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Golriz M, El Sakka S, Majlesara A, Edalatpour A, Hafezi M, Rezaei N, Garoussi C, Arwin J, Saffari A, Raisi H, Abbasi A, Mehrabi A. Hepatic Hemodynamic Changes Following Stepwise Liver Resection. J Gastrointest Surg 2016; 20:587-94. [PMID: 26573852 DOI: 10.1007/s11605-015-3021-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/04/2015] [Indexed: 02/07/2023]
Abstract
AIM Extended liver resection has increased during the last decades. However, hepatic hemodynamic changes after resection and the consequent complications like post hepatectomy liver failure are still a challenging issue. The aim of this study was to systematically evaluate the role of stepwise liver resection on hepatic hemodynamic changes. METHODS To evaluate this effect we performed 25, 50, and 75 % sequential liver resections in 10 pigs. Before and after each resection, the hepatic artery flow and portal vein flow in relation to the remnant liver volume (RLV) as well as hepatic vascular pressures were measured and compared between the groups. RESULTS Following sequential liver resection, the hepatic artery flow /100 g decreases and the portal vein flow increases up to 17 and 167 % following extended liver resection (75 %), respectively. Also, during stepwise liver resection, the portal vein pressure increases gradually up to 33 % following extended hepatectomy (75 %). CONCLUSION Sequential decrease in the RLV decreases the hepatic artery flow /100 g and increases the portal vein flow /100 g and portal vein pressure. As the consequence, the liver goes under more poor-oxygenated blood supply and higher pressure. This may be one of the most important mechanisms of the post hepatectomy liver failure in case of extended liver resection.
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Saroa El Sakka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Ali Majlesara
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Arman Edalatpour
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Mohammadreza Hafezi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Nahid Rezaei
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Camelia Garoussi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Jalal Arwin
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Arash Saffari
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Hanna Raisi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Arezou Abbasi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Synchronous totally laparoscopic management of colorectal cancer and resectable liver metastases: a single center experience. Langenbecks Arch Surg 2015; 400:495-503. [PMID: 25681240 DOI: 10.1007/s00423-015-1281-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 02/04/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE The simultaneous management of primary colorectal cancer and synchronous liver metastases has been reported extensively in open surgery. Data regarding feasibility, safety, and outcomes of the laparoscopic procedure is emerging from the experience of a few surgical centers. This paper aims at discussing the technique and results of a one-step laparoscopic approach for colorectal cancer and liver metastases resection on a series of 35 patients. METHODS Between January 2008 and December 2013, 18 males and 17 females (median age 71 years) underwent colorectal and hepatic laparoscopic resection for colorectal metastatic cancer. RESULTS Thirty-five colorectal resections and 66 liver resections were performed; no conversion to open surgery has been indicated. Median blood loss was 200 ml, median operative time 240 min, and median hospital stay was 8 days (range 4-30). According to Clavien-Dindo classification, two class II complications, two class IIIb complications, and one class IV complication were recorded. Two high-risk patients died within 30 days from surgery. CONCLUSIONS This series confirms the feasibility of synchronous laparoscopic colorectal and hepatic resections. To ensure the best outcomes, a careful selection of patients is needed. However, most patients can benefit from this surgical approach.
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Ribeiro HSDC, Stevanato-Filho PR, Costa WLD, Diniz AL, Herman P, Coimbra FJF. Prognostic factors for survival in patients with colorectal liver metastases: experience of a single brazilian cancer center. ARQUIVOS DE GASTROENTEROLOGIA 2013; 49:266-72. [PMID: 23329221 DOI: 10.1590/s0004-28032012000400007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 08/22/2012] [Indexed: 12/17/2022]
Abstract
CONTEXT Liver metastases are a common event in the clinical outcome of patients with colorectal cancer and account for 2/3 of deaths from this disease. There is considerable controversy among the data in the literature regarding the results of surgical treatment and prognostic factors of survival, and no analysis have been done in a large cohort of patients in Brazil. OBJECTIVES To characterize the results of surgical treatment of patients with colorectal liver metastases, and to establish prognostic factors of survival in a Brazilian population. METHOD This was a retrospective study of patients undergoing liver resection for colorectal metastases in a tertiary cancer hospital from 1998 to 2009. We analyzed epidemiologic variables and the clinical characteristics of primary tumors, metastatic disease and its treatment, surgical procedures and follow-up, and survival results. Survival analyzes were done by the Kaplan-Meier method and the log-rank test was applied to determine the influence of variables on overall and disease-free survival. All variables associated with survival with P<0.20 in univariate analysis, were included in multivariate analysis using a Cox proportional hazard regression model. RESULTS During the period analyzed, 209 procedures were performed on 170 patients. Postope-rative mortality in 90 days was 2.9% and 5-year overall survival was 64.9%. Its independent prognostic factors were the presence of extrahepatic disease at diagnosis of liver metastases, bilateral nodules and the occurrence of major complications after liver surgery. The estimated 5-year disease-free survival was 39.1% and its prognostic factors included R1 resection, extrahepatic disease, bilateral nodules, lymph node involvement in the primary tumor and primary tumors located in the rectum. CONCLUSION Liver resection for colorectal metastases is safe and effective and the analysis of prognostic factors of survival in a large cohort of Brazilian patients showed similar results to those pointed in international series. The occurrence of major postoperative complications appears to be able to compromise overall survival and further investigation in needed in this topic.
