Synchronous Liver Resection

Peter Lodge

Powerpoint File

Colorectal cancer remains the second most common cause of cancer death in the Western World. Haematogenous spread to the liver occurs in 40-60% of colorectal cancer patients. Synchronous lesions are detected in 15-25% and metachronous metastases are detected in a similar percentage within three years of potentially curative colorectal resection. Liver resection remains the “gold standard” potentially curative treatment for colorectal liver metastases with reported median survival times of 35-69 months. Synchronous metastases have been presumed to represent a more aggressive tumour. This presumption, however, has not been proven in our experience and in most other reports. This earlier belief may have influenced the attitude of the referring clinician for patients with liver metastases by referring patients with metachronous metastases sooner than those with synchronous metastases.

Several groups have recently examined the question of whether patients presenting with synchronous liver metastases should be offered concurrent liver and colorectal resection or whether it is more appropriate to carry out staged colectomy and hepatectomy. The Mayo Clinic group led by David Nagorney has looked at this in a series of 96 consecutive patients – 64 underwent concurrent surgery and 32 had staged procedures1. Patient demographics were similar. Post-operative morbidity, disease free survival and overall survival was similar for the two groups and there was no perioperative mortality reported. The overall duration of hospitalisation was significantly shorter for concurrent than for staged resections. A recent Japanese study has come to similar conclusions2. This group looked at 39 consecutive patients with synchronous colorectal liver metastases who underwent single stage hepatectomy with colorectal resection. The only risk factor identified for post-operative morbidity was the volume of liver resected although age and tumour differentiation affected long term survival. This group concluded that a 1-stage procedure was desirable except in patients aged over 70 and those with poorly differentiated primary tumours.

In Europe, the Strasbourg group led by Daniel Jaeck is best known for their aggressive approach to colorectal metastases. Their article in the British Journal of Surgery in 2003 looked at 97 patients who had presented with synchronous disease3. 35 underwent synchronous hepatic and colorectal resection and 62 a delayed hepatectomy. The morbidity rate did not differ significantly and the overall survival rate was similar. Leslie Blumgart’s group at the Memorial Sloan Kettering Cancer Center in New York have also reported on their experience in 20034. 240 patients were studied – 134 underwent simultaneous resection and 106 had a delayed hepatectomy. In both this series and Jaeck’s study, the simultaneous group were undergoing a less extensive liver resection for classically more favourable metastases. However, there were less peri-operative complications in the simultaneous group with a shorter overall hospitalisation. The mortality rate was similar (3 patients in each group) . This group have recommended simultaneous resection as a safe option with similar outcomes but reduced complications and costs. Several other small experiences have been reported.

Our own experience with hepatectomy for colorectal liver metastases suggest that many of the old criteria for resection should now be left behind5-8. Advances in liver resection procedures and adjuvant therapies mean that fewer liver tumours should be considered as unresectable. Earlier referral and rapid assessment are required to improve outcomes. The development of larger cancer centres with both the ability and capacity to plan simultaneous resection is an important consideration for the future. Currently in the U.K. logistics and capacity issues prevent this practice in all but a very few cases.

References

1. Chua et al. Concurrent vs staged colectomy and hepatectomy for primary colorectal cancer with synchronous hepatic metastases. Dis Colon Rectum 2004; 47: 1310-6
2. Tanaka K et al. Outcome after simultaneous colorectal and hepatic resection for colorectal cancer with synchronous metastases. Surgery 2004; 136: 650-9.
3. Weber JC et al. Simultaneous resection of colorectal primary tumour and synchronous liver metastases. Br J Surg 2003; 90: 956-62.
4. Martin R et al. Simultaneous liver and colorectal resection are safe for synchronous colorectal liver metastasis. J Am Coll Surg 2003; 197: 233-42.
5. Sharpe J, Hamady ZZ, Lodge JP. Hepatic resection for colorectal metastasis; time to challenge the accepted doctrine. Minerva Chir. 2005 Oct;60(5):375-89.
6. Nishio H, Hidalgo E, Hamady ZZ, Ravindra KV, Kotru A, Dasgupta D, Al-Mukhtar A, Prasad KR, Toogood GJ, Lodge JP. Left hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role. Ann Surg. 2005 Aug;242(2):267-75.
7. Lodge JP, Menon KV, Fenwick SW, Prasad KR, Toogood GJ. In-contiguity and non-anatomical extension of right hepatic trisectionectomy for liver metastases. Br J Surg. 2005 Mar;92(3):340-7.
8. Hamady ZZ, Kotru A, Nishio H, Lodge JP. Current techniques and results of liver resection for colorectal liver metastases. Br Med Bull. 2004 Oct 27;70:87-104.