Resection For Synchronous Colorectal Liver Metastases Research Articles

The impact of a multi-hospital network on the inequality in odds of receiving resection or ablation for synchronous colorectal liver metastases

Background This study investigates whether inequalities in the utilization of resection and/or ablation for synchronous colorectal liver metastases (SCLM) between patients diagnosed in expert and non-expert hospitals changed since a multi-hospital network started. Materials and methods Patients diagnosed with SCLM between 2009 and 2020 were included. The likelihood of receiving ablation and/or resection was analyzed in the prenetwork (2009–2012), startup (2013–2016), and matured-network (2017–2020) periods. Results Nationwide, 13.981patients were diagnosed between 2009 and 2020, of whom 1.624 were diagnosed in the network. Of patients diagnosed in the network’s expert hospitals, 36.7% received ablation and/or resection versus 28.3% in nonexpert hospitals (p < 0.01). The odds ratio (OR) of receiving ablation and/or resection for patients diagnosed in expert versus nonexpert hospitals increased from 1.38 (p = 0.581, pre-network), to 1.66 (p = 0.108, startup), to 2.48 (p = 0.090, matured-network). Nationwide, the same trend occurred (respectively OR 1.41, p = 0.011; OR 2.23, p < 0.001; OR 3.20, p < 0.001). Conclusions Patients diagnosed in expert hospitals were more likely to receive ablation and/or resection for SCLM than patients diagnosed in non-expert hospitals. This difference increased over time despite the startup of a multi-hospital network. Establishing a multi-hospital network did not have an effect on reducing the existing unequal odds of receiving specialized treatment. Synopsis Specialized oncology treatments are increasingly provided through multi-hospital networks. However, scant empirical evidence on the effectiveness of these networks exists. This study analyzes whether a regional multi-hospital network was able to improve equal access to specialized oncology treatments.

The Role of Preoperative Chemotherapy in the Management of Synchronous Resectable Colorectal Liver Metastases: A Meta-Analysis.

The indications of preoperative chemotherapy, for initially resectable synchronous colorectal liver metastases, remain controversial. This meta-analysis aimed to assess the efficacy and safety of preoperative chemotherapy in such patients. Six retrospective studies were included in the meta-analysis with 1036 patients. Some 554 patients were allocated to the preoperative group, and 482 others were allocated to the surgery group. Major hepatectomy was more common in the preoperative group than in the surgery group (43.1% vs. 28.8%, p < 0.001). Furthermore, the percentage of patients with more than three liver metastases was higher in the preoperative group compared to the surgery group (12.6% vs. 5.4%, p < 0.002). Preoperative chemotherapy showed no statistically significant impact on overall survival. Combined disease free/relapse survival analysis of patients with high disease burden (liver metastases > 3, maximum diameter > 5 cm, clinical risk score ≥ 3) demonstrated that there is a 12% lower risk of recurrence in favor of preoperative chemotherapy. Combined analysis showed a statistically significant (77% higher probability) of postoperative morbidity in patients who received preoperative chemotherapy (p = 0.002). Preoperative chemotherapy should be suggested in patients with high disease burden. The number of cycles of preoperative chemotherapy should be low (3-4) to avoid increased postoperative morbidity. However more prospective studies are needed to clarify the exact role of preoperative chemotherapy in patients with synchronous resectable colorectal liver metastases.

Oncological outcomes of neoadjuvant chemotherapy in patients with resectable synchronous colorectal liver metastasis: A result from a propensity score matching study.

