Chances, challenges and outcomes of patients with complex bilobar colorectal liver metastases approached by a combined multimodal therapy with liver resection and local ablative therapy

Abstract

Background and Objectives: In treatment of colorectal liver metastases (CRC-LM), liver surgery combined with systemic therapies and local ablation (LAT) allows improved survival. This study aims at the outcomes of patients with complex bilobar CRC-LM who were intended to undergo multimodal therapy with liver resection and LAT. Methods: Forty-three CRC-LM patients with recommendation for multimodal treament were extracted from 5878 tumor board decisions between 2014 and 2017. Outcome variables included patient survival, as well as completion of hepatic clearance. Prognostic factors were identified by correlation and a Cox proportional hazards model. Results: Out of 43 patients only 23 achieved complete clearance of CRC-LM. Oneand 3-year overall survival of patients with cleared liver disease was 100% and 91.7%, respectively, as compared to 83.8% and 12.1%. Incomplete hepatic clearance was the strongest independent risk factor for overall survival (hazards ratio [HR],

Perioperative screening and management in elective complex hepatobiliary surgery

“…Factors, which significantly influence outcomes include the nature of the background hepatic dysfunction and the planned type of surgery/extent of liver resection [2,3 ▪ ,11 ▪ ]. Unfortunately, at present there is no single modality that can reliably predict postoperative liver dysfunction.…”

“…There is increased morbidity and mortality in patients with moderate-to-severe steatosis who undergo major hepatic resection [1,3 ▪ ,16 ▪ ]. Steatosis leads to impaired hepatic microcirculation, which can decrease the resistance to ischemia–reperfusion injury thereby increasing risk of PHLF to 14% compared with 4% in patients without steatosis [2,11 ▪ ,17 ▪ ]. Perioperative risk in patients with cirrhosis is influenced by hepatic dysfunction, portal hypertension and other attendant complications [18,19 ▪ ].…”

“…Neoadjuvant chemotherapy, particularly oxaliplatin (sinusoidal obstruction syndrome) and irinotecan (steatohepatitis) can be hepatotoxic and is associated with increased morbidity and PHLF [2,5 ▪▪ ,18]. However, the benefits of neoadjuvant therapy may counterbalance any hepatotoxic effects, which are often reversible.…”

“…In addition to FLR volume, the volumetric response to PVE is an important prognostic factor and can help identify patients at high risk of PHLF and death. A significantly higher risk of PHLF is observed in patients demonstrating 5% or less FLR hypertrophy after embolization [2,3 ▪ ,11 ▪ ,30 ▪ ,37]. Systemic reviews and meta-analyses have shown that patients undergoing resection after PVE demonstrated a significantly lower incidence of PHLF and death in these patients compared with series reporting outcomes after major hepatectomy without PVE [5 ▪▪ ,22,28 ▪▪ ,30 ▪ ,37].…”

“…Advances in anaesthetic and surgical management of patients undergoing complex hepatobiliary (HPB) surgery have led to substantial reductions in postoperative complications. Although elective, it remains an onerous undertaking and multiple factors contribute to the attendant increased risks [1,2,3 ▪ ,4 ▪▪ ]. An accurate preoperative risk stratification of these patients allows their treatment plans to be adjusted according to the severity and nature of the underlying liver disease, as well as to the type of surgery being undertaken [5 ▪▪ ,6 ▪▪ ].…”