Laparoscopic and robot-assisted one-stage resection of colorectal cancer with synchronous liver metastases: a pilot study

Background/purpose

One-stage resection of primary colon cancer and synchronous liver metastases is considered an effective strategy of cure. A laparoscopic approach may represent a safe and advantageous choice for selected patients with the aim of improving the early outcome.

Methods

Between January 2008 and October 2008, 7 patients underwent one-stage laparoscopic resection for primary colorectal cancer combined with laparoscopic or robot-assisted liver resection.

Results

A total of five laparoscopic left-colon, one right-colon, and one rectal resections were performed. Three patients underwent preoperative left-colon stenting and two received neoadjuvant chemotherapy. The patient with rectal cancer underwent neoadjuvant radiotherapy. Liver procedures included one bisegmentectomy (segments 2, 3), 3 segmentectomies, 6 metastasectomies, and four laparoscopic ultrasound-guided radiofrequency ablations (LUG-RFAs). One patient with multiple liver metastases was managed by a two-stage hepatectomy partially conducted by a totally laparoscopic approach. The overall postoperative morbidity was null. The median hospital stay was 10 days (range 7–10 days).

Conclusions

This pilot study suggests that laparoscopic one-stage colon and liver resection is feasible and safe. Robot assistance may facilitate liver resection, increasing the number of patients who may benefit from a minimally invasive operation.     

The liver-first approach for synchronous colorectal liver metastasis: a 5-year single-centre experience

BackgroundFor patients who present with synchronous colorectal carcinoma and colorectal liver metastasis (CRLM), a reversed treatment sequence in which the CRLM are resected before the primary carcinoma has been proposed (liver-first approach). The aim of the present study was to assess the feasibility and outcome of this approach for synchronous CRLM.MethodsBetween 2005 and 2010, 22 patients were planned to undergo the liver-first approach. Feasibility and outcomes were prospectively evaluated.ResultsOf the 22 patients planned to undergo the liver-first strategy, the approach was completed in 18 patients (81.8%). The main reason for treatment failure was disease progression. Patients who completed treatment and patients who deviated from the protocol had a similar location of the primary tumour, as well as comparable size, number and distribution of CRLM (all P > 0.05). Post-operative morbidity and mortality were 27.3% and 0% following liver resection and 44.4% and 5.6% after colorectal surgery, respectively. On an intention-to-treat-basis, overall 3-year survival was 41.1%. However, 37.5% of patients who completed the treatment had developed recurrent disease at the time of the last follow-up.ConclusionsThe liver-first approach is feasible in approximately four-fifths of patients and can be performed with peri-operative mortality and morbidity similar to the traditional treatment paradigm. Patients treated with this novel strategy derive a considerable overall-survival-benefit, although disease-recurrence-rates remain relatively high, necessitating a multidisciplinary approach.     

Laparoscopic major liver resection in Korea: a multicenter study

Introduction

We report our experience with laparoscopic major liver resection in Korea based on a multicenter retrospective study.

Materials and methods

Data from 1,009 laparoscopic liver resections conducted from 2001 to 2011 were retrospectively collected. Twelve tertiary medical centers with specialized hepatic surgeons participated in this study.

Results

Among 1,009 laparoscopic liver resections, major liver resections were performed in 265 patients as treatment for hepatocellular carcinoma, metastatic tumor, intrahepatic duct stone, and other conditions. The most frequently performed procedure was left hemihepatectomy (165 patients), followed by right hemihepatectomy (53 patients). Pure laparoscopic procedure was performed in 190 patients including 19 robotic liver resections. Hand-assisted laparoscopic liver resection was performed in three patients and laparoscopy-assisted liver resection in 55 patients. Open conversion was performed in 17 patients (6.4 %). Mean operative time and estimated blood loss in laparoscopic major liver resection was 399.3 ± 169.8 min and 836.0 ± 1223.7 ml, respectively. Intraoperative transfusion was required in 65 patients (24.5 %). Mean postoperative length of stay was 12.3 ± 7.9 days. Postoperative complications were detected in 53 patients (20.0 %), and in-hospital mortality occurred in two patients (0.75 %). Mean number and mean maximal size of resected tumors was 1.22 ± 1.54 and 40.0 ± 27.8 mm, respectively. R0 resection was achieved in 120 patients with hepatic tumor, but R1 resection was performed in eight patients. Mean distance of safe resection margin was 14.6 ± 15.8 mm.