The efficacy and safety of neoadjuvant chemotherapy (NAC) in treating resectable synchronous colorectal liver metastases (CRLM) remain controversial. Data from CRLM patients who underwent simultaneous liver resection between January 2015 and December 2019 were collected from the Surveillance, Epidemiology, and End Results (SEER) database (SEER cohort, n=305) and a single Chinese Cancer Center (NCC cohort, n=268). Using a 1:2 ratio of propensity score matching (PSM), the prognostic impact of NAC for patients who underwent NAC before surgical treatment and patients who underwent surgical treatment alone was evaluated. After PSM, there was no significant difference in overall survival (OS) between patients receiving NAC prior to CRLM resection and those undergoing surgery only, in both the NCC and SEER cohorts (each P > 0.05). Age was an independent predictor of OS only in the SEER cohort (P = 0.040), while the pN stage was an independent predictor for OS only in the NCC cohort (P = 0.002). Furthermore, Disease-free survival (DFS) was comparable between the two groups in the NCC cohort. In a subgroup analysis, the DFS and OS in the NAC- group were significantly worse than those in the NAC+ group for patients with more than two liver metastases in the NCC cohort (P < 0.05 for both). NAC did not have a significant prognostic impact in patients with resectable synchronous CRLM. However, patients with more than two liver metastases could be good candidates for receiving NAC.

Combined liver and colorectal resections for synchronous metastases is safe and efficient when performed at a quaternary referral center

Presenter: Kevin Choong MD | City of Hope Cancer Center Background: The operative sequencing for patients with resectable synchronous colorectal liver metastases remains controversial. Retrospective institutional studies have shown relative safety and lower lengths of stay in combined versus staged resections. National database studies, however, have reported increased morbidity with combining major liver resection with concurrent colorectal resections. This has led to questions regarding this approach, especially in non-specialized centers. In this study, we hypothesize that combined colorectal and liver resections for synchronous metastases is both safe and efficient. Methods: A retrospective review of combined resections for synchronous colorectal liver metastases at a quaternary referral center from 2015-2020. Clinicopathologic and perioperative data was collected. Univariate and multivariate analyses were performed to identify risk factors for major post-operative complications. Results: One hundred one patients were identified, with 35 undergoing major liver resections (>3 segments) and 66 undergoing minor liver resections. Primary tumors were in the right colon in 20 (19.8%), the left colon in 57 (56.4%), and the rectum in 24 (23.8%). Patients who underwent minor liver resection had higher BMI (27.1 vs. 24.6, p = 0.04) and were more likely to be ASA 4 (36.3% vs. 17.1%, p = 0.04). Locoregional stage of the primary colorectal cancer did not differ between major and minor liver resections. The vast majority of patients (94%) received neoadjuvant therapy and there was no significant difference in the duration or regimen between those undergoing major or minor liver resection. Major liver resections were more likely to receive blood transfusions (28.6% vs. 9.1%, p = 0.01). However, estimated blood loss (433.4 ml vs. 352.2 ml, p = 0.19), case duration (451.9 min vs. 481.4 min, p = 0.27), and length of stay (9.7 days vs. 8.0 days, p = 0.18) were no different between major and minor liver resection. Post-operatively, patients undergoing major liver resection had higher rates of post-hepatectomy liver failure (34.2% vs. 7.6%, p = 1 (p1, no factors were associated with significantly increased odds of major complication. Conclusion: Combined resection for synchronous colorectal liver metastases when performed at a quaternary referral center is both safe and efficient.

Efficacy analysis on laparoscopic simultaneous resection of primary colorectal cancer and liver metastases

