Short-Term Outcomes after Combined Colon and Liver Resection for Synchronous Colon Cancer Liver Metastases: A Population Study

Abstract

Introduction

The timing of surgical resection for stage IV colon cancer with liver metastasis and the safety of simultaneous colon and liver resection remains controversial. The purpose of our study was to evaluate short-term outcomes after combined colon and liver resection (CCLR) versus colon resection (CR) or liver resection alone (LR) using a population database.

Methods

The National Inpatient Sample was used to select patients who had surgery for colon cancer from 2002 to 2006. We evaluated for in-hospital morbidity, mortality, and prolonged length of stay (PLOS). Our analysis was done using design-weighted unadjusted analysis and logistic regression.

Results

We identified 361,096 patients during our study period (CCLR 3,625; CR 322,286; LR 35,185). CCLR was not associated with an increased risk of complications (odds ratio (OR) 1.12; 95 % confidence interval (CI) 0.94–1.33; P = 0.21) or PLOS (OR 1.19; 95 % CI 0.99–1.4; P = 0.06) compared with CR. In-hospital mortality occurred in 3.5 % of patients who underwent CCLR and was not significantly associated with mortality compared with CR alone (OR 1.17; 95 % CI 0.79–1.74; P = 0.43). Liver lobectomy with CR was associated with a PLOS and a trend toward increased morbidity and mortality. Significant predictors of complications, mortality, and PLOS included: age >70 years, male gender, nonprivate health insurance, and Elixhauser score >1.

Conclusions

CCLR with limited liver resection can be performed with similar morbidity and mortality to colectomy alone. For patients who require hepatic lobectomy, however, strong consideration should be given to a staged approach.

Appendices

Appendix 1: List of Included International Classification of Diseases-9th Edition Procedure and Diagnosis Codes

ICD-9 Diagnosis Codes for Study Cohort

Malignant neoplasm of the colon:

• 153.0 Hepatic flexure

• 153.1 Transverse colon

• 153.2 Descending colon

• 153.4 Cecum

• 153.6 Ascending colon

• 153.7 Splenic flexure

• 153.8 Other specified sites of large intestine

• Exclude

• 154.0-154.9 Malignant neoplasm of the rectum or anus

Secondary malignant neoplasm of the liver:

• 197.7 Liver cancer, specified as secondary

• Exclude

• 155.0 Liver cancer, primary

• 155.1 Intrahepatic bile ducts

• 155.2 Liver cancer, not specified as primary or secondary

• 571.0-571.9 Chronic liver disease and cirrhosis

ICD-9 Procedure Codes for Study Cohort

Colon cancer procedure codes:

• 45.71 Multiple segmental colon resection

• 45.72 Cecum with terminal ileum

• 45.73 Right colectomy

• 45.74 Transverse

• 45.75 Left colectomy

• 45.76 Sigmoid

• 45.79 Colectomy (partial/segmental/subtotal)

• 45.8 Total colectomy

• 45.81 Laparoscopic total intra-abdominal colectomy

• 48.62 Low anterior resection

• 17.31 Laparoscopic multiple segmental resection of large intestine

• 17.33 Laparoscopic right hemicolectomy

• 17.34 Laparoscopic resection of transverse colon

• 17.35 Laparoscopic left hemicolectomy

• 17.36 Laparoscopic sigmoidectomy

Liver cancer procedure codes:

• 50.2 Local excision or destruction of liver tissue or lesion

• 50.22 Partial hepatectomy (Wedge)

• 50.23 Open ablation of liver lesion or tissue

• 50.24 Percutaneous ablation of liver lesion or tissue

• 50.25 Laparoscopic ablation of liver lesion or tissue

• 50.26 Other and unspecified ablation of liver lesion or tissue

• 50.29 Other destruction of lesion of liver

• 50.3 Lobectomy of the liver

Surgical Complication Codes

ICD-9 Procedure Codes

Operational:

• 46.94 Revision of anastomosis of large intestine

• 46.93 Revision of anastomosis of small intestine

• 50.0 Hepatectomy (liver abscess drainage)

