Review
Synchronous resection for colorectal liver metastases: The future

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Abstract

Colorectal Cancer is a common malignancy. Many patients have metastatic disease at presentation and a significant proportion subsequently go onto develop metastatic disease, following surgery for the primary disease.

Some groups advocate that synchronous metastatic disease should be resected at the same time as the primary, whereas others believe that outcomes are better following delayed resection for metastatic disease. The following review aims to outline the arguments in favour of both and to suggest some broad guidelines.

Section snippets

Background

As many as 25% of colorectal cancer patients will have liver metastasis (CRLM) at presentation and a further 20–30% will develop metachronous disease following colorectal surgery.1 Hepatectomy is feasible in 20% of cases and five year survival rates of up to 37–58% have been reported.2

When hepatic metastases are diagnosed concurrently with the primary colorectal tumour, the timing of surgical intervention remains controversial. Traditionally most centres have adopted a staged treatment with the

Arguments against synchronous resection

Traditionally patients who have simultaneous detection of hepatic metastases and primary colorectal disease were regarded as a less favourable group in terms of tumour biology, as metastasis had occurred even before diagnosis.3, 4, 5 Most surgeons have advocated resection of the primary disease first, followed by hepatic resection if the disease has remained operable in the interval time period.6

R0 resection may appear technically feasible at the time of surgery for the primary, however,

Arguments for synchronous resection

Several developments over the past few years have challenged the classical strategy of interval hepatic resection. In particular the continuing development of anaesthesia and critical care, improvements in radiological imaging and developments in hepato-biliary surgery have allowed traditional methods to be questioned.6 Increased pressures to decrease health care costs have also contributed to alternative approaches being considered. Clear disadvantages associated with staged resections include

Recommendations

We believe that there are certain situations which preclude a synchronous resection. Liver metastases found during emergency colorectal cancer resection (following obstruction, perforation or bleeding) should not be resected synchronously due to the high likelihood of peritoneal and other overt disease.25 Additionally, cases where the probability of post-operative liver insufficiency is increased (cirrhotics or patients in whom a major hepatectomy is being undertaken) should not undergo

Conflict of interest statement

None of the authors have any conflicting interests.

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