Laparoscopic resections of colorectal cancer and synchronous liver metastases: a case controlled study

Laparoscopic versus open resection of primary colorectal cancers and synchronous liver metastasis: a systematic review and meta-analysis

PURPOSE

Combined resection of primary colorectal cancer and associated liver metastases is increasingly common. This study compares peri-operative and oncological outcomes according to surgical approach.

METHODS

The study was registered with PROSPERO. A systematic search was performed for all comparative studies describing outcomes in patients that underwent laparoscopic versus open simultaneous resection of colorectal primary tumours and liver metastases. Data was extracted and analysed using a random effects model via Rev Man 5.3 RESULTS: Twenty studies were included with a total of 2168 patients. A laparoscopic approach was performed in 620 patients and an open approach in 872. There was no difference in the groups for BMI (mean difference: 0.04, 95% CI: 0.63-0.70, p = 0.91), number of difficult liver segments (mean difference: 0.64, 95% CI:0.33-1.23, p = 0.18) or major liver resections (mean difference: 0.96, 95% CI: 0.69-1.35, p = 0.83). There were fewer liver lesions per operation in the laparoscopic group (mean difference 0.46, 95% CI: 0.13-0.79, p = 0.007). Laparoscopic surgery was associated with shorter length of stay (p < 0.00001) and less overall postoperative complications (p = 0.0002). There were similar R0 resection rates (p = 0.15) but less disease recurrence in the laparoscopic group (mean difference: 0.57, 95% CI:0.44-0.75, p < 0.0001).

CONCLUSION

Synchronous laparoscopic resection of primary colorectal cancers and liver metastases is a feasible approach in selected patients and does not demonstrate inferior peri-operative or oncological outcomes.

SAGES/AHPBA guidelines for the use of minimally invasive surgery for the surgical treatment of colorectal liver metastases (CRLM)

BACKGROUND

Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM.

METHODS

Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research.

RESULTS

The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence.

CONCLUSIONS

These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.

Clinical efficacy of laparoscopic radical hepatectomy and laparotomy for hepatocellular carcinoma and factors of postoperative recurrence

Objective

For exploring the clinical efficacy of laparoscopic radical hepatectomy and laparotomy for hepatocellular carcinoma and analysing related factors of postoperative recurrence.

Methods

Totally 212 patients with hepatocellular carcinoma admitted to our hospital between April 2017 and December 2020 were enrolled, and all of them were followed up after the operation. According to the treatment modes, the patients were assigned to a laparotomy group (n=106) and a laparoscopic group (n=106). Perioperative indicators, haematological examination results, complications and recurrence were compared between the two groups. The recurrence time of hepatocellular carcinoma after the operation was confirmed by imaging examination with definite mass, and logistic multivariate analysis was used for analyzing the risk factors associated with postoperative recurrence.

Results

Patients in both groups were comparable in terms of general baseline data. The laparoscopic group experienced longer operation time and shorter incision length, less intraoperative blood loss, early time to have the first off-bed activity and time to eat liquid and shorter hospital stay than the laparotomy group (all P<0.05). Seven days after the operation, the laparoscopic group showed notably lower levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), tumour necrosis factor-α (TNF-α), interleukin-8 (IL-8), and C-reactive protein (CRP) than the laparotomy group (all P<0.05), and also showed notably higher levels of immunoglobulin A (IgA), IgG and IgM than the laparotomy group (all P<0.05). Additionally, the laparotomy group showed a higher total incidence rate of complications than the laparoscopic group (19.81% vs. 9.43%, P<0.05). During the one-year follow-up, the laparotomy group was not greatly different from the laparoscopic group in recurrence rate (22.64% (24/106) vs. 16.98% (18/106), P>0.05). Multivariate analysis showed that average tumour diameter and microvascular invasion were risk factors for postoperative recurrence (P<0.05).

Conclusion

Laparoscopic radical hepatectomy for hepatocellular carcinoma can reduce the influence on liver function and immune function, with less damage to tissues, and can ameliorate postoperative inflammatory reaction, and promote postoperative recovery of patients as soon as possible. There are many factors influencing the postoperative recurrence of hepatocellular carcinoma, and average tumour diameter and microvascular invasion are the risk factors.

Safety and long-term prognosis of simultaneous versus staged resection in synchronous colorectal cancer with liver metastasis: a systematic review and meta-analysis

PURPOSE

The optimal time point for surgical resection of synchronous colorectal liver metastases (SCLMs) is still controversial. This meta-analysis evaluated the safety and long-term prognoses of simultaneous and staged resection of SCLM to provide a reference for clinical selection.

