The impact of synchronous liver resection on the risk of anastomotic leakage following elective colorectal resection. A propensity score match analysis on behalf of the iCral study group

Association Between Cross-Stapling Technique in Mechanical Colorectal Anastomosis and Short-term Outcomes

BACKGROUND

The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered possible risk factors for anastomotic leakage.

OBJECTIVE

This study aimed to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis after minimally invasive surgery.

DATA SOURCES

A systematic review of the published literature was undertaken. PubMed/MEDLINE, Web of Science, and Embase databases were screened up to July 2023.

STUDY SELECTION

Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction compared with the conventional method of double-stapled anastomosis were included.

INTERVENTIONS

Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared.

MAIN OUTCOME MEASURES

The rate of anastomotic leak was the primary end point of interest. Perioperative details including postoperative morbidity were also appraised.

RESULTS

There were 2537 patients from 12 studies included for data extraction, with no significant differences in age, BMI, or proportion of high ASA score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure than for the conventional procedure (OR = 0.38 [95% CI, 0.26-0.56]). The incidences of overall postoperative morbidity (OR = 0.57 [95% CI, 0.45-0.73]) and major morbidity (OR = 0.48 [95% CI, 0.32-0.72]) following modified stapled anastomosis were significantly lower than following conventional double-stapled anastomosis.

LIMITATIONS

The retrospective nature of most included studies is a main limitation, essentially because of the lack of randomization and the risk of selection and detection bias.

CONCLUSIONS

The available evidence supports the modification of the conventional double-stapled technique with the elimination of 1 of both dog-ears as it is associated with a lower incidence of anastomotic-related morbidity.

Simultaneous resection for colorectal cancer with synchronous liver metastases: current state-of-the-art

BACKGROUND

A large proportion of patients with colorectal cancer (CRC) presents with synchronous colorectal liver metastases (sCRLM) at diagnosis. Surgical approaches for patients with sCRLM have evolved over the past decades. Simultaneous resection (SR) of CRC and sCRLM for selected patients has emerged as a safe and efficient alternative approach to traditional staged resections.

METHODS

A comprehensive review of the literature was performed using MEDLINE/PubMed and Web of Science databases with the end of search date October 30, 2023. The MeSH terms "simultaneous resections" and "combined resections" in combination with "colorectal liver metastases," "colorectal cancer," "liver resection," and "hepatectomy" were searched in the title and/or abstract.

RESULTS

SRs aim to achieve maximal tumor clearance, minimizing the risk of disease progression and optimizing the potential for long-term survival. Improvements in perioperative care, advances in surgical techniques, and a better understanding of patient selection criteria have collectively contributed to reducing morbidity and mortality associated with these complex procedures. Several studies have demonstrated that SR are associated with reduced overall length of stay and lower costs with comparable morbidity and long-term outcomes. In light of these outcomes, the proportion of patients undergoing SR for CRC and sCRLM has increased substantially over the past 2 decades.

CONCLUSION

For patients with sCRLM, SR represents an attractive alternative to the traditional staged approach and should be selectively used; however, the decision on whether to proceed with a simultaneous versus staged approach should be individualized based on several patient- and disease-related factors.

Postoperative morbidity after simultaneous versus staged resection of synchronous colorectal liver metastases: Impact of hepatic tumor burden

BACKGROUND

We sought to characterize the risk of postoperative complications relative to the surgical approach and overall synchronous colorectal liver metastases tumor burden score.

METHODS

Patients with synchronous colorectal liver metastases who underwent curative-intent resection between 2000 and 2020 were identified from an international multi-institutional database. Propensity score matching was employed to control for heterogeneity between the 2 groups. A virtual twins analysis was performed to identify potential subgroups of patients who might benefit more from staged versus simultaneous resection.

RESULTS

Among 976 patients who underwent liver resection for synchronous colorectal liver metastases, 589 patients (60.3%) had a staged approach, whereas 387 (39.7%) patients underwent simultaneous resection of the primary tumor and synchronous colorectal liver metastases. After propensity score matching, 295 patients who underwent each surgical approach were analyzed. Overall, the incidence of postoperative complications was 34.1% (n = 201). Among patients with high tumor burden scores, the surgical approach was associated with a higher incidence of postoperative complications; in contrast, among patients with low or medium tumor burden scores, the likelihood of complications did not differ based on the surgical approach. Virtual twins analysis demonstrated that preoperative tumor burden score was important to identify which subgroup of patients benefited most from staged versus simultaneous resection. Simultaneous resection was associated with better outcomes among patients with a tumor burden score <9 and a node-negative right-sided primary tumor; in contrast, staged resection was associated with better outcomes among patients with node-positive left-sided primary tumors and higher tumor burden score.

CONCLUSION

Among patients with high tumor burden scores, simultaneous resection of the primary tumor and liver metastases was associated with an increased incidence of postoperative complications.

Impact of cumulative operative time on postoperative complication risk in simultaneous resections of colorectal liver metastases and primary tumors

BACKGROUND

Simultaneous resection of colorectal liver metastases (CLM) and primary colorectal cancers (CRC) is nuanced without firm rules for selection. This study aimed to identify factors associated with morbidity after simultaneous resection.

