Bilobar Colorectal Liver Metastases Research Articles

Mid-transversal hepatectomy: breaking new ground in parenchymal sparing hepatectomies.

We, herein, describe a case of complex parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases (CRLMs). A 61-year-old woman, previously operated for an occlusive adenocarcinoma of the transverse colon and undergoing adjuvant chemotherapy, developed metachronous bilobar CRLMs. After administration of a II line chemotherapy with partial response, she was referred to our hospital. The pre- and post-treatment imaging recognized seven liver lesions, with a bilobar distribution involving segments 3, 4, 5, 8, and 7. After multidisciplinary team evaluation, the surgical strategy was planned by means of three-dimensional reconstruction and simulation software. The planned and executed procedure consisted of a unique transection plane comprising partial resection of segments 3-4-5-8-7, thus removing the central transversal portion of the liver. Accurate preoperative planning and intraoperative ultrasound for resection guidance allowed us to achieve a complex parenchymal sparing procedure in an advanced disease that would be usually candidate for major resection and staged hepatectomy.

Debulking Hepatectomy for Colorectal Liver Metastasis Conveys Survival Benefit.

(1) Background: Despite advances in surgical technique and systemic chemotherapy, some patients with multifocal, bilobar colorectal liver metastases (CRLM) remain unresectable. These patients may benefit from surgical debulking of liver tumors in combination with chemotherapy compared to chemotherapy alone. (2) Methods: A retrospective study including patients evaluated for curative intent resection of CRLM was performed. Patients were divided into three groups: those who underwent liver resection with recurrence within 6 months (subtotal debulked, SD), those who had the first stage only of a two-stage hepatectomy (partially debulked, PD), and those never debulked (ND). Kaplan-Meier survival curves and log-rank test were performed to assess the median survival of each group. (3) Results: 174 patients underwent liver resection, and 34 patients recurred within 6 months. Of the patients planned for two-stage hepatectomy, 35 underwent the first stage only. Thirty-two patients were never resected. Median survival of the SD, PD, and ND groups was 31 months, 31 months, and 19.5 months, respectively (p = 0.012); (4) Conclusions: Patients who underwent a debulking of CRLM demonstrated a survival benefit compared to patients who did not undergo any surgical resection. This study provides support for the evaluation of intentional debulking versus palliative chemotherapy alone in a randomized trial.

HPB P20 Radical Single Stage Liver Resection of Bilobar Colorectal Liver Metastases

Abstract Background Surgical resection of Colorectal Liver Metastases (CRLM) offers the best long-term patient survival with current 5-year survival rates of 50%. However, bilobar CRLM often require an individualised patient approach with the primary goals being oncological resection of metastases and adequate future liver remnant. A number of surgical approaches can be used for bilobar CRLM including resection ± ablation, two stage hepatectomy ± portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy (ALPSS), or extended hepatectomy. We describe our approach of single stage parenchymal preserving (SSPP) liver resection for bilobar CRLM. Methods All patients with bilobar CRLM that underwent liver resection in a single, tertiary, specialist cancer centre in the UK between April 2018 to December 2021 were included. All liver resections were carried out using an open approach and 6-8 weeks after the cessation of chemotherapy. Pringle was used in all patients. We assessed peri-operative and oncological outcomes as well as disease-free (DFS) and overall (OS) patient survival. Results A total of n=42 patients underwent SSPP surgery during the study period. Median age was 54 years (range 36-71) and 93% were performance status=0. Pre-operative chemotherapy was administered in n=39 patients. A median of 4 lesions were resected (range 3-12). Median blood loss was 450mls (range 115-2500mls). R0 resection rate was 95%, with no post-operative liver failure and no peri-operative mortality. Bile leak rate was 10% and n=1 required massive blood transfusion. Median DFS was 13 months, and n=26 patients recurred by the end of the study period. Of these, n=14 were suitable for further treatment. Five-year OS was 77%. Conclusions SSPP liver resection for bilobar CRLM is associated with low peri-operative complications and good oncological outcomes. Early recurrence is noted but patients remain eligible for further liver- directed therapies or systemic treatment allowing for good overall patient survival.