Conclusions

Laparoscopic major liver resection has become a reliable option for treatment of liver disease in Korea.     

Searching for the link; mechanisms underlying liver regeneration and recurrence of colorectal liver metastasis post partial hepatectomy

Despite excellent treatment of primary colorectal cancer, the majority of deaths occur as a result of metastasis to the liver. Recent population studies have estimated that one quarter of patients with colorectal cancer will incur synchronous or metachronous colorectal liver metastasis. However, only one quarter of these patients will be eligible for potentially curative resection. Tumor recurrence occurs in reportedly 60% of patients undergoing hepatic resection, and the majority of intrahepatic recurrence occurs within the first 6 months of surgery. The livers innate ability to restore its homeostatic size, and volume facilitates major hepatic resection that currently offers the only chance of cure to patients with extensive hepatic metastases. Experimental and clinical evidence supports the notion that following partial hepatectomy, liver regeneration (LR) paradoxically drives tumor progression and increases the risk of recurrence. It is becoming increasingly clear that the processes that drive liver organogenesis, regeneration, and tumor progression are inextricably linked. This presents a major hurdle in the management of colorectal liver metastasis and other hepatic malignancies because therapies that reduce the risk of recurrence without hampering LR are sought. The processes and pathways underlying these phenomena are multiple, complex, and cross‐communicate. In this review, we will summarize the common mechanisms contributing to both LR and tumor recurrence.     

Repeat hepatectomy for colorectal metastases

The utility of repeat hepatectomy for patients with colorectal metastases to the liver was sought. A complete review of the results of surgical treatment of patients having a repeat hepatectomy was presented. Then, the data on 170 patients in whom multiple clinical variables had been tabulated were selected for special study. These statistical analyses showed that there were no special clinical features present at the time of primary resection of the large bowel cancer that could distinguish these patients. There were some differences in the clinical features of these patients at the time of first and second liver resections. The disease-free interval, method of diagnosis, presence of extrahepatic disease, incidence of complete resection, and postoperative morbidity showed significant differences. The 5-year survival of the group as a whole was 32%. Only those clinical features which involved the completeness of cancer resection had a significant impact on survival. To optimize selection for a long-term survival, no extrahepatic disease should be present and the second hepatectomy should involve removal of all visible tumor. Repeat hepatectomy for colorectal metastases was thought to be justified if the patient was made clinically disease-free, because surgery remains the only potentially curative treatment. The repeat hepatectomy was relatively safe with a low morbidity and conferred a 32% long-term survival.     

A standard definition of major hepatectomy: resection of four or more liver segments

BackgroundWhile commonly used to describe liver resections at risk for post-operative complications, no standard definition of ‘major hepatectomy’ exists. The objective of the present retrospective study is to specify the extent of hepatic resection that should describe a major hepatectomy.MethodsDemographics, diagnoses, surgical treatments and outcomes from patients who underwent a liver resection at two high-volume centres were reviewed.ResultsFrom 2002 to 2009, 1670 patients underwent a hepatic resection. Post-operative mortality and severe, overall and hepatic-related morbidity occurred in 4.4%, 29.7%, 41.6% and 19.3% of all patients. Mortality (7.4% vs. 2.7% vs. 2.6%) and severe (36.7% vs. 24.7% vs. 24.1%), overall (49.3% vs. 40.6% vs. 35.9%) and hepatic-related (25.6% vs. 16.4% vs. 15.2%) morbidity were more common after resection of four or more liver segments compared with after three or after two or fewer segments (all P < 0.001). There were no significant differences in any post-operative outcome after resection of three and two or fewer segments (all P > 0.05). On multivariable analysis, resection of four or more liver segments was independently associated with post-operative mortality and severe, overall, and hepatic-related morbidity (all P < 0.01).ConclusionsA major hepatectomy should be defined as resection of four or more liver segments.     

Laparoscopic liver resection: experience of 53 procedures at a single center

Background/Purpose

The short-term outcome following laparoscopic liver resection at a single center is presented.

Methods

Fifty-three procedures were carried out in 47 patients, between August 1998 and April 2004 (6 patients were resected on two occasions). A previous laparotomy and/or hepatectomy had been done in 83% and 26% of the procedures, respectively. Colorectal metastasis was the main indication for treatment (42/53). A total laparoscopic approach was applied.