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Metrakos P, Kakiashvili E, Aljiffry M, Hassanain M, Chaudhury P. Role of Surgery in the Diagnosis and Management of Metastatic Cancer. EXPERIMENTAL AND CLINICAL METASTASIS 2013:381-399. [DOI: 10.1007/978-1-4614-3685-0_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
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Macafee DAL, Gemmill EH, Lund JN. Colorectal cancer: current care, future innovations and economic considerations. Expert Rev Pharmacoecon Outcomes Res 2012; 6:195-206. [PMID: 20528555 DOI: 10.1586/14737167.6.2.195] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
For those involved in colorectal cancer management, the present day is an exciting time. There is a multitude of new techniques to be considered for early detection (screening). National population screening for 60-69-year olds in England is due to start this year. Also, minimally invasive surgical techniques and multimodal pathways of care are aiding faster recovery, and there are increasing options for both adjuvant and palliative therapies. This article summarizes how colorectal cancer is currently managed in the UK and discusses the developments that are in the early stages of clinical use or on the horizon. Current management is discussed in detail in the hope that innovators reading the article may identify areas for improvement and allow comparison of new interventions with what are currently the gold standards. As changes are moving so fast, this review will probably only relate to the next 10 years at most. It does not provide a detailed reference list to support all therapies but indicates the key publications that will enable more detailed reading.
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Affiliation(s)
- David A L Macafee
- Specialist Registrar, Section of Surgery, Department of Surgery, Derby City Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
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Verberne CJ, Wiggers T, Vermeulen KM, de Jong KP. Detection of recurrences during follow-up after liver surgery for colorectal metastases: both carcinoembryonic antigen (CEA) and imaging are important. Ann Surg Oncol 2012; 20:457-63. [PMID: 22948771 DOI: 10.1245/s10434-012-2629-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The follow-up of patients treated for colorectal liver metastases (CRLM) is not standardized. The accuracy of an increase in carcinoembryonic antigen (CEA) levels for finding recurrences after treatment for CRLM is compared in this retrospective cohort study with the accuracy of routine imaging modalities of liver and chest. METHODS Data from all patients in follow-up after intentionally curative treatment for CRLM from 1990 to 2010 were analyzed. All patients underwent the same follow-up schedule. The way in which recurrences became apparent (i.e., CEA increase, routine imaging, or both) was registered. The specificity and sensitivity of increases in CEA before finding recurrent disease were calculated by receiver operating characteristic (ROC) curves. An economic evaluation of the cost per resectable tumor recurrence was performed. RESULTS ROC curves showed that a significant CEA increase was defined as a 25 % increase from the previous value. Recurrences were detected in 46 % of the procedures through CEA increase concomitant with positive imaging, in 23 % through CEA increase without positive findings on routine imaging, and in 31 % through positive imaging without an increase in CEA. The resectability of recurrences did not differ between triggers. Cost per curable recurrence was <euro>2,196 for recurrences found via CEA alone and <euro>6,721 for recurrences found with imaging and CEA. CONCLUSIONS In the follow-up of patients after liver surgery for CRLM, a 25 % increase in CEA serum level can accurately detect recurrences, but routine imaging is indispensable. In patients with CRLM, we advocate both CEA monitoring and imaging in the follow-up after liver surgery.
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Affiliation(s)
- Charlotte J Verberne
- Department of Abdominal Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Jones RP, Jackson R, Dunne DFJ, Malik HZ, Fenwick SW, Poston GJ, Ghaneh P. Systematic review and meta-analysis of follow-up after hepatectomy for colorectal liver metastases2. Br J Surg 2012; 99:477-86. [DOI: 10.1002/bjs.8667] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2011] [Indexed: 12/22/2022]
Abstract
Abstract
Background
The evidence surrounding optimal follow-up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time.
Methods
A systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow-up protocol and long-term survival data were included. For meta-analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow-up.
Results
Thirty-five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow-up. Patients undergoing intensive early follow-up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5-year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow-up had a median survival of 40·2 (33·4 to 47·0) months, with a 5-year overall survival rate of 38·4 (32·6 to 44·3) months.
Conclusion
Evidence regarding follow-up after liver resection is poor. Meta-analysis failed to identify a survival advantage for intensive early follow-up.