Factors of oncological failure in two stage hepatectomy for colorectal liver metastases

BackgroundTwo-stage hepatectomy (TSH) has increased the chance of surgical resections for bilobar colorectal liver metastases (CRLM). Nevertheless, drop-out between stages and early recurrence rates raise the question of surgical futility in some situations. This study aimed to identify factors of TSH oncological failure. MethodsPatients with bilobar CRLM eligible for TSH in three tertiary centers between 2010 and 2021 were included, and divided in Failure and Success groups. Oncological failure was defined as failure of the second stage hepatectomy for tumor progression or recurrence within 6 months after resection. ResultsAmong 95 patients, 18 (18.9%) had hepatic progression between the two stages, and 7 (7.4%) failed to complete the second stage hepatectomy. After TSH, 31 (32.6%) patients experienced early recurrence. Overall, 38 (40.0%) patients experienced oncological failure (Failure group). The Failure group had lower median DFS (3 vs. 32 months, p < 0.001) and median OS (29 vs. 70 months, p = 0.045) than the Success group. On multivariable analysis, progression between the two stages in the future liver remnant (OR = 15.0 (3.22–113.0), p = 0.002), and maximal tumor size ≥40 mm in the future liver remnant (OR = 13.1 (2.12–117.0), p = 0.009) were independent factors of oncological failure. ConclusionRecurrence between the two stages and maximal tumor size ≥40 mm in the future liver remnant were associated with TSH failure for patients with bilobar CRLM.

Vessel-Guided Mesohepatectomy for Liver Partition and Staged Major Parenchyma-Sparing Hepatectomies with Super-Selective Portal Vein Embolization or Enhanced ALPPS to Achieve R0 Resection for Colorectal Liver Metastases at the Hepatocaval Confluence.

Background. R0 minor parenchyma-sparing hepatectomy (PSH) is feasible for colorectal liver metastases (CRLM) in contact with hepatic veins (HV) at hepatocaval confluence since HV can be reconstructed, but in the case of contact with the first-order glissonean pedicle (GP), major hepatectomy is mandatory. To pursue an R0 parenchyma-sparing policy, we proposed vessel-guided mesohepatectomy for liver partition (MLP) and eventually combination with liver augmentation techniques for staged major PSH. Methods. We analyzed 15 consecutive vessel-guided MLPs for CRLM at the hepatocaval confluence. Patients had a median of 11 (range: 0-67) lesions with a median diameter of 3.5 cm (range: 0.0-8.0), bilateral in 73% of cases. Results. Grade IIIb or more complications occurred in 13%, median hospital stay was 14 (range: 6-62) days, 90-day mortality was 0%. After a median follow-up of 17.5 months, 1-year OS and RFS were 92% and 62%. In nine (64%) patients, MLP was combined with portal vein embolization (PVE) or ALPPS to perform staged R0 major PSH. Future liver remnant (FLR) volume increased from a median of 15% (range: 7-20%) up to 41% (range: 37-69%). Super-selective PVE was performed in three (33%) patients and enhanced ALPPS (e-ALPPS) in six (66%). In two e-ALPPS an intermediate stage of deportalized liver PSH was necessary to achieve adequate FLR volume. Conclusions. Vessel-guided MLP may transform the liver in a paired organ. In selected cases of multiple bilobar CRLM, to guarantee oncological radicality (R0), major PSH is feasible combining advanced surgical parenchyma sparing with liver augmentation techniques when FLR volume is insufficient.

Prognostic impact of R1 resection margin in synchronous and simultaneous colorectal liver metastasis resection: a retrospective cohort study

