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Predicting Limited Survival After Resection of Synchronous Colorectal Liver Metastases: a Propensity Score Matched Comparison Between The Primary First And The Simultaneous Strategy. J Gastrointest Surg 2023:10.1007/s11605-023-05633-9. [PMID: 36857012 DOI: 10.1007/s11605-023-05633-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/11/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND The best surgical approach to treat synchronous colorectal liver metastases (CRLM) remains unclear. Here, we aimed to identify prognostic factors associated with limited survival comparing patients undergoing primary-first resection (PF) and simultaneous resection (SR) approaches. METHODS We retrospectively reviewed clinical data of 217 patients who underwent resection for synchronous CRLMs between January 1, 2011, and December 31, 2021. There were 133 (61.2%) PF resection and 84 (38.8%) SRS. The two groups of patients were compared using propensity score matching (PSM) analysis and cox analysis was performed to identify prognostic factors for overall survival (OS). RESULTS After PSM, two groups of 71 patients were compared. Patients undergoing SR had longer operative time (324 ± 104 min vs 250 ± 101 min; p < 0.0001), similar transfusion (33.3% vs 28.1%; p = 0.57), and similar complication rates (35.9% vs 27.2%; p = 0.34) than patients undergoing PF. The median overall survival and 5-year survival rates were comparable (p = 0.94) between patients undergoing PF (48.2 months and 44%) and patients undergoing SR (45.9 months and 30%). Multivariate Cox analysis identified pre-resection elevated CEA levels (HR: 2.38; 95% CI: 1.20-4.70; P = .01), left colonic tumors (HR: 0.34; 95% CI: 0.17-0.68; P = .002), and adjuvant treatment (HR: 0.43; 95% CI: 0.22-0.83; P = .01) as independent prognostic factors for OS. CONCLUSIONS In the presence of synchronous CRLM, right colonic tumors, persistent high CEA levels before surgery, and the absence of adjuvant treatment identified patients characterized by a limited survival rate after resection. The approach used (PF vs SR) does not influence short and long-term outcomes.
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Furuke H, Arita T, Kuriu Y, Shimizu H, Kiuchi J, Yamamoto Y, Konishi H, Morimura R, Shiozaki A, Ikoma H, Kubota T, Nakanishi M, Fujiwara H, Okamoto K, Otsuji E. The survival after recurrence of colorectal cancer: a retrospective study focused on time to recurrence after curative resection. Surg Today 2021; 52:239-250. [PMID: 34269851 DOI: 10.1007/s00595-021-02336-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The significance of the duration of the recurrence-free survival after curative resection for colorectal cancer remains unclear. The purpose was to reveal the association between time to recurrence after surgery and the survival after recurrence. METHODS Patients with stage II and III colorectal cancer who underwent curative resection between 2007 and 2015 were retrospectively reviewed (n = 645). Patients with recurrence after surgery (n = 133) were divided into 2 groups: early recurrence (within 13 months after surgery, n = 63) and late recurrence (more than 13 months after surgery, n = 70). The overall survival after recurrence and clinicopathological features were compared between early recurrence, late recurrence, and without recurrence groups. RESULTS The overall survival after recurrence was significantly shorter in patients with early recurrence occurring at less than 13 months (hazard ratio: 1.70, p = 0.03). A high preoperative CA19-9 level (odds ratio [OR]: 2.38, p = 0.03), venous invasion (OR: 2.26, p = 0.03), and the absence of adjuvant chemotherapy (OR: 2.08, p = 0.04) were independently correlated with early recurrence. CONCLUSION Early recurrence was associated with a poor prognosis after recurrence. Venous invasion correlated with early recurrence. Adjuvant chemotherapy may reduce the risk of early recurrence. These results indicate the importance of prudent surveillance and the aggressive application of adjuvant chemotherapy.
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Affiliation(s)
- Hirotaka Furuke
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Tomohiro Arita
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan.
| | - Yoshiaki Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Hiroki Shimizu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Jun Kiuchi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Yusuke Yamamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Hirotaka Konishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Atsushi Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Takeshi Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Masayoshi Nakanishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Kazuma Okamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan
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The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology. Updates Surg 2021; 73:1247-1265. [PMID: 34089501 DOI: 10.1007/s13304-021-01100-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.
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Two-Stage Hepatectomy and ALPPS for Advanced Bilateral Liver Metastases: a Tailored Approach Balancing Risk and Outcome. J Gastrointest Surg 2019; 23:2391-2400. [PMID: 30820795 DOI: 10.1007/s11605-019-04145-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Two-stage hepatectomy (TSH) with or without portal vein ligation (PVL) or portal vein embolization (PVE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) are surgical strategies in the treatment of advanced colorectal liver metastases (CRLM). The role of each strategy is yet ill defined. The aim of this analysis is to share our center experience with conventional TSH with or without PVL/PVE and ALPPS in patients with advanced bilateral CRLM. PATIENTS AND METHODS Data were extracted from a prospectively collected institutional database. Complication rates according to the Dindo-Clavien classification, overall and recurrence-free survival data were analyzed. RESULTS Between 2008 and 2017, 790 liver resections were performed in 611 patients with CRLM. Out of 320 patients with bilateral disease, TSH (as right or extended right hepatectomy) with or without PVL/PVE was performed in 50 patients and ALPPS in 8. Stage 2 was completed in 36 (72%) out of 50 TSH/PVL/PVE and in all ALPPS patients (100%). Median follow-up was 15.8 months (0.9 to 111.9 months). On an intention-to-treat basis, the median overall survival was 26.7 (21.8-35.1 range) months after TSH/PVL/PVE and 36.2 months (11.3-61.2 range) after ALPPS (p = 0.809). In the TSH/PVL/PVE cohort, the median overall survival was 29.9 (19.0-40.3) months in patients who completed stage 2 compared to 13.8 months in patients who did not (p < 0.001). Disease recurred in 60% in the TSH/PVL/PVE cohort and in 87.5% in the ALPPS cohort (p = 0.777). The median recurrence-free survival was 5.9 (1.7-18.6) months after TSH/PVL/PVE and 3 (1.6-14.8) months after ALPPS (p = 0.680). CONCLUSION The treatment of advanced bilateral CRLM remains a surgical and oncological challenge. A tailored approach to bilateral CRLM uses TSH/PVL/PVE as first and ALPPS as second rescue treatment in order to achieve resectability in patients with extensive tumor burden not amenable to one-stage resection. ALPPS should be reserved for patients with no other surgical options.
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Albati NA, Korairi AA, Al Hasan I, Almodhaiberi HK, Algarni AA. Outcomes of staged hepatectomies for liver malignancy. World J Hepatol 2019; 11:513-521. [PMID: 31293719 PMCID: PMC6603508 DOI: 10.4254/wjh.v11.i6.513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/27/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023] Open
Abstract
Liver malignancies are the fifth most common cause of death worldwide. Surgical intervention with curative intent is the treatment of choice for liver tumors as it provides long-term survival. However, only 20% of patients with metastatic liver lesions can be managed by curative liver resection. In most of the cases, hepatectomy is not feasible because of insufficient future liver remnant (FLR). Two-stage hepatectomy is advocated to achieve liver resection in a patient who is considered to not be a candidate for resection. Procedures of staged hepatectomy include conventional two-stage hepatectomy, portal vein embolization, and associating liver partition and portal vein ligation for a staged hepatectomy. Technical success is high for each of these procedures but variable between them. All the procedures have been reported as being effective in achieving a satisfactory FLR and completing the second-stage resection. Moreover, the overall survival and disease-free survival rates have improved significantly for patients who were otherwise considered nonresectable; yet, an increase in the morbidity and mortality rates has been observed. We suggest that this type of procedure should be carried out in high-flow centers and through a multidisciplinary approach. An experienced surgeon is key to the success of those interventions.
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Affiliation(s)
- Naif A Albati
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ali A Korairi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ibrahim Al Hasan
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Helayel K Almodhaiberi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Abdullah A Algarni
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
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Chen C, Liang C, Lu C, Liu Y, Lu S, Hung C. Prognostic factors of radiofrequency ablation therapy for liver metastases from colorectal cancer. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Chun‐Hsien Chen
- Division of Hepatogastroenterology, Department of Internal MedicineChiayi Chang Gung Memorial Hospital Chiayi Taiwan
| | - Chih‐Ming Liang
- Division of Hepatogastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chien‐Chang Lu
- Department of Colorectal SurgeryKaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Yueh‐Wei Liu
- Department of SurgeryKaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Sheng‐Nan Lu
- Division of Hepatogastroenterology, Department of Internal MedicineChiayi Chang Gung Memorial Hospital Chiayi Taiwan
| | - Chao‐Hung Hung
- Division of Hepatogastroenterology, Department of Internal MedicineChiayi Chang Gung Memorial Hospital Chiayi Taiwan
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Mor E, Al-Kurd A, Yaacov AB, Aderka D, Nissan A, Ariche A. Surgical outcomes of two-stage hepatectomy for colorectal liver metastasis: comparison to a benchmark procedure. Hepatobiliary Surg Nutr 2019; 8:29-36. [PMID: 30881963 DOI: 10.21037/hbsn.2018.12.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Two-stage hepatectomy (TSH) with portal vein embolization (PVE) is associated with high morbidity and mortality and may result in liver failure due to insufficient future liver remnant. The objectives of this investigation were to evaluate the short-term outcomes of patients with colorectal cancer liver metastasis who underwent TSH with PVE, and to critically review the selection criteria for TSH-PVE. Methods A retrospective review of all patients who were operated due to bi-lobar CRLM during the years 2007-2017 was performed. Patients who underwent TSH-PVE were compared to those who underwent right hepatectomy (RH) only. Results Twenty-nine patient underwent TSH, 25 of whom (86.2%) completed both stages. These patients demonstrated a major complication rate of 17%, and a 90-day mortality rate of 3.4%. Most complications (80%) were related to the colonic resection, and one patient developed liver failure. Patients who suffered complications had a trend towards more baseline comorbidities and more liver lesions. Ablative techniques were utilized in 76%. When compared to 35 patients who underwent sole RH, no significant difference was demonstrated in major complication rate (20%) or mortality (0%). Conclusions TSH is a relatively safe procedure in selected patients. Ablative techniques can reduce the occurrence of liver insufficiency and should be used liberally when possible. Factors such as number of lesions, comorbidities and the timing of colonic resection should be considered and evaluated in order to improve the outcomes of the procedure.