METHODS

A systematic literature search for studies published by October 2022 was performed using PubMed, Web of Science, Embase, Scopus and Cochrane Library. The evaluated outcome parameters were total, gastrointestinal and hepatic complications, as well as perioperative mortality, intraoperative blood loss, total hospital stay, 5-year disease-free survival (DFS) and 5-year overall survival (OS).

RESULTS

This meta-analysis included 22 nonrandomised and one randomised study comprising 4862 patients. The patients undergoing simultaneous resection of SCLM had similar total (OR = 0.88, 95% CI [0.66-1.19], P = 0.409), gastrointestinal (OR = 1.19, 95% CI [0.89-1.59], P = 0.241) and hepatic (OR = 1.04, 95% CI [0.83-1.31], P = 0.734) complications, as well as perioperative mortality (OR = 1.79, 95% CI [0.88-3.64], P = 0.108), 5-year DFS (HR = 1.26, 95% CI [0.96-1.66], P = 0.098) and 5-year OS (HR = 1.13, 95% CI [0.95-1.34], P = 0.164). Lower intraoperative blood loss (SMD = - 0.39, 95% CI [- 0.60 to - 0.18], P < 0.001) and shorter total hospital stay (WMD = - 5.43, 95% CI [- 7.29 to - 3.58], P < 0.001) were observed in the simultaneous-resection group versus the staged group.

CONCLUSIONS

Simultaneous resection is safe and effective for SCLM patients. The long-term prognosis is equivalent to that of the traditional staged resection. Correct selection of resectable SCLM patients for the simultaneous resection of the primary tumour and liver metastases can be the first choice. Owing to the potential heterogeneity, more RCTs should be included to verify our conclusions.

Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: a systematic review and meta-analysis

BACKGROUND

While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor.

METHODS

PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD).

RESULTS

From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17).

CONCLUSIONS

Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.

The Value of Laparoscopic Simultaneous Colorectal and Hepatic Resection for Synchronous Colorectal Cancer Liver Metastasis: A Propensity Score Matching Study

Purpose

The aim of this study is to investigate the value of total laparoscopic simultaneous colorectal and hepatic resection in patients with synchronous colorectal cancer liver metastases (sCRLMs).

Methods

sCRLM patients who underwent simultaneous resection from December 2014 to December 2018 in Shanghai Cancer Center, Fudan University were recruited and analyzed retrospectively. The patients were divided into laparoscopic, open, and hybrid surgery groups. The intraoperative information, postoperative short-term outcome, and long-term survival were compared among the three groups. Propensity score matching (PSM) was performed to balance baselines.

Results

A total of 281 patients were recruited. After PSM, 34 patients were selected from both the laparoscopic and the open surgery group. Forty-seven patients were also selected from both the laparoscopic and the hybrid surgery group. The clinicopathologic baselines between the laparoscopic surgery group and the other two groups were well matched. All the operation-related indicators between laparoscopic surgery and hybrid surgery were similar. However, compared with open surgery, laparoscopic surgery showed significantly longer operation time (229.09 ± 10.94 min vs. 192.24 ± 9.49 min, p = 0.013) and less intraoperative blood loss [100.00 (50.00–300.00) ml vs. 200.00 (150.00–400.00) ml, p = 0.021]. For postoperative morbidity, there was no significant difference between the laparoscopic surgery group and the hybrid or the open surgery group (23.40% vs. 31.91% and 17.65% vs. 26.47%, p = 0.356 and p = 0.380). Long-term survival analysis showed that there were no significant differences in all 1-, 3-, and 5-year overall survival, liver recurrence-free survival (RFS), and whole RFS between laparoscopic surgery and hybrid surgery (p = 0.334, p = 0.286, and p = 0.558) or open surgery (p = 0.230, p = 0.348, and p = 0.450).

Conclusions

Laparoscopic simultaneous resection for sCRLM shows slight advantages in surgical safety and short-term outcome, and does not compromise long-term survival.

Laparoscopic Radical Resection of Colorectal Cancer in the Treatment of Elderly Colorectal Cancer and Its Effect on Gastrointestinal Function

Objective

To explore the efficacy and safety of laparoscopic radical resection of colorectal cancer in the elderly patients and its impact on gastrointestinal function.