BackgroundA margin ≥ 1 mm is considered a standard resection margin for colorectal liver metastasis (CRLM). However, microscopic incomplete resection (R1) is not rare since aggressive surgical resection has been attempted in multiple and bilobar CRLM. This study aimed to investigate the prognostic impact of resection margins and perioperative chemotherapy in patients with CRLM.MethodsA total of 368 of 371 patients who underwent simultaneous colorectal and liver resection for synchronous CRLM between 2006 and June 2017, excluding three R2 resections, were included in this study. R1 resection was defined as either abutting tumor on the resection line or involved margin in the pathological report. The patients were divided into R0 (n = 304) and R1 (n = 64) groups. The clinicopathological characteristics, overall survival, and intrahepatic recurrence-free survival were compared between the two groups using propensity score matching.ResultsThe R1 group had more patients with ≥ 4 liver lesions (27.3 vs. 50.0%, P < 0.001), higher mean tumor burden score (4.4 vs. 5.8%, P = 0.003), and more bilobar disease (38.8 vs. 67.2%, P < 0.001) than the R0 group. Both R0 and R1 groups showed similar long-term outcomes in the total cohort (OS, P = 0.149; RFS, P = 0.414) and after matching (OS, P = 0.097, RFS: P = 0.924). However, the marginal recurrence rate was higher in the R1 group than in the R0 group (26.6 vs. 16.1%, P = 0.048). Furthermore, the resection margin did not have a significant impact on OS and RFS, regardless of preoperative chemotherapy. Poorly differentiated, N-positive stage colorectal cancer, liver lesion number ≥ 4, and size ≥ 5 cm were poor prognostic factors, and adjuvant chemotherapy had a positive impact on survival.ConclusionsThe R1 group was associated with aggressive tumor characteristics; however, no effect on the OS and intrahepatic RFS with or without preoperative chemotherapy was observed in this study. Tumor biological characteristics, rather than resection margin status, determine long-term prognosis. Therefore, aggressive surgical resection should be considered in patients with CRLM expected to undergo R1 resection in this multidisciplinary approach era.

Toronto Management of Initially Unresectable Liver Metastases from Colorectal Cancer in a Living Donor Liver Transplant Program.

Living donor liver transplantation (LDLT) is an attractive option for patients with unresectable, bilobar colorectal liver metastases (CRLM). However, it is not available in most centres beyond study protocols. This study describes the interim experience with LDLT for CRLM at a large North American transplant and hepatobiliary centre. Adults with unresectable CRLM, receiving systemic chemotherapy were recruited into a prospective clinical trial. Data on demographics, referral patterns, and clinical characteristics were extracted from October 2016 to February 2023. Patients were divided into three groups: transplanted, resected, and control (excluded, with continuation of systemic chemotherapy). Overall survival (OS) and recurrence-free survival (RFS) were compared. 81 referred patients were assessed for LDLT. 7 received transplants, 22 underwent resection, and 48 control. All had similar pre-assessment baseline characteristics. Median time from initial assessment to transplantation was 15.4 months. The control population had significantly worse post-assessment OS than the transplanted population (p=0.002) and resected population (p<0.001). The median post-operative follow-up duration was 21.4 months (resection) and 14.8 months (LDLT). There was no difference in OS between the transplanted and resected populations (1-year 100% vs. 93.8%; 3-year 100% vs. 43.3%, p=0.17). However, RFS was superior in the LDLT group (1-year 85.7% vs. 11.4%; 3-year 68.6% vs. 11.4%, p=0.012). Most patients with unresectable CRLM referred for LDLT are deemed ineligible for trial inclusion. However, the excellent oncologic outcomes in patients who meet criteria for LDLT supports its role in highly selected populations. Future results after the trial's completion will inform long-term outcomes.

Multiple Laparoscopic Liver Resection for Colorectal Liver Metastases.

Over the past decades, liver cancer's minimally invasive approach has primarily become as a new standard of oncological care. Colorectal liver metastases (CRLM) are one of the most developed indications of laparoscopic liver resection (LLR). CRLM resection is still the best treatment known in terms of survival. As multiple CRLM are found in up to 80% of cases at diagnosis (Manfredi S. and al, Annals of Surgery 2006), a lot of possible technical management approaches are described. With the development of the parenchymal-sparing strategy, multiple concomitant laparoscopic liver resections (LLR) are gaining acceptance. However, no recommendation is available regarding its indications and feasibility. Also, laparoscopic two-stage hepatectomy is developing for bilobar CRLM, and this also does not have established recommendation. The purpose of this paper was to highlight novelty and updates in the field of multiple minimally invasive liver resections. A review of the international literature was performed. The feasibility of laparoscopic concomitant multiple LLR and two-stage hepatectomy for CRLM as well as their outcomes were discussed. These clarifications could further guide the implementation of minimal resection in multiple colorectal liver metastases therapies.