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Affiliation(s)
- R P Jones
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Liverpool, UK
- Department of Hepatobiliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - R Jackson
- Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - D F J Dunne
- Department of Hepatobiliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - H Z Malik
- Department of Hepatobiliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - S W Fenwick
- Department of Hepatobiliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - G J Poston
- Department of Hepatobiliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - P Ghaneh
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Liverpool, UK
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Yamashita YI, Adachi E, Toh Y, Ohgaki K, Ikeda O, Oki E, Minami K, Sakaguchi Y, Tsujita E, Okamura T. Risk factors for early recurrence after curative hepatectomy for colorectal liver metastases. Surg Today 2011; 41:526-32. [PMID: 21431486 DOI: 10.1007/s00595-010-4471-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 11/18/2010] [Indexed: 12/19/2022]
Abstract
PURPOSE With the broadening indications for hepatectomy to treat colorectal liver metastases (CRLM), early recurrence is a major problem. The aim of this study is to identify risk factors of early recurrence, defined as recurrence within 1 year after surgery. METHODS A retrospective analysis was performed on 121 consecutive patients who underwent hepatectomy for CRLM. RESULTS Among 121 patients, 52 (43.0%) developed early recurrence. The independent risk factor for early recurrence was "number of liver metastases ≥ 3" (odds ratio 2.65). There were significantly more patients with liver recurrence (51.9%) and recurrence beyond curative surgical resection (63.5%) in those with early recurrence. In addition, patients with three or more liver metastases had significantly more liver recurrence (66.7%; P = 0.02) and recurrence beyond curative surgical resection (70.8%; P = 0.04). The overall survival rates of both patients with early recurrence (5-year survival rate 20%) and those with three or more liver metastases (5-year survival rate 24%) were significantly worse. CONCLUSIONS The independent risk factor for early recurrence is the "number of liver metastases ≥ 3." Patients with three or more liver metastases have a significantly higher risk of liver recurrence and a higher rate of recurrence beyond curative surgical resection, and these are correlated with a poor prognosis.
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Affiliation(s)
- Yo-ichi Yamashita
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan
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Gomez D, Sangha VK, Morris-Stiff G, Malik HZ, Guthrie AJ, Toogood GJ, Lodge JPA, Prasad KR. Outcomes of intensive surveillance after resection of hepatic colorectal metastases. Br J Surg 2010; 97:1552-60. [PMID: 20632325 DOI: 10.1002/bjs.7136] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- D Gomez
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Zhang S, Gao F, Luo J, Yang J. Prognostic factors in survival of colorectal cancer patients with synchronous liver metastasis. Colorectal Dis 2010; 12:754-61. [PMID: 19508508 DOI: 10.1111/j.1463-1318.2009.01911.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM To determine the factors affecting the survival in colorectal cancer patients with synchronous liver metastases. METHOD A total of 168 patients who had been treated colorectal cancer with synchronous liver metastases at Guangxi Medical University from January 2000 to December 2005 were identified. Criteria studied consisted of gender, age, time of symptoms, primary tumour location, primary tumour circumference, histological type, grade (tumour differentiation), T-status, N-status, large bowel obstruction, type of operation, primary tumour resection, ascities, location, number and diameter of liver lesions, preoperative CEA and chemotherapy. Survival curves were plotted using the Kaplan-Meier method. Multivariate analysis was conducted by Cox regression analysis. RESULTS The mean survival time for all patients was 18.71 (SEM = 1.59) months. The 1, 2, 3 and 5-year survival rates were 55.95%, 23.21%, 12.30%, 8.0% respectively. Univariate analysis share of grade (tumour differentiation), N-status, large bowel obstruction, operation, primary tumour resection, location, number and the most diameter of liver lesions, extrahepatic transfer, preoperative CEA level and chemotherapy to be predictors of survival. In the Cox regression analysis, the N-status, large bowel obstruction, operation, diameter of liver lesion and extrahepatic transfer were independent factors related to survival. CONCLUSION Tumour differentiation, N-status, bowel obstruction, operation, primary tumour resection, location of liver metastasis, number of liver metastasis, diameter of liver metastasis, extrahepatic transfer, preoperative CEA level and chemotherapy are related to the survival of patients with colorectal cancer and synchronous liver metastases.
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Affiliation(s)
- S Zhang
- Department of Colorectal Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
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Abstract
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.
