Published online Apr 27, 2020. doi: 10.4240/wjgs.v12.i4.159
Peer-review started: November 21, 2019
First decision: December 13, 2019
Revised: February 21, 2020
Accepted: March 5, 2020
Article in press: March 5, 2020
Published online: April 27, 2020
Multiple liver-directed therapies, including hepatic resection, exist for patients with neuroendocrine liver metastases (NELM). While surgical resection is associated with the best long-term outcomes, the current indications for and outcomes of surgery for NELM from a population perspective are not well understood.
A better understanding of the frequency and predictors of postoperative complications will improve shared-decision making for patients with NELM, especially given the expanding number of liver-directed and systemic therapies available.
The purpose of the current study was to define the current indications for surgery for NELM, characterize the short-term outcomes of patients undergoing surgery, and evaluate predictors of complications using a population-based approach.
A retrospective review of the 2014-2017 American College of Surgeons National Surgical Quality Improvement Program targeted hepatectomy database was performed to identify patients who underwent hepatic resection for NELM. Perioperative characteristics and 30-d morbidity and mortality were analyzed.
Among 669 patients who underwent liver resection for NELM, the number of metastases resected ranged from 1 to 9 though the most common (45%) number of tumors resected was one. The majority (68%) of patients had a largest tumor size of < 5 cm and most patients underwent partial hepatectomy (71%). The majority of operations were open (82%) versus laparoscopic (17%) or robotic (1%). In addition, 30% of patients underwent intraoperative ablation while 45% had another concomitant operation including cholecystectomy (28.8%), bowel resection (20.2%), or partial pancreatectomy (3.4%). Overall 30-d morbidity and mortality was 29% and 1.3%, respectively. On multivariate analysis, American Society of Anesthesiologists class ≥ 3, open approach, formal hemi-hepatectomy or trisectionectomy, and prolonged operative time were associated with higher 30-d morbidity. Concomitant procedures including intraoperative ablation, small bowel resection, or pancreatectomy were not independently associated with higher morbidity.
In this contemporary population-based analysis, we demonstrated that hepatic resection can be performed with relatively low postoperative morbidity and mortality for patients with NELM. Concomitant operations such as cholecystectomy, bowel resection, pancreatectomy, and liver ablation can safely be performed and do not contribute to increased morbidity. Careful patient selection, minimizing operative time, and utilizing minimally invasive approaches may help reduce postoperative morbidity. While multiple therapeutic options exist for NELM, given the excellent long-term outcomes observed in the literature and the satisfactory short-term outcomes demonstrated in the current study, surgical resection should remain the standard of care when feasible.
This study highlights the current population-based indications for liver resection for patients with neuroendocrine liver metastases and confirms satisfactory short-term outcomes. In light of these findings, future research should focus on expanding the indications for hepatic resection particularly given the increasing number of liver-directed and systemic therapy options available. Future prospective studies should evaluate the optimal sequencing of liver-directed therapies including neoadjuvant and adjuvant strategies to improve long-term outcomes.