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Affiliation(s)
- Eyal Mor
- Department of General and Oncological Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Abbas Al-Kurd
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Almog Ben Yaacov
- Department of General and Oncological Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Dan Aderka
- Department of Oncology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Aviram Nissan
- Department of General and Oncological Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Arie Ariche
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Department of Hepatobiliary Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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Yu J, Li N, Tang Y, Wang X, Tang Y, Wang SL, Song YW, Liu YP, Li YX, Jin J. Outcomes after hypofractionated stereotactic radiotherapy for colorectal cancer oligometastases. J Surg Oncol 2019; 119:532-538. [PMID: 30609038 DOI: 10.1002/jso.25361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 12/18/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES To assess the efficacy and the effect of biologic effective dose (BED) on outcomes treated by hypofractionated stereotactic radiotherapy for colorectal cancer (CRC) oligometastases. METHODS Patients with CRC oligometastases treated at our hospital between 2009 and 2016 were included. The relationship between BED and risk of local recurrence was assessed. Recursive partitioning analysis (RPA) was used to evaluate the effect of BED on outcomes. RESULTS A total of 48 patients were included in this study. Median follow-up time of surviving patient was 15 months (range, 3-82 months). The 1-year local control rate was 85%. The risk of local recurrence decreased sharply when BED was >90 Gy10 . RPA showed BED of 100 Gy 10 was the appropriate dose for recurrence risk stratification. BED ≥ 100 Gy 10 was significantly better than BED < 100 Gy 10 for achieving 1-year local control (94.4% vs 63.2%; P = 0.022) and 1-year OS (100% vs 73.4%; P = 0.028). One patient who received long-term antiangiogenic treatment died of massive intestinal hemorrhage; no other grade 3 or above early or late events were observed. CONCLUSIONS Hypofractionated stereotactic radiotherapy provides favorable outcomes with acceptable toxicities in CRC oligometastases. BED ≥ 100 Gy is associated with better outcomes.
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Affiliation(s)
- Jing Yu
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xin Wang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Stewart CL, Warner S, Ito K, Raoof M, Wu GX, Kessler J, Kim JY, Fong Y. Cytoreduction for colorectal metastases: liver, lung, peritoneum, lymph nodes, bone, brain. When does it palliate, prolong survival, and potentially cure? Curr Probl Surg 2018; 55:330-379. [PMID: 30526930 DOI: 10.1067/j.cpsurg.2018.08.004] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Camille L Stewart
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Susanne Warner
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Kaori Ito
- Department of Surgery, Michigan State University, Lansing, MI
| | - Mustafa Raoof
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Geena X Wu
- Division of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Jonathan Kessler
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA
| | - Jae Y Kim
- Division of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Yuman Fong
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA.
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Vigano L, Darwish SS, Rimassa L, Cimino M, Carnaghi C, Donadon M, Procopio F, Personeni N, Del Fabbro D, Santoro A, Torzilli G. Progression of Colorectal Liver Metastases from the End of Chemotherapy to Resection: A New Contraindication to Surgery? Ann Surg Oncol 2018; 25:1676-1685. [PMID: 29488188 DOI: 10.1245/s10434-018-6387-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Not all patients with resectable colorectal liver metastases (CLM) benefit from liver resection (LR); only patients with disease progression during chemotherapy are excluded from surgery. OBJECTIVE This study was performed to determine whether tumor behavior (stable disease/progression) from the end of chemotherapy to LR impacts prognosis. METHODS Patients undergoing LR after tumor response or stabilization during chemotherapy were considered. Overall, 128 patients who underwent examination by two imaging modalities (computed tomography/magnetic resonance imaging) after chemotherapy with a > 3-week interval between the two imaging modalities were analyzed. Any variation in CLM size was registered. Tumor progression was defined according to the response evaluation criteria in solid tumors (RECIST) criteria. RESULTS Among 128 patients with stable disease or partial response to preoperative chemotherapy, 32 (25%) developed disease progression in the chemotherapy to LR interval, with a disease progression rate of 17% when this interval was < 8 weeks. Survival was lower among patients with progression than those with stable disease [3-year overall survival (OS) 23.0 vs. 52.4%, and recurrence-free survival (RFS) 6.3% vs. 21.6%; p < 0.001]. Survival was extremely poor in patients with early progression (< 8 weeks) (0.0% 2-year OS, 12.5% 6-month RFS). Disease progression in the chemotherapy to LR interval was an independent negative prognostic factor for OS and RFS [hazard ratio 3.144 and 2.350, respectively; p < 0.001]. CONCLUSIONS Early disease progression in the chemotherapy to LR interval occurred in approximately 15% of patients and was associated with extremely poor survival. Even if these data require validation, the risk for early disease progression after chemotherapy should be considered, and, if progression is evident, the indication for surgery should be cautiously evaluated.
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Affiliation(s)
- Luca Vigano
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Shadya Sara Darwish
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Milan, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Carlo Carnaghi
- Medical Oncology and Hematology Unit, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Milan, Italy
| | - Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Fabio Procopio
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Nicola Personeni
- Medical Oncology and Hematology Unit, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Milan, Italy
| | - Daniele Del Fabbro
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Armando Santoro
- Medical Oncology and Hematology Unit, Humanitas Clinical and Research Center, Humanitas University, Rozzano, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy.
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11
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Torzilli G, Viganò L, Cimino M, Imai K, Vibert E, Donadon M, Mansour D, Castaing D, Adam R. Is Enhanced One-Stage Hepatectomy a Safe and Feasible Alternative to the Two-Stage Hepatectomy in the Setting of Multiple Bilobar Colorectal Liver Metastases? A Comparative Analysis between Two Pioneering Centers. Dig Surg 2018; 35:323-332. [PMID: 29439275 DOI: 10.1159/000486210] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/10/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Two-stage hepatectomy (TSH) is the present standard for multiple bilobar colorectal metastases (CLM). As alternative, ultrasound-guided one-stage hepatectomy (E-OSH) has been proposed even for deep-located nodules to compare TSH and E-OSH. METHODS All consecutive TSH at the Paul Brousse Hospital and E-OSH at the Humanitas Research Hospital were considered. The inclusion criteria were ≥6 CLM, ≥3 CLM in the left liver, and ≥1 lesion with vascular contact. A total of 74 TSH and 35 E-OSH were compared. RESULTS The 2 groups had similar characteristics. Drop-out rate of TSH was 40.5%. In comparison with the cumulated hepatectomies of TSH, E-OSH had lower blood loss (500 vs. 1,100 mL, p = 0.009), overall morbidity (37.1 vs. 70.5%, p = 0.003), severe morbidity (14.3 vs. 36.4%, p = 0.04), and liver-specific morbidity (22.9 vs. 40.9%, p = 0.02). R0 resection rate was similar between groups. E-OSH and completed TSH had similar overall survival (5-year 38.2 vs. 31.8%), recurrence-free survival (3-year 17.6 vs. 17.7%), and recurrence sites. CONCLUSIONS E-OSH is a safe alternative to TSH for multiple bilobar deep-located CLM. Whenever feasible, E-OSH should even be considered the preferred option because it has excellent safety and oncological outcomes equivalent to completed TSH, without the drop-out risk.
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Affiliation(s)
- Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Luca Viganò
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Katsunori Imai
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
| | - Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Doaa Mansour
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Denis Castaing
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
| | - Ren Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
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Stockmann M, Bednarsch J, Malinowski M, Blüthner E, Pratschke J, Seehofer D, Jara M. Functional considerations in ALPPS - consequences for clinical management. HPB (Oxford) 2017; 19:1016-1025. [PMID: 28844397 DOI: 10.1016/j.hpb.2017.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/28/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Since perioperative morbidity and mortality in ALPPS are extraordinarily high, a deeper understanding of actual liver function during the procedure is essential to make the approach safer. METHODS Data from 17 patients who underwent ALLPS were analyzed regarding their course of liver function capacity assessed with the LiMAx test and compared to an equal-sized matched cohort of patients that underwent PVE. RESULTS A comparison of LiMAx prior to and following ALPPS Step I (330 [258-385] vs. 197 [144-224] μg/kg/h, p = 0.003) and prior to and following PVE (386 [330-519] vs. 378 [336-455] μg/kg/h, p = 0.534) demonstrated a significant drop in function after ALLPS. A volume/function analysis predicting FLR function regarding step II revealed an excellent correlation of predicted versus assessed postoperative liver function with a mean relative difference of 9 (-6 to 18)% and an ICC of 0.905 (123 [74-138] vs. 107 [77-175] μg/kg/h, p = 0.310). CONCLUSIONS We provide evidence that liver function capacity is significantly impaired due to ALPPS step I. This is particularly notable when compared to PVE. Our data also shows that the portal ligated liver lobe still continues to contribute significantly to overall liver function. Therefore, FLR function after step II is still predictable by volume/function analysis.
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Affiliation(s)
- Martin Stockmann
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jan Bednarsch
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Maciej Malinowski
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Elisabeth Blüthner
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Daniel Seehofer
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Maximilian Jara
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
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13
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Cracco A, Roy M, Simpfendorfer CH. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy combined with two-stage hepatectomy for multiple and bilobar desmoplastic small round cell tumor liver metastases. J Gastrointest Oncol 2017; 8:E60-E64. [PMID: 28890830 DOI: 10.21037/jgo.2017.07.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Desmoplastic small round cell tumor (DSRCT) is a rare mesenchymal tumor usually affecting young patients. Local dissemination is common, and liver is the most common site for extraperitoneal metastases. Multimodal management has been shown to be the most effective treatment. Some authors consider liver metastases especially bi-lobar disease as a contraindication for surgical resection. We present a case of a DSRCT with bi-lobar metastases in an adult patient who underwent multi-modal management along with hepatectomy. A 51-year-old man was found to have a large intraperitoneal mass with bi-lobar liver metastases during work up for new onset reflux and abdominal pain. Biopsy confirmed it as DSRCT. The patient was treated with multi-modal therapy including cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), two-stage hepatectomy (TSHP) combined with (90Y) Yittrium-90 radioembolization of the right hepatic lobe and systemic chemotherapy. The patient had a right-sided pleural empyema one month after the surgery for which he required right-sided video-assisted thoracoscopy and decortication. He remains disease free at 2 years follow-up. DSRCT with bi-lobar liver metastases are best managed with multimodal therapy. TSHP seems to be a feasible and safe option in selected cases, with a potentially good outcome.