Modified ALPPS for the Treatment of a Patient with Bilobar Colorectal Liver Metastases

Modified ALPPS for the Treatment of a Patient with Bilobar Colorectal Liver Metastases

Current trends and outcomes of surgical treatment of colorectal cancer with liver metastasis

Aim. To analyze multimodal treatment outcomes in patients with liver metastases from colorectal cancer, who were treated at multidisciplinary cancer clinic. Material and methods. From 2007 to 2021, 315 colorectal cancer patients with liver metastases underwent liver resections (201, 63.8 %), radiofrequency ablation (RFA) (29, 9.2 %), microwave ablation (MWA) (22, 6.9 %), transarterial chemoembolozation (TACE) in combination with RFA (22, 6.9 %), and TACE + RFA + TACE combination (41, 13.2 %) at the department of liver and pancreas surgery, Moscow Botkin Clinical Hospital. Results. A 90-day mortality rate was 1.9% in 6 patients who underwent liver resection. Postoperative complications after liver resection were observed in 49 patients (24.3 %). The overall 5- and 10-year survival rates after liver resection were 38.8 % and 23.2 %, respectively. The factors of poor prognosis after liver resection were: age over 70 years (p=0.03), localization of the primary tumor in the right half or rectum (p=0.037), three or more metastatic foci in the liver (p=0.01), maximum size of the tumor of more than 5 cm (p=0.021), synchronous colorectal liver metastases (p=0.039), and bilobar colorectal liver metastases (p=0.007). Postoperative complications after RFA, TACE + RFA, TACE + RFA + TACE WERE 5.8 %, 9.1 % and 7.3 %, respectively. In patients with a size of metastases of no more than 3 cm, the 3-year disease-free and overall survival rates after rfa were 45.8 % and 54.2 %, respectively. In patients with a size of metastases from 3 to 5 cm, the 3-year disease-free and overall survival rates after TACE + RFA + TACE were 56.1 % and 63.4 %, respectively. Conclusion. In colorectal cancer patients with liver metastases, multimodal treatment within a multi-disciplinary setting demonstrated significant improvements in their survival.

Surgical outcomes of simultaneous resection of synchronous multiple bilobar colorectal liver metastases

Surgical outcomes of simultaneous resection of synchronous multiple bilobar colorectal liver metastases

Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy

Jehovah’s Witness patients presenting for liver surgery pose challenges to the anesthetists as well as the surgeons, due to their abstinence from receiving blood products. Despite this, surgery is the only curative option for operable colorectal liver metastases (CRLM). We report a case of a Jehovah’s Witness with multiple comorbidities who had a parenchyma sparing hepatectomy (PSH) complicated by intraoperative bleeding. A 52-year-old ASA II patient with hypertension, diabetes and ischemic heart disease on dual antiplatelet therapy was scheduled for open PSH for multiple bilobar CRLMs. He was prehabilitated with an emphasis on enhancing erythropoiesis and improving his functional capacity. PSH was done using a Cavitron ultrasonic surgical aspirator (CUSA) with intermittent Pringle maneuver, a low central venous pressure and restricted intravenous fluids. His postoperative recovery was complicated by a minor upper gastrointestinal bleed that was managed conservatively.&#x0D; The authors certify that informed written consent has been obtained from patient for publication.&#x0D; Keywords: Jehovah’s Witness; Liver surgery; Anesthesia; Hepatectomy&#x0D; Citation: Dassanayake V, Sivaganesh S, Subasinghe D, Pitigala P. Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy. Anaesth. pain intensive care 2021;26(1):119–122 ;&#x0D; DOI: 10.35975/apic.v26i1.1787&#x0D; Received: October 16, 2021, Reviewed: October 28, 2021, Accepted: November 07, 2021

Predictors of Disease Recurrence Following Clearance of Bilobar Colorectal Liver Metastases: An International Multicentre Study