Objective: To investigate the short-term outcomes of laparoscopic simultaneous resection of primary colorectal cancer and liver metastases in patients with resectable synchronous colorectal liver metastases (SCRLM). Methods: A descriptive case series study was performed. Clinicopathological data of patients with SCRLM who underwent laparoscopic simultaneous resection of colorectal cancer and liver metastases in Zhongshan Hospital between December 2015 and September 2018 were retrieved from a prospective colorectal cancer database. Perioperative presentations and short-term outcomes were analyzed. Results: A total of 53 patients were enrolled with average age of(61.7±11.3) years. Among them, 32 were male (60.4%) and 21 were female (39.6%). Twenty-five patients (47.2%) were American Society of Anesthesiologists (ASA) grade I and 28 (52.8%) were grade II. All the patients completed laparoscopic simultaneous resection without conversion. The average operation time was (320.2±114.5) min. The estimated blood loss was 150.0 (45.0-2000.0) ml, and only 2 cases (3.8%) received intraoperative transfusion. Postoperative pathologic results revealed that the average primary tumor size was (5.4±1.9) cm; 4 cases (7.5%) were T1-2 stage and 48 cases (90.6%) were T3-4 stage; 40 patients (75.5%) had lymph node metastasis; 19 (35.8%) had vascular involvement; 24 (45.3%) had neural invasion. The median number of liver metastases was 1.0 (1-8), and the average size of largest liver metastases was (3.0±1.9) cm. The median margin of liver metastases was 1.0 (0.1-3.5) cm, and only 1 case was R1 resection. The average time to the first postoperative flatus was (67.9±28.9) h, and the average time to the liquid diet was (107.0±33.8) h. The average postoperative indwelling catheterization time was (85.6±56.4) h. The average postoperative hospital stay was (9.2±4.4) d, and the average cost was (82±26) thousand RMB. No death within postoperative 30-day was found. The morbidity of postoperative complication was 32.1% (17/53) and 3 patients developed grade III to IV complications which were improved by conservative treatment. The median follow-up period was 23.2 months. During follow-up, 19 patients (35.8%) developed recurrence or metastasis, and 4 (7.5%) died. The 1- and 2-year disease-free survival (DFS) rates were 68% and 47% respectively, and the 1- and 2-year overall survival rates were 95% and 86% respectively. Conclusions: Laparoscopic simultaneous resection of primary colorectal cancer and liver metastases is safe and feasible in selected patients with SCRLM. Postoperative intestinal function recovery is enhanced, and morbidity and oncological outcomes are acceptable.

Impact on operative outcomes of laparoscopic simultaneous resection of colorectal cancer and synchronous liver metastases.

The efficacy of laparoscopic simultaneous resection of primary colorectal cancer and synchronous colorectal liver metastases (SCRLM) remains unclear. We retrospectively evaluated data from 258 patients who had undergone simultaneous curative resection of the primary tumor and SCRLM from 2006 to 2017. We compared surgical outcomes between open, hybrid (laparoscopic colorectal resection and open hepatectomy), and pure laparoscopic approaches. Surgical outcomes were also evaluated between the open hepatectomy (OH) group (ie, open/hybrid surgery) and the laparoscopic hepatectomy (LH) group (ie, pure laparoscopic surgery) in 141 patients later in the study period (2013-2017), when the clinical indications for laparoscopic hepatectomy were restricted to simple wedge resection and/or left lateral sectionectomy in our center. The pure laparoscopic approach was associated with significantly less intraoperative blood loss and a significantly shorter postoperative hospital stay than the open and hybrid approaches. Late in the study period, operative outcomes in the LH group (n = 37) were more favorable than for the OH group (n = 104) in terms of intraoperative blood loss and postoperative hospital stay. In patients with rectal cancer, however, earlier postoperative recovery in the LH group did not differ significantly from the OH group. Laparoscopic simultaneous resection of SCRLM with the primary tumor by simple hepatectomy is safe and may enhance patients' postoperative recovery, especially in patients with colon cancer.

Perioperative safety in patients with resectable synchronous colorectal liver metastases.

Worldwide, at least a quarter of the patients with colorectal cancer (CRC) are diagnosed with metastatic disease at presentation and many of them eventually succumb to their disease. A third of these patients may have their metastatic disease burden confined to the liver. It has been estimated that about 15–25% of CRC patients initially present with synchronous resectable liver metastases (SRLM) (1). These patients represent a group whose oncologic prognosis has significantly improved over the past decades (2).

Minimally Invasive versus Open Simultaneous Resections of Colorectal Cancer and Synchronous Liver Metastases: A Meta-Analysis

