Repeat resection of liver metastases

Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients

BACKGROUND

Laparoscopic liver resection (LLR) for metastatic colorectal cancer (mCRC) remains controversial. The objective of this manuscript was to perform a metaanalysis comparing outcomes of LLR with open liver resection (OLR) in patients with hepatic mCRC, and to identify which patients were suitable candidates for LLR.

STUDY DESIGN

A PubMed search identified 2,122 articles. When filtered for case-matched articles comparing LLR with OLR for mCRC, 8 articles were identified consisting of 610 patients (242 LLR, 368 OLR). A random effects metaanalysis was performed.

RESULTS

The 2 groups were well-matched for age, sex, American Society of Anesthesiologists score, tumor size, number of metastases, extent of major hepatectomy, and use of neoadjuvant/adjuvant chemotherapy. The mean number of metastases in the LLR and OLR groups were 1.4 and 1.5, respectively (P = .14). Estimated blood loss was less in LLR group (262 vs 385 mL; P = .049). Transfusion rate was significantly less in LLR group (9.9 vs 19.8%; P = .004). There was no difference in operative time (248.7 vs 262.8 min; P = .85). Length of stay (LOS) was less in the LLR group (6.5 vs 8.8 days; P = .007). The overall complication rate was less in LLR group (20.3% vs 33.2%; P = .03). Importantly, there was no difference in the 1-, 3-, and 5-year disease-free survival (DFS) or overall survival (OS) rates.

CONCLUSION

In carefully selected patients with limited mCRC (1 or 2 tumors), LLR provides marked perioperative benefits without compromising oncologic outcomes or long-term survival. Specifically, LLR offers decreased blood loss, LOS, and overall complication rates with comparable 5-year OS and DFS.

Management of rectal cancer and liver metastatic disease: which comes first?

In the last few decades there have been significant changes in the approach to rectal cancer management. A multimodality approach and advanced surgical techniques have led to an expansion of the treatment of metastatic disease, with improved survival. Hepatic metastases are present at one point or another in about 50% of patients with colorectal cancer, with surgical resection being the only chance for cure. As the use of multimodality treatment has allowed the tackling of more complicated cases, one of the main questions that remain unanswered is the management of patients with synchronous rectal cancer and hepatic metastatic lesions. The question is one of priority, with all possible options being explored. Specifically, these include the simultaneous rectal cancer and hepatic metastases resection, the rectal cancer followed by chemotherapy and then by the liver resection, and finally the “liver-first” option. This paper will review the three treatment options and attempt to dissect the indications for each. In addition, the role of laparoscopy in the synchronous resection of rectal cancer and hepatic metastases will be reviewed in order to identify future trends.

Repeat hepatectomy for recurrent colorectal liver metastases is associated with a high survival rate

BACKGROUND

The outcome after a repeat hepatectomy for recurrent colorectal liver metastases (CLM) is not well defined. The present study examined the morbidity, mortality and long-term survivals after a repeat hepatectomy for recurrent CLM.

METHODS

Data on patients who underwent surgery for recurrent CLM between 1993 and 2009 were retrospectively evaluated. Patients who underwent radiofrequency ablation at the time of first treatment or at recurrence of CLM were excluded.

RESULTS

Forty-three patients underwent a repeat hepatectomy for recurrent CLM. At the time of recurrence, patients had a median of 1 (1-3) lesions and the median tumour size was 2 (0.5-8.7) cm. The post-operative morbidity and mortality rates were 12% and 0%, respectively. After a median follow-up of 33 months from a repeat hepatectomy, 5-year overall and progression-free survival rates were 73% and 22%, respectively. Using multivariate analysis, the largest initial CLM ≥5 cm and positive surgical margins at initial resection were independently associated with a worse survival after surgery for recurrent CLM. Positive surgical margins at repeat hepatectomy were a predictive factor for an increased risk of further recurrence.

DISCUSSION

A repeat hepatectomy for recurrent CLM was associated with excellent survival, low morbidity and no mortality. Surgeon-controlled variables, including margin-negative resection at first and repeat hepatectomy, contribute to good oncological outcome.

Hepatectomy for recurrent colorectal liver metastases after radiofrequency ablation

BACKGROUND

The results of surgery for recurrent colorectal liver metastases (CLM) after radiofrequency ablation (RFA) have not been evaluated.

METHODS

From 1993 to 2009, data on patients who underwent resection or RFA for recurrent CLM were collected prospectively. Inclusion criteria for this study were RFA as initial treatment for CLM and resection of recurrent CLM after RFA. Postoperative results and oncological outcomes were analysed.

RESULTS

Twenty-eight patients (median number of tumours 1 (1-3), median size 2·8 (2·0-4·0) cm) met the inclusion criteria. Of these, 22 had recurrence at the site of RFA only, two developed new lesions, whereas four had both recurrent and de novo metastases. At the time of resection, patients had a median of 1 (1-13) CLM with a median maximum tumour diameter of 5·0 (1·8-11·0) cm, significantly larger than at the time of RFA (P = 0·021). Ninety-day postoperative morbidity and mortality rates were 46 per cent (13 of 28) and 7 per cent (2 of 28) respectively. After a median follow-up of 35 (0-70) months, 3-year overall and disease-free survival rates calculated by Kaplan-Meier analysis were 60 and 29 per cent respectively. Plasma carcinoembryonic antigen level over 5 ng/ml at the time of resection and a rectal primary tumour were associated with worse survival (P = 0·041 and P = 0·021 respectively).

CONCLUSION

Resection for recurrence after RFA is associated with significant morbidity and modest long-term benefit.

Benefit of laparoscopy for rectal resection in patients operated simultaneously for synchronous liver metastases: preliminary experience

BACKGROUND

Resection of the rectal primary neoplasm with synchronous liver metastases (LM) is warranted, because this is the only strategy with curative potential. Combined resection remains controversial because of the risk of morbidity and necessity of a curative abdominal approach to warrant liver resection. Laparoscopic colorectal resection may be beneficial and could facilitate this procedure.

METHODS

Between February 2006 and June 2007, 10 patients underwent 1-step laparoscopic resection for primary rectal cancer combined with open resection of synchronous LM.

RESULTS

All patients underwent a laparoscopic mesorectal excision (n = 10). Liver resections included right hepatectomy (n = 1), bi- or trisegmentectomy (n = 3), and metastasectomy (n = 6). The rectosigmoid specimen was extracted through the right subcostal or a short midline incision used for open liver resection, except in 3 patients who underwent a 1-step totally laparoscopic resection of both the colorectal and hepatic neoplasms. The overall morbidity was 40%. The median hospital stay was 12 days (range, 5-40). Overall morbidity (29% vs 40%) and hospital stay (12 vs 12 days) were similar to those observed in a previous cohort of 27 patients undergoing laparoscopic mesorectal excision only.

CONCLUSION

This pilot study suggests that laparoscopic rectal resection with synchronous resection of LM is feasible with low morbidity and short hospital stay. Moreover, laparoscopy facilitates the operation approach for synchronous major hepatectomy.