Outcome following repeat liver resection for colorectal liver metastases

Hospital variation and outcomes after repeat hepatic resection for colorectal liver metastases: a nationwide cohort study

BACKGROUND

Approximately 70% of patients with colorectal liver metastases (CRLM) experiences intrahepatic recurrence after initial liver resection. This study assessed outcomes and hospital variation in repeat liver resections (R-LR).

METHODS

This population-based study included all patients who underwent liver resection for CRLM between 2014 and 2022 in the Netherlands. Overall survival (OS) was collected for patients operated on between 2014 and 2018 by linkage to the insurance database.

RESULTS

Data of 7479 liver resections (1391 (18.6%) repeat and 6088 (81.4%) primary) were analysed. Major morbidity and mortality were not different. Factors associated with major morbidity included ASA 3+, major liver resection, extrahepatic disease, and open surgery. Five-year OS after repeat versus primary liver resection was 42.3% versus 44.8%, P = 0.37. Factors associated with worse OS included largest CRLM >5 cm (aHR 1.58, 95% CI: 1.07-2.34, P = 0.023), >3 CRLM (aHR 1.33, 95% CI: 1.00-1.75, P = 0.046), extrahepatic disease (aHR 1.60, 95% CI: 1.25-2.04, P = 0.001), positive tumour margins (aHR 1.42, 95% CI: 1.09-1.85, P = 0.009). Significant hospital variation in performance of R-LR was observed, median 18.9% (8.2% to 33.3%).

CONCLUSION

Significant hospital variation was observed in performance of R-LR in the Netherlands reflecting different treatment decisions upon recurrence. On a population-based level R-LR leads to satisfactory survival.

Value and prognostic factors of repeat hepatectomy for recurrent colorectal liver metastasis

BACKGROUND

More than 50% of patients with colorectal cancer develop liver metastases. Hepatectomy is the preferred treatment for resectable liver metastases. This review provides a perspective on the utility and relevant prognostic factors of repeat hepatectomy in recurrent colorectal liver metastasis (CRLM).

DATA SOURCES

The keywords "recurrent colorectal liver metastases", "recurrent hepatic metastases from colorectal cancer", "liver metastases of colorectal cancer", "repeat hepatectomy", "repeat hepatic resection", "second hepatic resection", and "prognostic factors" were used to retrieve articles published in the PubMed database up to August 2020. Additional articles were identified by a manual search of references from key articles.

RESULTS

Despite improvements in surgical methods and perioperative chemotherapy, recurrence remains common in 37%-68% of patients. Standards or guidelines for the treatment of recurrent liver metastases are lacking. Repeat hepatectomy appears to be the best option for patients with resectable metastases. The commonly reported prognostic factors after repeat hepatectomy were R0 resection, carcinoembryonic antigen level, the presence of extrahepatic disease, a short disease-free interval between initial and repeat hepatectomy, the number (> 1) and size (≥ 5 cm) of hepatic lesions, requiring blood transfusion, and no adjuvant chemotherapy after initial hepatectomy. The median overall survival after repeat hepatectomy ranged from 19.3 to 62 months, and the 5-year overall survival ranged from 21% to 73%. Chemotherapy can act as a test for the biological behavior of tumors with the goal of avoiding unnecessary surgery, and a multimodal approach involving aggressive chemotherapy and repeat hepatectomy might be the treatment of choice for patients with early recurrent CRLM.

CONCLUSIONS

Repeat hepatectomy is a relatively safe and effective treatment for resectable recurrent CRLM. The presence or absence of prognostic factors might facilitate patient selection to improve short- and long-term outcomes.

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.

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.

Current role of trisectionectomy for hepatopancreatobiliary malignancies

BACKGROUND

Trisectionectomy is a treatment option in extensive liver malignancy, including colorectal liver metastases (CRLM). However, the reported experience of this procedure is limited. Therefore, we present our experience with right hepatic trisectionectomy (RHT) for CRLM as an example and discuss the changing role of trisectionectomy in the context of modern treatment alternatives based on a literature review.

METHODS

Between January 1993 and December 2014 all patients undergoing RHT at a single center in the UK for CRLM were included. Patient and tumor characteristics were reviewed and a multivariate analysis was done. Based on a literature review the role of trisectionectomy in the treatment of HPB malignancies was discussed.

RESULTS

A total of 211 patients undergoing RHT were included. Overall perioperative morbidity was 40.3%. Overall 90-day mortality was 7.6% but reduced to 2.8% over time. Multivariate analysis identified additional organ resection (P = .040) and blood transfusion (P = .028) as independent risk factors for morbidity. Multiple tumors, total hepatic vascular exclusion, and R1 resection were independent risk factors for significantly decreased disease-free and disease-specific survival. Further surgery for recurrence after RHT significantly prolonged survival compared with palliative chemotherapy only.

CONCLUSION

With the further development of surgical and multimodal treatment strategies in CRLM the indications for trisectionectomy are decreasing. Having being formerly associated with high rates of perioperative morbidity and mortality, this single-center experience clearly shows that these concomitant risks decrease with experience, liberal use of portal vein embolization and improved patient selection. Trisectionectomy remains relevant in selected patients.

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.

Radioembolization treatment for liver metastases

The liver is an organ that, due to vascularisation and functions, is prone to metastases. Most liver metastases are observed in cases of gastrointestinal cancers in: stomach, colon, gallbladder, and bile ducts. Metastatic lesions are also observed in lung, breast, thyroid, kidney, and pancreatic cancer. One of the best known and most effective ways of liver lesion treatment is Metastasectomy. Unfortunately, lesions are frequently inoperable. Apart from chemotherapy, it is possible to apply local treatment such as TACE (trans-arterial chemoembolisation), RFA (Radio Frequency Ablation), and SBRT (Stereotactic Body Radiation Therapy). One of the newest methods of inoperable lesion treatment is radioembolisation (SIRT). Intravascular administration of microspheres containing radioisotope 90Y allows delivery of a higher dose of radiation directly to the tumour than traditional radiation with an external beam, while maintaining a small dose to healthy liver methods. Conducted clinical studies confirm the efficacy and safety of SIRT. It is an interesting alternative to other ways of treatment.