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Affiliation(s)
- Alejandro Cracco
- Department of Hepatobiliary and Pancreas Surgery, Cleveland Clinic Florida, FL, USA
| | - Mayank Roy
- Department of Hepatobiliary and Pancreas Surgery, Cleveland Clinic Florida, FL, USA
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14
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Wanis KN, Buac S, Linecker M, Ardiles V, Tun-Abraham ME, Robles-Campos R, Malago M, de Santibañes E, Clavien PA, Hernandez-Alejandro R. Patient Survival After Simultaneous ALPPS and Colorectal Resection. World J Surg 2017; 41:1119-1125. [PMID: 27837237 DOI: 10.1007/s00268-016-3818-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Liver resection combined with colorectal surgery (CRS) is the only curative option in many patients presenting with synchronous colorectal cancer and liver metastases (CRLM). Simultaneous resection has been shown to offer benefits in patients with low hepatic tumor load; however, in the setting of in situ colorectal tumor with extensive CRLM and a small predicted future liver remnant (FLR), the use of simultaneous ALPPS and CRS is controversial, lacking outcome data. METHODS Thirty-one cases of simultaneous ALPPS and CRS prospectively entered into the International ALPPS Registry were examined. Univariate analysis was used to identify factors associated with 90-day mortality after stage-2. RESULTS Thirty patients (97%) completed both stages. CRS was performed during stage-1 in 22 patients (73%). Seven patients (23%) had severe complications (Clavien-Dindo ≥ IIIb) following stage-2 ALPPS. The 90-day mortality rate was 15%. Patients who had a severe complication after stage-1 were significantly more likely to have 90-day mortality following stage-2 (p = 0.002). MELD score > 10 on postoperative day-5 after stage-1 was also significantly associated with 90-day mortality (p = 0.011). Disease-free survival and overall survival were 36% and 76% at 1 year, respectively. CONCLUSIONS In light of the high mortality and poor long-term survival identified in this series, the adoption of ALPPS with CRS cannot be recommended without further data. Patients who suffer severe complications or have an elevated MELD score after stage-1 are at higher risk of mortality following stage-2.
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Affiliation(s)
- Kerollos Nashat Wanis
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Suzana Buac
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Michael Linecker
- Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina
| | - Mauro Enrique Tun-Abraham
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada
| | - Ricardo Robles-Campos
- Department of General Surgery, Liver Transplant Unit, Virgen De La Arrixaca University Hospital, Murcia, Spain
| | - Massimo Malago
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, University College London, London, UK
| | - Eduardo de Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina
| | - Pierre-Alain Clavien
- Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Roberto Hernandez-Alejandro
- Division of Hepatobiliary Surgery and Transplantation, Department of Surgery, University of Rochester, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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15
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Wanis KN, Pineda-Solis K, Tun-Abraham ME, Yeoman J, Welch S, Vogt K, Van Koughnett JAM, Ott M, Hernandez-Alejandro R. Management of colorectal cancer with synchronous liver metastases: impact of multidisciplinary case conference review. Hepatobiliary Surg Nutr 2017; 6:162-169. [PMID: 28652999 DOI: 10.21037/hbsn.2017.01.01] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND While no evidence exists to support mandatory multidisciplinary case conference (MCC) review for patients with synchronous colorectal cancer and liver metastases, this unique population may benefit greatly from multidisciplinary discussion. METHODS We retrospectively identified patients who underwent liver resection with curative intent for colorectal liver metastases (CRLM) at a tertiary center between January 2008 and June 2015. The characteristics of patients discussed at a weekly regional MCC were examined, and the effect of MCC review on treatment approach was assessed. RESULTS Sixty-six patients underwent elective surgery for synchronous colorectal cancer and liver metastases during the study period. Twenty-nine patients (44%) were presented at a MCC. Presentation was associated with greater likelihood of undergoing simultaneous or liver-first resection (P≤0.0001), with no difference in the extent of liver resection or location of primary tumor between the groups. A greater proportion of patients received chemotherapy and/or radiation following MCC discussion, without statistical significance. CONCLUSIONS The treatment approach for patients with synchronous colorectal cancer and liver metastases may be significantly altered based on MCC review. Multidisciplinary discussion is advocated in order to facilitate equal access to individualized care.
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Affiliation(s)
- Kerollos N Wanis
- Department of Surgery, Western University, London Health Sciences Centre, London, Canada
| | - Karen Pineda-Solis
- Department of Surgery, Western University, London Health Sciences Centre, London, Canada
| | - Mauro E Tun-Abraham
- Department of Surgery, Western University, London Health Sciences Centre, London, Canada
| | - Jake Yeoman
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Stephen Welch
- Department of Oncology, Western University, London Health Sciences Centre, London, Canada
| | - Kelly Vogt
- Department of Surgery, Western University, London Health Sciences Centre, London, Canada
| | - Julie Ann M Van Koughnett
- Department of Surgery, Western University, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London Health Sciences Centre, London, Canada
| | - Michael Ott
- Department of Surgery, Western University, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London Health Sciences Centre, London, Canada
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Rabinel P, Dousse D, Muscari F, Suc B. Management of liver cancer. The Surgeon's point of view. Rep Pract Oncol Radiother 2017; 22:176-180. [PMID: 28490990 DOI: 10.1016/j.rpor.2017.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 12/27/2016] [Accepted: 02/06/2017] [Indexed: 02/07/2023] Open
Abstract
During the last twenty years, a huge progress has been achieved in the treatment of liver cancer and recent strategies include interventional radiology, chemotherapy regimens and surgery. Meanwhile, Stereotactic Body Radiation Therapy (SRBT) has developed in the treatment of all organs with millimetre accuracy, very few side effects and a high control rate. So, SRBT has become a therapeutic weapon in his own right in liver tumour treatment. Many publications have reported encouraging results in colorectal liver metastasis, hepatocellular carcinoma on cirrhosis and peripheric cholangiocarcinoma. It is important that radiation therapists involve systematic multidisciplinary "liver tumour" meetings to discuss therapeutic indications and initiate treatments quickly.
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Affiliation(s)
- Pierre Rabinel
- Department of Digestive Surgery and Liver Transplantation, Rangueil Hospital, 1, Avenue du Pr Jean Poulhès TSA 50032, 31059 Toulouse Cedex, France
| | - Damien Dousse
- Department of Digestive Surgery and Liver Transplantation, Rangueil Hospital, 1, Avenue du Pr Jean Poulhès TSA 50032, 31059 Toulouse Cedex, France
| | - Fabrice Muscari
- Department of Digestive Surgery and Liver Transplantation, Rangueil Hospital, 1, Avenue du Pr Jean Poulhès TSA 50032, 31059 Toulouse Cedex, France
| | - Bertrand Suc
- Department of Digestive Surgery and Liver Transplantation, Rangueil Hospital, 1, Avenue du Pr Jean Poulhès TSA 50032, 31059 Toulouse Cedex, France
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17
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Cassinotto C, Dohan A, Gallix B, Simoneau E, Boucher LM, Metrakos P, Cabrera T, Torres C, Muchantef K, Valenti DA. Portal Vein Embolization in the Setting of Staged Hepatectomy with Preservation of Segment IV ± I Only for Bilobar Colorectal Liver Metastases: Safety, Efficacy, and Clinical Outcomes. J Vasc Interv Radiol 2017; 28:963-970. [PMID: 28283401 DOI: 10.1016/j.jvir.2017.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/12/2016] [Accepted: 01/04/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To assess frequency of adverse events, efficacy, and clinical outcomes of percutaneous portal vein embolization (PVE) in patients with bilobar colorectal liver metastases undergoing staged hepatectomy with preservation of segment IV ± I only. MATERIALS AND METHODS Retrospective analysis was performed of 40 consecutive patients who underwent right PVE after successful left lobectomy between 2005 and 2013. Rates of adverse events, future liver remnant (FLR) > 30% compared with baseline liver volume, clinical success (completion of staged hepatectomy with clearance of liver metastases), and overall survival were analyzed. RESULTS PVE was performed using polyvinyl alcohol particles (n = 7; 17.5%), particles plus coils (n = 23; 57.5%), and N-butyl cyanoacrylate glue plus ethiodized oil (n = 10; 25%). Technical success was 100%. After PVE, 20% (n = 8) of patients exhibited portal venous thrombosis, ranging from isolated intrahepatic portal branch thrombosis to massive thrombosis of the main portal vein (n = 3) and responsible for periportal cavernoma and portal hypertension in 5 patients. Of patients, 23 (57.5%) had FLR ≥ 30%, and 21 (52.5%) had clinical success. Six patients had significant stenosis or occlusion of the left portal vein or biliary system after original left lobectomy, which was independently associated with FLR < 30% (R2 = 0.24). Clinical success was the only independent variable associated with survival (R2 = 0.25). CONCLUSIONS PVE for staged hepatectomy with preservation of segment IV ± I only is technically feasible, leading to adequate hypertrophy and clinical success rates in these patients with poor oncologic prognosis. Portal venous thrombosis is greater after the procedure than in the setting of standard PVE.