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Affiliation(s)
- Dhanwant Gomez
- Department of Hepatobiliary Surgery and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Choi JY, Choi JS, Kim MJ, Lim JS, Park MS, Kim JH, Chung YE. Detection of hepatic hypovascular metastases: 3D gradient echo MRI using a hepatobiliary contrast agent. J Magn Reson Imaging 2010; 31:571-8. [DOI: 10.1002/jmri.22076] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Macafee DAL, Waller M, Whynes DK, Moss S, Scholefield JH. Population screening for colorectal cancer: the implications of an ageing population. Br J Cancer 2008; 99:1991-2000. [PMID: 19034277 PMCID: PMC2607219 DOI: 10.1038/sj.bjc.6604788] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Population screening for colorectal cancer (CRC) has recently commenced in the United Kingdom supported by the evidence of a number of randomised trials and pilot studies. Certain factors are known to influence screening cost-effectiveness (e.g. compliance), but it remains unclear whether an ageing population (i.e. demographic change) might also have an effect. The aim of this study was to simulate a population-based screening setting using a Markov model and assess the effect of increasing life expectancy on CRC screening cost-effectiveness. A Markov model was constructed that aimed, using a cohort simulation, to estimate the cost-effectiveness of CRC screening in an England and Wales population for two timescales: 2003 (early cohort) and 2033 (late cohort). Four model outcomes were calculated; screened and non-screened cohorts in 2003 and 2033. The screened cohort of men and women aged 60 years were offered biennial unhydrated faecal occult blood testing until the age of 69 years. Life expectancy was assumed to increase by 2.5 years per decade. There were 407 552 fewer people entering the model in the 2033 model due to a lower birth cohort, and population screening saw 30 345 fewer CRC-related deaths over the 50 years of the model. Screening the 2033 cohort cost £96 million with cost savings of £43 million in terms of detection and treatment and £28 million in palliative care costs. After 30 years of follow-up, the cost per life year saved was £1544. An identical screening programme in an early cohort (2003) saw a cost per life year saved of £1651. Population screening for CRC is costly but enables cost savings in certain areas and a considerable reduction in mortality from CRC. This Markov simulation suggests that the cost-effectiveness of population screening for CRC in the United Kingdom may actually be improved by rising life expectancies.
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Affiliation(s)
- D A L Macafee
- Department of Surgery, Royal Victoria Infirmary, Newcastle-upon, Tyne NE1 4LP, UK.
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Al-Asfoor A, Fedorowicz Z, Lodge M. Resection versus no intervention or other surgical interventions for colorectal cancer liver metastases. Cochrane Database Syst Rev 2008:CD006039. [PMID: 18425932 DOI: 10.1002/14651858.cd006039.pub4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND About one in four of patients with metastatic colorectal cancer have metastases isolated to the liver, of which 10% to 25% are eligible for ablation of the liver metastases, improving the five year survival rate. Treatments include hepatic resection and other modalities using cryosurgery and radiofrequency thermal ablation. Although new modalities allow safe ablation of liver metastases without the need for surgical intervention, there are still no clear guidelines on the appropriate management of patients with colorectal cancer and hepatic metastases. OBJECTIVES The primary objectives were to compare resection of liver metastases to no intervention and other modalities of intervention (including cryosurgery and radiofrequency ablation) in terms of the benefits and harms for each intervention. SEARCH STRATEGY Searches were conducted of the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE databases up to October 2006. In addition, references were scrutinized in identified eligible trials. SELECTION CRITERIA Only randomized controlled trials reporting patients (regardless of age and sex) who had had curative surgery for adenocarcinoma of the colon or rectum, had been diagnosed with liver metastases and who were eligible for liver resection (i.e. with no evidence of primary or metastatic cancer elsewhere) were considered. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a form designed for this review. Discrepancies were resolved by consensus. MAIN RESULTS Only one trial involving 123 people (87 male 36 female) was included. The data from this ten year prospective, randomized clinical trial suggest that hepatic cryosurgery is effective in the treatment of resectable and nonresectable liver metastases. The results show intra-operative tumor reduction (>/=90% or </= 97%) and extended higher survival in these patients. The study indicated a five year and ten year survival rate of 44% and 19% after cryosurgery, respectively. However, it was not possible to separate out and unravel the outcomes data that related only to the participants (66.6%) with liver metastases from colorectal cancer as opposed to those with liver metastases from other primary tumors. AUTHORS' CONCLUSIONS There is currently insufficient evidence to support a single approach, either surgical or non-surgical, for the management of colorectal liver metastases. Therefore, treatment decisions should continue to be based on individual circumstances and clinician's experience. The authors conclude that local ablative therapies are probably useful, but that they need to be further evaluated in a randomized controlled trial.