Methods

A total of 122 elderly patients with colorectal cancer admitted to our hospital from March 2020 to June 2021 were selected as the research subjects, and they were divided into the control group (n = 61) and the observation group (n = 61). The control group was treated with traditional laparotomy, and the observation group was treated with laparoscopic radical resection of colorectal cancer. The clinical data of operation time, incision length, intraoperative bleeding volume, and hospitalization time in the two groups were recorded. Serum motilin (MTL) and gastrin (GAS) levels were measured pre- and post-operatively. The duration of abdominal distension, the time for the abdominal sound to return to normal, the time for the anal exhaust to normal, and the time for normal food intake were recorded after operation. The patients were followed up for 6 months post-operatively, and the complications during follow-up were recorded.

Results

The total response rate of the observation group (95.08%) was higher than that of the control group (81.97%) (P < 0.05). The operation time, incision length, intraoperative bleeding volume, and hospitalization time of the observation group were lower than those of the control group (P < 0.05). The duration of abdominal distension, the time for bowel sounds to return to normal, the time for the anus to exhaust gas to normal, and the normal eating time in the observation group were all lower than those in the control group (P < 0.05). After surgery, the levels of MTL and GAS in the two groups were lower than those before surgery, and those in the observation group were lower than those in the control group (P < 0.05). The total incidence of complications in the observation group (3.28%) was lower than that in the control group (13.12%) (P < 0.05).

Conclusion

Laparoscopic radical resection of colorectal cancer in the elderly patients has good effect, short operation time, less trauma, less blood loss during operation, short hospital stay, good recovery of gastrointestinal function, fewer complications, and high safety.

Laparoscopic liver resection for colorectal liver metastases - short- and long-term outcomes: A systematic review

BACKGROUND

For well-selected patients and procedures, laparoscopic liver resection (LLR) has become the gold standard for the treatment of colorectal liver metastases (CRLM) when performed in specialized centers. However, little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.

AIM

To provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.

METHODS

A systematic search was performed in PubMed, EMBASE, Web of Science and the Cochrane Library using the keywords "colorectal liver metastases", "laparoscopy", "liver resection", "prognostic factors", "outcomes" and "survival". Only publications written in English and published until December 2019 were included. Furthermore, abstracts of which no accompanying full text was published, reviews, case reports, letters, protocols, comments, surveys and animal studies were excluded. All search results were saved to Endnote Online and imported in Rayyan for systematic selection. Data of interest were extracted from the included publications and tabulated for qualitative analysis.

RESULTS

Out of 1064 articles retrieved by means of a systematic and grey literature search, 77 were included for qualitative analysis. Seventy-two research papers provided data concerning outcomes of LLR for CRLM. Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes. Qualitative analysis of the collected data showed that LLR for CRLM is safe, feasible and provides oncological efficiency. Multiple research groups have reported on the short-term advantages of LLR compared to open procedures. The obtained results accounted for minor LLR, as well as major LLR, simultaneous laparoscopic colorectal and liver resection, LLR of posterosuperior segments, two-stage hepatectomy and repeat LLR for CRLM. Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.

CONCLUSION

In experienced hands, LLR for CRLM provides good short- and long-term outcomes, independent of the complexity of the procedure.

The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology

At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.

Laparoscopic procedure is associated with lower morbidity for simultaneous resection of colorectal cancer and liver metastases: an updated meta-analysis

Background

It has been demonstrated that simultaneous resection of both primary colorectal lesion and metastatic hepatic lesion is a safe approach with low mortality and postoperative complication rates. However, there are some controversies over which kind of surgical approach is better. The aim of study was to compare the efficacy and safety of laparoscopic surgeries and open surgeries for simultaneous resection of colorectal cancer (CRC) and synchronous colorectal liver metastasis (SCRLM).

Methods

A systemic search of online database including PubMed, Web of Science, Cochrane Library, and Embase was performed until June 5, 2019. Intraoperative complications, postoperative complications, and long-term outcomes were synthesized by using STATA, version 15.0. Cumulative and single-arm meta-analyses were also conducted.

Results

It contained twelve studies with 616 patients (273 vs 343, laparoscopic surgery group and open surgery group, respectively) and manifested latest surgical results for the treatment of CRC and SCRLM. Among patients who underwent laparoscopic surgeries, they had lower rates of postoperative complications (OR = 0.66, 95% CI: 0.46 to 0.96, P = 0.028), less intraoperative blood loss (weight mean difference (WMD) = − 113.31, 95% CI: − 189.03 to − 37.59, P = 0.003), less time in the hospital and recovering after surgeries (WMD = − 2.70, 95% CI: − 3.99 to − 1.40, P = 0.000; WMD = − 3.20, 95% CI: − 5.06 to − 1.34, P = 0.001), but more operating time (WMD = 36.57, 95% CI: 7.80 to 65.35, P = 0.013). Additionally, there were no statistical significance between two kinds of surgical approaches in disease-free survival and overall survival. Moreover, cumulative meta-analysis indicated statistical difference in favor of laparoscopic surgery in terms of morbidity was firstly detected in the 12th study in 2018 (OR = 0.66, 95% CI: 0.46 to 0.96, P = 0.028) as the 95% CI narrowed.

