Feasibility, safety and efficacy of two-stage hepatectomy for bilobar liver metastases of colorectal cancer: a LiverMetSurvey analysis

Health Economic Evaluation of Patients With Colorectal Liver Metastases Randomized to ALPPS or TSH: Analysis From the LIGRO Trial

Objective

This is a preplanned, health economic evaluation from the LIGRO trial. One hundred patients with colorectal liver metastases (CRLM) and standardized future liver remnant <30% were randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or two-staged hepatectomy (TSH).

Summary Background Data

TSH, is an established method in advanced CRLM. ALPPS has emerged providing improved resection rate and survival. The health care costs and health outcomes, combining health-related quality of life (HRQoL) and survival into quality-adjusted life years (QALYs), of ALPPS and TSH have not previously been evaluated and compared.

Methods

Costs and QALYs were compared from treatment start up to 2 years. Costs are estimated from resource use, including all surgical interventions, length of stay after interventions, diagnostic procedures and chemotherapy, and applying Swedish unit costs. QALYs were estimated by combining survival and HRQoL data, the latter being assessed with EQ-5D 3L. Estimated costs and QALYs for each treatment strategy were combined into an incremental cost-effectiveness ratio (ICER). Nonparametric bootstrapping was used to assess the joint distribution of incremental costs and QALYs.

Results

The mean cost difference between ALPPS and TSH was 12,662€, [95% confidence interval (CI): -10,728-36,051; P = 0.283]. Corresponding mean difference in life years and QALYs was 0.1296 (95% CI: -0.12-0.38; P = 0.314) and 0.1285 (95% CI: -0.11-0.36; P = 0.28), respectively. The ICER was 93,186 and 92,414 for QALYs and life years as outcomes, respectively.

Conclusions

Based on the 2-year data, the cost-effectiveness of ALPPS is uncertain. Further research, exploring cost and health outcomes beyond 2 years is needed.

Contemporary Surgical Management of Colorectal Liver Metastases

Colorectal cancer is the third most common cancer in the United States and the second most common cause of cancer-related death. Approximately 20-30% of patients will develop hepatic metastasis in the form of synchronous or metachronous disease. The treatment of colorectal liver metastasis (CRLM) has evolved into a multidisciplinary approach, with chemotherapy and a variety of locoregional treatments, such as ablation and portal vein embolization, playing a crucial role. However, resection remains a core tenet of management, serving as the gold standard for a curative-intent therapy. As such, the input of a dedicated hepatobiliary surgeon is paramount for appropriate patient selection and choice of surgical approach, as significant advances in the field have made management decisions extremely nuanced and complex. We herein aim to review the contemporary surgical management of colorectal liver metastasis with respect to both perioperative and operative considerations.

Factors of oncological failure in two stage hepatectomy for colorectal liver metastases

BACKGROUND

Two-stage hepatectomy (TSH) has increased the chance of surgical resections for bilobar colorectal liver metastases (CRLM). Nevertheless, drop-out between stages and early recurrence rates raise the question of surgical futility in some situations. This study aimed to identify factors of TSH oncological failure.

METHODS

Patients with bilobar CRLM eligible for TSH in three tertiary centers between 2010 and 2021 were included, and divided in Failure and Success groups. Oncological failure was defined as failure of the second stage hepatectomy for tumor progression or recurrence within 6 months after resection.

RESULTS

Among 95 patients, 18 (18.9%) had hepatic progression between the two stages, and 7 (7.4%) failed to complete the second stage hepatectomy. After TSH, 31 (32.6%) patients experienced early recurrence. Overall, 38 (40.0%) patients experienced oncological failure (Failure group). The Failure group had lower median DFS (3 vs. 32 months, p < 0.001) and median OS (29 vs. 70 months, p = 0.045) than the Success group. On multivariable analysis, progression between the two stages in the future liver remnant (OR = 15.0 (3.22-113.0), p = 0.002), and maximal tumor size ≥40 mm in the future liver remnant (OR = 13.1 (2.12-117.0), p = 0.009) were independent factors of oncological failure.

CONCLUSION

Recurrence between the two stages and maximal tumor size ≥40 mm in the future liver remnant were associated with TSH failure for patients with bilobar CRLM.

The role of ischaemia-reperfusion injury and liver regeneration in hepatic tumour recurrence

The risk of cancer recurrence after liver surgery mainly depends on tumour biology, but preclinical and clinical evidence suggests that the degree of perioperative liver injury plays a role in creating a favourable microenvironment for tumour cell engraftment or proliferation of dormant micro-metastases. Understanding the contribution of perioperative liver injury to tumour recurrence is imperative, as these pathways are potentially actionable. In this review, we examine the key mechanisms of perioperative liver injury, which comprise mechanical handling and surgical stress, ischaemia-reperfusion injury, and parenchymal loss leading to liver regeneration. We explore how these processes can trigger downstream cascades leading to the activation of the immune system and the pro-inflammatory response, cellular proliferation, angiogenesis, anti-apoptotic signals, and release of circulating tumour cells. Finally, we discuss the novel therapies under investigation to decrease ischaemia-reperfusion injury and increase regeneration after liver surgery, including pharmaceutical agents, inflow modulation, and machine perfusion.