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Affiliation(s)
- Christophe Cassinotto
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada; Departments of Diagnostic and Interventional Radiology, Pathology, Digestive Oncology, and Visceral Surgery, Hôpital Haut-Lévêque, University Hospital of Bordeaux, Pessac, France.
| | - Anthony Dohan
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - Benoît Gallix
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - Eve Simoneau
- Hepato-Pancreato-Biliary and Abdominal Organ Transplant Surgery (E.S., P.M.), Royal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - Louis-Martin Boucher
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - Peter Metrakos
- Hepato-Pancreato-Biliary and Abdominal Organ Transplant Surgery (E.S., P.M.), Royal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - Tatiana Cabrera
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - Carlos Torres
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - Karl Muchantef
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
| | - David A Valenti
- Department of RadiologyRoyal Victoria Hospital, McGill University Health Center, 1001 Boulevard Decarie, Montreal, QC H4A 3J1, Canada
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Two-stage hepatectomy in two regional district community hospitals: perioperative safety and long-term survival. TUMORI JOURNAL 2016; 103:170-176. [PMID: 28058712 DOI: 10.5301/tj.5000589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Surgical resection offers the best chance of cure for patients with colorectal liver metastases (CRLMs). Two-stage hepatectomy (TSH) has been demonstrated to be safe and effective to obtain curative resection in patients with multiple, bilobar CRLMs that are unresectable in a single procedure. Up to now TSH has been the prerogative of dedicated liver surgery centers. The aim of this study was to assess the safety and effectiveness of TSH also in community hospitals. METHODS Of 294 patients operated on for CRLMs between September 1997 and June 2012 in 2 district community hospitals (belonging to the same regional healthcare district), 43 (14.6%) were scheduled for TSH. Thirty-eight/43 received neoadjuvant and/or bridge chemotherapy (2 neoadjuvant only, 4 neoadjuvant and bridge, 32 bridge only). RESULTS The mean follow-up was 35.74 ± 29.53 months. Five-year overall survival (OS) was 31.4%, with a median survival time of 31 months. Twenty-nine patients completed the planned procedure (OS: 42.9%; median 47 months), while 14 did not because of disease progression (OS: 0%; median 13 months). No operative mortality occurred within the first 90 days either after the first or second stage. CONCLUSIONS Our results suggest good efficacy and safety of TSH even when performed in a community hospital setting. Shifting patient selection from neoadjuvant to bridge chemotherapy had no impact on outcome once the clearing of the liver had been achieved. In patients presenting with synchronous CRLMs, simultaneous colorectal resection and clearing of the less involved hemiliver as the first surgical step is feasible without any negative impact on outcome.
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Torzilli G, Adam R, Viganò L, Imai K, Goransky J, Fontana A, Toso C, Majno P, de Santibañes E. Surgery of Colorectal Liver Metastases: Pushing the Limits. Liver Cancer 2016; 6:80-89. [PMID: 27995092 PMCID: PMC5159716 DOI: 10.1159/000449495] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The recent advent of more effective chemotherapy and the development of surgical procedures have expanded the pool of resectable patients with colorectal liver metastases (CLM). Two-stage hepatectomy (TSH), associated liver partition and portal vein ligation for staged hepatectomy (ALPPS), and ultrasound-guided enhanced one-stage hepatectomy (e-OSH) are the surgical solutions proposed for these patients, but the range of indications for these procedures vary from institution to institution. SUMMARY The advantages and disadvantages of each approach are herein discussed. Patients who drop out between the staged operations of TSH limit its success rate, although predictive scores may help with patient selection and thereby optimize the results. Safety and oncological suitability are concerns to be addressed when considering ALPPS. These concerns notwithstanding, ALPPS has introduced an innovative concept in surgery: the monosegmental remnant liver. Studies involving e-OSH have proven the oncological suitability of tumor exposure once the CLM is detached from major intrahepatic vessels. This finding could expand the indications for e-OSH, although the technical challenges that it entails limit its spread among the surgical community. The liver-first approach involves the clearance of tumors from the liver before the colorectal primary is tackled. This approach fully justifies the complexity of e-OSH. KEY MESSAGES Predictive scores limiting the interstage dropout of TSH, partial and monosegmental ALPPS, and R1 vascular e-OSH justified by solid long-term results represent new insights that could help refne the patient assignment to each of these approaches. Additionally, liver transplantation is an emerging treatment for CLM that should be taken into account.
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Affiliation(s)
- Guido Torzilli
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Hu-manitas Clinical and Research Hospital, Rozzano, Italy,*Guido Torzilli, MD, PhD Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Humanitas Clinical and Research Hospital, Via Manzoni, 56, IT–20089, Rozzano, Milano (Italy), Tel. +39 02 8224 4769, E-Mail
| | - René Adam
- Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse, Villejuif, France
| | - Luca Viganò
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Hu-manitas Clinical and Research Hospital, Rozzano, Italy
| | - Katsunori Imai
- Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse, Villejuif, France
| | - Jeremias Goransky
- Department of General Surgery, Division of Hepatobiliary and Pancreatic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Andrea Fontana
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Hu-manitas Clinical and Research Hospital, Rozzano, Italy
| | - Christian Toso
- Department of Visceral and Transplantation Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Pietro Majno
- Department of Visceral and Transplantation Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Eduardo de Santibañes
- Department of General Surgery, Division of Hepatobiliary and Pancreatic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Coimbra FJF, Ribeiro HSDC, Marques MC, Herman P, Chojniak R, Kalil AN, Wiermann EG, Cavallero SRDA, Coelho FF, Fernandes PHDS, Silvestrini AA, Almeida MFA, de Araújo ALE, Pitombo M, Teixeira HM, Waechter FL, Ferreira FG, Diniz AL, D'Ippolito G, D'Ippolito G, Begnami MDFDS, Prolla G, Balzan SMP, de Oliveira TB, Szultan LA, Lendoire J, Torres OJM. FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2016; 28:222-30. [PMID: 26734788 PMCID: PMC4755170 DOI: 10.1590/s0102-6720201500040002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023]
Abstract
Background : Liver metastases of colorectal cancer are frequent and potentially fatal event
in the evolution of patients with these tumors. Aim : In this module, was contextualized the clinical situations and parameterized
epidemiological data and results of the various treatment modalities established.
Method: Was realized deep discussion on detecting and staging metastatic colorectal
cancer, as well as employment of imaging methods in the evaluation of response to
instituted systemic therapy. Results : The next step was based on the definition of which patients would have their
metastases considered resectable and how to expand the amount of patients elegible
for modalities with curative intent. Conclusion : Were presented clinical, pathological and molecular prognostic factors,
validated to be taken into account in clinical practice.
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Affiliation(s)
| | | | | | - Paulo Herman
- American Hepato-Pancreato-Biliary Association, São Paulo, Brazil
| | - Rubens Chojniak
- American Hepato-Pancreato-Biliary Association, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Marcos Pitombo
- American Hepato-Pancreato-Biliary Association, São Paulo, Brazil
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Kilburn DJ, Chiow AKH, Lewin J, Kienzle N, Cavallucci DJ, Bryant R, O'Rourke N. Laparoscopic approach to a planned two-stage hepatectomy for bilobar colorectal liver metastases. ANZ J Surg 2016; 86:811-815. [DOI: 10.1111/ans.12748] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Daniel James Kilburn
- Hepatopancreatobiliary Unit; Department of Surgery; Royal Brisbane and Women's Hospital, Queensland Health; Herston Queensland Australia
| | - Adrian Kah Heng Chiow
- Hepatopancreatobiliary Unit; Department of Surgery; Royal Brisbane and Women's Hospital, Queensland Health; Herston Queensland Australia
| | - Joel Lewin
- Hepatopancreatobiliary Unit; Department of Surgery; Royal Brisbane and Women's Hospital, Queensland Health; Herston Queensland Australia
| | - Nicholas Kienzle
- Department of Medical Imaging; Royal Brisbane and Women's Hospital, Queensland Health; Herston Queensland Australia
| | - David Joseph Cavallucci
- Hepatopancreatobiliary Unit; Department of Surgery; Royal Brisbane and Women's Hospital, Queensland Health; Herston Queensland Australia
| | - Richard Bryant
- Hepatopancreatobiliary Unit; Department of Surgery; Royal Brisbane and Women's Hospital, Queensland Health; Herston Queensland Australia
| | - Nicholas O'Rourke
- Hepatopancreatobiliary Unit; Department of Surgery; Royal Brisbane and Women's Hospital, Queensland Health; Herston Queensland Australia
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Drop-out between the two liver resections of two-stage hepatectomy. Patient selection or loss of chance? Eur J Surg Oncol 2016; 42:1385-93. [DOI: 10.1016/j.ejso.2016.03.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/22/2016] [Accepted: 03/21/2016] [Indexed: 12/25/2022] Open
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Philips P, Groeschl RT, Hanna EM, Swan RZ, Turaga KK, Martinie JB, Iannitti DA, Schmidt C, Gamblin TC, Martin RCG. Single-stage resection and microwave ablation for bilobar colorectal liver metastases. Br J Surg 2016; 103:1048-54. [PMID: 27191368 DOI: 10.1002/bjs.10159] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 02/14/2016] [Accepted: 02/15/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients undergoing liver resection combined with microwave ablation (MWA) for bilobar colorectal metastasis may have similar overall survival to patients who undergo two-stage hepatectomy, but with less morbidity. METHODS This was a multi-institutional evaluation of patients who underwent MWA between 2003 and 2012. Morbidity (90-day) and mortality were compared between patients who had MWA alone and those who underwent combined resection and MWA (CRA). Mortality and overall survival after CRA were compared with published data on two-stage resections. RESULTS Some 201 patients with bilobar colorectal liver metastasis treated with MWA from four high-volume institutions were evaluated (100 MWA alone, 101 CRA). Patients who had MWA alone were older, but the groups were otherwise well matched demographically. The tumour burden was higher in the CRA group (mean number of lesions 3·9 versus 2·2; P = 0·003). Overall (31·7 versus 15·0 per cent; P = 0·006) and high-grade (13·9 versus 5·0 per cent; P = 0·030) complication rates were higher in the CRA group. Median overall survival was slightly shorter in the CRA group (38·4 versus 42·2 months; P = 0·132) but disease-free survival was similar (10·1 versus 9·3 months; P = 0·525). The morbidity and mortality of CRA compared favourably with rates in the existing literature on two-stage resection, and survival data were similar. CONCLUSION Single-stage hepatectomy and MWA resulted in survival similar to that following two-stage hepatectomy, with less overall morbidity.
