Timing of hepatectomy in resectable synchronous colorectal liver metastases (SCRLM): Simultaneous or delayed?

Abstract

The optimal surgical strategy for treatment of patients with synchronous colorectal liver metastases (SCLRM) remains controversial. We conducted a systematic review and metaanalysis of all observational studies to define the safety and efficacy of simultaneous versus delayed resection of the colon and liver. A search for all major databases and relevant journals from inception to April 2012 without restriction on languages or regions was performed. Outcome measures were the primary parameters of postoperative survival, complication, and mortality, as well as other parameters of blood loss, operative time, and length of hospitalization. The test of heterogeneity was performed with the Q statistic. A total of 2,880 patients were included in the meta-analysis. Long-term oncological pooled estimates of overall survival (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.81-1.14; P 5 0.64; I 2 5 0) and recurrence-free survival (HR: 1.04; 95% CI: 0.76-1.43; P 5 0.79; I 2 5 53%) all showed similar outcomes for both simultaneous and delayed resections. A lower incidence of postoperative complication was attributed to the simultaneous group as opposed to that in the delayed group (modified relative ratio [RR] 5 0.77; 95% CI: 0.67-0.89; P 5 0.0002; I 2 5 10%), whereas in terms of mortality within the postoperative 60 days no statistical difference was detected (RR 5 1.12; 95% CI: 0.61-2.08; P 5 0.71; I 2 5 32%). Finally, selection criteria were recommended for SCRLM patients suitable for a simultaneous resection. Conclusion: Simultaneous resection is as efficient as a delayed procedure for long-term survival. There is evidence that in SCRLM patients simultaneous resection is an acceptable and safe option with carefully selected conditions. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion. (HEPATOLOGY 2013;57:2346-2357 C olorectal cancer (CRC) remains the second leading cause of cancer-related death in Western Europe and North America, and there are more than 940,000 new cases annually and nearly 500,000 deaths each year worldwide. [1][2][3] Up to 50% of patients with CRC might have liver metastases during the course of the disease, and 15% to 20% have synchronous colorectal liver metastases (SCRLM) at the time of diagnosis, whereas an additional 20% to 25% develop metachronous hepatic tumors. [4][5][6][7] The presence of liver metastases has an important influence on patient prognosis, and the median survival is 2.3 to 21.3 months for patients in whom the cancer is nonresected. 3,5,[8][9][10] Furthermore, liver resection has been accepted as the only treatment offering the chance for a cure and long-term survival, with 5-year survival rates of 25% to 60% and 10-year survival rates of 22% to 26% reported in the literature. [11][12][13][14][15][16][17][18][19] However, optimal timing of liver surgery for synchronous metastases remains controversial and continues to evolve. 20 Previously, most series reporting on the surgical management ...

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.…”

Pooled analysis of the surgical treatment for colorectal cancer liver metastases

“…After completing the literature searches and analyses, a recent review came to our attention [28]. The conclusions of this meta-analysis of 2880 patients agree with the previous studies: OS (HR 0.96; 95%CI 0.81-1.14; p = 0.64; I 2 = 0) and disease free survival (DFS) (HR 1.04; 95%CI 0.76-1.43; p = 0.79; I 2 = 53%) are similar for both simultaneous and delayed resections.…”

Metástasis Hepáticas De Origen Colorrectal Sincrónicas: ¿intervención Simultánea O Secuencial?

“…Existen varios trabajos de revisiones 17,21,23,24 y en todas ellas los autores encuentran los mismos problemas: 1) La definición de MHCRS no es la misma para todos los autores; 2) Son trabajos retrospectivos; 3) no siempre se comparan grupos con MHCRS y estrategias diferentes sino que son series de resultados con una u otra estrategia y 4) En general, los candidatos a cirugía simultánea son mejores que los de cirugía secuencial. Con estos datos, la mayoría coinciden en que la cirugía simultánea se puede realizar con los mismos resultados sólo en casos seleccionados, pero, en pacientes con peor status preoperatorio o candidatos a resecciones hepáticas mayores, la cirugía secuencial sería la indicada, con menor morbimortalidad y ahorrando posiblemente alguna intervención hepática innecesaria 15,17,23,24 .…”

“…El número de MH fue mayor en el grupo 2, algo esperable, ya que la cirugía simultánea la realizamos sólo en casos de 3 o menos metástasis hepáticas tal y como recomiendan la mayoría de los autores 12,21,23,24 . Por el mismo motivo el índice de resecabilidad fue mayor en el grupo 1 así como el porcentaje de resecciones hepáticas aunque sin significación estadística.…”

“…La supervivencia a 1, 3 y 5 años fue de 75%, 45% y 36% en el grupo 1 y de 76%, 49% y 29% en el grupo 2, cifras similares a las encontradas en la literatura [5][6][7]12,15,[20][21][22][23][24]29 (Tabla 3) sin diferencias significativas entre ambos grupos.…”