Recurrence of liver metastases from colorectal cancer and repeat liver resection

OBJECTIVE

The purpose of this study was to assess the resectability and effectiveness of repeat hepatectomy for relapsing liver metastases of colorectal origin in terms of morbidity, mortality, overall survival, and disease-free survival.

METHODS

A retrospective study was performed on a prospective cohort of patients with colorectal liver metastases who underwent repeat surgery at Hospital Universitario San Cecilio, Granada (Spain), from March 2003 to June 2013. Primary outcome variables included survival and morbidity within 30 days post-surgery.

RESULTS

A total of 147 patients with colorectal liver metastases underwent surgical excision during the study period; 61 patients had liver recurrence, and 34 of these received repeat surgery. The overall survival rate at 5 and 10 years for resected patients (n=27/34) was 48% and 48%. Mean hospital stay was 8.9 ± 3.5 days, morbidity was 9%, and mortality was 0%.

CONCLUSION

Repeat liver resection for colorectal liver metastases is a safe, effective surgical procedure whose results are similar to those obtained after initial liver resection.

Repeat hepatectomy is independently associated with favorable long-term outcome in patients with colorectal liver metastases

Up to three‐quarters of patients undergoing liver resection for colorectal liver metastases (CRLM) develop intrahepatic recurrence. Repeat hepatic resection appears to provide the optimal chance of cure for these patients. The aim of this study was to analyze short‐ and long‐term outcomes following index and repeat hepatectomy for CRLM. Clinicopathological data were obtained from a prospectively maintained database. Perioperative variables and outcomes were compared using the Chi‐squared test. Variables associated with long‐term survival following index and second hepatectomy were identified by Cox regression analyses. Over the study period, 488 patients underwent hepatic resection for CRLM, with 71 patients undergoing repeat hepatectomy. There was no significant difference in rates of morbidity (P = 0.135), major morbidity (P = 0.638), or mortality (P = 0.623) when index and second hepatectomy were compared. Performance of repeat hepatectomy was independently associated with increased overall and cancer‐specific survival following index hepatectomy. Short disease‐free interval between index and second hepatectomy, number of liver metastases >1, and resection of extrahepatic disease were independently associated with shortened survival following repeat resection. Repeat hepatectomy for recurrent CRLM offers short‐term outcomes equivalent to those of patients undergoing index hepatectomy, while being independently associated with improved long‐term patient survival.

Repeat Hepatectomy for Recurrent Colorectal Liver Metastases: Is it Worth the Challenge?

INTRODUCTION

Repeat hepatectomy (RH) is considered a valuable option for management of recurrent colorectal liver metastases (R-CLM). Here, the outcome of RH for R-CLM was compared to that of patients who underwent single hepatectomy (SH) after subdividing the later according to re-recurrence status.

METHODS

Between 2001 and 2013, patients who received hepatectomy for CLM and R-CLM were included in study. Patients with non-resectable R-CLM were excluded.

RESULTS

One hundred sixteen patients were included: 86 patients in SH group and 30 patients in RH group. Repeat hepatectomy group had more synchronous CLM (76.7 versus 50 %, p = 0.011). From the 86 patients who underwent SH, 69 patients did not have R-CLM. Survival analysis was done from the time of first hepatectomy for the no R-CLM group and the time of RH for the RH group. The 3- and 5-year survival rates for the no R-CLM group were 66.4 and 48.8%, respectively, and for the RH group were 56 and 44.8% respectively (p = 0.841). Multivariate analysis showed that larger size of R-CLM is an independent risk factor for survival after RH.

CONCLUSION

Repeat hepatectomy for R-CLM shows a comparable OS to non-recurrent CLM after single hepatectomy, despite the RH group had higher incidence of synchronous CLM.

Effectiveness of surgery in liver metastasis from colorectal cancer: experience and results of a continuous improvement process

PURPOSE

The aim of this study was to estimate the effectiveness of surgery in liver metastasis from colorectal cancer.

METHODS

We conducted a prospective and observational study of patients with colorectal liver metastasis operated on at the San Cecilio University Hospital of Granada from March 2003 until June 2013. The primary variables of the result were survival and morbidity before 30 days of the post-operative period. We also measured preoperative and surgical variables.

RESULTS

A total of 147 patients with liver metastasis of colorectal origin underwent surgical removal during the period of study, 38 of whom had repeat surgery. 34 had a second resection, 3 had a third one and one only patient had a fourth one, for a total of 185 registered operations. The global 5-year survival rate was 38 and 17 % after 10 years. There were 115 patients who had neither radiofrequency nor exploratory laparotomy, 38 % of them survived over 60 months. The average disease-free time was 23.6 months ± 47.3, with significant differences observed between types of procedures. Patients that were operated on just once (n = 25) had a five-year actuarial survival rate of 35 %, a morbidity rate of 24 % and a mortality rate of 0.6 % (1 patient only). The average hospital stay was 13.8 days and the disease-free time was 15.8 months.

CONCLUSION

The results obtained in our surgical unit in terms of morbidity, mortality and five-year actuarial survival rates are comparable to those of other units at large institutions, which are currently considered the standards of quality.

Selecting patients for a second hepatectomy for colorectal metastases: an systemic review and meta-analysis

BACKGROUND

Opinions on the suitability of repeat hepatectomy for patients with recurrent colorectal liver metastases (CRLMs) vary among studies. We conducted a meta-analysis to establish the criteria for selecting the best candidates for a second hepatectomy.

METHODS

Database and manual searches were performed to identify comparative or prognostic studies published up to October 2013. Outcomes of interest included disease characteristics, perioperative outcomes, and long-term survival after initial and second hepatectomies for patients with CRLM. Study quality was appraised using the Newcastle-Ottawa scale and a modified Hayden's score.

