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Idrees JJ, Bagante F, Gani F, Rosinski BF, Chen Q, Merath K, Dillhoff M, Cloyd J, Pawlik TM. Population level outcomes and costs of single stage colon and liver resection versus conventional two-stage approach for the resection of metastatic colorectal cancer. HPB (Oxford) 2019; 21:456-464. [PMID: 30266492 DOI: 10.1016/j.hpb.2018.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The objective of the current study was to compare outcomes among patients combined colon (CR) and liver resection (LR) for the treatment of simultaneous colorectal liver metastasis (CRLM) versus patients undergoing two-stage CR and LR. METHODS Patients undergoing surgery for CRLM between 2004 and 2014 were identified using the Nationwide Inpatient Sample (NIS). Propensity-score matching was used to compare patients undergoing CR + LR with patients undergoing two-stage CR and LR. RESULTS Among 83,410 patients, CR + LR was performed in 5659 (6.7%), stage C + LR was performed in 5659 (6.7%), while isolated CR and LR was performed in 70,177 (84.0%) and 7574 (9.3%) patients, respectively. The number of patients undergoing CR + LR increased from 423 in 2004 to 580 in 2014 (Δ = +37%). Patients undergoing CR + LR had lower postoperative morbidity (CR + LR vs. two-staged CR and LR: 38.5% vs. 61.2%), shorter LOS (median LOS: 8 days [IQR: 7-12] vs. 14 days [IQR: 10-21]), and lower postoperative mortality (3.1% vs. 5.9%) versus patients undergoing two-stage CR and LR. Compared with patients undergoing two-staged CR and LR, median hospital costs were $13,093 lower for patients undergoing CR + LR (median costs: $36,775 [IQR: 26,416-54,245] vs. $23,682 [IQR: 16,299-32,996]). CONCLUSION CR + LR was increasingly performed for treatment of CRLM. Compared with two-staged CR and LR, CR + LR was associated with improved outcomes and lower costs.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Faiz Gani
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Brad F Rosinski
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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52
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Krell RW, D'Angelica MI. Treatment sequencing for simultaneous colorectal liver metastases. J Surg Oncol 2019; 119:583-593. [DOI: 10.1002/jso.25424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/08/2019] [Indexed: 12/20/2022]
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Chow FCL, Chok KSH. Colorectal liver metastases: An update on multidisciplinary approach. World J Hepatol 2019; 11:150-172. [PMID: 30820266 PMCID: PMC6393711 DOI: 10.4254/wjh.v11.i2.150] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/24/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023] Open
Abstract
Liver metastasis is the commonest form of distant metastasis in colorectal cancer. Selection criteria for surgery and liver-directed therapies have recently been extended. However, resectability remains poorly defined. Tumour biology is increasingly recognized as an important prognostic factor; hence molecular profiling has a growing role in risk stratification and management planning. Surgical resection is the only treatment modality for curative intent. The most appropriate surgical approach is yet to be established. The primary cancer and the hepatic metastasis can be removed simultaneously or in a two-step approach; these two strategies have comparable long-term outcomes. For patients with a limited future liver remnant, portal vein embolization, combined ablation and resection, and associating liver partition and portal vein ligation for staged hepatectomy have been advocated, and each has their pros and cons. The role of neoadjuvant and adjuvant chemotherapy is still debated. Targeted biological agents and loco-regional therapies (thermal ablation, intra-arterial chemo- or radio-embolization, and stereotactic radiotherapy) further improve the already favourable results. The recent debate about offering liver transplantation to highly selected patients needs validation from large clinical trials. Evidence-based protocols are missing, and therefore optimal management of hepatic metastasis should be personalized and determined by a multi-disciplinary team.
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Affiliation(s)
| | - Kenneth Siu-Ho Chok
- Department of Surgery and State Key Laboratory for Liver Research, the University of Hong Kong, Hong Kong, China
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54
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Matsuoka H, Morise Z, Tanaka C, Hayashi T, Ikeda Y, Maeda K, Masumori K, Koide Y, Katsuno H, Tanahashi Y, Nakajima S, Hanai T, Kato Y, Sugioka A, Uyama I. Repeat hepatectomy with systemic chemotherapy might improve survival of recurrent liver metastasis from colorectal cancer-a retrospective observational study. World J Surg Oncol 2019; 17:33. [PMID: 30770753 PMCID: PMC6377761 DOI: 10.1186/s12957-019-1575-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although hepatectomy for metastatic colorectal cancer (mCRC) prolongs survival in up to 40% of people, recurrence rates approach 70%. We used a multidisciplinary approach to treat recurrent liver metastases, including chemotherapy, surgery, and palliative care. On the other hand, development of chemotherapeutic agents is remarkable and improves long-term survival. However, whether chemotherapy and repeat hepatectomy combination therapy improve survival or not is still unclear. The aim of this study was to analyze the outcomes of repeat hepatectomy with systemic chemotherapy for mCRC. METHODS Following Institutional Review Board approval, we reviewed the records of all patients who underwent hepatectomy for mCRC between 1974 and 2015 at Fujita Health University Hospital. We used the Kaplan-Meier method to estimate overall survival from the first and last hepatectomy in multi hepatectomy cases after 2005 and compared outcomes between groups using the log-rank test. RESULTS A total of 426 liver resections were performed for mCRC; of these, 236 cases were performed after 2005 (late group). In 118 (50%) cases, the site of recurrence was the liver, 59 (50%) underwent repeat hepatectomy, and 14 cases had ≥ 2 repeat hepatectomies. Overall survival (OS) before and after 2005 was 42.2 and 64.1 months, respectively, with the late group having better OS compared to the early (1974-2004) group. OS for single hepatectomy cases was 83.2 months, for two hepatectomies was 42.9 months, and for three hepatectomies was 35.3 months. In total, 59 patients did not undergo surgery after recurrence with an OS of 28.7 months. Mortality of the second and third repeat hepatectomy was 1.7% and 15.3%, respectively. CONCLUSION Repeat hepatectomy with systemic chemotherapy for mCRC is feasible and might achieve improved survival in carefully selected patients.
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Affiliation(s)
- Hiroshi Matsuoka
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Zenichi Morise
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Chihiro Tanaka
- College of Pharmacy, Kinjo Gakuin University, 2-1723 Oomori Moriyama, Nagoya City, Aichi 463-8521 Japan
| | - Takahiro Hayashi
- College of Pharmacy, Kinjo Gakuin University, 2-1723 Oomori Moriyama, Nagoya City, Aichi 463-8521 Japan
| | - Yoshiaki Ikeda
- College of Pharmacy, Kinjo Gakuin University, 2-1723 Oomori Moriyama, Nagoya City, Aichi 463-8521 Japan
| | - Koutarou Maeda
- Fujita Health University Hospital International Medical Center, 1-98 Dengakugakubo Kutsukake-cho, Toyoake city, Aichi 470-1192 Japan
| | - Koji Masumori
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Yoshikazu Koide
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Hidetoshi Katsuno
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Yoshinao Tanahashi
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Sanae Nakajima
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Tsunekazu Hanai
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Yutaro Kato
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Atsushi Sugioka
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
| | - Ichiro Uyama
- Department of Surgery Fujita Health University, 1-98 Dengakugakubo Kutsukake-cho, Toyoake City, Aichi 470-1192 Japan
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Goumard C, Nancy You Y, Okuno M, Kutlu O, Chen HC, Simoneau E, Vega EA, Chun YS, David Tzeng C, Eng C, Vauthey JN, Conrad C. Minimally invasive management of the entire treatment sequence in patients with stage IV colorectal cancer: a propensity-score weighting analysis. HPB (Oxford) 2018; 20:1150-1156. [PMID: 30005993 DOI: 10.1016/j.hpb.2018.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 05/11/2018] [Accepted: 05/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with stage IV colorectal cancer (CRC), minimally invasive surgery (MIS) may offer optimal oncologic outcome with low morbidity. However, the relative benefit of MIS compared to open surgery in patients requiring multistage resections has not been evaluated. METHODS Patients who underwent totally minimally invasive (TMI) or totally open (TO) resections of CRC primary and liver metastases (CLM) in 2009-2016 were analyzed. Inverse probability of weighted adjustment by propensity score was performed before analyzing risk factors for complications and survival. RESULTS The study included 43 TMI and 121 TO patients. Before and after adjustment, TMI patients had significantly less cumulated postoperative complications (41% vs. 59%, p = 0.001), blood loss (median 100 vs. 200 ml, p = 0.001) and shorter length of hospital stay (median 4.5 vs. 6.0 days, p < 0.001). Multivariate analysis identified TO approach vs. MIS (OR = 2.4, p < 0.001), major liver resection (OR = 4.4, p < 0.001), and multiple CLM (OR = 2.3, p = 0.001) as independent risk factors for complications. 5-year overall survival was comparable (81% vs 68%, p = 0.59). CONCLUSION In patients with CRC undergoing multistage surgical treatment, MIS resection contributes to optimal perioperative outcomes without compromise in oncologic outcomes.
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Affiliation(s)
- Claire Goumard
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Masayuki Okuno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Onur Kutlu
- Department of Surgery, University of Miami, Miami, FL, USA
| | - Hsiang-Chun Chen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eve Simoneau
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo A Vega
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yun-Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Eng
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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56
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Lin Q, Jian M, Niu ZC, Xu PP, Zheng P, Xu JM. Prognostic impact of KRAS and BRAF mutations in patients who underwent simultaneous resection for initially resectable colorectal liver metastases. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2018; 11:5981-5991. [PMID: 31949686 PMCID: PMC6963078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/25/2018] [Indexed: 06/10/2023]
Abstract
This study aimed to explore the prognostic impact of KRAS and BRAF mutations in patients who underwent simultaneous resection for synchronous colorectal liver metastases (SCRLMs) that were initially resectable. Clinicopathological and outcome data of 139 consecutive patients with SCRLMs who underwent resection between July 2003 and July 2013 was collected from our prospectively established SCRLM database. The KRAS and BRAF genotypes were evaluated in the primary cancer tissues by pyrosequencing. The prognostic value of KRAS and BRAF status was assessed by Kaplan-Meier and Cox regression analyses. KRAS and BRAF mutated in 28.8% and 7.2% of the patients with SCRLMs, respectively, but the genotypes did not significantly associate with any clinicopathologic characteristics. By Kaplan-Meier survival analysis, we found KRAS mutation was not significantly associated with short overall survival (OS) (P = 0.213), but was significantly correlated with short disease-free survival (DFS) (P = 0.041); BRAF mutation was significantly associated with both short OS and DFS (P = 0.001, P<0.001, respectively). Multivariate survival analysis showed KRAS mutation was an independent negative prognostic factor for DFS (P = 0.005) and BRAF mutation was an independent negative prognostic factor for OS and DFS (P = 0.001, P<0.001, respectively). KRAS and BRAF mutation similarly contributed to an adverse prognostic effect in patients who underwent simultaneous resection for SCRLMs that were initially resectable. These findings should suggest the use of KRAS and BRAF status in current practice as an important determinant for precision surgery for initially resectable SCRLMs.
