the survival benefit of routine or "selective" lymphadenectomy.

CONCLUSION

Currently, there is no evidence of survival benefit for routine or selective lymphadenectomy. Survival rates are low in patients with positive lymph nodes draining the liver irrespective of whether they are detected by routine lymphadenectomy or by macroscopic involvement. Further trials in this patient group are required.

Optimizing the outcome of surgery in patients with rectal cancer and synchronous liver metastases

BACKGROUND

This study evaluated the outcome of patients treated for rectal cancer and synchronous hepatic metastases in the era of effective induction radiotherapy and chemotherapy.

METHODS

All patients undergoing surgical treatment of rectal cancer and synchronous liver metastases between 2000 and 2007 were identified retrospectively from a prospectively collected database. Three approaches were followed: the classical staged, the simultaneous and the liver-first approach.

RESULTS

Of 57 patients identified, the primary tumour was resected first in 29 patients (group 1), simultaneous resection was performed in eight patients (group 2), and 20 patients underwent a liver-first approach (group 3). The overall morbidity rate was 24.6 per cent; there was no in-hospital mortality. Median in-hospital stay was significantly shorter for the simultaneous approach (9 days versus 18 and 15 days for groups 1 and 3 respectively; P < 0.001). The overall 5-year survival rate was 38 per cent, with an estimated median survival of 47 months.

CONCLUSION

Long-term survival can be achieved using an individualized approach, with curative intent, in patients with rectal cancer and synchronous liver metastases. Simultaneous resections as well as the liver-first approach are attractive alternatives to traditional staged resections.

Surgical resection versus non-surgical treatment for hepatic node positive patients with colorectal liver metastases

BACKGROUND

Involvement of hepatic lymph node in patients with colorectal liver metastases is associated with poor prognosis.

OBJECTIVES

To determine the benefits and harms of curative liver resection with lymphadenectomy versus other treatments for colorectal liver metastases with hepatic node involvement.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and LILACS until September 2009 for identifying the randomised trials.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing liver resection (alone or in combination with radiofrequency ablation or cryoablation) versus other treatments (neo-adjuvant chemotherapy, chemotherapy, or radiofrequency ablation) in patients with colorectal liver metastases with hepatic node involvement.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials for inclusion.

MAIN RESULTS

We were unable to identify any randomised clinical trial fulfilling the inclusion criteria of this review. We were also unable to identify any quasi-randomised or cohort studies, which could meaningfully answer this important issue.

AUTHORS' CONCLUSIONS

There is no evidence in the literature to assess the role of surgery versus other treatments for patients with colorectal liver metastases with hepatic node involvement. High quality randomised clinical trials are feasible and are necessary to determine the optimal management of patients with colorectal liver metastases with hepatic node involvement.

Outcomes of simultaneous and delayed resections of synchronous colorectal liver metastases

BACKGROUND

The optimal strategy for the treatment of synchronous colorectal liver metastases has not been established yet. In this study, we present the outcomes and survival rates of the patients who underwent simultaneous or delayed resections.

METHODS

We performed a retrospective analysis of liver resections in our institution between 1997 and 2006.

RESULTS

Among the 89 patients presenting with synchronous colorectal liver metastases, 28 underwent simultaneous and 61 underwent delayed resection. Age, sex and localization of the primary tumour were similar in the 2 groups. Duration of surgery and hospital stay were longer in the simultaneous resection group, and blood loss was also greater in this group. However, these factors did not influence the frequency of complications, which did not differ between the groups. When we included data from initial colectomy, these differences were either not significant or in favour of synchronous resection. In the delayed resection group, colon resection was performed in different hospitals. The 1-, 3- and 5-year survival rates were 78%, 70% and 45%, respectively, in the simultaneous and 88%, 55% and 38%, respectively, in the delayed resection groups.

CONCLUSION

In select patients, the risk of simultaneous resection of synchronous colorectal liver metastases is comparable to delayed resection, and increases in blood loss and operating time associated with simultaneous resections do not have a negative influence on long-term outcome. Positive outcomes of simultaneous liver resections in our study could be a result of good patient selection or experience with oncological liver surgery.

Synchronous colorectal liver metastases: is it time to reconsider traditional paradigms of management?