RESULTS

A total of 7226 patients from 27 studies were included. Recurrent CRLMs after initial hepatectomy were more likely to be solitary (RR = 0.86, P = 0.045), unilobar (RR = 0.60, P < 0.001), and smaller (WMD = -0.66, P < 0.001). Postoperative morbidity and mortality were comparable between initial and second hepatectomies (RR = 1.10, P = 0.191; RR = 0.78, P = 0.678, respectively). In high-quality studies, patients showed better survival after a second hepatectomy than those after a single hepatectomy (HR = 0.68, P = 0.022). Patients meeting the following six predictors survived longer after second hepatectomy: disease-free survival after initial hepatectomy >1 y (P = 0.034); solitary CRLM at second hepatectomy (P < 0.001); unilobar CRLM at second hepatectomy (P = 0.009); maximal size of CRLM at second hepatectomy ≤ 5 cm (P = 0.035); lack of extrahepatic metastases at second hepatectomy (P < 0.001); and R0 resection at second hepatectomy (P < 0.001).

CONCLUSIONS

Second hepatectomy is a safe and feasible procedure for patients with recurrent CRLM. In fact, in well-selected patients it improves overall survival. The established criteria can help clinicians to select the best candidates for second hepatectomy and to achieve better long-term outcomes after resection.

Repeat liver resection after a hepatic or extended hepatic trisectionectomy for colorectal liver metastasis

OBJECTIVE

A right and left hepatic trisectionectomy and an extended trisectionectomy are the largest liver resections performed for malignancy. This report analyses a series of 23 patients who had at least one repeat resection after a hepatic trisectionectomy for colorectal liver metastasis (CRLM).

METHODS

A retrospective analysis of a single-centre prospective liver resection database from May 1996 to April 2009 was used for patient identification. Full notes, radiology and patient reviews were analysed for a variety of factors with respect to survival.

RESULTS

Twenty-three patients underwent up to 3 repeat hepatic resections after 20 right and 3 left hepatic trisectionectomies. In 18 patients the initial surgery was an extended trisectionectomy. Overall 1-, 3- and 5-year survival rates after a repeat resection were 100%, 46% and 32%, respectively. No factors predictive for survival were identified.

CONCLUSION

A repeat resection after a hepatic trisectionectomy for CRLM can offer extended survival and should be considered where appropriate.

A systematic review of repeat hepatectomy for recurrent colorectal liver metastases

BACKGROUND

Selected patients with recurrent colorectal liver metastases (CLM) may be resectable by repeat hepatectomy approach. In this review, we aim to collate and evaluate the published evidence for repeat hepatectomy in patients with recurrent CLM.

METHODS

Searches of the Medline and Embase databases were undertaken to identify studies of repeat hepatectomy in patients with recurrent CLM focusing on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes.

RESULTS

Twenty-two observational studies were reviewed. A total of 1,610 patients underwent second hepatectomy for recurrent CLM. The median percentage of extra-hepatic disease was 15 % (range, 0-39 %). Preoperative chemotherapy was reported in 5/22 studies. Major liver resection was undertaken in 25 % (range, 9-59 %) of patients and the R0 resection rate was 90 % (range, 77-96 %). Postoperative morbidity and mortality after the second hepatectomy were 23 % and 1.2 %, respectively. Recurrence rate after second hepatectomy was 63.9 % (range, 42-91 %) with a median follow-up period of 32 months (range, 19-59 months). Median overall survival was 35 months (range, 19-56 months). The 3-year and 5-year overall survival rates were 55 % (range, 11-82 %) and 42 % (range, 31-73 %), respectively.

CONCLUSION

Second hepatectomy is safe and feasible in selected patients with recurrent CLM and is associated with acceptable perioperative and survival outcomes. Future prospective studies are required to further define the patient selection criteria for repeat hepatectomy and the exact role of perioperative chemotherapy.

Repeat liver resection for colorectal metastases

BACKGROUND

Following resection of colorectal liver metastases (CLMs) up to 75 per cent of patients develop recurrent liver metastases. Although repeat resection remains the only curative therapy, data evaluating the outcome are deficient. This study analysed postoperative morbidity, mortality and independent predictors of survival following repeat resection of CLMs.

METHODS

Data on surgical treatment of primary and recurrent CLMs between 1994 and 2010 were collected retrospectively, and compared with those for single hepatic resections carried out during the same period. Independent predictors of survival were evaluated by means of univariable and multivariable Cox regression models.

RESULTS

In this interval 1026 primary resections of CLMs were performed and 94 patients underwent repeat CLM excision. Overall postoperative morbidity and mortality rates were low (15·8 and 1·3 per cent respectively), with no statistical difference in patients undergoing repeat surgery (P = 0·072). Compared with single liver resections, overall survival was improved in repeat resections (P = 0·003). Multivariable analysis revealed that size of primary CLM over 50 mm was an independent predictor of survival (hazard ratio (HR) 2·61; P = 0·008). Only major hepatic resection was associated with poorer outcome following repeat surgery (HR 2·62; P = 0·009). International Union Against Cancer stage, number of CLMs, age at surgery and need for intraoperative transfusion had no impact on survival after repeat resection.

CONCLUSION

Recurrent CLM surgery is feasible with similar morbidity and mortality rates to those of initial or single CLM resections.

Repeat hepatectomy for recurrent colorectal metastases

BACKGROUND

The oncological benefit of repeat hepatectomy for patients with recurrent colorectal metastases is not yet proven. This study assessed the value of repeat hepatectomy for these patients within current multidisciplinary treatment.

METHODS

Consecutive patients treated by repeat hepatectomy for colorectal metastases between January 1990 and January 2010 were included. Patients undergoing two-stage hepatectomy were excluded. Postoperative outcome was analysed and compared with that of patients who had only a single hepatectomy.

RESULTS

A total of 1036 patients underwent 1454 hepatectomies for colorectal metastases. Of these, 288 patients had 362 repeat hepatectomies for recurrent metastases. Some 225 patients (78·1 per cent) had two hepatectomies, 52 (18·1 per cent) had three hepatectomies, and 11 patients (3·8 per cent) had a fourth hepatectomy. Postoperative morbidity following repeat hepatectomy was similar to that after initial liver resection (27·1 per cent after first, 34·4 per cent after second and 33·3 per cent after third hepatectomy) (P = 0·069). The postoperative mortality rate was 3·1 per cent after repeat hepatectomy versus 1·6 per cent after first hepatectomy. Three- and 5-year overall survival rates following first hepatectomy in patients who underwent repeat hepatectomy were 76 and 54 per cent respectively, compared with 58 and 45 per cent in patients who had only one hepatectomy (P = 0·003). In multivariable analysis, repeat hepatectomy performed between 2000 and 2010 was the sole independent factor associated with longer overall survival.