Introduction: Presence of bilobar colorectal liver metastases (BiCRLM) is a relatively poor prognostic indicator. With careful pre-operative planning, tumour clearance is offered for increased number of patients with BiCRLM. Some of the options are associated with higher postoperative morbidity, mortality rates and it is important to identify patients who benefit from such interventions. The study aims to assess the clinical and pathological determinants of recurrent disease in patients with BiCRLM. Study period and data collection: An international multicentre study was set up with endorsement from the EAHPBA. Predefined electronic case report forms were made available from BiCRLM.org website. Patients with at least two lesions each on the right and left hemiliver (minimum four) and considered for clearance of liver disease (single+/-two-stage hepatectomy+/-ablation) between 2012 and 2018 were recruited. Recurrence patterns and factors influencing recurrence were evaluated using stepwise regression analysis. Results: A total of 1243 patients were included. Recurrence was encountered in 77.3% (liver: site of previous resection/ablation:24%; liver: new location:50%; lungs:31%; peritoneum:11%. Median time to recurrence from liver surgery was 10.1months. 40% died with cancer at a median follow-up duration of 20 months. T-stage(p=0.24) and N-stage(0.18) of primary, chemotherapy at primary resection(0.02), number of liver lesions(p=0.001) and their radiological response(p=0.04), margin status of liver resection (0.004) had significant influence on the above outcomes. Conclusion: TN staging of primary, liver tumor load, chemosensitivity, margin positivity influence the oncological outcomes following clearance of BiCRLM. These factors should be taken into consideration in selection and surgical planning of patients with BiCRLM.

Liver-First Approach for Synchronous Colorectal Metastases: Analysis of 7360 Patients from the LiverMetSurvey Registry

BackgroundThe liver-first approach in patients with synchronous colorectal liver metastases (CRLM) has gained wide consensus but its role is still to be clarified. We aimed to elucidate the outcome of the liver-first approach and to identify patients who benefit at most from this approach.MethodsPatients with synchronous CRLM included in the LiverMetSurvey registry between 2000 and 2017 were considered. Three strategies were analyzed, i.e. liver-first approach, colorectal resection followed by liver resection (primary-first), and simultaneous resection, and three groups of patients were analyzed, i.e. solitary metastasis, multiple unilobar CRLM, and multiple bilobar CRLM. In each group, patients from the three strategy groups were matched by propensity score analysis.ResultsOverall, 7360 patients were analyzed: 4415 primary-first, 552 liver-first, and 2393 simultaneous resections. Compared with the other groups, the liver-first group had more rectal tumors (58.0% vs. 31.2%) and higher hepatic tumor burden (more than three CRLMs: 34.8% vs. 24.0%; size > 50 mm: 35.6% vs. 22.8%; p < 0.001). In patients with solitary and multiple unilobar CRLM, survival was similar regardless of treatment strategy, whereas in patients with multiple bilobar metastases, the liver-first approach was an independent positive prognostic factor, both in unmatched patients (3-year survival 65.9% vs. primary-first 60.4%: hazard ratio [HR] 1.321, p = 0.031; vs. simultaneous resections 54.4%: HR 1.624, p < 0.001) and after propensity score matching (vs. primary-first: HR 1.667, p = 0.017; vs. simultaneous resections: HR 2.278, p = 0.003).ConclusionIn patients with synchronous CRLM, the surgical strategy should be decided according to the hepatic tumor burden. In the presence of multiple bilobar CRLM, the liver-first approach is associated with longer survival than the alternative approaches and should be evaluated as standard.

Laparoscopic liver resection for bilobar multiple metachronous liver metastases in patient with rectal cancer

Laparoscopic liver resection (LLR) of multiple colorectal liver metastases (CRLM) is challenging but has become more practical recently due to progression in operative technique. We aimed to present laparoscopic detection of multiple CRLM using intraoperative ultrasonography (IOUSG) and LLR for scattered CRLM. A 65-year-old male was admitted with multiple liver metastases during follow-up for mid-rectal cancer. The patient had already undergone laparoscopic lower anterior resection 6 months ago and had completed the sixth adjuvant chemotherapy with capecitabine. Magnetic resonance imaging presented metastatic tumor about 5 cm in size in segment 6 of liver and multiple small metastases in segment 3, 4, 5, 7, and 8 of liver. The surgery was performed in supine position and five trocars were inserted. After detection of tumors using IOUSG to mark the site of the tumors, we performed bisegmentectomy about tumors of segment 5 and 6, and 3 tumorectomy of liver about tumors of segment 3, 4, and 7 + 8. Immediately after surgery, all specimens were cut to check whether the tumors were included and whether the resection margin was sufficient. The operative time was 350 minutes and estimated blood loss was 80 mL. Pringle maneuver was performed 5 times in 15 minutes. All tumor resection margin were grossly confirmed as negative. There were no immediate postoperative complications. The patient was discharged on the day 7 of postoperative hospital stay. LLR is safe and feasible technique even for bilobar multiple CRLM.