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Macafee DAL, Whynes DK, Scholefield JH. Risk-stratified intensive follow up for treated colorectal cancer - realistic and cost saving? Colorectal Dis 2008; 10:222-30. [PMID: 17645572 DOI: 10.1111/j.1463-1318.2007.01297.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Intensive follow-up post surgery for colorectal cancer (CRC) is thought to improve long-term survival principally through the earlier detection of recurrent disease. This paper aims to calculate the additional resource and cost implications of intensive follow up post-CRC resection, examine the possibility of risk-stratifying this follow up to those at highest risk of recurrence and investigating the impact that population screening might have on the future cost and outcomes of follow up. METHOD Two follow-up regimens were constructed: the 'standard' follow-up protocol used the principles of the British Society of Gastroenterology (BSG) guidelines whilst the 'intensive' follow-up protocol used the most intensive arm of the follow up after colorectal surgery (FACS) trial. Using ONS data, the number of CRC diagnosed in a given year was calculated for 2003 and projected for 2016 based on the population of England and Wales. The resource requirements and costs of follow up over a 5-year period were then calculated for the two time periods. Risk stratifying entry to follow up and the introduction of population CRC screening were then considered. RESULTS For the 2003 cohort, an intensive follow-up program would detect 853 additional resectable recurrences over 5 years with 795 fewer subjects requiring palliative care. An additional 26 302 outpatient appointments, 181 352 CEA tests and 79 695 CT scans over 5 years would be required to achieve this. The cost of investigating subjects who would never develop detectable recurrences was pound15.6 million. The cost per additional resectable recurrence was pound18 077, a figure also found for a nonscreened population in 2016. An identical intensive follow-up policy with biennial FOBT screening in 2016 saw the cost per additional resectable recurrence rise to pound36 255. CONCLUSION Intensive follow up will detect considerably more resectable recurrences but at considerable cost and it is unclear if such follow up will be achievable in an already over-stretched NHS. If population-based CRC screening increases the number of Dukes A cancers this may offer the possibility of risk-stratifying future follow up to those at highest risk of recurrence; minimizing tests on those who will never have recurrent disease and better utilizing our scarce resources.
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Affiliation(s)
- D A L Macafee
- Department of Surgery, James Cook University Hospital, Middlesborough, Cleveland, UK.
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Karuna ST, Thirlby R, Biehl T, Veenstra D. Cost-effectiveness of laparoscopy versus laparotomy for initial surgical evaluation and treatment of potentially resectable hepatic colorectal metastases: a decision analysis. J Surg Oncol 2008; 97:396-403. [DOI: 10.1002/jso.20964] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Preoperative prognostic score for predicting survival after hepatic resection for colorectal liver metastases. Ann Surg 2007; 246:806-14. [PMID: 17968173 DOI: 10.1097/sla.0b013e318142d964] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite indications for resection of colorectal liver metastases having expanded, debate continues about identifying patients that may benefit from surgery. METHODS Clinicopathologic data from a total of 700 patients was gathered between January 1993 and January 2006 from a prospectively maintained dataset. Of these, 687 patients underwent resection for colorectal liver metastases. RESULTS The median age of patient was 64 years and 36.8% of patients had synchronous disease. The overall 5-year survival was 45%. The presence of an inflammatory response to tumor (IRT), defined by an elevated C-reactive protein (>10 mg/L) or a neutrophil/lymphocyte ratio of >5:1, was noted in 24.5% of cases. Only the number of metastases and the presence or absence of an IRT influenced both overall and disease-free survival on multivariable analysis. A preoperative prognostic score was derived: 0 = less than 8 metastases and absence of IRT; 1 = 8 or more metastases or IRT, and 2 = 8 or more metastases and IRT-from the results of the multivariable analysis. The 5-year survival of those scoring 0 was 49% compared with 34% for those scoring 1. None of the patients that scored 2 were alive at 5 years. CONCLUSION The preoperative prognostic score is a simple and effective system allowing preoperative stratification.
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Gomez D, Malik HZ, Bonney GK, Wong V, Toogood GJ, Lodge JPA, Prasad KR. Steatosis predicts postoperative morbidity following hepatic resection for colorectal metastasis. Br J Surg 2007; 94:1395-402. [PMID: 17607707 DOI: 10.1002/bjs.5820] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies are available on the effect of steatosis on perioperative outcome following hepatic resection for colorectal liver metastasis (CRLM). METHODS Patients undergoing resection for CRLM from January 2000 to September 2005 were identified from a hepatobiliary database. Data analysed included laboratory measurements, extent of hepatic resection, blood transfusion requirements and steatosis. RESULTS There were 386 patients with a median age of 66 (range 32-87) years, of whom 201 had at least one co-morbid condition and 194 had an American Society of Anesthesiologists grade of I. Anatomical resection was performed in 279 patients and non-anatomical resection in 107; 165 had additional procedures. Steatosis in 194 patients was classified as mild in 122, moderate in 60 and severe in 12. The overall morbidity rate was 36 per cent (139 patients) and the mortality rate was 1.8 per cent (seven patients). Admission to the intensive care unit, morbidity, infective complications and biochemical profile changes were associated with greater severity of steatosis. Independent predictors of morbidity were steatosis, extent of hepatic resection and blood transfusion. CONCLUSION Steatosis is associated with increased morbidity following hepatic resection. Other predictors of outcome were extent of hepatic resection and blood transfusion.