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Affiliation(s)
- Qi Lin
- Department of General Surgery, Zhongshan Hospital, Fudan University Shanghai, China
| | - Mi Jian
- Department of General Surgery, Zhongshan Hospital, Fudan University Shanghai, China
| | - Zheng-Chuan Niu
- Department of General Surgery, Zhongshan Hospital, Fudan University Shanghai, China
| | - Ping-Ping Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University Shanghai, China
| | - Peng Zheng
- Department of General Surgery, Zhongshan Hospital, Fudan University Shanghai, China
| | - Jian-Min Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University Shanghai, China
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Moris D, Tsilimigras DI, Machairas N, Merath K, Cerullo M, Hasemaki N, Prodromidou A, Cloyd JM, Pawlik TM. Laparoscopic synchronous resection of colorectal cancer and liver metastases: A systematic review. J Surg Oncol 2018; 119:30-39. [DOI: 10.1002/jso.25313] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/12/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Dimitrios Moris
- Department of SurgeryWexner Medical Center, The Ohio State UniversityColumbus Ohio
- Division of Surgical OncologyJames Cancer Hospital and Solove Research Institute, The Ohio State UniversityColumbus Ohio
- Department of SurgeryDuke University Medical CenterDurham North Carolina
| | - Diamantis I. Tsilimigras
- Department of SurgeryWexner Medical Center, The Ohio State UniversityColumbus Ohio
- Division of Surgical OncologyJames Cancer Hospital and Solove Research Institute, The Ohio State UniversityColumbus Ohio
| | - Nikolaos Machairas
- Third Department of Surgery, National and Kapodistrian University of Athens Medical SchoolAthens Greece
| | - Katiuscha Merath
- Department of SurgeryWexner Medical Center, The Ohio State UniversityColumbus Ohio
- Division of Surgical OncologyJames Cancer Hospital and Solove Research Institute, The Ohio State UniversityColumbus Ohio
| | - Marcelo Cerullo
- Department of SurgeryDuke University Medical CenterDurham North Carolina
| | - Natasha Hasemaki
- Third Department of Surgery, National and Kapodistrian University of Athens Medical SchoolAthens Greece
| | - Anastasia Prodromidou
- Third Department of Surgery, National and Kapodistrian University of Athens Medical SchoolAthens Greece
| | - Jordan M Cloyd
- Department of SurgeryWexner Medical Center, The Ohio State UniversityColumbus Ohio
- Division of Surgical OncologyJames Cancer Hospital and Solove Research Institute, The Ohio State UniversityColumbus Ohio
| | - Timothy M Pawlik
- Department of SurgeryWexner Medical Center, The Ohio State UniversityColumbus Ohio
- Division of Surgical OncologyJames Cancer Hospital and Solove Research Institute, The Ohio State UniversityColumbus Ohio
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De Raffele E, Mirarchi M, Cuicchi D, Lecce F, Ricci C, Casadei R, Cola B, Minni F. Simultaneous curative resection of double colorectal carcinoma with synchronous bilobar liver metastases. World J Gastrointest Oncol 2018; 10:293-316. [PMID: 30364774 PMCID: PMC6198303 DOI: 10.4251/wjgo.v10.i10.293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/05/2018] [Accepted: 08/21/2018] [Indexed: 02/05/2023] Open
Abstract
Synchronous colorectal carcinoma (SCRC) indicates more than one primary colorectal carcinoma (CRC) discovered at the time of initial presentation, accounts for 3.1%-3.9% of CRC, and may occur either in the same or in different colorectal segments. The accurate preoperative diagnosis of SCRC is difficult and diagnostic failures may lead to inappropriate treatment and poorer prognosis. SCRC requires colorectal resections tailored to individual patients, based on the number, location, and stage of the tumours, from conventional or extended hemicolectomies to total colectomy or proctocolectomy, when established predisposing conditions exist. The overall perioperative risks of surgery for SCRC seem to be higher than for solitary CRC. Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with CRC and synchronous liver metastases (CRLM), even though the cumulative risks of the two procedures need to be adequately evaluated. Simultaneous resections have the noticeable advantage of avoiding a second laparotomy, give the opportunity of an earlier initiation of adjuvant therapy, and may significantly reduce the hospital costs. Because an increasing number of recent studies have shown good results, with morbidity, perioperative hospitalization, and mortality rates comparable to staged resections, simultaneous procedures can be selectively proposed even in case of complex colorectal resections, including those for SCRC and rectal cancer. However, in patients with multiple bilobar CRLM, major hepatectomies performed simultaneously with colorectal resection have been associated with significant perioperative risks. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option for selected patients with multiple CRLM involving both liver lobes. Parenchymal-sparing liver resection, instead of major or two-stage hepatectomy for bilobar disease, seemingly reduces the overall operative risk of candidates to simultaneous colorectal and liver resection, and may represent the most appropriate surgical strategy whenever possible, also for patients with advanced SCRC and multiple bilobar liver metastases.
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Affiliation(s)
- Emilio De Raffele
- Unità Operativa di Chirurgia Generale, Dipartimento dell’Apparato Digerente, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna 40138, Italy
| | - Mariateresa Mirarchi
- U.O. di Chirurgia Generale, Dipartimento Strutturale Chirurgico, Ospedale “Antonio e Margherita, ” Tortona (AL) 15057, Italy
| | - Dajana Cuicchi
- Unità Operativa di Chirurgia Generale, Dipartimento dell’Apparato Digerente, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna 40138, Italy
| | - Ferdinando Lecce
- Unità Operativa di Chirurgia Generale, Dipartimento dell’Apparato Digerente, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna 40138, Italy
| | - Claudio Ricci
- Unità Operativa di Chirurgia Generale, Dipartimento dell’Apparato Digerente, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna 40138, Italy
| | - Riccardo Casadei
- Unità Operativa di Chirurgia Generale, Dipartimento dell’Apparato Digerente, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna 40138, Italy
| | - Bruno Cola
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Alma Mater Studiorum, Policlinico S.Orsola-Malpighi, University of Bologna, Bologna 40138, Italy
| | - Francesco Minni
- Unità Operativa di Chirurgia Generale, Dipartimento dell’Apparato Digerente, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna 40138, Italy
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Wu Y, Liu F, Song W, Liang F, Wang L, Xu Y. Safety evaluation of simultaneous resection of colorectal primary tumor and liver metastasis after neoadjuvant therapy: A propensity score matching analysis. Am J Surg 2018; 218:894-898. [PMID: 30268420 DOI: 10.1016/j.amjsurg.2018.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/10/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Considering the surgical safety and perioperative complications, simultaneous resection after neoadjuvant therapy is not commonly recommended. METHODS A total of 253 patients were included in study. Comparison of the short-term outcomes was performed after propensity score adjustment in Group A (n = 96) and Group B (neoadjuvant therapy, n = 96). RESULTS There was no postoperative mortality. After matching, the differences from surgical confounders were well-balanced. Morbidity (15.6% vs. 15.6%, p = 0.981), and Clavien-Dindo grade of complications (p = 0.710) were similar. No difference was found when the complications were divided according to the origin (general, colorectal and hepatic). Length of the hospital stays also did not differ between the groups (p = 0.482). More importantly, there was no increase in the number of patients with delayed adjuvant treatment after surgery in Group B. CONCLUSIONS Neoadjuvant treatment did not increase morbidity, length of hospital stays and influence adjuvant treatment after simultaneous resection.
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Affiliation(s)
- Yuchen Wu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Fangqi Liu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Wang Song
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Fei Liang
- Clinical Statistical Center, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Lu Wang
- Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China.
| | - Ye Xu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China.
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Ponomarenko AA, Rybakov EG, Achkasov SI, Torchua NR, Shelygin YA. [Risk factors of postoperative complications in patients with synchronous colorectal cancer liver metastases]. Khirurgiia (Mosk) 2018:10-16. [PMID: 30199046 DOI: 10.17116/hirurgia201808210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM Univariate and multivariate analysis of various risk factors and morbidity in patients with synchronous colorectal cancer (CRC) liver metastases. MATERIAL AND METHODS Prospective data of 173 patients with synchronous CRC liver metastases have been analyzed from January 2013 to February 2017 at the Ryzhikh State Coloproctology Research Center. RESULTS In multivariate analysis significant risk factors of morbidity were age ≤61 years, the largest liver metastasis ≥ 2.1 cm (odds ratio (OR) 2.99; 95% CI 1.4-6.5), number of liver metastases >1 (OR 2.5; 95% CI 1.1-5.5), bilobar liver injury (OR 2.5; 95% CI 1.3-4.8), blood loss (OR 1.001; 95% CI 1.0001-1.002). Model for prediction of complications was constructed (AUC 0.79). CONCLUSION Simultaneous surgery is not risk factor of complications. Probability of complications is increased in advanced tumor and consequently more traumatic surgery. Predictive model is useful for prognosis of complications and describes surgical experience of State Coloproctology Research Center.