CONCLUSION

Repeat hepatectomy for recurrent colorectal metastases offers long-term survival in selected patients.

Repeat hepatic resection for colorectal liver metastases

BACKGROUND

Some 75-80 per cent of patients undergoing liver resection for colorectal liver metastases develop intrahepatic recurrence. A significant number of these can be considered for repeat liver surgery. This study examined the outcomes of repeat liver resection for the treatment of recurrent colorectal metastases confined to the liver.

METHODS

Patients who underwent repeat liver resection in a single tertiary referral hepatobiliary centre were identified from a database. Clinicopathological variables were analysed to assess factors predictive of survival.

RESULTS

A total of 195 patients underwent repeat resection between 1993 and 2010. Median age was 63 years, and the median interval between first and repeat resection was 13·8 months. Thirty-three patients (16·9 per cent) underwent completion hemihepatectomy or extended hemihepatectomy and the remainder had non-anatomical or segmental resection. The 30-day mortality rate was 1·5 per cent, and the overall 30-day morbidity rate was 20·0 per cent. Overall 1-, 3- and 5-year survival rates were 91·2, 44·3 and 29·4 per cent respectively. Tumour size 5 cm or greater was the only independent predictor of overall survival (relative risk 1·71, 95 per cent confidence interval 1·08 to 2·70; P = 0·021). Neoadjuvant chemotherapy before resection, perioperative blood transfusion, bilobar disease, R1 resection margin and multiple metastases were among factors that did not significantly influence survival.

CONCLUSION

Repeat hepatic resection remains the only curative option for patients presenting with recurrent colorectal liver metastases.

Second surgery or chemotherapy for relapse after radical resection of colorectal cancer metastases

PURPOSE

Limited data suggest that second resections for colorectal cancer metastases may improve survival, but no study has compared surgery with chemotherapy in this setting. Therefore, we retrospectively compared the clinical outcome of potentially resectable patients who received a second metastasectomy with those who did not in our single-centre experience.

METHODS

We retrospectively reviewed the clinical records of all patients treated for metastatic colorectal cancer in our centre over a period of 12 years. We selected patients who relapsed after radical resection of metastases from colorectal cancer and were deemed resectable again by our multidisciplinary team. We then compared the clinical outcome of those who received a second operation with those who refused surgery and also evaluated the role of prognostic factors.

RESULTS

We identified 60 patients fulfilling the inclusion criteria. Twenty-nine underwent a second resection and 31 refused surgery. Median overall survival rates were 58.7 and 24.0 months, median times to progression were 14.4 and 6.6 months. Patients who received surgery plus perioperatory chemotherapy (18/29) had a significantly better outcome; 4/29 achieved long-term disease-free survival.

CONCLUSIONS

Our study suggests that in highly selected metastatic colorectal cancer patients, a multimodal treatment plan, including a second resection, can achieve longer survival with respect to medical therapy.

Repeat hepatectomy for liver metastases from colorectal primary cancer: a review of the literature

INTRODUCTION

After hepatectomy for metastases from colorectal cancer (CRC), approximately 50% to 70% of patients develop recurrent hepatic metastases. This recurrence is limited to the liver in about one-third of cases. The purpose of this study is to report a comprehensive review of the literature concerning the results of repeat hepatectomy for recurrent liver metastases from CRC.

METHODS

An electronic literature search was conducted to identify all medical articles published concerning repeat hepatectomy for liver metastases of colorectal origin during the period January 1990 to December 2010.

RESULTS

After a second hepatectomy, the mean mortality was 1.4% and the mean morbidity rate was 21.3%. The 5-year survival ranged from 16% to 55%. After a third or fourth hepatectomy, the mean mortality rate was 0% and the mean morbidity rate was 24.5%. After a third hepatectomy, the 5-year survival ranged from 23.8% to 37.9%. After a fourth hepatectomy, the 5-year survival was 9.3% to 36%.

CONCLUSION

Repeat hepatectomy seems justified, since it may result in prolonged survival with acceptable rates of morbidity and mortality, results similar to those seen after initial hepatectomy.

Repeat hepatectomy for metastatic colorectal cancer is safe but marginally effective

BACKGROUND

Although hepatectomy for metastatic colorectal cancer (mCRC) offers prolonged survival in up to 40% of people, recurrence rates are high, approaching 70%. Many patients experience recurrent disease in the liver after initial hepatectomy. We examined our experience with repeat hepatectomy for mCRC.

METHODS

After Institutional Review Board approval, we reviewed the records of all patients at a single institution who underwent hepatectomy for mCRC. Repeat hepatectomy was defined as partial liver resection any time after the initial hepatectomy for recurrent mCRC. We estimated time to recurrence and survival by using the Kaplan-Meier method and compared outcomes between groups by using the log-rank test.

RESULTS

From 1998 to 2008, 405 patients underwent hepatectomy for mCRC, and 215 (53%) experienced disease recurrence at a median of 13 months. Of 150 patients with liver-only or liver-predominant recurrence, 52 (35%) underwent repeat hepatectomy. The median time to recurrence after repeat hepatectomy was 10 months, and median overall survival was 19 months. There was one (1.9%) perioperative death, and there were 14 (27%) major complications. The median overall survival in the repeat hepatectomy group from the time of recurrence after initial hepatectomy was 22 months, compared with 15 months in the 98 patients with liver recurrence who were not selected for repeat hepatectomy (P=0.02).

CONCLUSIONS

Repeat hepatectomy for mCRC is feasible in highly selected patients, with acceptable perioperative morbidity and mortality. Although repeat hepatectomy should be considered, recurrence rates are high. Although the initial hepatectomy for mCRC is potentially curative, recurrence of metastatic disease in the liver is unlikely to be cured.