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Affiliation(s)
- P Philips
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - R T Groeschl
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - E M Hanna
- Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - R Z Swan
- Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - K K Turaga
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - J B Martinie
- Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - D A Iannitti
- Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - C Schmidt
- Department of Surgery, Ohio State University, Columbus, Ohio, USA
| | - T Clark Gamblin
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - R C G Martin
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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Donati M, Stavrou GA, Stang A, Basile F, Oldhafer KJ. 'Liver-first' approach for metastatic colorectal cancer. Future Oncol 2016; 11:1233-43. [PMID: 25832880 DOI: 10.2217/fon.14.316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The liver-first approach was proposed for the first time in 2006 to obtain resectability of stage IV colorectal cancer patients and complete the therapeutic plan. From then some groups have used this new revolutionary approach reporting promising results. Other alternative strategies have been proposed for metastatic patients. The authors reviewed the literature weighing the pros and cons of each strategy proposed to manage these advanced tumor stages. The therapeutic options are analyzed in the light of oncologic problems and evidence. Also problems, questions and perspectives are given. Even if the 'liver-first' approach seems to be a promising strategy, the ideal diagnostic-therapeutic flowchart for metastatic colorectal cancer is still difficult to standardize. The great heterogeneity of this population of patients is one of the main problems. A 'tailored approach' philosophy is necessary to calibrate, in a multidisciplinary setting, a case-by-case choice of therapeutic options.
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Affiliation(s)
- Marcello Donati
- Department of Surgery & Medical-Surgical Specialties, General & Oncologic Surgery Unit, Vittorio-Emanuele University Hospital, University of Catania, 95122 Catania, Italy
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25
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Laparoscopic Approach for Primary Colorectal Cancer Improves Outcome of Patients Undergoing Combined Open Hepatic Resection for Liver Metastases. World J Surg 2015; 39:2573-82. [DOI: 10.1007/s00268-015-3127-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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26
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Wiederkehr JC, Avilla SG, Mattos E, Coelho IM, Ledesma JA, Conceição AF, Wiederkehr HA, Wiederkehr BA. Associating liver partition with portal vein ligation and staged hepatectomy (ALPPS) for the treatment of liver tumors in children. J Pediatr Surg 2015; 50:1227-31. [PMID: 25783345 DOI: 10.1016/j.jpedsurg.2014.10.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 09/28/2014] [Accepted: 10/01/2014] [Indexed: 12/11/2022]
Abstract
Resection is the only curative treatment option for primary and secondary malignant tumors of the liver. Although curative resection is associated with long-term survival rates, it can only be performed in 10% of patients with primary tumors and 25% of patients with liver metastases. Liver insufficiency is one of the most serious postoperative complications of patients undergoing extensive liver resections. When total liver resection is necessary liver transplant is mandatory, with the burden of long-term immunosuppression and its complications. Among several different strategies to increase the resectability of liver tumors, portal vein occlusion (embolization or ligature), bilateral tumor resection in two stages, and resection combined with loco regional therapy are the most popular. A new strategy for patients with marginally resectable liver tumors previously considered to be unresectable was formally reported by Baumgart et al. in 2011, originally developed by Hans Schlitt in 2007. This technique consists of a two-staged hepatectomy with initial portal vein ligation and in situ splitting of the liver parenchyma, and it is known as ALPPS (associating liver partition with portal vein ligation for staged hepatectomy). The aim of this study is to present the first series of pediatric patients with marginally resectable liver tumors previously considered to be unresectable treated with two-stage hepatectomy with initial portal vein ligation and in situ splitting of the liver parenchyma. Two patients were diagnosed with hepatoblastoma, and one each with rhabdomyosarcoma, hepatocellular carcinoma, and nodular focal hyperplasia. ALPPS technique was considered whenever the future liver remnant (FLR) was 40% or less of the total liver volume (TLV) determined by CT or MRI scans. The ratio of FLR to TLV before the first procedure ranged from 0.15 to 0.38, with a mean±sd of 0.253±0.07. In all patients, a rapid growth of the FLR was observed. Estimates of the FRL volume prior to surgical treatment ranged from 110cc to 750cc, with a mean±sd of 361.6±213.75cc. Just before the second procedure, the volume of the remnant liver ranged from 225cc to 910cc, with a mean±sd of 563.6cc±221.7cc. The FRL volume increase had a mean±sd of 72.56%±29.05%, with a median of 83.8%. The second procedure was performed after 7 to 12days with a median of 11days. The only postoperative complication observed in one patient was an asymptomatic right pleural effusion that was aspirated during the second procedure with no further complications. ALPPS was shown to be effective and a safe procedure to treat large tumors in children.
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Affiliation(s)
- Julio Cesar Wiederkehr
- Federal University of Paraná, Curitiba Brazil; Division of Liver Transplantation and Surgery, Hospital Pequeno Príncipe, Curitiba Brazil.
| | - Sylvio Gilberto Avilla
- Division of Liver Transplantation and Surgery, Hospital Pequeno Príncipe, Curitiba Brazil
| | - Elisângela Mattos
- Division of Liver Transplantation and Surgery, Hospital Pequeno Príncipe, Curitiba Brazil
| | - Izabel Meister Coelho
- Division of Liver Transplantation and Surgery, Hospital Pequeno Príncipe, Curitiba Brazil
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Ramia JM, Adel F, de La Plaza R, Veguillas P, García-Parreño J. Laparoscopic first stage in a two-stage hepatectomy. Cir Esp 2015; 93:125-7. [PMID: 24094926 DOI: 10.1016/j.ciresp.2013.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 05/09/2013] [Accepted: 05/23/2013] [Indexed: 02/07/2023]
Affiliation(s)
- José Manuel Ramia
- Unidad de Cirugía Hepatobiliopancreática. Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - Farah Adel
- Unidad de Cirugía Hepatobiliopancreática. Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Roberto de La Plaza
- Unidad de Cirugía Hepatobiliopancreática. Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Pilar Veguillas
- Unidad de Cirugía Hepatobiliopancreática. Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Jorge García-Parreño
- Unidad de Cirugía Hepatobiliopancreática. Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
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Faitot F, Soubrane O, Wendum D, Sandrini J, Afchain P, Balladur P, de Gramont A, Scatton O. Feasibility and survival of 2-stage hepatectomy for colorectal metastases: definition of a simple and early clinicopathologic predicting score. Surgery 2014; 157:444-53. [PMID: 25633729 DOI: 10.1016/j.surg.2014.09.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 08/13/2014] [Accepted: 09/18/2014] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Bilobar colorectal metastases may be treated by a 2-stage surgical strategy. The risk of drop out after the first stage hepatectomy remains high and is associated with a nearly zero survival rate at 3 years. Our goal was to evaluate the factors predictive of the feasibility of the strategy and long-term survival, based on simple clinical and histologic features obtained from the first stage specimen. PATIENTS AND METHODS Patients who underwent a first stage hepatectomy with curative intent were included. Preoperative clinical parameters and histologic features of the primary neoplasm and metastases obtained at the first stage hepatectomy were analyzed and compared between patients who did or did not undergo the second stage operation. A group of comparable patients treated only by chemotherapy was used as a control group. RESULTS The feasibility rate of this 2-stage resection was 76% (38/50 patients). Median survival was greater in patients treated with chemotherapy alone than for those who failed the second stage. A clinicopathologic score including male sex, segment 1 metastasis, need for >3 resection(s)/radiofrequency ablation(s), vascular invasion in the primary, need for change in type of chemotherapy, and microscopic biliary invasion by the metastasis was predictive of feasibility of the second stage and disease-free survival in patients achieving the second stage. CONCLUSION Combining preoperative clinical parameters with pathologic features of the primary and the metastatic lesions obtained during first stage hepatectomy predicted accurately patients who failed the second stage, and the long-term outcomes. Considering both clinical and pathologic parameters may help to define the best oncologic strategy by choosing between an exclusive chemotherapeutic or a surgical strategy.
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Affiliation(s)
- Francois Faitot
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Saint Antoine, Paris, France
| | - Olivier Soubrane
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Saint Antoine, Paris, France
| | | | | | | | | | | | - Olivier Scatton
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Saint Antoine, Paris, France.
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29
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Two-Stage Hepatectomy Versus 1-Stage Resection Combined With Radiofrequency for Bilobar Colorectal Metastases. Ann Surg 2014; 260:822-7; discussion 827-8. [DOI: 10.1097/sla.0000000000000976] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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30
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Siriwardena AK, Mason JM, Mullamitha S, Hancock HC, Jegatheeswaran S. Management of colorectal cancer presenting with synchronous liver metastases. Nat Rev Clin Oncol 2014; 11:446-59. [PMID: 24889770 DOI: 10.1038/nrclinonc.2014.90] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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31
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Hwang M, Jayakrishnan TT, Green DE, George B, Thomas JP, Groeschl RT, Erickson B, Pappas SG, Gamblin TC, Turaga KK. Systematic review of outcomes of patients undergoing resection for colorectal liver metastases in the setting of extra hepatic disease. Eur J Cancer 2014; 50:1747-1757. [PMID: 24767470 DOI: 10.1016/j.ejca.2014.03.277] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/08/2014] [Accepted: 03/18/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Surgical resection for patients with colorectal liver metastases (CRLM) can offer patients a significant survival benefit. We hypothesised that patients with CRLM and extra hepatic disease (EHD) undergoing metastasectomy had comparable survival and describe outcomes based on the distribution of metastatic disease. METHODS A systematic search using a predefined registered protocol was undertaken between January 2003 and June 2012. Primary exposure was hepatic resection for CRLM and primary outcome measure was overall survival. Meta-regression techniques were used to analyse differences between patients with and without extra hepatic disease. FINDINGS From a pool of 4996 articles, 50 were retained for data extraction (3481 CRLM patients with EHD). The median survival (MS) was 30.5 (range, 9-98) months which was achieved with an operative mortality rate of 0-4.2%. The 3-year and 5-year overall survival (OS) were 42.4% (range, 20.6-77%) and 28% (range, 0-61%) respectively. Patients with EHD of the lungs had a MS of 45 (range, 39-98) months versus lymph nodes (portal and para-aortic) 26 (range, 21-48) months versus peritoneum 29 (range, 18-32) months. The MS also varied by the amount of liver disease - 42.2months (<two lesions) versus 39.6months (two lesions) versus 28months (⩾three lesions). INTERPRETATION In the evolving landscape of multimodality therapy, selective hepatic resection for CRLM patients with EHD is feasible with potential impact on survival. Patients with minimal liver disease and EHD in the lung achieve the best outcome.