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Affiliation(s)
- A A Ponomarenko
- Ryzhikh State Coloproctology Research Center of Healthcare Ministry of Russia, Moscow, Russia
| | - E G Rybakov
- Ryzhikh State Coloproctology Research Center of Healthcare Ministry of Russia, Moscow, Russia
| | - S I Achkasov
- Ryzhikh State Coloproctology Research Center of Healthcare Ministry of Russia, Moscow, Russia
| | - N R Torchua
- Ryzhikh State Coloproctology Research Center of Healthcare Ministry of Russia, Moscow, Russia
| | - Yu A Shelygin
- Ryzhikh State Coloproctology Research Center of Healthcare Ministry of Russia, Moscow, Russia; Russian Medical Academy of Continuing Postgraduate Education of Healthcare Ministry of Russia, Moscow, Russia
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Howard C, Clements TW, Edwards JP, MacLean AR, Buie WD, Dixon E, Grondin SC, Gomes A, McColl M, Cleary SP, Jayaraman S, Daigle R, Ball CG. Synchronous colorectal liver metastases: a national survey of surgeon opinions on simultaneous resection and multidisciplinary cooperation. Hepatobiliary Surg Nutr 2018; 7:242-250. [PMID: 30221152 DOI: 10.21037/hbsn.2017.12.01] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background The management of patients with synchronous colorectal liver metastases (sCRLM) has evolved significantly (improved chemotherapy, hepatic surgery advancements, colonic stenting, consultation synergies). We sought to better understand surgeon viewpoints on optimal referral patterns and the delivery of simultaneous resections. Methods A 40 question on-line survey was offered to members of the Canadian surgical community. Statistical analysis was descriptive. Results A total of 52 surgeons responded. Most colorectal surgeons (CRS) had access to and a good working relationship with regional hepatobiliary (HPB) surgeons (86%) and medical oncologists (100%). The majority (92%) believed there was a role for simultaneous resection of sCRLM, with 69% having first hand experience. Many CRS (62%) discussed all cases of known hepatic metastases with HPB prior to any resection. When a lesion was asymptomatic/minimally symptomatic, most CRS (92%) discussed them with medical oncology/HPB prior to resection (8%). Bilobar metastases (58%), patient comorbidities (35%), portal lymphadenopathy (35%), and patient age (15%) restricted CRS from obtaining HPB consultations. Many CRS (46%) did not believe that resecting hepatic metastases prior to the primary lesion might be beneficial. Most CRS (60%) reported they could not accurately predict hepatic resectability, with only 27% familiarity with evidence-based guidelines. Despite working in smaller hospitals with less access to HPB and less experience with simultaneous resections, non-CR general surgeons more commonly supported a 'liver-first' approach. Conclusions There was general agreement between CRS and general surgeons on numerous topics, but additional education is required with regard to HPB surgical capabilities and to provide truly individualized patient-centered care.
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Affiliation(s)
- Carrie Howard
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Clements
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Janet P Edwards
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anthony R MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - W Donald Buie
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Sean C Grondin
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anthony Gomes
- Department of Surgery, Lethbridge Regional Hospital, Lethbridge, AB, Canada
| | - Michael McColl
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Sean P Cleary
- Departments of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shiva Jayaraman
- Departments of Surgery, University of Toronto, Toronto, ON, Canada
| | - Renelle Daigle
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Le Souder E, Azin A, Wood T, Hirpara D, Elnahas A, Cleary S, Wei A, Walker R, Parsyan A, Chadi S, Quereshy F. The effect of a simultaneous versus a staged resection of metastatic colorectal cancer on time to adjuvant chemotherapy. J Surg Oncol 2018; 118:86-94. [DOI: 10.1002/jso.25122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/07/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Emily Le Souder
- Faculty of Medicine; University of Toronto; Toronto Ontario Canada
| | - Arash Azin
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Trevor Wood
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Dhruvin Hirpara
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Ahmad Elnahas
- Division of General Surgery; University Health Network; Toronto Ontario Canada
| | - Sean Cleary
- Subspecialty General Surgery; Mayo Clinic; Rochester Minnesota
| | - Alice Wei
- Division of General Surgery; University Health Network; Toronto Ontario Canada
| | - Richard Walker
- Faculty of Medicine; Queen's University; Kingston Ontario Canada
| | - Armen Parsyan
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Sami Chadi
- Division of General Surgery; University Health Network; Toronto Ontario Canada
| | - Fayez Quereshy
- Division of General Surgery; University Health Network; Toronto Ontario Canada
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Vallance AE, van der Meulen J, Kuryba A, Charman SC, Botterill ID, Prasad KR, Hill J, Jayne DG, Walker K. The timing of liver resection in patients with colorectal cancer and synchronous liver metastases: a population-based study of current practice and survival. Colorectal Dis 2018; 20:486-495. [PMID: 29338108 DOI: 10.1111/codi.14019] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/12/2017] [Indexed: 12/13/2022]
Abstract
AIM There is uncertainty regarding the optimal sequence of surgery for patients with colorectal cancer (CRC) and synchronous liver metastases. This study was designed to describe temporal trends and inter-hospital variation in surgical strategy, and to compare long-term survival in a propensity score-matched analysis. METHOD The National Bowel Cancer Audit dataset was used to identify patients diagnosed with primary CRC between 1 January 2010 and 31 December 2015 who underwent CRC resection in the English National Health Service. Hospital Episode Statistics data were used to identify those with synchronous liver-limited metastases who underwent liver resection. Survival outcomes of propensity score-matched groups were compared. RESULTS Of 1830 patients, 270 (14.8%) underwent a liver-first approach, 259 (14.2%) a simultaneous approach and 1301 (71.1%) a bowel-first approach. The proportion of patients undergoing either a liver-first or simultaneous approach increased over the study period from 26.8% in 2010 to 35.6% in 2015 (P < 0.001). There was wide variation in surgical approach according to hospital trust of diagnosis. There was no evidence of a difference in 4-year survival between the propensity score-matched cohorts according to surgical strategy: bowel first vs simultaneous [hazard ratio (HR) 0.92 (95% CI: 0.80-1.06)] or bowel first vs liver first [HR 0.99 (95% CI: 0.82-1.19)]. CONCLUSION There is evidence of wide variation in surgical strategy in dealing with CRC and synchronous liver metastases. In selected patients, the simultaneous and liver-first strategies have comparable long-term survival to the bowel-first approach.
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Affiliation(s)
- A E Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - J van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - S C Charman
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - K R Prasad
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J Hill
- Department of General Surgery, Manchester Royal Infirmary, Manchester, UK
| | - D G Jayne
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Chen YW, Huang MT, Chang TC. Long term outcomes of simultaneous laparoscopic versus open resection for colorectal cancer with synchronous liver metastases. Asian J Surg 2018; 42:217-223. [PMID: 29804706 DOI: 10.1016/j.asjsur.2018.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND/OBJECTIVE Because of the advancements in the surgical techniques of liver resection and improvements in anesthesia and postoperative critical care, the simultaneous resection of synchronous colorectal cancer with liver metastasis either by the laparoscopic procedure or by the open resection method has been considered as a safe and acceptable option. However, there is limited information on the comparison of postoperative outcomes between laparoscopic surgery and open surgery. This study investigated the clinical results and postoperative outcomes of laparoscopic simultaneous resection of synchronous colorectal cancer with liver metastasis in comparison with those of open surgery. METHODS Patients with synchronous colorectal cancer and liver metastasis who underwent simultaneous resection at Shuang Ho Hospital from 2009 to 2017 were identified. The patient demographics, perioperative morbidity, and survival rates were analyzed. RESULTS A total of 38 patients underwent simultaneous resection of synchronous colorectal cancer with liver metastasis. Laparoscopic procedure was performed for 16 patients, and the remaining 22 patients underwent open surgery. No significant differences were observed in the patient characteristics between the two groups. There was no perioperative mortality in both groups. The 1- and 3-year disease-free survival rates were 56% and 35% in the laparoscopic group and 70% and 15% in the open surgery group, respectively. The 1- and 3-year overall survival rates were 100% and 84% in the laparoscopic group and 73% and 48% in the open surgery group, respectively. CONCLUSION In selected patients, laparoscopic surgery for simultaneous resection of synchronous colorectal cancer with liver metastasis seems to be safe and had a similar outcome to that of open surgery.
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Affiliation(s)
- Ying-Wei Chen
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taiwan; Division of General Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taipei, Taiwan; Department of surgery, Taipei Medical University Shuang-Ho Hospital, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City. 235, Taiwan.
| | - Ming-Te Huang
- Division of General Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taipei, Taiwan; Department of surgery, Taipei Medical University Shuang-Ho Hospital, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City. 235, Taiwan.
| | - Tung-Cheng Chang
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taiwan; Graduate Institute of Clinical Medicine, Taipei Medical University, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Department of surgery, Taipei Medical University Shuang-Ho Hospital, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City. 235, Taiwan.
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Jansen-Winkeln B, Tagkalos E, Heimann A, Gaiser T, Hirsch D, Gockel I, Mittler J, Lang H, Heinrich S. Pringle maneuver increases the risk of anastomotic leakage after colonic resection in rats. HPB (Oxford) 2018; 20:392-397. [PMID: 29306581 DOI: 10.1016/j.hpb.2017.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 09/29/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many centers use the Pringle's maneuver during liver resections. Since this maneuver might impair healing of bowel anastomoses, we evaluated its influence on the healing of colonic anastomosis in rats. METHODS Male Wistar rats underwent median laparotomy and sigmoid resection with end-to-end anastomosis under inhalation anesthesia. Thereafter, rats received a 25 minutes Pringle's maneuver (PM, group 1) or were kept under anesthesia for the same period of time (group 2). The anastomotic bursting pressure (BP) was measured on postoperative days (POD) 3, 6 and 9. Hematoxylin and Eosin (H&E) staining was used for histopathological evaluation of the anastomosis. The Mann-Whitney U and χ2 -tests were used, p<0.05 values were considered significant. RESULTS All animals (n=48) lost body weight (BW) until POD3 (95.2% vs. 85.7%, p=0.003), and BW remained lower after PM (106.2% vs. 92.8%, p=0.001). The anastomotic BP was lower in group 1 compared to group 2 on POD 3 (116mmHg vs. 176.28mmHg, p=0.001), POD 6 (182.8mmHg vs. 213mmHg, p=0.029) and POD 9 (197.2mmHg vs. 251.7mmHg, p=0.009), and mortality was higher in group 1 (1 vs. 7, p=0.022). CONCLUSIONS Pringle's maneuver increases anastomotic complications in rats. Therefore, a Pringle's maneuver should be avoided during simultaneous liver and colorectal surgery.