METHODS

Using a prospective database, patients undergoing simultaneous CLM-CRC resection from 1/1/2017-7/1/2020 were analyzed. Regression modeling estimated impact of colorectal resection type, Kawaguchi-Gayet (KG) hepatectomy complexity, and perioperative factors on 90-day complications.

RESULTS

Overall, 120 patients underwent simultaneous CLM-CRC resection. Grade≥2 complications occurred in 38.3% (n = 46); these patients experienced longer length of stay (median LOS 7.5 vs. 4, p < 0.001) and increased readmission (39% vs. 1.4%, p < 0.001) compared to patients with zero or Grade 1 complications. Median OR time was 298 min. Patients within highest operative time quartile (>506 min) had higher grade≥2 complications (57%vs. 23%, p = 0.04) and greater than 4-fold increased odds of grade≥2 morbidity (OR 4.3, 95% CI (Confidence Interval) 1.41-13.1, p = 0.01). After adjusting for Pringle time, KG complexity and colorectal resection type, increasing operative time was associated with grade≥2 complications, especially for resections in highest quartile of operative time (OR 7.28, 95% CI 1.73-30.6, p = 0.007).

CONCLUSION

In patients undergoing simultaneous CLM-CRC resection, prolonged operative time is independently associated with grade≥2 complications. Awareness of cumulative operative time may inform intraoperative decision-making by surgical teams.

Predicting Limited Survival After Resection of Synchronous Colorectal Liver Metastases: a Propensity Score Matched Comparison Between The Primary First And The Simultaneous Strategy

BACKGROUND

The best surgical approach to treat synchronous colorectal liver metastases (CRLM) remains unclear. Here, we aimed to identify prognostic factors associated with limited survival comparing patients undergoing primary-first resection (PF) and simultaneous resection (SR) approaches.

METHODS

We retrospectively reviewed clinical data of 217 patients who underwent resection for synchronous CRLMs between January 1, 2011, and December 31, 2021. There were 133 (61.2%) PF resection and 84 (38.8%) SRS. The two groups of patients were compared using propensity score matching (PSM) analysis and cox analysis was performed to identify prognostic factors for overall survival (OS).

RESULTS

After PSM, two groups of 71 patients were compared. Patients undergoing SR had longer operative time (324 ± 104 min vs 250 ± 101 min; p < 0.0001), similar transfusion (33.3% vs 28.1%; p = 0.57), and similar complication rates (35.9% vs 27.2%; p = 0.34) than patients undergoing PF. The median overall survival and 5-year survival rates were comparable (p = 0.94) between patients undergoing PF (48.2 months and 44%) and patients undergoing SR (45.9 months and 30%). Multivariate Cox analysis identified pre-resection elevated CEA levels (HR: 2.38; 95% CI: 1.20-4.70; P = .01), left colonic tumors (HR: 0.34; 95% CI: 0.17-0.68; P = .002), and adjuvant treatment (HR: 0.43; 95% CI: 0.22-0.83; P = .01) as independent prognostic factors for OS.

CONCLUSIONS

In the presence of synchronous CRLM, right colonic tumors, persistent high CEA levels before surgery, and the absence of adjuvant treatment identified patients characterized by a limited survival rate after resection. The approach used (PF vs SR) does not influence short and long-term outcomes.

Simultaneous, single-docking robotic resection for right colon cancer with synchronous liver metastases

BACKGROUND

How best to manage colorectal cancer patients presenting resectable synchronous liver metastasis is still a matter of debate. A number of different available therapeutic strategies exist, with significant differences in terms of optimal timing and/or sequence of resection of the primary tumor and liver disease [1]. Over the last years, simultaneous resections are increasingly adopted for properly selected patients [1-3]. However, the application of minimally invasive surgery to combined colorectal and liver surgery is still controversial, especially in the case of liver disease requiring technically demanding resections [2,3].

VIDEO

The presented video illustrates the details of a single-docking robotic right colectomy combined with ultrasound-guided, parenchymal-sparing resection of liver segments 6 and 7, as performed to treat a patient with locally advanced colorectal cancer and metastatic disease isolated to the right liver. Port placement strategy and main instrumentation employed are illustrated in Fig. 1, and Fig. 2, respectively. The total duration of surgery was 380 minutes. The hepatic hilum was encircled to allow extracorporeal Pringle maneuver during liver resection, though no clamping was eventually required. Right colectomy with central vascular ligation was thus carried out and an intracorporeal ileocolic anastomosis performed. The patient had an uneventful postoperative course.

CONCLUSIONS

When feasible, minimally invasive simultaneous resection may offer distinct advantages over conventional surgery while respecting the tenets of appropriate oncological resection [2,3]. The well-known benefits of minimally invasive surgery, including shorter overall hospital length of stay, reduced morbidity, and lower blood loss, are combined with the need to recover from a single major surgery. Robotic resection may be particularly suited for technically challenging procedures, such as colectomy combined with liver metastasectomies with unfavorable anatomical accessibility [3,4].