Predictors of long-term survival in patients with colorectal liver metastases: a single center study and review of the literature

PURPOSE

Prognosis after resection of liver metastases of colorectal cancer is influenced by a variety of clinical factors. For more than 20 years, efforts have been made to restructure and simplify prognostic parameters into clinical scores. We evaluated the influence of various clinical and pathological factors on survival and recurrence and developed a simple model for risk stratification.

METHODS

We have analyzed a total of 13 prognostic factors in 382 consecutive and prospectively enrolled R0-resected patients and applied our data set to ten published prognostic scoring systems. Prognostic factors that influenced disease-specific and disease-free survival were included into a model clinical risk score.

RESULTS

The 5- and 10-year observed survival rates were 43% and 28%, respectively, for all 382 patients. The disease-specific 5- and 10-year survival rates were 49% and 37%, respectively; the 5- and 10-year recurrence rates were 68% and 70%, respectively. For patients with synchronous liver metastases, survival was not affected by the timing of liver resection. The prognosis after treatment of any recurrence was best after the accomplishment of a repeated R0 situation, independent of the location of the recurrence. In the multivariate analysis, the disease-specific survival and recurrence rates were statistically significantly influenced by more than three lymph node metastases of the primary tumor, more than two lesions within the liver, and the presence of extrahepatic tumor.

CONCLUSIONS

From these data, we have developed a simple score for the risk stratification which may be useful for future studies on interdisciplinary management of colorectal liver metastases.

Surgical management of colorectal liver metastases

Colorectal cancer is the third most commonly diagnosed cancer with approximately half of the patients developing liver metastases during the course of their disease. Modern multimodal therapies have improved the overall survival. Liver resection remains the most important modality in the treatment of colorectal liver metastases. The evolution of the criteria for resectability has resulted in more patients being offered a hepatectomy. This is further augmented with the utilization of adjuncts to liver resection, including portal vein embolization and local ablative techniques. Two-stage hepatectomy is also being used to increase resectability. Overall survival is improved by the deployment of new chemotherapeutic agents and the use of combination chemotherapy. Neoadjuvant chemotherapy is a promising development in the treatment of colorectal liver metastases. Patients with colorectal liver metastases can achieve long-term survival. A multidisciplinary approach is essential in the management of these patients.

Surgical management of colorectal liver metastases

Colorectal cancer is the third most commonly diagnosed cancer with approximately half of the patients developing liver metastases during the course of their disease. Modern multimodal therapies have improved the overall survival. Liver resection remains the most important modality in the treatment of colorectal liver metastases. The evolution of the criteria for resectability has resulted in more patients being offered a hepatectomy. This is further augmented with the utilization of adjuncts to liver resection, including portal vein embolization and local ablative techniques. Two-stage hepatectomy is also being used to increase resectability. Overall survival is improved by the deployment of new chemotherapeutic agents and the use of combination chemotherapy. Neoadjuvant chemotherapy is a promising development in the treatment of colorectal liver metastases. Patients with colorectal liver metastases can achieve long-term survival. A multidisciplinary approach is essential in the management of these patients.

Use of intraoperative ablation as an adjunct to surgical resection in the treatment of recurrent colorectal liver metastases

OBJECTIVE

To evaluate the role of intraoperative ablation as an adjunct to resection in patients with recurrent colorectal liver metastases (rCLM).

METHODS

All patients undergoing curative-intent reoperative surgery for rCLM from 1992 to 2009 at a tertiary cancer center were included. Overall survival (OS) and recurrence-free survival (RFS) were compared between patients treated with resection alone or in combination with ablation.

RESULTS

A total of 112 reoperative hepatectomies were performed, of which 16 were combined with ablation. The proportion of patients treated with resection and ablation increased from 0% to 41%. Patients undergoing resection and ablation had a greater tumor burden (median, 4 vs. 1, p < 0.0001) and higher baseline clinical risk scores (median, 3 vs. 2, p = 0.065) than patients undergoing resection alone. Patients undergoing resection and ablation had lower intraoperative blood loss than patients undergoing resection alone (344 vs. 877 ml, p = 0.018). Five-year OS from the time of surgery was 48.6%. In multivariable analysis, there was no significant difference in OS or RFS based on the treatment modality.

CONCLUSION

In patients with rCLM, the use of intraoperative ablation can extend the limits of surgical resection in patients with disease that might otherwise not be amenable to complete resection.

Assisted hepatic resection using a toroidal HIFU device: an in vivo comparative study in pig

PURPOSE

Bleeding is the main cause of postoperative complications during hepatic surgery. Blood loss and transfusions increase tumor recurrence in liver metastases from colorectal cancer. A high intensity focused ultrasound (HIFU) device with an integrated ultrasound imaging probe was developed for the treatment of colorectal liver metastasis.

METHODS

The HIFU toroidal-shaped transducer contains 256 elements (working frequency: 3 MHz) and can create a single conical lesion of 7 cm3 in 40 s. Then, the volume of treatment can be significantly increased by juxtaposing single lesions. Presented here is the use of this device in an animal model as a complementary tool to improve surgical resection in the liver. Before transecting the liver, a wall of coagulative necrosis was performed using this device in order to minimize blood loss and dissection time during hepatectomy. Resection assisted by HIFU was compared to classical dissections with clamping [intermittent Pringle maneuver (IPM) group] and without clamping (control group). For each technique, 14 partial liver resections were performed in seven pigs. Blood loss per dissection surface area and resection time were the main outcome parameters.

RESULTS

Conserving liver blood inflow during hepatic resection assisted by HIFU did not increase total blood loss (7.4 +/- 3.3 ml cm(-2)) compared to hepatic resection performed during IPM and controlled blood inflow (11.2 +/- 2.2 ml cm(-2)). Lower blood loss was measured on average when using HIFU, even though difference with clamping (IPM) was not statistically significant (p = 0.09). Resection assisted by HIFU reduced blood loss by 50% compared to control group (14.0 +/- 3.4 ml cm(-2), p = 0.03). The duration of transection when using HIFU (13 +/- 3 min) was significantly lower compared to clamping (23 +/- 4 min, p < 0.01) and control (18 +/- 3 min, p = 0.02). Precoagulation also resulted in sealing blood vessels with a diameter of less than 5 mm, and therefore the number of clips needed in the HIFU group was significantly lower (0.8 +/- 0.2 cm(-2)) when compared to clamping (1.6 +/- 0.2 cm(-2), p < 0.01) and control (1.8 +/- 0.4 cm(-2), p < 0.01).