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Affiliation(s)
- Boris Jansen-Winkeln
- Department of General, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Axel Heimann
- Institute for Neurosurgical Pathophysiology, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Timo Gaiser
- Department of Pathology, University Hospital Mannheim, Mannheim, Germany
| | - Daniela Hirsch
- Department of Pathology, University Hospital Mannheim, Mannheim, Germany
| | - Ines Gockel
- Department of General, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Jens Mittler
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital Mainz, Mainz, Germany.
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Safety and efficacy of synchronous robotic surgery for colorectal cancer with liver metastases. J Robot Surg 2018; 12:603-606. [PMID: 29704203 DOI: 10.1007/s11701-018-0813-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/16/2018] [Indexed: 12/30/2022]
Abstract
Timing of resection and treatment of colorectal cancer (CRC) with liver metastases varies based on patient characteristics and center protocols. Concerns of increased morbidity and mortality (M&M) related to anesthetic time and blood loss have limited widespread adaptation of synchronous colorectal and liver resections. Furthermore, technical challenges have made minimally invasive synchronous resections less common. We present our series of synchronous robotic surgery for CRC with liver metastases. Retrospective review of prospectively collected data of patients with stage IV CRC with liver metastases treated at a tertiary center from February 2013 to June 2014. Patients who underwent synchronous robotic surgery for CRC with liver metastasis(es) were included and selected by a multidisciplinary cancer committee. Data included patient demographics, disease stage, OR time, EBL, and complications. All resections were performed robotically by the same well-experienced surgeons. A radiologist was present for intraoperative ultrasound. Liver treatment was performed first in consideration of intraoperative bleeding risk. Sixty-six patients with Stage IV CRC were seen at the tertiary center during the study period. Six patients met inclusion criteria (2 male, 4 female). Mean age was 59.3 years and mean BMI was 23.46. Mean of 2.25 liver segments were resected and mean of 1.75 liver segments were ablated. Four patients underwent metastatectomy; three with concurrent microwave ablation. One patient had ablation without resection and another had no identifiable lesion on ultrasound. The colonic resections included 3 low anterior resections, 2 abdominal perineal resections (APR), and 1 right hemicolectomy. Mean operative time was 401 min (349-506 min) with mean EBL of 316 mL (150-1000 mL). No conversions to an open approach occurred. Median length of stay (LOS) was 4.5 days (3-10 days). Complications included delayed wound healing after an APR and a delayed rectal anastomotic failure after ileostomy reversal. There was no 30-day mortality. At a mean follow-up of 19 months, one death occurred at 26 months and the remaining patients had documented metastatic disease. Synchronous resection for metastatic CRC carries risks. We report our series of synchronous robotic surgery for CRC with liver metastases. The robotic approach contributed to low blood loss, appropriate LOS, and no 30-day mortality. Morbidity experienced was consistent with the procedures and not related to the robotic technique. This series supports the potential benefits of synchronous resection from a technical standpoint. Further data are required to determine treatment and survival benefits. Limitations include small number and retrospective review of data.
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67
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Chen SY, Stem M, Cerullo M, Gearhart SL, Safar B, Fang SH, Weiss MJ, He J, Efron JE. The Effect of Frailty Index on Early Outcomes after Combined Colorectal and Liver Resections. J Gastrointest Surg 2018; 22:640-649. [PMID: 29209981 DOI: 10.1007/s11605-017-3641-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 11/13/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although previous studies have examined frailty as a potential predictor of adverse surgical outcomes, little is reported on its application. We sought to assess the impact of the 5-item modified frailty index (mFI) on morbidity in patients undergoing combined colorectal and liver resections. METHODS Adult patients who underwent combined colorectal and liver resections were identified using the ACS-NSQIP database (2005-2015). The 5-item mFI consists of history of chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, and partial/total dependence. Patients were stratified into three groups: mFI 0, 1, or ≥ 2. The impact of the mFI on primary outcomes (30-day overall and serious morbidity) was assessed using multivariable logistic regression. Subgroup analyses by age and hepatectomy type was also performed. RESULTS A total of 1928 patients were identified: 55.1% with mFI = 0, 33.2% with mFI = 1, and 11.7% with mFI ≥ 2. 75.9% of patients underwent wedge resection/segmentectomy (84.6% colon, 15.4% rectum), and 24.1% underwent hemihepatectomy (88.8% colon, 11.2% rectum). On unadjusted analysis, patients with mFI ≥ 2 had significantly greater rates of overall and serious morbidity, regardless of age and hepatectomy type. These findings were consistent with the multivariable analysis, where patients with mFI ≥ 2 had increased odds of overall morbidity (OR 1.41, 95% CI 1.02-1.96, p = 0.037) and were more than twice likely to experience serious morbidity (OR 2.12, 95% CI 1.47-3.04, p < 0.001). CONCLUSIONS The 5-item mFI is significantly associated with 30-day morbidity in patients undergoing combined colorectal and liver resections. It is a tool that can guide surgeons preoperatively in assessing morbidity risk in patients undergoing concomitant resections.
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Affiliation(s)
- Sophia Y Chen
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Miloslawa Stem
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Marcelo Cerullo
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Susan L Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Sandy H Fang
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Radiofrequency ablation is beneficial in simultaneous treatment of synchronous liver metastases and primary colorectal cancer. PLoS One 2018; 13:e0193385. [PMID: 29543821 PMCID: PMC5854258 DOI: 10.1371/journal.pone.0193385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 02/11/2018] [Indexed: 12/21/2022] Open
Abstract
Background In patients with resectable synchronous colorectal liver metastases (CRLM), either two-staged or simultaneous resections of the primary tumor and liver metastases are performed. Data on radiofrequency ablation (RFA) for the treatment of CRLM during a simultaneous procedure is lacking. The primary aim was to analyze short-term and long-term outcome of RFA in simultaneous treatment. A secondary aim was to compare simultaneous resection with the colorectal-first approach. Methods Retrospective analysis of 241 patients with colorectal cancer and synchronous CRLM between 2000–2016. Median follow-up was 36.1 months (IQR 18.2–58.8 months). A multivariable analysis was performed to analyze the postoperative morbidity, using the comprehensive complication index. A propensity matched analysis was performed to compare survival rates. Results In multivariable analysis, the best predictor of lower complication severity was treatment with RFA (p = 0.040). Higher complication rates were encountered in patients who underwent an abdominoperineal resection (p = 0.027) or age > 60 years (p = 0.022). The matched analysis showed comparable overall survival in RFA treated patients versus patients undergoing a liver resection with a five year overall survival of 39.4% and 37.5%, respectively (p = 0.782). In a second matched analysis, 5-year overall survival rates in simultaneously treated patients (43.8%) was comparable to patients undergoing the colorectal first approach (43.0%, p = 0.223). Conclusions RFA treatment of CRLM in simultaneous procedures is associated with a lower complication severity and non-inferior oncological outcome as compared to partial liver resection. RFA should be considered a useful alternative to liver resection.
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Current Trends on the Treatment Sequence for Colorectal Cancer with Liver Metastases. CURRENT COLORECTAL CANCER REPORTS 2018. [DOI: 10.1007/s11888-018-0402-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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70
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Xue L, Williamson A, Gaines S, Andolfi C, Paul-Olson T, Neerukonda A, Steinhagen E, Smith R, Cannon LM, Polite B, Umanskiy K, Hyman N. An Update on Colorectal Cancer. Curr Probl Surg 2018; 55:76-116. [PMID: 29631699 DOI: 10.1067/j.cpsurg.2018.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lai Xue
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | | | - Sara Gaines
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Ciro Andolfi
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Terrah Paul-Olson
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Anu Neerukonda
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Emily Steinhagen
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Radhika Smith
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Lisa M Cannon
- Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Blasé Polite
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | | | - Neil Hyman
- Department of Surgery, University of Chicago Medicine, Chicago, IL.
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Ishioka K, Hokuto D, Nomi T, Yasuda S, Yoshikawa T, Matsuo Y, Akahori T, Nishiwada S, Nakagawa K, Nagai M, Nakamura K, Ikeda N, Sho M. Significance of bacterial culturing of prophylactic drainage fluid in the early postoperative period after liver resection for predicting the development of surgical site infections. Surg Today 2018; 48:625-631. [PMID: 29380135 DOI: 10.1007/s00595-018-1629-8] [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: 10/10/2017] [Accepted: 01/18/2018] [Indexed: 11/29/2022]
Abstract
PURPOSES The relationship between the results of bacterial drainage fluid cultures in the early postoperative period after liver resection and the development of surgical site infections (SSIs) is unclear. We evaluated the diagnostic value of bacterial cultures of drainage fluid obtained on postoperative day (POD) 1 after liver resection. METHODS The cases of all consecutive patients who underwent elective liver resection from January 2014 to December 2016 were analyzed. The association between a positive culture result and the development of SSIs was analyzed. RESULTS A total of 195 consecutive patients were studied. Positive drainage fluid cultures were obtained in 6 patients (3.1%). A multivariate analysis revealed that a positive drainage fluid culture was an independent risk factor for SSIs (odds ratio: 8.04, P = 0.035), and combined resection of the gastrointestinal tract was a risk factor for a positive drainage fluid culture (P = 0.006). Among the patients who did not undergo procedures involving the gastrointestinal tract, there was no association between drainage fluid culture positivity and SSIs. CONCLUSIONS The detection of positive culture results for drainage fluid collected on POD 1 after liver resection was associated with SSIs. However, among patients who did not undergo procedures involving the gastrointestinal tract, it was not a predictor of SSIs.
