Postoperative complications following aggressive repeat hepatectomy for colorectal liver metastasis have adverse oncological outcomes

HEPATECTOMIES: INDICATIONS AND RESULTS FROM A REFERENCE HOSPITAL IN THE BRAZILIAN AMAZON

BACKGROUND

Hepatectomy is historically associated with higher morbidity and mortality, related to intraoperative blood loss and biliary fistulas. Technological advances and improvements in surgical and anesthetic techniques have led to greater safety in performing these surgeries.

AIMS

The aim of this study was to analyze morbidity and mortality in patients undergoing hepatectomy.

METHODS

Retrospective cohort study of patients undergoing liver resections. The type of hepatectomy, indications, need for intraoperative blood transfusion, hospital stay, complications, and postoperative mortality were analyzed.

RESULTS

A total of 48 hepatectomies were performed during the studied period, the most common being 26 (54.16%) major hepatectomies, distributed among 13 (50%) left hepatectomies, 11 (42.30%) right hepatectomies, and 2 (7.70%) others. In total, 24 (45.84%) minor hepatectomies were performed, 11 (50%) mono segmentectomies, and 5 (22.72%) left lateral hepatectomies. The main indications for resection in benign diseases were 6 (12.50%) neotropical hepatic hydatidosis, five (10.41%) intrahepatic lithiasis, and in primary malignancies, 9 (18.75%) hepatocarcinomas. There was no need for an intraoperative blood transfusion. Hospital stays after surgery ranged from 2 to 40 days (average=7 days), and 41 (85.42%) patients went to the ICU in the first 72 h after surgery. In total, 9 (18.75%) patients developed postoperative complications. Overall mortality was 2.08%.

CONCLUSIONS

Hepatocellular carcinoma and neotropical hydatidosis were the main diseases with surgical indication, and major hepatectomies were the most performed procedures. Morbidity and mortality were in line with results from major global centers.

Postoperative Complications Result in Poor Oncological Outcomes: What Is the Evidence?

The majority of patients with solid tumors undergo a curative resection of their tumor burden. However, the reported rate of postoperative complications varies widely, ranging from 10% to 70%. This narrative review aims to determine the impact of postoperative complications on recurrence and overall survival rates following elective cancer surgeries, thereby providing valuable insights into perioperative cancer care. A systematic electronic search of published studies and meta-analyses from January 2000 to August 2023 was conducted to examine the effect of postoperative complications on long-term survival after cancer surgeries. This comprehensive search identified fifty-one eligible studies and nine meta-analyses for review. Recurrence-free survival (RFS) and overall survival (OS) rates were extracted from the selected studies. Additionally, other oncological outcomes, such as recurrence and cancer-specific survival rates, were noted when RFS and OS were not reported as primary outcomes. Pooled hazard ratios and 95% confidence intervals were recorded from the meta-analyses, ensuring the robustness of the data. The analysis revealed that long-term cancer outcomes progressively worsen, from patients with no postoperative complications to those with minor postoperative complications (Clavien-Dindo grade ≤ II) and further to those with major postoperative complications (Clavien-Dindo grade III-IV), irrespective of cancer type. This study underscores the detrimental effect of postoperative complications on long-term oncological outcomes, particularly after thoracoabdominal surgeries. Importantly, we found a significant gap in the data regarding postoperative complications in surface and soft tissue surgical procedures, highlighting the need for further research in this area.

Postoperative complications predict poor outcomes only in patients with a low modified clinical score after resection of colorectal liver metastases: a retrospective cohort study

The aim was to identify the optimal criteria of postoperative complications (POCs) for predicting oncological outcomes after hepatectomy for colorectal liver metastases (CRLMs) and to investigate the variable prognostic implications of POCs according to the modified clinical score (M-CS). We identified 751 patients who underwent curative hepatic resection for CRLM between 2007 and 2018. Patients were categorized based on the M-CS. The impact of the severity [≥ Clavien-Dindo grade (C-D) III or comprehensive complication index (CCI) ≥ 26.2] or type [any infectious complications of POC (Inf-poc)] of POC on overall survival (OS) and recurrence-free survival (RFS) was assessed by univariate and multivariable analyses in different groups. Patients with a major or infectious complication were not associated with either RFS or OS in multivariable analysis of the whole cohort. However, patients with a high CCI had a worse OS (HR 1.51, P = 0.004). Among patients with low M-CS, patients with high CCI had worse OS (HR 1.49, P = 0.035) and RFS (HR 1.32, P = 0.048) than those without high CCI. In contrast, the survival disadvantage of a high CCI was not present in patients with a high M-CS. Compared to Inf-poc or major complications, a high CCI decreased long-term OS in patients treated with hepatectomy for CRLM. High CCI has a variable prognostic impact after hepatic resection for CRLM depending on the M-CS. POC is not a decisive factor to justify the use of hepatectomy for CRLM in patients with high M-CS.