Results

Three of the 53 (6%) procedures were converted to laparotomy. In one additional procedure, radiofrequency ablation was done instead of resection. Sixty liver resections were done during the 49 procedures completed laparoscopically as planned (9 patients had concomitant resections performed). Nonanatomic (45/60) and anatomic (15/60; left lobectomies) resections were done. Tumor tissue was found in the resection margins of 6% of the specimens. The free margin was very short in 8% of the specimens. The morbidity was 16%. There was no mortality. Blood transfusions were given following 26% of the procedures. The median hospital stay was 3.5 days (range, 1–14 days) and the median number of days on which there was a need for opioids was 1 (range, 0–11 days).

Conclusions

Laparoscopic liver resection can be performed safely and seems to offer short-term benefits to the patients. Randomized studies are required to further evaluate the potential benefits of this treatment.     

结直肠癌肝转移外科治疗的共识与争议

结直肠癌肝转移是导致结直肠癌患者死亡的主要原因。目前,循证医学证据表明手术切除是结直肠癌肝转移患者有效且可能获得长期生存的惟一治疗方式。随着外科技术尤其是微创外科技术的进步,越来越多的患者可从外科手术中获益。化学药物的发展以及贝伐单抗和西妥昔单抗等靶向药物的应用,使不可切除的结直肠癌肝转移转化为可切除,从而使更多患者获得治愈的机会。对于无法根治性切除的患者,外科手术联合射频治疗的方法可延长生存期。多学科合作团队诊治模式的广泛应用,使结直肠癌肝转移的治疗更加精准。     

Laparoscopic hepatectomy for liver tumors: proposals for standardization

Background/purpose

We draw on our experience with laparoscopic hepatectomy (LH) to present recommendations for standardization of LH for the treatment of liver tumors.

Methods

At our center, 90 LHs were performed from April 1993 to January 2008. These were divided equally into early cases and late cases, and short-term postoperative results were compared. Forty-nine of the LH procedures were total-laparoscopic procedures, 16 were hand-assisted procedures, and 25 were laparoscopy-assisted procedures. The tumors were malignant in 76 cases and benign in 14 cases.

Results

Among late cases, the numbers of malignant tumors and tumors located in the posterosuperior region of the liver (Segments VII, VIII, and IVb) were significantly higher than among early cases; however, operative blood loss and postoperative hospital stay were significantly lower in the late cases (158.9 ± 213.4 vs. 377.6 ± 421.2 cc, P = 0.007; and 8.7 ± 3.6 vs. 15.3 ± 8.7 days, P = 0.0001, respectively). No operative deaths occurred in either group.

Conclusions

Although LH does have a steep learning curve, we believe that it can be standardized and provide a less invasive surgical option—with no reduction in disease curability—for the treatment of liver tumors in selected patients.     

Simultaneous colorectal and parenchymal-sparing liver resection for advanced colorectal carcinoma with synchronous liver metastases: Between conventional and mini-invasive approaches

The optimal timing of surgery in case of synchronous presentation of colorectal cancer and liver metastases is still under debate. Staged approach, with initial colorectal resection followed by liver resection (LR), or even the reverse, liver-first approach in specific situations, is traditionally preferred. Simultaneous resections, however, represent an appealing strategy, because may have perioperative risks comparable to staged resections in appropriately selected patients, while avoiding a second surgical procedure. In patients with larger or multiple synchronous presentation of colorectal cancer and liver metastases, simultaneous major hepatectomies may determine worse perioperative outcomes, so that parenchymal-sparing LR should represent the most appropriate option whenever feasible. Mini-invasive colorectal surgery has experienced rapid spread in the last decades, while laparoscopic LR has progressed much slower, and is usually reserved for limited tumours in favourable locations. Moreover, mini-invasive parenchymal-sparing LR is more complex, especially for larger or multiple tumours in difficult locations. It remains to be established if simultaneous resections are presently feasible with mini-invasive approaches or if we need further technological advances and surgical expertise, at least for more complex procedures. This review aims to critically analyze the current status and future perspectives of simultaneous resections, and the present role of the available mini-invasive techniques.     