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Affiliation(s)
- Kohei Ishioka
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Takeo Nomi
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Takahiro Yoshikawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Yang Q, Liao F, Huang Y, Jiang C, Liu S, He W, Kong P, Zhang B, Xia L. Longterm effects of palliative local treatment of incurable metastatic lesions in colorectal cancer patients. Oncotarget 2018; 7:21034-45. [PMID: 26992234 PMCID: PMC4991510 DOI: 10.18632/oncotarget.8090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/24/2016] [Indexed: 12/20/2022] Open
Abstract
We assessed the value of palliative local treatment of incurable metastatic lesions in colorectal cancer patients. Consecutive patients with metastatic colorectal cancer treated between 2003 and 2014 were retrospectively reviewed. Propensity score matching was used to create comparable palliative local treatment and chemotherapy alone groups (n = 272 in each group). The primary endpoint was overall survival, which was calculated using Kaplan-Meier survival analyses. Factors possibly influencing survival were evaluated by univariate and subsequently by multivariate analyses. Palliative local treatment prolonged survival as compared with chemotherapy alone (38.73 vs. 19.8 months, p < 0.01). Univariate and subsequent multivariate analyses showed that primary stage IV at initial diagnosis; high CA199 level and LDH at the time of diagnosis were independent factors for a poor prognosis. Palliative local treatment improved survival better than chemotherapy alone in patients with 0, 1, 2, or 3 of the prognostic factors (p < 0.01). Patients administered treatment for pulmonary metastases survived longer than those treated for metastases elsewhere (56.77 vs. 35.43 months, p = 0.01). Surgical treatment provided marginally longer survival than non-surgical treatment (44.87 vs. 35.43 months, p = 0.05). These findings suggest palliative local treatment has survival benefit for selected patients with incurable metastatic colorectal cancer.
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Affiliation(s)
- Qiong Yang
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Department of Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Fangxin Liao
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Yuanyuan Huang
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Chang Jiang
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Shousheng Liu
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Wenzhuo He
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Pengfei Kong
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Bei Zhang
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
| | - Liangping Xia
- VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P.R. China
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Precision Medicine for CRC Patients in the Veteran Population: State-of-the-Art, Challenges and Research Directions. Dig Dis Sci 2018; 63:1123-1138. [PMID: 29572615 PMCID: PMC5895694 DOI: 10.1007/s10620-018-5000-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/23/2018] [Indexed: 12/16/2022]
Abstract
Colorectal cancer (CRC) accounts for ~9% of all cancers in the Veteran population, a fact which has focused a great deal of the attention of the VA's research and development efforts. A field-based meeting of CRC experts was convened to discuss both challenges and opportunities in precision medicine for CRC. This group, designated as the VA Colorectal Cancer Cell-genomics Consortium (VA4C), discussed advances in CRC biology, biomarkers, and imaging for early detection and prevention. There was also a discussion of precision treatment involving fluorescence-guided surgery, targeted chemotherapies and immunotherapies, and personalized cancer treatment approaches. The overarching goal was to identify modalities that might ultimately lead to personalized cancer diagnosis and treatment. This review summarizes the findings of this VA field-based meeting, in which much of the current knowledge on CRC prescreening and treatment was discussed. It was concluded that there is a need and an opportunity to identify new targets for both the prevention of CRC and the development of effective therapies for advanced disease. Also, developing methods integrating genomic testing with tumoroid-based clinical drug response might lead to more accurate diagnosis and prognostication and more effective personalized treatment of CRC.
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74
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Kim N, Park Y. Treatment strategies for locally advanced rectal cancer with synchronous resectable liver metastasis. FORMOSAN JOURNAL OF SURGERY 2018. [DOI: 10.4103/fjs.fjs_139_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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75
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Gavriilidis P, Sutcliffe RP, Hodson J, Marudanayagam R, Isaac J, Azoulay D, Roberts KJ. Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:11-19. [PMID: 28888775 DOI: 10.1016/j.hpb.2017.08.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/30/2017] [Accepted: 08/08/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This was a systematic review and meta-analysis to compare outcomes between patients undergoing simultaneous or delayed hepatectomy for synchronous colorectal liver metastases. BACKGROUND The optimal strategy for treating liver disease among patients with resectable synchronous colorectal liver metastases (CRLM) is unclear. Simultaneous resection of primary tumour and liver metastases may improve patient experience by reducing the number of interventions. However, there are concerns of increased morbidity compared to delayed resections. METHODS A systematic literature search was performed using EMBASE, Medline, Cochrane library and Google scholar databases. Meta-analyses were performed using both random-effects and fixed-effect models. Publication and patient selection bias were assessed with funnel plots and sensitivity analysis. RESULTS Thirty studies including 5300 patients were identified. There were no statistically significant differences in parameters relating to safety and efficacy between the simultaneous and delayed hepatectomy cohorts. Patients undergoing delayed surgery were more likely to have bilobar disease or undergo major hepatectomy. The average length of hospital stay was six days shorter with simultaneous approach [MD = -6.27 (95% CI: -8.20, -4.34), p < 0.001]. Long term survival was similar for the two approaches [HR = 0.97 (95%CI: 0.88, 1.08), p = 0.601]. CONCLUSION In selected patients, simultaneous resection of liver metastases with colorectal resection is associated with shorter hospital stay compared to delayed resections, without adversely affecting perioperative morbidity or long-term survival.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK; Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, 94010 Créteil, France.
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - James Hodson
- Statistician at the Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK
| | - Ravi Marudanayagam
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - John Isaac
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
| | - Daniel Azoulay
- Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor University Hospital, 94010 Créteil, France
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, B15 1NU, UK
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76
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Salvador-Rosés H, López-Ben S, Casellas-Robert M, Planellas P, Gómez-Romeu N, Farrés R, Ramos E, Codina-Cazador A, Figueras J. Oncological strategies for locally advanced rectal cancer with synchronous liver metastases, interval strategy versus rectum first strategy: a comparison of short-term outcomes. Clin Transl Oncol 2017; 20:1018-1025. [PMID: 29273957 DOI: 10.1007/s12094-017-1818-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 12/09/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The goal of treatment for patients with synchronous liver metastases (SLM) from rectal cancer is to achieve a complete resection of both tumor locations. For patients with symptomatic locally advanced rectal cancer with resectable SLM at diagnosis, our usual strategy has been the rectum first approach (RF). However, since 2014, we advocate for the interval approach (IS) that involves the administration of chemo-radiotherapy followed by the resection of the SLM in the interval of time between rectal cancer radiation and rectal surgery. METHODS From 2010 to 2016, 16 patients were treated according to this new strategy and 19 were treated according RF strategy. Data were collected prospectively and analyzed with an intention-to-treat perspective. Complete resection rate, duration of the treatment and morbi-mortality were the main outcomes. RESULTS The complete resection rate in the IS was higher (100%, n = 16) compared to the RF (74%, n = 14, p = 0.049) and the duration of the strategy was shorter (6 vs. 9 months, respectively, p = 0.006). The incidence of severe complications after liver surgery was 14% (n = 2) in the RF and 0% in the IS (p = 1.000), and after rectal surgery was 24% (n = 4) and 12% (n = 2), respectively (p = 1.000). CONCLUSION The IS is a feasible and safe strategy that procures higher level of complete resection rate in a shorter period of time compared to RF strategy.
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Affiliation(s)
- H Salvador-Rosés
- Department of Digestive Surgery, Doctor Josep Trueta University Hospital, IdIBGi, Avinguda de França, S/N, 17007, Girona, Spain.
- University of Barcelona, Barcelona, Spain.
| | - S López-Ben
- Department of Digestive Surgery, Doctor Josep Trueta University Hospital, IdIBGi, Avinguda de França, S/N, 17007, Girona, Spain
| | - M Casellas-Robert
- Department of Digestive Surgery, Doctor Josep Trueta University Hospital, IdIBGi, Avinguda de França, S/N, 17007, Girona, Spain
- University of Barcelona, Barcelona, Spain
| | - P Planellas
- Department of Digestive Surgery, Doctor Josep Trueta University Hospital, IdIBGi, Avinguda de França, S/N, 17007, Girona, Spain
| | - N Gómez-Romeu
- Department of Digestive Surgery, Doctor Josep Trueta University Hospital, IdIBGi, Avinguda de França, S/N, 17007, Girona, Spain
| | - R Farrés
- Department of Digestive Surgery, Doctor Josep Trueta University Hospital, IdIBGi, Avinguda de França, S/N, 17007, Girona, Spain
| | - E Ramos
- Department of Digestive Surgery, Bellvitge Hospital, University of Barcelona, Barcelona, Spain
| | - A Codina-Cazador
- Department of Digestive Surgery, Doctor Josep Trueta University Hospital, IdIBGi, Avinguda de França, S/N, 17007, Girona, Spain
- University of Barcelona, Barcelona, Spain
| | - J Figueras
- University of Barcelona, Barcelona, Spain
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77
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Sunil S, Restrepo J, Azin A, Hirpara D, Cleary S, Cleghorn MC, Wei A, Quereshy FA. Robotic simultaneous resection of rectal cancer and liver metastases. Clin Case Rep 2017; 5:1913-1918. [PMID: 29225824 PMCID: PMC5715581 DOI: 10.1002/ccr3.1138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/18/2017] [Accepted: 07/24/2017] [Indexed: 12/17/2022] Open
Abstract
Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic‐assistance has been rarely reported. We demonstrate that robotic‐assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.