Development and validation of a novel risk score to predict overall survival following surgical clearance of bilobar colorectal liver metastases

BACKGROUND

Bilobar liver metastases from colorectal cancer pose a challenge for obtaining a satisfactory oncological outcome with an adequate future liver remnant. This study aimed to assess the clinical and pathological determinants of overall survival and recurrence-free survival among patients undergoing surgical clearance of bilobar liver metastases from colorectal cancer.

METHODS

A retrospective international multicentre study of patients who underwent surgery for bilobar liver metastases from colorectal cancer between January 2012 and December 2018 was conducted. Overall survival and recurrence-free survival at 1, 2, 3 and 5 years after surgery were the primary outcomes evaluated. The secondary outcomes were duration of postoperative hospital stay, and 90-day major morbidity and mortality rates. A prognostic nomogram was developed using covariates selected from a Cox proportional hazards regression model, and internally validated using a 3:1 random partition into derivation and validation cohorts.

RESULTS

A total of 1236 patients were included from 70 centres. The majority (88 per cent) of the patients had synchronous liver metastases. Overall survival at 1, 2, 3 and 5 years was 86.4 per cent, 67.5 per cent, 52.6 per cent and 33.8 per cent, and the recurrence-free survival rates were 48.7 per cent, 26.6 per cent, 19.2 per cent and 10.5 per cent respectively. A total of 25 per cent of patients had recurrent disease within 6 months. Margin positivity and progressive disease at liver resection were poor prognostic factors, while adjuvant chemotherapy in margin-positive resections improved overall survival. The bilobar liver metastases from colorectal cancer-overall survival nomogram was developed from the derivation cohort based on pre- and postoperative factors. The nomogram's ability to forecast overall survival at 1, 2, 3 and 5 years was subsequently validated on the validation cohort and showed high accuracy (overall C-index = 0.742).

CONCLUSION

Despite the high recurrence rates, overall survival of patients undergoing surgical resection for bilobar liver metastases from colorectal cancer is encouraging. The novel bilobar liver metastases from colorectal cancer-overall survival nomogram helps in counselling and informed decision-making of patients planned for treatment of bilobar liver metastases from colorectal cancer.

Mixed reality combined with ALPPS for colorectal liver metastases, a case report

INTRODUCTION

Improvement of treatments for patients suffering from colorectal carcinoma and extended liver metastases has increased the overall survival and enables more patients to undergo surgical therapy. If the future liver remnant (FLR) is expected to be low, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a potential treatment with high feasibility and an increase in overall survival. The evolving mixed reality technology could support hepatobiliary surgery. This case report demonstrates for the first time the combination of mixed reality technology and ALPPS procedure for a patient with low expected FLR.

PRESENTATION OF CASE

A 49-year-old patient is presented with adenocarcinoma of the caecum with bilateral liver metastasis. After colon resection, a palliative chemotherapy was administered with good response and partial remission, so curative liver resection was intended. Based on the low expected FLR, calculated from the 3D-model of the liver, we decided to perform an in-situ split resection supported by mixed reality intraoperatively. The total operation time was 6 + 2 h. During both steps no blood transfusion was required and no major complication occurred. The patient was discharged 15 days after the second step. Final pathology revealed multiple predominantly necrotic metastases of the pre-existing colon carcinoma (ypM1, R0).

DISCUSSION

After the first step of ALPPS, an increase of the FLR up to 57 % was achieved, so the second step was performed on postoperative day (POD)11. The 3D-model and the intraoperative use of mixed reality supported our decision making and intraoperative navigation. This technique could be implemented on a larger scale to support complex liver resections.

CONCLUSION

The combination of mixed reality with ALPPS resulted in a good surgical outcome and should be considered as a potential alternative for liver resections.

Two-stage hepatectomy in resection of colorectal liver metastases - a single-institution experience with case-control matching and review of the literature

BACKGROUND

Two-stage hepatectomy (TSH) has been proposed for patients with bilateral liver tumours who have a high risk of posthepatectomy liver failure after one-stage hepatectomy (OSH). This study aimed to determine the outcomes of TSH for extensive bilateral colorectal liver metastases.

PATIENTS AND METHODS

A retrospective review of a prospectively maintained database of liver resections for colorectal liver metastases was conducted. The TSH group was compared to the OSH group in terms of perioperative outcomes and survival. Case-control matching was performed.

RESULTS

A total of 632 consecutive liver resections for colorectal liver metastases were performed between 2000 and 2020. The study group (TSH group) consisted of 15 patients who completed TSH. The control group included 151 patients who underwent OSH. The case-control matching-OSH group consisted of 14 patients. The major morbidity and 90-day mortality rates were 40% and 13.3% in the TSH group, 20.5% and 4.6% in the OSH group and 28.6% and 7.1% in the case-control matching-OSH group, respectively. The recurrence-free survival, median overall survival, and 3- and 5-year survival rates were 5 months, 21 months, 33% and 13% in the TSH group; 11 months, 35 months, 49% and 27% in the OSH group; and 8 months, 23 months, 36% and 21%, respectively, in the case-control matching-OSH group, respectively.

CONCLUSIONS

TSH used to be a favourable therapeutic choice in a select population of patients. Now, OSH should be preferred whenever feasible because it has lower morbidity and equivalent oncological outcomes to those of completed TSH.