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Affiliation(s)
- D Gomez
- Hepatobiliary and Transplantation Unit, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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Finch RJB, Malik HZ, Hamady ZZR, Al-Mukhtar A, Adair R, Prasad KR, Lodge JPA, Toogood GJ. Effect of type of resection on outcome of hepatic resection for colorectal metastases. Br J Surg 2007; 94:1242-8. [PMID: 17657718 DOI: 10.1002/bjs.5640] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-anatomical liver resections have become more common in the management of colorectal liver metastases. This study examined survival and patterns of recurrence following surgery for colorectal liver metastases. METHODS Data were collected prospectively on all patients who had hepatic surgery for colorectal liver metastases at St James' University Hospital, Leeds between 1993 and May 2003, and analysed with respect to type of resection. RESULTS A total of 96 patients underwent non-anatomical liver resection, 280 patients had an anatomical resection, and 108 patients had a combined procedure. There was no significant difference in overall survival between the anatomical and non-anatomical groups (hazard ratio 1.14 (95 per cent confidence interval 0.60 to 2.17); P = 0.691). Intrahepatic recurrence was significantly less common in the anatomical group, whereas morbidity and mortality rates were lower in the non-anatomical group. On multivariable analysis, multiple metastases and poorer primary T stage predicted poorer overall survival and a positive resection margin predicted poorer disease-free survival. CONCLUSION Non-anatomical resection can be performed with lower rates of surgical morbidity and mortality than anatomical resection, and does not disadvantage the patient in terms of overall survival.
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Affiliation(s)
- R J B Finch
- Hepatobiliary and Transplant Unit, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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Analysis of Prognostic Factors Influencing Long-term Survival After Hepatic Resection for Metastatic Colorectal Cancer. World J Surg 2007; 32:93-103. [DOI: 10.1007/s00268-007-9285-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Al-Asfoor A, Fedorowicz Z. WITHDRAWN: Resection versus no intervention or other surgical interventions for colorectal cancer liver metastases. Cochrane Database Syst Rev 2007:CD006039. [PMID: 17943879 DOI: 10.1002/14651858.cd006039.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND About one in four of patients with metastatic colorectal cancer have metastases isolated to the liver, of which 10-25% are eligible for ablation of the liver metastases, improving the 5-year survival rate. Treatments include hepatic resection and non-surgical tumor ablation using cryosurgery and radiofrequency thermal ablation. Although new modalities allow safe ablation of liver metastases without the need for surgical intervention, there are still no clear guidelines on the appropriate management of patients with colorectal cancer and hepatic metastases. OBJECTIVES The primary objectives were to compare resection of liver metastases to no intervention and other modalities of intervention (including cryosurgery and radiofrequency ablation), in terms of the benefits and harms for each intervention. SEARCH STRATEGY We identified randomized controlled trials from MEDLINE, Embase, and the Cochrane Controlled Trials Register up to October 2006, based upon the search strategy developed for MEDLINE, and revised appropriately for each database. In addition, references were scrutinized in identified eligible trials. SELECTION CRITERIA We only considered randomized controlled trials reporting patients of any age and sex, who have had curative surgery for adenocarcinoma of the colon or rectum, diagnosed with liver metastases that are candidates for liver resection, i.e., with no evidence of primary or metastatic cancer elsewhere. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed trial quality using a data-extraction form designed for this review. Discrepancies were resolved in consensus. MAIN RESULTS Only one trial fulfilled our inclusion criteria. The data of this 10-year prospective, randomized clinical trial suggest that hepatic cryosurgery is effective in the treatment of resectable and non-resectable liver metastases. The results show intra-operative tumor reduction (> or = 90% < or = 97%) and extended higher survival in these patients. The study indicated a 5-year and 10-year survival rate of 44% and 19% after cryosurgery, respectively. However, it was not possible to separate out and unravel the outcomes data that related only to the participants (66.6%) with liver metastases from colorectal cancer as opposed to those with liver metastases from other primary tumors. AUTHORS' CONCLUSIONS There is currently insufficient evidence to support a single approach, either surgical or non-surgical for the management of colorectal liver metastases. Therefore, treatment decisions should continue to be based on individual circumstances and clinician's experience. We concede that local ablative therapies are probably useful, but they need to be further evaluated in a randomized controlled trial.
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Affiliation(s)
- A Al-Asfoor
- Salmaniyah Medical Complex, Ministry of Health, Box 12, Manama, Bahrain.