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Affiliation(s)
- Supreet Sunil
- Division of General Surgery University Health Network Toronto Ontario Canada
| | - Juliana Restrepo
- Division of General Surgery University Health Network Toronto Ontario Canada.,Division of General Surgery University of Toronto Toronto Ontario Canada
| | - Arash Azin
- Division of General Surgery University Health Network Toronto Ontario Canada.,Division of General Surgery University of Toronto Toronto Ontario Canada
| | - Dhruvin Hirpara
- Faculty of Medicine University of Toronto Toronto Ontario Canada
| | - Sean Cleary
- Division of General Surgery University Health Network Toronto Ontario Canada.,Division of General Surgery University of Toronto Toronto Ontario Canada
| | - Michelle C Cleghorn
- Division of General Surgery University Health Network Toronto Ontario Canada
| | - Alice Wei
- Division of General Surgery University Health Network Toronto Ontario Canada.,Division of General Surgery University of Toronto Toronto Ontario Canada
| | - Fayez A Quereshy
- Division of General Surgery University Health Network Toronto Ontario Canada.,Division of General Surgery University of Toronto Toronto Ontario Canada
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78
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Zhang XF, Beal EW, Weiss M, Aldrighetti L, Poultsides GA, Bauer TW, Fields RC, Maithel SK, Marques HP, Pawlik TM. Timing of disease occurrence and hepatic resection on long-term outcome of patients with neuroendocrine liver metastasis. J Surg Oncol 2017; 117:171-181. [PMID: 28940257 DOI: 10.1002/jso.24832] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/17/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The objective of the study was to evaluate the impact of timing of disease occurrence and hepatic resection on long-term outcome of neuroendocrine liver metastasis (NELM). METHODS A total of 420 patients undergoing curative-intent resection for NELM were identified from a multi-institutional database. Date of primary resection, NELM detection and resection, intraoperative details, disease-specific (DSS), and recurrence-free survival (RFS) were obtained. RESULTS A total of 243 (57.9%) patients had synchronous NELM, while 177 (42.1%) developed metachronous NELM. On propensity score matching (PSM), patients with synchronous versus metachronous NELM had comparable DSS (10-year DSS, 76.2% vs 85.9%, P = 0.105), yet a worse RFS (10-year RFS, 34.1% vs 59.8%, P = 0.008). DSS and RFS were comparable regardless of operative approach (simultaneous vs staged, both P > 0.1). Among patients who developed metachronous NELM, no difference in long-term outcomes were identified between early (≤2 years, n = 102, 57.6%) and late (>2 years, n = 68, 42.4%) disease on PSM (both P > 0.1). CONCLUSIONS Patients with synchronous NELM had a higher risk of tumor recurrence after hepatic resection versus patients with metachronous disease. The time to development of metachronous NELM did not affect long-term outcome. Curative-intent hepatic resection should be considered for patients who develop NELM regardless of the timing of disease presentation.
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Affiliation(s)
- Xu-Feng Zhang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Luca Aldrighetti
- Department of Surgery, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Ryan C Fields
- Department of Surgery, Washington University, School of Medicine, St Louis, Missouri
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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79
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Feo L, Polcino M, Nash GM. Resection of the Primary Tumor in Stage IV Colorectal Cancer: When Is It Necessary? Surg Clin North Am 2017; 97:657-669. [PMID: 28501253 DOI: 10.1016/j.suc.2017.01.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Management of metastatic colorectal cancer requires accurate staging and multidisciplinary evaluation, leading to a consensus treatment plan with the ultimate goal of increasing survival and improving the quality of life, while taking into consideration the patient's performance status, disease burden, and goals of care. Since the introduction of multidrug chemotherapeutic regimens, survival of patients with metastatic colorectal cancer has improved. Many patients with unresectable disease are undergoing surgery for asymptomatic primary tumors despite evidence that it is usually a futile intervention. Palliative measures for local control of the primary tumor include colonic stents, laser therapy, and fulguration.
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Affiliation(s)
- Leandro Feo
- Colorectal Service, Department of Surgery, Catholic Medical Center, 100 McGregor Street, Suite 3100, Manchester, NH 03102, USA
| | - Michael Polcino
- Division of Colorectal Surgery, St. Barnabas Hospital, 4422 Third Avenue, Bronx, NY 10457, USA
| | - Garrett M Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1233 York Avenue, New York, NY 10065, USA.
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80
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Treatment strategies for rectal cancer with synchronous liver metastases: surgical and oncological outcomes with propensity-score analysis. Clin Transl Oncol 2017; 20:221-229. [PMID: 28707036 DOI: 10.1007/s12094-017-1712-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal sequence of surgery for rectal cancer (RC) with synchronous liver metastases (SLM) is controversial. OBJECTIVES The primary objective was to explore differences between the rectum first (RF) and the liver first strategy (LF) to achieve the complete resection (CR) of both tumors. METHODS Patients diagnosed of RC with resectable or potentially resectable SLM were included. Data collected prospectively were analyzed with an intention-to-treat perspective, adjusting for between-sample differences (propensity score). The complete resection rate (CRR) was the main outcome variable. RESULTS During a 5-year period, 23 patients underwent the LF strategy and 24 patients the RF strategy. Median overall survival (OS) was 32 months in the LF group and 41 months in the RF group (p = 0.499), and was 51 and 17 months, respectively, for patients achieving or not achieving CR of both tumors (p < 0.001). CRR's were 65% in liver first group and 63% in rectum first group, (p = 0.846). No between-strategy differences in morbidity or duration of treatment were observed. CONCLUSIONS This study supports the notion that the achievement of CR of RC and SLM should be the goal of oncological treatment. Both RF and LF strategies are feasible and safe, but no between-strategy differences have been found in the CRR.
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81
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Zhou F, Yu X, Liang P, Han Z, Cheng Z, Yu J, Liu F, Hu Y. Does primary tumor location impact the prognosis of colorectal liver metastases patients after microwave ablation? - Lessons from 10 years' experience. Oncotarget 2017; 8:100791-100800. [PMID: 29246023 PMCID: PMC5725065 DOI: 10.18632/oncotarget.18764] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/09/2017] [Indexed: 12/26/2022] Open
Abstract
Thermal ablation has been considered as an alternative for local curative intent in patients with unresectable colorectal liver metastases. The influence of primary tumor location on the prognosis of colorectal liver metastases patients who have undergone microwave ablation has yet to be determined. We reviewed 295 patients who underwent microwave ablation for colorectal liver metastases at our institution between March 2006 and March 2016. Univariate and multivariate analyses were performed to identify predictors of overall and progression-free survival. Technical success was achieved in 96.6% of patients (n = 289), with a post-procedural complication rate of 2.0% (n = 6). After a median follow-up of 24 (range, 2–86) months, comparable overall survival rates (p = 0.583) were observed in patients with different primary tumor locations. Patients with colorectal liver metastases originating from left-sided primary colon cancer exhibited a better progression-free survival than patients whose colorectal liver metastases had originated from right-sided primary colon cancer (hazard ratio: 0.67, 95.0% confidence interval: 0.48–0.94; p = 0.012), which was further confirmed in a multivariate analysis after adjustment for other potential prognostic factors. Stratification based on primary tumor location should be taken into consideration in the assessment of disease progression in patients who intend to undergo microwave ablation for colorectal liver metastases.
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Affiliation(s)
- Fubo Zhou
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiaoling Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhiyu Han
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhigang Cheng
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Fangyi Liu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Yi Hu
- Department of Oncology, Chinese PLA General Hospital, Beijing 100853, China
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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: 2.0] [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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83
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Simultaneous Resection for Synchronous Colorectal Liver Metastasis: the New Standard of Care? J Gastrointest Surg 2017; 21:975-982. [PMID: 28411351 DOI: 10.1007/s11605-017-3422-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/02/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Optimal surgical management for patients with synchronous colorectal cancer liver metastasis is controversial. We provide an analysis of surgical utilization and outcomes for patients presenting with synchronous colon and rectal cancer liver metastasis between simultaneous and staged approaches. METHODS SPARCS database was used to follow patients undergoing surgery for colorectal cancer with liver metastases from 2005 to 2014. Using International Classification of Diseases, Ninth Revision codes, we identified patients undergoing staged and simultaneous resection. Our primary endpoint was major events at 30-day follow-up. RESULTS Of the patients, 1430 underwent surgery for synchronous colorectal primary and liver metastases between 2005 and 2014. There was no difference in adjusted rates of major events or anastomotic leak. Patients undergoing simultaneous resection were significantly less likely to experience prolonged length of stay (OR = 0.28; 95% CI = 0.21-0.37) or high hospital charges (OR = 0.24; 95% CI = 0.17-0.32) compared to staged resection even among patients undergoing total hepatic lobectomy and complex colorectal resection. CONCLUSIONS Simultaneous resection was found to be equally as safe as staged resection even when evaluating patients undergoing more complex operations, and led to lower health care utilization. Under appropriate clinical circumstances, simultaneous resection offers benefits to patients and the health care system and should be the recommended surgical approach.
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84
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Maistrenko NA, Khvatov AA, Sazonov AA. POSTOPERATIVE COMPLICATIONS OF COMBINED SURGERIES IN PATIENTS WITH DISSEMINATED FORMS OF COLON CANCER. GREKOV'S BULLETIN OF SURGERY 2017. [DOI: 10.24884/0042-4625-2017-176-2-86-94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE. The authors investigated the peculiarities and character of complications in gerontological patients with disseminated forms of colon cancer after combined and extended operative interventions. MATERIALS AND METHODS. A retrospective analysis of treatment results of 154 patients was made. The single-stage combined operations were performed on 32 patients of the first group with IV stage of colon cancer. The operation included removing of primary tumor and liver metastases. Combined and extended operative interventions were carried out on 122 patients of the second group with locally-advanced colorectal cancer (T3-4N1-3M0). The patients of both groups were divided into 2 subgroups according to the age: subgroup A - over 60 years of age, subgroup B - younger than 60. Comparison of parameters of postoperative period was made separately in each group between subgroups. RESULTS. There weren’t noted any reliable increase in rate of surgical complication in patients of elderly and senile age with disseminated forms of colon cancer after combined operations. These operations accompanied by high risk of development of functionally-somatic complications as a rule connected with decompensation of concurrent pathology. CONCLUSIONS. The authors recommend to make the careful assessment of general somatic status of gerontological patients with disseminated forms of colorectal cancer and apply the multidiscipline approach in order to balance on time the concurrent pathology after combined operations.