Safety and Feasibility of Laparoscopic Right or Extended Right Hemi Hepatectomy Following Modulation of the Future Liver Remnant in Patients with Colorectal Liver Metastases: A Systematic Review

Background: Major hepatectomies after future liver remnant (FLR) modulation are technically demanding procedures, especially when performed as minimally invasive surgery. The aim of this systematic review is to assess current evidence regarding the safety and feasibility of laparoscopic right or extended right hemihepatectomies after FLR modulation. Materials and Methods: The Medline, PubMed, Cochrane Library, and Embase databases were searched for studies involving laparoscopic right or extended right hemihepatectomies after FLR modulation, from their inception to December 2021. Two reviewers independently selected eligible articles and assessed their quality using the Newcastle-Ottawa Quality Assessment Scale (NOS). Baseline characteristics and outcomes were extracted from the included studies and summarized. Results: Six studies were included. In these studies, the median length of stay after the second stage ranged from 4.5 to 15.5 days and postoperative complication rates between 4.5% and 42.8%. Overall, 7.4% of patients developed liver failure, and 90-day mortality occurred in 3.2% of patients. The R0 resection rate was 93.5%. Only one study reported long-term outcomes, describing comparable 3-year overall survival rates following laparoscopic and open surgery (80% versus 54%, P = .154). Conclusions: The current evidence is scarce, but it suggests that in experienced centers, laparoscopic right or extended right hemihepatectomy, following FLR modulation, is a safe and feasible procedure.

Hepatic Resection in Patients with Colo-Rectal Liver Metastases: Surgical Outcomes and Prognostic Factors of Single-Center Experience

Introduction: Surgical resection has a fundamental role in increasing the chance of survival in patients with colorectal liver metastases. The guidelines have been modified and expanded in time in order to increase the number of patients that can benefit from this treatment. The aim of this study is to analyze the main prognostic factors related to overall and disease-free survival of a series of consecutive patients undergoing liver resection for colorectal liver metastases (CRLM). Materials and Methods: A retrospective review of patients undergoing liver resection for CRLM between April 2018 and September 2021 was performed. Clinical data and laboratory parameters were evaluated using the log-rank test. OS and DFS were estimated using the Kaplan-Meier method. Results: A retrospective study on 75 patients who underwent liver resection for CRLM was performed. The OS and DFS at 1 and 3 years were 84.3% and 63.8% for OS, 55.6% and 30.7% for DFS, respectively. From the analysis of the data, the most significant results indicate that: patients with a lower CEA value <25 ng/mL had an OS of 93.6% and 80.1% at 1 and 3 years, with an average of 36.7 months (CI 95% 33.1–40.3); moreover, patients with a value equal to or greater than 25 ng/mL had a 1-year survival equal to 57.4%, with an average of 13.8 months (CI 95% 9.4–18.2) (p < 0.001); adjuvant chemotherapy increases by 3 years the overall survival (OS: 68.6% vs. 49.7%) (p = 0.013); localization of the primary tumor affects OS, with a better prognosis for left colon metastases (OS at 42 months: 85.4% vs. 42.2%) (p value = 0.056); patients with stage T1 or T2 cancer have a better 3 years OS (92.9–100% vs. 49.7–56.3%) (p = 0.696), while the N0 stage results in both higher 3 years OS and DFS than the N + stages (OS: 87.5% vs. 68.5% vs. 24.5%); metachronous metastases have a higher 3 years OS than synchronous ones (80% vs. 47.4%) (p = 0.066); parenchymal sparing resections have a better 3 years DFS than anatomical ones (33.7% vs. 0%) (p = 0.067); a patient with a parenchymal R1 resection has a much worse prognosis than an R0 (3 years OS: 0% vs. 68.7%) (p < 0.001). Conclusions: CEA value of less than 25 ng/mL, localization of the primary tumor in the left colon, primary tumor in stage T1/2 and N0, metachronous presentation, R0 resection, fewer than four metastases, and use of adjuvant chemotherapy are all parameters that in our analysis have shown a correlation with a better prognosis; moreover, the evaluation of the series is in line with the latest evidence in the literature in defining the non-inferiority of minimally invasive and parenchymal sparing treatment compared to the classic laparotomic approach with anatomic resection.

Short- and long-term outcomes of hepatectomy combined with intraoperative radiofrequency ablation for patients with multiple primarily unresectable colorectal liver metastases: a propensity matching analysis

BACKGROUND

Hepatectomy combined with intraoperative radiofrequency ablation (IORFA) is a strategy to eliminate all tumors in patients with multiple colorectal liver metastases (CRLM). This study aimed to evaluate the surgical and oncological outcomes of hepatectomy + IORFA for multiple unresectable CRLM.

METHODS

We included patients who underwent combined hepatectomy and IORFA for multiple unresectable CRLM (n = 67) or hepatectomy alone (n = 268) for CRLM. Patients were matched in a 1:1 propensity score analysis to compare the short- and long-term outcomes between groups.

RESULTS

Patients in hepatectomy + IORFA group had a median number of 10 liver lesions. Postoperative morbidity and the rate of major complications was similar between groups (P = 0.362, P = 1.000). The median overall survival (OS), progression free survival (PFS) and hepatic recurrence free survival (HRFS) was similar between groups (3-year OS: 54.2% versus 60.9%, P = 0.389; 3-year PFS: 7.9% versus 19.6%, P = 0.148; 3-year HRFS: 16.7% versus 31.5%, P = 0.202). Re-hepatectomy or radiofrequency ablation was used to treat 47.5% of hepatic recurrences, and the median OS was significantly higher than for patients treated with systemic treatment alone (P < 0.001).