Limited Effect of Perioperative Systemic Therapy in Patients Selected for Repeat Local Treatment of Recurrent Colorectal Cancer Liver Metastases

Objectives

The aim of this study was to determine the potential benefit of perioperative systemic therapy on overall and progression-free survival after repeat local treatment in patients suffering from recurrent colorectal cancer liver metastasis (CRLM).

Background

The optimal treatment strategy in patients with recurrent CRLM needs to be clarified, in particular for those suffering from early recurrence of CRLM.

Methods

In this multicenter observational cohort study, consecutive patients diagnosed with recurrent CRLM between 2009 and 2019 were retrospectively identified in 4 academic liver surgery centers. Disease-free interval after initial local treatment of CRLM was categorized into recurrence within 6, between 6 and 12, and after 12 months. Perioperative systemic therapy consisted of induction, (neo)adjuvant, or combined regimens. Overall and progression-free survival after repeat local treatment of CRLM were analyzed by multivariable Cox regression analyses, resulting in adjusted hazard ratios (aHRs).

Results

Out of 303 patients included for analysis, 90 patients received perioperative systemic therapy for recurrent CRLM. Favorable overall (aHR, 0.45; 95% confidence interval [CI], 0.26-0.75) and progression-free (aHR, 0.53; 95% CI, 0.35-0.78) survival were observed in patients with a disease-free interval of more than 12 months. No significant difference in overall and progression-free survival was observed in patients receiving perioperative systemic therapy at repeat local treatment of CRLM, stratified for disease-free interval, previous exposure to chemotherapy, and RAS mutation status.

Conclusions

No benefit of perioperative systemic therapy was observed in overall and progression-free survival after repeat local treatment of recurrent CRLM.

RE-HEPATECTOMY MEANS MORE MORBIDITY? A MULTICENTRIC ANALYSIS

Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival.

The effect of the robotic platform in hepatectomy after prior liver and non-liver abdominal operations: a comparative study of clinical outcomes

Improvements in outcomes after primary hepatectomy have increased the eligibility of patients for reoperative hepatectomies, but this can be fraught with technical difficulties, particularly via a minimally invasive approach. The robotic approach provides superior visualization, articulated instrumentation, platform stability, and increased dexterity when compared to conventional laparoscopy. We sought to investigate the effect brought by the robotic system in the outcome of these operations. We followed 234 patients who underwent robotic liver resection from 2012 to 2021 for retrospective analysis. Patients were classified as: no prior abdominal operation, prior abdominal operation(s), and prior liver resection. Cohorts were compared by one-way ANOVA and 2 × 3 contingency table analyses. For illustrative purposes, data are presented as median (mean ± SD). Significance was accepted at p < 0.05. Of the 234 patients studied, 114 underwent primary hepatectomy, 105 had a prior laparoscopic or open abdominal operation (cholecystectomy, herniorrhaphy, colectomy, and appendectomy), and 15 had a redo hepatectomy. Demographic and preoperative ASA, MELD, neoplasm size, and extent of liver resection were similar among the cohorts. There were no statistically significant differences between the three cohorts for all outcome variables including blood loss, operative duration, intensive care unit length of stay, overall length of stay, morbidity, mortality, and readmission rate. There were no differences in morbidity nor mortality between patients undergoing primary nor reoperative robotic hepatectomy. The advantages afforded by the robotic platform may have contributed to the equalization of outcomes.

Survival Benefit of Repeat Local Treatment in Patients Suffering From Early Recurrence of Colorectal Cancer Liver Metastases

BACKGROUND

A uniform treatment strategy for patients suffering from early recurrence after local treatment of CRLM is currently lacking. The aim of this observational cohort study was to assess the potential survival benefit of repeat local treatment compared to systemic therapy in patients suffering from early recurrence of CRLM.

PATIENTS AND METHODS

Patients who developed recurrent CRLM within 12 months after initial local treatment with curative intent were retrospectively identified in Amsterdam University Medical Centers between 2009-2019. Differences in overall and progression-free survival among treatment strategies were assessed using multivariable Cox regression analyses.