The role of R0/R1vasc resection in the treatment of patients affected by marginal resectable colorectal liver metastases: A pairwise propensity score match analysis

Increasingly, patients with multiple colorectal liver metastases (CRLM) are surgically treated. R1par surgery remains one of the negative prognostic factors for overall survival (OS). According to our data on R1 in main intrahepatic vascular contact (MVC), we investigate the oncological outcome of patients with multiple bilobar disease with bilateral MVC (BC), compared to patients with unilateral MVC (UC) and patients with disease and no MVC (NC). This single-institution study included patients who underwent hepatectomy for multiple (≥ 4) bilobar CRLM lesions from 2004-2019. Three-hundred-fifty-five patients meet the inclusion criteria. One-hundred-thirty-two patients with R1par resection were excluded. Three groups were defined: NC, UC, BC. After pairwise propensity score match 145 patients were analyzed. No differences between groups were observed in the preoperative variables. Increased surgical time, hilar clamping, and blood loss were reported in the BC group. Postoperative minor morbidity, liver failure rate, overall and local recurrences were higher in the BC group. BC patients were more likely to be re-resected. Cumulative OS 3-5 years survival in NC, UC, BC were 54%-40%, 49%-35%, 57%-24% (p < 0.91). At multivariate analysis, factors influencing OS, were N status of the primitive lesions, RAS status, and repeated hepatectomy. Patients with BC and lesions ≥ 4 are generally considered unresectable or suitable for staged hepatectomy. This retrospective study shows that these patients can be submitted to the so called enhanced-one-staged hepatectomy with the same oncological results, however surgical complexity, postoperative minor morbidity and postoperative liver failure are increased.

Combined liver resection and radiofrequency ablation for bilobar multiple colorectal liver metastasis

Combined liver resection and radiofrequency ablation for bilobar multiple colorectal liver metastasis

One-stage laparoscopic parenchymal sparing liver resection for bilobar colorectal liver metastases: safety, recurrence patterns and oncologic outcomes.

Laparoscopic liver resections (LLR) of bilobar colorectal liver metastases (CRLM) are challenging and the safety and long-term outcomes are unclear. In this study, the short- and long-term outcomes and recurrence patterns of one-stage LLR for bilobar CRLM were compared to single laparoscopic resection for CRLM. This single-center study consisted of all patients who underwent a parenchymal sparing LLR for CRLM between October 2011 and December 2018. Demographics, perioperative outcomes, short-term outcomes, oncologic outcomes and recurrence patterns were compared. Data were retrieved from a prospectively maintained database. Thirty six patients underwent a LLR for bilobar CRLM and ninety patients underwent a single LLR. Demographics were similar among groups. More patients received neoadjuvant chemotherapy in the bilobar group (55.6% vs 34.4%, P = 0.03). There was no difference in conversion rate, R0 resection and transfusion rate. Blood loss and operative time were higher in the bilobar group (250ml (IQR 150-450) vs 100ml (IQR 50-250), P < 0.001 and 200min (IQR 170-230) vs 130min (IQR 100-165), P < 0.001) and hospital stay was longer (5days (IQR 4-7) vs 4days (IQR 3-6), P = 0.015). The bilobar group had more technically major resections (88.9% vs 56.7%, P < 0.001). Mortality was nil in both groups and major morbidity was similar (2.8% vs 3.3%, P = 1.0). There was no difference in recurrence pattern. Overall survival (OS) was similar (1yr: 96% in both groups and 5yr 76% vs 66%, P = 0.49), as was recurrence-free survival (RFS) (1yr: 64% vs 73%, 3yr: 38 vs 42%, 5yr: 38% vs 28%, P = 0.62). In experienced hands, LLR for bilobar CRLM can be performed safely with similar oncologic outcomes as patients who underwent a single LLR for CRLM.