The aim of this meta-analysis was to compare the efficacy and safety of simultaneous resections between the minimally invasive approach (MIA) and the open approach (OA) for patients with colorectal cancer (CRC) and synchronous colorectal liver metastases (SCRLM). A systematic search was conducted in the Cochrane Library, PubMed, EMBASE and Ovid databases (until May 5, 2016). Studies comparing the perioperative results and long-term outcomes for patients undergoing simultaneous CRC and SCRLM resections between the two approaches were evaluated. Six studies were identified, which included 164 minimally invasive and 213 open simultaneous resections of CRC and SCRLM. MIA was associated with lesser surgical blood loss (mean difference = -155.85 mL; 95% confidence interval: -305.64 to -6.06, P = 0.04) and shorter length of postoperative stay (mean difference = -3.16 days; 95% confidence interval: -4.00 to -2.31, P < 0.00001.). The other perioperative results, including operating time, operative blood transfusion, intestinal function recovery time, and postoperative complications, did not differ significantly. No significant difference in the disease-free survival and overall survival rates between the two approaches was observed. In conclusion, compared with the OA, the MIA for simultaneous CRC and SCRLM resections is safe and effective for the treatment of SCRLM with lesser surgical blood loss and shorter length of postoperative stay. The MIA may be an alternative to the OA for simultaneous CRC and SCRLM resections for appropriately selected patients with resectable SCRLM.

Selection for surgery and survival of synchronous colorectal liver metastases; a nationwide study

BackgroundResection of colorectal liver metastases (CRLM) is associated with improved survival but we currently have limited population-based data on selection for surgery. MethodsPatients in the Swedish Colorectal Cancer Register reported with liver metastases at diagnosis in 2007–2011 were identified. Clinical characteristics including American Society of Anesthesiologists classification, type of hospital and health care region were retrieved. Linkage to the National Patient Register and Statistics Sweden provided information on liver resection and socioeconomic variables. ResultsSynchronous CRLM was found in 4243/27,990 (15.2%) patients, of whom 1094 (25.8%) also had concurrent lung metastases. Of 3149 patients with liver-only metastases, 556 (17.8%) were subjected to liver resection. The resection rate varied by subsite; right-sided 11.7%, left-sided 19.7% and rectal cancer 22.7% (p = 0.001). It varied by type of hospital 14.1–23.6%, by region 11.5–22.7%, and was 19.8% in men and 14.9% in women (all p < 0.001).The adjusted odds were 0.74 (0.59–0.93) for females, 0.58 (0.46–0.74) for general district and 0.50 (0.37–0.68) for district hospital patients, and there were large regional differences. Patients >75 years were very unlikely to receive liver surgery 0.22 (0.15–0.32).In patients subjected to liver surgery, median survival was 57 months, 5-year survival rate was 45.4%, and those with left-sided colon cancer had the best outcome (48.8%; p = 0.02). Five-year hazard ratio for patients not subjected to liver surgery was 4.3 (3.7–5.0). ConclusionNationwide outcome after resection of synchronous CRLM was impressing but ambiguous selection mechanisms and inaccessibility need to be resolved. The implications of subsite deserve further attention.

Feasibility of the liver-first approach for patients with initially unresectable and not optimally resectable synchronous colorectal liver metastases.

To investigate the outcomes of patients with colorectal cancer and initially unresectable or not optimally resectable liver metastases, who were treated using the liver-first approach in the era of modern chemotherapy in Japan. We analyzed and compared data retrospectively on patients with asymptomatic resectable colorectal cancer and initially unresectable or not optimally resectable liver metastases, who were treated either using the liver-first approach (n=12, LF group) or the primary-first approach (n=13, PF group). Both groups of patients completed their therapeutic plan and there was no mortality. Postoperative morbidity rates after primary resection and hepatectomy, and post-hepatectomy liver failure rate were comparable between the groups (p=1.00, p=0.91, and p=0.55, respectively). Recurrence rates, median recurrence-free survival since the last operation, and 3-year overall survival rates from diagnosis were also comparable between the LF and PF groups (58.3 vs. 61.5%, p=0.87; 10.5 vs. 18.6months, p=0.57; and 87.5 vs. 82.5%, p=0.46, respectively). The liver-first approach may be an appropriate treatment sequence without adversely affecting perioperative or survival outcomes for selected patients.

Determinants of long-term outcome in patients undergoing simultaneous resection of synchronous colorectal liver metastases.