RESULTS

A total of 135 patients were included. Median overall survival of 41 months [range 4-135] was observed in patients who received repeat local treatment, consisting of upfront or repeat local treatment after neoadjuvant systemic therapy, compared to 24 months [range 1-55] in patients subjected to systemic therapy alone (adjusted HR = 0.42 [95%-CI: 0.25-0.72]; P = .002). Prolonged progression-free survival was observed after neoadjuvant systemic therapy followed by repeat local treatment, as compared to upfront repeat local treatment in patients with recurrent CRLM within 4 months following initial local treatment of CRLM (adjusted HR = 0.36 [95%-CI: 0.15-0.86]; P = .021).

CONCLUSION

Patients with early recurrence of CRLM should be considered for repeat local treatment strategies. A multimodality approach, consisting of neoadjuvant systemic therapy followed by repeat local treatment, appeared favorable in patients with recurrence within 4 months following initial local treatment of CRLM.

Repeat hepatectomy justified in patients with early recurrence of colorectal cancer liver metastases: A systematic review and meta-analysis

BACKGROUND

The benefit of repeat hepatectomy in patients with early recurrence of colorectal cancer liver metastases (CRLM) is questioned, in particular in those suffering from recurrence within three to six months following initial hepatectomy. The aim of this review was therefore to assess whether disease-free interval was associated with overall survival in patients undergoing repeat hepatectomy for recurrent CRLM.

METHODS

A systematic review and meta-analysis was conducted, according to PRISMA guidelines. PubMed, Embase and Cochrane Library databases were searched from database inception to 6th June 2020. Observational studies describing results of repeat hepatectomy for recurrent CRLM, including (disease-free) interval between hepatic resections and overall survival were included. Patients undergoing repeat hepatectomy within three months or additional resection of extrahepatic disease were excluded from meta-analysis.

RESULTS

The initial search identified 2159 records, of which 28 were included for qualitative synthesis. A meta-analysis of 15 cohort studies was performed, comprising 1039 eligible patients. Median overall survival of 54.0 months [95 %-CI: 38.6-69.4] was observed after repeat hepatectomy in patients suffering from recurrent CRLM between three to six months compared to 53.0 months [95 %-CI: 44.3-61.6] for patients with recurrent CRLM between seven to twelve months (adjusted HR = 0.89, 95 %-CI: 0.66-1.18; p = 0.410), and 60.0 months [95 %-CI: 52.7-67.3] for patients with recurrent CRLM after twelve months (adjusted HR = 0.70, 95 %-CI: 0.53-0.92; p = 0.012).

CONCLUSIONS

Disease-free interval is considered a prognostic factor for overall survival, but should not be used as selection criterion per se for repeat hepatectomy in patients suffering from recurrent CRLM.

Significance of preoperative nutritional status as a predictor for short-term and long-term outcomes of patients undergoing surgery for stage IV colorectal cancer

PURPOSE

The clinical impact of the preoperative nutritional status has not fully been understood in an aggressive surgical approach for stage IV colorectal cancer (CRC).

METHODS

The clinical records of 399 patients with stage IV CRC who underwent surgery for the primary tumor were reviewed. The predictive powers of reported nutritional/inflammatory indices of postoperative morbidity were compared, and their correlations with both the short- and long-term outcomes were investigated.

RESULTS

Among the 10 tested nutritional/inflammatory indices, the Controlling Nutritional Status (CONUT) score showed the highest performance for predicting major morbidity (area under the curve [AUC], 0.605; P = 0.067) and any morbidity (AUC, 0.605; P = 0.001). When stratifying the population into 4 undernutrition grades based on the CONUT score, the CONUT undernutrition grades were found to show good correlations with the Clavien-Dindo grades of postoperative morbidity (P < 0.001) and the length of hospital stay (P < 0.001). Multivariate analysis confirmed the CONUT undernutrition grade was significantly associated with the survival outcomes in patients with stage IV CRC (light: hazard ratio [HR], 1.12; 95% CI, 0.80-1.58; moderate: HR, 1.54; 95% CI, 1.02-2.33; severe: HR, 3.61; 95% CI, 1.52-8.62).

CONCLUSIONS

Preoperative nutritional status is a useful predictive marker for both the short- and long-term outcomes of surgical interventions for stage IV CRC.