Prediction of remnant liver volume using 3D simulation software in patients undergoing R1vasc parenchyma-sparing hepatectomy for multiple bilobar colorectal liver metastases: reliability, clinical impact, and learning curve

BackgroundAssessment of the future liver remnant (FLR) is routinely performed before major hepatectomy. In R1-vascular one-stage hepatectomy (R1vasc-OSH), given the multiplanar dissection paths, the FLR is not easily predictable. Preoperative 3D-virtual casts may help. We evaluated the predictability of the FLR using the 3D-virtual cast in the R1vasc-OSH for multiple bilobar colorectal liver metastases (CLM). MethodsThirty consecutive patients with multiple bilobar CLMs scheduled for R1vasc-OSH were included. Predicted and real-FLRs were compared. Propensity score-matched analysis was used to determine the impact of 3D-virtual cast on postoperative complications. ResultsMedian number of CLM and resection areas were 12 (4–33) and 3 (1–8). Median predicted-FLR was 899 ml (558–1157) and 60% (42–85), while for the real-FLR 915 ml (566–1777) and 63% (43–87). Median discrepancy between predicted and real-FLR was −0.6% (p = 0.504), indicating a slight tendency to underestimate the FLR. The difference was more evident in more than 12 CLMs (p = 0.013). A discrepancy was not evident according to the number of resection areas (p = 0.316). No mortality occurred. Patients in virtual-group had lower major complications compared to nonvirtual-group (0% vs 18%, p-value 0.014). ConclusionFLR estimation based on 3D-analysis is feasible, provides a safe surgery and represents a promising method in planning R1vasc-OSH for patients with multiple bilobar CLMs.

Resection of colorectal liver metastases: prognostic impact of tumor burden score varies according to unilobar versus bilobar metastatic spread

Presenter: Diamantis Tsilimigras MD | The Ohio State University Background: The prognostic impact of tumor burden score (TBS) after resection of colorectal liver metastasis (CRLM) relative to metastatic spread (i.e. unilobar vs bilobar) remains ill-defined. Methods: Patients who underwent hepatectomy for CRLM between 2001-2018 were identified using an international multi-institutional database. The impact of tumor burden score (TBS2= largest CRLM diameter)2 + (number of CRLM)2] and modified TBS (mTBS2 = ex × TBS2, if unilobar metastasis, χ = 0; if bilobar metastasis, χ = 1) on overall survival (OS) was assessed. Results: Among 1,324 patients, median number of metastatic lesions was 2 (IQR: 1-3) and the median size of largest metastatic lesion was 3cm (IQR: 2.0-5.0cm) resulting in a median TBS of 4.2 (IQR: 2.8-6.1). A total of 354 (26.7%) had low TBS (9). Bilobar CRLM were present among 34.3% (n=454) of patients. Overall median and 5-year OS were 49.3 months (95%CI: 45.2-53.4) and 42.8%, respectively. In examining the entire cohort, TBS was associated with long-term prognosis (5-year OS, low TBS: 52.6% vs medium TBS: 39.0% vs high TBS: 40.6%, p<0.001). Although CRLM lobar spread did not predict worse outcomes among patients with low TBS (5-year OS; unilobar: 52.7% vs bilobar: 53.9%, p=0.95), patients with medium TBS and bilobar disease had worse outcomes compared with individuals with high TBS and unilobar disease (32.9% vs 40.6%, p=0.02). On multivariable analysis, bilobar CRLM spread was associated with worse OS (HR=1.25, 95%CI 1.06-1.49). A modified TBS that accounted for bilobar metastatic CRLM spread was able to better stratify OS compared with the traditional TBS (5-year OS; low mTBS: 47.3% vs medium mTBS: 40.5% vs high mTBS: 26.4%, p<0.001; Figure). Conclusion: Bilobar CRLM predicted worse outcomes among patients with CRLM, especially among individuals with medium/high TBS. A mTBS that accounts for bilobar CRLM spread is a more accurate prediction tool than the traditional TBS.