Timing of Hepatectomy for Resectable Synchronous Colorectal Liver Metastases: For Whom Simultaneous Resection Is More Suitable - A Meta-Analysis

Abstract

BackgroundThe optimal timing of resection for synchronous colorectal liver metastases is still controversial. Retrospective cohort studies always had baseline imbalances in comparing simultaneous resection with staged strategy. Significantly more patients with mild conditions received simultaneous resections. Previous published meta-analyses based on these studies did not correct these biases, resulting in low reliability. Our meta-analysis was conducted to compensate for this deficiency and find candidates for each surgical strategy.MethodsA systemic search for major databases and relevant journals from January 2000 to April 2013 was performed. The primary outcomes were postoperative mortality, morbidity, overall survival and disease-free survival. Other outcomes such as number of patients need blood transfusion and length of hospital stay were also assessed. Baseline analyses were conducted to find and correct potential confounding factors.Results22 studies with a total of 4494 patients were finally included. After correction of baseline imbalance, simultaneous and staged resections were similar in postoperative mortality (RR = 1.14, P = 0.52), morbidity (RR = 1.02, P = 0.85), overall survival (HR = 0.96, P = 0.50) and disease-free survival (HR = 0.97, P = 0.87). Only in pulmonary complications, simultaneous resection took a significant advantage (RR = 0.23, P = 0.003). The number of liver metastases was the major factor interfering with selecting surgical strategies. With >3 metastases, simultaneous and staged strategies were almost the same in morbidity (49.4% vs. 50.9%). With ≤3 metastases, staged resection caused lower morbidity (13.8% vs. 17.2%), not statistically significant.ConclusionsThe number of liver metastases was the major confounding factor for postoperative morbidity, especially in staged resections. Without baseline imbalances, simultaneous took no statistical significant advantage in safety and efficacy. Considering the inherent limitations of this meta-analysis, the results should be interpret and applied prudently.

Impact of totally laparoscopic combined management of colorectal cancer with synchronous hepatic metastases on severity of complications: a propensity-score-based analysis

“…The advantages of laparoscopy over open surgery have been high lightened in many series, in the setting of both isolated colorectal [12][13][14][15] and hepatic resections [16][17][18][19][20]. Furthermore, more recently even safety and efficacy of combined resections have been reported [7][8][9][10][11], with shorter length of stay and reduced morbidity compared with staged approaches if performed in a selected population of patients [6][7][8]. Although the debate regarding the optimal timing for resection of SCLM is still open [6][7][8], mainly because of concerns regarding a presumptive higher frequency of colonic anastomosis leakage, even combined, totally laparoscopic approach for CRC and SCLM is experiencing a growing trend [21][22][23][24].…”

“…Although the optimal management strategy for patients with SCLM is still a debated issue [6][7][8], safety and efficacy of combined resections of colorectal tumors and liver & Francesca Ratti ratti.francesca@hsr.it metastases have been widely reported, with documented benefits in terms of reduced postoperative morbidity and shorter length of stay, in spite of oncological outcomes comparable to those of staged treatments [7][8][9][10][11]. Moreover, technological advances and acquirement of adequate surgical expertise lead to widespread diffusion of minimally invasive approaches, both for primary CRC [12][13][14][15] and for liver metastases [16][17][18][19][20]: At the same time, even patients' awareness about benefits of laparoscopy (better postoperative pain control, earlier return to autonomous self-care and superior cosmetic result) has increased and contributed to its success.…”

Managing synchronous liver metastases from colorectal cancer: A multidisciplinary international consensus

“…When both the primary tumour and the metastases are resectable, simultaneous resection can be performed in selected patients undergoing limited hepatectomy with similar outcomes to sequential surgery [80,81,13]. Simultaneous resection should be discouraged when the hepatectomy would be major (involving three or more segments) or when complex rectal surgery is to be performed, due to significantly higher postoperative mortality and morbidity [82].…”

“…Currently, preoperative chemotherapy is increasingly being used and, if the CRC is asymptomatic, may be administered before surgery of the primary tumour with the aim of downsizing the metastases and improving resectability rates. As mentioned above, simultaneous resections for CRC and synchronous LM have been shown to be favorable in a number of studies, although caution should be exercised for major combined resections or in patients with comorbid conditions, due to the higher risk of mortality and complications related to simultaneous surgery in this setting [80,81,13,82].…”

Management of colorectal cancer with synchronous liver metastases: impact of multidisciplinary case conference review

“…Of note, no difference was found in location of the primary tumor or extent of liver resection required for patients presented at MCC compared to those who were not discussed, suggesting that the tumor burden of the groups was fairly equivalent. Additionally, the modest sample size of the cohort precludes an indepth analysis of the long-term oncological outcomes following simultaneous versus two-staged resection of colorectal cancer and associated liver metastases; however this question has been addressed in large meta-analyses, with no significant differences in survival identified (30)(31)(32). Furthermore, while simultaneous colorectal resection and major liver resection should be approached with caution, it has been performed safely in experienced centers (33)(34)(35) and may be considered in order to minimize the number of surgeries and overall length of treatment.…”