Percutaneous ablation of post-surgical solitary early recurrence of colorectal liver metastases is an effective "test-of-time" approach

Standard treatment of early recurrence of colorectal liver metastases (CLM) after liver resection (LR) is chemotherapy followed by loco-regional therapy. We reviewed the outcome of a different strategy ("test-of-time" approach): upfront percutaneous ablation without chemotherapy. Twenty-six consecutive patients with early solitary liver-only recurrence amenable to both resection and ablation (< 30 mm, distant from vessels) undergone "test-of-time" approach were analyzed. Early recurrence had a median size of 17 mm and occurred after a median interval from LR of 4 months. Primary efficacy rate of ablation was 100%. Five patients are alive and disease-free after a mean follow-up of 46 months. Five patients had local-only recurrence; all had repeat treatment (LR = 4; Ablation = 1) without chemotherapy. Local recurrence risk was associated with incomplete ablation of 1-cm thick peritumoral margin. The remaining 16 patients had non-local recurrence, 13 early after ablation. Overall, six (23%) patients had ablation as unique treatment and 13 (50%) avoided or postponed chemotherapy (mean chemotherapy-free interval 33.5 months). Ablation without chemotherapy of early liver-only recurrence is a reliable "test-of-time" approach. It minimized the invasiveness of treatment with good effectiveness and high salvageability in case of local failure, avoided worthless surgery, and saved chemotherapy for further disease progression.

Chances, challenges and outcomes of patients with complex bilobar colorectal liver metastases approached by a combined multimodal therapy with liver resection and local ablative therapy

BACKGROUND AND OBJECTIVES

In treatment of colorectal liver metastases (CRC-LM), liver surgery combined with systemic therapies and local ablation (LAT) allows improved survival. This study aims at the outcomes of patients with complex bilobar CRC-LM who were intended to undergo multimodal therapy with liver resection and LAT.

METHODS

Forty-three CRC-LM patients with recommendation for multimodal treament were extracted from 5878 tumor board decisions between 2014 and 2017. Outcome variables included patient survival, as well as completion of hepatic clearance. Prognostic factors were identified by correlation and a Cox proportional hazards model.

RESULTS

Out of 43 patients only 23 achieved complete clearance of CRC-LM. One- and 3-year overall survival of patients with cleared liver disease was 100% and 91.7%, respectively, as compared to 83.8% and 12.1%. Incomplete hepatic clearance was the strongest independent risk factor for overall survival (hazards ratio [HR], 5.86; p = .009). Risk factors for incomplete clearance were higher age (r = .34; p = .026), comorbidities (r = .40; p = .008), major complications (r = .34; p = .024), and prolonged intensive care unit stay (r = .41; p = .017).

CONCLUSION

Completion of hepatic clearance is crucial to achieve long-term survival in patients with complex bilobar CRC-LM. Careful patient selection and treatment planning should avoid treatment failure before completing the intended therapy plan when multimodal treatments are planned.

Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints?

The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.

Survival after repeat hepatectomy for recurrent colorectal liver metastasis: A review and meta-analysis of prognostic factors

BACKGROUND

Frequent recurrent hepatic metastasis after hepatic metastasectomy is a major obstacle in the treatment of colorectal liver metastasis (CRLM). We performed the present systematic review to evaluate the short- and long-term outcomes after repeat hepatectomy for recurrent CRLM and determine factors associated with survival in these patients.

DATA SOURCES

An electronic search of PubMed database was undertaken to identify all relevant peer-reviewed papers published in English between January 2000 and July 2018. Hazard ratios (HR) with 95% confidence interval (95% CI) were calculated for prognostic factors of overall survival (OS).

RESULTS

The search yielded 34 studies comprising 3039 patients, with a median overall morbidity of 23% (range 8%-71%), mortality of 0 (range 0-6%), and 5-year OS of 42% (range 17%-73%). Pooled analysis showed that primary T3/T4 stage tumor (HR = 1.94; 95% CI: 1.04-3.63), multiple tumors (HR = 1.49; 95% CI: 1.10-2.01), largest liver lesion ≥5 cm (HR = 1.89; 95% CI: 1.11-3.23) and positive surgical margin (HR = 1.80; 95% CI: 1.09-2.97) at initial hepatectomy, and high serum level of carcinoembryonic antigen (HR = 1.87; 95% CI: 1.27-2.74), disease-free interval ≤12 months (HR = 1.34; 95% CI: 1.10-1.62), multiple tumors (HR = 1.64; 95% CI: 1.32-2.02), largest liver lesion ≥5 cm (HR = 1.85; 95% CI: 1.34-2.56), positive surgical margin (HR = 2.25; 95% CI: 1.39-3.65), presence of bilobar disease (HR = 1.62; 95% CI: 1.19-2.20), and extrahepatic metastases (HR = 1.60; 95% CI: 1.23-2.09) at repeat hepatectomy were significantly associated with poor OS.

