Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: A case matched study

https://doi.org/10.1016/j.ejso.2009.11.007Get rights and content

Abstract

Background

Traditionally, a staged operative approach has been used for patients with synchronous colorectal cancer and liver metastases in the U.K. With improved outcomes from hepatic resection the role of a synchronous operative approach needs re-evaluated.

Methods

32 consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach were individually case matched (according to: age; sex; ASA grade; type of hepatic and colonic resection) with patients that had undergone a staged approach. The following variables were analysed: operative blood loss; in hospital morbidity and mortality; duration of hospital stay; disease free and overall survival.

Results

Operative blood losses were: synchronous group, median 475 mL (range 150–850 mL) vs median 425 mL (range 50–1700 mL), (p > 0.050). There were no significant differences in morbidity: (34% synchronous group vs 59%, p = 0.690) with no recorded mortality. Synchronous group had a shorter hospital stay (median 12 days [range 8–21] vs 20 [range 7–51], p = 0.008). There were no statistical differences between synchronous and staged patients for disease free and overall survival: 10 months (95% CI 5.8–13.7) versus 14 (95% CI 12.2–16.3; p = 0.487) and 21% versus 24% at 5 years (p = 0.838).

Conclusion

This present study provides supporting evidence for synchronous operative procedures in patients with colorectal liver metastases.

Introduction

Synchronous colon cancer with liver metastases presents a unique opportunity to deal simultaneously with both the primary and secondary disease. With at least 25% of patients with colorectal cancer presenting with liver metastases at time of initial diagnosis, there is potential to perform combined hepatic and colonic resections, as well as local ablative techniques at the same laparotomy.1 This synchronous operative approach offers the advantage to the patient of a single laparotomy and hospital stay, allowing early instigation of aggressive adjuvant therapy when indicated. In addition, one hospital stay is likely to be more cost effective than the traditional staged approach with up to twelve weeks, the usual interval, between colonic resection and hepatic resection.

Despite these potential advantages, the staged approach remains the standard policy in most colorectal units in the United Kingdom. This is primarily based on evidence from earlier studies that suggested a significantly higher morbidity and mortality in patients undergoing synchronous resections compared to a staged approach.2, 3, 4, 5, 6 Indeed, one study reported mortality as high as 17% in patients undergoing synchronous resections.7

The quality of hepatic surgery has improved greatly over the last two decades with advances in surgical and anaesthetic techniques, as well as radiological imaging, leading to improved short and long term outcomes.8, 9, 10, 11 Furthermore, with the introduction of radiofrequency (RF) ablation12, 13, 14 and other ablative techniques, the traditional exclusion criteria of bilobar disease and multiple hepatic metastases are no longer absolute contraindications to performing partial hepatectomy. As a result, attention has turned again to the role of synchronous resections, where caution is still advised especially if major colonic or hepatic surgery is being considered.15, 16

It has been the policy in this small volume surgical department to pursue a synchronous operative approach in the treatment of metastatic colorectal cancer. To determine short and long term patient outcomes, this study cased matched patients undergoing synchronous procedures to patients undergoing staged procedures.

Section snippets

Patients

Ethical approval for this study was obtained from the local research and ethics committee. Thirty two consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach (synchronous group) were individually case matched with patients that had undergone a staged approach (staged group). The patients in the staged group had their colonic resection performed at another hospital and were subsequently referred to this unit for treatment of their

Results

There were no statistical differences found between the synchronous and staged groups for age, sex and ASA grade. In addition, there were no differences in TNM staging and Clinical Risk Score between the two groups with similar numbers of patients having undergone chemotherapy and/or radiotherapy (Table 1). Seventy–eight percent of colorectal operations were classified at major resections with 22% major hepatic resections performed (Table 2). RF ablation was performed in six patients (five

Discussion

The evidence for performing staged colonic and hepatic resections comes from several earlier studies that suggested an associated greater blood loss, higher morbidity and higher mortality with synchronous surgery.2, 3, 4, 6 However, the majority of these studies were performed before the time frame of significant improvements in patient outcomes with hepatic resection. In addition, it is difficult to evaluate these early studies as there was no accepted definition of the term synchronous

Conclusion

In conclusion, this study provides supporting evidence for the role of synchronous procedures in patients with colorectal liver metastases confirming that major colorectal resections can be safely performed in tandem with hepatic resections to provide effective oncological surgery.