• 54.19 Other laparotomy (drainage of intraperitoneal abscess or hematoma)

• 51.98 Other percutaneous procedures on biliary tract (perc transhepatic biliary drainage)

Hematologic:

• 99.0 Transfusion of blood and blood components

• 99.03 Other transfusion of whole blood

• 99.04 Transfusion of packed cells

• 99.05 Transfusion of platelets

ICD-9 Diagnosis Codes

Hematologic:

• 280.0 Blood loss

• 998.1 Hemorrhage or hematoma or seroma complicating a procedure

• 453.41 DVT NOS-lower extremity

• 453.42 DVT of deep vessels of lower extremity

• 451.83 DVT of upper extremity

Wound:

• 729.92 Non traumatic hematoma of soft tissue

• 998.12 Hematoma complicating a procedure

• 998.13 Seroma complicating a procedure, non-infected

• 998.3 Disruption of wound; dehiscence of operation wound, disruption of any suture material or other closure method, rupture of operation wound

• 998.30 Disruption of wound, unspecified

• 998.31 Disruption of internal operation-includes disruption of muscle or muscle flap

• 998.59 Other postoperative infection; abscess (stitch, wound)

• 86.04 Other incision with drainage of skin and subcutaneous tissue

Systemic:

• 038.0-038.0 Septicemia

• 780.60 Fever, unspecified

• 790.7 Bacteremia

• 995.9 Systemic inflammatory response syndrome

• 995.91 Sepsis without acute organ dysfunction

• 995.92 Severe sepsis with acute organ dysfunction

Respiratory:

• 415.11 Iatrogenic pulmonary embolism and infarction

• 415.1 Pulmonary embolism and infarction

• 518.0 Pulmonary collapse-atelectasis

• 480.0, 480.1-480.3, 480.8, 480.9 Viral pneumonia

• 482, 482.0-482.4, 482.8, 482.9 Bacterial pneumonia

• 483.0 Mycoplasma pneumonia

• 486 Pneumonia, organism unspecified

• 481 Pneumococcal pneumonia

• 507.0 Aspiration pneumonia

• 997.31 Ventilator associated pneumonia

• 997.3 Respiratory complications

• 518.82 Other pulmonary insufficiency, NOS-ARDS

• 518.5 Pulmonary insufficiency following trauma or surgery

• 512.1 Iatrogenic pneumothorax post-op

• 512 Pneumothorax

• 521.0 Spontaneous tension pneumothorax

• 518.4 Acute edema of the lung, includes postoperative

• 518.7 Transfusion related acute lung injury

• 511.0 Pleurisy

• 511.1 Pleurisy with effusion

• 799.1 Respiratory arrest

Cardiovascular:

• 997.02 Iatrogenic stroke or hemorrhage (post-op)

• 435 Transient cerebral ischemia

• 436 Acute but ill-defined cerebrovascular disease

• 451 Phlebitis and thrombophlebitis

• 410.0-410.9 Acute myocardial infarction

• 427.0-427.9 Arrhythmia (427.5 cardiac arrest)

Gastrointestinal:

• 997.4 Digestive system complication (complication of anastomosis, hepatic failure, hepatorenal syndrome, intestinal obstruction- as due to a procedure)

• 560.1 Paralytic ileus

• 787.02 Nausea alone

• 787.01 Nausea with vomiting

• 787.0 Nausea and vomiting

• 008.45 Clostridium difficile

• 577.0 Acute pancreatitis

• 576.2 Obstruction of the bile duct

• 576.3 Perforation of bile duct

• 572 Liver abscess and sequelae of chronic liver disease

• 567.29 Subphrenic peritonitis

• 570 Acute and subacute necrosis of liver

• 572.2 Hepatic coma

• 557.0 Acute vascular insufficiency of intestine

• 569.5 Abscess of intestine

• 567.22 Peritoneal abscess

Renal:

• 584 Acute renal failure

• 584.5 ATN

• 584.9 ARF, unspecified

Genitourinary:

• 599.0 Urinary tract infection

• 788.20 Urinary retention