BackgroundIt remains unclear which patients can benefit from simultaneous resection of synchronous colorectal liver metastases (SCRLMs). This study aimed to examine the prognostic value of patient- and tumor-related factors in predicting long-term outcomes of patients undergoing simultaneous resection of SCRLMs and to help patients select a suitable therapeutic regimen and proper surveillance.MethodsClinicopathological and outcome data of 154 consecutive SCRLM patients who underwent simultaneous resection between July 2003 and July 2013 were collected from our prospectively established SCRLM data and analyzed with univariate and multivariate methods, and the prognostic index (PI) was formulated based on the regression coefficients (β) of the Cox model. The patients were classified into high- and low-risk groups according to the PI value; the cut-off point was the third quartile.ResultsThe 5-year overall survival rate was 46%, and the 5-year disease-free survival rate was 35%. Five factors were found to be independent predictors of poor overall survival (OS) by multivariate analysis: positive lymph node status, vascular invasion, BRAF mutation, the distribution of bilobar liver metastases (LMs) and non-R0 resection of LMs. Compared to low PI (≤5.978), high PI (>5.978) was highly predictive of shorter OS. Three factors were found to be independent predictors of poor disease-free survival (DFS) by multivariate analysis: tumor deposits, BRAF mutation and bilobar LM distribution. We also determined the PI for DFS. Compared to low PI (≤2.945), high PI (>2.945) was highly predictive of shorter DFS.ConclusionsSimultaneous resection of SCRLM may lead to various long-term outcomes. Patients with low PI have longer OS and DFS, while those with high PI have shorter OS and DFS. Thus, patients with high PI may receive more aggressive treatment and intensive surveillance, This model needs further validation.

Short- and long-term outcomes in simultaneous resection of colorectal cancer and liver metastasis with minimally invasive or open surgery.

e14647 Background: Minimally invasive colorectomy and hepatectomy became a realizable option for patients with colorectal and liver cancer, respectively. However, the role of minimally invasive resection for patients undergoing a simultaneous operation for synchronous colorectal liver metastases (SCRLMs) had not been established. This study compared the short- and long-term outcomes between minimally invasive and open resections for patients undergoing simultaneous surgery for SCRLMs by matched-pair analysis. Methods: We reviewed 36 consecutive SCRLM patients who underwent minimally invasive simultaneous resection of colorectal cancer and liver metastases, and another 36 matched with clinicopathologic variables at the same period. Clinicopathologic data and survival outcome were recorded in CRLM database. Results: The two groups had similar clinicopathologic variables. In the minimally invasive group, the estimated blood loss, bowel function return time and postoperative hospital stays was significantly less than in the open group, although the operating time was significantly longer. The two groups did not differ significantly in terms of overall and disease-free survival. Conclusions: Minimally invasive simultaneous resection of SCRLMs is a safe and feasible option for selected patients.

Benefits of simultaneous laparoscopic resection of primary colorectal cancer and liver metastases

Recently, consensus on the optimal strategy for resectable synchronous colorectal liver metastases (LM) seems to have shifted toward simultaneous resection. However, there are still relatively few reports about simultaneous laparoscopic resection. The aim of this study is to evaluate the outcomes of patients who underwent simultaneous laparoscopic resection. We evaluated 14 patients who underwent simultaneous resection of primary colorectal cancer and LM in our hospital from 2004 to 2012. Patients were selected by matched pair analysis based on the number of LM (≤4) and tumor size (≤5 cm). We divided them into two groups: the simultaneous laparoscopic resection of primary colorectal cancer and LM (Lap-S) group (n = 7) and the simultaneous open resection of primary colorectal cancer and LM (Open-S) group (n = 7). Clinical and oncologic outcomes were compared between the groups. The Lap-S patients were significantly older than the Open-S patients. The mean operative times of Lap-S and Open-S were 472 min and 466 min, respectively. The mean blood loss was significantly smaller in the Lap-S group (153 mL) than in the Open-S group (496 mL). There was no surgical mortality in either group. The incidence of postoperative complications in the Lap-S and Open-S groups was 12.3% and 33.0%, respectively. The mean postoperative hospital stay was significantly shorter in the Lap-S group (16 days) than in the Open-S group (36 days). There was no significant difference in long-term survival between the two groups. Lap-S patients had equivalent long-term outcomes to Open-S patients. Therefore, given its technical feasibility and safety, Lap-S may be one of the most promising options in selected patients.