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85
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Prolyl Hydroxylase Inhibition Enhances Liver Regeneration Without Induction of Tumor Growth. Ann Surg 2017; 265:782-791. [DOI: 10.1097/sla.0000000000001696] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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86
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Dulundu E, Attaallah W, Tilki M, Yegen C, Coskun S, Coskun M, Erdim A, Tanrikulu E, Yardimci S, Gunal O. Simultaneous resection for colorectal cancer with synchronous liver metastases is a safe procedure: Outcomes at a single center in Turkey. Biosci Trends 2017; 11:235-242. [PMID: 28216517 DOI: 10.5582/bst.2017.01019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The optimal surgical strategy for treating colorectal cancer with synchronous liver metastases is subject to debate. The current study sought to evaluate the outcomes of simultaneous colorectal cancer and liver metastases resection in a single center. Prospectively collected data on all patients with synchronous colorectal liver metastases who underwent simultaneous resection with curative intent were analyzed retrospectively. Patient outcomes were compared depending on the primary tumor location and type of liver resection (major or minor). Between January 2005 and August 2016, 108 patients underwent simultaneous resection of primary colorectal cancer and liver metastases. The tumor was localized to the right side of the colon in 24 patients (22%), to the left side in 40 (37%), and to the rectum in 44 (41%). Perioperative mortality occurred in 3 patients (3%). Postoperative complications were noted in 32 patients (30%), and most of these complications (75%) were grade 1 to 3 according to the Clavien-Dindo classification. Neither perioperative mortality nor the rate of postoperative complications after simultaneous resection differed among patients with cancer of the right side of the colon, those with cancer of the left side of the colon, and those with rectal cancer (4%, 2.5%, and 2%, respectively, p = 0.89) and (17%, 33%, and 34%, respectively; p = 0.29)]. The 5-year overall survival of the entire sample was 54% and the 3-year overall survival was 67 %. In conclusion, simultaneous resection for primary colorectal cancer and liver metastases is a safe procedure and can be performed without excess morbidity in carefully selected patients regardless of the location of the primary tumor and type of hepatectomy.
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Affiliation(s)
- Ender Dulundu
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Wafi Attaallah
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Metin Tilki
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Cumhur Yegen
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Safak Coskun
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Mumin Coskun
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Aylin Erdim
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Eda Tanrikulu
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Samet Yardimci
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
| | - Omer Gunal
- Department of General Surgery, Marmara University Pendik Teaching and Research Hospital
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87
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Bergeat D, Rayar M, Mouchel Y, Merdrignac A, Meunier B, Lièvre A, Boudjema K, Sulpice L. Preoperative bevacizumab and surgery for colorectal liver metastases: a propensity score analysis. Langenbecks Arch Surg 2017; 402:57-67. [DOI: 10.1007/s00423-017-1551-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/01/2017] [Indexed: 12/25/2022]
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88
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Lim C, Doussot A, Osseis M, Salloum C, Gomez Gavara C, Compagnon P, Brunetti F, Calderaro J, Azoulay D. Primary Tumor Versus Liver-First Strategy in Patients with Stage IVA Colorectal Cancer: A Propensity Score Analysis of Long-term Outcomes and Recurrence Pattern. Ann Surg Oncol 2016; 23:3024-3032. [DOI: 10.1245/s10434-016-5265-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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89
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Wei D. Surgical treatment of low rectal cancer: Current status and future prospects. Shijie Huaren Xiaohua Zazhi 2016; 24:3238-3247. [DOI: 10.11569/wcjd.v24.i21.3238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rectal cancer is a common type of malignant tumor in China, and its incidence rate is rising year by year. Middle and low rectal cancer accounts for 70%-80% of all rectal cancer cases. The treatment concept requires not only radical resection of tumor, but also preservation of the anal and urogenital function, in order to improve the quality of life. Improved surgical technique requires laparoscopic minimally invasive surgery, to reduce trauma and shorten hospital stay. To improve the 5-year disease-free survival rate, correct treatment of distant metastases, especially liver metastases, is required. By improving the accuracy of preoperative staging of rectal cancer, applying neoadjuvant therapy, and following the principle of total mesorectal excision, patients can benefit in terms of increased resection rate, decreased operation complication incidence, increased sphincter preservation, decreased local recurrence and increased overall survival rate. With the development of medical technology, minimally invasive surgery for low rectal cancer has been developed rapidly. Surgical resection is the only curative method in the therapy of rectal cancer and liver metastases. However, there are still some doubts concerning what to resect first in cases of synchronous rectal cancer and liver metastases in order to achieve the best results. In this paper, we discuss new progress in the surgical treatment of low rectal cancer and rectal cancer liver metastases.
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90
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Dervenis C, Xynos E, Sotiropoulos G, Gouvas N, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Chrysou E, Emmanouilidis C, Georgiou P, Karachaliou N, Katopodi O, Kountourakis P, Kyriazanos I, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Tekkis P, Triantopoulou C, Tzardi M, Vassiliou V, Vini L, Xynogalos S, Ziras N, Souglakos J. Clinical practice guidelines for the management of metastatic colorectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:390-416. [PMID: 27708505 PMCID: PMC5049546 DOI: 10.20524/aog.2016.0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/10/2016] [Indexed: 12/12/2022] Open
Abstract
There is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus. The aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines. Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed. Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC. Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus. One hundred and nine statements were developed. Ninety experts voted for those statements. The median rate of abstain per statement was 18.5% (range: 0-54%). In the end of the process, all statements achieved a large consensus. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized. R0 resection is the only intervention that may offer substantial improvement in the oncological outcomes.
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Affiliation(s)
- Christos Dervenis
- General Surgery, "Konstantopouleio" Hospital of Athens, Greece (Christos Dervenis)
| | - Evaghelos Xynos
- General Surgery, "InterClinic" Hospital of Heraklion, Greece (Evangelos Xynos)
| | | | - Nikolaos Gouvas
- General Surgery, "METROPOLITAN" Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Ioannis Boukovinas
- Medical Oncology, "Bioclinic" of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, "Venizeleion" Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Christos Emmanouilidis
- Medical Oncology, "Interbalkan" Medical Center, Thessaloniki, Greece (Christos Emmanoulidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institut, Barcelona, Spain (Niki Carachaliou)
| | - Ourania Katopodi
- Medical Oncology, "Iaso" General Hospital, Athens, Greece (Ourania Katopoidi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - Ioannis Kyriazanos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, "Ippokrateion" Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, "Theageneion" Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, "Agioi Anargyroi" Hospital of Athens, Greece (Joseph Sgouros)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | | | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Louiza Vini
- Radiation Oncology, "Iatriko" Center of Athens, Greece (Lousa Vini)
| | - Spyridon Xynogalos
- Medical Oncology, "George Gennimatas" General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Nikolaos Ziras
- Medical Oncology, "Metaxas" Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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91
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Simultaneous Minimally Invasive Treatment of Colorectal Neoplasm with Synchronous Liver Metastasis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9328250. [PMID: 27294144 PMCID: PMC4884597 DOI: 10.1155/2016/9328250] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
Purpose. To analyse perioperative and oncological outcomes of minimally invasive simultaneous resection of primary colorectal neoplasm with synchronous liver metastases. Methods. A Medline revision of the current published literature on laparoscopic and robotic-assisted combined colectomy with hepatectomy for synchronous liver metastatic colorectal neoplasm was performed until February 2015. The specific search terms were "liver metastases", "hepatic metastases", "colorectal", "colon", "rectal", "minimally invasive", "laparoscopy", "robotic-assisted", "robotic colorectal and liver resection", "synchronous", and "simultaneous". Results. 20 clinical reports including 150 patients who underwent minimally invasive one-stage procedure were retrospectively analysed. No randomized trials were found. The approach was laparoscopic in 139 patients (92.7%) and robotic in 11 cases (7.3%). The rectum was the most resected site of primary neoplasm (52.7%) and combined liver procedure was in 89% of cases a minor liver resection. One patient (0.7%) required conversion to open surgery. The overall morbidity and mortality rate were 18% and 1.3%, respectively. The most common complication was colorectal anastomotic leakage. Data concerning oncologic outcomes were too heterogeneous in order to gather definitive results. Conclusion. Although no prospective randomized trials are available, one-stage minimally invasive approach seems to show advantages over conventional surgery in terms of postoperative short-term course. On the contrary, more studies are required to define the oncologic values of the minimally invasive combined treatment.
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92
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Gani F, Pawlik TM. Assessing the Costs Associated with Volume-Based Referral for Hepatic Surgery. J Gastrointest Surg 2016; 20:945-52. [PMID: 26768005 DOI: 10.1007/s11605-015-3071-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although proposed as a means for quality improvement, little is known regarding the economic consequences of volume-based referral. The objective of the current study was to investigate the relationship between inpatient costs and hospital volume. METHODS Patients undergoing elective liver surgery were identified using the Nationwide Inpatient Sample from 2001 to 2012. Multivariable hierarchical regression analyses were performed to calculate and compare risk-adjusted costs and postoperative outcomes across hospital volume terciles. RESULTS A total of 27,813 patients underwent surgery at 2207 hospitals. Although costs were comparable across the three volume groups (all p > 0.05), patients who developed a postoperative complication incurred a higher overall cost (complication vs. no complication; median costs $17,974 [IQR 13,865-25,623] vs. $41,731 [IQR 27,008-64,266], p < 0.001). In contrast, while the incidence of postoperative complications (low vs. intermediate vs. high; 22.0 vs. 19.2 vs. 13.0 %, p < 0.001) and subsequent failure-to-rescue (low vs. intermediate vs. high; 16.6 vs. 24.7 vs. 15.1 %, p < 0.001) was lower at high-volume hospitals, costs associated with "rescue" were substantially higher at high-volume hospitals (low vs. intermediate vs. high; $39,289 vs. $36,157 vs. $48,559, both p < 0.001). CONCLUSIONS Compared with lower volume hospitals, improved outcomes among patients who developed a complication at high-volume hospitals were associated with an increased cost.
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Affiliation(s)
- Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street Blalock 688, Baltimore, MD, 21287, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street Blalock 688, Baltimore, MD, 21287, USA.