Conclusion

Compared with open surgeries, laparoscopic surgeries are safer (postoperative complications and intraoperative blood loss) and more effective (length of hospital stay and postoperative stay), and it can be considered as the first option for management of SCRLM in high-volume laparoscopic centers.

Trial registration

CRD42020151176

Survival Advantage of Laparoscopic Versus Open Resection For Colorectal Liver Metastases: A Meta-analysis of Individual Patient Data From Randomized Trials and Propensity-score Matched Studies

OBJECTIVE

To perform an individual participant data meta-analysis using randomized trials and propensity-score matched (PSM) studies which compared laparoscopic versus open hepatectomy for patients with colorectal liver metastases (CLM).

BACKGROUND

Randomized trials and PSM studies constitute the highest level of evidence in addressing the long-term oncologic efficacy of laparoscopic versus open resection for CLM. However, individual studies are limited by the reporting of overall survival in ways not amenable to traditional methods of meta-analysis, and violation of the proportional hazards assumption.

METHODS

Survival information of individual patients was reconstructed from the published Kaplan-Meier curves with the aid of a computer vision program. Frequentist and Bayesian survival models (taking into account random-effects and nonproportional hazards) were fitted to compare overall survival of patients who underwent laparoscopic versus open surgery. To handle long plateaus in the tails of survival curves, we also exploited "cure models" to estimate the fraction of patients effectively "cured" of disease.

RESULTS

Individual patient data from 2 randomized trials and 13 PSM studies involving 3148 participants were reconstructed. Laparoscopic resection was associated with a lower hazard rate of death (stratified hazard ratio = 0.853, 95% confidence interval: 0.754-0.965, P = 0.0114), and there was evidence of time-varying effects (P = 0.0324) in which the magnitude of hazard ratios increased over time. The fractions of long-term cancer survivors were estimated to be 47.4% and 18.0% in the laparoscopy and open surgery groups, respectively. At 10-year follow-up, the restricted mean survival time was 8.6 months (or 12.1%) longer in the laparoscopy arm (P < 0.0001). In a subgroup analysis, elderly patients (≥65 years old) treated with laparoscopy experienced longer 3-year average life expectancy (+6.2%, P = 0.018), and those who live past the 5-year milestone (46.1%) seem to be cured of disease.

CONCLUSIONS

This patient-level meta-analysis of high-quality studies demonstrated an unexpected survival benefit in favor of laparoscopic over open resection for CLM in the long-term. From a conservative viewpoint, these results can be interpreted to indicate that laparoscopy is at least not inferior to the standard open approach.

Current status of laparoscopic liver resection for the management of colorectal liver metastases

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. The commonest site of spread is the liver, with up to 40% of patients developing colorectal liver metastasis (CLRM) during the course of their lifetime. Significant advances in surgical techniques, as well as breakthroughs in chemotherapy and biologic agents, have resulted in dramatic improvements in prognosis. A multimodal approach comprising of liver resection coupled with systemic therapy offers these patients the best chance of cure. The arrival of laparoscopic liver resection (LLR) within the last 3 decades has added a whole new dimension to the management of this condition. Today, CLRM is one of the most frequent indications for LLR globally. Meta-analyses of retrospective studies and two randomized trials have demonstrated superior short-term outcomes following LLR, with no differences in mortality rates. Oncologically, R0 resection rates are comparable to the open approach, while overall and disease-free survival rates are also similar. As surgeons gain confidence, boundaries are pushed even further. High-volume centers have published their early experiences with complex LLR of recurrent CLRM as well as totally laparoscopic synchronous resection of CRC and liver metastases, with very encouraging results. In the presence of extensive bilobar CLRM, two-stage hepatectomy (TSH) and associating liver partition with portal vein ligation (ALPPS) may be adopted to augment an inadequate future liver remnant to facilitate metastasectomy. Interestingly, the adoption of LLR for these techniques also seem to confer additional benefits. Despite the plethora of advantages, LLR comes with its own unique set of limitations such as a steep learning curve and high cost. The surgical world eagerly awaits the results of prospective trials currently underway in order to further advance the management of this disease.