CONCLUSIONS

Combining hepatectomy and IORFA could provide comparable survival rates for patients with multiple unresectable CRLM compared to those with resectable CRLM treated with hepatectomy alone.

Optimal patient selection for successful two-stage hepatectomy of bilateral colorectal liver metastases

Two-stage hepatectomy (TSH) is one of the specific surgical techniques that can expand the pool of resectable patients with initially unresectable colorectal liver metastases (CRLM). The indication of TSH for CRLM is only bilateral, multinodular disease, which cannot be resected by a single hepatectomy. TSH is nowadays considered an effective treatment for selected patients, with acceptable morbidity/mortality rates and promising long-term outcomes. However, not all eligible patients can benefit from the TSH strategy. One of the most important issues is dropout from the strategy (failure to complete both of the two sequential procedures), because the survival of such patients is drastically worse compared with patients who can complete both stages. Another important issue is the early recurrence rate and subsequent poor survival even after completion of TSH. Thus, the selection of appropriate patients who can really benefit from the TSH strategy is crucial. This review discusses the optimal patient selection for TSH, which should be helpful for the development of treatment strategies for patients with extensive CRLM.

Liver transplantation versus liver resection for colorectal liver metastasis: a survival benefit analysis in patients stratified according to tumor burden score

Liver transplantation (LT) for colorectal liver metastasis (CRLM) may provide excellent survival rates in patients with unresectable disease. High tumor load is a risk factor for recurrence and low overall survival (OS) after liver resection (LR). We tested the hypothesis that LT could offer better survival than LR in patients with high tumor load. LR performed at Padua University Hospital for CRLM was compared with LT for unresectable CRLM performed both at Oslo and Padua. High tumor load was defined as tumor burden score (TBS) ≥ 9, and inclusion criteria were as in the SECA-I transplant study. 184 patients were eligible: 128 LRs and 56 LTs. 5-year OS after LR and LT was 40.5% and 54.7% (P = 0.102). In the high TBS cohort, 5-year OS after LR and LT was 22.7% and 52.2% (P = 0.055). In patients with Oslo score ≤ 2 and TBS ≥ 9 (13 LR; 24 LT) the 5-year OS after LR and LT was 14.6% and 69.1% (P = 0.002). The corresponding disease-free survival (DFS) was 0% and 22.9% (P = 0.005). Selected CRLM patients with low Oslo score and high TBS could benefit from LT with survival outcomes that are far better than what is achieved by LR.

Centralized repeated resectability assessment of patients with colorectal liver metastases during first-line treatment: prospective study

BACKGROUND

Metastasectomy is probably underused in metastatic colorectal cancer. The aim of this study was to investigate the effect of centralized repeated assessment on resectability rate of liver metastases.

METHODS

The prospective RAXO study was a nationwide study in Finland. Patients with treatable metastatic colorectal cancer at any site were eligible. This planned substudy included patients with baseline liver metastases between 2012 and 2018. Resectability was reassessed by the multidisciplinary team at Helsinki tertiary referral centre upfront and twice during first-line systemic therapy. Outcomes were resectability rates, management changes, and survival.

RESULTS

Of 812 patients included, 301 (37.1 per cent) had liver-only metastases. Of these, tumours were categorized as upfront resectable in 161 (53.5 per cent), and became amenable to surgery during systemic treatment in 63 (20.9 per cent). Some 207 patients (68.7 per cent) eventually underwent liver resection or ablation. At baseline, a discrepancy in resectability between central and local judgement was noted for 102 patients (33.9 per cent). Median disease-free survival (DFS) after first resection was 20 months and overall survival (OS) 79 months. Median OS after diagnosis of metastatic colorectal cancer was 80, 32, and 21 months in R0-1 resection, R2/ablation, and non-resected groups, and 5-year OS rates were 68, 37, and 9 per cent, respectively. Liver and extrahepatic metastases were present in 511 patients. Of these, tumours in 72 patients (14.1 per cent) were categorized as upfront resectable, and 53 patients (10.4 per cent) became eligible for surgery. Eventually 110 patients (21.5 per cent) underwent liver resection or ablation. At baseline, a discrepancy between local and central resectability was noted for 116 patients (22.7 per cent). Median DFS from first resection was 7 months and median OS 55 months. Median OS after diagnosis of metastatic colorectal cancer was 79, 42, and 17 months in R0-1 resection, R2/ablation, and non-resected groups, with 5-year OS rates of 65, 39, and 2 per cent, respectively.

CONCLUSION

Repeated centralized resectability assessment in patients with colorectal liver metastases improved resection and survival rates.

ALPPS Improves Survival Compared With TSH in Patients Affected of CRLM: Survival Analysis From the Randomized Controlled Trial LIGRO

OBJECTIVE

To evaluate the oncological outcome for patients with colorectal liver metastases (CRLM) randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or 2-stage hepatectomy (TSH).

BACKGROUND

TSH with portal vein occlusion is an established method for patients with CRLM and a low volume of the future liver remnant (FLR). ALPPS is a less established method. The oncological outcome of these methods has not been previously compared in a randomized controlled trial.

METHODS

One hundred patients with CRLM and standardized FLR (sFLR) <30% were included and randomized to resection by ALPPS or TSH, with the option of rescue ALPPS in the TSH group, if the criteria for volume increase was not met. The first radiological follow-up was performed approximately 4 weeks postoperatively and then after 4, 8, 12, 18, and 24 months. At all the follow-ups, the remaining/recurrent tumor was noted. After the first follow-up, chemotherapy was administered, if indicated.