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93
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Silberhumer GR, Paty PB, Denton B, Guillem J, Gonen M, Araujo RLC, Nash GM, Temple LK, Allen PJ, DeMatteo RP, Weiser MR, Wong WD, Jarnagin WR, D'Angelica MI, Fong Y. Long-term oncologic outcomes for simultaneous resection of synchronous metastatic liver and primary colorectal cancer. Surgery 2016; 160:67-73. [PMID: 27079362 DOI: 10.1016/j.surg.2016.02.029] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/05/2016] [Accepted: 02/24/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Twenty-five percent of patients with colorectal cancer present with simultaneous liver metastasis. Complete resection is the only potential curative treatment. Due to improvements in operative and perioperative management, simultaneous liver and colon resections are an accepted procedure at specialized centers for selected patients. Nevertheless, little is known about the long-term, oncologic results of simultaneous operative procedures compared with those of staged operations. METHODS Patients with colorectal cancer and simultaneous liver metastases presenting for complete resection at a tertiary cancer center were identified. Patients who received the primary colon resection at an outside institution were excluded from analysis. RESULTS Between 1984 and 2008, 429 patients underwent operative treatment for colorectal cancer with simultaneous liver metastasis. Of these, 320 (75%) had simultaneous resection and 109 had staged resection. There was no difference in the distribution of primary tumor locations between the 2 groups. Mean size of the hepatic metastases was significantly greater in the staged group (median 4 cm vs 2.5 cm; P < .01). Neither disease-free nor overall survival differed significantly between the 2 treatment strategies. The extent of the liver procedure (more than 3 segments) was identified as a risk factor for decreased disease-free and overall survival (both P < .01). CONCLUSION Simultaneous liver and colorectal resections for metastatic colorectal cancer are associated with similar long-term cancer outcome compared with staged procedures.
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Affiliation(s)
- Gerd R Silberhumer
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Philip B Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian Denton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jose Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Raphael L C Araujo
- Department of Surgery, Hepatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Garret M Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Larissa K Temple
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter J Allen
- Department of Surgery, Hepatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ronald P DeMatteo
- Department of Surgery, Hepatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin R Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - W Douglas Wong
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William R Jarnagin
- Department of Surgery, Hepatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael I D'Angelica
- Department of Surgery, Hepatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, CA.
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94
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Buettner S, Gani F, Amini N, Spolverato G, Kim Y, Kilic A, Wagner D, Pawlik TM. The relative effect of hospital and surgeon volume on failure to rescue among patients undergoing liver resection for cancer. Surgery 2016; 159:1004-12. [DOI: 10.1016/j.surg.2015.10.025] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/01/2015] [Accepted: 10/23/2015] [Indexed: 01/18/2023]
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95
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Lianos GD, Glantzounis GK. Synchronous colorectal liver metastases: treatment dilemmas and hopes for improving oncological outcomes. Future Oncol 2016; 12:1743-6. [PMID: 27020479 DOI: 10.2217/fon-2016-0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Georgios D Lianos
- Department of Surgery, Ioannina University Hospital & School of Medicine, University of Ioannina, Ioannina, Greece
| | - Georgios K Glantzounis
- Department of Surgery, Ioannina University Hospital & School of Medicine, University of Ioannina, Ioannina, Greece
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96
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Ratti F, Catena M, Di Palo S, Staudacher C, Aldrighetti L. Impact of totally laparoscopic combined management of colorectal cancer with synchronous hepatic metastases on severity of complications: a propensity-score-based analysis. Surg Endosc 2016; 30:4934-4945. [PMID: 26944725 DOI: 10.1007/s00464-016-4835-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/15/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Thanks to widespread diffusion of minimally invasive approach in the setting of both colorectal and hepatic surgeries, the interest in combined resections for colorectal cancer and synchronous liver metastases (SCLM) by totally laparoscopic approach (TLA) has increased. Aim of this study was to compare outcome of combined resections for SCLM performed by TLA or by open approach, in a propensity-score-based study. STUDY DESIGN All 25 patients undergoing combined TLA for SCLM at San Raffaele Hospital in Milano were compared in a case-matched analysis with 25 out of 91 patients undergoing totally open approach (TOA group). Groups were matched with 1:2 ratio using propensity scores based on covariates representing disease severity. Main endpoints were postoperative morbidity and long-term outcome. The Modified Accordion Severity Grading System was used to quantify complications. RESULTS The groups resulted comparable in terms of patients and disease characteristics. The TLA group, as compared to the TOA group, had lower blood loss (350 vs 600 mL), shorter postoperative stay (9 vs 12 days), lower postoperative morbidity index (0.14 vs 0.20) and severity score for complicated patients (0.60 vs 0.85). Colonic anastomosis leakage had the highest fractional complication burden in both groups. In spite of comparable long-term overall survival, the TLA group had better recurrence-free survival. CONCLUSION TLA for combined resections is feasible, and its indications can be widened to encompass a larger population of patients, provided its benefits in terms of reduced overall risk and severity of complications, rapid functional recovery and favorable long-term outcomes.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Saverio Di Palo
- Gastrointestinal Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Carlo Staudacher
- Gastrointestinal Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
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97
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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: 1.1] [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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98
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Page AJ, Gani F, Crowley KT, Lee KHK, Grant MC, Zavadsky TL, Hobson D, Wu C, Wick EC, Pawlik TM. Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection. Br J Surg 2016; 103:564-71. [DOI: 10.1002/bjs.10087] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/13/2015] [Accepted: 11/19/2015] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Enhanced recovery after surgery (ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery.
Methods
An evidence-based, standardized perioperative care pathway was developed and implemented prospectively among patients undergoing open liver surgery between 1 January 2014 and 31 July 2015. Perioperative outcomes, including length of hospital stay, postoperative complications and healthcare costs, were compared between groups of patients who had surgery before and after introduction of the ERAS pathway. Provider perceptions regarding the perioperative pathway were assessed using an online questionnaire.
Results
There were no differences in patient or disease characteristics between pre-ERAS (42 patients) and post-ERAS (75) groups. Although mean pain scores were comparable between the two groups, patients treated within the ERAS pathway had a marked reduction in opioid use on the first 3 days after surgery compared with those treated before introduction of the pathway (all P < 0·001). Duration of hospital stay was shorter in the post-ERAS group (median 5 (i.q.r. 4–7) days versus 6 (5–7) days in the pre-ERAS group; P = 0·037) and there was a lower incidence of postoperative complications (1 versus 10 per cent; P = 0·036). Implementation of the ERAS pathway was associated with a 40·7 per cent decrease in laboratory costs (−US $333; −€306, exchange rate 4 January 2016) and a 21·5 per cent reduction in medical supply costs (−US $394; −€362) per patient. Although 91·0 per cent of providers endorsed the ERAS pathway, 33·8 per cent identified provider aversion to a standardized protocol as the greatest hurdle to implementation.
Conclusion
The introduction of a multimodal ERAS programme following open liver surgery was associated with a reduction in opioid use, shorter hospital stay and decreased hospital costs. ERAS was endorsed by an overwhelming majority of providers.
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Affiliation(s)
- A J Page
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - F Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - K T Crowley
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland, USA
| | - K H K Lee
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland, USA
| | - M C Grant
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Maryland, USA
| | - T L Zavadsky
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - D Hobson
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - C Wu
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Maryland, USA
| | - E C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - T M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
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99
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Colorectal cancer with synchronous hepatic metastases: Systematic review of reports comparing synchronous surgery with sequential bowel-first or liver-first approaches. Eur J Surg Oncol 2016; 42:159-65. [DOI: 10.1016/j.ejso.2015.11.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 11/08/2015] [Indexed: 12/16/2022] Open
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100
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Buettner S, Wagner D, Kim Y, Margonis GA, Makary MA, Wilson A, Sasaki K, Amini N, Gani F, Pawlik TM. Inclusion of Sarcopenia Outperforms the Modified Frailty Index in Predicting 1-Year Mortality among 1,326 Patients Undergoing Gastrointestinal Surgery for a Malignant Indication. J Am Coll Surg 2015; 222:397-407.e2. [PMID: 26803743 DOI: 10.1016/j.jamcollsurg.2015.12.020] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/10/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although it is a useful metric for preoperative risk stratification, frailty can be difficult to identify in patients before surgery. We sought to develop a preoperative frailty-risk model combining sarcopenia with clinical parameters to predict 1-year mortality using a cohort of patients undergoing gastrointestinal cancer surgery. STUDY DESIGN We identified 1,326 patients undergoing hepatobiliary, pancreatic, or colorectal surgery between 2011 and 2014. Sarcopenia defined by psoas density was measured using preoperative cross-sectional imaging. Multivariable Cox regression analysis was performed to identify preoperative risk factors associated with 1-year mortality and used to develop a preoperative risk-stratification score. RESULTS Among all patients identified, 640 (48.3%) patients underwent pancreatic surgery, 347 (26.2%) underwent a hepatobiliary procedure, and 339 (25.5%) a colorectal procedure. Using sex-specific cut-offs, 398 (30.0%) patients were categorized as sarcopenic. Sarcopenic patients were more likely to develop postoperative complications vs non-sarcopenic patients (odds ratio [OR] 1.80, 95% CI 1.42 to 2.29; p < 0.001). Overall 1-year mortality was 9.4%. On multivariable analysis, independent risk factors for 1-year mortality included increasing age (65 to 75 years: [hazard ratio (HR) 1.81, 95% CI 1.05 to 3.14] greater than 75 years [HR 2.79, 95% CI 1.55 to 5.02]), preoperative anemia hemoglobin < 12.5 g/dL (HR 1.68, 95% CI 1.17 to 2.40), and preoperative sarcopenia (HR 1.98, 95% CI 1.36 to 2.88; all p < 0.05). Using these variables, a 28-point weighed composite score was able to stratify patients by their risk for mortality 1 year after surgery (C-statistic = 0.70). The proposed score outperformed other indices of frailty including the modified Frailty Index (C-statistic = 0.55) and the Eastern Cooperative Oncology Group (ECOG) performance score (C-statistic = 0.57) (both p < 0.05). CONCLUSION Sarcopenia was combined with clinical factors to generate a composite risk-score that can be used to identify frail patients at greatest risk for 1-year mortality after gastrointestinal cancer surgery.
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Affiliation(s)
- Stefan Buettner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Doris Wagner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Yuhree Kim
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | | | - Martin A Makary
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Ana Wilson
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Kazunari Sasaki
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Neda Amini
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Faiz Gani
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
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