Meta‐analysis of simultaneous versus staged resection for synchronous colorectal liver metastases

Aim: There is no clear consensus on the optimal timing of surgical resection for synchronous colorectal liver metastases (SCLM). This study is a meta‐analysis of the available evidence. Methods: Systematic review and meta‐analysis of trials comparing outcomes following simultaneous resection with staged resection for SCLM published from 1990 to 2010 in PubMed, Embase, Ovid and Medline. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either the fixed effects or random effects model. Results: Nineteen non‐randomized controlled trials (NRCT) studies were included in this analysis. These studies included a total of 2724 patients: 1116 underwent simultaneous resection and 1608 underwent staged resection. Meta‐analysis showed that shorter hospital stay (P < 0.001) and lower total complication rate (P < 0.001) were observed in patients undergoing simultaneous resection group. The overall survival rate in the simultaneous resection group did not statistically differ with that in the staged resection group at 1 year (P = 0.13), 3 years (P = 0.26), 5 years (P = 0.38), as well as the 1, 3 and 5 years disease‐free survival rates (respectively, P = 0.55; P = 0.16; P = 0.12). No significant difference was noted between the two groups in terms of mortality (P = 0.16), intraoperative blood loss (P = 0.06) and recurrence (P = 0.47). Conclusion: Simultaneous resection is safe and efficient in the treatment of patients with SCLM while avoiding a second laparotomy. In selected patients, simultaneous resection might be considered as the preferred approach. However, the findings have to be carefully interpreted due to the lower level of evidence and the existence of heterogeneity.     

Laparoscopic versus open left lateral hepatectomy

Laparoscopic liver surgery is becoming more popular, and many high-volume liver centers are now gaining expertise in this area. Laparoscopic left lateral hepatectomy (LLLH) is a standardized and anatomically well-defined resection and may transform into a primarily laparoscopic procedure for cancer surgery or living donor hepatectomy for transplantation. Five case–control series were identified comparing a total of 167 cases (86 cases of LLLH plus 81 cases of open left lateral hepatectomy). Groups were matched by age and sex, with broadly similar indications for surgery and resection techniques. LLLH is associated with shorter hospital stays and less blood loss without compromising the margin status or increasing complication rates. Donors of LLLH grafts did not have higher graft-related morbidity. Prospective studies are required to define the safety in terms of disease-free and overall survival in this new avenue in laparoscopic liver surgery.     

Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy?

Laparoscopic hepatectomy (LH) has become popular as a surgical treatment for liver diseases, and numerous recent studies indicate that it is safe and has advantages in selected patients. Because of the magnified view offered by the laparoscope under pneumoperitoneal pressure, LH results in less bleeding than open laparotomy. However, gas embolism is an important concern that has been discussed in the literature, and experimental studies have shown that LH is associated with a high incidence of gas embolism. Major hepatectomies are done laparoscopically in some centers, even though the risk of gas embolism is believed to be higher than for minor hepatectomy due to the wide transection plane with dissection of major hepatic veins and long operative time. At many high-volume centers, LH is performed at a pneumoperitoneal pressure less than 12 mmHg, and reports indicate that the rate of clinically severe gas embolism is low. However, more studies will be necessary to elucidate the optimal pneumoperitoneal pressure and the incidence of gas embolism during LH.     

Repeat liver resection after a hepatic or extended hepatic trisectionectomy for colorectal liver metastasis

Objective: A right and left hepatic trisectionectomy and an extended trisectionectomy are the largest liver resections performed for malignancy. This report analyses a series of 23 patients who had at least one repeat resection after a hepatic trisectionectomy for colorectal liver metastasis (CRLM).Methods: A retrospective analysis of a single-centre prospective liver resection database from May 1996 to April 2009 was used for patient identification. Full notes, radiology and patient reviews were analysed for a variety of factors with respect to survival.Results: Twenty-three patients underwent up to 3 repeat hepatic resections after 20 right and 3 left hepatic trisectionectomies. In 18 patients the initial surgery was an extended trisectionectomy. Overall 1-, 3- and 5-year survival rates after a repeat resection were 100%, 46% and 32%, respectively. No factors predictive for survival were identified.Conclusion: A repeat resection after a hepatic trisectionectomy for CRLM can offer extended survival and should be considered where appropriate.     

Perioperative chemotherapy with bevacizumab and liver resection for colorectal cancer liver metastasis

Background:

Surgery remains the only curative option for patients with colorectal cancer liver metastases (CRLM). Perioperative chemotherapeutic strategies have become increasingly popular in the treatment of CRLM. Although the role of bevacizumab (Bev) in this setting remains unclear, its widespread use has raised concerns about the use of Bev as part of perioperative chemotherapy.