CONCLUSIONS

This method holds promise for future clinical applications in resection of liver metastases.

Laparoscopic liver surgery: new frontiers

Laparoscopic liver resection (LHR) has shown classical advantages of minimally invasive surgery over open counterpart. In spite of introduction in early 1990's only few centres worldwide adapted LHR to routine practice. It was due to considerable technical challenges and uncertainty about oncologic outcomes. Surgical instrumentation and accumulation of surgical experience has largely enabled to solve many technical considerations. Intraoperative navigation options have also been improved. Consequently indications have been drastically expanded nearly reaching criteria equal to open liver resection in expert centres. Recent studies have verified oncologic integrity of LHR. However, mastering of LHR is still a quite demanding task limiting expansion of this patient friendly technique. This emphasizes the necessity of systematic training for laparoscopic liver surgery. This article reviews the state of the art of laparoscopic liver surgery lightening burning issues of research and clinical practice.

Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome

OBJECTIVE

To analyze the immediate and long-term outcome after laparoscopic resection of colorectal liver metastases and difference between observed and predicted [Fong's and Basingstoke Predictive Index (BPI) scores] survivals.

BACKGROUND

: Laparoscopic liver resection has been reported safe and feasible and improves postoperative course. The oncologic outcomes after resection of colorectal metastases are poorly reported.

METHODS

Between August 1998 and January 2010, 122 patients underwent laparoscopic resection for colorectal liver metastases during 135 procedures at Rikshospitalet. Patients undergoing surgery between August 1998 and June 2009 were included in research analysis. The patients had median Fong's and BPI's scores of 2 (0-5) and 7 (0-23), respectively. Mainstream analysis of hospital data was done on intent-to-treat basis. Intraoperative incidents and postoperative complications were analyzed according to the Satava and Clavien-Dindo classifications. Median follow-up was 24 (0-100) months.

RESULTS

One hundred fifty-one liver resections were performed in 107 patients during 118 procedures: 117 nonanatomic and 34 anatomic liver resections. There were 5 conversions to laparotomy (4.2%). The resection margin was free of tumor tissue in 141 (93.4%) of 151 specimens, and the distance between the resection margin and tumor tissue was median 6 (0-40) mm. Intraoperative incidents occurred in 14 cases (11.9%), including 5 (4.2%), 8 (6.8%), and 1 (0.8%) cases of grades I, II, and III, respectively. Postoperative complications were observed in 16 cases (14.3%), including 2, 3, 7, 3, 0, and 1 cases of grades I, II, IIIa, IIIb, IV, and V, respectively. During follow-up, 21 patients received repeat liver resection of recurrences (11 by laparoscopy and 10 by laparotomy). The 5-year overall survival rates were 51% as laparoscopically completed cases and 47% as intent-to-treat. The observed actuarial survival values exceeded the values expected by Fong's and BPI's score, with 10.2% and 6.7% as laparoscopically completed cases and with 3.8% and 2.4% as intent-to-treat, respectively.

CONCLUSIONS

Laparoscopic resection is a favorable alternative to open liver resection for patients with colorectal liver metastases. The observed actuarial survival values after laparoscopic resection surpass the values expected by major scoring systems.

Outcomes of intensive surveillance after resection of hepatic colorectal metastases

BACKGROUND

The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated.

METHODS

Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated.

RESULTS

Five-year disease-free and overall survival rates were 28.3 and 32.3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3.9 per cent in 278 patients managed palliatively (P < 0.001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was 12,338 pounds per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4.28 years per resection and the cost per life-year gained was 2883 pounds.

CONCLUSION

Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained.

Long-term outcomes and quality of life after rectal carcinoma surgery

Background

A cohort study was undertaken to investigate the long-term oncological outcome, late adverse effects and quality of life (QOL) after treatment for rectal cancer.

Methods

This was an analysis of prospectively collected data from 268 consecutive patients with rectal carcinoma treated between 1995 and 1997 at the Department of Surgery, University Hospital Erlangen, Germany.

Results

Median follow-up was 8·8 years. The overall 10-year survival rate was 48·1 per cent. Of 219 patients who had a curative resection, 67 developed recurrent disease and 13 had second malignancies. Seventy patients had either a permanent stoma or a late adverse effect. Anorectal dysfunction and small bowel obstruction were significantly more common among patients who had multimodal treatment (P &lt; 0·001 and P = 0·049 respectively). Analysis of QOL in 97 long-term survivors showed that receiving chemoradiotherapy, a permanent stoma and lower-third rectal carcinoma were associated with significantly worse outcomes on several measures.

Conclusion

Late adverse effects and recurrences occurred in a significant number of patients during long-term follow-up. QOL varied according to tumour location and treatment type.

Prognostic scores for colorectal liver metastasis: clinically important or an academic exercise?

OBJECTIVES

Over the last decade, various groups have proposed prognostic scoring systems for patients with colorectal liver metastasis (CLM) treated with hepatic resection. The aims of the current study were to evaluate the differences between and clinical importance of these prognostic scoring systems and to determine their clinical applicability.

METHODS

Relevant articles were reviewed from the published literature using the MEDLINE database. The search was performed using the keywords 'colorectal cancer', 'metastases', 'liver resection' and 'hepatectomy'.

RESULTS

Twelve prognostic scoring systems were identified from 1996 to 2009. Six of these originated from European institutions, three from Asian and three from North American centres. The median study sample was 288 patients (range 81-1568 patients) and median follow-up was 35 months (range 16-52 months). All studies were retrospective in nature and the numbers of groups proposed by the various scoring systems ranged from three to six. All the studies used the Cox proportional hazard model for multi-variable analysis.