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Affiliation(s)
- Michael Hwang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Thejus T Jayakrishnan
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Danielle E Green
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ben George
- Division of Medical Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - James P Thomas
- Division of Medical Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ryan T Groeschl
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sam G Pappas
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Maywood, IL, United States
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Kiran K Turaga
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States.
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Lykoudis PM, O'Reilly D, Nastos K, Fusai G. Systematic review of surgical management of synchronous colorectal liver metastases. Br J Surg 2014; 101:605-12. [PMID: 24652674 DOI: 10.1002/bjs.9449] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2014] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- P M Lykoudis
- Hepatopancreatobiliary Surgery and Liver Transplantation, 8 South, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
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Reissfelder C, Rahbari NN, Bejarano LU, Schmidt T, Kortes N, Kauczor HU, Büchler MW, Weitz J, Koch M. Comparison of various surgical approaches for extensive bilateral colorectal liver metastases. Langenbecks Arch Surg 2014; 399:481-91. [PMID: 24615142 DOI: 10.1007/s00423-014-1177-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 02/18/2014] [Indexed: 12/12/2022]
Abstract
PURPOSE Tailored operative strategies have been proposed for patients with bilobar colorectal liver metastases (CLM). The aim of the study was to evaluate the long-term outcome, safety and efficacy, including cancer-specific survival, morbidity, and mortality, of three different surgical strategies for extensive bilateral CLM. METHODS This is a retrospective study of a prospective database of 356 consecutive patients, who underwent hepatic resection due to CLM between January 2003 and January 2009. Fifty-nine patients underwent three different therapeutic approaches: 22 patients with portal vein embolization (PVE) + staged resections, 11 patients with staged resections solely, and 26 patients with an extensive liver resection and simultaneous or subsequent radiofrequency ablation (RFA). RESULTS The three groups were comparable regarding their general patient characteristics. The overall morbidity and mortality rates were 27.1 and 1.7 %, respectively. There were no significant differences in morbidity, mortality, or survival between the three groups. The median survival of all patients was 48 months, with a recurrence-free survival of 30 months. CONCLUSIONS The clearance of bilobar CLM can be achieved by various strategies, all of them providing an acceptable mortality rate and survival for the patients. Therefore, patients with bilobar liver metastases should receive a procedure tailored for their individual extent of disease.
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Affiliation(s)
- Christoph Reissfelder
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany,
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Kianmanesh R, Piardi T, Tamby E, Parvanescu A, Bruno O, Palladino E, Bouché O, Msika S, Sommacale D. Liver angulometry: a simple method to estimate liver volume and ratios. HPB (Oxford) 2013; 15:976-84. [PMID: 23472855 PMCID: PMC3843616 DOI: 10.1111/hpb.12079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 01/21/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Volumetry is standard method for evaluating the volumes of the right liver (RL), left liver (LL), left lateral segments (LLS), total liver (TL) and future liver remnant (FLR). The aim of this study was to report a simple technique based on measurements of liver angles (angulometry) that can be used to predict liver ratios. METHODS Fifty computed tomography (CT) scans obtained in subjects with normal liver were studied. Four CT scan levels were preselected: level 1 passed by the upper part of the hepatic veins; level 2 passed by the left portal vein branch division; level 3 passed by the right portal vein branch division, and level 4 passed by the gallbladder bed. Left and right tangent lines passing the liver edges were drawn and joined to the centre of the vertebra defining the TL angle. Two lines through, respectively, the plane of the middle hepatic vein and the left portal branches determined the angles of the RL, LL and LLS. Volumetric and angulometric data obtained on levels 2 and 3 in 50 different subjects were compared. RESULTS Level 2 CT scans represented the most accurate way of obtaining angulometric measurements. The mean ± standard deviation (SD) angles of the TL and LL were 134 ± 12 ° and 55 ± 12 °, respectively. The mean ± SD percentages of the TL represented by the LL in angulometry and volumetry were 38 ± 7% and 36 ± 6%, respectively (non-significant difference). The mean ± SD percentages of the TL represented by the LLS in angulometry and volumetry were 25 ± 4% and 20 ± 3%, respectively (P < 0.05). The mean ± SD overestimation of the percentage of the TL represented by the LLS in angulometry was 2.7 ± 7.0%. CONCLUSIONS Angulometry is a simple and accurate technique that can be used to estimate the ratio of the FLR to TL volume on one or two CT (or magnetic resonance imaging) slices. It can be helpful for clinicians, especially before right or extended right hepatectomy and after right portal vein occlusion techniques.
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Affiliation(s)
- Reza Kianmanesh
- Department of Digestive Surgery, University of ReimsReims, France,Department of Digestive Surgery, Louis Mourier University Hospital Centre, University of Paris 7Paris, France
| | - Tullio Piardi
- Department of Digestive Surgery, University of ReimsReims, France
| | - Esther Tamby
- Department of Digestive Surgery, University of ReimsReims, France
| | - Alina Parvanescu
- Department of Digestive Surgery, Louis Mourier University Hospital Centre, University of Paris 7Paris, France
| | - Onorina Bruno
- Department of Liver Surgery, University of Paris 7Paris, France,Department of Radiology, Beaujon University Hospital Centre, University of Paris 7Paris, France
| | - Elisa Palladino
- Department of Digestive Surgery, University of ReimsReims, France
| | - Olivier Bouché
- Department of Digestive Oncology, Robert Debré University Hospital Centre, University of ReimsReims, France
| | - Simon Msika
- Department of Digestive Surgery, Louis Mourier University Hospital Centre, University of Paris 7Paris, France
| | - Daniele Sommacale
- Department of Digestive Surgery, University of ReimsReims, France,Department of Liver Surgery, University of Paris 7Paris, France
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McNally SJ, Parks RW. Surgery for colorectal liver metastases. Dig Surg 2013; 30:337-47. [PMID: 24051581 DOI: 10.1159/000351442] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 04/10/2013] [Indexed: 12/27/2022]
Abstract
Half of all patients with colorectal cancer develop metastatic disease. The liver is the principal site for metastases, and surgical resection is the only modality that offers the potential for long-term cure. Appropriate patient selection for surgery and improvements in perioperative care have resulted in low morbidity and mortality rates, resulting in this being the therapy of choice for suitable patients. Modern management of colorectal liver metastases is multimodal incorporating open and laparoscopic surgery, ablative therapies such as radiofrequency ablation or microwave ablation and (neo)adjuvant chemotherapy. The majority of patients with hepatic metastases should be considered for resectional surgery, if all disease can be resected, as this offers the only opportunity for prolonged survival.
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Affiliation(s)
- S J McNally
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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Lam VWT, Laurence JM, Johnston E, Hollands MJ, Pleass HCC, Richardson AJ. A systematic review of two-stage hepatectomy in patients with initially unresectable colorectal liver metastases. HPB (Oxford) 2013; 15:483-91. [PMID: 23750490 PMCID: PMC3692017 DOI: 10.1111/j.1477-2574.2012.00607.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/19/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable using the two-stage hepatectomy (TSH) approach. This review was conducted with the aim of collating and evaluating published evidence for TSH in patients with initially unresectable CLM. METHODS Searches of the MEDLINE and EMBASE databases were undertaken to identify studies of TSH in patients with initially unresectable CLM. Studies were required to focus on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes. RESULTS Ten observational studies were reviewed. A total of 459 patients with initially unresectable CLM were selected for the first stage of TSH. Preoperative chemotherapy was used in 88% of patients and achieved partial and stable response rates of 59% and 39%, respectively. Postoperative morbidity and mortality after the first stage of TSH were 17% and 0.5%, respectively. Portal vein embolization (PVE) was used in 76% of patients. Ultimately, 352 of the initial 459 (77%) patients underwent the second stage of TSH. Major liver resection was undertaken in 84% of patients; the negative margin (R0) resection rate was 75%. Postoperative morbidity and mortality after the second stage of TSH were 40% and 3%, respectively. Median overall survival was 37 months (range: 24-44 months) in patients who completed both stages of TSH. In patients who did not complete both stages of TSH, median survival was 16 months (range: 10-29 months). The 3-year disease-free survival rate was 20% (range: 6-27%). CONCLUSIONS Two-stage hepatectomy is safe and effective in selected patients with initially unresectable CLM. Further studies are required to better define patient selection criteria for TSH and the exact roles of PVE and preoperative and interval chemotherapy.
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Affiliation(s)
- Vincent W T Lam
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | | | - Emma Johnston
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Michael J Hollands
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Henry C C Pleass
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Arthur J Richardson
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
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Gauzolino R, Castagnet M, Blanleuil ML, Richer JP. The ALPPS technique for bilateral colorectal metastases: three "variations on a theme". Updates Surg 2013; 65:141-8. [PMID: 23690242 DOI: 10.1007/s13304-013-0214-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 05/04/2013] [Indexed: 12/11/2022]
Abstract
The aim of this study was to assess feasibility of technical variations of the associating liver partition and portal vein ligation for staged hepatectomy technique (ALPPS) with regard to three different ways of liver splitting. The ALPPS technique was applied in the classic form consisting in ligation of the right portal vein, limited resections on the left lobe and splitting along the umbilical fissure; the right lobe was removed 1 week later. The first variation was "left ALPPS": ligation of the left portal vein, multiple resections on the right hemiliver and splitting along the main portal fissure. The second variation was "rescue ALPPS", consisting in simple splitting of the liver along the main portal fissure several months after a radiological portal vein embolization that did not allow satisfactory liver hypertrophy. The third variation was "right ALPPS", consisting in ligation of the posterolateral branch of right portal vein, left lateral sectionectomy, multiple resections on the right anterior and left medial section and splitting along the right portal fissure. In all cases auxiliary deportalized liver was removed 1 week later. 4 patients with colorectal metastases were included. Morbidity was defined according to the Clavien-Dindo classification: grade I (2 events), grade IIIb (1 event). Postoperative mortality was nil. Median follow-up was 4 months and to date all patients are still alive. ALPPS technique, in its "classical" and modified forms, is a good option for selected patients with bilateral colorectal metastases and represents a feasible alternative to classical two-stage hepatectomy.