RESULTS

The resection rate, according to the intention-to-treat principle, was 92% (44 patients) for patients randomized to ALPPS compared with 80% (39 patients) for patients randomized to TSH (P = 0.091), including rescue ALPPS. At the first postoperative follow-up, 37 patients randomized to ALPPS were assessed as tumor free in the liver, and also 28 patients randomized to TSH (P = 0.028). The estimated median survival for patients randomized to ALPPS was 46 months compared with 26 months for patients randomized to TSH (P = 0.028).

CONCLUSIONS

ALPPS seems to improve survival in patients with CRLM and sFLR <30% compared with TSH.

One-stage laparoscopic parenchymal sparing liver resection for bilobar colorectal liver metastases: safety, recurrence patterns and oncologic outcomes

BACKGROUND AND PURPOSE

Laparoscopic liver resections (LLR) of bilobar colorectal liver metastases (CRLM) are challenging and the safety and long-term outcomes are unclear. In this study, the short- and long-term outcomes and recurrence patterns of one-stage LLR for bilobar CRLM were compared to single laparoscopic resection for CRLM.

METHODS

This single-center study consisted of all patients who underwent a parenchymal sparing LLR for CRLM between October 2011 and December 2018. Demographics, perioperative outcomes, short-term outcomes, oncologic outcomes and recurrence patterns were compared. Data were retrieved from a prospectively maintained database.

RESULTS

Thirty six patients underwent a LLR for bilobar CRLM and ninety patients underwent a single LLR. Demographics were similar among groups. More patients received neoadjuvant chemotherapy in the bilobar group (55.6% vs 34.4%, P = 0.03). There was no difference in conversion rate, R0 resection and transfusion rate. Blood loss and operative time were higher in the bilobar group (250 ml (IQR 150-450) vs 100 ml (IQR 50-250), P < 0.001 and 200 min (IQR 170-230) vs 130 min (IQR 100-165), P < 0.001) and hospital stay was longer (5 days (IQR 4-7) vs 4 days (IQR 3-6), P = 0.015). The bilobar group had more technically major resections (88.9% vs 56.7%, P < 0.001). Mortality was nil in both groups and major morbidity was similar (2.8% vs 3.3%, P = 1.0). There was no difference in recurrence pattern. Overall survival (OS) was similar (1 yr: 96% in both groups and 5 yr 76% vs 66%, P = 0.49), as was recurrence-free survival (RFS) (1 yr: 64% vs 73%, 3 yr: 38 vs 42%, 5 yr: 38% vs 28%, P = 0.62).

CONCLUSION

In experienced hands, LLR for bilobar CRLM can be performed safely with similar oncologic outcomes as patients who underwent a single LLR for CRLM.

How should liver hypertrophy be stimulated? A comparison of upfront associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and portal vein embolization (PVE) with rescue possibility

Background

The role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in comparison to portal vein embolization (PVE) is debated. The aim of this study was to compare successful resection rates (RR) with upfront ALPPS vs. PVE with rescue ALPPS on demand and to compare the hypertrophy of the liver between ALPPS and PVE plus subsequent rescue ALPPS.

Methods

A retrospective analysis of all patients treated with PVE for colorectal liver metastasis (CRLM) or ALPPS (any diagnosis, rescue ALPPS included) at five Scandinavian university hospitals during the years 2013-2016 was conducted. A Chi-square test and a Mann-Whitney U test were used to assess the difference between the groups. A successful RR was defined as liver resection without a 90-day mortality.

Results

A total of 189 patients were included. Successful RR was in 84.5% of the patients with ALPPS upfront and in 73.3% of the patients with PVE and rescue ALPPS on demand (P=0.080). The hypertrophy of the future liver remnants (FLRs) with ALPPS upfront was 71% (48-97%) compared to 96% (82-113%) after PVE and rescue ALPPS (P=0.010).

Conclusions

Upfront ALPPS offers a somewhat higher successful RR than PVE with rescue ALPPS on demand. The sequential combination of PVE and ALPPS leads to a higher overall degree of hypertrophy than upfront ALPPS.

Microwave Thermoablation of Colorectal Liver Metastases Close to Large Hepatic Vessels Under Pringle Maneuver Minimizes the "Heat Sink Effect"

BACKGROUND

Liver resection and thermoablation are the mainstay of the surgical management of colorectal liver metastases (CRLM). The main limitation of thermoablation is the "heat-sink" effect for nodules next to large vessels. Herein, we report the preliminary results of microwave ablation (MWA) with associated Pringle maneuver to overcome this flaw.

METHODS

From November 2017, we performed intraoperative MWA with Pringle maneuver for nodules ≤3 cm with immediate proximity to large vessels (distance ≤ 5 mm, diameter ≥ 3 mm). We collected characteristics of nodules, surgical procedures and postoperative morbidity. Diameter of the ablation area, especially the ablative minimal margin, was calculated for each nodule. Recurrence was also evaluated.

RESULTS

Nineteen patients underwent MWA with Pringle maneuver for 23 nodules. Nineteen (83%) ablated nodules were located in segments VI, VII and VIII, and one nodule was in segment I. Median size of nodules was 15 mm (10-21). No deaths occurred. Six patients (38%) experienced complications, among them only one was subsequent to the thermal ablation. Ablative minimal margin was ≥5 mm for 19 (83%) nodules. Margin was not sufficient for four nodules, among them only 2/23 cases (8.7%) of in situ recurrence occurred after 12 months of median follow-up.