CONCLUSIONS

There is no 'ideal' prognostic scoring system for the clinical management of patients with CLM for hepatic resection. These prognostic scoring systems are clinically relevant with respect to survival but have not been used for risk stratification in controversial areas such as the administration of chemotherapy or surveillance programmes.

Interaction of tumour biology and tumour burden in determining outcome after hepatic resection for colorectal metastases

AIMS

To determine the outcome of colorectal liver metastasis (CRLM) patients based on tumour burden, represented by tumour number and size, and tumour biology as assessed by an inflammatory response to tumour (IRT) and margin positivity.

METHODS

Data were collated from CRLM patients undergoing resection from January 1993 to March 2007. Patients were divided into: low (<or=3 metastases and/or <or=3 cm); moderate (4-7 metastases and/or >3-<or=5 cm); and high (>or=8 metastases and/or >5 cm) tumour burden.

RESULTS

Seven hundred and five patients underwent resection, of which 154 (21.8%), 262 (37.2%) and 289 (41.0%) patients were in the low, moderate and high tumour burden groups, respectively. The 5-year disease-free (P < 0.001) and overall (P < 0.001) survival were significantly different between the groups. IRT (P < 0.001), extent of resection (P < 0.001) and margin (P < 0.001) also differed between the groups. Sub-group analysis revealed that IRT was the only adverse predictor for disease-free and overall survival in the low group. In the moderate group, IRT predicted poorer disease-free survival on multi-variate analysis. In the high group, R1 resection and transfusion were predictors of poorer disease-free survival and age >or=65 years, R1 resection and IRT were adverse predictors of overall survival.

CONCLUSION

Resection margin influenced the outcome of patients with high tumour burden, hence the importance of achieving clear margins. IRT influenced the outcome of patients with less aggressive disease.

Repeat curative intent liver surgery is safe and effective for recurrent colorectal liver metastasis: results from an international multi-institutional analysis

INTRODUCTION

Although 5-year survival approaches 55% following resection of colorectal liver metastasis, most patients develop recurrent disease that is often isolated to the liver. Although repeat curative intent surgery (CIS) is increasingly performed for recurrent colorectal liver metastasis, only small series have been reported. We sought to determine safety and efficacy of repeat CIS for recurrent colorectal liver metastasis as well as determine factors predictive of survival in a large multicenter cohort of patients.

METHODS

Between 1982 and 2008, 1,706 patients who underwent CIS--defined as curative intent hepatic resection/radiofrequency ablation (RFA)--for colorectal liver metastasis were identified from an international multi-institutional database. Two hundred forty-six (14.4%) patients underwent 301 repeat CIS. Data on clinico-pathologic factors, morbidity, and mortality were collected and analyzed.

RESULTS

Following initial CIS, 645 (37.8%) patients had recurrence within the liver. Of these, 246 patients underwent repeat CIS for recurrent disease. The majority had hepatic resection alone as initial therapy (n = 219; 89.0%). A subset of patients underwent third (n = 46) or fourth (n = 9) repeat CIS. Mean interval between surgeries was similar (first --> second, 19.1 months; second --> third, 21.5 months; third --> fourth, 11.3 months; P = 0.20). Extent of hepatic resection decreased with subsequent CIS (>or=hemihepatectomy: first CIS, 30.9% versus second CIS, 21.1% versus third/fourth CIS, 16.4%; P = 0.004). RFA was utilized in one quarter of patients undergoing repeat CIS (second CIS, 21.1% versus third/fourth CIS, 25.5%). Mortality and morbidity were similar following second, third, and fourth CIS, respectively (all P > 0.05). Five-year survival was 47.1%, 32.6%, and 23.8% following the first, second, and third CIS, respectively. Presence of extra-hepatic disease was predictive of worse survival (HR = 2.26, P = 0.01).

CONCLUSION

Repeat CIS for recurrent colorectal liver metastasis can be performed with low morbidity and near-zero mortality. Patients with no extra-hepatic disease are best candidates for repeat CIS. In these patients, repeat CIS can offer the chance of long-term survival.

'Close shave' in liver resection for colorectal liver metastases

INTRODUCTION

The optimal size of clear liver resection margin width in patients with colorectal liver metastases (CRLM) remains controversial. The aim of this study was to investigate the effects of margin width on long-term survival after liver resection for CRLM with a policy of standard neo-adjuvant chemotherapy.

METHODS

Consecutive patients (n=238) who underwent liver resection for CRLM were included over a ten-year period. All patients with synchronous or early (<2 years) metachronous tumours were treated with neo-adjuvant chemotherapy. Data were recorded prospectively.

RESULTS

Overall survival of the cohort at 1, 3 and 5 years were 90.3%, 68.1% and 56.1% respectively. The incidence of cancer involved resection margins (CIRM) was 5.8%. Patients with macroscopically involved resection margins had a poorer overall survival than those with microscopically involved margins (p=0.04). Involved resection margins had a poorer overall survival (p=0.002) than patients with clear margins. Width of clear resection margin did not affect long-term survival.

CONCLUSION

CIRM independently predicts poor outcome in patients with CRLM. Clear margin width does not affect survival. A standard policy of neo-adjuvant chemotherapy may be associated with a low incidence of CIRM and improved long-term outcome of sub-centimetre margin widths, resembling those with >1cm resection margins.

Laparoscopic resection of left liver segments using the intrahepatic Glissonian approach

BACKGROUND

Recent advances in laparoscopic techniques have resulted in growing indications for laparoscopic hepatectomy. However, this procedure has not been widely developed, and anatomic segmental liver resection is not currently performed due to difficulty controlling the segmental Glissonian pedicles laparoscopically. This study aimed to report a novel technique for laparoscopic anatomic resection of left liver segments using the intrahepatic Glissonian approach based on small incisions according to anatomic landmarks such as Arantius' and round ligaments.

METHODS

Nine consecutive patients underwent laparoscopic liver resection using the intrahepatic Glissonian technique from April 2007 to June 2008. Five patients underwent laparoscopic bisegmentectomy 2-3, one laparoscopic left hemihepatectomy, two resections of segment 3, and one resection of segment 4.