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. 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).

Efficacy of the Predicted Operation Time (POT) Strategy for Synchronous Colorectal Liver Metastasis (SCLM): Feasibility Study for Staged Resection in Patients with a Long POT

BackgroundThe optimal surgical strategy for resectable synchronous colorectal liver metastases (SCLM), whether simultaneous or staged resections, still remains obscure. The aim of this study was to assess the efficacy of the predicted operation time (POT) strategy, which recommends staged resections in case of POT ≥6 h, otherwise selecting simultaneous resection. MethodsThis was a prospective, nonrandomized, single-institution study. Fifty-nine patients with SCLM underwent tumor resection according to the POT strategy, with patients with a longer POT (≥6 h) undergoing staged resection. Morbidity, overall hospitalization, tumor resection rates, and survival were compared with that of 86 patients who underwent simultaneous resection for SCLM irrespective of POT from 1992 to 2004. ResultsThe former simultaneous and the latter POT strategy groups were similar in terms of patient and tumor demographics as well as surgical procedures. Of the 59 POT group patients, 26 patients (44 %) experienced 40 postoperative complications. Comparing the surgical results of simultaneous resection from 1992 to 2004 and those of resection according to the POT strategy, morbidity (64 vs. 44 %, p = 0.02), frequency of anastomotic leakage (21 vs. 5 %, p < 0.01), and length of hospital stay (27 vs. 18 days, p < 0.01) were significantly lower in the latter group, while tumor resection rates (85 vs. 87 %, p = 0.77) were not different. ConclusionsThe POT strategy is effective in reducing the morbidity in SCLM patients by selecting staged resections in the high-morbidity-risk group without adverse effects on oncologic outcome.

Comparison of oncological outcomes between neoadjuvant and adjuvant chemotherapy combined with surgery for resectable synchronous colorectal liver metastases

BackgroundThe role of neoadjuvant chemotherapy for resectable colorectal liver metastases is a subject of debate. We compared the oncologic outcomes between neoadjuvant chemotherapy and adjuvant chemotherapy combined with surgery for resectable synchronous colorectal liver metastases. MethodsWe analyzed 30 patients who underwent liver resection for resectable colorectal liver metastases combined with oxaliplatin-based neoadjuvant or adjuvant chemotherapy between May 2003 and August 2010. We assessed recurrence-free and overall survival in patients treated using neoadjuvant chemotherapy compared with those who received adjuvant chemotherapy. ResultsOf the 30 patients with colorectal liver metastases, 15 underwent neoadjuvant chemotherapy and 15 underwent adjuvant chemotherapy. Nine (60%) patients in the adjuvant group relapsed and nine (60%) patients in the neoadjuvant group relapsed. The neoadjuvant chemotherapy group had no significant difference in recurrence-free and overall 3-y survival (37.5% versus 45.0%, P = 0.938; 44.0% versus 66.7 %, P = 0.466) compared with the adjuvant chemotherapy group. ConclusionOur results indicate that neoadjuvant chemotherapy is not inferior to adjuvant chemotherapy for resectable colorectal liver metastases, although the study was not randomized and included a limited number of patients.

Laparoscopic major hepatectomy can be safely performed with colorectal surgery for synchronous colorectal liver metastasis

BackgroundThe optimal strategy for resectable synchronous colorectal liver metastases remains controversial. Although some authors advocate a staged treatment, an increasing number of studies have reported that combined colorectal and liver resection is safe. Laparoscopic combined resection in primary colorectal cancer with synchronous liver metastases has been reported but there are no specific data for major liver resections. In the present study, we evaluated the feasibility of a simultaneous entirely laparoscopic procedure, in the light of the benefits of laparoscopy in both colon and liver surgery, and discussed the benefits of this strategy. MethodsTwo cases are presented of totally laparoscopic major liver resections associated with laparoscopic colorectal resections for synchronous liver metastases with the emphasis on the technical aspects. Duration of surgery, blood loss and post-operative outcome were evaluated. ResultsLaparoscopic right hepatectomy or left hepatectomy with simultaneous colon resection for liver metastasis was feasible and safe with only one suprapubic 5-mm trocar added to the usual trocar sites. The mean duration of surgery was 327min with a mean estimated blood loss of 200ml. The post-operative course was uneventful. DiscussionIn selected patients, laparoscopic major hepatectomies for unilobular synchronous metastases can be safely performed simultaneously with colorectal surgery.