CONCLUSIONS

Repeat hepatectomy is a safe and effective therapy for recurrent CRLM. Long-term outcome is predicted mainly by factors related to repeat hepatectomy.

Repeat hepatectomy for recurred colorectal liver metastasis: is it justified?

Purpose

Liver resection is considered the only curative treatment modality for colorectal liver metastasis. The recurrence rate after hepatectomy is >50%. Two or more hepatectomies are applied to treat recurred metastases. We assessed the efficiency and feasibility of repeat hepatectomy and analyzed the prognostic factors after a repeat hepatectomy.

Methods

In total, 248 patients were diagnosed with recurred liver metastasis between January 2003 and May 2016. Second and third hepatectomies were performed in 70 and 7 patients, respectively. The other 171 patients did not undergo a repeat hepatectomy. Clinical features were collected from the medical records. We analyzed survival rates of the repeat hepatectomy group and the nonrepeat hepatectomy group. We also investigated factors affecting overall and disease-free survival of patients who received a repeat hepatectomy using univariate and multivariate analyses.

Results

Median overall survival was significantly higher in the repeat hepatectomy group than in the nonrepeat group (83.0 months vs. 25.0 months, P < 0.001). The morbidity and mortality rates of repeat hepatectomy were 9.1% and 0%, respectively. Median overall and disease-free survival of the repeat hepatectomy group were 62.0 and 51.0 months, respectively. The number of recurred tumors was the only significant factor for disease-free survival (P = 0.029). None of the factors affected overall survival.

Conclusion

Repeat hepatectomy is necessary, effective, and safe for treating recurred colorectal liver metastasis. Repeat hepatectomy can be considered in patients with fewer than three recurred metastatic tumors.

Current status of surgical treatment of colorectal liver metastases

Liver metastasis (LM) is one of the major causes of death in patients with colorectal cancer (CRC). Approximately 60% of CRC patients develop LM during the course of their illness. About 85% of these patients have unresectable disease at the time of presentation. Surgical resection is currently the only curative treatment for patients with colorectal LM (CRLM). In recent years, with the help of modern multimodality therapy including systemic chemotherapy, radiation therapy, and surgery, the outcomes of CRLM treatment have significantly improved. This article summarizes the current status of surgical treatment of CRLM including evaluation of resectability, treatment for resectable LM, conversion therapy and liver transplantation for unresectable cases, liver resection for recurrent CRLM and elderly patients, and surgery for concomitant hepatic and extra-hepatic metastatic disease (EHMD). We believe that with the help of modern multimodality therapy, an aggressive oncosurgical approach should be implemented as it has the possibility of achieving a cure, even when EHMD is present in patients with CRLM.

Surgical salvage of recurrence after resection of colorectal liver metastases: incidence and outcomes

Surgical resection remains the primary curative treatment option for patients with colorectal liver metastases. While the majority of patients will develop tumor relapse within or outside of the liver after hepatic metastasectomy, a subset of these patients may be amenable to salvage surgical resection. However, outcomes for this approach are not well defined. In this article, we summarize the current evidence for the incidence, feasibility and outcomes of salvage resection for recurrence after initial resection of colorectal liver metastases.

Bilobar versus unilobar multiple colorectal liver metastases: a propensity score analysis of surgical outcomes and recurrence patterns

BACKGROUND

Bilobar multiple colorectal liver metastases (MCLM) are often considered incurable or associated with a poor prognosis even after R0 resection. This study was designed to compare the long-term outcomes and recurrence patterns after one-stage resection in patients with bilobar versus unilobar MCLM.

METHODS

The records of patients undergoing parenchymal-sparing intent hepatectomy between 1994 and 2015 were reviewed. Survival and recurrence patterns were analyzed by propensity score matching.

RESULTS

The study population included 140 patients: 81 patients with bilobar MCLM versus 59 patients with unilobar MCLM. In the propensity score matching analysis (bilobar, n = 35 vs. unilobar, n = 35), the short-term outcomes did not differ between the two groups. Five-year overall survival (54.8% in bilobar vs. 51.2% in unilobar; P = 0.388) and recurrence-free survival (28.5% in bilobar vs. 36.2% in unilobar; P = 0.261) also did not differ. No significant differences were found in liver-only recurrence (22.9% in bilobar vs. 25.7% in unilobar; P = 1.000) and other recurrence patterns.

CONCLUSIONS

The clearance of bilobar MCLM by one-stage resection of parenchymal-sparing intent provided comparable long-term survival to unilobar MCLM.