RESULTS

One patient required a blood transfusion. The mean operation time was 180 min (range, 120-300 min), and the median hospital stay was 3 days (range, 1-5 days). No patient had postoperative signs of liver failure or bile leakage. No postoperative mortality was observed.

CONCLUSION

The main advantage of the intrahepatic Glissonian procedure over other techniques is the possibility of gaining a rapid and precise access to the left Glissonian sheaths facilitating left hemihepatectomy, bisegmentectomy 2-3, and individual resections of segments 2, 3, and 4. The authors believe that the intrahepatic Glissonian technique facilitates laparoscopic liver resection and may increase the development of segment-based laparoscopic liver resection.

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases: a ten year study

BACKGROUND

Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery.

METHODS

283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors.

RESULTS

Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively.

CONCLUSIONS

Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.

Intrahepatic Glissonian approach for laparoscopic right segmental liver resections

BACKGROUND

Experience with laparoscopic procedures and recent advances in laparoscopic devices have created an evolving interest in the application of these techniques to liver resection. However, laparoscopic liver resection has not been widely developed and anatomical segmental liver resection is not currently performed due to difficulty to control segmental Glissonean pedicles laparoscopically.

METHODS

Seven consecutive patients underwent laparoscopic liver resection using an intrahepatic Glissonian approach from April 2007 to September 2007. Three patients underwent laparoscopic bisegmentectomy 6-7 and 4 patients underwent laparoscopic right hemihepatectomy.

RESULTS

Blood transfusion was required in 1 patient. Mean operation time was 460 minutes (range 300-630 minutes). The median hospital stay was 5 days (range 3-8 days). One patient developed bile leakage that was treated conservatively. No patient had postoperative signs of liver failure. No postoperative mortality was observed.

CONCLUSIONS

The main advantage over other techniques is the possibility to gain a rapid and precise access to the right posterior and anterior sheaths facilitating right hemihepatectomy, and right anterior and posterior sectionectomies. We believe that the described technique facilitates laparoscopic liver resection by reducing the technical difficulties in pedicle control and may increase the development of segment-based laparoscopic liver resections.

Peritumoural, but not intratumoural, lymphatic vessel density and invasion correlate with colorectal carcinoma poor-outcome markers

To evaluate whether lymphatic vessel density (LVD) and lymphatic vessel invasion (LVI) are useful markers of worse outcome in colorectal carcinoma and if LVD and LVI correlate to the classical clinical-pathological parameters, we analysed 120 cases of colorectal carcinomas selected from the files of Division of Pathology, Hospital das Clinicas, São Paulo University, Brazil. Assessment of LVD and LVI was performed by immunohistochemical detection of lymphatic vessels, using the monoclonal antibody D2-40. Higher LVD was found in the intratumoural area, when comparing with normal and peritumoural areas (p < 0.001). However, peritumoural LVD, but not intratumoural, correlated with both colonic-wall-invasion depth (p = 0.037) and liver metastasis (p = 0.012). Remarkably, LVI was found associated with local invasion (p = 0.016), nodal metastasis (p = 0.022) and hepatic metastasis (p < 0.001). Peritumoural LVD and LVI are directly related to histopathological variables indicative of poor outcome such as lymph-node status and liver metastasis.

Comparison of hepatic recurrences after resection or intraoperative radiofrequency ablation indicated by size and topographical characteristics of the metastases

AIMS

Intraoperative use of radiofrequency ablation (IRFA) to treat liver metastases is controversial. The aim of this study was to compare local recurrence rate and survival after IRFA versus resection.

METHODS

Three groups from 99 patients were consecutively operated on for 307 liver metastases with 2years of follow up: group 1, IRFA alone (n=34); group 2, IRFA plus resection (n=28); group 3, resection alone (n=37). The choice of IRFA or resection was made on the basis of the sizes and topographies of the metastases with the goal of achieving R0 treatment.

RESULTS

Mortality was zero; morbidity was 9%, 11% and 11% in the three groups respectively. Median follow-up after surgery was 30months. Total hepatic recurrences occurred in 59 (60%) patients. Median survival without hepatic recurrence was 17months with no difference between the three groups (P=0.474). Total local recurrence occurred in 4 (12%) patients in group 1, in 2 (8%) patients in group 2, and in 2 (6%) patients in group 3. Survival at 2years was no different in the three groups.

CONCLUSION

Assessing IRFA indications by size and the topographical characteristics of the liver metastases yields identical local recurrence rates to resection after 2years of follow up.

Hepatic resection for metastatic gastrointestinal and pancreatic neuroendocrine tumours: outcome and prognostic predictors

BACKGROUND

Treatment modalities for hepatic metastases from neuroendocrine tumours (NETs) include surgery, somatostatin analogues and arterial embolization. The aims of this study were to evaluate the outcome of patients following surgery and to identify prognostic predictors of recurrent disease.

PATIENTS AND METHODS

This was a retrospective clinico-pathological analysis of patients managed with hepatic NET metastases over a 13-year period (January 1994 to December 2006).

RESULTS

Eighteen patients with hepatic metastases from NET were identified with a median age of 53 years (range 31-75). The localization of the primary tumour was the terminal ileum (n=8), pancreas (n=7), appendix (n=2) or duodenum (n=1). Twelve patients had synchronous disease and six patients developed metachronous hepatic tumours over a median period of 20 months (range 6-144). Presenting symptoms included abdominal pain (n =13), recurrent diarrhoea (n=7) and flushing (n=7). Fifteen patients underwent surgery with complete cytoreduction and three patients had partial cytoreduction. The overall 2- and 5-year actuarial survival rates were 94% and 86%, respectively. The 2- and 5-year disease-free rates following hepatic resection with complete cytoreduction were both 66%. Partial or complete control of endocrine-related symptoms was achieved in all patients with functioning tumours following surgery. Recurrent disease occurred in four patients following complete cytoreductive surgery. Resection margin involvement was associated with developing recurrent disease (p=0.041).

CONCLUSION

Surgical resection for hepatic NET metastases results in good long-term survival in selected patients and resection margin involvement was associated with recurrent disease.