Decision making process in simultaneous laparoscopic resection of colorectal cancer and liver metastases. Review of literature

Purpose:

The benefits of laparoscopic approaches to treat colorectal cancer (CRC) and colorectal liver metastases (CRLM) separately are well established. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged. The objective of this review with practical reports is to discuss technical aspects required for patient selection to perform simultaneous laparoscopic approaches for CRC and CRLM.

Methods:

Literature review of oncological factors associated with patient selection for surgical treatment of CRLM and the use of laparoscopy in those cases, and report of technical aspects for simultaneous CRC and CRLM approaches.

Results:

Simultaneous laparoscopic resection has been successful in many series of selected patients, although it seems to be safer to perform minor and major liver resection with non-extended colorectal resections, and to avoid two high-risk procedures at the same time.

Conclusions:

Simultaneous CRC and CRLM resections seem to be safe when patients are carefully selected, also considering the risk of recurrence concerning oncologic outcomes. The pre-planning of simultaneous resection is mandatory to plan trocar positioning, procedure sequencing, and patient position.

The safety and feasibility of a single incision in simultaneous resection for patients with colorectal cancer liver metastases

Background

The approach of performing a simultaneous resection for patients with colorectal cancer liver metastases has been lauded universally, but the operation procedures have differences. In general, colorectal lesions are removed laparoscopically; however, some liver metastases cannot be resected under laparoscopy. For these patients, the traditional approach of performing a simultaneous resection which utilizes the inferior abdominal midline incision and the right subcostal incision is preferred. In this study, we assessed the safety and feasibility of the single right subcostal incision approach for patients with either rectal or sigmoid colon cancer and liver metastasis who underwent simultaneous resection.

Methods

A total of 85 patients with rectal or sigmoid colon cancer and liver metastases who underwent simultaneous resection from January 2012 to December 2016 in the Cancer Hospital Chinese Academy of Medical Sciences were identified. Clinicopathological data, as well as operative and perioperative outcomes, were collected and analyzed retrospectively.

Results

Overall, 42 patients were included in this study, 26 (61.9%) patients underwent simultaneous resection with a single surgical incision (right subcostal incision), and 16 (38.1%) underwent simultaneous resection with dual surgical incisions (inferior abdominal midline incision and right subcostal incision). Compared to the dual-incision approach, the single-incision approach had a shorter operation time (328.0 vs. 420.0 min, P=0.006) but had no significant differences in total hospitalization time, postoperative hospitalization time, intraoperative blood loss, time of postoperative drainage tube extraction, time to the first postoperative bowel movement, and postoperative complications (P>0.05).

Conclusions

The single-incision approach (right subcostal incision) is feasible and safe for patients with either sigmoid colon or rectal cancer and liver metastases.

Simultaneous Colon and Liver Laparoscopic Resection for Colorectal Cancer with Synchronous Liver Metastases: A Single Center Experience

Background: The one-stage approach for colorectal cancer (CRC) with synchronous liver metastases (SLM) has demonstrated advantages, when feasible, in terms of oncological radicality and reduction in sanitary costs. The simultaneous laparoscopic approach to both colon cancer and liver metastases joins the advantages of mini-invasiveness to the one-stage approach. Methods: During the period from February 2011 to July 2017, a single surgeon performed 17 laparoscopic colorectal operations with simultaneous liver resection for CRC with SLM. Colorectal procedures included 9 rectal resections, 6 left colectomies, and 2 right colectomies. Associated hepatic resections included 1 left hepatectomy, 1 right posterior sectionectomy, 2 segmentectomies, and 13 wedge resections. We analyzed retrospectively the patient's short-term outcome and operative and oncologic results. Results: There was no conversion to open surgery. Six patients (35%) had minor complications (Clavien-Dindo grade I-II), whereas only 2 patients (12%) had major complications (Clavien-Dindo grade III-IV) and no mortality occurred. The median time of discharge was 8.6 (range 5-36) days. We obtained 94% of R0 resection margin on the liver specimen and 100% of negative distal and circumferential margin in case of rectal resection. An average of 20 lymphnodes were retrieved in the colorectal specimen. Conclusions: Simultaneous mini-invasive colorectal and liver resection is a challenging but feasible procedure. The advantages of treating primary cancer and metastases in the same recovery justify the morbidity rate, especially because the most of the complications are minor and no cases of mortality occurred. Further experience is needed to better understand how to reduce the morbidity rate.