CONCLUSIONS

In this preliminary study, MWA with Pringle maneuver was associated with a low related morbidity rate and favorable oncological outcome, especially when the radiological minimal margin was sufficient.

Two-Stage Hepatectomy for Bilateral Colorectal Liver Metastases: A Multi-institutional Analysis

BACKGROUND

Two-stage hepatectomy (TSH) is an important tool in the management of bilateral colorectal liver metastases (CRLM). This study sought to examine the presentation, management, and outcomes of patients completing TSH in major hepatobiliary centers in the United States (US).

METHODS

A retrospective review from five liver centers in the US identified patients who completed a TSH procedure for bilateral CRLM.

RESULTS

From December 2000 to March 2016, a total of 196 patients were identified. The majority of procedures were performed using an open technique (n = 194, 99.5%). The median number of tumors was 7 (range 2-33). One-hundred and twenty-eight (65.3%) patients underwent portal vein embolization. More patients received chemotherapy prior to the first stage than chemotherapy administration preceding the second stage (92% vs. 60%, p = 0.308). Median overall survival (OS) was 50 months, with a median follow-up of 28 months (range 2-143). Hepatic artery infusion chemotherapy was administered to 64 (32.7%) patients with similar OS as those managed without an infusion pump (p = 0.848). Postoperative morbidity following the second-stage resection was 47.4%. Chemotherapy prior to the second stage did not demonstrate an increased complication rate (p = 0.202). Readmission following the second stage was 10.3% and was associated with a decrease in disease-free survival (p = 0.003). OS was significantly decreased by positive resection margins and increased estimated blood loss (EBL; p = 0.036 and p = 0.05, respectively).

CONCLUSION

This is the largest TSH series in the US and demonstrates evidence of safety and feasibility in the management of bilateral CRLM. Outcomes are influenced by margin status and operative EBL.

Liver Transplantation for Colorectal Liver Metastasis

Purpose of Review

Accumulating evidence suggest that selected patients with nonresectable liver only metastases from colorectal cancer can be offered liver transplantation with acceptable outcome. This review provides an update on the scientific literature.

Recent Findings

The SECA-I study showed an estimated 5-year survival of 60% in a heterogenous patient population and guided the development of the first clinical selection criteria. In the sequel SECA-II trial, an estimated 5-year survival of 83% was obtained. A recent study shows that an Oslo score of 0–2, a metabolic tumor volume below 70 cm3 on PET-CT or Fong score of 0–2 at time of listing, can stratify patients with superior survival. Recurrence is common, but about 70% are slow-growing lung metastases, whereof the majority are resectable.

Summary

Liver transplantation for colorectal liver metastasis is an option in highly selected patients. Futile use of grafts can be avoided by applying stringent selection criteria.

Predicting liver metastases growth patterns: Current status and future possibilities

Colorectal cancer is highly incident worldwide and presents a health burden with elevated mortality rate despite prevention, detection, and treatment, mainly due to metastatic liver disease. Histological growth patterns of colorectal cancer liver metastases have emerged as a reproducible prognostic factor, with biological implications and therapeutic windows. Nonetheless, the histological growth patterns of colorectal cancer liver metastases are only known after pathological examination of a liver resection specimen, thus limiting the possibilities of pre-surgical decision. Predicting the histological growth pattern of colorectal cancer liver metastases would provide valuable information for patient-tailored medicine. In this article, we perform a review of the histological growth patterns and their implications, with a focus on the possibilities for their prediction.

Impact of the strategy for curative treatment of synchronous colorectal cancer liver metastases

AIM OF THE STUDY

Fourteen to seventeen percent of patients suffering from colorectal cancer have synchronous liver metastases (sCRLM) at the time of diagnosis. There are currently three possible strategies for curative management of sCRLM: "classic", "combined", and "liver-first". The aim of our research was to analyze the effects of the three surgical management strategies for sCRLM on postoperative morbidity and mortality and overall and recurrence-free survival.

PATIENTS AND METHODS

Patients treated for sCRLM between October 2000 and May 2015 were included. We defined three groups: (1) "classic": surgery of primary tumor and then surgery of sCRLM; (2) "combined": combined surgery of primary tumor and sCRLM: and (3) "liver-first": surgery of sCRLM and then surgery of primary tumor.

RESULTS

During this period, 170 patients who underwent 209 hepatectomies were included ("classic": 149, "combined": 34, "liver-first": 26). The rate of severe complications was higher in the "combined" group compared to the "classic" group (35% vs. 12%, P=0.03), and the "liver-first" group (35% vs. 19%, P=0.25), while there were significantly fewer liver resections. Overall survival at 5 years in our cohort was 46%, without significant differences between the groups, and a median survival of 54 months. Recurrence-free survival of the patients in our cohort was 24% at 5 years, with a median survival time without recurrence of 14 months, without significant differences between the groups.

CONCLUSION

All three strategies were feasible and there were no differences regarding overall and recurrence-free survivals between the three approaches. The "combined" strategy group had significantly more severe complications and did not provide better oncological results, despite less aggressive liver disease and more limited liver resections.

Laparoscopic versus open two-stage hepatectomy for bilobar colorectal liver metastases: A bi-institutional, propensity score-matched study

BACKGROUND

The safety and feasibility of laparoscopic, two-stage hepatectomy for bilobar colorectal liver metastases is poorly evaluated.