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Malik HZ, Gomez D, Wong V, Al-Mukthar A, Toogood GJ, Lodge JPA, Prasad KR. Predictors of early disease recurrence following hepatic resection for colorectal cancer metastasis. Eur J Surg Oncol 2007; 33:1003-9. [PMID: 17350218 DOI: 10.1016/j.ejso.2007.01.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 01/05/2007] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND With the broadening indications of hepatic resection for colorectal liver metastases (CRLM), the exact group of patients who would benefit from surgery is still debatable. The aim of this study was to identify predictors for early recurrence, defined as recurrence within 6 months of CRLM resection, in order to identify those patients who may require further pre-operative radiological staging of the disease prior to surgery. METHODS Prospectively collected dataset of patients undergoing curative resection for CRLM during the 10-year period (January 1993-May 2003) were analyzed. Patients who received neo-adjuvant chemotherapy and patients who underwent repeat hepatic resections whose primary resection was not performed during the study period were excluded. RESULTS Four hundred and thirty patients (89%) were included in the analysis. Eighty-six (20%) patients developed early recurrence. Early recurrence was associated with poorer outcome when compared to late recurrences (p<0.001). The predictor of early recurrence on multivariable analysis was the presence of eight or more metastases (p=0.036). CONCLUSION We have identified a group of patients with multiple metastases who recur early following resection of CRLM. We suggest that these patients should be considered for additional pre-operative radiological workup in the form of PET scanning to identify those patients who would be deemed suitable for resection.
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Affiliation(s)
- H Z Malik
- Hepatobiliary and Transplantation Unit, The Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Beckett Street, Leeds, UK
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Regge D, Campanella D, Anselmetti GC, Cirillo S, Gallo TM, Muratore A, Capussotti L, Galatola G, Floriani I, Aglietta M. Diagnostic accuracy of portal-phase CT and MRI with mangafodipir trisodium in detecting liver metastases from colorectal carcinoma. Clin Radiol 2006; 61:338-47. [PMID: 16546464 DOI: 10.1016/j.crad.2005.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Revised: 12/06/2005] [Accepted: 12/21/2005] [Indexed: 12/23/2022]
Abstract
AIM To compare the diagnostic accuracy of single section spiral computed tomography (CT) and magnetic resonance imaging (MRI) with tissue-specific contrast agent mangafodipir trisodium (MnDPDP) in the detection of colorectal liver metastases. MATERIAL AND METHODS One hundred and twenty-five consecutive patients undergoing surgery for primary and/or metastatic disease were evaluated using CT (5 mm collimation and reconstruction interval, pitch 2), two-dimensional fast spoiled gradient echo (2D FSPGR) T1 and single shot fast-spin echo (SSFSE) T2 weighted breath-hold MRI sequences, performed before and after intravenous administration of MnDPDP. The reference standards were intraoperative ultrasound and histology. RESULTS The per-patient accuracy of CT was 72.8 versus 78.4% for unenhanced MRI (p = 0.071) and 82.4% for MnDPDP-enhanced MRI (p = 0.005). MnDPDP-enhanced MRI appeared to be more accurate than unenhanced MRI but this was not significant (p = 0.059). The sensitivity of CT was 48.4% versus 58.1% for unenhanced MRI (p = 0.083) and 66.1% for MnDPDP-enhanced MRI (p = 0.004). The difference in specificity between procedures was not significant. The per-lesion sensitivity was 71.7, 74.9 and 82.7% for CT, unenhanced MRI, and MnDPDP-enhanced MRI, respectively; the positive predictive value of the procedures was respectively 84.0, 96.0 and 95.8%. MnDPDP-enhanced MRI provided a high level diagnostic confidence in 92.5% of the cases versus 82.5% for both unenhanced MRI and CT. The kappa value for inter-observer variability was >0.75 for all procedures. CONCLUSIONS The diagnostic accuracy and sensitivity of MnDPDP-enhanced MRI is significantly higher than single section spiral CT in the detection of colorectal cancer liver metastases; no significant difference in diagnostic accuracy was observed between unenhanced MRI and MnDPDP-enhanced MRI.
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Affiliation(s)
- D Regge
- Radiology Unit, Institute for Cancer Research and Treatment, Candiolo, Torino, Italy.
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Evrard S, Mathoulin-Pelissier S. Controversies between surgical and percutaneous radiofrequency ablation. Eur J Surg Oncol 2006; 32:3-5. [PMID: 16274954 DOI: 10.1016/j.ejso.2005.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Accepted: 09/05/2005] [Indexed: 10/25/2022] Open
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Jones OM, Rees M, John TG, Bygrave S, Plant G. Biopsy of resectable colorectal liver metastases causes tumour dissemination and adversely affects survival after liver resection. Br J Surg 2005; 92:1165-8. [PMID: 15997444 DOI: 10.1002/bjs.4888] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver resection is increasingly being performed for metastatic colorectal cancer. This study assessed the need for preoperative biopsy of suspected metastases and whether biopsy has any effect on long-term survival. METHODS Prospectively collected data on patients who underwent liver resection for colorectal metastases between 1986 and 2003 were reviewed retrospectively. The endpoints of morbidity, operative mortality and long-term survival were compared between patients who had biopsy before referral (group 1) and those who did not (group 2). RESULTS Patient demographics and disease distribution were similar for 90 patients in group 1 and 508 in group 2. Seventeen patients (19 per cent) who had undergone biopsy either at the time of colorectal resection or radiologically had evidence of needle-track deposits. Operative mortality and morbidity rates in the two groups were similar. The 4-year survival rate after liver resection was 32.5 (s.e. 5.5) per cent in group 1, compared with 46.7 (2.8) per cent in group 2 (P = 0.008). CONCLUSION Needle-track deposits are common after biopsy of suspected colorectal liver metastases. Biopsy of metastases confers poorer long-term survival on patients after liver resection and cannot be justified in patients with potentially resectable disease.