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Eveno C, Karoui M, Gayat E, Luciani A, Auriault ML, Kluger MD, Baumgaertner I, Baranes L, Laurent A, Tayar C, Azoulay D, Cherqui D. Liver resection for colorectal liver metastases with peri-operative chemotherapy: oncological results of R1 resections. HPB (Oxford) 2013; 15:359-64. [PMID: 23458567 PMCID: PMC3633037 DOI: 10.1111/j.1477-2574.2012.00581.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 08/26/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Retrospective analysis of outcomes of R0 (negative margin) versus R1 (positive margin) liver resections for colorectal metastases (CLM) in the context of peri-operative chemotherapy. METHODS All CLM resections between 2000 and 2006 were reviewed. Exclusion criteria included: macroscopically incomplete (R2) resections, the use of local treatment modalities, the presence of extra-hepatic disease and no peri-operative chemotherapy. R0/R1 status was based on pathological examination. RESULTS Of 86 eligible patients, 63 (73%) had R0 and 23 (27%) had R1 resections. The two groups were comparable for the number, size of metastases and type of hepatectomy. The R1 group had more bilobar CLM (52% versus 24%, P = 0.018). The median follow-up was 3.1 years. Five-year overall and disease-free survival were 54% and 21% for the R0 group and 49% and 22% for the R1 group (P = 0.55 and P = 0.39, respectively). An intra-hepatic recurrence was more frequent in the R1 group (52% versus 27%, P = 0.02) and occurred more frequently at the surgical margin (22% versus 3%, P = 0.01). DISCUSSION R1 resections were associated with a higher risk of intra-hepatic and surgical margin recurrence but did not negatively impact survival suggesting that in the era of efficient chemotherapy, the risk of an R1 resection should not be considered as a contraindication to surgery.
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Affiliation(s)
- Clarisse Eveno
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Mehdi Karoui
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University HospitalCréteil, France,Department of Digestive Surgery, AP-HP, Pitié Salpetrière University HospitalParis, France
| | - Etienne Gayat
- Department of Biostatistics and Clinical Epidemiology, AP-HP, Saint-Louis University HospitalParis, France
| | - Alain Luciani
- Department of Radiology, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Marie-Luce Auriault
- Department of Pathology, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Michael D Kluger
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University HospitalCréteil, France,Section of Hepatobiliary Surgery and Liver Transplantation, New York Presbyterian Hospital – Weill Cornell Medical CenterNYC, NY, USA
| | - Isabelle Baumgaertner
- Department of Medical Oncology, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Laurence Baranes
- Department of Radiology, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Alexis Laurent
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Claude Tayar
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Daniel Azoulay
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University HospitalCréteil, France
| | - Daniel Cherqui
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University HospitalCréteil, France,Section of Hepatobiliary Surgery and Liver Transplantation, New York Presbyterian Hospital – Weill Cornell Medical CenterNYC, NY, USA,Correspondence Daniel Cherqui, Section of Hepatobiliary Surgery and Liver Transplantation, New York Presbyterian Hospital – Weill Cornell Medical Center, 525 East 68th Street, Rm F-1917, Mail Box 287, New York, NY 10065, USA. Tel: +1 212 746 2127. Fax: +1 212 746 8948. E-mail:
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Guillaud A, Pery C, Campillo B, Lourdais A, Laurent S, Boudjema K, Boudjema K. Incidence and predictive factors of clinically relevant bile leakage in the modern era of liver resections. HPB (Oxford) 2013; 15:224-9. [PMID: 23374363 PMCID: PMC3572284 DOI: 10.1111/j.1477-2574.2012.00580.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/07/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the incidence, the impact on survival and the predictive factors of bile leakage (BL) in a recent large monocentric series of liver resections performed in a referral tertiary care centre. BACKGROUND Previous reports dealing with bile leakage (BL) after liver resection are rare and have displayed conflicting results regarding incidence, impact on follow-up and predictive factors. METHODS A retrospective review of the records of 912 patients who underwent a total of 1001 consecutive liver resections without biliary reconstruction, performed between January 2005 and May 2011. BL was defined by the presence of bile in the abdominal drains, a radiologically or surgically drained bilioma or biliary peritonitis. BL severity was established according to the Clavien-Dindo classification. Fifty-eight pre-, per- and post-resection variables were analysed and the independent BL predictive factors were identified using logistic regression. RESULTS The incidence of BL was 8%. Clavien-Dindo I-II, IIIa, IIIb or IV rates were 29%, 35%, 32.5% and 2.5%, respectively. BL did not increase in-hospital mortality (2.5% versus 2.9%, P = 1.0), but doubled the median duration of hospital stay (16 versus 9 days, P < 0.001) and increased 1-year mortality (11% versus 5%, P = 0.03). Multivariate analysis identified that pre-operative bevacizumab [odds ratio (OR) = 2.9, confidence interval (CI) 95% = 1.58-5.41] P = 0.001], a major hepatectomy [OR = 2.6 (CI 95% = 1.48-4.76) P = 0.001], a two-stage hepatectomy [OR = 2.5 (CI 95% = 1.17-5.52) P = 0.018], the selective clamping technique [OR = 2.6 (CI 95% = 1.03-6.78) P = 0.042], R1 or R2 resection [OR = 2.6 (CI 95% = 1.52-4.64) P = 0.001] and the absence of a methylene blue test [OR = 2.6 (IC 95% = 1.43-4.65) P = 0.002] were independent risk factors of BL. CONCLUSION BL remains frequent after liver resection. It has a dramatic impact on patient survival and care costs. Its incidence could be reduced by avoiding the pre-operative use of bevacizumab, avoiding selective clamping and performing a blue dye test in all resections.
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Affiliation(s)
- Antoine Guillaud
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1Rennes, France
| | - Claire Pery
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1Rennes, France
| | - Boris Campillo
- Département d'Information Médicale, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1Rennes, France
| | - Anne Lourdais
- Département d'Information Médicale, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1Rennes, France
| | - Sulpice Laurent
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1Rennes, France
| | - Karim Boudjema
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1Rennes, France
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Goyer P, Karoui M, Vigano L, Kluger M, Luciani A, Laurent A, Azoulay D, Cherqui D. Single-center multidisciplinary management of patients with colorectal cancer and resectable synchronous liver metastases improves outcomes. Clin Res Hepatol Gastroenterol 2013; 37:47-55. [PMID: 22521121 DOI: 10.1016/j.clinre.2012.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 02/07/2012] [Accepted: 03/06/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Management of patients with synchronous liver metastasis (SLM) is complex and the surgical decision process should be based on a comprehensive oncological strategy. The aim of the study was to compare outcome of single-center management of patients with colorectal cancer (CRC) and resectable SLM to those of referred patients for liver resection only after removal of their primary tumor (PT). METHODS Between 2000 and 2007, 47 patients with CRC and SLM underwent resection of both the PT and metastases under our care (unicentric) and 32 were referred after resection of their PT. RESULTS The two groups were comparable for demographics, PT and metastatic disease data. In unicentric group, 23% received upfront chemotherapy with the PT in place, 53% had a combined CRC and SLM resection, 11% had a two-stage hepatectomy with resection of the primary during the first stage and 36% underwent delayed hepatectomy. The number of surgical interventions, the delay between diagnosis and liver resection (9 vs. 5 months, P < 0.001), the median number of cycles of chemotherapy before hepatectomy (12 vs. 6 months, P < 0.001) were significantly higher in the referred group. Postoperative morbidity was significantly higher in the referred group (75 vs. 47%, P = 0.023). The median follow-up was 43 months. OS and DFS were not significantly different between the two groups. CONCLUSION Although the survival benefit is not proven, single-center management of patients with CRC and resectable SLM reduces the number of interventions, the number of cycles of chemotherapy and postoperative morbidity.
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Affiliation(s)
- Perrine Goyer
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri-Mondor University Hospital, 94000 Créteil, France
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Two-stage hepatectomy with effective perioperative chemotherapy does not induce tumor growth or growth factor expression in liver metastases from colorectal cancer. Surgery 2013; 153:179-88. [DOI: 10.1016/j.surg.2012.06.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 06/08/2012] [Indexed: 12/29/2022]
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Solbiati L, Ahmed M, Cova L, Ierace T, Brioschi M, Goldberg SN. Small liver colorectal metastases treated with percutaneous radiofrequency ablation: local response rate and long-term survival with up to 10-year follow-up. Radiology 2012; 265:958-68. [PMID: 23091175 DOI: 10.1148/radiol.12111851] [Citation(s) in RCA: 257] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine the long-term (10-year) survival of patients with colorectal liver metastases treated with radiofrequency (RF) ablation and systemic chemotherapy with intention to treat. MATERIALS AND METHODS Institutional review board approval was obtained for this study. From 1997 to 2006, 99 consecutive patients with 202 small (0.8-4.0 cm; mean: 2.2 cm ± 1.1) metachronous colorectal liver metastases underwent ultrasonography-guided percutaneous RF ablation with internally-cooled electrodes in association with systemic chemotherapy. Patients ineligible for surgery (n = 80) or whose lesions were potentially resectable and who refused surgery (n = 19) were included. Patients were followed up with contrast agent-enhanced computed tomography and/or magnetic resonance imaging for a minimum of 3 years to more than 10 years after RF ablation (n = 99, 67, 49, and 25 for 3, 5, 7, and 10 or more years, respectively). Overall local response rates and long-term survival rates were assessed. For each of these primary endpoints, Kaplan-Meier curves were generated and log-rank tests were used to assess for statistically significant differences. RESULTS Primary and secondary technical success rates were 93.1% (188 of 202) and 100% (14 of 14), respectively. Local tumor progression occurred in 11.9% (24 of 202) metastases, and 54.2% (13 of 24) of these were re-treated. Patient survival rates increased with re-treatment versus no re-treatment (P < .001). At follow-up, 125 new liver metastases were found, and of these 32.8% (41 of 125) were treated with RF ablation. Overall survival rates were 98.0%, 69.3%, 47.8%, 25.0%, and 18.0% (median: 53.2 months) at 1, 3, 5, 7, and 10 years, respectively. The major complication rate was 1.3% (two of 156), and there were no procedure-related deaths. At the time this article was written, 32.3% (32 of 99) of the patients were alive, and 67.7% (67 of 99) were deceased, with a median follow-up of 72 months. CONCLUSION Adding RF ablation to systemic chemotherapy achieved local control in a large majority of metachronous colorectal liver metastases. The 3- to 10-year survival rates of this relatively large series of patients were essentially equivalent to those of most surgical series reported in the literature.