Conflict of interest

There is no conflict of interest in this manuscript.

Funding

No funding was received for this study.

References (29)

  • J. Scheele

    Hepatectomy for liver metastases

    British Journal of Surgery

    (1993)
  • D. Jaeck et al.

    Surgical treatment of synchronous hepatic metastases of colorectal cancers. Simultaneous or delayed resection?

    Annales de Chirurgie

    (1996)
  • J.S. Bolton et al.

    Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma

    Annals of Surgery

    (2000)
  • J.D. Cunningham et al.

    One hundred consecutive hepatic resections. Blood loss, transfusion, and operative technique

    Archives of Surgery

    (1994)
  • Cited by (35)

    • Surgical treatment of stage IV colorectal cancer with synchronous liver metastases: A systematic review and network meta-analysis

      2020, European Journal of Surgical Oncology
      Citation Excerpt :

      Throughout the years many different definitions have been used to describe synchronous liver metastases. Most commonly synchronous metastases were reported as LM diagnosed at the time of diagnosis of the primary tumor [20,25,34,41,57,58], diagnosed preoperatively [22,28,30,33,37,50,63], diagnosed before or during the primary tumor surgery [17,24,29,32,39,42,52–55,61,62]. Others defined synchronicity as LM diagnosed one year before to three months after the diagnosis of the primary tumor [38], discovered before or at the time of diagnosis of the primary tumor [18], before initiation of treatment [31], diagnosed within 30 [51] or 90 days of the diagnosis of the primary tumor [6], diagnosed within 12 months after diagnosis of the primary tumor and before any surgical intervention [21], diagnosed before, during surgery of within 6 [64] or 12 months after primary tumor resection [60].

    • Population level outcomes and costs of single stage colon and liver resection versus conventional two-stage approach for the resection of metastatic colorectal cancer

      2019, HPB
      Citation Excerpt :

      Furthermore, using propensity score matching, we were able to compare relative outcomes between the two patient groups. In a recently published systematic review, Ali and colleagues reported that the occurrence of major complications and mortality after CR + LR ranged from 18 to 30% and 0.0–3.5%, respectively.14 Consistent with these findings, in the current study, postoperative morbidity and mortality following CR + LR were 38.5% and 3.1%, respectively.

    • Simultaneous versus delayed hepatectomy for synchronous colorectal liver metastases: a systematic review and meta-analysis

      2018, HPB
      Citation Excerpt :

      Furthermore, if simultaneous resection is safe, it could improve the patient experience, by reducing the time to definitive surgical control of all disease, reducing the total number of interventions and reducing the costs of hospital treatment. It may also reduce the time to adjuvant chemotherapy.20,30,39 However, the optimal strategy for the treatment of synchronous CRLM is unclear, as there are no randomised trials in this setting.

    • Evaluation of the safety and efficacy of simultaneous resection of primary colorectal cancer and synchronous colorectal liver metastases

      2014, Surgery (United States)
      Citation Excerpt :

      In these studies, the liver metastatic lesions tended to be more severe in the staged resection group than in the simultaneous resection group. In a case-matched study, Moug et al29 demonstrated that there was no difference in OS and RFS between patients who underwent simultaneous resection and those who underwent staged resections; therefore, no clear benefit from intermittent resection was confirmed. Capussotti et al22 suggested that patients with SLM from colorectal cancer with a T4 primary colorectal cancer, those with liver metastasis with infiltration of nearby structures, and, particularly, those with more than three hepatic nodules should receive neoadjuvant chemotherapy.

    • A meta-analysis comparing simultaneous versus delayed resections in patients with synchronous colorectal liver metastases

      2013, Surgical Oncology
      Citation Excerpt :

      The results of the sensitivity analysis are summarized in Table 4. The sensitivity analysis included ten studies ([6,10,22–29]) that scored more than seven stars on the modified Newcastle–Ottawa Scale, ten studies ([10,22,28–35]) that were published after the year 2007, and twelve studies ([8,22,24–27,31,33,34,36,37]) with a total number of patients greater than 50 in the simultaneous resection group. Analysis of the high-quality studies did not show any significant differences between the two groups in terms of: blood loss or the duration of surgery.

    View all citing articles on Scopus
    View full text