METHODS

We reviewed retrospectively 86 consecutive patients who underwent complete two-stage hepatectomy (left lobe clearance as the first stage and standard/extended right hepatectomy as the second stage) for bilobar colorectal liver metastases between 2007 and 2017 in 2 tertiary centers. Short- and long-term outcomes were compared between laparoscopic and open two-stage hepatectomy before and after propensity score matching.

RESULTS

Laparoscopic two-stage hepatectomy was performed in 38 patients and open two-stage hepatectomy in 48. After propensity score matching, 25 laparoscopic and 25 open patients showed similar preoperative characteristics. For the first stage, a laparoscopic approach was associated with lesser hospital stays (4 vs 7.5 days; P < .001). For the second stage, a laparoscopic approach was associated with less blood loss (250 vs 500 mL; P = .040), less postoperative complications (32% vs 60%; P = .047), lesser hospital stays (9 vs 16 days; P = .013), and earlier administration of chemotherapy (1.6 vs 2 months; P = .039). Overall survival, recurrence-free survival, and liver-recurrence-free survival were comparable between the groups (3-year overall survival: 80% vs 54%; P = .154; 2-year recurrence-free survival: 20% vs 18%; P = .200; 2-year liver-recurrence-free survival: 39% vs 33%; P = .269). Although both groups had comparable recurrence patterns, repeat hepatectomies for recurrence were performed more frequently in the laparoscopic two-stage hepatectomy group (56% vs 0%; P = .006).

CONCLUSION

Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases is safe and feasible with favorable surgical and oncologic outcomes compared to open two-stage hepatectomy.

Multidisciplinary management of liver metastases in patients with colorectal cancer: a consensus of SEOM, AEC, SEOR, SERVEI, and SEMNIM

Colorectal cancer (CRC) has the second-highest tumor incidence and is a leading cause of death by cancer. Nearly 20% of patients with CRC will have metastases at the time of diagnosis, and more than 50% of patients with CRC develop metastatic disease during the course of their disease. A group of experts from the Spanish Society of Medical Oncology, the Spanish Association of Surgeons, the Spanish Society of Radiation Oncology, the Spanish Society of Vascular and Interventional Radiology, and the Spanish Society of Nuclear Medicine and Molecular Imaging met to discuss and provide a multidisciplinary consensus on the management of liver metastases in patients with CRC. The group defined the different scenarios in which the disease can present: fit or unfit patients with resectable liver metastases, patients with potential resectable liver metastases, and patients with unresectable liver metastases. Within each scenario, the different strategies and therapeutic approaches are discussed.

Communicating with the hepatobiliary surgeon through structured report

Communicating radiological findings to hepatobiliary surgeons is not an easy task due to the complexity of liver imaging, coexistence of multiple hepatic lesions and different surgical treatment options. Recently, the adoption and implementation of structured report in everyday clinical practice has been supported to achieve higher quality, more reproducibility in communication and closer adherence to current guidelines. In this review article, we will illustrate the main benefits, strengths and limitations of structured reporting, with particular attention on the advantages and challenges of structured template in the preoperative evaluation of cirrhotic and non-cirrhotic patients with focal liver lesions. Structured reporting may improve the preoperative evaluation, focusing on answering specific clinical questions that are requested by hepatobiliary surgeons in candidates to liver resection.

Predictive factors of histological response of colorectal liver metastases after neoadjuvant chemotherapy

BACKGROUND

Colorectal cancer is the third most common cancer in men and the second most common in women worldwide. Almost a third of the patients has or will develop liver metastases. Neoadjuvant chemotherapy (NAC) has recently become nearly systematic prior to surgery of colorectal livers metastases (CRLMs). The response to NAC is evaluated by radiological imaging according to morphological criteria. More recently, the response to NAC has been evaluated based on histological criteria of the resected specimen. The most often used score is the tumor regression grade (TRG), which considers the necrosis, fibrosis, and number of viable tumor cells.

AIM

To analyze the predictive factors of the histological response, according to the TRG, on CRLM surgery performed after NAC.

METHODS

From January 2006 to December 2013, 150 patients who had underwent surgery for CRLMs after NAC were included. The patients were separated into two groups based on their histological response, according to Rubbia-Brandt TRG. Based on their TRG, each patient was either assigned to the responder (R) group (TRG 1, 2, and 3) or to the non-responder (NR) group (TRG 4 and 5). All of the histology slides were re-evaluated in a blind manner by the same specialized pathologist. Univariate and multivariate analyses were performed.

RESULTS

Seventy-four patients were classified as responders and 76 as non-responders. The postoperative mortality rate was 0.7%, with a complication rate of 38%. Multivariate analysis identified five predictive factors of histological response. Three were predictive of non-response: More than seven NAC sessions, the absence of a radiological response after NAC, and a repeat hepatectomy (P < 0.005). Two were predictive of a good response: A rectal origin of the primary tumor and a liver-first strategy (P < 0.005). The overall survival was 57% at 3 yr and 36% at 5 yr. The disease-free survival rates were 14% at 3 yr and 11% at 5 yr. The factors contributing to a poor prognosis for disease-free survival were: No histological response after NAC, largest metastasis > 3 cm, more than three preoperative metastases, R1 resection, and the use of a targeted therapy with NAC (P < 0.005).

CONCLUSION

A non-radiological response and a number of NAC sessions > 7 are the two most pertinent predictive factors of non-histological response (TRG 4 or 5).