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Affiliation(s)
- O M Jones
- Department of Hepatobiliary Surgery, North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA, UK
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Griffiths EA, Browell DA, Cunliffe WJ. Evaluation of a pre-operative staging protocol in the management of colorectal carcinoma. Colorectal Dis 2005; 7:35-42. [PMID: 15606582 DOI: 10.1111/j.1463-1318.2004.00702.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The optimum strategy for pre-operative staging of colorectal carcinoma (CRC) has yet to be defined. A protocol for staging CRC patients was set up in this hospital in 1998. The protocol included complete colonic visualization together with assessment of the liver and lung for potential metastatic disease. Pelvic imaging was required to assess the local spread of rectal tumours. Our aim was to evaluate prospectively this protocol. PATIENTS AND METHODS Data from all patients diagnosed with primary CRC between January 1999 and December 2002 were prospectively collected and analysed. RESULTS There were 295 patients; 56 (19%) patients presented as an emergency and were excluded. The study group consisted of 239 patients (206 had elective surgery and 33 had no resectional surgery). In the patients who presented electively; 88% had complete colonic imaging; 87% chest imaging; 90% had liver imaging; 91% of rectal tumours had pelvic imaging. Overall 75% of the elective patients completed the staging protocol. Reasons for incomplete staging were numerous and most were justifiable. Findings which influenced clinical management included alteration in surgical approach (14), lung metastases (7), primary lung cancers (2), definite liver metastases (25), possible liver metastases (8), neo-adjuvant radiotherapy required (27), advanced local disease (9) and other incidental findings (12). CONCLUSION Our protocol influenced further management decisions in 39% of patients. Better stratification of patient care is possible, with the ultimate aim to avoid unnecessary surgery. However, complete staging is not always possible to perform.
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Affiliation(s)
- E A Griffiths
- Department of Surgery, Queen Elizabeth Hospital, Gateshead, UK
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Stewart GD, O'Súilleabháin CB, Madhavan KK, Wigmore SJ, Parks RW, Garden OJ. The extent of resection influences outcome following hepatectomy for colorectal liver metastases. Eur J Surg Oncol 2004; 30:370-6. [PMID: 15063889 DOI: 10.1016/j.ejso.2004.01.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2004] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The acceptable indications for liver resection in patients with colorectal metastases have increased significantly in the last decade. It is thus becoming more difficult to ascertain the limitations for selection as the boundaries have been greatly extended. This has resulted in not only more extensive resections, but more atypical and bilobar resections. The aim of this study was to compare the outcome of patients undergoing different extent of liver resection in a specialist unit. METHODS All patients undergoing liver resection for colorectal metastases at the Royal Infirmary of Edinburgh between October 1988 and April 2001 were reviewed. Patients were allocated into one of three groups: standard group, extended group, and segmental group. Patient information was collected from a prospectively completed database. RESULTS One hundred and thirty-seven patients had liver resections for colorectal metastases during the study period. There were 69 standard hepatectomies, 41 extended resections and 27 segmental resections. CEA level was significantly lower in the segmental group(p = 0.012). There was a significant difference between the groups in terms of median operating time (p < 0.0001, Kruskal-Wallis test), operative blood loss (p = 0.006, Kruskal-Wallis test) and post-operative stay ( p = 0.036, Kruskal-Wallis test). Major post-operative complications were similar between standard and extended resections but less following segmental resection (p = 0.050. Predicted median survival was 51 months following standard resection, 23 months following extended resection and 59 months after segmental resection ( p = 0.037, log rank test), however, there was no difference between the three groups for actual 5-year survival (p = 0.662, Pearson chi-square test). CONCLUSION Morbidity and mortality rates were comparable with other previous studies as was overall survival, although survival in patients undergoing extended resections was reduced. There was an acceptable level of morbidity and mortality for all three groups. Patients undergoing segmental resection had fewer complications, shorter length of stay, and the longest median survival suggesting adequate oncological clearance. Segmental resection has a role for favourably placed tumour deposits if oncological clearance can be ensured. Extended liver resections have a role for selected patients with bilobar colorectal metastases or large solitary deposits close to the hepatic vein confluence.
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Affiliation(s)
- G D Stewart
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, University of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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