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Affiliation(s)
- Luigi Solbiati
- Department of Interventional Oncologic Radiology, General Hospital of Busto Arsizio, Busto Arsizio, Italy
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A comparative study of patients with and without associated digestive surgery in a two-stage hepatectomy setting. Langenbecks Arch Surg 2012; 397:1289-96. [PMID: 23053455 DOI: 10.1007/s00423-012-1002-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 09/06/2012] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of this study was to compare the feasibility and outcomes of two-stage hepatectomy in patients with or without accompanying digestive surgery. METHODS We analyzed prospectively data from 56 patients with colorectal liver metastases undergoing two-stage hepatectomy between 1995 and 2009. Patients undergoing associated digestive resection (group I, n = 32) were compared with patients without associated digestive surgery (group II, n = 17). RESULTS The feasibility rate was 87.5% (49 patients). Neither the type and extent of hepatectomy nor the type of chemotherapy administered differed between the two groups. The median interval between hepatectomies was 1.79 and 2.07 months for groups I and II, respectively (not significant). One patient (group I) died of liver failure after the second hepatectomy. Postoperative morbidity rates were comparable: 37.5% (group I) vs. 35.5% (group II) after the first hepatectomy and 46.9% (group I) vs. 52.9% (group II) after the second hepatectomy. The median hospital stay after the first hepatectomy was longer in group I (13.5 days) than in group II (10 days) (P < 0.01). Median follow-up was 54 months. The median overall survival (OS) was 45.8 months, and 3- and 5-year OS were 58 and 31%, respectively. Median OS was longer for group II (58 months) than for group I (34 months) (P = 0.048). CONCLUSIONS Digestive tract resection associated with two-stage hepatectomy does not increase postoperative mortality or morbidity nor does it lead to delay in chemotherapy or a reduction in cycles administered. The need for digestive tract surgery should not affect the surgical management of two-stage hepatectomy patients.
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Loos M, Friess H. Is there new hope for patients with marginally resectable liver malignancies. World J Gastrointest Surg 2012; 4:163-5. [PMID: 22905283 PMCID: PMC3420982 DOI: 10.4240/wjgs.v4.i7.163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 07/18/2012] [Accepted: 07/20/2012] [Indexed: 02/06/2023] Open
Abstract
Advances in surgical technique and better perioperative management have significantly improved patient outcomes after liver surgery. Even major hepatectomy can be performed safely with low morbidity and mortality. Post-resection liver failure is among the most feared complications after extended hepatectomy. In order to increase the future liver remnant (FLR) and to expand the pool of candidates for surgical resection, Schnitzbauer et al recently presented a new 2-stage surgical approach which combines right portal vein ligation (rPVL) with in situ splitting (ISS) of the liver parenchyma. In comparison to other current strategies, such as interventional portal vein embolization, hypertrophy of the FLR was more pronounced (median volume increase = 74%; range: 21%-192%) and more rapid (after a median of 9 d; range: 5-28 d) after rPVL and ISS. In this commentary, we discuss the technical aspects and clinical impact of rPVL combined with ISS. Based on the reported data, this new 2-stage therapeutic approach represents a promising new strategy for patients with locally advanced liver disease, previously regarded as marginally resectable or even unresectable, potentially enabling curative resection. However, morbidity is significant and mortality not negligible.
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Affiliation(s)
- Martin Loos
- Martin Loos, Helmut Friess, Department of Surgery, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
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Vauthey JN, Abbott DE. Commentary on "Feasibility study of two-stage hepatectomy for bilobar liver metastases". Am J Surg 2012; 203:698-9. [PMID: 22326822 DOI: 10.1016/j.amjsurg.2011.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 11/18/2011] [Accepted: 11/18/2011] [Indexed: 02/03/2023]
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Chua TC, Liauw W, Chu F, Morris DL. Summary outcomes of two-stage resection for advanced colorectal liver metastases. J Surg Oncol 2012; 107:211-6. [PMID: 22648977 DOI: 10.1002/jso.23170] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 05/04/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical resection is associated with improved long-term survival in patients with colorectal liver metastases (CLM). However, majority of patients have unresectable bilobar advanced liver metastases. Two-stage resection (TSR) allows selected patients to achieve complete resection when combined with chemotherapy and interventional radiological procedures. METHODS Electronic search of the MEDLINE and PubMed databases (January 2000-October 2011) to identify studies examining the outcomes of the surgical approach of TSR of advanced CLM was undertaken. RESULTS Twelve studies were examined. This comprised 488 patients. A median of 77% (range: 64-100%) of planned patients completed TSR. The most common reason for failure was due to disease progression observed in a median of 100% (range: 56-100%) of patients. Second-stage resection appeared to be more morbid compared to first-stage resection with higher complication rates (33% vs. 14%) and requiring more blood transfusions (3 U vs. 1 U). Completed TSR achieved a median survival of 37 (range: 18-66) months, median 3-year survival rate of 60% (range: 45-84%), and median 5-year survival rate of 48% (range: 32-70%). In patients who failed TSR, the median survival was 16 (range: 10-29) months. CONCLUSION In carefully selected candidates with advanced bilobar CLM, the TSR approach achieves long-term survival in patients who would otherwise be considered for palliative chemotherapy only. Despite failing to complete TSR, patients had an encouraging survival outcome that appeared to compare favorably over palliative chemotherapy alone.
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Affiliation(s)
- Terence C Chua
- Hepatobiliary and Surgical Oncology Unit, Department of Surgery, University of New South Wales, Kogarah, Sydney, New South Wales, Australia
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Heinrich S, Lang H. Liver metastases from colorectal cancer: technique of liver resection. J Surg Oncol 2012; 107:579-84. [PMID: 22566374 DOI: 10.1002/jso.23138] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 04/09/2012] [Indexed: 12/19/2022]
Abstract
Liver resection has become standard for the treatment of metastatic colorectal cancer (CRC): anterior approach, hanging manoeuvre, or total vascular exclusion techniques as well as 3-dimensional imaging enable safe resections even in difficult cases. Furthermore, modern chemotherapy, portal vein embolization/ligation, and two-stage procedures increase the resectability of metastasis, and repeat resections are feasible for recurrence. In addition to characteristics of the primary, CEA, extent of metastasis, resection margins, and extrahepatic disease, hilar lymph node metastases appear prognostic.
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Affiliation(s)
- Stefan Heinrich
- General and Abdominal Surgery, University Hospital of Mainz, Mainz, Germany
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Robles R, Marín C, Lopez-Conesa A, Capel A, Perez-Flores D, Parrilla P. Comparative study of right portal vein ligation versus embolisation for induction of hypertrophy in two-stage hepatectomy for multiple bilateral colorectal liver metastases. Eur J Surg Oncol 2012; 38:586-93. [PMID: 22560404 DOI: 10.1016/j.ejso.2012.03.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 03/13/2012] [Accepted: 03/26/2012] [Indexed: 12/12/2022] Open
Abstract
AIM In patients with two-stage hepatectomy (TSH) for multiple bilobar liver metastases from colorectal cancer, few clinical series compare functional remnant hypertrophy of the liver volume between right portal vein ligation (PVL) and embolisation (PVE). Our objective is to analyse the effectiveness of portal vein ligation to achieve hypertrophy of the functional remnant volume (FRV) of the liver and to compare the results with portal vein embolisation in a series of patients with multiple bilobar liver metastases from colorectal carcinoma. PATIENTS AND METHODS Between September 2001 and September 2011 we performed a TSH in 41 patients with multiple bilobar colorectal liver metastases. A right PVL was performed in 23 patients with an insufficient FRV (three patients did not complete the second stage due to tumour progression and were excluded). We prospectively compare these results with the increased remnant volume obtained in 18 patients with right PVE. RESULTS The median FRV was higher in the patients with PVE, rising from 501 ml (range 309-703) to 636 ml (range 387-649), than those with PVL, rising from 510 ml (range 203-824) to 595 ml (range 313-1213) (p < 0.05). The median %FRVI was higher in the patients with PVE (median 40%; range 21-65%) than those with PVL (median 30%; range 21-60%) (p < 0.05). CONCLUSIONS PVL and PVE were effective in all cases for obtaining hypertrophy of the FRV before major liver resection. Right PVE obtains better results and should be used where necessary to achieve a further increase in volume.
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Affiliation(s)
- R Robles
- Virgen de Arrixaca University Hospital, Faculty of Medicine, University of Murcia, Liver Surgery and Liver Transplantation Unit, Spain.
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Right Portal Vein Ligation Combined With In Situ Splitting Induces Rapid Left Lateral Liver Lobe Hypertrophy Enabling 2-Staged Extended Right Hepatic Resection in Small-for-Size Settings. Ann Surg 2012; 255:405-14. [DOI: 10.1097/sla.0b013e31824856f5] [Citation(s) in RCA: 930] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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