Multidisciplinary approach of liver metastases from colorectal cancer

Colorectal cancer liver metastases (CRLM) represent most of the causes of death in patients with colorectal cancer. Surgical resection is the only treatment that can provide the possibility of prolonged survival, or even cure, for patients with CRLM. Over the last few decades, survival of these patients has improved dramatically thanks to more effective chemotherapy, extension of surgical indications, and development of new surgical procedures. In particular, patients with initially unresectable CRLM can achieve downsizing of the tumor by using various chemotherapies and the tumor can become resectable. It has been shown that such patients have a 33% 5‐year survival and a 23% 10‐year survival rate after surgery, which is a little bit lower than that of patents with resectable CRLM but significantly higher than patients without surgery. However, a decision‐making strategy for patients with CRLM is difficult because there is a wide variety of treatments and no definitive consensus. As an example, much variation among institutions exists on the resectability rate in patients with unresectable CRLM. Also, it is recommended that all patients with CRLM be managed by a multidisciplinary approach (MDA) to select the best strategy. In the future, new treatment procedures (e.g. immune checkpoint blockade, liver transplantation) may contribute to improve prognosis; hence, the necessity for MDA for the treatment of CRLM will further increase.

Risk assessment for liver resection

BACKGROUND

In recent years, the profile for patients undergoing complex liver resections has changed, with mortality rates remaining generally stable. With these factors in mind, the objective of this study was to evaluate the variables associated with surgical outcomes after hepatectomy and identify groups at high risk for postoperative mortality.

METHODS

The records of 1,796 patients who underwent liver resection of more than one liver segment at the Department of General and Transplantation Surgery, University Hospital Heidelberg, Germany, were analyzed. The primary end point was a 90-day in-hospital mortality. Logistic regression analyses were performed to identify risk factors associated with mortality. A risk score was created in accordance with weighted points based on the odds ratios obtained from multivariate logistic regression analyses. External validation of the score was performed, using data derived from 281 patients at the board-certified center for liver surgery in Karlsruhe, Germany.

RESULTS

The overall patient morbidity rate (Clavien-Dindo Grade II or greater) was 32%. The 30- and 90-day mortality rates were 3.0% and 4.5%, respectively. In multivariate analysis, factors independently associated with risk for 90-day in-hospital mortality were age ≥60 years (OR 3.71), ASA classification III (OR 2.94), ASA IV (15.66), perihilar cholangiocarcinoma (OR 5.65), intrahepatic cholangiocarcinoma (OR 3.08), INR ≥ 1.1 (OR 2.43), g-GT ≥ 60 U/L (OR 2.86), platelet count ≤ 120/nL (OR 5.52), creatinine ≥ 2 mg/dL (OR 9.85), and right trisectionectomy (OR 2.88). The 90-day mortality-risk score that was created based on these factors effectively stratified patients into very low risk (0-1 points, 0.2% mortality rate in 662 patients), low risk (2-3 points, 2.9% mortality rate in 769 patients), medium risk (4-5 points, 14.7% mortality rate in 232 patients), and high risk (≥6 points, 33% mortality rate in 57 patients) groups (P < .0001). As a performance metric, the C-index for the proposed risk score for 90-day mortality was 0.86; whereas external validation revealed that this C-index was 0.89 (P = .0002).

CONCLUSION

Based on patient-related factors and procedure-specific variables, the proposed preoperative-risk score can be used to identify high-risk patients to determine 90-day mortality after liver resection.

Two-stage hepatectomy aiming for the development of intrahepatic venous collaterals for multiple colorectal liver metastases

Background

Aggressive hepatectomy with venous resection has a higher risk of postoperative liver failure (POLF) than hepatectomy without venous reconstruction; however, venous reconstruction is technically demanding. We performed a novel two-stage hepatectomy (TSH) without venous reconstruction in a patient with bilobar multiple colorectal liver metastases located near the caval confluence, waiting for the development of intrahepatic venous collaterals between procedures.

Case presentation

A 60-year-old man was referred to our hospital with sigmoid colon cancer accompanied by intraabdominal abscess and two synchronous liver metastases. One of the liver tumors (tumor 1) was located in segment 8 near the caval confluence and was attached to both the right hepatic vein (RHV) and middle hepatic vein (MHV). The other tumor (tumor 2) in the left lobe invaded the umbilical portion of the portal vein. Both liver metastases decreased in size after four cycles of panitumumab/5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) therapy. Radical liver resection was planned because tumor 1 had not invaded the MHV. However, three-dimensional volumetric software showed that the non-congested volume of the future liver remnant was estimated at 354 ml, which corresponded to 26.3% of the total liver volume. TSH was scheduled to avoid POLF. We first performed limited resection of segment 8 with resection of the RHV root. After the first hepatectomy, the development of intrahepatic venous collaterals between the RHV and MHV was seen on computed tomography and magnetic resonance imaging. The estimated non-congested future liver remnant was 1242 ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58 days after the first hepatectomy. We saw no adhesions around the porta hepatis, and the left hepatic artery and left branch of the portal vein were safely exposed and divided. Intraoperative Doppler ultrasonography revealed intrahepatic venous collaterals arising from RHV to MHV. The patient’s postoperative course was uneventful, and he underwent eight cycles of panitumumab/FOLFOX therapy for 5 months after the second hepatectomy.

Conclusions

Our TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.