BACKGROUND

Patients with synchronous colorectal liver metastases (CLM) are typically treated with initial colorectal resection followed by arbitrary and prolonged courses of chemotherapy. Partial hepatectomy is considered only for patients without interval disease progression. This review describes the rationale for this treatment approach and the recent developments suggesting that this management paradigm should be reconsidered.

RESULTS

Because asymptomatic colorectal cancer often does not lead to complications, and given the potential benefit of chemotherapy in downsizing unresectable to resectable liver disease, most patients with asymptomatic primary tumors and unresectable synchronous CLM should be first treated with chemotherapy. In contrast, initial hepatic resection should be considered for resectable synchronous CLM. Survival benefits from prehepatectomy chemotherapy have not been established. Several reports demonstrate morbidity after hepatic resection from extended durations of irinotecan- and/or oxaliplatin-based prehepatectomy chemotherapy. Although shorter treatment periods may not have these deleterious effects on subsequent hepatic resection, prospective studies reveal that most patients with supposedly aggressive disease with short treatment durations will not be identified. Moreover, a complete radiologic response to prehepatectomy chemotherapy is not only rare but also does not equate with a complete pathological response. Finally, several studies suggest that simultaneous colorectal and minor hepatic resections can performed safely with benefits in total morbidity when compared with traditional staged procedures.

CONCLUSIONS

The traditional treatment paradigm centering on the utility of prehepatectomy chemotherapy for resectable synchronous CLM should be reconsidered. Recent developments underscore the need for prospective randomized controlled trials evaluating the optimal timing of hepatectomy relative to chemotherapy.

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

OBJECTIVE

A systematic review of the literature was undertaken to estimate the differences in length of hospital stay, morbidity, mortality and long-term survival between staged and simultaneous resection of synchronous liver metastases from colorectal cancer to determine the level of evidence for recommendations of a treatment strategy.

METHOD

A Pub-med search was undertaken for studies comparing patients with synchronous liver metastases, who either had a combined or staged resection of metastases. Twenty-six were considered and 16 were included based on Newcastle Ottawa Quality Assessment Scale. All studies were retrospective and had a general bias, because the staged procedure was significantly more often undertaken in patients with left-sided primary tumours and larger, more numerous and bi-lobar metastases. Analyses of primary outcomes were performed using the random effects model.

RESULTS

For the reason of the heterogeneity of the observational studies, no odds ratios were calculated. In 11 studies, there was a tendency towards a shorter hospital stay in the synchronous resection group. Fourteen studies compared total perioperative morbidity and lower morbidity was observed in favour of a combined resection. Fifteen studies compared perioperative mortality, which seemed to be lower with the staged approach. Eleven studies compared 5-year survival, which seemed to be similar in the two groups.

CONCLUSION

No randomized controlled trials were identified, and hence a meta-analysis was not performed. The evidence level is II to III with grade C recommendations. Synchronous resections can be undertaken in selected patients, provided that surgeons specialized in colorectal and hepatobiliary surgery are available.

Benefit of laparoscopy for rectal resection in patients operated simultaneously for synchronous liver metastases: preliminary experience

BACKGROUND

Resection of the rectal primary neoplasm with synchronous liver metastases (LM) is warranted, because this is the only strategy with curative potential. Combined resection remains controversial because of the risk of morbidity and necessity of a curative abdominal approach to warrant liver resection. Laparoscopic colorectal resection may be beneficial and could facilitate this procedure.

METHODS

Between February 2006 and June 2007, 10 patients underwent 1-step laparoscopic resection for primary rectal cancer combined with open resection of synchronous LM.

RESULTS

All patients underwent a laparoscopic mesorectal excision (n = 10). Liver resections included right hepatectomy (n = 1), bi- or trisegmentectomy (n = 3), and metastasectomy (n = 6). The rectosigmoid specimen was extracted through the right subcostal or a short midline incision used for open liver resection, except in 3 patients who underwent a 1-step totally laparoscopic resection of both the colorectal and hepatic neoplasms. The overall morbidity was 40%. The median hospital stay was 12 days (range, 5-40). Overall morbidity (29% vs 40%) and hospital stay (12 vs 12 days) were similar to those observed in a previous cohort of 27 patients undergoing laparoscopic mesorectal excision only.

CONCLUSION

This pilot study suggests that laparoscopic rectal resection with synchronous resection of LM is feasible with low morbidity and short hospital stay. Moreover, laparoscopy facilitates the operation approach for synchronous major hepatectomy.