Methods:

We retrospectively reviewed all patients who received Bev and underwent liver resection between July 2004 and July 2008 at the McGill University Health Center. Chemotherapy-related toxicity, response to chemotherapy, surgical morbidity and mortality, liver function and survival data were assessed.

Results:

A total of 35 patients were identified. Of these, 26 (74.3%) patients received oxaliplatin-based cytotoxic chemotherapy, six (17.1%) received irinotecan-based therapy and the remainder received both agents. A total of 17 patients (48.6%) underwent portal vein embolization prior to resection and 12 (34.3%) underwent staged resection for extensive bilobar disease. A median of six cycles of preoperative Bev were administered. Nine patients (25.7%) experienced grade 3 or higher chemotherapy-related toxicities. Four events were deemed to be related to Bev. The overall response rate was 65.7% (complete and partial response). One patient progressed on therapy, but this did not prevent R0 resection. The incidence of postoperative morbidity was 42.3%. A total of 21.7% of complications were Clavien grade 3 or higher. There were no perioperative mortalities. There were no cases of severe sinusoidal injury or steatohepatitis. The Kaplan–Meier estimate of 4-year survival was 52.5%.

Conclusions:

These data confirm the safety of chemotherapy regimens which include Bev in the perioperative setting and demonstrate that such perioperative chemotherapy in patients with CRLM does not adversely affect patient outcome. There was no increase in perioperative morbidity compared with published rates. The addition of Bev to standard chemotherapy may improve response rates, which may, in turn, impact favourably on patient survival.     

Laparoscopic liver resection: a systematic review

Background

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature.

Methods

Studies about LLR published before September 2008 were identified and their results summarized.

Results

Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required.

Conclusions

Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.     

Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis

BackgroundAs indications for liver resection expand, objective measures to assess the risk of peri-operative morbidity are needed. The impact of sarcopenia on patients undergoing liver resection for colorectal liver metastasis (CRLM) was investigated.MethodsSarcopenia was assessed in 259 patients undergoing liver resection for CRLM by measuring total psoas area (TPA) on computed tomography (CT). The impact of sarcopenia was assessed after controlling for clinicopathological factors using multivariate modelling.ResultsMedian patient age was 58 years and most patients (60%) were male. Forty-one (16%) patients had sarcopenia (TPA ≤ 500 mm²/m²). Post-operatively, 60 patients had a complication for an overall morbidity of 23%; 26 patients (10%) had a major complication (Clavien grade ≥3). The presence of sarcopenia was strongly associated with an increased risk of major post-operative complications [odds ratio (OR) 3.33; P= 0.008]. Patients with sarcopenia had longer hospital stays (6.6 vs. 5.4 days; P= 0.03) and a higher chance of an extended intensive care unit (ICU) stay (>2 days; P= 0.004). On multivariate analysis, sarcopenia remained independently associated with an increased risk of post-operative complications (OR 3.12; P= 0.02). Sarcopenia was not significantly associated with recurrence-free [hazard ratio (HR) = 1.07] or overall (HR = 1.05) survival (both P > 0.05).ConclusionsSarcopenia impacts short-, but not long-term outcomes after resection of CRLM. While patients with sarcopenia are at an increased risk of post-operative morbidity and longer hospital stay, long-term survival is not impacted by the presence of sarcopenia.     

Hepatic resections for bilobar liver metastases from colorectal cancer

The present study was performed to assess survival benefits in patients who underwent a hepatic resection for isolated bilobar liver metastases from colorectal cancer. Thirty-eight patients underwent a curative hepatic resection for isolated colorectal liver metastasis. Among them, 11 patients had bilobar liver metastases and 19 had a solitary metastasis. The remaining 8 patients had unilobar multiple lesions. We investigated survival in two groups those with bilobar and those with solitary metastatic tumors. Survival and disease-free survival were 36% and 18% at 5 years, respectively, in the patients with bilobar liver metastases, while these survivals were 43% and 34% in the patients with solitary liver metastasis. In the 38 patients, repeated hepatic resections were performed in 15 patients with recurrent liver disease. The 5-year survival and disease-free survival rates for these patients were 38% and 27%, respectively, after the second hepatic resections. Of the 11 patients with bilobar liver metastases, 5 underwent a repeated hepatic resection, and they all survived for over 42 months. Based on our observations, a hepatic resection was thus found to be effective even in selected patients with either bilobar nodules or recurrence in the remnant liver.