Anterior Approach vs Conventional Hepatectomy for Resection of Colorectal Liver Metastasis

Abstract

IMPORTANCETumor relapse after partial hepatectomy for colorectal liver metastasis (CRLM) remains an unsolved issue. Intraoperative manipulation of the liver during conventional hepatectomy might enhance hematogenous tumor cell spread. The anterior approach is an alternative approach that may reduce intraoperative tumor cell dissemination.OBJECTIVE To determine the efficacy and safety of the anterior approach compared with conventional hepatectomy in patients undergoing resection for CRLM. DESIGN, SETTING, AND PARTICIPANTSThis randomized clinical study evaluated the efficacy and safety of the anterior approach compared with conventional hepatectomy in adult patients with CRLM who were scheduled for hepatectomy from February 1, 2003, to March 31, 2012, at a tertiary-care hospital. A total of 80 patients with CRLM were randomized to the anterior approach and conventional hepatectomy groups in a 1:1 ratio. Bone marrow and blood samples were analyzed for disseminated tumor cells and circulating tumor cells (CTC) using cytokeratin 20 reverse transcriptase-polymerase chain reaction analysis. Data were analyzed from April 1 to December 1, 2018, using intention to treat.INTERVENTIONS Anterior approach vs conventional hepatectomy. MAIN OUTCOMES AND MEASURESThe primary end point was intraoperative CTC detection in central blood samples after liver resection. Secondary end points included postoperative morbidity, mortality, and long-term survival. RESULTS Among the 80 patients included in the analysis (48 men [60%]; mean [SD] age, 61 [10] years), baseline characteristics, including preoperative CTC detection, were comparable between both groups. There was no statistically significant difference in intraoperative CTC detection between patients in the conventional hepatectomy (5 of 21 [24%]) and anterior approach (6 of 22 [27%]) groups (P > .99). Except for a longer operating time in the anterior approach group (mean [SD], 171 [53] vs 221 [53] minutes; P < .001), there were no significant differences in intraoperative and postoperative outcomes between both study groups. Although detection of CTC was associated with poor overall (median, 46 [95% CI,(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52) vs 81 [95% CI, 54-107] months; P = .03) and disease-free (median, 40 [95% CI,(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46) vs 60 [95% CI, 46-74] months; P = .04) survival, there was no significant difference in overall (median, 73 [95% CI, vs 55 [95% CI, 35-75] months; P = .43) and disease-free (median, 48 [95% CI,(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56) vs 40 [95% CI, 28-52] months; P = .88) survival between the conventional hepatectomy and anterior approach groups. Also, there was no significant difference in patterns of recurrence between both groups.CONCLUSIONS AND RELEVANCE This randomized clinical trial found that the anterior approach was not superior to conventional hepatectomy in reducing intraoperative tumor cell dissemination in patients undergoing resection of CRLM.

Infrahepatic Inferior Vena Cava Clamping does not Increase the Risk of Pulmonary Embolism Following Hepatic Resection

“…In the present analysis, all included patients underwent routine thromboprophylaxis. Of note, the rate of clinically relevant posthepatectomy hemorrhage was found to be comparable to other studies [ 31 , 32 ].…”

Survival Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-2)

“…Additionally, any patients who underwent liver resection combined with radiofrequency or microwave ablation were excluded [ 12 ]. Although the anterior approach was used during minimally invasive major hepatectomy, both anterior and posterior approaches were used during open procedures [ 13 ]. Although the safety of concomitant liver resection and colorectal resection has even been shown in robotic-assisted patients, those who underwent simultaneous colorectal surgery were not included in any of the 3 groups [ 14 ].…”

Comparison of ultrasound-guided radiofrequency ablation and hepatectomy for colorectal liver metastasis: A protocol for systematic review and meta-analysis

“…[8] Hepatectomy is currently the most reliable; hepatectomized patients can now achieve long-term survival. [9] However, recurrence has been reported in 50% to 80% of hepatectomized patients, with remnant liver recurrence being the most common and representing approximately half of all recurrences. [10] Ultrasound-guided radiofrequency ablation (RFA), as a common minimally invasive treatment modality, has been widely used in clinical practice for the local control of liver tumors, and previous reports have demonstrated that thermal ablation had an advantage over surgical resection in being less invasive for hepatocellular carcinoma [11,12] ; therefore, it can also be an alternative option for patients with unresectable CRLM.…”