Timing of multimodality therapy for resectable synchronous colorectal liver metastases: a retrospective multi-institutional analysis.

The optimal timing of chemotherapy relative to resection of synchronous colorectal liver metastases (SCRLM) is not known. The objective of this retrospective multi-institutional study was to assess the influence of chemotherapy administered before and after hepatic resection on long-term outcomes among patients with initially resectable SCRLM treated from 1995 to 2005. Clinicopathologic data, treatments, and long-term outcomes from patients with initially resectable SCRLM who underwent partial hepatectomy at three hepatobiliary centers were reviewed. Four hundred ninety-nine consecutive patients underwent resection; 297 (59.5%) and 264 (52.9%) were treated with chemotherapy before and after resection. Chemotherapy strategies included pre-hepatectomy alone (n = 148, 24.7%), post-hepatectomy alone (n = 115, 23.0%), perioperative (n = 149, 29.0%), and no chemotherapy (n = 87, 17.4%). Male gender (p = 0.0029, HR = 1.41 [1.12-1.77]), node-positive primary tumor (p = 0.0046, HR = 1.40 [1.11-1.77]), four or more SCRLM (p = 0.0005, HR = 1.65 [1.24-2.18]), and post-hepatectomy chemotherapy treatment for 6 months or longer (p = 0.039, HR = 0.75 [0.57-0.99]) were associated with recurrence-free survival after discovery of SCRLM. Carcinoembryonic antigen >200 ng/ml (p = 0.0003, HR = 2.33 [1.48-3.69]), extrahepatic metastatic disease (p = 0.0025, HR = 2.34 [1.35-4.05]), four or more SCRLM (p = 0.033, HR = 1.43 [1.03-2.00]), and post-hepatectomy chemotherapy treatment for 2 months or longer (p < 0.0001, HR = 0.59 [0.45-0.76]) were associated with overall survival. Pre-hepatectomy chemotherapy was not associated with recurrence-free or overall survival. Patients treated with perioperative chemotherapy had similar outcomes as patients treated with post-hepatectomy chemotherapy only. We conclude that chemotherapy administered after but not before resection of SCRLM was associated with improved recurrence-free and overall survival. However, prospective randomized trials are needed to determine the optimal timing of chemotherapy.

Surgical approaches of resectable synchronous colorectal liver metastases: Timing considerations

To compare the safety and efficacy of simultaneous versus two stage resection of primary colorectal tumors and liver metastases. From January 1996 to May 2004, 103 colorectal tumor patients presented with synchronous liver metastases. Twenty five underwent simultaneous colorectal and liver surgery and 78 underwent liver surgery 1-3 mo after primary colorectal tumor resection. Data were retrospectively analyzed to assess and compare the morbidity and mortality between the surgical strategies. The two groups were comparable regarding the age and sex distribution, the types of liver resection and stage of primary tumors, as well as the number and size of liver metastases. In two-stage procedures more transfusions were required (4 +/- 1.5 vs 2 +/- 1.8, pRBCs, P < 0.05). Chest infection was increased after the two-stage approach (26% vs 17%, P < 0.05). The two-stage procedure was also associated with longer hospitalization (20 +/- 8 vs 12 +/- 6 d, P < 0.05). Five year survival in both groups was similar (28% vs 31%). No hospital mortality occurred in our series. Synchronous colorectal liver metastases can be safely treated simultaneously with the primary tumor. Liver resection should be prioritized over colon resection. It is advisable that complex liver resections with marginal liver residual volume should be dealt with at a later stage.