Up to 15% of patients with colorectal cancer have synchronous liver metastases. Wich is optimal timing of hepatectomy ?
I think that we all agree the controversies and debates regarding this area, some groups adhering even to a liver first approach, and secondary colorectal resection. I am also very interested about the answers to this question!
My guiding idea, although not very evidence based is : never a simultaneous liver resection larger than one segment for rectal surgeries, and two liver segments for colonic resections.
I will recommend also the following article.
http://www.ncbi.nlm.nih.gov/pubmed/23458152
I do prefer to avoid mixing major liver resections with colonics. If small a wedge resection is needed , I would do it . However there are authors reporting their experiences in this , last month Berti et el has reported on their laparoscopic simultaneous resections in
We will perform simultaneous colon and 2 segment resections routinely, we have also done them laproscopically if appropriate for that particular patient. We will not perform the colon resection if the patient has received avastin unless the patient is willing to have a loop ileostomy, otherwise we will go with liver first strategy. We prefer liver first strategy for most 4 to 5 segment resections.
if the patient is needed a small liver resection, his general condition is very good, and the surgeon's experience in liver surgery is excellent, the simultaneous liver resection is an excellent procedure, especially in laparoscopic approach.
In cases of major colorectal surgery only minor liver resections are safe (1-2 segments). The liver first approach is in some casesa useful way to treat the patient.
In cases of liver only metastatic CRC patients, we prefer "chemo-first" approach. In regression or stable disease liver first resection is preferred in rectal cancer patient, followed by radiotherapy and staged resection of the primary tumor. Laparoscopic approach is preferred. In case of colon cancer, "primary first", or simultaneous approach is preferred.
The best surgical strategy to deal with synchronous liver metastases still remains controversial and farther evidence-based research is needed for a generally accepted surgical approach.
In patients presenting with primary colon cancer and synchronous metastases and suffering from symptoms of the primary tumour, e.g. occlusion or bleeding, resection of the primary tumour should be considered before starting chemotherapy.
For patients presenting with synchronous liver metastases and no symptoms from the primary tumour initial systemic chemotherapy is recommended, followed by reevaluation for surgery. This strategy will allow early aggressive disease progression to become manifest. If there is widespread disease progression, resection will likely provide no specific benefit. If the disease responded or is stable, resection of the primary tumour and the metastases could be attempted.
Simultaneous resection of the primary and metastatic disease is clearly preferable from the patent's perspective. Several surgical case series and a meta-analysis have failed to confirm inferior survival or greater morbidity for patients who undergo a one-stage procedure as compered to staged resection, unless a major hepatic resection (3 or more segments ) is needed. One-stage surgery is a reasonable option for patients with low- volume potentially resectable liver metastases.
The reverse strategy(liver-first approach), first reported by Mentha and colleagues in 2006, may be particularly beneficial for patients presented with rectal cancer and synchronous major hepatic involvement. These patients often require a combination of chemotherapy, radiotherapy, and a complex pelvic operation. The classic staged approach in these patients can result in a significant delay in the treatment of the metastatic disease that may become inoperable.
I would agree with the earlier comments that >3 segment hepatic resections should be avoided in the context of concomitant colon surgery.
Thank you dear colleagues for your comments. The variety of your considerations underline the importance of experience as well as results reported in literature
Thank you Pr G Garcea. Colon resection and simultaneous major hepatectomy should be avoided.
In accordance with guidelines I will have to agree with Prof. Tsalis. What should also be mentioned with regards to combined resections is that there is emerging evidence that they can be safely performed purely laparoscopically:
Article Laparoscopic synchronous resection of colorectal cancer and ...
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