Tailored multistage minimally invasive management of resectable stage IV colorectal cancer offers optimal postoperative outcomes and long-term survival: a propensity-score weighting analysis

Abstract

Background: In patients with stage IV colorectal cancer (CRC), minimally invasive surgical (MIS) resection with curative intent may offer optimal oncologic outcome with low morbidity. However, the relative benefit of MIS compared to open surgery in patients requiring multistage resections has not been evaluated. Methods: Patients from a single institution who underwent totally MIS or totally open (TO) resection of CRC primary and liver metastases (CLM) in 2009–2016 were analyzed. Repeat MIS - liver, -transthoracic liver, or -lung surgery met inclusion. Inverse probability of weighted adjustment by propensity score (based on covariates representing tumor severity and surgical difficulty) was performed before analyzing risk factors for postoperative complications and survival. Results: The study included 164 patients, 43 MIS vs. 121 TO. TO resection had higher rates of synchronous CLM (83% vs. 63%, p = 0.01), multiple CLM (58% vs. 40%, p = 0.04) and major liver resection (33% vs. 16%, p = 0.04) before adjustment. Before and after adjustment, TMI patients had significantly less cumulated postoperative complications (41% vs. 59%, p = 0.001), blood loss (median 100 ml vs. 200 ml, p = 0.001) and shorter length of hospital stay (median 4.5 vs. 6 days, p < 0.001). Multivariate analysis identified 3 independent risk factors for postoperative complications: TO approach vs. MIS (OR = 2.4, p < 0.001), major liver resection (OR=4.4, p < 0.001), and multiple CLM (OR = 2.3, p = 0.001). 5-year overall survival was 81% vs 68% in TMI vs. TO patients (p = ns). Conclusion: In patients with CRC undergoing resection of the primary tumor and CLM multistage treatment planning, MIS resection contributes to optimal perioperative outcomes with no compromise in oncologic outcomes.